The Georgia Collaborative ASO’s Clinical Department is based on an understanding that the unique needs of each Individual are supported in the context of hope, recovery, resiliency, and independence. The Clinical Department is organized into three main, interconnected functions: 1) Utilization Management, 2) Care Coordination Program, and 3) Pre-admission Screening and Resident Review (PASRR). Each of these functions creates and supports systems of care that achieve a systematic and coordinated approach to superior quality that is clinically appropriate, cost effective, data-driven, and person-centered. We integrate this approach to ensure best-practice treatment and supports that achieve the Individual’s personal goals.
- Care Coordination
The Georgia Collaborative ASO’s Care Coordination Program is a community-based program designed to support and serve Individuals within the behavioral health and co-occurring developmental disability population with the most complex care needs or during critical transition periods. Being in the community allows the Care Coordination Program to support the Individual in partnership with all community-based providers, DBHDD regional offices, facilities, Individuals, families, and any other stakeholders to ensure access to high-quality services so Individuals can reach their recovery goals. The goal of The Georgia Collaborative ASO’s Care Coordination program is to Connect the Unconnected.
- Certified Peer Specialists
Certified Peer Specialists (CPS) and Certified Recovery Empowerment Specialists (CARES) are Individuals who have lived experience with a mental health or substance use challenge which allows them to uniquely connect in a meaningful way with Individuals thereby showing by example that long-term recovery is attainable. They are also trained in principles of recovery and resiliency, wrap-around services, and traditional peer support.
- Community Transition Specialists
The Community Transition Specialists (CTS) provide outreach and discharge appointment coordination to support an Individual’s transition from an acute level of care to a community-based provider. The CTS works with facility discharge planners and community providers to support aftercare services. We recognize that these level of care transitions can be challenging for an Individual. The CTS may attend discharge planning meetings and facility meetings to strengthen transitions for Individuals at risk for multiple hospitalizations. Community Transition Specialists are either Certified Peer Specialists (CPS) or Certified Addiction Recovery Empowerment Specialists (CARES).
- Covered Services and Level of Care Guidelines
- The Georgia Collaborative ASO’s Utilization Management processes determine medical necessity based on the most recent version of the Service Guidelines contained within the Georgia DBHDD Provider Manual for Community Behavioral Health Providers. For PRTF/CBAY level of care, the most recent version of the Georgia DBHDD PRTF/CBAY policy is used.
- PASRR Provider Resources
Preadmission Screening and Resident Review (PASRR) is a federal requirement designed to prevent the inappropriate placement of Individuals with mental illness or intellectual and developmental disabilities in long-term care. PASRR requires that all applicants to a Medicaid-certified nursing facility be evaluated for mental illness, intellectual and developmental disabilities, and/or a related condition; be offered the most appropriate setting for their needs (in the community, a skilled nursing facility, or in an acute care setting); and receive the services that they need in the appropriate setting.
- Specialized Care Coordinators
Specialized Care Coordinators (SCC) are licensed behavioral health clinicians who provide clinical oversight for Individuals with complex clinical histories and/or multiple hospitalizations. An SCC seeks to outreach and engage the Individual’s provider(s), support network, and community-based services to best support the entire system of care. The SCC will routinely outreach to community-based providers and medical providers to support the Individual’s treatment, resolve service barriers, and partner with providers to create innovative ways to maximize an Individual’s community goals.
- Utilization Management
The Georgia Collaborative ASO’s Clinical Utilization Management program encompasses management of care from the point of entry through discharge using medical necessity criteria as defined by DBHDD. Behavioral Health (BH) providers are required to comply with utilization management policies, procedures and associated review processes. Providers who only offer Intellectual Developmental Disabilities (IDD) services currently do not engage with The Georgia Collaborative ASO’s utilization management program. Utilization processes for IDD services are managed through the DBHDD Regional Field Offices. However, behavioral health services for individuals that have dual BH and IDD diagnoses are supported.
Examples of utilization review activities in The Georgia Collaborative ASO’s utilization management program include determinations of medical necessity for pre-authorization, concurrent review, retrospective review, discharge planning, and coordination of care.