The PBH Multi-Level Model of Care Management |
Published: October, 2001
|
The Routine Care Model
The Intensive Care Management (ICM) Model
The Extended Care Management (ECM) Model
The Assertive Care Management (ACM) Model
The PBH protocol for patient placement begins with the mandate that any member seeking treatment should be rapidly matched with a network provider at the appropriate level of care. Open and timely access to care is a cornerstone of the PBH philosophy. Every member accessing care is directed to a provider, based upon the assessment of risk, acuity, specialty need, and member preference. The treatment modalities and procedures authorized at the point of initial access vary according to patient need and the licensure of the practitioner.
Once an episode of care has been initiated, the goal for a managed behavioral healthcare organization is to implement ongoing utilization management and care management activities that provide value to members and providers. PBH seeks to simplify processes for routine utilization management since intensive monitoring programs provide little value for treating practitioners or for PBH. Instead, PBH seeks to devote the majority of its resources to the care of our most severely disturbed members. This is accomplished through the PBH multi-level model of care management.
Each model will be described in operational terms, but a summary of the goals for each model provides a context for understanding the overall design of care management within PBH, and demonstrates how each of the models are interconnected. The goals of the four care management models are:
- Routine Care Model: Authorize necessary services in an efficient manner.
- Intensive Care Management (ICM) Model: Crisis stabilization.
- Extended Care Management (ECM) Model: Prevention of long-term disability.
- Assertive Care Management (ACM) Model: Foster an optimal level of functioning for the most chronically impaired members and reduce their reliance on hospital care by facilitating their engagement with a full range of outpatient resources.
Back to Top
The Routine Care Model
The Routine Care Model has been developed for outpatient utilization management of patients with low clinical risk and acuity. Its goal is to simplify the treatment authorization process for PBH practitioners. Four sessions are authorized at the time of referral. The Provider Assessment Report (PAR, the PBH treatment plan) is submitted to PBH after the second session, and up to eight (8) additional sessions are authorized, at the provider's request, for cases of mild to moderate severity. More than eight additional sessions are authorized to complete a treatment episode for more severe and complex cases.
The goal is to identify complex cases early in a treatment episode so that a PBH Care manager can authorize whatever dimensions of care are medically necessary. Practitioners are asked to complete the PAR with a view of the anticipated course of treatment for the patient. The PAR asks the practitioner to determine the number of additional sessions needed to complete treatment. The goal is to avoid a continual process of authorizing care a few sessions at a time. However, when unexpected stressors appear in the course of treatment, or the treatment plan requires clarification, it is best for the PBH Care manager and the treating practitioner to speak by telephone.
PBH recognizes that an episodic care model is inappropriate for patients with severe mental illnesses such as Bipolar Disorder and Major Depressive Disorder. Patients with these disorders generally require ongoing medication maintenance, as well as problem-focused, goal-oriented interventions at various points in treatment. At the same time, it must be recognized that there are members with an SMI diagnosis who adhere to recommended treatments and demonstrate stable functioning. Ongoing care for these members is best managed under the Routine Care Model since the role of the PBH Care Manager is limited to authorizing necessary services.
The Routine Care Model is intended to manage the care of members with all types of behavioral health disorders, including substance abuse problems. The PBH "Patient Placement Guidelines for Substance Use Disorders" identify the criteria for placing chemically dependent individuals at the appropriate level of care. Since most treatment for chemically dependent members is provided within structured treatment programs, there is a limited need for care management activities by PBH Care managers. Members with substance abuse problems are more likely to require some level of care management by PBH when there is a co-existing mental illness and/or severe dysfunction.
The goal of the Routine Care Model is to authorize necessary services in an efficient manner. Accordingly, PBH continually seeks to improve its processes and utilizes suggestions from practitioners as a primary source of new ideas.
Back to Top
The Intensive Care Management (ICM) Model
PBH has developed the Intensive Care Management (ICM) Model for managing the care of members with the highest levels of acuity. This model applies to the management of care for members at higher levels of care such as inpatient, partial hospital and residential treatment, and it is used to manage acute conditions on an outpatient basis. While most members presenting with high acuity have a severe mental illness, there are also many instances of members without an SMI diagnosis needing management under ICM due to a maladaptive reaction to situational stressors.
PBH embraces the philosophy of treating patients in the least restrictive environment, and this often depends in practice on the judicious use of outpatient resources. Dimensions of care may include any of the following:
- The combination of psychotropic medications with psychological or psychosocial treatments
- The use of support groups and other community resources in conjunction with professional services
- The coordination of behavioral health services with those provided by the patient's primary care physician
- The use of more frequent outpatient sessions during a time of acute crisis
These measures can reduce a patient's acuity and prevent the need for treatment at a more intrusive level of care. PBH has structured the ICM Model as a collegial, consultative dialogue with the treating professional. The goal is to ensure that the most effective treatment resources are used in the most efficient manner for patients who are at risk for admission to a higher level of care. PBH recognizes that levels of care such as inpatient hospitalization must be used at times to ensure the safety of members. At the same time, the delivery of essential outpatient interventions in a timely manner can prevent a clinical course that progresses to a more intrusive level of care. The goal of the ICM Model is the early identification of complex, high-risk cases that need thoughtful treatment planning, maximizing the use of outpatient resources.
There are four potential paths for admission to ICM:
- At the time of the initial access call the PBH Care manager determines that a referral is needed on an urgent or emergent basis.
- A judgment is made by the PBH Care manager reviewing the PAR or patient self-report data (e.g., Life Status Questionnaire) that the member poses high risk due to the severity of illness and level of impairment.
- A member becomes acutely suicidal or homicidal in the course of a treatment episode, resulting in admission to ICM as soon as the PBH Care manager receives this information.
- Upon admission to an inpatient, partial hospital, or residential facility, care is managed under the ICM model.
There are two levels of management within the ICM model based on the acuity of the member's clinical presentation, ICM-Acute and ICM-Subacute. Whenever a member is initially identified as needing care management under the ICM model, the ICM-Acute protocol is initiated. The ICM Care manager is then expected to use clinical judgment as acuity decreases and to reduce the level of management to either ICM-Subacute or to the Routine Care Model.
Members are managed under the ICM-Acute model throughout the duration of an inpatient stay, as well as during any period of high acuity at other levels of care. Partial hospital and residential care are typically managed under the ICM-Subacute model, but Care managers may occasionally use clinical judgment and choose to manage cases under the ICM-Acute model.
The ICM-Acute model involves telephonic review of treatment planning and patient progress every one to three days. The initial focus of the ICM process is confirming the diagnosis and developing a formulation of the case. Case formulation always includes consideration of medical conditions that might contribute to the patient's psychiatric presentation. Similarly, undetected substance abuse or dependence is an important consideration in the diagnostic process. The ICM process seeks to implement the most effective treatment plan with highly acute patients, and PBH Care Managers routinely review these cases with senior clinicians and Medical Directors within the company. The ICM model primarily involves Care Manager review with treating practitioner(s) and facility review staff, but there is occasional direct contact with members/families. It is typical for members assigned to management under the ICM-Acute model to remain at this level of care management for one to two weeks.
The ICM-Subacute model involves telephonic review at least every 7 days for facility-based care and at least every 30 days for outpatient care. The ICM-Subacute protocol gives the ICM Care Manager wide latitude for outpatient care, since the scheduling of follow-up contacts with the treating practitioner is spaced over greater intervals as the member's condition stabilizes. ICM Care Managers utilize clinical judgment and engage in a daily process of triage to determine how to allocate their time with members assigned to their caseload. Since a majority of ICM patients are likely to be seeing more than one behavioral healthcare practitioner, an essential goal for the Care manager is to facilitate the coordination of care. It would be typical for members assigned to management under the ICM-Subacute model to remain at this level of care management for one to three months. The goal of the ICM model is crisis stabilization.
Back to Top
The Extended Care Management (ECM) Model
The Extended Care Management (ECM) Model has been developed to manage the care of severely mentally ill (SMI) members who appear to be at risk for recurrent acute episodes of illness along a pathway toward severe and persistent mental illness (SPMI). The typical member requiring management under the ECM model has had at least one inpatient stay and is at risk for future hospital admissions. The ECM model is focused on SMI members with the highest likelihood of developing a chronic psychiatric disability. A common route of admission into the ECM model is as a step-up from the ICM model.
The need for the ECM model is apparent when one understands the natural course of illness for members with Major Depressive Disorder, the most common SMI diagnosis for members accessing care. National data show that fifty percent of individuals with one episode of Major Depression will have a second episode. Of those experiencing a second episode, ninety percent will have yet another episode. In other words, depression is a chronic, relapsing and remitting disorder, and it is important that treatment planning be based on this reality.
The mission of the ECM Care Manager is to ensure that members with chronic psychiatric conditions remain engaged in continuous care in order to minimize the destructive impact of their illnesses on work and social functioning. It may not be possible to eliminate acute episodes of illness for individuals with severe disorders such as depression and bipolar disorder, but it is possible to aggressively treat these episodes and minimize their disabling impact. One important aspect of this is the prevention of a maladaptive reliance on institutional care. Much like the ICM Care Manager, the ECM Care Manager authorizes intensive outpatient services, as needed, and facilitates coordination among behavioral health and primary care providers.
There is another important population to be served through the ECM model, namely, seriously emotionally disturbed (SED) children and adolescents. SED is a concept derived from federal legislation regarding the education of children with handicaps. These children and their parents typically feel overwhelmed by repeated crises at home and at school. It is common for some of the most functionally impaired youngsters to present with co-existing mood disorders, conduct disorders, and substance abuse problems. Extended care management is intended to foster adherence to an appropriate treatment plan and coordinate with services provided through the school system.
PBH stresses the need for using and coordinating multiple community resources and publicly funded agencies to support the family system. Parents of SED children generally need to be guided through the process of accessing appropriate services through their school districts. Children identified as SED by their school districts are entitled to a wide array of special education and counseling services. The ECM Care Manager ensures that there is good coordination between publicly funded services and the multiple dimensions of outpatient care that are authorized and managed by PBH.
The ECM model involves telephonic review with the treating practitioner(s) at least every 30 days. Like the ICM model, there is occasional direct contact with members and families. Like the ICM-Subacute protocol, the ECM Care Manager is given wide latitude since the scheduling of follow-up contacts with the treating practitioner is spaced based upon the member's current level of stability. ECM Care Managers engage in a daily process of triage to determine how to allocate their time.
PBH monitors clinical outcomes with members placed in ECM using the Life Status Questionnaire (LSQ) and Youth Life Status Questionnaire (YLSQ). The goal is to identify problems as they arise and carefully and proactively monitor clinical outcomes, so that we can intervene to improve the course of care. Practitioners are mailed a packet of LSQ/YLSQ forms when the member is admitted to ECM, and they are asked to administer these with the member. The first point of administration is upon admission to ECM, then every other session for the next four visits, and then on a quarterly basis. The packet includes instructions for administration and a summary of information about the instruments.
It is typical for members assigned to management under the ECM model to remain at this level of care management for several months, and for many the duration can exceed one year. The goal of the ECM model is the prevention of long-term disability.
Back to Top
The Assertive Care Management (ACM) Model
The Assertive Care Management (ACM) Model targets chronically ill members who use the most intensive levels of behavioral health services frequently as a result of their inability to adhere to an appropriate outpatient treatment plan. ACM has three overriding goals: 1) to minimize the use of higher levels of service that do not contribute directly to the member's ability to function effectively in the community; 2) to ensure that the member has access to those services and supports necessary to sustain his or her functioning in the community; and 3) to support the member and the practitioner(s) in ways that ensure successful implementation of the practitioner's treatment plan.
The Assertive Care Management model generally targets adults with severe and persistent mental illness (SPMI) and children or adolescents suffering from serious emotional disturbance (SED). However, SPMI or SED designations are not by themselves sufficient for admission to ACM. The model is aimed at members with severe behavioral health disorders that result in persistent disability and an over-reliance on higher levels of care, particularly acute hospitalization. For many persons with SPMI or SED, the hospital becomes the primary locus for the management of personal difficulties. Whether this over-reliance on inpatient care is driven by the member or by a provider who feels unable to manage the member's clinical risk on an ambulatory basis, the pattern itself inhibits the member's development of coping skills and adaptive behaviors. The predisposition to use higher levels of care is a critical criterion for entrance into ACM.
Members who warrant management under the ACM model typically have a history of failure to engage in sustained, effective outpatient care along with multiple hospitalizations within a relatively brief period of time. Often, these members have resisted or refused outpatient treatment while favoring inpatient care for stabilization in times of crisis. In rare cases members have been receiving behavioral health services outside of the PBH service system and PBH Care Managers have been unable to work with the non-contracted practitioners to ensure appropriate care.
The primary focus of the ACM process is ensuring both effective collaboration between the ACM Care Manager (ACM CM) and the treating providers, and effective participation in treatment on the part of the member. The ACM CM and all practitioners work together in a collegial manner to ensure that the member functions at an optimal level in the community. In addition, the ACM CM is expected to maintain liaisons with social service agencies, courts, schools and other community-based organizations to ensure that the member has access to the range of supports necessary to maintain adequate community functioning. The ACM CM is expected to understand eligibility requirements and funding arrangements in order to facilitate the member's access to all necessary services.
ACM is an innovative and unique role for clinicians working in a managed behavioral healthcare organization. Compared to more traditional Care Managers, the Assertive Care Manager maintains a higher level of involvement with the member, the member's family or support system, and the clinicians providing services to the member. Contacts with all of these parties are more frequent, and the focus of the care management effort is more long-range and comprehensive than in more routine care management.
Because the ACM Care Manager's involvement is so intensive, it is crucial to maintain appropriate clinical boundaries relative to the member, the member's service providers, and the people constituting the member's social support system. It is particularly important for the ACM CM to make it clear to all involved, especially the member, that he or she is not the provider of clinical services. Rather, the ACM CM's role is to support the member and practitioner(s) in ways that ensure successful implementation of the treatment plan.
The ACM process starts with efforts to ensure that the member engages in outpatient care with appropriately skilled practitioners, and then, in conjunction with the treating practitioners, shifts to a focus on identifying and resolving obstacles to the treatment plan and to a successful outcome. Along the way the ACM CM endeavors to coordinate the efforts of all parties providing treatment services and support to the member.
The designated ACM CM maintains care management responsibility across all levels of care until the member achieves a stable level of functioning in the community. Once the network of supports required to maintain that stability is in place, the member is transitioned to management under the ECM model. ACM is a highly effective intervention for certain chronically ill members, while others, due to a variety of bio-psycho-social reasons, are not impacted by such care management efforts.
ACM CMs are encouraged to maintain a population-based perspective that demands an ongoing assessment of whether valuable care management resources are being allocated in an optimal manner. In other words, while the ACM CM is expected to focus on the member's needs and persist in searching for creative ways to achieve therapeutic goals, the CM is also expected to view his or her time as a valuable commodity to be shared with the greatest number possible of potentially responsive members.
Any Care Manager may refer a member for care management under the ACM Model by completing the ACM Referral Form. The ACM Clinical Supervisor reviews the case and makes a determination of the member's appropriateness for ACM or another care management model. If the case is determined to be appropriate for ACM, the Supervisor assigns the case to an available ACM CM.
The ACM CM is responsible for enrolling the member in ACM. The member is called by the ACM CM to discuss how the program operates and what the potential value might be for the member. The treating practitioners are contacted as well, since practitioner involvement is essential for ACM. In the rare instance that the treating practitioners do not wish to participate, reassignment of the case to new practitioners can be explored when feasible. However, ACM cannot proceed when there is no support from the treating practitioners. Members who express an interest in the program are asked to sign a consent form that allows the ACM CM to contact people who may be involved in implementation of the treatment plan. These people may include, for example, practitioners, family members, school psychologists or teachers, and the primary care physician.
The ACM CM arranges to have regular phone contact with the member to encourage treatment compliance, assess progress, and assist the member in accessing necessary services. The ACM CM may also send psychoeducational materials to the member and his or her family or provide them with information about community resources. In addition, the ACM CM orients the treating practitioners to the ACM process, and emphasizes the boundary between care management and treatment. The frequency of contact with practitioners is determined by clinical judgment of the ACM CM.
The amount of telephonic contact with the member will vary, both from one member to the next and over the course of time with any given member. There are two levels of intensity for contact with the member under the ACM Model: Monitoring Contact and Stabilizing Contact.
Monitoring Contact is the less intensive level of contact under ACM. This level of contact is maintained primarily to monitor ongoing risk of decompensation or relapse for members who either are in a period of relative stability or are adverse to more intensive contact. Members are also maintained in this status when all parties agree that brief, scheduled contacts are optimal for a chronically impaired individual. Many fragile members can benefit from simply knowing that the Care Manager is always available when needed.
Stabilizing Contact is the more intensive level of contact with the member, and it is maintained during times of instability or crisis. This level of involvement is maintained until the member is stable or expressing a clear desire for Monitoring Contact. Treating practitioners are informed whenever the ACM CM transitions the member from one level of contact to another.
The ACM CM is expected to maintain contact with the member's family, caregivers, or other persons providing the patient with social support. Every effort should be made to engage these persons to support the member's adherence with treatment recommendations. These people, particularly family members or caregivers, are excellent sources of information about how well the member is responding to treatment.
The ACM CM is responsible for collaborating with the treating practitioner(s) in developing a plan for the number and frequency of sessions based on the treatment needs of the member. Sessions for psychotherapy (individual, family or group sessions), medication monitoring, and other specialty services are authorized for a level of frequency that meets the member's clinical need. It is the Care Manager's responsibility to make the most effective use of the available benefit. In states where mental health parity laws govern health benefit plans, the ACM CM is responsible for ensuring that practitioners understand benefit levels, deductibles and co-payments.
Positive treatment outcomes often depend on the provision of "wrap-around" services such as sober living and other supported living arrangements, parent/family training and education, respite services and other in-home support services, club house programs, and specific independent living and vocational rehabilitation services. The use of such services should be encouraged, and the ACM CM may exercise creativity in developing strategies for using them.
PBH monitors clinical outcomes with members in ACM using the Life Status Questionnaire (LSQ) and Youth Life Status Questionnaire (YLSQ). Practitioners are mailed a packet of LSQ/YLSQ forms when the member is placed in ACM, and they are asked to follow the same protocol for administration as outlined under the ECM model.
It is typical for members assigned to management under the ACM model to remain at this level of care management for one year or more. The goal of the ACM model is to foster an optimal level of functioning for the most chronically impaired members and to reduce their reliance on hospital care by facilitating their engagement with a full range of outpatient resources.
Back to Top
  | 
