DMHSAS Info Memo 2010-03

DLTC / DMHSAS Information Memo Series index page

STATE OF WISCONSIN
Department of Health Services
Division of Mental Health and Substance Abuse Services
DMHSAS Info Memo Series 2010-03
Date: March 17, 2010

Index Title: DHS 40 Mental Health Day Treatment Services for Children Interpretation of Best Practice

To: Listserv

For:
All Children’s Day Treatment programs
Area Administrators / Assistant Area Administrators Bureau Directors
County Departments of Community Programs Directors
County Departments of Developmental Disabilities Services Directors
County Departments of Human Services Directors
County Departments of Social Services Directors
Program Office Directors / Section Chiefs
Tribal Chairpersons / Human Services Facilitators

From: John Easterday, Ph.D, Administrator

Subject: DHS 40 Mental Health Day Treatment Services for Children Interpretation of Best Practice

Document Summary

This memo provides additional information and direction regarding the interpretation and implementation of the Level system written within the Children’s Mental Health Day Treatment Administrative Code, DHS 40. All of the standards in DHS 40 remain in place. This memo attempts to clarify and expand upon the distinction between Level I, Level II and Level III; to strengthen the importance of acquiring a good clinical evaluation / assessment of each child to determine if there are unidentified co-morbid mental illnesses that require treatment; and to emphasize obtaining all the necessary clinical records prior to admission.

DHS 40.03 (15) “Mental health day treatment services for children” means non-residential care provided on prescription of a physician in a clinically supervised setting that provides case management and an integrated system of individual, family and group counseling or therapy or other services assembled pursuant to an individually prepared plan of treatment that is based upon a multi-disciplinary assessment of the client and his or her family and is designed to alleviate emotional or behavioral problems experienced by the client related to his or her mental illness or severe emotional disturbance.”

When the original DHS 40 level system was developed in rule, the Department’s conceptualization and understanding of oppositional and conduct disorders was different from our current knowledge and understanding of these diagnoses. Today, research has provided a more in-depth understanding of the complex development and co-morbidity of these disorders. The development of oppositional or conduct disorder is a complex process involving interactions between a child’s biology, psychology, and environment. A child’s treatment needs cannot be based solely on diagnosis.

Experts in the treatment of children encourage providers to evaluate the path of development of conduct issues. A child who has mood or anxiety problems, or is struggling with attention problems, post traumatic stress issues, etc., may present with symptoms that are similar to children with oppositional and conduct issues. The child may present with symptoms of depression (anger), anxiety (irritability, refusal), or inattention (impulsivity). The child’s “environment” (family, school personnel, community) may inadvertently reinforce these symptoms leading to negative consequences.

The experience of “trauma” may be a compounding variable in the treatment of children. Some experts indicate trauma experiences alter a person’s neuroanatomy in a way that clearly influences their presentation and interactions with their environment.

In this memo, the Department of Health Services will emphasize the recommendation that providers utilize a comprehensive assessment process to evaluate children and facilitate placement in day treatment programming.

Current Definitions:

Chapter DHS 40.03(11) “Level I services”

Chapter DHS 40.03(11) “Level I services” means services designed to assist clients whose needs are principally derived from conduct disorders or oppositional disorders and are best met by extended participation in a therapeutic milieu of structured services including individual, group, and family counseling, educational support or direct academic instruction and recreational therapy.

Chapter DHS 40.03(12) “Level II services”

Chapter DHS 40.03(12) “Level II services” means services designed to assist clients whose needs are principally derived from intransigent and severe mental health disorders and are best met by intense, extended psychiatric or psychotherapeutic treatment in combination with a continuum of other individual and family support services.

Chapter DHS 40.03 (13) “Level III services”

Chapter DHS 40.03 (13) “Level III services” means services designed to assist clients whose needs are principally derived from an acute episode of a mental health disorder and are best met by intense, short-term treatment in a psychiatric or psychotherapeutic setting.

Considerations for Assessment and Treatment of Children in Day Treatment Settings:

• It is important to have a clear conceptualization and understanding of the individual child’s development, history, trauma experiences, needs and strengths.
• Collaboration with a child’s family system, school, human services and other community partners, is a foundation for assessment and progress in treatment.
• The development of a “conduct” or “oppositional defiant disorder” is a progressive process. A child often has symptoms associated with other mental health disorders that complicate and sometimes facilitate the development of the conduct issues. For example, a child may have initially had Post Traumatic Stress Disorder (PTSD) / Attention Deficit Hyperactivity Disorder (ADHD) / depression / anxiety (these are just a few) and as a result had interactions with the world that resulted in the development of an oppositional or conduct disorder. It is important to identify and treat these other possible diagnoses.
• Each child is unique, and his / her experiences, interactions, supports, and needs, influence their development.
• Mental health providers need to be well trained in best practices and able to apply trauma informed care concepts.
• Mental health professionals have a professional obligation to provide the least restrictive treatment option available to a child that safely meets his / her needs.

Department of Health Service Best Practice Recommendations

Each day treatment program should develop an admission process that includes a comprehensive assessment, treatment planning, and collaborative engagement with the child’s and family’s community. The assessment process, and documentation, will provide important information to the provider to determine the most appropriate and least restrictive level of day treatment program. Assessment documentation should meet the following requirements:

Referral for Admission 40.08(4):

“Admission to a program shall be arranged through the program director or clinical coordinator or designee. The program director or clinical coordinator or designee shall encourage the child and his or her family or foster family to participate in the intake process, as well as representatives from school, human services and other treatment programs currently serving the child and family. A program shall require the agency referring a child for services to provide all available reports and evaluations that identify the basis for the referral and the child’s need for services.”

This list should include: An assessment not less than 3 months old by a psychiatrist if the child is on psychotropic medication; the most current Individualized Education Plan (IEP); discharge summaries from all hospitalizations within the last year; any safety / risk / trauma information from parents, mental health providers, school personnel; and all mental health and substance abuse treatment related records for the year preceding referral.

The clinical coordinator must be involved with the decision to admit a child into day treatment and the Admission Summary must be written by the clinical coordinator or other mental health professional.

The Admission Summary should be written in a narrative style that reveals the diagnostic thought process and reasons that led to the decision to admit. This summary would provide a thoughtful, individualized summary of the child’s diagnostic profile, needs and strengths. The Summary would differentiate the school’s needs, family’s needs, county’s needs and the needs of the child; and how these needs will be addressed by being admitted to Day Treatment.

The Admission Summary would include:

• Individuals contacted and involved in the referral for admission, and dates of meetings / contacts
• Descriptions and dates of materials reviewed in the referral process
• Diagnostic summary, summary of medications, dosages and dates;
• Summary of psychological testing, including IQ testing
• Summary of residential, inpatient and outpatient mental health treatment
• Current and past legal involvement
• Summary of IEP, teacher concerns and school interventions
• Documentation of contact and involvement in the decision to admit of the referring county’s mental health authority
• Discussion regarding other least restrictive alternatives, i.e., wraparound initiatives Coordinated Service Team / Integrated Services Projects, Comprehensive Community Services, etc and why they are not appropriate to meet the child’s needs at this time. And, plan for discharge that may include these less restrictive alternatives.
• Plan for involvement with a psychiatrist if the child is on psychotropic medications.

Criteria for Admission DHS 40.08(3):

“For a program to admit a child:

• The child shall have a primary psychiatric diagnosis of mental illness or severe emotional disorder (the diagnosis should be obtained from a licensed psychiatrist, M.D. or Ph.D)
• The child shall be unable to obtain sufficient benefit from a less restrictive treatment program;
• Based upon the information available at the time of referral, there shall be a reasonable likelihood that the child will benefit from the services being offered by the program.
• The child shall meet one or more of the following criteria:
  • Be exhibiting significant dysfunction in 2 or more of the basic domains of his or her life and requiring the services offered by the program in order to acquire or restore the skills necessary to perform adequately in those areas;
  • Be in need of a period of transition from a hospital, residential treatment center or other institutional setting as part of the process of returning to live in the community; or
  • Be experiencing a period of acute crisis or other severe stress, so that without the level of services provided by the program, he or she would be at high risk of hospitalization or other institutional placement”.

A child should not be admitted or considered for admission until all relevant assessment information has been gathered and reviewed. Providers will attempt to obtain all of the mental health (psychiatric, outpatient, hospital, institutional) records, school records and records from any other provider that contains information immediately relevant to the child’s treatment, for the past year, prior to admission. Primarily for levels II and III, if this can not be accomplished, the provider should document their reasoning for proceeding without reviewing all of the past records. A review of past treatment history and what less restrictive programs / treatments have been considered and why that level of treatment would not benefit the child at this time. The assessment of reasonable likelihood of benefit from the services being offered by the program should be based on the child’s needs and strengths and how these needs and strengths will be addressed by the program. This information will be documented in the admission summary.

Each child should participate in a comprehensive mental health assessment prior to admission to determine diagnoses and other treatment needs.

If a psychiatric evaluation has not been completed within 3 months of initial assessment for day treatment, then one should be scheduled by the admission date into the day treatment program and completed within 3 months of admission.

The child and family, other primary and mental health providers, educators, and other support systems should all be included in the assessment process.

Written consent for admission must be based on the concepts of informed consent, which requires the admitting program to provide enough information for the parent to make an informed choice.

Prior to, or upon admission into a day treatment program, a multi-disciplinary team should be scheduled to obtain consultation in determining a child’s appropriateness for the level of day treatment program being initiated and to initiate the treatment planning process per DHS 40.08 (4).

Upon admission and prior to the creation of the treatment plan, an initial safety plan should be written that considers risk factors, trauma history, medications and possible side effects, and de-escalation responses to behaviors that are designed to avoid the use of seclusion and restraint.

The day treatment program should document the multi-disciplinary team’s review of appropriateness for the level of program into which the child is being admitted.

Assessment

The assessment and treatment plan will include information addressing the individual needs of the child as well as specific strategies that will be utilized in an attempt to treat the child.

The assessment and treatment plan will include information regarding a child’s trauma experiences and a clear picture as to how the treatment provider will modify treatment approaches in order to avoid re-traumatization.

The assessment and treatment plan will include an assessment of “risk.” Examples of risk considerations include:

• Awareness of the context in which past problematic behaviors have occurred. Does the child act out only toward his / her caregivers? Or does the acting out occur in all settings?
• Is the harmful behavior planned or impulsive? Not all impulsivity is a risk factor, a child who acts out impulsively is not the same level of risk as a child who acts out aggressively and impulsively.
• Is the behavior limited to certain domains or consistent across domains?
• Has the child been able to successfully manage his or her behavior? If so, what strategies were employed?
• The assessment of the risk must be comprehensive and well documented. Higher risk in this area may make a lesser restrictive approach impossible, even if not tried previously.
• An individualized safety / crisis plan should be developed to address the child’s risk areas.

Considerations for Least Restrictive Treatment

Examine all of the potential community-based services to determine the most appropriate service package for the child. Integrated Services Projects (ISP) or Coordinated Services Team (CST) and Comprehensive Community Services (CCS) can assist in supporting the child and family in the community.

Evaluate if lesser restrictive treatment has been given an adequate trial and / or is available, and document in the admission summary the reasons why a less restrictive alternative is not available.

Consider possible modifications within the treatment environment that would best meet the child’s needs. For example, is it clinically and / or logistically, possible for the child to receive one-on-one attention in that setting?

Distinctions and Considerations to Determine Day Treatment Level (I, II or III) of Care:

Under current rule a child admitted to a Level I program should have treatment needs that are principally derived from conduct disorders or oppositional disorders. This “definition” does not adequately match or fully reflect current recommendations from experts in the treatment community. The DHS supports a position that a child with a primary mental health disorder may be appropriate to consider for Level I Day Treatment, depending on the child's individual functional needs.

Level I programs tend to be freestanding, community-based programs that provide both half and full day programming options. The community-based day treatment program is able to coordinate with other community providers, including psychiatrists, to meet the child’s individual needs.

Level II programs tend to be affiliated with a residential or 24-hour treatment facility. The children in Level II programs need more treatment, medication management, and clinical oversight for their ongoing mental health issues.

Level III programs have been primarily associated with more intensive treatment settings such as hospitals. Children who are typically admitted to a Level III Day Treatment are experiencing more acute mental health episodes. Active psychosis or other significant mental health impairments may require on site psychiatric attention.

For each level of day treatment services, the program should utilize the assessment process to review their considerations, including, but not limited to the considerations noted below, and document in the admission summary narrative the program’s decision-making and clinical reasoning specific to the considerations. Accepting a child into day treatment is based on a careful review of these considerations and a finding that the child is appropriate for that level of day treatment, and that other less restrictive alternatives are not available or will not meet the child’s needs.

General Considerations for Admission into Day Treatment (all levels):

• Child has a primary mental health disorder.
• Less restrictive treatment has been attempted or considered.
• The level of day treatment being considered is the least restrictive placement.
• A safety / crisis plan should be developed to address the identified risk issues.
• Assessment of a child’s trauma history and treatment implications.
• Assessment of a child’s Alcohol and Other Drug Abuse (AODA) history and treatment needs and implications.
• Assessment of a child’s suicide risk (risk to others) history and safety concerns.
• Acuity of child’s needs.
• Assessment of a child’s history of sexual perpetration and safety concerns.
• Review of any past hospitalizations and treatment implications.
• Assessment of level of supervision needed and staff availability.
• Assessment of medical, mental health, cognitive, neuropsychological problems or other behaviors that make participation in day treatment program impossible.
• Assessment of a child’s ability to work in a group setting.
• Family / care giver is willing to participate in the treatment process.
• Child responds well to positive behavioral supports and can learn coping strategies.

Considerations Specific to Admission into Level I Day Treatment:

• Verbally aggressive and threatening. May strike out occasionally. Use of weapons.
• May have a criminal record and may have gang involvement.
• Can control behavior and de-escalate with support.
• The child’s mental status is such that there is no active psychosis or delusions, etc
• The child’s current problems or behaviors do not make participation in a community-based day treatment program impossible.
• If on medications, medication management can be coordinated with prescriber and achieved safely within the community.

Considerations Specific to Admission into Level II Day Treatment:

• Requires more intensive medication management and clinical oversight. DHS 40.07 (1)(b) 1 and 2.
• Stable on medications in a structured setting.
• Not actively suicidal, but may have suicidal thoughts, but able to develop a safety / crisis plan to manage the level of risk that is being assessed. A safety / crisis plan is in place.
• A child’s stability is such that there are clinical concerns / considerations regarding a child’s environment that require an out-of-home placement, in conjunction with day treatment services, to determine and / or meet a child’s needs.
• Child is able to learn coping skills and responds to positive behavioral supports with repeated and consistent teaching.

Considerations Specific to Admission into Level III Day Treatment:

• Level of aggressive risk and occasional explosions.
• Unstable mental health issues requiring support and supervision.
• Close medication supervision and monitoring of side effects is necessary.
• Moderate to high acuity - ongoing need for evaluation regarding need for hospitalization.
• Dangerousness risk is moderate and requires a good safety plan in place.
• May be dangerous at times, to self and others and will need close monitoring and supervision.
• May have some criminal juvenile justice involvement.
• Able to learn coping skills and responds to positive behavioral supports with repeated and consistent teaching.

Considerations for Continued Treatment within Day Treatment (all levels):

• General and specific Day Treatment level admission considerations (above).
• If seclusion or restraint occurs as a result of an emergency (child is dangerous to self or others), the program must review appropriateness of continued treatment within that level of program. This should be documented in the child’s chart.
• Risk of suicide or self harm.
• Requires no or minimal use of isolation, seclusion, or restraint.
• Requires excessive support beyond the 1:1 ratio.
• Violent, unprovoked impulsive aggression (assaults) towards staff or others.
• Ongoing trauma concerns that manifest in ever-present threat of violence.
• Child’s response or lack of response to de-escalation attempts.
• Inability to remain abstinent of drugs / alcohol.
• Child is not responding to treatment – needs multi-agency / team review of the treatment plan and placement.

Ongoing Assessment / Reassessment – Review of Case Progress

Each child’s continued stay in day treatment should be reassessed every three months to determine if the level of care is appropriate, all treatment concerns are addressed and to assess the possibility of other, less restrictive, community supports and services. This is in addition to Review of Case Progress per DHS 40.10 (5).

If substance abuse issues are present, an alcohol and other drug abuse (AODA) assessment should be arranged or provided by the program. The assessment should be provided by a licensed mental health professional, trained to provide AODA assessments, or a substance abuse counselor. The treatment needs identified in the AODA assessment should be addressed within the day treatment program’s interagency treatment plan. Updates regarding the AODA services should be documented within the day treatment progress report and / or treatment plan.

A referral to a community Wraparound Initiative, either the Integrated Services Project (ISP) or the Coordinated Services Team (CST), or the Comprehensive Community Services Program (CCS), when available, should be strongly considered.

When the Medicaid Prior Authorization request for day treatment is submitted, it should state what level of day treatment program is being requested and document that the child is appropriate for the level being requested. This can be done in the child’s initial assessment upon admission and in treatment updates at three-month intervals thereafter.

Psychiatric Reassessment Best Practice

If a child continues in treatment beyond a 6-month time period, an updated psychiatric review should be completed. The day treatment program’s treatment plan should reflect an ongoing and updated medication review.

If a child is on psychotropic medications, the day treatment program should consult with the child’s or program’s psychiatrist or psychologist (DHS 40.06 (4)(b) or (d)) to complete a comprehensive clinical review of the child’s needs to determine if there are any co-morbid mental health conditions, e.g., depression, anxiety, PTSD, etc. or other needs that have not been diagnosed or identified and need to be treated. As stated earlier in this memo, there are many possible mental health conditions that may be confounded in the complex presentation that a child may exhibit. It is important to identify and treat these conditions. Following the consultation, the program should consult with the existing prescriber or make appropriate referrals.

Summary of DHS Interpretations of Best Practices for Day Treatment Programs

A child with a primary mental health disorder may be appropriate to consider for Level 1 Day Treatment. The current administrative rule notes a child’s needs would be principally derived from conduct disorders or oppositional disorders. This clarifies that there are other diagnoses that may be appropriate for Level 1 Day Treatment services.

A child should not be admitted or considered for admission until attempts to gather all assessment information have been made. Providers will attempt to obtain all of the mental health (psychiatric, outpatient, hospital, institutional) records, school records and records from any other provider that contains information immediately relevant to the child’s treatment, for the past year, prior to admission

Prior to, or upon, admission into a day treatment program, a multi-disciplinary team meeting should be held to determine a child’s appropriateness for the level of day treatment program and the treatment plan being initiated.

Psychiatry services should be initiated and fostered in accordance with a child’s needs and treatment plan.

Three month reassessments of the level of day treatment program should be conducted as described above.

When the MA Prior Authorization request for day treatment is submitted, it should state what level of day treatment program is being requested and document that the child is appropriate for the level being requested.

Trauma informed care assessment and treatment best practice principles should be applied.

Central Office Contact:

George Hulick
Bureau of Prevention Treatment and Recovery
Division of Mental Health and Substance Abuse Services
1 W. Wilson St., P.O. Box 7851
Madison, WI 53707-7851

Telephone: (608) 266.0907
Email: George.Hulick@wisconsin.gov

Regional Office Contact:

DQA Certification Staff

Mark Hale
Behavioral Health Certification Section
Division of Quality Assurance
1 W. Wilson St., P.O. Box 7851
Madison, WI 53707-7851

Telephone: (608) 264.9894
Email: Mark.Hale@wisconsin.gov

Last Revised:  July 12, 2010