Group Living-Low Intensity - Partners Health Management



State Funded ServicesFamily Living – High Intensity – YM755MetNot MetN/ARequired Elements to Approve Service???If member has Medicaid, check if LTCS has been requested previously. If LTCS has been denied, this criteria is Met. If LTCS hasn’t been requested previously, ask provider why. Provide education about LTCS. If provider indicates there are barriers to requesting LTCS, this criteria is Not Met, staff the request with Supervisor.Family Living High would transition to LTCS Level 3. Transition to LTCS is required if member meets criteria.NOTES: Initial Review CriteriaMetNot MetN/ARequired Elements to Approve Service??There is a mental health diagnosis present or the person has a condition that may be defined as a developmental disability as defined in GS 122C-3 (12a) AND??The person with a developmental disability has an NC-SNAP or Supports Intensity Scale (SIS) and other documents per the Partners BHM Benefit Plan AND ??The person is experiencing difficulties in at least one of the following areas based on the current admission assessment, comprehensive clinical assessment and/or psychological evaluation:Functional impairment, Crisis intervention/diversion/aftercare needs, and/or At risk of placement outside the natural home setting AND??The person’s level of functioning has not been restored or improved and may indicate a need for clinical interventions in a natural setting if any of the following apply: At risk for out of home placement, hospitalization, and/or institutionalization due to symptoms associated with diagnosis Presents with intensive verbal and limited physical aggression due to symptoms associated with diagnosis, which are sufficient to create functional problems in a community setting. At risk of exclusion from services, placement or significant community support systems as a result of functional behavioral problems associated with the diagnosis. Requires a structured setting to foster successful integration into the community through individualized interventions and activities.???The person requesting this service may require a significant amount of individual space within the home setting.???The person requesting this service may have frequent crisis and require constant supervision.???Natural supports and community supports been assessed and attempted.???The service goals/interventions will assist the individual to prepare to live as independently as possible.???The service goals/interventions focus on and will assist the individuals in becoming connected to naturally occurring support systems and relationships in the community to provide and enhance opportunities for meaningful community participation.???The service is provided by professionally trained parent substitutes who work intensively with the individual in providing basic living, socialization, therapeutic and skill-learning needs.???This is an initial or continuing service request for up to 365 days maximum per Partners BHM Benefit Plan and is within the current treatment plan???There is a supportive, therapeutic relationship between the provider/caregiver and the client which addresses and/or implements interventions outlined in the service plan. These may include working intensively with individuals in providing for their basic living, socialization, therapeutic and skilled learning needs.???The service goals/interventions adhere to the principles of normalization and community integration.???Person Centered Planning has resulted in goals/outcomes based on the service definition criteria.Family Living – High Intensity – YM755Continuation/ Utilization Review CriteriaMetNotMetN/ARequired Elements to Approve Service???This is an initial or continuing service request for up to 365 days maximum per Partners BHM Benefit Plan and is within the current treatment plan??There is a mental health diagnosis present or the person has a condition that may be defined as a developmental disability as defined in GS 122C-3 (12a) AND??The person with a developmental disability has an NC-SNAP or Supports Intensity Scale (SIS) and other documents per the Partners BHM Benefit Plan AND ???The desired outcome or level of functioning has not been restored, improved, or sustained over the time frame outlined in the recipient’s service plan or the person continues to be at risk for relapse based on the history on the tenuous nature of the functional gains OR???Any one of the following applies:The recipient has achieved initial service plan goals and additional goals are indicated. The recipient is making satisfactory progress toward meeting goals.The recipient is making some progress, but the service plan (specific interventions) need to be modified so that greater gains which are consistent with the recipient’s premorbid level of functioning are possible or can be achieved.The recipient is not making progress: the service plan must be modified to identify more effective interventions.The recipient is regressing the service plan must be modified to identify more effective interventions.Service Maintenance Criteria???The recipient is functioning effectively with this service and discharge would otherwise be indicated, Family Living High should be maintained when it can be reasonably anticipated that regression is likely to occur if the service is withdrawn. ???The decision is based on any one of the following:Evidence that gains will be lost in the absence of Family Living Moderate is documented in the service record ORIn the event there are epidemiologically sound expectations that symptoms will persist and that ongoing treatment interventions are needed to sustain functional gains, the presence of a DSM-5 (or any subsequent editions of this reference material) diagnosis would necessitate a disability management approach. Family Living – High Intensity – YM755Discharge CriteriaMetNot MetN/ARequired Elements to Approve Request???The recipient’s level of functioning has improved with respect to the goals outlined in the service plan, or no longer benefits from this service. ???This decision is based on one of the following:The recipient has achieved service plan goals, discharge to a lower level of care is indicated. The recipient is not making progress, or is regressing, and all realistic treatment options within this modality have been exhaustedGuidance: Family Living – High Intensity: Traditional models of Family Living High include but are not limited to:-Therapeutic Home;-Professional Parenting;-Specialized Foster Care,-Host Homes used for temporary, non-crisis placementsExamples of this type of service include (but are not limited to): primary alternative family, secondary alternative family, on-call or crisis family, host home for temporary, non-crisis placement.Initial Review: All Criteria Met: ? YES – APPROVE ? NO - Review with Clinical ReviewerComments: UM Reviewer Name, Credentials: Date: Clinical Review: ? Approved ? Send to Peer ReviewComments: Clinical Reviewer Name, Credentials: Date: ................
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