UM Guidelines

Applies to BlueCare Only.

Clinical Indications for Admission to Intensive Outpatient Program

• Admission to SCCFT[A] is judged appropriate as indicated by the presence of ALL of the following (1)(2)(3):
  • Member demonstrates symptoms consistent with a covered DSM-IV or DSM-5 diagnosis and an intellectual and/or developmental disorder
  • Member’s symptoms are serious enough to jeopardize the community placement but not severe enough to require a more intensive level of care (4)
  • The member and family voluntarily consent to treatment with these services
  • Traditional outpatient services do not sufficiently meet the member’s and family’s needs Member’s support system is temporarily too unstable or weak to manage member’s behaviors without extra supports

Discharge Criteria

• Continued SCCFT is generally needed until 1 or more of the following is met:
  • SCCFT care is no longer necessary due to adequate patient stabilization or improvement as indicated by ALL of the following:
    • Weight recovery sufficient as indicated by 1 or more of the following:
      • Healthy weight goal achieved and stable
      • Weight recovery optimized as indicated by ALL of the following:
        • Weight is less than goal but stable with current treatment.
        • No current plan for significant change in treatment or re-evaluation (eg, second opinion)
    • The member has not been hospitalized in an acute psychiatric setting or restrictive setting in the last three months
    • The member’s level of functioning is adequate to ensure safety and stability within the community
    • The member’s support system has been substantially strengthened as identified in the attainment of goals identified on the individualized service plan
    • The majority of goals in the child’s/youth’s  individualized service plan have been met and a discharge plan with follow-up appointments is in place
  • SCCFT is judged no longer appropriate due to inadequate response or consent as indicated by 1 or more of the following:
    • Member deterioration (physical or psychiatric) requires higher level of care
    • Member/guardian no longer consents to treatment and there is no court order for treatment
    • Member has not made progress despite participation and is judged not likely to improve at this level of care.
    • Inadequate participation in treatment by member and/or supports
      

References

1. Sebelius, K, Hyde, PS, Vecchio, P, Randolph, F, Blau, G.  The comprehensive community mental health services for children and their families program: Evaluation findings –annual report to congress. Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services 2010:1-35.  retrieved from  http://store.samhsa.gov/product/Comprehensive-Community-Mental-Health-Services-for-Children-and-Their-Families-Program-Evaluation-Findings/All-New-Products/PEP12-CMHI2010.
2. Mann,C, Hyde, PS. Joint CMCS and SASMHSA Informational bulletin regarding coverage of behavioral health services for children, youth, and young adults with significant mental health conditions May, 2013: 1-11. Substance Abuse and Mental Health Services Administration and Centers for Medicare and Medicaid Services.
3. Medicaid reimbursement for wraparound care coordination for children and youth with complex behavioral health needs: Policy statement and recommendations to the centers for Medicare and Medicaid services (CMS) from the national wraparound initiative September, 2011:1-4. National Wraparound Initiative, retrieved from www.nwi.pdx.edu.
4. Lamb, CE. Alternatives to admission for children and adolescents: providing intensive mental healthcare services at home and in communities: what works? Current Opinion in Psychiatry 2009;22(4):345-50.
5. Walker, JS, Bruns, EJ. Building on practice-based evidence: Using expert perspectives to define the wraparound process.  Psychiatric Services, 57:1579-1585.

Footnotes

[A] Specialized Comprehensive Child and Family Treatment (SCCFT) services are high-intensity, goal-specific services designed to provide stabilization and deter the imminent risk of out of home placement, including state custody or higher levels of care. SCCFT services concentrate on child/family/guardian behaviors and interactions with the goal of reaching an appropriate point of stabilization so the individual can be transitioned to a less intensive outpatient service.  SCCFT services can be provided in home, community, or office-based settings using a frequency appropriate for the intensity and imminent risk presented by the clinical situation, but typically at least 3-5 sessions a week.  SCCFT services are available 24 hours a day, 7 days a week. SCCFT services can include therapeutic and/or skills training interventions that support improved functioning of the child/youth and the family unit so the imminent crises are averted. Services are designed to utilize and foster individual and family strengths and utilization of community supports, both formal and informal. This intensive care coordination component of SCCFT is designed to initially “wrap” families with supports but ultimately to help families independently navigate systems to meet their formal and informal needs. SCCFT services are delivered through a team approach to children with high risk behaviors and family instability. Session frequency will titrate over time as youth and family stabilize.