660-5-52-.01 Purpose. This policy provides DHR staff with procedures to follow when assessing a child’s need for inpatient psychiatric services (diagnosis, evaluation, and treatment), and when appropriate, the subsequent admission to and discharge from the hospital setting. This policy is not applicable to situations where children require services from Bryce Hospital since commitment to the State Department of Mental Health is required.

Author: Jerome Webb

Statutory Authority: R.C. v. Fuller case (R.C. v. Hornsby, No. 88-H-1170-N, Consent Decree) (M.D. Ala. Approved December 18, 1991)

History: New Rule: Filed October 7, 2003; effective November 11, 2003.

(1) policy has been developed to comply with the following operating principles or standards of the R.C. Consent Decree:

(a) Section VIII. 48(c). The "system of care" shall not initiate or consent to the placement of a class member in an institution or other facility operated by DMH/MR or by DYS unless the placement is the least restrictive, most normalized placement appropriate to the strengths and needs of the class member.

(b) Section VIII. 51(d). The "system of care" shall forbid summary discharges from placements. DHR shall promulgate a policy acceptable to both parties, that describes steps that must be taken prior to a class member’s discharge from a placement. The policy may permit, in exceptional circumstances, the placement of a class member in a temporary, emergency setting without prior notice to DHR.

(2) This policy was also developed to comply with the R.C. Consent Decree Implementation Plan, "System Processes and Services" chapter, page 16, which states ". . . DHR will adopt -- through policy and/or licensure standards -- specific criteria, mutually acceptable to the parties, for referral and admission to, as well as discharge from, foster homes, therapeutic foster homes, group facilities, psychiatric hospitals, and institutions operated by DMH/MR or DYS." All other principles of the R. C. Consent Decree (e.g., least restrictive environment, close proximity, and those related to maintaining contact with family) apply during hospitalization unless otherwise specified in a child’s individualized service plan (ISP).

Author: Jerome Webb

Statutory Authority: R.C. v. Fuller case (R.C. v. Hornsby, No. 88-H-1170-N, Consent Decree) (M.D. Ala. Approved December 18, 1991)

History: New Rule: Filed October 7, 2003; effective November 11, 2003.

(1) The ISP team shall be fully involved when assessing the need for, and appropriateness of, inpatient services even though child welfare staff and supervisors have primary responsibility for completing the referral and admission process. The referral and admission process includes assessing a child’s need for inpatient services; confirming the need with a qualified professional; and obtaining SDHR consultation and approval for service delivery.

(2) A qualified professional must be a physician licensed under Alabama law to practice medicine; or a master’s level psychologist or a psychological technician licensed under Alabama law; or a master’s level professional counselor licensed under Alabama law; or a master’s level social worker (non-DHR employee) licensed under Alabama law or who has specialized training in psychiatric care; or a registered nurse who has completed a master’s degree in psychiatric nursing.

(3) Assessing The Needs For Inpatient Services - Inpatient services shall only be considered when a child cannot be safely evaluated and/or treated on an outpatient basis or in a less restrictive setting. The provision of supportive services shall always be considered prior to inpatient referral. ISP team members shall assess information gathered about behavioral indicators and prior services and treatment interventions.

(4) Confirming The Need For Inpatient Services – Once the ISP team has determined that the child is unable to be served in a less restrictive setting and that inpatient services appear to be needed, that need must be confirmed by a qualified professional prior to contact with SDHR for placement approval. The qualified professional shall not be on staff at the hospital setting where inpatient services will be sought. The qualified professional shall personally assess the child, and as appropriate, the child’s family members and other caregivers. The qualified professional shall obtain and document information regarding specific needs related to exhibited behaviors; risk of harm to self or others; diagnosis; clear evidence that the child’s needs can not be met on an outpatient basis or in a less restrictive setting with supportive services being provided; and whether services require an inpatient setting, and, if so, the anticipated length of the hospital stay. Confirmation by the qualified professional may be provided in an ISP meeting, a case staffing with the professional and other appropriate child and family planning team members in attendance, or it may be provided to the child and family planning team in writing.

(5) If a service provider recommends inpatient services and the ISP team is not in agreement, a second opinion may be sought. If deemed necessary, the second opinion shall be provided by a qualified professional not on staff at the hospital where services will be sought. The child welfare staff are responsible for contacting that professional to obtain confirmation that inpatient services are necessary.

(6) State DHR Consultation And Approval - Inpatient psychiatric services require State Office approval prior to the child’s admission. The SDHR consultant having responsibility for providing consultation and approval for child welfare services shall be contacted during the assessment process to assist the ISP team in determining both the need for, and appropriateness of, inpatient services. When a qualified professional has confirmed the need for inpatient services, the consultant shall be contacted for placement approval. If it is necessary to hospitalize a child for inpatient psychiatric services on the weekend or after office hours, the supervisor must notify the SDHR consultant of the child’s hospitalization on the next working day.

(a) Extensions – When inpatient services are needed beyond 14 days, extensions are considered on a case-by-case basis. Information required for extensions includes child’s current status; a description of the progress made during hospitalization; barriers which are impeding progress toward discharge; supportive services offered and delivered to address the barriers; a description of efforts made to develop supportive services which will facilitate the child’s safe placement in a less restrictive setting; and documentation supporting the need for an extension (i.e., treating physician or therapist’s statement), estimated length of the extension, and if a second (2^nd) opinion is considered necessary. Prior approvals for extensions also require the SDHR consultant’s approval.

Author: Jerome Webb

Statutory Authority: R.C. v. Fuller case (R.C. v. Hornsby, No. 88-H-1170-N, Consent Decree) (M.D. Ala. Approved December 18, 1991)

History: New Rule: Filed October 7, 2003; effective November 11, 2003.

660-5-52-.04 Discharge.

(1) Discharge Planning – Discharge planning shall begin immediately upon a child’s admission to the hospital and continue throughout inpatient service delivery. The ISP team shall partner with hospital staff responsible for the planning and delivery of services and make every effort to hold an ISP meeting at the time of the child’s admission in order to be involved in the development of the hospital’s treatment plan. The ISP team must consider the type and extent of services being delivered, the child’s progress (or lack thereof), and the qualified professional’s recommendations for stepping the child down to a less restrictive environment where needs can be met. The ISP shall address the inpatient services provided to meet the child’s needs, identify the most appropriate and least restrictive placement setting to meet those needs, and the steps to be taken by the ISP team members prior to and at the time of the child’s discharge.

Author: Jerome Webb

Statutory Authority: R.C. v. Fuller case (R.C. v. Hornsby, No. 88-H-1170-N, Consent Decree) (M.D. Ala. Approved December 18, 1991)

History: New Rule: Filed October 7, 2003; effective November 11, 2003.

660-5-52-.05 Financial Responsibility.

(1) Financial resources must be explored to determine the appropriate payment method for inpatient services, and the following payment methods shall be considered in the order listed.

(a) Private Pay/Insurance - Private payment/insurance is to be considered as the first method of payment if the child and/or the child’s family has financial resources or private medical insurance to cover the cost of inpatient psychiatric services.

(b) Medicaid - Medicaid eligibility determinations must be made for all children in DHR custody, and when the hospital accepts Medicaid, the worker is responsible for providing the child’s Medicaid eligibility information to the hospital’s billing department.

(c) County Flex Funds – Flex funds is the next option, and they shall be utilized prior to requesting SDHR payment for inpatient services.

(d) SDHR Payment – Requests for SDHR payment of hospital bills for inpatient psychiatric services shall only be sought after all other financial resources have been considered and utilized.

Author: Jerome Webb

Statutory Authority: R.C. v. Fuller case (R.C. v. Hornsby, No. 88-H-1170-N, Consent Decree) (M.D. Ala. Approved December 18, 1991)

History: New Rule: Filed October 7, 2003; effective November 11, 2003.