Criteria for Admission
The specified requirements for severity of need, intensity and quality of service must be met to satisfy the criteria for admission.
I. Admission – SeverityofNeed
Criteria A and B must be met to satisfy the criteria for severity of need.
A. The individual is unable to maintain an adequate level of functioning outside the treatment program due to a mental health disorder as evidenced by all of the following:
1) Severe psychiatric symptoms that require medical stabilization.
2) Significant interference or failure in at least one functional area (social, occupational/vocational, educational) and /or absence of social support resources.
3) Inability to perform the activities of daily living, (personal hygiene, self-care, meal preparation and nutrition), interpersonal and leisure skills.
B. The treatment necessary to improve and/or stabilize the individual’s condition requires the frequency, intensity and duration of contact provided by a day program as evidenced by all of the following: 1) Failure to improve/stabilize with less intensive treatment that was accompanied by services of
alternative delivery systems.
2) Passive or active opposition to treatment and the risk of severe adverse consequences if treatment is not pursued.
3) The individual’s medical and mental health needs can be adequately monitored and managed by the staff of the facility.
4) The individual cannot be safely maintained and effectively treated at a less intensive level of care. 5) The individual cannot require a level of structure and supervision beyond the scope of the program.
II. Admission – IntensityandQualityofService
Criteria A and B must be met to satisfy the criteria for intensity and quality of service.
A. Treatment plan is individualized and appropriate to the individual’s changing condition with realistic and specific goals/objectives.
B. All services and treatment are carefully structured to achieve optimum results in the most efficient manner consistent with sound clinical practice, including evaluating and/or prescribing appropriate
© 2015 Magellan Health Inc. v1
72 Criteria for Continued Stay
III. Criteria for Continued Stay
Criteria A, B, C and D must be met to satisfy criteria for continued stay.
A. The individual’s condition continues to meet admission guidelines for this level of care.
B. There is reasonable likelihood of substantial benefit as a result of active continuation in the therapeutic program as demonstrated by objective behavioral measurements of improvement.
C. The consumer is making progress toward goals and is actively participating in the interventions.
D. The individual does not require a more intensive level of care, and no less intensive level of care would be appropriate.
© 2015 Magellan Health Inc. v1
73
TOC
Day Treatment, Mental Health, Child and Adolescent
Criteria for Admission
The specified requirements for severity of need and intensity and quality of service must be met to satisfy the criteria for admission.
I. Admission – Severity of Need
Criteria A, B, C, D, and E must be met to satisfy the criteria for severity of need.
A. There is clinical evidence that the individual has a DSM-5 diagnosis that requires and can reasonably be expected to respond to therapeutic intervention in a structured milieu.
B. Exacerbation or persistence of a long-standing psychiatric disorder results in symptoms of thought, mood, behavior, or perception that significantly impair functioning.
C. The individual is capable of mastering more complex (age appropriate) personal and interpersonal life skills (e.g., problem solving, assertiveness, self-advocacy, shopping, meal preparation, development of leisure skills, and the use of community resources).
D. The individual is medically stable and does not require the 24-hour medical/nursing monitoring or
procedures provided in an inpatient, PRTF, TGH, or PRFC services, but requires three to five hours of care up to five times a week.
E. The individual can reasonably be expected to benefit from mental health/substance use disorder treatment at this level and needs structure for activities of daily living.
II. Admission – Intensity and Quality of Service
Criteria A, B, C, D, E, F and G must be met to satisfy the criteria for intensity and quality of service.
A. In order for a day treatment program to be safe and therapeutic for an individual, professional and/or social supports must be identified to the individual outside of program hours.
B. The individualized plan of treatment includes a structured program which provides active treatment each program day, no less than three to five hours of care, and comprehensive behavioral health services no less than five times a week.
C. Children/adolescents admitted to day treatment will receive comprehensive behavioral health services which may include, but are not limited to, group and individual therapy, home based services/outreach, family therapy, psychiatric evaluation, medication therapy, and medication follow-up, and emergency and crisis intervention services, as necessary.
D. Day Treatment should lead to the attainment of specific goals through specific therapeutic interventions and allows for transition of the child/adolescent to an outpatient level of care.
© 2015 Magellan Health Inc. v1
74
E. All services are provided under the supervision of a Supervising Practitioner, preferred to be a child psychiatrist if the individual is below the age of 12 years.
F. A Urine Drug Screen (UDS) is considered when progress is not occurring, when substance misuse is
suspected, or when substance use and medications may have a potential adverse interaction. After a positive screen, additional random screens are considered and referral to a substance use disorder provider is
considered.
G. The individual is not considered an imminent risk to self or others, does not sufficient impairment (i.e., has no active suicidal ideation with or w/o plan or intent, no active command hallucinations of self harm or harm to others, able to do ADLs independently, has a low propensity for physical aggression) which requires a higher level of care and is not considered a high risk for runaway.
Criteria for Continued Stay
III. Continued Stay
Criteria A, B, C, D and E must be met to satisfy the criteria for continued stay.
A. Despite reasonable therapeutic efforts, clinical evidence indicates at least one of the following:
1) The persistence of problems that caused the admission to a degree that continues to meet the admission criteria (both severity and intensity of service needs), or
2) The emergence of additional problems that meet the admission criteria (both severity of need and intensity of service needs), or
3) Difficulty and/or lack of coordination of a variety of outpatient services by providers/individual/family support necessitating Day Treatment to ensure this missing component, or
4) That disposition planning and/or attempts at therapeutic re-entry into a less-intensive of care have resulted in, or would result in exacerbation of the psychiatric illness to the degree that would necessitate continued Day Treatment.
B. Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved or adjustments in the treatment plan to address lack of progress are evident. Treatment planning is individualized and appropriate to the individual's changing condition with realistic and specific goals and objectives stated.
C. When medically necessary, appropriate psychopharmacological intervention has been prescribed and/or evaluated.
D. Care is rendered in a clinically appropriate manner and focused on individual's behavioral and functional outcomes as described in the discharge plan. There is documented active discharge planning.
E. There is evidence of at least weekly family and/or support system therapeutic involvement (unless there is an identified, valid reason why such a plan is not clinically appropriate or feasible).
© 2015 Magellan Health Inc. v1
75
TOC