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MBHOs set the bar on complex case management

October 27, 2014
by Julia Brown
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The industry is changing the way it measurers complex case management. As of this year, the National Committee for Quality Assurance (NCQA) has added complex case management to its Managed Behavioral Healthcare Organization (MBHO) accreditation standards. The newly added standards were modeled from similar accreditation standards for health plans created in 2007.

“The standards for health plans and MBHOs have evolved over time, but whole new sections had been added to our health plan standards that weren’t immediately added to the MBHO program, in part because it was unclear what the specific role in the area was,” says Tricia Barrett, vice president, product development, NCQA.

Barrett says the environmental shift of individuals with serious mental illness into managed care programs took part in influencing the accreditation additions. 

“Over the last five years, there has been an increasing amount of attention given to the integration of behavioral health with medical care, the importance of thinking holistically about individuals and thinking similarly about behavioral healthcare as is thought about physical health concerns,” she says. “It was time to move the expectations that we had of managed care health plans around complex case management into the behavioral health managed care organization space.”

Whether performed by a health plan that has responsibility across physical and mental health or done in a carved-out MBHCO for the behavioral health condition, individuals with complex behavioral health needs should have access to the support that can be provided through a case management program, she says.

Setting the standards

In order to determine NCQA standards, a process of assessing research, real-life practices, input from the community and best practices in care management takes place.

“We always look to the field. What will push the industry from where we are today to some idealized state?” she says. “We don’t set the bar at what’s happening now and just validate that. We always set the bar above that, where experts agree there would be a strong case management program.”

It’s important that a MBHO thoroughly understands who it will be supporting with its case management in order to allocate sufficient staff and resources, Barrett says. And when it comes to identifying cases, there should be a balance between a working database approach as well as a mechanism for referrals.

“We don’t want them to be haphazard. We want them to have a systematic method and not just whatever some smart person sitting in the company thinks might be good,” she says.

Programs must have clinical and organizational research to back them up and some reason to believe that the approach is going to be effective for the specific patient identified.

A few of the NCQA standards are centered on workflow, questioning how case managers are supported in their work and what mechanisms have been established to assure that the necessary communication takes place during a turnover, for example, so patients are getting the help they need.

“Are [MBHOs] making sure the patients actually get through their process? How good are they at actually administrating the nice program they’ve designed based on the needs of their patients?” Barrett says.

Although it’s not a specific requirement of NCQA, MBHOs should also consider involving providers and patients into their design.

 “It’s clear from the literature that a case management program run by a managed care organization is far more successful if it’s highly integrated with the delivery system,” she says.