Assessment tool helps CMs develop treatment plan

Psychiatric evaluation 'gets it right the first time'

One behavioral health company finds that effective psychiatric case management comes when treatment decisions focus on one simple issue: Is the patient getting better?

"For us, managed care means appropriate care, not limited care. We think limiting care to a prescribed number of days is short-sighted. We'd rather get it right the first time than face complications down the road. If an individual needs a certain level of treatment, we provide it thoroughly on the front end," explains Patrick F. Donchez, MA, CEAP, vice president of EASE/case management services for Integra, a behavioral health company in King of Prussia, PA.

Other case managers agree. "If a patient has a severe alcohol problem and we don't treat it thoroughly, and they end up in a hospital intensive care unit with alcohol-related health problems, are we saving money? We're not. We believe that managed mental health care is appropriate mental health care for the individual at the present time," says Ann M. Romanello, RN, CCM, case manager for disability management at Pitney Bowes in Stamford, CT.

To ensure that Integra case managers get treatment decisions right the first time, Donchez says they rely on the clinical opinion of the attending provider and the results of an assessment tool called COMPASS INT, developed by Compass Health Services, also in King of Prussia, PA. Integra tested several different instruments for concurrent review and outcomes measurement in behavioral health for more than 10 years. Originally developed at Integra, COMPASS was spun off in 1994 to fully realize the system's broader applications beyond behavioral managed care organizations. "The breakthrough in developing the current assessment tool came when we began treating therapy as an active process," explains Donchez. "Treatment needs are constantly changing. We use the COMPASS system to ensure that individuals receive the right level of care for their particular level of distress. If a patient is in outpatient care and is not progressing, we don't wait until the patient has problems at work to provide more intensive treatment." Integra uses several aspects of the COMPASS system to measure treatment effectiveness: COMPASS OP in outpatient settings, and COMPASS INT, indicating the need for admission and for discharge from inpatient and alternative levels of treatment.

Pitney Bowes is so impressed with the accuracy of the COMPASS system, it recently contracted with Integra to provide its employee assistance and behavioral health services. "We did extensive due diligence and Integra, and its use of the COMPASS system to make treatment decisions and report outcomes, came out on top," says Romanello.

Before, during, after

Integra mails the COMPASS tool to providers and facilities prior to a patient's initial session. The system provides a questionnaire for the patient to fill out and a separate questionnaire for the provider to complete. Both the provider and patient responses are used to produce a Mental Health Index (MHI) score, says Donchez. (See graph, p. 36.) "We have the benefit of both the provider's view and the patient's view. Many behavioral health case management programs rely on progress from the provider only. By relying on provider progress reports, case managers may not have a complete or accurate picture of the patient's progress," he notes.

Similarly, telephonic case management models may not be enough to develop a complete picture of a patient's progress, notes Donchez. "Patients and providers are far more likely to get their defenses up in a verbal exchange than on paper. Written responses tend to be more candid," he notes.

The MHI is an aggregate score based on three primary subscales of the instrument. (See graph, p. 37.) Those three subscales include:

• well-being assessment;

• current symptoms;

• life functioning.

Think of it as a mental lab test

"The MHI can be compared to a CBC, or complete blood count. The physician compares the patient's CBC to the normal range and prescribes and adjusts medications based on the cell count. The COMPASS MHI compares patients to normal function ranges. The score helps guide the provider and the case manager to set treatment levels and goals," explains Donchez. "For example, if the MHI comes back functioning at or near normal, the case manager may guide the provider to switch to an educational component and then final closure of treatment. Likewise, a score of 'severe' on one of the subscales may lead the case manager to recommend more intense treatment, or perhaps, a consultation with a psychiatrist to consider the need for medication," he adds.

The questionnaires are readministered roughly every four weeks, depending on the intensity of the treatment. "By readministering the tool concurrently, the case manager can easily track a patient's progress. If the patient is not moving forward in treatment, the case manager can work with the provider to establish a more effective treatment plan," says Donchez. "Another thing case managers must consider is that research indicates that if you do not see some elevation in well-being in the first four sessions of treatment, the patient will not achieve success with that provider," he notes.

"If we don't see any movement on well-being in the first four sessions, we look for a consult, consider a different provider, or a different therapy," notes Donchez.

Another tool the COMPASS system provides the case manager is the Therapeutic Bond Score, which measures the strength of the relationship between the provider and the patient. (See graph, p. 37.) "If the bond score is high but the patient is not progressing as expected in treatment, the case manager will work with the provider to develop a new treatment plan. If the bond score is low, it might be used to make a decision to change providers, but that is not common. There are many other areas that need to be explored first," says Donchez.

"When a patient is not progressing, or is reluctant to return to work, there may be many underlying causes," agrees Romanello. "The case manager must explore all the possible barriers to the patient's progress," she adds. Romanello suggests case managers look to personal and workplace issues for barriers to treatment progress. Those issues include the following:

Patient fears losing employment.

"In this decade of downsizing, many employees fear they will lose their job. They even go out on a stress claim and stay out indefinitely, sometimes even hoping to push themselves from disability right into retirement," explains Romanello. "Case managers can check with the human resources department to determine whether loss of employment is a possibility, and, perhaps, reassure the patient that his or her job is secure."

Primary provider delays appropriate referral.

"Many managed care plans provide disincentives to primary care physicians to discourage referrals. We've imposed a mandatory psych consult within two weeks for any patient out on a mental disability claim to a physician of the primary physician's choice to have the patient evaluated for medications and make sure they are on the appropriate treatment plan," explains Romanello.

Patient reports difficulties with return to work.

"Many times patients report problems with return to work, but when the case manager contacts the employer's human resources department they often find there is no barrier on the employer's side," says Romanello. "Sometimes, the case manager can work with the human resources department to move the patient to a different location or department within the company where the patient is more comfortable."

Health plan limits benefits.

"Many health maintenance organizations have no substance abuse rehabilitation coverage. We often go in there and make recommendation that the HMO pay anyway. If it's a capitated HMO, we go to the director of health care planning and ask for a medical override. If we can prove that the treatment we're recommending is standard and appropriate, we usually have no difficulties getting it covered," she adds.

Patient can switch therapists right away

Conversely, if a patient requests a new provider early in therapy, Integra grants the request without question, regardless of the patient's MHI or Therapeutic Bond Score. "If a patient goes to see a therapist the first time, and asks to see someone else, we don't question that decision. At that point in treatment, the individual is seeking help, and if in their mind they see something in that provider that is interfering with their treatment, we automatically refer the patient to another therapist. The therapist-patient bond is a partnership - without it, the patient won't progress," says Donchez.

[For more information about the COMPASS Intensive system, contact: COMPASS Information Services, 1060 First Ave., Suite 410, King of Prussia, PA 19406. Telephone: (610) 992-7060.]