Participation in OptumHealth New Mexico s Quality Improvement Program

Transcription

1 QUALITY IMPROVEMENT Participation in OptumHealth New Mexico s Quality Improvement Program OptumHealth New Mexico is committed to the highest quality of care in a manner consistent with the dignity and rights of our consumers. We are also dedicated to meeting or exceeding the expectations of our customers. The OptumHealth New Mexico Quality Improvement (QI) Program monitors: accessibility; quality of care; appropriateness, effectiveness, and timeliness of treatment; consumer satisfaction and other metrics as defined by our stakeholders. The QI Program is comprehensive and incorporates review and evaluation of all aspects of the behavioral health care delivery systems. You are encouraged to offer feedback to us on the various QI projects and processes. OptumHealth New Mexico has established committees that address concerns related to consumers, clinicians, facilities, and OptumHealth. These committees include the Statewide QM/QI Council, Multicultural Services Advisory Council, Peer Review Committee, Pharmacy & Therapeutics Committee, Clinical Advisory Committee and Provider Advisory & Engagement Committee. In accordance with your Participation Agreement you agree contractually to comply with the OptumHealth QI Program and will cooperate with and assist OptumHealth and customers in their efforts to adhere to all applicable laws, regulations and accreditation standards. The key components of the QI Program required of you as a participating provider include (but are not limited to): Ensuring that care is appropriately coordinated and managed between you and the consumer s primary medical physician and other treating clinicians and/or facilities Cooperation with On-site Audits and requests for treatment and financial records Cooperation with the consumer grievance process (e.g. supplying information necessary to assess and respond to a grievance) Responding to inquiries by OptumHealth New Mexico Quality Improvement staff Participation in OptumHealth New Mexico Quality Improvement studies related to enhancing clinical care or service for consumers Helping to ensure consumers receive rapid follow-up upon discharge from an inpatient level of care OptumHealth makes information available about the QI Program, including a description of the QI Program and work plan and a report on OptumHealth New Mexico s progress in meeting its goals. Some of the activities that may involve you are described in more detail below. Critical Incidents The New Mexico Interagency Behavioral Health Collaborative defines a critical incident as an occurrence that represents actual or potential serious harm to the well being of a consumer or to others by the consumer. Critical Incidents are further defined as a reportable incident that may include, but is not limited to, abuse, neglect, or exploitation; death; environmental hazards; law enforcement intervention that encompasses the full range of covered services. This includes all unexpected occurrences involving death or serious physical or psychological injury, or risk thereof, which occur during the course of a consumer receiving behavioral health treatment. 47

2 If you are aware of a Critical Incident involving a consumer, you must notify OptumHealth New Mexico in writing within 24 hours of occurrence, using the OptumHealth New Mexico Critical Incident Reporting form. Additional information and a copy of this form can be located at Submit your completed form via fax or mail at: OptumHealth New Mexico Attn: Quality Improvement Department 8801 Horizon Blvd NE, Suite #260 Albuquerque, NM FAX: Examples of Critical Incidents include, but are not limited to: Attempted suicides Abuse or neglect Homicides, suicides and other deaths Adverse reactions to treatment Damage to property Environmental Hazard Elopements Financial exploitation Injuries/emergency services Medication or treatment errors Self-injurious behaviors (non-lethal intent) Sexual behaviors Violent or assaultive behaviors (non-lethal intent) Involuntary hospitalizations Detentions for protective custody Detentions or arrests for criminal activity OptumHealth New Mexico has established processes and procedures to investigate and address Critical Incidents. This may include review by a committee with appropriate representation from the various behavioral health disciplines. You are required to cooperate with Critical Incident investigations. Please be aware that the following state departments require additional notification of Critical Incidents beyond OptumHealth s critical incident process. These departments include: Children, Youth and Family Department (CYFD) Department of Health (DOH) Aging and Long Term Care Services Department (ALTCSD) New Mexico Correction Department (NMCD) Practice Guidelines OptumHealth has adopted clinical guidelines from nationally recognized behavioral health organizations, including the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry. The guidelines are meant to be used by professionals in their practices. OptumHealth New Mexico will annually measure practitioner performance against clinical practice guidelines. The Best Practice Guidelines are available through links on optumhealthnewmexico.com. Your feedback is encouraged on all guidelines and any suggestions on new guidelines to be considered for adoption are 48

3 welcome. If you would like a paper copy of these guidelines please contact your Regional Provider Relations Representative. Audits: On-site, Treatment Records, Financial Records OptumHealth representatives visit practice locations and facilities to conduct a variety of on-site audits, including but not limited to, routine clinical quality audits, environmental site audits, quality of care audits (to address concerns identified through Critical Incident reporting or consumer complaints, for example) and financial viability audits. Environmental audits may be conducted as part of the routine quality audit process or, for facilities without national accreditation or state certification it may be part of the credentialing and recredentialing process. Any facility, regardless of accreditation, may be subject to an On-site Audit for any potential quality of care concerns brought to the attention of OptumHealth. During an On-site Audit, charts are reviewed for documentation of diagnosis, treatment plan, verification of services provided to members and other elements. You are expected to maintain adequate medical records on all consumers. Prior to a scheduled audit visit, you will be notified of the specific types of charts that will be reviewed. Failure to document services and/or dates of services may lead to a request for a Corrective Action Plan. Financial viability audits include a review of specific records to assess financial stability with a goal of strengthening the viability for the long-term. Some examples of records that are reviewed as part of the financial audit are income statements and balance sheets. As with any audit, you will be notified of the specific requirements prior to the review Audit tools are based on standards set forth by the State of New Mexico, National Committee on Quality Assurance (NCQA), The Joint Commission (formerly JCAHO) an independent, not-for-profit organization that evaluates and accredits more than 16,000 health care organizations and programs in the United States, HIPAA and OptumHealth. Audit tools are available for reference on optumhealthnewmexico.com. Consumer Satisfaction Surveys On at least an annual basis, OptumHealth New Mexico participates in the Consumer & Family Satisfaction Project (C/FSP), a Consumer Satisfaction Survey of a representative sample of consumers receiving outpatient and inpatient behavioral health services. The results of the survey are compared to performance goals. Improvement action plans are developed through the Quality Management/Quality Improvement Council to address any areas not meeting the standard. The improvement activities are not provider specific but address system issues. Both the survey results and action plans are shared as appropriate with consumers and families, providers and other stakeholders. Provider Satisfaction Surveys OptumHealth New Mexico regularly conducts a satisfaction survey of a representative sample of providers delivering behavioral health services to OptumHealth consumers. This survey obtains data on consumer satisfaction with OptumHealth New Mexico services including utilization management, care coordination, provider services, and claims administration. Medical Record Documentation OptumHealth New Mexico requires providers to meet medical record documentation standards including legibility. At a minimum each record will contain the following: 49

4 patient identification information (on each page or electronic file); personal demographic data (date of birth, sex, race or ethnicity (if available), mailing address, residential address, employer, school, home and work telephone numbers, name and telephone numbers of emergency contacts, marital status, consent forms and guardianship information); date and time of data entry and date and time of encounter; provider identification; allergies and adverse reactions to medications; past medical history for patients seen two or more times; status of preventive services provided or at least those specified by HSD, summarized in an auditable form (a single sheet) in the medical record within six months of enrollment; diagnostic information; medication history including what has been effective and what has not, and why; identification of current problems; history of smoking, alcohol use and substance abuse; reports of consultations and referrals; reports of emergency care, to the extent possible; and advance directive for adults. Each clinical encounter shall contain the following information: history (and physical examination) for presenting complaints containing relevant psychological and social conditions affecting the patient s behavioral health, including mental health (psychiatric) and substance abuse status; plan of treatment; diagnostic tests and the results; drugs prescribed, including the strength, amount, directions for use and refills; therapies and other prescribed regimens and the results; follow-up plans and directions (such as, time for return visit, symptoms that shall prompt a return visit); consultations and referrals and the results; and any other significant aspect of the member s physical or behavioral health care. Additionally, any consumers who see a behavioral health provider for two or more services shall have the following documentation as part of the medical record: a mental status evaluation that documents affect, speech, mood, thought content, judgment, insight, concentration, memory and impulse control; DSM-IV diagnosis consistent with the history, mental status examination or other assessment data; a treatment plan consistent with diagnosis that has objective and measurable goals and time frames for goal attainment or problem resolution; documentation of progress toward attainment of the goal; and preventive services such as relapse prevention and stress management. Medical Record Retention All consumer medical records must be retained for a minimum of ten years. Definition of Cultural Competency, Established Guidelines and Provider Responsibility: Definitions and Established Guidelines: 50

5 U.S. Department of Health and Human Services: Administration on Developmental Disabilities, 2000 The term cultural competence means services, supports or other assistance that are conducted or provided in a manner that is responsive to the beliefs, interpersonal styles, attitudes, language and behaviors of individuals who are receiving services, and in a manner that has the greatest likelihood of ensuring their maximum participation in the program. Substance Abuse and Mental Health Services Administration, Center for Mental Services Cultural Competence includes: Attaining the knowledge, skills, and attitudes to enable administrators and practitioners within system of care to provide effective care for diverse populations, i.e., to work within the person s values and reality conditions. Recovery and rehabilitation are more likely to occur where managed care systems, services, and providers have and utilize knowledge and skills that are culturally competent and compatible with the backgrounds of consumers their families, and communities. Cultural competence acknowledges and incorporates variance in normative acceptable behaviors, beliefs and values in determining an individual s mental wellness/illness, and incorporating those variables into assessment and treatment. The standards for Culturally and Linguistically Appropriate Services (CLAS) issued by the U.S. Department of Health and Human Services (HHS) Office of Minority Health (OMH) respond to the need to ensure that all people entering the health care system receive equitable and effective treatment in a culturally and linguistically appropriate manner. The CLAS are proposed as a means to correct inequities that currently exist in the provision of health services and to make these services more responsive to the individual needs of all patients/consumers. The standards are intended to be inclusive of all cultures and not limited to any particular population group or sets of groups; however, they are especially designed to address the needs of racial, ethnic, and linguistic population groups that experience unequal access to health services. Ultimately, the aim of the standards is to contribute to the elimination of health disparities and to improve the health of all Americans. Cultural competence recognizes the broad scope of the dimensions that influence an individual s personal identity. Providers will request the following information on intake: race age ethnicity class/socioeconomic status language education sexual orientation religious/spiritual orientation gender & gender identity relationship status primary language spoken proficiency reading/writing primary language physical/developmental disability In support of these definitions and guidelines, OHNM will require all Providers to include as part of their policy statement and orientation to services, a statement that informs Consumers, [The service provider] shall not deny services or benefits to any individual or family on the basis of race, age, religion, color, gender, sexual orientation, ancestry, national origin, medical condition, or physical or mental disability. Providers will ensure services are culturally sensitive and provide culturally appropriate prevention, outreach, assessment and intervention. 51

6 The Provider will also be asked to incorporate cultural and traditional factors such as language accommodations and or traditional healing practices to ensure cultural competency. It is important that the therapist respect and honor the belief systems of the Consumer/Family/Treatment Guardian. All documents, forms, explanations and education will be in a format that is understood by the Consumer/Family/Treatment Guardian and respects his/her cultural considerations. The Provider will use language that is understood by the Consumer/Family/Treatment Guardian and make accommodations for any form of visual, hearing or developmental disability according to ADA requirements. Regulatory Requirements: All Providers are responsible for reviewing any and all New Mexico Administrative Codes, Regulations, Policy Manuals, Best Practices, Contract and other requirements applicable to the services provided. This information can be obtained on the web or from the issuing agency itself. If there is a conflict between the requirements in the OHNM Provider Manual and Statutory regulations or codes, the stricter of the two will be adhered to. TREATMENT RECORD DOCUMENTATION REQUIREMENTS In accordance with your Agreement, you are required to maintain high quality medical, financial and administrative records related to the behavioral health services you provide. These records must be maintained in a manner consistent with the standards of the community, and conform to all applicable laws and regulations including, but not limited to, state licensing and/or national certification board standards. In order to perform required utilization management and quality improvement activities, OHNM may request access to such records, including, but not limited to, claims records and treatment record documentation. You are permitted under HIPAA Treatment, Payment or Healthcare Operations to provide requested records as contractually required. In accordance with HIPAA and the definition of Treatment, Payment or Healthcare Operations, you must provide such records upon request. Federal, state and local government or accrediting agencies may also request such information as necessary to comply with accreditation standards, laws or regulations applicable to OHNM and its Payors, customers, clinicians, and facilities. OHNM may review your records during a scheduled On-Site Audit or may ask you to submit copies of the records to OHNM for review. An On-Site Audit and/or Treatment Record Review may occur for a number of reasons, including, but not limited to: Reviews of facilities without national accreditation such as The Joint Commission, CARF or other agency approved by OHNM Audits of high-volume clinicians Routine random audits Audits related to claims coding or billing issues Audits concerning quality of care issues identified by OHNM or brought to OHNM s attention by members, family members or their representatives Audits of clinicians with a home office 52

7 Audits related to a member complaint regarding the physical environment of an office or facility The audits may focus on the physical environment (including safety issues), policies and procedures, and/or thoroughness and quality of documentation within treatments records. OHNM has established a passing performance goal of 85% for both the Treatment Record Review and On- Site Audit. On-Site Audit or Treatment Record Review scores under 85% will require a written Corrective Action Plan (CAP). Scores under 80% require submission of a written CAP and a re-audit within six months of the implementation of the CAP. Guidelines contained in this section are subject to change. Content Standards OHMM expects that all non-electronic treatment records are written legibly in blue or black ink, and at a minimum include: Consumer Rights: All records will contain evidence the following was provided: information regarding Personal Health Information (PHI), HIPAA and, if applicable, 42 CFR Part 2 re-disclosure requirements information regarding: o treatment options o the right to refuse treatment o evidence it is understood by the consumer (documented acknowledgment, signature, etc.) All Consumers shall be informed that if he/she is unable to participate fully in treatment decisions, he/she has the right to be represented by a family member or guardian (authorized representative). All Consumers shall be informed and receive information regarding: the Provider s complaint/grievance procedure the right to file a grievance with Optum if the facility has not addressed the complaint/grievance to the consumer's satisfaction All Consumers or legally authorized persons shall receive information: about his/her illness the course of treatment prognosis for recovery in terms the consumer can understand The Provider shall notify the Consumer that they have a right to have an interpreter if one is needed. For Adolescent/Children Behavioral Health Providers Only: The Provider shall explain to each Consumer what his or her legal rights are in a manner consistent with the Consumer s ability to understand and makes this information available to the Consumer in writing, or in any other medium appropriate to the Consumer s level of development. A written explanation of these rights is given to the parent/legal guardian upon admission. Assessments: 53

8 The reason for admission or initiation of services must be clearly documented and in the Consumer s own words. The record will contain: a clear summary of presenting problems the results of mental status exam(s) relevant psychological and social conditions affecting the Consumer s medical and psychiatric status the source of such information An initial assessment during admission documents: history of smoking, alcohol and substance abuse (includes past, present, frequency, duration, and method of administration) personal and family history education and employment history legal history treatment history (mental health and/or substance abuse) communication and cognitive history social and emotional history rehabilitation and vocational history Consumer strengths non-traditional and natural supports physical/sexual abuse or neglect/trauma leisure and recreational preferences cultural and spiritual/religious variables that may impact treatment risk for behavior that is life-threatening or otherwise dangerous to the client or others including the need for special supervision and intervention, or the lack of risk for behavior Adolescent and Youth Provider Assessments document, in addition to the above-mentioned: prenatal events perinatal events a complete developmental history (physical, psychological, social, intellectual and academic). For Consumers 12 years of age and older, documentation includes: past and present use of cigarettes or alcohol illicit, prescribed or over-the-counter medications. A past medical history should be collected for those individuals seen 2 or more times. A medical and psychiatric history will include: previous treatment dates clinician or facility identification therapeutic interventions and responses sources of clinical data relevant family information. Each record shall contain clear documentation of: medication allergies adverse reactions and relevant medical conditions if the member has no known allergies, history of adverse reactions or relevant medical conditions, this should be prominently noted. 54

9 Providers will determine if the Consumer has a current Primary Care Physician. If a current medical condition is identified and the Consumer does not have a Primary Care Physician, the Provider will refer the Consumer to attempt to address the medical condition(s). A full Mental Status Exam shall be documented for every Consumer. If a Consumer is receiving Mental Health Treatment, a Substance Abuse screening shall be conducted and if a Consumer is receiving Substance Abuse Treatment, then a Mental Health screening shall be conducted. Each record must show prominent documentation (assessment and reassessment) of special status situations, when present, including but not limited to: imminent risk of harm suicidal or homicidal ideation self-injurious behaviors or elopement potential It is also important to document the absence of such conditions. Assessments shall be updated when there has been a significant change in the Consumer s clinical presentation and annually otherwise. All five DMS-IV diagnoses, consistent with the presenting problems(s), history, mental status examination, and other assessment data, should be documented and signed by a licensed clinician. Medication: Psychiatric notes will reflect: target symptoms rationale for medications treatment recommendations response to medications Written informed consent for medication(s) (in a language understood by the Consumer and/or Guardian) is documented. This includes: benefits risks side effects alternatives of the medication(s) Clear and uniform medication tracking that provides a thorough picture of all medications taken by the patient from the onset of care through discharge includes the following: the Consumer and/or Guardian received information about the illness or target symptoms for which the medication was prescribed what medications have been prescribed the dosages of each the dates of initial prescriptions or refills, if a prescribing provider or facility Standing, PRN and STAT orders for all prescription and over-the counter medications An evaluation of the Consumer's response to the medication and adjustments are made as needed Changes in medication and/or dosage should be clearly documented along with the clinical rationale for the changes 55

10 When medications are prescribed that require serum level monitoring and/or other laboratory tests: those tests are completed the results are documented the record documents the consumer is notified of the results. Treatment Plans: There record reflects evidence the treatment/service planning process is individualized and ongoing. Except for In-patient Hospitalization, the comprehensive treatment/service plan: is developed within 30 days of admission critical problems that will be the focus of this episode of care are prioritized documents and utilizes the consumer s strengths documents specific behavioral changes targeted documents goals/objectives in measurable terms there are short and long-term goals there is a timeframe for goal attainment/resolution and a rationale for the timeframe goals/objectives are individualized and realistic identifies barriers to treatment and discharge includes cultural/religious aspects identified as important by the Consumer there is both mental health and substance abuse goals/objectives for those with Co-Occurring Disorders identifies the specific services that will be provided documents Consumer (and, when individuated, family) involvement in treatment planning The treatment/service plan review/update documents assessment of the following in measurable terms: progress, or lack thereof, toward each treatment goal and objective progress toward and/or identification of barriers to discharge consumer s response to all interventions including specific behavioral interventions consumer s response to medication consideration of significant events, incidents, and/or safety issues during the review period revision of goals, objectives and interventions if applicable any changes in diagnoses, mental status or level of functioning, Progress Notes: Progress notes shall reflect the following for each clinical encounter: relevant clinical interventions, findings and recommendations consistent with goals/objectives strengths and limitations in achieving treatment plan goals and objectives progress or lack of progress toward stated goals/objectives an on-going assessment of consumer safety issues (e.g., dangerous to self or others) and how these have been addressed any referrals made to other clinicians, agencies or other therapeutic services date and time of data entry and date and time of encounter responsible clinician s name, professional degree, license, and relevant identification number For all Outpatient Services, all progress notes document: follow-up activities related to Consumers who miss and/or reschedule appointments who was present during the session 56

11 the start and stop times of the encounter the billing code that was submitted for that session OHNM will evaluate and expect to see supervision of the clinical record for non-independent licensed practitioners and peer review/consultation for independent licensed practitioners and practicing clinical supervisor/directors. For Consumers receiving services for six (6) months or longer, there is documentation of preventative/recovery services as appropriate (relapse prevention, stress management, peer directed programs, wellness programs, etc). This must be summarized and easily identifiable in the record. Discharge Plan and Summary: Documentation of on-going discharge planning (beginning at the initiation of treatment) includes the following elements: criteria for discharge an evaluation of high risk behaviors or the potential for such options for additional or alternative services better able to meet the consumer s needs, if applicable specific criteria for discharge to a less restrictive setting identification of barriers to completion of treatment and interventions to address those barriers identification of support systems a projected discharge date which is updated as clinically indicated Upon completion, termination or transfer from services, a discharge summary will be completed within 30 days and includes: a summary of the presenting problem a summary of the course of treatment the gains or lack of progress made during the course of treatment barriers that contributed to the lack of progress, if appropriate any interventions the Consumer did or did not respond to, including medications aftercare plans that include: o the name o address o contact information of the facility and/or provider o appointment date and time if the Consumer has a Co-Occurring Disorder, there should be aftercare plans for both mental health and substance abuse services. Coordination of Care: Coordination of care should occur: at the initiation of treatment throughout the treatment as clinically indicated at the time of transfer to another treating clinician, facility, or program at the conclusion of treatment Providers are expected to use due diligence to collect collateral information and coordinate appropriately for each Consumer served. This could include prior providers, emergency contacts, consultants, schools, Probation/Parole, Employee Assistance Programs, housing, employers, the Courts, Department of Vocational Rehabilitation, ancillary and other non-behavioral health providers. 57

12 Providers will consider resources, such as self-help groups, when making referrals for outside natural supports and aftercare options. Other treatment providers should be notified by the treating clinician of the following: a summary of the Consumer s evaluation diagnoses treatment plan summary (including any medications) the name of the treating clinician. Outpatient psychiatrists and other prescribing professionals shall be notified by the treating clinician of any clinically significant abnormal laboratory or other medical findings and recommendations. Primary Care Physicians will be notified of any drug therapy, lab/radiology reports, sentinel events, discharge from services and all transitions in levels of care. To the extent Providers have received consent, there will be communication with an outpatient psychiatrist or other physician or health care professional who will follow the consumer for outpatient medication management upon discharge during the course of the stay for Consumers diagnosed with a Co-Occurring Disorder (COD). All records will document referrals to other clinicians, services, community resources, and/or wellness and prevention programs. If the Consumer refuses to allow coordination of care to occur, this refusal and the reason for the refusal must be documented. General Record Requirements: Each record will contain the following elements regardless of service-type: The Member s name or identification number on each page of the record Treatment records should be made contemporaneously with treatment description and include the date of entry; if records are not contemporaneously made with treatment, then the date of service should be noted along with date of entry Clear and uniform modifications; any error is to be lined through so that it can still be read, then dated and initialed by the person making the change When care involves more than one family member, separate treatment records must be maintained 58