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ALERT® - Letters and Care Advocate Phone Calls

Letters

When a potential targeted risk is identified through either the Wellness Assessment (WA) or claims information, a letter may be sent to you from United Behavioral Health (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 (see the section below – The Clinical Review). Various Optum algorithms are used to identify potential risks that could affect outpatient treatment. Presented below are examples of potential risks identified by ALERT.

  • 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 Level of Care 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 Level of Care Guidelines that may be appropriate for the member in the event that the member may need to step up or down in level of care. Consult a Care Advocate for assistance regarding benefit eligibility for potential services
  • Consult Best Practices that may be applicable for your intervention.
  • Consult the Supplemental and Measurable Guidelines, if clinically applicable.
  • Check that treatment interventions address potential and confirmed risks.
Example: Global Distress (click here)

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:

  • establishing and maintaining a therapeutic alliance
  • educating and reassuring the patient concerning the panic disorder
  • evaluating particular symptoms and monitoring them over time
  • evaluating types and severity of functional impairment
  • enhancing treatment compliance
  
  • working with the patient to address early signs of relapse
  • considering group treatment as a possible intervention, if appropriate
  • identifying and addressing co-morbid conditions; working with other health professionals; educating family members and enlisting their help when appropriate

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 Level of Care 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

The Clinical Review: A Care Advocate Phone Call

Most clinician notifications by Optum related to potential risk issues are in the form of letters. However, certain potential risks warrant a Clinical Review with the treating clinician.

When such a case arises, you will receive a phone call from a Optum Care Advocate who is a licensed mental health professional. A Care Advocate will call as soon as the potential risk is identified. In an effort to be time-effective in the intervention, Care Advocates request a call back within two business days. It is important to return the Care Advocate’s call, even if you are unable to do so within this time frame.

The purpose of these calls is to inform the clinician of potential risk(s) identified through ALERT that may affect the member’s treatment outcome. This conversation might include, but is not limited to, a discussion about the member’s engagement in treatment, current mental status, and/or whether Optum can help mobilize additional resources that may support outpatient therapy. The use of clinical reviews is limited to members identified with certain targeted potential risks.

In the event that a Care Advocate is unable to speak with a clinician within the two-business day timeframe, the Care Advocate will make a call directly to the member, or member representative to discuss the identified risk(s). However, the preferred ALERT care advocacy contact is with the treating clinician.

Presented below are risks identified by ALERT which may result in a phone call. Various Optum algorithms are used to identify potential risks that could affect outpatient treatment.

  • Risk for treatment at a level of care higher than routine outpatient treatment in order to ensure the safety of member or others.
  • Risk for a deviation from normal baseline functioning, substance use, days missed from work, medical visits and a recent history of a higher level of care.
  • Combined risks that if found in isolation would result in a letter. Some combinations we frequently see include: The need to assess for care higher than routine outpatient together with chemical dependency risk; high level of stress and medical-behavioral co-morbidity; workplace risk and chemical dependency risk; and caregiver strain and workplace risk
  • Some members may not be identified with any risk targeted by the ALERT algorithms. However, information derived from claims may still result in a call from a Care Advocate

Information that may be reviewed in the Care Advocate Call

  • Confirm or rule out the identified potential risk
  • Confirm that the member meets the Level of Care Guidelines for Outpatient Treatment, thereby taking into consideration that his or her needs are able to be met on an outpatient basis rather than at a higher level of care
  • The Level of Care Guidelines that may be appropriate for the member in the event they are need to step up or down in level of care. Consult a Care Advocate with assistance regarding benefit eligibility for potential services.
  • Best Practices that may be applicable for the member’s presentation
  • Supplemental and Measurable Guidelines, if clinically applicable
  • Check that treatment interventions address any confirmed risks

Participating in a Clinical Review:

  • Return the Care Advocate’s call. Otherwise you will receive additional calls on the same Optum member
  • Begin by identifying the Optum member by name
  • Be prepared to speak about the clinical status of the member in outpatient therapy and identify potential needs of the Optum member, including any gaps in treatment
  • If you have more than one Care Advocate calling you on more than one member, give the name of each of the members in question when you call. You can usually do all the clinical reviews in one phone call
Example: Workplace Risk Combined with Chemical Dependency Risk (click here)

An Optum member beginning treatment with you completes the Wellness Assessment (WA) when you offer it to her in the first session. As part of your assessment, you see that her treatment will involve substance abuse issues. You then receive a phone call from an ALERT Care Advocate regarding the identification of a potential chemical dependency risk that may affect the success of routine outpatient treatment. In this clinical review, the Advocate addresses treatment interventions while assessing member benefit availability in consideration of additional components of care.

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

Quality services provided to this member would include:

  • conducting a complete assessment
  • assessing the patient's safety and clinical status
  • addressing intoxication and withdrawal symptoms when necessary
  • addressing co-morbid psychiatric and general medical conditions
  • establishing and maintaining a therapeutic alliance with the patient
  • motivating the patient to change
  • educating the patient about substance use disorders
  • developing and implementing an overall treatment plan
  
  • developing and facilitating the patient's adherence to a treatment plan
  • many patients benefit from involvement in self-help meetings
  • establishing goals of treatment that include the achievement of abstinence or reduction in the use and effects of substances, reduction in the frequency and severity of relapse to substance use, and improvement in psychological and social functioning
  • preventing relapse, reducing morbidity and sequelae of substance use disorders

Assessment and Coordination
Examples of general medical problems that may be directly related to substance use include cardiac toxicity resulting from acute cocaine intoxication, respiratory depression and coma in severe opiate overdose, and hepatic cirrhosis after prolonged heavy drinking. General medical conditions frequently associated with opiate-dependent individuals who inject opiates include bacterial endocarditis, HIV infection, and hepatitis. Patients whose substance use disorder is accompanied by diminished self-care and/or high levels of risk-taking behavior are at increased risk of experiencing malnutrition, physical trauma, and HIV infection. 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
Members should be treated in the least restrictive setting that is assessed to be safe and effective. Decisions regarding the site of care should be based on the patient's ability to cooperate with and benefit from the treatment offered, refrain from illicit use of substances, and avoid high-risk behaviors as well as the patient's need for structure and support or particular treatments that may be available only in certain settings. Some commonly available treatment settings include hospitals, partial hospitalization programs, and outpatient programs. Patients move from one level of care to another based on these factors and an assessment of their ability to safely benefit from a different level of care. 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 SUD Crisis Assessment Services, SUD Ambulatory Detoxification, SUD Residential Detoxification, or the SUD Inpatient Detoxification Level of Care guidelines.

The MH Outpatient Termination criteria will need to be considered for discharge planning. For questions specific to Optum member benefit availability, you may call the number on the back of the member’s insurance card.

* For Texas-specific guidelines, see Texas CADA Level of Care Guidelines.

The Optum SUD Outpatient Level of Care Guidelines need to be considered in your delivery of treatment.

  • The treatment plan supports continuity and coordination of care with appropriate mental health and medical professional(s) and available community resources.
  • All coordination of care activities should be documented.
  • The member’s family/social support system is included in care, unless clinically contraindicated.
  • The frequency and duration of outpatient visits is based upon a safe and timely achievement of treatment goals.