Network Management Plan

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2 Table of Contents I. System of Care Development and Management... 4 A. System of Care Integration:... 4 B. Federal Block Grants:... 5 C. Recipient Eligibility:... 6 D. Implementation of Children s and Adult s System of Care:... 6 E. Implementation of Services for Co occurring Population:... 7 F. Use of Evidence based Practices (EBPs):... 8 G. Cultural & Linguistic Competence:... 8 H. Access to Appropriate Level of Care:... 9 II. Utilization Management Systems A) Utilization Management Overview: B) Housing Initiative: C) Waiting List Initiative: D) UM System Enhancements: E) Continuous Integrated System of Care and System Efficiencies: III. Network/Subcontractor Management and Subcontractor Relations A) Procurement Process Overview: B) Request for Qualification (RFQ):... Error! Bookmark not defined. C) Future Procurement Plan:... Error! Bookmark not defined. D) Pre Contracting Process: E) Contract Management: F) Contract Accountability Division (Contract Monitoring) Overview: G) Monitoring Reports, Onsite Reviews, Investigations and Corrective Actions: H) Accountability for Performance and Quality of Services Overview: I) Invoice Validation: J) Cost Containment Activities: K) Outcome Performance and Data Submission: L) Incident Reporting and Resolution including the evaluation of individual served safety and need for intervention as applicable: IV. Continuous Quality Improvement Systems A) Network Accreditation: P age

3 B) Subcontracted Provider CQI Program: C) System Improvements and Technical Assistance and Training: V. Data Collection, Reporting and Analysis A) Data Collection Provider Reporting Mechanism B) Data Reporting Data Submission: C) Data Trainings, Meetings and Work Sessions VI. Financial Management and Oversight A) Budget Oversight and Review: B) Redirection from Restrictive to Community Based: C) Securing diverse financial resources: D) Invoice Validation: E) Cost Containment Activities: F) Innovations Leading to Cost Efficiencies: P age

4 I. System of Care A. System of Care Integration: South Florida Behavioral Health Network has adopted the following System of Care (SOC) principles which are consistent with the Department s and have been embedded within the delivery system including subcontracts: 1) Family/Consumer Driven 2) Youth Guided (as appropriate) 3) Cultural and Linguistic Competence 4) Community Based Services 5) Gender Responsiveness Services 6) Recovery and Resiliency Focused SFBHN has also embraced the system of care values and is working to ensure that the values are rooted throughout the entire continuum of care: 1) Family members and youth are active members of the board 2) The system of care values are clearly delineated in all provider contracts 3) The SOC values are embedded within the contract monitoring tools 4) SFBHN Divisions conduct administrative and programmatic oversight and reviews to ensure and find evidence of these values in the services provided by its network provider 5) Conduct fidelity checks through the FACES evaluation team to then be expanded to all subcontracts As the managing entity SFBHN is able to: 1) Subcontract state and federal dollars with community providers for services quickly and seamlessly 2) Develop a continuum of coordinated service aimed at addressing the needs of the children, youth, families and adults served by individual providers 3) Encourage the development of partnerships to strengthen the availability of community supports 4) Utilize continuous quality assurance process to identify system wide and provider specific challenges 5) Utilize data to drive funding allocation and validate provider performance and billing 6) Utilize data from various sources (CFS, SAMHIS, KIS) as a component of the monitoring and CQI process SFBHN has developed and manages an integrated network of behavioral health services that is accessible and responsive to individuals in need of services, along with their families and community stakeholders. Support across all levels is necessary to ensure integration throughout the system of care. SFBHN is committed to managing a system of care that is supported by consumers, families, community stakeholders, providers and other resources. SFBHN maintains Memorandum of Understandings (MOUs) with multiple system partners to ensure integration of behavioral health services with multiple systems of care. For the integration with the Child Welfare System, SFBHN has continued to partner and maintained an MOU with Our Kids of Miami Dade/Monroe, Inc. (Our Kids) which is the Community Based Care (CBC) for Circuits 11 and 16. As the lead agency for services that oversee an integrated system of 4 P age

5 foster care and related services, Our Kids has joined with SFBHN in a collaborative agreement to meet the goals of behavioral health and wellness for these children and their foster families. Promoting the safety and well being of children includes many services that are inter related between the Managing Entity for Mental Health and Substance Abuse and the Lead Agency for Community Based Services. SFBHN has worked with Our Kids to: 1) Maintain a Memorandum of Understanding 2) Provide training and technical assistance regarding families, children and substance abuse to Our Kids Case Managers and other staff 3) Coordinate referrals for care through Utilization Management of SFBHN 4) Provide consultation to Our Kids on issues related to Behavioral Health practices and other services 5) Provide education and resource information on the availability of behavioral health system of care to youth aging out of the foster care system Specific examples of collaboration between Our Kids and SFBHN include: 1) Development of Psychotropic Medication Training by SFBHN s Medical Director to be included in Our Kids training curriculum. 2) Our Kids embedding SFBHN s SOC principles into their prevention contracts and agreement to include in their service contracts once there are eligible for recontracting. 3) Our Kids serves as an active member on SFBHN s Families and Communities Empowered for Success (FACES) Initiative Board and Program Subcommittee providing feedback into the service delivery system. 4) Partnership to include SFBHN s training (i.e. WrapAround, Motivational Interviewing (MI)) into Our Kids training curriculum. 5) Participation on staffings for consumers with complex needs that need access to behavioral health services. 6) Participation in Multi Disciplinary Team (MDT) staffings. 7) Interagency Family Intervention Specialist (FIS) staffings with SFBHN, Our Kids, Protective Investigations (PI), and FIS Provider to meet the needs of the Department and the PIs. SFBHN will continue to partner with Our Kids to address the needs to of the Child Welfare System and expanded system capacity as possible within existing resources. It is noted that Our Kids has the Department s Purchase of Therapeutic Services (Category ) funds that could be redirected to expand capacity within the System of Care. B. Federal Block Grants: Those Subcontracted Providers who enter into agreement with the Managing Entity for federal block grant funds are contractually required to comply with all of the requirements of the Substance Abuse Prevention and Treatment or Community Mental Health Block Grants Subparts I and II of Part B of Title XIX of the Public Health Service Act, s. 42 U.S.C. 300x 21 et seq. (as approved September 22, 2000) and the Health and Human Services (HHS) Block Grant regulations (45 CFR Part 96). Additionally, the Subcontracted Provider is expected to submit required reports as defined within Exhibit A Required Reports. Federal block grant requirements are monitored during: 1) Budget review process ensures that grant dollars are properly allocated to 5 P age

6 eligible services 2) Data submission, accuracy, and invoice validation 3) Monitoring visits conducted by the Contract Accountability Division. A specific tool is applied that includes, but is not limited to, the SAPTBG organizational requirements; data requirements; and other specific requirements for each of the special target populations. C. Recipient Eligibility: By entering into the contract, each Subcontracted Provider agrees that all persons meeting the target populations identified within the contract and further defined in s F.S., are eligible for services. Crisis stabilization, substance abuse detoxification, and addiction receiving facility services shall be provided to all persons meeting the criteria for admission. Recipient eligibility is reviewed during the Subcontracted Provider s monitoring visit to ensure the Subcontracted Provider s compliance with the contract requirement. D. Implementation of Children s and Adult s System of Care: System of Care (SOC) is a service delivery approach that builds partnerships to create a broad, integrated process for meeting consumers' multiple needs. This approach is based on the principles of interagency collaboration; individualized, strengths based care practices; cultural competence; community based services; accountability; and full participation of consumers, families and youth at all levels of the system. SFBHN partners with the Department and multiple stakeholders to continually review the SOC and ensure meeting the community s and the consumers needs and identification of service gaps. This has been participatory process which has engaged all system partners (consumers, providers, and stakeholders) to: 1) Develop and communicate new policies and changes in existing policies 2) Develop processes 3) Address Challenges 4) Identify Solutions 5) Communicate opportunities to improve the SOC as found through monitorings, CQI reviews, and evaluation of performance measures SFBHN participates and/or conducts various planning meetings for continuous feedback into the SOC. These planning meetings include: 6 P age Monthly 1) Addictions Services Board (ASB) 2) Adult System of Care (ASOC) Planning Meetings with the Department 3) Children s (CSOC) & Prevention System of Care Planning Meetings with the Department 4) Coordinated Outreach Meeting (Homeless Trust) 5) Consumer Network Meeting 6) CBC Alliance Meeting 7) CCST Provider Meeting 8) Drug Court Meeting (Juvenile & Dependency) 9) Executive Committee (EC) Meeting 10) FACES Program Subcommittee 11) FACES Evaluation Subcommittee 12) FACES Policy Workgroup 13) HIV/AIDS Partnership Committee

7 14) Model Court Meeting 15) Re Entry Partnership Committee 16) TANF Subcommittee Meeting Bi Monthly 1) Board of Directors Meeting 2) Data Group Meeting 3) FACES Governance Board Meeting 4) SOC/QI Board Subcommittee Meeting Quarterly 1) ASOC Provider/Stakeholder Meeting 2) CSOC Provider/Stakeholder Meeting 3) CSU/Detox Program s Directors Meeting 4) DCF Planning Council 5) FACT Advisory Committee 6) FACES Cultural Linguistic Committee 7) Forensic Stakeholders Meeting 8) Peer Specialist Training and Support Meeting 9) Regional Prevention Meeting 10) South Florida State Hospital Stakeholders Meeting 11) Statewide Consumer Network Grant Advisory Committee SFBHN and its contracted providers ensure that community residents eligible for public services receive treatment quickly without running a bureaucratic maze. In collaboration with SFBHN, the network providers ensure that their services move individuals and families toward self sufficiency and to be productive, integrated members of the community A full description of all the services purchased through SFBHN is available in SFBHN s consolidated Program Description. SFBHN has been successful in enhancing the SOC by acquiring and managing multiple grants. These grants serve to assist in the transformation of our system of care while supplementing funding streams, integrating services, and/or enhancing best practices. SFBHN is continually evaluating the SOC as described in the CQI Program Plan to ensure services are responsive to consumers and families individualized needs ensuring the best value for the community, the State, and the individuals served. SFBHN submits monthly CQI Reports to the Department documenting and highlighting trends within our System of Care. CQI E. Implementation of Services for Co occurring Population: Brief History of CCISC: In 2004, with a mission to provide more welcoming, accessible, integrated, continuous, and comprehensive services to individuals with co occurring psychiatric and substance disorders, forty three (43) mental health and substance abuse treatment service providers, advocacy organizations, and funders agreed to adopt the Comprehensive, Continuous, Integrated System of Care (CCISC) model for designing systems change to improve outcomes within the context of existing resources. CCISC is based on clinical consensus best practice principles (Minkoff, 1998, 2000) which espouse an integrated clinical treatment philosophy that makes sense from the perspective of both the mental health system and the substance disorder treatment system. 7 P age

8 SFBHN providers have engaged in numerous activities to further implementation of the CCISC Model. These activities include, but are not limited to: local meetings with DCF and SFBHN, clinical trainings, and provider self assessments. SFBHN providers utilize the COMPASS and CODECAT tools to evaluate program and clinician competencies related to the CCISC model. In terms of ME management of the CCISC initiative, SFBHN has implemented: 1) Contract language through subcontracts requiring agency compliance with the CCISC initiative. Agencies are monitored annually to ensure compliance with contract requirements; 2) Inclusion of CCISC in Agency QA/QI Reports; 3) Agencies continue submission of Annual CCISC Reports including Action Plans, COMPASS scores, and CODECAT scores; 4) Continued technical assistance offered to providers through individual meetings, SFBHN initiatives and SOC/QI Committee; 5) Identification of data elements and changes to database structures that will allow for the consistent identification of consumers entering the system of care with cooccurring disorders so that the ME can better understand and address the needs of these consumers and their treatment process; 6) Clinical competencies training, (Training and Technical Assistance). F. Use of Evidence based Practices (EBPs): SFBHN has facilitated the implementation of various Evidence based Practices through community wide initiatives and system implementation including Motivational Interviewing (MI), the Global Appraisal of Individual Needs (GAIN), WrapAround, Wellness Recovery Action Plan (WRAP), Seeking Safety, and Functional Family Therapy (FFT). In addition to the EBPs listed above, SFBHN subcontractors have implemented additional EBPs within the network. These EBPs include, but are not limited to: Cognitive Behavioral Therapy (CBT), Dyadic Therapy, Brief Strategic Family Therapy (BSFT), Life Skills, and Adolescent Community Reinforcement Approach (ACRA). Providers continually identify best practices which are relevant to the work being implemented at their agency and meet the need of the individuals they serve. SFBHN requires providers to report which EBPs are being utilized at their agency and are reported as part of their contract requirements through their Agency Program Descriptions. SFBHN plans to procure its Adult and Children System of Care to ensure that a minimum of 80% of all contract funding will be redirected to support EBPs by its subcontractors. G. Cultural & Linguistic Competence: SFBHN has experience working with diverse populations. Within the Southern Region, it is essential to have linguistic competency in at least 3 languages (English, Spanish and French/Creole). SFBHN staff have competency in all three languages. Part of the cultural competency is to ensure that staff at the provider agency meets the cultural and linguistic needs of the individuals being served. As part of the subcontracting process providers are required to submit Civil Rights Compliance Checklists which identify staff and consumer compositions. Contract language identifies that network providers shall ensure that services meet linguistic and cultural needs of recipients and provide communication services such as sign language or translators (as example). It additionally identifies that the Subcontracted Provider have an Auxiliary Aids and Services Plan. 8 P age

9 Within the monitoring process, SFBHN addresses the cultural abilities of each agency, based on the population they serve as it pertains to providers cultural and linguistic competency plans. The Contract Accountability Division includes as part of its regular monitoring activities a monitoring tool specific to the Culturally and Linguistically Appropriate Services standards, Title VI of the Civil Rights Act of 1964, 65 Federal Register , and ADA. CQI processes including investigations further monitor compliance and quality of same for agencies. Additionally through its FACES Initiative, SFBHN has implemented a Cultural Linguistic Competence (CLC) Committee Meetings which meets quarterly to discuss CLC issues with our system. Through the implementation of the FACES Initiative, the CSOC providers have completed a CLC Self Assessment which identifies strengths and opportunities for improvement regarding CLC with our CSOC. CSOC providers are working on developing CLC action plans based on these selfassessments. SFBHN is committed to engaging a wide array of diverse stakeholders who reflect the unique multicultural community we serve in the Southern Region. In an effort to gain comprehensive information on the cultural demographics of the FACES Initiative s stakeholders including SFBHN staff members, the CLC Committee developed the FACES Stakeholders Survey. Based on the results of the surveys and self assessments, SFBHN has implemented and facilitated trainings to address specific disparities and topics identified such as Gay, Lesbian, Trans Gendered Identification, Peer Integrations, and Religious/Spiritual Affiliations. SFBHN has a consulting agreement in place to provide CLC technical assistance (TA) to the system of care. The CLC Coordinator provides technical assistance to the community on overall CLC system issues, support and education providers plans, and specialized TA for providers as needed. H. Access to Appropriate Level of Care: SFBHN ensures that behavioral health services are coordinated and developed into an integrated network of services accessible and responsive to individuals in need of substance abuse and mental health services, families, and community stakeholders. As incorporated into contract language: The network provider shall meet the standards for timely access to care along the lines of those required by ME, accrediting bodies and the Medicaid prepaid plans as identified below: 9 P age 1) Emergent need: within six (6) hours of first contact 2) Urgent need: within 48 hours of first contact; 3) Routine need: within 10 business days of first contact. SFBHN has developed and implemented a Utilization Management (UM) Manual which describes current methods to access services presently being managed by SFBHN. The UM Manual and how SFBHN manages UM functions is discussed in detail in the UM Section of this presentation. Further, access to care is found within the Consumer and Family Services Manual which includes: a) services provided by the SOC and how to access the services, including a provider directory; b) emergency services and what to do in case of a psychiatric or medical emergency; c) the consumers rights and information on how to file complaints or grievances; d) information regarding available auxiliary aids and services, and how to requests these services; e) cost sharing and fee payment

10 requirements; and f) information regarding how to select a practitioner or change practitioners if the consumer served wishes to. Additionally, SFBHN established an 800 call in number ( ) to assist consumers in contacting the ME for assistance which is noted in the Manual. Finally, SFBHN has implemented various CQI activities to monitor providers compliance with access performance measures as specified in the contract. These activities include, but are not limited to: the Provider Report Card, Secret Shopper Calls, Client Satisfaction Surveys, Census Reports, Waitlist Reports, Seeking Placement Reports, and Retention Reports. Consumer records are reviewed during CQI and Investigative activities to further evaluate and monitor compliance with access. II. Utilization Management Systems A) Utilization Management Overview: Utilization Management (UM) is a system for the evaluation of the appropriateness, clinical need and efficiency of behavioral health services, procedures and facilities according to established criteria and/or guidelines. SFBHN s specific goals of utilization management include elimination/management of wait lists, the maximum utilization of treatment resources, and the delivery of clinically appropriate services in the least restrictive setting and most cost effective manner. SFBHN s UM systems include preauthorization for multiple services as well as retrospective reviews and focused reviews of individuals receiving services and subcontractors whose utilization of services is outside of expected parameters. Utilization management includes methods used to manage the system of care to ensure access to the appropriate level of care, at the right frequency and for the appropriate duration. It also includes financial screening to ensure maximization of fiscal resources including other third party payors such as, but not limited to KidCare, Medicaid, Medicare, and other HMOs. These methods may include programs of intervention and/or diversion. Utilization management includes not only managerial and supervisory strategies, methods and tools to ensure timely access to care, but also includes processes to promote continuous improvement to manage resources. As the Managing Entity for South Florida, South Florida Behavioral Health Network (SFBHN) is enhancing our automated utilization management system to include additional treatment authorization and management reports for the system of care. The SFBHN conducts oversight, reporting and management of the behavioral health services for individuals served. In the event that waiting lists do develop, the managing entity implements procedures for managing the substance abuse and mental health waiting list for all applicable levels of care including provision of interim services through utilization management strategies. The SFBHN conducts initial and continued stay authorizations for applicable levels of care as described in the contract with the Department in order to ensure timely access to behavioral health services and minimize the wait lists. The authorization processes include: 1) Timeliness standards for authorization review. All authorization reviews must adhere to timeline standards for the services provided and departmental, statutory, and judicial regulations or requirements. 2) Processes for communicating UM decision making criteria to practitioners including any standardized tools and assessments for use in determining placement and/or level of care. 10 P age

11 11 P age 3) Provisions for providing timely reconsiderations, or second opinions, when a request for authorization for a particular service is denied. (A reconsideration differs from a grievance in that grievances are used when a recipient or member of the covered population believes that he or she has been treated improperly, whereas a reconsideration is a request to review authorization or reauthorization for a particular service.) The second opinion shall be obtained according to the timeliness standards for the service in question as outlines in the Reconsiderations section of the UM manual. The UM Manual protocols include managing the systems most costly services such as Residential, Detoxification, Crisis Stabilization, and Short Term Residential. These procedures meet the Department s requirements and define the processes to be utilized to minimize over and underutilization of services. B) Housing Initiative: It is the goal of SFBHN to develop a partnership with community housing providers, organizations and agencies to facilitate access to supportive housing resources to individuals who are dealing with a mental illness and/or co occurring disorder. This Supportive Housing Initiative is geared towards the identification and development of supportive housing services that complement/facilitate access to those individuals currently in our residential system of care and/or those who have the skills to benefit from supportive housing. SFBHN actively manages various activities surrounding housing including: tracking of subcontractors housing performance measures, developing and facilitating housing workgroup, partnering with Homeless Trust and/or community stakeholders which are leaders in housing, and establishing innovative collaborative to assist consumers in access housing. C) Waiting List Initiative: The local DCF office implemented UM in 1999 beginning with Substance Abuse (SA) Residential Level II treatment. Based on the DCF (SAUM) Manual published in 2004, prior to DCF implementing UM amongst SA: 1) Clients waiting for Residential Level II prior this initiative ranged from 186 up to 1000 consumers at a given time. 2) During the first month of implementation, the waiting list was reduced from 186 down to 42 consumers. 3) During the second month of implementation, the list was further reduced to 32 consumers. 4) Between , waiting list numbers have fluctuated based on demand and availability. For FY , waiting list numbers each month have ranged from 43 to 143, with the average being at 80. Although some consumers are waiting for specific programs, most consumers on the waiting list are waiting for the next clinically appropriate vacancy. Typically, at least 2 or 3 of the different programs are appropriate for a given consumer s needs. The average wait for placement is approximately 2 to 3 weeks. The local office attributed the below reasons for the waiting list Reductions: 1) Centralization of a Waiting List with oversight provided by the Department of Children & Families. 2) Utilization of and access to all available appropriate community resources, treatment programs, and levels of care. 3) Utilization of alternate funding sources where available.

12 In 2004, DCF transitioned the UM of SA services to SFBHN (SFPC at the time). SFBHN maintained the Department s practices and began developing systems to expand on the Department s work. D) UM System Enhancements: On such system enhancement was to move the entire SA system into the utilization of the Global Appraisal of Individual Needs (GAIN). The GAIN is a recognized evidenced based assessment instrument that is web based. E) Continuous Integrated System of Care and System Efficiencies: As mentioned in the SOC Section and fully described in the CQI Section, SFBHN is continually evaluating the SOC to ensure services are responsive to consumers and families individualized needs ensuring the best value for the community, the State, and the individuals served. SFBHN submits monthly CQI Reports to the Department documenting and highlighting trends within our System of Care. These reports include utilization, retention, average length of stay, waitlist, and census reports which assist SFBHN make timely decisions concerning Utilization Management. The procurement process will create efficiencies by requiring prospective providers to submit innovative ideas and plans to provide comprehensive systems of care for geographic areas or specialized services. Within the proposed systems of care, the system is expected to identify, provide and coordinate services for consumers seeking services. Additionally, the prospective providers are required to demonstrate cost efficiencies through but not limited to resource consolidation, cost sharing, and other innovative ideas. III. Network/Subcontractor Management and Subcontractor Relations A) Procurement Process Overview: It is the policy of SFBHN to provide opportunities for organizations to become part of the system of care managed by SFBHN. SFBHN recognizes that full and open competition is a basic tenet of the procurement of public funds and that competition reduces the appearance of favoritism and inspires public confidence. In keeping with SFBHN s commitment to full and open competition, SFBHN intends to competitively procure services. The procurement process is described in detail in the competitive procurement plan. SFBHN is committed the Department s goal of investing the treatment funds it manages with providers that use evidence based practices. Our goal is to improve client outcomes and more efficiently utilize our limited community resources. B) Contracting Process: After each procurement process or renewal year, the Subcontracted Provider is responsible for providing a number of pre contracting documents for review prior to entering into contract negotiations. The documents include but are not limited to: 1) Copy of certificate of status from the Florida Department of State Division Corporations 2) Most current Florida Department of Children and Families and if applicable, Agency for Health Care Administration issued licensees. 3) Program Descriptions 12 P age

13 4) Copy of National Accreditation Certificate, or, if not yet accredited, submission of a detailed explanation of steps taken in the past year to attain accreditation 5) Projected budgets 6) Financial audit Items such as accreditation and state licenses are verified during this process additionally verified during the contract monitoring process. C) Contract Management: It is the policy of SFBHN to provide opportunities for organizations to become part of the system of care managed by SFBHN. SFBHN recognizes that full and open competition is a basic tenet of the procurement of public funds and that competition reduces the appearance of favoritism and inspires public confidence. Contract managers are assigned, in writing, by the Contract Management Supervisor, the contract management responsibilities and the contract workload. The Contract Manager is the single point of contact through which all contracting information flows between SFBHN and the provider. The contract manager is responsible for enforcing compliance with administrative and programmatic terms of the contract and requesting corrective actions for non compliance. The contract manager is the individual responsible for maintaining the official contract file. The SFBHN contract and any documents incorporated by reference (including the state s contract with SFBHN) establish the basis of accountability for provider performance and define the expectations for the delivery of quality services. SFBHN contracts are in compliance with applicable state and federal laws, rules, regulations, Department of Children and Families Operating Procedures/contract directives, as applicable, and SFBHN policies and procedures. Contract language defines the expectation that Subcontracted Providers comply with all Federal and State requirements, data submission and outcome performance expectations, incident reporting policies, recipient eligibility requirements, and service delivery requirements. D) Contract Accountability Division (Contract Monitoring) Overview: The SFBHN Subcontract Accountability Plan provides specific details describing the monitoring process. SFBHN s Contract Accountability Division monitors its network providers in accordance with section F.S. to ensure compliance with federal and state laws, rules, and regulations and the contract with SFBHN. A monitoring schedule is created based on a risk assessment using predetermined factors to rank providers high, medium, low to determine order, frequency and level of oversight (i.e., on site or desk review). Pursuant to section F.S. SFBHN limits the scope of administrative, licensure, and programmatic monitoring for providers who are accredited. SFBHN identified twenty (20) critical factors used to establish risk levels. Some of those factors include, but not limited to: program type, accreditation status, amount of funding, and timely & accurate data submission, incident reporting, data to invoice congruence, history of corrective action plans, and financial stability. Determining the level of risk allows the Contract Accountability Division to pay the necessary 13 P age

14 attention to areas identified as potential weaknesses and determine if an onsite review is necessary. Providers ranked as a high risk are monitored on site on an annual basis. Those determined medium and low risk are monitored at a minimum, once every three (3) years. The Contract Accountability Division in collaboration with other SFBHN Divisions meet bi monthly in what is called a Scope Development Meeting to identify all areas of concern that must be incorporated in the monitoring process. The following information is gathered from contract managers or other SFBHN Divisions: 14 P age 1) Client Sample List. Clients are randomly selected in programs identified in the cost center selection. 2) Service Event Validation & Medicaid. Detailed Service Event Reports are provided monthly along with Medicaid Eligible/ billable reports, if applicable, to verify services that were Medicaid eligible and billed to the ME. Additionally, Service Data Reports identifying bundled services are also obtained for review. 3) Invoice Validation Report. Request to the Finance Division for an Invoice Validation of the cost centers identified in the scope. 4) Provider Contract File. A review of the providers contract files for all current documentation. 5) Subcontracts, exhibits, program descriptions, current audits and other reports with the provider. The information gathered during the scope development meeting allows the Contract Accountability Division to develop a Charter and a Monitoring Plan. The monitoring plan includes the programs, cost centers, and sample sizes to be reviewed during the monitoring. It may be necessary to revise the monitoring plan based on information gathered subsequent to the planning stage. The Department s concern about any subcontracted provider will be incorporated into the scope of the monitoring for that provider. Monitoring consists of the following processes: Interviewing individuals, observations, inquiries, and analytical procedures. 1) Document review is the most common monitoring technique. Documents commonly reviewed during on site monitoring include, but not limited to client files, staff personnel files, procedures, reports, and publications, accreditation reports, financial reports, and incident reporting logs. 2) Interviews may be performed with provider staff to substantiate information found in documents or gathered during observations, or to obtain information about processes and procedures that is not found in documents. 3) Certain contract compliance requirements may be monitored through actual observation of evidential matters. For example, inventory records may be validated by observing property. Contract Monitors develop monitoring tools that are customized based on the terms or conditions of a particular contract and the scope of monitoring. A sample of a monitoring tool is attached for reference. Each monitoring tool will generally: 1) Identify requirements that are based on contract terms and conditions. 2) Identification of compliance and non compliance.

15 3) Allow for notations and explanations for findings, especially where the provider is non compliant. Contract Monitors analyze detailed service data reports provided monthly by SFBHN s CQI and IT Division to verify accuracy and ensure compliance. Data is filtered and reviewed to detect trends and duplicity of billing. E) Monitoring Reports, Onsite Reviews, Investigations and Corrective Actions: Each Division has the opportunity to evaluate Subcontracted Providers based on their compliance with the expectations of the contract along with other consumer based issues. As such and when applicable, a report (monitoring report, investigation report, etc.) is generated. These reports may identify that the monitored Subcontracted Provider has findings that they are mandated to address with a corrective action plan (CAP). SFBHN will accept or reject a CAP and require the provider to resubmit an acceptable plan. The CAP(s) will remain open until such time SFBHN confirms full implementation of the CAP. CAP issued by the Contract Accountability Division must comply with the rules established by the DCF and through Managing Entity policies. In coordination with the issuing Division, the contract manager is responsible for tracking the CAP, coordinating internal meetings to review the CAP and provide response to the provider. It may be necessary for the Managing Entity to provide technical assistance to the Subcontracted Provider to ensure that the actions identified within the CAP are in compliance with the contract, are efficient and meaningful, and ensure the improvement of the service quality to the consumer. F) Accountability for Performance and Quality of Services Overview: The Contract Management Unit with support from the Finance Division, System of Care Division, the Continuous Quality Improvement and Information Technology Division, and the Contract Accountability Division work to ensure accountability of contracted funds, compliance with contract language and for the quality of services. Accountability takes place through a variety of methods, including but not limited to, monthly review of compliance and quality elements of each provider through the Provider Report Card, review of contractually required programmatic or administrative reports, quarterly continuous quality assurance and quality improvement reports, Subcontractor Accountability Monitoring, Contract Manager issued Corrective Action Plans, complaint and grievance protocols, performance outcome monitoring (Exhibit D, SAMH Performance Outputs and Outcomes), incident reporting, trending and investigations, and monitoring of an agency s ability to effectively and accurately execute evidence based practices, emerging trends, and promising practices. These elements were identified as the most important for the success of the providers, consumers, and for SFBHN. SFBHN is continually evaluating the SOC as described in the below CQI Section to ensure services are responsive to consumers and families individualized needs ensuring the best value for the community, the State, and the individuals served. Results of the monthly report cards, contract monitoring reports, performance outcomes, CQI reports, and programmatic reports will identify trends and determine training needs and technical assistance activities. Additionally, trends are communicated to relevant stakeholder through such avenues as the meetings identified in the System of Care section above and through network training opportunities. SFBHN submits monthly CQI Reports to the Department documenting and highlighting trends within our System of Care. 15 P age

16 Annually, the Contract Accountability Division documents in a tutorial, common findings and concerns identified during the monitoring of our providers. These common findings and concerns are analyzed and tracked for trends in an effort to ensure quality improvement by presenting the information to providers with compliance tips and ways to avoid findings. G) Invoice Validation: On a monthly basis, invoice verification reports are issued by the Information Technology Division that contain the information from providers individual Exhibit G, displaying an associated cost for data submitted to the KIS system. These are utilized by the SFBHN fiscal department to compare against the provider submitted paper invoice and back up documentation. Any invoice with a variance greater than 5% between the data and invoice is adjusted to match the data submitted by the provider. In addition, in preparation for monitoring s, Contract Accountability Monitors obtain monthly detailed service reports from the IT Division. These reports contain service event information submitted by providers. The Contract Monitors utilize these reports to compare with the information obtained from the consumer file selected for the monitoring. In some instances this monitoring process has resulted in paybacks. H) Cost Containment Activities: During the pre contracting phase, the Finance Division conducts reviews of provider budgets to ensure that the costs allocated to the proposed cost centers are reasonable, allowable, and necessary. The review conforms to the requirements set out in Rule 65E 14, F.A.C. The review of the provider budgets prompt rate negotiations with provider/vendors. Beginning FY , it is a contractual requirement for agencies providing Comprehensive Community Service Teams (CCST) to dedicate 60.19% of their time to providing direct care to consumers. CCST is a service that is reimbursed based on staff hour (availability) and though it allows for flexibility for providing a team approach (to include peer support services) for treatment it creates the potential of a decrease in the number of consumers receiving services. Providers are contractually required to document their time on a duty roster and this information must be supported by the data submission. Any variance detected during the invoice to data validation process, or during a contract monitoring, will result in an adjustment to the invoice or in a payback. For fiscal year , SFBHN negotiated the reduction of the administrative cost for network providers. The administrative cost was reduced to 13% or less for all contracted SAMH services. The cost savings were reallocated to support the increase of direct services. The provider s Projected Cost Center Operating and Capital Budget evidence the reduction and redistribution of the cost savings. It is the intent of SFBHN to negotiate the reduction the cost of administration in accordance with the Administrative Cost Reduction Plan. Through its various departments, SFBHN utilizes an approach which offers the state and the community the best value available in response to the needs of the system of care. SFBHN strives to eliminate/maintain wait lists, maximize treatment resources, and the delivery of clinically appropriate services in the least restrictive setting and most cost effective manner. As the Managing Entity for South Florida, South Florida Behavioral Health Network (SFBHN) is continuously enhancing our System of Care. 16 P age

17 I) Outcome Performance and Data Submission: All contracts define the expectations relating to outcome performance and data submission. The CQI Division monitors providers substance abuse and mental health performance outputs and outcomes based upon an agency s monthly data report. The agency may be placed on corrective action to improve outcomes. Providers are required to submit as part of their plan, steps necessary to improve the reporting of the data, increases the number of consumers served, or other actions that would be necessary for improvement of performance outcomes. The Contract Manager provides support to the CQI Division in tracking the submission of the CAP s. Data submission is further defined in the Data Collection, Reporting and Analysis section below. J) Incident Reporting and Resolution including the evaluation of individual served safety and need for intervention as applicable: SFBHN and its network of providers are contractually required to use IRAS in reporting incidents as authorized by CFOP All reportable incidents are reviewed by the Risk Management and Compliance Coordinator. If a report is incomplete, the Risk Management and Compliance Coordinator will contact the provider for additional information. The Risk Management and Compliance Coordinator shall ensure that timely notification is/has been made by the provider in the incident report to the appropriate individuals, to include the Contract Manager, and agencies. Desk review/on site investigations are conducted when warranted for death, suicides and elopements if trends are noted. Incident report summaries are tracked for trends. SFBHN provides technical assistance to providers as appropriate. As part of the contract monitoring process, the Contract Accountability Division monitors network provider s internal reporting logs against reported incidents. It is additionally tracked on the Provider Report Card. IV. Continuous Quality Improvement Systems The CQI Division, with support from other Divisions, use the below in order to evaluate the quality of care, evaluate provider performance, identify the need for technical assistance, identify service gaps and for planning purposes. As further described within the CQI Program Plan, the following list of sample tools and processes are used for evaluation or identification: 1) Provider Report Card: Evaluates the performance of providers on the following aspects a. Data submission validation and accuracy and improvement of outcomes and performance b. Fiscal solvency and stability c. System of care quality and utilization management d. Continuous quality improvement e. Contract compliance and contract monitoring f. Corrective action plan(s) identification The performance indicated on the Report Card will be used to determine incentives or penalties. As example, when lapse funds are available only those providers who demonstrated positive performance will be eligible for lapse funding. Additionally, the Report Card is used for Desk Reviews of contracted providers who are either 17 P age

18 medium or low risk as determined by the Contract Accountability Unit s Risk Assessment. 2) The CQI Division monitors Exhibit D performance monthly through performance reports provided to the providers and quarterly through the CQI Division who evaluates if the provider is addressing those measures not being met in a timely and efficient manner. If the provider is not addressing the under producing measure per SFBHN expectations, the provider may be placed on corrective action to improve outcomes. Providers are required to submit as part of their plan; steps necessary to improve the reporting of the data, increase the number of consumers served, or other actions that would be necessary for improvement of performance outcomes. 3) Secret Shopper Exercise: Conducted to determine if providers are polite and empathic, asking if the caller needs auxiliary aid assistance, providing proper referrals, and wait times for the next available appointment, or other obstacles hindering access. 4) CQI Monthly Qualitative Data Reports: Individual served outcomes and utilization management data is trended and analyzed to determine quality of services, provider performance, need for technical assistance, risk management, time and distance from home, and identification of service gaps. 5) All complaints and health and safety incident report trends are investigated. Findings are used to make improvements to providers provision of care along, assigning accountability to the provider, and used to evaluate providers performance. Corrective actions are tracked as part of the Report Card. Additionally, findings from investigations are used as training opportunities for similar providers. 6) Consumer satisfaction surveys are collected, trended and analyzed. The findings are to be provided to the providers and for those whose collective score less than 80% will be required to submit a corrective action plan. These findings will be used to determine the level of quality provided by the provider and the need for technical assistance. 7) Findings from contract monitoring and contract requirements such at required reports are used to identify potential areas for provider improvement. 8) SFBHN promotes effective and quality programming across its continuum of care. The network providers are responsible in addressing quality indicators of program successes and ensuring fidelity for program implementation. Each network provider is required to outline a quality assurance and improvement plan that demonstrates quality being continually monitored to achieve that organization s planned outcomes. A) Network Accreditation: SFBHN has incorporated contract language in its current subcontractor contract that requires them to take appropriate steps to obtain national accreditation during state fiscal year in order to promote best practices and the highest quality of care. The network provider shall provide the ME with their full accreditation and licensing reports upon request. Providers whose contract or annual service reimbursement amount exceeds $35,000 but is less than $350,000 and serve more than three unrelated persons, must comply with the CARF Standards for Unaccredited Providers. All providers under SFBHN must be either accredited, seeking accreditation and have a plan, or meet the non accredited provider section. For those providers who fall into the later and 18 P age

19 have asked for assistance, SFBHN will conduct Learning Partnerships to assist them along in the process. B) Subcontracted Provider CQI Program: SFBHN has made it a contractual requirement for providers to have a CQI program that requires each service network provider develop a written plan which addresses the minimum guidelines for the network provider s continuous quality improvement program, including, but not limited to: 1) Individual care and services standards to include transfers and referrals, cooccurring supportive services, and trauma informed services. 2) Individual records maintenance and compliance. 3) Staff development standards. 4) Service environment safety and infection control standards. 5) Peer review and utilization management review procedures. 6) Incident reporting policies and procedures that include verification of corrective action and a provision that specifies that a person who files an incident report may not be subjected to any civil action by virtue of that incident report. 7) Fraud, waste, abuse and other potential wrongdoing auditing, monitoring, and remediation procedures. The quality improvement program must also: 1) Composition of quality assurance review committees and subcommittees, purpose, scope, and objectives of the continuous quality assurance committee and each subcommittee, frequency of meetings, minutes of meetings, and documentation of meetings. 2) Provide a framework for evaluating outcomes, including: a. Output measures, such as capacities, technologies, and infrastructure that make up the system of care. b. Process measures, such as administrative and clinical components of treatment. c. Outcome measures pertaining to the outcomes of services; 3) Provide for a system of analyzing those factors which have an effect on performance; 4) Provide for a system of reporting the results of continuous quality improvement reviews; and, 5) Incorporate best practice models for use in improving performance in those areas which are deficient. 6) For agencies utilizing seclusion and restraint procedures and as required by law (65E 5.180), establishment and utilization of a Seclusion and Restraint Oversight Committee responsible for the timely review of each use of seclusion and restraint to include: a. Circumstances that lead to the event. b. Nature of the de escalation efforts and alternatives to seclusion and restraint are attempted. c. Staff response to the incident. d. Ways to effectively support the person s constructive coping in the future and avoid the need for future seclusion and restraint. C) System Improvements and Technical Assistance and Training: The continuous quality improvement process (CQI) looks at the relationship between several components and utilizes this analysis to improve the system as a whole. As the ME, SFBHN monitors providers in several ways to ensure that services are being provided in the most effective 19 P age

20 and efficient manner. Data is analyzed and system trends are identified and reviewed by both the CQI and SOC departments. Reports are generated to review performance outcomes, utilization, consumer access, retention and other pertinent measure that reflect the network performance. As part of a collaborative process, the ME and DCF Southern Region staff meet on a monthly basis to review and discuss these CQI reports. This process results in identification of system needs. Areas identified as needing a system wide improvement are addressed through training that is provided to the network. When individual providers are identified as performing below the norm, they are contacted to discuss these concerns and a technical assistance visit is scheduled at the provider to address these issues. Training and Technical assistance are also provided to the network as part of an ongoing collaboration with several community partners. When training needs are identified, SFBHN works with partners to bring training to the community. One such collaboration includes partnership with the Addiction Technology Transfer Center (ATTC) Network to provide training to the Network and stakeholders. V. Data Collection, Reporting and Analysis South Florida Behavioral Health Network (SFBHN) requires all subcontracted providers to submit data containing the demographic, service and outcomes data for all clients paid via their respective contracts in accordance with state prescribed requirements. Providers submit data for clients paid via Substance Abuse & Mental Health dollars (SAMH), Medicaid, Local Match, Temporary Assistance for Needy Families (TANF), Purchase of Therapeutic Services (PTS) and Title 21 to SFBHN for inclusion in the state Substance Abuse and Mental Health Information System (SAMHIS). The SFBHN data submission requirements adhere to the format and submission frequency defined by Pamphlet 155 2, Mental Health and Substance Abuse Measurement and Data of the Department of Children and Families (DCF). A) Data Collection Provider Reporting Mechanism When a provider has been awarded funding, data submission options are discussed and determined based on both their data processing capabilities and the volume of data generated monthly. Providers may submit their data to SFBHN in one of two ways: 1) By entering data directly into SFBHN s KIS server (currently done through a utility called KIS Express), or 2) Generating batch files which are then uploaded through SFBHN s KISWeb portal. Regardless of the chosen method, providers must report data in a way that is compliant with the specifications set by the state in the current version of DCF Pamphlet SFBHN does not allow providers to report their subcontracted data directly to the state. Only SFBHN is authorized to upload the data. This allows for SFBHN IT staff to thoroughly analyze and isolate potential inaccuracies, missing information and common errors to ensure that the dataset submitted is as accurate and complete as possible. B) Data Reporting Data Submission: The state requires that data from a month is uploaded to SAMHIS on or before the 11th day of the following month. Because of the number of providers involved and the time required for verification and preparation, SFBHN has set its own deadlines to assure data is received, processed and uploaded to the state on time. 20 P age