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Realigning for recovery

January 1, 2008
by Katie Profitt, PCC
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An agency decreases costs while serving more clients

During the past two years, Greater Cincinnati Behavioral Health Services (GCB) has embarked on a recovery initiative. Following the President's New Freedom Commission on Mental Health's final report, which called for a major transformation in the delivery of mental health services, GCB transformed its philosophy, organizational structure, service delivery, and overall identity to one rooted in recovery. For recovery-based ideas to become reality within our daily practices, the entire organization had to be involved in the restructuring. As a result of this ongoing work, GCB now has a greater assurance that its services are based on need and are helping individuals become empowered to recover.

At the forefront of this transformation was the development and introduction of a utilization management initiative. Utilization management is the process of using clinical information to determine a set level of care that guides future service delivery. Our goal was to develop and implement a recovery-based, clinically sound, and consistent process of assessment and reassessment that would enable us to identify a level of care for each individual we serve and ensure we are providing the right amount of service, at the right time, and at the right cost.


We established clear objectives for this initiative, which included:

  • Implementing level-of-care assignments

  • Facilitating access to and availability of needed services

  • Facilitating service coordination and continuity of care

  • Creating and implementing a set of review criteria, protocols, practices, and policies

  • Providing prospective authorization and retrospective review of clinical services

  • Monitoring service and utilization trends

  • Recommending changes in practices and resource use

  • Improving clinical consistency across the agency

Four Levels of Care

We developed four levels of care and a service framework to help guide our service delivery and to help ensure services are clinically indicated based on each individual's:

  • diagnoses;

  • global assessment of functioning (GAF);

  • Ohio Mental Health Consumer Outcomes’ Subscales of Symptom Distress, Community Functioning, and Quality of Life; and

  • individual needs.

We also recommended treatment guidelines for each level of care and regularly referred to our Recovery Paradigm (table) to guide our work.

Table. GCB's new recovery paradigm

Old Paradigm

Recovery Paradigm

Care is long term and based on the assumption that clients always will need services.

Care is provided only as long as needed and is based on the assumption that clients will recover.

The most care is the best care.

The focus is on the right amount of the right type of care at the right time. The wrong care or too much care can be as counterproductive as too little care.

The service package is based solely on staff's clinical judgment.

The service package is based on assessment of medical necessity, levels of care, and best practices with client input.

Clients need someone to make decisions for them.

Only by making their own choices can clients become empowered.

Clients participate in whatever services they want.

Clients participate in services they want within the parameters of assessed needs.

If we cannot provide what the clients need, then we look for natural resources.

We provide services only when the clients’ needs cannot be met through the use of natural resources.

The four levels of care are as follows.

Engagement. This is our most intensive level and includes ACT services. Individuals within this level of care:

  • might not acknowledge their illness;

  • are resistant to traditional treatment;

  • have poor prior treatment outcomes;

  • have active symptoms that interfere with multiple life areas;

  • might be unmotivated to engage in treatment;

  • are frequently homeless or institutionalized; and

  • need many emergency-type resources and interventions.

Motivation. In this level of care individuals are aware of our services and available choices, yet they have:

  • limited confidence, skills, and supports to attain their goals; and

  • functional impairments that necessitate psychosocial rehabilitation, case management, and significant mental health service support.

These individuals may begin to set recovery goals and are aware of their needs, but they require a lot of help becoming motivated to learn the skills they need and to manage their illnesses and lives in general.

Supportive. This level of care is designed to service individuals who:

  • are motivated to keep appointments;

  • are able to proactively manage their symptoms and medications;

  • are aware of the consequences of their decisions; and

  • have developed the skill sets needed to accomplish their goals.

These individuals are well on their way in their recovery. They have decreased their need for mental health supports and have increased their own natural support networks.

Empowerment. This is our least intensive level of care. Individuals in this level: