LTSS clinical guidelines help health plans navigate the challenges of increased demand

February 28, 2018
Jessica Carpenter
Jessica Carpenter, MS, RD, LDN
Senior Director, Disability and Community Services

Long term services and supports (LTSS) clinical guidelines are the foundation of a successful LTSS utilization management program. Strong guidelines help health plans drive LTSS programs toward positive outcomes such as consistency in decision making, clinically appropriate services, contained costs and program integrity. The goal is ensuring individuals receive the right service, in the right setting, and at the right time.

As the independent living movement continues to advance, more individuals with disabilities are seeking to live in their own homes or within a community setting. As such, there has been an increased demand for LTSS. Increased demand combined with service supports of varying costs and inconsistencies in service delivery across provider types can lead to challenges in LTSS delivery, including inappropriate utilization of services.

LTSS clinical guidelines support health plans in navigating the challenges increased demand can bring. Clinical guidelines help in mitigating service inconsistencies, and ensure that only those services that are medically necessary, least costly, and most appropriate for the individual are authorized for use.

In order to achieve optimal outcomes that satisfy the individual, provider, and payer, clinical guidelines should be developed with a comprehensive approach that utilizes the experience of LTSS experts from a variety of backgrounds.  The guidelines need to consider the design of the LTSS program, identified populations and delivery approach.

UMass Medical School’s work developing and integrating LTSS clinical guidelines into a utilization management program resulted in cost avoidance and savings of over $22 million annually for the Massachusetts Medicaid program.

Our team uses evidence-based best practices and national standards when working with health plans and state Medicaid programs on LTSS clinical guideline development and integration. We provide clinical consultation including:

  • Post-implementation assessment of the quality of implemented LTSS clinical guidelines, 
  • Evaluation of overall compliance and review of if guidelines are meeting desired outcomes,   
  • Continuous quality reviews, including use of stakeholder feedback for guideline improvement, and
  • Training of appropriate staff and LTSS providers.