METS

What is the METS Program Trying to Accomplish?

The METS team partners with you to create an integrated care plan that supports members in their recovery journey. Your METS team consists of a Clinical Liaison and often times a Coordinator. Clinical Liaisons are licensed clinicians who use their experience to partner with you to provide administrative and clinical support. They leverage a strengths-based approach to help identify and overcome potential barriers, support care coordination and provide resources to promote successful treatment outcomes. The Coordinators supplement the recovery process by addressing social determinants of health barriers and linking members to community resources that line up with their goals. If Coordinators are not available in the market, referrals to care management are made as needed.

What’s Going to Happen in this Process?

A Members Empowered to Succeed (METS) Clinical Liaison will reach out to you via telephone or email to arrange a call to:

1. Discuss the member identified for the METS program.
2. Confirm the best way to secure clinical information that will be requested prior to an initial consult call. This includes the member’s most recent treatment plan, assessment and the last progress notes to review.
3. Schedule an initial consult call. This call may take up to 20–30 minutes depending on the existing clinical information that was provided prior and the member’s needs.
4. Discuss follow-up consultation scheduling. Regular, ongoing communications will continue, most often in the form of a phone conversation lasting up to 15 minutes. These will be scheduled at periodic intervals during a member’s participation, which may last for up to 12 months.

What is the Time Commitment?

We are flexible and will work to accommodate your schedule as much as possible. The initial clinical consultation may take up to 20–30 minutes. This time can be reduced if the member’s most recent treatment plan, assessment and the last progress notes are provided for review. Periodic communications will occur, most often in a phone consultation, lasting up to 15 minutes. Member support in the METS program can last for up to 12 months.

What are the Benefits and is Participation Voluntary?

The METS program partners with you to develop a comprehensive care strategy to match the member’s needs, incorporating their goals, strengths/interests and desired outcomes. The success of the program hinges on the strength of this partnership. While your participation is required, we are aligned in the same goal when it comes to the members — to increase access to care and improve health outcomes. The METS program is part of the contractual requirement in which providers collaborate in quality improvement measures and medical record review activities. This collaborative approach to integrated care helps support treatment plans, medication adherence and recovery.

How are Members Selected?

Members are identified using historical claims data over the past 12 months. Those with a higher frequency and duration of behavioral health and/or SUD outpatient services are selected for participation.

Is a Release Needed to Exchange Information about the Member?

No, a release of information is not required. Protected Health Information (PHI) that is used or disclosed for purposes of treatment, payment, or healthcare operations is permitted by Health Insurance Portability and Accountability Act (HIPAA) Privacy Rules (45 CFR 164.506) and does not require consent or authorization from the member.

How Should I Tell the Member You Are Involved?

Your Clinical Liaison will either partner with a Coordinator or make a referral to care management to ensure the member is informed.

Are You Denying Treatment for the Member?

No, our goal is to partner with you and the member to identify additional supports needed for successful treatment progress. You can leverage METS resources and supportive materials on treatment, titration/discharge planning and care coordination.

The METS team does not perform authorization reviews. If you have any questions related to medical necessity criteria and authorization processes, please direct inquiries to the health plan’s Utilization Management Department. Our team can provide that contact information if needed.

Can We Refer Members to METS?

No, members cannot be referred to the program at this time. If you have a member you believe requires additional assistance, we can verify their METS program eligibility. If they do not qualify for METS, we can connect you with the health plan’s care management program or member services to assist them further.

Important steps of treatment planning

•  Treatment plan goals should:
  • Align with assessment, diagnosis, and presenting symptoms
  • Be member driven and individualized
  •  Serve as a guide towards the client’s recovery and be referenced frequently
• Clinical Documentation in a treatment plan should include interventions that are being used, measurable target dates for each goal, and member’s strengths.

Creating a member-focused treatment plan using specific, measurable, attainable, relevant, and time frame (smart) goals

• This method helps goals to be measured and adjusted over time to show incremental progress or regression.
  •  If progress is not occurring, ask yourself, “What can we do differently?” and reflect changes in the updated treatment plan if the goal needs to be amended to improve attainability.
• Goals should have a time frame of no more than 90 days.
  • Can the goal be met in 1 month, 2 months, or 3 months?
• Goals should be member driven and align with their desired outcome.
  • Use direct member quotes for identified goals to use member language and ensure their understanding.
•  Goals should be strengths based and individualized.
•  It is recommended that each goal has two interventions: one for the member and one for the provider.

Tools to aid in smart goal development

• Biopsychosocial assessment – triage for member’s needs
• Diagnosis and presenting problem – clear supportive symptoms and behaviors that align with diagnosis
• In-depth interview with member and support – assess the desired outcome and strengths
• Motivational interviewing – consider stage of change the member is in and how they want treatment to help them

Considerations

• Baseline behaviors and what is attainable for the member
• Barriers to meeting the goal
• Developmental age and stage of the member
• Goals should be updated after a crisis, hospitalization or change in diagnosis
• Ensure that the timeframe and interventions for the goal align
• Goal should be tangible and able to answer “yes” or “no” if the goal was met at the treatment review

What is care coordination?

• The intentional exchange of information between two or more participants (including the member) who are involved in the member’s care to facilitate the appropriate delivery of healthcare services.
• Care coordination is an essential element in treatment planning, service titration, and the discharge planning processes.

Who should coordinate care?

•  Care coordination includes a variety of individuals on the treatment team:
  • Behavioral health providers (e.g., Counselors, social workers, substance use counselors, Psychiatrist)
  • Physical health providers (e.g., PCP, Pharmacist, Neurologist)
  • Specialty care services (e.g., Physical Therapists, Occupational Therapists, Speech Therapy)
  • Educational and community supports (e.g., Teachers, School Psychologists, mentors)
  • Family members (e.g., parent, guardian, spouse, sibling)

Considerations

•  Release of information must be signed by the member or their guardian prior to any outreach.
• Method of care coordination is based on each member’s needs (e.g., phone, fax, meeting).
• Request and review records from previous or current providers to align care and member needs.
• Notify member and/or guardian about coordination occurring.

What could happen if coordination of care does not occur?

• Multiple providers may be treating different diagnosis and/or presenting problems.
•  Multiple treatment plans with competing goals can complicate or impede the treatment process for the member.
• Symptoms may become exacerbated.
• Duplication of efforts and services provided may occur.

Why is patient engagement important in behavioral healthcare?

• Improves health outcomes and the sustainment of the individual treatment plan
• Fosters patients’ desire to be involved in decisions regarding their healthcare
• Encourages patients to be active decision-makers in their treatment planning
•  Promotes health literacy, allowing for increased understanding of health information and services
• Provides an open line of communication for questions about their treatment and overall wellbeing

What is the APP measure?

The APP measure assesses the percentage of children and adolescents 1 to 17 years of age who had a new prescription for an antipsychotic medication, without a clinical indication and documentation of psychosocial care as first-line treatment (90 days prior to new prescription through 30 days after).

What can you do to help?

• Before prescribing children and adolescents any antipsychotic medication, you should complete or refer your patients for a trial of first-line, evidenced-based psychosocial care.
•  When prescribed, antipsychotic medications should be part of a comprehensive, multi-modal plan for coordinated treatment that includes psychosocial care.
• Periodically the ongoing need for continued therapy with antipsychotic medications should be reviewed.

What is titration?

• Titration implies stepping the member down in their services to match their clinical presentation, progress, baseline, and supports.
  • Example: Member A was receiving therapy 4x/month. Due to member’s progress, increase in supports, and coping skills, Member A is being titrated to receive therapy 2x/month. Member will be evaluated with current service package and continue titration of services as progress continues.
• Services should also be reduced slowly when recovery is occurring to avoid worsening of symptoms, feelings of abandonment by the client, and empower the use of skills learned.

Why is titrating services important?

• Promotes independence and working toward effective independent functioning
  • Discharge should be discussed with the member openly at the start and throughout treatment. A key goal of therapy is to work toward effective independent functioning.
  • This process includes helping members identify their natural support systems and assisting with coordination of care to support their step-down plan and access community-based resources.
  • Studies demonstrate that it is not necessary to be in therapy for years to achieve improvement in symptoms.
• Helps to ensure individualized treatment
  • Treatment type and duration should always be matched appropriately to the nature and severity of the member’s presenting problems.
  • Length of treatment also varies with the type of treatment provided.
• Discourages unhealthy attachments
  • Titration helps discourage unhealthy attachments to treatment providers because it promotes independence and monitors the member’s progress. It ensures that a member isn’t stuck in one level of care or becomes too dependent on a provider or services.

Barriers to titration services

• Sunshine Health recognizes that barriers may be present for providers and members.
• If symptoms worsen, services can be titrated up to increase frequency and duration of services, if the documentation supports the medical necessity of those services and authorization is obtained.

Discharge planning process

• Discharge planning is not a one-time event. It requires collaboration with the entire treatment team including providers, member, family, and additional supports.
• Discharge planning should begin on the first day of treatment and continue to be assessed and frequently discussed with the member.
• The discharge plan should be written clearly and agreed to by the member.
• Titrating services, which is the continuous appraisal of current needs, will also help identify when discharge is appropriate.
• Discharge should occur when: All the treatment goals and needs have been addressed, OR member has reached their baseline, OR the member has reached the maximum benefit of services for that level of care.

Step-down planning process

• Members should begin their step-down plan when they have shown improvement and are meeting their goals and objectives.
• Members should also have been compliant with treatment recommendations and are no longer severely functionally impaired.
• To prepare for transition, encourage the use of the skills learned in treatment:
  • Self-care reminders
  • Coping skills
  • Medication regiments
  • Accessing and utilizing support systems
• Recommend potential referrals to connect the member to natural supports prior to discharge to allow practice using services such as:
  • AA/NA and sponsors
  • Senior centers or respite
  • Employment programs
  • Spiritual or religious supports
  • Community mentors or peer support specialists
  • Sports/hobby groups
  • Online supports (e.g., apps, online groups)
• Discharge plans and instructions on how to return for care if needed should be provided to the member and openly discussed. They should be informed that they can resume services if needed.

Consider family readiness

• Refer family to parent education/training, if needed.
• Equip the family with tools and steps to take if the need for treatment arises again.
• Ensure the family’s inclusion on discharge planning.