MHN monitors the utilization of behavioral healthcare services in order to facilitate the delivery of cost-effective behavioral healthcare.
When we talk about utilization you might think we're really talking about avoiding over utilization. In fact, the focus of our Utilization Management process is on care - the delivery of appropriate care in the appropriate setting. We believe that when the MHN care management team approves payment for only medically necessary care, both under and over-utilization are prevented.
To reach decisions regarding medical necessity, care managers consider the following factors:
- Patient characteristics such as severity of symptoms, severity of psychosocial stressors, acuity of symptoms, prior treatment efforts, the clinical diagnosis, and level of impairment in functioning;
- Clinical outcomes research and clinical practice/level of care guidelines;
- Local system and provider capabilities.
This process allows the Care Manager to answer the question, "Where and how can this patient be treated safely and most effectively in an environment that will promote optimal functioning?"
Underutilization poses its own set of problems. When patients do not receive the care they need initially, they may relapse, require treatment at a higher level of care, or be more likely to require a medical leave for a psychiatric disability.
At MHN we are aiming for optimal utilization in our care management and utilization management processes.