Best and Worst Practices In Private Sector Managed Mental Healthcare

Best (& Worst) Practices In Private Sector Managed Mental Healthcare Part I: Level-Of-Care Criteria May 1999 Corporate philosophy
The introductions, preambles, executive summaries and statements of philosophy demonstrated significant differences among the vendors. However, while we describe some best practices in this section, please note that one concern with several of the criteria sets was that the intentions expressed in the introductory statements were not reflected in the actual criteria themselves. In fact, in some cases, they were directly contradictory. Given this caveat, the panel agreed that the best practices included level-of-care criteria sets that embraced the following concepts: Improving functioning and/or enhancing well-being (three of seven companies): "The goal of all behavioral health treatment should be directed at improving the individual's functioning in their usual environment through symptom reduction, education, and psychosocial stabilization." Consumer responsibility (two of seven companies): "We are committed to supporting individuals in becoming responsible participants in their treatment." Treatment in the least restrictive environment that is appropriate to meeting the consumer's needs (four of seven companies): "[Vendor] is committed to the philosophy of providing treatment at the most appropriate, least intensive level-of-care necessary to provide safe and effective treatment and meet the individual patient's biopsychosocial needs. We see the continuum of care as a fluid pathway, where individuals may enter treatment at any level and be moved to more or less intensive settings or levels of care as their changing clinical needs dictate." Individualized treatment planning, including attention to psychosocial, occupational and cultural factors: note that this latter topic is covered in more detail on pages 21 and 22 (three companies-two somewhat superficially, one comprehensively): "Psychosocial factors to consider when making [medical necessity determinations] include: homelessness, housing issues, lack of social support, physical disability, financial difficulties, lack of access to medical/dental care, recent critical life event, chronic illness, isolation, lack of transportation, lack of daycare, active legal issues, performance pressure and/or non-supportive school environment, and recent release from a period of incarceration. Workplace issues to consider include: safety-sensitive position, medical leave of absence, performance pressure/non-supportive work environment, supervisory referral, EAP referral, regulatory compliance issues, and work/treatment schedule conflict." Two other best practices the panel recommends, but for which we could not find sample language in any of the criteria sets, include the following: Vendor adopts an orientation of "recovery." Vendor allows the consumer's preferences among treatment options to play a role in the process. Beyond the omission of key concepts in the documents, we identified the following worst practice: One criteria set dedicated considerable text in its introduction to defending why it had decided to label consumers of mental health services as "patients." Our panel found this to be an odd location for this debate, and the vast majority disagreed with the decision. The consumer movement has long embraced terms such as "consumer" and "client" over that of "patient," and we find it offensive that any person or organization would label people against their will-regardless of the intentions in using the label. In addition, we believe this approach "over-medicalizes" and does damage to those people who are largely seeking psychosocial services or who would not access care under such labels due to stigma.		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