By: Barbara Ann Dunn, ACSW, LCSW, Director, Program Innovation and Outcomes, Magellan Healthcare
Appropriateness and Effectiveness
An appropriate service should be effective. These two Key Decisions are inextricably linked and are often the basis of medical necessity. Evidence-based practices assign a defined appropriate population and a set of measures demonstrating effectiveness and provide a good example of how the community at large and managed care can agree. More work may be required, however, to come to agreement on how the Child and Adolescent Needs and Strengths (CANS) is used to identify the appropriate population. In my first post on Access, I mentioned that in the best of all worlds, there would be two or three years of data on youth in a program using the CANS, the data could drive identification of youth with better outcomes, and then algorithms would be created for decision-making for youth access to programs. Matching a population to a service in managed care requires use of data to achieve meaningful outcomes.
One of the strengths of managed care is the capacity to collect, measure and analyze data. It is required for external reviews and accreditations, waiver applications and healthcare effectiveness. Using the CANS to identify appropriate and effective services for multisystem-involved youth should be standard in Medicaid managed care. Presentation of CANS data with other measures on provider reports and dashboards can be enabled by integrating CANS applications into existing systems and web portals. It would seem simple then to identify youth populations making progress with a level of care and prove treatment effectiveness. There are overarching populations in which we have been able to achieve such results, providing further validation of algorithms.
There are also times when specificity eludes the data, since “community-based” includes many interventions, and even “evidence-based practices” are at times practiced without fidelity measurement. Managed care relies on partnerships with providers and researchers to best understand effective treatment of youth populations. In one of our studies, we created a Family Functioning Scale and a Coping Scale with items across both domains. Both had a high correlation (Chronbach’s alpha) with a change in depression, at 0.89 on the Family Functioning Scale and 0.81 on the Coping Scale (where 1 is a perfect correlation or predictor of positive outcome). It’s not clear what interventions were used with the families, but it is clear those interventions helped the families improve functioning and the youth reduce feelings of depression.
Which brings us to the final proof of appropriateness and effectiveness: the effectiveness for individual youth.
On an individual level, managed care looks to service providers to identify the salient needs and strengths in the plan of care. This could occur when a care or treatment plan is authorized, during wraparound coaching or as part of an audit process. One practice for Magellan Behavioral Health of Pennsylvania is a mid-treatment review. The paired CANS and treatment plan are reviewed with the treatment team to consider effectiveness. Without the pressure of authorization, the care manager and treating provider can use the CANS to focus on the individual and family needs, including the clinical formulation, i.e. the theory behind the CANS score. Managed care looks at the evidence of CANS use for clinical formulation. It is a care manager’s joy when the CANS is used well in the clinical formulation, because most of them were once providers and came to managed care to make a difference on a broader scale.
For the most part, the Pathways Model, with items mapped as pathways, targets and outcomes, has been the most advantageous model we’ve seen. It fits well in many treatment plan formats, allowing providers to use their own treatment plan templates. The Pathways Model (Figure 1) nestles comfortably into a functional behavioral assessment approach. The structure works for the novice CANS clinician as well as for the advanced. A wonderful description of this model in case conceptualization can be found in the Praed Foundation training archives “PsychoCANSalysis”.
Figure 1: Types of Needs Based on the Pathways Model2
The Foundational Why Wheels (Figure 2) tool has been of particular assistance when a team is unable to sort out the pathways, targets and outcomes. In this model, the most pressing needs are determined by brainstorming for drivers of these needs. The top two or three pressing needs each get a Why Wheel. CANS items are then mapped to the behavior and drivers. The resulting map of drivers reorients the team to targets of intervention and outcomes expected. When laid out visually as drivers, a compelling picture can help a family connect actions to reactions and causes to effects. The model as used by Multisystemic Therapy has a well-established track record.
Figure 2. Foundational Why Wheels3
Standardized assessment is an established best practice for measuring appropriateness and effectiveness. The CANS in practice excels at both. When the practice is done well, youth and families flourish and successfully complete their programs. We will look at this in the final blog on Key Decision 5, Transitions.
 Dunn, B. (2015) Lessons Learned: The TCOM Partnership of Funder, Manager Care, and Provider. TCOM Conference Presentation. Nov 2015
 Fernando, A.D. (2013) PsychoCANSalysis: Making Room for Case Conceptualization in Treatment Planning with the CANS. 9th Annual CANS Conference. Retrieved from TCOMTraining.com.
 Cardenas, J., Fernando, A.D., & Hilley, L. (2014). What, Why, and How: Collaborative Treatment Planning. 10th Annual CANS Conference, Chicago, IL. Nov. 13, 2014.