Cardinal Innovations Child Continuum of Care Philosophy March 2014
Disclaimer Information provided in this presentation pertains only to the counties in the Cardinal Innovations Healthcare Solutions Region. This information is specific to the Cardinal Innovations Region and may not apply to other LME, MCOs, providers, stakeholders or individuals outside the Cardinal Innovations catchment area. Presentation slides are brief, bullet-points of information and should not be used out of context. Copyright 2014 Cardinal Innovations Healthcare Solutions. All rights reserved.
Cardinal Innovations Clinical Design Philosophies A High Quality Network Ensures access Is financially sustainable Uses best practices Achieves outcomes Reduces overall cost to society
Access and Management Styles Low barriers to crisis care Low barriers to and management of lower levels of care Higher management for higher levels of care
High Performing Providers Receive more hands off management If you are doing only what is medically necessary, at a high level of quality, we want to get out of your way
Resources UM Guidelines System of Care Care Review process Care Coordination Community Partners Links to housing, schools, DSS, etc. Training and community education
Philosophies of Care Quality and accountability Innovation and specialization Cultural/linguistic competency Recovery Self-determination Community-based and least restrictive settings Safe and secure environments
Strong System of Basic Services Comprehensive Community Clinic (CCC) Model Serve MH and SA, regardless of age High quality assessments Family, group, individual therapy Psychiatric services for all levels of complexity Safety net Open access
High Quality Assessments What elements should these include? Presenting and associated problems Behavioral and physical health histories, including treatment Current and past medications: outcomes, adherence Family/social histories
High Quality Assessments What elements should these include? Review of biological, psychological, familial, social, environmental and developmental dimensions Biopsychosocial formulation Diagnoses (justified) Treatment recommendations Evidenced Based Practices (EBPs) Service setting Referrals
Key Elements of Service Review Diagnostic integrity Appropriate Level of Care (LOC) Effective coordination of care and communication Appropriate discharge planning and referrals Use of EBPs to fidelity
Key Elements of Service Review Use of Clinical Guidelines Measurement-based care Adequacy of informed consent Compliance with all relevant service definitions, contractual requirements
Core Best Practices Measurement-based care Use evidenced based tools or other tracking tools and adjust care over time according to response Coordinated care Clinical Guidelines/EBP usage
Core Expected Outcomes What is Cardinal Innovations looking for? Improvement in symptoms, behaviors, skills Improvement in quality of life Reduction in total cost of care to society Reduced usage of higher levels of care to the greatest extent that is safe
Expectations for Child Service Providers
Outpatient Services Reminders No authorization required for physician services, including E&M Codes 24 unmanaged sessions for Medicaid outpatient individual, family and group therapy For H-codes, services are requested by session vs. units For consumers in enhanced services that have a therapy component, prior authorization is required for additional therapy
Outpatient Services Reminders Requests should be sessions per the life time of the TAR When authorizations past the unmanaged units are requested, clearly outline the treatment modalities being utilized Modalities should be evidenced based practices whenever possible and consistent with clinical guidelines based on diagnosis
Services with Therapy Included It is the expectation that services that already include therapy, provide therapy to meet the consumer s needs e.g., IIHS, Level III, Day Treatment, MST, PRTF, SAIOP If the consumer has specialized needs or is preparing for transition to step down, additional therapy may be requested, but this must be clearly clinically supported in the PCP
Services with Therapy Included If additional therapy is requested with enhanced services that include therapy, prior authorization must occur The request must clearly support why additional therapy is needed and how providers will be coordinating services
Child Residential Authorizations For new Level III-IV requests: Requires TAR + PCP + Assessment completed in the last 30 days For new PRTF requests: Requires TAR + PCP + Psychological Testing For requests for Level III past 180 days: TAR + Independent Psychiatric or Psychological assessment, clearly indicating why needs cannot be met in a less restrictive setting (recommend this be scheduled well before consumer reaches 180 days)
Child Residential Authorizations For requests for Level II past 270 days: TAR + PCP update stepping consumer down to Level I or TAR + PCP update + Assessment clearly showing why needs cannot be met in less restrictive services and that progress toward goals is occurring; document how strategies and interventions will be modified to increase effectiveness of services
Residential Treatment Therapy should be a key component for all children in treatment Family Therapy is an essential part of transition planning Level III providers should provide within their services Individual Therapy and Family Therapy each a minimum of two times per month PRTF providers should provide within their services at a minimum Individual Therapy weekly and Family Therapy two times per month
Residential Treatment Therapy should be provided by a fully licensed clinician, unless a request for exception has been previously approved by Cardinal Innovations All children in residential treatment should be actively receiving psychiatric services, preferably by a Child and Adolescent Psychiatrist PRTF providers should have a psychiatrist available as needed but should provide services to children at least weekly (face to face)
Responsibilities for Coordination Providers should be actively communicating with everyone involved with the consumer, including therapists, school, family, community stakeholders (e.g., DSS, DJJ) and primary care physicians Residential providers should be communicating with providers who will provide step down services to ensure these are in place prior to discharge for smooth transition
Responsibilities for Coordination Discharge Planning should be documented from admission, and this should include realistic measurable criteria based on progress vs. expected full completion of every goal If assistance is needed to identify providers, call the Access Line at 1.800.939.5911 Providers should work to identify natural and community supports for consumers, and invite them to participate in planning meetings
Contact Information Medical Director, Craig Hummel, MD 704.939.7704 Craig.hummel@cardinalinnovations.org Associate Medical Director, Keith McCoy, MD 919.913.4075 Keith.mccoy@cardinalinnovations.org UM Director, Christine Beck, LPC, LCAS 704.939.7842 Christine.beck@cardinalinnovations.org
Contact Information Email for MHSA utilizationm@cardinalinnovations.org Email for IDD DD-UM@cardinalinnovations.org
Questions?