Mental Health and Substance Abuse Treatment Partial Hospitalization Criteria

1. Severity of illness:

   All of the criteria listed below must be met to meet medical necessity for inpatient partial mental health:

   • The patient has a diagnosed mental illness that is listed in the DSM-V manual.

   • The patient has symptoms or behaviors that significantly interfere with relationships, self-care, or vocational functioning.

   • There is clinical evidence that the patient’s condition requires a structured program with frequent nursing and/or medical supervision, intervention and/or treatment which cannot be provided in a less intensive outpatient setting.

   • The patient receives individual/group/family therapy a minimum of four hours per day and three to five days per week.

   • The enrollee is evaluated by a board certified psychiatrist within 48 hours of admission and a minimum of once a week thereafter.

   • The enrollee is assessed by a licensed mental health provider at least once per day and the medical record is documented.

   • The patient does not appear to present a danger to self or others, and is able to function adequately outside of the hospital.

   • The patient is cognitively intact to participate in the program.

   • The patient is motivated to participate in the program.

   • The patient is medically stable to participate in the program.

2. Intensity of Service

   All criteria must be met to meet intensity of service:

   • In order for the partial hospital program to be therapeutic for the patient, professional and/or social supports must be identified and available to the patient outside of the program hours.

   • The individualized plan of treatment includes a structured program of services with evaluation by a board certified psychiatrist within 48 hours, frequent nursing and medical supervision, intervention and/or treatment for at least 4 hours per scheduled day.

   • The individualized plan of treatment for partial hospitalization requires treatment by a multidisciplinary team and should include family and/or support system involvement.

   • A discharge plan is initially formulated that is directly linked to the behaviors and/or symptoms that resulted in admission to the partial hospitalization program.

Criteria for Continued Stay

3. Continued Stay

   All criteria must be met to meet continued stay:

   • Despite reasonable therapeutic efforts, clinical evidence indicates at least one of the following:

     1. The persistence of symptoms and behaviors that caused the admission to a degree that continues to meet the admission criteria (both severity of illness and intensity of service).
     2. The emergence of additional symptoms and behaviors that meet the admission criteria (both severity of illness and intensity of service).
     3. That discharge planning, or attempts at therapeutic re-entry into the community have resulted in, or would result in exacerbation of the psychiatric illness to the degree that would necessitate continued partial hospitalization.

   • The current or revised treatment plan can be reasonably expected to bring about significant improvement in the presenting or newly defined symptoms and behaviors.