Presentation on theme: "Mobile and Assertive Community Treatment The clinical review process and the Medical Necessity Criteria."— Presentation transcript:
Mobile and Assertive Community Treatment The clinical review process and the Medical Necessity Criteria
Principles of MTS/ACT Services Mobile Treatment is designed for children, adolescents, and adults with serious mental disorders which are exemplified by non- compliance and vulnerability to provide treatment in the least intensive setting that is able to meet the Individual’s clinical needs. These services are provided by a multidisciplinary treatment team and are available to the consumer on a 24/7 basis
Severity of Need & Intensity of Services The individual’s condition must require intensive, assertive mental health treatment and supportive services delivered by a multidisciplinary team, providing a minimum of weekly face-to-face contact.
C&A Admission MNC All of the following criteria are necessary for admission: A. The consumer has a primary DSM-IV Dx that is the cause of significant psychological impairment. B. Individual is at risk for out-of-home placement & either: The Individual has not maintained, on a continuous basis, community mental health services that are prescribed, or The Individual is exhibiting behavior that is a risk of harm or self-harm C. The primary caretaker: Has the goal of maintaining the child or adolescent safely in the home, and Agrees to participate in Mobile Treatment services.
C&A Continued Stay MNC All of the following criteria are necessary for continuing treatment at this level of care: A. The consumer continues to meet Adm criteria despite Tx efforts, or there is emergence of additional problems consistent with the admission criteria. B. Documentation exists of failed attempts to integrate the Individual into traditional Outpatient treatment. C. There is clinical evidence of symptom improvement using the service or, if there’s no improvement, there is documentation of Tx plan changes and/or a 2nd opinion of the Tx plan. (Tx plan is working or is being changed) D. The primary caretaker continues to support in-home placement and the Mobile Treatment services.
Adult Admission MNC All of the following criteria are necessary for admission: A. The consumer has a PMHS Priority Population Dx, which is the cause of significant psychological, personal care, and social impairment. B. The impairments result in at least one of the following: A clear/current threat to being able to live in the customary setting The consumer is homeless & would need a higher level of care if Mobile Tx or ACT services weren’t provided. An emerging/impending risk to self or others. Inability to engage in traditional outpatient treatment C. Inability to form a therapeutic relationship on an ongoing basis as evidenced by one or more of the following: Frequent use of emergency rooms for psychiatric reasons Psychiatric hospitalizations Arrest for reasons associated with the Individual’s mental illness.
Adult Continued Stay MNC All of the following criteria are necessary for continuing treatment at this level of care: A. The consumer continues to meet admission criteria despite treatment efforts, or there is emergence of additional problems consistent with the admission criteria. B. There is clinical evidence of symptom or functional improvement; however, - the individual continues to be at risk for a higher LOC based on the consumer’s response to attempts to reduce the frequency or intensity of services in a planned way, or - there is documented evidence that the individual is at risk due to the tenuous nature of clinical/functional gains.
Adult Continued Stay MNC C. There is documented evidence that the consumer has either: - Limited or no progress toward goals and there are changes to the treatment plan/interventions, or - Limited or no progress toward goals and there are changes to the treatment plan/interventions, or - Progress toward goals and there are changes to the treatment plan to support the consumer’s transition to traditional outpatient services (i.e. scheduling and assisting consumer with appointments, assisting consumer with using public transportation independently, support consumer’s efforts to actively participate in treatment, etc.) - Progress toward goals and there are changes to the treatment plan to support the consumer’s transition to traditional outpatient services (i.e. scheduling and assisting consumer with appointments, assisting consumer with using public transportation independently, support consumer’s efforts to actively participate in treatment, etc.)
Case Examples and Discussions Documentation That Led To Follow Up Phone Calls From ValueOptions®
Case Example #1 Ct has Hx of severe depression & PTSD & difficulty maintaining in the community. Though Ct currently has an apartment, Ct has had ongoing issues w/ self injury & dissociative episodes of lost “hours” to “days” of time. Due to low self esteem, anhedonia & triggers of trauma, Ct has difficulty caring for self & apartment. Ct doesn’t do laundry regularly, often runs out of food, & needs prompting from MTS to buy items he needs for his home (i.e. shower curtain). Ct abused his benzos but agreed to discontinue them after an arrest that occurred during a drug induced dissociative episode. MTS assisted Ct w/ the court date & is actively involved in Ct's probation for a theft charge. Ct regularly voices suicidal ideation and sometimes doesn’t respond to MTS. Ct also does not care for his physical health (i.e. had severe flu & refused ED until MTS called 911 after he passed out from his fever).
Case Example #1 Discussion This was generally a pretty clear picture of barriers are to traditional OP services. What’s missing is language that demonstrates the MTS is working w/ the consumer toward “Transition”. The activities of the MTS appear to be ongoing maintenance tasks, not steps toward transition. Actually, the consumer appears to have made some progress: has secured/maintained housing and has reportedly stopped abusing benzos. Given the serious nature of the consumer’s SA problem: Is the consumer in SA Tx? Is the consumer in SA Tx? If not, what is the MTS doing to get the consumer in (or working toward) SA Tx? If not, what is the MTS doing to get the consumer in (or working toward) SA Tx?
Case Example #2 Ct has Schizoaffective D/O and generally displays cycles of severe depression, disorganized thinking, and isolation, followed by an improved outlook. Currently lives in a residential setting due to problems w/ attention and memory. MTS has made attempts to integrate the ct into traditional OP Tx (i.e. MTS has given Ct a bus schedule and has ridden the bus route w/ ct. Ct was only successful 1 out of 4 times and she refuses to try again, due to the belief/fear she will get lost and the fact that she also experienced a panic episode while riding the bus). Ct has made improvements while receiving MTS services. Ct will not be able to function in the community without MTS services at this time.
Case Example #2 Discussion In this example, the details of attempted transition efforts are very strong. However, the details on what progress has been made, what the threat to housing is, and what MTS is actively doing that avoids ED visits or incarceration for this consumer are all unanswered questions. It’s not clear in this review what MTS is doing to help her keep her housing, avoid hospitalization or incarceration, improve her mental status, secure entitlements, stabilize crises, etc.
Case Example #3 Ct continues to report auditory hallucinations & severe paranoid ideations (Ct won’t leave her house except on rare occasions & only when accompanied by the ACT team). Most contacts w/ the client continue to be in the community; Ct continues to refuse to come into the office for scheduled MH appointments. Ct hasn’t kept any of her scheduled somatic appointments. Each time the ACT team arrives at her home for transport to see her PCP, Ct expresses paranoid ideations w/ poor response to reassurance from the team that someone will be w/ her the entire time. Ct continues to receive her oral meds & it is clearly evident that w/out ACT services the client would receive no somatic or psychiatric care and would therefore decompensate with a probable IP MH adm.
Case Example #3 Discussion This case appears to be in a maintenance mode. There is an implied plan to transition to lower levels of care in that the ACT team meets with her in the community. However, there’s no threat to housing and there’s no explanation of changes being made to the treatment plan. It’s not clear in this review what ACT is doing to help her keep her housing, avoid hospitalization or incarceration, improve her mental status, secure entitlements, stabilize crises, access somatic care, etc.
Case Example #4 Ct is Dxed w/ Paranoid Schizophrenia, is non- compliant w/ meds, doesn’t make himself avail- able for appts, is disorganized, has flight of ideas, somatic delusions, and poor judgment. The MTS must provide MH Tx & meds to the Ct. W/out the MTS, Ct would not receive any of his prescribed meds, nor would he make any attempts to keep his scheduled appts. As a result, the Ct would decompensate and require a higher level of care.
Case Example #4 Discussion There are no documented attempts (or intent) to transition to lower levels of care. The documen- tation is maintenance oriented. S/Sxs of the consumer’s illness are present but behaviors demonstrating dangerousness to self or others, threats to housing, emergency room utilization, etc. are absent. There is no documentation regarding progress and no noted change in Tx plan to address this lack of progress.
Case Example #5 Ct has come a long way w/ the support of MTS. However, Ct continues to require MTS due to her paranoia. Ct has weeks at a time where she’s unable to keep appts in the community & requires enormous outreach to get back on track. Ct has several somatic issues that MTS is assisting her with (obesity, diabetes, hypertension, & chest pains). Ct requires encouragement & education regarding the somatic issues & for follow up w/ the PCP. Ct has a long Hx of homelessness & hospitalizations.
Case Example #5 Discussion This requests lacks the detail of what “has come a long way” means or is referring to. There is no documentation addressing a MTS plan to help the consumer be ready to transition to a lower level of care. The threat to housing, the crisis services provided to avoid ED utilization, and the efforts the MTS makes to avoid incarceration are not clear. The ValueOptions Care Manager rightly wondered if there was any difference between this request and requests she sees for Intensive Case Management.
Case Examples and Discussions Good Documentation
Case Example #6 Continues to have major difficulties interacting w/ others. Continued outbursts are intimately related to his mood, irritability, and distrust of others. In recent months, he’s been charged w/ obstructing an investigation & has had several run- ins w/ the local police dept. He’s recently begun discussing his SA Hx & began SA Tx last month. Although Ct has main- tained housing for 3 months, he remains at risk for eviction/ homelessness due to aggressive behavior w/ neighbors/land- lord. Anger management remains an issue for Ct &, in part, it prevents him from being employed or making friends. Although MTS has discussed transitioning to less intensive services, it’s not been feasible due to his isolation & antisocial behaviors. Ct just started developing a relationship w/ MTS.
Case Example #6 Discussion The case is one that clearly outlines the deficits due to Dx, the current behaviors secondary to those diagnoses, the current barriers to transitioning to a lower level of care, the threat of consequence (housing and legal) if not in the intensity of MTS, the follow through on the subject of identifying a SA problem, and notation that transition is the goal on the mind of the MTS staff.
Case Example #7 Ct continues to be paranoid (government is monitoring him). Ct continues to have flat affect, dysphoric mood, & mumbles to himself. In the last 3 months, psychiatrist has increased visits w/ Ct & reviewed his medication. Judgment, concentration & attention span are poor. Requires multiple prompts to complete simple tasks. Ct made minimal progress toward transition to lower level of care. When approached about an OP referral, he stared at the speaker and said "what does that mean?”. Currently, MTS is providing education about OP services & community resources as well as how to write down dates for scheduled appointments in a way that would give him time to get ready to be picked up for groups. Ct’s hygiene has improved & he’s starting to dress appropriately for the weather. He’s starting to have limited interactions w/ peers.
Case Example #7 Discussion In this example, it is clear what his Dx is, what behaviors are secondary to the Dx, what the progress has been, what the threats are to independent living, what the MTS team is actively doing to assist the consumer in the community, and why a multidisciplinary team is still indicated. It is also clear that the goal of MTS is to transition the Ct to a lower level of care (and/or community services). The documentation is clear that the consumer is no where near ready for transition.
Case Example #8 Initial Request: Ct Dxed w/ Paranoid Schizophrenia & at risk for losing housing w/ family due to their inability to cope w/ Ct's symptoms. Ct frequently threatens family & neighbors & has legal Hx due to this behavior. Last April, Ct was on an LOA from a state hospital to visit a PRP but neither went to the appt nor returned to the hospital. Ct has a Hx of IP MH care & states she uses ERs for MH care, “a lot”. Referral from hospital reports 15+ IP MH adms in recent Hx. Ct has not followed up w/ OP referrals upon D/C from IP nor has she been med compliant. Insight is very poor.
Case Example #8 Discussion It is clear that there is a threat to housing, that there is a significant MH Dx, that the behaviors secondary to this Dx are the cause of significant impairment, and it is clear that, without MTS services, the consumer would be at risk for incarceration, hospitalization, non-compliance with meds, and non-compliance with MH Tx.
Suggestions for future requests Have the MNC in front of you while writing your request Have the MNC in front of you while writing your request Use slide # 22 & 24 if you want a template for your reviews Use slide # 22 & 24 if you want a template for your reviews Be clear about the risks for hospitalization, homelessness, out of home placement, expulsion, incarceration, etc. Be clear about the risks for hospitalization, homelessness, out of home placement, expulsion, incarceration, etc. Make sure your attached supporting documents are up to date Make sure your attached supporting documents are up to date If this is one of many requests, over a long period of time, be clear in justifying why this level of intensity is still necessary If this is one of many requests, over a long period of time, be clear in justifying why this level of intensity is still necessary The narative should include what the MTS is actively doing (or planning to do) to support/treat this member? The narative should include what the MTS is actively doing (or planning to do) to support/treat this member? No need to repeat in the narrative what is already stated elsewhere No need to repeat in the narrative what is already stated elsewhere If we need to call you and you want us to call your cell phone, please put this # in the “contact phone #” field If we need to call you and you want us to call your cell phone, please put this # in the “contact phone #” field Never put the consumer/consumer’s family contact info in this field Never put the consumer/consumer’s family contact info in this field Never copy and paste from the last review Never copy and paste from the last review