1. Residential Rehabilitation The clinical review process and the Medical Necessity Criteria

2. Principles of RRP Services Residential Rehabilitation Programs (RRPs) for adults provides support in a residence outside of the Individual’s own home and provides needed resources and support not sufficiently available within the Individuals own existing social support system. RRPs provide services based upon the Individual’s needs in varying levels of support: General Support - Staff is available, on-call, 24/7 and provides, at a minimum, three face-to-face contacts per Individual/week, or 13 face-to-face contacts/month. Intensive Support - Staff provides services daily, on-site, in the residence, w/ a minimum of 40 hours/week, up to 24 hours/day, 7 days/week.

3. Severity of Need/Intensity of Service Medical necessity for admission to a RRP must be documented by the presence of all of the MNC. Medical necessity for admission to a RRP must be documented by the presence of all of the MNC. Location and length of service varies based on the Individual’s needs and medical necessity. Location and length of service varies based on the Individual’s needs and medical necessity. Active involvement of the Individual, family, or significant others involved in the Individual’s treatment should be sought. Active involvement of the Individual, family, or significant others involved in the Individual’s treatment should be sought.

4. General Admission MNC (P1) All of the following (A through E) are necessary for admission: A. The consumer has a PMHS specialty mental health DSM-IV diagnosis which is the cause of significant functional and psychological impairment, and the Individual’s condition can be expected to be stabilized through the provision of medically necessary supervised residential services in conjunction with medically necessary treatment, rehabilitation, and support. B. The Individual requires active support to ensure the adequate, effective coping skills necessary to live safely in the community, participate in self-care and treatment, and manage the effects of his/her illness. As a result of the Individual’s clinical condition (impaired judgment, behavior control, or role functioning) there is significant current risk of one of the following:

5. General Admission MNC (P2) Hospitalization or other inpatient care as evidenced by the current course of illness or by the past history of the illness Hospitalization or other inpatient care as evidenced by the current course of illness or by the past history of the illness Harm to self or others as a result of the mental illness and as evidenced by the current behavior or past history Harm to self or others as a result of the mental illness and as evidenced by the current behavior or past history Deterioration in functioning in the absence of a supported community-based residence that would lead to the other items. Deterioration in functioning in the absence of a supported community-based residence that would lead to the other items. C. The Individual’s own resources and social support system are not adequate to provide the level of residential support and supervision currently needed as evidenced for example, by one of the following:

6. General Admission MNC (P3) The Individual has no residence and no social support; The Individual has no residence and no social support; The Individual has a current residential placement, but the existing placement does not provide sufficiently adequate supervision to ensure safety and ability to participate in treatment; or The Individual has a current residential placement, but the existing placement does not provide sufficiently adequate supervision to ensure safety and ability to participate in treatment; or The Individual has a current residential placement, but the Individual is unable to use the existing residence to ensure safety and ability to participate in treatment, or the relationships are dysfunctional and undermine the stability of treatment The Individual has a current residential placement, but the Individual is unable to use the existing residence to ensure safety and ability to participate in treatment, or the relationships are dysfunctional and undermine the stability of treatment D. The Ct is able to reliably cooperate w/ the rules/supervision & to contract reliably for safety in the supervised residence. E. All less intensive levels of Tx have been determined to be unsafe or unsuccessful.

7. Intensive Admission MNC (P1) All of the following (A through I) are necessary for admission: A. (& B.) The consumer has a Priority Population Dx which is the cause of significant functional & psychological impairment & the Individual’s condition can be expected to be stabilized through the provision of medically necessary, supervised, residential services in conjunction w/ medically necessary treatment, rehabilitation, & support. C. The Individual has a Hx of at least one of the following: criminal behavior, Tx and/or med non-compliance, SA, aggressive behavior, psychiatric hospitalizations, psychosis, and/or poor reality testing AND

8. Intensive Admission MNC (P2) And currently presents with at least one of the following behaviors or risk factors that require daily structure and support in order to manage - Safety risk, active delusions, active psychosis, poor decision making skills, impulsivity, inability to perform ADL skills to maintain tasks necessary to live in the community, impaired judgment (including social boundaries), inability to self- protect in community situations, inability to safely self-medicate or otherwise self-manage the illness, aggression, inability to access community resources necessary for safety, and/or impaired community living skills

9. Intensive Admission MNC (P3) D. The Individual requires active support to ensure the adequate, effective coping skills necessary to live safely in the community, participate in self-care and Tx, and manage the effects of his/her illness. As a result of the Individual’s clinical condition (impaired judgment, behavior control, or role functioning) there is significant current risk of one of the following: hospitalization or other inpatient care as evidenced by the current course of illness or by the past history of the illness, harm to self or others as a result of the mental illness and as evidenced by the current behavior or past history, or deterioration in functioning in the absence of a supported community-based residence that would lead to the other items.

10. Intensive Admission MNC (P4) E. The Individual’s own resources & social supports are not adequate to provide the level of residential support and supervision currently needed as evidenced for example, by one of the following: The Individual has no residence and no social support The Individual has no residence and no social support The Individual has a current residential placement, but the existing placement does not provide sufficiently adequate supervision to ensure safety and ability to participate in Tx The Individual has a current residential placement, but the existing placement does not provide sufficiently adequate supervision to ensure safety and ability to participate in Tx The Individual has a current residential placement, but the Individual is unable to use the existing residence to ensure safety and ability to participate in Tx, or the relationships are dysfunctional and undermine the stability of Tx The Individual has a current residential placement, but the Individual is unable to use the existing residence to ensure safety and ability to participate in Tx, or the relationships are dysfunctional and undermine the stability of Tx

11. Intensive Admission MNC (P5) F. The Individual is judged to be able to reliably cooperate with the rules and supervision provided and to contract reliably for safety in the supervised residence. G. The Individual must also be receiving Psychiatric Rehabilitation Program (PRP) services. H. Priority for this level of care is given to Individuals currently hospitalized in state psychiatric hospitals that are ready for discharge and for Individuals at risk of hospitalization or due to the need for mental health support and treatment are at risk for incarceration or homelessness. I. All less intensive levels of treatment have been determined to be unsafe or unsuccessful.

12. Continued Stay MNC (P1) All of these are necessary for continuing Tx: A. The consumer continues to meet admission criteria. B. There is continued risk of deterioration in functioning that may lead to inpatient admission or harm to self and/or others. C. There is evidence that the resources and social support system, which are available to the Individual outside the supervised residence continue to be inadequate to provide the level of residential support and supervision currently needed for safety, self-care or effective treatment despite current treatment, rehabilitation and discharge planning.

13. Continued Stay MNC (P2) D. Progress in relation to specific symptoms/ impairments/dysfunction is clearly evident and can be described in objective terms, but goals of treatment have not been achieved or adjustments in the treatment plan to address the lack of progress are evident and/or a second opinion on the treatment plan has been considered. E. There is documented active planning for transition to a less intensive level of care

14. Case Examples and Discussions Documentation That Led To Follow Up Phone Calls From ValueOptions®

15. Case Example #1 Initial Intensive: Ct has been diagnosed with Psychotic D/O NOS and Personality D/O NOS. He has a history of hospitalizations and substance abuse. He was referred for mental health supports and education, stable housing, and community support linkage. This agency will provide the Ct. with linkage to a day program for mental health education, substance abuse education and coping skills. The agency will provide case management, medication monitoring, linkage to NA and AA, and ADL skills building.

16. Case Example #1 Discussion This is a good picture of what services a RRP provides but it lacks information about the consumer’s current functioning; the consumer’s current living situation (what are the threats to maintaining that housing?); the risk to the consumer (health, housing, legal, etc.), what the history of treatment efforts has been, and why/how a lower level of care would be either inadequate or unsafe to try.

17. Case Example #2 Concurrent Review, Intensive: Ct’s progress has been steady during this auth period. He needs medication monitoring. He needs to coordinate his activities independently. He requires staff assistance at the current level of care until he can function with less supervision and support. He hopes to obtain his driver’s license, live independently, and get a job. He will learn how to create and use a budget. He will plan weekly menus, prepare grocery lists, buy groceries, cook healthy and nutritious meals independently. He will avoid psychiatric hospitalizations and remain mentally stable for the next 6 months.

18. Case Example #2 Discussion Consumer’s goals are clear & appear sound. However, the documentation fails to demonstrate that the consumer meets the MNC. For example, there is nothing that talks about the consumer’s current symptoms of mental illness; nothing linking those symptoms to the rehabilitative needs of the consumer; nothing about what progress the consumer has made, nothing about how the Tx plan will be changed to address a lack of progress; & there is no documentation of active planning to step down to a lower LOC.

19. Case Example #3 Concurrent Review General: Ct. is a 35 YO male diagnosed with schizoaffective d/o and HTN. He has a Hx. of med noncompliance. He denies his illness. He has his meds monitored to prevent psychiatric and somatic issues that could lead to hospitalization. He is working toward improving his independent living skills. He wants to find a job, get a driver’s license, and find his own house.

20. Case Example #3 Discussion Consumer’s goals are clear & appear sound. However, the documentation fails to demonstrate that the consumer meets the MNC. For example, there is nothing that talks about the consumer’s current symptoms of mental illness; nothing linking those symptoms to the rehabilitative needs of the consumer; nothing about what progress the consumer has made, nothing about how the Tx plan will be changed to address a lack of progress; & there is no documentation of active planning to step down to a lower LOC.

21. Case Example #4 Concurrent Review, General: Ct’s conditional release ended in 6/13. Ct is so excited to be off of it & moving toward independence. Ct continues to reside w/in the RRP w/ the goal of graduating/moving into supportive housing. She’s currently self-monitoring her meds & is doing well w/ this. Ct has not displayed any difficulties managing her illness & has been relatively symptom- free. She struggles w/ family relationships; often arguing w/ her sister. S sometimes forgets her appointments but, overall, is able to manage these independently. She’s overweight & has said she would like to lose 20 lbs. She quit smoking but still struggles with saving money. She is looking for a job.

22. Case Example #4 Discussion The consumer’s goals and progress are clear. What isn’t clear is the psychiatric diagnosis, the symptoms that drive a functional impairment, or a functional impairment that requires supervised residential services. If a house was available, what about her current, day-to-day functioning would prevent her from living independently? What about her day-to-day functioning would put her at risk for out of home placement?

23. Case Examples and Discussions Good Documentation

24. Case Example #5 Intensive Concurrent: Ct struggles w/ managing his hygiene. He doesn’t shower regularly due to visions/voices telling him not to. This directly affects his program attendance and MD appt compliance due to embarrassment. Ct tends to isolate due to paranoia that others talk about him. This prevents him from attending PRP outings/socializing w/ his roommates. Ct is disorganized & impulsive which has created outstanding debt; he struggles w/ paying off past balances & runs out of money before the end of the month. Due to his disorganization, the Ct is not able to monitor his own meds; easily gets confused re: which pills are which or when he took his last dose. Ct is able to clean home when prompted & is compliant w/ meds due to staff med monitoring. Ct works w/ voc services to find employment. When psychosis decreases, will discuss step down to general services due to the consumer having no family or social supports outside of current RRP services.

25. Case Example #5 Discussion The consumer’s diagnosis, current symptoms, levels of impairment, and potential for deterioration are clear. His own social supports and resources would not meet his needs. There is a good sense of the progress the consumer is making but there is also a good sense of the goals needing continued RRP services. In addition to this, there is even a thought process documented regarding the criteria for discharge planning to begin.

26. Case Example #6 Concurrent Review, Intensive: Ct has Schizophrenia & attends PRP daily, is dressed appropriately for most weather conditions (however, he tends to wear sunglasses & a jacket at all times, even at home), & Ct isolates from others due to paranoia. All of these represent Ct’s baseline. Ct. is unable to stay focused for more than 15 mins due to AH/VH. Staff work w/ Ct to improve social skills. Ct is disorganized & has a hard time commun- icating his needs or budgeting money. Due to social anxiety, he feels uncomfortable speaking up & is taken advantage of by peers. Ct needs assistance maintaining a clean living environ- ment. Staff make a cleaning schedule & assist daily. Grand- mother visits x1/month but is in poor health & is not a discharge resource. Client’s goal for independent housing is a driver for Ct compliance w/ ADL skill building.

27. Case Example #6 Discussion The consumer’s diagnosis, current symptoms, levels of impairment, and potential for deterioration are clear. His own social supports and resources would not meet his needs. There is a good sense of the progress the consumer is making but there is also a good sense of the goals needing continued RRP services. In addition to this, there is even a thought process documented regarding the criteria for discharge planning to begin.

28. Case Example #7 Concurrent Review, General: Ct is diagnosed w/ Schizophrenia & experiences paranoia, isolation, & disorganization. Due to his paranoia, he tends to stay in his room & hasn’t been attending all the days of PRP. Ct is disorganized & neglects his personal appearance; he is often disheveled w/ poor grooming; he’s struggled to find a job due to his ADLs. His apt is usually in disarray. Staff work w/ Ct on improved organizational skills & keeping track of his appts. The disor- ganization also affects his ability to manage his meds. He’s able to self-administer w/ a packer but needs staff to monitor him packing & to call in refills on time. Staff attend appts w/ Ct & regularly collaborate w/ his Tx providers. Ct. is able to fix simple meals. W/out continued services, Ct would be at increased risk for isolation, decompensation, hospitalization, & homelessness. Sister lives in Washington State and is not a discharge resource.

29. Case Example #7 Discussion The consumer’s diagnosis, current symptoms, levels of impairment, and potential for deterioration are clear. His own social supports and resources would not meet his needs. There is a good sense of the progress the consumer is making but there is also a good sense of the goals needing continued RRP services. In addition to this, there is even a thought process documented regarding the criteria for discharge planning to begin.

30. Case Example #8 Initial General: Ct has been a member of our PRP program for several years. Ct lost her job about 6 months ago & was evicted from her home; resulting in homelessness for the last 3 months. She’s been sleeping in her car. Ct was recently suicidal & stayed in a crisis bed. She continues to experience depression & some AH. Her depression causes her to be unable to get out of bed, search for a new job, or take care of her ADLs. She’s had poor med compliance in the last few weeks. Ct’s mother died in the last year, and this seems to have led to some of Ct’s decompensation. Despite ongoing PRP, Ct has struggled to take her meds. She’s impulsive, often sleeping w/ strangers & getting into verbal conflicts w/peers because she says things w/out thinking. She’s seen for OP Tx at __. She’s never been hospitalized but is at risk due to her recent SI. She is eager to receive services.

31. Case Example #8 Discussion Consumer’s Dx is causing significant impairment Consumer has been unable to care for herself for several months and is in need of some skill building Consumer has recently had some threat to self, a significant decompensation, and has accessed crisis services as a result The CSA has vouched for the idea that she has tried all safe and lower levels of care that are available in the community Consumer is homeless and has no known supports

32. Suggestions for future requests Have the MNC in front of you while writing your request Have the MNC in front of you while writing your request For concurrent reviews, do not spend a lot of time detailing history or what services a RRP provides, but focus on current symptoms, presentation, and how this links to the client’s goals For concurrent reviews, do not spend a lot of time detailing history or what services a RRP provides, but focus on current symptoms, presentation, and how this links to the client’s goals If the PRP worker does not know the symptoms or have all the information, please collaborate with the therapist before submitting the review. Do not give VO the phone number for the therapist. If the PRP worker does not know the symptoms or have all the information, please collaborate with the therapist before submitting the review. Do not give VO the phone number for the therapist. Put the contact name of someone who will quickly be able to respond to any questions that VO might have Put the contact name of someone who will quickly be able to respond to any questions that VO might have If the current IRP doesn’t allow for all of the information being asked for, please use the clinical narrative free text box in ProviderConnect or submit an attachment if more space is needed If the current IRP doesn’t allow for all of the information being asked for, please use the clinical narrative free text box in ProviderConnect or submit an attachment if more space is needed Don’t put progress as “ongoing”, “minimal”, “great”, or “this is a new goal”. Be specific and detail the progress (or lack thereof) made on the most recent goals Don’t put progress as “ongoing”, “minimal”, “great”, or “this is a new goal”. Be specific and detail the progress (or lack thereof) made on the most recent goals