- About 6% of enrollment use behavioral health benefits – the vast majority of members utilize outpatient care. Average number of session for outpatient care is 6.5 visits; over 90% of members complete care within 20 visits. New Avenues performs utilization management based upon data driven algorithms for medical necessity review points to ensure that members are receiving effective care based upon industry best practices
- Less than 1% of the enrollment incur 35-45% of behavioral health costs. Charges for an average inpatient stay for a behavioral health disorder are in the range of $11,300 as opposed to average charges for an outpatient case at under $900 per episode of care. Aggressive case management efforts are made to engage members with serious behavioral health conditions to participate in treatment and case management
- 2011: robust case management efforts to ensure post hospital follow-up for patients with serious mental health conditions resulted in69% of patients being seen within 7 days of a hospital discharge; 88% were seen within 30 days
- Readmissions were reduced by 50% in 2011 over 2010 as a result of case management interventions. MBHN readmission rates within 30 days were less than 6%, far below national averages
- New Avenues has specialized case management programs designed for members with depressive mood disorders, high risk serious behavioral health conditions, autism spectrum disorders, and workplace performance issues
New Avenues delivers comprehensive behavioral health clinical management programs that use dynamic strategies to ensure quality, use of evidenced based practices, and cost effective treatment. Health plans looking to manage costs, risk and quality, achieve results through New Avenues' dynamic approach to behavioral health benefit administration that features:
- Risk management by tracking utilization, costs trends, and outlier situations
- Specialty-designed case management programs for members with severe depressive disorders, autism spectrum disorders, chronic behavioral health conditions, and high risk cases; members are engaged in treatment and psycho-educational support programs to build recovery and resilience
- Use of industry best clinical practices and efficient care by monitoring provider treatment through proprietary medical necessity review protocols
- A service culture that emphasizes our commitment to helping people manage personal and family problems with the utmost respect, compassion, sensitivity and confidentiality
- Performance metrics: We continually monitor quantitative measures of quality of care indicators that include access, service, satisfaction, and utilization
Managing Behavioral Health Benefits under Parity Environment:
On July 1, 2010, the federal government’s Mental Health Parity and Addiction Equity Act Interim Final Rules went into effect for employer health plans with over 50 employees. The parity and health care reform expanded responsibilities for employers in providing coverage for mental health and substance abuse benefits. Under these regulations, visit and day limits were prohibited and utilization review processes such as pre-certification practices became much more limited. The current environment intensifies the need for health plans to take dynamic approaches to managing behavioral health benefits. New Avenues has responded with unique, proprietary evidenced based approaches to providing comprehensive behavioral health clinical management programs that help individuals and meet pragmatic cost containment strategies.
The Utilization Review Program is the foundation of the delivery system and is characterized by:
- Diligent, knowledgeable in-patient pre-authorization reviews by experienced psychiatric nurses supported by a board certified psychiatrist available for daily reviews and peer-to-peer consultations
- Proprietary evidenced based outpatient medical necessity review program designed from 5 years of data on utilization patterns for outpatient care
- Utilization Review utilizing NCQA recognized Medical Necessity Guidelines developed by The Mihalik Group
- Dynamic case management outreach approaches to helping persons with serious behavioral health conditions
- Strong expectations of providers to coordinate and communicate behavioral health treatment with primary care physicians
- Integration approaches to coordinating case management of behavioral health needs with case managers handling members’ chronic medical conditions.
MBHN Care Management Services Provide:
- Referral Assistance for employees and their families to identify an appropriate in-network provider with the subspecialty to treat each person’s unique behavioral health needs.
- 24 hour availability for emergencies.
- Telephonic assessment, referral assistance, emergency assistance, and utilization review performed by experienced care managers who are psychiatric nurses or licensed masters level social workers with oversight by aboard certified psychiatrist as Medical Director.
- Depression Disease Management program for members with moderate to severe major Depressive disorders– the #1 most prevalent behavioral health condition.
- Case Management Protocols for Autism Spectrum Disorders.
- Case Management for high risk cases with severe or chronic conditions
- Commitment to quality and evidence-based care.
- Credentialing and Utilization Review programs operated according to National Committee for Quality Assurance (NCQA) standards.
- Integration with medical plan at several interface points including eligibility, case management, and primary care communication.
- Reports on utilization benchmarked with national metrics.
- An integrated EAP/Work-Life program that can be designed to enhance any health plan.
The Purpose of Case Management:
- Encourage adherence to treatment,
- Coordinate and help individuals navigate care with all providers and the individual’s primary care physician,
- Provide information and tools to empower individuals to understand their condition and find solutions,
- Encourage healthy lifestyle,
- Engage family support systems, and most importantly
- To intervene early so that each individual has the utmost opportunity to recover.
Over half of our professional care management resources are directed to delivering case management outreach to persons with serious behavioral health conditions affecting their work performance, social or family functionality, and well-being.