David W. Eckert, LMHC, NCC, CRC Senior Consultant at CCSI s Center for Collaboration in Community Health

Transcription

1 David W. Eckert, LMHC, NCC, CRC Senior Consultant at CCSI s Center for Collaboration in Community Health The Managed Care Technical Assistance Center of New York

2 What is MCTAC? MCTAC is a training, consultation, and educational resource center that offers resources to all mental health and substance use disorder providers in New York State. MCTAC s Goal Provide training and intensive support on quality improvement strategies including business, organizational and clinical practices, to achieve the overall goal of preparing and assisting providers with the transition to Medicaid Managed Care.

3 Who is MCTAC?

4 MCTAC Partners David W. Eckert, LMHC, NCC, CRC Senior Consultant Areas of expertise: behavioral health documentation, person-centered practice, CQI

5 6 topics covering effective clinical practices that improve outcomes for clients/consumers and set the stage for successful UM review 6 Applied Learning Discussions of case examples 3 OMH-specific 3 OASAS-specific Suggestions for some managed care company expectations Please complete the evaluations so we know how to improve this series in the future

6 Review the components of effective case conceptualization Connect conceptualization to Treatment Planning, tracking, and documentation of progress Documentation with an eye for Medical Necessity and Utilization Management Facilitate integration of concepts with examples Take away concrete next steps to implement in practice

7 Process by which an MCO decides whether specific health care services, or specific level of care are appropriate for coverage under an enrollee s plan Primary purpose of UM is to ensure that services are necessary, appropriate, and cost-effective Maintain fidelity and integrity of service provisions while meeting UM standards and requirements Required for reimbursement Intended to be consistent with optimal care for clients/consumers For more information about UM, visit and contact managed care companies serving your clients/consumers

8 Degree to which the documentation in client Progress Notes aligns with the goals, objectives, and interventions documented in the Treatment Plan; the agreed-upon contract for care. MCOs would like to see evidence that Treatment Plans have been co-authored by the clinician and the client and demonstrate a clear understanding of how the problems and functional deficits that result from the diagnoses will be addressed. Objectives that specify measurable behavioral change help us capture the client s progress toward recovery. Treatment Plan reviews should provide measurable evidence of progress or clear evidence that the approach to treatment has changed when progress is not being made. The Progress Notes should clearly relate back to the Treatment Plan, include the key elements of medical necessity, evidence of person-centered practice, and client motivation to change. Primary purpose of UM is to ensure that services are necessary, appropriate, and costeffective. For more information about UM, visit and contact managed care companies serving your clients/consumers

9 1) Formulate Well 2) Focus Treatment 3) Follow the Plan

10 For more information, visit mctac.org: UM for OMH programs: presentation slides UM for OASAS programs: presentation slides LOCADTR guidance Prior Authorization Request: For coverage of a new service, whether for a new authorization period or within an existing authorization period, made before such service is provided to the enrollee. Outpatient mental health office and clinic services DO NOT require prior authorization Concurrent Review Request: For continued, extended or additional authorized services beyond what is currently authorized by the Contractor within an existing authorization period. Discharge Review: For inpatient, this review occurs prior to discharge to assure that plans are in place for a safe and supported re-entry into the community Retrospective Review: Takes place, on an individual or aggregate basis, after the service is provided Outlier Management: Examples of potential over or underutilization

11 During Concurrent Review and Reauthorization, solid documentation will increase likelihood that services will be authorized by MCO In preparation for UM review, must show evidence of progress throughout the course of treatment Discharge Review (Inpatient Services) helps ensure that there is a plan for safe re-entry into the community Helps providers prepare for Retrospective Review to evaluate overall program performance Assists with Outlier Management by identifying under and overutilization of services

12 Assessment and conceptualization demonstrate necessity of service, how the treatment fits into the bigger picture of client recovery/other services received (preauthorization) Engaging client in selecting treatment focus and in prioritizing goals demonstrates a person-centered approach and enhances motivation Monitoring progress on clearly defined behavioral objectives helps treatment remain focused (concurrent review) Clearly defined and measurable discharge criteria set the stage for brief, problem-focused treatment with expectations for termination and plans for transfer of care to other services, community, natural supports, etc. (discharge review)

13 Treatment approach (EBP) is outlined in initial Plan to address functional need, dictating the services provided to the client from the date the plan is established until the plan is up for review. The objectives in the Treatment Plan represent the specific behavioral changes and steps toward recovery in measurable terms. Progress Notes document (evidence-based) interventions provided to the client, steps the client has taken towards goal acquisition, challenges or barriers towards goal attainment and need for continued services (medical necessity). Progress should be continually monitored throughout treatment and should be quantified whenever possible.

14 MCOs want to know: Basic demographics and diagnoses What are the individual s psychosocial needs? Symptoms support diagnosis and lead to functional deficits in the person s life. (A standardized and MCO approved functional assessment can help demonstrate this.) Treatment targets the functional deficits to reduce or eliminate the impact of the diagnoses. (Established in the Treatment Plan) Documentation needs to include: Treatment has been ordered or prescribed by the appropriate individual credentials are critical The service should be generally accepted as effective for the mental illness/addiction being treated The individual must be willing to participate in treatment The individual must be able to benefit from services provided, and they are in the right level of care There must be evidence of active client participation in treatment

15 Evidence-Based Practices dictate the use of specific measurement tools to evaluate progress. Administer these instruments with the fidelity outlined in the model used. Use of level of care determination tools, rating scales and standardized interviews can also facilitate conversations about measurable change LOCADTR DSM 5 Cultural Formulation Interview CTAC Output to Outcomes: Administer at the time of the initial Assessment or Treatment Plan Re-administer as often as feasible, but at least at the point of each Treatment Plan Review Examples: Beck s Depression Inventory (BDI), Beck s Anxiety Inventory (BAI), The Bipolar Affective Disorder Dimensional Scale (BADDS),The Child PTSD Symptom Scale, CAGE Questionnaire, Substance Abuse Subtle Screening Inventory (SASSI), and many more!

16 Well-written objectives drive effective Treatment Plans! Follow a specific formula: Simple, Measurable, Achievable Realistic, and Time-limited (SMART) Realistic, Understandable, Measurable, Behavioral, and Achievable Objectives should be written with client and crossed off the list when achieved The onus of change is placed on the client and action-oriented objectives create momentum toward recovery

17 Jill will obtain an AA sponsor of her choosing within the next 3 months. In the next 90 days, Stephanie will identify at least 3 ways she can establish healthier interpersonal boundaries with her family. Over the next 90 days, Manuela will exercise for at least 30 minutes at a time, 3 days a week. Between now and January 1 st, Dexter will arrive at school on time and attend for the full day on at least 4 out of 5 possible school days. NOT John and parent will attend psychiatric appointments with psychiatrist. (This is an intervention, not an objective.) Mary will report that she has insight into her depression and her mood has improved.

18 MCOs want to know: How does this treatment fit into the bigger picture of client recovery and other services received? Template needed so providers are prepared to share details regarding client s treatment needs and progress MCO and provider work together to ensure that client s needs and the standards of medical necessity are being met MCO and provider collaborate to ensure that clients are treated at the least restrictive and most effective level of care MCO and provider work together to ensure that level of care transitions go smoothly

19 Staff that understands UM processes and goals; know how to clearly communicate clinical data requirements to MCOs Whenever possible, agency UM staff have access to the MCO Provider Manual to understand the MCO expectations and procedures for preauthorization and ongoing authorization of services Documentation template to identify treatment data points for tracking and reporting purposes Effective integration of spreadsheets and data bases between UM and CQI teams Link with billing and coding functions for reporting purposes

20 TPRs are completed and appropriate signatures are obtained within the 90 day framework. The overall Goals are reassessed. Measurable progress related each Objective is documented. Client s view of overall progress with each Objective is documented and quotes are utilized whenever possible. Whenever possible, valid and reliable outcome measures, related to the EBPs utilized, are administered and scored as part of the TPR process. Measurable progress toward Discharge Criteria is documented. If a decision is made for treatment to continue, the rationale and medical necessity for continuing treatment is documented. Create alternative plan for treatment if client is not making progress or is becoming more symptomatic.

21 Quarterly or Monthly Reporting from Documentation Total number of clients active in treatment. Length of stay by diagnosis. Show-rates by: client, clinician, and diagnosis. Percentage of clients completing all or most treatment goals/objectives. Percentage of clients successfully discharged. Percentage of clients lost-to-contact. Percentage of clients seen once and never returned.

22 MCOs want to know: Can I obtain summaries on both individual clients and on clinic performance in general? Operationalizing Treatment Plan Adherence in Practice Clinical, financial, UM, and CQI staff understand their roles and work collaboratively Clinical staff utilize a UM template to accurately document key UM data points and can efficiently partner with MCOs to share relevant treatment information. Financial staff track and communicate status of approvals and denials to clinical team so that they can problem-solve with MCOs as needed. Utilization Management staff understand the relevant clinical documentation and data points to ensure effective communication with the MCOs. The CQI team pulls together the data on clinical outcomes and financial metrics (MCO approval rates, show rates, productivity, etc.) to share with management of all departments to drive agency CQI processes.

23 Concrete strategies increase reliability and validity of case conceptualization Concept mapping Chalkboard Case Conceptualization (Ellis et al., 2013) Conceptualization should evolve as information is gathered Make use of existing data Previous assessments Work with the Care Manager PSYCKES, LGUs, others Data feedback loops should be used to track whether adjustments to treatment plan need to be made

24 Healthcare reform is here to stay Utilization Management requirements fit well within the framework of high quality care Treatment Plan adherence and including measurable objectives help increase client motivation as they gain an increased understanding of the purpose of treatment and gain quantifiable evidence of change. Having clear discharge criteria provides hope by signifying an endpoint for treatment. These changes in practice require more upfront work, especially if it is a new skill. However, in the long run, they are a solid investment as they support the foundation of our recovery-based service system. Before you go, please take a minute to complete the survey (link located in the comments section to the right)

25 Identify a UM liaison within your organization The UM liaison should review provider manuals created by MCOs to familiarize himself/herself with terminologies and expectations and disseminate this information within the organization If you supervise, consider incorporating concept mapping to facilitate greater integration of ideas Attend next webinars covering additional related content Applied Learning Discussion on 11/17/15 (OMH-noon, OASAS-1pm) Next Webinar: Supporting Case Conceptualization as a Supervisor (webinar 12/1/15) Seek consultation and support for enhancing health information technology capacity that streamlines the documentation process Before you go, please take a minute to complete the survey (link located in the comments section to the right)

26 Please take a few minutes to complete the follow up survey. Located here: Your feedback is very important to us!

27 Adams, N., & Grieder, D.M., Treatment planning for person-centered care, (2 nd Ed). Academic Press. Ellis, M. V., Hutman, H., & Deihl, L. M. (2013). Chalkboard case conceptualization: A method for integrating clinical data. Training and Education in Professional Psychology, 7(4), 246. Before you go, please take a minute to complete the survey (link located in the comments section to the right)

28 Please any questions, comments, or suggestions to with the subject line Treatment Plan webinar Questions from this webinar and next week s will be answered at the Applied Learning Discussion on November 17 th OMH at noon OASAS at 1pm Before you go, please take a minute to complete the survey (link located in the comments section to the right)