FINAL PRESENTATION Utilization Management March April … › sites › default › files ›...

The Managed Care TechnicalAssistance Center of New York

March- April 2016

• The session will go from 9:00 am until 1:00 pm

• We will have a break at 11:00 pm

• A copy of the PowerPoint will be on the MCTAC website (www.mctac.org)

• Feedback Forms

• Reminder: Information and timelines are current as of the date of the presentation.

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

• Continuity of Care Requirements • OMH UM Requirements (OMH Session):

o PROS Requirementso ACT Requirementso CDT, IPRT & Partial Hospitalization Requirementso Outpatient Clinic Requirements

• OASAS UM Requirements (OASAS Session):o Clinic Requirementso Opioid Treatment Programs (OTP)o Outpatient Rehab Requirements

• State Regulations and How They Drive UM Requirements• Outlier Management• Integrating Effective Clinical Practices to Support Successful

Utilization Management Processes

• Transforming the Systemo Employing a person-centered approach to UM

• Minimize disruptions for current clientso No authorizations required for first 90 dayso Can continue with current provider for 2 years, even if

provider Is out of network• Promote access to outpatient services

o No prior authorization for clinico No concurrent review authorizations before 30 visits

• Promote evidence based careo Encourage plans and providers to dialog about

approacheso Encourage plans to develop innovative strategies to care

management

• Inpatient psychiatric services in Article 28 facilities • Part 599 clinic services • Behavioral health services in Part 598 integrated clinics • Personalized Recovery Oriented Services (PROS) programs operated under

Part 512 • Continuing Day Treatment (CDT) programs operated under Part 587 • Intensive Psychiatric Rehabilitation Treatment (IPRT) programs operated

under Part 587 • Assertive Community Treatment (ACT) programs operated under Part 508 • Partial Hospitalization (PH) programs operated under Part 587 • Inpatient Psychiatric Hospitalization Services operated under Parts 580 or

582 • Comprehensive Psychiatric Emergency Programs (CPEPs) operated under

Part 590 • Crisis Intervention • Behavioral Health Home and Community Based Services (BHHCBS):

available to eligible Health and Recovery Plan (HARP) and HARP-eligible HIV Special Needs Plan (SNP) enrollees only

• OASAS Clinic

• OASAS Opioid Treatment Program

• OASAS Outpatient Rehab

• OASAS 820 Residential Programs

Definition: A course of ambulatory behavioral health treatment, other than ambulatory detoxification and withdrawal services, which began prior to the Effective Date of the Behavioral Health Benefit Inclusion in each geographic service area in which services had been provided at least twice during the six months preceding the Behavioral Health Benefit Inclusion Date by the same provider to an Enrollee for the treatment of the same or related a behavioral health condition.”

• 90 day transition language prohibits plans from applying utilization review criteria for a period of 90 days from the effective date of the Behavioral Health benefit inclusion in either NYC or the rest of state, respectively. Accordingly, plans must accept existing plans of care.

• 2 year continuity of care language affirms plans must permit enrollees to continue receiving services from their current provider(s) for “Continuous Behavioral Health Episodes of Care” (as defined in the Model Contract) for up to 24 months from the date of the Behavioral Health benefit inclusion in either NYC or the rest of state, respectively. Notwithstanding, plans may use OMH-approved UR criteria to review duration and intensity of such episodes of care.

This guidance regards utilization management for ambulatory behavioral health (BH) services that will be effective when the MCOs, including MMCPs, HARPs, and HIV SNPs assume management of these services in the adult Medicaid Managed Care Program. These services include routine outpatient office and clinic care as well as the full range of BH specialty services. MCOs will not use prior authorization for Medicaid BH outpatient office and clinic services as of the implementation of the behavioral health carve-in. MCO responses to the RFQ indicated the intent to minimize use of prior authorization for routine BH outpatient office and clinic services as it has proven an inefficient form of utilization management. In addition, parity requirements prohibit the imposition of non-quantitative treatment limits or benefit exclusions based on medical necessity or medical appropriateness when there are no such limits for similar medical/surgical services.

Prior Authorization Request A Service Authorization Request by the enrollee, or a provider on the enrollee’s behalf, 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.

Concurrent Review Request A Service Authorization Request by an enrollee, or a provider on Enrollee’s behalf for continued, extended or additional authorized services beyond what is currently authorized by the Contractor within an existing authorization period.

• PROS is a comprehensive recovery oriented program for individuals with severe and persistent mental illness.

• Single plan of care, the program model integrates treatment, support, and rehabilitation in a manner that facilitates the individual's recovery.

• Person-centered, strength based, and comprised of a menu of group and individual services designed to assist a participant to overcome mental health barriers and achieve a desired life role.

Pre-Admission -- Begins with initial visit and ends when Initial Service Recommendation (ISR) is submitted to Plan. Providers bill the monthly Pre-Admission rate but add-ons are not allowed. Pre-Admission is open-ended with no time limit.

No Prior Authorization or Concurrent Review

PlanPrior Authorization

Concurrent Review

Empire Blue Cross Blue Shield HealthPlus No No

Fidelis No No

Healthfirst No No

UnitedHealthcare (Optum) No No

Wellcare No No

Affinity (Beacon) No No

Metro Plus (Beacon) No No

VNS Select (Beacon) No No

Emblem (Beacon) No No

Amida Care (Beacon) No No


Concurrent Review

Capital District No No

Crystal Run (Beacon) No No

Excellus (Centene) No No

HealthNow BlueCross Blue Shield of WNY (Health Integrated)

No No

Independent Health (Beacon) No No

MVP (Beacon) No No

YourCare (Beacon) No No

Total Care (Beacon) No No

Individualized Recovery Planning -- Admission begins when ISR is approved by Plan. Initial Individualized Recovery Plan (IRP) must be developed within 60 days of the admission date. Upon admission, providers may offer additional services and bill add-on rates accordingly for:

• Clinical Treatment;• Intensive Rehabilitation (IR); or• Ongoing Rehabilitation and Supports (ORS)

Prior authorization will ensure that individuals are not receiving duplicate services from other clinical or HCBS providers.Yes to Prior Authorization and No to Concurrent Review


Concurrent Review

Empire Blue Cross Blue Shield HealthPlus Yes No

Fidelis Yes No

Healthfirst Yes No

UnitedHealthcare (Optum) Yes No

Wellcare Yes No

Affinity (Beacon) Yes No

Metro Plus (Beacon) Yes No

VNS Select (Beacon) Yes No

Emblem (Beacon) Yes NoAmida Care (Beacon) Yes No


Concurrent Review

Capital District Yes No

Crystal Run (Beacon) Yes No

Excellus (Centene) Yes No


Yes No

Independent Health (Beacon) Yes No

MVP (Beacon) Yes No

YourCare (Beacon) Yes No

Total Care (Beacon) Yes No

Begins when IRP is approved by Plan. Concurrent review and authorizations should occur at 3-month intervals for IR and ORS services and at 6-month intervals for Base/ Community Rehabilitation and Support (CRS) and Clinic Treatment services.

Yes to Prior Authorization and Concurrent Review


Concurrent Review

Empire Blue Cross Blue Shield HealthPlus Yes Yes

Fidelis Yes Yes

Healthfirst Yes Yes

UnitedHealthcare (Optum) Yes Yes

Wellcare Yes Yes

Affinity (Beacon) Yes Yes

Metro Plus (Beacon) Yes Yes

VNS Select (Beacon) Yes Yes

Emblem (Beacon) Yes Yes

Amida Care (Beacon) Yes Yes


Concurrent Review

Capital District Yes Yes

Crystal Run (Beacon) Yes Yes

Excellus (Centene) Yes Yes

HealthNow BlueCross BlueShield of WNY (Health Integrated)

Yes Yes

Independent Health (Beacon) Yes Yes

MVP (Beacon) Yes Yes

YourCare (Beacon) Yes Yes

Total Care (Beacon) Yes Yes

• ACT teams deliver comprehensive services to individuals with serious mental illness whose needs have not been met by traditional service delivery approaches

• ACT is an evidence-based practice that incorporates treatment, rehabilitation, case management, and support services delivered by a mobile, multi-disciplinary mental health team. ACT supports recipient recovery through an individualized approach

• ACT services are developed through a person-centered service planning process and adjusted as needed in daily ACT team meetings

• As noted in the guidance, prior and concurrent review authorization is required for ACT. OMH requires the following schedule of assessments and care planning for ACT recipients under the NYS Medicaid fee-for-service program: o Immediate needs assessment should be completed within

7 days of admissiono Initial Comprehensive Service Plan should be completed

within 30 days of admission oComprehensive Service Plan reviewed and revised as

indicated every 6 months

• New ACT referrals must be made through local Single Point Of Access (SPOA) agencies. Plans will collaborate with SPOA agencies around determinations of eligibility and appropriateness for ACT following forthcoming NYS guidelines.

• The referring provider (e.g., hospital provider, Health Home care manager, or other behavioral health provider) contacts the Mainstream Managed Care Organization (MMCO) or HARP, respectively, to request ACT referral. Provider and MMCO/HARP care manager review whether the member meets ACT level of care admission criteria. MMCO/HARP notifies the referring provider of level of care determination within 24 hours.

• If the MMCO/HARP does not approve ACT level of care, MMCO/HARP works with the referring provider to develop an alternate service plan to meet the member’s clinical, rehabilitation and recovery needs. The referring provider has appeal options as described in MMCO/HARP model contract.

• If the MMCO/HARP approves ACT level of care, the MMCO/HARP provides the referring provider with list of in-network ACT teams.

• The referring provider submits ACT application with notice of MMCO/HARP level of care authorization and list of in-network ACT teams to SPOA.

• SPOA will assign appropriate referrals to ACT teams according to their standard prioritization algorithms, balancing clinical and payor priorities (e.g., AOT, Non-Medicaid, Dual-eligible and Managed Medicaid).

Yes to Prior Authorization and Concurrent Review


Concurrent Review


Fidelis Yes Yes

Healthfirst Yes Yes


Wellcare Yes Yes







Concurrent Review




HealthNow BlueCross BlueShield of WNY (Health Integrated)

Yes Yes





Service Type Prior Authorization Concurrent Review

CDT YES YES

IPRT YES YES

Partial Hospital YES YES


Concurrent Review


Fidelis Yes Yes

Healthfirst No No


Wellcare Yes Yes







Concurrent Review





Yes Yes






Concurrent Review


Fidelis Yes Yes

Healthfirst No No


Wellcare Yes Yes






Plan Prior Authorization

Concurrent Review





Yes Yes






Concurrent Review


Fidelis Yes Yes

Healthfirst Yes Yes


Wellcare Yes Yes







Concurrent Review





Yes Yes





MMCOs/HARPs must pay for at least 30 visits per calendar year without requiring authorization. Clinic off-site services will not fall into the 30 day

count for no prior authorization requests

MMCOs/HARPs must ensure that concurrent review activities do not violate parity law.

Service TypePrior Authorization

Concurrent Review

Outpatient mental health office and clinic services including: initial assessment; psychosocial assessment; and individual, family/collateral, and group psychotherapy

NO YES

Outpatient mental health office and clinic services: psychiatric assessment; medication treatment

NO NO

Outpatient mental health office and clinic services: off-site clinic services

YES YES

*Further guidance on clinic off-site services is pending.

NYS ROS Resident with MedicaidManaged Care

coverage:

Pre 7/1/2016Payer

Continuity of Care Applies

30 visits without Prior Auth Applies

Attending the MH clinic prior to 7/1/2016

Fee-for-service Yes Yes (Does not applyuntil October 1)

Attending the MH clinic prior to 7/1/2016

Medicaid Managed Care Plan

No Yes

Begins attending the MH clinic on or after 7/1/2016

Fee-for-Serviceor Medicaid Managed Care Plan

No Yes


Concurrent Review


Fidelis No No

Healthfirst No No


Wellcare No Yes

Affinity (Beacon) No Yes (med mgmt. No)

Metro Plus (Beacon) No Yes (med mgmt. No)



Amida Care (Beacon) No Yes (med mgmt. No)


Concurrent Review

Capital District No Yes

Crystal Run (Beacon) No Yes (med mgmt. No)



No No


MVP (Beacon) No No

YourCare (Beacon) No Yes (med mgmt. No)

Total Care (Beacon) No Yes (med mgmt. No)

ServicePrior

AuthorizationConcurrent Review

Authorization State: Additional GuidanceOutpatient mental health office and clinic services including: initial assessment; psychosocial assessment; and individual, family/collateral, and group psychotherapy

No Yes MMCOs/HARPs must pay for at least 30 visits per calendar year without requiring authorization. MMCOs/HARPs must ensure that concurrent review activities do not violate parity law.

Outpatient mental health office and clinic services: psychiatric assessment; medication treatment

No No

Outpatient mental health office and clinic services: off-‐site clinic services

Yes Yes OMH will issue further guidance regarding off-‐site clinic services.

Psychological or neuropsychological testing

Yes N/A

ServicePrior

Authorization

Concurrent Review

Authorization State: Additional GuidancePersonalized Recovery Oriented Services (PROS) Pre-‐Admission Status

No No

Begins with initial visit and ends when Initial Service Recommendation (ISR) is submitted to Plan. Providers bill the monthly Pre-‐Admission rate but add-‐ons are not allowed. Pre-‐Admission is open-‐ended with no time limit.

PROSAdmission: Individualized Recovery Planning

Yes No

Admission begins when ISR is approved by Plan. Initial Individualized Recovery Plan (IRP) must be developed within 60 days of the admission date. Upon admission, providers may offer additional services and bill add-‐on rates accordingly for:• Clinical Treatment;• Intensive Rehabilitation (IR); or• Ongoing Rehabilitation and Supports (ORS).Prior authorization will ensure that individuals are not receiving duplicateservices from other clinical or HCBS providers.

PROSActive Rehabilitation

Yes Yes

Begins when IRP is approved by Plan. Concurrent review and authorizations should occur at 3-‐month intervals for IR and ORS services and at 6-‐month intervals for Base/ Community Rehabilitation and Support (CRS) and Clinic Treatment services.


March- April 2016

• OASAS will not allow Plan routine requests for outpatient approvals for admission or continuing stay.

• Clinic includes Intensive Outpatient Service (IOS) – all admissions to IOS should be reported to the plan. Some plans will request a report of admission to IOS. The purpose is to enable plans to ensure appropriate care management for these members. Most programs will use the LOCADTR report to notify.

See OASAS guidance regarding use of LOCATDR tool to inform level of care determinations.OASAS encourages plans to identify individual or program service patterns that fall outside of expected clinical practice but will not permit regular requests for treatment plan updates for otherwise routine outpatient and opioid service utilization; The contractor will allow enrollees to make unlimited self referrals for substance use disorder assessment from participating providers without requiring prior authorization or referral from the enrollee’s primary care provider.MMCOs/HARPs must ensure that concurrent review activities do not violate parity law.


Concurrent Review


Fidelis No No

Healthfirst No No


Wellcare No No







Concurrent Review





No No


MVP (Beacon) No No




• Clinic includes Intensive Outpatient Service (IOS) – all admissions to IOS should be reported to the plan. Some plans will request a report of admissions to IOS. The purpose is to enable plans to ensure appropriate care management for these members. Most programs will use the LOCADTR report to notify.

OASAS encourages plans to identify individual or program service patterns that fall outside of expected clinical practice but will not permit regular requests for treatment plan updates for otherwise routine outpatient and opioid service utilization; 150-200 visits per year are within an average expected frequency for opioid treatment clinic visits.

The contractor will allow enrollees to make unlimited self-referrals for substance use disorder assessment from participating providers without requiring prior authorization or referral from the enrollee’s primary care provider.

MMCOs/HARPs must ensure that concurrent review activities do not violate parity law.

No to Prior Authorization and Concurrent Review


Concurrent Review


Fidelis No No

Healthfirst No No


Wellcare No No






Plan Prior Authorization

Concurrent Review





No No

Independent Health (Beacon) No NoMVP (Beacon) No NoYourCare (Beacon) No NoTotal Care (Beacon) No No


• Programs must complete a LOCADTR at admission.

• Programs must inform the plan of an admission to this level of care, most programs will send the LOCADTR report – programs should talk with plans about their process and expectations.

Plans may require notification through a completed LOCADTR report for admissions to this service within a reasonable time frame. The contractor will allow enrollees to make unlimited self-referrals for substance use disorder assessment from participating providers without requiring prior authorization or referral from the enrollee’s primary care provider.MMCOs/HARPs must ensure that concurrent review activities do not violate parity law.

No to Prior Authorization and Concurrent Review


Concurrent Review


Fidelis No No

Healthfirst No No


Wellcare No No







Concurrent Review





No No


MVP (Beacon) No No



ServicePrior

Authorization

Concurrent Review

Authorization State: Additional GuidanceOASAS-certified Part 822 clinic services, including off-site clinic services

No No See OASAS guidance regarding use of LOCATDR tool to inform level of care determinations.OASAS encourages plans to identify individual or program service patterns that fall outside of expected clinical practice but will not permit regular requests for treatment plan updates for otherwise routine outpatient and opioid service utilization; 30-50 visits per year are within an average expected frequency for OASAS clinic visits. The contractor will allow enrollees to make unlimited self referrals for substance use disorder assessment from participating providers without requiring prior authorization or referral from the enrollee’s primary care provider.MMCOs/HARPs must ensure that concurrent review activities do not violateparity law.

Medically supervised outpatient substance withdrawal

No No Plans may require notification through a completed LOCADTR report foradmissions to this service within a reasonable time frame.

ServicePrior

Authorization

Concurrent Review

Authorization State: Additional Guidance

OASAS Certified Part 822 Opioid TreatmentProgram (OTP) services

No No

OASAS encourages plans to identify individual or program service patterns that fall outside of expected clinical practice but will not permit regular requests for treatment plan updates for otherwise routine outpatient and opioid service utilization; 150-200 visits per year are within an average expected frequency for opioid treatment clinic visits. The contractor will allow enrollees to make unlimited self-referrals for substance use disorder assessment from participating providers without requiring prior authorization or referral from the enrollee’s primary care provider.MMCOs/HARPs must ensure that concurrent review activities do not violate parity law.

OASAS Certified Part 822 OutpatientRehabilitation

No No

Plans may require notification through a completed LOCADTR report foradmissions to this service within a reasonable time frame. The contractor will allow enrollees to make unlimited self-referrals for substance use disorder assessment from participating providers without requiring prior authorization or referral from the enrollee’s primary care provider.MMCOs/HARPs must ensure that concurrent review activities do not violate parity law.

Integrating Effective Clinical Practices to Support Successful Utilization

Management Processes

• MCTAC Webinar series:o Case conceptualization and treatment planningo Documentation and supervisiono Client education and family engagement

• Sets the stage for effective authorization, concurrent review, discharge planning

• Integrates best practices and data collection to support recovery

• Supports effective services that are necessary, appropriate, and cost-effective

• Common concernsoDon’t know/understand what is happeningoLonger wait to start up servicesoForced to switch providers oLimits on service durationoNumber of people involved in personal issues

and treatment decisions

• What basic questions should my agency be able to answer?o What is managed care? What is an MCO?o What is a Health Homeo What is a HARP?o What are HCBS services?

• Who should be able to answer these questions?o All levels of staff should know enough to answer basic

questions, especially billing, counselor, director

• Clarify what is happening• Be clear about recovery framework• Reduce clients’ anxiety• Sensitivity to underlying issues

o Losso Fear of changeo Abandonmento Not convinced of recovery potentialo Vulnerability to relapse/symptom flare-upo Pressure to accomplish within tight timeframes

• Avoid “blame” (us v. them mentality)

• Synthesizes client experience, theory, and researcho Focus on daily life functioning goals that are meaningful to the

client/consumer

• Promotes client engagement• Identifies client strengths and suggests ways to build client

resilience• Guides the selection, focus, and sequence of evidence-based

interventionso Suggests the simplest and most cost-efficient interventions

• Anticipates and addresses challengeso Helps understand when interventions aren’t working and suggest

alternative routes for change

• Enables high quality supervision• Fits within the system’s goals for improving care and reducing cost

• Basic background informationo Demographics, diagnosis, etc.

• What are the clinical markers that dictate the necessary level of care?o Outcome of psychiatric evaluation, psychosocial needs,

response to previous treatment/lower levels of care, recovery goals

o Proactive crisis plan including warm lines, natural supports, any ER-based care coordination

o For PROS/ACT, why is a lower level of care not appropriate?

o For substance use services, document that the LOCADTR was used for determination of level of care-admission and change in level of care

• Presenting problemso Basic demographics & diagnoses. What are the individual’s

psychosocial needs? • Predisposing factors

o Why is the treatment necessary? What else has been tried and why wasn’t it sufficient?

• Precipitating factorso What prevents this person from being successful at a lower level

of care?• Perpetuating factors

o What will be accomplished by this treatment? • Protective/positive factors

o How does this treatment fit into the bigger picture of client recovery and other services received?

• Well-written objectives drive effective Treatment Plans• Follow a specific formula:

o Simple, Measurable, Achievable Realistic, and Time-limited (SMART)

o Realistic, Understandable, Measurable, Behavioral, and Achievable (RUMBA)

• 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

• Template can facilitate sharing details regarding client’s treatment needs and progress

• Consider agreed-upon contract for care in which MCO and provider work together with client and family to ensure needs are met in the least restrictive and most effective setting

• 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 • 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

• 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

• Symptoms support diagnosis and lead to functional deficits in the person’s lifeo A standardized and MCO approved functional assessment can help

demonstrate this

• Treatment targets the functional deficits to reduce or eliminate the impact of the diagnosedo Established in the Treatment Plan

• Documentation needs to include:o Treatment has been ordered or prescribed by the appropriate individual –

credentials are criticalo The service should be generally accepted as effective for the mental

illness/addiction being treatedo The individual must be willing to participate in treatmento The individual must be able to benefit from services provided, and they

are in the right level of careo There must be evidence of active client participation in treatment

• Individualized treatment plan and services, rather than a “cookie cutter approach”o Based on golden thread running through

• Conceptualization• Assessments • Goal setting• Treatment planning• Discharge planning

• MCOs will look for evidence of individualized care.

• Recommendation of the President’s New Freedom Commission relate to family issues:

Mental health care is consumer and family driven.

• In NYS, “big picture” goals include developing a person-and family-oriented system. It’s important to work towards aligning with that goal and to document that it is happening.

• Essential is that consumer defines who’s in his or her family and support network

§ Document consumer’s choice and how family involvement may inform and support individualized recovery goals

• Broadening the network or “team” of people who can work together to assist person

• Relapse/readmission prevention is typically most effective when early warning signs of relapse are identified and monitored

• Increased revenue by increasing “show rates” in outpatient settings, and when people are transitioning from more restrictive settings into outpatient settings

• Improved consumer views about and satisfaction with treatment and their relationships with practitioners

• If it isn’t documented, it didn’t happen• Documentation to support UM

o Individual-specific • Medical Necessity • Evidence Based/Best Practices• Clarity of notes• Progress towards goals• Golden Thread

o Program/agency-specific • Length of stay – episode of treatment • Frequency of visits• By diagnosis and demographics• Engagement rates• Understand outliers

o Outcomes• Use of ER • Hospitalizations• Integrated health outcomes

• Are appropriate Evidenced Based Practices (EBPs) being used, when available?

• If co-occurring disorder, have cross-systems assessments been completed?o SUD assessment for people in mental health programso MH evaluation for people in substance use disorder treatment

• Are treatment plans and interventions updated if relevant issues arise before scheduled service plan updates?

• Are progress notes reflective of:o Client progress towards goalso Person-centered approacho Recovery orientationo Interventions that use EBPs

• As part of treatment planning and moving towards discharge, we must be able to identify and document progress towards treatment goals

• Do you have a tool to help define client’s progress?

o An assessment tool will help you be consistent across clients

o Training is needed to ensure interrater-reliability

• What are your options if your agency doesn’t have a standard assessment tool?

o DSM 5 – Section III – Emerging Measures and Models

o CTAC Output to Outcomes tool

• Ultimately, measuring a client’s progress will lead to understanding how to move towards recovery

§ MCOs will require increased focus on step down/program completion/discharge

§ Dischargeo Discharge planning starts at admission

• With attainable goals and planning for recovery

§ Interventions may not be long-termo Clear criteria for completion or step-down

o Leads to increased turnover of clientso Has serious administrative implications

§ To stay ahead of MCOs, supervision should reflect MCO expectations

§ Is the diagnosis accurate? Do interventions match diagnosis?

§ Does documentation reflect medical necessity?

§ Are treatment goals SMART?

o Specific, Measurable, Attainable, Realistic, Time-limited

§ Is golden thread clear from documentation?

Assessment (diagnosis) → treatment plan → goals/objectives

→ interventions → discharge

§ Do clinicians have supports they need? o Professional development

• Basic understanding of Managed Care • Script for discussion with MCO• Trainings – i.e., specific to best practice/EBP

§ Do you have what you need?o Clear understanding of your roleo Technical resources - EHR or equivalento Other supports – tracking visits, authorizations, data,

outcomes

• What is an outlier?

• Outlier management?o Utilization lower than expected - review to understand

progress or identify barriers to engagement o Utilization higher than expected – review level of care and

treatment plan, interventions, and quality of care

o Providers should understand expected number of visits per treatment episode to help identify and manage outliers

Q and A

FINAL PRESENTATION Utilization Management March April … › sites › default › files ›...

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