Quality Management Program Description/Plan (QMPD/P)

Transcription

1 Quality Management Program Description/Plan (QMPD/P)

2 Table of Contents I Mission Statement and Philosophy... 3 II Scope of Quality Management Program Description/Plan... 3 III Quality Improvement Principles... 6 IV Quality Improvement Goals... 6 V Quality Improvement Objectives... 7 VI Quality Improvement Projects... 7 VII Performance Improvement Projects... 8 VIII Quality Improvement Activities... 9 IX Authority & Responsibility... 9 X Quality Management Committees, Roles, and Activities XI Performance Measures XII Assessment and Satisfaction XIII Reporting of Outcomes Cross-Functional Team Relationships Quality Improvement Tools

3 Quality Management Program Description / Plan I. Mission Statement and Philosophy: Mission: CenterPoint Human Services is a managed care organization responsible for assuring that accessible, quality and accountable care is available for those with mental health, intellectual and developmental disabilities and substance abuse challenges. Vision: CenterPoint Human Services will become the best practice public model of managed care for exceptional and compassionate oversight of the provision of care for those with mental health, intellectual and developmental disabilities and substance abuse challenges. Values: We will live out our mission by: Respecting and valuing all individuals Serving individuals and families with compassion and care Maintaining an unwavering commitment to high quality care given by our provider network Being responsible stewards of the funds entrusted to us Seeking to raise awareness of the needs and challenges of behavioral health in our community Operating with transparency, openness, responsiveness and in collaboration with the many partners within the counties we serve QI Philosophy: CenterPoint Human Services, a Managed Care Organization (MCO), maintains a quality management program that promotes objective and systematic measurement, monitoring and evaluation of Mental Health, Substance Abuse, and Intellectual/Developmental Disabilities (MH/SA/I/DD) services, and implements quality improvement activities based upon the findings. The MCO supports a culture committed to continuous quality improvement by using a feedback loop model of conceptualizing, planning, implementing, evaluating and using what is learned from evaluating to feed back into conceptualizing, planning, implementing and so on. Evaluation information is used for program and training planning. II. Scope: The scope of the Quality Management Program includes both internal and external customers/clients (enrollees and stakeholders{including MH, SA and I/DD}, the NC Division of Mental Health/Developmental Disabilities/Substance Abuse Services, the NC Division of Medical Assistance, providers, and MCO staff). The MCO promotes collaboration, coordination, and communication across all internal and external customers, including enrollees, families, and stakeholders in ways that are appropriate, meaningful, and efficient. The MCO has multiple Cross- Functional Teams (CFTs) in place that facilitate the integration and communication necessary to provide quality services. The individual CFTs, together with the Quality 3

4 Operations Team (QOT) both drive and oversee the Quality Management Program at the MCO, with each CFT having its own unique set of responsibilities. The CFT structure enables coordination and communication with other departments and committees within the MCO. Consumer and Family Advisory Committee (CFAC) representatives sit on the Board Finance, QI and Human Rights Committees, and the CFAC Chair participates in Board meetings. Staff liaisons provide the linkage between CFTs and the relevant Board or other committee through their participation. Please refer to the attached Cross- Functional Team Relationships schematic for membership in the various CFTs. The purpose of the CenterPoint Quality Management Program Description/Plan (QMPD/P) is two-fold. It provides a means by which the MCO can assess information about and from service providers acting on behalf of the MCO in providing MH, SA and I/DD services. In addition, it identifies the process by which the MCO monitors its own performance and conducts those activities designed to realize improvement(s) and increased efficiencies wherever possible within agency operations and in improving quality and outcomes. This includes assuring that adequate resources are available to carry out the day-to-day responsibilities of the Quality Management Program. The Quality Management Program uses a continuous quality improvement model of Design, Discover, Remediation and Improvement (DDRI) in order to improve quality and outcomes for recipients of MH, SA, and I/DD services. Data is collected, and a baseline and interventions are established. Data is collected again, and, if the goal is not met, analysis is conducted to determine why, and interventions are added or changed as needed. This process is continued until the desired improvement and/or outcomes are achieved. The model is explained below: Design The design for the quality improvement strategy (QIS), which describes how we will proactively strive for quality and identify areas for improvement, should embody a CQI approach. The design includes processes and safeguards to prevent low quality outcomes, including the performance measures that are used to assure that providers are qualified, participants are healthy and safe, and payments are appropriate. These same metrics are also used to prioritize quality improvement efforts. Discovery Discovery is how we verify that the QIS design is being implemented and is functioning as intended. It includes both data gathering and analysis, and it is during the discovery process that any significant quality problems should be found. The primary mechanism for discovery is the use of performance measures, which evaluate how well the MCO meets its benchmarks. This discovered information plays a dual role in driving immediate fixes to identified problems, as well as guiding system-wide changes in pursuit of overall quality improvements. Remediation In the DDRI model, R stands for remediation or fixing of individual quality problems that have been identified. Remediation plays an essential role in helping to meet compliance requirements. Aggregated remediation data are valuable for not only demonstrating compliance, but identifying potential areas for quality improvement efforts. Improvement Improvement denotes those efforts taken to fix or prevent quality problems across the system, not just for one individual. For example, discovery data may indicate a system-wide problem with timely reporting of 4

5 level III incidents, and show where breakdowns in existing systems are occurring. Based on these data, the team may develop new guidance, protocols, or trainings for relevant staff. The impact of this improvement can be measured through repeating original data collection, to see if performance measures have improved, or through new metrics designed to assess if behaviors and compliance have changed. Outcome measures and instruments are developed and adopted through the CFTs and are consistent with the PBH model. The CFTs generate Performance Dashboard Indicators within the scope of each CFT. These Performance Dashboard Indicators collectively provide a comprehensive reporting structure. The defined indicators track internal/external measures on both system-wide and individual levels. This reporting structure allows the QM Program to monitor, track and report on all applicable performance measures. This includes Quality Improvement Projects, Performance Improvement Projects, Quality Improvement Activities and Internal Quality monitoring. The MCOs Health Information System is managed by the IS Department and is vital to the success of the quality improvement strategy. The system utilizes AlphaMCS which gives the ability to manage care, patient demographics, provider applications and contracts, service referrals, service provision along with provider monitoring. The ability to manage care efficiently is essential to the success of an at-risk MCO. AlphaMCS also performs rules based claims processing and interfaces to Dynamic GP. The interface brings invoice payment information from GP to AlphaMCS including check number, date, amount and details that can then be utilized for 835 and remittance advice generation. The MCO uses Business Intelligence (BI) software to assist in managing the large quantity of data that comes from multiple sources. The BI software gives staff the ability to drill down to the smallest details. The MCO has the ability to create ad hoc reports internally when standard reports do not meet the immediate need. The IS Department uses internal data sources and stays in control of the data by validating internally. There is a clear report request process that allows all staff to submit reporting needs. All reports are thoroughly tested in-house by test users before being put into production. Data mining is used to analyze the data from different perspectives and summarize it into useful information that can be used to inform decision making at all levels. This clear control of the data enables the MCO to monitor the covered services and sites and provide meaningful data on Network providers. This information is summarized in both the Medicaid and IPRS Category of Services Summary Report. These reports use paid claims to highlight the cost of services and identify the top ten providers per service category. This information assists the MCO in identifying which services need to be monitored more closely. The reports give projected trends for the following year for the following service categories: Inpatient Community Support BH Long-term Residential PRTF Case Management Outpatient ACTT MST/IHHS Partial Hospitalization/Day Treatment Psychosocial Rehabilitation Crisis Services CAP-MR 5

6 ICF-MR Ongoing reporting is an integral part of the organizational oversight responsibility held ultimately by the MCO s Board. Quarterly, the Board receives a written report of the Quality Improvement Projects (QIPs) and Performance Improvement Projects (PIPs) within the MCO s Quarterly Report and the minutes from the Board Global Continuous Quality Improvement Committee (GCQIC). The Executive Team, inclusive of the senior clinical staff (Medical Director/Chief Clinical Officer [CCO] and the Chief Operations Officer [COO]), is also a component of the MCO s quality management structure. The Board GCQIC and the MCO Cross-Functional Teams (CFTs), utilize reports to monitor progress and to determine if additional interventions are needed in order to improve quality and outcomes. All committees maintain approved minutes of all their meetings. III. Quality Improvement Principles Quality Improvement is a systematic approach to assessing services and improving them on a priority basis. The CenterPoint approach to quality improvement is based on the following principles: Continuous Improvement Processes must be continually reviewed and improved. Small incremental changes do make an impact and an opportunity to make things better is almost always present Leadership Involvement Strong leadership, direction and support of quality improvement activities by the MCO Board and CEO are key to performance improvement. This involvement of organizational leadership assures that quality improvement initiatives are consistent with the mission and strategic plan Data informed practices Successful QI processes create feedback loops, using data to inform practice and measure results. Fact-based decisions are likely to be correct decisions Prevention over Correction Continuous Quality Improvement seeks to design good processes to achieve excellent outcomes rather than fix processes after the fact Statistical Tools For Continuous Improvement of care, tools and methods are needed that foster knowledge and understanding. CenterPoint uses a defined set of analytic tools such as cause and effect diagrams, histograms, flowcharts and control charts to turn data into information. IV. Quality Improvement Goals To develop a comprehensive, meaningful, soundly executed quality improvement, utilization, and care coordination management strategy To integrate a quality improvement approach in all aspects of the behavioral health plan management To implement a standardized and comprehensive CQI program that will address and be responsive to the behavioral health needs of the enrollee population To create an effective and responsive CQI program that allows for early detection and resolution of issues that affect the plan s enrollees, families, practitioners or providers To measure, monitor and improve performance of behavioral healthcare in key aspects of clinical and service quality for enrollees, providers and practitioners To demonstrate improved outcomes in behavioral healthcare and services to its enrollees. To foster a supportive environment to assist practitioners and providers to improve the safety and outcome of their clinical practice To continually monitor, evaluate and optimize behavioral healthcare resource utilization in collaboration with contracted practitioners and providers 6

7 To ensure that state and federal regulatory requirements are met and that policies and procedures support the requirements To ensure that cultural competence is integrated through the accessibility, availability, appropriateness and quality of care given to people of all cultures, races and ethnicities. V. Quality Improvement Objectives The following objectives were designed to assist the plan in meeting its goals: Develop an annual CQI work plan that outlines activities, objectives, responsible person(s) and timeframes. Monitor the work plan on a quarterly basis Develop, implement and monitor action plans to improve behavioral healthcare Integrate mechanisms for evaluating consumer safety into existing CQI activities Incorporate stakeholder input into CQI functions Initiate Quality Improvement Activities (QIAs) that are relevant to the populations served by CenterPoint Provide the technical assistance necessary to improve quality and enrollee outcomes Develop and distribute enrollee information that improves knowledge regarding consumer safety as it relates to self-care and clinical practice guidelines Include network practitioners and providers in the development, monitoring and evaluation of Quality Improvement Activities, practice guidelines, standards and interventions to improve outcomes Facilitate continuity of care between providers and state and local hospitals to promote exchange of information, appropriate diagnosis, treatment and referral for services for behavioral health disorders Communicate the results of QI activities to the relevant staff, relevant CFTs and the Quality Operations Team (QOT) Develop, implement and monitor processes that assure culturally competent care to all people Complete a comprehensive analysis of all CQI studies, consumer and provider surveys or monitoring results against performance goals, benchmarks when available, and previous performance Track and trend performance measures, including, but not limited to, Access to Services, Grievances and Satisfaction and other measures, including Progress Indicators and/or Performance Contract measures identified by DMA and the North Carolina Department of Health and Human Services (NCDHHS) contracts Identify barriers to improvement, implement action plans to improve or correct identified problems or meet acceptable levels of performance on measures Monitor and improve compliance with accreditation standards and regulatory requirements governing managed care organizations. VI. Quality Improvement Projects: In compliance with URAC accreditation standards, the MCO maintains no less than two quality improvement projects (QIPs) per accredited program (Health Call Center, Health Utilization Management and Health Network). Establishing QIPs is an expectation in the Performance Contract between the MCO and NCDMA and NCDHHS. QIPs address opportunities for error reduction or performance improvement related to functions covered by the MCO s accreditation. At least one QIP per accredited program addresses enrollee safety for the populations served. If clinical in nature, the MCO s CCO is involved in 7

8 QIP development and judgments about the use of clinical quality measures and clinical aspects of performance. The MCO ensures that QIPs exist to improve quality and outcomes in MH, SA, and in I/DD services. For each QIP, the MCO: a) Utilizes baseline data to establish measureable goals for quality improvement b) Designs and implements strategies to improve performance, quality, and outcomes of care c) Establishes projected timeframes for meeting goals for QI d) Re-measures level of performance at least annually e) Documents changes or improvements relative to the baseline measurement f) Conducts an analysis if the performance goals are not met g) Implements additional interventions to address the goals Documentation of the above requirements can be found on the QIP form, with summary results and analysis documented and shared inter-departmentally, among CFTs and with other external stakeholders. VII. Performance Improvement Projects: The MCO will develop and implement performance improvement projects (PIPs) that are in compliance with the requirements set forth in the DMA contract, including compliance with 42 CFR and the CMS Quality Framework. Project topics will be determined jointly by the MCO and DMA from the list of clinical and non-clinical focus listed in the DMA contract. Over the two-year term of the contract, the MCO will develop and implement a minimum of three PIPs. During year one of the contract, the MCO will develop and implement a minimum of two PIPs. One project will focus on a clinical area and one will focus on a non-clinical area. During year two of the contract, the MCO will develop and implement at least one additional PIP for a total of three PIPs. Baselines will be established the first year of each project and the MCO will set benchmarks for each project based on currently accepted standards, past performance data or available national data. The MCO will obtain the approval of DMA before terminating any of the required PIPs. Reports on all PIPs will be submitted to DMA no later than July 31st of each year. PIP topics will be identified through continuous data collection and analysis by MCO of comprehensive aspects of enrollee care and member services. Topics will be systematically selected and prioritized to achieve the greatest practical benefit for enrollees. Quality Management will provide opportunities for enrollees to participate in the selection of project topics and the formulation of project goals. The MCO s performance improvement for each selected topic is measured using one or more quality indicators and will measure changes in health status, functional status or satisfaction. Indicators will be objective, clearly/unambiguously defined and based on current clinical knowledge or health services research. Some indicators will be selected for which data are available that allow comparison of the MCO s performance to that of similar Plans or to local, state or national benchmarks. Baseline measure of its performance on each selected indicator will be established and will measure changes in performance. Measurement will continue for at least one year after the desired level of performance is achieved. A project demonstrates improvement by achieving a benchmark level of performance defined in advance by CMS or DMA. Benchmarks will be based on currently accepted standards, past performance data or available national data. Samples will be random and will be of sufficient size to detect targeted amounts of improvement. The samples used for the baselines and repeat measurements of the indicators will be chosen using the same sampling frame and methodology. The MCO will: 8

9 Continue to measure quality indicators for at least one year after the performance improvement project is completed, in order to demonstrate sustained improvement Collect and use data from multiple sources, such as medical record reviews, focused care studies, claims and encounter data, HEDIS measures, grievances, utilization review and member satisfaction surveys. Use findings from performance improvement projects to analyze: a. the delivery of services b. quality of care and appropriateness of care c. over and underutilization of services d. disease management strategies e. outcomes of care Mechanisms for detection of over and underutilization of services: The Care Management CFT and the Clinical Operations Team analyze enrollee encounter and authorization data on a quarterly basis to determine utilization patterns and establish a baseline. The data is reviewed at the systemic, provider-specific and consumer-centric points of view. The MCO has drill down capabilities in the Information System and Reporting structure to allow for customized review based on the findings. Acceptable utilization range for each service is clearly defined. Outliers that exceed acceptable deviation from this range are analyzed for further patterns and definition of next steps. Based on the issues identified, next steps range from systemic to client specific and may include focused monitoring, enrollee Person-Centered Plan review, revisions to the Benefit Plan or other indicated measures. Data analysis also identifies trends such as treatment lasting more than a year, enrollees receiving multiple services, or inpatient re-admissions or re-arrests. VIII. Quality Improvement Activities: Quality improvement activities emerge from a systematic and organized framework for improvement. This framework, adopted by CenterPoint s leadership, is understood, accepted and utilized throughout the organization, as a result of continuous education and involvement of staff at all levels in performance improvement. All MCO departments that are not leading a QIP have at a minimum one Quality Improvement Activity (QIA). QIAs are developed and implemented based on performance data in areas such as enrollee and provider satisfaction, network availability issues and medical record audit results. For each QIA, the MCO: a) Utilizes baseline data to establish measureable goals for quality improvement b) Designs and implements strategies to improve performance, quality, and outcomes of care c) Establishes projected timeframes for meeting goals for QI d) Re-measures level of performance at least annually e) Documents changes or improvements relative to the baseline measurement f) Conducts an analysis if the performance goals are not met g) Implement additional interventions to address the goals IX. Authority & Responsibility: Quality Management (QM) is included as a core function of the Performance Contract between the MCO the NCDHHS and DMA. Article XI of the Bylaws of the MCO Board of Directors addresses Quality Management, and establishes the GCQIC as a committee of the Board. 9

10 The QMPD/P is maintained and administered through the MCO s Board-appointed GCQIC, Medical Director/CCO (CCO), Chief Executive Officer /Area Director (CEO), the Executive Team, the Quality Operations Team (QOT) and the Quality Management CFT. While the Board has oversight authority for QM, the terms and conditions of the QMPD/P are subject to modification upon the approval of the Executive Team. The MCO recognizes the value and need for a highly qualified senior clinical staff person as the most appropriate person to oversee all clinical aspects of the organization and to have the authority and responsibility for the overall operation of QM, serving on the GCQIC, Executive Team, QOT, QM CFT, Care Management CFT, Clinical Advisory Committee (CAC), Clinical Operations Team and Credentialing Committee. The CCO meets qualifications by having a current, unrestricted license in the state of North Carolina, experience performing clinical oversight for the enrollee populations served, post-graduate experience in direct patient care, and Board certification. The accreditation responsibilities of the CCO are as follows: Assuring that the organization has access to and utilizes qualified professionals with clinical experience for the functions and enrollee populations served by the organization Being available in a timely manner to all clinical staff for supervision, consultation, or guidance for clinical operational aspects of the accredited programs, including development of QIPs of a clinical nature Overseeing clinical decision-making aspects of all programs such that the CCO is responsible and accountable to the MCO for decisions affecting enrollees and the clinical aspects of the organization Engaging in periodic consultation with practitioners in the field e.g., participation in a professional advisory board, panel meetings, individual consultation meetings with providers, internal criteria review, documented peer to peer conversations, and soliciting feedback from Specialists. X. Quality Management Committees, Roles & Activities: A. The MCO Board shall: 1. Administer the QMPD/P through the GCQIC, CEO, the Executive Team, and the QOT 2. Approve all Policies 3. Provide input and approval for long-term planning 4. Create mission, vision, long-term direction/strategic plan. B. The MCO Executive Team (ET) shall: 1. Be comprised of the Chief Executive Officer (CEO), Chief Administrative Officer (CAO), Chief Clinical Officer (CCO), Chief Financial Officer (CFO), Chief Information Officer (CIO) and Chief Operations Officer (COO) 2. Meet twice a month and maintain minutes 3. Approve/monitor QOT recommendations, Strategic Plan, Annual Implementation Plan with organizational and departmental goals and MCO Procedures 4. Discuss/resolve QOT reports, Performance Dashboard Indicators, Critical Issues and Requests 5. Review and annually approve the Quality Management Program Description/Plan. C. The MCO Quality Operations Team (QOT) shall: 1. Be comprised of the CAO (Co-Lead), CCO (Co-Lead), CEO, CFO, COO, CIO, QM Director, Community Operations Director, Provider Network Director, Care Coordination Director, 10

11 I/DD Clinical Director and Waiver Contract Manager 2. Develop/plan: Strategic Plan Annual Implementation Plan (Plan) for ET approval; coordination of Performance Dashboard Indicators with Plan; and indicators for tracking results in any identified area 3. Monitor: QM CFT performance results against Plan; reports on MCO performance results compared with benchmarks; plans of correction where needed, and enrollee/provider satisfaction surveys 4. Discuss/plan: evaluation of CFT reports and actions; analysis of CFT impacts/synergy; identification of successes; and obstacle/problem identification and solutions 5. Approves Performance Dashboard Indicators, all CFT work plans, Quality Improvement Projects (QIPs) and Performance Improvement Projects (PIPs). D. The Quality Management CFT shall: 1. Be comprised of QM Director (Lead), CCO (Co-Lead), Waiver Contract Manager, Provider Network Director, CIO, Community Operations Director, Utilization Review Director, Care Coordination Director, Human Resources Manager, CFO, Contracts Manager and a Report Writer 2. Develop/monitor QM Performance Dashboard Indicators; performance against identified targets; quality of care; provider performance; performance improvement projects and indicators; Annual CQI Plan; enrollee health and safety reports, e.g., restrictive interventions; client rights violations; grievances and appeals; Annual Quality Management Program Evaluation and network/service outcomes 3. Review/recommend procedures relevant to CFT s scope; enrollee/provider satisfaction surveys; and performance trends to determine need for further study and/or GCQIC actions to address problems. E. Global Continuous Quality Improvement Committee (GCQIC) 1. The GCQIC includes participation of a Board member (Lead), CCO (Co-Lead), QM Director, Provider Network Director, CABHAs, providers (with efforts to include representatives from all disabilities/counties), specialty practitioners, enrollee/family representatives, Consumer Affairs Specialist, community agency representatives, and the Community Operations Director; the CEO and COO serve as ex officio members 2. The GCQIC Chair is appointed by the Board Chair 3. The GCQIC meets on at least a quarterly basis 4. Reviews and advises MCO regarding the provider network and service system in the following areas: Annual Global GCQIC plan, goals, performance improvement projects, best practice and quality initiatives, network performance on key quality indicators, quality system issues, aggregate data and analysis on complaints and grievances, enrollee and provider satisfaction survey results in aggregate, results reported by GCQIC, access to care standards and performance, and preventative health programs. F. Care Management CFT 1. The focus of the Care Management CFT is macro level oversight of care including access to and utilization of clinical and support services as evidenced by the work of Customer Services, Utilization Management & Care Coordination 2. Membership includes the CCO (Lead), Waiver Contract Manager, QM Director, Network Operations Director, Care Coordination Director, Clinical Director I/DD, Customer Services Director, UR Director, COO, CFO and a Report Writer 3. Develops/plans/monitors CM Performance Dashboard Indicators, CM CFT Work Plan, Clinical Design Plan that sets clinical direction/strategies to move utilization to best practice 11

12 services, UM Plan, researches and identifies evidence based/promising practices, establishes clinical protocols and identifies training needs, identifies outliers & high cost/high risk utilizers; monitors Care Management effectiveness; reports trends & patterns, high cost/high risk criteria, clinical practice guidelines and Clinical Decision Support Tools 4. Oversees appropriateness of services, access to primary care and service authorizations/ denials 5. Reviews/recommends (b)(3) services for implementation; quality review of enrollee Person- Center Plans, including crisis plans; procedures relevant to CFT s scope; and enrollee/ provider satisfaction surveys. G. Financial Operations CFT 1. The focus of the Financial Operations CFT is to oversee financial and business performance including finances, staffing, provider network contracting, facilities management, Risk Management and Corporate Compliance 2. Membership includes the CFO (Lead), Waiver Contract Manager, QM Data Manager, Provider Network Director, Clinical Director I/DD, UR Director, Customer Services Director, Corporate Compliance Officer, Human Resources Manager and a Report Writer 3 Develops/plans/monitors Performance Dashboard Indicators; Financial Operations CFT Work Plan; Rates; Resource allocation; financial impact of alternative service definitions, new services, new providers; Payback plan parameters; Corporate Compliance Plan; and the Risk Management Plan 4. Monitors/reviews financial forecasts, utilization trends, prompt pay performance, Coordination of Benefits (COB) requirements and audits, provider financial audits, provider contract performance, detection & investigations of clinical/financial fraud/abuse by providers and plans of correction, staffing, equipment and facilities needs and utilization, implementation and training on Corporate Compliance Plan, Health & Safety Committee and oversight for internal investigation processes, and procedures relevant to CFT s scope. H. Network Operations CFT 1. The focus of the Network Operations CFT is to enhance provider network strength and quality through needs assessments, implementation of evidence based/promising practices, and monitoring provider performance and outcomes 2. Membership includes the Provider Network Director (Lead), Waiver Contract Manager, QM Director, Care Coordination Director, Community Operations Director, Accounting Manager, Credentialing Specialist, Corporate Compliance Specialist, fraud and abuse and a Report Writer 3. Develops/plans/monitors Performance Dashboard Indicators, Network Operations CFT Work Plan, Provider Report Card, Needs Assessments, Network Capacity Study & Accessibility Analysis, Network Development Plan, service priorities based on the Network Capacity Study & Network Development Plan & defines RFPs/RFIs, enrollee transitions to closed network, enrollee wait times, network provider service records, annual network provider training calendar, e.g., selected seminars, timely communication, provider forums and Friday s, and procedures relevant to CFT s scope 4. Reviews/recommends relevant reports and information from all CFTs, trends grievances/appeals by type, provider, service, trends incidents by type, provider, service, summary report of allocations/ utilization/claims paid, enrollee/provider satisfaction surveys and provider performance trending & monitoring. I. Consumer & Community Affairs CFT (Cultural Competency) 12

13 1. The focus of the Consumer & Community Affairs CFT (Cultural Competency) is to build and strengthen relationships with stakeholders and community partners through outreach, communication and education to support enrollee empowerment, recovery and selfdetermination; lead planning and collaboration to promote cultural competency within the MCO and provider network 2. Membership includes the Community Operations Director (Lead), Waiver Contract Manager, QM Compliance Manager, Public Affairs Officer, Community Operations Manager, Network Development Manager, Community Outreach and Education Specialist and a Report Writer 3. Develops/plans/monitors Performance Dashboard Indicators; CFT Work Plan to include exploration of enrollees/family member involvement in daily operations; Social Marketing & Communications Plan; I/DD educational events; Hispanic outreach initiatives; housing initiatives; enrollee employment initiatives; transportation initiatives; System of Care; law enforcement liaison activities and Crisis Intervention Team (CIT); representation/participation in relevant county activities; transition of enrollees served by providers not joining the network; Peer Support Specialist training; enrollee outreach & education, i.e. Wellness & Recovery Action Plan training; procedures relevant to CFT s scope; and support/educate CFAC, DD Advisory Committee, SOC Collaboratives and the Jail/Mental Health Task Force 4. Reviews enrollee/provider satisfaction surveys and the Social Marketing and Communication Plan. J. Business Processes and Decision Support CFT 1. The focus of the Business Processes and Decision Support CFT is to identify system development priorities and address performance and process challenges, resulting in improved quality of operations and service delivery 2. Membership includes the Chief Information Officer (Lead), Waiver Contract Manager, QM Data Manager, Billing and Claims Manager, Network Operations Manager, COO, Corporate Compliance Specialist Fraud and Abuse and a Report Writer 3. Develops/plans/monitors Performance Dashboard Indicators for Business Processes & Decision Support, e.g., downtime; Business Processes & Decision Support Work Plan; MIS Strategic Plan covering development priorities, hardware needs/budgets, etc.; Help Desk requests, patterns, trends, response times; reporting needs of MCO, its departments and CFTs; audits for data integrity and MIS operational and capital budgets 4. Reviews procedures relevant to the CFT s scope. K. MCO Clinical Units The Clinical Advisory Committee (CAC) (External) is advisory in nature. The focus is to function as the Experts from the field in providing input and feedback in MCO clinical areas. Membership includes the CCO (Chair), the COO, a CFAC representative, enrollee/family representative(s), providers from all disabilities, an external psychiatrist, an advocacy group representative, and ad hoc invited guests/consultants as required for specific matters. a) The primary duties of the CAC are to: i. Review: Clinical Design Plan, UM Plan, including Clinical Decision Support Tools (at least annually) and proposed Benefit Plans ii. Make recommendations on new clinical practices, and provide feedback regarding feasibility of new ideas and proposed changes, e.g. rates in rural areas The Clinical Operations Team (COT) (Internal) is advisory in nature. The focus is to prepare materials for consideration by the CAC. Membership includes the CCO (Chair), COO, UR Director, QM Director, 13

14 Customer Services Director, Care Coordination Director and the Network Operations Manager. a) The primary duties of the COT are to: i. Develop clinical procedures ii. Address clinical issues iii. Monitor trends in clinical operations iv. Develop the UM Plan v. Develop other clinical materials as identified The focus of the Corporate Compliance Committee (CCC) is to provide guiding standards for decisions and actions for clinical and business operations. Membership includes the CFO (Chair), QM Director, COO, CAO, Contract Manager, and the HR Manager. a) The primary duties of the CCC are to: i. Conduct an annual review of the Corporate Compliance Plan ii. Establish, monitor, and enforce professional and ethical standards iii. Oversee continued compliance in all required standards and regulations iv. Review allegations of fraud and abuse v. Recommend preventative measures regarding fraud and abuse The focus of the Credentialing Committee (CC) is to provide an objective evaluation of the qualifications of licensed professionals to be admitted to the MCO s provider network. Membership includes the CCO (Chair), Credentialing Specialist, Network Operations Manager, QM Compliance Manager, and licensed provider representatives. a) The primary duty of the CC is to implement the MCO s credentialing plan and process under the direction of the CCO The Morbidity and Mortality Committee is advisory in nature. The focus of the Morbidity and Mortality Committee is to evaluate causes of morbidity and mortality, avoid preventable deaths and avoid complications. The committee is chaired by the CCO and composed of Provider Relations Specialists, Provider Network Director, Utilization Management Director, Quality Management Director and Network Operations Manager. a) Primary duties of the Morbidity and Mortality Committee are: i. Evaluate causes of morbidity and mortality ii. Increase connection of physical and mental health coordination iii. Recommend measures to prevent deaths and avoid complications iv. Obtain and use data gathered from NC IRIS and NCTOPPS v. Report and connect with other MCO clinical committees The Utilization Review Committee is chaired by the Utilization Management Director and composed of Utilization Management Specialists (MH/SA) and Utilization Management Specialists (I/DD). The focus of the sub-committee is to enhance the effectiveness and consistency of UR planning and decisions. a) The primary duties of the Utilization Management Committee are: i. Review of care of individual enrollees with complex and/or challenging needs ii. Inter-rater reliability testing iii. Peer review L. Continuous Quality Improvement Planning The MCO supports a culture committed to continuous quality improvement by using the DDRI quality improvement model. Evaluation information is used for program and training planning. Guidance to staff on quality management priorities and projects is expected and documented as a function of the CFTs, the 14

15 CCO and the Quality Management Director. Enrollee participation, input and feedback shall be assured through: Participation on the GCQIC Task-oriented focus groups; educational/training opportunities Enrollee Satisfaction Surveys Participation on the Consumer and Family Advisory Committee (CFAC) RFP/RFA review Membership and participation in local and State advocacy organization activities Participation on the Human/ (Client) Rights Committee Public Session at County Commissioners and community meetings Needs assessments Focus groups Staff participation, input and feedback shall be assured through: Involvement as team, program, and department members accountable for exemplifying and projecting organizational values in the performance of their designated job responsibilities Participation in the supervision process and at staff meetings Participation on standing internal planning and monitoring committees and teams, such as the CFTs Participation in QIPs Organizational representation in the community as participants in the collaborative community educational, advocacy and service improvement initiatives, including speaking engagements, consortiums, training programs, etc. Participation in training needs assessments and other types of needs assessments When aware of any quality assurance issues, providing notification to management as appropriate Community, collateral and other stakeholder input and feedback assured through: Consumer and Family Advisory Committee (CFAC) DD Advisory Committee System of Care Community Collaboratives CenterPoint Area Provider Council Community agency representation on MCO committees MCO representation on community committees Community needs assessments Public session at Board and County Commissioners meetings Annual public hearing on the budget conducted by County Commissioners Annual community forums Focus groups XI. Performance Measures - The MCO collects, trends, and analyzes data from multiple sources to evaluate quality and appropriateness of care. These performance measures monitor progress, drive quality and provide topic areas for Quality Improvement Activities. The MCO annually submits to DMA data and measurements for quality of care and service performance measures. This includes specific information on how the QM program monitors, tracks & reports on applicable performance measures, performance guarantees & incentives, including thresholds for discontinuation of QI activities & sites monitored. Sources and data utilized include, but are not limited to: 15

16 A. The MCO measures the performance of the agency and/or providers on the basis of the following criteria, sources, and objectives: 1. Performance Expectations established in the DMA Contract and the Performance Contract with the NC Division of Health and Human Services 2. MCO Strategic Plan 3. QIPs 4. PIPs 5. QIAs 6. MCO Organizational Goals 7. Performance expectations compliant with URAC accreditation standards 8. Provider-reported outcomes 9. Provider Scorecard B. Data Trending and Analyses: 1. Enrollee and provider trends: incidents, complaints received by the MCO, human (client) rights, outcomes, use of state facilities, use of emergency services and hospital emergency departments, service utilization rates and perceptions of care 2. MCO operations: management of state funds and Call Center, Utilization Management and Health Network outcomes C. Network Incentives: 1. Systems for reimbursement, bonuses or incentives to health care providers based directly on enrollee utilization of services has the potential to negatively influence services delivered and thus the health care of enrollees. 2. Mechanisms are implemented to protect the clinical treatment needs of consumers when such incentives are offered. 3. Financial incentives are used when a reasonable expectation exists for improved consumer outcomes. 4. The MCO has processes in place to monitor and confirm the delivery of appropriate, high quality consumer care. 5. The requirement for oversight is included in provider contracts/agreements and is implemented concurrently with implementation of the financial incentives. D. MCO Incentives: 1. The MCO is prohibited from implementing Utilization Management procedures that provide incentives for the individual or entity conducting utilization reviews to deny (reduce, terminate, or suspend), limit, or discontinue medically necessary services to any enrollee. 2. Utilization Management decision making is based only on appropriateness of care and service and the existence of coverage. 3. The MCO does not specifically reward practitioners or other individuals for issuing denials of coverage or services. 4. Financial incentives for Utilization Management decision makers do not encourage decisions that result in underutilization. XII. Assessment of Satisfaction: A. The MCO addresses enrollee satisfaction via: 1. Enrollee satisfaction with network services 2. Enrollee satisfaction surveys for Customer Services process 3. Enrollee satisfaction surveys for grievance processes 4. Enrollee satisfaction surveys from the NC Division of Mental Health/Developmental 16

17 Disabilities/Substance Abuse Services (DMH/DD/SAS) 5. Enrollee satisfaction surveys conducting by a third party vendor with results submitted to DMA B. The MCO addresses Client Satisfaction: The MCO utilizes its systems and procedures to assess and monitor client satisfaction, as it relates to the business to business relationship with the NCDHHS, including its entities: DMA and the DMH/DD/SAS. In general, to the extent that the MCO meets the performance indicators, client satisfaction with the MCO's services are confirmed. When the MCO is not able to consistently meet expectations, it takes corrective action to improve performance. 1. Performance Indicators a) The primary mechanism for assuring client satisfaction is to successfully perform the responsibilities and duties entrusted to the MCO by NCDHHS. NCDHHS has established various performance indicators, which the MCO is contractually obligated to meet. Although successfully meeting these performance indicators only infers client satisfaction, the MCO has historically received feedback from its client that is consistent with achievement of performance indicators. b) Evaluation of client satisfaction includes review and analysis of data relevant to performance indicators, including, but not limited to: i. Community Systems Progress Report (quarterly) ii. iii. Performance Contract Report (quarterly) Results of onsite visits or monitoring (if any) conducted by NCDHHS or others c) The MCO s results for performance indicators are reported in the appropriate QM committee, with discussion to determine what action is needed, if measures were not met. 2. Informal Client Feedback The MCO s CEO interacts with the client on a regular basis in a variety of venues and is able to obtain first-hand information with regard to satisfaction with the MCO s performance. The CEO shares this feedback with the MCO staff, as appropriate, and during discussion in the Executive Team meetings. XIII. Reporting of Outcomes: A. The MCO provides outcomes reports (utilized to guide and direct the MCO s actions to improve quality and outcomes in the delivery of MH, SA, and I/DD services) in the following settings: 1. Quality Operations Team meetings 2. CFT meetings 3. Quarterly GCQIC meetings 4. Child and Family Advisory Committee (CFAC) meetings 5. Quarterly Human/ (Client) Rights Committee meetings 6. Board meetings 7. Quarterly and Annual Reports (provided to County Commissioners, NC Division of MH/DD/SAS, providers, employees, CFAC, other stakeholders) 8. Employee staff meetings 9. CenterPoint Area Provider Council meetings 10. Annual Community Forum 17

18 Attachment A. Cross-Functional Team Relationships 18

19 Global Continuous Quality Improvement Committee (GCQIC) Team Reports To Responsibilities Decision Authority Level Focus: Support, monitor and evaluate all quality improvement activities and efforts to improve the quality of care provided both within CenterPoint and throughout the network of providers and report results and recommendations to the Board of Directors. Members: Lead: Board Representative(Co-Lead: CCO) Quality Management Director Providers Specialty practitioners Consumer/family representative(s) Community agency representatives Network Operations Director Ex officio -CEO -COO Interfaces with: QM CFT Board Review and advise MCO regarding the provider network and service system in the following areas: Annual CQI Work Plan, goals, performance improvement projects, best practice and quality initiatives Network performance on key quality indicators Quality system issues Aggregate data and analysis on complaints and grievances Consumer and provider satisfaction survey results in aggregate Conclusions and recommendations from the Quality Management CFT Monitor system efforts to support behavioral health and primary care integration Reports to the Board Advisory 19

20 Executive Team (ET) Team Reports To Responsibilities Decision Authority Level Focus: Oversee overall performance and strategic direction of MCO, including achievement of goals and objectives. Members: Chief Executive Officer (CEO) Chief Administrative Officer (CAO) Chief Operations Officer (COO) Medical Director/Chief Clinical Officer (CCO) Chief Financial Officer (CFO) Chief Information Officer (CIO) Interfaces with: Board of Directors Board Committees Consumer & Family Advisory Committee (CFAC) CenterPoint Area Provider Council (CAPC) DD Advisory Committee Stakeholders/Advocates Quality Operations Team (QOT) Health & Safety Committee Corporate Compliance Committee CEO Develops/Recommends for Board approval: Budget Policies Strategic Plan Benefit Design Plan Rate Setting Corporate Compliance Plan Risk Management Plan Social Marketing & Communications Plan Approves/Monitors: QOT recommendations Strategic Plan Annual Implementation Plan with organizational and departmental goals MCO Procedures Discusses/Resolves: QOT reports Performance Dashboard Indicators Critical Issues Requests MCO operational priorities Strategic Plan Annual Implementation Plan, with organizational and departmental goals MCO Procedures Quality Operations Team recommendations Issues not resolved at a lower level Clinical practice guidelines Press releases Annual CQI Plan Final recommendations to Board on: - Budget - Policies - Strategic Plan - Benefit Design Plan - Rate setting - Corporate Compliance Plan - Risk Management Plan - Social Marketing & Communications Plan - Quality Improvement Plan 20