METS

What's going to happen in this process?

A METS Clinical Liaison will reach out to you via telephone, email, or fax to arrange a call to discuss a member identified for the program. Typically, information such as the member’s most recent treatment plan and assessment are helpful in sharing the member’s current treatment goals and progress. The Clinical Liaison would also like to know any barriers in the member’s treatment and any current needs. We prefer to speak directly with the member’s treating provider to ensure the information needed is accessible during our conversation.

What is the time commitment?

We work with you to select a day and time that fits your schedule. The initial meeting takes approximately 30 minutes depending on the amount of detail that you can provide regarding the member’s complexity of needs. Ongoing communication takes place monthly and can be done by secure email or a brief phone call. The member typically remains in the program for 3-9 months.

How are members selected?

Members with high intensity use of behavioral health outpatient services in comparison to other members within the state for at least 12 months are identified using historical claims data.

Is participation voluntary?

No, this is not voluntary. Our providers are contractually required to participate in quality improvement and medical record review activities including but not limited to clinical indicators and outcomes; appropriateness of care; quality initiatives; Healthcare Effectiveness Data and Information Set (HEDIS) measures; and medical record reviews. Our goal is to support you in developing a care strategy that best matches the member’s needs to the lowest acuity setting considering the member’s goals and desired outcomes.

What release is needed so we can give you information about the member?

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

What are you trying to accomplish?

The purpose of METS is to focus on the recovery and resiliency of each individual member and assist in ensuring that they are supported to remain in their community at the appropriate level of services. We do this by partnering with you and the member to encourage collaboration and coordination of additional resources that will progress the member in treatment. METS provides the additional administrative and clinical support often needed in order to assist you in delivering quality, personalized care for high utilizing members. We assist in addressing identified barriers that may be interfering with having more successful treatment outcomes.

How should i tell the member you’re involved?

METS will reach out to the member directly to share the program details and inform the member how to reach their Member Engagement Service Coordinator.

Are you denying treatment for the member?

No, our goal is to work with you and the member to help identify additional supports that may be needed for successful progress in treatment. The METS team does not do utilization management authorization reviews and all questions related to medical necessity criteria and authorizations should be directed to Sunshine Health’s Utilization Management Team (who reviews authorization requests). METS can assist in providing supportive materials to you as the provider on treatment planning, discharge planning, coordination of care, and titration of services which are great tools to consider when assessing a member’s treatment and progress.

Can we refer members to you?

Members are not referred to this program at this time. If you have a member who requires assistance, we can verify their eligibility with the METS program and connect you with  Sunshine Health’s case management program or member services.

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 can you do to help increase patient engagement?

The RESPECT model is widely used by clinicians to develop rapport with patients. The model encourages you to examine your own cultural biases and take them into account when treating patients from all walks of life. This will help with enhancing communication and ultimately improving treatment outcomes.

The RESPECT Model stands for:

R — Rapport

• Connect with your patient through open communication and dialogue to assist them in asking questions and bringing up tough or uncomfortable topics
• Try to see the situation from your patient’s point of view
• Do not make judgements
• Avoid making assumptions

E — Empathy

• Remember your patient is there for help
• Seek your patient’s rationale for their behavior or illness
• Verbally acknowledge your patient’s feelings

S — Support

• Ask about your patient’s barriers to care and compliance with their healthcare
• Help your patient overcome barriers
• Involve family members or significant others as appropriate
• Reassure your patient you are there to help

P — Partnership

• Let your patient know you will be working together to address problems

E — Explanations

• Check with your patient often during the conversation to assess understanding
• Use verbal clarification techniques

C — Cultural Competence

• Respect your patient and their cultural beliefs
• Understand that your patient’s view may be defined by their ethnic or cultural stereotypes
• Be aware of your own biases and preconceptions
• Know your limitations in addressing behavioral health concerns across different cultures
• Recognize if your approach is not working with your patient

T — Trust

• Self-disclosure may be an issue for some of your patients
• Take the necessary time and work to establish trust

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.