By Barbara Ann Dunn, ACSW, LCSW, Director, Program Innovation and Outcomes, Magellan Healthcare
Engagement
In my last post we looked at Key Decision 1 (Access) and how managed care uses the Child and Adolescent Needs and Strengths (CANS) to enable access to services. Key Decision 2, Engagement, is about bringing people from access — opening the door — to becoming equal partners in the helping system.
Engagement is built on respect and understanding that youth and family are experts in their own lives and need to captain their own ships. Engagement uses a fully person-centered discovery and planning process. Person- and family-centered treatment planning is a collaborative process where care recipients participate in the development of treatment goals and services provided, to the greatest extent possible.[1] We can all agree the principles of wraparound or Child and Adolescent Service System principles; managed care has a specific, although sometimes unwelcomed role.
Managed care organizations (MCOs) are tasked with operationalizing engagement. This can sometimes look like a checklist rather than family-driven care, as operationalization includes timeframes and standards for everything: forms, consents, plans, child and family meetings, authorization, and even how often helpers and family are required to meet. Figuring out how to balance competing demands of engagement and the activities required for services requires a tremendous amount of consideration and care. Fortunately, the CANS offers a place where engagement and operationalization converge.
The CANS anchor items help to operationalize and engage through a common language that is easy to understand, providing scalability for action, and enabling transparency necessary for family-driven planning. Transparency is at the heart of truth-telling, i.e. rating CANS items accurately; respectful truth-telling enables powerful family-driven planning. The common language helps with this:
- A needs definition is one of the following: no need, prevention, action or action right now.
- A strengths definition is one of the following: a centerpiece strength, a useful strength, a strength to be built or no identified strength.
The CANS asks the hard questions and opens the door for families to explore the answers together. Sometimes, a standardized assessment uncovers what a family cannot articulate without being prompted by the right questions. When family members voices are heard and accepted, engagement is possible.
Engagement stems from creating a shared vision, and a shared vision needs a shared language. The CANS socializes the language of needs and strengths, functioning, and action across family and systems. A skilled facilitator will use the CANS in the background while assessing needs and strengths, and the family and youth self-assess on relevant items using the anchor items. In the Magellan of Wyoming Care Management Entity, the strengths, needs and culture discovery (SNCD) is the first step in the wraparound process, creating a shared vision with the family and youth.
If you’re wondering which comes first, the SNCD or the CANS – the SNCD, or the family and youth story in their own words, always comes first. Then, the family care coordinator introduces the CANS language on needs, strengths and action-based scoring. This facilitates consensus and understanding of needs and strengths, plan steps, and desired outcomes. The group can then work together to develop the plan of care.
Just using the CANS is not enough. When a facilitator discusses CANS ratings with the family, a guide booklet that defines the process and terms can help the family validate the ratings. This helps create transparency, but it is only the beginning. I recall one provider years ago completing the iconic paper bubble form in pencil after reviewing the referral material. When he met with the family, he gave them an eraser and allowed them to rescore anything they didn’t agree with. That eraser was a powerful tool for engagement.
Sometimes tension accompanies disagreement, and when there is disagreement, there is no shared vision. This may be an indication that the family is not ready to engage. The CANS facilitator is trained on how to recognize readiness for change and approach differences in ratings. Family desires or their readiness to engage can come up against operational requirements which may involve certain CANS scores for eligibility or timeframes to be met. MCOs should have care coordinators assist when the engagement process is derailed by the operationalizing of engagement.
In some cases, the operationalizing of engagement must be modified based on what happens through actual engagement. The engagement process, including the initial CANS and first plan of care, for the Magellan of Wyoming CME was originally operationalized to 30 days based on waiver requirements. For many families who needed immediate crisis assistance, 30 days was not enough time to complete all the tasks of engagement. Authorizations were at risk. Providers and families were stressed. Magellan Healthcare proposed re-operationalizing engagement to better match the phases of wraparound with a different payment model. Magellan would pay for a 14-day “pre-engagement” period, rolled into waiver rates, and the waiver tasks of engagement would be sequentially stretched to 46 days for the SNCD, CANS and plan of care. In all, the tasks of engagement would be allocated 60 days, better matching the wraparound phases. To test if this improved the rates of families engaging, we tracked disengagement. Family engagement was baselined at 16% disengaged and tracked quarterly, revealing a range of 13%-16%. CANS tracking additionally demonstrated increased needs identification and quarter-over-quarter increases in youth showing improvement (historically 50% and tracked quarterly ranging from 51% to 64%).
Proper operationalizing of engagement allows for family and youth to participate as fully as possible in using the CANS for reflection, self-advocacy and self-direction. From there, how do we link family and youth to appropriate and effective services? In my next post, we will look at Key Decisions 3, appropriate services, and 4, effective services.
[1] https://www.samhsa.gov/section-223/care-coordination/person-family-centered
