CARE MANAGEMENT PROGRAM AND PLAN

Transcription

1 CARE MANAGEMENT PROGRAM AND PLAN 2015

2 INTRODUCTION... 2 PURPOSE... 3 SCOPE... 3 CARE MANAGEMENT... 3 CARE MANAGEMENT PRINCIPLES... 4 TRSN CARE MANAGEMENT PROGRAM... 4 CARE MANAGEMENT PROGRAM STRUCTURE... 4 TRSN Governing Board... 5 TRSN Advisory Board... 5 Quality Management Committee (QMC)... 5 TRSN Administrator... 5 Psychiatric Medical Director... 6 Contracted Care Manager... 6 Quality Manager... 6 Information Systems Administrator... 6 CARE MANAGEMENT RESPONSIBILITIES... 7 Care Coordination... 8 Case Management... 8 Information System Management... 9 Utilization Management... 9 Resource Management... 9 Risk Management CARE MANAGEMENT ACTIVITIES Data Collection Data Reporting Data Analysis CARE MANAGEMENT PROCESSES Care Management Committee Meetings Clinical Directors Meetings Provider Directors Meetings TRSN Management Team Meetings Advisory Board Meetings Governing Board Meetings Ombudsman Services Quality Review Team Services CARE MANAGEMENT PLAN GOALS OBJECTIVES Care Coordination Case Management Utilization Management Information Systems Management Resource Management Risk Management CARE MANAGEMENT ASSESSMENT EXTERNAL ASSESSMENT External Quality Review Organization (EQRO) INTERNAL ASSESSMENT Care Management Program Evaluation i Page

3 Introduction Regional Support Networks (RSN), contract with the Department of Social and Health Services (DSHS) as Prepaid Inpatient Health Plans (PIHP), to provide mental health services through contracted providers for children and adults who are eligible Medicaid-covered enrollees. Mental health services are also provided, as funds allow, to non-medicaid enrollees. Any person regardless of funding source is eligible for crisis services. Oversight of each RSN is provided on behalf of DBHR by the Division of Behavioral Health and Recovery (DBHR). (TRSN) is located in rural Southwest Washington and is comprised of Lewis, Pacific, and Wahkiakum Counties. TRSN stretches from the Pacific Ocean to east of Mt. Rainier in the Cascade mountain range encompassing 3,947 square miles and approximately 101,000 people. Regional Support Network Map 10/2012 TRSN provides funding for, and oversight of, direct services delivered by its contracted providers. TRSN staff themselves do not provide direct mental health services to clients. TRSN contracts with Cascade Mental Health Services, Willapa Behavioral Health, and Wahkiakum County Mental Health Services to provide direct mental health services for each of TRSN s three counties. The mission of is to ensure that people of all ages experiencing mental illness can better manage their illness; achieve their personal goals; and live, work and participate in their community. 2 P age

4 Purpose The following Care Management Program and Plan serve as the foundation of the commitment of TRSN to continuously assess the efficiency and effectiveness of its provider network through periodic review and evaluation. TRSN monitors for clinically appropriate services provided in a consistent cost efficient manner, based on the individual needs of the client, which result in positive client outcomes and achievable satisfaction levels. Clinically Appropriate Services Efficiently Managed Resources Client Outcomes Client Satisfaction Scope TRSN s Care Management Program is comprehensive in nature extending to all network providers and contractors involved in delivering community mental health services. TRSN reviews and indirectly manages client care from the point of entry, through treatment and delivered services, to discharge. All delivered client services are subject to review. Care Management Care Management is a set of clinical management oversight functions designed to monitor, evaluate, and guide decision making about the cost and efficiency of mental health services delivered to all TRSN enrollees. Care Management focuses on oversight of care coordination, case management, information systems management, utilization management, resource management, and risk management. Care Management is intended to complement quality management/improvement activities. 3 P age

5 Care Management Principles TRSN is committed to the management and delivery of necessary services that are: Managed in a manner that appropriately allocates resources in order to provide an optimum, achievable quality of client care in a cost-effective manner. Value added, cost effective, and client and organization promoting. Timely, clinically appropriate, and provided in the least restrictive environment and in the most caring, sensitive and confidential manner possible. Considerate of individual client care decisions and facilitation at critical treatment junctures to assure clients care is coordinated, received when they need it, likely to produce good outcomes, and is neither too little nor too much service to achieve the desired results. Not structured in such a way as to provide incentives to any individual or entity to deny, limit, or discontinue medically necessary mental health services to any enrollee. TRSN Care Management Program The Care Management (CM) Program describe the structure, responsibilities, activities, and processes employed to achieve a comprehensive system through which TRSN collects and analyses information from multiple sources in an effort to assess efficiency and effectiveness of services and identify areas of below standard performance. The Care Management program tracks progress, identifies areas for correction or improvement, and recognizes program strengths. Care Management Program Structure 4 P age

6 TRSN Governing Board The TRSN Governing Board is responsible for authorizing and promoting the activities of the Care Management Program. The Board authorizes the CM Program via its review, evaluation, and approval of the CM Plan. The Board appoints the members of the Quality Management Committee (QMC) which also functions as the Care Management Committee. The Board promotes the CM Program by holding all Network Providers accountable for ongoing participation in its processes and taking appropriate action in response to QMC recommendations. The Board ensures CM Program effectiveness through receipt of regular reports of network wide care assessment and improvement activities and review of the effectiveness of the care management program in achieving desired priorities and improvement goals. The Governing Board delegates oversight of the Care Management Program to the TRSN Administrator and the Quality Management Committee (QMC). TRSN Advisory Board TRSN solicits client and family voice through the TRSN Advisory Board, which is made up of 51% clients or former clients, to provide feedback on reports presented at QMC and input into the policy, procedure, and work plans used in the Care Management Program. Quality Management Committee (QMC) The Quality Management Committee (QMC) oversees the Care Management program by reviewing all care management activities and assuring they remain appropriately focused and cohesive. The QMC includes TRSN and provider staff, representatives from the Governing Board, Advisory Board, QRT, Ombuds, local Tribe, and client and family advocates. TRSN Administrator The TRSN Administrator reviews and implements any policy decisions, changes, improvements, penalties, or sanctions that result from Care Management Activities, subject to the approval of the Governing Board. The Administrator is responsible for implementing corrective action with the Provider Network should care concerns warrant that level of intervention. The Administrator ensures the CM Program effectiveness through receipt of regular reports of network wide Care Management activities and review of the effectiveness of the care management program in achieving desired priorities and goals. The Administrator meets with the Provider Directors to discuss their administrative perspective of CM activities and concerns, supervises the Quality Manager, and provides primary linkage with the External Quality Review Organization. The TRSN Administer delegates supervision of the Care Management Program to the Psychiatric Medical Director. 5 P age

7 Psychiatric Medical Director The overall responsibility and leadership for the Care Management Program lies with the Psychiatric Medical Director. The Medical Director is qualified to provide guidance, leadership, oversight, utilization, and quality assurance for the mental health programs in coordination with the administrative and clinical staff. The Psychiatric Medical Director delegates day to day planning, assessment, measurement, and implementation of the to the TRSN Quality Manager. Contracted Care Manager TRSN contracts with Behavioral Health Options Inc. (BHO) for utilization and case management services. BHO provides prior and concurrent authorization of outpatient services, authorization and extension of inpatient services, and review of medical necessity and recommendation of level of care. BHO also provides notification of denial for services, coordination and recommendations for inpatient discharge, and periodic reporting to TRSN. Quality Manager The TRSN Quality Manager (QM) functions as the Clinical Review Manager and Children s Mental Health Services Coordinator. As the Clinical Review Manager, the QM conducts clinical chart reviews, monitors network adherence to authorized care, and facilitates the network Clinical Directors meetings. The Children s Mental Health Services Coordinator is responsible for oversight of the continuum of care for Children s services. The QM also conducts utilization reviews and maintains the Level of Care criteria. The QM works in conjunction with the TRSN Administrator and IS Administrator monitor network resources. The Quality Manager facilitates the Quality Management Committee which also functions as the Utilization Management Committee and provides the linkages between the CM Plan and the Quality Management (QM) Plan. Information Systems Administrator The Information Systems Administrator is responsible for developing, updating, validating and submitting the data reports used for the Care Management Program. The IS Administrator monitors information systems security and performance. The IS Administrator participates in and provides data reports for TRSN Administrative meetings, Clinical Director s meetings, and Quality management meetings. 6 P age

8 Care Management Responsibilities CARE MANAGEMENT 7 P age

9 Care Coordination Care Coordination functions to reduce fragmentation, prevent avoidable conditions, and promote independence and self-care. Care Coordination begins with access to and authorization of an initial service package (Level of Care - the intensity of treatment required to diagnose, treat, preserve, or maintain a client s physical or emotional status) based on a review or direct evaluation of the individual to assure that the service package will meet the individual's needs and continuing or additional services once the initial package has been exhausted. Care Coordination also includes implementation of an individual service plan within the client s preauthorized service package (LOC) that meets identified needs, determination of discharge criteria (clinical outcomes to be met before or at the time of the client s discharge), and discharge planning (the process of assessing the client s needs after discharge and ensuring that the necessary services are in place or referred before discharge). Care Coordination promotes coordination of mental health services and social support across different organizations and providers. Care Coordination includes consultation, coordination, and referral both within and outside the provider network to determine standardized expectations, alternative creative approaches to care, and a single plan of service. Case Management Case Management functions to ensure that specific clients (e.g., those at high risk and/or requiring complex care; those with special needs arising from age, gender, cultural differences or physical condition; those with concerns relating to their care) receive the specialized services designed to address and coordinate issues relating to their care. Case Management promotes coordination and communication across disciplines within the organization delivering mental health care. Case Management is usually required for individuals who have a serious mental illness or a major psychotic disorder who need ongoing support in areas such as housing, employment, social relationships, and community participation. Case Management helps clients with better understanding of mental illness, increases participation in treatment, and provides first-hand information for revision of treatment strategies and appropriate referral when necessary. Case Management includes review of assessment and treatment services against clinical practice standards. Clinical practice standards include but are not limited to Evidenced-Based Practice 8 P age

10 guidelines and community standards governing activities such as coordination of care among treating professionals. Information System Management An information system (IS) provides information that organizations require to manage themselves efficiently and effectively. Information Systems include the hardware, software, data, applications, communication, and people that collect, process, and store data. IS Management is necessary to make sure all parts of the information system are operating correctly and efficiently. Utilization Management Utilization Management functions to evaluate how services are being delivered and used and to confirm that they are being utilized in a way which is efficient and cost effective. Primary objectives of Utilization Management are to assure clients are receiving timely access to medically necessary services at the correct Level of Care according to state Access to Care Standards (ACS) and TRSN clinical criteria. Additional purposes are to assess the effectiveness of the individualized treatment plan and to promote the client s progress toward attaining identified treatment outcomes and achieving independence and self-care. Utilization Management examines patterns and trends of service delivery to identify and address potential overutilization and underutilization of services. Overutilization- Initiation of services without level of need determination, continuing services beyond medical necessity, services that are not shown to be effective in treating the enrollee s condition or symptoms. Underutilization- Lack of admission, intake assessment without engagement, no services within last 30 days, services less frequent than clinically indicated, no service initiation, premature discharge. Resource Management Resource Management functions to ensures resources are being used in the most efficient way possible to provide appropriate levels of care while maximizing access to and use of age, linguistic, and culturally competent services and. The goal of resource management is to balance resources available with resources used to maximize utilization. TRSN completes ongoing and periodic analysis of its provider network, including staffing, facilities, equipment, and services, to evaluate if resources were used in the most efficient way possible. 9 P age

11 Risk Management Risk management functions to determine areas of vulnerability, attempts to control circumstances that pose a threat to safety of clients, and initiates appropriate remedial action when necessary to reduce or eliminate risk. Risk management includes review of critical incidents for the purposes of determining the root or systemic cause(s) of the incident and reducing the likelihood of similar incidents in the future as well as review of aggregate, trended data regarding providers so that both system-wide and individual provider opportunities are addressed. Care Management Activities Data Collection Data is developed from a variety of sources including, but not limited to the following: TRSN, Ombuds, QRT, and provider data. Data may also be developed from EQRO or DSHS. Data is collected on a variety of topics including encounter related data, utilization monitoring, eligibility, client satisfaction surveys, complaint and grievance logs, geo access reports, incident reports, annual clinical and administrative reviews, and special studies. Data Collection includes: Selection of a process or outcome to be measured, on a priority basis. Identification and/or development of performance indicators for the selected process or outcome to be measured. Aggregating data so that it is summarized and quantified to measure a process or outcome. Administrative and Contract Compliance Reviews TRSN monitors sub-contractor compliance with contracts, policies, and procedures and include audits and inspections of records for: Monthly performance monitoring Performance measures Contract deliverables Clinical Record and Service Review TRSN organizes an annual Clinical Service Review of each provider, using a structured review protocol to review compliance with Revised Code of Washington (RCW), Washington 10 P age

12 Administrative Code (WAC), contracts, guidelines, and standards. Senior clinical staff from the other provider agencies may participate in this process, including children and geriatric mental health specialists and medical staff. TRSN may also include client advocates in the review process to assess client involvement in the treatment planning process and whether the recovery plan is written showing client voice and is clear and free of mental health jargon. The TRSN Clinical Director provides feedback to providers when problems in service provision or documentation are seen, including potential fraud and abuse. This may lead to corrective action or other interventions, in accord with contract language. Peer review Peer review of client files are conducted by a mental healthcare professional to determine if the care provided by other mental healthcare professionals appears to be necessary and appropriate. Peer Reviews may occur with the client s treatment team when there is disagreement about authorization decisions, or concerns about the current course of treatment. Management Information System (MIS) Reviews: MIS reviews determines if the information systems are safeguarding assets, maintaining data integrity, and operating effectively to achieve the organization's goals or objectives and include audits and inspections of records for: Encounter validation Timely access to care performance indicators Scheduled error/correction reports Utilization Review The review of utilized services consists of multiple tools, including: prospective review, ongoing concurrent review; retrospective review; special studies; and review of grievances and appeals. Prospective review- Examines the need for proposed services before admission to determine the appropriateness of the setting, procedures, treatments, and length of stay. Concurrent review- Assesses the need for continued stay, assures that the current course of treatment is appropriate and effective in resolving symptoms that led to admission, and 11 P age

13 ensures collaboration between all involved parties in the development of a comprehensive aftercare and discharge plan. Retrospective review- Evaluates appropriateness of care and consumption of resources after a client is discharge. Special studies- Focuses on a specific program, issue, or problem. TRSN Quality Manager provides review of care to a provider s outpatient and inpatient clients. TRSN s UM provider provides prospective and concurrent reviews as part of authorizing initial and continued care, in accord with TRSN criteria and protocols. Risk Reviews TRSN organizes an annual review of compliance with laws, regulations, principles and policies and include audits and inspections for: Provider license /credentials Fraud and Abuse reporting Business continuity planning Americans with Disability Act (ADA) compliance Financial/Fiscal Reviews TRSN organizes an annual review of compliance with laws, regulations, principles and policies and include audits and inspections of records for: Revenue and Expenditure Third Party Revenue Customer Service and Grievance Reviews TRSN s Ombuds compiles quarterly reports of complaints and grievances. These reports are reviewed and analyzed for trends and findings reported to QMC. Surveys TRSN s Quality Review Team (QRT) completes surveys to collect information on satisfaction with TRSN services. Surveys include Allied Providers, Customer Service, Staff, as well as additional ad hoc surveys. 12 P age

14 TRSN also utilizes the Mental Health Statistics Improvement Program (MHSIP) survey results published at MHSIP Consumer Surveys measure concerns that are important to consumers of publicly funded mental health services in the areas of Access, Quality/Appropriateness, Outcomes, Overall Satisfaction and Participation in Treatment Planning. Data Reporting Aggregate reports are generated regularly and as needed to identify and analyze trends in the delivery of clinically necessary care. Data is gained from each of the sources above and information about findings from these sources, such as length of stay, incidence rates and overall utilization, is organized into reports that are reviewed regularly for the purpose of formulating recommendations regarding network operations and providers. TRSN also utilizes DBHR s statewide SCOPE reports as available on the System for Communicating Outcomes, Performance & Evaluation website. Data Analysis Data analysis involves examining facts and data to assess the outcome of the care provided, assess the stability of processes or outcomes to determine whether there is an undesirable degree of variation or a failure to perform at an expected level, and assessing whether a new or improved process meets performance expectations. Data analysis includes: Identification of trends, patterns, gaps or non-conforming results/outliers. Validating procedure for fault elimination. Definition of problems and their root cause. Aggregate data, collected accurately and systematically, may be relied upon to establish baseline performance, describe a process, assess program stability by describing program functions and outcomes, identify areas for improvement, and finally determine if change has met established objectives. 13 P age

15 Care Management Processes Care Management Committee Meetings TRSN s Quality Management Committee also functions as the Care Management Committee. The Quality Management Committee (QMC) meets at least quarterly. The QMC includes TRSN and provider staff, representatives from the Governing Board, Advisory Board, QRT, Ombuds, and local Tribe, client and family advocates. The QMC is facilitated by the Quality Manager. Meetings may also be co-facilitated by a QMC member selected by the QMC. The QMC oversees the Care Management Program by reviewing all Care Management activities and assuring they remain appropriately focused and cohesive. After review and discussion, recommendations from the Quality Management Committee are either forwarded to the Governing Board or returned by QMC to the Clinical Directors Committee for further review. The responsibilities of the QMC include: Reviewing and approving the ; Monitoring trends in utilization and performance data; Comparing performance and utilization data to standards and thresholds; Recommending action for concerning trends (such as exceeding authorized services hours and/or duration of time); Reviewing current network sufficiency and recommending changes to the Governing Board and other TRSN committees, as necessary; Reporting on Care Management activities, results, and/or recommendations to the Governing Board through the TRSN Quality Manager and QMC minutes. 14 P age

16 Clinical Directors Meetings The Clinical Directors meeting (CDM) is held monthly. The meeting includes TRSN Quality Manager, TRSN IS Administrator, a clinical director from each contracted provider agency, and other TRSN staff as needed. The CDM is facilitated by the TRSN Quality Manager. The CDM meets to review, coordinate, and implement the Care Management Activities as defined in this plan. Working closely with QMC, this committee explores, in depth, the issues related to CM activities and develops plans and procedures necessary for implementation of initiatives. The CM responsibilities of the Clinical Directors Meeting include: Communication and collaboration of Care strategies, plans, and activities; Collecting and analyzing Care Management information from multiple indicators; Identifying overall trends and patterns that are evident throughout the region; Reviewing strengths and weaknesses of Care Management activities; Bringing consensus recommendations regarding Care Management to the Quality Management Committee (QMC). 15 P age

17 Provider Directors Meetings The Provider Directors meet as needed. The meeting includes TRSN Administrator, a director of each contracted provider agency and other TRSN staff as needed. The Provider Directors meeting is facilitated by the TRSN Administrator. The directors meet with the TRSN Administrator to identify and address shared issues of concern that affect contract implementation and efficiency of service provision and gain administrative perspective on utilization and performance reports. The CM responsibilities of the Provider Directors include: Reviewing funding, service capacity, and service utilization to allow TRSN to maintain an equitable distribution of resources throughout TRSN; Facilitating annual training to staff to support efficiency of service provision and awareness of relevant TRSN policies and procedure; Participating in the integrated TRSN client complaint and grievance reporting process including assuring QRT and Ombuds have adequate access to fulfill their designated roles and working to resolve identified issues in a timely fashion and at the lowest level; Maintaining appropriate licensing status and capacity to serve eligible clients with all required services, as well as appropriate IS capacity to document same; Distributing new or discretionary funding when available to periodically add needed staffing and/or specialty skills. Planning for implementation of contractual requirements or directives of the Governing Board. 16 P age

18 TRSN Management Team Meetings The TRSN Management team conducts and discusses reviews of funding, service capacity, and service utilization, and plans for implementation of contractual requirements or directives of the Governing Board. Advisory Board Meetings TRSN Advisory Board reviews recommendations and initiatives and provides feedback and input into the policy, procedure, and work plans used in the Care Management Program. The Advisory Board makes recommendations to the Governing Board regarding equitable distribution of resources throughout TRSN, distribution of new or discretionary funding when available, and Quality Improvement Initiatives. Governing Board Meetings The Governing Board reviews recommendations and approves TRSN plans and budgets that support appropriate licensed capacity to efficiently serve eligible clients with all contract required services while minimizing risk. 17 P age

19 Ombudsman Services TRSN provides unencumbered access to an independently contracted Ombudsman. The Ombuds receives and investigates grievances of TRSN clients and/or client s families. Grievances are often related to performance or utilization of services and are an important measure of a provider s ability to engage clients in treatment and work with them to ameliorate their presenting problems. Grievances information is collected from each provider to allow analysis of trends around types of grievances, grievances about particular facilities or providers, and the outcomes of the situations. The CM responsibilities of the Ombuds include: Collecting grievance information from clients and providers; Aggregating collected information in a format that identifies trends and patterns; Suggesting areas for further study and review based on trends and patterns observed; Recommending areas for Quality Improvement based on grievance data. 18 P age

20 Quality Review Team Services TRSN s Quality Review Team provides a vehicle for soliciting client voice regarding services. The QRT includes client and family advocates from each of TRSN s coverage areas. They conduct yearly satisfaction surveys of clients and families of clients and also conduct other face-to-face forums (interviews, speak outs, on site visits) in which clients and other community members can talk about their service experiences. QRT also conducts an annual Allied Provider survey, which helps the RSN understand how other service providers in the community and school staff perceive TRSN services. QRT shares its reports and recommendations with TRSN s Administrative team and Quality Management Committee (QMC) as well as the TRSN Governing Board. The QM responsibilities of the QRT include: Collecting client satisfaction information from clients and providers; Aggregating information gathered through QRT activities on clients, family members and allied providers satisfaction responses to TRSN/QMC in a format that identifies trends and patterns; Suggesting areas for further study and review based on trends and patterns observed; Recommending areas for Quality Improvement based on grievance data. 19 P age

21 The Care Coordination Plan outlines goals and objectives TRSN aims to meet in the coming year. Goals are ongoing long term outcomes TRSN strives to achieve. Objectives are the steps TRSN will take to achieve the goals. Goals Goals are based upon the following priorities: 1. Federal requirements for Prepaid Inpatient Health Plans 2. DSHS/PIHP and DSHS/SMHC contractual requirements 3. Stakeholder and client surveys related to satisfaction and health/function status 4. Additional items as indicated through analysis of measured performance data The following goals have been identified for the CM Plan: 1. Comply with regulatory and contractual requirements. 2. Carry out systematic data collection related to RSN and provider performance in order to monitor, evaluate, and improve: o members access to and satisfaction with clinical and administrative services; o the process of care and the outcome of care delivered to members; o continuity of care for all members. 3. Monitor and evaluate whether care and service provided meets or exceeds established local, state and national standards of care 4. Communicate data and its interpretation to internal and peer review committees for analysis and action. 5. Maintain capacity to provide all state-plan services 6. Maximizing access to and use of age, linguistic, and culturally competent services 7. Ensure resources are being used in the most efficient way possible 8. Maintain an active compliance program that is implemented throughout TRSN s internal operations and external provider network and includes: o Compliance Officer: person within TRSN with the primary responsibility to implement and coordinate the Business Ethics and Regulatory Compliance Program and associated activities. 20 P age

22 o Ethics and Compliance Committee: TRSN board designated committee with the responsibility to establish overall policy and standards for the Business Ethics and Regulatory Compliance Program and to provide oversight. 9. Ensure compliance with the laws, regulations, principles and policies that govern RSNs to: o Prevent fraudulent activities o Protect from liability by assessing the organization s ability to operate within the rules, regulations and policies set by the government, insurance programs and payers o Monitor both fiscal and quality of care issues. Objectives TRSN determines specific objectives (steps the RSN will take throughout the coming year) to achieve these goals. The Quality Management Committee (QMC) helps determine new objectives to reach these goals each year after analyzing the data presented in the annual CM Program evaluation and prioritizing areas of focus. Once the QMC identifies the objectives they develop performance indicators to be monitored throughout the year to measure if the objectives have been met. Specific objectives and indicators are updated annually. (See Matrix) TRSN continuously monitors Care Management objectives. Areas where performance is below the TRSN standard are discussed at monthly Clinical Director meetings. Areas not resolved within 90 days are brought to QMC for discussion. 21 P age

23 Care Coordination Focus Area Objective Data Source Report By / To Frequency Access to Care Request for service is documented AVATAR IS to QM to QMC Monthly Initial criteria is consistently applied Clinical Review QM to CDs and QMC Quarterly Re authorization criteria is consistently applied Clinical Review QM to CDs and QMC Quarterly Level of Care is appropriate to identified needs Clinical Review QM to CDs and QMC Quarterly Golden Thread Needs identified at intake are addressed on treatment plan Clinical Review QM to CDs and QMC Quarterly Progress notes are linked to treatment plan interventions *RPM AVATAR IS to QM to QMC Monthly Progress notes are linked to appropriate treatment plan goals Clinical Review QM to CDs and QMC Quarterly Clients with indicated safety needs have an active crisis plan Clinical Review QM to CDs and QMC Quarterly Service plans have discharge criteria established Clinical Review QM to CDs and QMC Quarterly Service plan goals are 50% achieved *RPM AVATAR IS to QM to Monthly CDs/QMC/DBHR Client Voice Service plans are signed by client /family Clinical Review QM to CDs and QMC Quarterly Service plans contain client/family voice on problem/goal AVATAR IS to QM to QMC Quarterly Re Authorization synthesis with client statement of progress Clinical Review QM to CDs and QMC Quarterly TRSN client/family voice at QMC QMC Roster QM to QMC Annually TRSN client/family voice on Advisory Board Advisory Board Roster QM to QMC Annually Positive survey responses on questions related to coordination of care Allied Provider/ Client QRT to QM/QMC Annually Satisfaction Survey Client Education Clients are offered a Mental Health Benefits Booklet at intake Clinical Review QM to CDs and QMC Annually Clients receive information about diagnosis Clinical Review QM to CDs and QMC Annually Clients receive information about medication Clinical Review QM to CDs and QMC Annually Advanced Directives Clinical Review QM to CDs and QMC Quarterly Medical Clients with no identified PCP at intake are referred to PCP Clinical Review QM to CDs and QMC Quarterly Written notification of intake/diagnosis to PCP when referred by EPSDT Clinical Review QM to CDs and QMC Quarterly Coordination of Care contacts at least one per client COC every 6 mo AVATAR/ CPT code IS to QM to QMC Monthly Level two EPSDT clients are referred for an individual support team*** Clinical Review QM to CDs and QMC Quarterly Consultation/ Supervision Medicaid Personal Care Non MHP staff or staff with an exception are supervised by a MHP Clinical Review QM to CDs and QMC Quarterly CMHAs have consultants available for special populations Contract Monitoring QM to QMC Annually Staff have annual training plan Contract Monitoring QM to QMC Annually Staff have regular supervision Contract Monitoring QM to QMC Annually Medicaid Personal Care approved within 5 days (10 with extension) Clinical Review QM to QMC Annually 22 P age

24 Case Management Age, cultural, and Clients with a primary language other than English are provided Interpreter billing TRSN Accountant Annually linguistically competent interpreter services Clients with a primary language other than English are provided written Grievances Clinical Review Ombuds QM to CDs and QMC Annually services translations Ethnic clients served proportionate to census Minority clients receive a specialist consultation AVATAR IS to QM to QMC Quarterly Clients who have received a minority consult have recommendations Clinical Review QM to CD and QMC Quarterly incorporated into treatment plan Attempts are made to contact the Tribal Authority when a Tribal Clinical Review QM to CDs and QMC Quarterly Member receive services Co Occurring Clients 13 years old are assessed for co occurring disorders utilizing AVATAR IS to QM Quarterly the GAIN SS QM to QMC Clients 13 years old assessed for co occurring disorders utilizing the AVATAR IS to QM Quarterly GAIN SS have appropriate quadrant assignments QM to QMC Clients assessed as Quadrant 3 or 4 on the GAIN SS are referred for a Clinical Review QM to CDs and QMC Quarterly COD assessment Medical Clients with serious or severe physical health issues identified at intake AVATAR/ Clinical IS and QM to CD and QMC Quarterly Complexity or reauthorization have a Coordination of Care goal on their treatment plan *PIP Review Transition Age Transition Age Youth (16 21) have goals on their treatment plans that Clinical Review QM to CDs and QMC Quarterly Youth address transition issues Inpatient Contact is made within 3 days of an enrollee s inpatient hospitalization AVATAR IS and QM to CD and QMC Quarterly Clinical Review Discharge planning is documented prior to discharge Clinical Review QM to CDs and QMC Quarterly Clients in long term hospital beds are assessed monthly for discharge Clinical Review QM to CDs and QMC Monthly on an ongoing basis A routine service shall be provided to Medicaid clients within 7 days AVATAR IS to QM Quarterly of discharge from a psychiatric inpatient hospital or E & T *CPM QM to QMC A service shall be offered to an individual within 7 days of discharge of AVATAR IS to QM Quarterly discharge from a psychiatric inpatient hospital or E & T QM to QMC Client receives a medication management appointment within 30 days AVATAR IS to QM Quarterly of discharge QM to QMC Min of one contact LRA/CR per month AVATAR IS to QM QM to QMC Quarterly 23 P age

25 Practice Guidelines and Evidence Based Practices Clients receive treatment per Practice Guidelines Clinical Review QM to CDs and QMC Quarterly Staff are trained in TF CBT Contract Monitoring Annually CMHAs are documenting EBP codes AVATAR IS to QM to QMC Quarterly Information Systems Management Data Reporting Timeliness Data Correction Data Integrity/ Validation TRSN submits encounters electronically to ProviderOne within 60 days of the close of each calendar month in which the encounters occurred TRSN submits periodic electronically to ProviderOne within 60 days of the close of each calendar month in which the encounters occurred CMHAs submit encounter data within 10 days of the close of each calendar month in which the encounters occurred Submitted data is reviewed for errors. When data is rejected due to errors; it is corrected and resubmitted within 30 calendar days of when the error report was produced MIS encounters with congruent progress note to support**core Performance Measure AVATAR Provider One IS to QMC and DBHR Quarterly AVATAR IS to QMC and DBHR Quarterly Provider One AVATAR IS to QMC and DBHR Quarterly AVATAR Provider One IS to QMC and DBHR Quarterly AVATAR IS to QMC and DBHR Annually Utilization Management Timely Access Request for Services (RFS) to intake within 10 business days AVATAR IS to QM to CDs/QMC Monthly Intake to outpatient authorization within 14 calendar days AVATAR IS to QM to CDs/QMC Monthly Intake to outpatient authorization within 28 calendar days AVATAR IS to QM to CDs/QMC Monthly RFS to first offered routine service within 28 calendar days AVATAR IS to QM to CDs/QMC Monthly Emergent services provided within 2 hours AVATAR IS to QM to CDs/QMC Monthly Urgent services provided within 24 hours AVATAR IS to QM to CDs/QMC Monthly Inpatient authorization within 12 hours BHO QM to QMC Quarterly Clients receive a second opinion within 30 days of request Grievance Report QM to QMC Grievances are acknowledged within 5 days and a decision provided Grievance Report QM to QMC within 90 days Appeal requests are acknowledged within 5 days and a decision AVATAR IS to QM to QMC provided within 45 days Authorization Approval/Denial ratio BHO QM to QMC Annually NOA sent within 14 days BHO QM to QMC Annually Authorization extensions are documented Clinical Review QM to CDs and QMC Quarterly Authorization extensions are in the best interest of the client Clinical Review QM to CDs and QMC Quarterly Least Restrictive Average monthly under census CACHE Census QM to QMC Annually Environment (10 beds in 2014) 24 Page

26 Over/under utilization Community hospital re admissions within 30 days BHO QM to QMC Annually Clients provided service hours within recommended parameters for AVATAR IS to QM Monthly LOC QM to CDs and QMC Clients seen within 30 days *Regional Performance Measure AVATAR IS to QM Monthly QM to CDs/QMC/DBHR Length of stay Average length of outpatient stay per service level AVATAR IS to QM to QMC Annually Average length of inpatient stay BHO IS to QM to QMC Annually Resource Management Current Enrollment Outpatient penetration rate (Medicaid/Non Medicaid) AVATAR IS to TRSN Annually Inpatient penetration rate BHO IS to TRSN Annually Diagnosis AVATAR IS to TRSN Annually Service Provision Service hours/client AVATAR IS to TRSN Annually Service hour/service code AVATAR IS to TRSN Annually Provider Network CMHAs Contract Review TRSN to QMC Annually Staff Contract Review TRSN to QMC Projected Enrollment Financial Outpatient penetration rate IS to TRSN Annually Inpatient penetration rate IS to TRSN Annually Third party revenue is identified, pursued, and recorded in accordance Financial Review Finance to QMC Annually with Medicaid being the payer of last resort Cost/service hour Financial Review Finance to QMC Annually Revenue and Expenditure Financial Reports and Certifications are due Financial Review Finance to QMC Annually within 45 days of the end of every second quarter Risk Management Incidents Number of incidents reported to TRSN DBHR incident database TRSN Admin to QMC Annually Fraud and Abuse Percentage of clients who verify services Verification letters TRSN to QMC Annually Data Security HIPAA/HITECH breaches reported Breach report Compliance officer to QMC Annually 25 P age

27 Care Management Assessment External Assessment External Quality Review Organization (EQRO) Each year DBHR uses an External Quality Review Organization (EQRO) to review all or part of each RSN s Care Management Program. The EQRO chosen is typically Acumentra. TRSN s EQRO review typically happens in June of each year. Acumentra will review Policy, Training, Data Collection and Analysis, and Monitoring and Oversight. Acumentra provides a summary report in which they score each area reviewed. Internal Assessment TRSN monitors provider contracts through receipt and review of contract deliverables, on-site visits, and record reviews. All collected data including external quality review findings, PIHP monitoring results, sub-contract monitoring activities, agency audits, client grievances and services verification are incorporated into this assessment. Care Management Program Evaluation The Care Management Program and Plan is reviewed on an ongoing basis and is formally reviewed annually. The annual program assessment includes an evaluation of the CM activities and the extent to which compliance was achieved with the specified performance standards and outcomes. Assessment is accomplished by comparing actual performance on an indicator with: Self over time. Pre-established standards, goals or expected levels of performance. Information concerning evidence based practices. Other clinics or similar service providers. The CM evaluation summarizes: Evaluates the effectiveness of the Quality Improvement Committee structure and the organizational structures that support implementation. Describes completed and ongoing CM activities that address effectiveness of clinical care and efficiency of service. 26 P age

28 Care Management Program and Plan Evaluates and analyzes the results of each CM activity described within the Program and Plan, including delegated functions, implemented during the year; Trend measures that assess performance in the effectiveness of clinical care and efficiency of service using charts, graphs, and tables showing performance over time. Identifies limitations and barriers to efficiency. Identifies opportunities for improvement, including efficient utilization, adequacy of resources, and minimization of risk. Identification of education/training needs Updates information within the plan to accurately reflect monitoring and oversight activities and recommends the upcoming year s activities including those that will carry over into the next year. Documentation of the annual review, findings, and recommendations are compiled through the Quality Management Committee and shared with the Advisory and Governing Board. These documents will be reviewed by the External Quality Review Organization as part of their annual audit. 27 P age