Mobile and Assertive
Community Treatment
The clinical review process and the
Medical Necessity Criteria
Principles of MTS/ACT Services
Mobile Treatment is designed for children,
adolescents, and adults with serious mental
disorders which are exemplified by noncompliance and vulnerability to provide treatment
in the least intensive setting that is able to meet the
Individual’s clinical needs.
These services are provided by a multidisciplinary
treatment team and are available to the consumer
on a 24/7 basis
Severity of Need & Intensity of Services
The individual’s condition must require
intensive, assertive mental health treatment
and supportive services delivered by a
multidisciplinary team, providing a minimum
of weekly face-to-face contact.
C&A Admission MNC
All of the following criteria are necessary for admission:
A. The consumer has a primary DSM-IV Dx that is the
cause of significant psychological impairment.
B. Individual is at risk for out-of-home placement & either:
 The Individual has not maintained, on a continuous basis,
community mental health services that are prescribed, or
 The Individual is exhibiting behavior that is a risk of harm
or self-harm
C. The primary caretaker:
 Has the goal of maintaining the child or adolescent safely
in the home, and
 Agrees to participate in Mobile Treatment services.
C&A Continued Stay MNC
All of the following criteria are necessary for continuing
treatment at this level of care:
A. The consumer continues to meet Adm criteria despite
Tx efforts, or there is emergence of additional problems
consistent with the admission criteria.
B. Documentation exists of failed attempts to integrate the
Individual into traditional Outpatient treatment.
C. There is clinical evidence of symptom improvement
using the service or, if there’s no improvement, there is
documentation of Tx plan changes and/or a 2nd opinion
of the Tx plan. (Tx plan is working or is being changed)
D. The primary caretaker continues to support in-home
placement and the Mobile Treatment services.
Adult Admission MNC
All of the following criteria are necessary for admission:
A. The consumer has a PMHS Priority Population Dx, which is the cause
of significant psychological, personal care, and social impairment.
B. The impairments result in at least one of the following:
 A clear/current threat to being able to live in the customary setting
 The consumer is homeless & would need a higher level of care if
Mobile Tx or ACT services weren’t provided.
 An emerging/impending risk to self or others.
 Inability to engage in traditional outpatient treatment
C. Inability to form a therapeutic relationship on an ongoing basis as
evidenced by one or more of the following:
 Frequent use of emergency rooms for psychiatric reasons
 Psychiatric hospitalizations
 Arrest for reasons associated with the Individual’s mental illness.
Adult Continued Stay MNC
All of the following criteria are necessary for continuing
treatment at this level of care:
A. The consumer continues to meet admission criteria
despite treatment efforts, or there is emergence of
additional problems consistent with the admission criteria.
B. There is clinical evidence of symptom or functional
improvement; however,
- the individual continues to be at risk for a higher LOC
based on the consumer’s response to attempts to reduce
the frequency or intensity of services in a planned way, or
- there is documented evidence that the individual is at
risk due to the tenuous nature of clinical/functional gains.
Adult Continued Stay MNC
C. There is documented evidence that the consumer has
either:
- Limited or no progress toward goals and there are
changes to the treatment plan/interventions, or
- Progress toward goals and there are changes to the
treatment plan to support the consumer’s transition to
traditional outpatient services (i.e. scheduling and
assisting consumer with appointments, assisting consumer
with using public transportation independently, support
consumer’s efforts to actively participate in treatment,
etc.)
Case Examples and Discussions
Documentation That Led To Follow Up
Phone Calls From ValueOptions®
Case Example #1
Ct has Hx of severe depression & PTSD & difficulty maintaining in
the community. Though Ct currently has an apartment, Ct has had
ongoing issues w/ self injury & dissociative episodes of lost
“hours” to “days” of time. Due to low self esteem, anhedonia &
triggers of trauma, Ct has difficulty caring for self & apartment. Ct
doesn’t do laundry regularly, often runs out of food, & needs
prompting from MTS to buy items he needs for his home (i.e.
shower curtain). Ct abused his benzos but agreed to discontinue
them after an arrest that occurred during a drug induced dissociative
episode. MTS assisted Ct w/ the court date & is actively involved
in Ct's probation for a theft charge. Ct regularly voices suicidal
ideation and sometimes doesn’t respond to MTS. Ct also does not
care for his physical health (i.e. had severe flu & refused ED until
MTS called 911 after he passed out from his fever).
Case Example #1 Discussion
This was generally a pretty clear picture of barriers are to
traditional OP services. What’s missing is language that
demonstrates the MTS is working w/ the consumer
toward “Transition”. The activities of the MTS appear to
be ongoing maintenance tasks, not steps toward
transition.
Actually, the consumer appears to have made some
progress: has secured/maintained housing and has
reportedly stopped abusing benzos.
Given the serious nature of the consumer’s SA problem:
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Is the consumer in SA Tx?
If not, what is the MTS doing to get the consumer in (or
working toward) SA Tx?
Case Example #2
Ct has Schizoaffective D/O and generally displays cycles of
severe depression, disorganized thinking, and isolation,
followed by an improved outlook. Currently lives in a
residential setting due to problems w/ attention and
memory. MTS has made attempts to integrate the ct into
traditional OP Tx (i.e. MTS has given Ct a bus schedule
and has ridden the bus route w/ ct. Ct was only successful
1 out of 4 times and she refuses to try again, due to the
belief/fear she will get lost and the fact that she also
experienced a panic episode while riding the bus). Ct has
made improvements while receiving MTS services. Ct
will not be able to function in the community without
MTS services at this time.
Case Example #2 Discussion
In this example, the details of attempted transition efforts
are very strong.
However, the details on what progress has been made, what
the threat to housing is, and what MTS is actively doing
that avoids ED visits or incarceration for this consumer
are all unanswered questions.
It’s not clear in this review what MTS is doing to help her
keep her housing, avoid hospitalization or incarceration,
improve her mental status, secure entitlements, stabilize
crises, etc.
Case Example #3
Ct continues to report auditory hallucinations & severe
paranoid ideations (Ct won’t leave her house except on
rare occasions & only when accompanied by the ACT
team). Most contacts w/ the client continue to be in the
community; Ct continues to refuse to come into the office
for scheduled MH appointments. Ct hasn’t kept any of
her scheduled somatic appointments. Each time the ACT
team arrives at her home for transport to see her PCP, Ct
expresses paranoid ideations w/ poor response to
reassurance from the team that someone will be w/ her
the entire time. Ct continues to receive her oral meds & it
is clearly evident that w/out ACT services the client
would receive no somatic or psychiatric care and would
therefore decompensate with a probable IP MH adm.
Case Example #3 Discussion
This case appears to be in a maintenance mode.
There is an implied plan to transition to lower
levels of care in that the ACT team meets with her
in the community. However, there’s no threat to
housing and there’s no explanation of changes
being made to the treatment plan.
It’s not clear in this review what ACT is doing to
help her keep her housing, avoid hospitalization or
incarceration, improve her mental status, secure
entitlements, stabilize crises, access somatic care,
etc.
Case Example #4
Ct is Dxed w/ Paranoid Schizophrenia, is noncompliant w/ meds, doesn’t make himself available for appts, is disorganized, has flight of ideas,
somatic delusions, and poor judgment. The MTS
must provide MH Tx & meds to the Ct. W/out the
MTS, Ct would not receive any of his prescribed
meds, nor would he make any attempts to keep his
scheduled appts. As a result, the Ct would
decompensate and require a higher level of care.
Case Example #4 Discussion
There are no documented attempts (or intent) to
transition to lower levels of care. The documentation is maintenance oriented. S/Sxs of the
consumer’s illness are present but behaviors
demonstrating dangerousness to self or others,
threats to housing, emergency room utilization,
etc. are absent. There is no documentation
regarding progress and no noted change in Tx
plan to address this lack of progress.
Case Example #5
Ct has come a long way w/ the support of MTS.
However, Ct continues to require MTS due to her
paranoia. Ct has weeks at a time where she’s
unable to keep appts in the community & requires
enormous outreach to get back on track. Ct has
several somatic issues that MTS is assisting her
with (obesity, diabetes, hypertension, & chest
pains). Ct requires encouragement & education
regarding the somatic issues & for follow up w/
the PCP. Ct has a long Hx of homelessness &
hospitalizations.
Case Example #5 Discussion
This requests lacks the detail of what “has come a
long way” means or is referring to. There is no
documentation addressing a MTS plan to help the
consumer be ready to transition to a lower level of
care. The threat to housing, the crisis services
provided to avoid ED utilization, and the efforts
the MTS makes to avoid incarceration are not
clear. The ValueOptions Care Manager rightly
wondered if there was any difference between this
request and requests she sees for Intensive Case
Management.
Case Examples and Discussions
Good Documentation
Case Example #6
Continues to have major difficulties interacting w/ others.
Continued outbursts are intimately related to his mood,
irritability, and distrust of others. In recent months, he’s been
charged w/ obstructing an investigation & has had several runins w/ the local police dept. He’s recently begun discussing his
SA Hx & began SA Tx last month. Although Ct has maintained housing for 3 months, he remains at risk for eviction/
homelessness due to aggressive behavior w/ neighbors/landlord. Anger management remains an issue for Ct &, in part, it
prevents him from being employed or making friends.
Although MTS has discussed transitioning to less intensive
services, it’s not been feasible due to his isolation & antisocial
behaviors. Ct just started developing a relationship w/ MTS.
Case Example #6 Discussion
The case is one that clearly outlines the deficits due
to Dx, the current behaviors secondary to those
diagnoses, the current barriers to transitioning to a
lower level of care, the threat of consequence
(housing and legal) if not in the intensity of MTS,
the follow through on the subject of identifying a
SA problem, and notation that transition is the
goal on the mind of the MTS staff.
Case Example #7
Ct continues to be paranoid (government is monitoring him). Ct
continues to have flat affect, dysphoric mood, & mumbles to
himself. In the last 3 months, psychiatrist has increased visits
w/ Ct & reviewed his medication. Judgment, concentration &
attention span are poor. Requires multiple prompts to
complete simple tasks. Ct made minimal progress toward
transition to lower level of care. When approached about an
OP referral, he stared at the speaker and said "what does that
mean?”. Currently, MTS is providing education about OP
services & community resources as well as how to write down
dates for scheduled appointments in a way that would give
him time to get ready to be picked up for groups. Ct’s hygiene
has improved & he’s starting to dress appropriately for the
weather. He’s starting to have limited interactions w/ peers.
Case Example #7 Discussion
In this example, it is clear what his Dx is, what
behaviors are secondary to the Dx, what the
progress has been, what the threats are to
independent living, what the MTS team is actively
doing to assist the consumer in the community,
and why a multidisciplinary team is still indicated.
It is also clear that the goal of MTS is to transition
the Ct to a lower level of care (and/or community
services). The documentation is clear that the
consumer is no where near ready for transition.
Case Example #8
Initial Request: Ct Dxed w/ Paranoid Schizophrenia
& at risk for losing housing w/ family due to their
inability to cope w/ Ct's symptoms. Ct frequently
threatens family & neighbors & has legal Hx due
to this behavior. Last April, Ct was on an LOA
from a state hospital to visit a PRP but neither
went to the appt nor returned to the hospital. Ct
has a Hx of IP MH care & states she uses ERs for
MH care, “a lot”. Referral from hospital reports
15+ IP MH adms in recent Hx. Ct has not
followed up w/ OP referrals upon D/C from IP nor
has she been med compliant. Insight is very poor.
Case Example #8 Discussion
It is clear that there is a threat to housing, that there
is a significant MH Dx, that the behaviors
secondary to this Dx are the cause of significant
impairment, and it is clear that, without MTS
services, the consumer would be at risk for
incarceration, hospitalization, non-compliance
with meds, and non-compliance with MH Tx.
Suggestions for future requests
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Have the MNC in front of you while writing your request
Use slide # 22 & 24 if you want a template for your reviews
Be clear about the risks for hospitalization, homelessness, out of
home placement, expulsion, incarceration, etc.
Make sure your attached supporting documents are up to date
If this is one of many requests, over a long period of time, be clear
in justifying why this level of intensity is still necessary
The narative should include what the MTS is actively doing (or
planning to do) to support/treat this member?
No need to repeat in the narrative what is already stated elsewhere
If we need to call you and you want us to call your cell phone,
please put this # in the “contact phone #” field
Never put the consumer/consumer’s family contact info in this field
Never copy and paste from the last review