Care Advocate Engagement via Written Communication

When a potential targeted risk is identified through either the Wellness Assessment (WA) or claims information, a letter may be sent to you from Optum to inform you, the treating clinician, of an identified issue that may affect outpatient treatment. In some circumstances, a Care Advocate will call you to conduct a Clinical Review. Various Optum algorithms are used to identify potential risks that could affect outpatient treatment. Presented below are examples of potential risks identified through the WA.

• Complications at the workplace resulting from missed days of work or reduced productivity
• Level of functioning may negatively affect coping skills, social and daily life activities
• Use of substances may need to be addressed to explore the impact on coping skills, social and legal functioning and overall health
• Medical conditions which could have co-existing behavioral health implications either as a result of the experience of the medical condition (i.e., depressive symptoms with End Stage Renal Disease) or of medical origin (i.e., depressive symptoms associated with Thyroid Disorder)
• Self-reporting of minimal behavioral health symptoms

When you receive a letter, please review your interventions to determine that they are aligned with the minimal expectations of Optum specific to the clinical presentation of the member. Steps that may be taken include:

• Confirm or rule out the identified potential risk
• Re-affirm that the member meets the Clinical Criteria Guidelines for Outpatient Treatment, thereby taking into consideration that their needs can be met on an outpatient basis rather than at a higher level of care
• Consider the Clinical Criteria Guidelines that may be appropriate for the member in the event the member may need to step up or down in level of care
• Providers have the option to consult a Care Advocate for assistance regarding community resources and benefit eligibility for potential services
• Consult Best Practices that may be applicable for your intervention
• Check that treatment interventions address potential and confirmed risks