First Mental Health, an MCO that operates the Medicaid substance abuse and mental health managed care program in Massachusetts as MHMA, Inc., looks for organizations and programs that:
Are consumer-oriented, e.g., have satisfaction surveys and use the information
Have no long waiting lists
Deliver focused treatment, e.g., an average of six outpatient sessions
Are part of a system that promotes clinical continuity, e.g., a consumer can move from service to service without interruption
Direct their attention to outcomes, e.g., functional levels and employment
Have an interest in innovation, with the ability to move rapidly and to be responsive
1. Centralized screening, assessment, intake, and crisis intervention services?
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2. Comprehensive outpatient services?
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3. Intensive outpatient services, or do you have strong network relationships with providers of such services?
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4. Partial hospitalization/day treatment services, or do you have strong network relationships with providers of such services?
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5. Short-term residential treatment, or do you have strong network relationships with providers of such services?
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6. Inpatient treatment, or do you have strong network relationships with providers of such services?
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For children and adolescents, do you deliver:
7. Centralized screening, assessment, intake, and crisis intervention services?
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8. Outpatient services?
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9. Intensive outpatient services, or do you have strong network relationships with providers of such services?
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10. Partial hospitalization/day treatment services, or do you have strong network relationships with providers of such services?
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11. Short-term residential treatment, or do you have strong network relationships with providers of such services?
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12. Inpatient treatment, or do you have strong network relationships with providers of such services?
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Service Characteristics
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13. Do you have skilled clinical staff assigned to all aspects of the screening and assessment process, including initial telephone contacts?
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14. Do your services ensure rapid access (1-2 days) to assessment services and initial placement?
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15. Do your services have a brief intervention focus, e.g., six to eight sessions for outpatient care, for most patients?
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16. Do you have internal case management services for focusing on repeating patients and others who have high utilization patterns?
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17. Do you have ensured linkages with primary healthcare providers for needed healthcare?
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18. Do you adapt standard services to meet the needs of special populations, such as mentally ill substance abusers, injecting drug users, and pregnant addicts?
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19. Are service needs constantly reevaluated, and service plans modified, based on patient progress?
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20. Are admission, treatment, and discharge criteria in place and used consistently by staff?
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21. Do your admission, treatment, and discharge criteria take into consideration the practice standards of managed care firms with which you have (or hope to have) contracts?
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22. Do your services ensure rapid linkage to succeeding levels of care?
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23. Do your services emphasize family involvement and use of natural support systems, including self-help groups?
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24. Do your services focus on patient outcomes and satisfaction?
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Quality Assurance (QA) and Utilization Management (UM)
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25. Do you have QA and UM procedures that have been shared with clinical staff?
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26. Does the staff you have designated to perform the QA/UM function review clinical activities for consistent use of established admission, treatment, and discharge criteria?
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27. Is the information from the QA/UM function received rapidly enough to assist clinicians during an episode of care?
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28. Does the QA/UM function include maintaining records of managed care appeals, and suggest strategies for improving relationships and/or modifying service delivery to reduce denials?
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29. Do you have sufficient staff assigned to the QA/UM function?
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30. To what extent is the QA/UM function designed to "stay ahead" of staff from managed care firms by anticipating their concerns?
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31. Do clinicians, clinical supervisors, and management all receive and act on regular QA and UM reports?
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32. Is the QA/UM function tied closely to your management information system?
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33. To what extent is the QA/UM function focused on patient outcomes?
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34. Are patient satisfaction surveys a regular function of QA/UM?
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Managed Care and Employee Assistance Program (EAP) Experience
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35. Do you have contract(s) with managed care firms or EAPs as a preferred provider?
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36. If yes to #35, are any of your contracts paid on a fee-per-case or a capitation basis?
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37. Do you offer an employee assistance program which includes crisis intervention, assessment and linkage to service, followup to assure receipt of appropriate services, and coordination of benefits?
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38. Does your EAP provide consultation to management on policies and procedures, training to managers and supervisors, assistance with specific cases, employee education and orientation programs, critical incident debriefing, and reporting on utilization and effectiveness?
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39. Has your EAP business increased over the last 2 years?
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Management Information Systems (MIS)
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40. Do you have an MIS which can retrieve patient information either online or in less than 1 hour?
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41. Does your MIS have integrated functions for client information; service utilization; financial information, including payer type by client; and client records?
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42. To what extent does your MIS permit single-source response inquiries from managed care organizations?
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43. To what extent does your MIS produce information that is used by clinicians, supervisors, and management?
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44. To what extent does your MIS integrate information from various programs and sites?
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45. Is your MIS designed so that client and service information can be reported to all major payers?
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46. Does your MIS generate patient invoices?
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Staff and Staff Training
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47. Do clinical staff accept shared responsibility with case managers from managed care organizations for clinical decisions?
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48. Are staff informed concerning the funding and managed care environment, including managed care criteria for admission and discharge?
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49. Have clinical and supervisory staff resolved concerns about cost, service quality, access, and managed care?
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50. Do you have an ongoing staff training program that includes brief service intervention skills, patient assessment and reassessment, and instructions on how to respond to managed care organizations?
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Organizational Relationships
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51. To what extent have you implemented referral and business arrangements with other behavioral healthcare organizations, e.g., mental health and substance abuse programs?
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52. To what extent have you implemented referral and business arrangements with primary or specialty healthcare organizations, e.g., hospital emergency rooms and physician group practices?
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53. To what extent have you been involved in economic arrangements with other healthcare?
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Board and Management
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54. Do you have significant experience at contract negotiation and management?
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55. To what extent is the board oriented to service effectiveness and business success?
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56. Are you experienced at strategic planning, modifying plans, and developing contingency plans to meet emerging opportunities and challenges?
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57. How well informed are board members and top management concerning healthcare reform, managed care, financing options, and interorganizational arrangements?
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58. Are mechanisms in place which would allow for prompt shifts in response to business opportunities?
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59. To what extent will the board and management be proactive and entrepreneurial in pursuit of managed care initiatives?
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Marketing
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60. Do you have marketing plans that target payers, referral sources, and the general public?
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61. Do you have sufficient staff resources assigned to the marketing function?
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62. To what extent does your service line emphasize acute and primary services (rather than long-term, rehabilitative, and wraparound care)?
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63. Have you prepared a managed care capability statement?
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64. To what extent have you made marketing presentations to the large employers in your service area?
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65. Do your costs per episode and lengths of stay compare favorably with the competition?
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Fiscal Analysis
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66. To what extent is your revenue diversified?
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67. Do you have adequate liquid reserves for at least 2-3 months operating expenses?
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68. Have you accumulated (or can you access) venture capital sufficient to respond to a major business opportunity?
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69. Have you maximized Medicaid revenue?
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70. Does your fiscal system, in combination with the MIS, allow analysis of cost-per-unit of service, cost-per-episode of care, and cost by disability type and level of functioning?
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71. Can the fiscal staff assist with pricing issues during contract negotiations, especially when capitated contracts are considered?
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72. Can the fiscal staff readily compare actual to anticipated revenue and expense by contract?
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Business Office
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73. Is the business office experienced at fee-for-service invoicing for Medicaid, preferred provider organization (PPO) contracts, insurance, patient fees, etc.?
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74. Does the business office conduct internal service audits to ensure that documentation of services in patient records can withstand an external audit?
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75. To what extent is the business office's invoicing function integrated into your MIS?
"planning and coordinating a package of health and social services that is individualized to meet a particular client's needs" (Moore, 1990, p. 444)
"[a] process or method for ensuring that consumers are provided with whatever services they need in a coordinated, effective, and efficient manner" (Intagliata, 1981)
"helping people whose lives are unsatisfying or unproductive due to the presence of many problems which require assistance from several helpers at once" (Ballew and Mink, 1996, p. 3)
"monitoring, tracking and providing support to a client, throughout the course of his/her treatment and after" (Ogborne and Rush, 1983, p. 136)
"assisting the patient in re-establishing an awareness of internal resources such as intelligence, competence, and problem solving abilities; establishing and negotiating lines of operation and communication between the patient and external resources; and advocating with those external resources in order to enhance the continuity, accessibility, accountability, and efficiency of those resources" (Rapp et al., 1992, p. 83)
"assess[ing] the needs of the client and the client's family, when appropriate, and arranges, coordinates, monitors, evaluates, and advocates for a package of multiple services to meet the specific client's complex needs." (National Association of Social Workers, 1992, p. 5)
Referral to other sources for these services if requested
Usually limited to responding to client questions about treatment issues, education about how to identify strengths and about self-help resources
Provides many services within unified package of treatment/case management services
Provision of therapeutic activities central to the model
Helps develop informal support systems
No
Development of informal resources - neighbors, church, family - a key principle of the model
Through implementation of drop-in centers and shelters
Emphasis on family and self-help support through therapeutic activities
Primary Case Management Activities
Broker/Generalist
Strengths Perspective
Assertive Community Treatment
Clinical/Rehabilitation
Responds to crisis
Responds to crises related to resource needs such as housing
Responds to crises related to both resource needs and mental health concerns; active in stabilization and then referral
Responds to crises related to both resource needs and mental health concerns; active in stabilization and then referral
Responds to crises related to both resource needs and mental health concerns; will stabilize crisis situation and provide further therapeutic intervention
Engages in advocacy on behalf of individual client
Usually only at level of line staff
Assertive advocacy, will pursue multiple administrative levels within agency
Assertive advocacy, will pursue multiple administrative levels within agency
Assertive advocacy, will pursue multiple administrative levels within agency
Engages advocacy in support of resource development
Not usually
Usually in context of specific client needs
Either advocates for needed resources or may create resources as part of case management services
Usually in context of specific client needs
Provides direct services related to resource acquisition as part of case management, e.g., drop-in center, employment counseling
Referral to resources that provide direct services
Provides services crucial to preparing client for resource acquisition activities, e.g., role playing, accompanying client to interviews
Provides many direct services within unified package of treatment/case management
Provides services that are part of rehabilitation services plan; skill-teaching
Appropriate for the following substance abuse populations
Injectable drug users; HIV positive and at-risk substance abusers
Male crack cocaine users; female polysubstance abusers
Chronic public inebriates; parolees with substance abuse problems; dually diagnosed clients
Figure 3-1
Characteristics of the Three Interagency Models
Single Agency
Characteristics
Small grassroots agency or major provider of services for a single problem or to a single population (may be "the only game in town")
Tends to control a niche in the social service market by default (other agencies are not interested or refuse to serve clients), history, design, or funding mandate
Often developed in response to an "acute" situation and implemented quickly
Less focused on organizational process than other case management models; more focused on client-related tasks
Interagency case management services built on informal agreements
Case manager hired by and accountable solely to the single agency
Positive Features
Responds to crises quickly
Tends toward more cohesive or homogeneous values than other models
Tends to have single point of access to substance abuse treatment or other services for clients
Agency maintains sole control over implementation and coordination of case management program
Clients relate to a single individual concerning all problems
Often can respond more flexibly to individual client needs
Has the opportunity to exercise a broad range of skills
Is self-determining and self-accountable (monitors its own services)
Negative Features
Less control over social environment (e.g., policies and funding) and accessibility to services
Less influence over broad policies affecting case management services
Without a broad constituency and widespread community support, more vulnerable when funding wanes or ends
More responsibility or burden on front-line case management staff to establish connections with other community agencies
Case manager may feel especially burdened or taxed by having sole responsibility for client
Can require considerable training to equip case manager to deal autonomously with the diverse needs of clients
Limited mix of services available to clients
Limited array of outcomes or solutions for client problems
Informal Partnership
Characteristics
Establishes and maintains informal partnerships or networks to respond to the needs of multiple populations with multiple problems
Initial motivation for forming partnerships may have been funding-driven as well as need-driven
Front-line case management staff from partnership agencies meet informally as a group (and without a formal contractual obligation) to discuss client cases
Supervisors and other staff also may become involved and form relationships to share client-related concerns
Staffing decisions are made internally by individual agencies
May evolve from a single agency model or be the model of choice from program inception
Less likely to have a lead agency than a formal consortium
Positive Features
Meets and functions only as needed
Avoids overlap of services
Has access to broader set of resources than single agency model
Coordinates care better among agencies at client level
Counters staff's feelings of isolation by sharing burden of client responsibility
Shares information and possibly resources with partner agencies
Negative Features
Multiple problem orientations of partnership members may conflict with one another
More opportunity to compromise individual agency goals with respect to clients
Not as quick to respond to emerging problems as single agency model case management
Investment of staff and time resources greater than for single agency models (e.g., time to attend meetings)
Possible breakdown of service coordination among multiple providers may result in service gaps and fragmented care
Clients may find it difficult to relate to multiple providers
Formal Consortium
Characteristics
Two or more providers linked by a formal contractual arrangement
Represents multiple values and philosophies
Agencies cooperate and work together for a common purpose, which is formalized in the contractual relationship
Agencies represent or cover multiple resources (e.g., housing and employment) in a particular social service market
Typically identifies a lead agency (often the agency that funds or obtained the funds for case management services) to coordinate the consortium's case management services
The case manager may be supported through pooled resources from members of the consortium or by the lead agency
The lead agency generally hires the case manager, although multiple agencies within the consortium may participate in the selection process
Accountability is shared across agencies
Case manager is accountable to the consortium
Entities primarily responsible for building and supporting the consortium (e.g., United Way; State, county, or city government; National Institutes of Health; or Centers for Disease Prevention and Control) may impose conditions or constraints on the case management process (e.g., mandated community involvement)
Takes time and effort to develop; requires substantial up-front investment
Focuses more on organizational process than other interagency case management models
Tends to have a longer-term or more chronic orientation than other case management models
Positive Features
Access to more resources
Broader structure of constituent, political, and community support when resources are limited or the economy is strained
More control in shaping the environment in which services are provided (e.g., more input into and control over policies, funding, and the kind of case management interventions and services that are offered)
More opportunities for coordination of care among agencies at both client and system level
Regularized contact between agencies increases occasions for strengthening service integration
Enhanced coordination across providers can decrease duplication of services
Consortium participants share information regarding changes in the organizational environment, available and declining resources, and treatment information
Negative Features
Can be slow to respond due to problems of coordination
Must contend with multiple definitions of a problem or solution that may spark conflict among consortium members
Time devoted to organizational process may reduce time given to client-related tasks
Clients may find it difficult to relate to multiple providers
Clients may need to travel to several locations for services
Multiple agency participation per case may involve higher costs and less intense personnel/agency involvement, without added benefit to client
Potential systemic conflict over which agency takes lead and whose philosophy prevails when differences occur
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