Optum By United Behavioral Health New Jersey Managed Long-Term Services and Support (MLTSS) Medicaid Level of Care Guidelines

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1 Optum By United Behavioral Health 2015 New Jersey Managed Long-Term Services and Support (MLTSS) Medicaid Level of Care Guidelines (AMHR) AMHR provides services in/by a licensed community residence. Services include, but are not limited to, the following: Assessment and evaluation Individual services coordination Training in daily skills Residential counseling Support services Crisis intervention counseling services Medication education and facilitation of proper administration techniques Health care monitoring and oversight services The goal of AMHR is to support and encourage the development of life skills required to sustain successful living in the least restrictive environment within the community. Levels of AMHR are: Supervised Residence A+ - refers to licensed group homes or apartments. Community mental health rehabilitation services are available 24 hours per day, seven days a week. This includes awake overnight staff coverage. Supervised Residence A refers to licensed group homes or apartments. Community mental health rehabilitation services are available 12 hours or more per day, but less than 24 hours per day, seven days a week. Supervised Residence B refers to licensed group homes or apartments. Community mental health rehabilitation services are available for 4 or more hours per day, but less than 12 hours per day, seven days per week. Supervised Residence C refers to licensed group homes or apartments. Community mental health rehabilitation services are available for one or more hours per week, but less than 4 hours per Optum is a brand used by United Behavioral Health and its affiliates.

2 day. Family Care (Level D) refers to a licensed program in a private home or apartment in which community mental health rehabilitation services are for 24 hours per day by a Family Care Home provider. INSTRUCTIONS FOR USE Optum s Level of Care Guidelines are used to standardize coverage determinations, promote evidence-based practices, and support member s recovery, resiliency, and wellbeing. Optum s Level of Care Guidelines are derived from generally accepted standards of behavioral health practice. These standards include guidelines and consensus statements produced by professional specialty societies, as well as guidance from governmental sources such as CMS National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). While this Level of Care Guideline does reflect Optum s understanding of current best practices in care, it does not constitute medical advice. Optum reserves the right, in its sole discretion, to modify its Level of Care Guidelines as necessary. 1. Admission Criteria 1.1. The member is eligible for Managed Long Term Services and Supports (MLTSS) benefits The member is a person 18 years or over who has been diagnosed with a Serious Mental Illness i that seriously impairs the member s capacity to live independently with appropriate supports as needed The member is referred to AMHR by a licensed professional of the healing arts, including physicians The member s current condition cannot be safely, efficiently and effectively assessed and/or treated in a less intensive setting due to changes in the member s signs and symptoms, level of functioning, and/or psychosocial and environmental factors (i.e., the why now factors leading to admission) Failure of treatment in a lower level of care is not a prerequisite for authorizing coverage The member is not in imminent risk of harm to self or others and/or property. 2

3 1.6. Co-occurring behavioral health and medical conditions ii can be safely managed Services are medically necessary iii. 2. Continued Service Criteria 2.1. The admission criteria are still met Services continue to be medically necessary The why now factors leading to admission have been identified and are integrated into the treatment and discharge plans Evidence-based rehabilitation practices are being provided timely with sufficient intensity to address the member s treatment needs The member s family and other natural resources are engaged to participate in the member s treatment as clinically indicated. 3. Discharge Criteria 3.1. The continued stay criteria are no longer met. Examples include: Services are no longer medically necessary The why now factors which led to admission have been addressed to the extent that the member can be safely transitioned to a less intensive level of care The why now factors which led to admission cannot be addressed and the member must be transitioned to a more intensive level of behavioral health or medical care The member meets the conditions for discharge as outlined in NJAC 10:37A iv The member moves outside the geographic area of the AMHR s responsibility. OR OR OR 3

4 3.4. The member declines or refuses services and requests discharge, despite the provider s best efforts to develop an acceptable rehabilitation plan with the member. 4. Clinical Best Practices 4.1. Evaluation and Treatment Planning By the fourteenth (14 th ) day of admission the provider collects information from the member and other sources as part of a comprehensive intake assessment of the following: The member s chief complaint; The presenting problem/reason for referral (i.e., the why now factors); The member s current mental status and DSM/ICD diagnosis; The member s psychiatric and medical histories including the histories of substance use; abuse, neglect and other forms of trauma; The history of treatment including use of services outside the scope of services provided in AMHR (e.g., the Emergency Room, mental health services, social services); Psychosocial and environmental problems; The member s previous living situation; Risk factors including those related to harm to self or others, as well as risk stemming from co-occurring behavioral health or medical conditions; Assessment of the member s coping strategies; The member s understanding of the need for change as context for planning services including interventions that will promote informed decisionmaking and participation in services; Resilience factors; Recovery and resiliency goals; The member s overall rehabilitation goal; The member s readiness for rehabilitation; Activities needed to improve the member s readiness such as motivational enhancement or learning activities; 4

5 The member s present level of skills and knowledge relative to the rehabilitation goal, and the skills and knowledge needed to achieve the member s rehabilitation goal; The member s present resources and the resources needed to achieve the member s rehabilitation goal A nursing assessment shall be completed by the fourteenth (14 th ) day of admission. The nursing assessment shall justify the need for AMHR, and recommend an appropriate level of service In the event that not all information is available at the time of the intake assessment or the nursing assessment, there must be enough information to guide development of the comprehensive service plan, and support the need for AMHR The provider and, whenever possible the member, use the findings of the intake assessment and the nursing assessment to develop a comprehensive service plan as close to the date of admission to AMHR as possible, but in no case more than thirty (30) days after the date of admission The service plan shall be based on the member s active participation and input regarding stated needs (goals and objectives) and interventions the member would like from the staff member, and shall contain the signatures of the member and responsible staff member, and the date. If the member is unwilling/unable to sign, this shall be documented The comprehensive service plan documents the skills, knowledge and resources needed to achieve the member s overall rehabilitation goal, and clinical treatment recommendations. The comprehensive service plan should include: Observable, measurable objectives aimed at assisting the member with achieving the overall rehabilitation goal; The specific intervention for each skill, knowledge or resource objective; The amount, frequency and expected duration of each intervention; The person responsible for providing the intervention; and Specific measurable criteria for termination or reduction in services in the current level of care. 5

6 Examples of areas that could be addressed in the comprehensive service plan include: Housing; Supportive service planning; Skill development (e.g., interpersonal, household management, personal hygiene, illness selfmanagement); Linkage with medical-surgical services; Linkage with mentally ill, chemical abuser (MICA), and substance abuse services; Employment, volunteer and educational opportunities; Finances; Transportation; Access to natural supports; Social, recreational, leisure and community involvement; and Benefits and entitlements The comprehensive service plan also addresses how: Communication with all other treatment and service providers will be maintained in routine and emergency circumstances; and The member s family and other natural resources will participate in services as clinically indicated Services focus on addressing the why now factors to the point that the member s condition can be safely, efficiently and effectively treated in a less intensive level of care The provider informs the member of safe and effective treatment or service alternatives that may meet the member s immediate needs, potential risks and benefits, and the member gives informed consent. In providing informed consent, the member acknowledges willingness and ability to participate in services including any safety precautions The comprehensive service plan should be reviewed and revised as necessary, by the 90 th day of admission and then no less frequently than every ninety (90) days thereafter during the first year of service and six months thereafter. Revisions shall be based on updated nursing assessments and all other relevant information. 6

7 The service plan shall be based on the member s active participation and input regarding stated needs (goals and objectives) and interventions the member would like from the staff member, and shall contain the signatures of the member and responsible staff member, and the date. If the member is unwilling/unable to sign, this shall be documented A nurse shall document face-to-face health care monitoring visits with the member every ninety (90) days. Documentation shall include: A review of the service plan as well as observations and progress notes made by direct care staff; An assessment of the member s health; and Any changes needed in treatment approaches or level of service Factors such as a change in the member s condition, a change in participation in AMHR services, or a change in utilization of services outside of the AMHR (e.g., the Emergency Room) prompt a reassessment of the comprehensive service plan sooner than regular schedule of reviews. When the member s condition has not improved or it has worsened, the reassessment should determine whether the comprehensive service plan should be modified, or the member s condition should be treated in another level of care Discharge Planning At the time of admission, the provider and, whenever possible, the member shall develop an initial discharge plan and estimate how long AMHR services should last During admission, the provider and, whenever possible, the member shall update the initial discharge plan in response to completion of rehabilitation objectives, and changes in the member s condition ensuring that: An appropriate discharge plan is in place prior to discharge; The discharge plan is designed to mitigate the risk that the why now factors which precipitated admission will reoccur; and The member agrees with the discharge plan. 7

8 For members continuing treatment outside of AMHR, the provider: Shares the discharge plan and all pertinent information with the treatment provider(s) prior to discharge Provides the member with information about: Recommended self-help and community resources; and How the member can resume AMHR services For members moving outside the AMHR s geographic area of responsibility, the AMHR provider shall discuss the need for and availability of AMHR services with the member and the member s treating provider. As needed, the AMHR provider will arrange for the transfer of AMHR services to a provider in the member s new service area. The AMHR provider shall maintain contact with the member until services are transferred. References 1. Anthony, W, Farkas, M. (2009). A Primer on the Psychiatric Rehabilitation Process. Retrieved from: content/uploads/2011/11/primer-on-the-psychiatric-rehabilitation- Process.pdf. 2. State of New Jersey, Administrative Code. (2009). Chapter 37A, Community Residences for Mentally Ill Adults. Retrieved from 3. State of New Jersey, Administrative Code. (2012). Chapter 77A, Adult Mental Health Rehabilitation Services Provided in/by Community Residence Programs. Retrieved from i Per NJAC 10:10 Serious Mental Illness means individuals who are in psychiatric crisis, or have a designated diagnosis of mental illness under the Diagnostic and Statistical Manual of Mental Disorders (DSM), and whose severity and duration of mental illness result in substantial functional disability. ii Per NJAC 10:37A a person is medically cleared when the person doesn t have an acute medical condition requiring inpatient hospitalization, does not need nursing home level of care, is able to evacuate the residence within three (3) minutes, and is capable of managing incontinence and other medical care needs. iii The New Jersey Division of Medical Assistance and Health Services defines medically necessary services as services or supplies necessary to prevent, evaluate, diagnose, correct, prevent the worsening of, alleviate, ameliorate, or cure a physical or mental illness or condition; to maintain health; to prevent the onset of an illness, condition, or disability; to prevent or treat a condition that endangers life or causes suffering or pain or results in illness or infirmity; to prevent the deterioration of a condition; to promote the development or maintenance of maximal functioning capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age; to prevent or treat a condition that threatens to cause or aggravate a handicap or cause physical deformity or malfunction, and there is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the enrollee. The services provided, as well as the type of provider and setting, must be reflective of the level of services that can be safely provided, must be consistent with the diagnosis of the condition and appropriate to the specific medical needs of the enrollee and not solely for the convenience of the enrollee or provider of service and in accordance with standards of good medical practice and generally recognized by the medical 8

9 scientific community as effective. Course of treatment may include mere observation or, where appropriate, no treatment at all. Experimental services or services generally regarded by the medical profession as unacceptable treatment are not medically necessary for purposes of this contract. Medically necessary services provided must be based on peer-reviewed publications, expert pediatric, psychiatric, and medical opinion, and medical/pediatric community acceptance. In the case of pediatric enrollees, this definition shall apply with the additional criteria that the services, including those found to be needed by a child as a result of a comprehensive screening visit or an inter-periodic encounter whether or not they are ordinarily covered services for all other Medicaid enrollees, are appropriate for the age and health status of the individual and that the service will aid the overall physical and mental growth and development of the individual and the service will assist in achieving or maintaining functional capacity. iv NJAC 10:37A defines the conditions under which a Provider Agency (i.e., a residence that delivers AMHR services) may discharge a person. They are: The person creates a substantial, continuing and immediate threat to the physical safety of other persons, or to the emotional or psychological health of other residents; provided, however, that the Provider Agency shall not discharge the person on this basis if the person has been civilly committed. The Provider Agency reasonably concludes that the person s clearly inappropriate behavior renders the program out of compliance with any agreement to which the Provider Agency is signatory as a lessee or with any applicable law or regulation. The person repeatedly violates a rule governing resident conduct, which is reasonable both in itself and its application, after the Provider Agency delivers to the person a written notice to cease violating such rule. No such rule shall be the basis for discharging a person unless it is reflected in a resident services agreement and/or other documents in compliance with these rules. The person has received maximum clinical benefit of the services offered by the Provider Agency, an appropriate alternative living arrangement (where the person has sufficient financial resources), other than a shelter, motel or hospital, is available to the person prior to discharge, and the program reasonably determines that discharge would be in the person s best clinical interests. The person is absent from the residence for a continuous period of thirty (30) days without providing the Provider Agency with notice of intent to return after the expiration of the 30-day period; provided, however, that continued absence beyond 30 days shall be a condition for discharge if such absence is not in the person s clinical best interest. The person has refused necessary and appropriate services offered by the Provider Agency pursuant to a properly developed treatment plan; the refusal is contrary to the person s clinical best interest; the person has failed to offer any alternative plan which would be consistent with the person s clinical interest; and an alternative living arrangement other than a hospital is available. 9