Download 4.302 Halfway House/Low Intensity Residential

Clinical Criteria
4.30
RESIDENTIAL TREATMENT SERVICES
4.302 Halfway House/Low Intensity Residential (Adults and Adolescents)
Description of Services: Low intensity residential substance use disorder programs (such as halfway houses)
are state licensed, supportive living environments that in general offer at least 5 hours per week of
substance abuse related services. The focus is on recovery, responsibility, improvement of functioning and
relapse prevention. Treatment efforts need to focus on the individual's response, as well as the continuity
and transfer of treatment gains during the individual's non-program hours in the home/community. A goal
is to enable successful transition to appropriate social, vocational or educational roles. This is an
intermediate level of care for individuals who do not need the structured supervision and more intensive
services of an inpatient unit or a more clinically managed residential setting but are not appropriate for less
restrictive levels of care. These programs may be combined with other levels of care such as IOP if
appropriate. Services may include individual, group and family sessions and are tailored to the individual’s
needs including psychosocial, occupational, cultural and linguistic factors. Self-help support meetings are
typically on site. Family involvement is important and must be initiated at admission unless contraindicated.
Development of a recovery support network is essential. Individuals meeting criteria for this level of care
may have an environment at home that is incompatible with recovery. Telephonic access to a physician and
emergency services must be available at all times. Licensure and credentialing requirements specific to
facilities and individual practitioners do apply and are found in our provider manual/credentialing
information.
In general the medical necessity for the treatment of substance abuse disorders for adolescents is similar to
that of adults. However, in considering the following criteria several factors unique to the adolescent
population should be taken into consideration. Among these are the cognitive and emotional developmental
aspects, any neurodevelopmental issues, and family support/supervision. In addition, an important area of
focus is the individual's external peer group (friends, schoolmates etc.), availability of school-based drug
prevention programs and how they affect the accomplishment of a successful outcome. Also it is necessary
to focus on problem solving skills, relapse prevention, social skills and academics as they relate to the
individual individual's treatment. The development of a social support network that enhances the likelihood
of successful treatment and maintained sobriety requires careful coordination amongst the treatment team,
parents and individual. In general, coexisting medical issues requiring higher levels of care are less common
in adolescents.
Important: While level of care determinations are considered in the context of an individual's
treatment history; Beacon Health Options never requires the attempt of a less intensive treatment
as a criterion to authorize any service.
Criteria
Admission Criteria
All of the following criteria are necessary for admission:
1.
The individual demonstrates symptomatology consistent with a substance
use diagnosis listed in the most current DSM which requires and can
reasonably be expected to respond to therapeutic intervention.
Reviewed: 1/21/13, 11/18/13, 11/17/14, 2/5/15, 11/17/15
Revised: 11/17/14, 2/5/15
Page 1 of 4
This criterion is consistent with NCD and/or LCD.
Beacon Health Options Policies and Procedure and Medical Necessity Criteria cover the operations of all entities within the BVO
Holdings, LLC corporate structure, including but not limited to Beacon Health Strategies LLC, Beacon CBHM LLC and
ValueOptions, Inc.
Clinical Criteria
2.
The individual is not sufficiently stable to be treated outside of a
supportive, structured, 24-hour therapeutic environment.
3.
If signs or symptoms of withdrawal are present, they can be safely managed
at this level of care.
4.
The individual demonstrates a capacity to respond favorably to
rehabilitative counseling, education and training in areas such as recovery,
problem solving, independent life skills, and relapse prevention and
medication compliance, as appropriate.
5.
The individual is able to function with some independence and participate
in community-based activities for limited periods of time that are
structured to develop self-reliance and reintegration into community.
Any medical or psychiatric issues present are stable and do not require on
site professional medical monitoring and intervention. Any medications
can be self-administered safely. Access to medication for treatment of
addiction is available.
7. The individual recognizes the need for change and is expected to be willing
and able to participate in the treatment process but has limitations in the
necessary skills to address relapse prevention.
6.
Psychosocial,
Occupational, &
Cultural & Linguistic
Factors
Exclusion Criteria
8.
The individual lacks family or community supports sufficient to maintain
him/her in the community with treatment at a lower level.
9.
Less restrictive settings have been unsuccessful or are not likely to be
adequate to treat the individual at this point in time.
These factors, as detailed in the Introduction, may change the risk assessment and should be
considered when making level of care decisions.
Any of the following criteria is sufficient for exclusion from this level of care:
1.
Suicidal/assaultive/destructive ideas, threats, plans or attempts as
evidenced by degree of intent, lethality of plan, means, hopelessness or
impulsiveness; or acute behavioral, cognitive, or affective loss of control
that could result in danger to self and/or others and cannot be controlled
in this setting.
2.
The individual has medical conditions or impairments that would prevent
beneficial utilization of services, or is not stabilized on medications.
3.
The individual requires a level of structure and supervision beyond the
scope of the program.
4.
The individual can be safely maintained and effectively treated at a less
intensive level of care.
5.
The primary problem is social, legal, economic (i.e. housing, family,
Reviewed: 1/21/13, 11/18/13, 11/17/14, 2/5/15, 11/17/15
Revised: 11/17/14, 2/5/15
Page 2 of 4
This criterion is consistent with NCD and/or LCD.
Beacon Health Options Policies and Procedure and Medical Necessity Criteria cover the operations of all entities within the BVO
Holdings, LLC corporate structure, including but not limited to Beacon Health Strategies LLC, Beacon CBHM LLC and
ValueOptions, Inc.
Clinical Criteria
conflict, etc.), or one of physical or mental health without a concurrent
substance use disorder meeting criteria for this level of care, or admission is
being used as an alternative to incarceration.
6.
Continuing Stay
Criteria
The service is in a location prohibitive to transferring of treatment gains to
the individual’s social, family, vocational or educational roles.
All of the following criteria are necessary for continuing treatment at this level of care:
1.
The individual’s condition continues to meet admission criteria at this level
of care.
2.
The individual’s treatment does not require a more intensive level of care,
and no less intensive level of care would be appropriate.
3.
Treatment planning is documented and individualized and appropriate to
the individual’s changing condition with realistic and specific goals and
objectives stated. Treatment planning includes active family or other
support system involvement unless contraindicated. The expected benefits
from all relevant treatment modalities are clear. The treatment plan has
been implemented and updated with consideration of all applicable and
appropriate treatment modalities and there is fair likelihood that the
individual will demonstrate progress in treatment.
4.
Progress in relation to specific symptoms or impairments is clearly evident
and can be described in objective terms, but goals of treatment have not yet
been achieved or adjustments in the treatment plan to address lack of
progress are evident.
5.
An individualized discharge plan has been developed which includes
specific realistic, objective and measurable discharge criteria and plans for
appropriate follow-up care. A timeline for expected implementation and
completion is in place but discharge criteria have not yet been met.
6.
Care is rendered in a clinically appropriate manner and focused on the
individual’s behavioral and functional outcomes as described in the
treatment plan.
7.
An individual is actively participating in treatment to the extent possible
consistent with his/her condition, or there are active efforts being made
that can reasonably be expected to lead to the individuals engagement in
treatment.
8.
Unless contraindicated, family/significant others are actively involved in
the treatment as required by the treatment plan, or there are active efforts
being made and documented to involve them.
9.
When medically necessary, appropriate psychopharmacological intervention
has been prescribed and/or evaluated. Ongoing monitoring of medication
compliance is evident.
Reviewed: 1/21/13, 11/18/13, 11/17/14, 2/5/15, 11/17/15
Revised: 11/17/14, 2/5/15
Page 3 of 4
This criterion is consistent with NCD and/or LCD.
Beacon Health Options Policies and Procedure and Medical Necessity Criteria cover the operations of all entities within the BVO
Holdings, LLC corporate structure, including but not limited to Beacon Health Strategies LLC, Beacon CBHM LLC and
ValueOptions, Inc.
Clinical Criteria
10. There is a documented active attempt at coordination of care with relevant
outpatient providers and community support systems.
11. Random screening tests for drugs of abuse should occur to monitor
adherence and ongoing progress. Testing meets medical necessity criteria
defined in 4.701-Substance use laboratory testing for drug and alcohol use.
Discharge Criteria
At least one of 1-6, in addition to 7 are sufficient for discharge from this level of care
1.
The individual’s documented treatment plan, goals and objectives have
been substantially met, and/or a safe, continuing care program can be
arranged and deployed at an alternate level of care.
2.
The individual no longer meets admission criteria, or meets criteria for a
less or more intensive level of care.
3.
The individual, family and/or significant other are competent but nonparticipatory in treatment or in following the program rules and regulations.
The non-participation is of such a degree that treatment at this level of care
is rendered ineffective or unsafe, despite multiple, documented attempts to
address non-participation issues.
4.
Consent for treatment is withdrawn, and it is determined that the individual
has the capacity to make an informed decision and does not meet criteria
for an inpatient level of care.
5.
Support systems, which allow the individual to be maintained in a less
restrictive treatment environment, have been thoroughly explored and/or
secured.
The individual is not making progress toward treatment goals and there is
no reasonable expectation of progress at this level of care.
and
7. An individual discharge plan is documented with appropriate and timely
follow up care in place.
6.
Reviewed: 1/21/13, 11/18/13, 11/17/14, 2/5/15, 11/17/15
Revised: 11/17/14, 2/5/15
Page 4 of 4
This criterion is consistent with NCD and/or LCD.
Beacon Health Options Policies and Procedure and Medical Necessity Criteria cover the operations of all entities within the BVO
Holdings, LLC corporate structure, including but not limited to Beacon Health Strategies LLC, Beacon CBHM LLC and
ValueOptions, Inc.