david w. eckert, lmhc, ncc, crc€¦ · the managed care technical assistance center of new york...
TRANSCRIPT
The Managed Care Technical Assistance Center of New York
David W. Eckert, LMHC, NCC, CRC
Senior Consultant at CCSI’s Center for Collaboration in Community Health
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.
Who is MCTAC?
MCTAC Partners
David W. Eckert, LMHC, NCC, CRC
Senior Consultant
Areas of expertise: behavioral health
documentation, person-centered
practice, CQI
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
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
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 www.MCTAC.org and contact managed care companies serving your clients/consumers
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 cost-effective.
For more information about UM, visit www.MCTAC.org and contact managed care companies serving your clients/consumers
1) Formulate Well
2) Focus Treatment
3) Follow the Plan
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
For more information, visit mctac.org:
UM for OMH programs: presentation slides
UM for OASAS programs: presentation slides
LOCADTR guidance
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
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)
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.
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
MCOs want to
know:
Basic demographics
and diagnoses
What are the
individual’s
psychosocial
needs?
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: http://outcomes.ctacny.com/
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!
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
“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 1st, 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.”
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
MCOs want to
know:
How does this
treatment fit into the
“bigger picture” of
client recovery and
other services
received?
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
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.
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.
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.
MCOs want to know:
Can I obtain
summaries on both
individual clients and
on clinic performance
in general?
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
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)
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)
Please take a few minutes to complete the follow up survey. Located here:
Your feedback is very important to us!
Adams, N., & Grieder, D.M., Treatment planning for person-centered care, (2nd 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)
Please email any questions, comments, or suggestions to [email protected] 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 17th
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)