UM Guidelines

Applies to BlueCare Only.

Clinical Indications for Admission to Specialized Supported Housing

• Admission to Specialized Supported Housing is indicated due to ALL of the following:
  • Age 18 or older
  • Is medically stable (Health status won’t impair or impede gains and benefits in SH – those qualifying for PAR or PASRR for a higher level of care (such as nursing home) are not appropriate
  • Serious mental illness is present, as indicated by ALL of the following:
    • Current primary DSM-V-TR diagnosis of moderate to severe I/DD or TBI diagnosis (excludes dementia)
    • Chronic mental illness has been present for at least 2 years.
    • Moderate dysfunction in daily living related to admission diagnosis for at least 3 months, as indicated by impairment in ALL of the following:
      • Interpersonal functioning: has lost all means of caregiver support within the community and cannot independently sustain a safe living environment due to mental illness
      • Ability to adapt to change – has had numerous, extended inpatient treatment attempts with one occurring within the last 6 months and has demonstrated failed community tenure with maximum effort of natural and community supports
      • Ability to concentrate and complete tasks – exhibits inability to complete tasks and concentrate, BUT has capacity to respond favorably to rehabilitative counseling and training and other psychosocial rehabilitative services
    • Treatment in the home and/or lower level of care is not sufficient to maintain symptomology and safety (i.e. aggressive behaviors towards self and others, extreme destruction of property)
    • Psychiatric, behavioral, or other comorbid conditions related to admission diagnosis have been associated with significant life disruption in past 2 years, as indicated by 1 or more of following: 
      • 2 or more inpatient hospitalizations AND Transitioning from a higher level of care, such as inpatient/subacute care and requires supervision in a structured setting due to mental health symptoms that prevent independent living and personal and community safety. 
      • 2 or more residential admissions AND transitioning from residential and needs structured housing services to maintain tenure in the community
      • Criminal justice involvement (eg, arrest, incarceration) transitioning from incarceration where significant mental health issues have been noted and requires structured setting due to mental health symptoms that prevent independent living and personal and community safety
    • I/DD primary and transitioning from a higher level of care (such as inpatient psych acute, sub-acute, residential) OR transitioning from ICF, CLS, home-based services due to being at risk of acute/sub-acute/residential placement
  • Complexity of the patient requiring special subsets of treatment as indicated by 1 or more of the following:
    • A need for Specialized Supported Housing and patient presents with ALL of the following criteria:
      • Valid I/DD or TBI ICD-10 Diagnosis with significant co-occurring mental health disorder or behavioral health condition, such as experiencing a disturbance in mood, affect or cognition, resulting in behavior that cannot be safely managed in a less restrictive setting.
      • There is an imminent risk that severe, multiple and/or complex psychosocial stressors will produce significant enough distress or impairment in psychological, social, occupational, or other important areas of functioning that treatment in a lower level of care will not suffice AND 1 or more of the following:
        • The supported individual has a co-occurring medical disorder or substance use disorder which complicates treatment of the presenting mental health condition to the extent that treatment in Specialized Supported Housing is necessary.
        • Member is at-risk of admission to a psychiatric hospital or an ICF/IID and they are at risk of losing their community level services and support.
        • Individuals in an acute setting, who are ready for discharge, but who cannot be safely supported in the community as they need additional treatment supports
        • Individual who requires a more secure setting due to elopement and wandering behaviors
  • Situation and expectations are appropriate for Specialized Supported Housing as indicated by ALL of the following:
    • Recommended treatment is necessary, appropriate, and not feasible with less intensive intervention (eg, less intensive support is unavailable or is not suitable to patient condition or history).
    • Targeted condition, symptoms, behaviors, and functional impairments related to underlying behavioral health disorder (or with potential to destabilize disorder) have been identified and are appropriate for long-term community-based residential care.
    • Ongoing therapeutic interventions, skilled care, or functional support (eg, support in activities of daily living) has been identified and can be safely performed in long-term skilled care facility.
    • Patient and family or caregivers, as appropriate, are willing to participate in treatment voluntarily.
    • There is no anticipated need for physical restraint, seclusion, or other involuntary control (eg, patient not actively violent or at risk for harm to self or others).
    • Medical and behavioral health providers, as appropriate, are willing and able to follow patient during course of service.
    • Biopsychosocial stressors potentially contributing to clinical presentation (eg, comorbidities, illness history, environment, social network, ability to cope, and level of engagement) have been assessed and are absent or manageable at proposed level of care.

Discharge Guidelines to Specialized Supported Housing

• Continued Specialized Supported Housing is generally needed until 1 or more of the following:
  • Specialized Supported Housing is no longer necessary due to adequate patient stabilization or improvement, as indicated by ALL of the following:
    • Patient and supports understand follow-up treatment and crisis plan.
    • Provider and supports are sufficiently available in outpatient setting.
    • Patient or caregiver can safely manage care in outpatient setting .
    • Risk status acceptable, as indicated by ALL of the following:
      • Danger to self or others manageable/treatable, as indicated by 1 or more of the following:
        • Absence of thoughts of suicide, homicide, or serious harm to self or to another
        • Thoughts of suicide, homicide, or serious harm to self or to another present but manageable/treatable at available lower level of care
  • Lack of decompensation due to mental health conditions warranting close staff supervision
  • Lack of crisis services or emergency response intervention in the past 3 months
  • Lack of psychiatric or residential hospitalization in the past 3 months
  • Lack of elopement or wandering behaviors
  • Medication adherence
  • Specialized Supported Housing is no longer indicated due to 1 or more of the following:
    • Higher level of care is indicated (eg, patient condition has deteriorated, a greater service intensity is necessary to support engagement in care or reinforce skills, or more intensive supervision is necessary to address clinical needs).
    • Patient or guardian refuses treatment
    • Level of supervision needs can be met in a lower level of care

References

Borderline Intellectual Functioning and Lifetime Duration of Homelessness among Homeless Adults with Mental Illness. Durbin A, Lunsky Y, Wang R, Nisenbaum R, Hwang SW, O'Campo P, Stergiopoulos V. Durbin A, et al. Healthc Policy. 2018 Nov;14(2):40-46. doi: 10.12927/hcpol.2018.25687. Healthc Policy. 2018. PMID: 30710440 Free PMC article.

Causes of homelessness prevalence: Relationship between homelessness and disability. Nishio A, Horita R, Sado T, Mizutani S, Watanabe T, Uehara R, Yamamoto M. Nishio A, et al. Psychiatry Clin Neurosci. 2017 Mar;71(3):180-188. doi: 10.1111/pcn.12469. Epub 2016 Dec 18. Psychiatry Clin Neurosci. 2017. PMID: 27778418

Cognitive impairment and homelessness: A scoping review. Stone B, Dowling S, Cameron A. Stone B, et al. Health Soc Care Community. 2019 Jul;27(4):e125-e142. doi: 10.1111/hsc.12682. Epub 2018 Nov 13. Health Soc Care Community. 2019. PMID: 30421478 Free PMC article.

Durbin, Anna & Isaacs, Barry & Mauer-Vakil, Dane & Connelly, Jo & Steer, Lorie & Roy, Sylvain & Stergiopoulos, Vicky. (2018). Intellectual Disability and Homelessness: a Synthesis of the Literature and Discussion of How Supportive Housing Can Support Wellness for People with Intellectual Disability. Current Developmental Disorders Reports. 5. 1-7. 10.1007/s40474-018-0141-6.

Homelessness and people with intellectual disabilities: A systematic review of the international research evidence. Brown M, McCann E. Brown M, et al. J Appl Res Intellect Disabil. 2021 Mar;34(2):390-401. doi: 10.1111/jar.12815. Epub 2020 Sep 22. J Appl Res Intellect Disabil. 2021. PMID: 32959955 Review.

Homelessness-'It will crumble men': The views of staff and service users about facilitating the identification and support of people with an intellectual disability in homeless services. McKenzie K, Murray G, Wilson H, Delahunty L. McKenzie K, et al. Health Soc Care Community. 2019 Jul;27(4):e514-e521. doi: 10.1111/hsc.12750. Epub 2019 Apr 14. Health Soc Care Community. 2019. PMID: 30983058

Intellectual disability among Dutch homeless people: prevalence and related psychosocial problems. Van Straaten B, Schrijvers CT, Van der Laan J, Boersma SN, Rodenburg G, Wolf JR, Van de Mheen D. Van Straaten B, et al. PLoS One. 2014 Jan 21;9(1):e86112. doi: 10.1371/journal.pone.0086112. eCollection 2014. PLoS One. 2014. PMID: 24465905 Free PMC article.

Padgett, D., Henwood, B. F., & Tsemberis, S. J. (2016). Housing First: Ending homelessness, transforming systems, and changing lives. New York, NY: Oxford University Press.

Prevalence of mental illness, intellectual disability, and developmental disability among homeless people in Nagoya, Japan: A case series study. Nishio A, Yamamoto M, Ueki H, Watanabe T, Matsuura K, Tamura O, Uehara R, Shioiri T. Nishio A, et al. Psychiatry Clin Neurosci. 2015 Sep;69(9):534-42. doi: 10.1111/pcn.12265. Epub 2015 Feb 9. Psychiatry Clin Neurosci. 2015. PMID: 25523066