Panelists selected access to services for people with acute conditions as a major area for review, as there was tremendous variation among vendors in terms of the definition of "dangerousness" and safety (potential harm to self or others) required for admission. In fact, we found that five of the documents over-simplified or excessively limited this definition. A best practice example from a vendor that addressed this issue thoughtfully included all of the following situations resulting from a mental illness (any one was sufficient to meet the definition):

• suicidal attempt;
  
• suicidal ideation with a plan and means;
  
• violent threats or behaviors with a risk of escalation or repeated behavior;
  
• recent history of self-mutilation;
  
• recent and significant risk-taking;
  
• loss of impulse control resulting in danger to self or others;
  
• hallucinations directing harm to self or others;
  
• behavior or psychomotor agitation/retardation that disrupts daily living activities significantly enough that the person cannot function at a less intensive level of care;
  
• disorientation or memory impairment severe enough to endanger the self or others;
  
• inability to maintain adequate nutrition or self care when family/community support cannot provide this care; and
  
• severe or life-threatening side effects from psychotropic drugs.
  

Another best practice for acute admission (and admission to other treatment settings) was identified in two criteria sets: prevention of further deterioration.

Treatment setting definitions

The panel was surprised and distressed to find such tremendous variance in how different treatment settings were defined. In fact, four criteria sets used definitions for one or more treatment settings for which most of the programs commonly considered in that category could not meet (a worst practice). The end result of such policies is that care in most of these programs would be denied authorization, or reimbursed at a lower level. The partial hospitalization setting was most often affected by this approach. Below are examples of "realistic" and "unrealistic" definitions of this particular program as examples (the panel estimates that less than 10% of partial hospitalization programs in the country would meet the requirements for the unrealistic definitions).

One Realistic Definition:

"This setting provides hospital-based treatment that does not allow for overnight stays. Usually it is on-site or physically close to an inpatient medical/psychiatric facility. Group activities are part of "therapeutic milieu," including psychotherapy groups which are conducted daily, with other rehabilitative treatment available."

Two Unrealistic Definitions:

1. "Partial hospitalization is a level-of-care tantamount to the acute level-of-care with the singular exception that the patient does not require 24 hour medical and nursing care. It is intended to be provided up to eight hours per day, up to seven times per week…There must be documentation for each day of treatment that attempts to transition the patient to a lower level-of-care that it would result in re-emergence of symptoms sufficient to meet partial hospitalization program admission criteria."

2. "Partial hospitalization is a nonresidential treatment program available seven days per week…"

The panel also noted that three criteria sets included the worst practice of including very loose definitions of some treatment settings, which gives the appearance that certain services are included, when they really are not. Intensive outpatient programs were the most common treatment setting to be affected by this approach.

Criteria "Exceptions" that Expand Access

Two companies incorporated exceptions allowing consumers to access the next highest level of service. We encourage other vendors to adopt similar best practices:

Key findings

"Report card" on information sharing

Methodology

Development process

Comprehensiveness

Corporate philosophy

Access issues

Compliance

Child and family issues

Substance abuse and co-occurring disorders

Cultural competence

Provider autonomy

Coordination/ consultation among providers

Denial notification and appeal processes

More observations, recommendations and areas for further study