DMHSAS Info Memo 2010-03
STATE OF WISCONSIN
Index Title: DHS 40 Mental Health Day Treatment Services for Children Interpretation of Best Practice
From: John Easterday, Ph.D, Administrator
Subject: DHS 40 Mental Health Day Treatment Services for Children Interpretation of Best Practice
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.
Considerations for Assessment and Treatment of Children in Day Treatment Settings:
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:
Criteria for Admission DHS 40.08(3):
“For a program to admit a child:
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.
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:
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):
Considerations Specific to Admission into Level I Day Treatment:
Considerations Specific to Admission into Level II Day Treatment:
Considerations Specific to Admission into Level III Day Treatment:
Considerations for Continued Treatment within Day Treatment (all levels):
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:
Telephone: (608) 266.0907
Regional Office Contact:
DQA Certification Staff
Telephone: (608) 264.9894
Last Revised: July 12, 2010