Community-Based Services: Medical Necessity Criteria
Description of Services:
The purpose of PC services is to assist individuals with severe mental illness to achieve community integration through valued living, learning, working, and social roles and to prevent hospitalization and relapse. The role of PC is therefore to facilitate consumer integration into the community, not to become a permanent outcome although it is recognized that some consumers may need the support of PC for long periods of time. This balance between recovery and clinical services is accomplished through the provision of individualized, comprehensive, non-residential, structured programming which provide, but are not limited to, counseling, case management, psychoeducation, pre-vocational services, social and leisure services, and psychiatric services, and shall be available to eligible individuals on an hourly basis for up to five hours per day at least five times per week.
Child or adolescent has a primary psychiatric diagnosis of mental illness or severe emotional disturbance.
Child or adolescent is unable to obtain sufficient benefit from a less restrictive treatment program.
There is a reasonable likelihood that the child/adolescent will benefit from the services offered by the program.
Child or adolescent meets one of the following criteria:
Exhibits significant dysfunction in two or more basic domains of life and requires the services offered by the program in order to acquire or restore the skills necessary to perform adequately in those areas.
Needs a period of transition from a hospital, residential treatment center, or other institutional setting as part of the process of returning to live in the community.
Experiences a period of acute crisis or other severe stress that may require hospitalization or institutional placement without the level of services provided by the program.
The child or adolescent meets program criteria regarding source of referral, funding restrictions, age range of children served, and client characteristics for which the program has been specifically designed.
Written consent of the child or adolescent’s parent or guardian, if the child is 14 years of age or older.
Quality of Care Standards
Criteria must be applied for any requested service either at admission or during continued stay.
The services provided to identify or treat, and illness are consistent with the diagnosis and treatment of a condition and the standards of good medical practice.
I. Admission Criteria (all must be met):
A. First priority for admissions into PC services shall be given to persons with severe and persistent mental illness in accordance with target populations.
1. The provider agency shall utilize the following inclusionary and exclusionary admission criteria, which are designed to assure the clinical appropriateness of each admission.
B. Inclusionary criteria:
In order to be considered eligible for partial care services, an individual must:
1. Demonstrate impaired functioning, that leads to a need to learn critical skills in order to achieve valued community roles and community integration, in at least one of the following domains on a continuing and intermittent basis, for at least one year:
i. Personal self-care;
ii. Interpersonal relationships;
v. Ability to live in the community; or
vi. Ability to acquire and/or maintain safe, affordable housing and is at risk of requiring a more restrictive living situation;
2. Be 18 years of age or older;
3. Demonstrate or possess clinical evidence to justify the necessity for partial care services. This necessity must be confirmed by the psychiatrist or advanced practice nurse and interdisciplinary treatment team and documented in the record;
4. Demonstrate the need for psychiatric rehabilitation and active treatment of no less than two hours and no more than 25 hours weekly.
5. At the time of referral or as a result of psychiatric evaluation provided or arranged or by the PA, have at least one of the following primary DSM diagnoses:
i. Schizophrenia or Other Psychotic Disorders (298.9);
ii. Major Depressive Disorder (296.xx);
iii. Bipolar Disorders (296.xx, 296.89);
iv. Delusional Disorder (297);
v. Schizoaffective Disorder (295.7); or
vi. Affective Disorders (300.xx);
6. Have a covered psychiatric disorder diagnosis consistent with codes of the DSM, including some 301.XX codes if the personality disorder is considered in the severe range and the individuals are at high risk of psychiatric hospitalization as a result; and
7. At the time of referral, meet one or more of the following criteria:
i. Acute service need:
(1) One or more contacts with a screening center or emergency service mental
(2) Two or more admissions to an inpatient behavioral health program including
short term care facilities; or
(3) One psychiatric hospitalization of three months or longer; or
ii. A Global Assessment of Functioning Scale score of between 11 and 70, as found in the DSM.
C. Exclusionary criteria: A consumer who presents any of the following criteria shall be excluded from participation in partial care services:
1. A primary diagnosis of substance use/dependence;
2. An imminent danger to self, others or property;
3. A primary diagnosis of "developmentally disabled"; or
4. Current participation in a PACT program, unless authorized in accordance with
i. Partial care/partial hospitalization (PC/PH) services shall not be available, except if clinically indicated and recommended by the PACT team, for up to the last 30 days before a beneficiary terminates from PACT services. The PACT agency shall obtain prior authorization for services before enrolling a beneficiary in a PC/PH program.
III. Discharge Planning:
Procedures for termination, transfer and referral of consumers shall be documented and shall ensure that the continuing service needs of consumers are met. Discharge criteria shall be identified at the time of admission and shall include the steps necessary to facilitate community integration. The criteria shall be documented in the initial service recommendations and individual recovery plans. For consumers being transferred to another service, a brief, succinct transition summary shall be prepared at the time of discharge communicating critical information and shall be forwarded to the receiving agency.
IV. Discharge Criteria
a) Discharge criteria shall be limited to the following specific reasons for termination from the program:
1. The consumer has achieved the service plan goals and needs no further treatment;
2. The consumer can be more effectively served by and has been linked to another program, agency or institution;
3. The consumer has either refused repeatedly to participate in major components of the program or stopped attending the program;
4. The consumer demonstrates dangerous, criminal, or other aggressive behavior that is unresponsive to interventions; or
5. Theconsumer has moved to a location that makes continued participation in the program impossible.
(b) When the consumer has stopped attending the program, significant outreach efforts to re-engage the consumer prior to termination, such as repeated telephone calls, correspondence and home visits shall be documented in the clinical record.
(c) Termination decisions shall be finalized only with approval of the direct care staff supervisor.
(d) Every effort shall be made to consider the consumer's preferences for continuing services and to include the consumer in the development of the discharge plan.
(e) The discharge plan shall include arranged follow-up care or justification for no follow-up care.
(f) A termination or transfer summary shall be written and maintained, separate from the progress notes. The summary shall be completed within 30 days of termination or transfer and include:
1. The presenting problem;
2. The admission date and date of service termination;
3. The course of treatment and consumer's status upon discharge;
4. The reason for termination;
5. The medication prescribed upon discharge;
6. To the extent known, the consumer's perspective on his or her experience in the program, and the consumer's stated reasons for leaving, if applicable; and
7. The discharge plan.