Continuum of Ambulatory Behavioral Health Services

A position paper from the Association for Ambulatory Behavioral Healthcare

by Laurel J. Kiser, Ph.D., MBA, Paul M. Lefkovitz, Ph.D., Lawrence L. Kennedy, M.D. and Mark A. Knight, MSW

—

The shift to ambulatory care, occurring across the healthcare spectrum, is now profoundly affecting the delivery of psychiatric and substance abuse services. Cost and quality considerations have driven innovation in ambulatory mental health services with the result that behavioral health is now one of the most dynamic sectors of the healthcare system. Payers and purchasers are recognizing the clinical and economic value of a continuum of care extending between 24-hour inpatient and traditional outpatient modes, and are designing benefits that support partial hospitalization, intensive outpatient and emerging types of intermediate treatment.

The rapid increase in treatment alternatives requires a further clarification of the clinical issues and service components essential to this type of care. Although intrinsically linked to 24-hour in-patient/residential care and standard one-hour-a-week outpatient treatment that form the traditional ends of the mental healthcare spectrum, ambulatory care has–until recently–been the under-used, undefined and poorly understood segment of the continuum. Ambulatory care challenges the conventional structure of service delivery by requiring that interventions be defined by function rather than setting, and that services be organized around the individual needs of the patient rather than the practice patterns of the provider. Further, the development of ambulatory care is the realization of the concept that treatment should be delivered in the community, in a manner which is closer to real life experience.

This paper proposes a coherent continuum of care model for ambulatory behavioral health services to facilitate the development and use of clinically appropriate levels of treatment. The model that follows describes three distinct levels of service structure and intensity and identifies meaningful definitional boundaries among these levels of care.

Each of these levels of care is differentiated by critical patient and service variables delineated across the ambulatory continuum. Because the appropriate level of care for a patient must be based on clinical needs and patient characteristics matched to service attributes, these variables are central to an understanding of the continuum. The proposed continuum model, accompanied by the patient and service variables, is intended to ensure that treatment needs take precedence over cost or other considerations that sometimes influence patient placement in the absence of more clinically relevant criteria.

Six Unifying Principles

A set of unifying principles–in part derived from extended experience with the partial hospitalization modality–lays the foundation for the continuum of ambulatory behavioral health services. These principles both differentiate the ambulatory service continuum from inpatient and traditional outpatient and unify the distinct levels of care within the continuum. These underlying principles are:

1. Ambulatory behavioral health services are designed for persons of all ages who present with a psychiatric and/or chemical dependency diagnosis and the need for treatment which is more intensive than outpatient office visits and less restrictive than 24-hour care.
2. Ambulatory behavioral health services consist of a coordinated array of active treatment components which are determined by an individualized treatment plan based upon a comprehensive evaluation of patient needs.
3. Ambulatory behavioral health services treat patients requiring intensive therapeutic intervention in a manner which simulates real-life experience and with the least amount of disruption to their normal daily functioning.
4. Ambulatory behavioral health services are available to patients on a consistent basis and are augmented with 24-hour crisis backup.
5. Ambulatory behavioral health services require active involvement of the service team and patient with both community and family resources.
6. Finally, due to the matching of patient needs with targeted interventions, the provision of treatment in the most appropriate, least restrictive environment, and the reliance on patient strengths, resources and family and community support systems, ambulatory behavioral health services are cost efficient.

Each level of care specified below is predicated upon these underlying principles. In this way, the continuum describes a cohesive, unified spectrum of treatment.

The Continuum of Ambulatory Behavioral Health Services: A Description

Figure 1 provides a graphic representation of the continuum of ambulatory behavioral health services highlighting three levels of care along the proposed continuum. While a number of program or treatment variations could be identified, the three levels discussed have been selected because they are functionally different types of interventions that can be clearly distinguished from each other by service characteristics and patient condition. The three levels of the continuum also describe the range of facility, community and home-based treatment that currently exists. Organized as a continuum, this system of ambulatory care enables the movement of patients to the most clinically appropriate and cost effective level of care.

Each of the three levels of care specified is characterized by patient and service variables which provide definition for that component level of care. Each of these variables is conceptualized along a parallel continuum from more intensive to less intensive. Table I provides an operational definition of these key service and patient variables. Tables 2 and 3 define the variables at each level of care along the ambulatory continuum.

The patient and service variables, though discrete, are interdependent and are intended to be used together. None of the service variables used alone could accurately describe the service nor could any one patient variable characterize a patient’s condition.

A brief description and examples of each ambulatory level of care follows.

While the prototype service for Ambulatory Level I is the traditionally defined partial hospital program, this level also includes other intensive, hospital diversion services including home-based crisis intervention or stabilization services. This level is conceptualized as an alternative to inpatient care with both patient and service variables matching that level of intensity. Functioning to provide crisis stabilization and acute symptom reduction, this level may also include a less intensive residential component such as the Inn model for adults or the family treatment home for children. The Standards and Guidelines for Partial Hospitalization, published by the Association for Ambulatory Behavioral Healthcare (formerly the American Association for Partial Hospitalization), outline the definition and programmatic requirements for facility-based partial hospitalization programs. Patients appropriate for Level I services are more severely disturbed and require the intensity and restrictiveness of care offered at this level. Patients appropriate for this level of care demonstrate disabling to severe symptoms resulting from either an acute illness or exacerbation of a chronic illness.

Ambulatory Level 2 services are characterized by active treatment, frequently with a rehabilitative or transitional function that incorporates into the treatment plan the benefits of stable, staff-supported milieu that extends beyond the treatment setting into the significant parts of the patient’s community network. Attendance at the program is more flexible and may not be needed on a full-time basis as Level 2 patients may function adequately in other structured settings, such as school or work. Milieu-based intensive outpatient programs are a good example of Level 2 programming. Another example of Level 2 programming targets individuals with chronic mental illness by incorporating a focus on psychosocial skill development with the goal of maintenance of functioning within the community.

Services in Ambulatory Level 3 are offered under the direction of a coordinated treatment plan, but do not necessarily include a stable patient community or structured programmatic activities. Level 3 care is differentiated from outpatient care by the number of hours of daily and weekly involvement, the multi-modal approach, and the availability of specified crisis intervention services 24-hours per day. Patients treated at this level of care either maintain their role functioning in several areas or have adequate family/community support such that they do not require a sense of community solely from treatment. Drop-In Centers are an example of this level of care for individuals with serious and persistent mental illness. This level also represents a step up from outpatient care for individuals who may need a more intensive array of services.

Conclusion

Rather than further fragment the mental health delivery system, this proposal presents a continuum of services which fit together conceptually by virtue of their common unifying principles and shared patient and service variables. Our goal in introducing this model is to stimulate further thinking and research to clarify the patient variables and therapeutic factors that will guide appropriate and effective patient -placement in the specific levels of care along the continuum. The Association for Ambulatory Behavioral Healthcare invites input and guidance from the field in further refining and enhancing this continuum model. AABH would like to thank the following individuals/organizations for their interest and input into this model.

• Alan Axelson, MD; lnterCare; Pittsburgh, PA
• John Cooke, Ph.D.; The Faulkner Center; Austin, TX
• Ronald D. Geraty, MD; MEDCO; Burlington, MA
• Leslie Lawson; Human Affairs International; Chicago. IL
• Maggie A. Moran, RN; MHSA Choate Health Management; Woburn, MA
• Shelia A. Pires, MPA; Human Service Collaborative; Washington, DC
• William R. Seelig, LCSW; Eastfield Ming Quong; Campbell, CA
• Steven M. Soreff, MD; Westboro State Hospital; Westboro, MA
• Sandra Speer, Ph.D.; AABH Board of Directors; Richmond, VA
• Sharon Warren, MD; Sheppard Pratt Health System; Baltimore, MD
• Robert Wise, MD; Blue Cross/Blue Shield of Illinois; Chicago, IL

We also thank the more than 150 people who participated in the Delphi process of relining this document or provided other formal feedback to AABH.

Table 1: Patient and Service Variables Across the Continuum

Table 2: The Continuum of Ambulatory Behavioral Healthcare Services — Service Variables

Table 3: The Continuum of Ambulatory Behavioral Healthcare Services — Patient Variables