Psychiatric Residential Treatment Facility (PRTF): Aligning Care Efficiencies with Effective Treatment. BHM Healthcare Solutions

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(1)

Psychiatric Residential Treatment

Facility (PRTF):

(2)

Presentation Objectives

Attendees will have a thorough

understanding of Psychiatric Residential

Treatment Facility (PRTF) Services from an

authorization perspective

Attendees will gain an understanding of the

importance of Medical Necessity Criteria as

it applies to PRTF

(3)

Understanding Medical

Necessity Criteria (MNC)

According to a presentation by NC Department of Health

and Human Services (Division of Medical Assistance)

Medical necessity is individual, but some generally

accepted components are:

• Intended to prevent, diagnose, correct, cure, alleviate, or preclude deterioration of a diagnosable condition that threatens life, causes pain or suffering, or results in illness of infirmity

(4)

Understanding Medical

Necessity Criteria (MNC)

General Criteria Covered Medicaid shall cover

procedures, products, and services related to this policy

when they are medically necessary, and:

a. the procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed

diagnosis of the illness or injury under treatment, and not in excess of the beneficiary’s needs;

b. the procedure, product, or service can be safely

furnished, and no equally effective and more conservative or less costly treatment is available statewide; and

(5)

Understanding PRTFs

Psychiatric Residential

Treatment Facilities (PRTFs)

provide non-acute inpatient

facility care for NC Medicaid

recipients (under 21 years of

age) who have a mental illness

and/or substance

abuse/dependency and need

(6)

Understanding PRTFs

PRTFs provide:

• Planned regimen of 24-hour

professionally directed evaluation, observation, medical monitoring and addiction treatment in an inpatient setting.

• They are appropriate for

adolescents whose subacute biomedical and emotional,

behavioral or cognitive problems are so severe that they require

(7)

Dimensional Substance Abuse

Admission Criteria

Direct admission to a

Level III.7 program is

available for the

adolescent who meets two

of Dimensions 1-6 with at

least one of the stability

specifications in

Dimensions 1 (acute

intoxication and /or

withdrawal) OR Dimension

2 (biomedical conditions or

problems) OR Dimension

3 (emotional, behavioral or

cognitive conditions).

DIMENSION 6: Recovery Environment

DIMENSION 5: Relapse, Continued Use or Continued Problem Potential

DIMENSION 4: Readiness to Change DIMENSION 3: Emotional, Behavioral or

Cognitive Conditions and Complications DIMENSION 2: Biomedical Conditions and

Complications

(8)

Dimensional Admission

Criteria: Level III.7

DIMENSION 1: Acute Intoxication and/or Withdrawal

1. The adolescent is experiencing or at risk of acute or sub acute intoxification or withdrawal with moderate to severe signs and symptoms.

DIMENSION 2: Biomedical Conditions and Complications

1. The adolescents status is

characterized by one of the following:

a. A biomedical complication of addiction or co-occurring biomedical condition that requires active nursing or

medical monitoring but does not require the resources of an acute care hospital

b. Continued alcohol or drug use places the adolescent at

(9)

Dimensional Admission

Criteria: Level III.7

DIMENSION 3: Emotional, Behavioral, or Cognitive Conditions and Complications

1. The adolescent’s status features one

or more of the following:

a. Dangerousness/Lethality-The adolescent is at moderate (and

unpredictable) risk of imminent harm (self or others) and needs

high-intensity 24-hour monitoring or

treatment, or secure containment, for safety.

b. Interference with Recovery Efforts- Severe interference and distraction with recovery efforts requires high-intensity residential treatment to stabilize emotional or behavioral problems and support engagement.

DIMENSION 3: (cont’d)

c. Social Functioning- Significant

impairments with severe symptoms (poor impulse control, disorganization, etc) that seriously impair functioning in family, social, school or work settings (repeatedly running away, seriously aggressive or disruptive behaviors) and cannot be managed at a less intensive level of care.

d. The adolescent evidences moderate to severe difficulties with activities of daily living and requires 24-hour supervision and high-intensity staff assistance.

e. The adolescent’s history (combined

(10)

Dimensional Admission Criteria:

Level III.7

DIMENSION 4: Readiness to change

1. The adolescent’s status is characterized by one of the following:

a. The adolescent has not related his or her problems to substance use or has not accepted the need for change

b. The adolescent has not demonstrated sufficient readiness to change and thus needs intensive motivating strategies, activities and processes available only in a 24-hour high-intensity structured

(11)

Dimensional Admission

Criteria: Level III.7

DIMENSION 5: Relapse, Continued Use or Continued Problem Potential

1. The adolescent’s status is

characterized by one of the following:

a. The adolescent is unable to interrupt a high severity or high frequency pattern of use with

imminent severe risk of dangerous consequences without

high-intensity 24-hour interventions

b. The modality of treatment requires this level of care (i.e., agonist or antagonist therapy, monitoring, case management and

documentation needed to arrange alternative level of care or

resource)

DIMENSION 6: Recovery Environment

1. The adolescent’s status is

characterized by one of the following:

a. The adolescent’s living

environment is dangerous to his or her recovery, and he or she

requires residential treatment to promote recovery goals or for protection

b. The adolescent requires this LOC to help him or her establish a

(12)

Managing Care: PRTF

Admission Criteria

All of the following must be met:

Are their symptoms consistent with a DSM-IV-TR

(Axis I-V) diagnosis that requires, and can

reasonably be expected to respond to,

therapeutic intervention?

(13)

Managing Care: PRTF

Admission Criteria

All of the following must be met:

The child/adolescent is experiencing emotional or behavioral problems in the home, community and/or treatment setting and is not sufficiently

stable either emotionally or behaviorally, to be treated outside of a highly structured 24-hour therapeutic environment.

(14)

Managing Care: PRTF

Admission Criteria

All of the following must be met:

The child/adolescent demonstrates a capacity to

respond favorably to rehabilitative counseling and

training in areas such as problem solving, life skills

development, and medication compliance training.

(15)

Managing Care: PRTF

Admission Criteria

All of the following must be met:

The child/adolescent has a history of multiple

hospitalizations or other treatment episodes

and/or recent inpatient stay with a history of poor

treatment adherence or outcome.

(16)

Managing Care: PRTF

Admission Criteria

All of the following must be met:

Less restrictive or intensive levels of treatment

have been tried and were unsuccessful, or are

not appropriate to meet the individual’s needs

(17)

Managing Care: PRTF

Admission Criteria

All of the following must be met:

The family situation and functioning levels are

such that the child/adolescent cannot currently

remain in the home environment and receive

community-based treatment

(18)

Managing Care: PRTF

Admission Criteria

Don’t assume that if

a patient relapses

(substance abuse)

after treatment at a

lower level of care

that PRTF is needed.

Relapse is an

(19)

Managing Care: PRTF Admission

Criteria (Substance Abuse)

Lapse vs. Relapse

“LAPSE” “RELAPSE”

Impulsive Planned

Short Duration Long period of use

They feel guilty High defensiveness

Small amount of use Large amount of use

Relatively low consequences Relatively high consequences

They want to stop using They aren’t sure if they want to stop

(20)

PRTF Admission Criteria

Key Questions

The following questions should be

asked:

• What precipitated this admission?

• What other treatment episodes has this patient had? What levels of care? What worked? What needs to be put in place now?

• Is the patient motivated for change?

• Is the family /care givers supportive? If not, why not? What can be done to improve this support?

(21)

Areas to Focus On

The child/adolescent has current or past behaviors that

indicate the need for PRTF as evidenced by suicidal or

homicidal ideation, physical aggression toward others,

self-injurious behavior, seriously risky behavior (running

away, sexual aggression, serial unprotected sex with

multiple partners, or substance use).

(22)

Managing Care: PRTF

Continued Stay Criteria

All of the following must be met:

The child/adolescent's condition continues

to meet admission criteria at this level of

care.

(23)

Managing Care: PRTF

Continued Stay Criteria

All of the following must be met:

The child/adolescent’s treatment does not

require a more intensive level of care, and no

less intensive level of care would be appropriate

(24)

Managing Care: PRTF

Continued Stay Criteria

All of the following must be met:

Treatment planning is individualized and appropriate to the recipient’s changing condition with realistic and specific goals and objectives stated. Treatment planning should include

active family or other support systems involvement, along with social, occupational and interpersonal assessment unless contraindicated. The expected benefits from all

relevant treatment modalities are documented. The treatment plan has been

implemented and updated, with consideration of all applicable and appropriate treatment modalities.

(25)

Managing Care: PRTF

Continued Stay Criteria

All of the following must be met:

All services and treatment are carefully structured

to achieve optimum results in the most time

efficient manner possible consistent with sound

clinical practice.

(26)

Managing Care: PRTF

Continued Stay Criteria

All of the following must be met:

If treatment progress is not evident, then there

is documentation of treatment plan

adjustments to address such lack of progress

(27)

Managing Care: PRTF

Continued Stay Criteria

All of the following must be met:

Care is rendered in a clinically appropriate

manner and focused on the child/adolescent’s

behavioral and functional outcomes

(28)

Managing Care: PRTF

Continued Stay Criteria

All of the following must be met:

An individualized discharge plan has been developed which includes specific realistic, objective and measurable discharge criteria and

plans for appropriate follow-up care. A timeline for expected

implementation and completion is in place but discharge criteria have not yet been met.

(29)

Managing Care: PRTF

Continued Stay Criteria

All of the following must be met:

Child/adolescent is actively participating in treatment to the

extent possible consistent with his/her condition, or there are

active efforts being made that can reasonably be expected to

lead to the child/adolescent’s engagement in treatment.

(30)

Managing Care: PRTF

Continued Stay Criteria

All of the following must be met:

Unless contraindicated, family, guardian, and/or custodian

is actively involved in the treatment as required by the

treatment plan, or there are active efforts being made and

documented to involve them.

(31)

Managing Care: PRTF

Continued Stay Criteria

All of the following must be met:

When medically necessary, appropriate

psychopharmacological intervention has been

prescribed and/or evaluated.

(32)

Managing Care: PRTF

Continued Stay Criteria

All of the following must be met:

There is documented active discharge

planning from the beginning of

treatment

(33)

Managing Care: PRTF

Continued Stay Criteria

All of the following must be met:

There is a documented active attempt at

coordination of care with relevant outpatient

providers when appropriate

(34)

Managing Care: PRTF

Continued Stay Criteria

Children/adolescents have difficulty maintaining treatment

gains if the family/supports haven’t done their work too!

Family/Supports Healthcare

(35)

Managing Care: PRTF

Continued Stay Criteria

• If treatment progress is not evident, then is there documentation of treatment plan adjustments to address such lack of progress (i.e.. Is the family/support system involved? If not why not? Have attempts to engage them been made? What happened? What now?)

• An individualized discharge plan has been developed with includes specific realistic, objective and measurable discharge criteria and plans for appropriate follow-up care. A timeline for expected

implementation and completion is in place but discharge criteria have not yet been met.

(36)

PRTF Understanding Discharge

• The consumer discharge date, and discharge plan are crucial elements in mapping out the care plan

• Reviewers should view the discharge plan as the end goal of treatment and evaluate whether the level of care prescribed is furthering the discharge goal according to the timeline

What is the

estimated

(37)

PRTF: Discharge Criteria

BOTH of the following must be met for Discharge:

The child or

adolescent can be

safely treated at

an alternative level

of care

An individualized

discharge plan

with appropriate,

realistic and timely

(38)

PRTF Understanding Discharge

In addition at least one of the following must also be met:

The treatment plan goals and objectives have been substantially met or a safe, continuing care program has been put in place at an alternate level of care.

Admission criteria is no longer met for this level of care and the patient can safely be treated in a less restrictive, intense environment.

The support system is competent but non-participatory in treatment or in following the program rules, to such a degree that treatment has been rendered ineffective or unsafe.

(39)

Presented by:

Lynnette Gordon, LPC, LCAS

UM director

Eastpointe LME/MCO

lgordon@eastpointe.net

910-298-7036

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