therapeutic day treatment (tdt) h0035 a refresher...•family contacts, either in person or by...

Therapeutic Day Treatment (TDT) H0035 a Refresher

Presented by the Clinical and Quality Teams

March 2016

After today’s training you will be able to:

•Determine DMAS Medical Necessity Criteria (MNC) for this level of care and the targeted member population for this level of care

•Demonstrate a better understanding of the DMAS Community Mental Health Rehabilitative Services Chapter IV

•Identify and Summarize regulations associated with this level of care

•Have adequate knowledge about the Service Authorization Requests (SRA) submission requirements for Therapeutic Day Treatment Services (TDT)

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Magellan Healthcare of Virginia

What is Therapeutic Day Treatment (TDT H0035)?

Service Definition from the Community Mental Health Rehabilitative Services Manual:

•Psychotherapeutic Interventions

• Medication education and management

• Promoting daily skills to improve social skills

• Enhancing interpersonal skills

•In addition the following elements will be implemented within programs greater than 2 hrs per day:

• Individual Counseling

• Group Counseling

• Family Counseling


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What is the target population for TDT?

•Children under the age of 21 years old

•Children that are experiencing significant emotional and behavioral disturbances


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Community Mental Health Rehabilitation Services Chapter IV Medical Necessity Criteria

•Members receiving TDT must have the functional capability to understand and benefit from the required activities and counseling of this service.

•To qualify for Therapeutic Day Treatment reimbursement members must MEET ALL including the Diagnostic, At Risk and Level of Care criteria


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Community Mental Health Rehabilitation Services Chapter IV Medical Necessity Criteria: Diagnostic Criteria

Members qualifying for this service shall demonstrate a clinical necessity for the service arising from mental, behavioral or emotional illness which results in significant functional impairments in major life activities.

The diagnosis must be the primary clinical issue addressed with the service targeted for treatment and meet the following criteria:

MEET ONE:

The diagnosis must support the mental, behavioral or emotional illness attributed to the recent significant functional impairments in major life activities.


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Community Mental Health Rehabilitation Services Chapter IV Medical Necessity Criteria: At Risk Criteria

Members qualifying for this service shall demonstrate a clinical necessity for the service arising from a condition due to mental, behavioral or emotional illness which results in significant functional impairments in major life activities.

MEET TWO:

a. Have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or out-of-home placement because of conflicts with family or community.

b. Exhibit such inappropriate behavior that documented, repeated interventions by the mental health, social services or judicial system are or have been necessary.

c. Exhibit difficulty in cognitive ability such that they are unable to recognize

personal danger or recognize significantly inappropriate social behavior.


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Community Mental Health Rehabilitation Services Chapter IV Medical Necessity Criteria: At Risk of Hospitalization

MEET ONE:

• (i) within the two weeks before the intake, the member shall be screened by an LMHP type for escalating behaviors that have put either the member or others at immediate risk of physical injury such that crisis intervention, crisis stabilization, hospitalization or other high intensity interventions are or have been warranted

• (ii) the parent/guardian is unable to manage the member's mental, behavioral, or emotional problems in the home and is actively, within the past two to four weeks, seeking an out-of-home placement

• (iii) a representative of either a juvenile justice agency, a department of social services (either the state agency or local agency), a community services board/behavioral health authority, the Department of Education, or an LMHP, as defined in 12VAC35-105-20, and who is neither an employee of or consultant to the IIH services or therapeutic day treatment (TDT) provider, has recommended an out of-home placement absent an immediate change of behaviors and when unsuccessful mental health services are evident


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Community Mental Health Rehabilitation Services Chapter IV Medical Necessity Criteria: At Risk of Hospitalization continued

Must meet one:

•(iv) the member has a history of unsuccessful services (either crisis intervention, crisis stabilization, outpatient psychotherapy, outpatient substance abuse services, or mental health skill building) within the past 30 days

•(v) the treatment team or family assessment planning team (FAPT) recommends IIH services or TDT for an individual currently who is either:

• (a) Transitioning (within the last 30 days) out of residential treatment facility Level C services

• (b) Transitioning (within the last 30 days) out of a group home Level A or B services

• (c) Transitioning (within the last 30 days) out of acute psychiatric hospitalization,

• (d) Transitioning (within the last 30 days) between foster homes, mental health case management, crisis intervention, crisis stabilization, outpatient psychotherapy, or outpatient substance abuse services.


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Community Mental Health Rehabilitation Services Chapter IV Medical Necessity Criteria: Out of Home Placement

Placement in one or more of the following:

•either a Level A or Level B group home

•regular foster home if the member is currently residing with his biological family and, due to his behavior problems, is at risk of being placed in the custody of the local department of social services

•treatment foster care if the member is currently residing with his

biological family or a regular foster care family and, due to the member's behavioral problems, is at risk of removal to a higher level of care

•Level C residential facility

•emergency shelter for the member only due either to his mental health

or behavior or both

•psychiatric hospitalization

•juvenile justice system or incarceration


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Community Mental Health Rehabilitation Services Chapter IV Medical Necessity Criteria: Level of Care

MUST MEET ONE (a-e) a. The member must require year-round treatment in order to sustain behavior or emotional gains. b. The member’s behavior and emotional problems are so severe they cannot be handled in self-contained or resource emotionally disturbed (ED) classrooms without: (1) TDT programming during the school day (2) TDT programming to supplement the school day or school year. c. The member would otherwise be placed on homebound instruction because of severe emotional/behavior problems that interfere with learning. d. The member must (i) have deficits in social skills, peer relations or dealing with authority; (ii) are hyperactive; (iii) have poor impulse control; (iv) are extremely depressed or marginally connected with reality. e. The member is placed or pending placement in a preschool enrichment and/or early intervention program but the members emotional/behavioral problems are so severe that it is documented that they cannot function or be admitted in these programs without TDT services.


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Community Mental Health Rehabilitation Services Chapter IV Medical Necessity Criteria: Discharge Criteria

•Medicaid reimbursement is not available when other less intensive services may achieve stabilization

•Reimbursement shall not be made for this level of care if the following applies:

• The member no longer meets the at risk criteria

• The level of functioning has improved with respect to the goals outlined in the Individualized Service Plan (ISP), and the member can reasonably be expected to maintain these gains at a lower level of treatment.

‒ ISP means a comprehensive and regularly updated treatment plan specific to the member’s unique treatment needs as identified in the clinical assessment.


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Community Mental Health Rehabilitation Services Chapter IV Medical Necessity Criteria: Discharge Criteria continued

Discharge is required when the member has achieved maximal benefit from this level of care and their level of functioning has not improved despite the length of time in treatment and interventions attempted and the member meets all of the discharge criteria: •The member does not require year-round treatment in order to sustain behavior or emotional gains •The member’s behavior and emotional problems are successfully managed in a self- contained or resource emotionally disturbed (ED) classrooms without: TDT programming during the school day or TDT programming to supplement the school day or school year. •The member is no longer at risk of being placed on homebound instruction because of severe emotional/behavior problems that interfere with learning •The member no longer needs supports or does not (i) have deficits in social skills, peer relations or dealing with authority; (ii) are hyperactive; (iii) have poor impulse control; (iv) are extremely depressed or marginally connected with reality •The member is able to be placed or admitted into a preschool enrichment and/or early intervention program but the member's emotional/behavioral problems without the documented need for supports provided by TDT services.


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Community Mental Health Rehabilitation Services Chapter IV: Covered Services

•Completing diagnostic evaluations, identifying treatment needs

•Consultation with teachers and others involved in the member’s treatment and observation in the classroom.

•Planning and implementing individualized pro-social skills curriculums and

interventions

•Monitoring progress in demonstrating the acquisition of pro-social skills

•Implementing cognitive-behavioral programming


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Community Mental Health Rehabilitation Services Chapter IV: Covered Services continued

•Planning and implementing individualized behavior modification programs and

monitoring progress

•Family contacts, either in person or by telephone, occurs at least once per week.

•Responding to and providing on-site crisis response during the school day and behavior management interventions throughout the school day

•Debriefing with the member and family to discuss the incident

• Providing individual, group, and family counseling

•Collaborating with all other community practitioners


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Community Mental Health Rehabilitation Services Chapter IV: Covered Services continued

•If the member is on medication related to their behavioral health needs, education about side effects, monitoring of compliance and referrals for routine physician follow up must be provided to the individual and parent/ guardian and documented.

•Response to medication and education, as well as compliance must also be documented.


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Community Mental Health Rehabilitation Services Chapter IV: Limitations

•The program must operate a minimum of two hours per day and may offer flexible program hours (e.g., before school, after school, or during the summer). A minimum of two or more therapeutic activities shall occur per day. This may include individual or group counseling/therapy and psycho-educational activities.

•Services shall be provided by an LMHP, LMHP-supervisee, LMHP-resident, LMHPRP, QMHP-C or QMHP-E.

•Therapeutic group activities, such as counseling, psychotherapy, and psycho-education are limited to no more than 10 members.


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Community Mental Health Rehabilitation Services Chapter IV: Limitations continued

•Medicaid will only reimburse for allowed service activities as defined in the ISP.

•Activities that are not allowed / reimbursed:

• Inactive time or time spent waiting to respond to a behavioral situation

• Transportation

• Time spent in documentation of individual and family contacts, collateral contacts, and clinical interventions

•Services must not duplicate those services provided by the school.


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12VAC30-50-130. Skilled Nursing Facility Services, EPSDT, School Health Services, and Family Planning. •Therapeutic day treatment (TDT):

• 2 hours per day with therapeutic interventions

• Limited to 780 units annually

• Service authorization shall be required for Medicaid reimbursement.

• Service-specific provider intakes shall be required at the onset of services and ISPs shall be required during the entire duration of services. Services based upon incomplete, missing, or outdated service-specific provider intakes or ISPs shall be denied reimbursement. Requirements for service-specific provider intakes and ISPs are set out in this section.

• These services may be rendered only by an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or a QMHP-E.


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Regulations: Code of Virginia for TDT

12VAC30-50-130. Skilled Nursing Facility Services, EPSDT, School Health Services, and Family Planning.

•Gives over all service definitions

•Service will be provided for 2 or more hours a day

•Maximum of 780 units per year

•Service authorization shall be required for Medicaid reimbursement

•Service provider specific intake

•Community-based services for children and adolescents under 21 years of age

•For more information about this regulation please reference: http://law.lis.virginia.gov/admincode/title12/agency30/chapter50/section130/


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http://law.lis.virginia.gov/admincode/title12/agency30/chapter50/section130/


Regulations: Code of Virginia for TDT

12VAC30-60-61. Services Related to the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT); Community Mental Health Services for Children.

•Overview of medical necessity criteria

•Discusses what hours the program can operate within

•Refers to DBHDS licensing requirements for minimum staff-to-individual ratio

•Reference marketing requirements found in 12VAC30-130-2000 for providers

•Discusses what provider should do if there is a lapse in services greater than 31 days

•Information about Individualized service plans are reference 12VAC30-50-226

•Discusses expectations for contact with primary care physician

•For more details about this regulation please reference: http://law.lis.virginia.gov/admincode/title12/agency30/chapter60/section61/


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When submitting an SRA, what should I include?

•Diagnosis

•Description of child’s immediate behaviors prior to admission and within the last 30 days

•Child’s functional level

•Clinical stability

•The level of family support

•Please ensure for the first continued stay review, that a member’s Individual Service Plan (ISP) is included


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SRA elements you will see on a Magellan Healthcare form

Initial Request Submission form will include the following:

1) VICAP/Intake (questions 1-9)

2) Service Coordination (questions 10-14)

3) Clinical (questions 15-29)

Continued Stay Request Submission form will include the following:

1) VICAP/Intake (questions 1-6)

2) Service Coordination (question 7-11)

3) Clinical (questions 12-27)


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SRA elements you will see on a Magellan Healthcare form: Initial and Concurrent Reviews: VICAP/Intake

Initial #3; Concurrent (CCR) #5: Was an independent clinical assessment completed through the Community Services Board (CSB/Behavioral Health Authority (BHA)?

Initial #9; CCR #6: Have you submitted an SRA for this service and for this individual within the last 30 days which was not approved?

Initial #10; CCR #7: Have Health, Safety, and Welfare issues been identified with this individual? If yes, has a Child Protective Services (CPS) referral been made? If no, what intervention(s) have been taken to address this concern?


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SRA elements you will see on a Magellan Healthcare form: Initial and Concurrent Reviews: Clinical

Initial #15; CCR #12: Date individual was admitted to Therapeutic Day Treatment Service.

Initial #18; CCR #16: Does the individual have difficult in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or out of home placement behaviors of conflicts with family or community?

Initial #19; CCR #17: Does the individual exhibit behaviors that require repeated interventions by the mental health, social services, or judicial system?


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SRA elements you will see on a Magellan Healthcare form: Initial and Concurrent Reviews: Clinical continued

Initial #20; CCR #18: Does the individual exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior?

Initial #26; CCR #24: List the treatment goals identified for the individual related to the behaviors listed above. If immediate physical threat to self or others is indicated in the VICAP, intake or during provision of service, include safety goals included in the ISP


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Legal disclaimers

Confidentiality Statement for Educational Presentations


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By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health, Inc. The information contained in this presentation is intended for educational purposes only and is not intended to define a standard of care or exclusive course of treatment, nor be a substitute for treatment. The information contained in this presentation is intended for educational purposes only and should not be considered legal advice. Recipients are encouraged to obtain legal guidance from their own legal advisors.

Confidentiality Statement for Providers


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The information presented in this presentation is confidential and expected to be used solely in support of the delivery of services to Magellan members. By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health, Inc. The information contained in this presentation is intended for educational purposes only and should not be considered legal advice. Recipients are encouraged to obtain legal guidance from their own legal advisors.

Thank You

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