QUALITY IMPROVEMENT PLAN AND PROGRAM DESCRIPTION

Transcription

1 QUALITY IMPROVEMENT PLAN AND PROGRAM DESCRIPTION REVISED AUGUST 12,2014

2 TABLE OF CONTENTS Organizational Overview Mission Executive Summary. 3 Race/Ethnicity of Service Area Governance Quality Management Program Overview..8 Continuous Quality Improvement Performance/Quality Improvement (PIP/QIP) Process Model Quality Management Resources..14 Quality Management Program Overview Committee Structure Departmental Collaboration Performance/Quality Improvement Projects Structure Performance/Quality Improvement Projects Workflow...33 Fiscal Year PIP/QIPs Eastpointe Sites It is expected that this document is a living document and should be updated and reported as changes and progress occurs. ** Represents Stakeholder representation. Quality Management Plan 2 [ ]

3 ORGANIZATIONAL OVERVIEW Our Mission Eastpointe works together with individuals, families, providers, and communities to achieve valued outcomes in our behavioral healthcare system. Executive Summary Eastpointe Local Management Entity/Managed Care Organization (LME/MCO) serves the eastern North Carolina counties of Bladen, Columbus, Duplin, Edgecombe, Greene, Lenoir, Nash, Robeson, Sampson, Scotland, Wayne, and Wilson. The twelve county area is a total of 7,475 square miles, has a total population of 827,792 individuals and is located in the far eastern section of the State of North Carolina. Twenty-five percent(25%) of these residents are enrolled in Medicaid. On January 1, 2013, Eastpointe Local Management Entity began operations to manage publicly-funded behavioral healthcare services under the 1915(b)(c) Medicaid Waiver to individuals with Mental Health and Substance Abuse needs and Intellectual Developmental Disabilities (MH/IDD/SAS). This includes coordination, facilitating and monitoring provision of state, federal and Medicaid funded services. The organization is overseen by a Board of Directors with membership as defined in G.S 122C. Eastpointe achieved URAC accreditation for three modules which include Health Call Center, Health Network Management and Health Utilization Management. Eastpointe s Local Business Plan (LBP) covers a three year period from , outlines the organization plan to meet state standards to ensure quality mental health, developmental disabilities and substance abuse services and outcome measures for evaluating program effectiveness. The Plan addresses both statewide and local initiatives, and covers all core administrative functions. The twelve counties that make up the catchment area are racially and ethnically diverse. A demographic analysis of the population by race based on 2012 Census reports for counties in the Eastpointe catchment area indicates that 55.0% (455,065) are Caucasian, 9.0% are Hispanic/ Latino (74,325) 34.1% (282,461) are African-American, 7.9% (65,650) are Native American/ Alaskan Native, and 0.8% are Asian/Native Hawaiian or other Pacific Islander; and 1.6% (12,841) are two or more races. The organization has the second largest Medicaid population statewide. The largest Native American populations reside in Robeson and Scotland counties. The following table illustrates the race/ethnicity of the Service Area or members/enrollees during SFY Quality Management Plan 3 [ ]

4 Race/Ethnicity of Service Area SFY 2013 County African American American Indian And Alaskan Native Asian Pacific Islander Caucasian Hispanic/ Latino Two or more Races Bladen 12, ,333 2, Columbus 17,913 1, ,188 2, Duplin 15, , , Edgecombe 32, ,994 2, Greene 8, ,483 3, Lenoir 24, ,800 3, Nash 35, ,737 6,015 1,398 Robeson 33,032 52,791 1,196 44,133 10,932 3,016 Sampson 17,596 1, ,484 10, Scotland 14,024 4, , Wayne 39, ,628 78,639 12,162 2,380 Wilson 32, ,909 7,724 1,029 Catchment Total 249,616 65,650 6, ,785 74,325 12,841 Figure 1 Source: N.C. Office of State Budget and Management (OSBM). (September, 2013; Accessed 4/20/14). Quality Management Plan 4 [ ]

5 Governance Eastpointe s Board of Directors Administrative oversight for Eastpointe LME/MCO is provided by the Board of Directors which functions as the governing body of all service programs. Current N.C. General Statute 122C requires the Board to have no fewer than eleven (11) and no more than 21 voting members. In conjunction with Eastpointe LME/MCO, The Board of Directors engages in comprehensive planning, budgeting, implementing and monitoring of community based mental health, intellectual development disabilities and substance abuse services (MH/IDD/SA). The Board meets on a monthly basis. The Board has five standing committees: Executive, Finance, Human Rights, Nominating and Governance and Policy Committee. The Area Director/Chief Executive Officer shall serve as an ex-officio member of all Standing Committees. Minutes of the Board meetings are posted on the Eastpointe website after they are approved by the Board. Executive Committee The Executive Committee is responsible for responding to the need for emergency session between regular Board meetings. The Executive Committee is composed of the Board Chair and the Chair of each Standing Committee. This committee reports all action to the Board of Directors. Finance Committee The Finance Committee has the responsibility of reviewing and making recommendations to the Board regarding financial issues that affect the organization. The committee is comprised of three (3) members of the Board. Committee members has expertise in budgeting and fiscal control. The committee meets at least six times per year. The Finance Committee has the responsibility for reviewing and making recommendations to the Board on the following issues: LME/MCO s annual financial and compliance audit All budget amendments Monitor all building and construction projects LME/MCO s annual operating budget Quarterly Financial Statements Quality Management Plan 5 [ ]

6 Governance Nominating and Governance Committee The Nominating and Governance Committee identifies qualified individuals to become Board members, consistent with criteria approved by the Board and applicable law. This committee develops and recommends corporate governance guidelines applicable to the organization. Additionally, the committee reviews and reassess adequacy of such guidelines periodically and recommends proposed changes to the board. The responsibilities of The Nominating and Governance Committee are: Oversee the evaluation of the Board and management of Eastpointe Periodically review the criteria for selection of new directors to serve on the Board and recommend proposed changes to the Board for approval, consistent with applicable law Evaluate candidates for board membership Periodically review and make recommendations regarding composition, size, purpose and structure of each of the Board s committees Policy Committee Eastpointe develops policies and procedures that promote effective and efficient operation of the organization according to Federal and State regulations and URAC Standards. The Policy Committee reviews all new policies and/or revised procedures to ensure they meet all requirements that will govern management of the LME/MCO. Appointment is made by the Board of Directors. The committee is responsible for review of all policy statements before going to the Board of Directors for final approval. Human Rights Committee Formerly known as The Client Rights Committee, the name was changed to conform to current developments in mental health reform. The Human Rights Committee (HRC) is a subcommittee of Eastpointe s Board of Directors. This committee ensures compliance with federal and state rules governing client rights for enrollees receiving services throughout the LME/MCO network. The purpose of the committee is to oversee the protection of enrollee s rights and to provide feedback and recommendations for system improvements. The Committee is comprised of 15 members across the LME/MCO who are either direct enrollees of services or family members representing Mental Health (MH), Intellectual Developmental Disabilities (IDD) and Substance Abuse Services (SAS). Eastpointe staff serve as liaisons to the committee and are non-voting members. Quality Management Plan 6 [ ]

7 Governance The purpose of the Human Rights Committee is to: Maintain ultimate responsibility for the assurance of consumer rights Review incident reports pertaining to seclusion, restrain and isolation timeout Review consumer grievances Review alleged violations of the rights of individuals or groups, including alleged abuse, neglect or exploitation Review concerns regarding the use of restrictive procedures Review the failure to provide needed services through Eastpointe Review grievances regarding incidents which occur within a contract agency after the governing body of the agency has reviewed the incident Consumer and Family Advisory Committee (CFAC) The CFAC committee is a self-directed and self-governing organization that advises the Board of Directors on the planning and management of the LME/MCO. The purpose of the committee is to ensure meaningful participation by Enrollees and families in enhancing the development and delivery of MH/IDD/SAS services within Eastpointe s network. Composition of membership reflects equitable representation from each disability,one family member and one consumer from each disability group across the catchment area. Membership represents the race and ethnicity of the community when possible. A few responsibilities include: Offer recommendations on areas of service eligibility and service array, including identifying gaps in services. Assist in the identification of under-serviced populations. Provide advice and consultation regarding development of additional services and new models of service. Participate in monitoring service development and delivery. Review and comment on the state and local service budgets. Observe and report on the implementation of state and local business plans. Participate in all quality improvement measures and performance indicators. Ensure consumer and family participation in all quality improvement projects at both the provider and LME/MCO levels. Quality Management Plan 7 [ ]

8 Quality Management Program Overview Eastpointe Quality Management (QM) Program fosters an environment that Quality is everyone s responsibility, by implementing W.E. Deming s philosophy that opportunities create chances for improvement and create interventions. The purpose of the Quality Management Program is to systematically monitor and evaluate access, appropriateness, safety and effectiveness of care utilizing a multidimensional approach. The Program focuses on health and safety, protection of rights, achievement of outcomes, accountability and strives to continually improve the system of care. The Quality Management Program aims to continuously improve all aspects of healthcare delivery through monitoring and analyzing data, modifying practices and developing initiatives to measure and improve services provided by the organization. Specifically, the QM Program includes, but is not limited to the following responsibilities and monitoring of key performance measures: Effectiveness of Care Measures Access and Availability Payment Denials Out of Network Services Patient and Provider Satisfaction (Grievance/Appeals, Patient Satisfaction Survey) Use of Services Health Plan Stability Plan Descriptive Information Health and Safety The Quality Management Plan/Program Description (QMPD) outlines the structure and process by which the agency monitors and evaluates services, integrates quality improvement activities throughout the organization and promotes collaboration through inter-departmental representation on teams and committees. The plan describes how the Quality Management Program ensures Federal, State and URAC requirements are met to create qualitative outcomes for the population served. The effectiveness of the Quality Management Program is reviewed and evaluated annually. The prior year s program activities are summarized and incorporated into the following years QM Program Description and Work Plan. Progress toward performance/quality improvement goals are evaluated yearly. Quality Management Plan 8 [ ]

9 Continuous Quality Improvement The Center for Medicaid/Medicare (CMS) Quality Framework serves as the foundation of Eastpointe s Quality Management program. The Program focuses on the seven dimensions of continuous quality improvement: participant access, participant centered service planning and delivery, provider capacity, participant safeguards, participant rights and responsibilities, participant outcomes and satisfaction and system performance. Figure 2 Enrollee Access - Eastpointe provides information to assist individuals with obtaining access to service. A Member Call Center operates 24 hours per day,7 days per week, 365 days per year to ensure members have access to services. Interpreter services, information regarding availability of non-emergency transportation and referral to community resources are available. Community Relations Department develops and disseminates educational resources for members/enrollees regarding access to care, transportation services and a variety of MH/ IDD/SAS topics. Enrollee Centered Service Planning and Delivery - Eastpointe ensures services and supports are implemented in accordance with the unique needs of the member/enrollee by completion of a Person Centered Plan (PCP)/Individual Support Plan (ISP). System of Care (SOC) is responsible for ensuring collaboration between a network of community based services to meet the needs of the child. Eastpointe collaborates with multiple community agencies such as CCNC, Juvenile Justice and Department of Social Services (DSS) to facilitate service planning to ensure service provision. Eastpointe is involved with local hospitals and manages three -way psychiatric inpatient bed contracts for individuals who are considered indigent. Quality Management Plan 9 [ ]

10 Continuous Quality Improvement Provider Capacity and Capabilities - Eastpointe ensures that there are sufficient providers within the community by monitoring the need for services, surveying the community, and completing the annual needs assessment. Enrollee Safeguards - Eastpointe has several processes to ensure health and safety of members and quality of care. Provider Monitoring review Level II and III incidents to ensure health and safety of individuals served. If the provider response raises concern, an onsite visit may occur. Quality of Care Concerns regarding health and safety are addressed immediately and may include referrals to DSS, Department of Health Service Regulation (DHSR) or Care Coordination. Enrollee Rights and Responsibilities - When an individual initiates services with Eastpointe, a statement of rights and responsibilities is mailed to them. Members have the right to make recommendations regarding enrollee rights and responsibilities policy. Enrollees also have the opportunity to voice complaints and file appeals about providers or other aspect of the organizations operations. Enrollee Outcomes and Satisfaction - Eastpointe monitors the network of providers through annual consumer satisfaction surveys, monitoring activities, mystery shopping/first responder capacity and incident reporting. Eastpointe also ensures compliance of the provider network, and monitoring via the North Carolina Treatment Outcomes and Program Performance System (NC-TOPPS) software program services are measured for outcomes. System Performance - Standardized monitoring tools, over and under utilization, submission of required data, quality of care reviews and complaint logs are a few methods used to measure provider performance. The Cultural Competency Committee was developed as a mechanism to ensure the organization meets the unique and diverse behavioral healthcare needs of all members in the population. Quality Management Plan 10 [ ]

11 The CMS Quality Framework is woven across the organization through design, discovery, remediation and improvement. These four components drive the operation and management of the QM Program and contribute to its continued success. Design The QM Program Description, work plan, annual review of policies and procedures, establishment of benchmarks illustrate the structure and process for how the program is designed. Multiple inter-departmental and external advisory committees have been established to be in compliance with state, federal and accrediting bodies. All Eastpointe staff receive training on policies and procedures annually, and are able to access these documents through the intranet and receive updates when revised. Discovery As part of the Discovery phase for continuous quality improvement, quality assurance monitoring is conducted throughout the organization. Several committees are responsible for the ongoing monitoring of these measures and report routinely to the Global Quality Improvement Committee (GQIC). Eastpointe s quality assurance monitoring includes, but is not limited to the following: Customer Service Accessibility - to monitor how quickly consumers can Access Eastpointe staff to address their needs (i.e., Telephone Statistics, such as Average Speed of Answer, and Abandonment rate). Provider Network Accessibility & Availability- to monitor the availability of providers to meet the needs of the population and the accessibility of those providers to treat members on an emergent, urgent, and routine basis. Utilization Metrics- Denial and Appeal Data- to monitor (i.e., percentage of cases denied, appeal overturn rate). Staff Documentation Audits- to monitor whether staff are following policies and documenting activities appropriately. (i.e. Call Center, UM, MH/SA Care Coordination, IDD: Individual Support Plans (ISP). Complaints to monitors complaints regarding Eastpointe s service delivery. Complaint data is analyzed to identify trends and also review response timeliness. Participant and Provider Satisfaction Survey Results- to monitor member/enrollee and provider satisfaction with Eastpointe s service delivery. Quality Management Plan 11 [ ]

12 Remediation: The Global Quality Improvement Committee is responsible for setting benchmarks for each of the above quality assurance measures and processes. When discovered, that a benchmark has not been achieved for two consecutive quarters, the remediation phase begins. Improvement Designing and implementing the corrective action plan begins the Improvement phase of continuous quality improvement. The Eastpointe designated staff or committee implements and evaluates Performance Improvement Projects (PIP) utilizing the PDSA improvement model to achieve the needed performance improvement following the below course to manage the QIP and ensure goals are met and maintained Figure 3 Quality Management Plan 12 [ ]

13 Performance/Quality Improvement Process The design, discovery and remediation phases establish the processes and data necessary for the GQIC to identify monitor and select a PIP/QIP to address the critical dimensions of care delivery and outcomes for the improvement phase. Designing and implementing the corrective action plan begins the improvement phase of continuous quality improvement. If a department fails to meet the performance standard for two consecutive quarters, a Corrective Action Plan (CAP) will be implemented and presented to the GQIC for review. When the implementation of a CAP does not resolve the specific issue (s) a PIP/QIP will be implemented. The Global Quality Improvement Committee and PIP/QIP workgroups implement and evaluates quality/performance improvement projects utilizing the Plan, Do, Study, Act (PDSA) Improvement Model to achieve improvement. The following diagram illustrates the PIP/QIP process to ensure goals are met and maintained ACT Plan the next cycle Can the change be implemented PLAN Define the objective, questions and predictions. Answer the questions (who? what? where? when?) Data collection to answer the questions STUDY Complete the analysis of the data. Compare data to the predictions. Summarize what was learned DO Carry out the plan Collect the data Begin analysis of the data Figure 4 Quality Management Plan 13 [ ]

14 Quality Management Resources The Quality Management (QM) Department encompasses Policy and Procedures, Training, Grievance and Appeals and Medical Records Management. These departments are embedded throughout the organization and ensure quality principles are executed. The QM Department provides resources necessary to support the day to day operations of the division. The Chief of Quality Management oversees the department, with collaboration and guidance from the Medical Director. The Medical Director serves as chair of the GQIC and is involved in all clinical (PIP/ QIP) initiatives. Policy and Procedures Policy and Procedures (P&P) ensure the organization implements state, federal and URAC standards. It governs core business processes of the organization, establishes accountability and ensures quality services are delivered to individuals. Policies and procedures guide the organizational and operational structure. Oversight for development of Policies and Procedures is supported by a Policy and Procedure Administrator, who is responsible for processing and tracking policies throughout the organization. The administrator serves as liaison for two subcommittees who are responsible for reviewing policies and procedures before implementation, ensure use of correct template and format consistency. Training Department The role of the Training Department is to ensure that all staff receive training which is appropriate to their position. The Training Department plays an integral role in new employee orientation by ensuring that all staff receive appropriate training before assuming assigned roles and responsibilities. In addition to new orientation training, Eastpointe provides staff with ongoing and annual training in order to keep staff up to date and maintain job knowledge. The department collaborates with Departmental Chiefs, Directors and Supervisors to review, update and approve all trainings to ensure they are current, appropriate and accessible for staff. Grievance and Appeals Department The Grievance and Appeals Department manages the grievance and appeals processes for enrollee/members and providers. Eastpointe believes There is no wrong door to file a complaint. Therefore, all staff are trained in assisting complainants with grievances. The department responds to complaints and questions from enrollees, providers and stakeholders. The department facilitates enrollee/member involvement and plays an integral role in the Appeals Process. The department assists enrollees/members with filing appeals when needed. Complainant appeals are reviewed and resolved by an Ad-Hoc Committee within 28 days from receipt. Medical Records/Data Management Medical Records/Data Management is responsible for maintaining enrollee medical records, files and statistics. The Department ensures all medical records are released according to Health Insurance Portability and Accountability Act (HIPAA) guidelines and compliant with relevant regulations and standards. Staff are responsible for entering LME Consumer Admission and Discharge Forms (LCAD) and submission and maintenance for Client Data Warehouse (CDW). Technical assistance is provided to Network Operations Providers to ensure clinical records meet requirements of the Records Management and Documentation Manual. The department assumes responsibilities for member records when the provider has gone out of business. Quality Management Plan 14 [ ]

15 Quality Management Program Overview The overall objective of the Quality Management Program is designed to implement state, federal regulations and national accreditation standards. The following describes how Eastpointe intends to comply with these standards. Meet or exceed CMS, DMA, DHHS, defined minimum performance levels on standardized quality measures annually QM Review Specialists conduct quarterly audits, assess for trends and data accuracy while working in collaboration with Department Directors and various committees. QM Review Specialists review medical records and/or data to determine the organization s level of performance and/or compliance. The Quality Management Department has implemented the following processes for monitoring internal performance in all functional areas: Authorization Time Frames Access to Care Standards daily Response to complaints and grievances daily Review of Appeals, Medical Necessity Denials quarterly Review of NC TOPPS updates daily Quarterly Audits: MH/SA Care Coordination process Member Call Center Documentation Appeals/Medical Necessity Denials The Quality Management Department utilizes information obtained from DMH/DD/SAS LME -MCO Quarterly Performance Measures and DMA 1915-B Waiver Measures to evaluate the organization s performance quarterly. This information is reported quarterly to the GQIC and various departments throughout the organization. Develop and implement Performance/Quality Improvement Projects Performance/Quality Improvement Projects (PIPS/QIPS) are initiated in response to identified problems, gaps, performance issues, accreditation requirements and or other performance initiatives. QM Review Specialists are assigned to one project to gather, analyze and process data related to the QI Projects. Updates on performance/quality improvement initiative are shared with staff quarterly. Implemented methods to detect over and under utilization of services The Quality Management Department (QM) recognizes over and underutilization of services impact services provided to members/enrollees. Keeping abreast of service utilization surrounding high cost/high risk is crucial to the success of the organization. The department conducts Eligibility of Benefits (CB #29) audits on a quarterly basis to determine if services billed for by providers were delivered to members. Results of the audit are forwarded to Provider Monitoring/Program Integrity and reported to the Global Quality Improvement Committee. Quality Management Plan 15 [ ]

16 Quality Management Program Overview The Utilization Management (UM) Department utilizes clinical care criteria related to best practices on current treatment protocols and national standards. Eastpointe UM Department analyzes and trends utilization data to identify normal and special cause variations that impacts patterns of utilization. Eastpointe established ranges for utilization of services and examines utilization patterns outside the established criteria ranges at an individual, provider, and at the aggregate system level. Penetration rates, inpatient recidivism, bed days per 1,000, emergency department (ED) visits and outpatient utilization are a few key measures analyzed for under and over utilization and identification of problem areas. Utilization data is discussed and analyzed for trends during System Performance Review and the Clinical/ Finance Committee. Clinical case reviews are also conducted to identify barriers to access, discharge from higher levels of care and/or gaps in service continuum. Mental Health and Substance Abuse (MH/SA) Care Coordination identifies and tracks high-cost and/or high-risk members/enrollees through inpatient admission reports generated by UM and Member Call Center within 24 hours. All members/enrollees admitted into Care Coordination receive an Intensity of Need (ION) rating based on number of psychiatric admissions, ED visits and other criteria. The Quality Management Department conducts quarterly reviews of MH/SA Care Coordination internal processes. The audit ensures follow up activities were conducted within appropriate time frames and member received level of community based services needed. Assess the quality and appropriateness of care furnished to member/enrollees Eastpointe's philosophy correlates with Division of Medicaid Assistance (DMA) expectations to ensure quality and appropriateness of care provided to enrollees. Development of a provider network comprised of the most qualified providers, coordination of care for individuals identified as high risk/high cost and collaboration with Community Care of North Carolina (CCNC) is a few ways the organization ensures timely, appropriate and cost efficient services. The Quality Management Department conducts record reviews of Innovations members to ensure oversight of plan implementation and service delivery on a quarterly basis. MH/SA Care Coordination audits are conducted quarterly to ensure coordination for members/enrollees discharged from state facilities or who have received inpatient admission or facility based crisis. The department also facilitates weekly Quality of Care Committee (QOC) which reviews cases of concerns originating from various departments throughout the organization. Provider Monitoring and IDD Care Coordinators monitor Back up staffing Plans to assess appropriateness of care furnished to members. Any situation identified as health and welfare issues are addressed immediately with the employer, representative and/or agency of choice. A plan of correction is required if the failure to provide back up staffing presents a health and safety concern. Quality Management Plan 16 [ ]

17 Quality Management Program Overview Enrollee progress and experience is also monitored through NC Treatment Outcomes and Program Performance System (NC-TOPPS). NC TOPPS Specialist ensures all NC-TOPPS assessments are submitted by reviewing the updates lists daily. Each provider is sent reminders daily and/or a phone call if within two days of the 14 day timeframe. The NC TOPPS Specialist works with providers to ensure complete and accurate reporting of member/enrollee progress and outcomes. Eastpointe values the satisfaction of enrollees/family members/stakeholders with service provided in the Eastpointe. Eastpointe has various ways enrollee satisfaction is measured. These include annual surveys and mystery shopping. The goal of these initiatives is to gather feedback on how various Eastpointe departments perform during random and anonymous monitoring. This system is used to pinpoint the need for additional training of staff. Eastpointe utilizes these tools to monitor provider customer service. Measure performance of Network Providers An important part of Eastpointe s role as a MCO is to monitor the performance of providers in the network. Provider performance is measured in a variety of ways to include but not limited to monitoring health and safety of members, rights protections, adherence to Best Practice Standards, review of incident reports, quality of care reviews, member satisfaction surveys, first responder capacity surveys and compliance with data submission requirements. The organization monitors providers use of service funds, investigates complaints and incidents. Eastpointe utilizes the Standardized Routine Provider Monitoring and Post Payment Review Tool to monitor providers compliance with clinical practice guideline. This tool assesses Provider performance in a given area or areas in an efficient manner, and identifies areas requiring more follow up or in-depth inquiry. In addition, Provider Monitoring conduct reviews of received complaints and targeted monitoring. Provider Availability and Call Center Triage Report measures the percent of members who are provided an appointment within specified timeframes. This is presented to GQIC on a quarterly basis. During FY 2013, Network Operations conducted a Demographic, Utilization and Network capacity study. The study analyzed Eastpointe eligible/member demographic characteristics, prevalence of behavioral health, insurance availability, provider capacity and individual practitioner availability. The result of this data was used in the development of the Network Development Plan for the upcoming year. Perception of Care surveys are conducted annually to provide information on the quality of care based on the perceptions of individuals and families who have received Medicaid and State Funded mental health and /or substance abuse services. Results of the survey are shared with CFAC, Human Rights and GQIC committees and are posted on Eastpointe s website. Quality Management Plan 17 [ ]

18 Quality Management Program Overview Provide Performance Feedback to Providers Eastpointe believes creating a partnership through open dialogue with providers will improve outcomes and quality of life for members/enrollees. Performance feedback is shared with providers through provider meetings, forums and training sessions. Eastpointe disseminates critical and time sensitive information through communication bulletins via the provider list serv. Provider Network Operations are assigned to specific providers to act as contact to respond to individual needs. All providers in the network receive a profile review at least every three(3) years. The Provider Monitoring Unit maintains a master schedule of profile review dues dates. At the conclusion of the review, a briefing of the outcome is provided. Copies of the results are mailed within 30 days to the provider. The QM Program utilizes data from surveys to identify opportunities for improvement, implements interventions as appropriate or evaluate the need for new or revised polices. Surveys are posted on the website to obtain feedback from members, providers and employees. The QM Department collects the surveys and presents the information to GQIC, Human Rights and CFAC committees. Quarterly and annual evaluations are also shared within the Provider Council and posted on Eastpointe's website for review. Develop and adopt clinically appropriate practice parameters and protocols Eastpointe uses established medical necessity criteria, clinical decision support tools and level of care tools that serve as the basis for consistent and clinically appropriate service authorization decisions for all levels of mental health, substance abuse and intellectual/developmental disability services. The Utilization Management (UM) and Member Call Center consistently adhere to adopted clinical practice guidelines. Inter-rater reliability Procedure (IRR) is a process that has been implemented by both departments to assure consistency in the application of departmental, state, federal and URAC guidelines. Studies are conducted every 3 months or as needed based upon staff level of expertise and results of prior reviews. Periodic inter-rater reliability studies are conducted and reviewed by Medical Director as part of Eastpointe s continuous quality improvement philosophy. Departmental and individual staff performance improvement plans are implemented if individual inter-rater reliability is below established benchmarks. In addition, QM Department performs quality assurance reviews to ensure compliance with established procedures. The Clinical Advisory Committee (CAC) comprised of Provider Agencies, Licensed Independent Practitioners (LIP) and Hospitals is one method the organization ensures practice guidelines are shared among a consensus of professionals. Practice guidelines are reviewed and updated periodically by the committee and in accordance with changes and developments in clinical research. The organization has developed processes to ensure that Utilization Management decisions, enrollee education decisions, coverage of services and all other decisions are consistent with practice guidelines. When areas of concern are identified, a discussion of clinical standards and the expectations are held. Providers are supported with clinical protocols and guidelines to enable them to meet the established standards, and recommendations for actions to correct the deficiencies. Quality Management Plan 18 [ ]

19 Quality Management Program Overview Evaluation of Access to Care for Members/Enrollees Eastpointe evaluates the adequacy of the provider community regarding issues such as cultural and linguistic competency of existing provider, provisions of evidenced based practices and treatment and availability of community services to address housing and employment issues. The organization has implemented several processes to ensure that medically necessary services are delivered in a timely and appropriate manner. During 2014, Eastpointe utilized the GEO Access Map which determines the location of providers in relation to where members live within the catchment area, and focus on areas that need recruitment. The network capacity report measures the number and type of active members/ enrollees and providers served by category in the catchment area. Eastpointe recognizes that timely access to care is critical to protect both health and safety and ensure positive outcomes. Eastpointe operates a 24 hour, 7 day per week, Member Call Center to link individuals to services in the 12 county area through a toll free crisis line. Members are screened and triaged by a licensed clinician who determines if the individual meets criteria for emergent, urgent, or routine care. The triage level determines scheduling and are as follows: Emergent-2 hours (Life-Threatening Emergent-Immediate) Urgent-48 hours Routine-10 working days ( DMA Contract) All appointments are followed up to ensure the member/enrollee has been seen and linked to services. During FY , two Quality Improvement Projects were initiated to measure percent of members who attended urgent appointments and to capture the percent of provider who report follow up appointments. Data revealed, timely response to the needs of members and linkage needed to increase. Development of The Cultural Competency Committee, was one mechanism to ensure the organization met the unique and diverse behavioral healthcare needs of all members/enrollees in the population. The committee consist of Eastpointe staff members, CFAC representatives, network provider representative, underserved populations and professional/community organizations. Provider Sufficiency A goal of Provider Network is to ensure adequate appointments available to members/enrollees to meet the standard. Eastpointe providers are held to the following standard in regards to Appointment Wait Time for Urgent Referrals: for scheduled appointments, members are not to wait no more than one hour; for walk-in appointments no later than two hours. During FY 2014, a needs assessment was conducted to access standards and provider capacity in relation to community needs. The assessment reviewed the needs of the population in the catchment area, identified gaps in the service array, perceived barriers and the number and variety of age disability providers for each service. Quality Management Plan 19 [ ]

20 COMMITTEE STRUCTURE As a part of the Continuous Quality Improvement Process, Eastpointe has established multiple inter-departmental and external advisory committees that report to the Global Quality Improvement Committee (GQIC) on a monthly basis. The committees serve as feedback loop to the organization and ensures that contractual requirements are met. Committee representation include Eastpointe staff, stakeholders and provider network. The organization recognizes that partnering with members, stakeholders and providers to find solutions will strengthen the service delivery system. Executive Team The Executive Team is comprised of Chief Executive Officer (CEO), Medical Director, Chief of Clinical Services, External Operations, Quality Management and Business Operations. These officers, in addition to the Director of Human Resources/Corporate Compliance are responsible for the overall management of the organization. The Executive Team review and approve all revised procedures as well as internal forms. The committee meets on a weekly basis. Leadership Team The purpose of the Leadership Team is to facilitate communication surrounding issues that affect the organization. This interdepartmental team is comprised of the Executive Team and Department Directors. The committee discusses current operations, reviews performance outcomes and distributes information throughout the organization. The members of this committee are responsible for implementing and monitoring goals within the organization. The CFAC chair serves on this committee. This committee meets on a monthly basis. Quality Management Plan 20 [ ]

21 COMMITTEE STRUCTURE Global Quality Improvement Committee (GQIC) The Global Quality Improvement Committee (GQIC) identifies and address opportunities for improvement of LME/MCO operations and the local service system. The committee is granted authority by Eastpointe Board of Directors and the Chief Executive Officer (CEO). The committee meets at least quarterly with the purpose of monitoring the organizations and provider performance, analyzing reports and data, recommending continuous quality improvement projects and evaluating the effectiveness of the continuous quality projects and interventions. The committee maintains minutes of all meetings, which are approved by the GQIC and posted on the website. Committee membership includes management representatives from each area of the organization, network providers and the CFAC chair. Absence without justifiable cause from three consecutive meetings within a 12-month period shall constitute removal as a voting member. A Quorum requirement constitutes 50% of the majority of voting members present. The Board of Directors provides oversight through review of routine reports from the Executive Team. The GQIC provides staff with oversight and guidance on quality management priorities, projects and policy direction. The medical director serves as chair of the committee. The (GQIC) is accountable to the Executive Team. This committee interacts with other committees as a guide for setting goals and objectives for the program. The responsibilities of the committee are: 1. Monitor and document key performance measures that is quantifiable and used to establish acceptable levels of performance including a baseline and at least an annual re-measurement 2. Approve selected Quality/Performance Improvement Projects and monitor for progress 3. Provide guidance to staff on QM priorities and projects 4. Approve Corrective Action Plans (CAP) to improve or correct identified problems or meet acceptable levels of performance 5. Review and approve the QM Program Description and QM work Plan annually 6. Receive and incorporate input from participating providers Quality Management Plan 21 [ ]

22 COMMITTEE STRUCTURE Systems Performance Review Committee (SPRC) The System Performance Review Committee evaluates the utilization of services with the goals that member/enrollees receive the appropriate level of services within reasonable time frame. The committee reviews key performance indicators related to over and under utilization, penetration rates, inpatient admissions and bed days per 1,000 consumers, emergency departments visits per 100 consumers and outpatient utilization. The committee reviews key performance indicators related to Effectiveness of Care, Use of Services and Access/Availability. This committee reviews individual cases and oversees high risk/high cost members/enrollees. The committee is chaired by the Medical Director and consist of Clinical Operations, Network Operations and Quality Management Departments. A CFAC Representative also serves on this committee. The committee meets on a quarterly basis. Clinical Advisory Committee (CAC) The purpose of the Clinical Advisory Committee is to work collaboratively to review evidencebased practices, identify training needs, evaluate utilization in relation to clinical guidelines and assist with the development of community standards of care. The committee is chaired by the MCO Medical Director. The Clinical Advisory Committee is comprised of Licensed Network providers and Eastpointe clinical staff representing various disciplines and disabilities from Eastpointe s network providers and practitioners. The committee reviews and approves all clinical criteria, scripts and tools annually. The committee meets monthly. Provider Network Council The Provider Network Council advises Eastpointe on communication, policy development, initiatives, projects and the impact of state responsible for monitoring and trending data from the provider network. The committee also assists in the development of plans to address concerns from the provider network and Eastpointe. The Provider Council receives regular updates regarding on-going projects, special projects and the latest information on pending changes from state and local organizations. The Group is one of the key operational committees of Eastpointe and, as such, has responsibilities to Network Providers in representing their interests and challenges, to members and family members and to Eastpointe in responding to standards, key indicators, initiatives and requirements. A CFAC Representative serves on this committee. The committee meets on a monthly basis. Quality Management Plan 22 [ ]

23 COMMITTEE STRUCTURE Credentialing Committee The Credentialing Committee (CC) is tasked with assuring that licensed independent practitioners meet standards for entrance into the Managed Care Organization (MCO). Chaired by the Medical Doctor,the Committee reviews licensure, education, sanctions, criminal background checks and other documents in order to decide if the applicant meets MCO standards. The committee evaluates and approves credentialing and re-credentialing applications for Licensed Independent Practitioners (LIP) and Associate Licensed Practitioners (APs)/agencies/hospitals. The Credentialing Committee may change a provider s credentialing status (i.e., suspension or revocation) on the basis of an action or non-action that is found to violate MCOs standards of practice. The Credentialing Committee makes reports to the applicable licensing boards for independent licensed practitioners based on audit findings. The committee meets at least quarterly or more frequently at the discretion of the chair. Cultural Competence Advisory Committee The Cultural Competency Committee in collaboration with network providers and the community address issues related to the ever expanding diverse populations for enrollees and staff in the provision of competent services. The purpose of the Cultural Competency Committee is to develop, implement and monitor agency and network provider s practices and procedures to ensure services and supports are culturally competent by striving to incorporate each individual s culture and heritage. The Committee is responsible for ensuring that Culturally and Linguistically Appropriate Services (CLAS) are delivered through the establishment, implementation and maintenance of the Cultural Competence Plan, as documented in this written Program Description the CCAC conducts an annual literature review to identify benchmarks that may be used to set quantifiable goals for the program. The Cultural Competency Committee consists of Eastpointe staff members, CFAC representatives, underserved populations, professional/community organizations, and network provider representatives. The committee meets as often as necessary, but at least every six (6) months. Provider Quality Management Director s Forum The Provider Quality Management Director s Forum was established in 2013, with the intentions of evoking discussion surrounding Quality Management activities and functions within a behavioral healthcare organization. The forum designed especially for QM Directors provides opportunities for Provider QM Directors to share ideas surrounding quality improvement activities within their agency. The forum meets monthly via face to face or webinar. Quality Management Plan 23 [ ]

24 COMMITTEE STRUCTURE Safety Committee The Safety committee is charged with the responsibility of implementing Eastpointe s Safety Plan, Policies and Procedures related to safety, and for all safety issues/concerns within the agency regarding facilities and staff. Representation from each site is included within this committee. Subcommittees have been established for each site under the supervision of the safety manager. The committee meets on a quarterly basis or as needed. Major responsibilities of the committee are as follows: 1. Complete annual and ongoing safety inspections per location 2. Review of Safety Plan Goals Communication Committee The Communication Committee is charged with reviewing member/enrollee literature before it s disseminated. The purpose of this committee is to ensure that information represented in these materials is accurately and clearly communicated to members/enrollees. The goals of the committee is to: 1. Review enrollee/member education materials for adherence to Medicaid contract requirements and adherence to the Federal Plain Language Guidelines. 2. Safeguard against misrepresentation in communication materials through review and approval process. Policy and Procedure Committee The Policy and Procedure (P&P) Committee reviews all new policies, retiring policies, and new or revised procedures to ensure that the P&Ps submitted by staff meet all the requirements of the Policy and Procedure Development Policy. The committee meets on a monthly basis or as needed. Functions of this committee include: 1. Ensure all elements/formats are met. 2. Investigate when a P&P is submitted that an existing P&P does not already exist. 3. Ensure all P&Ps submitted are tracked through the entire process. 4. Initiate the need for new polices and procedures. Quality Management Plan 24 [ ]

25 COMMITTEE STRUCTURE Corporate Compliance Committee The Corporate Compliance Committee is responsible for on-going review of the organizations Corporate Compliance Plan, coordination of area wide corporate compliance and program integrity activities both internal and external. Functions of this Committee include, but are not limited to review reports of potential fraud and/or abuse and internal investigations. The committee meets monthly and is chaired by the Corporate Compliance Officer. Responsibilities of Committee Members: 1. To be or become adequately knowledgeable of the department functions and responsibilities in order to represent your department s perspective on the issues at hand. This may include research and/or consulting with the Department Director and other department staff. 2. To regularly report to the member s department on the activities, decisions and actions of the compliance committee which directly affect the department s activities. Quality of Care Committee (QOC) The Quality of Care Committee reviews clinical and practice issues that are identified by various departments throughout the organization. The committee is comprised of Medical Director, Chief of Clinical Operations, Chief of Quality Management, Director of Provider Monitoring, Director of QI, UM Director and QM Review Specialists. The committee makes referrals to various departments within the organization. The Quality of Care Committee meets weekly or as needed to discuss cases of concern. The committee identifies patterns of over/under utilization of services. Reports Committee The Reports Committee is charged with reviewing both DMA 1915-B Waiver and DMH/DD/ SAS LME-MCO Performance Measures to ensure technical specifications are followed when reporting performance measures. The committees purpose is to ensure consistency, reduce duplication and establish uniformity when reporting. The committee reviews and validates data, assigns new reports and ensure reports meet North Carolina LME/MCO Performance Measurement and Reporting Guide. The committee meets twice montlhly or as needed. The following Organization Chart defines reporting illustrates and organizational relationships Quality Management Plan 25 [ ]

26 Global Quality Improvement Committee Quality Management Plan 26 [ ]

27 DEPARTMENTAL COLLABORATION Clinical Operations Department Clinical Operations provides leadership to the Member Call Center, Utilization Management, MH/SA Care Coordination, I/DD Care Coordination, Special Populations and Housing Departments. The Medical Director has oversight of all Clinical Operations. Member Call Center Eastpointe s Member Call Center provides one of the core functions of the MCO. Routine reports such as telephone average speed to answer, abandonment rate and service levels, enrollee inquiries and grievances, and enrollee satisfaction reports are shared with GQIC. Average Speed of Answer (ASA) and Abandonment Rate (ABR) are reviewed quarterly by the GQIC to assure state and URAC standards are met. QM Departments conduct quarterly audits to ensure accountability and adherence to standards. Innovations Care Coordination (IDD) Care Coordination is an administrative function of the LME/MCO. I/DD Care Coordination is provided for all enrollees in the Innovations Waiver and to individuals who are on the Innovations Waiver Registry of Unmet Needs. I/DD Care Coordination is responsible for developing the Individual Service Plan and budgets for Innovations Waiver enrollees. In conjunction with I/DD, the QM Department analyzes Innovations reports for accuracy, monitors Innovations Slot Tracking Report and conducts quarterly reviews of internal processes related to I/DD services (ISP reviews, Health and Safety audits). Mental Health/Substance Abuse (MH/SA) MH/SA Care Coordination is provided to enrollees identified as high risk, high cost, special healthcare, or referred by CCNC from Quadrant II (high behavioral needs, low medical needs) and Quadrant IV (high behavioral, high medical needs). MH/SA Care Coordination collaborates and consults with providers participates in discharge and ongoing treatment planning as needed to ensure these enrollees are receiving services that meet their needs. In conjunction with QM, MH/SA Care Coordination established an initiative regarding after care appointments for members who were discharged from inpatient facilities. Quality Management Plan 27 [ ]

28 DEPARTMENTAL COLLABORATION Housing Department The Housing Department collaborates with other stakeholders to develop and oversee housing resources available to members. The Department links members/enrollees to appropriate services and community supports while providing support during and for a period of time following transition. Special Populations Special Population Services assists with the development and oversight of activities impacting special populations (i.e. Traumatic Brain Injury (TBI), Military Personnel, deaf services, etc.) The department is supported by the Special Populations Specialist. During FY , questions were added to Screening, Triage and Referral (STR) tool to capture individuals who have suffered from head injuries. The Member Call Center also incorporated salutations to acknowledge individuals and family members who are veterans or actively serving. The QM Department reviews and validates the TBI report quarterly and submits to designated entity, Utilization Management (UM) Eastpointe UM Department reviews and approves authorization requests on State and Medicaid funded services. A Quality Review Specialist is assigned to the department to facilitate crossagency reporting and analysis of data. Quarterly audits ore conducted on Medical Necessity Denials and Appeals. Total number of authorizations received, percent processed in 14 days and number of authorizations requests processed in required time frames are reviewed monthly. Penetration rates, inpatient admissions and emergency department visits data are analyzed and trended. UM Staff refer clinical and practice concerns identified during review of clinical information to the Quality of Care Committee to ensure appropriate treatment. Quality Management Plan 28 [ ]

29 DEPARTMENTAL COLLABORATION Business Operations As part of the Global Quality Improvement Committee, the Financial Operations Department manages the financial resources of the organization. The department provides oversight of Facility Maintenance, Medicaid Contract Management, Information Technology (IT) and Financial Operations. The Chief of Business Operations leads this divisions. Information Technology The Information Technology (IT) Department is responsible for ensuring that all network and software systems are maintained. Housed within Business Operations, the department develops and maintains the operating system and provides technical assistance to both staff and providers. The department is responsible for safe and accurate handling of data, development of reports and coordination of internal operations. Technical and Helpdesk support is also managed in the department and is crucial to daily operations. Eastpointe s website is a key communication component for the agency. During fiscal year , a committee was established to ensure information on the website was current and accessible to visitors. Report writing is a crucial area for ensuring data integrity and consistency. The IT Department maintains a Data Manager and Report Writers that create reports. The report writers work closely with QM and various other departments to assure compliance with state guidelines. A weekly reports meeting is held to discuss progress of reports development which include various departments from Clinical, External Operations and Quality Management. Financial Operations Financial Operations manages the financial resources of the organization, including claims and reimbursement. Claims and reimbursement is one of the most critical and visible elements of the organization. Medicaid Contract Manager The Medicaid Contract Managers acts as the liaison between the state and the MCO to ensure compliance with the waiver contract. Facility Management Facility Management oversees the physical sites operated by the organization. Quality Management Plan 29 [ ]

30 DEPARTMENTAL COLLABORATION External Operations Department Eastpointe s External Operations Department is responsible for developing and managing the provider network. The department is responsible for the following functions: Community Relations, Network Management, Provider Monitoring/Program Integrity and Communications. The Chief of External Operations supervises the division. Community Relations The Community Relations Department has the privilege of being the Face of Eastpointe with a Community Relations Specialists assigned to each of the 12 counties, they are visible, active member of their assigned community. The Department educates community stakeholders on how to access services and help them understand the ever changing world of Mental Health. The Crisis Collaborative within the catchment area has been initiated and led by Community Relations Department and correlates with DHHS s Crisis Solution Initiative. They also work closely with internal departments such as Care Coordination with the Crisis Collaborative in efforts to reduce recidivism rates. Network Management Network Management develops and oversees the Provider Network of services for adults and children with Mental Health, Intellectual/Developmental Disabilities, and/or Substance Abuse. The Department provides necessary information to the Provider Network to ensure rules and regulations are met. Network Operations encompasses the following responsibilities: maintain Provider Choice Database and Training Calendar, assist with administrative, contractual and technical issues, recruit providers to meet the service needs of members and families and support the Provider Network through Provider Council, regular provider meetings and steering committees. Provider Monitoring/Program Integrity Provider Monitoring performs monitoring activities to ensure that required standards of care are followed by providers. The Department monitors health and safety of members, rights protections and quality of care. Provider Monitoring is charged with conducting compliance reviews and audits of medical records, administrative files, physical environment, and other areas of service including cultural competency reviews. Program Integrity Unit ensures compliance, efficiency and accountability of funded services by detecting and preventing fraud, waste and program abuse. The unit receives complaints from members, families, other providers, former employees of providers, community stakeholders and through federal and state referrals. The unit identifies patterns of fraud and abuse through the Fraud and Abuse Management System (FAMS). Communication Communications assists in the review and assessment of communication and marketing materials, documents, presentations and manages all media contacts. The Communications Officer serves as chair of the Communications Committee and is responsible for maintaining the organizations Communication Materials Log. Quality Management Plan 30 [ ]

31 Performance/Quality Improvement Projects Eastpointe identifies aspects of care and service that indicate areas of concern through continuous data collection and analysis from multiple sources that focus on clinical and non-clinical issues. When an area of concern is identified, topics are systematically selected and prioritized to achieve the greatest practical benefit for enrollees. The PIP/QIPs selected must achieve demonstrable and sustained improvement in significant aspects of care and are expected to have a favorable effect on mental health outcomes and enrollee satisfaction. Additionally, at least one of the selected PIP/QIPS per program must address enrollee safety for the population served For URAC accreditation, Eastpointe will have at least two active QIPs that address opportunities for either error reduction or performance improvement in place at all times related to the services covered by accreditation of Utilization Management, Provider Network, and Call Center services. The North Carolina Division of Mental Health, Developmental Disability and Substance Abuse Services (NC MH/IDD/SAS) and Division of Medicaid (DMA) require a minimum of three performance improvement projects. During year one of the contracts, a minimum of two performance improvement projects are developed which focus on clinical and non-clinical areas. During year two of the contract, at least one additional performance improvement project shall be developed; for a total of three performance improvement projects. The PIP/QIPS selected to fulfill the state requirements may also fulfill URAC requirements. All projects separately track Medicaid or State Funded populations. The GQIC is responsible for the approval of PIP/QIP within the organization. The GQIC reviews data from various committees, takes appropriate action when deficiencies or opportunities to improve care and services are identified and makes recommendations accordingly. The GQIC uses the following criteria to determine and prioritize PIP/QIPs: The impact of the project on the member/enrollee, Provider Network, and/or LME/MCO Safety Concerns for the member/enrollee, provider network and /or the LME Ability/Control to make the change required in the QIP Possible liability/cost/penalty and risk to the agency The resources that are available to assist with the project Quality Management Plan 31 [ ]

32 Performance/Quality Improvement Projects Performance/Quality Improvement Project (PIP/QIP) topics will be determined jointly by Eastpointe and DMA from the list of clinical and non-clinical focus areas listed below: Primary, secondary and/or tertiary prevention of acute/chronic mental illness conditions; Care of Acute chronic/mental illness conditions Recovery/outcome measures High-volume High-risk /services Continuity and Coordination of care Availability, Accessibility, and Cultural Competency of services Quality of provider/patient encounters; or Appeals and Grievance The Quality Management Program utilizes inter-departmental workgroups and stakeholder participation which are responsible for the coordination, implementation and on-going monitoring of their Quality Improvement. A provider representative serves on the Network PIP/QIP workgroup. These inter-departmental workgroups meet as least quarterly to monitor progress of the project and ensure consistency with URAC, DHHS and DMA requirements. Benchmarks for each project shall be set based upon past performance data, currently accepted standards or available national data. Both the Medical Director and Associate Medical Director serve on all PIP/ QIP workgroup (s) to ensure clinical expertise and judgment. Quality Review Specialist are assigned to each workgroup and are responsible for gathering and analyzing data and meeting schedules. Progress and findings of the projects are reported quarterly to the Global Quality Improvement Committee and Eastpointe employees. In order to promote quality throughout the organization, the progression of PIP/QIPs and other quality management activities are routinely communicated to all staff via through quarterly announcement. Members of the GQIC and organization staff are provided with regular updates on PIP/QIP performance and quality program goals. The following chart illustrates initiation of a performance/quality improvement project within the organization. Quality Management Plan 32 [ ]

33 START Stakeholder Provider Council CFAC QM Data Mgr. Data Collection based on action required Data indicates actionable item No End Yes Yes Q M Sp ecial is ts works i n co l labo ra tion w i th Ass ign ed Dep ar tmen t QM Specialists works in collaboration via Assigned Committee QM Specialist reviews reports for : Benchmark Met Further action based on review Yes Internal QM Dept. Procedures No Reports back to requestor Can immediate singular corrective action occurred End Yes No Discovery Phase Implement Is POC needed? QIP or PIP Opportunity Remediation Phase Improvement Phase Implement and Monitor Monitor Quarterly Figure 4 Quality Management Plan 33 [ ]

34 Fiscal Year PIP/QIP Decrease state psychiatric hospital 30 day readmissions for high risk members-active This Project focuses on individuals identified as high risk for readmission to a state psychiatric hospital within 30 days. The project was selected because Eastpointe's members experienced a rate of state psychiatric hospital readmission that exceeded the state average for 50% of the quarters during fiscal year Data is reviewed and analyzed from Division of Medical Assistance (DMA) 1915-B Waiver Measures and State Hospital Approved Claims. Interventions during this fiscal year include: MH/SA Care Coordinators participate in discharge planning, collaboration with CCNC regarding hospital readmissions, internal process that alerts Care Coordination when a member considered high risk access service through Member Call Center, follow up with member if appointments are not kept and Care Coordinators telephone local emergency rooms or daily census. Increase data reporting from providers regarding consumer attendance to routine followup-active Eastpointe is responsible for timely response to the needs of enrollees and for quick linkages to qualified providers. This project was selected because data indicated providers failed to record follow up attendance for routine visits. The project ensures timely access to services and promotes member s safety. Data was collected from the Avatar System and Member Appointment Follow up Form to calculate number of providers who documented appointment attendance. Interventions for FY include: inform providers of contractual requirements to report member attendance during several provider meetings, add Provider representation on QIP/PIP workgroup, share results with Provider Council. Providers not following state requirements will be referred to Provider Monitoring and findings presented to GQIC. Increase percent of calls answered within 30 seconds-active Eastpointe LME/MCO is evaluated by the North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (DMHDDSAS) and Division of Medicaid Assistance (DMA) on a quarterly basis regarding the percent of calls answered within 30 seconds. Ninety five percent (95%) of member calls should be answered within 30 seconds. This project was selected because Eastpointe fell below the required benchmark during 2/1/2013 thru 6/30/2013. Data was collected from the Cisco phone system for percent of calls answered within 30 seconds. Data is tracked and analyzed by QM Data Specialist on a monthly basis. Interventions include: identify peak hours and increase staff coverage by utilizing overtime, hire additional staff, implement workforce management tool Call Copy and explore skill base routing to including matching clinical and non clinical staff skills with callers need. Quality Management Plan 34 [ ]

35 Fiscal Year PIP/QIP Timely Access to Care: Increase percentage of members who received a face to face service within 48 hours New This Quality/Performance Improvement Project was selected because members failed to attend scheduled urgent appointments, despite follow up calls being made by the Member Call Center. For the past three quarters, data indicated that % of individuals determined to need urgent care were provided a face to face service within 48 hours. The remaining 32% were not seen within 48 hours. Timely access to care is critical to protect member s health and safety, minimize adverse consumer outcomes and promote consumer engagement in services. This project is related to Member Call Center and Network Management as it promotes timely response to the needs of members and for quick linkage to providers. Data will be gathered from the LME-MCO report of Access on a quarterly basis. Increasing member attendance for urgent appointments will assist in reducing state psychiatric hospital readmission rates. Initiation and Engagement : Increase continuity of Care -Pending This is a pending project that measures the percent of person (s) who initiate and become engaged in treatment. Data collected from Community Systems Progress Report for FY12-13( 1st- 3rd quarters) and DMH/DD/SAS LME-MCO Quarterly Performance Measures revealed that Eastpointe fell below the performance standard. Before inception, a root cause analysis is conducted to determine if stronger initiation/engagement varies among counties and providers. Implementation of this project is expected by Fall Increase continuity of care for existing and new members discharged from state hospitals - Pending This project was selected to improve efficacy of treatment by providers and improve availability of aftercare appointments with doctors. When members are discharged from psychiatric hospitals they are given a limited supply of medications. After care appointments are usually scheduled with clinicians instead of doctors, resulting in members not having an adequate supply of medications. Doctors appointments may be scheduled as far away as two weeks, resulting in hospital readmission. Improve the correct identification and categorization of Eastpointe complaints for more accurate tracking, trending, and organizational improvement-retired This Project was selected because Eastpointe recognized the need to have complaints captured to be accurate and more meaningful as well as to increase our ability to make organizational improvements. This project was retired November Increase clinical availability by use of non-clinical staff for the Eastpointe Call Center- Retired This project was selected to increase clinical availability for members/enrollees by utilizing non clinical staff. This project relieved clinicians of time spent on the phone providing basic information or demographic information and appointment setting for routine STRs. This project was retired July Quality Management Plan 35 [ ]

36 SITES Eastpointe 500 Nash Medical Arts Mall Rocky Mount, NC Eastpointe 100 South James Street, Suite B Goldsboro, NC Eastpointe 514 East Main Street Beulaville, NC Eastpointe 450 Country Club Road Lumberton, NC Quality Management Plan 36 [ ]