Good Morning, Welcome!

Transcription

1 Good Morning, Welcome! The Treatment Record Review presentation will begin shortly. This presentation will be recorded and available on MagellanofVirginia.com Questions may be asked following the presentation, as time allows. Quality Improvement Department January 26, 2016

2 The Treatment Record Review Process Quality Improvement Department January 26, 2016

3 Treatment Record Review (TRR)

4 What are Treatment Record Reviews (TRR)? Our Philosophy: In support of our commitment to quality care, we require that our providers maintain organized, well-documented member treatment records that reflect continuity of care for members. We expect that all aspects of treatment will be documented in a timely manner, including face to face encounters, telephone contacts, clinical findings and interventions. Treatment Record Review (TRR) is a method used to evaluate care being provided to members and to identify opportunities for improvement that will assist providers with addressing the overall quality of care that members receive. For quality improvement purposes, Magellan reviews a sample of treatment records from randomly selected providers. We conduct routine TRRs to monitor network provider treatment record documentation and record keeping practices against Magellan standards. The TRR also allows us to measure network provider performance against important clinical process elements of Clinical Practice Guidelines (CPGs).

5 Why are providers being asked to participate in TRR? We want our members to receive quality care. The information gathered during this process allows us to validate compliance with our standards and, if necessary, work to resolve issues that may impede the quality or success of member treatment. Provider agreement: For quality improvement purposes, Magellan generally reviews a random sample of treatment records from providers who received referrals from Magellan.

6 What do I need to do as a provider? Your responsibility is to: Follow the detailed instructions provided if you are selected for a review Make the records requested available for our review Cooperate with Magellan in developing and carrying out a quality improvement plan/corrective Action Plan (CAP) should opportunities for improvement be identified ( has not implemented a CAP process for TRR. Providers will be notified via Blast if a TRR CAP process is initiated.) Implement quality improvement plans if established

7 What will Magellan do? Magellan s responsibility is to: Provide detailed information prior to the review concerning the rationale, methods and standards employed in the review process Request the minimum necessary protected health information to perform medical record reviews Recommend and require steps to be taken to improve quality of treatment record documentation Work closely with you in carrying out a corrective action plan, if required. (Magellan of Virginia has not implemented a CAP process for TRR. Providers will be notified via Blast if a TRR CAP process is initiated.)

8 The Treatment Record Review Tool The following sections of the TRR Tool are reviewed: General Member Rights and Confidentiality Initial Evaluation Treatment Planning Ongoing Treatment Addendum for Children Coordination of Care Discharge Planning/Process Medication Management Clinical Practice Guidelines

9 The Treatment Record Review Tool Elements Section A General This section includes administrative expectations for treatment record keeping and documentation. Record is legible Consumer name or ID number noted on each page of record Entries are dated and signed by appropriately credentialed provider Record contains relevant demographic info including address, employer/school, phone, emergency contact, marital status

10 The Treatment Record Review Tool Elements Section B - Consumer Rights and Confidentiality Signed treatment informed consent form or refusal documented Patient Bill of Rights signed or refusal documented Psychiatric advance directives or refusal documented Informed consent for medications signed or refusal documented Release(s) for communication w/primary Care Physician, other providers and involved parties are signed or patient refusal documented

11 The Treatment Record Review Tool Elements Section C - Initial Evaluation Reason member is seeking services (presenting problem) and mental health status exam DSM diagnosis (Please use current DSM) History & symptomatology consistent with DSM criteria Psychiatric history Co-occurring (co-morbid) substance induced disorder assessed Current and past suicide/danger risk assessed

12 The Treatment Record Review Tool Elements Section C - Initial Evaluation (continued) Assess of consumer strengths, skills, abilities, motivation etc. Level of familial/supports assessed and involved as indicated Consumer Identified areas for improvement/outcomes documented Medical history Exploration of allergies and adverse reactions All current medications with dosages Discussion of discharge planning/linkage to next level

13 Section C: What does this mean? Can you give me examples? Psychiatric history: include previous or current treatment, hospitalizations, and medications. Make note which services the member found helpful and why. For member safety, please ensure that you clearly document assessment of current and past suicide and/or danger risk. **Please develop a comprehensive crisis plan/safety plan that meets the member s needs and utilize throughout treatment. Strengths: MOST important to identify what a member believes they are good at doing; these strengths will be tied into the individualized treatment plan! Strengths can be utilized to help support and motivate the member. History & symptomatology consistent with DSM criteria: Please ensure that initial and re-assessment include full clinical detail to support the active diagnosis.

14 The Treatment Record Review Tool Section D Section D - Individualized Treatment Plan Individualized strengths based treatment plan is current Measurable goals/objectives documented Goals/objectives have timeframes for achievement Goals/objectives align w/consumer identified areas for improvement/outcomes Use of preventive/ancillary services including community & peer supports considered

15 Section D: What does this mean? Can you give me examples? The Individualized Treatment Plan should contain measurable goals and address the member s desired outcomes. Involvement of natural supports including family, friends, and community connections, peer supports, and ancillary services should be discussed with the member and included in the plan when appropriate. The treatment plan should have both long and short term goals with reasonable, measurable and achievable objectives. The member should understand the goals and the objectives. They should be realistic, developmentally appropriate, culturally appropriate, utilize the member s strengths and consider the members limitations.

16 The Treatment Record Review Tool Section E Section E - Ongoing Treatment Documentation substantiates treatment at the current intensity of support (level of care) Progress towards measurable consumer identified goals & outcomes evidenced. If not, barriers are being addressed. Clinical assessments & interventions evaluated at each visit Substance use assessment is current/ongoing Comprehensive suicide/risk assessment is current/ongoing

17 The Treatment Record Review Tool Section E Section E - Ongoing Treatment (continued) Medications are current Member compliance or non-compliance with medications is documented; if noncompliant, interventions considered Evidence of treatment being provided in a culturally competent manner Family/support systems contacted/involved as appropriate/feasible Ancillary/preventive services considered, used and coordinated as indicated Crisis plan documented Discharge (D/C) planning/linkage to alternative treatment (level of care) leading to D/C occurring

18 Section E: What does this mean? Can you give me examples? Progress notes should include behavioral assessments, interventions addressed as outlined in the member s treatment plan, comprehensive risk assessment and any family or ancillary/preventive services or supports utilized. Medication: if a member is currently taking psychiatric medications it should be noted within the medical record. Please include dosages with all medication and the name of the prescribing physician. Family support systems can help a member move forward with recovery, and can be a resource for the member when they are struggling to move forward. Preventative services should be identified within the treatment plan and can include community resources such as support groups, local churches, mentoring, etc.

19 Crisis Planning/Safety Planning for Member What is a crisis? Crises are when a member s health or safety may be compromised Why have a crisis/safety plan? These plans are designed to provide the member with tools to use during a crisis, or to prevent a crisis completely When and how should a crisis plan be developed? During the initial assessment/first session as soon as high-risk behaviors are identified The sooner a plan is developed, the sooner members can begin practicing These plans should be a helpful tool for the member and should be written in the member s own words; the plan should be unique to the member Engage the member (parents/guardians, etc) in a discussion about past crises that have occurred. Discuss what happened, what was helpful/not helpful ** We recommend conducting and documenting a risk assessment at each visit and implementing the use of comprehensive crisis plans throughout treatment.

20 Crisis Planning/Safety Planning for the Member What should be included in a safety/crisis plan? Formats can vary, however plans should include, at minimum: Possible anticipated crises (suicidal, self-harm, running away, psychiatric hospitalization, physical aggression toward others, etc.) Description of triggers / warning signs that a crisis is approaching How the member/family can create a safe environment (remove weapons/guns, keep medications locked, etc.) Coping skills/interventions the member identifies that can help de-escalate or calm them Names and phone numbers/addresses of people they identify as helpful who they can talk with or visit with Emergency numbers (agency s on-call/after-hours phone number, local CSB crisis, 911, closest emergency room, etc.) Names and signatures of those who participated in the creation

21 Crisis Planning/Safety Planning for Member We ve developed a safety plan with the member. Now what? Ensure that the member has a copy of the safety plan Discuss where the member will keep the safety plan (on the refrigerator, saved as a picture on their cell phone, etc.) Regularly follow-up and review the safety plan with the member even if there hasn t been a crisis! This allows ongoing discussion and opportunity to practice the coping skills identified If a crisis has occurred, make sure you review the crisis plan with the member during your next session with the member Did they use any of the coping skills identified? Were they helpful? Are any revisions needed to the plan?

22 The Treatment Record Review Tool Section F Section F - Addendum for Special Populations Guardianship information noted (for minors only) Developmental history for children and adolescents

23 Section F: What does this mean? Can you give me examples? Guardianship information The relationship between the child and the adult responsible for his/her day-to-day care is clearly explained. If the guardian is not the biological parent, the role of the biological parent in the child's life is explained. Record contains complete contact information for the guardian Developmental History including prenatal and perinatal events

24 The Treatment Record Review Tool Section H Section H - Coordination of Care Evidence of provider request of consumer for authorization for Primary Care Physician (PCP) communication Evidence consumer refused authorization for PCP communication PCP communication after initial assessment/evaluation Evidence of PCP communication at other significant points in treatment, e.g.- Medication initiated, discontinued, or significantly altered- Significant changes in diagnosis or clinical status- At termination of treatment Treatment Record reflects continuity and coordination of care between primary behavioral health clinician and (note all that apply under comments): psychiatrist, treatment programs/institutions, other behavioral health providers, ancillary providers

25 Section H: What does this mean? Can you give me examples? Documentation in your treatment records should support your communication with a member s PCP, or document the member s refusal to allow the communication. PCP should be aware of any psychiatric medications prescribed. Physical health and mental health are connected! PCP should be aware of mental health concerns, and physical concerns should be ruled out for a cause of behavioral symptoms.

26 The Treatment Record Review Tool Section I Section I - Medication Management Medication flow sheet completed or progress note includes documentation of current psychotropic medication, dosages, date(s) of dosage changes Documentation of member education regarding reason for the medication, benefits, risks, and side effects (includes effect of medication in women of childbearing age and to notify provider if becomes pregnant, if appropriate) Documentation of member verbalization of understanding of medication education

27 The Treatment Record Review Tool Section J Section J Adverse Incident If record indicates that an adverse incident* occurred during treatment period, did Magellan receive an Incident Reporting form based on the established protocol (within 24 hours of the incident)? Magellan defines an adverse incident as: an unexpected occurrence in connection with services provided by Magellan, its subsidiaries and affiliates (Magellan), that led to or could have led to serious unintended or unexpected harm, loss, or damage, such as death or serious injury, to an member receiving services through Magellan or a third party that becomes know to Magellan staff. *Adverse incident reporting is currently only required for RTC level C providers

28 What should I expect after the review is complete? The Provider will receive a letter that includes the score for the Treatment Record Review (TRR) as well as a copy of the tool used for the review. The tool will identify areas for documentation improvement as well as suggestions. Once you have received your score, if you have questions please call the assigned clinical reviewer listed in your score letter.

29 Scoring Guide Final Score Requirements Minimal Deficiencies: No formal follow-up activity required; practitioner is requested to incorporate recommendations from the feedback report as a means to ensure that documentation demonstrates adherence to Magellan's CPGs Moderate Deficiencies: No formal follow-up activity required. However, Magellan identified some deficiencies within the documentation you submitted. These changes are not retroactive; therefore, please do not revise your current charts. Instead, implement the recommended changes going forward. 69-below Serious Deficiencies: Magellan identified several serious deficiencies within the documentation. These changes are not retroactive; therefore, please do not revise your current charts. Instead, implement the recommended changes going forward. *We are not requesting a Corrective Action Plan (CAP) based on this review. Please note that we may implement the CAP process for future TRRs. We will communicate our intent to initiate the CAP process to our providers via an blast.

30 Legal disclaimers

31 Confidentiality Statement for Educational Presentations By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health, Inc. The information contained in this presentation is intended for educational purposes only and is not intended to define a standard of care or exclusive course of treatment, nor be a substitute for treatment. The information contained in this presentation is intended for educational purposes only and should not be considered legal advice. Recipients are encouraged to obtain legal guidance from their own legal advisors.

32 Confidentiality Statement for Providers The information presented in this presentation is confidential and expected to be used solely in support of the delivery of services to Magellan members. By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health, Inc. The information contained in this presentation is intended for educational purposes only and should not be considered legal advice. Recipients are encouraged to obtain legal guidance from their own legal advisors.

33 Thanks