UM Guidelines

Applies to BlueCare Only.

Clinical Indications for Admission to Intensive Outpatient Program

• Intensive Care Coordination (ICC) is judged appropriate as indicated by ALL of the following):
  • The youth meets the criteria for serious emotional disturbance (SED) as defined by ALL of the following:
    • The youth has received a diagnosis within the last 12 months of a mental, behavioral, or *emotional disorder specified within the current Diagnostic and Statistical Manual (with exception of V codes, substance use, and developmental disorders, unless these disorders co-occur with another diagnosable disturbance) AND
    • The youth has exhibited 1 or more of the following characteristics over a long period of time and to a marked degree that adversely affects educational performance:
      • an inability to learn that cannot be explained by intellectual, sensory, or health factors
      • an inability to build and maintain satisfactory interpersonal relationships with peers and teachers
      • inappropriate types of behavior or feelings under normal circumstances
      • a general pervasive mood of unhappiness or depression
      • a tendency to develop physical symptoms or fears associated with personal or school problems
    • The youth demonstrates clinically significant functional impairment across multiple life domains, including Basic Well-Being, Living Environment & Safety, Cognition & Daily Functioning, Social & Interpersonal, and Behavioral Health. These impairments are evidenced by limitations in two or more domains, resulting in reduced ability to function independently, maintain stability in the home and community, and safely engage in daily activities.
  • The clinical documentation supports the need for the safety and structure of treatment provided the individual’s behavioral health issues are unmanageable as evidenced by ALL the following:
    • Documented history of multiple admissions to crisis stabilization programs or psychiatric hospitals within the past 12 months
    • Documented utilization of two or more crisis-oriented behavioral health services within the past (12 months), indicating the need for enhanced coordination and wraparound support i.e mobile crisis, crisis stabilization, emergency behavioral health evaluations, or other interventions aimed at stabilizing the youth and/or family in the community. OR two or more psychiatric hospitalizations within the past (12 months)
    • The individual has not progressed sufficiently OR has regressed
    • Past response to treatment has been minimal, even when treated at high levels of care for extended periods of time due to lack of, or insufficient coordination
    • The individual requires multiple services, other than Intensive Care Coordination, across different domains (e.g., medical, educational, social, therapeutic) that require coordination to ensure effective treatment and support
    • The child or youth’s support system is in need of intensive family support service interventions to stabilize care in the home and community
  • ALL the following statements are true: 
    • The individual does not have any of the following diagnoses considered to be a sole diagnosis: Rule-Out (R/O) diagnoses, Personality Disorders, Severe and Profound Intellectual/Developmental Disabilities
    • Individuals diagnosed with Conduct Disorder, Traumatic Brain Injury, Mild Intellectual/Developmental Disabilities, Moderate Intellectual/Developmental Disabilities, Autism Spectrum Disorder are excluded from admission unless there is clearly documented evidence that an additional psychiatric diagnosis is the foremost consideration for psychiatric intervention
    • The emotional impairment of the individual is not solely the result of a hearing impairment, vision impairment, deaf-blind impairment, language impairment, health impairment, specific learning disability, or a combination thereof

Continued Review Criteria

• Member continues to meet the following criteria for Intensive Care Coordination (ICC) as indicated by ALL of the following:
  • The youth’s clinical condition(s) continues to warrant ICC services in order to coordinate the youth’s involvement with multiple service providers
  • Progress toward Individualized Care Plan (ICP) identified goals is evident and has been documented based upon the objectives defined for each goal, but the goals have not yet been substantially achieved despite sound clinical practice consistent with Wraparound and Systems of Care principles
  • Progress has not been made and the ICC Team has identified and implemented changes and revisions to the ICC Plan to support the goals of the youth and family

Discharge Criteria

• The member is appropriate for discharge when 1 or more of the following conditions have been met:
  • The youth has reached their optimal level of functioning with available services and coordination.
  • The ICC Team determines that the youth’s documented ICC goals and objectives have been substantially met, and continued services are not necessary to prevent worsening of the youth’s behavioral health condition.
  • Consent for treatment is withdrawn.
  • The youth and parent/caregiver are not engaged in the ICC plan. Despite multiple, documented attempts to address engagement, the lack of engagement is of such a degree that it implies withdrawn consent or treatment at this level of care becomes ineffective or unsafe.
  • The youth is placed in a hospital, skilled nursing facility, psychiatric residential treatment facility, or other residential treatment setting and is unable to return to a family home environment or a community setting with community-based supports or ICC
    

References

Guideline developed at the request of the Division of TennCare.