A Review of the Beacon Health Options Clinical Case Management

Transcription

1 Clinical 3.50 CASE MANAGEMENT Intensive Case Management (Child/Adolescent) Description of Services: Intensive Case Management provides for a single point of coordination/accountability in managing the care of individuals designated as high risk and/or high complexity who have not been able to stabilize and improve in treatment through the use of standard care management strategies. The Intensive Care Manager provides comprehensive needs assessment, develops a care plan and coordinates appropriate services to meet an individual s treatment, support, and psychosocial, occupational, cultural linguistic needs. The goal is to promote self management capability, building on identified strengths to pursue individual centric goals and overcome challenges. The service enables the individual to live in the least restrictive environment possible and increase his/her adaptive capabilities. Services are varied and include the development of a highly individualized and integrated care plan. The Intensive Case Manager collaborates with the individual, treatment providers and community agencies to assist in assessment, planning, implementing, coordinating, monitoring and evaluating treatment options and services in order to promote quality, cost-effective outcomes. Frequency of telephonic contacts and interactions with the individual, treatment providers and other stakeholder are based on individual needs and assessed acuity. ICM program services are usually offered as a value-added service whether or not they are included in the individual s benefits. Licensure and credentialing requirements specific to facilities and individual practitioners do apply and are found in our provider manual/credentialing information. Admission Beacon Health Options Clinical and Quality Leadership provide centralized referral criteria for all Engagement Center sites. Based on local Engagement Center capacity and contract specific requirements, the Service Center works with Beacon Health Options Leadership to implement these criteria, determining how to maximize resources and prioritize referrals within the standard criteria. Beacon Health Options Informatics provides ongoing analysis of program data and outcomes to further inform the overall referral criteria and aggregate individual case risk weighting to target the most impactable individuals for program participation. In order to be considered for admission to the most intensive levels of ICM care management (Tier 2 and Tier 3), at a minimum an individual must meet each of the first three criteria. In order to be considered for the medical care coordination component of the program (Tier 1), an individual must meet criteria items two and four: 1. Demonstrate behavioral symptoms consistent with a DSM (the most current version of the DSM), diagnosis which requires and can reasonably be expected to respond to therapeutic intervention 2. Require assistance in obtaining and coordinating treatment, rehabilitation and social services 3. For participation in intensive care management interventions (Tier 2 or Tier 3), be identified as an individual with a status of high risk group (defined as a likelihood of self-injury, death, inability to care for self, in need of hospitalization to ensure safety, and/or prevent harm to others). Examples of factors indicating high risk might include, but not be limited to any of the Reviewed: 08/17/09, 08/16/10, 11/30/10, 11/21/11, 11/19/12, 11/18/13, 11/17/14, 2/5/15 Page 1 of 5 Beacon Health Options Policies and Procedure and Medical Necessity cover the operations of all entities within the BVO

2 Clinical following. The Engagement Center s clinical and quality leadership determine which factor(s) will be prioritized for program participation based on contractual requirements, program capacity, and population patterns: a. Multiple IP admissions - More than one inpatient admission within the past six months for primary behavioral health issues or co-morbid behavioral/ medical health conditions, and no evidence of ongoing treatment support subsequent to the IP discharge to resolve issues precipitating the need for acute care (actual threshold determined by the service center and clinical/quality leadership) b. Multiple ER admissions - More than one Emergency Room admissions in the past six months with psychiatric complaints and no evidence of ongoing treatment support within the last 60 days subsequent to the last ER discharge to resolve issues precipitating the need for acute care (actual threshold determined by the service center and clinical/quality leadership) c. Complex co-morbid behavioral and medical health conditions, including but not limited to diabetes, heart disease, obesity, HIV, pregnancy at risk for or diagnosed with postpartum depression or psychosis, requiring significant coordination between behavioral and medical treatment providers d. Significant suicidal or homicidal risk - Recent history (within the past six months) of serious life threatening attempts requiring medical treatment for which Intensive Care Management is indicated to ensure ongoing treatment support and promote patient safety e. Multiple failed Substance Abuse treatment attempts - for substance abuse as evidenced by 2 or more failures to follow-up with referrals or discontinued treatment Against Medical Advice (AMA) f. Repeated high risk behaviors - Determination of repeated high risk behaviors (as evidenced by a likelihood of self-injury, death, inability to care for self, hospitalization, and/or prevent harm to others) including, but not limited to, running away from treatment facilities, repeated noncompliance with treatment or medications, engaging in repeated selfinjurious behaviors, or involvement with protective services agencies g. Special vulnerable population segments (with no evidence of ongoing treatment support to resolve potential issues associated with their condition): Pregnant women with substance abuse disorders Child 5 yrs. old or younger with Bipolar diagnosis Child 10 yrs. old or younger with IP admit Special Needs Population (SNP) as defined per health plan agreements above and beyond the criteria for chronic health issues defined above (for example HIV/AIDS) Reviewed: 08/17/09, 08/16/10, 11/30/10, 11/21/11, 11/19/12, 11/18/13, 11/17/14, 2/5/15 Page 2 of 5 Beacon Health Options Policies and Procedure and Medical Necessity cover the operations of all entities within the BVO

3 Psychosocial, Occupational, and Cultural and Linguistic Factors Exclusion Clinical Child or adolescent with parent having history of SA/MH putting the child at risk Failed out-of-home placement(s) or significant disruption of a foster placement during the last 6 months Aging out of agency (child/adolescent) h. Complex psychiatric cases including those with multiple state/provider agency involvement requiring coordination of care between specialty providers (ex, eating disorder cases requiring coordination between individual and providers); multiple family individuals using BH or state services i. High utilizers individual in the top x% of overall behavioral health service utilization for employer group, health plan, risk group, contracted population (actual threshold determined by the service center and clinical/quality leadership) j. Diagnostic Specialty Unit referrals (Eating Disorder, Dual Diagnosis MH & SA, Complex Child and Adolescent cases, Other special need (Gambling, Sexual Addictions, Self-mutilation, OCD) k. New and/or Unstable High Risk Diagnosis (Eating Disorder, Schizophrenia, Schizoaffective, Dissociative Identity Disorder) - "unstable" defined as recent (past 6 months) admission to inpatient / higher level of care or a new diagnosis, and no indication of ongoing treatment or supportive services subsequent to the discharge or the indication of a new diagnosis. 4. Medical Care Coordination / Integrated Care - individuals with health issues and possible behavioral health concerns are referred for screening and service coordination as needed. These referrals will typically be managed in Tier One, lower intensity outreach with screening, resource coordination, and followups. Upon screening, individuals may be transitioned to higher intensity participation in the ICM program. Sample programs include Co-existing Condition Assessment, Medical Coordination, Mind-Body Health Screening, Substance Use after Care Coordination, and Depression Coordination. These factors, as detailed in the Introduction, may change the risk assessment and should be considered when making level of care placement decisions. Either of the following criteria is sufficient for exclusion from this level of care: 1. Individual chooses not to participate in this intensive care program or is unreachable. 2. Individual is currently in a hospital, not medically cleared or unable to participate in the process or execute the goals of the proposed plan of care Reviewed: 08/17/09, 08/16/10, 11/30/10, 11/21/11, 11/19/12, 11/18/13, 11/17/14, 2/5/15 Page 3 of 5 Beacon Health Options Policies and Procedure and Medical Necessity cover the operations of all entities within the BVO

4 Clinical Continued Stay Discharge All of the following criteria must be met for continued treatment at this level of care: 1. Individualized care management plan identifies: a. All services currently being provided, as well as those that are needed; b. Barriers to accessing needed services; c. Barriers to the individual's ability to benefit from current treatment; d. Resources, both clinical and psychosocial, that can assist the individual with satisfactory adjustment to limitations; e. Expected benefit from all relevant treatment modalities; f. Expected length of care management participation; and g. A specific plan to mobilize and monitor adequacy of alternative treatment options. 2. Individual actively participates with individual intensive care management care plan to the extent possible given individual s condition. Care givers and treatment providers participate with care management plan as needed. 3. Individual and treatment team agree that individual is benefiting from services. 4. Individual continues to meet admission criteria to the program. Any of the following criteria are sufficient for discharge from this level of care: 1. Individual is assessed to be safely engaged in ongoing treatment. The identified barriers to treatment have been resolved and the individual is able to participate in and benefit from more standard treatment and management programs without the need for the intensity and support of the ICM program. 2. The Individual has returned to functional or symptomatic baseline and there is no reasonable expectation of further improvement and no longer requires ICM. ICM goals have been met or services have been discontinued by the provider(s) because the individual no longer requires those services 3. Individual/family declines to accept the proposed treatment plan or a viable alternative or is unwilling or unable to participate in the treatment plan or follow appropriate recommendations 4. Lack of adequate, consistent progress to qualify for continued ICM services despite revisions to the treatment plan. Individual no longer meets criteria for services 5. Individual enters long term residential or custodial care. 6. Primary health insurance is no longer covered by Beacon Health Options (appropriate transition/coordination of care is provided by VO). 7. Ongoing CM services from another resource such as the Health Plan Care Manager or Disease Management Program are better positioned to address the Reviewed: 08/17/09, 08/16/10, 11/30/10, 11/21/11, 11/19/12, 11/18/13, 11/17/14, 2/5/15 Page 4 of 5 Beacon Health Options Policies and Procedure and Medical Necessity cover the operations of all entities within the BVO

5 Clinical individual s primary needs. VO s ICM may continue involvement as a secondary consultant as needed. 8. The multidisciplinary team agrees that the individual is ready for discharge from the ICM program or that the intended degree of stability has been reached. 9. Individual is not responsive to outreach attempts, supports or referrals Reviewed: 08/17/09, 08/16/10, 11/30/10, 11/21/11, 11/19/12, 11/18/13, 11/17/14, 2/5/15 Page 5 of 5 Beacon Health Options Policies and Procedure and Medical Necessity cover the operations of all entities within the BVO