Kiser, J.L., Trachta, A.M., Bragman, J.I., Curley-Spadaro, K., Cooke, J.D., Ramsland, S.E., and Fitzhugh, K.E. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) has refined the diagnostic categories of eating disorders, defining them as Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, Avoidant/Restrictive Food Intake Disorder (ARFID) and eating disorder not otherwise specified, which include a wide range of subclinical symptoms. A solid aftercare plan is crucial for success with this population. In the current healthcare environment, this level is also referred to as Primary Integrated Care and supported by the Center for Medicare and Medicaid Services (CMS) Integrated Health Model. These programs often allow children and adolescents to avoid inpatient hospitalization, decrease lengths of stay otherwise required in inpatient or residential settings, or to support the child/adolescent with any transitions such as foster care when needed. Historically, the availability of an intact support system was a prerequisite for PHP services. Many payers will have a requirement that a program meet the requirements of an accrediting body as a rule for program approval and reimbursement for services. 8.320.2 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services 2/1/20 to 12/31/20. Example metrics include, but are not limited to: Staff are not only the largest cost to programs, but also have the biggest impact on programming and quality in a program. Clinicians working from home need to carefully review their environment for any unintended personal disclosures that can occur such as visual clues about the location of your home, family information. The inclusion of two patient identifiers is helpful and often required on each document, such as a patient name and medical record number. and Barry, A.D. Standards and Guidelines for Partial Hospitalization and Intensive Outpatient Co-occurring Disorders Programs. The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Partial Hospitalization Programs L37633. The eighth edition addresses the changing environment of care resulting from the COVID pandemic and includes guidelines for alternative service delivery such as telehealth. For a Free Consultation, call: 855-808-4213 . The downloadable version of the Standards and Guidelines reflects the most recent publication and may not accurately reflect the online version. Recently in behavioral health, a few payers are developing protocols that are not in line with Medicare guidelines, which again can create challenges in programming and billing. In these cases, backup case management and peer support services can be essential. Both performance and clinical measurement will be addressed. It is designed for patients . The tool should be tested, standardized, and validated; The tool should be appropriate for the individual being treated; The tool should be able to be used for repeated measures to document change; The tool should be consumer friendly and easy for the individual to understand. If medications are changed during treatment, the types and dosages, clinician responsibility, and timing should be clearly documented with the rationale for the medication changes. 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. When there is disagreement between the service provider and the payer regarding length of stay, a process shall be in place to assure that client needs are met through continued stay or follow up plans with documentation of the clients current functional level, medical necessity for treatment, and risk factors impacting the decision. 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. and Lefkovitz, P.M. Standards and Guidelines for Partial Hospitalization Adult Programs. The latest medication advances, therapeutic techniques, and peer connections meet individuals where they are in a positive milieu that fosters support and change. Linkages or collaborations with primary care physicians, counselors, residential treatment personnel, case managers, or others may be necessary while the individual is in program to ensure that clinical information is accurate and that clinical initiatives are reasonable and relevant to the individuals home environment. Medically based/disease or illness management groups emerge from a more formalized rehabilitative illness management perspective which often aligns well with medically based continuums of care. Although an individual may have several pressing needs, those that are of so severe they require the intensity of services of an intermediate level of care should be the top priority of treatment. There are three primary regulatory bodies that write regulation or guidance in detail for providers in the local area: Many of the States have a department that is responsible for the licensing of behavioral health facilities. CMS and other agencies expect to see individual sessions prescribed as a necessary component of treatment during each episode of care. Facilities that provide treatment for both behavioral health conditions are not formally designated as a single treatment program in most areas. The program provides . Generally speaking, a program's average length of stay should reflect the population treated and primary program function. (Section 1-101.1 of the Code) "Accreditation." A process establishing that a program complies with nationally-recognized standards of . Psychiatrically trained medical professionals, including Physician Assistants and Nurse Practitioners may also be members of the physician team if regulations apply for such. Partial Hospitalization These programs are defined as structured and medically supervised day, evening and/or . The final rules pertaining to the implementation of the parity legislation were presented in November of 2013. While none of these focuses are mutually exclusive, a program tends to build their program from one of these perspectives. Treatment plans should be reviewed on a regular and consistent basis based on the assessment of the team and approved by the psychiatric supervisor and reflect changes based on feedback from the individual, staff members who provide services and medical professionals supervising treatment. We advocate for unified medical necessity guidelines among payers. Fiscal Administration. 4. If medications are dispensed on-site, appropriate staff must document medications that are administered on site. Postpartum Psychosis is a true psychiatric emergency. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. Marked impairments in multiple areas of his/her daily life are evident. Association for Ambulatory Behavioral Healthcare, 2015. In this case, communication within the team is essential. Limited case management and group therapy or psycho-educational services may be included in this setting along with individual therapy and medication management. Movement needs to be monitored hourly, determining how much movement or exercise is medically safe for each clients stability. Partial hospitalization is a short-term, intensive treatment (four to six weeks, fewer than 24 hours per day) for adults and children individuals not effectively served in community-based or intensive outpatient programs due to substance use, mental health co-occurring disorders. Presently, PHPs serve both shorter and longer episodes of care depending upon the primary functions defined earlier. Licensing and Operational Standards for Mental Health Facilities. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services (January 2003). First Edition. This program typically lasts about 10 business days. Often programs will struggle with deciding if their data elements are outside the norm. Level 2 programs provide essential addiction education and treatment components and have two gradations of intensity. All treatment planning activity must continue. Second Edition. See DSM-5 for details on these diagnostic categories, and the levels of severity. At times, a full participation during the first week may be impossible upon admission due to unavoidable personal responsibilities. Individuals in treatment include both those who participate voluntarily, as well as those mandated by the legal system. We must advocate for simplicity and consistency in the description of services offered in programs and the billing process. This role also includes developing operational management plans which address key financial considerations including contracting issues, insurance verification, pre-certification procedures, re-certification tracking, record management as per insurance expectations, retrospective appeal procedures, and productivity management. Archived Program Rules - Chapter 320 - Early and Periodic Screening, Diagnosis and Treatment. 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. The Standards and Guidelines will be updated as new reviews are completed in any of the areas addressed. Co-Occurring Disorders: Integrated Dual Disorders Treatment Implementation Resource Kit. Retrieved July 20, 2018, from http://www.mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/cooccurring/. Programs from around the country reveal the following clinical orientations or strategies that are reflected in their educational components: NOTE: Individual skills may be taught in each of these approaches. These services engage individuals in a non-talk therapy mode and can result in behavior clarity, new insights, and meaningful options for emotional expression and life balance. Providers utilize a wide variety of therapeutic techniques such as different forms of individual, family, or group therapies, and/or medication management. 104 CMR 27. In some regions, the direction of CMS fiscal intermediaries led to a reduction in the use of occupational services due to increased documentation demands and conflicting continuation of care criteria. This section contains specific considerations when developing a program for a population identified in the list. Clients with eating disorders may enter PHP level of care with a body mass index (BMI) which measures the relationship between height and weight, of 17.5 (adults) or less with a diagnosis of anorexia nervosa or may be of normal weight with a bulimia nervosa diagnosis, while they may be obese with a BMI of 30 or more or morbidly obese with a BMI or 40 or more. Ongoing clinical responsibility must continue and be clarified while individuals are awaiting follow up care. National Survey on Drug Use and Health, 2013. Partial hospitalization services must be vigorous and proactive as opposed to passive and custodial. The plan may address patient safety concerns, primary symptoms, self-esteem issues, coping skill deficits, priority decision points, level of motivation, recovery issues, barriers to treatment, and factors which impact readiness for discharge. Daily monitoring of medications, safety, symptoms, and functional level is deemed medically necessary. Initial Evaluation/Certification 104 CMR 28. In many program settings, the inclusion of individuals in different phases of recovery can be used to good clinical advantage. Eating disorder partial programs provide staff- supervised meal and snack groups, regular monitoring of weight and vital signs, and a variety of groups aimed at addressing symptom management and augmenting patients coping skills and strategies (as they relate to both the eating disorder and other behavioral health co-morbidities). The individuals family and/or legal caretakers must be involved. 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 With regard to treatment within one organizational continuum, programs should also maintain liaisons with specific providers including psychiatrists and other physicians, psychologists, social workers, psychiatric nurses, occupational therapists, case managers, rehabilitation practitioners, educators, and substance abuse counselors. Programs can usually expect to conduct program improvement planning following a review to address the issues discovered and highlighted as needing improvement. Clinicians should utilize language in documentation that notes telehealth use. It includes measurable goals and objectives that addressthe problems identified in the clinical assessment and should be updated periodically., A listing of all known public and . A significant improvement in functioning and symptom reduction is needed and achievable in order to resume role expectations and avert the loss of home, job, or family. 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. Group process theory has been based primarily on specific process dynamics over a course of time in an outpatient setting with relatively high-functioning individuals. For the purpose of this Part, the following terms are defined: "Abuse." Any physical injury, sexual abuse or mental injury inflicted on an individual other than by accidental means. The need for 24-hour containment has been determined to be unnecessary. Are usually community-based and free. Association for Ambulatory Behavioral Healthcare, 2012. Do not enable the chat feature during group. However, the individual often presents with an impaired willingness or capacity to positively connect with caretaker, family, friends, or community supports. Identifiers should be individualized so program staff and reviewers can uniquely identify each patient. Kiser, L., Lefkovitz, P., Kennedy, L. and Knight, M. The Continuum of Ambulatory Mental Health Services. Alexandria, Virginia. As partial hospitalization continued to evolve within the context of a continuum of services, the 1996 revision was intended to incorporate contemporary views of this specialized level of care.16 Specific standards and guidelines for child and adolescent programs were also completed at that time which attempt to delineate both similarities to adult programs and unique challenges.17 Intensive Outpatient Services were first addressed in a 1998 edition.18. Important information about regulatory coordination and program structure will also be provided. These services are provided primarily by medical practitioners within the context of treatment of general medical conditions. Partial hospitalization, also known as PHP (partial hospitalization program), is a type of program used to treat mental illness and substance abuse. Some programs choose to identify guidelines for early administrative discharge based on pre-determined number of relapses and other forms of treatment-interfering behaviors. . In some cases, a summary of daily notes is optional, but do not serve to replace individual notes. Encourage use of the raise hand feature if available on the platform. IOPs may be distinct service entities but are often included within applicable outpatient standards of operation. achieve effectiveness and best practices in service delivery. A socially isolated person with serious debilitating symptoms may also benefit from treatment even though they may report virtually no support system at all. Payment will not be made for compensable peer support American Association for Partial Hospitalization, 1991. This type of program usually provides daily service that people will access at least one day a week and up to 11 or less services in any one week. Some clients are reluctant to talk about behaviors that they believe others disapprove of, such as drug use or illegal activities. Limitations Noncovered-Reasonable and Necessary Denials CPT codes 90875 and 90876 Coding Information CPT/HCPCS Codes Expand All | Collapse All Group 1 (26 Codes) A strong connection between performance improvement and ongoing staff ownership of the process and adequate staff training is necessary to assure that performance improvement interventions are shared, realistic, meaningful, and achievable. Consider that each participant has differing levels of technical abilities or. On the other hand, integrated occupational therapy programs complement other services and teach valuable skills within an evidence -based model that contributes significantly to positive clinical outcomes. 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. Perception of care surveys gather information about how effectively the program engaged the individual through assessment, course of treatment, and discharge. 4-4-103, -5-4202, -5-4204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, . Fourth Edition. Many staff may not have this access either. . Programs should provide easy access to grievance procedures as required by regulatory agencies. Patients admitted to a partial hospitalization program must be under the care of a physician who is knowledgeable about the patient and certifies the need for partial hospitalization. The signing of treatment reviews is an indication of the agreement of all parties that the goals for treatment will move the individual toward recovery and discharge. PHPs and IOPs are characterized by formalized efforts to promote and maintain a stable and cohesive therapeutic milieu or community. 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. There must be a clinical determination that the additional treatment requested can result in improvement or stabilization of a documented persistent decline in functioning. 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. In some cases, removal from a given residence or placement in a residence or residential treatment setting may be a precondition for treatment. Miller, T.,Mol, J.M. Often primary care physicians, OBGYNs and Pediatricians need additional help and consultation from a trained psychiatric provider if they are going to be a part of the aftercare plan for clients, especially if they are managing medications. Our eating disorder partial hospitalization program in Dallas Texas addresses the physical, emotional, and spiritual aspects of our client's well-being. As a national provider organization, AABH advocates for the following objectives to improve systems of care and meet the needs of those we serve: The AABH Board of Directors appreciates the work of each behavioral health practitioner who is making a difference in partial hospital and intensive outpatient programs throughout the country. 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. A minimal ability and willingness to set goals to work toward the development of social support is often a requirement for participation. The record must document that specific treatment is ordered and supervised by an attending psychiatrist. Regardless of the length of stay, the participant experience should be paramount, and staff should work to assure a synergy among goals to be addressed, services rendered, and time available for clinical intervention whenever possible. Because of the complexity of this issue, additional collaboration among residential and acute ambulatory providers, regulatory groups, and insurers is recommended to clarify when a combination of services is appropriate and to develop joint strategies to decrease redundancies and cost while providing excellent care to each person. Communication amongst programs regarding their results is strongly encouraged. An integrated care team, psychiatrist, or primary care practitioner may then provide follow-up care. Some programs choose to identify guidelines for discharge based on a pre-determined number of relapses and/or other forms of treatment-interfering behaviors. The goal is to contribute to patient safety. The actual format and content in often determined by diagnostic profile, target group, or theoretical orientation. 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. For example, one may reference a PHP treating persons with mood disorder through a short-term, low-intensity, cognitive behavioral approach designed to improve functioning and mood, funded by private and public insurance, operating out of a not-for-profit general hospital setting.2. They provide therapy and education in an intensive group environment that cannot be provided through either an outpatient individual therapy model or a crisis-oriented inpatient unit. 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. Call Now to Begin the Recovery Process Today. 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