Northeast
Coordinate with Other Providers for Improved Member Care
In the Northeast Care Management Center’s 2008 treatment record reviews, we saw a decline in four of the five measures relating to coordination of care, with the overall score dropping from 60.9 percent to 53.6 percent.
Communication and coordination of care among all providers participating in a member’s treatment is essential to facilitate quality and continuity of care. And, Magellan requires providers to maintain organized, well-documented member treatment records that reflect continuity of care. We expect that all aspects of treatment will be documented in a timely manner, including face-to-face encounters, telephone contacts, clinical findings and interventions.
Tips from a Magellan Provider
Dolores Reilly, PsyD, a provider in Magellan’s network, and her staff place a high priority on maintaining thorough member records, as we have seen in our reviews of her records.
“What I consider good record-keeping is starting out first with a good evaluation,” says Reilly. “From that you can decide the treatment and treatment planning. And include a progress note after each session, one that is really streamlined and focused,” she says.
After typically conducting an evaluation using one, two, or sometimes three sessions (depending on the status of the patient), Reilly talks with the member about the treatment plan, which may or may not include medication. Whether or not it does, this is the time, at the end of the evaluation, when she asks the client for permission to contact the primary care physician (PCP).
“I explain that I let the PCP know that I am working with them in case something comes up down the road that would be important for the PCP to know, or in the event that medication is considered,” says Reilly. She has developed a release of information form and form for communicating with the PCP, which contains lines for the physician’s name, address, and the date; and some check-offs for what is recommended for the patient, e.g., what form of therapy. Reilly says, “I’ll share the diagnosis and my recommendations for treatment with the PCP, and include whether or not I recommend a medical or physical evaluation.”
“We send the letter to the PCP in the early part of the therapeutic relationship, probably after the third or fourth session, after the evaluation is completed. But, generally, telephone contact with the PCP on a regular basis is difficult, so that’s why, with sending it in writing, at least they know the patient is in therapy and the lines of communication are open in case something comes up that requires discussion,” says Reilly.
Reilly makes a copy of the letter and puts it in the record, with a short note. “Part of our paperwork includes a contact log, and we’ll note on the log that a PCP letter was sent on a certain date,” says Reilly.
Visit the Clinical Forms area of this website for sample documentation forms and review the Magellan Provider Handbook, including our treatment record review tool in Appendix A, for further information on treatment record documentation.