standards & guidelines for partial hospitalization

Standards and Guidelines for Partial Hospitalization Programs &

Intensive Outpatient Programs

Editors: James Rosser, LCSW, CMT-P & Stephen Michael, DrPH

2021

Contributors: Catherine Eckl, LCSW Lawrence Haber, PhD Gretchen Johnson, DNP, MSN, RN-BC Jessica Lavender, LPC-MHSP Stephen Michael, DrPH James Rosser, LCSW, CMT-P Luana Shiba-Harris, MPA/HAS, OTR Sara Tucker, MA LLP

Association for Ambulatory Behavioral Healthcare

Standards and Guidelines for PHP & IOP Page | 1

Table of Contents INTRODUCTION ............................................................................................................................................................ 2

DEFINITIONS ................................................................................................................................................................ 4

CONTINUUM OF CARE ................................................................................................................................................ 6

ROLE OF REGULATORY BODIES ............................................................................................................................. 10

ADMISSION PROFILES .............................................................................................................................................. 13

SPECIFIC ADMISSION CRITERIA ......................................................................................................................... 15

EXCLUSION CRITERIA .......................................................................................................................................... 17

CONTINUED STAY CRITERIA ............................................................................................................................... 18

PROGRAMMING ......................................................................................................................................................... 20

THERAPEUTIC MILIEU .......................................................................................................................................... 22 PROGRAM STAFF .................................................................................................................................................. 24

COORDINATION OF SERVICES: ........................................................................................................................... 26

LENGTH OF STAY: ................................................................................................................................................. 26

DOCUMENTATION ..................................................................................................................................................... 28

ASSESSMENT ........................................................................................................................................................ 28

PHYSICIAN ORDERS/SUPERVISION/CERTIFICATE OF NEED .......................................................................... 29

PSYCHIATRIC ASSESSMENT ............................................................................................................................... 29

TREATMENT PLAN ................................................................................................................................................ 30

TREATMENT REVIEWS ......................................................................................................................................... 30

MEDICATION MANAGEMENT ................................................................................................................................ 30

PROGRESS NOTES ............................................................................................................................................... 31 DISCHARGE SUMMARY ........................................................................................................................................ 31

ELECTRONIC MEDICAL RECORDS ...................................................................................................................... 32

LINKAGES ................................................................................................................................................................... 35

PERFORMANCE IMPROVEMENT/OUTCOME MEASUREMENT .............................................................................. 37

PERFORMANCE OUTCOMES ............................................................................................................................... 37

CLINICAL OUTCOMES ........................................................................................................................................... 40

BENCHMARKING METRICS .................................................................................................................................. 41 PROGRAM IMPROVEMENT................................................................................................................................... 41

TELEHEALTH .............................................................................................................................................................. 43

SUMMARY ................................................................................................................................................................... 47

APPENDIX A – EVOLUTION OF AABH STANDARDS AND GUIDELINES ................................................................ 48 REFERENCED DOCUMENTS .................................................................................................................................... 50

SPECIALTY POPULATION – CHILD & ADOLESCENT .............................................................................................. 53

SPECIALTY POPULATION – OLDER ADULTS .......................................................................................................... 55

SPECIALTY POPULATION – PERINATAL WOMEN .................................................................................................. 57

SPECIALTY POPULATION – EATING DISORDERS .................................................................................................. 59

SPECIALTY POPULATION – CHEMICAL DEPENDENCY ......................................................................................... 61

SPECIALTY POPULATION – CO-OCCURRING DISORDERS................................................................................... 63

FINAL COMMENTS ..................................................................................................................................................... 65



INTRODUCTION These Standards and Guidelines are presented from the perspective of the AABH national provider network. Key definitions related to partial hospitalization and intensive outpatient programming will be presented. Important information about regulatory coordination and program structure will also be provided. This document has been designed to enable programs to:

• achieve effectiveness and best practices in service delivery, • maintain regulatory compliance, and • provide safety through clinical guidelines, standards, and best practices.

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. These standards and guidelines focus on best practice for care in PHP and IOP settings; however, AABH acknowledges that some contracts with payers may override the standards in this document. It is therefore necessary for providers of PHP and IOP services to familiarize themselves with all current applicable requirements and interpretations for their local environment. PHPs and IOPs are designed to help individuals understand their illness, reduce the impact of functionally debilitating symptoms, and cope with challenging situational crises. People need to feel hope, find purpose, and care for others. Whenever possible, they want to keep their job and maintain their homes. The treatment mission of PHP and IOP services is to develop a setting that provides the tools for recovery. The latest medication advances, therapeutic techniques, and peer connections meet individuals "where they are" in a positive milieu that fosters support and change. PHPs and IOPs should represent the core of psychosocial treatments. The final rules pertaining to the implementation of the parity legislation were presented in November of 2013. 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. The identification of target populations with criteria for admission to, continuation of, and exclusion from each level of care will be delineated. Specific aspects of program design will be discussed as they apply to specialized practice settings. A description of the essential treatment services such as group, occupational, and psycho-educational therapies will be provided. As providers have found it helpful to provide specialized programming for sub-populations dealing with similar behavioral health challenges, these guidelines outline unique factors related to some of those specialty populations, including:



• Child & Adolescents • Older Adults • Perinatal Women • Eating Disorders • Chemical Dependency • Co-occurring Disorders

Necessary elements for documenting services provided include a discussion about electronic medical records. Linkages related to successful treatment will be considered. With recent changes to regulatory requirements in onsite visits, this document provides guidance in preparation for regulatory reviews. Outcomes have become increasingly more important not only internally, but to external agencies, including regulatory agencies, insurance providers and consumers. Both performance and clinical measurement will be addressed in this document.



DEFINITIONS Behavioral Health refers to the healthcare field concerned with mental health and substance use disorders and treatment. Intermediate Behavioral Health is the term used to identify partial hospitalization and intensive outpatient programs which distinguishes them from inpatient and outpatient services as part of the behavioral health continuum required for the implementation of parity legislation. These services are included as mandated essential behavioral healthcare benefits in insurance policies from 2014 onward. Programs are active, time-limited, ambulatory behavioral health day or evening treatment programs that offer therapeutically intensive, structured, and coordinated clinical services within a stable therapeutic milieu. All programs pursue the goals of stabilizing clinical conditions, reducing symptoms and impairments, averting or reducing inpatient hospitalization stays, and providing medically necessary treatment for individuals who cannot be effectively treated in a less intensive level of care.

Partial Hospitalization Programs (PHP) - Partial hospital implies a daily psychosocial milieu treatment of generally four or more hours duration a day with group therapy, psycho-educational training, and other types of appropriate therapy as the primary treatment modalities.

Intensive Outpatient Programs (IOP) – Intensive Outpatient implies more than traditional single service outpatient service, yet not significant enough to meet the requirements of a partial hospitalization program. This type of program usually provides daily service that people will access at least one day a week and up to 11 or less services in any one week.

Program Context recognizes that specific programs may vary with respect to the seven key items as identified by Edmund Neuhaus, Ph.D. in his article on flexible models of partial hospitalization2:

1. Types of diagnoses (e.g., psychotic, mood and anxiety disorders, personality disorders)

2. Theoretical orientation (e.g., cognitive behavioral) 3. Treatment objectives (e.g., stabilization, functional improvement, personality

change) 4. Treatment duration (i.e., length of stay) 5. Treatment intensity (i.e., hours and days per week) 6. Setting (e.g., private or public sector) 7. Payer of services (e.g., managed care, government-supported national health

care, such as national health insurance systems in Canada and Europe, and Medicare in the United States).

When PHPs or IOPs are described, it is useful to include all these elements. For example, one may reference a “PHP treating persons with mood disorder through a short-term, low-intensity, cognitive behavioral approach designed to improve functioning



and mood, funded by private and public insurance, operating out of a not-for-profit general hospital setting.”2 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. This function is utilized clinically to prevent self-harm, reduce acute symptomatic exacerbation, restore baseline functioning, and increase recovery skills. The defining characteristic of this function is the fact that PHP services are provided “in lieu of inpatient hospitalization.” Acute Symptom Reduction - This intensive PHP function focuses on the provision of sustained, goal-directed, clinical services to reduce the person’s acute symptoms and severe functional impairments as an exacerbation of a more chronic condition. 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. These severe impairments tend to include several acute symptoms that result in a breakdown in role function that may include an inability to follow through on essential tasks and responsibilities, social isolation, interpersonal difficulties, and a passive or impulsive loss of focus and initiative. Moderate or Specialized Symptom Reduction - This primary program function is the reduction of moderate symptoms and stabilization of function achieved through extended group therapeutic services generally provided in IOPs. Admission to these programs may be determined by functional level, specificity of the population (such as OCD), or treatment specialty such as DBT or CBT. Discharge from IOP programs is made to individual outpatient behavioral health specialists, integrated physical/behavioral settings, or primary care. Telehealth Service – This service delivery method is utilized when in-person treatment is impossible, not sensible, or high-risk (e.g., a medical pandemic). Provision of this method of service is appropriate when the persons served may be exposed to severe illness or attending in-person treatment may be impractical (e.g., transportation, distance, commute time, or no local expertise available to treat the impairment). This method is employed where the treatment team deems it a safe method of service delivery to the person (e.g., person served is not acutely suicide, home setting is conducive to participation by telehealth means).



CONTINUUM OF CARE Within a continuum of behavioral health care, PHPs and IOPs function as vital components. They provide therapy and education in an intensive group environment that cannot be provided through either an outpatient individual therapy model or a crisis-oriented inpatient unit. Traditional outpatient treatment lacks the needed intensity and range of interventions, while clients on inpatient units tend to lack the stability and focus to participate actively in a group educational setting. PHP and IOP treatment allow persons served to stabilization more successfully while in their own community environment. The intent of this summary is to place PHPs and IOPs in the full context of available treatment services, arranged by relative level of intensity from traditional outpatient care to 24-hour inpatient treatment. 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. More often the full array of services (when available) is delivered by a variety of organizations and individual providers within a given community. In 1999, AABH revised its continuum of care model to include 6 levels of ambulatory behavioral health services.3 The continuum model was designed to assist in the process of determining the appropriate level of care given the needs of the individual, and to advocate that this placement decision take precedence over cost or other non-clinical considerations. Several factors have emerged since the 1999 Continuum of Behavioral Health Services paper was last revised. The advent of the recovery model has influenced the treatment continuum, expanding the role of the consumer in determining services availability and design. 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. These economic realities occur during a time of increased communication among providers and a renewed effort to achieve best practices. 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. The Continuum of Behavioral Health Services Described: Table 1 provides a graphic representation of the Continuum of Behavioral Health Services, highlighting the six levels of care along the continuum. Organized as a continuum, this system of care enables the movement of individuals to the most clinically appropriate and cost-effective level of care.



Table 1 – Levels of Care (Behavioral Health)

Level of Care 1

Level of Care 2

Level of Care 3

Level of Care 4

Level of Care 5

Level of Care 6

Primary Care

Outpatient (Traditional)

Multi-modal Community-

based treatment

Intermediate Outpatient Residential/ Inpatient Recurring

Ambulatory Acute

Ambulatory

Coordinated (Integrated) Care Solo

practices, Medical clinics,

Medical care home

Private practices,

community agencies

(combined Level 1&2 Services)

IOP, Psych rehab, Club

House, Assertive

Community Treatment

PHP

A brief description and examples of each level of care follows:

Primary Care is “first line” health care providing screening, early identification, education, and often pharmacotherapy. These services are provided primarily by medical practitioners within the context of treatment of general medical conditions. Primary care services are generally delivered during a regular office visit. 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. Individuals receiving care from primary care providers often suffer from sub-clinical or relatively mild behavioral health conditions and are at-risk for developing severe behavioral health disorders. 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. The medical care home model, with its focus on integrating medical and behavioral health treatment, provides hope and promise of greater early identification, primary prevention, improved treatment outcomes, and decreased healthcare costs. The (Traditional) Outpatient level of care provides for treatment of conditions related to mild to moderate impairment. Individuals appropriate for care at this level are generally able to sustain themselves between relatively infrequent behavioral health appointments and to adhere to treatment recommendations with minimal intervention. Treatment at this level of care is usually limited to 1-4 sessions per month but may be provided less frequently in accordance with the individual’s needs. (Traditional) Outpatient care is typically site-based. Providers utilize a wide variety of therapeutic techniques such as different forms of individual, family, or group therapies, and/or medication management. Outpatient care may be short or long-term depending on the needs of the person. Limited case management and



group therapy or psycho-educational services may be included in this setting along with individual therapy and medication management. 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. For example, this level of care may include traditional outpatient counseling by one provider, medication management by another provider, and crisis and support services by a community agency (all three provider entities in separate settings serving as distinct “stand-alone” providers). Services at this level are offered with some degree of coordination, but do not include cohesive community or structured programmatic activities. They may also include wrap-around, case management, groups, peer supports, and related interventions. People treated at this level of care are able to maintain their role functioning in the community and generally have adequate family/community support. In the current healthcare environment, this level is also referred to as Primary Integrated Care and supported by the Center for Medicare and Medicaid Services (CMS) Integrated Health Model. Intermediate Ambulatory services consists of two levels of care depending on the intensity of services needed and the acuity to those being served:

a) Recurring Outpatient services provide treatment to individuals with moderate-to-severe disorders and related impairments who require interventions targeted at recovery through improved level of functioning, skill building, and disease management. Intensive Outpatient Programs are the most common form of Level 4 treatment. Program attendance is more flexible as individuals may function adequately in other structured settings, such as school or work. Level four is often characterized by consumer-driven treatment, which incorporates the benefits of a therapeutic milieu that extends beyond the treatment setting into the significant parts of the individual’s community network. An array of coordinated services, offered in one primary location with structured programmatic activities, is a hallmark of Intermediate Ambulatory care. These programs also include club house, assertive community treatment, psychiatric rehabilitation programs, and longer-term day treatment facilities.

b) The prototype for Acute Ambulatory services is PHP. This level includes intensive, hospital diversion services providing acute symptom reduction and crisis stabilization. Level 5 services provide rapid access (typically within 24 hours), incorporate a high degree of medical supervision, and an organized system of crisis coverage for individuals who require the intensity and restrictiveness of care offered at this level. Individuals appropriate for this level of care demonstrate disabling and severe symptoms resulting from either an acute illness or exacerbation of a chronic illness. Their condition is considered unstable with high risk of further escalation/de-compensation and they frequently present with a moderate-to-high risk of harm to self and/or others.



Residential/Inpatient services include two principal types of non-ambulatory, 24-hour supervised settings. Residential services are provided to individuals who require greater support, monitoring, and intensity of services than can be offered in acute ambulatory settings. Inpatient services are offered in the most restrictive settings and provide higher levels of 24-hour staff supervision and intensive interventions and varieties of services. Staff members assume responsibility for and control of the individual’s safety due to the individual’s severe, disabling symptoms. 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. Individuals requiring care at this level may have insufficient resources or access to critical supports systems including family and community.

Coordinated (Integrated Care) services are provided to people who have complicated medical and/or behavioral health issues. 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. Coordinated care services usually include a centralized global plan of treatment with assignment of providers for each issue needing to be addressed, including any social determinants of health identified as contributing to the medical/behavioral health issues. As a person moves through the continuum of care, the coordinated care services usually increase or decrease as reflected in the level of care that person is receiving. Ideally coordination services are managed by the same person/entity regardless of treatment level or location for that person. Coordinated care services aims to keep a key person/entity involved in the entire treatment process as a proxy for a person who may struggle with the complexities of the health system.



ROLE OF REGULATORY BODIES AABH provides these standards and guidelines as a broad representation of best practices in providing PHP and IOP without regard for local areas. The organization recognizes that many local factors can contribute to the detailed implementation of these standards and guidelines. While these guidelines may not be specific enough for any particular program, they provide an overview of the core areas that need to be addressed in PHP and IOP. There are three primary regulatory bodies that write regulation or guidance in detail for providers in the local area:

1. State licensing agencies Many of the States have a department that is responsible for the licensing of behavioral health facilities. These departments are usually found somewhere within the State's health department and can often be found by searching for licensing. 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. Your compliance officer is usually the best person to advise on any licensing requirements at the State level.

In addition to licensing requirements for your facility, your program staff may have requirements related to the Scope of Work for their license. Each State has licensing agencies that regulate the licensing of professional staff. Within each discipline a licensed professional will have outlined what services they can provide. Many of these scopes will include the specifics of topic areas that a discipline may be limited to in provision of services to a group or individual. Importantly, States vary in the scopes of work for many disciplines. For example, some States allow a psychiatric nurse to provide psychotherapy groups while others do not allow this. Be diligent in having copies of the scopes of work for each or the disciplines a program is using to staff the program. When ambiguity or conflict between scope of work and facility licensing exists, the facility licensing usually takes precedence. However, any licensing conflicts and decision related to resolving the conflict should be reviewed by the compliance and legal departments or an organization.

2. Accreditation organizations

Accreditation organizations are responsible for providing guidance to programs primarily on health and safety protocols for facilities. Recently, accreditation organizations have also begun to look closely at clinical indicators of quality in addition to health and safety. Accreditation of a program provides the community with increased confidence that a program meets minimum standards for safety and quality for the people the program serves. Each accreditation organization will have protocol manuals that detail what they expect to see when they conduct onsite reviews. These organizations usually conduct surveys of facilities on a regular basis and provide detailed reports on the areas where programs excel and where programs need improvement. Programs can usually expect to conduct program improvement planning following a review to address the issues



discovered and highlighted as needing improvement. There are three accreditation organizations used by behavioral health facilities:

a. The Joint Commission (TJC) (https://www.jointcommission.org/accreditation/behavioral_health_care.aspx)

b. Commission on Accreditation of Rehabilitation Facilities (CARF) (http://www.carf.org/home/)

c. Council on Accreditation (COA) (https://coanet.org/home/)

3. Payers of Services

A key player in detailing programming and documentation will be the organizations that pay for services. If a program accepts payments from multiple organizations, keeping the different requirements for each payer up to date can be a challenging task. In general, the Centers for Medicare and Medicaid Services (CMS) sets the standard for payer requirements, and most payers start with the Medicare guidelines when developing their own requirements. 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.

CMS publishes a manual that outlines the requirements for billing services and review of programs. CMS contracts with intermediaries to manage the requirements for PHP and IOP services. These intermediaries are referred to as MAC’s (Medicare Administrative Contractor) and each can develop their own interpretation of the CMS guidelines in determining appropriateness for services, documentation requirements and billing requirements. Programs that are planning to bill Medicare for services must establish a relationship with their MAC by notifying them of their intentions to bill for PHP/IOP services if they already have a Medicare Part A Billing Number, or they must apply for a Medicare Part A Billing Number by submitting an 855A application to their MAC for their region and locate the MAC’s LCD (Local Coverage Determination) for PHP and IOP.

Medicare Regulations: https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html?redirect=/home/regsguidance.asp List of MAC’s: https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs.html

CMS reviews claims and provides an opportunity to recommend changes to the PHP and IOP guidelines annually. Any changes are reported in the Federal Register. Final determination of changes is usually published in November of each year. Private Insurance and Medicare Advantage Plans each create their own protocols for PHP and IOP. Any time a program negotiates a contract with a private payer, including Medicare Advantage plans, the program should request the guidelines for PHP and

https://www.jointcommission.org/accreditation/behavioral_health_care.aspx

https://www.jointcommission.org/accreditation/behavioral_health_care.aspx

http://www.carf.org/home

https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html?redirect=/home/regsguidance.asp

https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html?redirect=/home/regsguidance.asp

https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs.html

https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs.html



IOP. The program must then review the guidelines and determine how to proceed with programming and documentation. Medicare Advantage Plans are obligated to follow the Medicare protocols for all Medicare covered people in PHP and IOP, including reimbursement rates. However, these plans can require pre-authorizations for both PHP and IOP services, and re-authorizations to continue services beyond the initial authorizations. Medicare Advantage Plans are not obligated to cover these levels of care. Medicaid is a federal health insurance benefit that is managed at the State level. This means the guidelines for PHP and IOP will vary from State to State. Each State should have an office that manages Medicaid. If the State is not using a managed Medicaid system, the guidelines should be requested from the State office that manages Medicaid. In States where Medicaid is contracted out to other insurance providers, a program may find that guidelines are managed by the State and apply to all insurance companies contracted or the contracts may give the individual insurance providers the freedom to create their own guidelines. The best way to find out about Medicaid guidelines is the first contact the State office responsible for guidelines and ask for guidance. While all three of these bodies can impact how a program provides services and determines appropriateness for care, state licensing agencies will have the regulations attached to laws in a State that must be followed. These regulations should be the primary guiding protocols followed for any program. In the absence of detailed state licensing regulation, a program must pay attention to requirements for Payers and accrediting bodies. Many payers will have a requirement that a program meet the requirements of an accrediting body as a rule for program approval and reimbursement for services. A program will sometimes find that it needs to create a program that meets the needs of the most restrictive protocols and design programming and billing to meet those criteria. In these cases, a program might find that different guidelines are in conflict. This will require a program to review the criteria and make a decision that is in the best interest of the program and the individuals being served. These types of conflicts often require multiple discussions with payers and accreditation organizations and may result in the program severing relations with one or more of the organizations.



ADMISSION PROFILES These four clinical profiles reflect individual scenarios that are appropriate for acute partial hospitalization program services.

1. Some individuals are at risk for inpatient hospitalization and require the intensive services of partial hospitalization treatment due to acute debilitating symptoms and/or some risk of harm to self or others. They tend to have limited insight into their illness accompanied by somewhat dysfunctional lifestyles and serious symptoms that have impacted their lives negatively in multiple ways. These persons may have been screened by primary care physicians, individual therapists, or other healthcare professionals and require the coordinated treatment interventions available in a PHP in order to facilitate engagement and acceptance of the impact the illness has had on their day-to-day functioning. The need for 24-hour containment has been determined to be unnecessary. The individual may require significant skills to make changes which prevent further deterioration between sessions. Daily monitoring of medications, safety, symptoms, and functional level is deemed medically necessary. A treatment plan is designed to provide insight, skills, support, and problem resolution to avert further symptom reduction or chaos. Follow-up may be provided by outpatient psychiatrists or the individual may be referred back to primary or physical/behavioral integrated outpatient care. In some cases, a specialized IOP may be recommended as follow-up for specific conditions.

OR 2. Some individuals display increased symptoms of a previously diagnosed

behavioral disorder and exhibit a progressive or sudden decline in functioning compared to baseline. The change in symptoms requires the intensity and structure of PHP to avert further deterioration. Such conditions frequently follow serious crises, stressors, or newly diagnosed acute physical problems. A less intensive level of care may have been insufficient to provide the treatment the individual requires to stabilize this decline. Debilitating symptoms may also accompany a life change, significant loss, or even the current ineffectiveness of previous coping skills. There is a medically determined reasonable expectation that the individual may improve or achieve stability through active treatment. An integrated care team, psychiatrist, or primary care practitioner may then provide follow-up care. This provider is often determined by the complexity of the illness, medications, and overall medical or case management needs.

OR 3. 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. 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. These individuals are typically found among those admitted for a “first episode of care” often referred from primary care or emergency departments. 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.

OR 4. 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. This condition may be exacerbated by age or secondary physical conditions. The intensity of the partial hospitalization level of care is medically necessary and the individual is judged to have the capacity to make timely and practical improvement. 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.

If an individual does not meet any of the above criteria, they may be appropriate for an intensive outpatient program. The primary goals of intensive outpatient programs are to monitor and maintain stability, decrease moderate symptomatology, increase functioning, and foster recovery. The individual may experience symptoms that produce significant personal distress and impairment in some aspects of overall functioning. Examples of these symptoms may include negative self-talk, crying spells, severe anxiety, poor sleep, or panic attacks. While some of the same presenting symptoms may be seen, individuals treated in partial hospitalization programs require daily monitoring and exhibit a more severe debilitation of overall functioning, as evidenced by multiple symptoms, significant emotional distress, risk of self-harm, passivity or impulsivity, and incapacity to cope with multiple stressors. In either case, the individual is unable to benefit from medication management or traditional outpatient therapy alone. Individuals may benefit from the IOP level of care if they:

1. Can demonstrate limited ability to function and handle basic life tasks/responsibilities

2. Can achieve reasonable outcomes through actions 3. Can demonstrate some capacity to identify, set, and follow through on treatment

plan without daily monitoring 4. Can prioritize tasks and function independently between sessions 5. Can respond adequately to negative consequences of behaviors 6. Can self-medicate between sessions

Criteria for admission to IOP include:

1. The presence of moderate symptoms of a serious psychiatric diagnosis 2. A significant impairment in one or more spheres of personal functioning 3. The clear potential to regress further without specific IOP services 4. The need for direct monitoring less than daily but more than weekly 5. Identified deficits that can be addressed through IOP services 6. A significant variability in daily capacity to cope with life situations



The individual may also exhibit specific deficits that are addressed in the intensive outpatient program, such as:

• Codependency • Low self-esteem • Therapy-interfering or self-destructive behaviors • Specific interpersonal skill deficits such as assertiveness • Anxiety or Depressive symptoms • Borderline, or other challenging personality traits • Obsessive-Compulsive Disorder • Poor Grief Reaction • PTSD • Early recovery from Chemical Dependency or dually diagnosed • Inability to cope with stress

Determining the appropriate level of care is the responsibility of the medical director or other admitting physician(s) for the program. In some cases, it may not be clear from diagnostic criteria alone which level of care is appropriate. A partial hospitalization program may be more appropriate in lieu of an intensive outpatient program if a number of these conditions are present:

1. Daily medication and overall symptom monitoring is needed 2. Immediate behavioral activation and monitoring is needed 3. Potential for self-harm is significant and requires daily observation and safety

planning 4. Coping skill deficits are severe and require daily reinforcement 5. A crisis situation is present and requires daily monitoring 6. Family situation is volatile and requires daily observation, client instruction and

support 7. Mood lability is extreme with potential to create destructive relationships or

environmental consequences 8. Hopelessness or isolation is a dominant feature of clinical presentation with

minimal current supports 9. Daily substance abuse monitoring is needed 10. Need for rapid improvement to return to necessary role expectations is present.

Each individual will present a unique array of strengths, skills, symptoms, and functional limitations. Some flexibility in programming should always be considered given individual circumstances

SPECIFIC ADMISSION CRITERIA The following clinical presentations must be considered to admit a person to intermediate behavioral health services:

● Behavioral Health Condition: Behavioral Health Symptoms: The individual exhibits serious and/or disabling symptoms related to an acute behavioral health condition or the exacerbation of



symptoms from a severe and persistent mental disorder that has not improved or cannot be adequately addressed in a less intensive level of care.

AND/OR Addictive Signs and Symptoms: The individual exhibits serious or disabling symptoms related to an acute substance use disorder or relapse following a period of sobriety. The individual is not judged to be in imminent danger of withdrawal or has recently undergone medical detoxification.

● Level of Functioning:

Marked impairments in multiple areas of his/her daily life are evident. This may include marked impairments that preclude adequate functioning in areas such as self-care, and/or other more specific role expectations such as managing money, working, cleaning, problem solving, decision-making, contacting supports, caring for others, addressing safety issues, complying with medications, or managing time in a meaningful way.

● Risk/Dangerousness:

The individual is not imminently dangerous to self or others and therefore not in need of 24-hour inpatient treatment. The individual may exhibit some identifiable risk for harm to self or others and may or may not admit to passive or active thoughts or inclinations toward harm to self or others yet is willing to work in program.

● Social Support System:

Historically, the availability of an intact support system was a prerequisite for PHP services. Ideally, the individual is or can be connected with a community-based support network and is able to function in their home environment. However, the individual often presents with an impaired willingness or capacity to positively connect with caretaker, family, friends, or community supports. A socially isolated person with serious debilitating symptoms may also benefit from treatment even though they may report virtually no support system at all. In these cases, backup case management and peer support services can be essential.

In other cases, an individual from a troubled or dysfunctional family may benefit as long as goals and interventions are designed to facilitate communication or reduce stress within the family unit, or even seek genuine supports outside of the identified family unit. A minimal ability and willingness to set goals to work toward the development of social support is often a requirement for participation. In some cases, removal from a given residence or placement in a residence or residential treatment setting may be a precondition for treatment.

● Readiness for Change:

The presence of significant denial or unwillingness to address change may often be inevitable due to the acute circumstances surrounding an admission especially from an emergency department or crisis worker. The individual must, however, have the capacity for minimum engagement in the identification of



goals for treatment, and minimal willingness to participate actively in relevant components of the program. 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.

● Level of Care Rationale:

The individual exhibits acute symptoms or loss of function that necessitates an intermediate level of care or has relapsed and failed to make significant clinical gains in a less intensive level of care yet does not need 24-hour containment. It is believed that the services available in intermediate level of care is sufficient to reduce symptoms and/or restore the individual’s functioning.

-OR- The individual is ready for discharge from a higher level of care but is judged to be in need of daily support, medication management, and intensive therapeutic interventions due to symptom acuity or functional impairment that cannot be provided in a traditional outpatient setting due to lack of comprehensive resources.

Clinically, the intermediately level of care option may provide the best fit due to quick access, resource concentration, a recovery focus, and built-in peer support. With increased attention population health, providers will be increasingly incentivized to use the most efficient treatment options available to contain costs and achieve positive clinical outcomes. Service utilization during each acute “episode of care” will become the focus of overall continuum management. EXCLUSION CRITERIA A person is not appropriate for participation in a partial hospitalization program or intensive outpatient program if the individual:

● 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

-OR- ● 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

-OR- ● Has cognitive dysfunction that precludes integration of newly learned material,

skill enhancement, or behavioral change -OR-

● 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 -OR-

● Has primarily social, custodial, recreational, or respite needs -OR-



● Has previously and currently displayed an unwillingness or incapacity to adhere to reasonable program expectations or personal responsibilities which are detrimental to the group and is unwilling or unable to contract for behavioral change.

CONTINUED STAY CRITERIA Following admission, recurring reviews should be conducted to determine whether individuals continue to meet medical necessity criteria and require ongoing services in a PHP. Clinical reviews for an individual in PHP should occur no less than once a week and may need to happen more frequently depending on the severity of symptoms that led to admission. For individual admitted to an IOP, recurring reviews should happen no less than once every 30 days, and again, may need to occur more frequently based on the symptoms present at the time of admission. Some payer contracts may also dictate the timing for recurring reviews. There must be a clinical determination that the additional treatment requested can result in improvement or stabilization of a documented persistent decline in functioning. The following criteria should be considered as part of the clinical presentation to determine ongoing need for the level of care being provided:

● Symptoms continue to impair multiple areas of daily functioning and medications are being adjusted

● Impaired insight and skill deficits place one at a significant risk for further functional deterioration

● Individual displays willingness yet difficulty understanding or coping with significant crises or stressors

● There is a continued significant risk for harm to self or others ● The presence of poor insight, skills, judgment, and/or awareness inhibits their

return to baseline functioning that is considered to be clinically achievable. In addition to diagnostic criteria above, there needs to be a demonstrated benefit from this level of active treatment. An individual must exhibit the first three following characteristics and may exhibit others listed below: Necessary:

● Successful engagement in the clinical process and willingness to address issues at whatever stage of treatment

● Active attendance and participation ● Capacity to gain insight and respond successfully to therapeutic interventions

Additionally (optional):

● Continued need for medication monitoring and intervention ● Capacity to make progress in the development of coping skills to meet baseline

functional needs ● Need for support and guidance in handling a major life crisis ● Continued need for managing risk accompanied by capacity to follow a safety

plan



● Commitment to developing and following through on a recovery-oriented discharge plan



PROGRAMMING PHPs and IOPs both employ integrated, comprehensive, and complementary evidence-based treatment approaches. Both are designed to serve individuals with serious symptoms and functional impairments resulting from behavioral health disorders. They strive to have a positive clinical impact on each individual’s support system and recovery environment. 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. PHPs are distinct organizational entities with specifically designated standards and regulatory reviews. IOPs may be distinct service entities but are often included within applicable outpatient standards of operation. Many payers include these standards in their outpatient operations protocols and might be referenced as recurring outpatient services. PHP programs may still meet appropriate standards as a distinct service while blending treatment staff and space with another level of care such as an IOP so long as they adhere to appropriate and applicable guidelines and maintain clear distinctions regarding the clinical impact of services rendered to participating individuals. One of the strengths of PHP and IOP programs is the applicability to a diverse array of client populations, clinical conditions, treatment settings, and formats. PHPs and IOPs can be distinguished by their primary program function or treatment objective. Services may be provided during the day, evening, and/or on the weekend. PHPs differ from IOPs in several ways:

PHP IOP Payment Method or Cost payment is on a per diem

basis for most private insurances. Medicare reimburses for a given number of specific services per day. Medical Assistance (where applicable) reimburses for hours of service in a given day

payment is on a per session basis for most insurance companies or specific individualized service for Medicare or Medical Assistance

Severity of dysfunction or behavioral symptoms

criteria for admission require more acute individual dysfunction, severity of symptoms, and potential for risk of harm to self or others

criteria for admission require moderate individual dysfunction, severity of symptoms, and potential for risk of harm to self or others

Hours and variety of intensive services per week

services offered at least 5 days per week with an

people usually attend between 6 and 12 hours of treatment per week



PHP IOP average of 6 hours of treatment per day

Applicable regulations specific State, “Joint Commission”, and other regulations

regulations are generally included within outpatient regulations, except for Medicare

Staffing patterns and responsibilities

staffing requirements are more specific regarding staff-client ratio with most clinical staff ratios are less than 1:12

Less regulation regarding size of caseload but caseloads tend to be larger than PHP

Duration of treatment (Length of stay)

tend to include shorter lengths of stay

tend to provide more sessions over a longer period of time

Intensity of physician and supervisory oversight

require a higher demand of physician oversight that often includes coverage and/or supervision for all hours when clients are present

require regular physician coverage that may vary depending upon local regulatory standards or payer requirements.

Presently, PHPs serve both shorter and longer episodes of care depending upon the primary functions defined earlier. Longer-term programs develop increased group continuity due to the familiarity gained through more extended treatment yet work with more pronounced symptoms and decreased functional levels with lower baselines. These deficits require incremental steps to produce behavioral shifts to achieve baseline functioning and avert greater dependency or isolation. Programs tend to fall into two basic categories that impact programming:

1. Specialty programs focus on a given age or diagnostic group. These tend to be associated with larger, urban, teaching based hospitals or community mental health centers (CMHCs) which serve a higher volume of people served and are therefore able to sub-group members into different tracks of specialty groups.

2. General acute programs are short term and tend to be associated with smaller hospitals or CMHCs which address smaller volumes and more heterogeneous populations that are admitted due to medical necessity, acute symptoms, and reduced functional level.

These distinctions are important since they may dictate the process, content, and structure of group therapy and psycho-educational sessions. Therapists are challenged within each type program to adapt techniques, goals, expectations, and member autonomy to achieve clinical success. The inclusion of educational aides, homework, and peer support are important adjuncts to the therapeutic process. The integration of physical/behavioral treatment can influence both types of programs by increasing the



expectation that the whole health of the individual be considered throughout the assessment and treatment process. The infusion of peer counselors is a dynamic that is also enhancing the experience for many individuals and should be encouraged by authorities and continuum leaders whenever possible. THERAPEUTIC MILIEU PHPs and IOPs are characterized by formalized efforts to promote and maintain a stable and cohesive therapeutic milieu or community. To assist in establishing a sense of program identity and community, the schedule should have a flexible yet coordinated array of therapeutic services indicating the days and times that specific services are scheduled. 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. Individuals are invited and encouraged to adopt an active participant and partnership role in the treatment process. Examples of evidence of such participation at the programmatic level often include community meetings, formal involvement in planning, assessing the value of therapeutic activities, and serving as agents of change within the therapeutic milieu. Programs should include space and opportunity for social interactions between peers while not engaged in formal therapeutic services. Specific components of the milieu include the following: Group Therapy Group therapy is a key building block of PHP/IOP treatment. Medicare regulations solidified the role of group therapy in PHP treatment when it was defined as one of the essential service units required each day. Group process theory has been based primarily on specific process dynamics over a course of time in an outpatient setting with relatively high-functioning individuals. 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. Psycho-Educational Services Psycho-educational services represent another basic building block of PHP/IOP treatment. The actual format and content in often determined by diagnostic profile, target group, or theoretical orientation. A complete package may include worksheets, workbooks, videos, computer-based learning, trainers, role-playing, expressive therapy and activity-based tasks. Programs from around the country reveal the following clinical orientations or strategies that are reflected in their educational components:

● Theme-based groups include a variety of specific topics that emerge from on-going team collaboration, client feedback, and ongoing reassessment of value.



● Medically based/disease or illness management groups emerge from a more formalized “rehabilitative illness management” perspective which often aligns well with medically based continuums of care.

● “Needs based” groups evolve from the personal life content identified in the assessment process. Common problems related to symptoms, life situation, and skill deficits lead to group topics.

● Theory/evidence-based groups are derived from cognitive-behavioral, dialectical, or other evidenced perspectives.

● Positive psychology focused topics address strength building themes in groups that maximizes individual potential.

● Recovery-based education builds upon steps designed to create self-monitoring and individual recovery.

● Subspecialty groups focus on the specifics of given targeted populations such as trauma, substance use, eating disorders, OCD, or cardiac/depressive conditions.

● Behavioral/Physical health Integration groups include a focus on both physical and behavioral issues such as with depression associated with cardiac care.

NOTE: Individual skills may be taught in each of these approaches. While none of these focuses are mutually exclusive, a program tends to build their program from one of these perspectives.

Individual Therapy Individual therapy within programs is designed to augment, clarify, or address issues which are considered by the clinician and client to be more appropriate for individual rather than a group focus. The development of a treatment plan, discussion of barriers to engagement, and intimate emotional issues are examples of the kinds of topics often reserved for individual time. Programs often have limited staff availability, so brief individual sessions may be the norm with more complex issues being reserved for follow-up outpatient treatment. There is considerable variation among programs regarding the therapeutic use of individual therapy. The rationale for this variation should be supported by client need and clinical judgment. CMS and other agencies expect to see individual sessions prescribed as a necessary component of treatment during each episode of care. Family Sessions Family sessions are designed to assist members in their understanding of the identified person’s condition and increase coping skills and group behaviors that can assist the client’s recovery. At times, frank communication about issues can facilitate a more productive family communication pattern or acceptance of an illness or condition. As with individual treatment, time is limited, and staff needs to maximize the experience often leaving some issues for more extensive family treatment following discharge. While direct face-to-face time with family members is preferable, telephonic contact may be a reasonable alternative if there are availability or time constraints. Occupational Therapy



Occupational therapy is also a dynamic component of many programs. In some regions, the direction of CMS fiscal intermediaries led to a reduction in the use of occupational services due to increased documentation demands and conflicting continuation of care criteria. On the other hand, integrated occupational therapy programs complement other services and teach valuable skills within an evidence -based model that contributes significantly to positive clinical outcomes. Creative/Expressive Therapies Creative/Expressive therapies are also significantly employed in PHP/IOP clinical settings. These services engage individuals in a non-talk therapy mode and can result in behavior clarity, new insights, and meaningful options for emotional expression and life balance. PROGRAM STAFF Multidisciplinary Team The multidisciplinary team is central to the philosophy of staffing within a partial hospitalization or intensive outpatient setting. Programs operate under the direction of a physician and a program leader. The physician provides supervision of the clinical needs of the individuals enrolled in the program. The program leader is responsible for the overall clinical and administrative operations of the program, including supervision and competency determination of the clinical staff, clinical documentation, program development, and performance improvement. This role also includes developing operational management plans which address key financial considerations including contracting issues, insurance verification, pre-certification procedures, re-certification tracking, record management as per insurance expectations, retrospective appeal procedures, and productivity management. Many programs opt to divide the program leadership into two roles. One focuses on the administration and operational functions of the program while the other focuses on the clinical aspects of programming and milieu. Multidisciplinary staff members must possess appropriate academic degree(s), licensure, or certification, as well as experience with the particular population(s) treated as defined by program function and applicable state regulations. Core clinical staff members come from diverse disciplines, such as psychiatry, psychology, social work, counseling, addictions, medicine, and nursing. Occupational, recreational, and creative arts therapists broaden and deepen the array of available services when offered. The provision of services allowed for each discipline is dictated by the scopes of work for a licensee in their particular State. Programs may also bolster their treatment staff with paraprofessionals, non-degreed individuals, students, and interns. Peer support is encouraged in programs where applicable regulations allow the use of peers who have been trained to support the clinical efforts of the program. Clear policies for determining assignments and duties are necessary. The services and support provided by the ancillary staff and volunteers is not often reimbursable in fee for service models. As value-base contracts grow in



behavioral health, payers may be influenced to reimburse programs that include ancillary staff for treatment support. High quality performance plans will guide the success of utilizing all support levels as members of a fully reimbursed multidisciplinary team. Regular staff meetings should occur to address clinical needs, milieu issues, changing programming features, and relevant administrative issues. These meetings are critical to achieve continuity of client care, address the identified needs of the therapeutic community, assure appropriate utilization of services, and maintain necessary operational efficiencies. Staff to Client Ratio Individuals receiving PHP and IOP services vary in symptom intensity, clinical needs, and stages of readiness for change. Given these factors, staff-to-client ratios tend to vary and are addressed by each program according to need and staffing requirements. The staff to client ratio is the most critical benchmark driving the cost and effectiveness of programs. A number of clinical factors may impact staff-to-client ratios in programs:

● Program function ● Overall acuity of symptoms ● Target population ● Type of programming offered ● Number of hours of structured treatment provided per day ● Average daily program attendance ● Individual assessment/therapy/intervention time needed ● Average length of stay ● Management of potential for self-harm or other emergencies ● Need for specialized nursing or case management services

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. IOPs may see staff-to-client ratios from 1:12 to 1:20 depending on the focus of the program or the acuity level of individuals in the program. Additional factors such as the presence of centralized intake, clinical complexity, medication challenges, family issues, insurance authorization procedures, and documentation needs, all impact staff-to-client ratio. All programs should consult with compliance officers in their organization to determine if there are specific staff-to-client ratios included within contracts. Role of Physicians Each program should have an identified medical director. This role is usually filled with a person who has advanced training in psychiatry, most notably a psychiatrist. Psychiatrically trained medical professionals, including Physician Assistants and Nurse Practitioners may also be members of the physician team if regulations apply for such. They should provide face-to-face services with each client upon admission for an evaluation and thereafter as clinically indicated. Programs must have clearly delineated



procedures for addressing a client’s detoxification, withdrawal, and other medical needs that require coordination with the client’s primary care provider. To manage medical and behavioral emergencies, policies should be developed to expedite admission for inpatient care if required and allow for timely pharmacological intervention. 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 role of physicians is typically not included in staff to client ratio. However, measures for physician involvement should be a part of all performance plans. COORDINATION OF SERVICES: A member of the clinical staff serves in a primary therapist/case management capacity to coordinate an individual's treatment within the program. This staff member should work consistently with the individual (and family as indicated) and follow the course of clinical treatment from admission through discharge. Priorities are to monitor progress, review treatment planning, coordinate therapeutic team efforts, and facilitate discharge planning. The need and staff time involved in case management can be significant, especially for those clients who are receiving treatment for the first time. Sometimes the primary treatment and the case management functions may be separated within a program. In this case, communication within the team is essential. These are often times when a given individual’s clear need (such as for new housing due to an imminent spousal separation) may not coincide with the individual’s actual desire for an appropriate referral. The negotiation of this variance is an important part of treatment. LENGTH OF STAY: An individual's length of stay is dependent upon the nature of presenting problems, an ongoing review of the clinical necessity for participation in the program, and review of the individual’s response to services provided. The necessity of and rationale for continued stay must also be documented in the medical record including the revised treatment plan when needed. Generally speaking, a program's average length of stay should reflect the population treated and primary program function. The average length of stay in short-term acute PHP may range from 5 to 30 days, while longer-term acute PHP may exceed 30 treatment days. 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. Full-time participation in the program at the onset of treatment serves to promote stabilization and cohesion. At times, a full participation during the first week may be impossible upon admission due to unavoidable personal responsibilities. Clinical judgment should drive whether or not a prospective client can benefit if attendance is less than ordered in the first week. There are also times during treatment when the



rationale for non-attendance is legitimate and in the overall best interests of the indivdual’s welfare. Examples may include childcare demands, appointments for services such as housing, or employment interviews. Also, the program expectations should be flexible in order to accommodate a decrease in the number of hours per day or days per week of individual participation over time as a person moves toward discharge. This plan facilitates efficient service delivery, an expeditious return to improved functioning in the individual's community, and a transition to less intensive levels of care. Transition between PHP and IOP, especially in facilities that offer these as a continuum of care, should be as seamless to the client as possible. Whenever possible, maintaining a consistent therapeutic milieu reduces the negative effects of transitions to a program with new peers and new staff. Procedures should be detailed to reduce missed days due to complications with transitions, especially those that can be caused by payer requirements for documenting the transition. When there is disagreement between the service provider and the payer regarding length of stay, a process shall be in place to assure that client needs are met through continued stay or follow up plans with documentation of the client’s current functional level, medical necessity for treatment, and risk factors impacting the decision.



DOCUMENTATION A clinical record must document what information is gathered, considered, or developed throughout treatment for each individual admitted. Medical records must be maintained in accordance with the current requirements of the applicable licensing and/or accrediting bodies, and the laws of the state within which the program resides. In some cases, local and regional expectations and standards regarding documentation requirements may vary and programs are reminded that documentation requirements may need to change based on different state requirements. The record must be organized in a manner that makes it accessible to those treating the patient. Organization should be clear for those who are less familiar with individualized medical recording formats and procedures like reviewers who conduct surveys through the observation of clinical records. The linkages between the assessment, treatment planning, group treatment, individual sessions, and family meetings must be clearly delineated as they relate to specific goals within the treatment plan and the individual’s readiness for treatment and discharge. The record must document that specific treatment is ordered and supervised by an attending psychiatrist. The documentation of medical supervision and certificate of need must be completed upon entry to the program and updated periodically based on individual need, program policy, and payer expectations. The format for documentation of each individual’s level of functioning, services needed and provided, response to treatment, and coordination of care can take varied forms but must be clearly delineated. The inclusion of two patient identifiers is helpful and often required on each document, such as a patient name and medical record number. Identifiers should be individualized so program staff and reviewers can uniquely identify each patient. Many programs are moving toward the inclusion of patient photographs due to an increase in the number of those served with similar names. A complete medical record should include the following: ASSESSMENT The initial assessment addresses the individual’s bio-psychosocial status and strengths including, but not limited to:

● Cognition/mental status ● emotional/psychological function ● activities of daily living ● nutritional status ● Social determinants of health ● historical data (including social, medical, legal, and occupational histories), ● barriers to treatment ● strengths ● stage of recovery ● cultural issues ● spirituality ● and medical issues



Each assessment needs to include screenings for potential risks, needs, physical evaluations, or referrals. 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. If screenings find significant concerns in any of these areas, program staff should include appropriate action items to address the concerns. Documentation of identified issues that will be addressed by others outside of program should be included as part of the assessment. 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. Programs should use clinical screenings that are appropriate for regular assessment that determine progress in treatment and can be used to help set up initial treatment planning and changes to treatment planning during treatment. The assessment tools in the record must include all relevant information and have the capacity to go beyond documentation of the presence or absence of specific criteria through checklists or drop-down boxes. It should provide the capacity for narrative description to reflect unique client dynamics or circumstances. It is important to indicate the timing of data collection when the record includes updates on previously obtained material. This assessment with screenings helps direct the diagnostic formulation of treatment and must clarify and prioritize client needs to be addressed in the program or elsewhere. PHYSICIAN ORDERS/SUPERVISION/CERTIFICATE OF NEED Treatment must be rendered under the supervision of a psychiatrist or medical professional licensed to diagnose behavioral health issues. The assigned medical professional certifies that the individual would require a higher level of care if the partial hospitalization program or intensive outpatient program were not available. This certification needs to be always current. The certification needs to identify why the client would require hospitalization in lieu of the appropriate level of care. Re-certifications are required by many payers within strict time guidelines. Payers may require different processes or timelines. Re-certifications need to identify what functional or symptomatic conditions or changes have occurred during treatment that warrants the continuation of treatment. PSYCHIATRIC ASSESSMENT This document addresses the presenting problem, psychiatric symptoms, mental status, physical status, diagnosis, rationale for care, and treatment focus for the person while in treatment. Additional certification, monitors, medications, or additional clinical data may be required due to internal organizational or regulatory requirements. The psychiatric assessment is the guiding document in creation of a treatment plan for each person in treatment. Each organization may also have criteria that must be included in the psychiatric assessment.



TREATMENT PLAN The plan of treatment is developed with the active participation and input of the individual in treatment and by the treatment team under the supervision of the treating psychiatrist. In some States, treatment planning may be supervised by a Physician Assistant or Nurse Practitioner with psychiatric licensing approved by the State. Needs are identified based upon the findings of the comprehensive assessment and strategies are identified to address areas of concern. Although an individual may have several pressing needs, those that are of so severe they require the intensity of services of an intermediate level of care should be the top priority of treatment. Goals must be clearly worded and achievable within the timeframe of the individual’s involvement in program. The record must provide the capacity to individualize goals to specific needs, emphasizing recovery principles and reflecting a language easily understandable to the individual. The identification and achievement of clearly targeted and mutually understood and agreed upon objectives is more likely to lead to recovery. The plan must be available to the clinical staff at the time-of-service to assure that interventions are focused and relevant. Progress toward or away from goals is to be addressed throughout the clinical record. The plan must address the diagnosis, stressors, personal strengths, type, and frequency of services to be delivered, and persons responsible for the development and implementation of the plan. The plan may address patient safety concerns, primary symptoms, self-esteem issues, coping skill deficits, priority decision points, level of motivation, recovery issues, barriers to treatment, and factors which impact readiness for discharge. Due to the nature of individual need and program design, it is expected that all needs which are addressed during treatment will not show up on all treatment plans. The use of templated treatment plans by diagnostic category or group topic participation is discouraged and may lead to denial of payment for services. TREATMENT REVIEWS Treatment planning is a progressive process that requires regular updates of all goals and services on the plan. Treatment plans should be reviewed on a regular and consistent basis based on the assessment of the team and approved by the psychiatric supervisor and reflect changes based on feedback from the individual, staff members who provide services and medical professionals supervising treatment. Consults, evaluation summaries, absentee notes, results of collateral contacts, treatment team notes, and progress summaries may also be included. All reviews should be documented in the record with agreement and signatures from the supervising medical professional, the treating staff and the person being treated. The signing of treatment reviews is an indication of the agreement of all parties that the goals for treatment will move the individual toward recovery and discharge. MEDICATION MANAGEMENT The degree to which an individual’s 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. 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. An individual’s understanding of prescribed medications should be reconciled with the medical record. If medications are changed during treatment, the types and dosages, clinician responsibility, and timing should be clearly documented with the rationale for the medication changes. If medications are dispensed on-site, appropriate staff must document medications that are administered on site. Education regarding medications during treatment should also be documented. Upon discharge, a list of medications that have been discontinued is to be available along with a list of all current medications and appropriate contraindications for the patient’s benefit. This record should be available to the individual, follow-up prescribing professional, and primary care provider. PROGRESS NOTES The individual’s progress or lack thereof toward identified goals is to be clearly documented in the record. The format for documentation of progress may take different forms but must include clinical data that justifies the necessity of ongoing treatment at this level of care, including progress related to the illness, symptoms, and debilitated functioning. A separate progress note is required for each service delivered, whether billable or not. In some cases, a summary of daily notes is optional, but do not serve to replace individual notes. When acceptable to given payers or state reviewers, a comprehensive user-friendly synopsis of a person’s progress through treatment may be provided. Progress notes reflect, but are not limited to:

● a brief summary of each specific intervention including the type of intervention provided (e.g., group or individual therapy)

● the observable symptoms ● the problems and goals addressed ● the individual’s response to the intervention ● and the progress described in measurable, behavioral, and functional terms.

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. DISCHARGE SUMMARY Discharge planning begins at the time of admission with the identification of specific discharge criteria and, if necessary, the identification and contact of follow-up options and availability. The summary includes the clinical status on admission, the diagnosis and any changes during treatment, progress made, skills developed, issues not addressed, plans to prevent relapse/foster recovery, aftercare appointments, referrals, a



medication summary, and assessment of risk. Discharge summaries should be completed within a reasonable amount of time after discharge and reflect the protocol of applicable regulatory bodies or organizational standards. A discharge instruction sheet should be made available to the individual summarizing medications, appointments, contraindications when appropriate such as driving, and emergency numbers, and other information deemed appropriate by the program or organization. Follow-up treatment professionals should also have access to discharge information. ELECTRONIC MEDICAL RECORDS The advent of the electronic medical record (EMR) or electronic health record (EHR)provides many new opportunities as well as challenges in the documentation process for intermediate levels of care. Given the overall potential to improve patient safety through error reduction and enhanced treatment through continuity of care, the EMR has become a permanent part of nearly all programs. Electronic record systems should reflect the clinical treatment process and allow the capture and representation of data in a user-friendly fashion. Each component of a comprehensive clinical record described above should be part of a quality electronic medical records. While the use of an EMR is required for hospital systems and most community providers are adopting them, the challenge of product selection can be significant. An effective monitoring strategy must be developed to assure accuracy and prevent errors in data submission and transmittal. The capacity to update and refine the system in a timely manner must be assured where administrative, clinical, regulatory, and performance improvement matters are concerned. 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. Access, treatment, and discharge data are key areas for tracking. As many EMR systems were initially designed for inpatient non-psychiatric care, data processes may be challenging. Each program should have a process in place to review EMR challenges that may interfere with the treatment process as well as the reimbursement process. PHP and IOP needs may or may not be adequately addressed due to unique “workflow documentation, and billing challenges. Accessibility of an individual’s data within the EMR is impacted by privacy and regulatory statutes and must be reflected in the EMR. The CARES Act of 2021 mandates that all providers of treatment make the full medical record, including behavioral health records, available to any individual who received services in that organization. Staff training regarding appropriate language and terminology in documentation should be standard component of staff training on an annual basis. The Institute of Medicine (IOM) published a 2011 report entitled Health IT and Patient Safety.5 This report suggests that a successful EMR is designed to enhance workflow without increasing workloads, allow for an easy transfer of information to and from other providers, and (hopefully) address the perils of unanticipated downtime. The goal is to



contribute to patient safety. Additional benefits should include enhanced tracking and report writing functions that improves decision-making through the collection of timely, accurate information. Examples include benchmarked metrics such as absenteeism, dropouts, and patient outcome data. The increased integration between physical and behavioral health care allows for new levels of cooperation in documenting and sharing information. The EMR further facilitates this opportunity for improved integration and information sharing. Once decisions regarding confidentiality are made, the nature of the handoffs between components within the continuum is equally important. This includes how the information within the EMR is accessed and utilized within a given program, and how it may or may not be built upon and updated between programs within a continuum. Generally, the receiving program should have access to all aspects of the treatment in the previous program within the continuum, and accurately identify the source of information gathered while minimizing the difficulties for an individual to resume treatment. A connection between the treatment plan and the progress notes is important to assure that the person writing the progress note has access to the plan during the writing of the note. The EMR should also allow multiple staff members to work within a record at the same time so efficiency can be gained while clinicians complete record reviews and notes concurrently. Each record section should conform to regulatory documentation requirements to assure that the notes meet billing requirements as well as clinical requirements. Linkages are also important. The EMR provides a unique opportunity to include other non-clinical pieces of treatment, such as linking to client education tools or treatment summaries that are easily accessed and printed off by patients when appropriate or necessary. The use of electronic signatures (for the clinicians and patients) is a valuable option if available as it prevents the need to re-scan documents into the EMR and assures timely document review by the treatment team. 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. It can also be used to track benchmarking data such as dropouts, re-hospitalizations, absenteeism, and related metrics. A built-in method of updating treatment plans and clinical information (using a “read and accept” format) without deleting everything prior to completing an intake is also a useful time-saver and increases accuracy. Additionally, systems may have ancillary features that will benefit an individual in treatment, such as mechanism to disallow inappropriate abbreviations in both medications and other information is also recommended. An internal safety reporting mechanism is also advised to assure that types of problems such as medication errors, falls, injuries, or other critical data can be recorded and monitored. Actual individual characteristics, monitors, and trends can be tracked through discrete clinical fields as



well. For instance, one might track the percentage of patients with housing issues, joblessness, or secondary substance abuse with minimal effort.



LINKAGES In view of PHPs and IOPs positions in the continuum of behavioral health services, programs must maintain liaison relationships with multiple behavioral health providers, physical health care providers, and others. There are three principal forms of linkage:

FIRST, internal linkages between programs, departments, or practitioners within the same organization. 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. SECOND, external behavioral health linkages between programs or practitioners that are separate organizational entities, such as a county case manager who refers a person to program to avert an inpatient stay. This would also include ongoing communication between program staff and a person’s residential program coordinator or community care manager while that person is in treatment. Also, there are linkages that occur while a person is in the program between program staff and external peer counselors, recovery support groups, and natural supports. THIRD, medical care linkages between the primary care providers including medical homes that shift the relationship toward integration or increased collaboration between specialized behavioral health programs and the ongoing medical management of the people in many healthcare models.

Effective communication and coordination in each of these primary linkages or connections is especially vital during handovers or level of care changes. Programs must also maintain strong linkages with emergency departments, inpatient psychiatric units, and chemical dependency programs in order to facilitate both admission and discharges. Additionally, liaison with outpatient services of less intensity is necessary in order to facilitate admissions and continuity of care, as well as to arrange for adequate continued treatment when partial hospitalization services are no longer necessary. Often the program is the first treatment setting for persons experiencing an acute exacerbation of symptoms. A wide range of referral options is essential to ensure that those persons in treatment are able to access a wide range of additional services. 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. Ongoing involvement and participation of family members and peer supports also cannot be overemphasized. 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. Linkages or collaborations with primary care physicians, counselors, residential treatment personnel, case managers, or others may be necessary while the individual is in program to ensure that clinical information is accurate and that clinical initiatives are reasonable and relevant to the individual’s home environment. Given a focus on healthcare integration, illness prevention, and the improvement of health outcomes, linkages between behavioral health and primary care providers is particularly important. Linkages should endeavor to coordinate care in an efficient and timely manner. Formal agreements may not be necessary, but an agreed upon process is necessary to assure that crucial treatment information is shared in a confidential manner which also allows for verbal communication between providers when deemed appropriate. With the increased use of electronic health records, staff need to be reminded that the electronic health record cannot substitute for direct verbal handoffs in many cases. Considerable ongoing communication exists regarding the interface between residential non-hospital treatment facilities and PHPs and IOPs. There is significant variation among states and within treatment continuums regarding the expectations and clinical resources and services provided by residential facilities. Because these services are often expected as part of the contracts or regulatory reviews, it is necessary to better understand when participation in both services is appropriate and when one or the other should be the sole behavioral health provider. Because of the complexity of this issue, additional collaboration among residential and acute ambulatory providers, regulatory groups, and insurers is recommended to clarify when a combination of services is appropriate and to develop joint strategies to decrease redundancies and cost while providing excellent care to each person. In general, a seamless flow between practitioners or facilities includes the sharing of clinical information, collaborative treatment planning, safety and recovery management, and discussion of potential financial or insurance related factors that may impact on a person’s responsibility for payment of services. Whenever possible, the person receiving services should be included in this process. A reasonable understanding of responsibility or expectations in the event that the individual does not follow through with the transition plan should be addressed between peer supports, practitioners, and/or care managers whenever possible. This final consideration is increasingly important in the world of accountable care. Ongoing clinical responsibility must continue and be clarified while individuals are awaiting follow up care. If that individual has completed a PHP or IOP and needs intervention prior to the transition to an outpatient appointment with a new psychiatrist, there must be a responsible party assigned to provide care in the interim.



PERFORMANCE IMPROVEMENT/OUTCOME MEASUREMENT PHPs and IOPs must have a written plan for quality improvement which includes both process/performance outcomes and clinical outcomes management. The plan should conform to guidelines set forth by accrediting bodies and regulatory agencies of local, state and federal government. The quality improvement plan constitutes a comprehensive and methodologically sound process for measuring treatment effectiveness, improving the delivery of care, and evaluating progress toward recovery. It should address the program's mission as well as the needs of individuals in treatment. The results of quality improvement and outcomes management are to be documented and incorporated into administrative, programmatic, and clinical decision-making processes. Efforts to achieve best practices require analyses of critical data points, clinical outcomes, and treatment processes. Whenever possible, programs should compare their results and findings through benchmarking with similar facilities. PERFORMANCE OUTCOMES Programs should monitor regular program related performance outcomes that focus on the overall health of the program. These metrics not only impact the financial outcomes of the program but can also be reflective of the overall impact the program is having for those who participate in programming. Ongoing performance reviews may address attendance rates, dropout percentages, treatment trends, satisfaction, clinical handoffs, discharge status, post-discharge adjustment, or readmission rates. The following core areas are examples of data elements that can be reviewed regularly as part of a performance review plan: INDIVIDUAL CHARACTERISTICS The tracking of specific diagnostic or other characteristics can be essential to program design or psycho-educational content. A given program’s 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. This variation may offer unique program performance improvement options. Example metrics include, but are not limited to:

● % of individuals within a diagnostic category ● % of individuals from in-patient units ● % of individuals with secondary substance abuse issues ● % of individuals with first episode of care

ACCESS ISSUES 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. Example metrics include, but are not limited to:

● No-shows, dropouts, or absenteeism



● Number of individuals served ● Daily census ● Admissions or referrals ● Length of stay ● Time from referral to admission

STAFF FUNCTION AND EFFICIENCY Staff are not only the largest cost to programs, but also have the biggest impact on programming and quality in a program. Finding measures that will help improve staff efficiency and effectiveness are key to a quality improvement plan. Example metrics include, but are not limited to:

● Amount of time spent in specific functions ● Direct treatment time ● Insurance certification/communication time ● Documentation time ● Intake time ● Family intervention time ● Individual therapy time (based on program goals) ● Shifting functions from one type of staff to another ● Staff demographics ● Frequency of psychiatric visit ● Recruitment and retention of staff ● Averting in-patient care

WORKFLOW 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. Example metrics include, but are not limited to:

● Insurance certification time ● Documentation time ● Treatment service time ● Handoff process and time ● Family connections ● Case management time ● Physical health management time ● Medication related staff function time

PROGRAMMING Metrics related to the services that are offered during the course of treatment allow program staff to evaluate how service offerings can be adapted to meet the needs of the population served over time. Example metrics include, but are not limited to:

● Increase or decrease the overall availability or amount of given services ● Shift the % of a given service within a specific day ● Increase in engagement with program participants ● Reduction in intake time ● Client satisfaction with specific groups or program elements



● Reduction in length of stay ● Development of clinical pathways related to specific diagnostic groups ● Increased follow-up with outpatient services following discharge ● Readmissions

HEALTH AND SAFETY All programs are evaluated on issues related to the health and safety of those people being served in a program. These are often reviewed during site visits, but internal processes need to be in place to review health and safety processes regularly. Example metrics include, but are not limited to:

● Medication reconciliation ● Second generation medication monitoring ● # of medication changes during episode of care ● Physical evaluations ● Specific disease monitoring such as Tuberculosis or Asthma ● # of psychotropic medications ● Fall monitoring or prevention ● Reported symptom and skill improvement ● Provision of written medication education

CONSUMER FEEDBACK Consumer feedback is essential in a comprehensive quality improvement plan. Most regulatory bodies have a requirement that consumer feedback in an integral part of programming. It is recommended that programs use a formal method to collect consumer feedback through perception of care surveys and/or care satisfaction surveys. Surveys should be user-friendly, relevant to the mission of the treatment program, and routinely completed by all participants during program and at discharge. The main objective is to receive feedback addressing the degree to which the program met the individual’s needs and assisted in achieving their goals. Perception of care surveys gather information about how effectively the program engaged the individual through assessment, course of treatment, and discharge. Additional elements include opinions related to the program’s use of effective treatment methods, relevance of therapeutic subject matter, cultural sensitivity, teamwork, and the overall quality of care. Recovery oriented service evaluations may also be helpful for programs. These tools provide further input regarding the program’s effectiveness in facilitating recovery steps and enhancing peer support for participating consumers. These should be conducted regularly throughout the treatment process to assess the impact of services at different stages of treatment. Programs might also include informal methods to collect consumer feedback, including individual, group, and community discussions, and the use of an anonymous approach such as a suggestion box. Many programs also include consumer input groups as a formal part of programming that is led by peers. Consumers should also be informed as to where to direct additional feedback or complaints, such as quality management



departments, local, state, and federal authorities, etc. Programs should provide easy access to grievance procedures as required by regulatory agencies. Overall, both formal and informal data can be used to improve the quality and responsiveness of services at the individual and program levels, and to identify and implement quality performance improvement initiatives. Sharing of the consumer feedback with internal program staff is essential and may often lead to the identification of performance improvement priorities and strategies which otherwise may have been unknown or overlooked. When possible, it is important that comparisons or benchmarks be used to enhance performance. When using comparisons to review programs, administrators should not penalize individual programs that have developed a plan to improve the program. CLINICAL OUTCOMES Outcomes management processes should examine the impact of the program on the clinical status of the individuals served. Programs should include clinical measures that assess current status of the individual’s symptoms and functioning. These outcome measures should measure change, so progress can be demonstrated. Clinical outcome measures should help guide the treatment process for each individual, but also be used in aggregate to guide the adaptation of services to meet the needs of the program. Regulatory agencies will often assess the use of outcome measures as a core part of a quality improvement plan for programming. When selecting outcome measures for the program, carefully consider the following:

● The tool should be tested, standardized, and validated; ● The tool should be appropriate for the individual being treated; ● The tool should be able to be used for repeated measures to document change; ● The tool should be consumer friendly and easy for the individual to understand.

Programs should take caution that using a single outcome measure with all participants in a program could create problems unless that tool has established itself to be broadly applicable to multiple diagnostic groups. Even in specialty programs that serve a focused group of diagnostics, individuals may need to be tracked on different clinical measures. For example, in a program that serves individuals with substance use issues, some may need to be tracked on depression, while others may need to be tracked for anxiety. Outcome measures should document progress towards meeting goals for discharge. Specific self-reported monitoring tools are often used within specific diagnostic groups or in specialty programs such as those for Older Adults or persons experiencing “Eating Disorders.” A number of programs report that they use these tools for daily symptom monitoring as part of the ongoing assessment process. While these tools are helpful in guiding the treatment process, they do not qualify as clinical outcome measures until they have been validated. Programs may wish to develop their own measures but should do so with the help of professionals who can test and validate the instrument for appropriateness with the specialty population.



BENCHMARKING METRICS AABH has an ongoing national benchmarking project that enables individual programs to record data on multiple indices and compares them with similar programs across the country. This array of metrics provides a given program with potential access, treatment, and staffing goals. Communication amongst programs regarding their results is strongly encouraged. Benchmarking, whether internal or compared to peers, provides an overview of how elements of a program are performing. Comparing benchmark measures to those of peers offers a greater integration of performance within the industry and particular to these levels of care. Often programs will struggle with deciding if their data elements are outside the norm. Participating in a peer-based benchmarking programs allows programs to evaluate how they compare to a larger group of programs. Some of the core benchmarking metrics that directly impact the financial or operational success of PHPs and IOPs include:

● Length of Stay ● Absenteeism, ● Annual Treatment Days ● Client/Staff Ratios ● Referrals ● Admissions ● Wait Time ● Staff composition ● Staff time by function

AABH holds process benchmarking workshops to assist program leaders and clinicians in better understanding the specific factors that contribute to superior outcomes. They are designed to identify best practices within programs. Each program is encouraged to identify other programs that are relevant to their individual target populations particularly if there are demographic or secondary diagnostic changes. PROGRAM IMPROVEMENT A comprehensive program improvement plan should include an internal review process to assess the appropriate use of program services. This process usually has two steps:

1. The primary therapist should be responsible for the quality reviews for their individual caseload and review their caseload regularly.

2. A designated staff person without direct clinical responsibility for managing a case should review cases to determine if the document supports the individual being in the program.

Programs should create a documentation system that allows for thorough but efficient review of a case at each step. Case reviews should be scheduled on a regular basis. An external audit should not be the impetus for utilization reviews. Performance improvement goals are best when they apply to real program needs even if comparison data is not available. When a given benchmark is not being addressed nationally, a program is advised to track their own metrics that are relevant to their specific population. The benchmark when no other exists can be a designated baseline



of a measure within the program. The program can benchmark against itself to demonstrate change over time. This recommendation is especially relevant to specialty programs. The overall performance improvement plan must be meaningful to actual program practitioners and include consumer feedback whenever possible. A strong connection between performance improvement and ongoing staff ownership of the process and adequate staff training is necessary to assure that performance improvement interventions are shared, realistic, meaningful, and achievable. It is recommended that at least one performance improvement project be on-going in which all staff participate and/or understand the progress and can speak about the results if asked by reviewers or significant others. Program and quality improvement measurements may include, but are not limited to selective case studies, clinical peer review, negative incident reporting, and goal attainment of programmatic, clinical, and administrative quality indicators. It may also incorporate access to care, length of stay, medical necessity criteria, or demographic data to evaluate treatment practices, treatment environment, the distribution of staff assignments, or the potential need for new services. Each program is challenged to provide effective care within increasing time constraints and with limited resources. The development of clinical pathways or treatment protocols offers the potential for systemic solutions to these issues.



TELEHEALTH 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. Telehealth services in PHP and IOP are demonstrating to be useful as an additional service modality. As programs choose to include telehealth service delivery methods to provide the best care possible to all participants during normal or challenging times, programs need to move thoughtfully into each modality used considering confidentiality, best care practices, the severity of our patients’ issues, and the risk for them and for us caused by changes in treatment methods. -

CONSIDERATIONS

● Only use approved platforms for any telehealth contacts . ● Platforms must be HIPAA compliant. ● Staff should only use laptops, PCs, and smartphones that are encrypted. ● All shifts to telehealth need approval of senior leadership ● Each area must balance the needs of individuals that want to attend in person

and those that wish to use telehealth. ● For individuals who are offered telehealth for PHP or IOP, programs must

offer the same level of programming offered onsite. Examples: ○ If a PHP offers four groups per day on five days a week, tele-health

needs to offer four groups per day on five days a week; ○ If an IOP offers three groups per day on three days a week, tele-health

needs to offer three groups per day on three days a week.

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. Many staff may not have this access either.

All monitoring of suicidal ideation, such as daily screens, must continue. All measurements tools must continue. All treatment planning activity must continue. The quality of the treatment delivered is the value programs offer to participants. Programs must maintain it. For each person seen through telehealth, the staff providing a treatment service must have the following readily available:

● Full name ● Verified address where they are at the time of the service (make note as it

changes) ● Verified phone number ● Verified email ● Emergency contact name and number ● Phone number of police station closest to patient’s location



Any individual offered telehealth services must consent to telehealth services and should acknowledge consent before the first session of telehealth service:

[SAMPLE LANGUAGE]

[Provide the statements through email or display on the screen during an intake or first session]

“Please read these statements before the first session and feel free to ask me any questions about this or other issues related to tele-psychotherapy: o I agree to be treated via telehealth and acknowledge that I may be liable for any relevant copays or coinsurance depending on my insurance plan. o I understand that this telehealth service is offered for my convenience and I am able to cancel and reschedule for an in-person service if I desire. o I also acknowledge that sensitive medical information may be discussed during this telehealth service appointment and that it is my responsibility to locate myself in a location that ensures privacy to my own level of comfort. o I also acknowledge that I should not be participating in a telehealth service in a way that could cause danger to myself or to those around me (such as driving or walking). If my provider is concerned about my safety, I understand that they have the right to terminate the visit. “

Document that the person has received this information and acknowledged it.

Clinician Guidelines and Considerations for Telehealth:

• All participants in a telehealth session must be in a private, secure location

to maintain HIPAA compliance for themselves (and for other group members).

• Clinicians must also be in a private, secure location to maintain HIPAA compliance for all. Clinicians working from home must have no family in the vicinity of the computer/device being used to provide service (working from home might require prior authorization from leadership).

• Clinicians should wear an organization identification badge and it must be visible to all participants in the session.

• Clinicians working from home need to carefully review their environment for any unintended personal disclosures that can occur such as visual clues about the location of your home, family information, etc.

• All sessions are to be conducted using video and audio wherever possible. This allows clinicians to assess the participants using all their clinical skills. A mixed group means mixed level of attention to participants.

• Consider that each participant has differing levels of technical abilities or experience.

• Consider providing a staff member for each telehealth group for technical



assistance, administrative duties, and telephone follow up on participants who drop or disappear from the screen.

• Respect that some participants are comfortable using telehealth services and some are not. Make every effort to meet the needs of all participants. Consider a preparatory contact over the platform prior to the first meeting, especially for groups.

• Greet each person individually in the group if providing a group service. • Always start with a “tech check” to make sure everyone can navigate

the platform and feels welcome. • 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 different.

• Enforce the same etiquette as at an in-person group meeting– no food, no checking phones, etc.

• Do not enable the “chat” feature during group. • Encourage use of the “raise hand” feature if available on the platform. • Mute participants and allow them to unmute when appropriate. • The quality of therapeutic presence is even more important in telehealth

than it is in person. “Holding the space” is much more challenging. Consider how staff will compensate.

• Explain to the group that clinicians may use different, more direct communication to manage group issues.

• Look into the camera- facial expressions are bigger and more visible than in person. People will notice distractibility. Clinicians should self-check frequently. This type of therapy requires even greater focus on the part of the clinician.

• When tech issues arise such as unstable WIFI, not knowing how the system works, etc. – clinicians should model social interaction and effective problem solving. 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.

• Clinicians should pay attention to the need to ground themselves in this new environment - this may be another opportunity to model coping strategies.

• 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 stress.

• Do not record sessions and make it clear that sessions are not recorded. • If suicide risk is present in the participant, take action immediately, including

staying online with them until help and safety has been secured. • Encourage all clinicians to Be their best clinical self.

Documentation: Clinicians should utilize language in documentation that notes telehealth use. The following Text (“Smartphrases” if using EPIC) is an example:



Individual Encounters:

“Consultation provided via telemedicine using two-way, real-time interactive telecommunication technology between the patient and the clinician. The interactive telecommunication technology included audio and video. We offered telemedicine as an option for care delivery and patient consented to this option.”

Patient location: *** Provider location: *** Other participants present with provider, with patient's verbal consent:*** Other participants present with patient: ***

Group Therapy Encounters: “Patient received group psychotherapy via telemedicine using two-way, real-time interactive telecommunication technology between the patients and the provider. The interactive telecommunication technology included audio and video. We offered telemedicine as an option for care delivery and the patient consented to this option.”

Patient location: *** Provider location: ***

All other documentation standards for a clinical record remain the same for telehealth and in-person/on-site participants.



SUMMARY PHPs and IOPs are active, time-limited, ambulatory behavioral health treatment programs that offer intensive, structured, and coordinated clinical services within a stable therapeutic milieu. Intermediate behavioral treatment represents the highest level of ambulatory care within the behavioral health continuum. This document describes current standards and guidelines for organizations providing these services and is intended to assist professional organizations involved in behavioral healthcare, national and local regulatory bodies, and third-party payers. It is also hoped that these guidelines will serve to assist in the development of new programs and further facilitate high-quality service delivery within existing settings. These Standards and Guidelines reflect both global and specific dimensions of partial hospitalization and intensive outpatient programs. With programming focusing on specific subpopulations, the guidelines summarize specific considerations for acute ambulatory programs providing services targeted to children and adolescents, older adults, individuals with co-occurring mental health and substance use disorders, individuals with substance use disorders without significant mental health disorders, individuals with eating disorders, and other subgroups as they become more widely recognized and treated specific to the uniqueness of a target population. Additionally, these Standards and Guidelines reflect a significant amount of work on the part of providers to identify best practices and vital aspects of this major component of behavioral healthcare. Continued collaboration among providers, managed care professionals, CMS, and other regulatory bodies is essential to assure ongoing program improvement, best practices, and financial viability.



APPENDIX A – EVOLUTION OF AABH STANDARDS AND GUIDELINES The original Standards and Guidelines for Partial Hospitalization established by the American Association for Partial Hospitalization was a landmark document in recognizing the modality of treatment known as partial hospitalization.13 It established parameters for defining partial hospitalization, was far reaching in its attempt to “guide the establishment of quality treatment programs and, hopefully, to encourage increased development and funding of the modality.” In 1991, the standards were revised to address the need for clarification of the definition of PHPs, and to further delineate the boundaries and unique characteristics of the treatment modality.14 The AAPH position paper, “The Continuum of Ambulatory Mental Health Services” (1993), proposed three distinct levels of ambulatory care, with partial hospitalization as a primary example of the most intensive of the three.15 The continuum model recognizes the importance of a broad range of non-residential services that augment partial hospitalization in meeting the needs of clients requiring greater intensity than traditional outpatient treatment. As partial hospitalization continued to evolve within the context of a continuum of services, the 1996 revision “was intended to incorporate contemporary views” of this specialized level of care.16 Specific standards and guidelines for child and adolescent programs were also completed at that time which attempt to delineate both similarities to adult programs and unique challenges.17 Intensive Outpatient Services were first addressed in a 1998 edition.18

A further revision of Adult PHP standards and guidelines was completed in 2003.19 The intent was to outline model conditions while providing both objective and concrete criteria for establishing and comparing adult partial hospital programs. AABH recognized that the significant population growth of older adults warranted the development of standards and guidelines for geriatric programs, last revised in 2007.20 The varied mental and physical capacities of seniors required individualized treatment, flexible treatment strategies, and unique aftercare challenges. In 2005, SAMHSA surveyed the population and determined that 21% or 5.2 million adults experienced both serious mental illness and co-occurring substance abuse problems.21 SAMHSA experts emphasized that the treatment outcome for consumers is enhanced when both illnesses are addressed simultaneously using an integrated approach. 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 AABH published the fourth edition of the Partial Hospitalization Program Standards and Guidelines in 2008.23 For the first time this document included summarized information regarding the evolution of partial hospitalization program standards and guidelines, the continuum of behavioral health services, standards and guidelines regarding partial hospitalization programs which target specific populations (child/adolescent, geriatric,



co-occurring, and chemical dependency), as well as a summary of standards and guidelines concerning intensive outpatient programs. The fifth edition was completed in 2012. That edition included a discussion of the impact of electronic medical record, a focus on the recovery movement, and guidelines for “eating disorder programs” among other additions.24 The update in 2015 updated relevant information about PHPs and specialty group guidelines.25

The seventh edition (2018) guidelines provided a significant change in the guidelines. The key elements of partial hospitalization and intensive outpatient programs have been combined as the core of the standards and guidelines. The specialty group guidelines have been streamlined to focus just on the elements that need to be addressed with the specific population. Finally, a new section of was added to address the role of regulatory bodies on programming and documentation. The eighth edition addresses the changing environment of care resulting from the COVID pandemic and includes guidelines for alternative service delivery such as telehealth. This edition also included the launch of the Standards and Guidelines as a living document for association members. The Standards and Guidelines will be updated as new reviews are completed in any of the areas addressed. A new “print” edition will be pulled every 2 years for those who choose to purchase the e-document.



REFERENCED DOCUMENTS

1. Hyde, Pamela S. "Report to congress on the nation’s substance abuse and mental health workforce issues." US Dept. for Health and Human Serv., Substance Abuse and Mental Health Serv.(Jan. 2013) 10, 2013.

2. Neuhaus, E. “Fixed Values and a Flexible Partial Hospital Program Model.”

Harvard Review of Psychiatry, Jan-Feb; 14(1):1-14, 2006. 3. Kiser, L., Lefkovitz, P., Kennedy, L., Knight, M., Moran, M., and Zimmer, C. “The

Continuum of Behavioral Healthcare Services.” Portsmouth, Virginia. Association for Ambulatory Behavioral Healthcare, 1999.

4. Yalom, Irvin D. Inpatient group psychotherapy. Basic Books, 1983.

5. Institute of Medicine of the National Academies. “Health IT and Patient Safety:

Building Safer Systems for Better Care.” Washington, D.C., 2011.

6. American Society of Addiction Medicine (ASAM) (April 2001). Second Edition – Revised of Patient Placement Criteria (ASAM PPC-2R). Retrieved July 20, 2018, from https://www.asam.org/docs/publications/asam_ppc_oversight_may_2011.

7. U.S. Department of Health and Human Services, Substance Abuse and Mental

Health Services Administration, Center for Mental Health Services. “Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders.” (November 2002). Retrieved July 20, 2018, from https://www.ncmhjj.com/wp-content/uploads/2014/10/Behavioral_Health-Primary_CoOccurringRTC.pdf.

8. Miller, W.R. and Rollnick, S. “Motivational Interviewing: Preparing People for

Change,” (2nd ed.). New York: Guilford, 2002.

9. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services (January 2003). “Co-Occurring Disorders: Integrated Dual Disorders Treatment Implementation Resource Kit.” Retrieved July 20, 2018, from http://www.mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/cooccurring/.

10. Bonari, L. P. Perinatal risks of untreated depression during pregnancy. Can J

Psychiat, 49, 726-735, 2004.

11. Robakis, T. & Williams, K. Biologically based treatment approaches to the patient with resistant perinatal depression. Archives of Women’s Mental Health, 16. 343-351, 2013.



12. Connellan, K., Bartholomaeus, C., Due, C., & Riggs, D. A systematic review of research on psychiatric Mother-Baby units. Archives of Women’s Mental Health 20. 373-388, 2017.

13. Casarino, J., Wilner, M., and Maxey, J. Standards and Guidelines for Partial

Hospitalization, Alexandria, Virginia. American Association for Partial Hospitalization, 1982.

14. Block, B. and Lefkovitz, P. Standards and Guidelines for Partial Hospitalization,

Alexandria, Virginia. American Association for Partial Hospitalization, 1991.

15. Kiser, L., Lefkovitz, P., Kennedy, L. and Knight, M. “The Continuum of Ambulatory Mental Health Services.” Alexandria, Virginia. American Association for Partial Hospitalization, 1993.

16. Kiser, L., Lefkovitz, P., Kennedy, L. and Knight, M. “The Continuum of

Ambulatory Mental Health Services.” Alexandria, Virginia. American Association for Partial Hospitalization, 1996.

17. Block, B. M., Arney, K., Campbell, D.J., Lefkovitz, P.M., Speer, S.K., and Kiser,

L.J. Standards and Guidelines for Partial Hospitalization Child and Adolescent Programs. Second Edition. Alexandria, Virginia. Association for Ambulatory Behavioral Healthcare, 1996.

18. Kiser, J.L., Trachta, A.M., Bragman, J.I., Curley-Spadaro, K., Cooke, J.D.,

Ramsland, S.E., and Fitzhugh, K.E. Standards and Guidelines for Level II Services: Intensive Outpatient. First Edition. Alexandria, Virginia. Association for Ambulatory Behavioral Healthcare, 1998.

19. Scheifler, P.L. and Lefkovitz, P.M. Standards and Guidelines for Partial

Hospitalization Adult Programs. Third Edition. Portsmouth, Virginia: Association for Ambulatory Behavioral Healthcare, 2003.

20. Gray, K., Michael, S., Lefkovitz, P., and Barry, A. Standards and Guidelines for

Partial Hospitalization Geriatric Programs. Third Edition. Portsmouth, Virginia: Association for Ambulatory Behavioral Healthcare, 2007.

21. Substance Abuse and Mental Health Services Administration News Release.

“National Survey on Drug Use and Health,” 2013.

22. Mol, J.M. and Barry, A.D. Standards and Guidelines for Partial Hospitalization and Intensive Outpatient Co-occurring Disorders Programs. Second Edition. Portsmouth, Virginia. Association for Ambulatory Behavioral Healthcare, 2007.



23. Mol, J.M., Miller, T., Lefkovitz, P.M., Michael, S., and Scheifler, P.L. Standards and Guidelines for Partial Hospitalization Programs. Fourth Edition. Portsmouth, Virginia. Association for Ambulatory Behavioral Healthcare, 2008.

24. Miller, T.,Mol, J.M. Standards and Guidelines for Partial Hospitalization

Programs. Fifth Edition. Portsmouth, Virginia. Association for Ambulatory Behavioral Healthcare, 2012.

25. Miller, T. Standards and Guidelines for Partial Hospitalization Programs. Sixth

Edition. Portsmouth, Virginia. Association for Ambulatory Behavioral Healthcare, 2015.



SPECIALTY POPULATION – CHILD & ADOLESCENT Definition/Target Population 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. These programs often allow children and adolescents to avoid inpatient hospitalization, decrease lengths of stay otherwise required in inpatient or residential settings, or to support the child/adolescent with any transitions such as foster care when needed. Typically, individuals 18 years of age and younger are served. However, this range may extend to 21 years of age dependent upon the individual’s developmental level and the goals and objectives and licensing requirements of any program. Child and adolescent programs provide an intensive therapeutic milieu that is designed to serve the child and/or adolescent (and their family) within the least restrictive therapeutically appropriate context. These programs are both community- and hospital-based and may be structured with after school or full day services. The overall expected outcome is the achievement of symptom and functional improvement on the part of the child/adolescent and the family. Specific Considerations

● They may be part of educational or residential facilities. However, they should be a separate, identifiable unit and represent a continuum of therapeutic modalities that are evidence based for children and adolescents.

● The individual’s family and/or legal caretakers must be involved. ● When developing program schedule, consider your population and how you will

structure school (i.e. teacher on staff vs. Monitored study time vs. Programming after school hours). State laws may apply. Some regulators have requirements about education components in these programs.

● Staff members must be trained and experienced in child and adolescent behavioral health, family therapy, milieu therapy, and therapeutic crisis intervention.

● Treatment modalities and techniques must be developmentally appropriate, and evidence-based for children and adolescents.

● The assessment and treatment plan should address improvement of social skills and functioning via the therapeutic milieu.

● Treatment should include collaboration with school, involved community agencies and established providers.

Performance and Outcomes

● Establishment of a safety plan that allows for the child/adolescent to maintain safety in a community setting.

● Improvement in symptoms and functioning to allow the child/adolescent to return to a school setting.

● Improvement in symptoms and functioning as evidenced by outcomes measurement tools that are evidence based for children and adolescents.



● Improvement in functioning and communication within the family system and/or home environment.

Sample Outcome Measures Measurement Condition/population use Link to information PHQ-9 Depression https://www.ncbi.nlm.nih.g

ov/pmc/articles/PMC6291233/

GAD-7 Generalized Anxiety https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5765270/

SCARED All Anxiety Spectrum Disorders

https://www.midss.org/content/screen-child-anxiety-related-disorders-scared

CRAFFT Substance Use https://crafft.org/ NICHQ Vanderbilt Assessment Scales

ADHD https://www.nichq.org/resource/nichq-vanderbilt-assessment-scales



SPECIALTY POPULATION – OLDER ADULTS Definition/Target Population Older Adult programs are an important means of delivering behavioral health treatment to adults age 55 and older. The achievement of clinical stability and a reduction in symptomatology must be considered in the context of realistic and achievable goals especially given the complex medical and psychosocial stressors that often impact the older adult population. A higher level of monitoring of overall behavioral health and physical functioning is important. The value of these programs in clarifying diagnoses, assessing function, and determining one’s capacity for independence or personal safety cannot be underestimated. Programs can provide daily symptom management, while at the same time, necessary case management services are engaged to foster the highest level of functioning possible. 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. Specific Considerations

● The presence of comorbid physical illness must be addressed and often makes the frequency and duration of attendance more challenging.

● The presence of substance abuse has often been underreported due to cultural or generational biases. Therefore, it is important to collect a thorough substance abuse history.

● A recovery model that focuses on increased quality of life is essential to give the older adult investment and purpose in treatment.

● Fatigue, sensory impairment, decreased concentration ability, and discomfort with transitions or changes in programmatic structure are challenging factors to address in program development.

● Many seniors live in isolation, so timely and appropriate aftercare is needed to ensure that gains made in the program remain.

● Cognitive and physical impairments may make day-long treatment services demanding for some individuals.

● Modifying the treatment techniques may be necessary in terms of presenting information more slowly and concretely and with a narrower focus than may be necessary with young and middle adults.

● 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.

● It is also important to address issues specifically faced by older adults such as grief and loss, changes in professional and personal roles, limitations of social support, impact of physical limitations on wellbeing, stigma related to aging, and death and dying.


● Performance Improvement for older adult programs is essential and should be determined by the mission and specific needs of those who are being served.



The processes and results of access, engagement, treatment, and discharge should be considered.

● A focus on medication adherence, therapeutic impact, and relationship between psychiatric and physical medications should also be considered.



SPECIALTY POPULATION – PERINATAL WOMEN Definition/Target Population Programs serving pregnant women or new mothers typically care for women with some type of Perinatal Mood and Anxiety Disorders (PMAD). The disorders are also commonly called Postpartum depression, perinatal mood disorders, or PMD. These disorders are characterized by significant changes to mood during pregnancy and up to 3 years postpartum. Examples of symptoms include high anxiety, sadness, depression, mood swings, elevated mood, irritability, intrusive thoughts, and more. Between 10-25% of women experience some form of PMAD during pregnancy or after the birth of a child. If left untreated, there is significant impact on women and their families.10 This includes depression, psychosis, bipolar disorder, anxiety, panic, obsessive compulsive disorders, and post-traumatic stress disorders. Suicide is the leading cause of death in the postpartum time period.11 Specific Considerations

● Postpartum Psychosis is a true psychiatric emergency. Mothers should never be left alone with a baby if they are diagnosed with postpartum psychosis. Women with postpartum psychosis will need referral into acute inpatient psychiatric treatment.

● Availability of a nursery is critical for new moms. If possible, consider a nursery onsite. Women in the program should have the option to bring babies to group or leave in nursery. Programs should consider the focus of some of their programming on maternal fetal attachment with bonding groups like infant massage, playing with baby, etc.)12

● Important to have prescribers with expertise in prescribing during pregnancy and lactation. Treatment aims to minimize fetal/neonatal exposure to both maternal mental illness and medication

● Clinicians in the program should be well versed in perinatal mood and anxiety disorders.

● It is important for programs to provide lactation consultation in the program as working through difficulties with breastfeeding is a common treatment goal with this population.

● Co-morbid substance use is common so drug screens should be administered upon admission and use assessed throughout the stay. In a perinatal program it is important to understand that the baby in utero also needs consideration from the program and moms that breastfeed who are using substances are also putting their babies at risk. These are important things to address during the course of treatment in these programs.

● Family work is crucial and should be a part of every client’s treatment plan. Dads can also struggle with paternal depression and the mental health of the whole family is key to successful outcomes. Programs should consider brief family therapy and referrals for family members that need additional treatment.



Resources from Post-Partum Support Internation may be helpful in finding additional support for spouses.

● 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).

● 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). A solid aftercare plan is crucial for success with this population. Often primary care physicians, OBGYN’s and Pediatricians need additional help and consultation from a trained psychiatric provider if they are going to be a part of the aftercare plan for clients, especially if they are managing medications. Consideration of teletherapy options is up and coming because of childcare needs and difficulties moms have leaving the home to get to appointments.


● Edinburgh Postnatal Depression Screening (available in many languages) ● PHQ-9, GAD-7 ● PBQ (Post-partum bonding questionnaire) ● MFAS (Maternal Fetal Attachment Scale)

Byrnes, L (2018). Perinatal mood and anxiety disorders. The Journal for Nurse Practicioners.14(7) p 507-513. Van Niel, M & Payne, J (2020). Perinatal Depression: A review. Cleveland Clinic Journal of Medicine. 87(5), 273-277.



SPECIALTY POPULATION – EATING DISORDERS Definition/Target Population 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. See DSM-5 for details on these diagnostic categories, and the levels of severity. Persons meeting “Severe and Extreme” level of severity should be treated within a Partial Hospital Psychiatric level of care setting, as long as the patient is medically stable. If medically unstable, inpatient hospitalization is necessary, stepping down to a PHP level of care. A growing body of evidence suggests that partial hospitalization outcomes are highly correlated with treatment intensity and that more successful programs involve patients at least 5 days/week for 8 hours/day Clients with eating disorders may enter PHP level of care with a body mass index (BMI) which measures the relationship between height and weight, of 17.5 (adults) or less with a diagnosis of anorexia nervosa or may be of normal weight with a bulimia nervosa diagnosis, while they may be obese with a BMI of 30 or more or morbidly obese with a BMI or 40 or more. Menses have usually ceased if body mass is extremely low or high. Specific Considerations

● Patients are assessed to be medically stable with labs to include but not limited to:

o complete blood count o comprehensive serum metabolic profile, including phosphorus and

magnesium o thyroid function test o Electrocardiogram (ECG), if clinically indicated o Body Mass Index (BMI) o Heart Rate o Screening for eating disorder behaviors o Any additional laboratory testing, as determined by the organization and in

accordance with the level of care provided. ● According to the American Psychiatric Association’s Eating Disorder Guideline

2006, clients who are appropriate for partial hospitalization need daily supervision and structure from meal to meal to gain or prevent purgative and binge eating behaviors. The structure is needed to monitor before, during and after eating meals and snacks.

● For those with AN, weight restoration may need daily monitoring to prevent re-feeding syndrome.

● Movement needs to be monitored hourly, determining how much movement or exercise is medically safe for each client’s stability. Medical oversight is necessary with additional daily, hourly structure to contain and monitor client movement.



● Medical personnel address ongoing medical and physical health issues and assess and manage medication therapies.

● Dietitians work with patients and their families to move in the direction of nutritional rehabilitation and weight restoration.

● Eating disorder partial programs provide staff- supervised meal and snack groups, regular monitoring of weight and vital signs, and a variety of groups aimed at addressing symptom management and augmenting patients coping skills and strategies (as they relate to both the eating disorder and other behavioral health co-morbidities).

● Initial discharge criteria are formulated upon admission and are based on objective data such as achievement of a certain percentage of ideal body weight or targeted weight gain, or weight loss (if binge eating) as well as ability to function with less structure daily.


● Specific instruments may be used to collect data about treatment effectiveness. These may include pre- and post- measurement on:

o Eating Disorders Questionnaire (EDQ) o Eating Disorders Inventory (EDI-2) o Eating Disorders Examination-Questionnaire 6th ed. (EDQ-Q6) o Questionnaire on Eating and Weight Patterns-Revised (QEWP-R) o Beck Depression and Anxiety Inventories (BDI) (BAI) o Press-Ganey o Basis 24 o Selected measures that are specific to each organization.



SPECIALTY POPULATION – CHEMICAL DEPENDENCY Definition/Target Population Chemical dependency partial hospitalization programs and intensive outpatient programs serve populations who present primarily with substance use disorders that have relatively minimal or no mental health disorders impacting current functioning. Programs for chemically dependent individuals are designed to serve those within a less restrictive environment (for example, less restrictive than inpatient or residential) which allows the individual to practice new recovery and coping skills within his/her natural environment and to assess the individual strengths and weaknesses associated with those recovery and coping skills. The program can also function as a first step to achieve a measure of sobriety, and to assist in determining a differential diagnosis once the individual has begun the recovery process. 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. As previously mentioned, individuals who have diagnoses for both mental health and substance use disorders of which only one is currently active, may be treated in a co-occurring (“dual diagnosis”) treatment setting, or in either an addictions or psychiatric treatment setting (depending upon which problem is currently active). Individuals in treatment include both those who participate voluntarily, as well as those mandated by the legal system. Services may include group, individual, couples, family therapy and medication management for symptom management. Evaluation for medication –assisted treatment (MAT) services may also be indicated. Specific Considerations

● Treatment is best conceptualized as a phased continuum of care that progresses from management of active symptoms and problems to establishing recovery/relapse prevention plans.

● Coordination and involvement with family members and significant others is an important part of treatment whenever possible.

● All chemical dependency PHP and IOP programs must have clearly delineated procedures for addressing client’s detoxification, withdrawal, and other medical needs. Additionally, any exclusionary citeria must be clearly defined.

● Confidentiality guidelines pertaining to individuals in chemical dependency treatment tend to be more restrictive than for those individuals in mental health treatment.

● Utilizing a Motivational Interviewing approach to assessment (as well as ongoing treatment) with individuals with chemical dependency is considered to be a best practice.

● Some programs choose to identify guidelines for early administrative discharge based on pre-determined number of relapses and other forms of treatment-interfering behaviors.




● The American Society of Addiction Medicine’s (ASAM) Patient Placement Criteria (ASAM PPC-2R) (previously mentioned) is considered a best practice for assessing and determining level of care placement for individuals with substance use disorders.6 This comprehensive approach focuses on the following areas, or dimensions:

1. Psychoactive substance history & detoxification status 2. Physical health 3. Emotional/behavioral/cognitive functioning 4. Readiness for change 5. Relapse potential 6. Recovery environment

● A certain measure of relapse is to be expected and treatment remains appropriate to client needs after clinical review.

Programs will use their identified outcome measure tool to track clients progress in the program.



SPECIALTY POPULATION – CO-OCCURRING DISORDERS Definition/Target Population Co-occurring behavioral illness (dual diagnosis) is defined as conditions experienced by individuals with concurrent DSM mental health and substance use disorder diagnoses. According to SAMHSA, “While these disorders may interact differently in any one person (e.g., an episode of depression may trigger a relapse into alcohol abuse, or cocaine use may exacerbate schizophrenic symptoms), at least one disorder of each type can be diagnosed independently of the other.”7

Specific Considerations

● Co-occurring treatment providers must be well versed in the diagnosis and treatment of concurrent mental health and substance use disorders. “Staff in settings providing integrated substance abuse and psychiatric treatment should be fully oriented in each other’s disciplines. Individuals with co-occurring disorders should be able to receive services from primary providers and case managers who are cross-trained and able to provide integrated treatment themselves.”7

● Traditionally, substance abuse and mental health facilities are treated as separate programs and are often licensed and reviewed separately in many states. Facilities that provide treatment for both behavioral health conditions and substance use disorders are not formally designated as a single treatment program in most areas. While there is significant financial and clinical impetus to provide these services in an integrated manner, state licensing dictates the extent to which programs may be integrated.

● Individuals with co-occurring disorders tend to relapse frequently, placing them at greater jeopardy of a marginalized social existence.

● The inclusion of motivational interviewing techniques has been an important addition to clinical programming and has led to increased engagement of individuals who display avoidance or ambivalence toward treatment.8

● In many program settings, the inclusion of individuals in different phases of recovery can be used to good clinical advantage.

● To ensure effectiveness of co-occurring programs, it is important to not rely only on patient report but to utilize data from various sources to ensure ongoing recovery.

● All co-occurring programs must have clearly delineated procedures and linkages for addressing client’s detoxification, withdrawal, and other medical needs.

● Treatment planning for the individuals with co-occurring disorders incorporates knowledge of both the mental health and substance use components of the illness.

● Utilizing a Motivational Interviewing approach to assessment (as well as ongoing treatment) with individuals with chemical dependency is considered to be a best practice.8



● The Co-Occurring Disorders: Integrated Dual Diagnosis Treatment Implementation Resource Kit provides the following four key principles for gathering information about mental health and addiction disorders:

1. Because many clients with severe mental illness have substance use disorders and vice versa, it is important to ask all clients about substances and mental health issues.

2. Gather information from other sources (family, hospital records, and urine screens) in addition to the client. Some clients are reluctant to talk about behaviors that they believe others disapprove of, such as drug use or illegal activities.

3. If information gathered from sources does not agree with what the client tells you, ask the client to help resolve the discrepancy.

4. Because assessments completed soon after meeting a client or in the context of intoxication, withdrawal, or severe psychiatric symptoms are inaccurate, it is important to continue to gather information over time.9

● Some programs choose to identify guidelines for discharge based on a pre-determined number of relapses and/or other forms of treatment-interfering behaviors.

● Programs are encouraged to be ready for medical emergencies related to substance abuse such as narcotic withdrawal crises 9 some programs keep medications onsite for emergency use and have staff competent in administration.

Performance and Outcomes ● The American Society of Addiction Medicine’s (ASAM) Patient Placement Criteria

(ASAM PPC-2R) (previously mentioned) is considered a best practice for assessing and determining level of care placement for individuals with substance use disorders.6 This comprehensive approach focuses on the following areas, or dimensions:

1. Psychoactive substance history & detoxification status 2. Physical health 3. Emotional/behavioral/cognitive functioning 4. Readiness for change 5. Relapse potential 6. Recovery environment

● Relevant factors such as relapse and recidivism, attendance at self-help meetings, level of sobriety, post-discharge adjustment (including improvement in housing status, use of recovery-oriented peer or social support, and vocational training/placement), and legal issues pre- and post-treatment may be measured.



FINAL COMMENTS As a national provider organization, AABH advocates for the following objectives to improve systems of care and meet the needs of those we serve:

● We must continue to respect the role of PHP and IOP within the behavioral healthcare continuum.

● We must honor the role of peer support and counseling within the behavioral health continuum.

● We must advocate for simplicity and consistency in the description of services offered in programs and the billing process.

● We encourage the use of alternative modes of treatment delivery, such as telehealth, when new modes are demonstrated to contribute to quality services.

● We advocate for unified “medical necessity guidelines” among payers. ● We wish to clarify the role and scope of service for Nurse Practitioners and

Physician Assistants and assure their inclusion as valued professionals within Intermediate Behavioral Health.

● We encourage a shift in the oversight focus from document analysis to a concern for outcomes and the overall client experience.

● We encourage an appreciation for the complexity of creating and sustaining a milieu that engages and appreciates each individual in their personal stage of change.

● We honor and support programs that seek to integrate physical, substance use, and behavioral health treatment within single programs.

● We encourage efforts by PHP and IOP staff to expand behavioral health techniques, skills, and resource libraries to overall health continuums and communities.

● Finally, we wish to fully integrate resilience and recovery principles and training into overall behavioral health care.

The AABH Board of Directors appreciates the work of each behavioral health practitioner who is making a difference in partial hospital and intensive outpatient programs throughout the country. We hope this document will be used in concert with active dialogue on a local, regional and national level to improve care and individual recovery.



© 2021. Association for Ambulatory Behavioral Healthcare. All rights reserved. No parts of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without the express written permission of the Executive Director of the Association for Ambulatory Behavioral Healthcare.

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