Clinical Decision Making for Child and Adolescent Behavioral Health Care in Public Sector Managed Care Systems
by Sheila A. Pires, M.P.A. and Katherine E. Grimes, M.D. M.P.H.
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 Purpose
Driven by a combination of factors, including broader dissemination of clinical research, expanded family and consumer voice, consent decrees, media reports and escalating health care costs, state regulatory and fiscal managers have taken on a greater role in oversight of child and adolescent behavioral health care delivery. The result is a plethora of attempts to organize, rationalize and account for the processes that children and families encounter from the earliest point in their recognition that they have a mental health or substance abuse treatment need to the highest level of restrictive care they might experience.
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State and Local Descriptions
A. Sample Sites Using State-Developed Guidelines
Arizona
• Arizona Uniform Behavioral Health Assessment Tool
These are qualitative guidelines developed at the state level, through a multi-stakeholder input process that provide guidance to Arizona’s regional managed care entities and providers on intake, assessment, and service planning expectations. The guidelines are used to ensure safety and access to appropriate services.
Delaware
• Clinical Services Management Criteria
These are qualitative clinical care guidelines for every level of care in the system, including both mental health and substance abuse services. They were developed at the state level by the Division of Child Mental Health Services, based on a review of the literature and input from clinical team leaders.
Hawaii
• Hawaii Interagency Performance Standards and Practice Guidelines
These are qualitative performance standards and practice guidelines developed at the state level by the DOH and DOE through a multi-level stakeholder process and are intended for use by the DOH and DOE personnel and contracted providers when developing individualized plans of care for children and youth and to monitor service performance. The guidelines also specify use of certain quantitative rating scales including the CAFAS, CASII, CBCL, and YSR.
Pennsylvania
• Guidelines for Mental Health Necessity Criteria (“Appendix T”)
• Guidelines for Best Practice in Child and Adolescent Mental Health Services
The State Office of Mental Health and Substance Abuse Services developed these guidelines with the advent of behavioral health managed care in PA to serve as broad, “medical necessity” criteria that would take into account the psychosocial, environmental and medical considerations. Appendix T provides decision-making guidance for the admission, continuing stay and discharge of children and adolescents in various treatment settings governed by the State Medicaid and mental health agencies.
Texas
• Child and Adolescent Texas Recommended Assessment Guidelines (CA-TRAG)
The State mental health authority developed the CA-TRAG, through a multi-stakeholder input process as part of the State’s Resiliency and Disease Management Initiative. The CA-TRAG is used by local mental health authority clinicians and contracted providers to assess service needs and recommend levels of care.
B. Sample Sites Using Existing Standardized Protocols (Including Proprietary and Open Domain) (See “Standardized Instruments” list below for more info)
Hawaii
• Child and Adolescent Functional Assessment Scale (CAFAS)
• Child and Adolescent Service Intensity Instrument (CASII)
• Child Behavior Checklist (CBCL)
• Youth Self Report (YSR)
Michigan
• Child and Adolescent Functional Assessment Scale (CAFAS)
Community Mental Health Authority of Clinton, Eaton, and Ingham Counties (MI)
• Local Level: Implementing CAFAS Within an Individualized Approach to Care
New Jersey
• Child and Adolescent Needs and Strengths (CANS)
North Carolina
• Child Levels of Care Criteria with CAFAS/Initial and Continuing Authorization Criteria
C. Sample Sites Using Formalized Individualized Wraparound Approaches
DAWN Project, Marion County (IN)
Mental Health Services Program For Youth (MHSPY) (MA)
Wraparound Milwaukee, Milwaukee County (WI)
These 3 sites employ a highly individualized, wraparound approach to service planning, in which standardized instruments play an adjunctive role, primarily to track progress. Initial treatment decisions, ongoing care, and treatment monitoring are done within the context of a structured Child and Family Team. Service planning is guided by “life domains” documents.
D. Sample Sites Using Existing Standardized Protocols
Child and Adolescent Functional Assessment Scale (CAFAS)
(Used by Hawaii, Michigan, and North Carolina in this sample)
The CAFAS, a proprietary instrument developed by Dr. Kay Hodges, is a rating scale based on an adult’s report of a child’s degree of functional impairment in day-to-day activities due to emotional, behavioral, psychological, psychiatric, or substance abuse problems.
Child and Adolescent Service Intensity Instrument (CASII) (formerly known as the Child and Adolescent Level of Care Utilization System or CALOCUS)
(Used by Hawaii in this sample)
The CASII is a semi-open domain tool developed by the American Academy of Child and Adolescent Psychiatry (AACAP) Work Group on Community Systems of Care to help determine level of care placement for a child or youth. It links a clinical assessment with standardized levels of care.
Child Behavior Checklist (CBCL) and Youth Self report (YSR)
(Used by Hawaii in this sample)
The CBCL, a proprietary instrument developed by Dr. Thomas Achenbach, is designed to assess the behavioral problems and social competencies of children as reported by parents or caregivers. It allows clinicians, parents, and teachers to crosscheck behaviors of children.
The YSR, also developed by Achenbach, is derived from the CBCL and is designed to be used by adolescents, ages 12-18, with the adolescent himself/herself completing the form.
Child and Adolescent Needs and Strengths (CANS)
(Used by New Jersey in this sample)
The CANS is an open domain, strengths-based, information integration tool developed by Dr. John Lyons. It is designed to support individualized care planning, as well as the planning and evaluation of service systems. |
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Amid state and local level efforts to make sense of the complex clinical arena of child and adolescent behavioral health care, there is an emerging knowledge base among clinicians and clinical services researchers that has led to a growing number of instruments that are available to help with some, if not all, of the decision points. However, these instruments or measures range from well established to newly created and have differing degrees of validation or standardization of the meaning of their results. Furthermore, despite the repeated calls from administrators for an “assessment tool” to answer their questions, no one instrument meets all possible administrative or clinical decision making needs.
It is also the case that different state and local administrators employ clinical decision making instruments for different purposes. In addition, the nomenclature that differentiates clinical decision making terms, such as measure, indicator, criterion, guideline, protocol, etc., is poorly specified, leading to non-standardized usage. Even when the same term is agreed upon, it may mean different things to people with different professional training, backgrounds, or positions within the service system.
Given the opportunity for improvement in both the overall service systems available to families and in the selection of appropriate services and supports for individual children and adolescents, it is timely to take a look at what some of the state and local entities with the most specified processes are finding in their search for useful supports to clinical decision-making at all levels of the system.
This study examines various clinical decision making approaches that a sampling of states or management entities within states are utilizing for child and adolescent behavioral health service delivery within a managed care environment. The study profiles a representative sample of 12 states and/or local managed care entities (MCE) that are using formal clinical decision making protocols, guidelines, and/or processes to inform decisions about the services and supports provided to children and adolescents with behavioral health disorders and their families. The study explores the types of clinical decision making guidelines, protocols or processes that are being used, state and MCE reasons for their use of formal tools and processes, their experience with the various tools being used, and the strengths and challenges of particular approaches.
The study provides an opportunity for a sample of states and local management entities to reflect on their experiences using particular clinical decision making approaches and protocols, to identify the strengths and challenges of their approaches, and the refinements they have made based on their experiences. Their reflections provide useful “lessons learned” for other states and MCEs who are considering use of clinical care guidelines for child and adolescent behavioral health care delivery within managed care environments. The ultimate purpose of the study is to provide a technical assistance resource for states and MCEs as they implement and refine clinical decision-making approaches for this population of children and families.
Sample of States and Local Management Entities
The states included are: Arizona, Delaware, Hawaii, Michigan, New Jersey, North Carolina, Pennsylvania, and Texas. The local management entities included are: the Community Mental Health Authority of Clinton, Eaton, and Ingham Counties in Michigan; the DAWN Project in Marion County, Indiana; the Mental Health Services Program for Youth operating in several local areas in Massachusetts; and, Wraparound Milwaukee in Milwaukee County, Wisconsin.
This sample of states and local management entities lends itself to a high-level grouping by the following categories:
• Group One: States or MCEs using clinical decision-making protocols that the state or MCE itself has developed
• Group Two: States or MCEs using existing standardized tools (e.g., proprietary and open domain instruments), including states/MCEs that have adapted a standardized protocol with the permission or involvement of the tool’s developer
• Group Three: States or MCEs using primarily an individualized, wraparound approach to service decision-making.
Multiple Uses for Clinical Decision Making Guidelines
In sum, the states and localities in this sample use clinical guidelines and protocols in multiple ways, including for:
• Eligibility determination for access to the system (i.e., pre-admission criteria)
• Eligibility determination for certain types of services or levels of care
• Utilization management regarding continuation with certain types of services or levels of care
• General guidance to managed care organizations and providers as to state expectations (not requirements) regarding service provision
• Decision support to guide individual service planning and care management
• Outcomes monitoring and quality improvement for the system.
Similar Goals
While states and management entities are using clinical guidelines in different ways to meet different needs, virtually all, with the exception of the 3 sites using formal wraparound approaches, described similar goals or objectives that they thought are being achieved as a result of using standardized criteria. These goals include:
• Ensuring appropriate access to services
• Promoting consistency and equity in service provision
• Providing objective rationales for service authorization decisions
• Moving the system to evidence-based and effective practices
• Providing data to better inform practice
• Providing visible progress indicators to families and youth consumers
• Aligning practice with system goals
• Monitoring system performance
• Improving the quality of care
• Increasing accountability throughout the system.
Common Challenges and Issues/Strategies to Address
The states and local management entities in this sample described many similar challenges and issues in implementing standardized clinical protocols or guidelines statewide or throughout a provider network, and several sites identified strategies to address each of these challenges including:
• Resistance and/or lack of capacity on the part of providers/clinicians/local management entities
• Costs and level of effort associated with training and fidelity
• Costs of collecting, analyzing, and using data generated by clinical tools and guidelines for quality improvement
• Consistency between use of standardized clinical guidelines/instruments and individualized, family-driven, culturally and linguistically competent service planning and ongoing care
• Issues associated with lack of service availability
Lessons Learned/Recommendations
The sites in this sample had a number of recommendations for others interested in implementing wide-scale use of standardized clinical protocols or guidelines based on “lessons learned,” which include:
• Select protocols that are meaningful to stakeholders and involve stakeholders in the selection or development of protocols or guidelines and in implementation strategies.
• Know what values, principles, and goals you are trying to promote in your system, and be clear that the protocols you have chosen or developed will support these values and goals.
• Provide adequate staffing and resources at a state or management entity level to implement a protocol-based system.
• Some of the featured states and localities have received significant grant support for collection and analysis of information from clinical measures. However, for settings without such support, it is important to include resources for data collection and analysis, or else to build such costs into rates assigned to management entities responsible for reporting the data.
• Integrate use of the protocols into everyday documentation requirements and everyday practice, rather than implementing them as an “add-on;” make them a part of the culture of the system.
• Keep open lines of communication with those using and affected by use of the protocols, i.e., families and youth, clinicians, provider agencies, and other child-serving systems, such as child welfare, education, and juvenile justice.
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