David Lloyd on Meeting Access-to-Care Performance Standards

by Rebecca Farley on August 11, 2010

Will you meet access-to-care performance standards? If the public and payers perceive community behavioral health organizations as having a prolonged wait time to treatment

… and if these organizations see their caseloads as “full,” which prevents new consumers from entering treatment, then the new managed payers will not look at community behavioral health providers as a valuable partner when designing new integrated healthcare models.

Click on “Comments” below to read the Q&A with David.

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{ 34 comments… read them below or add one }

Darla Boothman July 29, 2010 at 1:37 pm

With an integrated mental health/addictions/developmental disabilities electronic health record, it is becoming increasingly difficult to meet all the HIPAA, CFR, RCW and WAC requirements for each of the programs. Is there an agreement out there that says – one agency provides all these services, has multiple treatment plans for clients, departments can see each others information (ie MH sees CD plan), and reviewers such as the RSN are not breaching confidentiality when they review the record and see the “integrated” plans in the record?


David Lloyd August 5, 2010 at 11:17 am


I am not aware of this type or agreement outside the typcial business associate agreements that needs to provide information sharing procedures that support compliance with HIPAA and HITECH requirements.

The question you have asked will become more and more of the challenge as more and more providers move to electronic health records and then integrate the information in primary care and BH integration service delivery models.

If you learn of such a tool… Please confirm..

David Lloyd
MTM Services


Kristin McCloud July 30, 2010 at 5:03 am

What should providers of alcohol, tobacco, and other drug abuse prevention and mental illness prevention be preparing for? What new opportunities might there be for us?


David Lloyd August 5, 2010 at 11:26 am


Under healtcare payment reform focus areas and needs, there is general agreement that to bend the cost curve, there is a need to invert the Resource Allocation Triangle where in the past healthcare expenditures for Acute Care Services have been the highest and expenditures for prevention and primary care were the lowest. By shifting more expenditures to prevention/primary care, the outcomes that have been achieved are that acute and specality care costs go down.

Therefore, new service delivery modesl sucha as ACOs and PCP based medical homes will need good prevention providers.

Start measuring outcomes that you acheive with your prevention services that can help information integrated healthcare providers of how much they need your services to support bending the cost curve.

Hope that this helps.

David Lloyd
MTM Services


Kenn Dudek July 30, 2010 at 5:52 am

If a person has a medical home with another provider is there a possibility for a sub contracted relationship?

Do you foresee that all medicaid and medicare behavioral health services will be in managed care in three years?


David Lloyd August 5, 2010 at 11:32 am


That is our hope and one of our future service delivery opportunities. Our ability to provide accessible, quality, cost effective and outcome support services will be helpful to the new medical home service delivery model.

The future of Medicaid and Medicare service delivery management seems to be still being formulated. However, at this time we believe that Accountable Care Organizations and Medical Homes (PCP or CBHO based) will be service delivery vehicles. These new service delivey models include shared or full risk funding methodologies for the providers.

However, the role of MCOs and other “managed care entitites” is not as clear in that the shift is from a managed care entity managing the funding and benefits (as in th 1990s model of managed care) to the providers themselves managing the funding and benefits.

Hope that this helps.

David Lloyd
MTM Services


Sue Stuckless August 2, 2010 at 6:13 am

With the new rates, is it best to weight productivity?

In terms of documentation, will there be standardized templates that are available/recommended or is each agency working to create them?


David Lloyd August 5, 2010 at 11:39 am


Please review my response to Cindy’s question related to productivity that was posted today.

Summary is the new rates (if they are lower than the old rates) will require that your staff deliver additional hours of direct/billable service UNLESS one or more of the following occur:

1. Salary and fringe benefit reduction
2. Overhead cost reduction
3. New revenues that are not tied to direct/billable services delivered (i.e., grant funding)

Secondly, MTM has provided project management for statewide standardized documentation initaitives in MA, NY and OH. In the cases of these states there is a standardized template for all clinical documentation.

Absent a statewide standardized documentation initaitive, each agency will need to use their state level documentation standards/rules, payer documentation requirements, combined with federal level Medicaid and Medicare standards and any national accreditor standards to ensure that they are using a compliant documentation model.

Hope that this information is helpful.

David Lloyd
MTM Services


T. Chell August 4, 2010 at 12:49 pm

With increasing pressures for community mental health centers to serve more and more consumers, how can an agency determine an appropriate caseload size to ensure consumers enrolled in services are able to receive the amount of services they need to receive a benefit from services?

I would assume caseload sizes would be different for case managers, rehabilitation providers, physicians, etc. and would also be different for those providing office based vs. field-based services. Additionally, severity of illness and mixed caseload also plays a role in this calculation.

How do we determine the appropriate caseload size for workers? Are there any commonly accepted benchmarks, maximums, etc. or anybody doing research on this topic?


David Lloyd August 5, 2010 at 11:45 am

T. Chell:

We have developed a caseload calculator that integrates both quantitative and qualitative metrics to determine the appropriate caseload size for each type of clinical/direct care staff.

The metrics are:

1. Annual billable hour standard for the staff type
2. Number of hours of service that has been determined to be clinical required for level of care/benefit design within your agency (i.e., Level One clients receive 1 hour of therapy per month vs. Level Four clients receving 3 hours of therapy per month, etc.)
3. Mix of clients by LOC/Benefit Design Level within a specific clinician’s/direct service provider’s case load.

Hope that this helps.

David Lloyd
MTM Services


Ron Brand August 4, 2010 at 2:11 pm

1. Health reform envisions some different payment methods that might combine various services that are current paid as separate units. Many behavioral health providers focus on productivity and “service capacity” and billable hours. With different payment methods that might bundle several services or pay based on an “episode of care”, what changes would you anticipate in how provider organizations monitor “productivity”, compensate staff, forecast revenue, etc.

2. Many community behavioral health providers would say that their strength is an ability to coordinate and deliver a combination of services–medications, rehab., case management, therapy and support services–based on individual needs and goals.
However, some primary care-based health care home models emphasize a “care coordinator” plus a case consultation role for behavioral health specialists….and maybe a referral to a specialist as needed.
This type of relationship may not tap into the best of what a CBHO could offer, especially for a more complex patient situations. What suggestions do you have on how CBHO could position themselves in relationship to a primary care health care home….or even an Accountable Care Organization?


David Lloyd August 5, 2010 at 12:45 pm


Thanks for the very important questions….

First, my thinking is that the basic productivity levels (billable hours of service capacity provided) for staff can not be reduced if they were historically based on cost of service versus revenue received considerations. The level of productive may have to increase depending on the payment methodology (i.e., Bundled payment, episode of care, case rate, etc.) and the level of total payment that the ACOs and/or PCP based medical homes will offer.

The reason for this conclusion is:
1. In all cases we are going to have to provide the most efficient cost of services possible to ensure we can be competitive in our negotiations for provision of BH services within ACOs and PCP based medical homes. If we are not, then the ACO may look at other BH providers that will meet the specialty care cost model in their service array and/or develop their own BH service capacity “in house”.

2. There will be a need to change productivity performance models to align the direct services being provided by staff to the method that the BH organization will be paid for those services. An example of a case rate performance standard developed by a team provides the additional metrics:

Case Rate Payment Methodology:
Service Coordination

1. 1,200 billable hours billed per year
2. Case Load minimum size is 45 cases with 95% of caseload receiving two contacts per month consisting of at least one 15 minute minimum face to face contact and one 15 minute minimum telephonic contact per month

Compliance Rating:
1,200 hours of billable service delivered per year and 95%of caseload billed per month=Full Compliance
Less than 1,200 billable hours delivered and/or less than 95% of caseload billed per month=Non Compliance

The case rate model will probably need to be modified when bundled or episodes of care payment methodologies are considered to something like this:

SAMPLE Standard:
1. 1,200 billable hours billed per year
2. Case Load size based on the Level of Care mix of cases benchmarked monthly with 95% of caseload receiving following hours of service and contact numbers per month:
# Hrs/Mth # Contacts/Mth
Level One .5 1
Level Two 1.5 2
Level Three 3 4
Level Four 6 8

3. Outcomes:

i. Provider will have 90% of outcome ratings showing maintenance or improvement in the last survey period.
ii. Provider will have 80% positive Consumer Satisfaction Ratings regarding their opinions about services provided.
iii. Provider will demonstrate a reduction in ER visits and medication adherence rates (client report and clinician report) by integrating the following into service delivery:
a. Person Centered Approaches including Collaborative Concurrent Documentation
b. Personal / Life Goal identification
c. Person centered linkage between personal goals, identified BH needs, Tx Plan goals and objectives, and client/clinician interactions

Finally, other required outcomes identified by the ACO and/or PCP medical home will need to be incorporated into the outcomes section of the performance requirements for staff and/or programs.

Secondly, implementing performance standards based on hours of service, case load stepped care via LOC/benefit design, and outcome measurement as included in the above sample standard outcomes section will facilitate CBHOs to provide internal awareness of positive outcomes achieved which can be shared with ACOs and PCP medical home entities to demonstrate the benefits to these organizations to contract with the CBHO for a full service array of services to support the most complex SED and SMI clients. CBHOs will be in a very vunerable position in contact negotiations without the ability to share enhanced medication adherence, retention in treatment and reduced ER, Inpatient visits, etc. outcomes acheived with a full service array.

Hope that this information is helpful.

David Lloyd
MTM Services

Finally, the sample


Sherry Perlstein August 4, 2010 at 3:11 pm

Will primary care physicians and hospitals be required to establish formal realtionships with behavioral healthcare providers (and visa versa) under healthcare referorm?


David Lloyd August 5, 2010 at 10:26 am


The new healtcare reform focused healtcare delivery models such as Accountable Care Organizations, primary care practice based medical homes and FQHCs are not required to establish formal relationships with behavioral healthcare providers and vice versa.

In the case of Accountable Care Organizations and primary care based medical homes, BH providers will need to be able to demonstrate value. Value of Behavioral Health Services will depend upon our ability to:
Be Accessible (Fast Access to all Needed Services)
Be Efficient (Provide high Quality Services at Lowest Possible Cost)
Produce Outcomes!
Engaged Clients and Natural Support Network
Help Clients Self Manage Their Wellness and Recovery
Greatly Reduce Need for Disruptive/ High Cost Services

In the case of FQHCs the emphasis nationally has been to add their own BH service capacity in line with their funding increases under the new law as outlined below:

Community Health Centers (FQHCs) and Health Reform Update:
$11 Billion for Health Center Program Expansion- Beginning in FY2011
The health reform package contains a total of $11 billion in new funding for the Health Centers program over five years. $9.5 billion of this funding will allow health centers to expand their operational capacity to serve nearly 20 million new patients and to enhance their medical, oral, and behavioral health services. $1.5 billion of this funding will allow health centers to begin to meet their extraordinary capital needs, by expanding and improving existing facilities and constructing new sites.

Thererfore, BH centers will need to ensure that the following service delivery models are fully integrated into their practice in order to be a valuable potential partner within healthcare reform:

i. Reduce access to treatment processes and costs through a reduction in redundant collection of information and process variances
ii. Develop Centralized Schedule Management with clinic/program wide and individual clinician “Back Fill” management using the “Will Call” procedure
iii. Develop scheduling templates and standing appointment protocols for all direct care staff linked to billable hour standards and no show/cancellation percentages
iv. Design and implement No Show/Cancellation management principles and practices using an Engagement Specialist to provide qualitative support
v. Design and implement internal levels of care/benefit package designs to support appropriate utilization levels for all consumers
vi. Design and Implement re-engagement/transition procedures for current cases not actively in treatment.
vii. Collaborative Concurrent Documentation training and implementation
viii. Design and implement internal utilization management functions including:
a. Pre-Certs, authorizations and re-authorizations
b. Referrals to clinicians credentialed on the appropriate third party/ACO panels
c. Co-Pay Collections
d. Timely/accurate claim submission to support payment for services provided

Hope that this is helpful.

David Lloyd
MTM Services


Sue Stuckless August 5, 2010 at 10:05 am

Has the chat begun?


Jermine Alberty August 5, 2010 at 10:07 am

Will there be a transcript of the answers from today’s live chat.


admin August 5, 2010 at 10:11 am

Jermine, the comments will remain here. Hope this helps, Bob


Kristin McCloud August 5, 2010 at 10:08 am

I can’t see any chat either.


Karl V. Kovacs August 5, 2010 at 10:10 am

What should public mental health systems do to either form medical homes themselves or develop positive contracts with other medical home entities such as hospitals, HMOs, etc.?


David Lloyd August 5, 2010 at 10:31 am


Community Behavioral Healthcare providers can function as medical homes under healtcare reform act. Some of the qualifications are:

‘‘(B) SERVICES DESCRIBED.—The services described in this subparagraph are—
‘‘(i) comprehensive care management;
‘‘(ii) care coordination and health promotion;
‘‘(iii) comprehensive transitional care, including
appropriate follow-up, from inpatient to other settings;
‘‘(iv) patient and family support (including authorized
‘‘(v) referral to community and social support services,
if relevant; and
‘‘(vi) use of health information technology to link
services, as feasible and appropriate.

The last item will require that the CBHO have adequate electronic record systems to fully communicate with all healtcare providers that the clients need.

Hope that this helps.

David Lloyd
MTM Services


Cindy Kelly August 5, 2010 at 10:17 am

How do you determine productivity standards based on various services that are provided and incentives for all staff?


David Lloyd August 5, 2010 at 10:47 am


Productivity standards are best based on three metrics:

1. Part time or full time status of staff (FTE value) and the portion of their work that is devoted to direct clinical care vs. admin requirements (CFTE value)
2. Measure only the direct care services (billable services) that any funder will pay the agency for when properly delivered, documented and claimed/reported
3. Level of billable/direct service hours will need to equal a cost of service that is within the average revenue(s) for the services that that particular clinician will provide. The cost basis is calculated on salary, fringe level and overhead costs divided by the total number of billable hours the clinician is expected to deliver per year.

Currently, the national average productivity levels for in clinic therapists ranges from 1,200 hours to 1,350 hours per year.

For MDs/NPs the range is 1,300 to 1,400 hours per year.

The actual standard will depend on your agency’s average revenue received for each service type.
For community based staff the range is 1,050 to 1,200 hours per year.

Hope that his helps.

David Lloyd
MTM Services


Keith Morris August 5, 2010 at 10:18 am

The wait time for services often times are an outcome of no show appointments that take up time and create a degree of “rescheduling chaos”, espescially in the area of first appointment assessments to determine eligibility. What has been your experiences with same day assessments on a walk in basis?


David Lloyd August 5, 2010 at 10:40 am


Great point… The National Council organized Access and Engagement grant work that we have served as faculty for during the past three years have been a great collaborative learning envirornment for same day access to treatment models.

The same day access models cost less if you team has over a 30% no show rate for scheduled intakes based on cost of staff salary, fringe, overhead and loss revenue .

Below is the typical same day access model outline:

Open Scheduling Same Day Access – Master’s Level assessment provided the same day of call or walk in for help (If the consumer calls after 3:00 p.m. they will be asked to come in the next morning unless in crisis or urgent need)

1. Initial diagnosis determined
2. Level of Care and Benefit Design Identified with consumer
3. Initial treatment plan Developed based on Benefit Design Package
4. 2nd clinical appointment for TREATMENT within 8 days of Initial Intake
5. 1st medical appointment within 10 days of Initial Intake

Same day models have produced much better engagement in treatment as per below outcome study from Carlsbad MHC in Carlsbad, NM:

Carlsbad MHC produced data that demonstrate the following about the relationship between initial contact for help, Open access, second appointments and no-shows.  Sample size is 561 new customers who received an intake between January 1, 2009 and May 31, 2009.  The summary of outcomes identified are outlined below: 
a.  Approximately 95 percent of the customers who have their second appointment scheduled within 12.2 days of their Intake show for that appointment.  Therefore the 10 day access standard that is recommended is valid for  the second counseling service and medical appointment. 
b.  Approximately 70 percent of customers who have the second appointment scheduled 22 days or more after their intake did not show.
c.  100 percent of the customers whose second appointment was canceled by the Center – never came back.

Hope that this helps.

David Lloyd
MTM Services


Julie Dowling August 5, 2010 at 10:25 am


In your opinion, what would be the three greatest priortities for behavioral health care providers to best prepare themselves, the community and the people they serve for the changing health care environment?


David Lloyd August 5, 2010 at 10:34 am


The three greatest priorities are:

1. Timely access to treatment (not just an assessment)
2. Ability of the CBHO to provide stepped care using levels of care and benefit designs
3. Ability to measure the improved functionality of clients as a result of the services received

Then, proactively meet with hospitals, PCP practices, FQHCs, etc. to provide an awareness of the above three capacities.

Hope that this is helpful.

David Lloyd
MTM Servicers


Melissa August 5, 2010 at 10:41 am

Is it accurate to describe one possible ACO structure as a managed care organization without the insureance risk?


David Lloyd August 5, 2010 at 10:52 am


The requirements for an ACO under healthcare reform are outlined below:

Congress and CMS: an ACO would have at least one hospital, a minimum of 50 physicians (primary care and specialists), commit to be in business for at least 3-5 years, and serve at least 5,000 patients
1. If the ACO met pre-established quality goals, it would receive an incentive payment
2. Penalties would be assessed if care did not meet the quality goals established
3. Incentive payments and penalties would be split between the members of the ACO
4. The providers in the ACO would follow best practices, be patient-centered and contribute to the development of best clinical practices to build standards of evidenced-based medicine

Also, some payment models for ACOs:

Medicare: Allow providers organized as ACOs that voluntarily meet quality thresholds to share in the cost savings they achieve (2012)

Medicaid demonstration projects: Pay bundled payments for episodes of care that include hospitalizations (2010-2016); make global capitated payments to safety net hospital systems (FY2010-2012); Allow pediatric medical providers organized as ACOs to share in cost-savings (2012-2016)

Therefore, the risk is at the level of each member of the ACO and the payment methodolies being consider share the risk or fully shift the risk from Medicaid and Medicare to the ACO entities (i.e., bundle payments for a procedure and lenght of time that does not allow for additional billing in the event of follow up care needs such as post operative infections).

Hope that this helps.

David Lloyd
MTM Services


Gary Whittaker August 5, 2010 at 10:42 am

We recognize that getting past the common perception of “my caseload is full… I couldn’t possibly even consider taking on more clients” is one of the top challenges in preparing for NYS Clinic Restructuring. We know that we have underutilized capacity, because our average time spent on billable activities for clinicians is currently barely 50%, and no-show rates are in the range of 20% to 40%.

Can you recommend specific tools and techniques to implement a revised caseload structure based on identifying care level needs and assigning targets to each of these groups. It’s one thing to acknowledge the need to go in that direction… it’s another matter to actually implement that plan.

Is that the best place to start, in your opinion? If so… tools? parameters? training resources? We’d be grateful for specific direction. Thanks!


David Lloyd August 5, 2010 at 11:05 am


The Poll Results based on over 600 Registrants for the NC LIVE Webinar on Healthcare Reform and Enhanced Revenue that I presented on December 15, 2009 and January 12, 2010
1. From the clinicians’ perspective, are the caseloads in your organization “full” at this time?      
Yes = 74%   No = 26%
2. Indicate the no show/cancellation percentage last quarter in your organization for the intake/assessment appointments:
A. 0 to 19%   = 20%
B. 20 to 39%  = 42%
C. 40 to 59%  = 15%         
D. Not aware of percentage = 23%
3. Indicate the no show/cancellation percentage last quarter in your organization for Individual Therapy appointments:
A.  0 to 19%  = 24%
B.  20% to 39%  = 50%
C.  Not aware of percentage = 26%
Obviously the responses to number 1 above compared to number 2 and 3 above provide a critically important action focus. In the Healthcare Reform issue of the National Council Magazine released in June, I wrote an article to address being “full”. Excerpts from that article are as follows:

In my experience in consulting with CBHOs nationally during the past 15 years, the concept of clinicians’ caseloads being “full” creates significant challenge to improving access to treatment for consumers that are waiting for services. A summary of the indicators for “full” caseloads identified by many CBHOs are:
1. The historical number of cases that have defined a “full” caseload has been reached (i.e., 65 cases for Child/Adolescent therapist, 80 cases for adult therapists, etc.). It is difficult to understand how caseloads can be “full” at the same time the percentages of no show/canceled activity for both initial assessment and ongoing therapy appointments are at the levels identified in survey questions three and four above. The conclusion might be that caseloads are full at the beginning of each clinic day based on schedule rates; however, at the end of the day the services are not being delivered based on the percentage of time that no show/cancellations occurred each day.
2. Another factor defining “full” seems to be a holdover from the grant funding era that requires therapists to carry cases so that they can see the MD/APRN for medications. This protocol has resulted in a significant challenge for therapists in several areas:
a. At numerous CBHOs therapists report that they have two types of caseloads – “active” cases that are engaged and receiving therapy and inactive “active” cases that are being carried so that they can see the MD/APRN/NP for medications. The real challenge is that many of the “medications only” consumers are not in active treatment with the therapist based on extremely high no show/cancellation levels that requires the therapist to write progress notes documenting the no show activity.
b. In our compliance and risk management consultation assessments, many therapists are reviewing treatment plans for the meds only cases based on the frequency required by each state (i.e., every 90 days) noting the progress the consumer has achieved while the therapist has not seen the inactive “active” consumer in the 90 day period. When asked how the therapist assess progress or lack of progress in the review process, some of the responses that have been provided are:
i. Called the client to ask if they are doing okay
ii. Read the MDs/APRNs/NPs progress notes to confirm status
iii. Since consumer has not attended services scheduled, assumed that they were doing okay.
c. This process of carrying inactive “active” cases creates a significant amount of paperwork/documentation for the therapist that does not result in treatment being delivered which enhances the overwhelmed/full caseload response by staff. Also, this process begs the ethical question of why some consumers are experiencing extended delays into treatment when a significant number of open cases are not routinely attending/receiving services.
Therefore, indicators used to determine “full” caseloads may be based on a number of cases that requires a significant amount of charting and paperwork hours rather than based on “full” meaning each therapist is routinely delivering at or above the key direct service/billable hour performance standard. One of the new MTM Calculators being used by CBHOs is the Level of Care Caseload Calculator. This calculator measures the number of cases that a direct service provider needs to meet the monthly billable hour performance standard. The calculation is based on the number of direct service hours that are targeted to be provided at each level of care which includes an ability to identify the number of cases at each level and total caseload needed.

Secondly, an excellent way to measure the impact of carrying medications only cases in therapists’ caseloads is to run a utilization study of the following:
1. Identify the number of no show/cancellation events that individual therapists have had in the past four months and develop an average number per clinic day in the trend period.
2. Identify the percent of the therapists’ caseloads that have not been seen face to face by the therapists in the past four months (i.e., in one CBHO 722 cases (37%) of the 1,950 adult consumers in active caseloads had not be seen face to face by their therapist in four months.) This very demanding level of indirect paperwork/chart maintenance by therapists so that the client can see the MD/APRN creates a significant challenge to CBHOs as they are trying to respond to improve access to treatment for consumers not now in service.
3. Review the assessed needs and treatment goals/objectives the therapist has developed for each of the inactive active clients and then compare to the progress notes to confirm:
a. Have the goals/objectives in the plan changed or are they stagnant and broad in scope
b. Do the progress notes reflect therapeutic interventions provided and measure any outcomes achieved toward accomplishing the consumers goals/objectives
c. Measure the level of goal and objective attainment for these consumers (e.g. – what percentage of the goals and/or objectives have been attained in the past two years?)
d. Has the consumer signed the most current version of the treatment plan (therapist have reported that in many cases they find it difficult to get the consumer to come in to complete and sign their treatment plan)

Thirdly, the MTM Team has provided project management consult to develop statewide standardized clinical forms in Ohio, Massachusetts and New York. In all three of these initiatives a solution was developed for therapists carrying “medications only” cases in their caseloads.

A separate psychiatric/psychopharmacological management plan was developed that allows the medications only clients (not engaged in therapy) to be transferred out of therapists’ caseloads to a registered nurse who will develop the plan for 250 to 350 medications only clients in her/his caseload. The procedure provides for the nurse to schedule medications only clients every two to three months to provide a physical assessment (vital signs, weight, side effects, etc) and then provide the information to the MD/APRN to support their medication evaluation/management service that follows.

In presenting this new procedure to CBHO clinical teams the initial responses are something like “we don’t have enough nurses”; “our nurses are doing other tasks and do not have time to carry a caseload”; and/or “nurses salaries are higher than social workers”. The important objective assessment to consider is:

1. How many consumers are waiting for an initial Intake/Diagnostic Assessment face to face appointment with a therapist and how long are they waiting on average? Can we make this process timelier if we open up caseload capacity?
2. How many hours of billable direct service are being lost because therapist are maintaining charts for consumers that are not coming to therapy but are routinely showing for med appointments?
3. How many consumers are not showing repetitively for therapy appointments and what are the results at the end of the day to the therapist ability to delivery services they are uniquely trained to provide?
4. What is the level of lost billable hour revenues that therapist are currently experiencing with scheduling and re-scheduling consumers who are not showing?
When one CBHO completed this type of assessment, they determined that their annual costs and billable revenue lost for therapists carrying cases that only wanted medications and were only regularly attending medication evaluation appointments equaled 14% of their annual salary costs for therapists. With this level of objective information, the CBHO made a decision to engage and use additional nursing services to support the new meds only caseload management procedure.

In summary, as CBHOs move to a more managed and performance based payer mix as a part of parity and healthcare reform, new models of care will be need to be developed. A key opportunity is available for CBHOs to be at the table as valuable partners as these new models are being developed IF CBHOs have timely access to treatment and availabile service capacity to provide treatment.

However, if CBHOs are perceived by the public and payers to have a prolonged wait time to treatment, and if internally CBHOs are “full” thereby preventing new consumers from entering treatment, then the new managed payers will not look at CBHOs as a valuable and needed partner when designing new integrated healthcare models.

We are truly at a crossroads! Do we watch the parade of required healthcare reform integrated service delivery models develop and proceed to implementation without us or do we fully participate in the parade?

The concern is that without a capacity for timely access to treatment that meets the access to care performance standards of managed payers, and without a capacity to open new cases in active treatment due to being “full” now, CBHOs will not be able to actively participate.

Hopefully, the solutions options provided in this article will be helpful to begin fruitful discussions about CBHO’s capacity to provide treatment to residents that are not now in caseloads.

Hope that this is helpful. Please download the important Healthcare Reform Issue of NC Magazine from the National Council web site.

David Lloyd
MTM Services


Michael Hunter - Team Mental Health Services August 5, 2010 at 10:49 am

Sorry, the server errored out on me… Here is the full comment:

In regards to your response, copied below:

Is there any advice for economically adding Peer Support staff to the program design to assist with service coordination for MI and Co-Occurring disorders? Is it expected that Peer Supports will increase in demand, at the expense of the Bachelor level case manager?
Thank you.

The three greatest priorities are:
1. Timely access to treatment (not just an assessment)
2. Ability of the CBHO to provide stepped care using levels of care and benefit designs
3. Ability to measure the improved functionality of clients as a result of the services received
Then, proactively meet with hospitals, PCP practices, FQHCs, etc. to provide an awareness of the above three capacities.


David Lloyd August 5, 2010 at 11:10 am


Yes… The key factor for use will be to provide quality outcome based service for the most economical cost (the need to bend the cost curve for healthcare). Also, another focus will be to partner with ACOs and PCPs medical Homes to reduce the level of use by BH clients in general medical, speciality care, hospital ERs, etc.

Therefore, combining the two needs economical costs with demonstrated outcomes will require that BH providers use service coordination and support to produce the outcomes.

Hope that his helps.

David Lloyd
MTM Services


Meena Dayak August 5, 2010 at 11:08 am

David and others have written about many of the issues being discussed here. Download a PDF of 3 articles in National Council Magazine, Healthcare Reform issue — full caseloads, eliminating no-shows, improving access to care (David Lloyd, Noel Clark, Scott Lloyd).


Susan Hammond February 10, 2011 at 2:57 pm

What is the role of an Engagement Specialist and what are the achieved outcomes that this position is meeting for community health center’s that have utilized this resource?


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