Iowa Admin. Code r. 441-78.31
Services listed in paragraphs"g" to "m" shall be provided by hospitals on an outpatient basis and must be certified by the department before payment may be made. Other limitations apply to these services.
The monitoring of the services must be an ongoing plan and systematic process to identify problems in patient care or opportunities to improve patient care.
The monitoring and evaluation of the services are based on the use of clinical indicators that reflect those components of patient care important to quality.
Applications will consist of a narrative providing the following information:
These needed services must be provided either directly by the facility or through referral, consultation or contractual arrangements or agreements.
Special treatment needs of recipients by reason of age, gender, sexual orientation, or ethnic origin are evaluated and services for children and adolescents (as well as adults, if applicable) address the special needs of these age groups, including but not limited to, learning problems in education, family involvement, developmental status, nutrition, and recreational and leisure activities.
Professional disciplines which must be represented on the diagnostic and treatment staff, either through employment by the facility (full-time or part-time), contract or referral, are a physician (M.D. or D.O.), a licensed psychologist and a substance abuse counselor certified by the Iowa board of substance abuse certification. Psychiatric consultation must be available and the number of staff should be appropriate to the patient load of the facility.
A history of the use of alcohol and other drugs including age of onset, duration, patterns, and consequences of use; use of alcohol and drugs by family members and types of and responses to previous treatment.
A comprehensive medical history and physical examination including the history of physical problems associated with dependence.
Appropriate laboratory screening tests based on findings of the history and physical examination and tests for communicable diseases when indicated.
Any history of physical abuse.
A systematic mental status examination with special emphasis on immediate recall and recent and remote memory.
A determination of current and past psychiatric and psychological abnormality.
A determination of any degree of danger to self or others.
The family's history of alcoholism and other drug dependencies.
The patient's educational level, vocational status, and job performance history.
The patient's social support networks, including family and peer relationships.
The patient's perception of the patient's strengths, problem areas, and dependencies.
The patient's leisure, recreational, or vocational interests and hobbies.
The patient's ability to participate with peers and in programs and social activities.
Interview of family members and significant others as available with the patient's written or verbal permission.
Legal problems, if applicable.
Alcohol or drugs taken in greater amounts over a longer period than the person intended.
Two or more unsuccessful efforts to cut down or control use of alcohol or drugs.
Continued alcohol or drug use despite knowledge of having a persistent or recurrent family, social, occupational, psychological, or physical problem that is caused or exacerbated by the use of alcohol or drugs.
Marked tolerance: the need for markedly increased amounts of alcohol or drugs (i.e., at least a 50 percent increase) in order to achieve intoxication or desired effect or markedly diminished effect with continued use of same amount.
Characteristic withdrawal symptoms.
Alcohol or drugs taken often to relieve or avoid withdrawal symptoms.
The patient's perception of needs and, when appropriate and available, the family's perception of the patient's needs shall be documented.
The patient's participation in the development of the treatment plan is sought and documented.
Each patient is reassessed to determine current clinical problems, needs, and responses to treatment. Changes in treatment are documented.
The plan for continuing care must describe and facilitate the transfer of the patient and the responsibility for the patient's continuing care to another phase or modality of the program, other programs, agencies, persons or to the patient and the patient's personal support system.
The plan is in accordance with the patient's reassessed needs at the time of transfer.
The plan is developed in collaboration with the patient and, as appropriate and available, with the patient's written verbal permission with family members.
The plan is implemented in a manner acceptable to the patient and the need for confidentiality.
Implementation of the plan includes timely and direct communication with and transfer of information to the other programs, agencies, or persons who will be providing continuing care.
If an individual has completed all or part of the basic 28-day program, a repeat of the program will be reimbursed with justification. The program will include an aftercare component meeting weekly for at least one year without charge.
Professional disciplines which must be represented on the diagnostic and treatment staff, either through employment by a facility (full-time or part-time), contract or referral, are a physician (M.D. or D.O.), a licensed psychologist, a counselor with a master's or bachelor's degree and experience, a dietitian with a bachelor's degree and registered dietitian's certificate, and a licensed occupational therapist. The number of staff should be appropriate to the patient load of the facility.
A family history as well as self-assessment regarding chronic dieting, obesity, anorexia, bulimia, drug abuse, alcohol problems, depression, hospitalization for psychiatric reasons, and threatened or attempted suicide.
A history of purging behavior including frequency and history of vomiting, use of laxatives, history and frequency of use of diuretics, history and frequency of use of diet pills, ipecac, or any other weight control measures, and frequency of eating normal meals without vomiting.
A history of exercise behavior, including type, frequency, and duration.
A complete history of current alcohol and other drug use.
Any suicidal thoughts or attempts.
Sexual history, including sexual preference and activity. Sexual interest currently as compared to prior to the eating disorder is needed.
History of experiencing physical or sexual (incest or rape) abuse.
History of other counseling experiences.
Appropriate psychological assessment, including psychological orientation to the above questions.
A medical history, including a physical examination, covering the information listed in subparagraph (4) below.
Appropriate laboratory screening tests based on findings of the history and physical examination and tests for communicable diseases when indicated.
The patient's social support networks, including family and peer relationships.
The patient's educational level, vocational status, and job or school performance history, as appropriate.
The patient's leisure, recreational, or vocational interests and hobbies.
The patient's ability to participate with peers and programs and social activities.
Interview of family members and significant others as available with the patient's written or verbal permission as appropriate.
Legal problems, if applicable.
In addition to the diagnostic criteria, the need for treatment will be determined by a demonstrable loss of control of eating behaviors and the failure of the patient in recent attempts at voluntary self-control of the problem. Demonstrable impairment, dysfunction, disruption or harm of physical health, emotional health (e.g., significant depression withdrawal, isolation, suicidal ideas), vocational or educational functioning, or interpersonal functioning (e.g., loss of relationships, legal difficulties) shall have occurred.
The need for treatment may be further substantiated by substance abuse, out-of-control spending, incidence of stealing to support habit, or compulsive gambling.
The symptoms shall have been present for at least six months and three of the following criteria must be present:
Medical criteria including endocrine and metabolic factors (e.g., amenorrhea, menstrual irregularities, decreased reflexes, cold intolerance, hypercarotenemia, parotid gland enlargement, lower respiration rate, hair loss, abnormal cholesterol or triglyceride levels).
Other cardiovascular factors including hypotension, hypertension, arrhythmia, ipecac poisoning, fainting, or bradycardia.
Renal considerations including diuretic abuse, dehydration, elevated BUN, renal calculi, edema, or hypokalemia.
Gastrointestinal factors including sore throats, mallery-weiss tears, decreased gastric emptying, constipation, abnormal liver enzymes, rectal bleeding, laxative abuse, or esophagitis.
Hematologic considerations including anemia, leukopenia, or thrombocytopenia.
Ear, nose, and throat factors including headaches or dizziness.
Skin considerations including lanugo or dry skin.
Aspiration pneumonia, a pulmonary factor.
The presence of severe symptoms and complications as evaluated and documented by the medical director may require a period of hospitalization to establish physical or emotional stability.
The patient's perceptions of needs and, when appropriate and available, the family's perceptions of the patient's needs shall be documented.
The patient's participation in the development of the treatment plans is sought and documented.
Each patient is reassessed to determine current clinical problems, needs, and responses to treatment. Changes in treatment are documented.
Eating disorder programs will include an aftercare component meeting weekly for at least one year without charge.
Family counseling groups held in conjunction with the eating disorders program will be part of the overall treatment charge.
At least one physician responsible for responding to emergencies must be physically present in the hospital when patients are receiving cardiac rehabilitation services. The physician must be trained and certified at least to the level of basic life support.
A medical consultant shall oversee the policies and procedures of the outpatient cardiac rehabilitation area. The director shall meet with the cardiac rehabilitation staff on a regular basis to review exercise prescriptions and any concerns of the team.
A cardiac rehabilitation nurse shall carry out the exercise prescription after assessment of the patient. The nurse shall be able to interpret cardiac disrhythmia and be able to initiate emergency action if necessary. The nurse shall assess and implement a plan of care for cardiac risk factor modification. The nurse shall have at least one year of experience in a coronary care unit.
A physical therapist shall offer expertise in unusual exercise prescriptions where a patient has an unusual exercise problem.
A dietitian shall assess the dietary needs of persons and appropriately instruct them on their prescribed diets.
A social worker shall provide counseling as appropriate and facilitate a spouse support group. A licensed occupational therapist shall be available as necessary.
Postmyocardial infarction (within three months postdischarge).
Postcardiac surgery (within three months postdischarge).
Poststreptokinase.
Postpercutaneous transluminal angioplasty (within three months postdischarge).
Patient with severe angina being treated medically because of client or doctor preference or inoperable cardiac disease.
Referral form.
Physician's orders.
Laboratory reports.
Electrocardiogram reports.
History and physical examination.
Angiogram report, if applicable.
Operative report, if applicable.
Preadmission interview.
Exercise prescription.
Rehabilitation plan, including participant's goals.
Documentation for exercise sessions and progress notes.
Nurse's progress reports.
Discharge instructions.
It is not necessary that a course of therapy have as its goal restoration of the patient to the level of functioning exhibited prior to the onset of the illness although this may be appropriate for some patients. For many other patients, particularly those with long-term chronic conditions, control of symptoms and maintenance of a functional level to avoid further deterioration or hospitalization is an acceptable expectation of improvement. "Improvement" in this context is measured by comparing the effect of continuing versus discontinuing treatment. Where there is a reasonable expectation that if treatment services were withdrawn, the patient's condition would deteriorate, relapse further, or require hospitalization, this criterion would be met.
The diagnostic and treatment staff shall consist of a physician, a psychologist, social workers or counselors meeting the requirements for "mental health professionals" as set forth in rule 441-33.1 (225C,230A).
A history of the mental health problem, including age of onset, duration, patterns of symptoms, consequences of symptoms, and responses to previous treatment.
A comprehensive clinical history, including the history of physical problems associated with the mental health problem. Appropriate referral for physical examination for determination of any communicable diseases.
Any history of physical abuse.
A systematic mental health examination, with special emphasis on any change in cognitive, social or emotional functioning.
A determination of current and past psychiatric and psychological abnormality.
A determination of any degree of danger to self or others.
The family's history of mental health problems.
The patient's educational level, vocational status, and job performance history.
The patient's social support network, including family and peer relationship.
The patient's perception of the patient's strengths, problem areas, and dependencies.
The patient's leisure, recreational or vocational interests and hobbies.
The patient's ability to participate with peers in programs and social activities.
Interview of family members and significant others, as available, with the patient's written or verbal permission.
Legal problems if applicable.
Partial hospitalization services means an active treatment program that provides intensive and structured support that assists persons during periods of acute psychiatric or psychological distress or during transition periods, generally following acute inpatient hospitalization episodes.
Service components may include individual and group therapy, reality orientation, stress management and medication management.
Services are provided for a period for four to eight hours per day.
Day treatment services means structured, long-term services designed to assist in restoring, maintaining or increasing levels of functioning, minimizing regression and preventing hospitalization.
Service components include training in independent functioning skills necessary for self-care, emotional stability and psychosocial interactions, and training in medication management.
Services are structured with an emphasis on program variation according to individual need.
Services are provided for a period of three to five hours per day, three or four times per week.
Activity therapies, group activities, or other services and programs which are primarily recreational or diversional in nature. Outpatient psychiatric day treatment programs that consist entirely of activity therapies are not covered.
Geriatric day-care programs, which provide social and recreational activities to older persons who need some supervision during the day while other family members are away from home. These programs are not covered because they are not considered reasonable and necessary for a diagnosed psychiatric disorder.
Vocational training. While occupational therapy may include vocational and prevocational assessment of training, when the services are related solely to specific employment opportunities, work skills, or work setting, they are not covered.
For services that are not specifically included in the patient's treatment plan, a detailed explanation of how the services being billed relate to the treatment regimen and objectives contained in the patient's plan of care and the reason for the departure from the plan shall be given.
The person must have had adequate medical evaluation and treatment in the months preceding admission to the program including an orthopedic or neurological consultation if the problem is back pain or a neurological evaluation if the underlying problem is headaches.
The person must be free of any underlying psychosis or severe neurosis.
The person cannot be toxic on any addictive drugs.
The person must be capable of self-care; including being able to get to meals and to perform activities of daily living.
The patient's perception of needs and, when appropriate and available, the family's perception of the patient's needs shall be documented.
The patient's participation in the development of the treatment plan is sought and documented.
Each patient is reassessed to determine current clinical problems, needs, and responses to treatment. Changes in treatment are documented.
The plan for continuing care must describe and facilitate the transfer of the patient and the responsibility for the patient's continuing care to another phase or modality of the program, other programs, agencies, persons or to the patient and the patient's personal support system.
The plan is in accordance with the patient's reassessed needs at the time of transfer.
The plan is developed in collaboration with the patient and, as appropriate and available, with the patient's written verbal permission with the family members.
The plan is implemented in a manner acceptable to the patient and the need for confidentiality.
Implementation of the plan includes timely and direct communication with and transfer of information to the other programs, agencies, or persons who will be providing continuing care.
A repeat of the entire program for any patient will be covered only if a different disease process is causing the pain or a significant change in life situation can be demonstrated.
The person must have Type I or Type II diabetes.
The person must be referred by the attending physician.
The person shall demonstrate an ability to follow through with self-management.
Professional disciplines which must be represented by the diagnostic and treatment staff, either through employment by the facility (full-time or part-time), contract, or referral, are a physician (doctor of medicine or osteopathy), a respiratory therapist, a licensed physical therapist, and a registered nurse.
A diagnostic work up which entails proper identification of the patient's specific respiratory ailment, appropriate pulmonary function studies, a chest radiograph, an electrocardiogram and, when indicated, arterial blood gas measurements at rest and during exercise, sputum analysis and blood theophylline measurements.
Behavioral considerations include emotional screening assessments and treatment or counseling when required, estimating the patient's learning skills and adjusting the program to the patient's ability, assessing family and social support, potential employment skills, employment opportunities, and community resources.
Factors which would make a person ineligible include acute or chronic illness that may interfere with rehabilitation, any illness or disease state that affects comprehension or retention of information, a strong history of medical noncompliance, unstable cardiac or cardiovascular problems, and orthopedic difficulties that would prohibit exercise.
The patients and their families need to help determine and fully understand the goals, so that they realistically approach the treatment phase.
Patients are reassessed to determine current clinical problems, needs, and responses to treatment. Changes in treatment are documented.
Components of pulmonary rehabilitation to be included are physical therapy and relaxation techniques, exercise conditioning or physical conditioning for those with exercise limitations, respiratory therapy, education, an emphasis on the importance of smoking cessation, and nutritional information.
This rule is intended to implement Iowa Code section 249A.4.
Iowa Admin. Code r. 441-78.31