Chris Copeland, LCSW Chief Operating Officer, ICL The Managed Care - - PowerPoint PPT Presentation

The Managed Care Technical Assistance Center of New York

Chris Copeland, LCSW Chief Operating Officer, ICL

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,

• rganizational and clinical practices, to achieve the
• verall goal of preparing and assisting

providers with the transition to Medicaid Managed Care.

Who is MCTAC?

MCTAC Partners

Chris Copeland, LCSW Areas of expertise: Operations, Leadership, Supervision

• Three more topics covering effective clinical practices that improve outcomes for

clients/consumers and set the stage for successful UM review

• 1. Tracking and documentation
• 2. Client Education
• 3. Family Engagement
• More Applied Learning Discussions of case examples
• Two OMH-specific
• Two OASAS-specific
• Please complete evaluations so we know how to improve series in the future

• Supervision in the context of managed care
• How clinical supervision should adapt
• Using data and outcomes to help supervise

Overall – supervision is being taken from 1:1 task to a system task

• Organizational Alignment
• Director/Management and Supervisor
• Supervisor and Staff
• Staff and clients
• Upcoming Webinar
• Where is the clinical in managed care supervision?

• Process by which 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

• Authorizations – both Pre and continuing stay reviews
• Documentation
• Medical Necessity
• Evidence Based/Best Practices
• Clarity of notes
• Progress towards goals
• Golden Thread
• Focus on outliers
• Outcomes and Data

• What’s changed under managed care and what

hasn’t?

• Mental health
• Clinics: no authorizations with some important exceptions
• PROS/ACT: both Pre-auth and continuing stay reviews
• Need to be prepared to request auths and ready for continuing auths.
• Substance use disorder
• Clinics: no pre-authorizations or continuing stay reviews
• Judicial mandates still override other clinical decisions

• 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?
• Specific, Measurable, Attainable, Realistic, Time-limited
• Is golden thread clear from documentation?
• Assessment (diagnosis) → treatment plan → goals/objectives

→ interventions → discharge

• Individualized treatment plan and services (not “cookie cutter

approach”)

• Based on golden thread
• Assessments
• Goal Setting
• Treatment Planning
• MCOs will look for evidence of individualized care. Supervisors

need to track this.

• Are appropriate Evidenced Based Practices (EBPs) being used, when available?
• If co-occurring disorder, have cross-systems assessments been completed?
• SUD assessment for people in mental health programs
• 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:
• Client progress towards goals
• Person-centered approach
• Recovery orientation
• Interventions that use EBPs

• As part of treatment planning and moving towards discharge, we

must be able to identify client’s progress towards treatment goals

• Do you have a tool to help define client’s progress?
• An assessment tool will help you be consistent across clients
• Training is needed to ensure interrater-reliability
• What are your options if your agency doesn’t have a standard

assessment tool?

• DSM 5 – Section III – Emerging Measures and Models
• Ultimately, measuring a client’s progress will lead to understanding

when discharge is possible

• MCOs will require increased focus on step down/program

completion/discharge

• Discharge
• Interventions may not be long-term
• Discharge planning starts at admission
• With attainable goals
• Clear criteria for completion or step-down – published on the MCOs

websites

• Leads to increased turnover of clients
• Has serious administrative implications

• What is an outlier?
• Outlier management?
• Utilization lower than expected - review to understand progress or

identify barriers to engagement

• Utilization higher than expected – review level of care and

treatment plan, interventions, and quality of care

• Providers should understand expected number of visits per

treatment episode to help identify and manage outliers

• Look for patterns, trends and outliers based on:
• Individual clinicians
• Specific diagnoses
• Program sites
• Subpopulation characteristics
• Supervision should incorporate this understanding of

patterns

Length of stay – episode of treatment Frequency of visits By diagnosis Engagement rates Outcomes – indicators of improved health Use of ER – both psych and physical Hospitalizations – both psych and physical Integrated health outcomes – blood pressure, A1c levels

Over the next three years Value Based Payments will be increasingly the norm Value rather then Volume – value to who? Part of the context for change – that Managed Care is the first step not the end

• Supervision of interns is more than just clinical
• Must focus on outcomes in this new environment
• Clarity of writing is key (for all staff)
• Quality of notes
• Awareness of expected course of treatment
• Can an intern explain why they are using a particular intervention?

• Do clinicians have supports they need?
• 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?
• Clear understanding of your role
• Technical resources - EHR or equivalent
• Other supports – tracking visits, auths, data, outcomes

• Managed Care and UM changes how supervisors support

their clinicians.

• Supervisors should consider themselves internal auditors,

ensuring medical necessity and quality documentation is part of treatment plans before speaking with MCOs.

• This should be done in context of your organization so that

leadership, supervisors and clinicians are all on the same page when it comes to Utilization Management.

Before you go, please take a minute to complete the survey (link located in the comments section to the right)

• Understand your team’s caseload
• Maintain calendar for re-authorization
• Make sure charts/notes show
• Quality
• Medical necessity
• Progress or reason for lack thereof and
• And are Up-to-date
• Make sure there is an organizational plan for who speaks with the

MCOs.

Before you go, please take a minute to complete the survey (link located in the comments section to the right)

• Attend next webinars covering additional related content
• Next Webinar: Tracking and documentation (webinar 12/8/15)
• Applied Learning Discussion on 12/15/15 (OASAS-noon, OMH-1pm)

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!

• Please email any questions, comments, or suggestions to

mctac.info@nyu.edu with the subject line “Treatment Plan webinar”

• Questions from this webinar and next week’s will be answered at the

Applied Learning Discussion on December 15th

• 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)