POLICIES AND PROCEDURES

Transcription

1 Policy: Eastpointe Local Management Entity / Managed Care Organization (LME/MCO) shall develop and maintain a contract network of quality behavioral healthcare service providers based on consumer and community needs and resources available. Criteria for network participation focus on: Consumer needs, Ensuring quality of care, Ensuring quality of service, and Meeting the business needs of the organization. [URAC HNM 1-3] Definitions: NA Procedure: I) Types of Behavioral Healthcare Services [URAC NM 1(a)] The types of behavioral healthcare services offered within the Eastpointe contract network include those specialty services designed for the treatment of individuals with mental health, intellectual/developmental disability, and/or substance abuse needs/ issues. The specific array of services offered within the provider network is set forth by the HDDS through the Division of Mental Health, Development Disability and Substance Abuse Services (DMH/DD/SAS) and the Division of Medical Assistance (DMA). Services are categorized as either 1) Basic services, or 2) Enhanced services. The table that follows is a sample of these kinds of services and is not all inclusive. Basic Services Outpatient Treatment Medication Management Assessment Enhanced Services Ambulatory Detoxification Assertive Community Treatment Team (ACTT) Child and Adolescent Day Treatment Community Support Team (CST) Page 1 of 7

2 Diagnostic Assessment Intensive In Home Care (IIH) Medically Supervised or ADATC Detoxification/Crisis Stabilization Mobile Crisis Management Multi-systemic Therapy (MST) Non Hospital Detoxification Opioid Treatment Partial Hospitalization (PH) Facility Based Crisis Programs Psychosocial Rehabilitation (PSR) Substance Abuse Comprehensive Outpatient Treatment Program (SACOT) Substance Abuse Intensive Outpatient Program (SAIOP) Substance Abuse Medically Monitored Community Residential Treatment Substance Abuse Non-Medical Community Residential Treatment Children s Residential Treatment Services CAP-MR/DD Services Adult Developmental Vocational Program (ADVP) Inpatient Hospitalization II) Population Served [URAC NM 1(b)] As mentioned previously, Eastpointe has developed and maintains a network of providers to serve citizens of Bladen, Columbus, Duplin, Edgecombe, Greene, Lenoir, Nash, Robeson, Sampson, Scotland, Wayne and Wilson counties in North Carolina. Page 2 of 7

3 Most of the individuals served are uninsured or are eligible for services through the state s Medicaid program. The composition of the population in Eastpointe s catchment area is as follows: o The ethnic and racial makeup of the catchment area is determined according to the latest United States (US) Census Bureau data. The current ethnic and racial makeup of Eastpointe s Provider Relations staff is 60% Caucasians, 27% African Americans and 13% American Indian. The most recent US Census Bureau Data of 2009 indicates that the ethnic and racial makeup of Eastpointe s catchment area varies by county but ranges: % Caucasians, % African Americans, % persons of Hispanic or Latino origin, % American Indian and Alaska Native persons, all other groups (Asian persons, Native Hawaiian and other Pacific Islanders, and persons reporting two or more races) account for less than 2.5% of the population in any county within the Eastpointe catchment area. III) Provider Network Access and Availability Goals [URAC NM 2 (a); Core 34] Providers delivering services through state-funds are fully contracted with Eastpointe to deliver those services Eastpointe s network for state-funded services consists of sufficient numbers of providers to allow for adequate access to cover community needs. This is assured by monitoring the availability of service providers, existence of waiting lists, availability of resources and overall need determined in part by the Eastpointe Community Needs Assessment The types of providers in the network include licensed psychiatrists, social workers, psychologists, counselors and other licensed behavioral health professionals as well as providers who meet Medicaid Qualified Professional criteria Independent practitioners and group practices are included in the network, as well as provider agencies, as defined by the NC Division of Mental Health, Developmental Disability and Substance Abuse Services and/or Division of Medical Assistance. Page 3 of 7

4 Service providers are tailored to consider cultural, ethnic, racial makeup and the personal preference of consumers and families in the catchment area As a key performance measure, Eastpointe is continuously evaluating provider access and availability of providers for consumers seeking services. [URAC Core 34] Eastpointe utilizes a multi-faceted approach to setting goals and monitoring access and availability, which includes, but is not limited to: o Ease of access to the Call-Center [URAC NM 2 (a)] o Eastpointe has set specific objectives for telephone performance indicators to ensure the consumer has easy access to the Call-Center in order to obtain a provider referral/appointment. The specific timeliness standards are: Average Blockage Rate: Eastpointe has established the goal that 5% or less of incoming calls will be blocked. Average Speed of Answer: Eastpointe has established a goal of answering incoming calls within 30 seconds. Average Abandonment Rate: Eastpointe has established a goal of only 5% or less of incoming calls are abandoned. o Timeliness for Being Seen [URAC NM 2 (a)] o Eastpointe facilitates 24 hour, 7 day per week consumer access to providers for urgent and emergent, and routine services in the four-county geographical covered area through a main local telephone number, as well as a toll-free crisis line. o Generally, consumers initiate the provider referral process by contacting Eastpointe by calling either one of the designated telephone numbers. o Consumers are screened and triaged by a licensed clinician who determines if the consumer meets criteria for emergent, urgent, or routine care. The triage level determines scheduling and are as follows: Non-Life-Threatening Emergent-2 hours Life-Threatening Emergent-Immediate (Dispatch 911 or the mobile crisis team) Page 4 of 7

5 Urgent-48 hours Routine-10 working days o Providers of crisis services are expected to provide urgent and emergent appointments, which is set forth in their contract. o Post Discharge Follow-up Appointments [URAC NM 2 (a)] Completed within 7 days of discharge. o Provider Sufficiency [URAC NM 2 (a)] Eastpointe has established a goal of ensuring a sufficient number of providers in the area such that, when eligible consumers contact the Call- Center for a referral, they will have a choice of at least two providers for every service, except for those services with very limited usage and where alternative providers cannot be recruited. o It is the responsibility of the Provider Network to ensure that there are adequate appointments available to the call center to meet the standard. If there are not enough appointments available, Provider Network staff will contact the providers to open additional appointment slots. If the provider is not response to the request the company will be contacted for a plan of correction. o The Eastpointe Global Quality Improvement Committee (GQIC) reviews data collected monthly regarding availability of appointments, separated by level of need, to ensure we are maintaining our standard. If data becomes a concern it shall be reported to the Call Center Director and Provider Network Director for additional follow-up. Reporting of concerns related to appointment availability may also come from Call Center staff or consumer complaints. IV) Oversight [URAC NM (b/c)] The GQIC provides oversight of access and availability by reviewing various reports related to access and availability goals and will ask the designated program manager for a Page 5 of 7

6 corrective action plan when performance is continually outside the set performance standards. When the implementation of a corrective action plan still does not resolve the specific issue(s), the GQIC may call for a particular quality improvement project (QIP) to address and correct specific access and availability issues. QIPs are intended to provide concentrated focus on a specific problem that has been identified with data, and is time-limited and consumer-focused. Provider access and availability QIPs are generally an inter-departmental effort, including participants from the following functions: [Core 5] o Quality Improvement o Provider Operations o Care Coordination o Access o Utilization Management V) Provider Selection Criteria Integrated Payment and Reporting System (IPRS) Network Providers accepted into the Eastpointe contract network must be fiscally stable, ethical, adhere to all laws, rules and regulations, be committed to accessibility, including adherence to all local and state health and safety requirements [URAC NM 3 (a) (b) & (c)] The provider must support expertise with licensure, education, training, and experience with a culturally diverse population as required to perform the specific service(s) for which they have been endorsed and/or contracted and/or have an MOA with Eastpointe to perform [URAC NM 3 (a), (b), & (c)] Contracted services should support evidence-based practice [URAC NM 3 (a) & (b)] The provider, if not a qualified professional, must document training/supervision as required per 10A NCAC 27G.0104 (Staff Definitions) Person Center planning and treatment which supports the consumer s input and involvement is a requirement in order to enter into a contract or memorandum of Page 6 of 7

7 agreement with the Local Management Entity/Managed Care Organization (LME/MCO) The LME/MCO must assure that all State and Federal guidelines are followed and include but not limited to: consumer rights; billing and reimbursement protocols; privacy and confidentiality mandates; and, applicable service definition and/or other applicable regulations The provider is expected to promote the shared mission, values and vision of the LME/MCO Providers must have: o Relevant board-certification(s), where applicable o State licensure including current license(s) and history of license(s) in all jurisdictions, where applicable o Evidence of a current Drug Enforcement Agency (DEA) certificate or state controlled dangerous substance certificate, if applicable o Correct & complete certificate of insurance that meets the required limits as outlined in the contract Applications are received from providers to join the Eastpointe behavioral healthcare provider network and are reviewed to ensure that the provider meets the requirements per the service definition(s) that are applicable. Additional Criteria o It is important to point out that each application must be considered individually. o Depending on what has been submitted, there may be a need for investigation and a thorough review by the Quality Assurance/Monitoring Staff before a decision can be made. o The business needs of Eastpointe, as well as the service needs of the community are taken into account with each application submitted. Additional information can also be found in the Provider Agreement and Provider Operations Manual. Page 7 of 7