Behavioral Health Partnership –
Child Psychiatric
Level of Care Guidelines
Guidelines for Making Level of Care Decisions
These Level of Care guidelines are designed to assist care managers and providers in assessing a child’s clinical presentation and determining the appropriate level of care. This document should be used as a guideline for facilitating access to the treatment setting and interventions based on a child’s severity of illness and intensity of service need. In general, children should be placed in the least restrictive level of care that is warranted by the severity of presenting symptoms, degree of functional impairment and environmental circumstances. The level of treatment intervention should match the presentation that necessitated the intervention. The ASO will allow for multiple levels of care to be authorized concurrently for the purpose of treatment continuity and flexibility in service planning. In all cases, the ASO will give due consideration to family choice and the provider’s expertise and will engage in a highly collaborative care decision-making process with providers and families.
These guidelines are governed by the definitions of “medical necessity”, “medical appropriateness” and “EPSDT” (for children under twenty-one (21)) included at the end of this document. Costs may be factored into decision-making only when two alternative treatments are equally effective.
A. Application of the Criteria
The application of the severity of illness criteria may be influenced by a variety of factors related to the child’s psychiatric condition and living environment. Aspects of a child’s condition that might warrant consideration in making level of care decisions include the following:
• Co-morbid psychiatric conditions
• Co-morbid substance abuse conditions
• Co-morbid developmental disabilities
• Co-morbid biomedical conditions
• Persistence of symptoms
• Relapse potential
• Prevalence of risk behaviors and victimization issues
Environmental factors that may influence level of care decisions include:
• Residence (e.g., home, shelter, residential center)
• Family functioning
• Major life events
• Abuse/neglect
• Treatment motivation
• Educational functioning
Although admission and continued care decisions should not be made solely on the basis of environmentally based risk, these factors need to be considered in treatment planning. Environmentally based factors may provide the impetus for continuing services or for facilitating access to a higher or lower level of care. Strengths and protective factors should be considered in all care decision making.
When clinical presentation supports more than one level of care, the intensity of service need, prior treatment history and the presence of protective factors are used to determine the most appropriate level of care.
B. Mitigating Factors
Although efforts should always be made to review a child’s course of treatment and level of care determination based on clinical and environmental factors listed above, there are particular events that might require a decision that falls out of the parameters listed above. Special consideration may be made for the following circumstances:
• Court ordered evaluation or treatment.
• The level of care that the child needs and is eligible for is currently not available and the child’s safety and well being requires placement in an alternative level of care, irrespective of clinical need.
• There is limited availability of the identified community provider network and to discharge out of one level of care to a less restrictive level of care without these identified supports in place would place the child at risk for clinical deterioration.
C. Medicaid Definitions
1. Medical Necessity - Health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or to prevent a medical condition from occurring.
2. Medical Appropriateness - Health care that is provided in a timely manner and that meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally-effective, alternative treatments or diagnostic modalities.
3. EPSDT – Connecticut Medicaid recipients under the age of twenty one (21) are entitled to the benefits of the Early and Periodic, Screening, Diagnosis and Treatment (EPSDT) program which includes an age-appropriate behavioral health and developmental assessment and any medically necessary follow-up treatment.
The HUSKY A MCOs are responsible for ensuring the provision of an assessment of a child’s behavioral health. A child may be referred to either the MCO or the ASO for an inter-periodic screen by a professional who comes in contact with a child outside of the formal health care system. The ASO is responsible for ensuring the provision of an inter-periodic assessment of a child’s behavioral health when a child is referred either directly to a behavioral health provider in the BHP network or to an ASO care manager.
The ASO’s care managers or other ASO staff must authorize all medically necessary behavioral health services that may be recommended or ordered pursuant to an EPSDT periodic or inter-periodic screening including medically necessary health care services that are not otherwise covered under the Connecticut Medicaid program. Care managers or other ASO staff are also required to facilitate access to such services when contacted by the recipient or the recipient’s designated representative.