UM Guidelines

Applies to BlueCare Only.

Clinical Indications for Admission to Intensive Outpatient Program

• Admission to Specialized Comprehensive Treatment Team (SCTT) is judged appropriate as indicated by ALL of the following:
  • Member must be twelve years of age or older
  • Member’s diagnoses include severe psychiatric, behavioral, or other comorbid conditions
  • Severe dysfunction in daily living for adult or adolescent (e.g., severe regression with inability to provide for self, threatening behaviors, complete withdrawal from all social interactions, neglect of self-care, inability to maintain any appropriate school behavior or academic achievement, severely diminished ability to assess consequences of own actions, acts of severe property damage, etc.)
  • The member’s behaviors have measurably escalated within the past 30 days, showing significant change in school, home, or community functioning
  • Symptoms require multi-level intervention, and the family/caregiver (if applicable) agrees to actively participate in SCTT
  • The member's current condition cannot safely, efficiently, and effectively be assessed and/or treated in a less intensive level of care due to acute changes in the member's symptomology and/or psychosocial and environmental factors (i.e., the factors leading to admission)
  • Patient has history of outpatient services and is at risk of recurrent psychiatric hospitalization or institutionalization, as indicated by 1 or more of the following:
    • 2 or more inpatient hospitalizations within the past 12 months
    • Inpatient length of stay greater than 30 (consecutive) days in the past 12 months
    • Excessive use (e.g., 2 or more visits in 90-day period) of crisis or emergency services
    • Recent discharge from a higher level of care, such as inpatient/subacute care
    • High risk or recent history of criminal justice involvement (e.g., arrest, incarceration, parole, or probation)
  • The member's current condition can be safely, efficiently, and effectively assessed and/or treated in the proposed level of care. Assessment and/or treatment of acute changes in the member's signs and symptoms and/or psychosocial and environmental factors (i.e., the factors leading to admission) require the intensity of services provided in the proposed level of care.
  • Targeted symptoms, behaviors, and functional impairments related to underlying behavioral health disorder have been identified and are appropriate for SCTT program.
  • There is a reasonable expectation that services will improve the member's presenting problems within a reasonable period of time or admission diagnosis present is judged likely to deteriorate in absence of treatment at proposed level of care.
  • Individual is expected to be able to adequately participate in and respond as planned to proposed treatment.
  • Treatment is not primarily for the purpose of providing social, custodial, recreational, or respite care.
  • Intensive, time-limited support services are likely to avert an inpatient admission or long term out of home placement. Services are expected to return the adolescent/family or adult/caregiver to a level of functioning where handoff to natural supports and the decrease of the intervention of formal systems can safely occur.

Continued Review Criteria

• Member continues to meet the following criteria for Specialized Comprehensive Treatment Team (SCTT) as indicated by ALL of the following:
  • Member is twelve years of age or older
  • Member’s diagnoses include severe psychiatric, behavioral, or other comorbid conditions
  • Severe dysfunction in daily living for adult or adolescent (e.g., severe regression with inability to provide for self, threatening behaviors, complete withdrawal from all social interactions, neglect of self-care, inability to maintain any appropriate school behavior or academic achievement, severely diminished ability to assess consequences of own actions, acts of severe property damage, etc.)
  • Symptoms require multi-level intervention, and the family/caregiver (if applicable) agrees to actively participate in SCTT
  • The member’s current condition cannot safely, efficiently, and effectively be assessed and/or treated in a less intensive level of care due to acute changes in the member’s symptomology and/or psychosocial and environmental factors (i.e., the factors leading to admission)
  • The member’s current condition can be safely, efficiently, and effectively assessed and/or treated in the proposed level of care. Assessment and/or treatment of acute changes in the member’s signs and symptoms and/or psychosocial and environmental factors (i.e., the factors leading to admission) require the intensity of services provided in the proposed level of care.
  • Targeted symptoms, behaviors, and functional impairments related to underlying behavioral health disorder have been identified and are appropriate for SCTT program.
  • There is a reasonable expectation that services will improve the member’s presenting problems within a reasonable period of time or admission diagnosis present is judged likely to deteriorate in absence of treatment at proposed level of care.
  • Individual is expected to be able to adequately participate in and respond as planned to proposed treatment.
  • Treatment is not primarily for the purpose of providing social, custodial, recreational, or respite care.
  • Intensive, time-limited support services are likely to avert an inpatient admission or long term out of home placement. Services are expected to return the adolescent/family or adult/ caregiver to a level of functioning where handoff to natural supports and the decrease of the intervention of formal systems can safely occur.
• Treatment is being provided and considered “active” as indicated by ALL of the following:
• Member continues forward progress from presenting admission needs
• Reasonably expected to improve and is demonstrating progress on measurable goals and objectives
• Member and/or caregiver actively participating

Discharge Criteria

• The member is appropriate for discharge when 1 or more of the following conditions have been met:
  • The symptoms and behaviors identified as meeting authorization requirements (i.e., admission criteria) have measurably decreased and functioning has improved to a point that care can be transitioned to viable plan at a less intensive level of care (e.g. standard CM, outpatient treatment, etc.) as indicated by ALL of the following:
    • Person has successfully reached individually established goals for discharge AND person has successfully demonstrated an ability to function in major role areas (i.e., work, social, self-care) without ongoing assistance from the SCTT program
    • Risk status minimized as indicated by ALL of the following:
      • No recent Thoughts of suicide or serious Harm to self
      • No recent thoughts of homicide or serious Harm to another
      • Patient and supports understand follow-up treatment and crisis plan.
    • Functional improvement sufficient as indicated by 1 or more of the following:
      • Minimal or no current impairment in self-care or role functioning attributable to psychiatric disorder
      • Functioning optimized as indicated by ALL of the following:
        • Functioning stable with current treatment and support
        • No current plan for significant change in treatment (eg, no evidence base to indicate another acute treatment will yield an improved outcome) or re-evaluation (e.g., second opinion)
    • Medical needs limited as indicated by 1 or more of the following:
  • Absence of any current medical comorbidity, substance use problem, and adverse medication effect
  • Any current medical comorbidity, substance use problem, and adverse medication effect is manageable in maintenance outpatient care.
    
  • There is lack of measurable progress by the member/family/caregiver and/or there is no clinical intervention that will likely change the lack of participation.
  • The member/family/caregiver is unwilling or unable to participate in treatment

References

Chappell, E. Case Management:  Tennessee Department of Mental Health in collaboration with the Bureau of Tenncare March 27, 2012.  Retrieved from http://www.tn.gov/mental/omd/omd_docs/FINALAdult_MHCM.pdf.

Clark, C., Rich, A.R. Outcomes of homeless adults with mental illness in a housing program and in case management only. Psychiatric Services 2003; 54(1), 78-83.

Congressional Research Service (CRS). CRS report for congress: Medicaid targeted case management (TCM) benefits. March 27, 2008. Retrieved from http://www.tn.gov/mental/omd/omd_docs/FINALAdult_MHCM.pdf.

Kolbasovsky, A., Reich, L., Meyerkopf, N. Reducing six‐month inpatient psychiatric recidivism and costs through case management. Case Management Journals 2010; 11(1), 2-10.

Mueser, K.T., Bond,G.R., Drake,R.E., Resnick,S.G. Models of community care for severe mental illness: A review of research on case management. Schizophrenia Bulletin 1998; 24(1), 37-74.

Sherman, P.S., Ryan, C.S. Intensity and duration of intensive case management services. Psychiatric Services 1998; 49(12), 1585-1590.

Ziguras, S.J., Stuart, G.W. A meta-analysis of the effectiveness of mental health case management over 20 years. Psychiatric Services 2000; 51(11), 1410-1421.