Decision Support Can Enhance Patient Care

All addiction and mental health professionals are familiar with this scenario. The daily challenge of identifying the best treatment plans for patients is complicated by a large volume of clients, high levels of recidivism, multiple morbidities, and discussion with insurance plans on coverage availability. Ideally, the addiction professional can focus on the treatment that is most clinically appropriate for each patient. But in the real world, he/she spends a good deal of time justifying or negotiating for a level of care that a payer concludes is not approvable. In the end, decisions often are made quickly out of necessity and are based on the professional's “clinical gut.”

There is a way to make clinically appropriate decisions faster, more consistently, and less painfully. Behavioral health organizations are discovering evidence-based decision support criteria, which already are being adopted by organizations such as hospitals, managed care organizations, and third-party payers. The most effective decision support tools include evidence-based guidelines that enable professionals to evaluate each patient based on clinical characteristics such as behavior, symptoms, functioning, and social risks. They also contain decision paths that facilitate timely and consistent decision-making by care managers, utilization reviewers, and providers by offering a shared source of information. Such tools help behavioral health professionals by:

• Providing standardized guidelines for making the best initial and subsequent level-of-care decisions for each patient;

• Providing information to help in developing a more targeted treatment plan (separating clinical versus psychosocial issues);

• Providing information necessary to negotiate for the most appropriate care when a level of care is excluded or exhausted; and

• Creating a common language among care managers in organizations across the spectrum of healthcare, thus saving critical time in getting the right care to patients in a timely manner.

Behavioral health criteria are offered by various vendors in both traditional printed publications and as software applications that integrate with workflow to further simplify and automate the process.

Sifting through research

According to the Delfini Group, LLC, more than 10,000 articles each month are published in medical journals—a staggering number that is simply impossible for an individual care provider or even an organizational team to read, evaluate, and synthesize in a meaningful way. Standard clinical guidelines offer a way to integrate the latest and best evidence-based research and clinical trials in a timely manner.

Development of the criteria typically draws on the expertise and experience of a range of physicians, nurses, and other healthcare professionals, combined with consensus-building and validation among clinical experts. Teams of criteria developers conduct extensive reviews of the latest evidence-based medical literature and validate the information with experts in the appropriate specialties and subspecialties. Systematic development techniques commonly used include:

• Searches for literature in peer-reviewed, industry, and specialty medical journal publications;

• Literature review and appropriate grading and application of non evidence-based medical information;

• Content review and collaboration;

• Practice standards review;

• Specialty guideline review; and

• Expert opinion content review via external clinical consultants who provide a geographic view of practice patterns.

The collected and validated information is then translated into concise summaries of the literature on a given condition. These narratives may, for example, present the current research on a given topic and address controversial treatment options and emerging technologies.

Determining most appropriate care

Decision support tools directly support the work addiction professionals perform. First, use of criteria can facilitate prompt initiation of care when patients are referred from a primary care provider. Confirmation that a referral is appropriate and eligible for coverage can be addressed in a timely manner. This is particularly effective when the primary care provider or referring organization also uses decision support tools.

Second, level-of-care criteria help clinicians and care managers consider a patient's severity of illness, comorbidities, and complications in real time. Based on the individual's needs, guidelines help determine the most appropriate level of care. Level-of-care criteria drive decisions on initial placements, with a range encompassing inpatient detoxification or psychiatric care; inpatient or outpatient rehabilitation; partial hospitalization, residential, and intensive community-based treatment; and intensive outpatient and outpatient treatment. Further, checkpoints enable the care manager to identify progress, plateau, or achievement of goals, and to assess discharge or transfer readiness. Criteria do not replace clinical judgment, but guide clinicians toward the most efficient and safest level in a timely and consistent manner.


Lollie Dubiel, RN
Finally, criteria are developed in a way that recognizes the complexity of behavioral health issues and does not provide a “one size fits all” approach to patient level-of-care determination. For example, criteria allow for consideration of whether the patient is an adult, adolescent, or child, and whether the patient has multiple diagnoses. In addition, criteria often can be modified to accommodate local and organizational guidelines. Using such criteria results in decisions based on well-researched scientific knowledge and clinical best practices.

Behavioral health criteria complement—not replace—addiction professionals’ clinical decision-making. The professional can be sure he/she is drawing on solid peer-reviewed research that is current and has been reviewed and integrated into the care guidelines by clinical professionals. An initial level-of-care assessment based on the individual patient's needs can be achieved quickly and efficiently, and in a way that is consistent across patients, care managers, and clinicians. This frees the professional to devote more time and focus to developing and implementing a treatment plan that meets the patient's unique needs.

Using evidence-based criteria cuts down on the time it takes for the results of research to be reflected in treatment, dramatically reducing the wait for the benefits of new knowledge to reach patients. It enables clinicians to make level-of-care decisions more efficiently. It allows the addiction professional to spend more time focused on tailoring treatment plans to individual patients. And it reduces the lead time for level-of-care assessment, treatment plan development, and eligibility approvals, so that the plan can be put into effect more quickly.

Making the case

Once an addiction or mental health professional understands an individual's clinical needs, has leveraged knowledge of the latest clinical research, has applied his/her own expertise and judgment, and has identified an available and appropriate treatment setting, some might think the work is complete. But often it's not. The provider may find that the appropriate care is deemed excluded or that coverage is exhausted, and it becomes necessary to justify the recommendation.

By using criteria, behavioral health professionals can present the basis for their decisions: guidelines backed by the research, evaluation, and experience of clinical experts. And because the data are documented and readily available, the professional saves valuable time in the reassessment process and facilitates appropriate care to the patient as soon as possible.

In addition to behavioral health organizations, thousands of organizations across many healthcare segments are using decision support criteria; these include managed care organizations, hospitals, care management companies, workers’ compensation insurers, and government entities. The factors driving this trend include the need to ensure that regulations are adhered to, and the desire to guarantee appropriate and consistent care.

When patients’ treating providers and insurance payers are both using clinical care criteria, they are making their determinations of eligibility based on the same data being used by the behavioral health specialist. This not only ensures that care decisions are being based on the full spectrum of the latest and best research, but it means that providers and payers are “speaking the same language.” Because payers are familiar with the basis for provider recommendations, negotiations for care can be conducted more quickly and from a common basis of understanding.

Addiction professionals can leverage the knowledge around clinical criteria and the resulting guidelines to more efficiently and consistently identify an appropriate level of care based on a patient's individual clinical needs, and then can focus on tailoring treatment plans. As more payer organizations also use clinical care guidelines, recommendations are more likely to be in line with payer expectations. Evidence-based decision support criteria form one more new and powerful tool for the dedicated addiction professional to draw on in the quest to provide the most appropriate care for each patient in the most efficient way possible.

Lollie Dubiel, RN, is Senior Product Manager at McKesson Health Solutions in Newton, Massachusetts. At McKesson, she leads the development of InterQual decision support criteria tools for behavioral health. She serves as the McKesson representative to the Software and Technology Vendors’ Association (SATVA). Her e-mail address is lollie.dubiel@mckesson.com.