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The criteria differed greatly in terms of the level of decision-making authority accorded to the attending/treating clinician versus the vendors' Care Managers.
Care Management
The panel identified a considerable number situations where it felt the vendors' care management staffers were given excessive authority. The following are some examples of this worst practice approach to care management.
- "The Care Manager should determine if a patient's condition prohibits him/her from making use of the service." The attending provider is in a better position to make this determination. (Of further note, the example offered was an actively psychotic patient in recreational therapy. Our panel was surprised and disturbed that this vendor did not think such a patient would benefit from this service.)
- "If a patient is not compliant, the care manager may consult with that patient to determine his/her willingness to comply with other alternatives." This approach is potentially very disruptive to the consumer/clinician relationship, as it circumvents the provider.
- In one document, the care managers were directed to encourage the provider to assign "homework" to the consumer. While this may be a beneficial approach with a portion of consumers, it is not science-based nor is it appropriate for everyone.
- "The Care Manager should consider if transfer to a more appropriate location is warranted [based on the characteristics of other consumers being treated in the setting]." This statement gives an incredible amount of power to the Care Manager that our panel believes should rest with the attending provider.
Documentation requirements
The following are examples of worst practices where the panel identified documentation requirements that far exceed the norm in terms of reasonableness of oversight:
- [For continued stay in inpatient detoxification]: "Physical signs and symptoms of acute withdrawal… must be documented three times daily."
- [For residential treatment for children and adolescents with substance disorders]: "The provider must be able to document that the individual…is mentally competent and stable enough to benefit from…the program. Individual days during any part of the stay where the patient does not meet this criterion cannot be certified as medically necessary."
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Introduction
Key findings
"Report card" on information sharing
Methodology
Development process
Comprehensiveness
Corporate philosophy
Access issues
Compliance
Child and family issues
Substance abuse and co-occurring disorders
Cultural competence
Provider autonomy
Coordination/ consultation among providers
Denial notification and appeal processes
More observations, recommendations and areas for further study
Acknowledgments
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