F. PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY
Definition
Psychiatric residential treatment facility (PRTF) is an inpatient psychiatric facility that provides psychiatric and other therapeutic and clinically informed services to individuals under age 21, whose immediate treatment needs require a structured 24 hour residential setting that provides all required services (including schooling) on site. Services provided include, but are not limited to, multi-disciplinary evaluation, medication management, individual, family and group therapy, parent guidance, substance abuse education/counseling (when indicated) and other support services including on site education, designed to assist the young person to achieve success in a less restrictive setting. This level of care primarily serves as a step down from acute psychiatric inpatient care. On occasion, it may be appropriate for children to be admitted directly from the community.
Authorization Process and Time Frame for Service
This level of care requires prior authorization. The initial authorization generally covers thirty days. Subsequent reviews are generally required every thirty days. Extended stays may be subject to Intensive Care Management review.
Medical Necessity Criteria:
6.1.1 Symptoms and functional impairment include all of the following:
6.1.1.1 Diagnosable DSM Axis I or Axis II disorder,
6.1.1.2 Symptoms and impairment must be the result of a psychiatric or substance abuse disorder, excluding V-codes,
6.1.1.3 Functional impairment not solely a result of Pervasive Developmental Disorder or Mental Retardation, and
6.1.1.4 GAF <40
6.1.2 Patient has recently met acute inpatient psychiatric criteria but has not met continued care criteria for the acute level of care. Child continues to demonstrate vulnerability to acute exacerbations as evidenced by intermittent acuity in hospital or history of rapid decompensation with transitions. Discharge to lower level of care would likely lead to the need for hospitalization.
6.1.3 Intensity of Service Need
6.1.3.1 The child meets criteria for discharge from a hospital setting but:
6.1.3.1.1 Key components of a residential or community based treatment plan are unavailable, or
6.1.3.1.2 All less restrictive treatment options have been examined and have been examined and determined to be ineffective and the individual requires 24 hour supervised care within a psychiatrically staffed residential environment as evidenced by:
• Patient’s behavior is sufficiently unstable to require immediate professional intervention to protect patient from harming self and others; or
• Patient is likely to require intermittent 1:1 supervision, constant observation, or frequent checks for safety; or
• Efforts to manage medical risk symptom or behavior in a lower level of care have been examined and have been determined to be ineffective or result in an acute escalation of behavior with risk of harm to self or others; or
• Patient requires close medical monitoring or skilled care to evaluate and adjust dosage of psychotropic medications and such medical management and dosage adjustment could not safely be conducted in a residential treatment center, or ambulatory setting; or
• Patient requires a medication taper and re-evaluation in a closely monitored setting. Previous attempts to taper medication have resulted in behavioral escalations that meet admission criteria for inpatient hospitalization.
Making of Level of Care Decisions
In any case in which a request for services does not satisfy the above criteria, the ASO reviewer must then apply the document Guidelines for the Making of Level of Care Decisions and in these cases the child/adolescent shall be granted the level of care requested when
1.) those mitigating factors are identified and
2.) not doing so would otherwise limit the child/adolescent ability to be successfully maintained in the community or is needed in order to succeed in meeting child/adolescent treatment goals.
Provider Advisory Group recommends section F.1.3.2 be deleted.
6.1.3.2 Exclusionary Criteria: Admission to a PRTF level of care should not be considered if the patient exhibits any one of the following criteria:
6.1.3.2.1 Need for prn medication on a daily basis; or
6.1.3.2.2 Need for one-to-one care at time of admission; or
6.1.3.2.3 Need for daily restraint/seclusion; or
6.1.3.2.4 High risk for elopement
6.2.1 Patient has met acute care criteria within past 30 days; and
6.2.2 There is evidence of active treatment and care management as evidenced by:
6.2.2.1 Patient and family participation in treatment consistent with care plan, or active efforts to engage the patient and/or family are in process. Type, frequency, and intensity of services are consistent with the treatment plan, and
6.2.2.2 A care plan with evaluation and treatment objectives appropriate for this level of care has been established. Treatment objectives are related to readiness for discharge and progress toward objectives is being made and monitored daily, and
6.2.2.3 Vigorous efforts are being made to affect a timely discharge (e.g., meeting with caseworker, convening aftercare planning meetings with aftercare providers, identifying and referring for aftercare or local systems of care, scheduling initial aftercare appointments).
6.2.3 If the patient does not meet criterion F.2.1, continued stay may still be authorized under any of the following exceptional circumstances:
6.2.3.1 Patient has clear behaviorally defined treatment objectives that can reasonably be achieved within 30 days and are determined necessary in order for the discharge plan to be successful, and there is no other suitable environment in which the objectives can be safely accomplished; or
6.2.3.2 Patient can achieve certain treatment objectives in the current level of care and achievement of those objectives will enable the patient to be discharged directly to the community rather than to another residential setting. Continued stays for this purpose may be as long as 30 days; or
6.2.3.3 Patient is expected to transfer to another institutional treatment setting within 30 days of discharge and continued stay at this level of care, rather than an interim placement, can avoid disrupting care and compromising patient stability. Continued stays for this purpose may be as long as 30 days; or
6.2.3.4 Patient is scheduled for discharge, but the patient’s community-based aftercare plan is missing critical components. These components have been vigorously pursued but are not available (including but not limited to such resources as placement options, psychiatrist or therapist appointments, day treatment or partial hospital programs, etc.). Authorization may be extended for up to 30 days with Intensive Care Management involvement, Under such circumstances, the ICM will work closely with the Managed Service System if the child is DCF involved or directly with the local providers or Community Collaboratives to address aftercare needs.
6.2.3.5 Patient would be highly vulnerable to rapid decompensation if discharged to home due to significant known stressors within the home environment that would not be mitigated sufficiently with home-based or other clinical services.