4.2 Special Considerations Involving
Partial Hospitalization and Residential Treatment Center (RTC) Care.
4.2.1 Family Therapy involving Partial
Hospitalization and RTC Admissions. In accordance with the appropriate
medical care standard, discharge planning should start with the
day of admission. The goal should be to restore the patient’s ability
to function in one or more major life activities. In the case of
a child under age 21, the environment to which the patient is to
be discharged is a major consideration. To be authorized, RTCs and
partial hospitalization programs are required to address the feasibility
of family therapy as part of the treatment plan.
4.2.1.1 Standards. A compliance requirement
of the RTC standards (see
32 CFR 199.4(b)(4)(vii)) and the partial hospitalization
standards is that the admission process must include the family’s
(or responsible relative’s or legal guardian’s) understanding of
residential or partial hospitalization treatment and of their involvement
in treatment as well as the probable Length-of-Stay (LOS) of the patient.
The RTC standards dictate that if the patient is not returning to
the family, appropriate documentation in the clinical record should
indicate the type of preparation made with other persons who will
be involved with the patient upon discharge. The RTC and partial
hospitalization standards require that all specific therapeutic
modalities be spelled out in the treatment plan, including family therapy.
4.2.1.2 Under the accrediting
body’s standards by an accrediting organization approved by the Director,
Defense Health Agency (DHA), a specific plan for
involving the family in the treatment plan, when indicated. There
is also a requirement that the patient’s record shall contain documentation
of family members involvement in the patient’s treatment program.
If appropriate, a separate record may need to be maintained on each
family member involved in the patient’s treatment program.
4.2.2 Detailed Description of Family
Therapy in Treatment Plan. Family therapy is an integral part of
the treatment of children and adolescents and should be included
in all mental health treatment plans unless circumstances exist
which make such treatment contraindicated. Treatment plans must provide rationale
for why such therapy is not being provided. In all cases, this is
an issue subject to medical review, dependent on the needs of the
individual patient.
4.2.3 Family is Geographically Distant
from the Child. If the family is not in the area, the patient may
not be a candidate for partial care as individuals in this program
return to their home setting daily, and effective family interaction
is essential. If an RTC accepts a child for admission whose parents
are geographically distant, the facility must document its plans
for including the family in therapy, in accord with RTC standards
and the appropriate medical care standard. If one or both parents
reside a minimum of 250 miles from the RTC, the RTC has the flexibility
of setting up therapy with the parents at the distant locality,
while the child is in treatment in the RTC.
Additionally,
the RTC may elect to provide family therapy via Telemedicine in
accordance with existing Telemedicine requirements (see Section 22.1). The parent’s
therapist and child’s therapist must collaborate in all cases. Collaboration
between therapists is the responsibility of the RTC and must be
documented in the medical records.
4.2.4 Geographical distance of the
patient’s family is not considered an appropriate reason to exclude
the family from the treatment plan. By accepting a child for admission,
the RTC or Partial Hospitalization Program (PHP) is acknowledging
that it can provide the specific treatment appropriate to the individual
child’s needs and is responsible for taking only those children
whom it feels it can help through the development of an appropriate
treatment program designed to maximize the patient’s ability to
function in one or more major life activities.
4.2.5 Circumstances Where Family
Therapy is Inappropriate. If family therapy is inappropriate due
to the particular circumstances of the case, supporting documentation
and rationale must be provided in the treatment plan. An example
of such circumstances might include not returning to the family
unit following treatment. Authorization shall be denied for RTC
care if the patient’s treatment plan does not address the provision
of family therapy. The contractor shall notify the
DHA via the TRICARE Regional Office (TRO) if it finds that a facility’s
treatment planning demonstrates a pattern of failure to provide
for family therapy, as this constitutes a violation of the standards
and may reflect domiciliary care.