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Behavioral Health Utilization Management (BHUM) has always been a complex component of the healthcare system. As a leader in behavioral health with over 25 years of experience, I have seen firsthand the challenges providers and managed care organizations have faced balancing their medical necessity processes while trying to incorporate the entire member’s needs. In addition to being a healthcare leader, I am also a parent of a child with rare cancer called epithelioid hemangioendothelioma (EHE). I understand that not every individual can always fit into one standardized treatment plan. Sometimes we need to consider other factors and think outside the box to help individuals live their most optimal lives.
I joined MetroPlusHealth as the Director of Behavioral Health Utilization Management in 2021, focusing on creating a utilization management model as MetroPlusHealth brought behavioral health in-house. In my role, I work closely with our state stakeholders, community providers, and internal partners to take current medical necessity criteria and incorporate social determinants of health needs to create our ‘One Point of Contact’ Model.
Having a targeted utilization management approach is a unique opportunity that has allowed MetroPlusHealth to fully integrate our shared mission to partner on behalf of the member. The company’s goal is to ensure the members’ most immediate medical, social, and behavioral needs are evaluated and addressed, which is a part of the discharge plan. This is done while partnering with the inpatient team to assist with discharge planning and managing the members’ needs.
We often think of “One Point of Contact” as a one-stop shop for the provider. This allows less provider abrasion and avoids having multiple staff from a health plan calling the provider by simplifying the process.
Most of our behavioral health admissions require a registration process that allows a set number of days before the medical necessity is applied. The BHUM Clinician immediately starts to gather information to focus less on the approved days and more time on the member.
This can decrease re-admissions, increase community engagement, and connect members to gaps in care. An example of a gap in care is not having an annual mammogram, missing a dental appointment, or not following up with a chronic medical condition.
The ‘One Point of Contact’ Model can achieve the following:
• Simplify the process: We have one identified point of contact during inpatient admission who communicates with the inpatient provider.
• Increase collaboration for optimal success: BHUM Clinicians partner with medical & behavioral board-certified medical directors, case managers, health home liaisons, housing specialists, pharmacists, peers, and more to customize treatment plans.
• MetroPlusHealth Case Managers work closely with schools, foster care agencies, housing programs, food insecurity resources, behavioral health, and substance use disorder providers. The Behavioral Case Manager will collaborate with everyone from the providers to the families and individual members who identify in their life.
• Based on a Line of Business members can be eligible for Community Oriented Recovery Empowerment Services (CORE) or Children Special Services (CSS) which give access to Employment, Educational, and habilitative services.
Changing the way our providers work with us takes commitment and resources. We are fortunate to work with some of the best providers in New York City. The MetroPlusHealth Behavioral Health team’s access to medical and behavioral clinicians with many community experiences makes us succeed. I am often impressed sitting in my office with my door open, listening to our staff working with providers and members trying to secure behavioral health appointments and securing appointments for mammograms, dental, and housing all in the same call. These are the moments when you know what we are doing matters the most.