Parity and Healthcare Reform: Community Behavioral Health at a Crossroads

www.TheNationalCouncil.org

Responding to Healthcare Reform and Parity: A Qualitative Approach to Enhanced Treatment Capacity

David Lloyd, PresidentMTM ServicesWebsite: www.MTMServices.orgE-mail: [email protected]

Sandy Myers, Vice President of Behavioral HealthColeman Professional Services, Kent, OHE-mail: [email protected]


Poll Questions.1. From the clinicians perspective, are the

caseloads in your organization full at this time?

Yes or No

2Presented By: David Lloyd, MTM Services and Sandy Myers, Coleman Professional Services


Poll Questions.2. Has your CBHO developed and

implemented clinical pathways, levels of care and/or benefit designs?

Yes or No



Poll Question3. Does your CBHO have an ongoing internal

utilization review/re-authorization process to organization wide clinically appropriate service levels and array being delivered to clients with the same level of need?

Yes or No



Poll Results based on over 600 Registrants for the NC LIVE Webinar on Healthcare Reform Presented by David Lloyd, MTM Services on December 15, 2009 and January 12, 2010

1. From the clinicians perspective, are the caseloads in your organization full at this time?Yes = 74% No = 26%

2. Do you know the cost and days of wait for your organizations first call to treatment plan completion process?

Yes = 41% No = 59%3. Indicate the no show/cancellation percentage last quarter in your organization for the

intake/assessment appointments:A. 0 to 19% = 20%B. 20 to 39% = 42%C. 40 to 59% = 15%

D. Not aware of percentage = 23%4. Indicate the no show/cancellation percentage last quarter in your organization for Individual

Therapy appointments:A. 0 to 19% = 24%B. 20% to 39% = 50%C. Not aware of percentage = 26%



Todays Webinar: Internal Benefit Designs/ Levels of Care to Help Provide Treatment Capacity to Respond to Healthcare Reform Recommended Action Objectives

1. Define a definition of treatment and therefore what is not treatment

2. Identify current caseload members that are not actively in treatment and develop transition plans

3. Develop internal benefit package designs/Levels of Care criteria that serve as clinical guidelines; support for appropriate utilization levels for all consumers; and to provide guidance for internal utilization management/quality improvement processes.



Solution Areas That Need to Be Addressed:1. Define a definition of treatment and therefore what is not

treatment:

Sample Definition:

Behavioral health therapeutic interventions provided by licensed or trained/certified staff either face to face or by payer recognized telephonic/ Telepsychiatry processes that address assessed needs in the areas of symptoms, behaviors, functional deficits, and other deficits/ barriers directly related to or resulting from the diagnosed behavioral health disorder.



Solution Areas That Need to Be Addressed:2. Identify current caseload members that are not actively in

treatment and develop transition plans



Solution Areas That Need to Be Addressed:3. Develop internal benefit package designs/Levels of

Care criteria that serve as clinical guidelines; support for appropriate utilization levels for all consumers; and to provide guidance for internal utilization management/quality improvement processes.



Level of Care-Benefit Package Design Functions1. Purpose is to establish Clinic-wide Course of Treatment Guidelines to

Facilitate appropriate array and utilization levels for services2. Enhances the ability of the center to measure outcomes achieved

based on reduce service utilization variance. NOTE: Under Healthcare Reform, we will have to manage our own course of treatment and associated outcomes or a ACO or another entity will.

3. Enhanced Engagement in Treatment: Provide an awareness to consumers at entry to services the types of services and duration of services the practice has found most helpful to meet their treatment needs so that the consumer will know and the staff will know what services are needed to complete that level of care

4. Provides an enhanced recovery/ resiliency based service planning and service delivery approach for consumers and families

5. Facilitates being able to focus centralized scheduling for each consumer based on the service frequency ordered in the service plan which is based on the benefit design/level of care guidelines

Presented By: David Lloyd, President

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Open Scheduling Same Day Access Model Consumer Engagement Standards

1. Open Scheduling Same Day Access - Masters Level assessment provided the same day of call or walk in for help (If the consumer calls after 3:00 p.m. they will be asked to come in the next morning unless in crisis or urgent need)

2. Initial diagnosis and assessed service needs determined3. Level of Care and Benefit Design Identified with

consumer that includes an estimate of time needed4. Initial treatment plan Developed based on Benefit Design

Package 2nd clinical appointment for TREATMENT within 8 days of Initial Intake 1st medical appointment within 10 days of Initial Intake

Presented By: David Lloyd, MTM Services and Sandy Myers, Coleman Professional Services

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www.TheNationalCouncil.org 12Presented By: David Lloyd, MTM Services and Sandy Myers, Coleman Professional Services

Sample: Adult Mental Health Benefit Design Level Two


Sample: Adult Mental Health Benefit Design Level Two


Sample: Child/Adolescent Mental Health Benefit Design Level Three Carlsbad Mental Health Center


Sample: Child/Adolescent Mental Health Benefit Design Level Two Carlsbad Mental Health Center


Level of Care Utilization Summary


A Level of Care Guideline was designed at Coleman Professional Services in 2001 using the following resources: A Training Curriculum for Met Net Protocols for Level of Care Metro

Behavioral Health Care Network. March 1999. Level of Care Criteria and Guidelines for Use. Published by the National

Community Mental Healthcare Council as a Joint Venture with the Behavioral Health Network of Vermont.

The impetus to design this tool included: Utilization management to improve access to psychiatry and

counseling. Risk management to assure services meet the basic elements of

medical necessity. Manage care within the constraints of the contracts.



The Level of Care guidelines provide the framework for determining eligibility, service mix, service intensity, and length of stay. The components Coleman Behavioral Healths Level of Care Criteria include:

Definition of each Level Admission Criteria Continued Stay Criteria Discharge Criteria Estimated Length of Stay Menu of Services Utilization Expectations



Coleman Professional Services Level of Care GuidelinesLevel I:

> Goal: Learn coping skills that support resolution of the crisis and/or symptom distress.

> Definition: This level of care provides brief and time-limited services to clients who are living either independently or with minimal support in the community and who have achieved significant recovery from past episodes of illness. Treatment and service needs do not require supervision or frequent contact. Staff can provide services in the community, office, school, or clinic. Interventions can include: individual, group, or family psychotherapy, psychiatry, and limited case management. On-call and crisis services should be made available.



Admission Criteria:1. Diagnostic criteria: Axis I or II psychiatric

disorder as defined in the DSM IV.2. Risk of Harm: Minimal risk of harm to Low

risk of harm 3. Functional Status: DLA -20 based GAF of

51 and higher4. Engagement-Positive engagement



Level I (continued)Continued Stay Criteria:1. Diagnostic criteria: Axis I or II psychiatric disorder as

defined in the DSM IV.2. Risk of Harm: Minimal risk of harm to Low risk of

harm.3. Functional Status: Minimal to mild Impairment in

school, work or social functioning. Having consistent difficulties in social role functioning and meeting obligations such as parental responsibilities or performing at expected level in work or school.

4. Engagement: Positive Engagement 21Presented By: David Lloyd, MTM Services and

Sandy Myers, Coleman Professional Services


Discharge Criteria:1. Demonstrates significant improvement in

functioning following a period of deterioration2. Shows strong desire to change.3. Is enthusiastic about treatment, is trusting, and

shows strong ability to utilize available resources.4. Understands recovery process and personal role

in a successful recovery plan.5. Condition has worsened, and a higher level of

care is needed.



Level 1 Level II Level III Level IV

DLA Based GAF

51 or higher 41 to 50 31 to 40 21 to 30

Estimated Length of Stay

6-9 months 9 months to 3 years

6 months to 1 year

18 days

Service Utilization

CPST 1-5 hours per month(not to exceed 5 hours per episode)

2-9 hours per month (not to exceed 108 hours per year)

6-16 hours per month (not to exceed 200 hours per year)

.30-6 hours per week

Counseling 1-2 hours per month (not to exceed 4 hours per episode)

1-2 hours per month (not toexceed 10 hours per episode

1-4 hours per month (not to exceed 18 hours per episode)

0-2 hours per week

Psychiatry 0-1.25 hours(not to exceed 4 hours per episode)

0-1.25 hours per month (not to exceed 5 hours per year)

0-1.25 hours per month (not to exceed 6 hours per year)

.30-1 hour per week



> In the most recent modification, the DLA-20 based GAF scores were added for each level of care. DLA -20 helps to objectively assess clients

current functioning thus, better addresses medical necessity.

The DLA -20 is a functional assessment that is used to get an objective, reliable, and valid GAF estimate.

The DLA-20 co-author is Willa S. Presmanes, M.Ed., M.A.



DLA-20 Assessment Sample



The Process for Monitoring Level of Care

Monitoring Level of Care in a paper record world Monitoring Level of Care within an EMR Monitoring Level of Care utilizing SPQM



Maintaining Level of Care Utilization SPQM Dashboard Measurement

Monthly reports to monitor by provider Monthly reports to monitor by product Monthly reports to monitor by consumer



Total Year, Total Month (Total Ctime)

2009 2010 Total

Case Service Total 1 2 3 4 5 Total

14.3 1.0 1.0 22.0

8.0 2.3 2.3 17.5

11.8 17.3

11.8 2.0 1.0 1.0 0.5 1.0 5.5 17.3

11.0 1.0 1.0 17.0

7.8 3.0 1.5 1.0 1.0 6.5 14.3

8.0 1.0 2.0 1.0 0.5 4.5 12.5

9.3 1.8 1.0 2.8 12.0

12.0 12.0

Staff Specific High Utilizer Clients by Payor and Services

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www.TheNationalCouncil.org 29


Updating the Level of Care for People Served and the Organization:

Frequency of Updates for People Served> The level of care is completed upon admission, updated at

least annually and each time the individual moves to a higher or lower level of care.

Organizational Updates of the Level of Care Guideline> The tool has been modified 4 times since inception. The

modification to the service utilization standards have been based on benchmarking from the utilization data.



Impact of Level of Care on Consumers

> Include Level of Care in consumer orientation processes and in treatment planning.

> Factors required to initiate recovery are often quite different than the factors that later serve to maintain and enrich recovery (Humphreys, Moos & Finney, 1995). Interventions that are effective at an early stage of recovery may

be ineffective at a later stage of recovery. Identify the resources that are available to consumers to maintain

and enrich recovery.



Thank you for your attendance..

> Questions> Follow Up.



David Lloyd, Founder and PresidentMTM Services

Website: www.MTMServices.orgE-Mail: [email protected]

Mr. Lloyds book published by The National Council:

How to Deliver Accountable Care

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Slide Number 1Poll Questions.Poll Questions.Poll QuestionPoll Results based on over 600 Registrants for the NC LIVE Webinar on Healthcare Reform Presented by David Lloyd, MTM Services on December 15, 2009 and January 12, 2010Todays Webinar: Internal Benefit Designs/ Levels of Care to Help Provide Treatment Capacity to Respond to Healthcare Reform Recommended Action Objectives Solution Areas That Need to Be Addressed:Solution Areas That Need to Be Addressed:Solution Areas That Need to Be Addressed:Level of Care-Benefit Package Design FunctionsOpen Scheduling Same Day Access Model Consumer Engagement Standards Sample: Adult Mental Health Benefit Design Level TwoSample: Adult Mental Health Benefit Design Level TwoSlide Number 14Sample: Child/Adolescent Mental Health Benefit Design Level Two Carlsbad Mental Health CenterLevel of Care Utilization SummarySlide Number 17Slide Number 18Coleman Professional Services Level of Care GuidelinesAdmission Criteria:Level I (continued)Continued Stay Criteria:Discharge Criteria:Slide Number 23Slide Number 24Slide Number 25Slide Number 26Maintaining Level of Care Utilization SPQM Dashboard MeasurementSlide Number 28Slide Number 29Slide Number 30Slide Number 31Thank you for your attendance..Slide Number 33

Parity and Healthcare Reform: Community Behavioral Health at a Crossroads

Health & Medicine

sandy myers

types of services

duration of services

definition of treatment

appropriate utilization

appropriate service

service utilization

orglevel of care