DRAFT
- 5/4/05
Intermediate care refers to a continuum of ambulatory psychiatric treatment programs that offer therapeutically 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 site-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.
This level of care requires pre-authorization. Time frame for initial authorization varies 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 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.
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.
Medical Necessity Criteria:
Admission Criteria
Symptoms and functional impairment include all of the following:
Diagnosable DSM Axis I or Axis II diagnosis
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 severe and dangerous or
Deliberate
attempts to inflict serious injury on another person or
Dangerous or destructive behavior as evidenced by indication of episodic impulsivity or physically or sexually aggressive impulses tat are moderately endangered to self or others (e.g., status offenses, self mutilation, running away from home or placement with voluntary return, fire setting, violence toward animals, affiliation with dangerous peer groups) or
Psychotic symptoms or behavior that poses a moderate risk to the safety of the child or other s (e.g., hallucination, marked impairment of judgment) or
Marked mood lability as evidenced by frequent or abrupt mood changes accompanied by verbal or physical outbursts/aggression and /or destructive behaviors or marked depression, anxiety or withdrawal from activities, relationships and peers
And meets at least one of the following criteria:
Intensity of Service Need
The child or youth requires an organized, structured program up to 5 days per week. The intensity of service and the length of stay varies 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)
PHP: Child/adolescent demonstrates more acute symptoms (e.g.,, recently met acute care criteria) 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 and management. 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 3-5 days per week for a brief period of time. 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) and lack of success in shorter term intermediate programs, or other
community –based services.
Patient has met admission criteria within the past 48 hours as 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 15 days and are determined necessary fin 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 for up to 10 days for PHP and 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.