An Example of a Written Member Engagement

An Optum member beginning treatment with you completes a Wellness Assessment (WA) when you offer it to her in the first session. As part of your assessment, you see that she is experiencing a high level of distress. About a week later, you receive a letter from Optum indicating that this member presents with a potential risk that may affect the success of routine outpatient treatment due to a high level of distress. The level of distress indicated by her responses on the WA is considered high for routine outpatient care.

To further this example, you have diagnosed this Optum member with a Panic Disorder. Optum has adopted and promotes The American Psychiatric Association’s Best Practice Guidelines for Treatment with Patients of Panic Disorder as summarized below.

Quality services provided to this member would include:

In every case, the Optum member should be fully informed about the availability and relative advantages and disadvantages of CBT, medications, and other forms of treatment. Prevalent co-morbid psychiatric factors that should be considered include potential suicidality, substance use, mood disorders, other anxiety disorders, personality disorders, and significant dysfunction in personal, social, or vocational areas.

Assessment and Coordination of Care
Important general medical conditions that may be seen, or confused with panic disorder include an array of cardiovascular, pulmonary, neurological, endocrinologic, and gastrointestinal conditions. Panic attacks are associated with physical symptoms and may be misinterpreted as general medical condition. Some general medical conditions (and/or effects of medications prescribed to treat them) may manifest themselves as panic symptoms, and general medical illness may be associated with co-morbid panic disorder. Conditions that have been specifically associated with panic disorder, but not etiologically-based, include irritable bowel syndrome, migraine headaches, and pulmonary disease. Coordinating care with the Optum member’s primary care physician is recommended. The Optum Exchange of Information form can be used in this case.

Appropriate Level of Care
The possibility of inpatient treatment should be considered, especially for individuals with co-morbid depression who are at risk for suicide attempts or patients whose Panic Disorder is complicated with substance use and who may require detoxification.

Some of the guidelines that may need to be considered to ensure that this member receives the proper level of care can be found by reviewing the MH Crisis Assessment or MH 23-Hour Observation documents. The MH Outpatient Termination criteria will need to be considered for discharge planning. For questions specific to Optum member benefit availability, you can call the number on the back of the member’s insurance card.

The Optum Mental Health Outpatient Clinical Criteria Guidelines need to be considered in your delivery of treatment:

• The member is not at imminent risk of harm to self or others and exhibits adequate behavioral control to be treated in the outpatient setting
• You and the member, or representative, set clear, reasonable, and objective treatment goals for the member’s symptoms and diagnosis
• The member’s family/social support system is included in care, unless clinically contraindicated
• The treatment plan includes coordination with appropriate professional and community resources, when applicable
• Document all coordination of care communications
• The frequency and duration of outpatient visits should provide for safe and timely achievement of treatment goals