By: Barbara Ann Dunn, ACSW, LCSW, Director, Program Innovation and Outcomes, Magellan Healthcare
The Child and Adolescent Needs and Strengths (CANS) is a multi-purpose tool developed for children’s services to support decision making, including level of care and service planning, to facilitate quality improvement initiatives, and to allow for the monitoring of outcomes of services. I am often asked “How does managed care use the CANS?” Those of you who ascribe to Transformational Collaborative Outcomes Management (TCOM) likely recognize that managed care plays an increasing role in using clinical decision support tools and value-based programs The CANS offers a common language to look at resource needs and make the balancing of resources more transparent.
John Lyons frames the use of the CANS as part of “Five Key Decisions:” access, engagement, appropriateness, effectiveness and transitions. This framework on CANS use may be helpful for understanding how managed care uses decision support tools, and the CANS in particular, as the CANS has bonus options beyond the usual clinical decision support tools. With this and upcoming blog posts, I’ll discuss each of the five key decisions. This first post on the Access dimension of the Five Key Decisions will not only demystify managed care, but also help you to advocate for the transformational system that youth and families need.
Access refers to screening for a target population, such as using CANS algorithms for matching needs to services. This identifies youth who will benefit from a certain level of care or service, as well as those who will not. We know from early research that youth with lower needs than the level of care is designed to address, such as residential, will have poorer outcomes.
When it comes to using the CANS as an eligibility tool for 1915 Medicaid waiver eligibility or services, there are apprehensions. Do service gatekeepers using the CANS over-report needs? With 11 other wraparound programs, Magellan Healthcare joined the national analysis led by the University of Washington that addressed this question. Systems using the CANS for eligibility did report more needs than systems not using it for eligibility. However, an independent care manager audit found under-reported needs when compared to the needs identified in the standardized Independent Behavioral Health Assessment tool. In other words, the gatekeepers were not found to be over-reporting needs nor focusing on meeting the eligibility algorithms, but on assessing the youth and family needs and strengths. This is the right thing to do.
In the best of all worlds, there would be two or three years of data on youth in a program using the CANS before anyone creates or uses an algorithm for targeting access. That data would drive identification of youth with better outcomes. Then, algorithms would be created for decision-making on youth access to programs. Unfortunately, that can take more time than the funding permits, particularly when a Medicaid Waiver requires an eligibility tool from the start.
Sometimes the algorithm is borrowed from other states, then stakeholders consider the target populations along with the CANS items, and the result is put into waiver or program requirements. This happens before the managed care organization (MCO) is involved. Usually, there is a request for proposal process that multiple MCOs respond to with their solution for the requirements set forth in the waiver and program design. The state or jurisdiction will select the proposal best meeting the rubric set forth. The selected MCO then implements the program based on the waiver and other state requirements but doesn’t often have input into the algorithm creation.
The MCO can, however, validate that an algorithm is capturing the target population using the CANS profiles, outcomes data and other information about youth in the program. This data is then presented to the state or jurisdiction to discuss potential changes to the algorithms.
One Magellan experience with the algorithms in Louisiana followed the process above, yet youth were not being fully identified for the high-risk waiver. Investigation of the CANS data found that the youth with the highest risk of inpatient and residential services were actually two populations, and one was being missed in the high-risk algorithm. Using the CANS profiles of youth at actual high risk and demonstrating that this new algorithm met the Louisiana regulations for youth at risk of inpatient services, Magellan proposed a second algorithm using select CANS risk items at a level of a 3. The state brought the justification to the Centers for Medicare & Medicaid Services, which approved. As youth were reassessed, they were screened into the high-risk waiver.
MCOs, with their advanced analytics capabilities, can provide valuable insights to state and local agencies to inform ongoing adjustments to algorithms to ensure that youth have access to the appropriate level of care.
In my next post on the second Key Decision, engagement, we will discuss moving people from access to being “equal partners in the system” (John Lyons). Check back soon.
 Lyons, J.S. & McCollough, J.R. (2006). Monitoring and managing outcomes in residential treatment: Practice-base evidence in search of evidence-based practice. Journal of the American Academy of Child & Adolescent Psychiatry, 45, 257-251.