Jane is a behavioral health professional at a community mental health center. One workday morning she gets a message from the insurance company of a client who had a recent backslide, informing her that the client's benefits are exhausted. Jane then sees a new client who has both addiction and psychosocial issues. Her next client needs a residential setting and appropriate openings are available, but his payer says this level of care is excluded. Jane has assessed the needs of all three clients and made care recommendations for two of them, but her day has just begun.
All addiction and mental health professionals are familiar with this scenario. The daily challenge of identifying the best treatment plans for patients is complicated by a large volume of clients, high levels of recidivism, multiple morbidities, and discussion with insurance plans on coverage availability. Ideally, the addiction professional can focus on the treatment that is most clinically appropriate for each patient. But in the real world, he/she spends a good deal of time justifying or negotiating for a level of care that a payer concludes is not approvable. In the end, decisions often are made quickly out of necessity and are based on the professional's "clinical gut."
There is a way to make clinically appropriate decisions faster, more consistently, and less painfully. Behavioral health organizations are discovering evidence-based decision support criteria, which already are being adopted by organizations such as hospitals, managed care organizations, and third-party payers. The most effective decision support tools include evidence-based guidelines that enable professionals to evaluate each patient based on clinical characteristics such as behavior, symptoms, functioning, and social risks. They also contain decision paths that facilitate timely and consistent decision-making by care managers, utilization reviewers, and providers by offering a shared source of information. Such tools help behavioral health professionals by:
* Providing standardized guidelines for making the best initial and subsequent level-of-care decisions for each patient;
* Providing information to help in developing a more targeted treatment plan (separating clinical versus psychosocial issues);
* Providing information necessary to negotiate for the most appropriate care when a level of care is excluded or exhausted; and
* Creating a common language among care managers in organizations across the spectrum of healthcare, thus saving critical time in getting the right care to patients in a timely manner.
Behavioral health criteria are offered by various vendors in both traditional printed publications and as software applications that integrate with workflow to further simplify and automate the process.
Sifting through research
According to the Delfini Group, LLC, more than 10,000 articles each month are published in medical journals--a staggering number that is simply impossible for an individual care provider or even an organizational team to read, evaluate, and synthesize in a meaningful way. Standard clinical guidelines offer a way to integrate the latest and best evidence-based research and clinical trials in a timely manner.
Development of the criteria typically draws on the expertise and experience of a range of physicians, nurses, and other healthcare professionals, combined with consensus-building and validation among clinical experts. Teams of criteria developers conduct extensive reviews of the latest evidence-based medical literature and validate the information with experts in the appropriate specialties and subspecialties. Systematic development techniques commonly used include:
* Searches for literature in peer-reviewed, industry, and specialty medical journal publications;
* Literature review and appropriate grading …