Health plan targets members at risk for suicide

System picks up cues often missed by clinicians

Clinicians at PacifiCare Behavioral Health use a variety of techniques to identify patients who may be at risk for suicide, beginning with a member’s first call to the managed behavioral health plan’s behavioral health line, which is staffed by customer service associates trained to identify members who need immediate interventions.

When patients are in treatment, the health plan uses its ALERT (Algorithms for Effective Reporting and Treatment) system to assist clinicians in identifying members who may be at risk for suicide.

The ALERT system uses a 30-item Life Status Questionnaire, which patients complete in their practitioner’s office on their first, third, and fifth treatment and every five sessions after that.

In addition, clinicians are asked to complete a one-page assessment form during the patient’s treatment. Information on the patient’s questionnaire goes into PacifiCare Behavioral Health’s database system, where it is compared to information given by the provider.

Identifying patients

ALERT identifies patients who may be at high risk for conditions that have not been identified by the practitioner and automatically routes the data to the PacifiCare Behavioral Health care managers.

If the patient’s assessment conflicts significantly with his or her therapist’s, the care managers will work with the treating practitioners to make treatment modifications, including increasing the intensity of treatment.

"If the ALERT program indicates a higher intensity of care is needed, we suggest that the member see the provider more frequently and authorize more treatment," says Cassandra Loch, LCSW, chief of staff for the Santa Ana, CA-based managed behavioral plan.

The ALERT system is used for members enrolled in the company’s mental health and chemical dependency benefit programs who access behavioral health care services.

The ALERT database contains treatment patterns and outcomes data for approximately 100,000 patients.

Researchers at PacifiCare Behavioral Health developed the ALERT system following a three-year study involving 43,000 patients and 3,500 mental health providers. The study showed that clinicians miss early warning signs of suicides 57% of the time, compared with information in reports filed by patients themselves.

The rate dropped to 39% when clinicians were made aware of the differences between their assessment and the patient’s responses.

Handling calls

Health plan data indicated that 4.5% of patients in behavioral health treatment are at high risk for suicide, chemical dependency, or premature termination of treatment.

About 8% of behavioral health plan members account for nearly half of all behavioral health treatment spending.

The staff at PacifiCare Behavioral Health’s call center answer approximately 32,000 calls per month, Monday through Friday, 6 a.m. to 7 p.m. The number doesn’t include after-hours coverage, which also is available for members.

Calls range from parents who want their child assessed for attention deficit disorder to people who are severely depressed, distraught, and suicidal.

The behavioral health call center team includes highly trained customer service associates and licensed care managers who manage benefits for several employer groups, unions, and health plans.

"If someone wants to access their mental health benefits, they can call us 24 hours a day and talk to one of our customer service associates, who are trained to triage the call and figure out what the potential risk issues might be," Loch says.

The customer service associates follow a standard questionnaire designed to determine if there are any risk issues.

If the associate thinks that a member may be at risk and needs immediate attention, he or she immediately transfers the member to a licensed clinical care manager, who completes a more in-depth assessment to determine the best referral.

The follow-up from this point depends on the needs of the members.

"A lot of people call when they are going through stress at work or home and need only a few counseling sessions. They are offered a referral to a practitioner in their area to contact for a routine appointment. Others who have a higher level of distress may not be able to wait for a routine appointment, so the care managers will assist in finding an appointment for an immediate face-to-face assessment," Loch reports.

The customer service associates are trained to figure out the specific needs of members and refer them to licensed clinicians, if necessary. If the member is not identified as needing to speak with a licensed care manager, the customer service associate can provide the member with a routine referral in the member’s area.

When a call is transferred to a licensed clinician, an assessment is completed to determine the severity of the situation and whether the member needs to go to the hospital immediately or if he or she can be seen for a face-to-face evaluation within 24 hours.

Following up

In the more severe cases, the care managers follow up with the member and the provider and monitor the case until the member is stable and engaged in treatment, Loch says.

"We put our clinical resources toward the cases that need the most intensive care management. If a person sees a therapist for eight sessions for job or marital stress, we usually don’t need to intervene in those cases," Loch says.

On the other hand, if a caller identifies him- or herself as suicidal, the staff immediately get in touch with a provider to set up a face-to-face assessment for the member.

The care manager will speak with the member and/or other family members to coordinate the appointment and to make sure that the member is seen. If necessary, the care manager may call the member every day until he or she sees the provider and gets into treatment.

Other members may be chronically ill, with fluctuating levels of distress. In these cases, the PacifiCare Behavioral Health staff may have contact with the provider and member on a monthly basis.

Long-term cases in which members have been hospitalized or are at a higher risk are contacted more frequently.

"People who are chronically, persistently mentally ill, who rely on the hospital as a primary source of treatment, are referred for case management services. We are always monitoring for any red flags that indicate a change in the treatment approach is needed," Loch says.

Staff training

In essence, the degree to which a care manager gets involved with a member’s care is based on the clinical issues and needs of that member. The ALERT system helps to identify when and how care managers need to intervene by flagging high-risk cases for the care managers.

The customer service associates typically have a bachelor’s degree and are required to go through six to eight weeks of training, including three weeks of classroom training, before they listen in on live calls. The training is a combination of learning the clinical system as well as role-playing and learning to identify members who may need to speak with a care manager by picking up cues.

"Members often won’t say that they are depressed, but there are often clues that the customer service associate can pick up on," she says.

The customer service associates use a scripted questionnaire that is a combination of open- and close-ended questions.

"The computer system is so sophisticated that, based on answers to the questions, it prompts the customer service associates to transfer a call to a licensed clinician," Loch notes.

The licensed clinicians are all masters-prepared and are a combination of licensed clinical social workers, licensed marriage family therapists, and licensed psychologists.

The systems at PacifiCare Behavioral Health support the diverse needs of its patient population by the intense staff training. The staff are trained to customize their approach on cases based on the individual needs of the patient.

"We are constantly monitoring the clinical needs of our patients to determine the intensity and level of care management needed," Loch says.