Plan Member Gets Appropriate Mental Health Services After Reason Behind Emergency Room Misuse Identified

Client

A private sector construction company with 115 local employees, covering 135 total lives on its benefit plan.

Challenge

A survey conducted by Apex discovered that the highest chronic condition among the client’s employee population was depression, which represented 9.1 percent of the workforce.

The company also was experiencing an abnormally high spend related to mental health care for a dependent on an employee’s benefit plan. Apex’s Kinetiq Health team discovered a large amount of this spend originated from high utilization of emergency room services, hospitalizations and treatment related to alcohol dependency.

With practical medical experience in their arsenal, Apex’s clinical strategists knew that costs related to this plan member shouldn’t be so unusually high and were likely associated with inpatient hospitalization for a behavioral crisis.

Solution

Apex was able to identify the issues and determine through claims analysis that the plan member was reaching a near-crisis level. The team was able to identify a high level of ongoing risk and leveraged Apex’s deep relationships with carriers to receive updates on the individual.

In checking on this plan member, Apex contacted the carrier to see if the individual was participating in Case Management, or if any other outreach had been made. The individual had not responded to outreach being made.

With practical medical experience in their arsenal, Apex’s clinical strategists (including registered nurses, licensed clinical pharmacist and license clinical social worker) knew that costs related to this plan member shouldn’t be so unusually high and were likely associated with inpatient hospitalization for a behavioral crisis.

Results

By identifying the employee’s medical and behavioral issues and specific needs, the Kinetiq Health team was able to establish individualized care paths to manage chronic conditions.

The employee was steered to an appropriate place of service for ongoing monitoring. While a dollar amount of savings can’t truly be identified, Apex’s goal to prevent an inpatient behavioral crisis was accomplished.

While specific care was targeted to this plan member, the Kinetiq Health team also increased mental health education among the client’s entire employee population.

This solution was also helpful during renewal discussions and annual reviews of the performance of the client’s benefits program and plans.

Case Study

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