INTERMEDIATE CARE
Definition
Intermediate care refers to a continuum of ambulatory psychiatric treatment programs that offer intensive, coordinated and structured therapeutic and assessment services within a stable therapeutic milieu. These programs encompass partial hospital (PHP), intensive outpatient (IOP) and extended day treatment (EDT) levels of care. All programs require psychiatric evaluation, treatment planning and oversight and serve as a step down to, or diversion from, inpatient levels of psychiatric care. Multiple treatment modalities (i.e, individual therapy, group therapy, family therapy, medication management, therapeutic recreation) are integrated within a single treatment plan that focuses on patient specific goals and objectives. Services are office based although some programs may allow for structured off -site activity. Programs vary according to intensity of service (day/hours offered weekly) and length of stay.
Authorization Process and Time Frame for Service
This level of care requires prior authorization. Time frame for initial authorization is individualized according to intensity of client need and type of program for which admission is sought. Generally, PHP and IOP provide more intensive service over a brief period of time to stabilize a client’s functioning, while EDT offers ( less: delete less) clinical intervention and more (therapeutic recreation ??) over a longer period of time to help the patient achieve success in a less restrictive setting that incorporates community-based activities into the treatment plan. Some IOP level services are specialized in clinical focus or treatment model and are operated as intensive service components of outpatient clinics.
Use of Guidelines
The following guidelines are to be used when determining access to any of these three levels of Intermediate Care. Differences in admission, intensity of service need, and continued care for each of theses three services are addressed in the service grid to be used conjointly with these guidelines.
Level of Care Guideline: (Medical Necessity Criteria):
Admission Criteria
Symptoms and functional impairment include all of the following:
Diagnosable DSM Axis I or Axis II disorder
Symptoms and impairment must be the result of a psychiatric disorder,
excluding V-codes
Functional impairment not solely a result of Pervasive Developmental Disorder or Mental Retardation and
Recent and/or persistent presentation (e.g., over 6 month period) of at least one of the following Symptom Categories:
Suicidal gestures and/or attempts or
Self-mutilation that is moderate to severe and dangerous or
Deliberate attempts to inflict serious injury on another person or
Dangerous or destructive behavior as evidenced by episodes of impulsive or physically or sexually aggressive behavior that present a moderate risk or
Psychotic symptoms or behavior that poses a moderate risk to the safety of the child or others or
Marked mood lability as evidenced by frequent or abrupt mood changes accompanied by verbal or physical outbursts/aggression or
Marked depression or anxiety as evidenced by significant disruption of activities of daily living or relationships with families and peers.
And meets at least one of the following criteria:
Intensity of Service Need
The child or youth requires an organized, structured program several days each week. The intensity of service and the length of stay vary according to child needs’s and the corresponding program
The above symptoms cannot be contained, attenuated, evaluated and treated in a lower level of community based care as evidenced by one of the following:
One or more recent efforts to provide outpatient treatment have been unsuccessful or
Recent attempts to engage the child and/or family in outpatient therapy have been unsuccessful or the patient and caregivers have been noncompliant with treatment or
The above problems occur in context of a regular and significant outpatient therapeutic relationship despite efforts to augment such treatment (e.g., medication consultation, or increased outpatient therapy visits or addition of family/parent therapy, psychological assessment, group therapy, etc)
Program Specific Requirements:
PHP: Child/adolescent demonstrates severe level of symptomotology requiring 4-6 hours/day of structured programming five days a week for a brief period of time. May need continued diagnostic work and medication evaluation. May have been unsuccessful in IOP or other day program.
IOP: Child/adolescent demonstrates moderate level of symptomotology requiring 2-4 hours/day of structured programming for 2-5 days per week for a brief period of time. Some specialized IOP programs may require longer lengths of stay. Requires little or no additional diagnostic work but may require medication management. Has been unsuccessful in out patient or other community based programs.
EDT: Child/adolescent demonstrates moderate level of symptomotology that appears to be persistent in nature (i.e., greater than six months) although may be the result of an acute exacerbation of symptoms and lack of success in shorter term intermediate programs, intensive home-based programs or other community –based services.
Continued Care Criteria
Patient has met admission criteria within the past three (3) days for PHP, five (5) days for IOP, and thirty (30) days for EDT evidenced by:
The child or youth’s symptoms or behaviors persist at a level of severity documented at the most recent start for this episode of care; or
The child or youth has manifested new symptoms or maladaptive behaviors that meet admission criteria and the treatment plan has been revised to incorporate new goals, and
Evidence of active treatment and care management as evidenced by:
A care plan has been established with evaluation and treatment objectives appropriate for this level of care. Treatment objectives are related to readiness for discharge and progress toward objectives is being monitored weekly and
Child and caregiver participation in treatment is consistent with care plan or active efforts to engage the child and caregiver are in process. Type, frequency and intensity of services are consistent with treatment plan and
Vigorous efforts are being made to affect a timely discharge (e.g., meeting with caseworker, convening aftercare planning meetings with aftercare providers , identifying resources and referring for aftercare or care coordination, scheduling initial aftercare appointments)
If child/adolescent does not meet above criteria, continued stay may still be authorized under any of the following circumstances:
Child/adolescent has clear behaviorally defined treatment objectives that can reasonably be achieved within 5 days for PHP, 10 days for IOP and 30 days for EDT, and are determined necessary in order for the discharge plan to be successful, and there is not suitable environment in which the objectives can be safely accomplished; or
Child/Adolescent 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 a more restrictive setting; or
Child/adolescent is scheduled for discharge , but the community-based aftercare plan is missing critical components. The 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 intensive outpatient treatment etc.) Authorization may be extended in increments for up to 5 days for PHP, 10 days for IOP and up to 30 days for EDT. Under such circumstances, the Intensive Care Manager will work closely with the Managed Service System if the child is DCF involved or directly with local providers or Community Collaboratives to address aftercare needs.