On October 31, 1963 President John F. Kennedy signed into law the Community Mental Health Act (also known as the Mental Retardation and Community Mental Health Centers Construction Act of 1963). It was the last piece of legislation JFK signed before his assassination. For millions of Americans, JFK's final legislation ended the nightmare of being warehoused in institutions and opened the door to a new era of hope and recovery—to a life in the community. The auspicious occasion of the 50th anniversary will appropriately parallel a sustained effort by the Heart and Soul of Change Project to reach those in public behavioral health (PBH). This is the first question of a series of Q and As about public behavioral health and implementation of PCOMS. Mary Haynes wrote this piece about PCOMS, medical necessity, and the "golden thread."

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Dr. Barry L. Duncan, Director____________________________________________________________________
Training and Implementation of the Partners for Change Outcome Management System
Public Behavioral Health and PCOMS: Questions and Answers
How Do Funder Mandates of Medical Necessity Fit with PCOMS?
Medical necessity is defined as the justification for the services that are needed for the diagnosis or
treatment of a medical condition., The concept is most often used by payers to denote whether a service is
“reasonable and necessary” and meets accepted standards of medical practice. In mental health services,
insurance companies, including Medicaid and Medicare, determine payment for services based on their
decision as to whether or not a particular treatment, test, or procedure is “medically necessary.” Activities
that are billed for must be justified as reasonable, necessary and appropriate, and based on evidence-based
clinical standards of care. Clinical record documentation must provide clear evidence for medical necessity
throughout the flow of the record, which is called the Golden Thread. The thread begins with assessment
and diagnosis and is then carried into goals that are identified on the treatment/service plan, including
identification of interventions designed to ameliorate the symptoms of the diagnosed condition. The thread
continues as the record documents the implementation of those interventions and their benefit in the
contact/progress notes.
At first glance it might seem that the Partners for Change Outcome Management System (PCOMS) would
be at odds with meeting medical necessity standards: PCOMS does not emphasize the formulation of a
“correct” diagnosis, nor presuppose that any given intervention will be effective based on that diagnosis, or
that treatment will necessarily focus directly on symptom amelioration. Nevertheless, PCOMS is an
excellent fit with medical necessity standards.
PCOMS calls for a full exploration of the problem(s) for which the client is seeking help, clear
identification of the client’s goals, the selection of interventions based on collaboration between the
provider and the client, and especially, an ongoing evaluation of whether or not the client is responding to
any intervention offered. The regular use of the Outcome Rating Scale and Session Rating Scale, or
PCOMS provides a focus which is often missing in mental health services. Ongoing conversation about the
meaning of the client’s scores better ensures that the client and provider share a common understanding
about both the process and the outcome of the service. This leads to greater clarity about goals and the
methods to reach them. Ideally, the initial ORS score on the domain relevant to each goal is incorporated
into the treatment/service plan as a reference point, and updated scores are then reported in the progress
notes. This is particularly important for the continuity of the Golden Thread because symptoms are often
not directly targeted by interventions in mental health services. Staff who have implemented PCOMS have
reported that the treatment/service plan and the progress notes “practically write themselves” to meet
medical necessity standards when the information from the measures is fully incorporated into the sessions.
Written by Mary Haynes, Ph.D with input from David Hanna, Ph.D., Jodi Daly, Ph.D., & Bob Bohanske,
Ph.D.