PROVIDER ALERT. Alert #: PA Issued: April Detoxification Providers. Revisions to Detoxification Protocols.
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1 PROVIDER ALERT Alert #: PA Issued: April 2011 To: Subject: Detoxification Providers Revisions to Detoxification Protocols Dear Provider, The CT Behavioral Health Partnership is dedicated to ongoing communication and collaboration with Providers throughout the state, and welcomes suggestions about ways to enhance the systems and procedures in place for authorizing services at all levels. As a result of recent feedback from a number of Detoxification Providers, we have reviewed the ValueOptions CareConnect system protocol that has been used for Detoxification authorizations. The focus was on finding ways to streamline the process and reduce the length of time required to complete either a pre-certification or continued stay review. Based on that evaluation, we have instituted changes to the process that we believe will reduce the review time significantly but still gather information necessary to insure a competent review of each request. First, we have created a dedicated staffing queue for detoxification-related inquiries, and have identified specific, experienced staff to address those calls. This priority will insure that calls are address promptly, and by clinicians who are familiar with this level of care and the authorization process. Second, our clinical staff will be using a modified format in place of the standard one and also will be gathering only the minimum, information necessary to make a determination of medical necessity. We have eliminated approximately 40% of the total content areas from the original protocol to streamline the process sufficiently. After making these changes, we have performed tests of the revised process to determine ease of use and estimate approximate length of time to perform a review. From those tests, we estimate that reviews can be completed in approximately minutes. This estimate is based on the expectation that Providers will ensure that their reviewers are prepared and experienced in the review process. We have created a template for Providers that shows the information to be collected. Additional time can be saved if Providers are familiar with the process and are prepared with
2 answers at the time of the contact. We anticipate sending the template to detoxification Providers by 4/25 to assist in their preparations for authorization requests. In addition, we anticipate continuing to adapt the review process over time as data is collected and we develop a better picture of the service requests and the Providers performance. One area for future exploration, based on the data, is the potential development of a bypass program for detoxification services, similar to the program now in place for hospital inpatient units. That development will be based on the ongoing collaboration and communication between the CT BHP and the Provider community. We are looking forward to that ongoing partnership. If you have any questions or concerns, please do not hesitate to contact the CT BHP Call Center at Provider Relations CT Behavioral Health Partnership Attachment: CT BHP Inpatient Detox Template
3 Inpatient Detox Template - CTBHP Member Demographics Name: CT Medicaid # Requested Start Date: Type of Service: Substance Abuse Level of Care Select Type of Care Inpatient Detox Freestanding IP RFT - SA Inpatient Detox Hospital IP Hospital Inpatient Detox Hospital IP Psych Facility Residential Rehab Review Date (today s date): Calling Provider / Facility: Admit Date: Facility Address: Member s Current Location: ER Jail/Detention Facility Provider Office Home/Community Group Home Shelter Foster Home School Nursing Home Assisted Living Facility Supervised Housing Supportive Housing Primary Requester / Referral Source: Court/Legal EAP Provider Employer Guardian Household Member Member Parent PCP Provider/Facility School Social Services Spouse Unmarried Partner Crises/Respite/Shelter/Safehome PRTF RTC/GH Foster Family DCF/Social Services CARES DMHAS LMHA Name of Place / Facility / Institution who referred member (be specific): If Child, DCF Legal Status: Committed CPS In-Home Delinquency Pending Dual Committed FWSN FWSN Pending Juvenile Justice Non Committed Open Investigation Order of Temporary Custody Pending 136 Probate Protective Supervision Termination of Parental Rights Voluntary (age of majority) Voluntary Services Voluntary Services Pending Diagnosis AXIS I AXIS II AXIS III None Allergies Alzheimer s Disease Anemia Arthritis or Rheumatism Asthma Cancer or Leukemia Cardiovascular Problems Chronic Pain Chronic Obstructive Pulmonary Disease Circulation Problems in Arms and Legs Congestive Heart Failure (CHF) Coronary Artery Disease (CAD) Diabetes
4 Disabilities or Physical Impairments Emphysema or Chronic Bronchitis Epilepsy/Seizures Fibromyalgia Glaucoma High Blood Pressure (hypertension) Head Injury HIV / AIDS Kidney Disease Liver Disease Migraine Headaches Multiple Sclerosis Obesity Parkinson s Disease Pregnancy Skin Disorders (severe burns, leg ulcers, etc.) Speech Impediment or Impairment Stomach Problems (e.g., acid reflux, ulcers) Stroke / Effects of Stroke Thyroid or other Glandular Problem Urinary Tract or Prostate Problems Med Condition Seriously Impacting Member s Health AXIS IV None Educational Problems Financial Problems Housing Problems Occupational Problems Other Psychosocial and Environmental Problems Problems with access to Health Care Services Problems related to interaction with Legal System/Crime Problems with Primary Support Group Problems related to Social Environment Substance Abuse SUBSTANCE ABUSE (MUST COMPLETE IF SUBSTANCE ABUSE OR ALCOHOL INDICATED) Check all that apply: Alcohol Amphetamines / Stimulants (diet pills, speed, Ecstasy, Ritalin, etc.) Barbiturates (sedatives, downers, etc.) Cocaine (crack, powder, etc.) Hallucinogens (LSD, mescaline, etc.) Inhalants (glue, gasoline, solvents, nitrates, etc.) Marijuana or Hashish Opioids (Heroin, Morphine, etc.) Over-the-counter Cold or Cough Medications (dextromethorpan, etc.) PCP (Phencyclidine) Pain Killers (Codeine, Demerol, etc.) Sleeping Pills Steroids Tranquilizers (Valium, Xanax, other anxiolytics, etc.) Other Prescription Drugs Other Non-prescription Drugs or substances Primary Drug/Substance Total Years of Use Length of Current Use Amount of Use Frequency of Use Date Last Used 0-5 years Less than 1 month Daily 6-10 years 1-6 months 4X per week years 6 mos-1 year 4-6X per week years 1 year or longer 2-3X per week 20+ years Secondary Drug/Substance Total Years of Use Length of Current Use Amount of Use Frequency of Use Date Last Used 0-5 years Less than 1 month Daily 6-10 years 1-6 months 4X per week years 6 mos-1 year 4-6X per week years 1 year or longer 2-3X per week 20+ years
5 Tertiary Drug/Substance Total Years of Use Length of Current Use Amount of Use Frequency of Use Date Last Used 0-5 years Less than 1 month Daily 6-10 years 1-6 months 4X per week years 6 mos-1 year 4-6X per week years 1 year or longer 2-3X per week 20+ years Withdrawal Symptoms: Check all that Apply: None Nausea Tremors Past DT s Vomiting Agitation Black Outs Current Seizures Cramping Hallucinations Current DT s Past Seizures Other? Vitals Blood Pressure: / Temperature: Pulse: Respiration: Blood Alcohol: ASAM / Other Patient Placement Criteria Dimension 1 Intoxication/Withdrawal Potential Dimension 2 Biomedical Conditions Dimension 3 Emot/Beh/Cogn Conditions Dimension 4 Readiness to Change Dimension 5 Relapse Potential Dimension 6 Recovery Environment Treatment History Psychiatric Treatment in the past 12 Months: Check All that Apply: None Outpatient (excluding current course of treatment) Outcome: Improved No Change Worse
6 Treatment Compliance (Non-Med): Poor Fair Good Intensive Outpatient / Partial Hospital Program Outcome: Improved No Change Worse Treatment Compliance (Non-Med): Poor Fair Good Hospitalization (Including residential and group home) Outcome: Improved No Change Worse Treatment Compliance (Non-Med): Poor Fair Good Number of Psychiatric Hospitalizations in the Past 12 Months: Number of Psychiatric Hospitalizations in Lifetime: Substance Abuse Treatment in the Past 12 Months: Check All that Apply: None Outpatient (excluding current course of treatment) Outcome: Improved No Change Worse Treatment Compliance (Non-Med): Poor Fair Good Intensive Outpatient / Partial Hospital Program Outcome: Improved No Change Worse Treatment Compliance (Non-Med): Poor Fair Good Hospitalization (Including residential and group home) Outcome: Improved No Change Worse Treatment Compliance (Non-Med): Poor Fair Good Number of Substance Abuse Hospitalizations in the Past 12 Months: Number of Substance Abuse Hospitalizations in Lifetime: Medical Treatment in the Past 12 Months: Check All that Apply: None Routine Medical Treatment Significant Medical Treatment - Please explain: Is member currently on Psychotropic Medication? Yes No Psychotropic Medications Date of Most Recent Med Evaluation: Any Medication Changes this Month? Yes No Do Meds Require Serum Blood Levels? Yes No Enter Current Meds Prescribed Medication: Dosage: Frequency: Medication: Dosage: Frequency: Treatment Request & Discharge Planning Medication: Dosage: Frequency: Primary Barrier to Progress and Treatment: Adequate Housing Residence
7 Discharge Treatment setting not available Family not able to support Family not willing to support HX of Interrupted treatment Lack of Community Support Language Barrier Legal Mandate Par / Adult active SA in HM Par / Adult in Home is Acc Transportation Treatment non-compliance None Other Planned Discharge Level of Care: Community Support Team Outpatient Targeted Case Mgt Inpatient 23 Hour CSU Partial Hospital RTC GH Halfway House Day Services IOP / SOP Alternative Community Support Day Treatment Foster Care In-Home & Family Services Placement Services PRTF Residential Child Care Respite Specialty Children s Program Subacute Other Assertive Community Treatment Facility Based Crisis Intensive In-Home MST NCMC Only Ambulatory Detox NCMC Only Medically SPVSD/ADATC NCMC Only Non-Hospital Med Detox NCMC Only SA Med Monitored Resi NCMC Only SA Non Med Resi Over 21 Opioid Treatment Psychosocial Rehab SACOT Planned Discharge Residence: AWOL CCP/High Meadow Correctional Facility Foster Home Home Independent Living Juvenile Detention Nursing Home/SNF/Assistant Living RTC/Group Home State Hospital Therapeutic Foster Care Transfer to Alt. Psych or Rehab Facility Transfer to Medical Other: Effective Start Date: Expiration Date: # of Requested Units: # of Approved Units:
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