A presentation to the NYS ASAP 14 th Annual Conference

Transcription

1 A presentation to the NYS ASAP 14 th Annual Conference Lisa Lite Rottmann Jon S. Rice NYS OASAS NYS OMH May 6,

2 NYSCRI Is Not 2

3 Then what is NYSCRI? A standardized integrated clinical record set that supports compliance with applicable funders, Federal and State regulatory authorities (CMS, OMH, OASAS) and National accreditation organizations (TJC, CARF, COA) 3

4 NYSCRI Overview The NYSCRI project was initiated in response to providers need for a standardized clinical form set Development was a collaborative partnership between providers, OMH, OASAS, recipients, families, and MTM consulting services Over 40 MH and SUD providers were initially involved in this initiative with over 70 dedicated staff who participated in the work teams Designed for OMH/OASAS licensed outpatient & residential programs for adults and children 4

5 Timeline & Data 2010 Statewide Users (Agencies) Users 43 Planning First Annual Update 2009 Long Island Pilot 5

6 Benefits of NYSCRI Compliance timely and cost effective provider support for corporate compliance Quality of Care promotes person centered and recovery oriented systems of care Efficiency saves time and money through faster, less redundant, and more accurate documentation Foundation for EMR s compliant with Federal Mandate for Electronic Health Records 6

7 Compliance 7

8 Sample Compliance Grid 8

9 Medical Necessity Defined Medical necessity starts with a practitioner evaluating a client or patient and authorizing or rendering services that fall within the scope of their license. Medically necessary services are those that prevent the client from getting worse (either deteriorating or prolonging the illness) or developing new problems. The definition also asserts the role of medically necessary services in dealing not just with the symptoms or signs of an illness but the impact of the illness on the ability of the individual to function. This speaks directly to rehabilitation services, which are primarily focused on maintaining or raising the functional level of the client. 9

10 Medical Necessity Linkages Assessment Data Diagnosis Strengths Personal Goals Assessed Needs Service Plan Goals Service Plan Objectives Interventions and Services Interactions Directed by Service Plan Recorded in Progress Notes 10

11 Five NYSCRI Documentation Golden Thread Linkage Processes 1. Comprehensive Assessment (CA) Identifies Treatment Recommendations/ Assessed Needs 2. CA Updates Identifies New Assessed Needs and Treatment Recommendations 3. Individualized Action Plan (IAP) Links goals to specific Assessed Needs and Treatment Recommendations 4. IAP Review/Revision Links goals to specifically Assessed Needs and Treatment Recommendations and/or changes in Objectives, Therapeutic Interventions, Frequency, Duration and/or Responsible Type of Provider. 5. Progress Notes Links interventions being delivered to specific Goal(s)/Objective(s) and identified client response and outcomes/progress towards Goal(s)/Objective(s). 11

12 Assessment Support for Identification of Assessed Behavioral Health Needs 12

13 Individual Action Plan Support for Goal Linkage to Assessed Needs 13

14 IAP Support for Inclusion of Interventions 14

15 Progress Note Support for Link to IAP and Inclusion of Intervention 15

16 Progress Note Support for Documentation of Progress 16

17 Progress Note Support for Identification of Salient Issues and Assessment Update Decision Making 17

18 Update Sections of the CA Update Form 18

19 Quality of Care Promotes consistent assessment, planning & service documentation that is: Person Centered and Strengths based Recovery/Resiliency focused Outcome oriented Supports Collaborative Documentation Promotes information sharing & collaboration among providers through standardized terminology and documentation processes Reduces errors through use of decision support 19

20 Person Centered and Person Driven Services Person Centered Services : Focus on the person / family in the context of their personal life goals, individual strengths, unique barriers, etc. Person Driven Services: Involving the individual/ family in directing the plan of care (developing, reviewing, updating service planning) 20

21 Assessment 21

22 Assessment 22

23 Individual Action Plan 23

24 Progress Notes 24

25 Efficiency Saves time and money through faster, and more accurate documentation Standardized training can reduce costs Reduces cost of individually developed EMR capacity at each provider agency Reduces redundancy in collecting information Standardized revisions and updates issued as needed to sustain product integrity over time Compliant with a wide variety of regulatory and payer requirements and is therefore more protection against adverse audits Supports Collaborative Concurrent documentation 25

26 Efficiency Data Example 26

27 Data Mapping and EMR Certification NYCRI forms are compatible with EMR formats All NYSCRI Forms were data mapped to identify all form data elements and question choices. Critical documentation linkage elements (to support demonstration of medical necessity) between the Assessment, Individual Action Plan, and Progress Notes have also been identified. 27

28 EMR Vendor Certification A process is in place to certify EMR vendors who apply on a voluntary basis This certification process insures that all data elements and documentation linkage components are reflected in the vendor s EMR product, maintains the integrity of NYSCRI. The certification process is to be updated to insure that changes and updates to the NYSCRI form set are reflected in EMR updates. Currently 7 certified vendors and others in process. 28

29 NYSCRI Certified Vendors Accumedic Computer Systems, Inc. AllSector Technology Group, Inc. Celerity LLC DocuTrac Inc. IMA Information Management Associates, Inc. PrecisionCare Software, Inc. TenEleven Group, Inc. This list is available thru the OMH & OASAS websites 29

30 NYSCRI The Scope Assessment Comprehensive OMH Residential Case Management Psychiatric Legal Addendum Military Addendum Brief Medical Screening Communicable Disease Assessment Individualized Action Plan Standard Psychopharmacology Relapse Prevention Discharge Summary/Plan Progress Note Pre Admission Daily/Shift Coordination of Care Group Nursing Psychopharmacology Psychotherapy Session 30

31 Form Usage Index 31

32 FORM ACCESS 32

33 Quality Improvement The NYSCRI forms and manuals cannot remain static if they are to continue to meet their intended goals. The forms and manuals must be updated to reflect changes in state and federal regulations and accrediting body standards. The forms must also be updated to reflect a continuous improvement process based on input from users in the field 33

34 Updating and Improving NYSCRI NYSCRI Review and Implementation Team (RIT) was created to manage the process of updating NYSCRI RIT structure and process continues the partnership between OMH and OASAS in supporting and sustaining NYSCRI RIT teams composed of representatives from OMH, OASAS, LGUs, Recipients, and MH and SUD programs with broad range of compliance, programmatic, and advocacy expertise. 34

35 Review and Implementation Team (RIT) Structure NYSCRI Executive Team RIT Oversight Team Compliance Team Forms & Manual Team 35

36 Current Status of NYSCRI Update Needs Version 2.0 NYSCRI form set released December 17, 2012 Data map to be issued to vendors Six Sigma Gathering feedback 36

37 Provider s Reflections on Benefits NYSCRI concepts and golden thread are highly useful. The NYSCRI project has simplified our efforts in having documents both clinically and regulatory sound. It has been a nightmare prior to NYSCRI. Thanks for all that have made it possible. We look forward to using more of these forms in the hopes of standardization with other providers and our State authority. Thanks for working on this. It needed to be done! 37

38 Questions and Feedback 38

39 Contact Information 39