CBAR Tiered structure - Magellan of Nebraska

Home Based Therapeutic Group Home: High Complexity
Community Based Alternatives to Residential
I. Admission – Severity of Need
Criteria A, B, C, D, E, F and G must be met to satisfy the criteria for severity of need.
A. The individual’s behavioral health condition can only be safely and effectively treated in a familycentered, therapeutic milieu with onsite behavioral health therapy and access to 24/7 on site crisis
response due to significant impairments in home, school and community functioning caused by
current mental health symptoms consistent with a DSM-5 diagnosis.
B. Less restrictive community based services have been given a fully adequate trial, and were
unsuccessful or, if not attempted, have been considered, but in either situation were determined to
be to be unable to meet the individual’s treatment needs and the reasons for that are discussed in
the application.
C. The individual’s symptoms, and/or the need for treatment in a 24/7 level of care (LOC), are not
primarily due to any of the following:
1) Mental Retardation or a Pervasive Developmental Disorder.
2) Organic mental disorders, traumatic brain injury or other medical condition.
D. The individual doesn’t require a more intensive level of care.
E. The individual doesn’t require primary medical or surgical treatment.
II. Admission – Intensity and Quality of Service
Criteria A, B, C, D, E and F must be met to satisfy the criteria for intensity and quality of service.
A. Home Based ThGH has been prescribed by a psychiatrist or psychologist who has documented
that a residential setting is the least restrictive clinically appropriate service that can meet the
specifically identified treatment needs of the individual.
B. Home Based ThGH is not being used for clinically inappropriate reasons, including as:
1) An alternative to incarceration, for preventative detention (e.g. to prevent running away or
truancy), or as a means of ensuring community safety in a individual exhibiting primarily delinquent
or antisocial behavior, or;
2) The equivalent of safe housing or permanency placement, or;
3) An alternative to parents’, guardian’s or agency’s capacity to provide a place of residence for the
individual, or
4) A treatment intervention, when other less restrictive alternatives are available.
C. The individual’s treatment goals are included in the pre-admission psychiatric or psychological
evaluation and include behaviorally defined objectives that require, and can reasonably be achieved
within, a Home Based ThGH setting.
D. The Home Based ThGH is required to coordinate with the individual’s community resources,
including schools, with the goal of transitioning the individual out of the program to a less
restrictive care setting for continued, sometimes intensive, services as soon as possible and
appropriate.
E. The Home Based ThGH program must incorporate some form of research-based, traumainformed programming and training.
F. Discharge planning begins upon admission, with concrete plans for the individual to transition
back into the community beginning within the first week of admission, with clear action steps and
target dates outlined in the treatment plan.
III. Continued Stay Criteria
Criteria A, B, C, D, and E must be met in order to satisfy the criteria for continued stay.
A. All of the admission guidelines continue to be met and this is supported by the written clinical
documentation.
B. There is a written, up-to-date Discharge Plan that:
1) Identifies the custodial parent or custodial caregiver at discharge,
2) Identifies the school the individual will attend at discharge,
3) Includes IEP recommendations, if necessary,
4) Outlines the aftercare treatment plan (discharge to another residential LOC is not an acceptable
discharge goal), and
5) Lists barriers to community reintegration, and progress made on resolving these barriers since
last review.
C. The individual is demonstrating progress in treatment and/or there is clinical evidence that
continued ThGH services can reasonably be expected to improve the individual’s symptoms, so that
Home Based ThGH services will no longer be necessary.
D. The Active Treatment Plan includes intensive family interventions, with a recommended
frequency of one family therapy session per week, although twice per month is minimally
acceptable. Family involvement begins immediately upon admission to Home Based ThGH. If the
minimum requirement cannot be met, the reasons must be reported, and continued efforts to
involve family members must also be documented. Under certain circumstances an alternate plan,
aimed at enhancing the individual’s connections with other family members and/or supportive
adults may be an appropriate substitute.
E. Less restrictive treatment options have been considered, but cannot yet meet the individual’s
treatment needs. There is sufficient current clinical information to show that Home Based ThGH
LOC continues to be the least restrictive level of care that can meet the individual’s mental health
treatment needs.
Home Based Therapeutic Group Home: Moderate Complexity:
Community Based Alternatives to Residential
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 home based, therapeutic
setting
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 the program 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 home based ThGH (mod complexity) 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. Home Based ThGH (mod complexity) 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.
E. All services are provided under the supervision of a Supervising Practitioner
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.
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 this level of care 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 services.
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).
Home Based Therapuetic Group Home: Low Complexity:
Community Based Alternatives to Residential
Depending on the services requested to treat the unique needs of the member in this tier, criteria
for either Outpatient Treatment and/or Community Treatment Aid will be used to determine
Medical Necessity for Services.
Outpatient Treatment Component:
The specified requirements for severity of need and intensity and quality of service must be met to
satisfy the criteria for the treatment review.
I.
Severity of Need
Criteria A, B, C, D, E, and F must be met to satisfy the criteria for severity of need.
A. The individual has, or is being evaluated for, a DSM- 5 diagnosis.
B. The presenting behavioral, psychological, and/or biological dysfunctions and functional
impairment (occupational, academic, social) are consistent and associated with the DSM-5.
C. One of the following:
1) the individual has symptomatic distress and demonstrates impaired functioning due to
psychiatric symptoms and/or behavior in at least one of the three spheres of functioning
(occupational, scholastic, or social), that are the direct result of a DSM-5 disorder. This is
evidenced by specific clinical description of the symptom(s) and specific measurable
behavioral impairment(s) of at least mild in occupational, academic or social areas, or
2) the individual has a persistent illness described in DSM-5 with a history of repeated
admissions to 24-hour treatment programs for which treatment is required to maintain
community tenure, or
3) there is clinical evidence that a limited number of additional treatment sessions are required
to support termination of therapy, although the individual no longer has at least mild
symptomatic distress or impairment in functioning. The factors considered in making a
determination about the continued medical necessity of treatment in this termination phase
are the frequency and severity of previous relapse, level of current stressors, and other
relevant clinical indicators. Additionally, the treatment plan should include clear goals
needing to be achieved and methods to achieve them in order to support successful
termination (such as increasing time between appointments, use of community resources,
and supporting personal success).
D. The individual does not require a higher level of care.
E. The patient demonstrates motivation to manage symptoms or make behavioral change
F. The patient is capable of developing skills to manage symptoms or make behavioral
change
II. Intensity and Quality of Service
Criteria A, B, C, D, E, F, G, H, I, J and K must be met to satisfy the criteria for intensity and quality of
service.
A. There is documentation of a DSM-5 diagnosis. The assessment also includes the precipitating
event/presenting issues, specific symptoms and functional impairments, community and natural
resources, personal strengths, and the focus of treatment.
B. There is a medically necessary and appropriate treatment plan, or its update, specific to the
individual’s behavioral, psychological, and/or biological dysfunctions associated with the DSM-5
disorder. The treatment plan is expected to be effective in reducing the individual’s occupational,
academic or social functional impairments and:
1) alleviating the individual’s distress and/or dysfunction in a timely manner, or
2) achieving appropriate maintenance goals for a persistent illness, or
3) supporting termination.
C. The treatment plan must identify all of the following:
1) treatment modality, treatment frequency and estimated duration;
2) specific interventions that address the individual’s presenting symptoms and issues;
3) coordination of care with other health care services, e.g., PCP or other behavioral health
practitioners;
4) the status of active involvement and/or ongoing contact with individuals family and/or
support system, unless there is an identified, valid reason why such contact is not clinically
appropriate or feasible;
5) the status of inclusion and coordination, whenever possible, with appropriate community
resources;
6) consideration/referral/utilization of psychopharmological interventions for diagnoses that are
known to be responsive to medication;
7) documentation of objective progress toward goals for occupational, academic or social
functional impairments, target-specific behavioral, psychological, and/or biological
dysfunctions associated with the DSM-5 psychiatric/substance-related disorder(s) being
treated. Additionally, specific measurable interim treatment goals and specific measurable end
of treatment goals are identified. Appropriate changes in the treatment plan are made to
address any difficulties in making measurable progress;
8) the description of an alternative plan to be implemented if the individual does not make
substantial progress toward the given goals in a specified period of time. Examples of an
alternative plan are psychiatric evaluation if not yet obtained, a second opinion, or
introduction of adjunctive or different therapies; and
9) the current or revised treatment plan can be reasonably expected to bring about significant
improvement in the problems meeting Severity of Need Criteria (I above). This evolving
clinical status is documented by written contact progress notes.
D. The individual has the capability of developing skills to manage symptoms or make behavioral
change and demonstrates motivation for change, as evidenced by attending treatment sessions,
completing therapeutic tasks, and adhering to a medication regimen or other requirements of
treatment.
E. Individual is adhering to treatment recommendations, or non-adherence is addressed with the
individual, and barriers are identified, interventions are modified, and/or treatment plan is
revised as appropriate.
F. Although the patient has not yet obtained the treatment goals, progress as relevant to presenting
symptoms and functional impairment is clearly evident and is documented in objective terms.
G. Treatment is effective as evidenced by improvement in SF-BH, CHI, and/or other valid outcome
measures.
H. Requested services do not duplicate other provided services.
I.
Visits for this treatment modality are recommended to be no greater than two sessions per
week, except for: (i) acute crisis stabilization, or (ii) situations where the treating provider
demonstrates more than one visit per week is medically necessary.
J. As the individual exhibits sustained improvement or stabilization of a persistent illness,
frequency of visits should be decreased over time (e.g., once every two weeks or once per
month) to reinforce and encourage self-efficacy, autonomy, and reliance on community and
natural supports.
K. All applicable elements in Admission-Intensity and Quality of Service Criteria are applied as
related to assessment and treatment, if clinically relevant and appropriate.
Community Treatment Aide (CTA), Child and Adolescent component:
Criteria for Authorization
The specified requirements for severity of need, and intensity and quality of service must be met to
satisfy the criteria for CTA services.
I. Admission - Severity of Need
Criteria A, B, C, D and E must be met to satisfy the criteria for severity of need.
A. An established DSM-5 diagnosis which requires and will respond to therapeutic intervention.
B. Presence of psychological symptoms.
C. The individual is enrolled in active outpatient treatment with a licensed therapist
D. The individual would require a more restrictive treatment environment without the services of a
CTA.
E. The individual is medically stable and does not require the 24-hour medical/nursing monitoring
or procedures provided in a hospital level of care.
II. Admission – Intensity and Quality of Service
Criteria A, B, C and D must be met to satisfy the criteria for intensity and quality of service.
A. A licensed therapist must supervise the CTA;
B. A treatment plan must be developed which includes CTA services.
C. The usual caregiver of the individual must be available in the treatment setting.
D. The focus of treatment is one of the following:
1) rehabilitate the individual’s social skills and relationship skills, or
2) aid the individual’s guardians in using appropriate discipline interventions, or
3) aid the individual in using appropriate coping skills to manage his/her behavior, or
4) other, as specifically stipulated and required by the supervising practitioner.
Criteria for Continued Stay
III. Continued Stay
Criteria A, B, C, D, E, F, G and H must be met to satisfy the criteria for continued stay:
A. Treatment is in process of implementation.
B. Active and timely treatment is focused upon stabilizing or reversing symptoms for which
treatment was initiated (or prescribed).
C. Interventions are consistent with the individual’s risk factors and assessment.
D. Treatment plan and service hours have been updated at least every 30 days to reflect the
individual/family’s progress.
E. Routine assessments and treatment progress updates are completed.
F. Individual and family, to the extent possible, are involved in treatment and discharge planning.
G. Treatment is not making the symptoms persistently worse.
H. Reasonable expectation, based on the individual’s clinical history and recent clinical experience,
that the current treatment is of benefit to the individual, such that withdrawal of treatment will
result in the individual’s decompensation or the recurrence of signs or symptoms that
necessitated treatment.