Partial Hospitalization Services
Partial hospitalization programs (PHPs) are structured to provide intensive psychiatric care through active treatment that utilizes a combination of the clinically recognized items and services described in §1861(ff) of the Social Security Act (the Act). The treatment program of a PHP closely resembles that of a highly structured, short-term hospital inpatient program. It is treatment at a level more intense than outpatient day treatment or psychosocial rehabilitation. Programs providing primarily social, recreational, or diversionary activities are not considered partial hospitalization.
A. Program Criteria.–PHPs work best as part of a community continuum of mental health services which range from the most restrictive inpatient hospital setting to less restrictive outpatient care and support. Program objectives should focus on ensuring important community ties and closely resemble the real-life experiences of the patients served. PHPs may be covered under Medicare when they are provided by a hospital outpatient department or a Medicarecertified CMHC. Partial hospitalization is active treatment that incorporates an individualized treatment plan which describes a coordination of services wrapped around the particular needs of the patient, and includes a multidisciplinary team approach to patient care under the direction of a physician. The program reflects a high degree of structure and scheduling. According to current practice guidelines, the treatment goals should be measurable, functional, time-framed, medically necessary, and directly related to the reason for admission.
A program comprised primarily of diversionary activity, social, or recreational therapy does not constitute a PHP. Psychosocial programs which provide only a structured environment, socialization, and/or vocational rehabilitation are not covered by Medicare. A program that only monitors the management of medication for patients whose psychiatric condition is otherwise stable, is not the combination, structure, and intensity of services which make up active treatment in a PHP.
B. Patient Eligibility Criteria.–
1. Benefit Category.–Patients must meet benefit requirements for receiving the partial hospitalization services as defined in §1861(ff) and §1835(a)(2)(F) of the Act. Patients admitted to a PHP must be under the care of a physician who certifies the need for partial hospitalization. The patient requires comprehensive, structured, multimodal treatment requiring medical supervision and coordination, provided under an individualized plan of care, because of a mental disorder which severely interferes with multiple areas of daily life, including social, vocational, and/or educational functioning. Such dysfunction generally is of an acute nature.
Patients meeting benefit category requirements for Medicare coverage of a PHP comprise two groups: those patients who are discharged from an inpatient hospital treatment program, and the PHP is in lieu of continued inpatient treatment; or those patients who, in the absence of partial hospitalization, would be at reasonable risk of requiring inpatient hospitalization. Where partial hospitalization is used to shorten an inpatient stay and transition the patient to a less intense level of care, there must be evidence of the need for the acute, intense, structured combination of services provided by a PHP. Recertification must address the continuing serious nature of the patients psychiatric condition requiring active treatment in a PHP. Discharge planning from PHP may reflect the types of best practices recognized by professional and advocacy organizations that ensure coordination of needed services and follow-up care.
These activities include linkages with community resources, supports, and providers in order to promote a patient’s return to a higher level of functioning in the least restrictive environment.
2. Covered Services.–Items and services that can be included as part of the structured, multimodal active treatment program, identified in §1861(ff)(2) include:
• Individual or group psychotherapy with physicians, psychologists, or other mental health professionals authorized or licensed by the State in which they practice (e.g., licensed clinical social workers, clinical nurse specialists, certified alcohol and drug counselors);
• Occupational therapy requiring the skills of a qualified occupational therapist. Occupational therapy, if required, must be a component of the physicians treatment plan for the individual;
• Services of other staff (social workers, psychiatric nurses, and others) trained to work with psychiatric patients;
• Drugs and biologicals that cannot be self administered and are furnished for therapeutic purposes (subject to limitations specified in 42 CFR 410.29);
• Individualized activity therapies that are not primarily recreational or diversionary. These activities must be individualized and essential for the treatment of the patient’s diagnosed condition and for progress toward treatment goals;
• Family counseling services for which the primary purpose is the treatment of the patient’s condition;
• Patient training and education, to the extent the training and educational activities are closely and clearly related to the individuals care and treatment of his/her diagnosed psychiatric condition; and
• Medically necessary diagnostic services related to mental health treatment. Partial hospitalization services that make up a program of active treatment must be vigorous and proactive (as evidenced in the individual treatment plan and progress notes) as opposed to passive and custodial. It is not enough that a patient qualify under the benefit category requirements §1835(a)(2)(F) unless he/she also has the need for the active treatment provided by the program of services defined in §1861(ff). It is the need for intensive, active treatment of his/her condition to maintain a functional level and to prevent relapse or hospitalization, which qualifies the patient to receive the services identified in §1861(ff).
3. Reasonable and Necessary Services.–This program of services provides for the diagnosis and active, intensive treatment of the individual’s serious psychiatric condition and, in combination, are reasonably expected to improve or maintain the individual’s condition and functional level and prevent relapse or hospitalization. A particular individual covered service (described above) as intervention, expected to maintain or improve the individual’s condition and prevent relapse, may also be included within the plan of care, but the overall intent of the partial program admission is to treat the serious presenting psychiatric symptoms. Continued treatment in order to maintain a stable psychiatric condition or functional level requires evidence that less intensive treatment options (e.g., intensive outpatient, psychosocial, day treatment, and/or other community supports) cannot provide the level of support necessary to maintain the patient and to prevent hospitalization.
Patients admitted to a PHP do not require 24 hour per day supervision as provided in an inpatient setting, and must have an adequate support system to sustain/maintain themselves outside the PHP. Patients admitted to a PHP generally have an acute onset or decompensation of a covered Axis I mental disorder, as defined by the current edition of the Diagnostic and Statistical Manual published by the American Psychiatric Association or listed in Chapter 5 of the most current edition of the International Classification of Diseases (ICD), which severely interferes with multiple areas of daily life. The degree of impairment will be severe enough to require a multidisciplinary intensive, structured program, but not so limiting that patients cannot benefit from participating in an active treatment program. It is the need, as certified by the treating physician, for the intensive, structured combination of services provided by the program that constitute active treatment, that are necessary to appropriately treat the patient’s presenting psychiatric condition.
For patients who do not meet this degree of severity of illness, and for whom partial hospitalization services are not necessary for the treatment of a psychiatric condition, professional services billed to Medicare Part B (e.g., services of psychiatrists and psychologists) may be medically necessary, even though partial hospitalization services are not. Patients in PHP may be discharged by either stepping up to an inpatient level of care which would be required for patients needing 24-hour supervision, or stepping down to a less intensive level of outpatient care when the patient’s clinical condition improves or stabilizes and he/she no longer requires structured, intensive, multimodal treatment.
4. Reasons for Denial.–
a. Benefit category denials made under §1861(ff) or §1835(a)(2)(F) are not appealable by the provider and the limitation on liability provision does not apply (HCFA Ruling 97-1). Examples of benefit category based in §1861(ff) or §1835(a)(2)(F) of the Act, for partial hospitalization services generally include the following:
• Day care programs, which provide primarily social, recreational, or diversionary activities, custodial or respite care;
• Programs attempting to maintain psychiatric wellness, where there is no risk of relapse or hospitalization, e.g., day care programs for the chronically mentally ill; or
• Patients who are otherwise psychiatrically stable or require medication management only.
b. Coverage denials made under §1861(ff) of the Act are not appealable by the provider and the Limitation on Liability provision does not apply (HCFA Ruling 97-1). The following services are excluded from the scope of partial hospitalization services defined in §1861(ff) of the Social Security Act:
• Services to hospital inpatients;
• Meals, self-administered medications, transportation; and
• Vocational training.
c. Reasonable and necessary denials based on §1862(a)(1)(A) are appealable and the Limitation on Liability provision does apply. The following examples represent reasonable and necessary denials for partial hospitalization services and coverage is excluded under §1862(a)(1)(A) of the Social Security Act:
• Patients who cannot, or refuse, to participate (due to their behavioral or cognitive status) with active treatment of their mental disorder (except for a brief admission necessary for diagnostic purposes), or who cannot tolerate the intensity of a PHP; or
• Treatment of chronic conditions without acute exacerbation of symptoms that place the individual at risk of relapse or hospitalization.
5. Documentation Requirements and Physician Supervision.–The following components will be used to help determine whether the services provided were accurate and appropriate.
Partial Hospitalization Program (PHP) is a non-24-hour diversionary treatment program that is hospital-based or community-based. The program provides diagnostic and clinical treatment services on a level of intensity similar to an inpatient program, but on less than a 24-hour basis. These services include therapeutic milieu; nursing; psychiatric evaluation; medication management; individual, group, and family therapy; peer support and/or other recovery-oriented services; substance use disorder evaluation and counseling; and behavioral plan development.
The environment at this level of treatment is highly structured, and there is a staff-to-Member ratio sufficient to ensure necessary therapeutic services, professional monitoring, and risk management. PHP may be appropriate when a Member does not require the more restrictive and intensive environment of a 24-hour inpatient setting but does need up to eight hours of clinical services, multiple days per week. PHP is used as a time-limited response to stabilize acute symptoms. As such, it can be used both as a transitional level of care, such as a step-down from inpatient services, as well as a stand-alone, diversionary level of care to stabilize a Member’s deteriorating condition, support him/her in remaining in the community, and avert hospitalization. Treatment efforts focus on the Member’s response during treatment program hours, as well as the continuity and transfer of treatment gains during the Member’s non-program hours in the home/community.
Components of Service
1. The provider complies with all provisions of the corresponding section in the General performance specifications.
2. The PHP offers short-term day programming consisting of therapeutically intensive, acute treatment within a stable therapeutic milieu. A psychiatrist oversees medication management and daily active treatment, as described within the Process Specifications section.
3. Full therapeutic programming is provided five days per week, with sufficient professional staff to conduct these services and to manage a therapeutic milieu. The scope of required service components provided in this level of care includes, but is not limited to, the following. Please refer to the per diem/service definition which is all-inclusive and includes the components covered in the rate for this service,
a. Bio-psychosocial evaluation
b. Psychiatric evaluation
c. Medical history
d. Physical examination/medical assessment (to assess for medical issues)
e. Pharmacology
f. Nursing assessment and services, or similar service provided by the program’s MD staffing
g. Individual, group, and family therapy
h. Case and family consultation
i. Peer support and/or other recovery-oriented services
j. Substance use disorder assessment and counseling
k. Development of behavioral plans and crisis prevention plans, and/or safety plans as part of the Crisis Planning Tools for youth, as applicable
4. For minor children and for adults who give consent, the provider makes documented attempts to contact the parent, guardian, family members, and/or significant others within 48 hours of admission, unless clinically or legally contraindicated. The provider provides them with all relevant information related to maintaining contact with the program and the Member, including names and phone numbers of key nursing staff, primary treatment staff, social worker/care coordinator/discharge planner, etc. If contact is not made, the Member’s health record documents the rationale.
5. The provider engages in a medication reconciliation process in order to avoid inadvertent inconsistencies in medication prescribing that may occur in transition of a Member from one care setting to another. The provider does this by reviewing the Member’s complete medication regimen at the time of admission (e.g., transfer and/or discharge from another setting or prescriber), and comparing it with the regimen being considered in the PHP. The provider engages in the process of comparing the Member’s medication orders newly issues by the PHP to all of the medications that he/she has been taking in order to avoid medication errors. This involves:
a. developing a list of current medications, i.e., those the Member was prescribed prior to admission to the PHP;
b. developing a list of medications to be prescribed in the PHP;
c. comparing the medications on the two lists;
d. making clinical decisions based on the comparison and, when indicated, in coordination with the Member’s primary care clinician (PCC); and
e. communicating the new list to the Member and, with consent, to appropriate caregivers, the Member’s PCC, and other treatment providers. All related activities are documented in the Member’s health record.
6. If a Member experiencing a behavioral health crisis contacts the provider, during business hours or outside business hours, the provider, based on his/her assessment of the Member’s needs and under the guidance of his/her supervisor, may: 1) offer support and intervention through the services of the PHP program, during business hours; 2) implement interventions to support the Member and enable him/her to remain in the community, when clinically appropriate, e.g., highlight elements of the Member’s crisis prevention plan and/or safety plan, encourage implementation of the plan, offer constructive, step-by-step strategies which the Member may apply, and/or follow-up and assess the safety of the Member and other involved parties, as applicable; 3) refer the Member to his/her outpatient provider; and/or 4) refer the Member to an ESP/MCI for emergency behavioral health crisis assessment, intervention, and stabilization.
a. Outside business hours, the provider offers telephonic coverage. An answering machine or answering service directing callers to call911, call the nearest ESP/MCI, or to go to a hospital emergency department (ED), does not meet the after-hours on-call requirements.
Staffing Requirements
1. The provider complies with all provisions of the corresponding section in the General performance specifications.
2. The provider complies with the staffing requirements of the applicable licensing body, the staffing requirements in the MBHP service-specific performance specifications, and the credentialing criteria outlined in the MBHP Provider Manual, Volume I, as referenced at www.masspartnership.com.
3. The staff includes a PHP Director or Supervisor who is an independently licensed, master’s-level or doctoral-level clinician. He/she is responsible for the clinical oversight and quality of care within the PHP, in collaboration with the medical director, and ensures the provision of all PHP service components. He/she is available for consultations regarding emergency or urgent situations.
4. The PHP has a written staffing plan that delineates the number and credentials of its professional staff, including an attending psychiatrist(s), nurses, social workers, and other mental health professionals to ensure that all required services are provided and performance specifications are met.
The Program Director or Supervisor collaborates with the medical director on the development and maintenance of the staffing plan for psychiatry.
5. Members have access to supportive milieu and clinical staff throughout the PHP hours of operation.
6. The provider has adequate psychiatric coverage to ensure all performance specifications related to psychiatry are met.
7. The provider appoints a medical director who is fully integrated into the administrative and leadership structure of the PHP and is responsible for clinical and medical oversight, quality of care, and clinical outcomes across all PHP service components, in collaboration with the PHP Director or Supervisor and the clinical leadership team.
a. The medical director is a psychiatrist who is board-certified and/or who meets MBHP’s credentialing criteria (Note: MBHP’s credentialing criteria for psychiatrists states that they must be boardcertified in general psychiatry by the American Board of Psychiatry and Neurology (ABPN) within two years of contracting with MBHP unless a waiver of this requirement is requested and received within two years of contracting with MBHP).
b. For providers with PHP programs for children and/or adolescents: If the medical director is not a child/adolescent psychiatrist, the provider appoints a staff psychiatrist to have the primary responsibility to assess and evaluate children and adolescents, one who is board-certified in general psychiatry and child fellowshiptrained and/or board-certified in child/adolescent psychiatry and/or who meets MBHP’s credentialing criteria for a child/adolescent psychiatrist.
c. The medical director’s role may include the provision of direct psychiatry services and also includes:
i. attendance at multi-disciplinary team meetings at least weekly;
ii. teaching, training, coaching, and consulting with the multidisciplinary team; and
iii. oversight and monitoring of prescribing clinicians.
d. The medical director’s role also includes the following functions, in collaboration with the PHP Director or Supervisor and clinical leadership team:
i. Integration of the various assessments of the Member’s needs and strengths into a coherent narrative that can be used for treatment planning within the PHP and in the Member’s home and community;
ii. Development and utilization of the PHP’s unifying theory of treatment to guide its mission, vision, and practice;
iii. Development of therapeutic programming; and
iv. Ensuring that programs remain family-centered, and, for programs serving youth, child-focused.
e. For providers with PHPs for children and/or adolescents, the medical director ensures psychiatric practice consistent with the best available evidence-based practices and parameters developed by the American Academy of Child and Adolescent Psychiatry (AACAP) when evaluating and treating youth with complex needs and/or medication regimens, e.g., when Members attending the program are on multiple psychiatric medications, or are in the custody of a state agency and are starting or continuing atypical antipsychotics. The medical director monitors this practice through oversight and supervision.
8. The provider assigns an attending psychiatrist to each Member.
a. For children and adolescents under the age of 14, the attending psychiatrist is one who meets MBHP’s credentialing criteria for a child/adolescent psychiatrist.
9. Psychiatric care is provided by the medical director and/or other psychiatrists who are board-certified and/or who meet MBHP’s credentialing criteria. Psychiatric care consists of the provision of psychiatric and pharmacological assessment and treatment to Members in the PHP. The program may also utilize a psychiatry fellow/trainee to provide psychiatric services, under the supervision of the medical director or another attending psychiatrist, in conformance with the Accreditation Council for Graduate Medical Education (ACGME), and in compliance with all Centers for Medicare and Medicaid Services (CMS) guidelines for supervision of trainees by attending physicians. The program may also utilize a psychiatric nurse mental health clinical specialist (PNMHCS) to provide psychiatric services, within the scope of their licenses and under the supervision of the medical director, as outlined within these performance specifications. The program may also utilize a psychiatric resident to provide psychiatric services, under the supervision of the medical director or another attending psychiatrist.
10. For PHPs that utilize a PNMHCS for medication management within their license and scope of practice, all of the following apply:
a. There is documented maintenance of: a collaborative agreement between the PNMHCS and the medical director; and a consultation log including dates of consultation meetings and list of all Members reviewed. The agreement specifies whether the PNMHCS or the medical director will be responsible for this documentation;
b. The supervision/consultation between the PNMHCS and the medical director is documented and occurs at least one (1) hour per week for PNMHCS staff, or at a frequency proportionate to the hours worked for those PNMHCS staff who work less than full-time. The format may be individual, group, and/or team meetings;
c. A documented agreement exists between the medical director and the PNMHCS outlining how the PNMHCS can access the medical director when needed for additional consultation;
d. The medical director, or another psychiatrist, is the attending psychiatrist for the Member when a PNMHCS is utilized to provide direct psychiatry services to a given Member. The PNMHCS is not the attending for any Member; and e. There is documented active collaboration between the medical director and the PNMHCS relative to Members’ medication regimens, especially those Members for whom a change in their regimen is being considered.
11. For PHPs that utilize a psychiatry fellow/trainee for medication management, all of the following apply:
Partial Hospitalization Program (Adult)
Partial hospitalization is a nonresidential treatment program that may or may not be hospital-based. The program provides clinical diagnostic and treatment services on a level of intensity equal to an inpatient program, but on less than a 24-hour basis. These services include therapeutic milieu, nursing, psychiatric evaluation and medication management, group and individual/family therapy, psychological testing, vocational counseling, rehabilitation recovery counseling, substance abuse evaluation and counseling, and behavioral plans. The environment at this level of treatment is highly structured, and there should be a staff-to-patient ratio sufficient to ensure necessary therapeutic services, professional monitoring, control and protection. Psychiatric partial hospital treatment may be appropriate when a patient does not require the more restrictive and intensive environment of a 24-hour inpatient setting, but does need up to eight hours of clinical services. Partial hospitalization is used as a time-limited response to stabilize acute symptoms. As such, it can be used both as a transitional level of care (i.e., step-down from inpatient) as well as a stand-alone level of care to stabilize a deteriorating condition and avert hospitalization. Treatment efforts need to focus on the individual’s response during treatment program hours, as well as the continuity and transfer of treatment gains during the individual’s non-program hours in the home/community. Psychiatric partial hospital treatment is separate and distinct from psychiatric social rehabilitation programs or day treatment programs, which also focus on maximizing an individual’s level of functioning (e.g., self-sufficiency, communication skills, social support network), but are usually less psychiatrically-based, located in a community setting, and focus more on the development or enhancement of an individual’s coping skills necessary for daily social and occupational functioning. .Family involvement from the beginning of treatment is important unless contraindicated. Frequency should occur based on individual needs.
Admission Criteria All of the following criteria are necessary for admission:
1. The individual demonstrates symptomatology consistent with a DSM-IV-TR (AXES I-V) diagnosis that requires and can reasonably be expected to respond to therapeutic intervention. Evaluation needs to include an assessment of substance abuse issues.
2. There is evidence of patient’s capacity and support for reliable attendance at the partial hospital program.
3. There is an adequate social support system available to provide the stability necessary for maintenance in the program OR the individual demonstrates willingness to assume responsibility for his/her own safety outside program hours.
4. There may be a risk to self, others, or property (e.g.. inability to undertake selfcare; mood, thought or behavioral disorder interfering significantly with activities of daily living; suicidal ideation or non-intentional threats or gestures; risk-taking or other self-endangering behavior) which is not so serious as to require 24-hour medical/nursing supervision, but does require structure and supervision for a significant portion of the day and family/community support when away from the partial hospital program.
5. The patient’s condition requires a comprehensive, multi-disciplinary, multi-modal course of treatment, including routine medical observation/supervision to effect significant regulation of medication and/or routine nursing observation and behavioral intervention to maximize functioning and minimize risks to self, others and property.
6. The treatment plan needs to clearly state what benefits the individual can reasonably expect to receive in program; the goals of treatment cannot be based solely on need for structure and lack of supports.
Psychosocial, Occupational, and Cultural and
Linguistic Factors
These factors, as detailed in the Introduction, may change the risk assessment and should be considered when making level of care decisions.
Exclusion Criteria Any of the following criteria are sufficient for exclusion from this level of care:
1. The individual is an active or potential danger to self or others or sufficient impairment exists that a more intense level of service is required.
2. The individual does not voluntarily consent to admission or treatment or does not meet criteria for involuntary admission to this level of care.
3. The individual has medical conditions or impairments that would prevent beneficial utilization of services.
4. The individual exhibits a serious and persistent mental illness consistent throughout time and is not in an acute exacerbation of the mental illness;
5. The individual requires a level of structure and supervision beyond the scope of the program (e.g., considered a high risk for non-compliant behavior and/or elopement).
6. The individual can be safely maintained and effectively treated at a less intensive level of care
7. The primary problem is social, economic (i.e. housing, family conflict, etc.), or one of physical health without a concurrent major psychiatric episode meeting criteria for this level of care, or admission is being used as an alternative to incarceration.
8. The focus of treatment is not primarily for peer socialization and group support.
Continued Stay Criteria
All of the following criteria are necessary for continuing treatment at this level of care:
1. The individual’s condition continues to meet admission criteria at this level of care;
2. The multi-disciplinary discharge planning process starts from the assessment and tentative plan upon admission, and includes the patient and family/significant other as appropriate
3. The individual’s treatment does not require a more intensive level of care, and no less intensive level of care would be appropriate.
4. Treatment planning is individualized and appropriate to the individual’s changing condition with realistic and specific goals and objectives stated. Treatment planning should include active family or other support systems, social, occupational and interpersonal assessment with involvement unless contraindicated. Family sessions as appropriate need to occur in a timely manner. Expected benefits from all relevant modalities, including family and group treatment, are documented.
5. All services and treatment are carefully structured to achieve optimum results in the most time efficient manner possible consistent with sound clinical practice.
6. Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved or adjustments in the treatment plan to address lack of progress are evident.
7. Care is rendered in a clinically appropriate manner and focused on individual’s behavioral and functional outcomes as described in the discharge plan.
8. When medically necessary, appropriate psychopharmacological intervention has
been prescribed and/or evaluated.
9. Patient is actively participating in treatment.
10. Co-ordination with relevant outpatient providers should be implemented.
Discharge Criteria Any of the following criteria are sufficient for discharge from this level of care:
1. The individual’s documented treatment plan, goals and objectives have been substantially met or a safe, continuing care program can be arranged and deployed at a lower level of care
2. The individual no longer meets admission criteria, or meets criteria for a less or more intensive level of care.
3. The individual, family, guardian and/or custodian are competent but nonparticipatory in treatment or in following the program rules and regulations. Nonparticipation is of such a degree that treatment at this level of care is rendered ineffective or unsafe, despite multiple, documented attempts to address nonparticipation issues. In addition, either it has been determined that involuntary inpatient treatment is inappropriate, or a court has denied a request to issue an order for involuntary inpatient treatment.
4. Consent for treatment is withdrawn, and it is determined that the individual has the capacity to make an informed decision and does not meet criteria for an inpatient level of care.
5. Support systems, which allow the individual to be maintained in a less restrictive treatment environment, have been thoroughly explored and/or secured.
6. The patient is not making progress toward treatment goals and there is no reasonable expectation of progress at this level of care despite treatment planning changes
7. There is a discharge plan with follow-up appointments in place prior to discharge.
