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 and application of non evidence-based medical information;
Content review and collaboration;
Practice standards review;
Specialty guideline review; and
Expert opinion content review via external clinical consultants who provide a geographic view of practice patterns.
The collected and validated information is then translated into concise summaries of the literature on a given condition. These narratives may, for example, present the current research on a given topic and address controversial treatment options and emerging technologies.
Determining most appropriate care
Decision support tools directly support the work addiction professionals perform. First, use of criteria can facilitate prompt initiation of care when patients are referred from a primary care provider. Confirmation that a referral is appropriate and eligible for coverage can be addressed in a timely manner. This is particularly effective when the primary care provider or referring organization also uses decision support tools.
Second, level-of-care criteria help clinicians and care managers consider a patient's severity of illness, comorbidities, and complications in real time. Based on the individual's needs, guidelines help determine the most appropriate level of care. Level-of-care criteria drive decisions on initial placements, with a range encompassing inpatient detoxification or psychiatric care; inpatient or outpatient rehabilitation; partial hospitalization, residential, and intensive community-based treatment; and intensive outpatient and outpatient treatment. Further, checkpoints enable the care manager to identify progress, plateau, or achievement of goals, and to assess discharge or transfer readiness. Criteria do not replace clinical judgment, but guide clinicians toward the most efficient and safest level in a timely and consistent manner.
Lollie Dubiel, RN