Minutes
Provider Advisory Group Meeting
June 14, 2005
Attendance: Susan Walkama, Jill Benson, Reginald Simmons, Vicki Veltri, Shelton Toubman, Linda Russo, Dana Marie Salvatore, Paul Piccione, Mark Schaefer, Alice Farrell
Meeting Convened at 3:10
Review of Minutes May 31, 2005 Meeting
Several changes were suggested:
Guidelines for Making Level of Care Determinations
1st paragraph change prose to propose
Acute Care Guidelines
Change suicide/homicide to suicidal/homicidal
Minutes were accepted with changes.
Final Review of Recommendations for "Guidelines for Making Level of Care Decisions"
It was recommended that the last sentence in the first paragraph be modified to read: "A high degree of collaborative decision making in all determinations will take place between the providers, care managers and families."
Significant discussion took place regarding the language proposed by Sheldon Toubman regarding ASO care manager deference to the provider's requested treatment recommendations. (Second paragraph first section)
Comments included:
_ This language needs to be included to allow for provider leadership in care when disputes arise.
_ Care decisions are sometimes driven by financial motivations, so protection needs to be in the care guideline criteria.
_ ASO is not at risk so the motivation to make decisions that are financially driven is reduced or eliminated.
_ ASO has the responsibility, as does the partnership, to insure that the best and most appropriate care practices are provided to families. There may be instances where the provider should be utilizing a different approach especially when the child is not improving.
_ Statement may not be clear. How will it be interpreted in practice?
_ Statement is intended to address only those situations where a dispute may arise or there is a gray area.
_ There are appeal processes in place to address these situations so is this language necessary?
A question was asked regarding how the recommendations of the work group will handled. Susan reported that a packet of all recommendations from the workgroup would be sent at the conclusion of the groups work to the Oversight Committee. Then the DSS/DCF Care Guideline workgroup that is comprised of Mark Schaefer and Paul Piccone from DSS, Karen Andersson and Bert Plante from DCF, Susan Walkama and Barbara Sheldon of the Oversight Committee and a DMHAS representative will make the decision on which of the recommendations to adopt. This was explained as Mark Schaefer has expressed concern about the language Sheldon has proposed and its lack of clarify and potential impact on care decisions that may not be in the best interest of clients.
These minutes and the most recent recommended changes will be sent to the entire workgroup once more for input prior to making a final decision on recommendations for this section of the guidelines on June 23.
Reginald Simmons suggested the guidelines should include some language on protective factors.
In the application of the criteria section:
First paragraph last sentence change to:
"Environmentally based factors may provide the impetus.... Strengths and protective factors should be considered in all care decision making."
Second paragraph " When the clinical presentation supports more than one level of care, the intensity of the service need, prior treatment and presence of protective factors are used to determine the most appropriate level of care."
Intermediate Care Guidelines
Sheldon pointed out that it was decided to recommend that we change "Medical Necessity Criteria" in each guideline to "Level of Care Guideline." Change will be made in groups' recommendations.
Discussion continued on whether IOP could be defined by an individual clients needs or if it needed to be a specific program with dedicated staff. It may be difficult to manage this as a level of care designed around a client, so issues that might limit an OP provider to bill a more intensive service by duration or frequency on an OP basis was discussed. At this point, there is a belief in the group that only one service type of the same type is allowed to be billed in a day. For example, only one group unit regardless of the duration of time of that group could be billed in a day. This was seen as a disincentive to running groups based on evidence based practices that might need to be 1 ½ to 2 hours in duration to meet the requirements of the model. Running multi-family groups without the client present might also be challenging with the current billing procedure codes that have been presented thus far. Also, running concurrent, but separate groups for the child and family to meet the requirements of an evidenced based practice might be challenging from a billing stand point. Paul Piccone wondered if the "edits" used in the billing process cold be changes to accommodate this or if alternative OP codes and rates could address these issues. The group will recommend that this be looked into to give providers greater flexibility and incentive to implement evidenced based practices on an OP basis that offer best service practices to clients and possibly greater service intensity when needed.
Other
In addition to the language change recommendations being made by the group and integrated into the care guidelines as we go, Susan will develop a list of all other recommendations made to date.