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TRICARE Policy Manual 6010.60-M, April 1, 2015
Providers
Chapter 11
Section 2.5
Psychiatric And Substance Use Disorder (SUD) Partial Hospitalization Program (PHP) Standards
Issue Date:  July 14, 1993
Revision:  C-13, November 15, 2017
1.0  ISSUE
Psychiatric and SUD PHP Standards.
2.0  DESCRIPTION
A PHP is a treatment setting capable of providing an interdisciplinary program of medically monitored therapeutic services, to include management of withdrawal symptoms, as medically indicated. Services may include day, evening, night, and weekend treatment programs which employ an integrated, comprehensive and complementary schedule of recognized treatment approaches. Partial hospitalization is a time-limited, ambulatory, active treatment program that offers therapeutically intensive, coordinated, and structured clinical services within a stable therapeutic environment. Partial hospitalization is an appropriate setting for crisis stabilization, treatment of partially stabilized mental health disorders, to include substance disorders, and a transition from an inpatient program when medically necessary.
3.0  POLICY
3.1  PHPs must be either a distinct part of an otherwise authorized institutional provider or a freestanding program. The treatment program must be under the general direction of a licensed TRICARE authorized physician employed by the PHP to ensure medication and physical needs of all the patients are considered. The primary or attending provider must be an authorized mental health provider, operating within the scope of his/her license. These categories include physicians, clinical psychologists, Certified Psychiatric Nurse Specialists (CPNSs), Certified Clinical Social Workers (CCSWs), marriage and family counselors, TRICARE Certified Mental Health Counselors (TCMHCs), pastoral counselors, and supervised mental health counselors who must practice under the supervision of TRICARE authorized physicians.
3.2  Authorization:
3.2.1  Hospital-Based PHPs. When a hospital is a TRICARE authorized provider, the hospital’s PHP also shall be considered a TRICARE authorized provider. Separate TRICARE certification of a hospital-based PHP is no longer required.
3.2.2  Freestanding PHPs must enter into a participation agreement with the Director, Defense Health Agency (DHA), or designee.
3.3  In addition, in order for a freestanding PHP to be authorized, the PHP shall comply with the following requirements:
3.3.1  The PHP shall be currently accredited by the Joint Commission (TJC) under the Commission on Accreditation of Rehabilitation Facilities (CARF), the Council on Accreditation (CoA), or an accrediting organization approved by the Director, DHA. The regional contractor may submit, via the TRICARE Regional Office (TRO), additional accrediting organizations for TRICARE authorization, subject to approval by the Director, DHA.
3.3.2  The PHP shall be licensed as a PHP to provide PHP services within the applicable jurisdiction in which it operates.
3.3.3  The PHP shall accept the allowable PHP rate, as provided in 32 CFR 199.14(a)(2)(ix), for freestanding PHPs and the TRICARE Reimbursement Manual (TRM), Chapter 13, Section 2, paragraph 3.7 for hospital-based PHPs as payment in full for services provided.
3.3.4  The PHP shall comply with all requirements applicable to institutional providers generally concerning accreditation requirements, concurrent care review, claims processing, beneficiary liability, double coverage, utilization and quality review, and other matters.
3.3.5  The PHP shall not be considered an authorized provider nor will any benefits be paid to the facility for any services provided prior to the date the facility is approved by the Director, Defense Health Agency (DHA), or designee.
3.3.6  All diagnostic and therapeutic mental health and SUD services must be provided by an authorized mental health provider. This includes all psychotherapy (individual, group, family or conjoint, psychoanalysis, collateral), psychological testing and assessment to include documentation of the outcomes of standardized assessment measures for Post-Traumatic Stress Disorder (PTSD), Generalized Anxiety Disorder (GAD), and Major Depressive Disorder (MDD) using the PTSD Checklist (PCL), GAD-7, and Patient Health Questionnaire (PHQ)-8, respectively, at baseline, at 60-120 day intervals, and at discharge (see Chapter 1, Section 5.1 for details). [Exception: PHPs that employ individuals with master’s or doctoral level degrees in a mental health discipline who do not meet the licensure, certification, and experience requirements for a qualified mental health provider but are actively working toward licensure or certification, may provide services within the all-inclusive per diem rate but the individual must work under the clinical supervision of a fully qualified mental health provider employed by the PHP.] All other program services shall be provided by trained, licensed staff.
3.3.7  Family therapy is an integral part of the treatment of children and adolescents and must be included in their mental health treatment plans. If the family is not in the area, the child or adolescent patient is probably not a candidate for partial care as individuals in this program return to their home setting daily, and effective family interaction is essential. If the family or patient is not cooperative in participating in family therapy, they may not be viable candidates for a partial program. By accepting a child or adolescent under the age of 21 for admission, a partial program is acknowledging that it can provide the specific treatment appropriate to that individual’s needs and is responsible for taking only those individuals whom it feels it can help through the development of an appropriate treatment program designed to encompass family therapy and maximize the patient’s ability to function in one or more major life activities. The requirement for family therapy is not considered met by telephonic therapy or multifamily group therapy. (See Chapter 7, Section 3.12.) If family therapy is clinically contraindicated, an exception to this requirement may be granted on a case-by-case basis by the clinical director, or designee.
3.3.8  Case management services required. The facility must provide case management services that help assure the patient appropriate living arrangements after treatment hours, transportation to and from the facility, arrangement of community based support services, referral of suspected child abuse to the appropriate state agencies, and effective after care arrangements, at a minimum.
3.3.9  Educational services required. Programs treating children and adolescents must ensure the provision of a state certified educational component which assures that patients do not fall behind in educational placement while receiving partial hospital treatment. The cost of educational services will not be funded separately from the per diem rate. The hours devoted to education do not count toward the therapeutic program.
3.3.10  The PHP shall enter into a written participation agreement with the Director, DHA, or designee. (See Section 12.3 and Addendum F.)
3.3.11  The PHP agrees to notify the referring military provider or Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) referral management office (on behalf of the military provider) when a Service member or beneficiary, in the provider’s clinical judgment, meets any of the following criteria:
•  Harm to self - The provider believes there is a serious risk of self-harm by the Service member either as a result of the condition itself or medical treatment of the condition;
•  Harm to others - There is a serious risk of harm to others either as a result of the condition itself or medical treatment of the condition. This includes any disclosures concerning child abuse or domestic violence;
•  Harm to mission - There is a serious risk of harm to a specific military operational mission. Such a serious risk may include disorders that significantly impact impulsivity, insight, reliability, and judgment;
•  Inpatient care - Admitted or discharged from any inpatient mental health or substance use treatment facility as these are considered critical points in treatment and support nationally recognized patient safety standards;
•  Acute medical conditions interfering with duty - Experiencing an acute mental health condition or is engaged in an acute medical treatment regimen that impairs the beneficiary’s ability to perform assigned duties;
•  Substance abuse treatment program - Entered into, or is being discharged from, a formal outpatient or inpatient treatment program.
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