Residential psych., children/adolescents
Residential psychiatric treatment (RTC, domiciliary care) is defined as 24-hour, supervised, inpatient level of care provided to children and adolescents who have long-term illnesses not likely to respond to short-term interventions. Programs should provide, in addition to diagnostic and treatment services, instruction and support toward attainment of basic living skills, which will enable them to live in the community upon discharge.
When a member lives in a state where admission and discharge criteria are defined under law, the state's criteria will supersede Priority Health's medical necessity criteria.
A. Medical necessity
All are required to consider for admission.
- The child or adolescent has been diagnosed with a psychiatric disorder by a licensed mental health professional.
- Symptoms of this illness accord with those described in the Diagnostic and Statistical Manual of Mental Disorders, Edition IV (DSM-IV).
- The diagnosis must have been arrived at prior to admission in a face-to-face encounter between the professional and the patient.
B. Admission criteria
All must be met to recommend admission.
- There is clear clinical evidence that the child/adolescent has a severe mental illness that requires a level of intensity of services not available in the community.
- The illness or disorder is likely to improve with active treatment.
- Without this intervention, there is clear evidence that the child/adolescent will likely decompensate and represent a proximal risk of serious harm to self or others.
C. Continuing care criteria
All must be met to recommend continuing care.
- The patient continues to exhibit signs and symptoms consistent with admission criteria.
- There is a complete, multidisciplinary, individualized treatment plan, which includes input from the patient and family.
- The treatment plan defines clear, measurable objectives leading to a goal of return to the community.
- There is documented evidence of active psychiatric care, which is symptom-focused and specific to the child's/adolescent's diagnosis.
- There is documented evidence of active family therapy at least weekly or clearly documented evidence that such is either impossible or medically contraindicated.
