Parity and Healthcare Reform: Community Behavioral Health at a Crossroads

by admin on July 11, 2010

Don’t miss David Lloyd’s webinar July 13 when he delivers recommendations, readiness assessment and strategies to help you prepare for healthcare reform.

Organizations will need to prepare for the effects of parity and healthcare reform by streamlining operations, increasing capacity and reducing variations in care, according to the experts.

Ask David your questions before the webinar by leaving a comment below.

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{ 15 comments… read them below or add one }

John Glantz July 11, 2010 at 2:45 pm

David, if a client is seen weekly, would you still suggest a weekly call reminder?

Thanks, John

Reply

Meena Dayak July 12, 2010 at 8:55 am

Should we be seeing all clients on a walk in basis only to avoid no-shows?

Reply

John July 12, 2010 at 11:25 am

Dear David Lloyd,
In developing a ‘Client Intake’ process/procedure, for a Residential/Transitional Housing program, which will offer ‘on-site Intake’ for off-site addiction services. What would constitute an effective Intake process/procedure, in-terms of vital intake-form content?
Thank you.

Reply

Susan Markley July 12, 2010 at 11:56 am

David, regarding reminders – I’d like to know if current practices have shifted to the use of email, text messages, or automated calls. If so, how has it affected the show rate?

Reply

David Lloyd August 5, 2010 at 7:41 am

What we did in west Texas we identified… And I think the key thing here is to identify the clients individually and sit down as a clinical team. We identified 78 clients in this particular center in west Texas that simply weren’t engaged. And how we knew that is the no show rates were exceptionally high for any service we’ve scheduled them, they didn’t participate. We found other indicators. They would not show for med management, immediately call in crisis needing meds, our nurse would issue the meds, they would then not show for the next appointment. The nurse would issue meds and then protocol said they have to come face-to-face. We’re not going to issue meds by phone anymore, and they would show up at the crisis center and use the S words so they could see a doctor, and what they wanted were their meds.

Reply

Karen Jenks July 12, 2010 at 2:19 pm

Any suggestions for balancing competing issues/needs—organizational need to offset no shows by double booking or overscheduling and the need to not burden our clients with excessive wait times for intakes.

Reply

Pete Winslett July 12, 2010 at 3:53 pm

An issue we see is 3rd Party not recognizing Credentials that Medicaid allows for services and if we do not follow the primary payor rule then Medicaid has no responsibility to pay.

Reply

Mike Early July 12, 2010 at 3:57 pm

David, with mental health parity will commercial insurances start covering more specialty mental health services such as case management, home base services? With more chronic issues Outpatient therapy is not recommended.

Thanks for any insight you can provide,
Mike Early

Reply

Charley Ramey July 31, 2010 at 4:19 pm

More from an organizational culture perspective do you have any suggestions for balancing competing issues and needs between organizational needs to offset no shows by double booking or over scheduling, for example, and then on balance the need to not burden clients with excessive wait times for intakes?

Reply

David Lloyd July 31, 2010 at 4:52 pm

I think, again, one of the things around organizational culture and one of the things that, I guess, we hearing a lot of is we have a lot of no shows, we’re full, a lot of people aren’t coming or some people aren’t coming. It’s usually the 20/80 rule. Twenty percent of the case loads represent about 80 percent of the no show traffic. But what we’re hearing also is we’re going to do some double booking.

In one center recently they had triple booked their doctors, and what we’re learning is that that is a very, very busy anxiety producing service delivery system. And what our concern is, is that our direct care staff, physicians, nurse practitioners, and/or therapists or case manager, and support staff will burn out. If I come to work every day and when I interviewed a medical team recently in the mid western state, I interviewed every doctor, nurse, and nurse practitioner I said what are the challenges here? What are the good things? One of the challenges they told me, one doctor put it pretty succinctly, he said, since we’ve started to triple book my appointments, he said I literally am absolutely so anxious as the day goes along that everybody will show up. He said I can’t ever relax in my day. And he said what I’m realizing over time is that it’s not helping me from a health standpoint, but it’s certainly not helping me with my approach to clients because I’m constantly trying to hurry in case everybody shows up next hour or next 30 minutes. [0:02:32]

And so I think double booking and triple booking we would suggest is the last way to go. What we recommend strongly is that you look at centralized scheduling, moving your appointments out of the clinician’s books into a centralized scheduler. That you do 36 to 48 hour call in advance to remind but also to ask if they’re coming. Do you still plan to see Doctor Jones Thursday at 4:00 or would it be better if I rescheduled you? That’s an empowerment to the consumer. And if they say no I can’t really come, then we reschedule them and immediately use a will call list which is the clinician developed list per clinician per week turned over to centralized scheduling that basically says if I have any cancellations this week, work this person into my schedule; same thing that you may have experienced with a dentist or a physician. They don’t have an appointment, but we’ll call you if there’s a cancellation. And then we give information to the consumers that here’s what will call status means. But you’re really taking a clerical position, managing schedule, backfilling, using the qualitative support of the will call list so that the clinician is driving which clients are called in the event of cancellation. What we’ve learned in that model is that we can really take care of the no show noise very, very well without double, triple booking. [0:03:51]

The other thing is remember the 20 percent 80 percent. We need to identify which clients aren’t coming and then move them to a different model such as a med clinic drop in. One team in Ohio reduced their med no show rates 49 percent overall by taking just the clients who had been repetitively scheduled not coming in, we renew the med by phone, and they’d not come in, we’d renew the med by phone, and we moved them to a drop in med clinic on Wednesday afternoons. And so when you start to look at the behavior of the consumer, how do we respond appropriately to give the service but in a different format, or a different way, or a different modality? So I think those might be some better ways than just double booking. [0:04:34]

Overall organizational culture, just a comment around levels of care benefit design, what we’re finding, as I said earlier, is that some teams will feel like this is a pulling back my clinical authority and what are you trying to do. Tell me what to do. And what we’re learning is that it needs to be focused in a good team development model where your clinical director, and your chief medical officer, and other clinical leadership are sitting at a table and developing these guidelines so that it’s not just a person’s decision. And as Sandy said, use your data to benchmark against what you’ve identified as a solution, and if it’s not appropriate change it. [0:05:12]

I think the other thing is benchmark it around this, and Sandy I heard you say this and I’m going to hand it off to you, is that we’re really trying to get, and I know Carlsbad (sp?) has this as their QY standard now. They want 80 percent of the consumers in each level assigned based on assessed need to complete that level. That’s a very different model than we’ve had as a QY initiative. But they really feel professionally if the person can complete the level, that they can help them recover, get better, and function better. So again, I’ll hand it off to you, Sandy, for other cultural challenges that you may have encountered.

Reply

David Lloyd July 31, 2010 at 4:27 pm

I think, again, one of the things around organizational culture and one of the things that, I guess, we hearing a lot of is we have a lot of no shows, we’re full, a lot of people aren’t coming or some people aren’t coming. It’s usually the 20/80 rule. Twenty percent of the case loads represent about 80 percent of the no show traffic. But what we’re hearing also is we’re going to do some double booking.

In one center recently they had triple booked their doctors, and what we’re learning is that that is a very, very busy anxiety producing service delivery system. And what our concern is, is that our direct care staff, physicians, nurse practitioners, and/or therapists or case manager, and support staff will burn out. If I come to work every day and when I interviewed a medical team recently in the mid western state, I interviewed every doctor, nurse, and nurse practitioner I said what are the challenges here? What are the good things? One of the challenges they told me, one doctor put it pretty succinctly, he said, since we’ve started to triple book my appointments, he said I literally am absolutely so anxious as the day goes along that everybody will show up. He said I can’t ever relax in my day. And he said what I’m realizing over time is that it’s not helping me from a health standpoint, but it’s certainly not helping me with my approach to clients because I’m constantly trying to hurry in case everybody shows up next hour or next 30 minutes. [0:02:32]

And so I think double booking and triple booking we would suggest is the last way to go. What we recommend strongly is that you look at centralized scheduling, moving your appointments out of the clinician’s books into a centralized scheduler. That you do 36 to 48 hour call in advance to remind but also to ask if they’re coming. Do you still plan to see Doctor Jones Thursday at 4:00 or would it be better if I rescheduled you? That’s an empowerment to the consumer. And if they say no I can’t really come, then we reschedule them and immediately use a will call list which is the clinician developed list per clinician per week turned over to centralized scheduling that basically says if I have any cancellations this week, work this person into my schedule; same thing that you may have experienced with a dentist or a physician. They don’t have an appointment, but we’ll call you if there’s a cancellation. And then we give information to the consumers that here’s what will call status means. But you’re really taking a clerical position, managing schedule, backfilling, using the qualitative support of the will call list so that the clinician is driving which clients are called in the event of cancellation. What we’ve learned in that model is that we can really take care of the no show noise very, very well without double, triple booking.

Reply

David Lloyd August 5, 2010 at 7:44 am

To add one more thing.

:Actually it’s been very successful. We just presented last Wednesday and Thursday at the Access and Engagement learning conference SMI cohort we tracked for it with ten different centers for a period of a year 350 SMI adults. Again, five of the centers were experimental centers and five were control, and we did nothing different at the five that were the control. But at the experimental centers we implemented collaborative concurrent documentation, person center planning, levels of care benefit design, Carlsbad (sp?) was one of those participants, over a period of time, and we really looked at training staff around the concepts and principles we’re talking about to engage the consumer in terms of time frame that you might be at this level and the services we’re going to offer.

Now what we found, and I’ll be glad to pop it up real quick because I have it, the outcomes were tremendously successful in the sense that if I look at the SMI cohort here, and I apologize if I’m making everybody dizzy, but I think if you look at the outcomes that were achieved were quite phenomenal, and I’m going to pick this up. But here are the measures we measured, medication adherence, clinician judgment and client report, kept rates. We feel that, again, if the treatment definition includes us providing therapeutic interventions, face-to-face or telephonically, then persons participating is a very important engagement concept. And if they’re not coming routinely, then that would probably indicate they’re not engaged, they’re not in treatment. And then the clinical outcomes to look for ER visits and possible psychiatric hospitalization visits. But I want to show you just some of the outcomes that’s pretty impressive.

The centers that were in what we call subset A were the experimental centers. Those were the ones with person centered collaborative documentation, and level of care benefit designs, person centered planning, discussion of engagement. A lot of the centers in subset A changed their support staff roles from support staff to customer service representatives and really went into customer service planning but just look at the yellow here. What the client reported, and we tracked clients 350 for 12 months as you can see so month two at the bottom to month 11 on the right. And what we found is at the beginning of our tracking, we entered data monthly, we asked the client were they adherent with their medications. Basically subset A centers, five, in the experimental group said that about 84 percent said they were compliant or adherent with their meds. Look at it at the eleventh month and what they’re saying here is the client’s reporting that they have a 94 percent compliance with adherence.

Now look at the green line, the green line is the subset B control group of centers where we did none of the person centered concurrent collaborative documentation, customer service engagement, and look at their level of report. It basically didn’t change. It changed maybe one percentile from about 83 to 84 percentage points across time. Look at their clinician report. This is where the clinician told us that this client, this SMI cohort member is adherent or not. Again, look at your yellow. Those were the experimental centers. They started at about 77 percent but grew to about 92 percent in terms of clinician report, the client is adherent in taking medications. Look at the green line, that’s the control group. We did nothing different there, and we stayed at about 80, 81 percent.

Reply

Karen August 23, 2010 at 9:34 am

Just needed to ask if we are able to receive CEU’s for [Participating] in this webinar???

Thanks ,
KLD,TCPS

Reply

admin August 24, 2010 at 11:52 am

KLD:

Unfortunately, because the webinars are free we are not able to offer CEU’s.

Bob

Reply

Karen Driskell August 23, 2010 at 9:36 am

Think you are all doing a great Job Keep up the Great Work!!!!!

Reply

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