Glossary

Arc - Pennsylvania. The Association for Retarded Citizens (ARC) is a voluntary, non-profit organization committed to advocating for the rights of all people who are mentally retarded. Arc, Pennsylvania, has county chapter affiliates in 60 of Pennsylvania's 67 counties.

Asperger's Syndrome. The essential features are severe and sustained impairment in social interaction and the development of restricted repetitive patterns of behaviors. Other features include a special interest and ability in reading, poor motor skills, and social withdrawal.

Assessment. The process of determining an individual's current and potential strengths, weaknesses, and needs. Uses formal and informal recurrent diagnosis and evaluation information provided by each service.

Attention Deficit Disorder (ADD). Neurological condition that is often evident from childhood. ADD may cause restlessness, disorganization, hyperactivity, distractibility, and mood swings.

Attention Deficit Hyperactivity Disorder (ADHD). Characterized by a very short attention span, impulsiveness, and hyperactivity.

Authorization. A document specifying the type, amount, and maximum payment for approved services sent to the service provider. See "Pre-Certification."

Autism. A lifelong, nonprogressive neurological disorder typically appearing before the age of three yeas. It is characterized by language and communication deficits, withdrawal from social contacts, and extreme reactions to changes in the immediate environment.

Base Service Unit (BSU). The intake/access location for all consumers which provides administrative direction and coordination and is responsible for providing for the most efficient and effective use of limited resources.

Behavioral Health. Refers to mental health and/or substance abuse services which, under managed care in Pennsylvania, are separated from physical health services.

Capitation. Involves a prepaid amount per month to the provider per covered member (PMPM).

Care Management (or Care Coordination). A set of activities which assures that every person served by the system has a single approved care (service) plan that is coordinated, not duplicative, and designed to assure cost effective and good outcomes. Initial and continuing authorizations are generated by care coordinators.

Case Management. The linking of a consumer to the service system and coordinating the various system components in order to achieve a successful outcome. The five case management activities are: (1) assessment, (2) planning, (3) linking, (4) monitoring, and (5) advocacy. Case management's primary goal is service provision for the consumer, not management of the system or its resources.

Case Manager. The person responsible for ensuring continuity of services. Also called service coordinator.

CHIP. Refers to the Children's Health Insurance Program which offers coverage for children of low-income families that cannot otherwise afford the health insurance. This program is managed by the Pennsylvania Insurance Department.

CHIPP. Is the Community Hospital Integration Program Project which provides funding to county mental health offices to improve infrastructure and place residents of state mental hospitals in community setting with adequate treatment and supports.

Clinical Psychologist. Works in the areas of personality assessment and prevention and treatment of emotional and mental disorders. One would usually work with individuals, groups, or families who have personal, social, emotional, or behavioral problems.

Clinical Social Worker. A person with specialized post-graduate training in social work aspects of psychiatry who uses techniques pertinent to both fields. These individuals are concerned with helping people find ways of dealing with mental health problems.

Complaint. Any problem that can be resolved informally presented by a consumer or anyone acting on the consumer's behalf that involves how their case is/was handled by MH/MR or a provider of MH/MR services.

Concurrent Review. A routine review by an internal or external utilization reviewer during the course of a patient's treatment to determine if continued treatment is medically necessary.

Consumer. A person who is receiving or has received behavioral health or mental retardation services from MH/MR or its providers. See "Member."

Consumer Monitoring. The continuous evaluation of a consumer's progress which leads to reassessment and the development of new plans, linkages, or other disposition. It is an activity of the case management function within the service functional area.

Continued Stay Review. A review conducted by an internal or external auditor to determine if the current place of service is still the most appropriate to provide the level of care required by the client.

Crisis Intervention. Any activity provided in the natural environment aimed at the reduction of acute emotional disabilities and their physical and social manifestations.

Early Intervention. Home-based services for children from birth through age two who have a developmental delay or disability. Services are designed to support families and foster normal development and sound experience in natural settings.

Grievance. A request for reconsideration of a decision by MH/MR or the provider to deny authorization or payment for a service which was prescribed for the consumer.

Length of Stay. The period within the service duration delimited by entry to and exit from a service.

Managed Care. A comprehensive approach to healthcare delivery that encompasses planning, educating, monitoring, coordinating, and controlling quality, access, and cost while considering the interests of patients, providers, and payers or a system that uses financial incentives and management controls to direct patients to providers who are responsible for giving appropriate care in cost-effective treatment settings. Such systems are created to control the cost of health care.

Medically Necessary. Services or supplies which meet the following tests:

• They are appropriate and necessary for the symptoms, diagnosis, or treatment of the medical condition.

• They are provided for the diagnosis or direct care and treatment of the medical condition.

• They meet the standards of good medical practice within the medical community in the service area.

• They are not primarily for the convenience of the plan member or a plan provider.

• They are the most appropriate level or supply of service which can safely be provided.

Member. Refers to a person who is receiving care from MH/MR or its providers. See "Consumer."

Mental Disability. The inability to meet individual and societal needs because of emotional or mental retardation problems.

Mental Health. A relatively enduring state of being in which an individual is reasonably satisfying to self, as reflected in his/her zest for living and feeling of self-realization. It also implies a large degree of adjustment to the social environment, as indicated by the satisfaction derived from interpersonal relationships, as well as achievements.

Mental Health/Mental Retardation Program (MH/MR). The local umbrella organization responsible for all public mental health and mental retardation services in the three-county area.

Mental Illness. A state of being in which an individual has difficulty in handling situations and feelings of an everyday nature. In certain instances, conditions are characterized by impairment of intellectual functions, the experience of shallow and unstable emotions, and difficulty in adapting to one's environment.

Mental Retardation. Significantly below average general intellectual functioning which originates during the developmental period and is associated with impairment in adaptive behavior. Mental retardation may be caused by genetic or metabolic defects, by problems before a child is born, by deprivation in early childhood, by a disease of the nervous system, by poisons, or by brain injury.

Network Model. A health plan that contracts with multiple physician groups or other providers to deliver health care to members (known as approved providers).

Neurosis. One of the major categories of emotional maladjustments, classified according to the predominant symptom of defense mechanism. Anxiety is the chief symptom, with the possibility of some impairment of thinking and judgment.

Ombudsman. A public official or representative appointed to investigate citizens' complaints against local agencies and programs that may be infringing on the rights of individuals.

PCP (Primary Care Provider). A Primary Care Provider such as a family practitioner, general internist, pediatrician, and sometimes ob/gyn. Generally, a PCP supervises, coordinates, and provides medical care to members of a plan. The PCP may initiate all referrals for specialty care. Within behavioral health, case managers are often the PCP or it may be a role of the outpatient therapist.

Personality Disorder. A group of disorders characterized by pathological trends in personality structure. It may show itself by lack of good judgment or poor relationships with others, accompanied by little anxiety and no personal sense of distress.

Pervasive Developmental Disorders. When a child does not meet the criteria for autism, the child may be given this diagnosis.

Pre-Certification. The prior authorization required by some managed care companies before health benefit payments will be authorized. See "Authorization."

Prevention Services. Services that substantially reduce the probability of the occurrence of mental disabilities resulting from social, emotional, intellectual, or biological disorder.

Primary Care. The initial health care contact, basically ambulatory in nature, with emphasis on prevention and continuity of care.

Provider Organization. A practice, clinic, mental health center, hospital, or other organization that is employed by managed health care or MH/MR programs to provide treatment services.

Provider (of Service) or Practitioner. An organization or individual whose primary activity is the provision of mental health, mental retardation, or human service care to individuals or is involved in the administration of facilities or institutions in which such care is provided and with whom the agency contracts.

Psychiatrist. A specialist in psychiatry, specifically a graduate of a medical school, licensed to practice and to prescribe medications, with postgraduate training in the detection, diagnosis, and treatment of mental and emotional disturbances. The disturbances may be of physical or emotional origin or result from a situational crisis.

Psychosis. A severe impairment of mental functioning that interferes with an individual's ability to meet the ordinary demands of life.

Title XVIII. The federal legislation which established Medicare, a program of hospital and medical insurance which pays for services for most consumers over age 65.

Title XIX. The federal legislation which established Medicaid, a joint federal and state program that provides Medical Assistance to low-income consumers of all ages who need care but cannot afford it.

Title XX. The federal legislation which established a variety of services to low-income individuals and families.

Triage. A formal system used to identify, classify, and treat people according to the severity of their condition(s).

Utilization. Can be expressed in a variety of ways:

• the extent to which a given group uses specified services in a specified period.

• the extent to which the members of a covered group use specified services over a specific period. Utilization rates are established to help in comprehensive health planning, budget review, and cost containment.