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An Example of Telephonic Member Engagement

An Optum member beginning treatment with you completes the Wellness Assessment (WA) when you offer it to her in the first session. As part of your assessment, you see that her treatment will involve substance abuse issues. You then receive a phone call from an ALERT Care Advocate regarding the identification of a potential chemical dependency risk that may affect the success of routine outpatient treatment. In this clinical review, the Advocate addresses treatment interventions while assessing member benefit availability in consideration of additional components of care.

To further this example, you have diagnosed this Optum member with a Substance-Related Disorder. Optum has adopted and promotes The American Psychiatric Association’s Best Practice Guidelines for Treatment of Patients with Substance Abuse Disorder as summarized below.

Quality services provided to this member would include:

  • conducting a complete assessment
  • assessing the patient's safety and clinical status
  • addressing intoxication and withdrawal symptoms when necessary
  • addressing co-morbid psychiatric and general medical conditions
  • establishing and maintaining a therapeutic alliance with the patient
  • motivating the patient to change
  • educating the patient about substance use disorders
  • developing and implementing an overall treatment plan
  • developing and facilitating the patient's adherence to a treatment plan
  • many patients benefit from involvement in self-help meetings
  • establishing goals of treatment that include the achievement of abstinence or reduction in the use and effects of substances, reduction in the frequency and severity of relapse to substance use, and improvement in psychological and social functioning
  • preventing relapse, reducing morbidity and sequelae of substance use disorders

Assessment and Coordination
Examples of general medical problems that may be directly related to substance use include cardiac toxicity resulting from acute cocaine intoxication, respiratory depression and coma in severe opiate overdose, and hepatic cirrhosis after prolonged heavy drinking. General medical conditions frequently associated with opiate-dependent individuals who inject opiates include bacterial endocarditis, HIV infection, and hepatitis. Patients whose substance use disorder is accompanied by diminished self-care and/or high levels of risk-taking behavior are at increased risk of experiencing malnutrition, physical trauma, and HIV infection. Coordinating care with the Optum member’s primary care physician is recommended. The Optum Exchange of Information form can be used in this case.

Appropriate Level of Care
Members should be treated in the least restrictive setting that is assessed to be safe and effective. Decisions regarding the site of care should be based on the patient's ability to cooperate with and benefit from the treatment offered, refrain from illicit use of substances, and avoid high-risk behaviors as well as the patient's need for structure and support or particular treatments that may be available only in certain settings. Some commonly available treatment settings include hospitals, partial hospitalization programs, and outpatient programs. Patients move from one level of care to another based on these factors and an assessment of their ability to safely benefit from a different level of care. Some of the guidelines that may need to be considered to ensure that this member receives the proper level of care can be found by reviewing the SUD Crisis Assessment Services, SUD Ambulatory Detoxification, SUD Residential Detoxification, or the SUD Inpatient Detoxification Clinical Criteria Guidelines.

The MH Outpatient Termination criteria will need to be considered for discharge planning. For questions specific to Optum member benefit availability, you may call the number on the back of the member’s insurance card.

* For Texas-specific guidelines, see Texas CADA Level of Care Guidelines.

The Optum SUD OutpatientClinical Criteria Guidelines need to be considered in your delivery of treatment.

  • The treatment plan supports continuity and coordination of care with appropriate mental health and medical professional(s) and available community resources.
  • All coordination of care activities should be documented.
  • The member’s family/social support system is included in care, unless clinically contraindicated.
  • The frequency and duration of outpatient visits is based upon a safe and timely achievement of treatment goals.