The panel analyzed the introductions, preambles, executive summaries, and philosophy statements of the different sets of level-of-care criteria, which demonstrated significant differences between these organizations in addressing the following concepts:
- Distinct attention to the special needs of children
- Meaningful involvement of families
- Emphasis on strengthsnot deficits
- Emphasis on quality versus cost containment
- Attention to cultural issues
Details are provided per company below.
Community Partnership of Southern Arizona
Distinct attention to the special needs of children The panel commends Community Partnership of Southern Arizona for developing review criteria forms that are distinctive for several children's treatment settings. However, the panel did not feel that the content of the forms addressed substantive issues differentiating the special needs of children.
Meaningful involvement of families The panel recognized the inclusion the following language as positive: "The patient and family must be appraised of discharge plans and participate in their implementation. Responsibility for the patient and family involvement rests with the hospital staff." In addition, we were pleased that the denial process included the family's role.
Emphasis on strengthsnot deficits Unfortunately, there was no attention to the strengths of the child or his/her family in this document.
Emphasis on quality versus cost containment This criteria set overemphasized costs more than any other document. The recurring terms "financial risk," "over-utilization," and "expended resources" illustrate this accentuation.
Attention to cultural issues The panel was disturbed that there was no attention to cultural issues in this document.
Other notes The materials supplied by this organization included a description of the utilization management process in general and the forms used to drive authorization decisions, as opposed to the criteria set approaches used by the other organizations. Most of the clinicians on the panel found the forms to be concise and to-the-point.
Contact
Attention to the special needs of children The document lacks age-specific setting descriptions and includes very little language pertaining to children.
Meaningful involvement of families There are statements that "the patient's family/guardians, where appropriate, are actively involved in treatment and are collaborating with the treatment team," which illustrates attention to this important issue.
Emphasis on strengthsnot deficits There is no meaningful language in the criteria set pertaining to identifying and maximizing the strengths of a child or his/her family.
Emphasis on quality versus cost containment The panel was pleased that it did not identify any language connoting an over-emphasis on cost containment.
Attention to cultural issues The panel was displeased that it did not identify any meaningful attention to cultural issues.
Other notes The introduction states strongly that the criteria "are not meant to replace the judgment of the attending clinician." It further notes that the criteria be used to review care against the "backdrop of clinical standards that have been developed by experts in the field." These positive statements show a recognition of the importance of clinical experience and best practices.
The EXCEL Group
Distinct attention to the special needs of children The only setting addressed in a child-specific manner was Bridges Academy, a licensed special education school that operates in place of residential placement. Otherwise, only very brief, cursory language on children is woven into the document.
Meaningful involvement of families The panel was displeased not to identify language relating to the role of families in treatment or discharge planning for children.
Emphasis on strengthsnot deficits The document repeatedly refers to regression and impairment, without any attention to the strengths of the family or child.
Emphasis on quality versus cost containment The panel did not identify any language indicating an over-emphasis on cost containment.
Attention to cultural issues The panel noted a lack of language demonstrating attention to cultural issues.
Other notes The panel objected to the use of the word "customer" instead of the terms "child," "youth," "person," or "consumer."
Horizon Behavioral Services
Distinct attention to the special needs of children There are only child-specific criteria for psychiatric inpatient care, and the other settings contain very little direction regarding different age groups. The panel was further troubled by the statements in the "general guidelines" requiring the presence of a DSM-IV diagnosis, as children are often not given diagnostic labels. As mentioned previously, decision-makers should encourage the usage of techniques that encourage the most accurate diagnosis, including the use of differential diagnoses when appropriate. However, the absence of a definitive diagnosis should not preclude access to a given treatment setting.
Meaningful involvement of families There is brief reference to "sufficient family supports" and "family therapy," but not meaningful involvement of families in the treatment of their children.
Emphasis on strengthsnot deficits While this document does attend to many functional elements, there is no emphasis on identifying and building on strengths.
Emphasis on quality versus cost containment The panel did not identify an over-emphasis on cost issues.
Attention to cultural issues There is no meaningful attention to cultural issues in this document.
Other notes The panel was very surprised that the Horizon Behavioral Services' (HBS) criteria overview statement stated that the "criteria are based on the protocols of the American Academy of Child and Adolescent Psychiatry (AACAP) and the American Psychiatric Association (APA)." In fact, the panel, which included two of the primary authors of the AACAP/APA document, found the content of HBS' document highly inconsistent with that of the product produced jointly by the two psychiatric organizations.
Cigna Behavioral Health (formerly MCC Behavioral Care)
Distinct attention to the special needs of children While there is attention to families, there was very little child-specific language in the document, and no attention to child-specific settings.
Meaningful involvement of families The inclusion of family and couples therapy was identified, and given kudos by the panel for the recognition of the linkage between family involvement and positive outcomes. In general, families, communities, and other support systems were given careful attention. The introduction language in particular illustrates a consumer and family focus, "the patient is considered a true partner in the therapy."
Emphasis on strengthsnot deficits The criteria reflect a positive model of recovery-based treatment drawing on consumers' strengths. There is clear recognition of individualized treatment needs.
Emphasis on quality versus cost containment The panel did not identify any language suggesting an over-emphasis on cost containment.
Attention to cultural issues The panel found there to be a lack of attention to cultural issues.
Other notes The panel found the introductory comments about the need to label people as "patients" awkward and inappropriate.
Northern Arizona Regional Behavioral Health Authority
Distinct attention to the special needs of children There was very minimal attention to age-specific considerations present in this document.
Meaningful involvement of families Nobody on the panel could even identify the use of the word "family" within this document.
Emphasis on strengthsnot deficits While the criteria do not address existing strengths of the child or his/her family, they do "promote progress towards the highest possible level of health and self-sufficiency."
Emphasis on quality versus cost containment The panel found that the criteria focus too much attention on cost. The term "least costly" was used extensively throughout the document.
Attention to cultural issues The panel identified some language in this criteria set that is culturally sensitive. That said, the panel suggests that additional language be incorporated to more adequately address this issue.
Other notes The document repeatedly refers to Service Planning Guidelines, which requires the reader to constantly cross-reference. We encourage the development of a single, integrated document.
Pinal Gila Behavioral Health Association
Distinct attention to the special needs of children This criteria set covered many treatment settings including wraparound services. However, there was virtually no consideration of age-specific issues.
Meaningful involvement of families There was no meaningful attention to family involvement in this document.
Emphasis on strengthsnot deficits There was no meaningful attention to child or family strengths in this criteria set.
Emphasis on quality versus cost containment The panel found this document to over-emphasize cost effectiveness.
Attention to cultural issues The panel found there to be a lack of attention to rural and cultural issues. This omission is especially troublesome given the population and geographical region served by this RBHA.
Other notes No introductory or philosophy statements were contained in the materials provided by this organization.
ValueOptions
Distinct attention to the special needs of children The criteria are not specific to children in the vast majority of settings. Within the criteria for these settings, however, there are a handful of references to ensuring that services are "age appropriate," but no detail is provided. Residential services are the only child-specific criteria. The panel did note that a very comprehensive list of settings was covered in the document, illustrating greater flexibility in selecting an appropriate site of care.
Meaningful involvement of families The panel commends the following language: "whenever possible, family and/or social supports should be involved in the treatment planning process." However, also contained is the requirement that families be involved in treatment in order for children and adolescents to continue to stay in outpatient, partial/structured day and community settings. This requirement should be removed as a lack of involvement of families should not be a barrier to continued mental health services.
Emphasis on strengthsnot deficits In the criteria for child and adolescent residential settings, the panel agreed that the use of the word "deficit," should be replaced with a less stigmatizing term that evokes a strength based model.
Emphasis on quality versus cost containment The panel did not identify any language suggesting an over-emphasis on cost containment.
Attention to cultural issues The panel did not identify any significant language reflecting attention to cultural issues.
Other notes The clinical philosophy statement in these criteria emphasized the importance of collegial relationships with providers, a positive inclusion that was not identified in other criteria sets.
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