PAGE 1 of 4 TITLE: BEHAVIORAL HEALTH PARTIAL HOSPITALIZATION AND OUTPATIENT PROGRAM: ASSESSMENT OF PATIENTS IN BHOP – (SAN DIEGO CAMPUS) IDENTIFIER: MER-BHU-PC-3532 APPROVED BY: BHU Leadership, Psych Sup, CNE, POC, MEC ORIGINAL FORMULATION: 10-01

APPROVED: 10-08

REVISED: 3-05, 3-08, 10-08 REVIEWED: 3-08, 10-08 KEYWORDS: ASSESSMENT, BHOP, PATIENTS

I.

PURPOSE To provide specific guidelines for the clinical assessments of patients being admitted to the Behavioral Health Partial Hospital Program (PHP) and Outpatient Program (OP).

II.

POLICY All patients will be screened and assessed for appropriate placement and/or referral to the Behavioral Health services that will best meet their needs and ensure appropriate psychiatric treatment. Clinical assessments must be completed within the time frame delineated below. The assessment process includes a Pre-Admission Screening, Admission Psychiatric Assessment, a Biopsychosocial Assessment, Suicide Risk Assessment and a Physical Health Screening. Additional specific clinical assessments are conducted per physician’s orders.

III.

PERSONNEL Physicians (MD’s) Community Relation Liaison (CRL) Program Manager Registered Nurses (RN’s) Treatment Coordinators (Therapists)

IV.

PROCEDURES A. Partial Hospitalization Program 1. Pre-Admission Screening is completed by the CRL or designee, within 14 days prior to admission, to determine the following: a. Whether or not the patient meets PHP admission criteria based on the initial clinical information gathered via the screening and collateral information. b. The name of the treating psychiatrist for the course of PHP treatment c. Name of the patient’s conservator or community case manager if applicable; contact conservator for consent to treat. d. Evaluation of transportation needs. e. Health insurance information.

TITLE: Behavioral Health Partial Hospitalization and Outpatient Program: Assessment of Patients in the BHOP/PHP Identifier: MER-BHU-PC-3532

Approval Date: 10-08

Page: 2 of 4

2. At Admission a. The patient meets with the staff designated to coordinate the admission process, orientation to the program, and complete admissions forms with staff assistance as needed. After completing the applicable assessments, the patient is given a tour of the department, and introduced to his/her first group therapy session. b. The Nursing Assessment will be completed up to within 48 hours before admission, or 24 hours after admission, and includes: i. The biological assessment portion of the Bio-Psychosocial Assessment ii. Suicide Risk Assessment iii. Nutrition Screen iv. Fall risk Assessment v. Medication Education Form c. The psychiatric assessment is completed and dictated by the psychiatrist within 24 hours of admission, and placed in the patient record within 48 hours of admission. i. When the patient is being admitted directly following an inpatient stay, the discharge summary and an admission note from the attending psychiatrist may serve as the admitting psychiatric evaluation. d.

A medical History and Physical (H&P), performed by a licensed physician (may be the attending psychiatrist) or nurse practitioner is completed within 48 hours and filed in the medical record. i. If an H&P has been completed within the past 30 days, a copy will be obtained, reviewed and included in the medical record with appropriate update. ii. New medical problems will be evaluated and entered in the medical record by the patient’s physician. iii. Nursing staff will confer with the physician to determine the necessity for opening a medical problem in the Master Treatment Plan for the purpose of following the problem.

e. Assessments completed by a BHOP therapist and placed in the medical record include: i. The psychosocial portion of the Bio-Psychosocial Assessment (within 3 treatment days) ii. Suicide Risk Assessment (within 3 treatment days) iii. The Integrated Summary (within 3 treatment days) iv. Master Treatment Plan (within 3 treatment days)

TITLE: Behavioral Health Partial Hospitalization and Outpatient Program: Assessment of Patients in the BHOP/PHP Identifier: MER-BHU-PC-3532

Approval Date: 10-08

Page: 3 of 4

f. The following additional assessments may be conducted by the appropriately licensed individual when the need is determined by the appropriate member of the treatment team: i. Chemical dependency assessment (within 3 treatment days) ii. Speech/language, hearing assessment iii. Psychological testing iv. Other assessments including but not limited to neurological, physical, occupational, and recreational functioning. g. The patients chart is labeled and incorporates the necessary forms into the record. Additional past medical records not obtained by the CRL are requested. 3. Re-assessment a. Treatment notes for each group therapy session, in the medical record. b. Interdisciplinary Treatment Plan Review occurs every 30 days following the first Master Treatment Plan re-certification. c. Suicide Risk is re-assessed as needed by the therapist, according to changes in patient condition and treatment needs. B.

Outpatient Program 1. All assessments are conducted as indicated for the Partial Hospitalization Program, with the following exceptions related to timelines: a. The psychosocial portion of the Bio-Psychosocial Assessment is completed within 7 treatment days b. Additional assessments i. The Suicide Risk Assessment is completed within 7 calendar days, unless heightened acuity requires immediate completion. ii. Chemical dependency assessment is completed within 7 treatment days as needed c. The Integrated Summary is completed within 7 calendar days d. If the patient has undergone a recent History and Physical within 30 days, the physician may choose to update the previous assessment or complete a General Health Statement that will suffice for admission to the program. e. All re-assessments are conducted as indicated for the Partial Hospitalization Program.

C.

When a patient is returning to PHP or OP within 2 weeks from inpatient hospitalization, an updated assessment of the patient will be provided as follows: a. The Nursing Update will establish the patient’s current condition and review medications that may have been changed during the inpatient stay b. The Therapist Update will establish any changes to patient’s psychological symptoms and level of functioning

TITLE: Behavioral Health Partial Hospitalization and Outpatient Program: Assessment of Patients in the BHOP/PHP Identifier: MER-BHU-PC-3532

D.

Approval Date: 10-08

Page: 4 of 4

Any deviation from the above outlined procedure, due to weekend admissions or other circumstances, must be documented in the Progress Notes section of the patient’s medical record.

V. SUPERSEDED Admission Process for BHOP MER-BHOP-PC-3547 VI. REFERENCES Medicare Fiscal Intermediary PHP Local Medical Review Policy Medicare Fiscal Intermediary Outpatient Local Medical Review Policy 2008 Joint Commission Standards for Behavioral Health Care, PC 1.10. 2.10 – 3.110 American Psychiatric Nurses Association Scope and Standards of Practice, Standard 1. Assessment Development Author Title/Discipline Utilization Review Management Coordinator

Author Name

Chapter Leader Title

Chapter Leader Name

Paul Martin

Approval/Endorsement Committee/Department

Name/Title of Chair

Approval / Endorsement Date

Medical Executive Committee

Dr. Glassman, Chair

August 20, 2008

Policy Oversight Committee

Kathy Seney, Chair

September 26, 2008

Psych Supervisory

Dr. Peter Seymour, Chair

June 12, 2008

Chief Nursing Executive

Lori Burnell

July 3, 2008

Director of BHU

Jerry Gold

July 3, 2008

PAGE 1 of 2 TITLE: BEHAVIORAL HEALTH PARTIAL HOSPITALIZATION AND OUTPATIENT PROGRAM – TREATMENT COORDINATION FOR BHOP - (SAN DIEGO CAMPUS) IDENTIFIER: MER-BHU-PC-3553 APPROVED BY: CNE, Asst Administrator Nursing, BHU CPC, POC, CNE, Admin Director of BHU ORIGINAL FORMULATION: 10-01

EFFECTIVE DATE: 5-09

REVISED: 2-03, 10-08, 5-09 REVIEWED: 11-05, 10-08 KEYWORDS: Behavioral Health, BHU, Coordination, Outpatient, Treatment I.

PURPOSE To identify a process in which patient’s critical needs are met within the context of the program as well as in conjunction with other support systems in the community.

II.

POLICY Outpatient Therapeutic hospital services are furnished incident to a physician’s service. A psychiatrist, physician, or clinical psychologist is on site within the hospital during service hours each program day, including Saturdays. Additionally, each patient who is admitted to Partial Hospitalization Program (PHP/Outpatient Program (OP) is assigned a Treatment Coordinator who will provide case management services and coordinate the patient’s treatment with the treatment team under the direction of the attending psychiatrist.

III.

PERSONNEL Program Managers Program Therapists Physicians Registered Nurses

IV.

(MD’s) (RN’s)

PROCEDURES A. The Program Manager or designee will assign the Treatment Coordinator to an admitting patient on or before the day of admission. B.

Treatment Coordinator will focus on introducing admitting patient to the program on day of admission to help with development of rapport and continuity of care for patient.

C.

The Treatment Coordinator will meet with patients within his/her case load on a regular basis to: 1. 2. 3. 4.

Review treatment goals, progress toward goals and discharge plan Manage with crisis situations Assist in problem-solving and referrals to other agencies as necessary When indicated, will communicate with patient’s conservator, payee, family, medical doctor, et al.

TITLE: BEHAVIORAL HEALTH PARTIAL HOSPITALIZATION AND OUTPATIENT PROGRAM: TREATMENT COORDINATION Identifier: MER-BHU-PC-3553

V.

Endorsed/Revised Date: 5-09

Page: 2 of 2

D.

Patients will be instructed to take all treatment issues to their Treatment Coordinator.

E.

The Treatment Coordinator will be responsible for maintaining each of his/her patient’s medical records.

REFERENCES The Joint Commission Standards for Behavioral Health Care PC.1.10 Provision of Care, Treatment and Services. Centers for Medicare & Medicaid Services (CMS) Outpatient prospective payment system (OPPS) rule published on November 18, 2008 and Section 20.5.1 of the Medicare benefit Policy Manual.

Development Author Title/Discipline Utilization Review Management Coordinator

Author Name

Chapter Leader Title

Chapter Leader Name

Committee/Department

Name/Title of Chair

Medical Executive Committee

No approval needed

Policy Oversight Committee

Kathy Seney

May, 2009

Chief Nursing Executive

Lori Burnell

May, 2009

Admin Director of BHU

Jerry Gold, PhD

May, 2009

Asst Administrator Nursing

Marlys Vespe

May, 2009

Paul Martin

Approval/Endorsement Approval / Endorsement Date

Scripps Behavioral Health Outpatient Services

MULTIDISCIPLINARY MASTER TREATMENT PLAN PATIENT INFORMATION

PATIENT: ____________________________________________ ADMISSION DATE: _________________________ TREATMENT COORDINATOR: ______________________________________ DATE: _________________________ AXIS I

DIAGNOSIS

II III IV: STRESSORS: V: CURRENT GAF: ESTIMATED LENGTH OF STAY: MEDICATIONS: Specific psychotropic medications and medication changes can be found on the Medication List and Treatment Plan Updates. PROB #

DATE OPENED

MASTER PROBLEM LIST (With signature of staff who identifies each problem)

INITIATED (I) or REFERRED (R)

DATE RESOLVED

Signature & credentials

Signature & credentials

Signature & credentials

Signature & credentials

Signature & credentials

Signature & credentials

Signature & credentials

*4CP* *4CP*

350-NS7260-0007 (03/24/06) LJG

Scripps Behavioral Health Outpatient Services

MULTIDISCIPLINARY MASTER TREATMENT PLAN PATIENT INFORMATION

PROB #:

PROBLEM STATEMENT (include symptoms, behaviors, and how they impact functioning):

STRENGTHS & LIMITATIONS AFFECTING THIS GOAL: LONG TERM GOALS (i.e., MUST include concrete, descriptive, measurable discharge criteria; the opposite of the problem). •

•

•

•

•

•

•

•

•

•

•

•

•

DATE OPENED

DATE RESOLVED

Scripps Behavioral Health Outpatient Services

MULTIDISCIPLINARY MASTER TREATMENT PLAN PATIENT INFORMATION

Short term, realistic, measurable goals [STATUS: RB=revised below; C=cancelled; E=extended; A=achieved] ST GOAL # : START DATE

TARGET DATE

(DURATION)

REVIEW DATE & STATUS

INTERVENTIONS

RESPONSIBLE STAFF

EXTENDED TARGET DATE

START DATE

ST GOAL #

:

TARGET DATE

(DURATION)

REVIEW DATE & STATUS

INTERVENTIONS

RESPONSIBLE STAFF

EXTENDED TARGET DATE

START DATE

ST GOAL #

:

TARGET DATE

(DURATION)

REVIEW DATE & STATUS

INTERVENTIONS

RESPONSIBLE STAFF

EXTENDED TARGET DATE

START DATE

ST GOAL #

:

TARGET DATE

(DURATION)

REVIEW DATE & STATUS EXTENDED TARGET DATE 350-NS7260-0007 (03/24/06)

INTERVENTIONS

RESPONSIBLE STAFF

Scripps Behavioral Health Outpatient Services MULTIDISCIPLINARY MASTER TREATMENT PLAN PATIENT INFORMATION

Short term, realistic, measurable goals [STATUS: RB=revised below; C=cancelled; E=extended; A=achieved] ST GOAL # : START DATE

TARGET DATE

(DURATION)

REVIEW DATE & STATUS

INTERVENTIONS

RESPONSIBLE STAFF

EXTENDED TARGET DATE

START DATE

ST GOAL #

:

TARGET DATE

(DURATION)

REVIEW DATE & STATUS

INTERVENTIONS

RESPONSIBLE STAFF

EXTENDED TARGET DATE

START DATE

ST GOAL #

:

TARGET DATE

(DURATION)

REVIEW DATE & STATUS

INTERVENTIONS

RESPONSIBLE STAFF

EXTENDED TARGET DATE

START DATE

ST GOAL #

:

TARGET DATE

(DURATION)

REVIEW DATE & STATUS EXTENDED TARGET DATE

INTERVENTIONS

RESPONSIBLE STAFF

Scripps Behavioral Health Outpatient Services MULTIDISCIPLINARY MASTER TREATMENT PLAN PATIENT INFORMATION

Short term, realistic, measurable goals [STATUS: RB=revised below; C=cancelled; E=extended; A=achieved] ST GOAL # START DATE

TARGET DATE

(DURATION)

REVIEW DATE & STATUS

INTERVENTIONS

RESPONSIBLE STAFF

EXTENDED TARGET DATE

START DATE

ST GOAL #

TARGET DATE

(DURATION)

REVIEW DATE & STATUS

INTERVENTIONS

RESPONSIBLE STAFF

EXTENDED TARGET DATE

START DATE

ST GOAL #

TARGET DATE

(DURATION)

REVIEW DATE & STATUS

INTERVENTIONS

RESPONSIBLE STAFF

EXTENDED TARGET DATE

START DATE

ST GOAL #

TARGET DATE

(DURATION)

REVIEW DATE & STATUS

INTERVENTIONS

RESPONSIBLE STAFF

EXTENDED TARGET DATE

*3CP* *3CP*

350-NS7260-0008 (03/24/06) LJG

Scripps Behavioral Health Outpatient Services MULTIDISCIPLINARY MASTER TREATMENT PLAN PATIENT INFORMATION

Short term, realistic, measurable goals [STATUS: RB=revised below; C=cancelled; E=extended; A=achieved] ST GOAL # START DATE

TARGET DATE

(DURATION)

REVIEW DATE & STATUS

INTERVENTIONS

RESPONSIBLE STAFF

EXTENDED TARGET DATE

START DATE

ST GOAL #

TARGET DATE

(DURATION)

REVIEW DATE & STATUS

INTERVENTIONS

RESPONSIBLE STAFF

EXTENDED TARGET DATE

START DATE

ST GOAL #

TARGET DATE

(DURATION)

REVIEW DATE & STATUS

INTERVENTIONS

RESPONSIBLE STAFF

EXTENDED TARGET DATE

START DATE

ST GOAL #

TARGET DATE

(DURATION)

REVIEW DATE & STATUS EXTENDED TARGET DATE

INTERVENTIONS

RESPONSIBLE STAFF