Partnerships in Care (PiC) Program

What is Care Coordination?

• The intentional exchange of information between two or more participants (including the member) who are involved in the member’s care to facilitate the appropriate delivery of healthcare services.
• Care coordination is an essential element in treatment planning, service titration, and the discharge planning processes.

The Benefits of Care Coordination

• Collaboration between the internal and external treatment team is emphasized to better serve the member.
• The member’s needs are supported, and a holistic system of care is integrated.
• It assists in the development of comprehensive treatment planning that leads to more appropriate services titration or referrals.
• Care coordination consists of anything that bridges gaps in the member’s recovery.
• A holistic approach to healthcare results in the best outcomes.

Who Should Coordinate Care?

• Care coordination includes a variety of individuals on the treatment team:
• Behavioral health providers (e.g., Counselors, Social Workers, Substance Use Counselors, Psychiatrists)
• Physical health providers (e.g., PCP, Pharmacists, Neurologists)
• Specialty care services (e.g., Physical Therapists, Occupational Therapists, Speech Therapy)
• Educational and community supports (e.g., Teachers, School Psychologists, Mentors)
• Family members (e.g., parent, guardian, spouse, sibling)

Considerations

• Release of information must be signed by the member or their guardian prior to any outreach.
• Method of care coordination is based on each member’s needs (e.g., phone, fax, meeting).
• Request and review records from previous or current providers to align care and member needs.
• Notify member and/or guardian about coordination occurring.

What Could Happen If Coordination of Care Does Not Occur?

• Multiple providers may be treating different diagnoses and/or presenting problems.
• Multiple treatment plans with competing goals can complicate or impede the treatment process for the member.
• Symptoms may become exacerbated.
• Duplication of efforts and services provided may occur.

Important Steps of Treatment Planning

• Treatment plan goals should:
  • Align with assessment, diagnosis, and presenting symptoms
  • Be member driven and individualized
  • Serve as a guide towards the client’s recovery and be referenced frequently
• Clinical Documentation in a treatment plan should include interventions that are being used, measurable target dates for each goal, and member’s strengths.

Creating a Member-Focused Treatment Plan Using Specific, Measurable, Attainable, Relevant, And Time Frame (SMART) Goals

• This method helps goals to be measured and adjusted over time to show incremental progress or regression.
  • If progress is not occurring, ask yourself, “What can we do differently?” and reflect changes in the updated treatment plan if the goal needs to be amended to improve attainability.
• Goals should have a time frame of no more than 90 days.
  • Can the goal be met in 1 month, 2 months, or 3 months?
• Goals should be member driven and align with their desired outcome.
  • Use direct member quotes for identified goals to use member language and ensure their understanding.
• Goals should be strengths based and individualized.
• It is recommended that each goal has two interventions: one for the member and one for the provider.

Tools to Aid in SMART Goal Development

• Biopsychosocial assessment – triage for member’s needs
• Diagnosis and presenting problem – clear supportive symptoms and behaviors that align with diagnosis
• In-depth interview with member and support – assess the desired outcome and strengths
• Motivational interviewing – consider stage of change the member is in and how they want treatment to help them

Considerations

• Baseline behaviors and what is attainable for the member
• Barriers to meeting the goal
• Developmental age and stage of the member
• Goals should be updated after a crisis, hospitalization or change in diagnosis
• Ensure that the timeframe and interventions for the goal align
• Goal should be tangible and able to answer “yes” or “no” if the goal was met at the treatment review

What is Titration?

• Titration implies stepping the member down in their services in order to match their clinical presentation, progress, baseline, and supports.
  • Example: Member A. was receiving therapy 4x/month. Due to member’s progress, increase in supports, and coping skills, Member A. is being titrated to receive therapy 2x/month. Member will be evaluated with current service package and continue titration of services as progress continues.
• Services should also be reduced slowly when recovery is occurring to avoid worsening of symptoms, feelings of abandonment by the client, and empower the use of skills learned. 

Why is Titrating Services Important?

• Promotes independence and working towards effective independent functioning
  • Discharge should be discussed with the members openly at the start and throughout treatment. A key goal of therapy is to work towards effective independent functioning.
  • This process includes helping members identify their natural support systems and assisting with coordination of care to support their step-down plan and access community-based resources.
  • Studies demonstrate that it is not necessary to be in therapy for years in order to achieve improvement in symptoms.
• Helps to ensure individualized treatment
  • Treatment type and duration should always be matched appropriately to the nature and severity of the member’s presenting problems.
  • Length of treatment also varies with the type of treatment provided.
• Discourages unhealthy attachments
  • Titration helps discourage unhealthy attachments to treatment providers because it promotes independence and monitors the member’s progress. It ensures that a member isn’t stuck in one level of care or becomes too dependent on a provider or services.

Barriers to Titration Services

• Sunflower Health Plan recognizes that barriers may be present for providers and members.
• If symptoms worsen, services can be titrated up to increase frequency and duration of services, if the documentation supports the medical necessity of that service and authorization is obtained.

Discharge Planning Process

• Discharge planning is not a one-time event. It requires collaboration with the entire treatment team including providers, member, family, and additional supports.
• Discharge planning should begin on the first day of treatment and continue to be assessed and frequently discussed with the member.
• The discharge plan should be written clearly and agreed to by the member.
• Titrating services, which is the continuous appraisal of current needs, will also help identify when discharge is appropriate.
• Discharge should occur when: All the treatment goals and needs have been addressed, OR member has reached their baseline, OR the member has reached the maximum benefit of services for that level of care.

Step-down Planning Process

• Members should begin their step-down plan when they have shown improvement and are meeting their goals and objectives.
• Members should also have been compliant with treatment recommendations and are no longer severely functionally impaired.
• To prepare for transition, encourage the use of the skills learned in treatment:
  • Self-care reminders
  • Coping skills
  • Medication regiments
  • Accessing and utilizing support systems
• Recommend potential referrals to connect the member to natural supports prior to discharge to allow practice using services such as:
  • AA/NA and sponsors
  • Senior centers or respite
  • Employment programs
  • Spiritual or religious supports
  • Community mentors or peer support specialists
  • Sports/hobby groups
  • Online supports (e.g., apps, online groups)
• Discharge plans and instructions on how to return for care if needed should be provided to the member and openly discussed. They should be informed that they can resume services if needed.

Consider Family Readiness

• Refer family to parent education/training, if needed.
• Equip the family with tools and steps to take if the need for treatment arises again.
• Ensure the family’s inclusion on discharge planning.

What is coordination of care?

• The deliberate exchange of communication of care activities between two or more participants involved in the member's care to achieve optimal treatment delivery and outcomes.
• Collaboration should always include the member.  
• Care coordination aligns treatment plans and wellness goals creating treatment fidelity across settings and persons.
• The goal of care coordination is to meet the member’s needs and deliver high-quality care through the exchange of information among treatment providers responsible for different aspects of care.

Coordination of care benefits:

• Improves outcomes for members and families
• Helps facilitate more comprehensive treatment planning  
• Provides a holistic approach to care
• Ensures appropriate dosage of prescribed services
• Offers a comprehensive view of services for treating providers
• Prevents potentially conflicting treatments and multiple treatment plans
• Aligns resources to member’s needs

Who should coordinate care:

Care coordination may include a variety of individuals on the treatment team based on the member’s unique needs. Clearly defined roles and an understanding of these roles can help all members of the care team communicate effectively and efficiently. This collaboration allows for a holistic view of treatment enabling the ability to identify potential barriers towards treatment success.

• Behavioral health providers (e.g., Counselors, Social Workers, Therapists, Psychiatrists)
• Physical health providers (e.g., PCP, Pharmacist, Neurologist)
• Specialty care services (e.g., Dentist, Optometrist, ENT, Dietician)
• Therapy services (e.g., Physical Therapists, Occupational Therapists, Speech Therapy)
• Educational and community supports (e.g., Teachers, School Psychologists, caregivers)
• Family members

Considerations:

• Release of information must be signed by the member or their guardian prior to any outreach
• Method of care coordination that is most appropriate based on member’s need (e.g., phone, fax, meeting)
• Request and review records from previous or current providers to align care and member’s needs
• Notify member and/or guardian about coordination occurring

References: McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination). Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun. (Technical Reviews, No. 9.7.) 3, Definitions of Care Coordination and Related Terms. Available from: https://www.ncbi.nlm.nih.gov/books/NBK44012/; Care Coordination. Content last reviewed August 2018. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/ncepcr/care/coordination.html;Friedman, A., Howard, J., Shaw, E. K., Cohen, D. J., Shahidi, L., & Ferrante, J. M. (2016). Facilitators and Barriers to Care Coordination in Patient-centered Medical Homes (PCMHs) from Coordinators' Perspectives. Journal of the American Board of Family Medicine : JABFM, 29(1), 90–101. https://doi.org/10.3122/jabfm.2016.01.150175

Quality Caregiver Training Should:

• Maximize outcomes for the member
• Improve family quality of life by assistance with mitigation of caregiver stressors
• Support generalization and maintenance of skills

Quality Caregiver Training is Achieved when Providers:

• Provide educational materials and tools that describe the basics of ABA and clearly outline principles being used to treat their loved one.
• Involve a systematic, individualized curriculum with goals tailored to family.
• Develop parent goals that are specific, measurable, achievable, relevant, and timely.
  • In developing these goals, ask caregivers: “What would make your life with your child easier?,”  “What skills would you like your child to develop?,” “What behaviors are most problematic for you and your child?,” and “Are there activities you want to be able to do, but can’t because of these behaviors?”
• Ensure caregiver training sessions occur at the clinically approved dosage.
  • If fulfilment is less than what is medically necessary, barriers that limit fulfillment should be documented and addressed.
• Include time dedicated for review of caregiver training goals from approved treatment plan, as well as time to address current concerns from caregivers.
• Provide structured training with a qualified health care professional. Quality caregiver training is not accomplished by simply having the caregiver or guardian present during treatment.
• Document caregiver training sessions including details around interventions used, caregiver participation, and progress towards caregiver goals.
• Document caregiver participation in the development of the treatment plan, and their understanding of the treatment plan (e.g., parent signature on treatment plan).

References; Albone-Bushnell, R. (2014). A list of core skills and knowledge necessary for parents of children birth to five years old with autism, as prioritized by practitioners with a behavioral perspective (Order No. 3689092). Available from Education Collection. (1678945631); Council of Autism Service Providers [CASP] (2024). Applied behavior analysis practice guidelines for the treatment of Autism Spectrum Disorder: Guidance for healthcare funders, regulatory bodies, service providers, and consumers [Clinical practice guidelines]. https://www.casproviders.org/asd-guidelines 

A Functional Behavioral Analysis (FBA) should take place within three months of the emergence of maladaptive behavior or if data indicates that the use of standard interventions is not producing desired outcomes.

What Should be Included?

Functional Behavioral Analysis (FBA)

An FBA is used to inform the design of a behavior program for maximum effectiveness and should include:

• Informed consent by individual or caregiver as appropriate
• Rationale for need of intervention and potential risks if not assessed/intervened
• Utilization of assessment methods (direct vs. indirect, etc.) and data collection procedures
• Operational definition of target behavior(s)
• Hypothesized function(s) of problem behavior(s) that include antecedents that predict the behaviors and consequences that maintain the behaviors
• Functionally equivalent replacement behaviors to be targeted for acquisition

Behavior Intervention Plan (BIP)

The BIP is developed to outline a function-based intervention plan that addresses the undesirable behavior and should include:

• Informed consent by individual or caregiver as appropriate
• Date of initiation as well as date of revisions/review
• Individualized plan tailored to member, implementer, and setting (e.g., family, siblings, staff, other service providers)
  • Antecedent and consequence-based interventions
  • Justification for restrictive interventions, if applicable
• Safety and/or Crisis Plan for behaviors that may cause harm to member, others, or environment
• Specific plan for generalization
• Information for how contingencies will fade to more natural contingencies to promote independence across all environments
• Visual representation of data to include:
  • Graph for each target behavior
  • Narrative summary indicating response to treatment (trends) for each behavior targeted
• Documentation of setting events that may impact behavior data (e.g., medication changes, divorce, modification to BIP) and how these are being addressed
• Outline for how often the behavior plan will be updated and how stakeholders will be trained
• Information regarding treatment fidelity checks

Considerations

• The FBA should be conducted within the environment where the behavior occurs; therefore, if a maladaptive behavior is occurring within the home setting, evaluation and treatment should also occur within that setting.
  • If services are not able to be provided within settings that are specific to member and family’s needs, rationale should be submitted regarding a plan for how this will be address.
• The BIP should be developed with caregiver preferences and abilities taken into consideration.
• The BIP should reflect stakeholders’ ability to implement the interventions.
• Appropriate alternative behaviors identified should be specifically targeted for increase within skill acquisition section.
• Throughout the treatment period frequently reassess and update intervention plans to address changes of behavior accordingly.

References: Council of Autism Service Providers [CASP] (2024). Applied behavior analysis practice guidelines for the treatment of Autism Spectrum Disorder: Guidance for healthcare funders, regulatory bodies, service providers, and consumers [Clinical practice guidelines, Version 3.0] https://www.casproviders.org/asd-guidelines

Importance of Medication Management

Given the number of individuals with autism who are also treated with psychiatric medication, collaboration of care with primary care physicians, psychiatrists, or other medical and/or behavioral health specialists is essential for the best treatment outcomes for a member. There are no FDA approved medications that target the core symptoms of ASD itself. However, co-occurring psychiatric disorders are common, affecting up to 70% of children with ASD (anxiety, ADHD, ODD most commonly). Medication is frequently prescribed to target non-core symptoms of ASD, such as irritability, aggression, hyperactivity, and anxiety. Behavior Analysts with their specialized expertise are an integral member of a multi-disciplinary treatment team. Coordinated efforts regarding medication management are important to:

• Maximize therapeutic outcomes
• Identify opportunities for titration of medications and reduction of dosage
• Review for opportunities of non-pharmacological, psychosocial treatments
• Assess for side effects and co-occurring medical complications
• Encourage collaboration that can positively influence the treatment plan

A behavior analyst’s role:

• Provide data on the effects of behavioral treatments on a member’s skill acquisition and/or behavior reduction prior to the introduction of medication.
• Share baseline data on any challenging behaviors that may be a barrier to learning in treatment.
• Share both qualitative and quantitative data with medical providers related to a member’s behavior. This valuable information supports the evaluation of the efficacy of a medication and provides opportunities for shaping treatment with medication.
• Observe side effects of medication and partner with members, parents, and/or caregivers to communicate concerns to medical providers.

Benefits of medication management collaboration:

• Develop a better understanding of the intent/purpose and desired results for the treatment with medication.
• Ensure metabolic labs and assessments occur for members on antipsychotics to enable early identification for potential comorbidities.
• Enable members to be more receptive to behavioral interventions, thereby improving the effectiveness of treatment with ABA.
• Improve treatment outcomes that can be achieved through integrated, collaborative care that relies on the expertise found in each discipline.

Prescription fulfillment refers to the amount of hours for services implemented in relation to the amount of services authorized. Also known as utilization of hours as approved.

Importance of Prescription Fulfillment

• Helps assess member achievements and identify potential barriers to response to treatment.
• Allows for evaluation of outcomes based on dosage.
• Lack of prescription fulfillment (e.g., lower-intensity treatment, delays in commencing treatment, and interruptions in treatment) may result in regression or lack of treatment outcomes.
• ABA Treatment Hour Considerations
• Additional services member accesses including school-based interventions, occupational therapy, speech therapy, physical therapy, play-based therapies and how many hours the member can realistically attend and manage for ABA.
  • If there is discrepancy between hours requested and member’s availability for services, please provide rationale and a coordination of services plan.
• Frequency, duration, and location of services recommended are consistent with the member’s diagnoses, skill deficits, behavioral excesses, and treatment goals.
• Progress toward goals is commensurate with level of care.
• Barriers to achieving desired level of care and how these barriers can be addressed.
  • ABA recommendation may differ from ABA request.
  • ABA recommendation should refer to treatment hours requested if no barriers are present.
  • ABA request refers to treatment hours that are able to be completed based on member’s needs and caregiver agreement taking into account member and provider availability and other factors that may act as barriers to treatment.
  • If there is a difference between these two dosages, providers should document barriers to member receiving full ABA recommended hours.

*Please note, providers may submit addendum to their approved authorization at any time. if additional units or codes need to be requested.

Assessing Fulfillment

• Assessing fulfillment and/or barriers to fulfillment can be done on a monthly basis, and long-term fulfillment can be reviewed during the reassessment period.
• Potential barriers that prevent members from accessing services may include:
  • Socioeconomic factors
  • Transportation needs
  • Conflicting schedules
  • Lack of childcare
  • Absence of ABA knowledge

Health plans may have benefits that are able to assist with addressing some of these barriers.

References: Council of Autism Service Providers [CASP] (2024). Applied behavior analysis practice guidelines for the treatment of Autism Spectrum Disorder: Guidance for healthcare funders, regulatory bodies, service providers, and consumers [Clinical practice guidelines]. https://www.casproviders.org/asd-guidelines

Transition Planning implies the gradual stepping down of services to match an individual’s clinical presentation, progress, and supports as they prepare to transition to a different level or environment of care.

Why is Transition Planning Important?

• Promotes a path toward effective independent functioning
  • Providers should openly discuss long-term desired outcomes for treatment with members and/or caregivers at the start and throughout treatment.
    
  • This includes helping caregivers identify their support systems outside of therapy and assisting with coordination of care.
• Helps to ensure individualized treatment
  • Treatment type and duration should always be matched appropriately to the nature and severity of the member’s presentation.
  • Authorization requests (hours, setting, and participants) should be based on the individualized needs of the member.

Developing a Transition Plan

Transition planning, or discharge criteria, should be identified at initiation of treatment and reviewed and adjusted as appropriate throughout the course of services. Criteria should be clearly defined and measurable, indicating the point at which services are appropriate for discontinuation and/or transfer to alternative or less intrusive levels of care. This may occur when:

• Member’s individual treatment plan and goals have been met.
• There is expected transition to the utilization of alternative treatment setting, such as a school setting.
• Documentation that there has been no clinically significant progress or measurable improvement towards treatment plan goals for a period of at least six months, nor is there any expectation of progress.

Components to Include within a Transition Plan

• Specific and measurable goals that are individualized to member that outline skills needing to be achieved to allow the member to continue to make progress with a lower level of care.
• Updated progress toward attainment of transition goals achieved over authorization period and achievement as compared to baseline presentation.
• Details indicating how hours are projected to be titrated based on achievement of transition plan goals.
  • If the member is school-aged but is not able to participate due to attending full time ABA, a transition plan for school needs to be supplied including communication with school system and Individualized Education Plan (IEP) status.
• Community resources that will support maintenance and generalization of skills for member and their family. This may include local and online options.  

Considerations

• Evaluate potential need to increase frequency of caregiver training as member approaches transition criteria to assist with generalization and maintenance of skills.
• Ensure family is equipped with the tools and resources they need to maintain or progress skills after discharge including steps to take if the need for treatment arises again.
• Transition planning and discharge considerations should be made with input from the member’s entire care team.

References: Council of Autism Service Providers [CASP] (2024). Applied behavior analysis practice guidelines for the treatment of Autism Spectrum Disorder: Guidance for healthcare funders, regulatory bodies, service providers, and consumers [Clinical practice guidelines]. https://www.casproviders.org/asd-guidelines