Michigan Engagement Center

Transcription

1 Michigan Engagement Center Quality Improvement Activities Provider Key Updates The ValueOptions Michigan Engagement Center is committed to being a center for excellence in developing and coordinating quality programs for members through our partnerships with you, our providers and practitioners. We are committed to meeting and exceeding standards set forth by oversight bodies such as NCQA and URAC. These clinical and service activities require your knowledge, leadership, input and cooperation. The following are key examples of quality improvement initiatives deemed essential by accreditation requirements and the needs identified by our providers and members: Improving Ambulatory Follow-Up after Hospitalization for Mental Illness The focus of this activity is to increase the rate of ambulatory follow-up for all ValueOptions members discharged from inpatient care. Consumers and consumer advocates have often talked about the revolving doors of acute care hospitals. Adequate management of early post-acute inpatient hospitalization discharge has been demonstrated to be an effective intervention in preventing early re-hospitalization of patients recently hospitalized for major affective disorders. In addition, non-compliance with recommendations for ongoing follow-up has been determined to be a major predictor of re-hospitalization. For 2011 there were increases realized for both measures by 3.8 percentage points and.8 percentage points respectively, however we did not meet our benchmarks. Although the benchmark at the 90 th percentile was not met, this quality improvement activity has continued to increase engagement of members into treatment after acute hospitalization over the last four year period.

2 Increasing Identification, Initiation and Engagement of Treatment of Members in Need of Alcohol and Drug Services This quality improvement activity is designed to identify members with alcohol or other drug disorders, initiate and engage them in treatment. Moreover, it is designed to determine if this reduces the incidence of relapse and improves therapeutic outcomes. The chronic, relapse-prone nature of alcohol and other drug (AOD) disorders makes a case for a system of accountability beyond the boundaries of a single treatment episode. There is evidence that early recognition and intervention have an impact on the success or failure in the treatment of a person s AOD disorder. How people manage their recovery following a specific episode of care is as important to the overall success as is the delivery of the care. Therefore, how a system of care organizes its services to support posttreatment sobriety is an important indicator of performance and outcome. For 2011 there were slight decreases in performance for both measurements however we met and exceeded the NCQA HEDIS 90 th percentile benchmarks. Stratification by age ranges within the HEDIS specifications (13-17 and 18+) illustrated the years were only imitating treatment at only 38.1% and engaging treatment at only18.7%. New initiatives in 2012 will focus on increasing both imitation and engagement of treatment for this age group Increasing Time in the Community for Members Treated for Major Depression The Depression Care Management Program project is designed to enhance identification of and targeted interventions for adult members (18-65) of ValueOptions Michigan Engagement Center who have been admitted to an inpatient facility with the diagnosis of Major Depressive (MDD) or Bipolar disorder (BD) (DSM IV through ). The primary purpose is to determine if intensive case management, educational materials designed to improve awareness of depression, importance of medication compliance and continuation with mental health treatment after discharge will reduce members from being recidivistic, increase time in the community and improve therapeutic outcomes. For this project recidivistic members are defined as having two (2) or more readmits within a 12 month period.

3 Even though we did not meet all of our projected goals for 2011, the total number of members with a Major Depressive disorder that had two or more inpatient admissions decreased to 5.9% and the readmission rate dropped by 11.9 percentage points. Indicators and Results: Measure # 1: Percentage of all members (18-65) with a Major Depressive disorder that have had two or more incidents of acute inpatient care within a 12 month reporting period Measure #2: Average number of days in the community for all members(18-65) with a Major Depressive disorder that have had two or more incidents of acute inpatient care within a 12 month reporting period Measure #3: Average 30 day readmission rate to an acute inpatient setting for all members (18-65) with a Major Depressive disorder within a 12 month reporting period Baseline 2009 Remeasure 2010 Remeasure 2011 Remeasure 2012 Goals 21.4% 11.6% 6.6% 5.9% 8.3% 56.6 Days 91.1 Days 88.4 Days Days 109 Days 9% 9.7% 8.4% 7.4% 8.1% Improving Follow-up for Members Seeking a Referral for Urgent or Emergent Treatment ValueOptions seeks to ensure appropriate care in a timely manner for all of its members. The importance of prompt care when members are in an emergent or urgent situation is established in ValueOptions Corporate Utilization Management Policies and Procedures C 2.13P and C2.14P. These situations call for Clinical Care Managers (CCM s) to facilitate a face to face assessment by a licensed mental health professional within 48 hours to the more urgent situations which require the CCM assures immediate emergency interventions by either contacting 911 or verifying that a responsible person will transport the member to a hospital. In 2011, there were increases realized for all three measures. Even though we did not meet our projected goals for 2011, there has been a true impact on the appropriate risk assignment, follow through and safety for these members.

4 Treatment Record Documentation The Quality Management Department of the ValueOptions Michigan Engagement Center conducts an annual audit of patient treatment records. This audit mirrors behavioral health best practice standards as a contractual obligation for all ValueOptions providers. These requirements are set forth in your provider contract and noted in the ValueOptions Provider Handbook. ValueOptions has adopted the treatment record documentation standards supported by NCQA, URAC and other accrediting bodies. These standards facilitate and promote efficient and effective treatment. Record reviews ensure that records are maintained in an organized format, which permits effective and confidential patient care and quality review. The treatment record review standards can be found in the ValueOptions Provider Handbook online at: There were a total of 450 record audits completed in 2011 an average score of 85.09%. This was a 2.3% increase in performance from the last reporting period in The audit showed evidence of coordination of care with the PCP in 62.7% of the records. This was a 10% increase from audits conducted in In 2011 the GLSC QM/UMC committee reviewed previous record results in addition to Coordination of Care data compiled from 2010 and identified Medical Coordination with Behavioral Health as a priority for a quality improvement activity. A Medical Coordination Service QIA was developed and implemented in Clinical Practice Guideline Adherence Promoting provider adherence to clinical practice guidelines is an integral component of the Michigan Engagement Center Quality Management Program. The QM/UMC and Clinical Advisory Committee members provide input into the bi-annual review and adoption of Clinical Practice Guidelines. Their recommendations are forwarded for consideration by National ValueOptions Corporate Quality Management in conducting the national review of guidelines. ValueOptions has adopted its guidelines from the American Psychiatric Association for: Assessing and treating suicidal behaviors Bipolar disorder Eating Disorders Major depression Schizophrenia Stress and posttraumatic stress disorder Substance abuse disorders Suicidal Behaviors Panic disorder ValueOptions has adopted its Attention Deficit Hyperactivity Disorder (ADHD) guidelines from the American Academy of Child and Adolescent Psychiatry, and Generalized Anxiety Disorder from the Canadian Psychiatric Association. ValueOptions has developed clinical practice guidelines for: Adult ADHD Autism Spectrum Disorder

5 Co-occurring related disorders Opioid-related disorders ValueOptions has adopted Opioid Related Disorders TIP 43 guidelines from SAMHSA. Practice guidelines are available on the ValueOptions website: guidelines.htm. If you would prefer a paper copy of any ValueOptions clinical practice guidelines, please call Copies of the APA guidelines can be downloaded from its website: Guidelines 1.aspx If you don t have Web access please calls APA customer service line access at Copies of the AACAP guideline on ADHD can be downloaded from: Copies of the Opioid Related Disorders Tip 43 guideline can be downloaded from Confidentiality ValueOptions has written policies regarding protected health information (PHI). These policies address disclosure of PHI, restrictions on the use of PHI, the ability to amend PHI, and the accounting process for disclosures and internal/external protection of oral, written and electronic information across the organization. To view the ValueOptions Privacy Statement follow this link: Coordination of Care between Behavioral Health practitioners and the Medical Delivery System The ValueOptions Michigan Engagement Center is committed to coordinating care delivery organizations for member with co-occurring mental health and medical diagnoses. To achieve a seamless flow of information the medical plans and VO clinical and quality leadership began to routinely meet to discuss workflow and process for members referred for behavioral health services. ValueOptions Quality Management developed an Access database designed to capture referrals both from and to the medical plans. Member reports were programmed to capture the date, reason and outcome of the referrals and are provided to the medical plans during the regular joint meetings. A Quality Improvement Activity project began in March 2011 to improve coordination of care. The combined efforts of both the clinical and quality units at GLSC in addition to health plan staff we have seen a significant improvement in all four measures this past year. This effort is critical as the members who qualify as co-occurring have significant risk for further complications if not treated adequately and outcomes improve significantly with coordination. Measures Baseline Remeasure % of Members referred to the 8.1% 26% Medical Plan % Contacted within 10 days 66% 68.7% % Who accepted a referral 63.4% 79.7% % Who attended the Initial appointment 59.4% 65.5%

6 For 2012 the following activities will be implemented: Work with our 2 large health plans to identify additional PCP practices to engage in depression screening and coordination of care. Complete a satisfaction survey of the current providers engaging in screening and coordination. Provide training for PCP practices interested in Adult Behavioral Health Screening. Preventative Health Programs ValueOptions, a behavioral health managed care company, maintains several preventative health programs. The objective of these programs is aimed at wellness and prevention by providing education, self-help strategies, referral and assessment. There are three main areas of focus for these programs which include Major Depressive Disorder, Post-Partum Depression and Attention Deficit Hyperactivity Disorder. All of the programs utilize clinically validated screening tools to indicate the possibility of a behavioral health issue in need of treatment. All the programs are easily accessed on ValueOptions web site by going to then clicking on Tips and Resources in the sidebar. Other educational material is also available on the website. A brief description of each program follows. Depression (Major Depressive Disorder/ MDD) Focused on increasing member knowledge of depression and its various types, treatment, and medication management. It utilizes the CES-D screening tool, a self-scoring clinically validated instrument to indicate the possibility of clinical depression. MDD affects 15-20% of the population. ADHD (Attention Deficit Hyperactivity Disorder) Focused on identifying six year old children considered at risk for ADHD (general prevalence rate is 6%). It also focuses on providing parents with strategies for managing their child. This program utilizes the clinically validated ADHD Rating Scale IV- Home Edition for detecting the possibility of ADHD. Postpartum Depression (PPD) affects an estimated 10% of new mothers. The program focuses on early detection and referral of moms who may be suffering from postpartum depression. It utilizes the highly validated Edinburgh postpartum depression scale (EPDS). All of the programs above utilize self-administered screening tools and are self-scoring. Information is available for each program on how to obtain a referral, or how to obtain additional information. Mental Health Screening for Adolescents: Teen Screen & ValueOptions Partnership In September 2009, the Institute of Medicine and U.S. Preventive Services Task Force released reports supporting primary care as an important setting for the early identification of mental illness in teens. In accordance with these recommendations, ValueOptions and its managed care partners have taken an innovative step in incorporating regular mental health screening for adolescents in primary care settings. ValueOptions and Columbia University launched a program to assist Kaiser Permanente providers in offering mental health checkups to 11 to 18-year-old patients during adolescent health care visits. Columbia University developed materials especially for this initiative, including an in-office screening questionnaire and a Quick Start Guide for Mental Health Checkups, to help participating doctors easily integrate mental screening in their offices. The evidence-based questionnaire can help adolescent health care providers evaluate if a teen is suffering from depression, anxiety or other conditions. Should the teen require further evaluation, providers and patients in the program are afforded a quick and easy referral process, through the use of the ValueOptions toll-free mental health referral line. This line provides immediate assistance from a licensed, master s-level clinical care manager in order to obtain a timely appointment with the ValueOptions full range of local mental health professionals.

7 The pilot project for the Teen Screen program was implement in 2009 and concluded in April of From April 1, 2010 through March 31, 2011 the number of mental health screenings in Primary Care Physician (PCP) offices increased by 2.0%. In addition, the number of teens with a positive mental health screening who were referred for behavioral health services increased by 6.0%. The Teen Screen prevention program continues to grow in the number of physicians who are participating. Through these initial and ongoing projects, ValueOptions and Columbia University hope to share its knowledge and experience to create a best practice model for managed care and behavioral health care companies across the U.S. If you would like more information on the Teen Screen-ValueOptions partnership or other primary care initiatives, visit: Member Satisfaction On an annual basis, Fact Finders Inc. conducts member and provider satisfaction surveys on behalf of ValueOptions. The GLSC is committed to understanding the needs of our members and will make the necessary changes to the way our staff manages customer service to improve satisfaction. Data is analyzed on key areas of clinical and administrative services. Member s satisfaction is evaluated through: Member surveys Reviewing member comments from surveys Tracking and reviewing contents of the complaints and inquires Soliciting qualitative feedback from stakeholders Member survey data is assessed for opportunities to improve member satisfaction. Questions are asked about satisfaction in the following areas: Access to care, claims, outcomes of service, hospital services, toll free number services, internet, therapist ratings, coordination of care and referral services. Results from 2011 demonstrated overall member satisfaction rate of 88.1%. This was a decline in satisfaction by 1.3% from Analysis, including significance testing on responses to questions, indicated that the greatest opportunity for improving overall member satisfaction with the services provided by Value Options was with the Toll Free Telephone Service. As a result, a quality improvement activity was developed to improve customer service on the Toll Free Telephone line. Provider Satisfaction The ValueOptions Michigan Engagement Center considers provider feedback aid in evaluating and improving processes. The satisfaction and general opinions of our providers offer insight into the ways in which system characteristics affect the quality of care delivered to members. Further, they offer an opportunity to identify, examine, and correct the concerns that could ultimately affect network adequacy. The ValueOptions Michigan Engagement Center evaluates provider satisfaction with the utilization management (UM) process through various mechanisms, including provider and member surveys, comments from the surveys and soliciting qualitative feedback from various stakeholders. The GLSC uses a company wide member satisfaction survey tool administered through Fact Finders, Inc., a market research firm located in Albany NY. Provider and member satisfaction with the UM Process is reviewed, at minimum, on an annual basis.

8 For 2011, the overall satisfaction rate was 95.6%. This illustrated an increase of 4.9 percentage point satisfaction from 2010 and we met and exceeded the 85% goal by 12.5 percentage points. Additionally, there was a 20.3 percentage point increase in satisfaction when providers compared ValueOptions to other MBHO s. Overall how satisfied are you with ValueOptions? 120% 100% 88.4% 94.4% 91.1% 95.6% 80% 60% 40% 20% 0% Very Satisfied 32.6% 57.8% 50.6% 53.1% Somewhat Satisfied 53.5% 36.7% 40.5% 42.5% Not Satisfied 14% 5.6% 8.9% 4.4% Overall Satisfaction 88.4% 94.4% 91.1% 95.6% Outbound Intensive Case Management / Focused Care Management ValueOptions s Intensive/Integrated Care Management (ICM) program is designed to serve members with the most complex care needs. These members are typically assessed to be at the highest risk within the health population for negative clinical outcomes related to mental health/substance abuse issues and co-morbid medical issues. With the advent of Federal Mental Health Parity legislation in 2010 and resulting changes in the use of traditional utilization management practices, ValueOptions s existing Intensive Case Management program continues to offer a clinically appropriate and cost-effective solution, advocating health behavior and proactively managing wellness and disease for members most in need. Referrals to ICM are made through routine rounds with the Review Team of higher level of care (HLOC) cases, referrals through the Outpatient Review Team, crisis calls coming through the Crisis Referral Line (CRL), referrals through medical / behavioral coordination and direct referral from VO internal leadership. Identification for focused intervention is based on case presentation, focusing on homicidal/suicidal, geriatric, eating disorders, substance abuse, child and adolescent and psychosis symptom complexes. Intervention includes safety planning, coordination of alternative level of care services and specialty programs, identifying in home support, and other services to increase success in the community. To better effectively and consistently articulate the various interventions to respond to member needs GLSC adopted in third quarter of 2010 the use of the following ICM Tier Levels (which is a VO National initiative): ICM Tier Level Intervention Intensity Tier 1 Integrated Care/Medical Coordination (lower level intervention) contacts in 30 days - Triage clinical needs, provide resources, follow-up as needed to confirm status. Formalized care plan is not required for Tier 1 members. Service connection and efficient coordination are the primary objectives.

9 Tier 2 Intensive Care Management Moderate (medium level intervention) Tier 3 Intensive Care Management Acute (highest level intervention) Weekly or bi-weekly in first month, and then monthly until care plan met. Program duration may be between 3 months to 12 months depending on chronicity and potential risk. Activities include: Assessment, Care Plan, Monitoring, Coordination, Reassessment Multiple contacts per week or weekly as needed in first weeks of engagement. Acute management period may last up to 30 to 60 days to stabilize and engage member in ongoing treatment. Member is re-evaluated for transition to Tier 2 ongoing care management when acute care plan goals are met. Overall ICM program duration targeted for 3 months to 12 months depending on chronicity and potential risk. Activities include: Assessment, Care Plan, Monitoring, Coordination, and Reassessment. For 2010 a total of 299 Tier 1 Integrated Care / Medical Coordination cases were handled and 915 Tier 2 and Tier 3 Intensive Care Management cases were identified. Recommendations for 2012 Clinical Operations and Quality Management continued in discussions regarding a segment of the intensive care management population involved in a possible outcomes study. These discussions have led to the decision for both a Medical Coordination Quality Initiative and an Intensive Case Management (Tier 2-3) Quality Initiative. Members Rights and Responsibilities ValueOptions is committed to respecting enrollee s rights and responsibilities Members have a right to: Receive information about the organization, services, practitioners and providers, and members rights and responsibilities. Be treated with respect and recognition of their dignity and right to privacy. Participate with practitioners in making decisions about their health care. A candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage. Voice complaints or appeals about the organization or care it provides. Make recommendations regarding the organization s members rights and responsibilities policies. Members have a responsibility to: Supply information (to the extent possible) Contact Us Michigan Engagement Center Quality Management , Ext National Network Providers Services Department Provider Relations Web Resources Treatment Guidelines Provider Handbook Treatment Record Standards Claim Forms Visit us at:

10 that the organization and its practitioners and providers need in order to provide care. Follow plans and instructions for care. Understand their health problems and participate in developing mutually agreed upon treatment goals, to the degree possible.