Adult Day Treatment Programs: A Comprehensive Guide to Health Care Services

Adult Day Treatment (ADT) programs are designed to alleviate symptoms of diagnosed mental illnesses and equip individuals with essential skills for more independent living within their communities. Functioning as short-term, community-based mental health initiatives, ADT programs deliver group psychotherapy, rehabilitative interventions, and various therapeutic group services. These services are provided by a multidisciplinary team under the expert clinical supervision of a mental health professional, ensuring comprehensive and effective care.

Who Can Provide ADT Programs?

To become recognized providers of adult day treatment programs, several types of organizations are eligible, ensuring a broad network of qualified health care services. These include:

• Accredited Hospitals: Hospitals with accreditation from The Joint Commission on Accreditation of Healthcare Organizations and licensure under Minnesota Statutes, 144.50 to 144.55 are qualified to offer ADT programs.
• Community Mental Health Centers: Centers meeting the definition under Minnesota Statutes, 256B.0625, subdivision 5 are also eligible providers.
• County-Contracted Entities: Organizations under contract with a county board to operate programs that adhere to the stipulations of Minnesota Statutes, 245.4712, subdivision 2, and Minnesota Rules, parts 9505.0170 to 9505.0475 can provide ADT services.

Staffing for ADT programs requires qualified professionals. Each member of the multidisciplinary team must, at a minimum, meet the standards for a mental health practitioner. Specifically, psychotherapy components within day treatment must be conducted by a mental health professional or a clinical trainee under supervision.

When conducting group psychotherapy, providers must adhere to group psychotherapy guidelines concerning staffing ratios and group sizes to ensure effective therapeutic environments.

Before initiating ADT services, it is crucial for a Minnesota Health Care Programs (MHCP) provider to receive official approval. Furthermore, providers who offer children’s day treatment to individuals aged 18-20 must also be CTSS-certified.

Treatment Supervision Standards

Providers of adult day treatment programs are mandated to comply with the guidelines detailed in the Treatment Supervision section of the MHCP Provider Manual. These standards ensure quality and consistency in treatment delivery.

Who is Eligible for ADT Programs?

Eligibility for adult day treatment programs is defined by specific criteria to ensure that services are directed to those who will benefit most from this level of health care. Eligible members must:

• Age Requirement: Be 18 years of age or older. Notably, individuals aged 18-20 may be eligible for adult day treatment, CTSS (Children’s Therapeutic Services and Supports), or both, depending on their specific medical needs.
• Clinical Criteria: Meet the outlined Admission Criteria or Continuing Stay Criteria, indicating a need for the intensity of services provided by ADT programs.

Members who are enrolled in a managed care organization (MCO) are required to access day treatment services through their MCO. It’s important to note that MCOs may have their own specific coverage and authorization requirements that members must adhere to.

Admission Criteria in Detail

For admission into an adult day treatment program, a member must meet several key criteria that demonstrate the necessity and appropriateness of this level of care:

1. Symptom Severity: The individual must be experiencing symptoms related to thought, mood, behavior, or perception that significantly impair their ability to function effectively at a lesser service intensity. This ensures that ADT programs are reserved for those whose needs exceed what can be managed in less intensive settings.
2. Cognitive Capacity: The member must possess the cognitive ability to actively engage in and benefit from the therapeutic interventions offered in the program. This criterion ensures that participants can actively participate in their treatment process.
3. Potential for Improvement: There must be a reasonable expectation that the member will experience improved functioning in critical areas such as work, school, or social relationships as a result of participating in the ADT program. This criterion emphasizes the program’s goal of fostering recovery and enhanced quality of life.
4. Need for Structured Treatment: The individual must require a highly structured and focused treatment approach to achieve noticeable improvement and prevent relapse, which could necessitate a higher level of care. This highlights the structured nature of ADT programs and their role in providing intensive support.
5. Primary Diagnosis: The member must have a primary diagnosis of mental illness, as confirmed by a comprehensive diagnostic assessment (DA). Diagnoses of dementia and other organic conditions are typically excluded, focusing the program on those with primary mental health disorders. The DA must be based on face-to-face evaluations assessing the nature, severity, and impact of behavioral difficulties, functional impairment, subjective distress, strengths, and available resources.
6. Functional Assessment: A functional assessment (FA) must be completed before the development of an Individual Treatment Plan. This FA should be updated at least every 180 days or whenever there is a significant change in the member’s functioning to ensure the treatment plan remains relevant and responsive to the member’s current needs.
7. Level of Care Assessment: A completed Level of Care Assessment or Necessity of Care Recommendation or Referral recommending ADT is required. This assessment must be completed no more than 30 days prior to receiving services and is valid for 180 days. It must be updated if there is a significant change in functioning or a significant life event.
8. Individual Treatment Plan (ITP): An Individual Treatment Plan (ITP) must be in place before services begin, as detailed in Minnesota Statutes, 245I.10. The ITP must include attainable, measurable goals directly related to day treatment services and be reviewed and updated at least every 180 days, including a discharge plan. The development of the ITP must be a collaborative, person-centered process involving the member and, with their permission, their family and support system. The ITP and any revisions require the member’s approval before treatment commences. If a member refuses to sign, the mental health professional must document the refusal and reasons on the plan.

Adult day treatment may also be considered appropriate for:

• Co-occurring Brain Injury: Members with a brain injury (BI) diagnosis that coexists with their primary mental illness diagnosis can benefit from ADT programs, addressing the complex needs of individuals with dual diagnoses.
• Court-Ordered Treatment or Potential Danger: Individuals under court-ordered treatment or those who are a potential danger to themselves may be suitable for ADT if the program offers sufficient structure and community support systems.
• Transitional Care: Members residing in inpatient or residential facilities (like nursing facilities, IMDs, hospitals, RTCs) may be eligible if an active discharge plan indicates a transition to independent living within 180 days. In these cases, a mental health professional must deem day treatment medically necessary and include it in the facility’s plan of care.

Continuing Stay and Discharge Criteria

Continuing Stay Criteria: To ensure ongoing appropriateness and effectiveness, continued participation in adult day treatment programs requires meeting specific criteria:

1. Ongoing Need: The member’s condition must continue to meet the initial admission criteria, evidenced by active psychiatric symptoms and ongoing functional impairment.
2. Treatment Progress: The Individual Treatment Plan must contain specific, measurable goals, and there should be documented progress towards these goals.
3. Discharge Planning: An active discharge plan must remain in place, guiding the member’s transition out of the program when appropriate.
4. Care Coordination: Documented attempts to coordinate care and transition to other services, as clinically indicated, are necessary to ensure a seamless continuum of care.

Discharge Criteria: Discharge from an ADT program is considered when any of the following conditions are met:

1. Goal Achievement: Treatment plan goals and objectives have been successfully met, indicating the program’s aims have been achieved.
2. No Longer Meets Criteria: The member no longer meets the criteria for continuing stay, suggesting their needs have changed or diminished.
3. Reduced Service Intensity Needed: The member’s mental health disorders have decreased to a point where a less intensive level of service is more appropriate, indicating progress and recovery.
4. Voluntary Withdrawal: If a member is voluntarily involved in treatment and no longer agrees to attend day treatment, respecting patient autonomy.
5. Need for Higher Level of Care: In cases of severe symptom exacerbation or disruptive/dangerous behaviors requiring a more intensive level of service. (Note: Chart should not be closed if return to day treatment is expected.)
6. Non-Participation: Persistent non-participation despite multiple engagement attempts and addressing non-participation issues.
7. Lack of Progress: Failure to make progress toward treatment goals with no reasonable expectation of future progress.
8. Lower Level of Intensity Required: The member no longer meets the intensity level required for ADT services, as determined by a Level of Care assessment.
9. Cognitive Incapacity: The member does not have or ceases to have the cognitive capacity to benefit from day treatment services. In such cases, referral to county human services or private agencies for alternative services like day habilitation programs, adult day care, or waiver program services is necessary.

Covered Services in ADT Programs

Adult day treatment programs offer a range of services designed to provide comprehensive mental health support. These covered services include:

1. Group Psychotherapy: At least one hour of group psychotherapy is provided, with a maximum of two hours per day. This therapy is central to addressing mental health symptoms and fostering recovery.
2. Service Frequency and Duration: Services are provided at least two days a week, for a minimum of three consecutive hours each day. ADT programs may also extend beyond three hours daily to meet individual needs.
3. Rehabilitative and Therapeutic Group Activities: Group time is dedicated to rehabilitative interventions and other intensive therapeutic services, delivered by a multidisciplinary team. These activities are crucial for skill-building and promoting independent living.
4. Group Size and Staffing: Groups consist of at least three and no more than 12 members. For groups of three to eight, a single mental health professional or practitioner is required. Larger groups of nine to 12 necessitate a team of at least two mental health professionals, two practitioners, or a combination of one professional and one practitioner to co-conduct the group, ensuring adequate attention and support for all participants.

ADT services are specifically designed to:

• Stabilize Mental Health Status: Help stabilize the member’s mental health condition, enabling them to effectively engage in and benefit from a less intensive level of care subsequently.
• Enhance Independent Living and Social Skills: Develop and improve the member’s skills necessary for independent living and socialization, fostering greater autonomy and community integration.

Noncovered Services in ADT Programs

Certain services and activities are not billable as part of adult day treatment, ensuring that ADT programs maintain their focus on medically necessary and therapeutic interventions. Noncovered services include:

1. Residential Restrictions: Services cannot be provided to members residing in nursing facilities, hospitals, institutes of mental disease, or state-operated treatment centers unless they have an active discharge plan indicating a move to an independent living setting within 180 days. This prevents ADT from substituting for residential care in the absence of a transition plan.
2. Primarily Recreational or Non-Therapeutic Activities: Services that are primarily recreation-oriented and lack medical supervision or therapeutic outcomes are not covered. This includes, but is not limited to:
   • Sports activities
   • Exercise groups
   • Craft hours
   • Leisure time
   • Social hours
   • Meal or snack time or preparation (unless clinically integral to eating disorder treatment)
   • Community activity trips
   • Tours
3. Non-Therapeutic Social or Educational Services: Social or educational services that do not have or cannot reasonably be expected to yield therapeutic outcomes related to the member’s mental health condition are excluded.
4. Consultations and Community Programs: Consultations with other providers or service agency staff about a member’s care, as well as prevention or education programs offered to the community, are not covered ADT services.
5. Substance Use Disorder as Primary Diagnosis: Day treatment for members with a primary diagnosis of substance use disorder is not covered under ADT for mental health; specific substance abuse programs should be utilized.
6. Excessive Psychotherapy: Psychotherapy exceeding two hours daily is not billable as ADT, encouraging balanced service delivery.
7. Excessive Service Hours: ADT service hours that surpass the 15-hour per week limit are not covered, promoting efficient resource allocation.
8. Non-Clinical Meal Preparation: Participation in meal preparation and eating that is not a direct part of a clinical treatment plan for an eating disorder is not covered.
9. Services Not in Treatment Plan: Services not explicitly included in the member’s treatment plan as medically necessary and appropriate are noncovered.
10. Less Intensive Services: Less intensive services, such as “club-house” or purely social programs that are not considered formal health care programs under MHCP, are not covered.

Authorization for ADT Services

For authorization policies and procedures, providers should refer to the general Authorization guidelines. Specific to adult day treatment, authorization is required in the following circumstances:

1. Exceeding Hour Limits: To exceed 115 hours of day treatment per calendar year, prior authorization is necessary to ensure appropriate utilization and medical necessity.
2. Concurrent Services: To provide adult day treatment services at the same time as other services, authorization is needed to coordinate care and justify the necessity of concurrent treatments.

To request authorization, providers must submit the following documentation:

1. MHCP Authorization Form (DHS-4695) (PDF) (unless using MN–ITS, the state’s online system).
2. Adult Mental Health Rehabilitative Services Authorization Form (DHS-4159A) (PDF).
3. The most current diagnostic assessment.
4. Current functional assessment.
5. Current level of care assessment determination.
6. Current individual treatment plan.
7. Progress notes from the past six sessions or two weeks, whichever is greater, to demonstrate ongoing need and treatment progress.
8. Discharge plan, discharge criteria, and projected discharge date, indicating a clear treatment trajectory and goals.
9. A detailed medical necessity explanation for the requested additional units of service, justifying the extended treatment duration.

Special Consideration for Concurrent Residential Crisis Stabilization: If a member is also undergoing residential crisis stabilization, special authorization considerations apply. The day treatment provider must submit an authorization request along with a support letter from the residential crisis stabilization provider if at least one of the following conditions is met:

1. Continuity of Care: The member was already participating in adult day treatment before crisis stabilization, and continuing these services would provide important life continuity.
2. Need for Intensive Therapy: The member requires more intensive therapeutic intervention than the crisis stabilization facility can offer, necessitating ADT services.
3. Specialized Therapeutic Needs: The member needs specific therapeutic interventions not available within the crisis stabilization program, such as specialized treatment for eating disorders or obsessive-compulsive disorder.
4. Transitional Support: The member is transitioning to day treatment following their stay at the crisis stabilization facility, using ADT as a step-down service.

Authorization for Targeted Clinical Services Programs: For targeted clinical services, all standard threshold and authorization requirements for adult day treatment apply, with additional documentation requirements:

1. Diagnostic assessment must be completed annually.
2. Functional and level of care assessments must be updated every 180 days.
3. The member’s treatment plan must include:
   • Treatment guidance for a six-month period.
   • Monthly reviews and updates on goals and objectives.
   • Progress notes for the previous two weeks (or quarterly reports for slower progress).
4. Optional additional assessments may include cognitive functioning and risk of re-offense, depending on the member’s needs and the program’s focus.

Billing for ADT Services

Providers are responsible for coordinating services effectively. For detailed billing requirements and guidance when submitting claims, providers should review the MHCP Billing Policy.

Key billing guidelines for adult day treatment include:

• Online Billing: Bill day treatment services online using MN–ITS 837P.
• No Modifiers: Do not use modifiers when billing for ADT services.
• Age Restrictions: Do not provide or bill for adult day treatment for children under 18 years of age.

The specific billing code for Adult Day Treatment is:

Adult Day Treatment