Hello and welcome. I'm Dr. Benjamin Dress, Professor and Rosalind Carter Chair in Mental Health at the Rollins School of Public Health at Emory University and Health Systems Expert for SMI Advisor. I'm pleased that you're joining us for today's SMI Advisor webinar, Managing Value, a Level of Care Utilization System, LOCUS family of tools. Next slide. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is the APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Next slide. Today's webinar has been designated for one AMA PRA Category 1 Credit for Physicians, one Continuing Education Credit for Psychologists, one Continuing Education Credit for Social Workers, and one Nursing Continuing Professional Development Contact Outreach. Credit for participating in today's webinar will be available until December 26, 2022. Next slide. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Select to download the PDF. Next slide. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. Next slide. Now I'm very happy to introduce you to the faculty for today's webinar, Dr. Wesley Sowers. Dr. Sowers is the Director of the Center for Public Service Psychiatry at the Western Psychiatric Hospital. He's also a Clinical Professor of Psychiatry at the University of Pittsburgh Medical Center. Dr. Sowers was the primary architect of the Level of Care Utilization System, or LOCUS. Thank you so much, Dr. Sowers, for leading today's webinar. Thank you, Ben. I am really happy to be here and thankful for this invitation to talk about value management with the LOCUS family of tools. I'll just start by saying that I have no conflicts of interest to disclose. I would like to just give you the objectives for today's session. At the end of the session, you should be able to discuss historical, economic, and clinical rationale for the development of standardized and reliable utilization systems for behavioral health. Be able to explain the relationship between the use of LOCUS and the enhanced value of services delivered, and describe the basic structure of LOCUS and its unique features. So, when we talk about value management, we're talking about balancing quality and cost or maximizing that ratio. Another way of thinking about that is how we can provide the right amount of care for good outcomes without the unnecessary use of resources. So, service intensity assessment is a process of finding that right balance. To do so, we need a structured method of assessment, a defined continuum of service options, and an algorithm for matching needs and services. Unfortunately, we really haven't had a standardized process for doing that assessment. And why do we need one? Well, standardization would provide a common language to enhance communication and collaboration between stakeholders, enhance continuous quality improvement efforts across systems, reduce the dysfunction and fragmentation of systems, identify service gaps, and improve resource management, and generally reduce administrative waste. So, what do we have instead and why do we have it? It's worth taking a look at the evolution of resource and service intensity management. Up through the 1980s, most decisions were clinician-driven and somewhat idiosyncratic, depending on what one's preferences were and training and so on. But this kind of lack of standardization led to rising costs and often questionable quality of care. There was a great deal of inconsistency in service need determinations, a lack of integration between mental health, physical health, and addictions, and fragmentation and discontinuity in our systems. Market forces were governing these decisions and little was being done to regulate them. Managed care organizations emerged as a market-based solution to these conditions. And here the waiter says, I'll give you a few moments to recover from the crisis. Although MCOs were originally conceived as a way to improve both quality and cost, there was no real accountability in place. And since they were primarily for profit entities, they mainly focused on costs and medical necessity criteria were created for that purpose. But it wasn't a great design and there were some problems with those criteria that were developed. They were initiated by a request for approval for services and they were criteria sets to determine eligibility for a requested service or intervention. So they didn't really provide a clinical assessment of needs. They didn't necessarily incorporate quantifiable dimensional ratings. There were generally separate criteria sets for admissions, continuing stay, and discharge. And they did not really inform treatment planning. They were predetermined service sets, generally speaking. In addition, they were not designed as a way to assess clinical needs just to determine eligibility for services. And there was no interaction or dynamism reflected in the criteria. So that really didn't make them very useful for treatment planning. So what would the ideal process for determining high value decision-making be? There needs to be a balance of quality and resource use. They should be outcome driven, looking at what provided for healthy individuals and communities. A complete continuum that would allow for individual planning, integrated care and resource management. And by that we mean putting those two things in the same hands. Universal standards that provided common language and administrative simplicity. I would just like to take a minute. Okay, let me skip ahead here. In the mid-1990s, I was working with a major behavioral health provider in Pittsburgh. And it was a large hospital system with an emphasis on substance use treatment. The first editions of the ASAM criteria were being circulated at the time. And we were getting beaten up by managed care decision-making. With those things in mind, back in 1995, I started thinking about how we could develop a tool that would accomplish the goals that we had just discussed and established a work group with the American Association for Community Psychiatry to see what we could come up with. And we first identified some principles that would guide that process. And these principles resulted from an extensive review of existing criteria sets and formed the foundation for the development of the LOCUS tool. So these principles included quantifiable dynamic dimensional ratings, flexibility and adaptability so that they could be used in a variety of situations. Integrated non-diagnostically related criteria informed by function rather than diagnosis, which was somewhat unuseful for these determinations. The idea of having something that could be reliably applied and give valid results. And we wanted to make it easy to use and understand so that it was intuitive and collaborative and empowering. So the ease of use was important to allow people to really participate in the process. So from this foundation, I began to lay out the structure of the tool, which I'm going to describe in a few minutes. In this slide, it says to answer your question, we may or may not be trying to have it both ways. And one of the compelling principles really was value, enhancing quality while reducing costs. So we really did want to have it both ways. So what makes these tools, let me just see another slide here, but I guess not. What makes these tools different? The adult LOCUS was released in 1996. The latest version was in 2016. It's a dimensional assessment tool that's quantifiable and interactive. It provides a unique resource continuum, which we'll be talking about. There are flexible levels of service intensity characterized by four variables, and it's very adaptable. And by 2016, 20 years, there was very, there was penetration in various settings across the United States and Canada. We had established some reliability and validity. LOCUS 20 was after 20 years of use was the third version. And it continues to be reviewed in the field and annual reviews are performed. The criteria though, have been remarkably resilient and really haven't changed a great deal over those 25, past 25 years. There's been a digital version available since 1998. In 2001, we developed the child and adolescent version of LOCUS and also XE in 2009. XE is the early childhood service intensity instrument. CA LOCUS was derived from LOCUS and developed in partnership with the American Academy of Child and Adolescent Psychiatry. It's for children and adolescents between six to 18 years old. It has the same structure and placement algorithm as LOCUS and incorporates the systems of care perspective. The early childhood service intensity instrument was developed by the American Academy for infants and children under six years of age. It follows the same principles as the parent tools, but has a slightly different structure and placement process. So what makes these tools different or unique? They really start with an assessment of service intensity needs, not a request for specific services. Service planning is really guided by the LOCUS assessment. It creates an individualized profile of issues that need to be addressed. A quantifiable dimensional ratings allow interaction and facilitate communication. There's just one set of criteria used for admission, continuing stay and transition. So it avoids the complication of those multiple criteria sets. It's accessible and transparent and quick and easy to use. We encourage collaboration and participation of people in services and encourages partnerships that we're going to talk about a little bit more between payers, providers and service users. In addition, there are some actual advantages for payers over their self-developed medical necessity criteria. It reduces the need for review processes and micromanagement. So more resources become available for treatment. Provides a common language for monitoring patient progress and becomes a more collaborative as opposed to adversarial process. Population data can facilitate bundled rate setting and a partial to full delegation of risk to providers. Informs the allocation of resources for network development. They also promote these partnerships between payers, providers and service users. Clients can be participants in their assessment and planning, enhancing their investment. Clinicians have greater autonomy and job satisfaction and they're more likely to make cost conscious decisions. The managed care organization can focus on quality and care coordination and all can share decision-making and responsibility and coordinate transitions to meet both acute and long-term needs. LOCUS has been around for 25 years, but it's been pretty suddenly become more widely recognized. And one of the factors that's brought LOCUS into a broader national attention, apart of course from the SMI advisory group, was the WIC decision in California. The WIC decision was a lawsuit challenging the proprietary criteria of United Behavioral Health and application of its medical necessity criteria. And the basic issue is what processes led to decisions about which services were approved? And were those processes and the decision in these cases more restrictive than generally acceptable standards of care? And were they self-serving for the managed care organization? The Ninth Circuit Court in California developed a very elaborate and very sophisticated analysis of the case and issued something like a 70-page report that in part suggested that LOCUS, CA LOCUS, EXE, and ASAM criteria were the generally accepted standards of care for service intensity assessment. Now, it was subsequently overturned in a rather brief and poorly considered, I would say, panel of the Ninth Circuit Court that actually said insurance coverage is not required to be consistent with the generally accepted standards of care, which is another one of these decisions that makes no sense. But that decision is now under appeal. But this whole process set off a significant regulatory reaction. And it resulted in legislation in California and some other states mandating professionally-targeted mandates, mandating professionally-developed, non-proprietary, non-profit guidelines for level of care decision-making. Other states like New York have made similar kind of mandates through administrative processes. So the WIT decision provided eight principles or identified eight principles of generally accepted standards of care derived primarily from LOCUS, I would say. And since you can't really read this slide very well, I'm going to just go ahead and list them out on this next slide. So the eight principles included the need for multi-dimensional assessment, the need to treat underlying conditions beyond current symptoms, integrated care of co-occurring conditions, the most effective treatment regardless of restrictiveness, err on the side of caution when making these decisions, includes both the maintenance of function and prevention of deterioration. There should be no limits on the duration of treatment and must account for the special needs of children. So as I said, the LOCUS family of tools were primarily the source of these principles and in addition, they offer a seamless continuum, an efficient method for translating assessment to recommendations, engagement in recovery for service users, and consistency in decision making, reducing bias and discrimination and idiosyncrasy in decision making. So we're going to be taking a closer look also at the value management functions it offers as well. But that, oh, we might as well take a look at this cartoon. First I did things for my parents' approval and then I did things for my parents' disapproval and now I don't know why I do things. So what the Lucas family of tools provides for us is knowing why we're doing things and being able to express that. But now I'd like to just move on to describe the dimensional rating system and give you a little bit better idea of how the tool is organized and how it works. So there are six dimensions and seven basic ratings that are required in a Lucas assessment. The first dimension is risk of harm, followed by functional status, medical, psychiatric, and addiction comorbidity. Recovery environment has two scales, one for stress and one support, and treatment and recovery history is the fifth, engagement and recovery status is the sixth. And we're going to look at these in more detail. But the rating system, each dimension has a five point scale and a criteria set for each numeric point in the scale. We select the highest rating in each dimension in which at least one of the criteria is met. And if no criteria is exact, we select the closest. If it's an uncertain, we choose the higher rating and that is how we err on the side of caution. And dimensional scores are summed to obtain a composite score. There are also independent criteria. So in some dimensions, higher scores indicate the need for intensive treatment, a safe and secure environment, and close monitoring of health status. These conditions override the composite score. So in the first three dimensions, high scores require placement in more intensive levels of care, regardless of the composite score. This is just a screenshot of the level of care determination grid. Across the top here are the basic levels of care. On the side here are the dimensional ratings. These middle areas just kind of describe the most appropriate ratings for a specific level of care. The composite scores are listed down around the bottom here. And up in this corner are the independent criteria that would override a composite score. So that just gives you a little bit of an idea of how that looks. And we're going to talk a little bit more about how we derive placement decision. But before we do that, we're just going to take another, a little closer look at some of these dimensions. Each dimension opens with a paragraph explaining the important aspects of choosing the most appropriate rating. And users should become familiar with all the information contained in the introduction and refer to them, sorry about that, as needed when scoring. The piece over on the right is not something that you're expected to read, but it's just to give you a general idea of what those introductory paragraphs look like and their basic order of magnitude. And so they're pretty easy to digest. So dimension one, risk of harm, considers potentially lethal outcomes, and that includes suicidal, homicidal ideation. Someone's ability to be aware of danger or behaviors that are provoked through intoxication. So it looks at current thoughts, intentions, and plans. It's a here and now assessment and assesses changes from baseline and chronic versus acute changes. So we consider various risk factors such as level of distress, past behaviors, impulsivity, and the effects of intoxication. And here's one of the dimensions in which high scores override the composite score. And this is just, again, a screenshot that gives you a little bit of an idea of how the instrument is organized. For each one of these ratings, there are designated anchors that can be chosen to match up with the assessment. I'm just going to go up to the four and five ratings as well. So not an opportunity to read through all of these, but just to give you an idea of how it's laid out and the process for selecting an appropriate rating. So going on to dimension two, we're looking at functional status. And that includes four factors. One's ability to fulfill obligations, maintain interpersonal interactions, vegetative or physical functions such as sleep disruption or appetite disruption, and one's ability to maintain self-care. We only rate disabilities that are due to behavioral health conditions. And for the purposes of this rating, physiologic withdrawal is considered a physical health condition. Once again, high scores of four or five override the composite score. Elements four have an A and B scale, stress and support. These elements interact to create an overall estimate of the environmental impact. We consider both professional and natural supports. And when we're looking, when somebody is ready for transition from a protected or highly supportive environment, we rate circumstances that they are likely to encounter. So on the stress scale, we look at things like interpersonal conflict, physical deterioration or concerns about physical health. One's environment in terms of safety or exposure to various toxic elements or activities. In the support dimension, again, natural and professional supports as well as their accessibility and willingness to engage. Those are things that are important for making these ratings. Dimension five is treatment and recovery history. And here's one place where we're looking at past responses to treatment rather than here and now. We look at the ability to not only respond to treatment, but to maintain recovery over time. We weigh recent experiences more heavily than those in the past. And this is especially pertinent to treatment planning as we don't want to keep trying the same treatments that have failed in the past. Dimension six is engagement and recovery status. And again, four factors that we're looking at, the understanding and recognition of a person's condition, their desire and readiness for change, their ability to use sources of assistance and their ability to accept responsibility for change. These are correlated to the Prochaska and DiClemente stages of change. And intuitively, lower ratings would require fewer external resources. So in this cartoon, it says, this is where I get most of my negative thinking done. And so, again, it's important in terms of engagement and recovery that people come to a place where they're ready to make positive change. So we're going to go on and look at the levels of care and service intensity. Once again, those levels of care are listed across the top of this grid. I'm just going to go on to the next slide where we just talk a little bit about some of the differences between the levels of care in LOCUS and other medical necessity criteria. Where, again, usually there's an eligibility criteria set for a predetermined service set. But the LOCUS levels of care or resource intensity are defined by four variables. One is the care environment. Another is clinical services. Another support services. And also crisis and prevention services. There's a locally derived menu of elements per variable at each level of care. Some elements are available at more than one level. Things like supported housing and case management. The average cost is proportional to the service intensity. So the higher levels of care are more costly as opposed to those that are less intensive. And so this provides an ideal and seamless continuum that people can move through without significant disruption. So one way to think about this is a little bit like choosing a restaurant. First, we decide what you need and want, and that's the level of care assessment. Things like how hungry are you? What kind of dietary restrictions? What kind of digestive disabilities? And where, what is available within your area? And that's the menu of services. Do you want to eat indoors, outdoors, fancy or rustic? And that would be the environment. Food type, quality and quantity, those would be the clinical services. And what kind of services, table services or pickup? Those are your support services. And you want to wear masks and social distance, have good ventilation. Those are the prevention analogies. Basic services are also available. And so these are services that are available to the entire population and don't require a qualifying rating. So these include prevention and health maintenance. Services generally are related to emergency and crisis as well as community health and prevention-focused care. So it might be things like homeless outreach, disaster first aid and screening, education, consultation and support. So this is kind of a stepwise view at the six levels of care. And we're going to go into each of these in a little bit more detail. So level one is recovery, maintenance and health management. And the clinical analog to that is a transition to independence for people that have progressed in their recovery and have completed care at some higher level of care. So it's not an entry level. And this often includes things like medication management and recovery maintenance therapy. These are folks that usually don't need a great deal of support. Level two is low-intensity community-based services. The clinical analog would be outpatient treatment, which is an entry level of care and usually provided in a clinic setting. It may include education and employment assistance and a limited range of support services are usually required at this level. Level three is high-intensity community-based services. The clinical analog might be something like intensive outpatient and non-restrictive facilities with a full array of treatment and service elements. So this provides more frequent and extended contacts and supports may include service coordination, supported housing and rehabilitation activities. The level four is medically monitored non-residential services. This is similar to partial hospital or intensive wraparound with a full array of treatments and interventions. An ACT team, for example, might fall under this category. Almost daily attention, usually scheduled at least five days a week with frequent psychiatric contracts and psychiatry on call. And there should be a prominent role at this level for service coordination, housing and rehabilitation. Level five is medically monitored residential services. The clinical analog is residential treatment programs of various kinds. Maybe respite facilities, DNA, rehabilitation programs. These are not secure settings, but they're highly structured. Psychiatric contacts usually at least weekly. There should be a full array of services available and in a team-based care format. And transition planning, addressing significant disabilities and barriers to community living is a big part of what occurs in these settings. So level six is medically managed residential services. And this is pretty analogous to what we refer to as inpatient treatment, either acute or long-term. They're secure settings and they're highly structured with restricted access. There's usually daily psychiatric contact and close monitoring. Crisis intervention and de-escalation activities are available with a full array of treatment options and team-based care, sorry about that, and also intensive transition planning. So we have just a few more minutes to go through some of how we talk about placement recommendations. So service intensity recommendations are derived from the dimensional rating scores and they can range from seven to 35. There's seven ratings of five possibilities each. We look at the grid, but there's also a decision tree or flow chart that is the basis for an algorithm that is used for computer-assisted decision-making. So composite score placements, these are the basic numeric ranges for each of the levels of care. But again, independent criteria of four or five override the composite on dimensions one through three. So what I have here is a screenshot of the LOCUS evaluation report that's generated by the computer-assisted program. It indicates the score on each dimension as well as the specific anchor or criteria that was selected to qualify for the dimensional score. It gives the composite score, in this case 17, and it also gives the recommended disposition and the actual disposition. So there are more than one factor associated with these recommendations. So the LOCUS recommendation is one of those, but the person being evaluated also has some say in the process and they may decline, for example, a recommendation for high-intensity treatment that they don't feel they need. And so in some cases that will override what LOCUS is recommending. Clinicians also have a role in making that determination, and if there is some compelling rationale that LOCUS does not account for, which is, I think, extremely rare, you know, they really are ultimately responsible for the recommendation and decision. The other factor that comes into play in many cases is the support system and family members that may have significant input, and this is especially true for children. So this is our report, and again, this is just another screenshot of the determination grid. So to summarize, LOCUS provides dimensional ratings that are simple, relevant, and dynamic. They're quantifiable ratings, they're interactive and enhance communication, and provide placement recommendations. They're integrated emotional health criteria, so they're diagnostically independent, and consider interactions between illness categories, and that, again, would be medical addiction and physical health. Some of the other qualities of LOCUS, they're easy to use and understand. They have an accessible, intuitive structure that allow empowerment and person-centered approaches. They're computer-friendly and very easily incorporated into medical records, electronic medical records. They have established reliability and validity. They inform individualized treatment planning and collaborative assessment. What LOCUS won't do is prescribe program design, specify treatment interventions, replace clinical judgment, or limit creativity. And so clinicians continue to play a very significant role in the clinical process. But LOCUS really provides a platform and structure upon which they can build. There are some supplemental items that accompany these instruments, training manuals. There's a semi-structured interview, pre and post-test practice cases and worksheets for that. There are some residential sub-levels that are described. We have worked on some guidelines for meeting primary care needs, as well as an automated treatment planner. Some of the extended uses of LOCUS, as we were just talking about, the dimensional service planning provides a structure to build planning upon. And it also provides a rationale for recommended service intensity and plan. And that's really important in our interactions with payers. There are really great opportunities for collaboration between patient, provider, and managed care organization. And the ability to delegate value management to providers and reduce administrative expenses and reallocate resources to treatment providers rather than administration. It provides a platform for integrated service documentation and the monitoring of the course of illness and the way that individuals use resources. So we can monitor the course of illness for individuals, but we can also do that for systems. And we can identify deficits in the service array based on the utilization of various levels of care. We can also track outcomes. And although LOCUS is not yet validated as an outcome tool, I think it's probably pretty easy to see how it might be used in that way. And we can track people's progression through the systems and their use of resources. The other thing that may arise is assistance in financing and bundled rate setting. So the fact that the cost of care is proportional to the level of care may allow more bundled rating arrangements and per diems, which again would reduce administrative burden. So I have some slides that I developed around the dissemination and implementation of LOCUS, but I'm gonna go through these just very quickly. There's been a steady increase over the past 25 years, but as I mentioned, some recent developments has really exploded the interest and implementation of LOCUS in many parts of the country. We would like to get a better balance between peers and providers and really put more quality control in place. But I'm just gonna end with this last cartoon. It says, perhaps your performance anxiety wouldn't be so bad if you performed better. And we definitely aim to have LOCUS help us perform. LOCUS help us perform. So I am gonna stop there and take any questions that you all have. Thanks so much, Dr. Sowers. That was really interesting and look forward to questions from the audience. The attendees, I also have some, but before we shift into Q&A, just wanna take a moment and let you know that SMI Advisor is accessible from your mobile device. If you, you can use the SMI Advisor app to access resources, education, and upcoming events, complete grading scales, and even submit questions directly to our team of SMI experts. You can download the app now at smiadvisor.org slash app. So again, wanna invite folks. Let's see. So when you're looking at contacting the clinical services, is that divided between all of the services provided? How is that divided up across clinical services? We have that question. Okay, I'm not sure that I quite understand how is the clinical services divided Okay, so it says, sorry, I'm just having a little trouble pulling it up. So if it's, if someone is level three treatment, would, should programming available, would one appointment with therapy, one appointment with case management, one employment with an employment specialist each week, would that be how it would be, would it be divided up? It may well be, you know, it's not a one size fit all. And that's what's a little bit unique about the LOCUS levels of care. You know, it basically provides a listing, or, you know, we talked about a menu of service elements that are available at a particular level of service intensity. And clinicians can then choose from those menus to meet the individual's needs. And so it's gonna be a little bit different for each individual. And that's what makes it distinct from other types of assessing criteria, where it's more of a cookie cutter approach. And, you know, we're fitting people into services rather than creating services that fit people. And so I hope that that answers the question. Thanks. I had a question also. I think a lot of folks listening in are frontline clinicians who may be, may or may not be working with a system that has the LOCUS. Is the LOCUS primarily targeted at kind of directors? So like a medical director or a particular organization, or can an individual clinician use it to kind of help gauge patient's needs and kind of appropriate level of services for the patient? Well, certainly an individual could use it. You know, probably what makes more sense is for systems-wide use. And, you know, that would certainly provide more uniformity and take advantage of the, you know, the multiple aspects of LOCUS and what it offers. And so, you know, systems adopting the instruments can really use it throughout their continuum and have a continuous record of what level and what kind of rating a person is given over the course of time so that we can follow the course of illness. And we can also just have linkages between levels of care that are usually not now available. And so, you know, it's certainly possible to use it on an individual basis, but we're really not able in that case to incorporate all the advantages that it offers. Great, thank you. Okay, we have a question about states. Are there any states that have adopted that you're aware of, the LOCUS, COLOCUS, or any of the other family of instruments for their process? Yeah, as I mentioned, you know, the WIC decision really expanded the number of states that are using it and using it across the continuum. So there were several states prior to that that mandated it for some levels of care or some aspects of services. But, you know, what's come out of this most recent decision-making is actual legislation in states like California, Oregon, Illinois, and I believe Oklahoma. Several other states are considering legislation that really designate professionally developed criteria that are non-proprietary as the standard for care. And New York State has done something similar, though not through a legislative process, but rather an administrative one. Thanks so much. I'm wondering, a little bit in that vein, with 988 becoming, you know, such an important issue, are you seeing kind of interest around the LOCUS, even a family of instruments among states or among providers to help think about kind of where they fit within the crisis continuum? Yeah, you know, crisis is definitely one place where, you know, LOCUS really makes a lot of sense and where, you know, a lot of people present and begin a treatment process. Georgia has been a state that has used it as part of their crisis continuum for some time, and I believe Arizona as well. 988 may actually enhance some of the demand for LOCUS. It really depends a little bit on the local arrangement of 988, which is, you know, not as uniform as it could be, and varies from place to place. But, you know, the 988 call can set some evaluation processes in motion, and, you know, the use of LOCUS, I think, would be a great option for that assessment. Thanks, and we have a question about kind of using LOCUS to track outcomes. You mentioned that towards the end of your talk. Are there any particular ways that you might recommend using the LOCUS in that regard, either dimensions of it that you'd be tracking over time or ways in which it might be incorporated into workflow? Well, you know, I think just when we think about it, the tracking of service intensity needs over the course of time really is a kind of outcome that we would look at. So, you know, LOCUS assessment is not a one-time rating. You know, we would obviously do an initial rating to get somebody in services, but once they are in services, we would repeat periodic reassessments. Okay, and that doesn't require starting from scratch, but building on the prior LOCUS rating. As we address various issues identified by LOCUS in treatment planning, and once we accomplish the objectives of the treatment plan, that LOCUS score is going to change. And that's going to tell us when somebody is ready for transition and can go to a less intensive level of care. And we can track that over time. We can see what successive LOCUS scores are and how intensive somebody's service needs are. And, you know, obviously with any recovery process, there may be setbacks every now and then, but, you know, what we would like to see is that somebody can, that people in general can progress through the continuum, you know, effectively and efficiently. Have you worked on the issue of inter-rater reliability at all? And is there any way of training as part of your training to address the issue of inter-rater reliability? Yeah, you know, somehow it seemed like the slides escaped the final presentation, but we do have extensive training opportunities. So in the past, we've mostly done live trainings. We are in the process of developing online asynchronous training so that people are really able to tune in to training at their convenience. And so training is important. The LOCUS tool is pretty intuitive, and that's one thing that makes it a little bit more accessible and usable. But, you know, there are consequences, so training is something that's important. We did do some inter-rater reliability, which is what we did, but it was some time ago. And so we're really planning to do more. We hope to have a new version of LOCUS in 2023. And once we do that, there may be, for the first time, some slight changes in the criteria sets. And so we wanted to wait until those revisions were in place to revisit inter-rater reliability and getting more significant data in that regard. Great. Well, thanks. I don't think we're going to have time for more questions, but, you know, clearly just a lot of interest from the group in this instrument. But I want to keep people on time. If there are any topics covered in this webinar that you'd like to learn more about or discuss with colleagues in the mental health field, you can post a question or comment on the SMI Advisors' Webinar Roundtable Topics Discussion Board. It's an easy way to network and share ideas with other clinicians who participate in the webinar. If you have questions about this or any other topic related to evidence-based care for SMI, you can get an answer within one business day from one of SMI Advisors' national experts on SMI. This service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals who have SMI. We'd just like to say also, real quickly, if I can, if people would like to actually look at the instrument or have any questions for me or others, that information is available at communitypsychiatry.org. Fantastic, thank you so much, Dr. Sowers. SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available on the Mental Health Addiction and Prevention TTCs, as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from mental health through the opioid epidemic. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes. We'll then move to Live Next to advance and complete the program evaluation before claiming your credit. Please join us on November 4th as Dr. Gail Donnett presents Achieving Healthy Weight for People Living with Serious Mental Illness. This free webinar will be November 4th from 12 to 1 p.m. Eastern Time, Friday. Thank you so much for joining us. Until next time, take care.

Managing Value

Level of Care Utilization System

LOCUS Family of Tools

SMI Advisor initiative

Serious Mental Illness

Dr. Wesley Sowers

Center for Public Service Psychiatry

Behavioral Health Conditions

Dimensional Ratings

Collaboration in Care