ABHW Member Company Spotlight – OptumHealth
Over the course of the year, ABHW will be spotlighting member companies for the Perspectives section of the website. Interviews conducted with ABHW’s members will highlight programs and initiatives they are offering; preparations underway for the implementation of the Patient Protection and Affordable Care Act (ACA); or other current topics of interest.
For this piece, ABHW obtained information about an initiative Optum has in Tennessee addressing high utilization of residential treatment by children and adolescents in the Medicaid program. OptumHealth, a part of Optum and an ABHW member, has 30-plus years of experience and is a provider of comprehensive mental health and substance abuse services. Their behavioral programs can be integrated with medical and health-specialty services to help ensure that behavioral issues are addressed anywhere they occur in the health care continuum.
Optum Tennessee: Helping Youths Remain in the Community while Supporting Their Recovery and Well-Being Background
In Tennessee, Optum™ is a subcontractor to our sister company UnitedHealthcare® Community & State (formerly AmeriChoice®), providing integrated management of medical and behavioral health services for over 550,000 members since April 2007. In 2009, Optum partnered with UnitedHealthcare Community & State on a health care quality initiative regarding high utilization of residential treatment by children and adolescents in the Tennessee Medicaid program. The goal of this initiative was to ensure youth who could receive the appropriate level of services in a community setting were not removed from their homes and needlessly admitted to residential treatment facilities.
Data provided to Optum from Mobile Crisis Teams suggest that when those providers evaluate members in the emergency room to determine if a behavioral health hospitalization is needed, there is a greater likelihood of admission than when the member is evaluated at home or in other community settings. The health plan identified this same phenomenon with residential treatment for children and adolescents. When a youth was presented to a residential treatment facility and was assessed by the clinical staff at that facility, there was a greater likelihood of recommendation for admission to that facility than if a referral was made without assessment at the facility.
In addition, the psychiatrists at these residential facilities were not involved in the initial assessment of these youth and had not evaluated their appropriateness for admission. There were many instances when a non-clinical person such as a probation officer, judge or family member recommended residential treatment. Individuals without clinical backgrounds may not be as aware of alternatives to residential treatment or may not know how to access community-based services that will enable a youth to remain at home.
Interventions in the Residential Treatment Quality Initiative include the following.
- Contracting with community providers to conduct comprehensive assessments of youth referred for residential treatment and their families. Assessments are completed at the youth’s home or other community settings within two business days of the request.
- An Optum utilization manager reviews the initial clinical information submitted by the residential treatment provider requesting admission, in addition to the written assessment completed on the child and family, and makes a determination about whether or not the member meets medical necessity criteria for residential treatment and if there are adequate community resources to maintain the youth at home.
- If admission to a residential facility does not appear to be medically necessary, the utilization manager consults with a Medical Director, and offers the requesting provider a peer-to-peer review.
- If the request for residential treatment is not authorized, intensive in-home services are set up for the youth and family to begin within 24 hours.
From May of 2009 through April of 2013, 2,412 in-home or community evaluations of youth referred for residential treatment were completed. 991 (41%) of these evaluations resulted in diversion from residential treatment, allowing the youth to remain in their homes with additional community-based services in place. As shown in Figure 1, there has been a year-over-year trend of increased diversion rates over this period of time as well. Only a small number (approximately 4% to 6%) of children and adolescents who were initially diverted were later admitted into a residential setting. This was due to a number of reasons, including increasing symptomatology that required a more intensive and structured level of treatment, or because of involvement with the State Child Welfare system, which often places children and adolescents in residential treatment as an alternative to having them become wards of the state.
Our successful approach to youth residential treatment diversion has been recognized by the Medicaid Health Plans of America Center for Best Practices in their 2012 Best Practices Compendium for Serious Mental Illness.
HEALTHCARE INTEGRATION IN THE ERA OF THE AFFORDABLE CARE ACT
Changes are occurring across the healthcare landscape, with a significant focus on integration of behavioral and physical health. This paper is intended to help inform these efforts by focusing on the long history Association for Behavioral Health and Wellness...[More]
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