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Intensive Residential Treatment Services (IRTS)

Revised: 02-07-2012


Intensive residential treatment services (IRTS) are time-limited mental health services provided in a residential setting to recipients in need of more restrictive settings (versus community settings) and at risk of significant functional deterioration if they do not receive these services. IRTS are designed to develop and enhance psychiatric stability, personal and emotional adjustment, self-sufficiency, and skills to live in a more independent setting.

IRTS must be:

• Directed to a targeted discharge date with specified recipient outcomes; and
• Consistent with evidence-based practices.


Eligible IRTS Providers
To be eligible, an IRTS facility must:

• Be licensed with a Variance (PDF) effective July 1, 2010 to Rule 36 for Intensive Residential Treatment Services (IRTS)
• Not exceed 16 beds;
• Have a contract with the host county agency which approves the IRT service; and
• Have a host county recommended and DHS approved rate.

Members of the IRTS interdisciplinary team must be qualified under one of the following criteria:

• Mental health professionals;
• Mental health practitioners;
• Certified Peer Specialists;
• Mental health rehabilitation workers; and
• A Registered Nurse who is also qualified as a mental health practitioner

IRTS providers must have:

• Sufficient staff for 24-hour coverage in the delivery of rehabilitative services described in the ITP;
• Staff available to safely supervise and direct activities of recipients given their level of behavioral and psychiatric stability, cultural needs, and vulnerability;
• The capacity to promptly and appropriately respond to emergent needs and make any necessary staffing adjustments to assure the health and safety of recipients, including providing medical services directly (through its own medical staff) or indirectly (through referral to medical professionals).

Treatment staff must have prompt access in person or by telephone to a mental health professional or a qualified mental health practitioner. An IRTS provider must ensure, at minimum, that:

• Staff are available to provide direction and supervision whenever recipients are present in the facility;
• Staff remain awake during all work hours;
• A staffing ratio of at least one staff to nine recipients each day and evening shift. If more than nine recipients are present, there must be a minimum of two staff during day and evening shifts, one of whom is a mental health professional or practitioner.


Eligible Recipients
An eligible IRTS recipient must:

• Be age 18 years or older;
• Be eligible for MA; and
• Meet the IRTS admission criteria.

Individuals who are age 17 years and transitioning to adult mental health services may be considered for IRT services if the service is determined to best meet their needs. IRTS providers must secure a licensing variance in this situation.

Recipients may receive IRTS instead of hospitalization, if appropriate.


IRTS Admission Criteria
A mental health professional must determine that a recipient needs mental health services that cannot be met with other available community-based services, is likely to experience a mental health crisis, or requires a more restrictive setting if IRTS are not provided. The professional may consult with a mental health case manager or other county advocate, and/or, with the recipient’s consent, a spouse, family member, or significant other. Admit a recipient to IRTS when the recipient:

• Has a mental illness (based on a diagnostic assessment);
• Has a completed functional assessment using the domains specified in statute and have three or more areas of significant impairment in functioning.
• Has a completed LOCUS assessment where a Level 5 is indicated.
• Is reasonably expected to commence or resume illness management and recovery skills/strategies at least at a minimal stage at this level of service and needs a 24-hour supervised, monitored and focused treatment approach to improve functioning and avoid relapse that would require a higher level of treatment;
• Is not responsive to an adequate trial of active treatment at a less intensive level of care;
• Needs a restrictive setting and is at risk of significant functional deterioration if intensive residential treatment services are not received; and
• Has one or more of the following:
• History of two or more inpatient hospitalizations in the past year;
• Significant independent living instability;
• Homelessness;
• Frequent use of mental health and related services yielding poor outcomes in outpatient/community support treatment.

IRTS Continuing Stay Criteria
Continue the recipients stay in IRTS when a mental health profession determines that a recipient’s mental health needs cannot be met by other, less intensive community-based services and:

• The recipient continues to meet admission criteria as evidenced by active psychiatric symptoms and continued functional impairment;
• Documentation indicates that symptoms are reduced, but discharge criteria have not been met;
• The essential goals are expected to be accomplished within the requested time frame; and
• Documentation exists that attempts have been made unsuccessfully to coordinate care and transition the recipient to other services.

IRTS Discharge Criteria
Discharge a recipient from IRTS when the recipient (recipient must meet at least one criterion):

• No longer meets continuing stay criteria
• Has met ITP goals and objectives;
• Shows evidence of decreased impairment of thought, mood, behavior or perception and less restrictive community-based alternatives exist and are appropriate;
• Has symptoms and needs that permit lesser level of service and adequate supports and services are in place;
• Is voluntarily involved in his/her ITP and no longer agrees to participate in the IRTS services;
• Exhibits severe exacerbation of symptoms, decreased functioning or disruptive or dangerous behaviors and requires a more intensive level of service;
• Has medical or physical health needs that exceed what can be brought into the residential treatment setting;
• Does not participate in the program despite multiple attempts to engage him/her and to address nonparticipation issues;
• Does not make progress toward treatment goals and there is no reasonable expectation that progress will be made; or
• Leaves against medical advice for an extended period (determined by written procedures of provider agency).

Covered Services
Plan and coordinate IRTS with the local mental health service delivery system. Recipients may access and receive IRTS outside of the facility when it would benefit the continuity of treatment and transition to the community. The following services must be provided within the IRTS program:

• Supervision and direction;
• Individualized assessment and treatment planning;
• Crisis assistance, development of health care directives and crisis prevention plans;
• Nursing services;
• Inter-agency case coordination;
• Transition and discharge planning;
• Living skills development, including:
• medication self administration,
• healthy living,
• household management,
• cooking and nutrition,
• budgeting and shopping,
• using transportation, and
• employment-related skills;
• Integrated dual diagnosis treatment (mental health and substance abuse treatment in a single treatment setting and single treatment regimen with an interdisciplinary approach, and be able to assess treatment readiness, use motivational interviewing, employ harm reduction strategies and a non-confrontational approach, as appropriate to the recipient’s needs);
• Illness management and recovery (educating about mental illness and treatment including characteristic symptoms and early warning signs of relapse, managing stress and developing relapse prevention plans, developing coping skills and strategies for coping with symptoms, developing social skills to improve effectiveness in interactions across a range of settings and situations, and identifying therapeutic and rehabilitative approaches available to recipients, such as DBT or treatment for OCD); and
• Family education (services to educate, inform, assist, and support family members in mental health illness and treatment, coping mechanisms, medication, community resources).

Authorization
• Providers must request authorization for services exceeding the 90 day limit. Authorization requests must include documentation supporting the medical necessity of a continuing stay.
• Submit MHCP Authorization Form (DHS-4695) and supporting documentation to obtain a authorization.
• Providers may use the ARMHS & Day Treatment Supplemental Authorization Form (DHS-4159A) as a guide to better address documentation requirements.
• If a recipient is readmitted to an IRTS within 15 days of discharge, the readmission counts toward the 90-day limit.

Billing
MHCP will reimburse IRTS for up to 90 days, based on a daily rate per provider as indicated in the host county contract.
• Bill only direct mental health service days; do not bill for days when direct services were not provided
• Use the MN–ITS 837P to bill for IRTS
• Use procedure code H0019

If a recipient is readmitted to IRTS within 15 days of discharge, the readmission counts toward the 90-day limit. Request authorization for days over 90 with documentation supporting the medical necessity of a continuing stay.

• Bill only direct mental health service days; do not bill for days when direct services were not provided
• Use the MN–ITS 837P to bill for IRTS
• Use procedure code H0019

IRTS
Code Description Units Limitations
H0019 Behavioral health; long-term residential (non-medial, non-acute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem 1 day Maximum 90 days
Readmission within 15 days counts toward 90-day limit
Request authorization for more than 90 days.

IRTS & Other Concurrent Services and Limitations
When requesting authorization, clearly document medical necessity for the additional service(s), including reasons IRTS does not/cannot meet recipient’s needs (e.g., specialty service, transitional service, etc. All services provided concurrently with IRTS must be coordinated with IRTS.
Other service Is service included in IRTS Can service be provided in addition to IRTS? Service Limitations
MH-TCM No Yes
• Rule 79 applies.
• IRTS must coordinate with recipient’s case manager.
Day Treatment No Only with authorization Day treatment provider must coordinate the plan of care with the IRTS provider and seek authorization for any day treatment services provided on the same day
Partial Hospitalization No Only with authorization
• IRTS provider must coordinate the plan of care with the partial hospitalization provider and seek authorization for any IRT services provided on the same day
• Partial hospitalization thresholds and limitations apply.
ACT No Yes
• ACT rate may be adjusted.
• ACT and IRTS may be provided concurrently without authorization.
ARMHS Yes Only with authorization except for Transition to Community Living ARMHS thresholds and limits apply to each service.
Crisis Response Services (Assessment or Intervention only) (mobile) No Yes
• May be billed separately.
• No authorization required.
Crisis stabilization - Non-residential Yes No
• A component of IRTS.
• Cannot be billed separately.
Crisis stabilization - Residential Yes No
• A component of IRTS.
• Be aware of recipient transfers.
• If recipient is approved for IRTS and residential crisis stabilization, bill only one approved daily rate. Only one of these two services can be billed for a recipient per day.
Psychiatric Physician Services Sometimes Yes
• May be provided by physician, psychiatric NP, CNS-MH, or physician extender if a member of the treatment staff.
• Bill separately only if not included in IRTS rate.
Outpatient Psychotherapy No Yes
• Outpatient psychotherapy limits apply.
Inpatient Hospitalization No No
• Inpatient hospitalization services are reimbursed separately from IRTS.
• IRTS may not be reimbursed for recipients admitted to an inpatient hospital.
Waivered Services No Yes
• County must approve concurrent care.
PCA or other medical services No Yes
• Service limits apply to each service.


Legal References
MS 256B.0622 Intensive rehabilitative mental health services
MS 245.461 to 245.486 Adult Mental Health Act

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