Outpatient Therapy

Definition:

Outpatient therapy services are ambulatory clinical services provided by a general hospital, private freestanding psychiatric hospital, psychiatric outpatient clinic, state-operated facility, or by a licensed mental health practitioner practicing independently or in a private practice group. This service involves the evaluation, diagnosis, and treatment of individuals, families or groups as well as medication management. Services are typically scheduled in advance, but may occur urgently without a scheduled appointment. Services are provided at a frequency designed to address immediate clinical need as directed by an individual or family treatment plan. Outpatient services are designed to promote, restore, or maintain age appropriate social/emotional functioning and are intended to be focused and time limited with services discontinued as the child/youth and family are able to function more effectively.

A child/adolescent can receive services from more than one provider (e.g., clinic, independent practitioner) at any given time offering individual, family, group or medication management services, provided the services are not duplicative. Based on clinical necessity and with review by a care manager, a client may be authorized to receive an outpatient service while simultaneously participating in a higher level of care.

Authorization Process and Time Frame for Service:

This level of care does not require prior authorization initially. However, registration is required which results in an initial authorization of twenty-six (26) sessions covering a twelve-month period of time. Visits in excess of 26 or those beyond the initial twelve-month period would require prior authorization.

Level of Care Guidelines:

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 or

Substance abuse disorder

Functional impairment not solely a result of Mental Retardation and

GAF <70

Intensity of Service Need

Child/adolescent is experiencing behavioral and/or emotional problems as described in the DSM-IV that can be assessed or safely addressed in an outpatient setting using one or more of the treatment modalities defined above.

Continued Care Criteria

The child/adolescent has met criteria for outpatient care and there is evidence of active treatment and care management as evidenced by

Patient and caregiver participation in treatment consistent with care plan,

or active efforts to engage the patient and/or caregiver are in process. Type, frequency and intensity of services are consistent with treatment plan, and

A care plan with evaluation and treatment objectives appropriate for this level of care has been established and treatment objectives are related to readiness for discharge, progress towards objectives is being monitored and the patient is making measurable progress but identified objectives have not yet been met.

If the patient does not meet criteria listed above, additional outpatient services may be authorized if either of the following are true:

There is evidence that the child/adolescent will not be able to maintain functioning without sustained or significant deterioration if treatment is discontinued or

There is an anticipated stressor within the child’s immediate social or family environment that, based on clinical history could reliably predict behavioral and emotional regression (i.e., impending birth of sibling, divorce of parents, scheduled medical procedure, change in home environment, etc.)

The child/adolescent/family does not meet continued care criteria if:

The patient has met treatment goals or the child/adolescent /family has demonstrated minimal or no progress toward treatment goals for a three month period and appropriate modifications of treatment plan have been made and implemented with no significant success, suggesting the child/adolescent/family is not benefiting from outpatient therapy services at this time.