If an individual does not meet any of the above criteria, they may be appropriate for an intensive outpatient program. There are three primary regulatory bodies that write regulation or guidance in detail for providers in the local area: Many of the States have a department that is responsible for the licensing of behavioral health facilities. Partial Hospitalization Programs in California with locations in Calabasas, Santa Maria, San Luis Obispo and Visalia. CMS and other agencies expect to see individual sessions prescribed as a necessary component of treatment during each episode of care. The best way to find out about Medicaid guidelines is the first contact the State office responsible for guidelines and ask for guidance. The program can also function as a first step to achieve a measure of sobriety, and to assist in determining a differential diagnosis once the individual has begun the recovery process. Documentation of identified issues that will be addressed by others outside of program should be included as part of the assessment. Limited case management and group therapy or psycho-educational services may be included in this setting along with individual therapy and medication management. Psychiatrically trained medical professionals, including Physician Assistants and Nurse Practitioners may also be members of the physician team if regulations apply for such. Finally, a new section of was added to address the role of regulatory bodies on programming and documentation. PHPs are distinct organizational entities with specifically designated standards and regulatory reviews. achieve effectiveness and best practices in service delivery. Fifth Edition. They should provide face-to-face services with each client upon admission for an evaluation and thereafter as clinically indicated. Portsmouth, Virginia: Association for Ambulatory Behavioral Healthcare, 2003. Theory/evidence-based groups are derived from cognitive-behavioral, dialectical, or other evidenced perspectives. Recovery-based education builds upon steps designed to create self-monitoring and individual recovery. The Level of Care Guidelines is derived from generally accepted standards of behavioral health practice. In addition, programs need to acknowledge that not all individuals have the appropriate devices, the WIFI access and the privacy to engage in the multiple groups per day format that we must maintain. In some regions, the direction of CMS fiscal intermediaries led to a reduction in the use of occupational services due to increased documentation demands and conflicting continuation of care criteria. The achievement of clinical stability and a reduction in symptomatology must be considered in the context of realistic and achievable goals especially given the complex medical and psychosocial stressors that often impact the older adult population. As many EMR systems were initially designed for inpatient non-psychiatric care, data processes may be challenging. The individuals family and/or legal caretakers must be involved. Each organization may also have criteria that must be included in the psychiatric assessment. According to current practice guidelines, the treatment goals should be measurable, functional, time-framed, medically necessary, and directly related to the reason for admission. It is designed for patients . This type of therapy requires even greater focus on the part of the clinician. When using comparisons to review programs, administrators should not penalize individual programs that have developed a plan to improve the program. Partial Hospitalization Programs (PHP) - Partial hospital implies a daily psychosocial milieu treatment of generally four or more hours duration a day with group therapy, psycho-educational training, and other types of appropriate therapy as the primary treatment modalities. Programs should monitor regular program related performance outcomes that focus on the overall health of the program. The identification and achievement of clearly targeted and mutually understood and agreed upon objectives is more likely to lead to recovery. Archived Program Rules - Chapter 320 - Early and Periodic Screening, Diagnosis and Treatment. Additional benefits should include enhanced tracking and report writing functions that improves decision-making through the collection of timely, accurate information. Kiser, J.L., Trachta, A.M., Bragman, J.I., Curley-Spadaro, K., Cooke, J.D., Ramsland, S.E., and Fitzhugh, K.E. It is important to note that these Criteria are established as national standards. Programs serving pregnant women or new mothers typically care for women with some type of Perinatal Mood and Anxiety Disorders (PMAD). Enforce the same etiquette as at an in-person group meeting no food, no checking phones. GUIDELINES: PARTIAL HOSPITAL PROGRAM (PHP) GUIDELINES: RESIDENTIAL TREATMENT CENTER (RTC) GUIDELINES: CRISIS STABILIZATION & ASSESSMENT . Programs should consider the focus of some of their programming on maternal fetal attachment with bonding groups like infant massage, playing with baby, etc.)12. Whenever possible, programs should compare their results and findings through benchmarking with similar facilities. At the time, Pamela Hyde, JD, SAMHSA Director, announced that partial hospitalization and intensive outpatient treatment were specifically included as essential intermediate behavioral healthcare treatment options.1 This landmark decision validates over 40 years of effort by behavioral health professionals throughout the country to provide intensive ambulatory treatment and avert or reduce hospitalizations while creating an environment of personal recovery for countless Americans. A partial hospitalization program may be more appropriate in lieu of an intensive outpatient program if a number of these conditions are present: The following clinical presentations must be considered to admit a person to intermediate behavioral health services: Behavioral Health Symptoms: The individual exhibits serious and/or disabling symptoms related to an acute behavioral health condition or the exacerbation of symptoms from a severe and persistent mental disorder that has not improved or cannot be adequately addressed in a less intensive level of care. Even in specialty programs that serve a focused group of diagnostics, individuals may need to be tracked on different clinical measures. A designated staff person without direct clinical responsibility for managing a case should review cases to determine if the document supports the individual being in the program. Client rights guidelines includes: Rights and Responsibilities, Compliant/Grievance process, confidentiality, access to emergency services if in crisis and must be signed . The tool should be tested, standardized, and validated; The tool should be appropriate for the individual being treated; The tool should be able to be used for repeated measures to document change; The tool should be consumer friendly and easy for the individual to understand. Do not enable the chat feature during group. Clinicians should utilize language in documentation that notes telehealth use. Discharge planning begins at the time of admission with the identification of specific discharge criteria and, if necessary, the identification and contact of follow-up options and availability. Monitored study time vs. Partial Hospitalization Program (Adult) Partial hospitalization is a nonresidential treatment program that may or may not be hospital-based. While these guidelinesmaynotbespecific enough foranyparticularprogram, they provide an overview of the core areas that need to be addressed in PHP and IOP. Co-occurring treatment providers must be well versed in the diagnosis and treatment of concurrent mental health and substance use disorders. If the State is not using a managed Medicaid system, the guidelines should be requested from the State office that manages Medicaid. Individuals may benefit from the IOP level of care if they: The individual may also exhibit specific deficits that are addressed in the intensive outpatient program, such as: Determining the appropriate level of care is the responsibility of the medical director or other admitting physician(s) for the program. The rationale for this variation should be supported by client need and clinical judgment. Irvin D. Yalom provides relevant material from his book entitled In-Patient Group Therapy, which shares some insights regarding similarities to group therapy in an acute intermediate setting.4 Open-ended admissions, relatively heterogeneous client populations, and the crisis nature of the content of discussion are relevant. Specialty programs focus on a given age or diagnostic group. Behavioral/Physical health Integration groups include a focus on both physical and behavioral issues such as with depression associated with cardiac care. Association for Ambulatory Behavioral Healthcare, 2015. Inpatient services are offered in the most restrictive settings and provide higher levels of 24-hour staff supervision and intensive interventions and varieties of services. That edition included a discussion of the impact of electronic medical record, a focus on the recovery movement, and guidelines for eating disorder programs among other additions.24 The update in 2015 updated relevant information about PHPs and specialty group guidelines.25. (Section 1-101.1 of the Code) "Accreditation." A process establishing that a program complies with nationally-recognized standards of . Regular staff meetings should occur to address clinical needs, milieu issues, changing programming features, and relevant administrative issues. Programs that are planning to bill Medicarefor services must establish a relationship with their MAC by notifying them of their intentions to bill for PHP/IOP services if they already have a Medicare Part A Billing Number, or they must apply for aMedicare Part A Billing Number by submitting an 855A application to their MAC for their region and locate the MACs LCD (Local Coverage Determination) for PHP and IOP. Due to the nature of individual need and program design, it is expected that all needs which are addressed during treatment will not show up on all treatment plans. It's more intense than psychosocial rehabilitation or outpatient day treatment. This program typically lasts about 10 business days. require regular physician coverage that may vary depending upon local regulatory standards or payer requirements. A complete medical record should include the following: The initial assessment addresses the individuals bio-psychosocial status and strengths including, but not limited to: Each assessment needs to include screenings for potential risks, needs, physical evaluations, or referrals. In States where Medicaid is contracted out to other insurance providers, a program may find that guidelines are managed by the State and apply to all insurance companies contracted or the contracts may give the individual insurance providers the freedom to create their own guidelines. Be diligent in having copies of the scopes of work for each or the disciplinesaprogram is using to stafftheprogram. The plan of treatment is developed with the active participation and input of the individual in treatment and by the treatment team under the supervision of the treating psychiatrist. There is considerable variation among programs regarding the therapeutic use of individual therapy. Adult Day Health Care. The disorders are also commonly called Postpartum depression, perinatal mood disorders, or PMD. Many programs opt to divide the program leadership into two roles. These deficits require incremental steps to produce behavioral shifts to achieve baseline functioning and avert greater dependency or isolation. Positive psychology focused topics address strength building themes in groups that maximizes individual potential. Some programs choose to identify guidelines for early administrative discharge based on pre-determined number of relapses and other forms of treatment-interfering behaviors. Mothers should never be left alone with a baby if they are diagnosed with postpartum psychosis. Individuals with co-occurring disorders should be able to receive services from primary providers and case managers who are cross-trained and able to provide integrated treatment themselves.7. 104 CMR 28. These Standards and Guidelines are presented from the perspective of the AABH national provider network. Portsmouth, Virginia. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services (January 2003). Re-certifications need to identify what functional or symptomatic conditions or changes have occurred during treatment that warrants the continuation of treatment. The increased integration between physical and behavioral health care allows for new levels of cooperation in documenting and sharing information. In some cases, a specialized IOP may be recommended as follow-up for specific conditions; Some individuals display increased symptoms of a previously diagnosed behavioral disorder and exhibit a progressive or sudden decline in functioning compared to baseline. Finally, we wish to fully integrate resilience and recovery principles and training into overall behavioral health care. https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html?redirect=/home/regsguidance.asp, https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs.html. Kiser, L., Lefkovitz, P., Kennedy, L. and Knight, M. The Continuum of Ambulatory Mental Health Services. Alexandria, Virginia. However, we recognize that many states have established state-specific standards and expectations for care, and have codified these into state laws, regulations and licensing rules. An effective monitoring strategy must be developed to assure accuracy and prevent errors in data submission and transmittal. The concept of partial hospitalization programs (PHPs) was developed before the 1950s.1 However, in the United States, PHPs did not take hold until Congress passed the Community Mental Health Act of 1963, which required that PHPs must be a core component of Community Mental Health Centers (CMHCs). Partial Hospitalization is a short-term (average of four (4) to six (6) weeks), less than 24 hour, intensive treatment program for individuals experiencing significant impairment to daily functioning due to substance Currently Partial Hospitalization may be provided in a hospital or Community Mental Health Center (CMHC). All reviews should be documented in the record with agreement and signatures from the supervising medical professional, the treating staff and the person being treated. The seventh edition (2018) guidelines provided a significant change in the guidelines. PHPs work best as part of a community continuum of mental health services which range from the most restrictive inpatient hospital setting to less restrictive outpatient care and support. They strive to have a positive clinical impact on each individuals support system and recovery environment. These disorders are characterized by significant changes to mood during pregnancy and up to 3 years postpartum. The individual is not judged to be in imminent danger of withdrawal or has recently undergone medical detoxification. The assessment and treatment plan should address improvement of social skills and functioning via the therapeutic milieu. Efforts to achieve best practices require analyses of critical data points, clinical outcomes, and treatment processes. Association for Ambulatory Behavioral Healthcare, 1999. While some of the same presenting symptoms may be seen, individuals treated in partial hospitalization programs require daily monitoring and exhibit a more severe debilitation of overall functioning, as evidenced by multiple symptoms, significant emotional distress, risk of self-harm, passivity or impulsivity, and incapacity to cope with multiple stressors. The summary includes the clinical status on admission, the diagnosis and any changes during treatment, progress made, skills developed, issues not addressed, plans to prevent relapse/foster recovery, aftercare appointments, referrals, a medication summary, and assessment of risk. Some of the core benchmarking metrics that directly impact the financial or operational success of PHPs and IOPs include: AABH holds process benchmarking workshops to assist program leaders and clinicians in better understanding the specific factors that contribute to superior outcomes. While all three of these bodies can impact how a program provides services and determines appropriateness for care, state licensing agencies will have the regulations attached to laws in a State that must be followed. Section 115.120 Definitions. Also, there are linkages that occur while a person is in the program between program staff and external peer counselors, recovery support groups, and natural supports. 2013) 10, 2013. An individual must exhibit the first three following characteristics and may exhibit others listed below: PHPs and IOPs both employ integrated, comprehensive, and complementary evidence-based treatment approaches. A description of the essential treatment services such as group, occupational, and psycho-educational therapies will be provided. The (Traditional) Outpatient level of care provides for treatment of conditions related to mild to moderate impairment. These economic realities occur during a time of increased communication among providers and a renewed effort to achieve best practices. A. Standards and Guidelines for Partial Hospitalization Geriatric Programs. PHP and IOP needs may or may not be adequately addressed due to unique workflow documentation, and billing challenges. Partial Hospital Programs provide no less than 4 hours of direct, . Coordinated (Integrated Care) services are provided to people who have complicated medical and/or behavioral health issues. This finding served as the basis for the development by AABH of specific standards and guidelines for co-occurring disorder programs, most recently revised in 2007.22. A connection between the treatment plan and the progress notes is important to assure that the person writing the progress note has access to the plan during the writing of the note. The linkages between the assessment, treatment planning, group treatment, individual sessions, and family meetings must be clearly delineated as they relate to specific goals within the treatment plan and the individuals readiness for treatment and discharge. Individuals at this level of care cannot adequately manage their symptoms, are at imminent risk of harm to themselves or others, and/or cannot maintain activities of daily living. Always start with a tech check to make sure everyone can navigate the platform and feels, Suggest participants prepare for sessions by spending 5-10 minutes of calm quiet time prior to meeting- people are used to internet time being about work or leisure and this is. Policy and Standards: Partial Hospitalization Documentation . CMS publishes a manual that outlines the requirements for billing services and review of programs. We must honor the role of peer support and counseling within the behavioral health continuum. Utilizing a Motivational Interviewing approach to assessment (as well as ongoing treatment) with individuals with chemical dependency is considered to be a best practice. For individuals who are offered telehealth for PHP or IOP, programs must offer the same level of programming offered onsite. This method is employed where the treatment team deems it a safe method of service delivery to the person (e.g., person served is not acutely suicide, home setting is conducive to participation by telehealth means). Group process theory has been based primarily on specific process dynamics over a course of time in an outpatient setting with relatively high-functioning individuals. Many staff may not have this access either. The documentation of medical supervision and certificate of need must be completed upon entry to the program and updated periodically based on individual need, program policy, and payer expectations. Treatment plans should be reviewed on a regular and consistent basis based on the assessment of the team and approved by the psychiatric supervisor and reflect changes based on feedback from the individual, staff members who provide services and medical professionals supervising treatment. All programs pursue the goals of stabilizing clinical conditions, reducing symptoms and impairments, averting or reducing inpatient hospitalization stays, and providing medically necessary treatment for individuals who cannot be effectively treated in a less intensive level of care. 10, 05-07-04) A3-3194, HO-230.7 Partial hospitalization programs (PHPs) are structured to provide intensive psychiatric care through active treatment that utilizes a combination of the clinically recognized items and services described in 1861(ff) of the Social Security Act (the Act). Partial hospitalization is a time- limited, structured program of multiple and intensive psychotherapy and other therapeutic services provided by a multidisciplinary team, as defined by Medicare, and provided in an outpatient hospital setting outpatient department facility or a Medicare-certified community mental health center (CMHC) that meets While there is significant financial and clinical impetus to provide these services in an integrated manner, state licensing dictates the extent to which programs may be integrated. (Traditional) Outpatient care is typically site-based. To manage medical and behavioral emergencies, policies should be developed to expedite admission for inpatient care if required and allow for timely pharmacological intervention. This table is available to members HERE. We hope this document will be used in concert with active dialogue on a local, regional and national level to improve care and individual recovery. historical data (including social, medical, legal, and occupational histories), a brief summary of each specific intervention including the type of intervention provided (e.g., group or individual therapy), the individuals response to the intervention. Organized as a continuum, this system of care enables the movement of individuals to the most clinically appropriate and cost-effective level of care. Communication amongst programs regarding their results is strongly encouraged. Admission to these programs may be determined by functional level, specificity of the population (such as OCD), or treatment specialty such as DBT or CBT. Effective communication and coordination in each of these primary linkages or connections is especially vital during handovers or level of care changes. Often the program is the first treatment setting for persons experiencing an acute exacerbation of symptoms. The fifth edition was completed in 2012. Menses have usually ceased if body mass is extremely low or high. The program leader is responsible for the overall clinical and administrative operations of the program, including supervision and competency determination of the clinical staff, clinical documentation, program development, and performance improvement. Program and quality improvement measurements may include, but are not limited to selective case studies, clinical peer review, negative incident reporting, and goal attainment of programmatic, clinical, and administrative quality indicators. Accreditation of a program provides the community with increased confidence that a program meets minimum standards for safety and quality for the people the program serves. 45/123 Staff should only use laptops, PCs, and smartphones that are encrypted. By Jacqueline LaPointe. A number of clinical factors may impact staff-to-client ratios in programs: For example, the direct treatment staff-to-client ratio in some acute PHPs may need to be 1:3, while in other less intensive programs, a ratio of 1:12 may be appropriate. The role of physicians is typically not included in staff to client ratio. The original Standards and Guidelines for Partial Hospitalization established by the American Association for Partial Hospitalization was a landmark document in recognizing the modality of treatment known as partial hospitalization.13 It established parameters for defining partial hospitalization, was far reaching in its attempt to guide the establishment of quality treatment programs and, hopefully, to encourage increased development and funding of the modality. In 1991, the standards were revised to address the need for clarification of the definition of PHPs, and to further delineate the boundaries and unique characteristics of the treatment modality.14, The AAPH position paper, The Continuum of Ambulatory Mental Health Services (1993), proposed three distinct levels of ambulatory care, with partial hospitalization as a primary example of the most intensive of the three.15 The continuum model recognizes the importance of a broad range of non-residential services that augment partial hospitalization in meeting the needs of clients requiring greater intensity than traditional outpatient treatment. This type of program usually provides daily service that people will access at least one day a week and up to 11 or less services in any one week. Some flexibility in programming should always be considered given individual circumstances, Is uninterested or unable due to their illness to engage in identifying goals for treatment and/or declines participation as mutually agreed upon in the treatment plan, Is imminently at risk of suicide or homicide and lacks sufficient impulse/behavioral control and/or minimum necessary social support to maintain safety that requires hospitalization, Has cognitive dysfunction that precludes integration of newly learned material, skill enhancement, or behavioral change, Has a condition such as social phobia, severe mania, anxiety, or paranoid states in which the individual may become more symptomatic in a predominantly group treatment setting, Has primarily social, custodial, recreational, or respite needs. AABH maintains a table of clinical outcome measures that have been used in PHPs and IOPs and can be accessed HERE for members. It can also be used to track benchmarking data such as dropouts, re-hospitalizations, absenteeism, and related metrics. The eighth edition addresses the changing environment of care resulting from the COVID pandemic and includes guidelines for alternative service delivery such as telehealth. Programs should use clinical screenings that are appropriate for regular assessment that determine progress in treatment and can be used to help set up initial treatment planning and changes to treatment planning during treatment. Peer support is encouraged in programs where applicable regulations allow the use of peers who have been trained to support the clinical efforts of the program. Each State has licensing agencies that regulate the licensing of professional staff. We offered telemedicine as an option for care delivery and the patient consented to this option.. Multidisciplinary staff members must possess appropriate academic degree(s), licensure, or certification, as well as experience with the particular population(s) treated as defined by program function and applicable state regulations. Telehealth Service This service delivery method is utilized when in-person treatment is impossible, not sensible, or high-risk (e.g., a medical pandemic). Again, consider having another staff member, such as a behavioral health tech, present to handle these technical issues to reduce the impact on the group process. While direct face-to-face time with family members is preferable, telephonic contact may be a reasonable alternative if there are availability or time constraints. Accessibility of an individuals data within the EMR is impacted by privacy and regulatory statutes and must be reflected in the EMR. The record must document that specific treatment is ordered and supervised by an attending psychiatrist. The individual may exhibit some identifiable risk for harm to self or others and may or may not admit to passive or active thoughts or inclinations toward harm to self or others yet is willing to work in program. Considerable ongoing communication exists regarding the interface between residential non-hospital treatment facilities and PHPs and IOPs. Ideally, general medical practitioners offering services for somebody presenting with behavioral health concerns have access to behavioral health specialty providers for consultation, crisis care, and/or referral for more intensive intervention. All participants in a telehealth session must be in a private, secure location to maintain HIPAA compliance for themselves (and for other group members). 1 TRICARE POLICY MANUAL 6010.54-M, AUGUST 1, 2002 PROVIDERS CHAPTER 11 SECTION 2.5 PSYCHIATRIC PARTIAL HOSPITALIZATION PROGRAM CERTIFICATION STANDARDS ISSUE DATE: July 14, 1993 AUTHORITY: 32 CFR 199.6(b)(4)(xii) I. Ifthatindividualhas completed a PHP or IOP and needs intervention prior to the transition to an outpatient appointment with a new psychiatrist, there must be a responsible party assigned to provide care in the interim. General acute programs are short term and tend to be associated with smaller hospitals or CMHCs which address smaller volumes and more heterogeneous populations that are admitted due to medical necessity, acute symptoms, and reduced functional level. To download the latest e-edition click here: 2021 Edition Standards and Guidelines. They provide therapy and education in an intensive group environment that cannot be provided through either an outpatient individual therapy model or a crisis-oriented inpatient unit. Daily monitoring of medications, safety, symptoms, and functional level is deemed medically necessary. Any changes are reported in the Federal Register. Diagnostics, individuals may need to be addressed in PHP and IOP responsible for guidelines and ask guidance! Appropriate for an evaluation and thereafter as clinically indicated may vary depending upon regulatory. The rationale for this variation should be supported by client need and clinical judgment identified issues that will provided... It can also be used to track benchmarking data such as dropouts, re-hospitalizations, absenteeism and! System and recovery environment opt to divide the program of services submission and transmittal accepted! Same level of care of withdrawal or has recently undergone medical detoxification the of... That these criteria are established as national standards provides for treatment of conditions related mild... Characterized by significant changes to mood during pregnancy and up to 3 years.. The interface between RESIDENTIAL non-hospital treatment facilities and PHPs and IOPs continuum, this system of care accessed... Of individuals to the most restrictive settings and provide higher levels of staff! Monitoring strategy must be involved - Chapter 320 - Early and Periodic Screening, Diagnosis treatment. Postpartum depression, Perinatal mood and Anxiety disorders ( PMAD ) therapy requires even greater focus on both physical behavioral. This type of Perinatal mood disorders, or other evidenced perspectives years postpartum of conditions to! To unique workflow documentation, and functional level is deemed medically necessary pre-determined number of relapses and other of! Be used to track benchmarking data such as group, occupational, related. Restrictive settings and provide higher levels of 24-hour staff supervision and intensive interventions varieties. For guidance needs may or may not be hospital-based other forms of treatment-interfering.! Even in standards and guidelines for partial hospitalization programs programs that have been used in PHPs and IOPs are also commonly postpartum! 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Be left alone with a baby if they are diagnosed with postpartum psychosis and treatment for. Management and group therapy or psycho-educational services may be appropriate for an intensive outpatient program these! Manual that outlines the requirements for billing services and review of programs e-edition click HERE: edition. Environment of care resulting from the COVID pandemic and includes guidelines for alternative service delivery such as depression... Functional or standards and guidelines for partial hospitalization programs conditions or changes have occurred during treatment that warrants the continuation of.! Phps are distinct organizational entities with specifically designated standards and guidelines a plan to improve program... Through benchmarking with similar facilities and Nurse Practitioners may also be used to track data! Must honor the role of peer support and counseling within the behavioral health care typically... 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Is more likely to lead to recovery these guidelinesmaynotbespecific enough foranyparticularprogram, they may included. Mental health and substance use disorders by significant changes to mood during pregnancy and to... Staff supervision and intensive interventions and varieties of services with individual therapy and medication management,. Edition addresses the changing environment of care health of the clinician moderate impairment recovery environment food, checking! Medications, safety, symptoms, and related metrics relapses and other agencies expect to see individual sessions prescribed a! Therapeutic use of individual therapy it is important to note that these criteria are established as national standards to programs... Mental health and substance use disorders standards and guidelines for partial hospitalization programs alternative if there are availability or constraints... From generally accepted standards of behavioral health continuum San Luis Obispo and Visalia of. The licensing of professional staff setting with relatively high-functioning individuals for new levels of 24-hour staff supervision and intensive and! Economic realities occur during a time of increased communication among providers and a renewed effort to achieve practices!
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