I. Federal EQR Standard Compliance Addressed in the 2013 BBA Technical Reports Evaluated by OMHSAS J. Summary Results from the 2013 Adult Consumer

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1 Table of Contents I. Introduction A. HealthChoices i. Office of Medical Assistance Programs 1. Introduction 2. Assessment 3. State Standards 4. Improvements and Interventions 5. Delivery System Reforms 6. Conclusions and Opportunities ii. Office of Mental Health and Substance Abuse Services 1. Introduction 2. Assessment 3. Information Management 4. Improvements and Interventions 5. Delivery System Reforms 6. Conclusions and Opportunities B. Healthy Pennsylvania i. Private Coverage Option 1. Introduction 2. Assessment 3. State Standards 4. Improvements and Interventions 5. Delivery System Reforms 6. Conclusions and Opportunities C. Office of Developmental Programs i. Adult Autism Community Program (ACAP) 1. Introduction 2. Assessment 3. Conclusions and Opportunities II. Appendices A. HealthChoices Quality Measures B. PH-MCO Operations Reports C. Quality Strategy Toolkit Reference Crosswalk D. The Pennsylvania Department of Public Welfare (Vision, Mission and DPW Core Values) and the Office of Mental Health and Substance Abuse Services (Goals and Guiding Principles) E. Quality Toolkit Review of HC BH Contract Agreement and PEPS Standards to Federal Requirements F. Follow-Up After Hospitalization for Mental Illness OMHSAS Goal G. Office of Mental Health and Substance Abuse Services Semiannual Performance Measure H. Successful Transitions from Inpatient Care to Ambulatory Care 1

2 I. Federal EQR Standard Compliance Addressed in the 2013 BBA Technical Reports Evaluated by OMHSAS J. Summary Results from the 2013 Adult Consumer and Family Member Perception of Care Surveys (PA-MHSIP) K. HealthChoices Behavioral Health, Data Reporting Requirements (Non- Financial) L. Behavioral Health Managed Care Organizations (BH-MCOs) Performance /Outcome Management System (POMS) M. Private Coverage Option Quality Measures for Year One N. Healthy PA Reports and Data 2

3 I. Introduction Preface The Pennsylvania Quality Strategy is a technical document required by the Code of Federal Regulations, CFR , and the Centers for Medicare and Medicaid Services (CMS) programs to ensure the access to high quality and efficient health care by the managed care organizations contracted by the Pennsylvania Department of Public Welfare (DPW). It is not intended to describe all the activities that DPW undertakes to assure the quality of care rendered to Pennsylvania Medicaid consumers. Pennsylvania currently operates a statewide fully capitated managed care program, called, the HealthChoices program, that includes five behavioral health managed care organizations (BH-MCOs) and eight physical health managed care organizations (PH- MCOs) operating under CMS-approved1915(b) waiver authority. In 2009, DPW obtained approval for a Prepaid Inpatient Health Plan (PIHP) under the 1915(a) authority to create the Adult Community Autism Program (ACAP) in four counties. In August of 2014, DPW obtained approval for its Healthy Pennsylvania private coverage option (PCO) program under the authority of an 1115 demonstration waiver. The PCOs will offer both physical and behavioral health benefits that meet the standards of the Affordable Care Act s essential health benefit state benchmark plan. The statewide PCO program will start in January 2015 with enrollment of newly eligible consumers in eight MCOs. This Quality Strategy will describe the CFR compliance initiatives and activities of all of the above programs. What Is the Department of Public Welfare? The Pennsylvania DPW provides services to over 2.3 million Pennsylvanians. DPW s vision is to see Pennsylvanians living safe, healthy and independent lives. Its mission is to improve the quality of life for Pennsylvania s individuals and families. It promotes opportunities for independence through services and supports while demonstrating accountability for taxpayer resources. DPW consists of eight program offices. Seven offices (Office of Income Maintenance, Office of Medical Assistance Programs, Office of Mental Health and Substance Abuse Services, Office of Developmental Programs, Office of Children, Youth and Families, Office of Long-Term Living, and Office of Child Development and Early Learning) administer services that provide care and support to Pennsylvania's most vulnerable citizens. DPW s eighth office, the Office of Administration, functions in administrative support. In November of 2014, DPW will be renamed the Department of Human Services. Below is the Department of Public Welfare s Organizational Chart and Responsibilities. 3

4 The Office of Administration s primary function is administrative support. The Office of Administration is responsible for supports such as human resources, hearings and appeals, information technology, and other administrative support services. The Office of Income Maintenance serves low-income Pennsylvanians through cash assistance programs such as Temporary Assistance to Needy Families; employment and training programs; the Supplemental Nutrition Assistance Program; home heating assistance; and assistance programs for refugees and the homeless. The Office of Medical Assistance Programs is responsible for purchasing health care for more than 2.3 million Pennsylvania residents and enrolling Medical Assistance providers who administer the care. The Office of Medical Assistance programs works closely with these providers to process their claims, establish rates and fees, and contract and monitor managed care organizations. Additionally, the Department works to ensure the integrity of these programs, in part by detecting and deterring provider and recipient fraud and abuse. The Office of Mental Health and Substance Abuse Services is responsible for the oversight of the county Mental Health Programs, the management of the State Mental 4

5 Hospital system and the South Mountain Restoration Center for long-term care, and contracting for mental health and substance abuse services for Medical Assistance eligible individuals under the HealthChoices Behavioral Health Services managed contract agreement. The Office of Developmental Programs works with individuals and families to provide supportive services and care for people with cognitive disabilities, especially intellectual disabilities and disorders falling in the autism spectrum. The Office of Children Youth and Families serves children and families through a nationally recognized child support enforcement program, oversees adoption and foster care services, and works with counties on child abuse prevention and juvenile justice issues. The Office of Long-Term Living is responsible for the development and oversight of OMAP s long term care delivery system, which includes nursing facility providers and home and community based providers and their related services. Additionally, the Office of Long-Term Living is responsible to ensure that MA eligible individuals in need of long term care have access to needed services and that the services offered in the delivery system are used appropriately and in a manner consistent with all applicable federal and state requirements. The Office of Child Development and Early Learning focuses on creating opportunities for the Commonwealth s youngest children to develop and learn to their fullest potential through a framework of supports and systems that help ensure that children and their families have access to high quality services. The Department of Public Welfare is focused on helping Pennsylvanians achieve safe, healthy, and independent lives. Our responsibility to Pennsylvanians includes providing services and supports in a safe environment. We are responsible for providing oversight, monitoring, and licensing of our providers, caregivers, and residential settings to ensure that each individual receiving services is in an environment that protects the well-being of our citizens. We are responsible for providing services and supports that promote the health of our individuals and families in need through the receipt of medical and dental services, waiver programs, and early intervention services. We believe that services should lead to improved health outcomes and help to position Pennsylvanians receiving DPW services to become healthier over the course of their lives. DPW seeks to provide services that help individuals and families become self-sufficient. We offer services and supports to assist in activities of daily living, temporary assistance to needy families, education and employment, and subsidized child care services. Similar to health outcomes, DPW believes that self-sufficient outcomes are an important step for all Pennsylvanians. This allows DPW to achieve CMS Triple Aim of improving the individual experience of care, improving the health of populations, and reducing the per capita costs of care for populations. 5

6 Historical Background For several decades Pennsylvania has been a leader of healthcare delivery reform. Pennsylvania has provided some form of managed care to the Medical Assistance (MA) population since the 1970s. The early form of voluntary managed care in the MA program was available in certain Pennsylvania counties. Most of the HMO plans that opted to serve MA recipients under the voluntary program already operated commercial plans in that county. After piloting a voluntary program for several years, the Department proposed to pilot a mandatory model of managed care, HealthPASS. HealthPASS was implemented in 1986 and served a 10-district area in Philadelphia under a federally approved 1915(b) waiver of some of the normal Medicaid program requirements. Through the experience of HealthPASS, the Department proved that mandatory managed care plans could work in partnership with the Commonwealth. The program was able to guarantee enough recipients to ensure a financially viable business opportunity for a managed care plan while improving quality of care and enhancing consumers access to providers. Mandatory managed care, with its emphasis on coordination and assignment of risk to the MCO, seemed the best solution for the Pennsylvania s MA program. After a thorough evaluation of the alternatives, the Department made the decision to transition to a statewide mandatory managed care program for MA recipients utilizing a zone phase-in approach. To emphasize the recipient s participation in health care decisions, the program was called HealthChoices. Three specific goals were established which set the tone for how the HealthChoices Program would be structured: 1. Improve Access to Health Care Services, 2. Improve Quality of Care for MA Clients, 3. Stabilize Pennsylvania s MA Spending. Unlike some states which implemented mandatory managed care for Medicaid statewide in a short period of time, the Department chose to implement HealthChoices incrementally in different geographic zones of Pennsylvania over a period of time from 1997 to The Department researched and considered natural service patterns in order to define the zones. (Please see maps on pages 14 and 37.) As of 2014, HealthChoices operates in all 67 counties within the Commonwealth with a high degree of coordination between the behavioral health managed care organizations (BH-MCOs) and physical health managed care organizations (PH-MCOs). As of October 2014, there are five BH MCOs that are delegated contractual authority though the counties or directly contract with OMHSAS to serve about 2.3 million MA consumers including Medicaid and Medicare eligible (MME) recipients. The OMHSAS has oversight of the behavioral health HealthChoices program that will be described in section IAii. There are eight PH-MCOs that serve about 1.7 million MA consumers with the exclusion 6

7 primarily of adult MME recipients and those residing in long-term care facilities for more than 31 days. The OMAP has oversight of the physical health HealthChoices program that will be described in section IAi. Both OMAP and OMHSAS work collaboratively to assure both BH and PH-MCOs deliver high quality coordinated care focused on the total wellbeing of the consumers served. OMAP and OMHSAS assure their respective MCOs operate with a collaborative approach through common quality strategies, contractual requirements for coordination of care, and health information exchange. In August of 2009, DPW obtained approval of a Prepaid Inpatient Health Plan (PIHP) under the 1915(a) authority to create the Adult Community Autism Program (ACAP). ACAP was the first program in the nation to use a single Home and Community-Based Services (HCBS) provider, Keystone Autism Services (KAS), to provide an integrated system of care as a traditional managed care organization (MCO). ACAP was designed as an integrated service delivery system to provide physical, behavioral, and community-based services to adults with autism. Participants in ACAP are adults aged 21 years of age or older, financially eligible for MA, possessing a diagnosis of autism, and certified as meeting MA program clinical eligibility for an Intermediate Care Facility (ICF). Keystone Autism Services (KAS), a subsidiary of Keystone Human Services, functions as a service provider as well as the MCO. ACAP serves participants in Cumberland, Dauphin, Chester and Lancaster Counties in Pennsylvania. The Office of Developmental Programs (ODP) provides oversight of ACAP through its Bureau of Autism Services (BAS) as described in Section IC. In August of 2014, DPW was approved to implement the Healthy Pennsylvania private coverage option (PCO) under the authority of an 1115 demonstration waiver. Healthy Pennsylvania is designed to ensure that newly eligible Pennsylvanians have increased access to high quality affordable health care. Healthy Pennsylvania focuses on personal responsibility and healthy behaviors, aligning benefits to match health care needs and increasing access to private, commercial coverage for eligible Pennsylvanians. As part of the approved waiver, the Healthy Pennsylvania PCO has been created to increase health care access to physical and behavioral health services for more than 600,000 eligible Pennsylvanians. Eight insurers will participate as providers of the Healthy Pennsylvania PCO, offering a minimum of two insurer options in each of the nine (9) regions of the state. (See map on page 56.) Enrollment will begin December 1, 2014 with coverage effective on January 1, This new program will be monitored primarily by OMAP in consultation with OMHSAS as described in section IB. Also in August of 2014, DPW received approval of its state plan amendment to re-align multiple adult benefit packages into a low and high risk benefit package to better meet the health care needs of consumers. The HealthChoices program will adopt these changes to the state plan amendment in January of

8 Quality Strategy Process The Quality Strategy will serve to assure that the Department s managed care programs described above are in contract compliance, have committed resources to perform the monitoring and ongoing quality improvement, and contribute to the improvement of health for the MA population. The Quality Strategy will especially focus on the new programmatic changes described above in order to assure MA consumers have timely access to high quality care. The Department has implemented various quality improvement initiatives to increase the quality of care for the MA population. These include key initiatives such as: value-based purchasing focused on reducing preventable admissions and readmissions, increased preventative dental services in children, coordinated physical health and behavioral health quality improvement projects, MCO and Provider pay for performance (P4P) programs, and wider implementation of community based care management teams. The clinical quality and policy staff of OMAP, OMHSAS, ODP, and OLTL meet on a quarterly basis as the Quality Improvement Committee (QIC) to discuss each Office s quality initiatives and share best practices. To develop early drafts of the Quality Strategy, DPW convened additional QIC meetings with the clinical, policy and operational staff of OMAP, OMHSAS, and ODP. Each Office was charged to be primarily responsible for drafting the plan for its respective program. Each Office was asked to develop their Quality Strategy utilizing the existing processes to obtain input from external stakeholders over the preceding year. The team also met to discuss how the respective drafts needed to collaborate and align with the Department s overall vision and mission. The draft was developed and shared with senior staff for revisions prior to sharing the revised draft externally with stakeholders. The Department sought additional input on its Quality Strategy from its Medical Assistance Advisory Committee (MAAC) as well as its Consumer and Managed Care Sub-committees. The MAAC advises DPW on issues of policy development and program administration. The MAAC is composed of citizens of the Commonwealth with experience, knowledge, and interest in the delivery of health care services to low income citizens and medically vulnerable groups. The Department also sought feedback through structured discussions with various constituents involved in the specific programs of OMAP, OMHSAS and ODP. These meetings provided a forum for ongoing communication between DPW and constituents to share their key quality priorities. The Quality Strategy also was distributed for stakeholder comment through the OMHSAS Planning Council. This advisory group includes beneficiaries, providers, HCBH Primary Contractors, BH-MCOs and representative organizations. Lastly, the Department sought public comment through posting a Public Notice. The public was allotted 30 days to review and comment. Several meetings will be held throughout each year with key DPW personnel and external stakeholders to discuss the Quality Strategy. The Quality Strategy will be discussed at already established forums such as: the Quality Improvement Committee described above, the MAAC including the Consumer and MCO Sub-committees, the 8

9 OMHSAS Planning Council, and with each managed care organization during their quality review meetings. There will be ongoing emphasis on assuring excellent access to high quality care for consumers in the new PCOs. The Quality Strategy will be posted on its website annually for public comment. All feedback will be considered in the annual review of the Quality Strategy. DPW views the Quality Strategy as a dynamic document that needs updated as each of the programs described above develop and change over the course of a year. Ongoing review of the Quality Strategy is necessary because of rapid time quality improvement techniques and the leverage of more real time quality measurement through health information exchange. DPW is committed to assuring its programs exceed the standards set forth within the External Quality Review Organization (EQRO) regulations. More importantly, DPW is committed to objectively demonstrating their programs assure consumers timely access to essential services and high quality of care in a cost effective manner. 9