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Principles for Systems of Managed Care
The Substance Abuse and Mental Health Services Administration's Center
for Mental Health Services (CMHS) provides national leadership for
improving the quality and availability of treatment and prevention
services for mental illness, particularly with respect to adults with
serious mental illness and children with serious emotional disturbances.
As part of its mission, CMHS promotes policies for managed care systems
by:
- promoting policies and standards for managed care systems that
reflect equity and parity in the treatment and rehabilitation of
persons with mental health care needs with other health care
needs;
- fostering the development of linkages and partnerships among and
between critical stakeholders such as consumers, family members,
advocates, Federal agencies, States, counties and local
communities, native American tribes, purchasers, managed care
organizations, and providers working within managed care systems;
- providing training and technical assistance to all stakeholders in
the mental health field in key policy areas for managed care
systems;
- collaborating with managed care systems to encourage the provision
of high quality and effective clinical and support services to
promote a high quality of life for persons with mental health care
needs; and
- promoting strategies for expanding health insurance coverage for
individuals who are under/uninsured.
CMHS recognizes that changes in health care financing and organization
make it imperative that all stakeholders work collaboratively in an
effort to deliver accessible, appropriate, comprehensive, culturally
competent, cost-effective services of the highest quality.
Policies and practices should address the concerns of all stakeholders
in the system and ultimately be responsive to the rights and needs of
the individual receiving the service.
Responsibility for the public health and well being of our citizens
should be shared. To foster this goal, the following principles are
offered to all stakeholders as public and private sector system
integration occurs.
Quality of Care
Managed care systems should:
- treat all persons with respect and dignity;
- be based on "best practices," model programs, innovation, and
continuous quality improvement;
- develop delivery and data collection systems to address the unique
developmental needs of children and their families;
- ensure that services are tailored to individual needs and
preferences, provided in the least restrictive and most natural
setting possible and built on the strengths of the consumer and
family;
- establish credential verification programs, assess critical
provider skills and competencies, and provide necessary training
to facilitate human resource development;
- provide mechanisms for resolution of provider disputes;
- ensure that services for adults directly include a continuum of
care consisting of, but not limited to, a comprehensive array of
flexible community living supports including prevention,
treatment, rehabilitation, support, psychiatric rehabilitation,
intensive case management, residential treatment, crisis, and
self-help services and also provide effective linkages to other
health and social services;
- ensure that services for children directly include a "wrap
around"
approach consisting of, but not limited to, flexible,
individualized, strengths-based, family-driven services
incorporating respite care, case management, day treatment,
recreational support, and other non-traditional home and
community-based services and also provide effective linkages to
other health and social services; and
- incorporate targeted prevention activities, especially at key
points of life transitions.
Consumer Participation and Rights
Managed care systems should:
- meaningfully involve consumers and family members in the planning,
development, delivery, evaluation, research and policy formation
of managed care systems including the determination of "medically
necessary" services;
- respect consumer choice of services, providers and treatment and
assure consumer informed voluntary consent. Individual treatment
plans should be based on the preferences and needs of consumers
and families with children;
- ensure that consumers receive necessary legal and ethical
protections and services;
- provide education to consumers and family members on their rights
and responsibilities;
- establish grievance, mediation, arbitration, and appeals
procedures to resolve consumer disputes in a timely manner.
Ombudsman services should be provided. Necessary services should
continue pending dispute resolution;
- support consumer rights and empowerment by providing education
about, and access to, local self-help groups and protection and
advocacy organizations; and
- ensure that confidentiality and privacy of consumer health care
information is protected at all times, particularly as electronic
information systems develop and expand. Release of specific
information should occur only with a signed release from either
the recipient of services or their legal guardian/representative.
Accessibility
Managed care systems should:
- ensure that services are culturally and linguistically
appropriate, available, acceptable, and accessible (including
geographically) to all individuals, with particular attention to
vulnerable populations;
- provide education about mental health benefits and ways to access
emergent, acute and routine care;
- provide services for individuals with pre-existing illness;
- work with provider networks that include community providers
experienced in working with vulnerable populations;
- make available necessary specialized services required by
participants that are not available through managed care system
provider networks; and
- ensure continuity of care during transition from the current
system to managed care environments and among different managed
care systems as contracts change.
Affordability
Managed care systems should:
- provide affordable interventions at all levels of the continuum of
care to reduce the prevalence and/or severity of mental illness
and resulting disability through early prevention and
identification of risk factors;
- ensure reasonableness of out-of-pocket costs and provide full
access to critical services, especially for indigent populations;
and
- provide appropriate mechanisms for consumers who want to seek care
from providers who may be outside the established networks.
Linkages and Integration
Linkages and Integration
Managed care systems should:
- coordinate with primary health care and substance abuse systems;
- utilize interagency collaborations with human services agencies
such as public health, social service, child welfare, education,
juvenile justice, criminal justice and long-term care systems; and
- assure linkage to critical services such as employment supports,
housing, transportation, self-care and mutual support
organizations, education and training opportunities, and
rehabilitation service.
Accountability
Managed care systems should:
- engage stakeholders in developing and assessing quality assurance
standards, and in incorporating performance, outcome (e.g.,
recovery and community integration) and consumer satisfaction
measures to evaluate plan performance over the long-term,
including measures of access, appropriateness, quality, outcome,
and cost effectiveness;
- employ various evaluation methods including report cards and
consumer satisfaction surveys and make the information available
for further analysis;
- collect, analyze and publicly disseminate reliable information to
foster system accountability and quality improvement; and
- develop information systems at the provider and managed care
network levels collecting data on demographics, service
utilization, revenues, costs, service outcomes, service provider
performance, consumer satisfaction, and quality of life.
CMHS welcomes input and suggestions for subsequent updates of these
principles
For more information, call SAMHSA's National Mental Health Information Center at 1-800-
789-CMHS (2647)
MC96-61
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