Can J Psychiat, 49, 726-735, 2004. Progress notes reflect, but are not limited to: Specific individual skills training, client generated progress sheets, participation in milieu activities, peer support building activities, family sessions, and case management meetings should also be documented regardless of whether the service is billable. The need for 24-hour containment has been determined to be unnecessary. These are important things to address during the course of treatment in these programs. When using comparisons to review programs, administrators should not penalize individual programs that have developed a plan to improve the program. While all levels of care in the continuum are important in providing a full recovery, these cuts have limited the availability of parts of the continuum in many communities. 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. Improvement in symptoms and functioning to allow the child/adolescent to return to a school setting. PHPs and IOPs may be free-standing programs, part of a distinct behavioral health organization, or a department within a general medical health care system. Full-time participation in the program at the onset of treatment serves to promote stabilization and cohesion. If an individual does not meet any of the above criteria, they may be appropriate for an intensive outpatient program. The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Partial Hospitalization Programs L37633. A number of clinical factors may impact staff-to-client ratios in programs: For example, the direct treatment staff-to-client ratio in some acute PHPs may need to be 1:3, while in other less intensive programs, a ratio of 1:12 may be appropriate. 8.320.2 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services 2/1/20 to 12/31/20. Programs may also bolster their treatment staff with paraprofessionals, non-degreed individuals, students, and interns. Medicare Advantage Plans are not obligated to cover these levels of care. Block, B. M., Arney, K., Campbell, D.J., Lefkovitz, P.M., Speer, S.K., and Kiser, L.J. Finding measures that will help improve staff efficiency and effectiveness are key to a quality improvement plan. High quality performance plans will guide the success of utilizing all support levels as members of a fully reimbursed multidisciplinary team. Intensive outpatient services have been developed to meet specific clinical needs when the individual is not determined to require the intensive daily services of partial hospitalization or is unable physically to meet the attendance requirements of such programs or when less frequent monitoring in inappropriate. A higher level of monitoring of overall behavioral health and physical functioning is important. Psycho-educational services represent another basic building block of PHP/IOP treatment. Sometimes specific levels of care or programs are not available in certain markets. People treated at this level of care are able to maintain their role functioning in the community and generally have adequate family/community support. Always start with a tech check to make sure everyone can navigate the platform and feels, Suggest participants prepare for sessions by spending 5-10 minutes of calm quiet time prior to meeting- people are used to internet time being about work or leisure and this is. Partial Hospitalization Program Partial hospitalization and intensive outpatient programs are therapeutic treatment experiences for individuals who require more than the conventional outpatient level of care but do not need the security of a locked unit or 24-hour care. The individuals progress or lack thereof toward identified goals is to be clearly documented in the record. Some flexibility in programming should always be considered given individual circumstances, Is uninterested or unable due to their illness to engage in identifying goals for treatment and/or declines participation as mutually agreed upon in the treatment plan, Is imminently at risk of suicide or homicide and lacks sufficient impulse/behavioral control and/or minimum necessary social support to maintain safety that requires hospitalization, Has cognitive dysfunction that precludes integration of newly learned material, skill enhancement, or behavioral change, Has a condition such as social phobia, severe mania, anxiety, or paranoid states in which the individual may become more symptomatic in a predominantly group treatment setting, Has primarily social, custodial, recreational, or respite needs. Efforts to achieve best practices require analyses of critical data points, clinical outcomes, and treatment processes. By providing an intensive level of care that spans the gap between traditional inpatient and outpatient levels of care, Child and Adolescent Partial Programs are an important part of the continuum of behavioral healthcare. In these cases, backup case management and peer support services can be essential. Acute Symptom Reduction - This intensive PHP function focuses on the provision of sustained, goal-directed, clinical services to reduce the persons acute symptoms and severe functional impairments as an exacerbation of a more chronic condition. When acceptable to given payers or state reviewers, a comprehensive user-friendly synopsis of a persons progress through treatment may be provided. With the increased use of technology, programs have an opportunity to address needs of those they serve through methods other than in-person/on-site programming. 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. The program must then review the guidelines and determine how to proceed with programming and documentation. Bill Type 12X (Hospital-Inpatient), 14X (Hospital-Other) is billed with Condition Code 41 (Partial Hospitalization). During the assessment period, each program should complete clinical assessments, outcome measures or screenings that have been verified as appropriate for the population that an individual fits into as determined by the attending physician. Patients are assessed to be medically stable with labs to include but not limited to: comprehensive serum metabolic profile, including phosphorus and magnesium, Electrocardiogram (ECG), if clinically indicated. It is designed for patients . To accomplish this, programs should develop and maintain liaison relationships with organizations such as hospitals, crisis stabilization units, primary care physicians, community therapists, supportive living programs, community support programs, self-help groups, crime victim councils, vocational assistance programs, employee assistance programs, home health services, and various other social service agencies and organizations. 104 CMR 29. Discharge from IOP programs is made to individual outpatient behavioral health specialists, integrated physical/behavioral settings, or primary care. We must continue to respect the role of PHP and IOP within the behavioral healthcare continuum. Individuals with co-occurring disorders tend to relapse frequently, placing them at greater jeopardy of a marginalized social existence. Clinicians in the program should be well versed in perinatal mood and anxiety disorders. Example metrics include, but are not limited to: Consumer feedback is essential in a comprehensive quality improvement plan. Service Planning This staff member should work consistently with the individual (and family as indicated) and follow the course of clinical treatment from admission through discharge. The quality of therapeutic presence is even more important in telehealth than it is in Holding the space is much more challenging. The quality of the treatment we deliver is the value we offer to patients. The federal agency originally introduced the Medicare Partial Hospitalization Program modification in March 2016. This document has been designed to enable programs to: Partial hospitalization programs (PHP) and intensive outpatient programs (IOP) may differ from one region to another due to multiple factors such as specialized workforce availability, culture, resources, or health insurance coverage inconsistencies. Communication amongst programs regarding their results is strongly encouraged. Codes G0129 and G0176 are only used, and therefore reimbursable, for partial hospitalization programs. These services are provided primarily by medical practitioners within the context of treatment of general medical conditions. CNA (Certified Nurse Aide) Registry. All chemical dependency PHP and IOP programs must have clearly delineated procedures for addressing clients detoxification, withdrawal, and other medical needs. Clinicians should pay attention to the need to ground themselves in this new environment - this may be another opportunity to model coping, Sitting in front of a screen for 45 minutes is very different from sitting in a group room in a chair- people are not shifting around and moving their bodies-staff and participants may need to take care to stretch and move around afterwards to reduce physical, Do not record sessions and make it clear that sessions are not. Policy needs to dictate the availability of a psychiatrist (or other physician) for consultation to non-physician providers, face-to-face with individuals in treatment during program hours, and by telephone off hours to provide direction in the care for all enrolled clients 24 hours a day, seven days a week. The Indiana Health Coverage Programs (IHCP) provides coverage for inpatient and outpatient behavioral health services - including mental health and addiction treatment services - in accordance with the coverage, prior authorization (PA), billing and reimbursement guidelines presented in this document. The Level of Care Guidelines is derived from generally accepted standards of behavioral health practice. 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. We must maintain it. 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. 104 CMR 28. At the time, Pamela Hyde, JD, SAMHSA Director, announced that partial hospitalization and intensive outpatient treatment were specifically included as essential intermediate behavioral healthcare treatment options.1 This landmark decision validates over 40 years of effort by behavioral health professionals throughout the country to provide intensive ambulatory treatment and avert or reduce hospitalizations while creating an environment of personal recovery for countless Americans. These services are included as mandated essential behavioral healthcare benefits in insurance policies from 2014 onward. Example metrics include, but are not limited to: An ongoing periodic analysis of job duties and workflow processes is recommended to assure that job-related functions are not outdated and are being performed in the most efficient and effective manner. These services may be present in a single organization such as a large community mental health center, a general hospital with comprehensive mental health services, or a free-standing provider location. guidelines including the Level of Care Utilization System (LOCUS), hildren's Level of are . Any time a program negotiates a contract with a private payer, including Medicare Advantage plans, the program should request the guidelines for PHP and IOP. 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. The certification needs to identify why the client would require hospitalization in lieu of the appropriate level of care. Postpartum Psychosis is a true psychiatric emergency. 10, 05-07-04) A3-3194, HO-230.7 Partial hospitalization programs (PHPs) are structured to provide intensive psychiatric care through active treatment that utilizes a combination of the clinically recognized items and services described in 1861(ff) of the Social Security Act (the Act). We encourage a shift in the oversight focus from document analysis to a concern for outcomes and the overall client experience. Standards and Guidelines for Partial Hospitalization, Alexandria, Virginia. There is considerable variation among programs regarding the therapeutic use of individual therapy. Programs should also incorporate interpersonal therapy and cognitive behavioral therapy as these have been effective in treatment of perinatal depression (Van Neil and Payne, 2020). Goals must be clearly worded and achievable within the timeframe of the individuals involvement in program. Such conditions frequently follow serious crises, stressors, or newly diagnosed acute physical problems. The change in symptoms requires the intensity and structure of PHP to avert further deterioration. Orientation materials and program guidelines should be designed to make program goals, procedures, and expectations explicit for individuals utilizing services as well as for their family members, supportive peers, and collaborating providers. Second Edition Revised of Patient Placement Criteria (ASAM PPC-2R). These individuals are at high risk for hospitalization or re-hospitalization, and a less intensive level of care has been unable to achieve clinical stability. Example metrics include, but are not limited to: Tracking data related to who is coming to program, how services are used and how long they are in program is important in reviewing quality along with programming issues. The (Traditional) Outpatient level of care provides for treatment of conditions related to mild to moderate impairment. By Jacqueline LaPointe. II. However, the individual often presents with an impaired willingness or capacity to positively connect with caretaker, family, friends, or community supports. Partial Hospitalization is a short-term (average of four (4) to six (6) weeks), less than 24 hour, intensive treatment program for individuals experiencing significant impairment to daily functioning due to substance Currently Partial Hospitalization may be provided in a hospital or Community Mental Health Center (CMHC). GUIDELINES: PARTIAL HOSPITAL PROGRAM (PHP) GUIDELINES: RESIDENTIAL TREATMENT CENTER (RTC) GUIDELINES: CRISIS STABILIZATION & ASSESSMENT . Accessibility of an individuals data within the EMR is impacted by privacy and regulatory statutes and must be reflected in the EMR. Consider a preparatory contact over the platform prior to the first meeting, especially for groups. This finding served as the basis for the development by AABH of specific standards and guidelines for co-occurring disorder programs, most recently revised in 2007.22. These types of services are provided by a single entity which may be included as part of a benefits package or purchased separately by/for a person needed assistance with navigating the complexity of the health system. The medical record should be designed to enhance accuracy, minimize recording duplication, eliminate inappropriate abbreviations, and minimize patient compliance errors.. At admission, a summary of all medications including psychiatric medications, non-psychiatric medications, over the counter medications and supplements must be completed, reconciled, and reviewed. The degree to which an individuals medications are managed and the extent to which they must be reconciled, tracked, or summarized may vary according to program mission, regulation, or defined clinical responsibility within the continuum. 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. In addition, programs need to acknowledge that not all individuals have the appropriate devices, the WIFI access and the privacy to engage in the multiple groups per day format that we must maintain. Half-day Partial hospitalization is an ambulatory treatment approach that includes coordinated, intensive, comprehensive, and multidisciplinary treatment usually found in a comprehensive inpatient psychiatric hospital program. To manage medical and behavioral emergencies, policies should be developed to expedite admission for inpatient care if required and allow for timely pharmacological intervention. Finally, we wish to fully integrate resilience and recovery principles and training into overall behavioral health care. This certification needs to be always current. Partial Hospitalization Program (PHP) Definition A partial hospitalization program (PHP) is a time limited, ambulatory treatment program offered during the day or evening hours, and is considered an acute day hospital or a level 2.5 program per American Society of Addiction Medicine (ASAM) guidelines. These individuals may be unable to achieve dramatic degrees of functional improvement but may be able to make significant progress in the achievement of personal self-respect, quality of life, and increased independence despite debilitating symptoms that may otherwise be intolerable. These screenings also include risk for harm to self or others, pain, abuse, substance abuse, nutrition, vocational/financial need, legal concerns, housing, family issues, preferred learning style/methods, and any other ongoing unique individual concerns which may require consideration. Again, consider having another staff member, such as a behavioral health tech, present to handle these technical issues to reduce the impact on the group process. Access, treatment, and discharge data are key areas for tracking. They may be part of educational or residential facilities. A partial hospitalization program (PHP) is a structured mental health program and type of addiction treatment where clients participate in activities during the day and return home at night. Miller, T.,Mol, J.M. Staff in settings providing integrated substance abuse and psychiatric treatment should be fully oriented in each others disciplines. A less intensive level of care may have been insufficient to provide the treatment the individual requires to stabilize this decline. Services are offered to individuals whose medical condition, including the possibility of severe withdrawal, is not as dangerous or severe as to warrant 24-hour inpatient or residential monitoring. Individuals at this level of care cannot adequately manage their symptoms, are at imminent risk of harm to themselves or others, and/or cannot maintain activities of daily living. Association for Ambulatory Behavioral Healthcare, 2008. Gray, K., Michael, S., Lefkovitz, P., and Barry, A. Many seniors live in isolation, so timely and appropriate aftercare is needed to ensure that gains made in the program remain. Group therapy is an important part of treatment as research indicates that group therapy for women with postpartum depression led to a reduction in depression scores (Byrnes, 2018). An external audit should not be the impetus for utilization reviews. Partial hospitalization services must be vigorous and proactive as opposed to passive and custodial. While this section is not inclusive of all specific populations, these represent the populations in which there are a significant number of programs, enough to be establishing best practice. Greet each person individually in the group if providing a group service. Initially, the individual may only be able to agree to begin treatment and form a basic treatment plan, and may require close monitoring, support, and encouragement to achieve and sustain active and ongoing participation. Irvin D. Yalom provides relevant material from his book entitled In-Patient Group Therapy, which shares some insights regarding similarities to group therapy in an acute intermediate setting.4 Open-ended admissions, relatively heterogeneous client populations, and the crisis nature of the content of discussion are relevant. Association for Ambulatory Behavioral Healthcare, 2012. Of equal importance is the capacity of the EMR to allow tracking within the report writing function that enables program staff to access and consider data that is related to program function and performance improvement. Additional certification, monitors, medications, or additional clinical data may be required due to internal organizational or regulatory requirements. PHPs and IOPs are designed to help individuals understand their illness, reduce the impact of functionally debilitating symptoms, and cope with challenging situational crises. The record must document that specific treatment is ordered and supervised by an attending psychiatrist. PHPs differ from IOPs in several ways: payment is on a per diem basis for most private insurances. Examples of these symptoms may include negative self-talk, crying spells, severe anxiety, poor sleep, or panic attacks. D. A program must have a clinical director who shall be approved as a supervisor by the Board of Professional Counselors and Therapists to supervise alcohol and drug counselors or trainees. This provider is often determined by the complexity of the illness, medications, and overall medical or case management needs; Some individuals display a relatively high baseline functioning prior to the onset of a behavioral health condition yet require treatment in a partial hospitalization program to provide medication stabilization, insight, and self-management skills to reduce symptoms and risk to self-harm. Daily monitoring of medications, safety, symptoms, and functional level is deemed medically necessary. For individuals who don't require a hospital stay or constant supervision, partial hospitalization programs can be an excellent alternative that allows them to dedicate time and attention to addressing their mental health condition while staying at home or with family members. There are no guidelines for how a State should license behavioral health facilities, which may lead to a need to search carefully for the licensing requirements. There is significant variation among states and within treatment continuums regarding the expectations and clinical resources and services provided by residential facilities. Generally speaking, a program's average length of stay should reflect the population treated and primary program function. We must advocate for simplicity and consistency in the description of services offered in programs and the billing process. Within a continuum of behavioral health care, PHPs and IOPs function as vital components. 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. Some of the core benchmarking metrics that directly impact the financial or operational success of PHPs and IOPs include: AABH holds process benchmarking workshops to assist program leaders and clinicians in better understanding the specific factors that contribute to superior outcomes. Watch Video. Dads can also struggle with paternal depression and the mental health of the whole family is key to successful outcomes. Commission on Accreditation of Rehabilitation Facilities (CARF). All programs should consult with compliance officers in their organization to determine if there are specific staff-to-client ratios included within contracts. As an example, an outpatient staff psychiatrist may need to coordinate a referral with the program staff to avert a hospitalization in the same organization. Multi-modal Outpatient or Community-based services are differentiated from traditional outpatient care by the greater number of hours of involvement, the multi-modal approach, and the availability of specified crisis intervention services 24 hours per day. Adult Brain Injury. In some cases, a summary of daily notes is optional, but do not serve to replace individual notes. These should be conducted regularly throughout the treatment process to assess the impact of services at different stages of treatment. The need and staff time involved in case management can be significant, especially for those clients who are receiving treatment for the first time. Along with the advent of the medical care home, the number of mental health professionals providing screening, consultation, limited counseling, and other behavioral health services on site in primary care settings has been growing rapidly in recent years. An example of this type of individual is a young mother with anxiety and depression who is unable to work and care for young children following separation from her significant other and needs rapid improvement to resume responsibilities; Some individuals experiencing behavioral health symptoms or dysfunction due to a chronic mental illness that severely and persistently impairs their capacity to function adequately on a day-to-day basis, despite efforts to achieve these goals through treatment in a less intensive level of care. Marketplace forces and cost containment efforts have often resulted in a decrease in service availability, more restrictive eligibility (medical necessity) requirements, and reduced lengths of stay. Programs can usually expect to conduct program improvement planning following a review to address the issues discovered and highlighted as needing improvement. A given programs metrics may vary significantly based on the diagnostic characteristics of those who attend program and may help direct changes to programming to better meet the needs of the population in program. The overall expected outcome is the achievement of symptom and functional improvement on the part of the child/adolescent and the family. Groups that are structured to be repetitive, slower, and engage patients at multiple sensory levels are very important and can reduce the impact of physical and cognitive limitations on treatment. The Standards and Guidelines will be updated as new reviews are completed in any of the areas addressed. This edition also included the launch of the Standards and Guidelines as a living document for association members. Partial Hospitalization - A program for adults or adolescents which provides active treatment designed to stabilize or ameliorate acute symptoms in a person who would otherwise need hospitalization. The inclusion of report writing functions is important since it can be used to send letters to primary care providers, and to extract relevant clinical data from the record and organize it into referral forms or reports. While none of these focuses are mutually exclusive, a program tends to build their program from one of these perspectives. Ideally, general medical practitioners offering services for somebody presenting with behavioral health concerns have access to behavioral health specialty providers for consultation, crisis care, and/or referral for more intensive intervention. 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