A. Residential Treatment Center:
Definition
A Residential Treatment Center (RTC) is a 24 hour facility licensed as such by the State of Connecticut or appropriately licensed by the state in which it is located, and not licensed as a hospital, that offers integrated therapeutic services, educational services and activities of daily living within the parameters of clinically informed milieu and based on a well defined, individually tailored treatment plan. This level of care is reserved for those children/adolescents whose psychiatric and behavioral status warrants the structure and supervision afforded by a self contained setting that has the ability to offer all necessary services including an on-site educational program, and provide line of sight supervision when necessary. Clinical consultation is available at all times and physical restraint may be used in emergency situations, as necessary to prevent immediate or imminent injury to the client or others. RTC frequently serves as a step down from psychiatric hospitalization or may serve as the treatment of choice when a child’s behavioral status places him or the community at risk should services be offered in a less restrictive setting.
Authorization Process and time Frame for Services
Admission to Residential Treatment requires the support of a DCF Area Office Director and the approval of the DCF Bureau of Behavioral Health, Medicine and Education. Each child/adolescent considered for this level of care must have had a Comprehensive Global Assessment (or other DCF approved evaluation) and any additional diagnostic services (i.e., face to face interview, psychological testing, medication evaluation, family interview) necessary to develop a complete clinical and psychosocial profile of the child’s service needs. This level of care is authorized and reviewed in intervals appropriate to the treatment needs of the child/adolescent and the specific focus of the intervention.
Level of Care Guidelines:
1.1.1 Severity of Symptoms and Functional Impairment,
1.1.2 Diagnosable DSM-IV Axis I or Axis II disorder,
1.1.3 Symptoms and impairment must be a result of a psychiatric or co-occurring substance abuse disorder, excluding V-codes, and
1.1.4 Chronic (>6-months) presentation of the following behaviors consistent with at least one of the following,
1.1.4.1 Recurrent suicidal gestures and/or attempts with significant risk of self-injury; or
1.1.4.2 Recurrent self-mutilation that requires non-urgent medical intervention and that presents some potential for danger, e.g., through infection; or
1.1.4.3 Recurrent deliberate attempts to inflict serious injury on another person; or
1.1.4.4 Unremitting reckless behavior suggesting an unwillingness to consider potential for risk to self or others (e.g. fire setting, psychosexual behavior problems; reckless driving; and other risk-taking behavior;) or
1.1.4.5 Unremitting impulsive, defiant, antagonistic or provocative behavior with potential for risk to self or others; or
1.1.4.6 Recurrent agitated and uncontrolled behavior including acts of violence against property or persons; or
1.1.4.7 Recurrent dangerous or destructive behavior; or
1.1.4.8 Recurrent psychotic symptoms/behavior that pose a significant risk to the safety of the child/adolescent or others, or markedly impaired functioning in one or more domains; or
1.1.4.9 Recurrent and marked mood lability resulting in severe functional impairment; or
1.1.4.10 Recurrent intimidation/threats of aggression with moderate to high likelihood that they will be acted upon and result in serious risk to others.
1.2.0 Intensity of Service Need
1.2.1 Individual requires residential treatment without 24-hour medical monitoring as evidenced by either:
1.2.1.1 The above symptoms cannot be contained, attenuated, evaluated and treated in a home type living situation with any combination of outpatient and intensive ambulatory services due to :
1.2.1.1.1 Child/Adolescent presents moderate risk for requiring restraint/seclusion as evidenced by the use of such during the 3-month period immediately preceding admission. Restraints were occasional (not more than once every two weeks), could be administered with fewer than 3 persons and did not present high risk of serious injury to self or others. Seclusions were not locked; or
1.2.1.1.2 Patient requires 24-hour awake supervision in order to safely manage behaviors in above or due to high AWOL risk, or
1.2.1.2 Documented efforts to provide intensive community-based treatment (e.g., , extended day treatment/intensive outpatient treatment, home-based services, intensive intervention within the school environment) while the child is living in a home type setting.(,e.g., birth, relative, adoptive, foster, therapeutic foster, or group home) have been implemented within the past six months and have not resulted in safe, manageable behavior in the home setting; or
1.2.1.3 Necessary, less restrictive intensive community-based services needed to support the child/adolescent in a home setting are not currently available and clinical issues require this level of care as an appropriate alternative.
1.3.1.1 Symptoms and impairment must be a result of a psychiatric or substance abuse disorder, excluding V-codes, and
1.3.1.2 Clinical or treatment circumstances consistent with one of the following:
1.3.1.2.1 Child/Adolescent has exhibited behavior consistent with admission criteria within the past 6 weeks; or
1.3.1.2.2 Child/Adolescent has been prevented from engaging in above qualifying behavior due to use of 1:1 supervision, frequent checks (q15), physical/mechanical restraint or locked seclusion; or
1.3.1.2.3 Child/Adolescent’s history, current presentation, and treatment progress strongly suggest that discharge to a lower level of care presents a high likelihood of deterioration in the patient’s condition, high-risk behavior, and the inability to continue to make progress on treatment goals. This might be evidenced by recent (e.g., past 8 weeks) history of failed attempts to transition from this level and type of care with adequate aftercare supports or deterioration in behavioral functioning during a recent period without this level of care, e.g., during holiday or day/multi-day passes
1.3.2 If the child/adolescent does not meet the above criteria, continued treatment may still be authorized under the following circumstances:
1.3.2.1 Child/adolescent 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 less restrictive environment in which the objectives can be safely accomplished; or
1.3.2.2 Child/adolescent can achieve certain treatment objectives including appropriate pharmacological treatment, in the current level of care and achievement of those objectives will enable the child/adolescent to be discharged directly to the community rather than to another restrictive setting; or
1.3.2.3 Child/adolescent is expected to transfer to another residential 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 the stability of the child/adolescent. Continued stays for this purpose may be as long as 30 days; or
1.3.2.4 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, therapeutic mentoring, etc.). Referral to the child’s DCF Area Office for review by the Managed Service System is indicated.
Note: 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 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.