POTOMAC CASE MANAGEMENT SERVICES, INC.
REFERRAL GUIDELINES
TARGETED CASE
MANAGEMENT/MENTAL HEALTH SERVICES
CHILDREN AND ADOLESCENTS
The purpose of this document
is to define and clarify guidelines when intensive case management for mental
health services meets the definition of medical necessity.
Principles for Referral
When a child or adolescent
has a mental disorder that requires professional evaluation and treatment,
he/she should be treated at the least intensive level appropriate for the
condition. Medical necessity for case
management services is established by satisfying the admission and continued
care guidelines outlined in the following sections. Satisfaction of admission and continued care
guidelines must be documented in the clinical record, based upon the conditions
and factors identified below before treatment will be authorized.
I. Guidelines for Admission
Intensive case management
services are appropriate for a child or adolescent, age 18 or under, with a
serious emotional disturbance whose condition requires intensive, assertive
assistance to appropriately and effectively access
needed mental health services. Children
and adolescents referred to this service should be diagnosed with a mental
disorder, display impaired role functioning and be at risk for needing a higher
level of care without the delivery of necessary services.
Case management services are
appropriate when all guidelines A1-A4 are met.
A. Severity
of Need
1. A clinical evaluation that indicates
the child or adolescent has a DSM IV diagnosis.
2. The child or adolescent displays a functional
impairment that substantially interferes with or limits the child or
adolescent’s role or functioning in the family, school or community activities.
3. At the time of initial eligibility
determination, the child or adolescent is at risk for needing a higher level of
care if necessary services are not delivered and has a condition that requires
intensive assertive assistance to access necessary mental health services.
4. At time of initial eligibility
determination, the child or adolescent meets at least one of the following:
(a) Requested
repeat hospital admissions within thirty (30) days;
(b) Redirected
from an emergency room to a less intensive level of care more than once in a
three (3) month period;
(c) Two or more hospitalizations within the
past six (6) months;
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(d) Admission
to a state facility totaling sixty (60) days within the past two (2) years;
(e) History of medication non compliance;
(f) Minimal support systems, or is in danger
of out of home placement;
(g) Multiple diagnoses such as mental
health-substance abuse, mental health-medical, mental health-mental retardation
and complex clinical cases;
(h) Difficulty in accessing vital outpatient
services;
(i) High
profile cases;
(j) Discharge from a hospital or
residential treatment center.
B. Intensity of Service
1. The services must be rendered by an
agency that has a written agreement with the appropriate Core Service Agency to
provide intensive mental health case management services for its defined
service area and is approved by the Department to provide the service.
2. The child or adolescent and his/her
parent or guardian must have access to the case management services provider 24
hours a day, 7 days per week.
3. Services provided shall include
assessment and reassessment, service plan development and regular updates of
such, linkage of the child or adolescent with both medically necessary and
other support services, monitoring of service provision and advocacy on behalf
of the child or adolescent.
4. Intensive case management must provide
a minimum of two (2) face-to-face contacts per month.
II. Guidelines
for Continued Care
Continuation of case management services is
appropriate for children or adolescents who meet each of the guidelines below.
A. Evidence of attempts to support the
child or adolescent in accessing necessary services without the assistance of
the case manager have not been successful.
B. The child or adolescent continues to be
at risk of needing a higher level of care if current services do not continue
to be available.
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