Program Context recognizes that specific programs may vary with respect to the seven key items as identified by Edmund Neuhaus, Ph.D. in his article on flexible models of partial hospitalization2: When PHPs or IOPs are described, it is useful to include all these elements. Portsmouth, Virginia. A person is not appropriate for participation in a partial hospitalization program orintensive outpatient program if the individual: Following admission, recurring reviews should be conducted to determine whether individuals continue to meet medical necessity criteria and require ongoing services in a PHP. Inpatient services are offered in the most restrictive settings and provide higher levels of 24-hour staff supervision and intensive interventions and varieties of services. A brief description and examples of each level of care follows: Primary Care is first line health care providing screening, early identification, education, and often pharmacotherapy. American Society of Addiction Medicine (ASAM) (April 2001). According to SAMHSA, While these disorders may interact differently in any one person (e.g., an episode of depression may trigger a relapse into alcohol abuse, or cocaine use may exacerbate schizophrenic symptoms), at least one disorder of each type can be diagnosed independently of the other.7. Partial Hospital Programs provide no less than 4 hours of direct, . Symptoms continue to impair multiple areas of daily functioning and medications are being adjusted, Impaired insight and skill deficits place one at a significant risk for further functional deterioration, Individual displays willingness yet difficulty understanding or coping with significant crises or stressors, There is a continued significant risk for harm to self or others. Adult Brain Injury. Treatment planning is a progressive process that requires regular updates of all goals and services on the plan. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. Telepsychiatry Guidelines . More often the full array of services (when available) is delivered by a variety of organizations and individual providers within a given community. Recently, accreditation organizations have also begun to look closely at clinical indicators of quality in addition to health and safety. A number of clinical factors may impact staff-to-client ratios in programs: For example, the direct treatment staff-to-client ratio in some acute PHPs may need to be 1:3, while in other less intensive programs, a ratio of 1:12 may be appropriate. While all levels of care in the continuum are important in providing a full recovery, these cuts have limited the availability of parts of the continuum in many communities. Neuhaus, E. Fixed Values and a Flexible Partial Hospital Program Model. Harvard Review of Psychiatry, Jan-Feb; 14(1):1-14, 2006. Additional benefits should include enhanced tracking and report writing functions that improves decision-making through the collection of timely, accurate information. When selecting outcome measures for the program, carefully consider the following: Programs should take caution that using a single outcome measure with all participants in a program could create problems unless that tool has established itself to be broadly applicable to multiple diagnostic groups. We have prepared this article to provide general guidelines for insurance billing for PHP. As a person moves through the continuum of care, the coordinated care services usually increase or decrease as reflected in the level of care that person is receiving. The inclusion of report writing functions is important since it can be used to send letters to primary care providers, and to extract relevant clinical data from the record and organize it into referral forms or reports. Gather information from other sources (family, hospital records, and urine screens) in addition to the client. All other documentation standards for a clinical record remain the same for telehealth and in-person/on-site participants. The Standards and Guidelines will be updated as new reviews are completed in any of the areas addressed. IOPs may be distinct service entities but are often included within applicable outpatient standards of operation. The Indiana Health Coverage Programs (IHCP) provides coverage for inpatient and outpatient behavioral health services - including mental health and addiction treatment services - in accordance with the coverage, prior authorization (PA), billing and reimbursement guidelines presented in this document. Treatment is best conceptualized as a phased continuum of care that progresses from management of active symptoms and problems to establishing recovery/relapse prevention plans. Whenever possible, they want to keep their job and maintain their homes. The individual is not judged to be in imminent danger of withdrawal or has recently undergone medical detoxification. Standards and Guidelines for Partial Hospitalization Child and Adolescent Programs. Additional elements include opinions related to the programs use of effective treatment methods, relevance of therapeutic subject matter, cultural sensitivity, teamwork, and the overall quality of care. Specific aspects of program design will be discussed as they apply to specialized practice settings. Clinicians must also be in a private, secure location to maintain HIPAA compliance for Clinicians working from home must have no family in the vicinity of the computer/device being used to provide service (working from home might require prior authorization from leadership ). THIRD, medical care linkages between the primary care providers including medical homes that shift the relationship toward integration or increased collaboration between specialized behavioral health programs and the ongoing medical management of thepeoplein many healthcare models. Cognitive and physical impairments may make day-long treatment services demanding for some individuals. CMS contracts with intermediaries to manage the requirements for PHP and IOP services. Chemical dependency partial hospitalization programs and intensive outpatient programs serve populations who present primarily with substance use disorders that have relatively minimal or no mental health disorders impacting current functioning. A reasonable understanding of responsibility or expectationsin the event thatthe individual does not follow through with the transition plan should be addressed between peer supports, practitioners, and/or care managers whenever possible. 1 TRICARE POLICY MANUAL 6010.54-M, AUGUST 1, 2002 PROVIDERS CHAPTER 11 SECTION 2.5 PSYCHIATRIC PARTIAL HOSPITALIZATION PROGRAM CERTIFICATION STANDARDS ISSUE DATE: July 14, 1993 AUTHORITY: 32 CFR 199.6(b)(4)(xii) I. This array of metrics provides a given program with potential access, treatment, and staffing goals. Miller, T.,Mol, J.M. For example, some States allow a psychiatric nurseto provide psychotherapy groups while others do not allow this. Consideration of teletherapy options is up and coming because of childcare needs and difficulties moms have leaving the home to get to appointments. Partial hospitalization is a time- limited, structured program of multiple and intensive psychotherapy and other therapeutic services provided by a multidisciplinary team, as defined by Medicare, and provided in an outpatient hospital setting outpatient department facility or a Medicare-certified community mental health center (CMHC) that meets A hospital is a licensed facility that offers services more intensive than those required for room, board, personal services and general nursing care, and offers facilities and beds for use beyond 24 hours by individuals requiring medical, surgical, psychiatric, testing, diagnosis, treatment, or care for illness, injury, deformity, infirmity, abnormality, disease, or pregnancy. The intensity of the partial hospitalization level of care is medically necessary and the individual is judged to have the capacity to make timely and practical improvement. Clinically, the intermediately level of care option may provide the best fit due to quick access, resource concentration, a recovery focus, and built-in peer support. Irvin D. Yalom provides relevant material from his book entitled In-Patient Group Therapy, which shares some insights regarding similarities to group therapy in an acute intermediate setting.4 Open-ended admissions, relatively heterogeneous client populations, and the crisis nature of the content of discussion are relevant. All monitoring of suicidal ideation, such as daily screens, must continue. Individuals receiving care from primary care providers often suffer from sub-clinical or relatively mild behavioral health conditions and are at-risk for developing severe behavioral health disorders. Gray, K., Michael, S., Lefkovitz, P., and Barry, A. An individuals understanding of prescribed medications should be reconciled with the medical record. Relevant factors such as relapse and recidivism, attendance at self-help meetings, level of sobriety, post-discharge adjustment (including improvement in housing status, use of recovery-oriented peer or social support, and vocational training/placement), and legal issues pre- and post-treatment may be measured. Medical oversight is necessary with additional daily, hourly structure to contain and monitor client movement. They strive to have a positive clinical impact on each individuals support system and recovery environment. PHPs and IOPs can be distinguished by their primary program function or treatment objective. . Surveys should be user-friendly, relevant to the mission of the treatment program, and routinely completed by all participants during program and at discharge. Discharge from IOP programs is made to individual outpatient behavioral health specialists, integrated physical/behavioral settings, or primary care. Child and adolescent programs provide an intensive therapeutic milieu that is designed to serve the child and/or adolescent (and their family) within the least restrictive therapeutically appropriate context. All co-occurring programs must have clearly delineated procedures and linkages for addressing clients detoxification, withdrawal, and other medical needs. According to current practice guidelines, the treatment goals should be measurable, functional, time-framed, medically necessary, and directly related to the reason for admission. The presence of significant denial or unwillingness to address change may often be inevitable due to the acute circumstances surrounding an admission especially from an emergency department or crisis worker. Provide at least 4 days, but not more than 5 out of 7 calendar days, of partial hospitalization program services Ensure a minimum of 20 service components and a minimum of 20 hours in a 7 calendar-day period Provide a minimum of 5 to 6 hours of services per day for an adult aged 18 years or older The plan must address the diagnosis, stressors, personal strengths, type, and frequency of services to be delivered, and persons responsible for the development and implementation of the plan. These organizations usually conduct surveys of facilities on a regular basis and provide detailed reports on the areas where programs excelandwhere programsneed improvement. Programs will use their identified outcome measure tool to track clients progress in the program. We hope this document will be used in concert with active dialogue on a local, regional and national level to improve care and individual recovery. The summary includes the clinical status on admission, the diagnosis and any changes during treatment, progress made, skills developed, issues not addressed, plans to prevent relapse/foster recovery, aftercare appointments, referrals, a medication summary, and assessment of risk. This includes how the information within the EMR is accessed and utilized within a given program, and how. The increased integration between physical and behavioral health care allows for new levels of cooperation in documenting and sharing information. This record should be available to the individual, follow-up prescribing professional, and primary care provider. Medicaid is a federal health insurance benefit that is managed at the State level. We encourage the use of alternative modes of treatment delivery, such as telehealth, when newmodesare demonstrated to contribute to quality services. They tend to have limited insight into their illness accompanied by somewhat dysfunctional lifestyles and serious symptoms that have impacted their lives negatively in multiple ways. Co-morbid substance use is common so drug screens should be administered upon admission and use assessed throughout the stay. However, measures for physician involvement should be a part of all performance plans. Partial Hospitalization Programs (PHP) - Partial hospital implies a daily psychosocial milieu treatment of generally four or more hours duration a day with group therapy, psycho-educational training, and other types of appropriate therapy as the primary treatment modalities. Programming after school hours). AABH maintains a table of clinical outcome measures that have been used in PHPs and IOPs and can be accessed HERE for members. Each organization may also have criteria that must be included in the psychiatric assessment. require regular physician coverage that may vary depending upon local regulatory standards or payer requirements. An integrated care team, psychiatrist, or primary care practitioner may then provide follow-up care. Specific programs may pursue one or more of the following major functions within a given organization: Acute Crisis Stabilization - The acute PHP function focuses on providing intensive, short-term programming in a structured therapeutic milieu. Daily monitoring of medications, safety, symptoms, and functional level is deemed medically necessary. If information gathered from sources does not agree with what the client tells you, ask the client to help resolve the discrepancy. The individual is ready for discharge from a higher level of care but is judged to be in need of daily support, medication management, and intensive therapeutic interventions due to symptom acuity or functional impairment that cannot be provided in a traditional outpatient setting due to lack of comprehensive resources. Accreditation of a program provides the community with increased confidence that a program meets minimum standards for safety and quality for the people the program serves. However, the individual often presents with an impaired willingness or capacity to positively connect with caretaker, family, friends, or community supports. A mixed group means mixed level of attention to participants. Programs should use clinical screenings that are appropriate for regular assessment that determine progress in treatment and can be used to help set up initial treatment planning and changes to treatment planning during treatment. Partial hospitalization, also known as PHP (partial hospitalization program), is a type of program used to treat mental illness and substance abuse. Because these services are often expected as part of the contracts or regulatory reviews, it is necessary to better understand when participation in both services is appropriate and when one or the other should be the sole behavioral health provider. Partial Hospitalization is a short-term (average of four (4) to six (6) weeks), less than 24 hour, intensive treatment program for individuals experiencing significant impairment to daily functioning due to substance Currently Partial Hospitalization may be provided in a hospital or Community Mental Health Center (CMHC). CNA (Certified Nurse Aide) Registry. In view of PHPs and IOPs positions in the continuum of behavioral health services, programs must maintain liaison relationships with multiple behavioral health providers, physical health care providers, and others. The multidisciplinary team is central to the philosophy of staffing within a partial hospitalization or intensive outpatient setting. Improvement in symptoms and functioning to allow the child/adolescent to return to a school setting. All shifts to telehealth need approval of senior leadership, Each area must balance the needs of individuals that want to attend in person and those that wish to use. Medical records must be maintained in accordance with the current requirements of the applicable licensing and/or accrediting bodies, and the laws of the state within which the program resides. Treatment Guidelines Care Based Guidelines 1. Importantly, States vary in the scopes of work for many disciplines. Standards and Guidelines for Level II Services: Intensive Outpatient. For those with AN, weight restoration may need daily monitoring to prevent re-feeding syndrome. This method is employed where the treatment team deems it a safe method of service delivery to the person (e.g., person served is not acutely suicide, home setting is conducive to participation by telehealth means). Admission to these programs may be determined by functional level, specificity of the population (such as OCD), or treatment specialty such as DBT or CBT. In States where Medicaid is contracted out to other insurance providers, a program may find that guidelines are managed by the State and apply to all insurance companies contracted or the contracts may give the individual insurance providers the freedom to create their own guidelines. Our mission is to promote Partial Hospitalization and Intensive Outpatient Programs as a vital component of the Behavioral Healthcare Continuum. Linkages should endeavor to coordinate care in an efficient and timely manner. Association for Ambulatory Behavioral Healthcare, 2015. The inclusion of two patient identifiers is helpful and often required on each document, such as a patient name and medical record number. Establishment of a safety plan that allows for the child/adolescent to maintain safety in a community setting. Commission on Accreditation of Rehabilitation Facilities (CARF). Programs for chemically dependent individuals are designed to serve those within a less restrictive environment (for example, less restrictive than inpatient or residential) which allows the individual to practice new recovery and coping skills within his/her natural environment and to assess the individual strengths and weaknesses associated with those recovery and coping skills. The provision of services allowed for each discipline is dictated by the scopes of work for a licensee in their particular State. Some individuals are at risk for inpatient hospitalization and require the intensive services of partial hospitalization treatment due to acute debilitating symptoms and/or some risk of harm to self or others. Bill Type 13X is billed with Condition Code 41 (Partial Hospitalization) and the HCPCS code is not 104 CMR 30. PHPs and IOPs may be free-standing programs, part of a distinct behavioral health organization, or a department within a general medical health care system. The services and support provided by the ancillary staff and volunteers is not often reimbursable in fee for service models. The format for documentation of each individuals level of functioning, services needed and provided, response to treatment, and coordination of care can take varied forms but must be clearly delineated. Consider that each participant has differing levels of technical abilities or. 10, 05-07-04) A3-3194, HO-230.7 Partial hospitalization programs (PHPs) are structured to provide intensive psychiatric care through active treatment that utilizes a combination of the clinically recognized items and services described in 1861(ff) of the Social Security Act (the Act). Staff members must be trained and experienced in child and adolescent behavioral health, family therapy, milieu therapy, and therapeutic crisis intervention. Moda Health Medical Necessity Criteria Mental Health Partial Hospitalization and Intensive Outpatient Treatment Page 1/5 . A partial hospitalization program may be more appropriate in lieu of an intensive outpatient program if a number of these conditions are present: The following clinical presentations must be considered to admit a person to intermediate behavioral health services: Behavioral Health Symptoms: The individual exhibits serious and/or disabling symptoms related to an acute behavioral health condition or the exacerbation of symptoms from a severe and persistent mental disorder that has not improved or cannot be adequately addressed in a less intensive level of care. Along with the advent of the medical care home, the number of mental health professionals providing screening, consultation, limited counseling, and other behavioral health services on site in primary care settings has been growing rapidly in recent years. A separate progress note is required for each service delivered, whether billable or not. The program director is a mental health professional with a minimum of 3 years of . Menses have usually ceased if body mass is extremely low or high. The seventh edition (2018) guidelines provided a significant change in the guidelines. In addition, programs need to acknowledge that not all individuals have the appropriate devices, the WIFI access and the privacy to engage in the multiple groups per day format that we must maintain. While direct face-to-face time with family members is preferable, telephonic contact may be a reasonable alternative if there are availability or time constraints. Level 2: Intensive Outpatient and Partial Hospitalization Programs . The assessment and treatment plan should address improvement of social skills and functioning via the therapeutic milieu. Our Behavioral Health Care guidelinesbuilt on the same principles of evidence-based medicine used to create our medical/surgical guidelines address medical necessity screening criteria to help make informed, consistent care decisions with confidence. This plan facilitates efficient service delivery, an expeditious return to improved functioning in the individual's community, and a transition to less intensive levels of care. The psychiatric assessment is the guiding document in creation of a treatment plan for each person in treatment. Ideally coordination services are managed by the same person/entity regardless of treatment level or location for that person. A growing body of evidence suggests that partial hospitalization outcomes are highly correlated with treatment intensity and that more successful programs involve patients at least 5 days/week for 8 hours/day. The program must then review the guidelines and determine how to proceed with programming and documentation. Intensive outpatient services have been developed to meet specific clinical needs when the individual is not determined to require the intensive daily services of partial hospitalization or is unable physically to meet the attendance requirements of such programs or when less frequent monitoring in inappropriate. Accessibility of an individuals data within the EMR is impacted by privacy and regulatory statutes and must be reflected in the EMR. Medicare Advantage Plans are not obligated to cover these levels of care. Archived Program Rules - Chapter 320 - Early and Periodic Screening, Diagnosis and Treatment. (a) Partial hospitalization services are services that - ( 1 ) Are reasonable and necessary for the diagnosis or active treatment of the individual's condition; ( 2 ) Are reasonably expected to improve or maintain the individual's condition and functional level and to prevent relapse or hospitalization; Additional certification, monitors, medications, or additional clinical data may be required due to internal organizational or regulatory requirements. Finally, we wish to fully integrate resilience and recovery principles and training into overall behavioral health care. Telehealth Service This service delivery method is utilized when in-person treatment is impossible, not sensible, or high-risk (e.g., a medical pandemic). Programs might also include informal methods to collect consumer feedback, including individual, group, and community discussions, and the use of an anonymous approach such as a suggestion box. Number of hours of structured treatment provided per day, Individual assessment/therapy/intervention time needed, Management of potential for self-harm or other emergencies, Need for specialized nursing or case management services. Considerable ongoing communication exists regarding the interface between residential non-hospital treatment facilities and PHPs and IOPs. For a Free Consultation, call: 855-808-4213 This will require a program to review the criteria and make a decision that is in the best interest of the program and the individuals being served. The CARES Act of 2021 mandates that all providers of treatment make the full medical record, including behavioral health records, available to any individual who received services in that organization. Standards and Guidelines for Partial Hospitalization Programs. The quality of the treatment we deliver is the value we offer to patients. Regulations, and Minimum Standards Authority: T.C.A. Intermediate Ambulatory services consists of two levels of care depending on the intensity of services needed and the acuity to those being served: Residential/Inpatient services include two principal types of non-ambulatory, 24-hour supervised settings. This means the guidelines for PHP and IOP will vary from State to State. Full-time participation in the program at the onset of treatment serves to promote stabilization and cohesion. Individuals in treatment include both those who participate voluntarily, as well as those mandated by the legal system. Services may be provided during the day, evening, and/or on the weekend. Second Edition. A standards applicability process in the Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC) identifies which standards apply to the various settings and populations and includes: Addiction treatment services including medication-assisted therapy Case management Child welfare/human services Corrections programs Can J Psychiat, 49, 726-735, 2004. Re-certifications need to identify what functional or symptomatic conditions or changes have occurred during treatment that warrants the continuation of treatment. Retrieved July 20, 2018, from https://www.ncmhjj.com/wp-content/uploads/2014/10/Behavioral_Health-Primary_CoOccurringRTC.pdf. Private Insurance and Medicare Advantage Plans each create their own protocols for PHP and IOP. and the progress described in measurable, behavioral, and functional terms. Third Edition. Comparing benchmark measures to those of peers offers a greater integration of performance within the industry and particular to these levels of care. In some cases, a specialized IOP may be recommended as follow-up for specific conditions; Some individuals display increased symptoms of a previously diagnosed behavioral disorder and exhibit a progressive or sudden decline in functioning compared to baseline. This assessment with screenings helps direct the diagnostic formulation of treatment and must clarify and prioritize client needs to be addressed in the program or elsewhere.. Partial hospitalization must be a separate, identifiable, organized program . Any additional laboratory testing, as determined by the organization and in accordance with the level of care provided. The presence of poor insight, skills, judgment, and/or awareness inhibits their return to baseline functioning that is considered to be clinically achievable. The intent of this summary is to place PHPs and IOPs in the full context of available treatment services, arranged by relative level of intensity from traditional outpatient care to 24-hour inpatient treatment. A focus on medication adherence, therapeutic impact, and relationship between psychiatric and physical medications should also be considered. An individual must exhibit the first three following characteristics and may exhibit others listed below: PHPs and IOPs both employ integrated, comprehensive, and complementary evidence-based treatment approaches. An individual's length of stay is dependent upon the nature of presenting problems, an ongoing review of the clinical necessity for participation in the program, and review of the individuals response to services provided. Include programs such as Depressed Anonymous, Emotions Anonymous, and the National Alliance on Mental Illness (NAMI). Traditionally, substance abuse and mental health facilities are treated as separate programs and are often licensed and reviewed separately in many states.
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