Level of Care Decisions
A 40 year-old female diagnosed with Schizophrenia, Paranoid type, currently receiving Medication Only services through her community mental health provider. This female has required 4 inpatient hospitalizations within the last 12 months, has as long history of chronic mental illness, she has not been compliant on her oral antidepressant and neuroleptic medications, she gave birth to a child recently and she continues to exhibit numerous positive characteristics of her schizophrenia. Based on this information alone it does not appear that this consumer’s treatment plan matches her level of care needs. A consumer such as this could benefit from additional mental health services to assist her in achieving and maintaining some greater stability in her functioning and symptom profile. Medication Only service is not a sufficient level of care intervention for this type of consumer at this time.
It is important, perhaps paramount, that the provider continually assesses her psychiatric status and mobilizes other services on her behalf. The mental health system’s responsiveness to their consumer’s changing clinical profile requires an objective and effective process of decision-making that includes awareness of changes, comprehension of guidelines and flexibility in assigning alternative or additional services; as the consumer’s condition improves then the intensity of services lessens; their condition worsens then the service interventions increase. In theory this is how it works. In practice, it only works when all the agency providers understand the level of care criteria and the services selection guidelines while at the same time are willing to mobilize those services as necessary.
As mental health consultants, providing telephone Triage and mental health benefits preauthorization, we are embedded in the process that involves making level of care assessments and assignments based on clinical criteria and services selection guidelines established by mental health boards. This decision-making requires a clear understanding of the various services offered and the criteria particular to each. Service Excellence is the goal; the Right service at the Right time for the Right cost. We strive to link consumers to the correct service (s) that are most clinically appropriate to meet the consumer’s needs as well as most cost-effective to the agency and community as a whole. Now, we understand that mental health assessment, treatment and outcome are not an exact science, nor are always assigning the correct services. Triage, for instance, is a consumer-initiated and self-report process that relies on consumer provided information in making the disposition. This information often changes, the consumer’s condition changes, reported information is intended to mean something different, is incomplete or, unfortunate to say, is at times fabricated to affect a certain outcome. So we understand that the accuracy in making level of care assignments is a variable and fluid phenomenon. At times it is a complicated process although skilled telemental health clinicians can provide accurate level of care decisions with a 15 to 20 minute phone call.
It is important, perhaps paramount, that the provider continually assesses her psychiatric status and mobilizes other services on her behalf. The mental health system’s responsiveness to their consumer’s changing clinical profile requires an objective and effective process of decision-making that includes awareness of changes, comprehension of guidelines and flexibility in assigning alternative or additional services; as the consumer’s condition improves then the intensity of services lessens; their condition worsens then the service interventions increase. In theory this is how it works. In practice, it only works when all the agency providers understand the level of care criteria and the services selection guidelines while at the same time are willing to mobilize those services as necessary.
As mental health consultants, providing telephone Triage and mental health benefits preauthorization, we are embedded in the process that involves making level of care assessments and assignments based on clinical criteria and services selection guidelines established by mental health boards. This decision-making requires a clear understanding of the various services offered and the criteria particular to each. Service Excellence is the goal; the Right service at the Right time for the Right cost. We strive to link consumers to the correct service (s) that are most clinically appropriate to meet the consumer’s needs as well as most cost-effective to the agency and community as a whole. Now, we understand that mental health assessment, treatment and outcome are not an exact science, nor are always assigning the correct services. Triage, for instance, is a consumer-initiated and self-report process that relies on consumer provided information in making the disposition. This information often changes, the consumer’s condition changes, reported information is intended to mean something different, is incomplete or, unfortunate to say, is at times fabricated to affect a certain outcome. So we understand that the accuracy in making level of care assignments is a variable and fluid phenomenon. At times it is a complicated process although skilled telemental health clinicians can provide accurate level of care decisions with a 15 to 20 minute phone call.
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