Outpatient Treatment Review (OTR) Process Guide and Recommendations

OTR Process Introduction Steps How to Complete Primary Complaint/Problem Section Listing of Goals Progress/Compliance Other Suggestions OTR Analysis

OTR Process Introduction The goal of this presentation is to improve the OTR process for both the provider and for CompCare by reducing the amount of paperwork, phone calls, time, and effort that go into the authorization of services.

OTR Process Steps: Provider submits an OTR by faxing a hardcopy or completing the form on-line. CompCare Care Manager (CM) reviews the submitted OTR.

OTR Process Steps: If clinical information on the OTR is incomplete or insufficient to authorize care: The CM asks the provider to call to review the OTR within two (2) business days of being contacted. If CM receives sufficient, additional clinical information, services are authorized. If not, the OTR is sent to an MD for medical necessity review. (Outpatient Medical Necessity Criteria can be found on the CompCare website).

OTR Process Denials: Care Managers cannot deny an OTR They can only authorize treatment Denials can be made by: A Psychologist for other Psychologists and Masters Prepared Practitioners. An MD for other MDs, Psychologists, and Masters Prepared Practitioners.

OTR Process How to Complete Although the entire OTR is reviewed, Care Managers focus on three areas: 1. Primary Complaint/Problem Section 2. Listing of Goals 3. Progress/Compliance

OTR Process – How to Complete Primary Complaint/Problem Section Located under Treatment Focus. Problems should be described in specific, concrete, and measurable terms. It is helpful to document problems in terms of observations. Example: The child hits his siblings between two and four times per week.

OTR Process – How to Complete Primary Complaint/Problem Section Non-specific problem: Anxiety Specific Example: The child is afraid to go to school and has not attended 10 out of 30 days over the past month. Non-specific problem: Depression Specific Example: The child has no friends and is afraid to talk to people outside the family.

OTR Process – How to Complete Listing of Goals Located under Treatment Focus. When the problem statement is written in a specific, measurable manner, it is then much easier to develop a realistic, measurable, and achievable goal.

OTR Process – How to Complete Listing of Goals Specific Problem: The child has no friends or is afraid to talk to people outside of his family. Specific Goal: The child must talk to three non- family members by the next review.

OTR Process – How to Complete Listing of Goals When the goals are measurable, both the clinician and reviewer can use this measurement to determine whether a treatment intervention is working. Problem Example: The child is afraid to go to school and has not attended 10 out of 30 days over the past month. Specific Goal: The child will decrease missed days from 10 per month to < 4 per month by October 31 st.

OTR Process – How to Complete Progress/Compliance Located at the bottom of the second column of the OTR. It is important to note specific progress toward the primary goal. It is helpful to document the goal in terms of what is traditionally known as “criteria for discharge.”

OTR Process – How to Complete Progress/Compliance Essentially, the OTR should detail the endpoint for treatment. Problem: The child fights with his siblings five times per week. Goal (“criteria for discharge”): No fighting behavior for six months. Progress: The child fights with his siblings 4 times per week.

OTR Process Other Suggestions: The provider delivering care should be responsible for filling out the OTR. Other providers giving care to the same member should submit a separate OTR to receive authorization for the services that they will provide.

OTR Analysis The purpose of this study was to determine whether or not the OTR, as it is currently being utilized, provides sufficient information to determine: 1.Severity of the patient's illness 2.The specific goals of treatment 3.The effectiveness of treatment The major accreditation organizations (i.e., JCAHO, CARF, etc.) expect that a treatment plan contain each of these parameters.

OTR Analysis An OTR should provide specific information so that: 1.It is clear to the reviewer that the patient/client requires treatment. 2.It is clear to the reviewer that the treatment is appropriate for the diagnosis and related problems. 3.It is clear to the reviewer whether or not there is progress being made.

CompCare OTR Analysis Results: Thirty (30) OTRs were randomly chosen from 100 recently submitted OTR’s. 7% met criteria for specific and measurable problems. 14% met criteria for specific and measurable goals. 0% met criteria for having both specific and measurable problems and goals.

Results of OTR Analysis The analysis revealed the following problems on selected OTR’s: Problems and goals were not measureable Provider lists the treatment process as a goal Treatment interventions listed are vague Treatment interventions did not appear to match the diagnosis

OTR Analysis Problem Identified: Non-measurable goals A clearly defined goal can be tracked from review to review and allows the therapist and reviewer to determine whether the treatment has been effective. Non-measurable problem: Client fights with peers Measurable problem: On average, the client fights with peers 5 times per month. Non-measurable goal: Decrease fighting with peers Measurable goal: Client will decrease fighting to less than 2 times per month by the next review.

OTR Analysis Problem Identified: Treatment process is listed as a goal Ideally, treatment goals should describe the “endpoint” of treatment. “Treatment Process” listed as goal : “help the member with anger.” Goal as Endpoint: The client will decrease fighting behavior to less than one time per month.

Results of OTR Analysis Problem Identified: Problems and Treatment Interventions listed are vague Problem: Aggressive Behavior Vague Intervention: Group Therapy 2 times per week Specific Intervention: Client will attend group therapy 2x’s per week and will identify 3-5 triggers for aggressive behavior by next review.

Results of OTR Analysis Problem Identified: Treatment intervention does not seem to match the diagnosis. Example: The OTR requests individual therapy services for an individual with “mental retardation.” Issue: Without additional information, it is difficult to determine whether this treatment is actually appropriate for the member. (member’s IQ, type of intervention used in individual therapy etc.)

Results of OTR Analysis Summary The OTR is the foundation for the outpatient review process. Problems should be stated in behavioral terms Goals should be objective and measureable Following these guidelines should assist in reducing additional work for both reviewers and providers.

Contact Information CompCare Website for Provider Information [Click on “Provider Resources”] Fax Number for OTRs