Parity and Healthcare Reform: Community Behavioral Health at a Crossroads

Responding to Healthcare Reform and Parity:
A Qualitative Approach to Enhanced
Treatment Capacity

David Lloyd, President Sandy Myers,
MTM Services Vice President of Behavioral Health
Website: www.MTMServices.org Coleman Professional Services, Kent, OH
E-mail: MTMServe@aol.com E-mail: Sandy.Myers@coleman-bh.com

www.TheNationalCouncil.org

Poll Questions….
1. From the clinicians’ perspective, are the
caseloads in your organization “full” at this
time?
□ Yes or □ No

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www.TheNationalCouncil.org Presented By: David Lloyd, MTM Services and
Sandy Myers, Coleman Professional Services

Poll Questions….
2. Has your CBHO developed and
implemented clinical pathways, levels of
care and/or benefit designs?
□ Yes or □ No

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Poll Question
3. Does your CBHO have an ongoing internal
utilization review/re-authorization process to
organization wide clinically appropriate
service levels and array being delivered to
clients with the same level of need?
□ Yes or □ No

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Poll Results based on over 600 Registrants for the NC LIVE Webinar on
Healthcare Reform Presented by David Lloyd, MTM Services on
December 15, 2009 and January 12, 2010
1. From the clinicians’ perspective, are the caseloads in your organization “full” at this time?
Yes = 74% No = 26%
2. Do you know the cost and days of wait for your organization’s first call to treatment plan
completion process?
Yes = 41% No = 59%
3. Indicate the no show/cancellation percentage last quarter in your organization for the
intake/assessment appointments:
A. 0 to 19% = 20%
B. 20 to 39% = 42%
C. 40 to 59% = 15%
D. Not aware of percentage = 23%
4. Indicate the no show/cancellation percentage last quarter in your organization for Individual
Therapy appointments:
A. 0 to 19% = 24%
B. 20% to 39% = 50%
C. Not aware of percentage = 26%

www.TheNationalCouncil.org 5
Presented By: David Lloyd, MTM Services and

Today’s Webinar: Internal Benefit Designs/ Levels of
Care to Help Provide Treatment Capacity to Respond to
Healthcare Reform – Recommended Action Objectives

1. Define a definition of “treatment” and therefore what is not
treatment
2. Identify current caseload members that are not actively in
treatment and develop transition plans
3. Develop internal benefit package designs/Levels of Care
criteria that serve as clinical guidelines; support for
appropriate utilization levels for all consumers; and to
provide guidance for internal utilization
management/quality improvement processes.

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Solution Areas That Need to Be
Addressed:
1. Define a definition of “treatment” and therefore what is not
treatment:
Sample Definition:
“Behavioral health therapeutic interventions provided
by licensed or trained/certified staff either face to
face or by payer recognized telephonic/
Telepsychiatry processes that address assessed
needs in the areas of symptoms, behaviors, functional
deficits, and other deficits/ barriers directly related to
or resulting from the diagnosed behavioral health
disorder.”
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Addressed:
2. Identify current caseload members that are not actively in
treatment and develop transition plans

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Addressed:
3. Develop internal benefit package designs/Levels of
Care criteria that serve as clinical guidelines;
support for appropriate utilization levels for all
consumers; and to provide guidance for internal
utilization management/quality improvement
processes.

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Level of Care-Benefit Package Design Functions
1. Purpose is to establish Clinic-wide Course of Treatment Guidelines to
Facilitate appropriate array and utilization levels for services
2. Enhances the ability of the center to measure outcomes achieved
based on reduce service utilization variance. NOTE: Under
Healthcare Reform, we will have to manage our own course of treatment
and associated outcomes or a ACO or another entity will.
3. Enhanced Engagement in Treatment: Provide an awareness to
consumers at entry to services the types of services and duration of
services the practice has found most helpful to meet their treatment
needs so that the consumer will know and the staff will know what
services are needed to complete that level of care
4. Provides an enhanced recovery/ resiliency based service planning
and service delivery approach for consumers and families
5. Facilitates being able to focus centralized scheduling for each
consumer based on the service frequency ordered in the service
plan which is based on the benefit design/level of care guidelines

www.TheNationalCouncil.org Presented By: 10
David Lloyd, President

Open Scheduling Same Day Access Model –
Consumer Engagement Standards
1. Open Scheduling Same Day Access - Master’s Level
assessment provided the same day of call or walk in for
help (If the consumer calls after 3:00 p.m. they will be
asked to come in the next morning unless in crisis or
urgent need)
2. Initial diagnosis and assessed service needs determined
3. Level of Care and Benefit Design Identified with
consumer that includes an estimate of time needed
4. Initial treatment plan Developed based on Benefit Design
Package
• 2nd clinical appointment for TREATMENT within 8 days of Initial Intake
• 1st medical appointment within 10 days of Initial Intake

www.TheNationalCouncil.org Presented By: David Lloyd, MTM Services and 11

Sample: Adult Mental Health Benefit Design Level Two

www.TheNationalCouncil.org Presented By: David Lloyd, MTM 12
Services and Sandy Myers, Coleman
Professional Services

Sample: Adult Mental Health Benefit Design Level Two

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Sample: Child/Adolescent Mental Health Benefit Design
Level Three – Carlsbad Mental Health Center

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Sample: Child/Adolescent Mental Health Benefit Design
Level Two – Carlsbad Mental Health Center

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Level of Care Utilization Summary


A Level of Care Guideline was designed at Coleman
Professional Services in 2001 using the following
resources:
• A Training Curriculum for Met Net Protocols for Level of Care Metro
Behavioral Health Care Network. March 1999.
• Level of Care Criteria and Guidelines for Use. Published by the National
Community Mental Healthcare Council as a Joint Venture with the
Behavioral Health Network of Vermont.
The impetus to design this tool included:
• Utilization management to improve access to psychiatry and
counseling.
• Risk management to assure services meet the basic elements of
medical necessity.
• Manage care within the constraints of the contracts.

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The Level of Care guidelines provide the
framework for determining eligibility, service mix,
service intensity, and length of stay. The
components Coleman Behavioral Health’s Level
of Care Criteria include:
• Definition of each Level
• Admission Criteria
• Continued Stay Criteria
• Discharge Criteria
• Estimated Length of Stay
• Menu of Services
• Utilization Expectations
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Coleman Professional Services Level
of Care Guidelines
Level I:
> Goal: Learn coping skills that support resolution of the crisis and/or
symptom distress.

> Definition: This level of care provides brief and time-limited services to
clients who are living either independently or with minimal support in the
community and who have achieved significant recovery from past episodes
of illness. Treatment and service needs do not require supervision or
frequent contact. Staff can provide services in the community, office,
school, or clinic. Interventions can include: individual, group, or family
psychotherapy, psychiatry, and limited case management. On-call and
crisis services should be made available.

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Admission Criteria:
1. Diagnostic criteria: Axis I or II psychiatric
disorder as defined in the DSM IV.
2. Risk of Harm: Minimal risk of harm to Low
risk of harm
3. Functional Status: DLA -20 based GAF of
51 and higher
4. Engagement-Positive engagement

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Level I (continued)
Continued Stay Criteria:
1. Diagnostic criteria: Axis I or II psychiatric disorder as
defined in the DSM IV.
2. Risk of Harm: Minimal risk of harm to Low risk of
harm.
3. Functional Status: Minimal to mild Impairment in
school, work or social functioning. Having consistent
difficulties in social role functioning and meeting
obligations such as parental responsibilities or
performing at expected level in work or school.
4. Engagement: Positive Engagement
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Discharge Criteria:
1. Demonstrates significant improvement in
functioning following a period of deterioration
2. Shows strong desire to change.
3. Is enthusiastic about treatment, is trusting, and
shows strong ability to utilize available resources.
4. Understands recovery process and personal role
in a successful recovery plan.
5. Condition has worsened, and a higher level of
care is needed.

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Level 1 Level II Level III Level IV

DLA Based 51 or higher 41 to 50 31 to 40 21 to 30
GAF
Estimated 6-9 months 9 months to 6 months to 1–8 days
Length of 3 years 1 year
Stay

Service Utilization
CPST 1-5 hours per 2-9 hours per 6-16 hours per .30-6 hours per
month month (not to month (not to week
(not to exceed 5 exceed 108 hours exceed 200 hours
hours per per year) per year)
episode)
Counseling 1-2 hours per 1-2 hours per 1-4 hours per 0-2 hours per week
month (not to month (not to month (not to
exceed 4 hours exceed 10 hours exceed 18 hours
per episode) per episode per episode)

Psychiatry 0-1.25 hours 0-1.25 hours per 0-1.25 hours per .30-1 hour per week
(not to exceed 4 month (not to month (not to
hours per exceed 5 hours exceed 6 hours 23
episode) Presented By: David Lloyd, MTM Services and
per year) per year)

> In the most recent modification, the DLA-20
based GAF scores were added for each level
of care.
• DLA -20 helps to objectively assess client’s
current functioning thus, better addresses
medical necessity.
• The DLA -20 is a functional assessment that is
used to get an objective, reliable, and valid GAF
estimate.
• The DLA-20 co-author is Willa S. Presmanes,
M.Ed., M.A.
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DLA-20
Assessment
Sample

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The Process for Monitoring Level
of Care

• Monitoring Level of Care in a paper record world
• Monitoring Level of Care within an EMR
• Monitoring Level of Care utilizing SPQM

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Maintaining Level of Care Utilization
SPQM Dashboard Measurement

• Monthly reports to monitor by provider
• Monthly reports to monitor by product
• Monthly reports to monitor by consumer

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Staff Specific High Utilizer Clients
by Payor and Services
Total Year, Total Month (Total Ctime)

2009 2010 Total
Case Service Total 1 2 3 4 5 Total

14.3 1.0 1.0 22.0

8.0 2.3 2.3 17.5

11.8 17.3

11.8 2.0 1.0 1.0 0.5 1.0 5.5 17.3

11.0 1.0 1.0 17.0

7.8 3.0 1.5 1.0 1.0 6.5 14.3

8.0 1.0 2.0 1.0 0.5 4.5 12.5

9.3 1.8 1.0 2.8 12.0

www.TheNationalCouncil.org 12.0 12.0 28

Updating the Level of Care for People Served
and the Organization:

Frequency of Updates for People Served
> The level of care is completed upon admission, updated at
least annually and each time the individual moves to a
higher or lower level of care.

Organizational Updates of the Level of Care Guideline
> The tool has been modified 4 times since inception. The
modification to the service utilization standards have been
based on benchmarking from the utilization data.

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Impact of Level of Care on
Consumers
> Include Level of Care in consumer orientation processes
and in treatment planning.

> Factors required to initiate recovery are often quite
different than the factors that later serve to maintain and
enrich recovery (Humphreys, Moos & Finney, 1995).
• Interventions that are effective at an early stage of recovery may
be ineffective at a later stage of recovery.
• Identify the resources that are available to consumers to maintain
and enrich recovery.

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Thank you for your attendance..

> Questions
> Follow Up….

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Mr. Lloyd’s book published by
The National Council:

How to Deliver
Accountable Care

David Lloyd, Founder and President
MTM Services

Website: www.MTMServices.org
E-Mail: MTMServe@aol.com

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Parity and Healthcare Reform: Community Behavioral Health at a Crossroads

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