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Clinical and Administrative Tools/Guidelines

AACP Guidelines for Psychiatric Leadership in Organized Delivery Systems for Treatment of Psychiatric and Substance Disorders

Preamble

The AACP has a long-standing commitment to the principle that provision of quality services should be the overriding goal of any mental health and/or substance abuse treatment delivery system. In the past few years, the influence of public and private sector managed care and health system reform initiatives has resulted in an enormous transformation of the service delivery system and the organization of care. Community Psychiatry is no longer practiced primarily in community mental health center settings responsible for geographically defined catchment areas. Rather, "communities' are increasingly defined by public and/or private payors who identify organized services delivery systems (incorporating multiple programs and multiple levels of care) to be responsible for the full spectrum of treatment to particular populations, often through some type of shared-risk financing. The rapidity of these changes - in both service delivery and in mechanisms for cost containment - has resulted in considerable uncertainty about how to continue to ensure that quality service provision remains a primary goal. With this in mind, the AACP has revisited its "Guidelines for Psychiatric Practice in Community Mental Health Centers" and is proposing this updated set of guidelines to address, specifically, the importance of identifying the role of psychiatric leadership within any organized service delivery system in ensuring quality service provision.

Principles

1. All organized mental health service delivery systems should identify one psychiatrist as the Medical Director and ensure that that individual has adequate salaried time to perform his/her administrative responsibilities. In systems which are so large as to encompass organized subsystems, each subsystem should have its own Medical Director as defined herein.

In addition, in any system which is sufficiently complex, the Medical Director should designate Associate Medical Directors to ensure adequate supervision of psychiatric services in order to maintain high standards of care in all system components.

2. Each program within an organized delivery system must have one physician identified to provide medical/clinical direction for that program, with the amount of time allocated for that function to be commensurate with the size and complexity of clinical need of that program.

3. The Medical Director shall have ultimate clinical authority, but must function primarily as a collaborator and team member, both with the administration and with clinicians of other disciplines, in order to be maximally effective in accomplishing the goals and functions of the position.

4. The Medical Director shall be delegated ultimate authority and responsibility for ensuring psychiatric oversight in each of the following clinical activities:

  1. Emergency Services: Review of all dispositions through a defined protocol.
  2. Acute Care Services: Admission and discharge decisions, level of care determinations, and direct supervision of care.
  3. Psychopharmacology: Direct evaluation of all patients and/or supervision of nurse prescribers through a defined protocol.
  4. Outpatient: Participation and leadership in regular interdisciplinary team case reviews including signing off on diagnoses and treatment plans.
  5. Long-Term Support/Rehabilitative/ResidentiaI Services: Participation and leadership in interdisciplinary treatment plan reviews.
  6. Other Medical Care

5. The Medical Director shall be delegated the ultimate authority and responsibility for ensuring psychiatric involvement and/or oversight in each of the following administrative areas:

  1. Development of job descriptions for system psychiatrists.
  2. Establishment of criteria for adequate psychiatric staffing within the system.
  3. Recruitment and supervision of psychiatrists.
  4. Staff training.
  5. Quality Assurance, CQI, Risk Management, and Outcome Evaluation.
  6. Utilization Review, Level of Care determinations, and appeals to third party payors.
  7. Developing standards of practice for psychiatric services in each program/level of care.
  8. Developing standards for continuity of case management and care as patients move through the system.
  9. Developing policies regarding medical and psychiatric evaluation, laboratory studies, risk assessment, treatment protocols, admission and discharge criteria, administrative discharge criteria.
  10. Medical Records/Documentation standards.
  11. Involvement in program budgeting, program planning, and program development.
  12. Establishment of criteria and processes for ensuring that clinical resources and programs are adequate and appropriate for the population served.

Model Job Description for the
System Medical Director

Responsibilities:

Unless the Chief Executive Officer (CEO) is properly trained and qualified to serve this purpose, the Medical Director has ultimate authority and responsibility for the medical/psychiatric services of the System. Specifically, this includes responsibility for:

  1. Assuring that all system patients receive appropriate evaluation, diagnosis, treatment, medical screening and medical/psychiatric evaluation whenever indicated, and that all medical/psychiatric care is appropriately documented in the medical record.
  2. Assuring psychiatric involvement in the development, approval, and review of all policies. procedures, and protocols that govern clinical care.
  3. Ensuring the availability, of adequate psychiatric staffing to provide clinical, medical, administrative leadership and clinical are throughout the system.
  4. Developing job descriptions for staff psychiatrists that are comprehensive, and permit involvement in therapeutic and program development activities, as well as application of specific medical expertise.
  5. Recruiting, evaluating, and supervising physicians (including residents and medical students), and overseeing the peer review process.
  6. Assuring that all clinical staff receive appropriate clinical supervision, staff development, and in-service training.
  7. Assuring, through an interdisciplinary process, the appropriate credentialing, privileging, and performance review of all clinical staff.
  8. Providing direct psychiatric services.
  9. Advising the CEO regarding the development and review of the System's programs, positions, and budgets that impact clinical services.
  10. Assisting the CEO be participating in a clearly defined and regular relationship with the Board of Director.
  11. Participate with the CEO in making liaisons with private and public payors, in particular with Medical Directors or equivalent clinical leadership in payor organizations.
  12. Assuring the quality of treatment and related services provided by the system's professional staff, through, participation (directly or by designee) in the system's ongoing quality assurance and audit processes.
  13. Providing oversight to ensure appropriate continuum of programs, level of care criteria, standards of practice and psychiatric supervision for each program. Internal review of level of care determinations and appeal of adverse UR decisions is an additional component of this process.
  14. Participating in the development of a clinically relevant, outcome evaluation process.
  15. Providing liaison for the system with community physicians, hospital staff, and other professional and agencies with regard to psychiatric services.
  16. Developing and maintaining, whenever possible, training programs in concert with various medical schools and graduate educational programs.

The Medical Director, by licensure, training, and prior clinical/administrative experience, shall be qualified to carry out these functions and shall have an approximate minimum of 50% of his/her time allocated to administration. In all but the smallest settings, this position should be no less than 32 hours per week.