QUALITY ASSURANCE/QUALITY IMPROVEMENT PROGRAM EVALUATION

Transcription

1 QUALITY ASSURANCE/QUALITY IMPROVEMENT PROGRAM EVALUATION SFY: July 1 st -June 30 th Report Completion Date: August 20, QIC Approval Date: September 1, Regulatory References: URAC Core v. 3.0 Standard 20

2 TABLE OF CONTENTS EXECUTIVE SUMMARY ACCESS TO SERVICES POPULATION CHARACTERISTICS Persons Served Access to Care Telephone Accessibility SERVICE AVAILABILITY Network Composition Credentialing and Re-credentialing Network Availability CONSUMER SATISFACTION GRIEVANCE MANAGEMENT PROVIDER DISPUTES SATISFACTION SURVEYS Community Relationship Survey Consumer Perception of Care Survey Provider Satisfaction Survey Client Satisfaction Survey CONSUMER SAFETY ADVERSE INCIDENT REPORTING & REVIEW INNOVATIONS WAIVER HEALTH & SAFETY MEASURES PERFORMANCE MEASURES SERVICE UTILIZATION- TARGETED SERVICES FINANCIAL PERFORMANCE PROGRAM MEASURES QUALITY IMPROVEMENT PROJECTS (QIP) QIP 1: REDUCING THE UTILIZATION RATE OF EMERGENCY DEPARTMENT VISITS QIP 2: TIMELY FOLLOW-UP AFTER COMMUNITY HOSPITAL DISCHARGES QIP 3: REDUCING THE AVERAGE LENGTH OF STAY IN PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES (PRTF) QIP 4: TIMELY SUBMISSION OF NC-TOPPS UPDATE ASSESSMENTS QUALITY ASSURANCE/QUALITY IMPROVEMENT ACTIVITIES ACCREDITATION/CERTIFICATION/EXTERNAL REVIEWS ORGANIZATIONAL QUALITY ACTIVITIES PLAN (OQAP) AUDITS CLINICAL STAFF PERFORMANCE MONITORING INFORMATION CONFIDENTIALITY & SECURITY MONITORING

3 EXECUTIVE SUMMARY Partners Behavioral Health Management (Partners BHM) is dedicated to assuring that the highest quality services are rendered by those providers who receive oversight by Partners BHM. Partners BHM s mission is as follows: Our mission is to manage a publicly funded healthcare system which addresses the mental health, substance abuse and intellectual/developmental disabilities needs of citizens in our service area through a comprehensive network of community service providers. Partners BHM ensures access to appropriate and individualized treatment which results in positive outcomes and ensures good stewardship of public funds. As the Local Management Entity (LME) and Managed Care Organization (MCO), Partners BHM oversees and manages consumer-centered local services for mental illness, intellectual and developmental disabilities and substance abuse. These services include, but may not be limited to, a 24 hour customer services call center, provider network and utilization management services. Partners BHM covers the economically and culturally diverse region of Burke, Catawba, Cleveland, Gaston, Iredell, Lincoln, Surry, and Yadkin counties of North Carolina. The Partners BHM Quality Assurance/Quality Improvement (QA/QI) Program helps to ensure that Partners BHM meets its regulatory and contractual responsibilities through continuous and systematic measurement and improvement of program systems and processes. The QA/QI program is the vehicle through which Partners BHM analyzes and responds to data collected by its consumer health information system, claims data, operational performance monitoring and other program measurement processes. The objective of the QA/QI program is to systematically use performance information and data to drive improved consumer outcomes, training and support. The functional structure of the program not only guides and supports business decisions but creates a system of continual integrity and readiness for external review agents such as the Department of Health and Human Services (DHHS) Intra-departmental Monitoring Team (IMT), External Quality Review (EQR) Organization, national accrediting bodies and other agents. The clinical operation of the QA/QI program is overseen by the Chief Medical Officer, who is a board certified physician. The Quality Improvement Committee (QIC), who is granted authority by the Partners BHM Board of Directors, meets no less than quarterly with the purpose of improving services by monitoring processes, implementing interventions, and evaluating the effectiveness of those intervention. It is also for guiding the QA/QI program including the annual review and approval of the QA/QI Plan and Program Description. The committee membership includes senior clinical staff, management and staff representatives of the organization as well as representatives from the provider network and consumer/family members. This report presents a summary of QA/QI program activities accomplished during the state fiscal year July 1, through June 30,. Page 2

4 Partners BHM Key Accomplishments SFY - Partners BHM has met its strategic goal of ensuring stability as a managed care organization. Partners BHM met the Division of MH/DD/SAS contract Performance standard of 90% of the expected NCTOPPS Update forms are received within the required time frames for three of four quarters (1 st Quarter, 3 rd Quarter, and 4 th Quarter) SFY -. Partners BHM applied for and received re-certification as a Quality Improvement Organization (QIO)-like entity from the Centers of Medicare and Medicaid Services (CMS). The certification is good for 5 years and will expire January Partners BHM, in partnership with local providers, opened two Integrated Health Center (IHC) hubs during SFY -, which provide consumers with access to same day services within 30 minutes or 30 miles of where they reside. Work is underway to open additional hubs in Iredell and Cleveland counties during SFY Partners BHM achieved its strategic goal of increasing enrollee education contacts, with a total of 7807 contacts for the entire organization as of June. Page 3

5 POPULATION CHARACTERISTICS ACCESS TO SERVICES PERSONS SERVED Medicaid Unduplicated Count of Medicaid Members 132, ,106 % Members Receiving MH Services 6.2% 6.1% % Receiving SA Services 1.1% 1.1% % Members Receiving DD Services 1.6% 1.5% *Data from MCO Monthly Report SFY - Uninsured (State/Block Grant Funding) Estimated Number of Uninsured in Catchment Area 121, ,782 % Uninsured Receiving MH Services 2.2% 1.5% % Uninsured Receiving SA Services 0.7% 0.7% % Uninsured Receiving DD Services 0.6% 0.5% *Data from MCO Monthly Report SFY - ACCESS TO CARE Partners Behavioral Health Management (Partners BHM) has responsibilities in offering consumers 24/7/365 access to services. Partners BHM serves the residents of eight counties in North Carolina who need behavioral health services; during non-business hours, including weekends and holidays. Customer Services serves residents of other counties throughout North Carolina as defined in contractual relationships with other N.C. Local Management Entities. Partners BHM fulfills these responsibilities with a call-center operation. The Call- Center fields various calls and performs screening, triage and referral. Partners BHM Call-Center does not perform health education, except in the context of screening, triage and referral when personnel are assisting the consumer with provider choice Partners BHM strives to provide timely access to routine, urgent and emergent behavioral health care for its consumers. URAC Health Call Center guidelines and the Division of Health and Human Services (DHHS) contracts provide specific requirements for ensuring that timely appointments are provided to consumers. Page 4

6 Emergent Goal: 95% of Emergent calls are scheduled to be seen by a provider within two [2] hours (URAC Standard: HCC 16) Emergent Calls Scheduled Within 2 Hours Benchmark: 95% 105% 100% 95% 90% 100% 100% 100% 100% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) *Data from Quarterly URAC Performance Dashboard SFY - % Calls Scheduled Benchmark Partners BHM met the benchmark of 95% of Emergent calls are scheduled to be seen by a provider within two [2] hours for all four quarters of SFY -. The 100% scores for all quarters is an improvement from SFY when Partners was below the benchmark for 1 st and 2 nd quarter. Will continue to meet or exceed the 95% benchmark. Urgent Goal: 85% of Urgent calls are scheduled to be seen by a provider within 48 hours (URAC Standard: HCC 16) 90.00% 85.00% 89.00% Urgent Calls Scheduled Within 48 hours Benchmark: 85% 86.15% 85.44% 85.30% 80.00% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) *Data from Quarterly URAC Performance Dashboard SFY: - % Calls Scheduled Benchmark Partners BHM met the benchmark 85% of Urgent calls are schedule to be seen by a provider within 48 hours for all quarters of SFY -. Although the overall compliance score did decrease slightly each quarter of the fiscal year, it still remained at or slightly above the benchmark. Will continue to meet or exceed the 85% benchmark. Page 5

7 Routine Goal: 85% of Routine calls are scheduled to be seen by a provider within fourteen [14] calendar days (URAC Standard: HCC 16) Routine Calls Scheduled Within 14 Calendar Days Benchmark: 85% % % 95.00% 90.00% 85.00% 80.00% 75.00% 99.00% 99.39% 99.05% 99.60% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) * Data from Quarterly URAC Performance Dashboard SFY: - % Calls Scheduled Benchmark Partners BHM exceeded the benchmark of 85% of Routine calls are scheduled to be seen by a provider within 14 days for all quarters of SFY -. The benchmark for Routine calls was also exceeded for all quarters of SFY: Will continue to meet or exceed the 85% benchmark. TELEPHONE ACCESSIBILITY Partners BHM has set specific objectives, based on URAC standards and contractual requirements, for telephone performance indicators and therefore measures actual performance against those objectives in real-time and on at least a monthly basis. Partners BHM utilizes a sophisticated telephone system [ShoreTel] that includes call management reporting. Call management reporting is able to track and record individual and aggregate telephone data. Call management reporting also provides Partners BHM staff with a variety of reports and historical data as well as providing the Customer Services Director with the ability to view real time departmental call activity on his/her PC desktop. Abandonment Rate Abandonment Rate (AR) is the percentage of calls offered to the automatic call distribution (ACD) system, that are terminated by the caller prior to being answered by a live staff person. The abandonment rate is calculated separately for the Customer Services (CS) Call Center and Utilization Management (UM) department. Goal: Customer Services and Utilization Management will maintain an abandonment rate of 5% or less. (URAC Standard: HCC 11c) Page 6

8 6% 5% 4% 3% 2% 1% 0% Call Abandonment Rate- Customer Services Benchmark: 5% or Less % % % % 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Mar) Benchmark % AR *Data from Quarterly URAC Performance Dashboard SFY - Call Abandonment Rate- Utilization Management Benchmark: 5% or Less 6% 5% 4% 3% 2% 1% 0% 1% 0% 0% 0% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) % AR Benchmark * Data from Quarterly URAC Performance Dashboard SFY: - Partners BHM has met the goal of maintaining abandonment rate of 5% or less for the Customer Services and Utilization Management call queues for SFY -. Will continue to maintain an abandonment rate of 5% or less. Average Speed to Answer Average Speed to Answer (ASA) is the average delay in minutes and seconds that inbound telephone calls encounter waiting in the telephone queue before being answered by a live staff person. The average speed to answer is calculated separately for the Customer Services Call Center and Utilization Management department. Goal: Customer Services and Utilization Management will maintain an average speed to answer of 30 seconds or less. (URAC Standard: HCC 11b) Page 7

9 Seconds Seconds Average Speed To Answer- Customer Services Benchmark: 30 Seconds or Less st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) ASA Benchmark *Data from Quarterly URAC Performance Dashboard SFY: - Average Speed To Answer- Utilization Management Benchmark: 30 Seconds or Less st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) ASA Benchmark * Data from Quarterly URAC Performance Dashboard SFY: - Partners BHM has met the goal of an average speed to answer of 30 seconds or less for both the Customer Services and Utilization Management call queues for SFY - Will continue to maintain an average speed to answer of 30 seconds or less. Blockage Rate Blockage Rate (BR) is the number of times a consumer calling into the Call Center experiences a busy signal. Goal: The Customer Services Call Center will maintain a blockage rate of 5% or less. (URAC Standard: HCC 11a) 10% Blockage Rate Benchmark: 5% 5% 0% 0% 0% 0% 0% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) Benchmark BR *Data from Quarterly URAC Performance Dashboard SFY: - Page 8

10 Partners BHM has met the goal of maintaining a blockage rate of 5% or less for SFY -. Goal for will be to maintain a blockage rate of 0% Answering Service Factor Answering Service Factor (ASF) is the percentage of calls offered to the automatic call distribution (ACD) system that are answered by the Call Center. Goal: The Customer Services Call Center will maintain an answering service factor of 95% or above. (DMH Requirement) Answering Service Factor Benchmark: 95% 99% 98% 97% 96% 95% 94% 93% 98% 98% 97% 97% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) ASF Benchmark *Data from Monthly Phone Performance Report (presented to QIC) Partners BHM has met the goal of maintaining an answering service factor of 95% or above for SFY -. Will continue to maintain an answering service factor of 95% or above for SFY Telephone Service Factor Telephone Service Factor (TSF) is the percentage of all calls answered by the Call Center that were answered in 30 seconds or less. Goal: The Customer Services Call Center will maintain a telephone service factor of 95% or above. (DMH Requirement) Page 9

11 100% 95% 90% 91% Telephone Service Factor Benchmark: 95% 97% 97% 97% 85% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar 4th Qtr (Apr-Jun) TSF Benchmark *Data from Monthly Phone Performance Report (Presented to QIC) Partners BHM met the goal of maintaining a telephone service factor of 95% or above for three of fourth quarters for SFY -. The telephone service factor was below 95% for the first quarter but was maintained at 97% for the rest of the fiscal year. Will continue to maintain a telephone service factor of 95% or above for Live Call Response All calls to the Call Center are to be answered live by a Customer Services Call Center staff person. The telephone call distribution system is designed to search for an available Call Center employee. In the unlikely event that there is no Call Center employee available to answer the call, the call will roll over to Customer Services support staff, Customer Services Supervisors or the Customer Services Director. The Customer Services Director and Supervisors monitor calls to ensure that the performance expectations of all calls answered live are met. Goal: The Customer Services Call Center will maintain a live call response of 100% (URAC Standard: HCC 13a) Live Call Responce for SFY - Benchmark: 100% 150% 100% 100% 100% 100% 50% 0% SFY SFY SFY *Data from Monthly Phone Performance Report (presented to QIC) % Compliance Benchmark Partners BHM has met the goal of maintaining a live call response of 100% for SFY -. Page 10

12 Minutes Will continue to maintain goal of a 100% live call response for During SFY - Partners BHM entered into a delegation agreement with Smoky Mountain LME/MCO and CenterPoint Human Services to take any over-flow calls to ensure all calls are answered by a live person. Clinical Staff Response Requirement Goal: In the event the Call Center voic system is utilized, Customer Services staff are required to return the call within thirty [30] minutes of being received. (URAC Standard: HCC 13c) Call Center Voic s Return in 30 Minutes or Less Benchmark: 30 Minutes st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) Benchmark Call Return Time * Data from Quarterly URAC Performance Dashboard SFY: - The telephone system for the Call Center is designed for calls to roll over to the next available clinician in the queue if the initial clinician is on another call so no caller has to utilize the voic system. Will continue to ensure voic will not be utilized for the call center SERVICE AVAILABILITY Partners BHM has developed and maintains a network of providers to serve citizens of Burke, Catawba, Cleveland, Gaston, Iredell, Lincoln, Surry and Yadkin counties in North Carolina. The types of healthcare services offered within the Partners BHM network include those specialty services designed for the treatment of individuals with mental health, developmental disability, and/or substance abuse services. The specific array of services offered within the provider network is set forth by the DHHS through the Division of Mental Health, Development Disability and Substance Abuse Services (DMH/DD/SAS) and the Division of Medical Assistance (DMA). Partners BHM network consists of enough providers sufficient to provide adequate access to cover community capacity. This is assured by monitoring the availability of service providers, existence of waiting lists, availability of resources and overall need determined in part by the Partners BHM Gap Analysis/Community Needs Assessment as well as intra-department communication. Page 11

13 NETWORK COMPOSITION Network Providers by Organization Type- SFY =15 Type Totals Agency/Integrated Care 5 Agencies 305 Hospitals 49 Licensed Independent Practitioners (LIP) and Professional Practice Groups 170 Facilities 10 *Data from Provider Information Report found on SQL Report Manager CREDENTIALING AND RE-CREDENTIALING Partners Behavioral Health Management (Partners BHM) is required to credential and re-credential all Applicants for participation in the closed Provider Network of Partners, including but not limited to Licensed Practitioners, Licensed Independent Practitioners, Agencies (including Group Practices and Licensed Facilities such as Psychiatric Residential Treatment Facilities) and Hospitals and/or Health Systems. Primary source verification for Partners BHM is currently delegated to Smoky Mountain LME/MCO as part of the Western Regional Partnership between Partners, Smoky Mountain and CenterPoint, which was created to promote standardization in the credentialing process within the western region of North Carolina. The Delegate is responsible for processing all applications submitted by Applicants seeking to participate in Partners BHM s Provider Network. The Delegate conducts the pre-screens, criminal records check, and all Primary Source Verifications on each Provider application prior to sending it back to Partners BHM for Credentialing Committee review and approval. Credentialing Status for SFY - Initial Credentialing Re-credentialing Agency Licensed Independent Practitioner *Data from Monthly Health Care Network Report (Presented to QIC) Goals: Written notification of credentialing decision is sent within 10 business days of the credentialing determination 95% of the time. (URAC Standard: HNM-CR 13) The delegated entity will maintain compliance with the standards outlined in the delegation agreement as evidenced by 95% or greater score for the delegation oversight audits completed by Partners BHM. (Credentialing Delegation Contract Standard) The contractual standards include: 1. All initial or re-credentialing files shall have PSV completed within 30 days from receipt of a clean application, excluding delays caused by non-responsiveness from the primary sources and any other factors clearly outside of Delegate s control. 2. All applications must be presented to the applicable LME/MCO Credentialing Committee within 180 days of signed application attestation date, including any re-attestation permitted by URAC. 3. All applications must show that the following information was verified and/or current prior to date of presentation to the LME/MCO Credentialing Committee, as applicable to the Provider type: Page 12

14 a. Accreditation, b. License, c. DEA certificate, d. Board certification, e. Criminal background check, f. OIG check, and g. Healthcare Personnel Registry check. Performance Results for Credentialing Program SFY - 1 st Qtr. (Jul-Sep) 2 nd Qtr. (Oct-Dec) 3 rd Qtr. (Jan-Mar) 4 th Qtr. (Apr-Jun) % of Written Notifications within 10 Business Days 100% 100% 100% 98% (Benchmark: 95%) % Compliance of Delegated CVO Files with Delegation Agreement Standards (Benchmark: 95%) 93% 93% 98% 98% *Data from Quarterly URAC Performance Dashboard Report SFY - Partners BHM met the goal of having written credentialing notifications sent to the provider within 10 of the credentialing decision 95% of the time. The delegated entity maintained compliance with the standards outlined in the delegation agreement as evidenced by 95% or greater score for the delegation oversight audits completed by Partners BHM for two of four quarters for SFY -. The quarters below the benchmark are when Medversant was still the delegated entity for primary source verification Corrective Action Implemented: Due to failing to meet the benchmark Medversant was required to credit Partners BHM three percent [3%] of the total monthly invoice fees in accordance to the delegation agreement. Beginning 11/1/14 Partners BHM implemented a delegation agreement with Smoky Mountain LME/MCO to provide review of credentialing application review and primary source verification. Will ensure the delegated entity will maintain an audit score of 95% for all four quarters of NETWORK AVAILABILITY Geo ACCESS Mapping Partners BHM annually evaluates the location of Providers and types of services in its capacity study, and determines the need for additional Providers. A Provider mapping program is maintained which allows Partners to associate location of Providers in relation to where individuals live within the catchment area. Goals: Partners BHM will ensure there are inpatient providers within a 60 mile radius for 95% of Partners consumers. (URAC Standard HNM 1b) Page 13

15 Partners BHM will ensure there are outpatient providers within a 30 mile radius for 90% of Partners consumers. (URAC Standard HNM 1b) Partners BHM met the benchmark of having inpatient providers within a 60 mile radius for 95% of Partners consumers Partners BHM met the benchmark of having outpatient providers within a 30 mile radius for 90% of Partners consumers Will continue to ensure there are an adequate number of providers in the network. Needs Assessment Study The Provider Capacity, Community Needs Assessment and Gaps Analysis was conducted by Total Care Solutions LLC. It addresses the requirements of the North Carolina Department of Health and Human Services and builds upon the Needs Assessment and Gaps Analysis also conducted by Total Care Solution. Progress in Addressing Priorities from Needs Assessment & Gaps Analysis Partners BHM currently has two hubs operating in the catchment area. The Lincoln Wellness Center at McBee Street, the Hub in Lincoln County, is operating and is a collaboration between Alexander Youth Network, Monarch, Phoenix Counseling, and Support, Inc. The Hub in Burke County, called Burke Integrated Health, opened in May and features the integration of primary and behavioral healthcare. Burke Integrated Health is a result of the expanded services of A Caring Alternative, Burke Primary Care, Catawba Valley Behavioral Healthcare and The Cognitive Connection. Development efforts are underway in the remaining counties. Partners BHM has worked to improve community re-entry for high need individuals being discharged from adult care homes and state facilities. As of February, 336 individuals in adult care homes are receiving In Reach placement and coordination services. Additionally 150 people have been diverted from adult care homes. People in state hospitals are receiving In-Reach services, and three are currently in process. Twenty-four individuals are in supported housing and 36 individuals are in the transition process through the Transitions to Community Living (TCL) Initiative. Fifteen individuals are currently receiving care coordination after their transition to supported housing. Partners BHM conducted a rate study in and developed rate setting models for several Medicaid and state funded services. As a result of the rate study, most service rates were increased. Along with the recently established provider performance measures that will go into effect July 1,, we believe this will support providers to be more competitive in attracting qualified, professional staff, and will improve service outcomes. Partners BHM has also streamlined the provider application and credentialing process, cleaned up and improved data that both providers and consumers can access, issued Request for Proposals (RFPs) for B3 services in the areas of peer support and respite and expanded B3 services for Page 14

16 community guide, supported employment, individual support, and one time transition. Partners worked with providers to assess barriers and also developed mechanisms to improve access to Multi Systemic Treatment (MST) for consumers through the Utilization Management process and are assessing an alternative payment mechanism to continue expansion of this service through the eight country area. Recommendations Continued from Needs Assessment While most of the other recommendations from last year s analysis have been actively addressed, the following recommendations will continue to receive attention and focus by Partners BHM in : Improve transportation options Increase housing options Facilitate more support groups for key constituencies Case Management Develop Provider Networks Improve service integration with acute/primary care Improve recovery-oriented systems of care for persons with substance abuse Newly Identified Needs/Gaps in Stigma and Drop-in Centers: While consumers who responded to the consumer survey were the most satisfied stakeholder group with current services, they did indicate a sense of embarrassment and stigma as the recipient of behavioral health services. They also identified a desire to have a safe place to go and hang out with peers who understand their situation and can provide support in a non-judgmental fashion. Child and Adolescent Continuum of Care: Input from the provider focus group and an analysis of service utilization data indicate a need to strengthen the continuum for children and adolescents. The outpatient services make up 70% of the Medicaid services for children. Additional data indicates important evidence based practices such as Medicaid funded Multi-Systemic Therapy is potentially underutilized as evidenced by only.03% of children and.79% for adolescents receiving these services. Supported Employment: An important barrier to services emphasized by community members/stakeholders, family members/caregivers, and consumers is lack of employment. This is a difficult barrier to resolve due to the poverty issues identified in the demographic section of this report suggesting jobs may be difficult to obtain in many of the Partners BHM catchment counties. One of the associated barriers indicated in the survey was lack of insurance and inability to pay for medications and services likely due to lack of employment. Page 15

17 CUSTOMER SATISFACTION GRIEVANCE MANAGEMENT Partners BHM provides and encourages any person or organization the right and ability to bring any complaint or grievance to the attention of Partners BHM in compliance with accreditation requirements; federal and state laws and regulations; state contracts; and any other controlling authorities. Grievances and complaints are accepted by all staff, in all forms and formats, including oral, written, and anonymous. Grievances will be processed formally or informally as appropriate. Partners BHM will comply with all regulatory expectations regarding timeframes for investigation, resolution and notification. Through appropriate committees and staffing, Partners BHM routinely tracks and analyzes complaint/grievance information to improve quality of care and service delivery GRIEVANCE CATEGORIES Abuse, Neglect and Exploitation: Any allegation regarding the abuse, neglect and/or exploitation of a child or adult as defined in APSM 95-2 (Client Rights Rules in Community Mental Health). Any suspicion must be immediately reported to the local Department of Social Services and reported into IRIS (as applicable). Access to Services: Any complaint where an individual is reporting that he/she has had difficulty or not been able to obtain services Administrative Issues: Any complaint regarding a Provider s managerial or organizational issues, deadlines, payroll, staffing, facilities, etc. Authorization/Payment Issues/Billing: Any complaint regarding the payment/financial arrangement, insurance, and/or billing practices regarding providers. Basic Needs: Any complaint regarding the ability to obtain food, shelter, support, SSI, medication, transportation, etc. Client Rights Issue: Any allegation regarding the violation of the rights of any consumer of mental health/developmental disabilities/substance abuse services. Clients Rights include the rights and privileges as defined in APSM 95-2 (Client Rights Rules in Community Mental Health) Confidentiality/ HIPAA: Any breach of a consumer s confidentiality and/or HIPAA regulations. LME/MCO Functions: Any complaint regarding LME functions such as Governance/ Administration, Care Coordination, Utilization Management, Customer Services, etc. Provider Choice: Any Complaint that a consumer or legally responsible person was not given information regarding available service providers. Quality of Care: Any complaint regarding inappropriate and/or inadequate provision of services, customer services and services including medication issues regarding the administration or prescribing of medication, including the wrong time, side effects, overmedication, refills, etc. Service Coordination Between Providers: Any complaint regarding the ability of providers to coordinate services in the best interest of the consumer. Other: Indicates a complaint that has no designated category in Alpha system (i.e. disagreements with changes regarding Relative As Direct Support Employee (RADSE), changes in Innovations services, reduction in service hours Page 16

18 SUMMARY OF GRIEVANCES Total Grievances for SFY st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) Total Grievances By or On Behalf of Consumer Not By or On Behalf of Consumer *Data from DMH/DD/SAS Quarterly Complaints Report SFY - Primary Nature of Complaint SFY - 1 st Qtr. (Jul-Sep) 2 nd Qtr. (Oct-Dec) 3 rd Qtr. (Jan-Mar) 4 th Qtr. (Apr-Jun) Abuse, Neglect, Exploitation Access to Services (difficulty or inability to obtain services) Administrative Issues by Provider Basic Needs Authorization/Payment/Billing (provider only) Confidentiality/HIPAA Consumer Rights LME/MCO Functions Provider Choice Quality of Care by Providers Service Coordination Between Providers Other *Data from DM/DD/SAS Quarterly Complaints Report SFY - A total of 292 grievances were received during SFY -. The highest number of grievances occurred during the 2 nd quarter with a total of 94 grievances. 92% of the grievances received were made by or on behalf of a consumer. Of the 292 grievances, 7.4% were categorized as abuse, neglect, or exploitation. Of the 292 grievances, 45.9% were categorized as quality of care. SUMMARY OF ACTIONS TAKEN Grievance Investigation Data for SFY: - 1 st Qtr. (Jul-Sep) 2 nd Qtr. (Oct-Dec) 3 rd Qtr. (Jan-Mar) 4 th Qtr. (Apr-Jun) Grievances that resulted in an investigation Grievances that did not result in an investigation *Data from DM/DD/SAS Quarterly Complaints Report SFY - Page 17

19 Grievance Investigation Results 1 st Qtr. (Jul-Sep) 2 nd Qtr. (Oct-Dec) 3 rd Qtr. (Jan-Mar) Substantiated Not Substantiated Partially Substantiated Not Resolved At Time of Quarterly Report th Qtr. (Apr-Jun) *Data from DM/DD/SAS Quarterly Complaints Report SFY - **Please note that a grievance not being resolved at the time of the quarterly report does not mean it was not resolved within the 30 day time frame. It is feasible that a grievance received during the latter half of the last month of a quarter may have a resolution date that falls within the next quarter. Resolution for Grievances Not Requiring Investigation 1 st Qtr. (Jul-Sep) 2 nd Qtr. (Oct-Dec) 3 rd Qtr. (Jan-Mar) 4 th Qtr. (Apr-Jun) Resolved by Working with Provider Referral to Community Resource and/or Advocacy Group Provided Information or Technical Assistance to Complainant Referral to External Licensing or State Agency Pending At Time of Quarterly Report *Data from DM/DD/SAS Quarterly Complaints Report SFY - **Please note that a grievance not being resolved at the time of the quarterly report does not mean it was not resolved within the 30 day time frame. It is feasible that a grievance received during the latter half of the last month of a quarter may have a resolution date that falls within the next quarter Of the 292 grievances received 46 (15.5%) resulted in an investigation. Of the 46 grievance investigations 4 (8.7%) were substantiated. Five of the 46 investigations (11%) resulted in recommendations to the provider. Four of the 46 investigations (8.7%) resulted in the provider submitting a plan of correction. Of the 250 non-investigations 49.6% were resolved by Partners BHM working with the provider. Of the 250 non-investigations 48% were resolved by Partners BHM by providing information and or technical assistance to the complainant. Of the 250 non-investigations 1.6% were resolved by referral to an external licensing or State agency. Page 18

20 GRIEVANCE RESOLUTION TIME FRAMES Goal: At least 90% of all grievances are resolved within 30 calendar days of receipt. (URAC Standard: Core 35d) Grievances Resolved within 30 Day Time Frame Benchmark: 90% 105% 100% 95% 90% 85% 100% 100% 100% 100% 1st Quarter (Jul-Sep) 2nd Quarter (Oct-Dec) 3rd Quarter (Jan-Mar) 4th Quarter (Apr-Jun) *Data from Quarterly URAC Performance Dashboard Report SFY - % Compliance Benchmark Partners BHM exceeded the goal of resolving at least 90% of all grievances within 30 calendar days for all quarter of SFY -. Will continue to ensure that all grievances are resolved within 30 days. PROVIDER DISPUTES In order to respect providers rights while simultaneously protecting consumers, Partners Behavioral Health Management (Partners BHM) maintains a formal process consistent with its written agreements to address alleged violations of the agreement by participating providers. This Dispute Resolution Process is available to any participating provider who wishes to initiate it. However, only certain types of disputes are subject to the process. The types of disputes that are subject to the dispute resolution process are those: Clinical Disputes: Involving professional competence or conduct issues. Administrative Disputes: Involving administrative issues. Provider Disputes for SFY - Clinical Disputes Administrative Disputes # received for SFY # Disputes Resolved 7 25 # Unresolved 0 0 # In Process 0 0 *Data from Provider Network Page 19

21 Days Goal: Provider disputes are resolved within 30 days of the provider s initiation of the dispute. (URAC Standard: HNM 14e) Disputes Resolution Time Frames- SFY: -15 Benchmark: 30 Days st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) Average # Days to Resolve Disputes Benchmark *Data from Monthly Health Care Network Report (Presented to QIC) Partners BHM did not meet the time frame benchmark for provider dispute resolution in the month of May. Based on the information provided by Provider Network the main issue appears to be timely delivery of the dispute resolution request to the designated staff responsible for provider disputes. Corrective Action Implemented: Providers are now directed to provider dispute resolution requests to the provider disputes distribution list. Provider Network has put measures in place to monitor the designated address to ensure the 30 day time frame is met. SATISFACTION SURVEYS COMMUNITY RELATIONSHIP SURVEY On October 27 th, Partners BHM sent out the Community Relationship Survey to our partner agencies and community stakeholders. This survey was designed to provide information on the level of satisfaction our partners and stakeholders have with Partners BHM and its role in the community. The survey was closed on November 10 th,. A total of 330 partners/stakeholders responded to this survey. Satisfaction with Partners BHM s Management of Services Answer Choices Responses Very Satisfied or Satisfied 58% Neither Satisfied or Dissatisfied 17% Highly Dissatisfied or Dissatisfied 20% Not Sure 5% *Data from Community Relationship Survey Results Page 20

22 Experience with Partners BHM Staff Answer Choices Responses Very Satisfied or Satisfied 80.5% Neither Satisfied or Dissatisfied 9.5% Highly Dissatisfied or Dissatisfied 10% *Data from Community Relationship Survey Results Report Do you feel that Partners is meeting its mission as outlined in the mission statement? Answer Choices Responses Yes 65.06% No 20.48% No Sure 14.46% *Data from Community Relationship Survey Results Report Partners received generally positive responses to the satisfaction of the community/stakeholders in regard to Partners BHM s role in the community CONSUMER PERCEPTION OF CARE SURVEY The North Carolina Mental Health and Substance Abuse Consumer Perception of Care Survey provides information on the quality of care in each LME/MCO catchment area, based on the perceptions of individuals and families who have received Medicaid or state-funded mental health and/or substance abuse services. The NC Division of MH/DD/SAS and LME/MCOs gather this information annually through consumer surveys. Samples of adult consumers ages 18 years and over, youth ages 12 to 17 years, and families/parents of children under 12 years of age complete the confidential surveys, in English or Spanish, at their provider agencies during a specified time period each year. The survey was administered between June 30, and July 28,. Partners BHM Required Survey Sample Size & Actual Survey Respondents Adult Survey Youth Survey Parent Survey Required Sample Size Number of Respondents *Data from Consumer Perception of Care Survey Results Report Page 21

23 Combined Survey Results Domain Adult Survey Results Youth Survey Results Parent Survey Results NC Aggregate Score Partners BHM Score NC Aggregate Score Partners BHM Score NC Aggregate Score Partners BHM Score Access 89% 91% 75% 78% 90% 93% Quality/Appropriateness 93% 95% N/A N/A N/A N/A General Satisfaction 91% 91% 81% 80% 92% 99% Outcomes 74% 74% 66% 65% 68% 81% Treatment Planning 84% 87% 71% 73% 93% 94% Cultural sensitivity N/A N/A 91% 89% 98% 98% Social Connectedness 74% 75% N/A N/A 87% 88% Functioning 74% 72% N/A N/A 69% 80% *Data from Consumer Perception of Care Survey Results Report For the Adult Survey, Partners BHM met or exceeded the State aggregate score for six of seven survey domains (Access, Quality/Appropriateness, General Satisfaction, Outcomes, Treatment Planning and Social Connectedness). Partners fell two percentage points below the State aggregate score for the Functioning domain. For the Youth Survey, Partners BHM met the State aggregate score for two of five survey domains (Access and Treatment Planning). Partners BHM fell one percentage point below the State aggregate score for the General Satisfaction domain and two percentage points below for the Treatment Planning and Cultural Sensitivity domains. For the Parent Survey, Partners BHM met or exceeded the State aggregate score for seven of seven survey domains. PROVIDER SATISFACTION SURVEY The DHHS Provider Satisfaction Survey was conducted on behalf of the North Carolina Department of Health and Human Services (DHHS), Division of Medical Assistance (DMA) by the Carolinas Center for Medical Excellence (CCME) of the providers participating in the 1915(b) (c) Medicaid Waiver program. The purpose of the survey was to assess provider perceptions of the nine LME/MCOs in North Carolina. The results from this survey allowed DMA to assess the LME/MCOs ability in the following three areas: 1. Interacting with their network providers 2. Providing training and support to their providers 3. Providing Medicaid Waiver materials to help their providers strengthen their practice The survey was initially sent out on August 20 th, with an initial collection period from August 20 th, to August 26 th, and a second collection period from August 27 th, to September 3 rd,. The survey was closed on September 4 th,. Page 22

24 A total of 411 providers who participate in Partners BHM s provider network were invited to participate in the survey. A total of 173 surveys were collected for a response rate of 42.1%, which was the fourth highest response rate for the nine LME/MCOs. Provider Satisfaction Survey Results Survey Question 2013 Score Score Comparison to 2013 Scores LME/MCO Staff Accessible 68% 79.8% Exceeded LME/MCO Staff Make Appropriate Referrals 53% 61.3% Exceeded LME/MCO Staff Responsive to Provider Needs 70% 79.2% Exceeded Customer Service Responsive to Stakeholders 53% 59% Exceeded Provides Consistent & Accurate Claims Information 60% 70.5% Exceeded Claims Training Meets Provider Needs. 61% 63% Exceeded Claims Processing Timely & Accurate 68% 83.8% Exceeded IT Training Informative & Meets Provider Need 60% 72.8% Exceeded Provider Network Meetings Informative & Helpful 56% 62.4% Exceeded Provider Network Keeps Providers Informed 82% 80.9% Below Provider Network Staff Knowledgeable 73% 75.7% Exceeded Provider Council Adequately Addresses Provider Interests 49% 58.4% Exceeded Overall Satisfaction With Provider Network 80% 78.6% Below LME/MCO Investigations Are Fair & Thorough 46% 63% Exceeded Requests For Corrective Action Plans Fair & Reasonable 44% 64.7% Exceeded Technical Assistance/Information Accurate & Helpful 68% 74.6% Exceeded Trainings Informative & Meet Provider Need 64% 66.5% Exceeded Authorizations Processed Within Required Time Frames 75% 82.1% Exceeded Denials for Treatment/Services Are Explained 57% 66.5% Exceeded Authorizations Are Accurate 75% 80.3% Exceeded Satisfied With Appeals Process 38% 48% Exceeded Partners BHM s Website Is Useful Tool 65% 64.7% Met Overall Satisfaction with Partners BHM 73% 80.3% Exceeded *Pink highlight indicates Partner BHM below NC Aggregate Score for 2013 survey *Red highlight indicates Partners BHM below NC Aggregate Score for survey *Green highlight indicates Partners BHM had highest LME/MCO score or tied with another LME/MCO for highest score for survey CLIENT SATISFACTION SURVEY The Client Satisfaction Survey was distributed to Partner BHM clients (DHHS, DMA) through Survey Monkey on 8/11/14. The survey asks five key questions regarding Partner BHM s contractual performance. Client Satisfaction Survey Results Survey Question Yes No Not Applicable Has Partners BHM met DMH contract standards? 66.67% 0% 33.33% Has Partners BHM met DMA contract standards? 66.67% 0% 33.33% Partners BHM Staff treated client with courtesy and respect? 100% 0% 0% Page 23

25 Partners BHM Staff Responsive to client s questions and/or needs? 100% 0% 0% Extremely Pleased Overall Satisfaction With Partners BHM Contractual Performance Responses: 3 Pleased Neutral Dissatisfied Extremely Dissatisfied Not Interacted with Partners BHM 0% 100% 0% 0% 0% 0% Page 24

26 CONSUMER SAFETY ADVERSE INCIDENT REPORTING & REVIEW Partners BHM seeks to ensure consumer safety and implements policies and procedures to ensure that staff understands how to manage consumer interactions or adverse incidents where consumers may be at risk. Additionally, Partners BHM tracks all reports of adverse incidents to ensure that interactions are handled appropriately and followed up in order to help ensure safety. Incident Review Committee (IRC) reviews and analyzes these reports to identify trends and opportunities for improvement. DEFINITIONS OF ADVERSE INCIDENTS Incident: An incident, as defined in 10A NCAC 27G.0103(b)(32), is any happening which is not consistent with the routine operation of a facility or service or the routine care of a consumer and that is likely to lead to adverse effects upon a consumer. Level I: Includes any incident, as defined above, which does not meet the definition of a Level II or III incident. Level I incidents are events that, in isolated numbers, do not significantly threaten the health or safety of an individual, but could indicate systematic problems if they occur frequently. Level II: Includes any incident, as defined in 10A NCAC 27G.0602, which involves a consumer death due to natural causes or terminal illness, or results in a threat to a consumer s health or safety or a threat to the health or safety of others due to consumer behavior. Level III: Includes any incident, as defined in 10A NCAC 27G.0602, that results in (1) a death, sexual assault or permanent physical or psychological impairment to a consumer, (2) a substantial risk of death, or permanent physical or psychological impairment to a consumer, (3) a death, sexual assault or permanent physical or psychological impairment caused by a consumer, (4) a substantial risk of death or permanent physical or psychological impairment caused by a consumer or (5) a threat caused by a consumer to a person's safety. INCIDENT REPORTING DATA Adverse Incident Reporting for SFY July -June 1 st Qtr. (Jul-Sep) 2 nd Qtr. (Oct-Dec) 3 rd Qtr. (Jan-Mar) 4 th Qtr. (Apr-Jun) Level 2 Critical Incident Reports received Level 3 Critical Incident Reports received Level II and Level III Incidents that resulted in Partners BHM on-site investigation Level II and Level III Incidents that resulted in DHSR Investigation *Data from the Consumer Relations Monthly Operating Report, June Results and Analysis: There were a total of 1830 incident reports submitted into IRIS for Partners BHM consumers for SFY -. 91% of the incidents reported were Level II incidents. 1% of the incidents reported resulted in Partners BHM on-site investigation. 3.4% of the incident reported resulted in DHSR investigation. Page 25

27 INNOVATIONS WAIVER HEALTH & SAFETY MEASURES Health & Safety Measures Reported Quarterly SFY - Performance Standard 1 st Qtr. (Jul-Sep) 2 nd Qtr. (Oct-Dec) 3 rd Qtr. (Jan-Mar) 4 th Qtr. (Apr-Jun) % Incidents in which action was taken to > 86% 87.76% 90.63% 100% 92.16% protect the consumer % Level II and Level III incidents reported within > 86% 94.23% 94.12% 100% 82.35% required timeframes % Incidents referred to the Division of Social <14% 0% 0.29% 0.73% 0.15% Services or the Division of Health Service Regulation. % of Level II and Level III incidents that received required follow-up from Partners BHM > 86% 100% 100% 94.34% 92.16% *Data from Innovations Waiver Performance Measures Report SFY: - Health & Safety Measures Reported Semi-Annually SFY - Performance Semi-Annual Standard Outcome (Jul-Dec) % Individual Support Plans (ISP) that address strategies to address health and safety risks *Data from Innovations Waiver Performance Measures Report SFY: - Semi-Annual Outcome (Jan-Jun) >86% 100% 100% Partners BHM met or exceeded the performance standard for all measures except for the Level II and Level III reports submission time frames during 4 th quarter SFY -. Documentation from the PBHM -15 Innovations Waiver Overview Report indicates that one specific provider s late report submissions caused Partners BHM to fall below the performance standard for 4 th quarter. This provider also had late submissions during 4 th quarter of SFY This provider was put on a plan of correction Page 26

28 SERVICE UTILIZATION- TARGETED SERVICES PERFORMANCE MEASURES COMMUNITY PSYCHIATRIC HOSPITALIZATION Inpatient Admission Statistics for SFY - 1 st Qtr. 2 nd Qtr. (Jul-Sep) (Oct-Dec) Mental Health Admissions Medicaid Non-Medicaid Substance Abuse Admissions Medicaid Non-Medicaid *Data from MCO Monthly Monitoring Report SFY - Mental Health Readmissions Medicaid 3 rd Qtr. (Jan-Mar) 4 th Qtr. (Apr-Jun) Percentage of Readmissions in 30 Days for SFY - 1 st Qtr. 2 nd Qtr. (Jul-Sep) (Oct-Dec) Non-Medicaid Substance Abuse Readmissions Medicaid Non-Medicaid *Data from MCO Monthly Monitoring Report SFY - Mental Health Substance Abuse 3 rd Qtr. (Jan-Mar) 4 th Qtr. (Apr-Jun) 13% 17% 12% 13% 8% 6% 6% 5% 10% 3% 15% 15% 9% 10% 5% 11% Average Length of Stay for Inpatient Admissions SFY - 1 st Qtr. (Jul-Sep) 2 nd Qtr. (Oct-Dec) 3 rd Qtr. (Jan-Mar) Medicaid Non-Medicaid Medicaid Non-Medicaid *Data from MCO Monthly Monitoring Report SFY - 4 th Qtr. (Apr-Jun) Page 27

29 Number of Bed Days Jul *Data from Executive Dashboard Report April **Bed day utilzation based on physical counts- not paid claims Inpatient Bed Utilization- July -April Aug Sep Oct Nov Dec Jan Feb Mar 3-way hospital beds Non-Medicaid Medicaid Apr The highest utilization of three-way hospital bed days occurred in October. The highest utilization of Non-Medicaid bed days occurred in August. The highest utilization of Medicaid bed occurred in August. CHILD/ADOLESCENT SERVICES Goal: Maintain a bed day benchmark of 2400 or less. 3,000 Psychiatric Residential Treatment Facility Bed Day Utilization- Mediciad Benchmark: ,000 1,000 1,514 1,592 1,607 1,503 1,546 1,645 1,586 1,226 1,314 1,305 0 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Medicaid PRTF bed day benchmark *Data from Executive Dashboard Report April **Bed day utilzation based on physical counts- not paid claims Partners BHM has maintained a bed utilization of less than 2400 bed days. The highest utilization of bed days occurred in December. Page 28

30 Multi-Systemic Therapy Multi-Systemic Therapy(MST) Utilization -Medicaid Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Unique consumers Medicaid New auths - Medicaid *Data from Executive Dashboard Report April ** MST and IIH utilization trends based on paid claims data Multi-Systemic Therapy (MST) Utilization - Non-Medicaid Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Unique consumers IPRS New auths - IPRS *Data from Executive Dashboard Report April ** MST and IIH utilization trends based on paid claims data There was no significant change in MST utilization during SFY -. Intensive In-Home Intensive In-Home Utilization- Medicaid Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Unique consumers Medicaid New auths - Medicaid *Data from Executive Dashboard Report April ** MST and IIH utilization trends based on paid claims data Page 29

31 Intensive In-Home Utilization- IPRS Jul Aug 0 Sep 3 1 Oct 5 3 Nov 5 0 Dec Jan 0 Feb 2 Mar 1 1 Apr Unique consumers IPRS New auths - IPRS *Data from Executive Dashboard Report April ** MST and IIH utilization trends based on paid claims data There was not a significant change in Intensive In-Home utilization during SFY -. EMERGENCY DEPARTMENT (ED) UTILIZATION (MEDICAID ONLY) Emergency Department Admissions for March -February Mar -May Jun -Aug Sep -Nov Dec -Feb ED Admits- MHDDSA diagnoses ED Admits- Active Consumers ED Admits- Readmissions within 30 days *Data from MCO Monthly Monitoring Report SFY - **Due to 3 month lag in receiving ED information, date parameters for this graph are March -February instead of using State Fiscal Year Of the 3,276 emergency department admissions between March and February for individuals with a MH/DD/SA diagnosis 51% were admissions for active consumers. Of the 3,276 emergency department admissions between March and February for individuals with a MH/DD/SA diagnosis 12.5% were readmissions within 30 days of discharge. Page 30

32 INTELLECTUAL DEVELOPMENTAL DISABILITY (IDD) SERVICE UTILIZATION $8,000,000 $7,000,000 $6,000,000 $5,000,000 $4,000,000 $3,000,000 $2,000,000 $1,000,000 $0 IDD Per Member Per Month (PMPM) Utilization Actual Monthly cost (paid claims only) Total PMPM July Aug Sept Oct Nov Dec Jan Feb Mar Apr *Data from Executive Dashboard Report April $6,000 Monthly Consumer Budget AVG Budget/Consumer PMPM Rate $5,000 $4,000 $3,000 $2,000 $1,000 $0 July Aug Sept Oct Nov Dec Jan Feb Mar Apr *Data from Executive Dashboard Report April The actual monthly cost for IDD consumers was below the total PMPM rate during July to April. The average budget per consumer was below the PMPM rate for all months except January. Page 31

33 Total Service Cost FINANCIAL PERFORMANCE Medical Expense Ratio 110.0% 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 92.7% 98.9% 92.3% 94.1% 92.1% 90.3% 91.5% 92.3% 92.3% 92.8% 84.3% 88.8% 87.2% 86.8% 88.2% 88.0% 88.0% 87.3% 87.3% 84.8% July Aug Sept Oct Nov Dec Jan Feb Mar Apr Medicaid MER IPRS MER 100% Line *Data from Executive Dashboard Report April $200,000,000 Fiscal Year to Date Budget to Actual Comparison - Medicaid $150,000,000 $100,000,000 $50,000,000 $0 Total FYTD Actual Total FYTD Budget *Data from Executive Dashboard Report April Non-Medicaid Budget to Actual 35,000,000 30,000,000 25,000,000 20,000,000 15,000,000 10,000,000 5,000,000 - Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Total YTD Actual Total YTD Budget *Data from Executive Dashboard Report April Page 32

34 CLAIMS Claims Data for SFY: - 1 st Qtr. (Jul-Sep) 2 nd Qtr. (Oct-Dec) 3 rd Qtr. (Jan-Mar) 4 th Qtr. (Apr-Jun) Clean Claims Received Medicaid 499, , , ,172 Non-Medicaid 92,277 85,817 88,548 92,211 Average Number of Days for Processing Medicaid Non-Medicaid Claims Denied Medicaid 52,655 49,818 54,930 62,793 Non-Medicaid 10,548 8,649 8,243 15,100 Claim denials overturned due to Provider Appeals (Medicaid Only) *Data from Executive Dashboard Report April Goal: 90% of all clean claims will be processed within 30 days. (DMA/DHHS Contract Standards) Days to Pay Clean Claims Benchmark: 90% Within 30 Days 105% 100% 95% 90% 85% 100% 100% 100% 100% 100% 100% 100% 100% 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter *Data from Executive Dashboard Report April Medicaid Non-Medicaid Benchmark Partners BHM exceeded the goal of 90% of all clean claims processed within 30 days for all quarters of SFY -. Partners BHM had no claim denials overturned due to provider appeal for all quarters of SFY to - Will continue to maintain claims processing goal. Page 33

35 PROGRAM MEASURES MH/SA CARE COORDINATION Care Coordination is an administrative function within Partners BHM s managed care system that is designed to be proactive in nature and ensure optimal care to at risk consumers in designated special healthcare needs populations. It is available to members in all three disability groups (Mental Health, Substance Abuse, and Intellectual/Developmental Disability). This section will only address MH/SA Care Coordination as elements of Intellectual/Developmental Disabilities are addressed in other sections of this report. MH/SA CC activities include the identification, coordination and monitoring of, linkage to behavioral health treatment services, rehabilitative, and/or facilitative services and supports depending on the consumer s individual needs and funding source. Care Coordination Statistics for SFY - Note: these are new measures that were first reported in October 1 st Qtr. (Jul-Sep) 2 nd Qtr. (Oct-Dec) 3 rd Qtr. (Jan-Mar) 4 th Qtr. (Apr-Jun) Average Number of Adult MH/SA Consumers Receiving Care Coordintion Services During Quarter Medicaid N/A Non-Medicaid N/A Average Number Child MH/SA Consumers Receiving Care Coordintion Services During Quarter Medicaid N/A Non-Medicaid N/A *Data from MCO Monthly Monitoring Report SFY - Goal: Ensure 85% of MH/SA inpatient readmissions are assigned to care coordintion (DMA/DMH Contract Standard) Percentage of MH/SA Readmissions Assigned to Care Coordination Benchmark: 85% 120% 100% 80% 60% 40% 20% 0% 100% 100% 100% 98.7% 97.4% 100% 100% 0% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) *Data from LME/MCO Monthly Monitoring Report SFY - Medicaid Non-Medicaid Benchmark Partners BHM exceeded the goal of ensuring 85% of MH/SA inpatient readmissions are assigned to care coordination for all quarters of SFY -. Page 34

36 Measurement of Non-Medicaid readmissions was not implemented by DMA/DMH until October, therefore first quarter of SFY - is reported as 0 in the above graph. Will continue to ensure MH/SA inpatient readmissions are assigned to care coordination. TRANISTION TO COMMUNITY LIVING INITITIVE The State of North Carolina entered into a settlement agreement with the United States Department of Justice in The purpose of this agreement was to make sure that persons with mental illness are able to live in their communities in the least restrictive settings of their choice. The NC Department of Health and Human Services is implementing the agreement through the Transition to Community Living Initiative (TCLI). The Transition to Community Living Initiative has six primary components: In-Reach and Transition: Providing or arranging for frequent education efforts and discharge planning targeted to individuals in adult care homes and state psychiatric hospitals. Diversion: Diverting individuals from being admitted to adult care homes. Housing: Providing community-based supportive housing with tenancy supports. Supported Employment: An evidence-based service to assist individuals in preparing for, identifying, and maintaining integrated, paid, competitive employment. Assertive Community Treatment: An evidence-based treatment and support model of services offering intensive customized, community-based services for people with mental illness. Quality Management: Using data to evaluate progress and outcomes Partners BHM Transition to Community Living Initative Statistics Calendar Year 2013 Calendar Year PASRR Screenings Processed In-Reach Transition Planning 5 17 Housed *Data from NC Deparmtent of Health and Human Services Transition to Community Living Initiative Annual Report Baseline Report * Data from NC Deparmtent of Health and Human Services Transition to Community Living Initiative Annual Report Partners BHM increased the number of PASRR screenings processed from 269 at the end of calendar year 2013 to 493 at the end of calendar year. Partners BHM increased the number of consumers receiving In-Reach services from 209 at the end of calendar year 2013 to 304 at the end of calendar year. Partners BHM increased the number of consumers in the transition planning process from 5 at the end of calendar year 2013 to 17 at the end of calendar year. Page 35

37 Partners BHM increased the number of consumers housed in the community from 12 at the end of calendar year 2013 to 28 at the end of calendar year. Barriers to Compliance: Many individuals continue to prefer residing in adult care homes to transitioning to the community despite education on the initiative by In-Reach staff. In-Reach staff will continue to visit identified individuals residing in adult care homes to provide education on the Transition to Community Living Initiative. PROGRAM INTEGRITY (PI) The Regulatory Compliance Program is designed to monitor adherence to applicable statutes, regulations and program requirements as well as to identify, prevent, reduce, and correct violations of legal or ethical conduct. Other goals achieved through the development of an effective Compliance Program include: improve operational quality, improve the quality of care for consumers, and healthcare costs. PI Monthly Case Activity July 4 Aug 5 5 Sept 11 1 Oct 6 Nov Dec Jan Feb 9 5 Mar Apr New Cases Closed Cases *Data from the Executive Dashboard Report- April Program Integrity Case Activity Two Year Comparison Provider Fraud & Abuse Cases Investigated Enrollee Fraud & Abuse Cases Investigated 0 0 Cases Referred to DMA Program Integrity 12 6 *Data from LME/MCO Monthly Monitoring Report SFY **Data from LME/MCO Monthly Monitoring Report SFY - The number of provider fraud and abuse cases investigated by Partners BHM increased during SFY -. No enrollee fraud and abuse cases were investigated during SFY or -. The number of fraud and abuse cases referred to DMA decreased during SFY -. Page 36

38 Will continue to investigate potential fraud and abuse cases and refer to DMA as needed. UTILIZATION MANAGEMENT SAR Processing SARs Received SAR Decisions for SFY - 1 st Qtr. 2 nd Qtr. (Jul-Sep) (Oct-Dec) 3 rd Qtr. (Jan-Mar) 4 th Qtr. (Apr-Jun) Medicaid 13,888 14,288 11,750 13,334 Non-Medicaid SARs Approved Medicaid 13,093 13,635 11,070 12,676 Non-Medicaid SARs Denied for Administrative Reasons Medicaid Non-Medicaid SARs Denied for Clinical Reasons Medicaid Non-Medicaid *Data from LME/MCO Monthly Monitoring Report SFY - Goals: 95% of all Standard SARS will be processed within 14 calendar days (DMA/DHHS Contracts; URAC Standard: HUM 19-21) 95% of all Expedited SARS will be processed within 72 hours (DMA/DHHS Contracts; URAC Standard: HUM 19-21) SAR Days to Decision- Medicaid Benchmark: 95% 102.0% 100.0% 98.0% 96.0% 94.0% 92.0% 99.6% 100% 99.9% 100% 99.9% 99.2% 99.8% 98.5% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) % Compliance- Standard SAR % Compliance- Expedited SAR Benchmark *Data from LME/MCO Monthly Monitoring Report SFY - Page 37

39 SAR Days to Decision- Non-Medicaid Benchmark: 95% 102.0% 100.0% 98.0% 96.0% 94.0% 92.0% 99.8% 100% 99.7% 99.9% 100% 100% 100% 98.4% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) *Data from LME/MCO Monthly Monitoring Report SFY - The goal of 95% of all Standard Timeframe SARs being processed in 14 calendars days was exceeded for all four quarters SFY -. The goal of 95% of all Expedited Timeframe SARs being processed within 72 hours was exceeded for all four quarters SFY Will maintain goal benchmark of 95% of SARs processed within required timeframes for SFY Appeals Process % Compliance- Standard SAR % Compliance- Expedited SAR Benchmark Appeals for SFY - 1 st Qtr. (Jul-Sep) 2 nd Qtr. (Oct-Dec) 3 rd Qtr. (Jan-Mar) 4 th Qtr. (Apr-Jun) Appeals Requests Received Medicaid Non-Medicaid *Data from LME/MCO Monthly Monitoring Report SFY - Goal: 30% or less of initial SAR decisions are overturned upon consumer appeal (URAC Standard: HUM 34) Initial SAR Decision Overturned SFY - Benchmark: 30% or less 40% 30% 20% 10% 0% 18% 18% 13.4% 10% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Quarter % Initial Decision Overturned Benchmark *Data from Quarterly URAC Performance Dashboard Report SFY - Page 38

40 The goal of 30% or less of initial SAR decisions being overturned upon appeal was met for all four quarters SFY -. Will continue to maintain 30% or less benchmark for SFY Goal: 95% of all Standard appeals are completed and written notification of the appeal decision is issued within 30 calendar days of receipt of the request for appeal (HUM 39) Standard Appeal Process Time Frame Benchmark: 95% % % 98.00% 96.00% 94.00% 92.00% 99.07% 98.7% 99.7% 100% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Quarter % Compliance Benchmark Partners BHM exceeded the compliance benchmark of 95% of Standard appeals completed within 30 calendar days for all four quarters of SFY -. Will maintain the 95% compliance benchmark for Standard appeals time frame for SFY Goal: 95% of all Expedited appeals are completed with verbal notification of the appeal decision to the requesting party within 72 hours of the request followed by written confirmation within 3 calendar days. Expedited Appeals Process Time Frame Benchmark: 95% 120% 100% 80% 60% 40% 20% 0% 0% 100% 100% 100% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) % Compliance Benchmark Page 39

41 Partners BHM exceeded the compliance benchmark of 95% of Expedited appeals completed in 72 hours. Will maintain the 95% compliance benchmark for Expedited appeals time frame for SFY Page 40

42 QUALITY IMPROVEMNET PROJECTS (QIP) Partners BHM currently has four Quality Improvement Projects (QIPs), as noted below. These were developed and prioritized to meet the clinical and non-clinical project requirements of Attachment M in the DMA contract, along with current accreditation standards. Each QIP is carried out under the guidance and oversight of the MCO Chief Medical Officer. QIP 1: REDUCING THE UTILIZATION RATE OF EMERGENCY DEPARTMENT (ED) VISITS FOR MEDICAID BEHAVIORAL HEALTH CONSUMERS (Clinical) URAC Accreditation Applicability: Health Call Center; Health Utilization Management DMA/DMH Applicability: Clinical Goal: Rate of 120 ED admissions per 10,000 Partners BHM Medicaid consumers Baseline: 6 months (Feb 2013-Jul 2013) Measurement 1: 6 months (Aug.2013 Jan ) Measurement Periods Measurement 2: 6 months (Feb -Jul ) Measurement 3: 6 months (Aug -Jan ) Rate of 139 per 10,000 Modified Baseline: (based on Emergency Department Claims Analysis report as of 3/30/) Rate of 129 per 10,000 Rate of 109 per 10,000 Modified Measurement 1: 6 months (Aug 2013-Jan ) Rate of 112 per 10,000 Rate of 125 per 10,000 Modified Measurement 2: 6 months (Feb -Jul ) Rate of 113 per 10,000 N/A- Moved to new measure criteria Modified Measurement 3: 6 months (Aug -Jan ) Rate of 109 per 10,000 In March the definition for an ED visit was re-defined to only include Facility services. Partners BHM has re-run the QIP performance data to demonstrate the results based on the new definition (see modified measurements above) Partners BHM has had consecutive measurement periods of meeting and/or exceeding the goal. Partners BHM will maintain this QIP into SFY but it is scheduled for evaluation in December to determine continuation timelines or termination. As this QIP has had consecutive measurement period of meeting and/or exceeding the goal, it will likely be concluded and replace with a new QIP, pending DMA approval per contract requirements. Partners BHM will continue to have the scope and number of formal active QIPs to meet accreditation and DHHS/DMA contract requirements. Page 41

43 QIP 2: TIMELY FOLLOW-UP AFTER COMMUNITY HOSPITIAL DISCHARGES WITHIN 7 DAYS FOR BEHAVIORAL HEALTH CONSUMERS URAC Accreditation Applicability: Health Call Center; Health Network Management DMA/DMH Applicability: Clinical Goal: 40% of Partners BHM Medicaid consumers who are discharged from a community hospital psychiatric inpatient unit receive follow-up treatment within 7 days. Baseline: 6 months (Jul 2013 Dec 2013) Measurement 1: 6 months (Jan -Jun ) Measurement Periods Interim Review: 6 months (Jul -Dec ) Measurement 2: ANNUAL (Jul -Jun ) 35.2% 38.6% 38.5% Pending Since reports are based on paid claims, there is at least a 90 day lag time between the close of the measurement period and available report data. Therefore data for Measurement 2 will not be available at least until September. The percentage of Medicaid consumers with 7 day follow-up after community hospital treatment decreased by a 0.1 percentage point from 38.6% at Measurement 1 to 38.5% at Interim Review. However this is still a 3.3 percentage point increase from the 35.2% baseline measurement. The interim review percentage is still below the 40% goal for this QIP. Barriers to Compliance: Silo processes in place between Customer Services, Care Coordination and Utilization Management Departments. Delayed notification to the MCO regarding discharges prior to the date of discharge. Need to receive at least 1-2 day notice of discharge in order to increase appropriate appointment scheduling options. Limited provider choices for appropriate linkage to services. Interventions Implemented: A script has been developed for Customer Services to use when making follow-up calls. The script will be used to verify transportation so that is not a barrier and can potentially be addressed by Care Coordination. Implementation Date: May Partners BHM will meet regularly with high-use hospitals, addressing timely discharge follow-up expectations with hospitals. Implementation Date: May Partners BHM will survey individuals using walk-in/same day access centers for hospital follow-up. Implementation Date: June Partners BHM will implement a Provider Recognition highlighting the top 10 performers in timely follow-up to generate positive completion. This would include top hospitals with individuals discharged and seen within 7 day timeframe and top performers within community providers. Implementation Date: June Page 42

44 This QIP will be maintained by Partners BHM into the next fiscal year. This QIP is scheduled for evaluation in December to determine continuation timelines. QIP 3: REDUCING AVERAGE LENGTH OF STAY IN PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES (PRTF) URAC Accreditation Applicability: Health Utilization Management; Health Network Management DMA/DMH Applicability: Clinical Initial Goal: Average Length of Stay (ALOS) of 298 days per Medicaid consumer in PRTF facilities (20% less than 373 days ALOS prior to becoming a MCO). Revised Goal 1 (Aug 2013-Jan ): ALOS of 238 days per Medicaid consumer (20% less than 298 in previous goal). Revised Goal 2 (Feb -Jan ): ALOS of 190 days per Medicaid consumer (20% less than 238 days in previous goal). Baseline: 6 months (Feb 2013-July 2013) Measurement Periods Measurement 1: 6 months (Aug 2013-Jan ) Interim Review: 6 months (Feb -Jul ) Measurement 2: ANNUAL (Feb -Jan ) 276 days 232 days 193 days 177 days Partners BHM has had consecutive measurement periods of exceeding the goals set for this QIP. Partners BHM will maintain this QIP into SFY but it is scheduled for evaluation in December to determine continuation timelines or termination. As this QIP has had consecutive measurement period of meeting and/or exceeding the goal, it will likely be concluded and replace with a new QIP, pending DMA approval per contract requirements. Partners BHM will continue to have the scope and number of formal active QIPs to meet accreditation and DHHS/DMA contract requirements. QIP 4: TIMELY SUBMISSION OF NC-TOPPS 3-MONTH UPDATE ASSESSMENTS URAC Accreditation Applicability: Health Network Management DMA/DMH Applicability: Non-Clinical/Organizational Goal: 90% of NC-TOPPS 3-Month Update Assessments will be completed and submitted within appropriate timelines (data is supplied from the State with a two-quarter lag). Page 43

45 Baseline: 3 months (SFY Q1 Report) Measurement 4: 3 months (SFY Q1 Report) Measurement Periods Measurement 1: 3 months (SFY Q2 Report) Measurement 2: 3 months (SFY Q3 Report) Measurement 3: 3 months (SFY Q4 Report) 86.9% 86.3% 82.7% 85% Measurement 5: Measurement 6: 3 months 3 months (SFY Q2 Report) (SFY Q3 Report) Measurement 7: 3 months (SFY Q4 Report) 93.5% 88.6% 90.1% 93.2% Partners BHM met or exceeded the 90% submissions goal for this QIP for three out of four quarter in SFY -. Partners BHM will maintain this QIP into SFY but it is scheduled for evaluation in December to determine continuation timelines. It is expected that this QIP will be continued for at least another year. Partners BHM will continue to have the scope and number of formal active QIPs to meet accreditation and DHHS/DMA contract requirements. Page 44

46 QUALITY ASSURANCE/QUALITY IMPROVEMENT ACTIVITIES ACCREDITATION/CERTIFICATION/EXTERNAL REVIEWS EXTERNAL QUALITY REVIEW (EQR) The contract between the North Carolina Department of Health and Human Services, Division of Medical Assistance (DMA), and The Carolinas Center for Medical Excellence (CCME) stipulates that CCME will conduct an External Quality Review (EQR) for Partners Behavioral Health Management, a Prepaid Inpatient Health Plan (PIHP) that provides services under contract with DMA. The EQR is conducted to determine the level of performance demonstrated by Partners Behavioral Health Management since beginning the 1915(b)(c) Medicaid Waiver program. Goals of the EQR: 1) Determine if Partners Behavioral Health Management was in compliance with service delivery as mandated in the PIHP contract with DMA. 2) Provide feedback for potential areas of further improvement. The EQR consisted of two segments. The first was a desk review of materials and documents requested from Partners BHM on 6/30/14. These items focused on administrative functions, committee minutes, enrollee and provider demographics, enrollee and provider educational materials, and the Quality Improvement and Medical Management Programs. The second segment was an onsite review conducted 8/27/14-8/29/14. The onsite visit focused on areas not covered in the desk review or needing further clarification. The activities included additional document review; a file review of denials, appeals, approvals, case management, credentialing and grievances; and interviews with Partners administration and staff. Summary of EQR Results: OVERALL COMPILAINCE SCORES- REVIEW Not Evaluated, 13.81% Not Applicable, 0.55% Not Met, 2.21% Partially Met, 12.15% Met, 71.27% *Data from NCEQR Compliance Report Page 45

47 Compliance Review Scores by Section Met Partially Not Met Not N/A Met Evaluated Administrative 100% 0% 0% 0% 0% Provider Services 63.79% 8.62% 3.45% 24.14% 0% Enrollee Services 60.98% 12.20% 0% 26.83% 0% Quality Improvement 78.57% 14.29% 7.14% 0% 0% Utilization Management 78.26% 19.57% 2.17% 0% 0% Delegation 50% 50% 0% 0% 0% State-Mandated Services 50% 0% 0% 0% 50% *Data from NCEQR Compliance Report Analysis: Overall Compliance: Partners BHM demonstrated general compliance with DMA contract requirements and Federal Regulations concerning the operations of a Medicaid PIHP. Partners Behavioral Health Management met percent of the standards for the Compliance Review. Compliance by Section: Administration: 100% of the standards in the Administration section were scored as Met. Provider Services: 63.79% of the standards in the Provider Services section were scored as Met. Because Partners BHM began the 1915(b)(c) Medicaid Waiver program on 2/1/13, no providers were due for re-credentialing at the time of the EQR. As a result some of the standards were scored as not evaluated. Partially Met and Not Met scores were in the areas of credentialing, adequacy of the provider network, clinical practice guidelines for behavioral health management and practitioner medical records. Enrollee Services: 60.98% of the standards in the Enrollee Services section were scored as Met. Standards scored as Partially Met were related to incomplete information on member s rights and responsibilities, member education and grievances. Standards related to the health plan conducting an annual survey of enrollee satisfaction were scored as Not Evaluated because the health plan is not required to conduct the survey. Quality Improvement: 78.57% of the standards in the Quality Improvement section were scored as Met. Standards scored as Partially Met were related to lack of information in the QM Program Description regarding monitoring provider compliance with clinical practice guidelines and deficiencies in the documentation of performance measures. One standard was scored as Not Met due to the lack of development of a Quality Improvement work plan. Utilization Management: Page 46

48 78.26% of the standards in the Utilization Management section were scored as Met. Standards scored as Partially Met were related to documentation in the UM Plan and documentation and process for medical necessity determinations, denials, and appeals. One standards was scored as Not Met due to lack of documentation regarding quotas for the number or percentage of claims denials. Delegation: 50% of the standards in the Delegation section were scored as Met. One standard was scored as Partially Met which was related to delegation oversight. State-Mandated Services: Partners provides all of the services and benefits specified in the contract. As this was Partners BHM s first EQR, the standard for addressing deficiencies in a previous EQR was scored as Not Applicable. Interventions Implemented: Partners BHM was required to submit a Corrective Action Plan (CAP) addressing standards that were scored as Partially Met or Not Met. The CAP was submitted and accepted by CCME. Partners BHM s implementation of the CAP will be reviewed by CCME during the next EQR scheduled for August. Partners BHM will ensure that all items in the CAP are implemented prior to the next EQR. With all deficiencies from the EQR addressed, it is the expectation that Partners BHM will have a higher overall compliance score for the EQR. QUALITY IMPROVEMENT ORGANIZATION (QIO)-LIKE CERTIFICATION In order to perform the medical and utilization review functions set forth in its contract with the North Carolina Department of Health and Human Services, Partners BHM must obtain certification as a QIO-Like Entity. The review and certification for QIO-Like status is performed by the Centers for Medicare & Medicaid Services, Center for Clinical Standards & Quality. Partners BHM was first certified as a QIO-Like Entity in October 2012 for three years. In April Partners was notified that the eligibility requirements had been revised and Partners would be expected to re-apply for certification in accordance with the new requirements at the end of the current certification period (October ). As a result of the revised requirements an entity granted QIO-Like status would be certified for a period of five years instead of three years. Partners BHM completed and submitted the application for certification in January. Partners was notified 8/4/15 that the request for certification had been granted for five years. URAC One of the qualifications for being a LME/MCO in North Carolina is to obtain and maintain accreditation with a nationally recognized accrediting organization. Partners BHM chose accreditation with URAC. Page 47

49 Partners was originally accredited by URAC in 2012 for three years. Partners submitted its application for re-accreditation and supporting documentation for the desk review in April. The desk review was completed in June with virtual on-site scheduled for August. Results will be reported in the evaluation. ORGANIZATIONAL QUALITY ACTIVITIES PLAN (OQAP) One of the issues identified in the EQR was that Partners BHM had not developed a quality improvement work plan. As a result the QM Department developed the Organizational Quality Activities Plan (OQAP). The OQAP contains the informal quality improvement activities conducted throughout the organization. These activities include: Partners BHM s Strategic Goals Partners BHM s Local Business Plan EQR Recommendations Internal Performance Improvement Plans QM & Compliance Goals OQAP Status SFY - Goal Ensure Partners BHM s Stability as a managed care organization (Partners BHM Strategic Goals) Develop and enhance the overall culture of Partners BHM (Partners BHM Strategic Goals) Measure success of MCO/Network through consumer outcomes and provider performance (Partners BHM Strategic Goals) Enhance Partners BHM s value to the communities served (Partners BHM Strategic Goals) Ensure consumers are transitioned safely and effectively into independent living in the community from an assisted living facility or long-term psychiatric hospitalization (Partners BHM Local Business Plan) Reduce the utilization rate of emergency department (ED) visits for Medicaid behavioral health consumers (Partners BHM Local Business Plan) Ensure ACCT and Supported Employment providers demonstrate growth-oriented outcomes with consumers for consumers involved in Transition to Community Living (TCL) (Partners BHM Local Business Plan) Ensure PRTF providers are outcome driven and family focused (Partners BHM Local Business Plan) Ensure the accuracy of the Registry of Unmet Needs (Partners BHM Local Business Plan) Ensure consumers leaving Inpatient or Facility-Based Care (FBC) are seen for aftercare within seven days (Partners BHM Local Business Plan) Decrease overutilization of Intensive In-Home and Therapeutic Foster Care Services (Partners BHM Local Business Plan) Improve timely submission of NC-TOPPS Providers (Partners BHM Local Business Plan) Status Completed On-going On-going On-going On-going On-going On-going On-going On-going On-going On-going On-going Page 48

50 Revise/Develop policies and procedures to incorporate EQR recommendations (EQR Recommendations) Revise committee charters and/or documentation to incorporate EQR recommendations (Partners BHM Local Business Plan) Ensure implementation of QIP interventions (EQR Recommendations) Log and track all organization initiatives (EQR Recommendations) The Denial letter for Non-Medicaid needs to be revised to explain how a consumer will request an expedited appeal (Internal Performance Improvement Plan) Overall assessment of services delivered to Partners BHM to ensure that the intensity matches the severity of the clinical conditions and that consumer receive services according to evidence based practices (Internal Performance Improvement Plan) Develop a written departmental resource plan (QM & Compliance Department Goals) Ensure increase awareness of department functions and effectiveness Develop and implement an internal and external communication plan Develop a department-wide training plan *Data from OQAP SFY - Completed Completed Completed Completed Completed On-going Completed On-going On-going Completed AUDITS The scope and content of the QA/QI Program is designed to continuously monitor, evaluate and improve the care and services provided to consumers and providers. One of the tools Partners BHM utilizes to complete these activities is the audit. There are variety of audits that are completed by Partners BHM during the course of the fiscal year. The purpose of audits is to ensure compliance with URAC standards, Partners BHM policies, procedures and Program Plans/Description, DMA Clinical Coverage Policies, Service Definitions for State-Funded Services, NC Innovations Technical Guide, and/or Department of Health and Human Services (DHHS) and Division of Medical Assistance (DMA) contract requirements for specific LME-MCO functions. Grievance Audit Goal: 90% or higher audit compliance with URAC standards and DHHS/DMA contract requirements (URAC Standard: CORE 35) 100% 95% 90% 85% 98% 98% Grievance Audit Results By Quarter Benchmark: 90% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) 95% 92% % Compliance Benchmark *Data from the Quarterly URAC Performance Dashboard Report SFY - Partners BHM met the goal of 90% audit compliance for all four quarters SFY -. Page 49

51 Will maintain 90% audit compliance for new fiscal year. SAR Process Audit Goal: 90% or higher audit compliance with URAC Health Utilization Management Standards and DHHS/DMA contract standards (URAC Standard: HUM 7-32) SAR Process Audit Results By Quarter Benchmark: 90% 110.0% 100.0% 90.0% 80.0% 99.6% 99.6% 98.8% 100% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) % Compliance Benchmark *Data from the Quarterly URAC Performance Dashboard Report SFY - Partners BHM met the goal of 90% audit compliance for all four quarters SFY -. Will maintain 90% audit compliance for new fiscal year QM is in the process of redesigning this audit process to increase accuracy and decrease duplication. Customer Services Call Center Goal: 90% or higher audit compliance with URAC Call Center standards and DHHS/DMA contract requirements (URAC Standard: HCC 3-22) Call Center Audit Results By Quarter Benchmark: 90% 120% 100% 80% 60% 40% 20% 0% 100% 99% 97% 0% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) % Compliance Benchmark *Data from the Quarterly URAC Performance Dashboard Report SFY - Page 50

52 Partners BHM met the goal of 90% audit compliance for three of four quarters SFY -. No audit was completed during the third quarter. Will maintain 90% audit compliance for new fiscal year QM is in the process of redesigning this audit process to increase accuracy and decrease duplication. Appeals Audit Goal: 90% or greater audit compliance with URAC Heath Utilization Management and DHHS/DMA contract requirements related to appeal of service authorization request denials (URAC Standard: HUM 33-41) Appeals Audit Results By Quarter Benchmark: 90% 110% 100% 90% 80% 93% 97% 99.5% 99% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) % Compliance Benchmark *Data from the Quarterly URAC Performance Dashboard Report SFY - Partners BHM met the goal of 90% audit compliance for all four quarters SFY -. Will maintain 90% audit compliance for new fiscal year QM is in the process of redesigning this audit process to increase accuracy and decrease duplication. Credentialing Audit Goal: 90% or greater audit compliance with URAC credentialing standards (URAC Standard: HN-CR 1-17) Credentialing Audit Results By Quarter Benchmark: 90% 110% 100% 90% 80% 100% 100% 100% 100% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) % Compliance Benchmark *Data from the Quarterly URAC Performance Dashboard Report SFY - Page 51

53 Partners BHM exceeded the goal of 90% audit compliance for all four quarters SFY -. Will maintain at least 90% audit compliance for new fiscal year QM is in the process of redesigning this audit process to increase accuracy and decrease duplication. CVO Delegation Audit Provider Network conducts audits of the credentialing functions performed by Medversant/Smoky Mountain LME-MCO on behalf of Partners BHM (Core 9; HN-CR17) Goal: The 95% audit compliance in regard to delegated functions URAC Standard: Core 9: HN-CR 17) % 95.00% 90.00% CVO Delgation Audit Results by Quarter Benchmark: 95% 98.29% 97.78% 93.16% 93.24% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) % Compliance Benchmark *Data from the Quarterly URAC Performance Dashboard Report SFY - The goal of 95% audit compliance was met for two of four quarters of SFY -. The two quarters that were below compliance involved Medversant delegation activities. As of November credentialing application processing and primary source verification has been delegated to Smoky Mountain LME-MCO Interventions: Medversant was required to credit Partners BHM a percentage of the total monthly invoice fees for the time they did not meet performance expectations. Smoky Mountain will continue to perform delegated credentialing functions. Smoky Mountain will maintain a 95% audit compliance. PCP Audit Goal: 90% audit compliance with PCP Instruction Manual requirements for PCPs submitted by providers as supporting documentation for service authorization requests (PCP Instruction Manual) Page 52

54 Provider PCP Audit Results by Quarter Benchmark: 90% 110% 100% 90% 80% 97% 99.5% 99% 100% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) % Compliance Benchmark *Data from the Quarterly URAC Performance Dashboard Report SFY - The goal was exceeded during all four quarters SFY - The audit process is currently under re-design. As PCPs are reviewed by Partners BHM staff during the UM process and during provider monitoring, this audit is one that is being looked at for phasing out due to duplication. Individual Support Plan (ISP) Audit Goal: 90% audit compliance with ISP development requirements (NC Innovations Technical Guide; DMA Clinical Coverage Policy 8-P) ISP Audit Results by Quarter Benchmark: 90% 150% 100% 50% 0% 0% 99% 98% 97% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) % Compliance Benchmark *Data from the Quarterly URAC Performance Dashboard Report SFY - No audit was conducted during 1 st quarter SFY - The goal of 90% audit compliance with ISP development requirements was exceeded for all three quarters SFY - that audit was completed. The audit process is currently under re-design. As ISPs are viewed by UM at least annually and by provider network during the routine monitoring process this audit is one being considered for phase-out. Page 53

55 Mental Health/ Substance Abuse (MH/SA) Care Coordination Audit Goal: 90% audit compliance with the MH/SA Care Coordination activity requirements (MH/SA Care Coordination Program Description) MHSA Care Corrdination Audit Results by Quarter Benchmark: 90% 110% 100% 90% 80% 100% 94% 94% 90% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) % Compliance Benchmark *Data from the Quarterly URAC Performance Dashboard Report SFY - The goal of 90% audit compliance was met or exceeded for all four quarters SFY -. Will continue to meet audit compliance goal for SFY QM is in the process of redesigning this audit process to increase accuracy and decrease duplication. Intellectual Developmental Disabilities (I/DD) Care Coordination Audit Goal: 90% audit compliance with IDD Care Coordination activity requirements (NC Innovations Technical Guide; Clinical Coverage Policy 8-P) IDD Care Coordination Audit Results by Quarter 120% 100% 80% 100% 96% 98% 98% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) % Compliance Benchmark *Data from the Quarterly URAC Performance Dashboard Report SFY - The goal of 90% audit compliance was met for all four quarters SFY -. Will continue to meet audit compliance goal for SFY The audit process is currently being re-designed. This audit will continue but the tool will be revised to improve quality and accuracy of the auditing process. Page 54

56 Personnel File Audit Goal: 90% audit compliance with URAC standards related to staff qualifications and management (URAC Standard: CORE 25-32) 110% 100% 90% 80% 100% Personnel File Audit Results Benchmark: 90% 99% SFY: SFY: - % Compliance Benchmark *Data from the Quarterly URAC Performance Dashboard Report SFY - All Partners BHM personnel files are audited annually The goal of 90% audit compliance was exceeded for SFY -. Will maintain 90% audit compliance for SFY CLINICAL STAFF PERFORMANCE MONITORING To ensure that clinical staff performing utilization management and health call center are complying with documented program operations and tools, supervisors regularly review work produced by each individual staff member through inter-rater evaluations and quality audits. Utilization Management Inter-Rater Reliability Testing (IRR) IRR testing is to be completed at a minimum of every 3 months involving a different service for each testing. If score falls below 85% a retest is completed within 30 days. Goal: Maintain an 85% or greater average test score (URAC Standard: Core 29b) IRR Test Results SFY - Red highlight indicates score below 85% benchmark Date Service Average Score September Partial Hospitalization 97% March Therapeutic Foster Care 76% April Therapeutic Foster Care- Retest 96% April Community Support Team 96% June Contract Peer Reviewers 81% *Data from Utilization Management Department Page 55

57 No test results for December Benchmark score of 85% was not met for Therapeutic Foster Care IRR. Staff was retested in April and met the benchmark with a score of 96%. Benchmark sore of 85% was not met for Contract Peer Reviewers IRR completed in June. It was determined by UM that the test for Contract Peer Reviewers was flawed and a revision, now using case scenarios instead of old cases for the review, was completed. The IRR using the revised tool was completed in July with a score of 100%. Will continue to complete IRR testing at least every 3 months. Will maintain an IRR score of 85% Customer Services Call Center Inter-Rater Reliability Testing (IRR) For call center staff IRR is completed at least twice per year. If individual staff cannot meet the 85% benchmark the following is implemented: Score Between 70%-84%: One additional re-test Score Below 70%: Staff member requires additional training and then re-testing Goal: Maintain an 85% or greater average test score (URAC Standard: Core 29b) IRR Test Results SFY - Benchmark: 85% % 90.00% 92.22% 97.78% 87.22% 97.78% 80.00% 70.00% IRR-1 IRR-1 Re-test IRR-2 IRR-2 Re-test Average Score Benchmark The average scores for the IRR testing met the benchmark of 85%. IRR Test 1: 18 Customer Services staff completed the IRR with four staff scoring below 85%. 11 staff completed IRR with a score of 100%. Three staff completed IRR with a score of 90% The four staff with scores below 85% were retested with three scoring 100% on the retest and one scoring 90%. IRR Test 2: 18 Customer Services staff completed the IRR with seven scoring below 85%. 10 staff completed IRR with a score of 100%. One staff completed IRR with a score of 90%. Page 56

58 The seven staff with scores below 85% were retested with four scoring 100% and 3 scoring 90%. Customers Services will continue to complete IRR testing at least twice per year with a benchmark score of 85%. Silent Call Monitoring The purpose of silent call monitoring is for insuring quality service is being given per telephone screenings and interactions with consumers, potential consumers and their families or significant others. Silent call monitoring also ensures that all telephone interactions are conducted in a professional manner and to provide supervision and direction to call center staff in a timely manner. Supervisors monitor at least 2 calls on each employee monthly. Goal: Maintain an average score of 85% for silent call monitoring (URAC Standard: Core 29b) Silent Call Monitoring Results SFY - Benchmark: 85% 110.0% 100.0% 90.0% 80.0% 70.0% 99.4% 99.6% 99.5% 98.0% 1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) Average Score Benchmark The goal of an average test score of 85% was met for all four quarters of SFY -. No individual staff scores fell below the 85% benchmark for all four quarters. Customer Services will continue with silent call monitoring for SFY Will maintain goal of 85% test score on all calls monitored. INFORMATION CONFIDENTIALITY & SECURITY MONITORING Partners BHM employees, committee members, board members and services providers within the network are all responsible for maintaining the confidentiality and security of Protected Health Information (PHI). Compliance with Partners BHM Policy & Procedure, State confidentiality rules and HIPAA Privacy and Security rules are monitored on a routine basis. Page 57

59 SECURITY INCIDENT RESPONSE AND REPORTING Partners BHM is responsible for identifying and responding to suspected or known security incidents and to mitigate, to the extent practicable, the harmful effects of substantiated security incidents. Security incidents may be internal (involving Partners staff) or external (involving providers). Goal: Ensure investigations of possible violations regarding HIPAA Privacy are completed and reported in accordance with HIPAA Privacy rules, URAC standards and Partners BHM Policy. (Core 15c) HIPAA Privacy Investigations SFY - 1 st Qtr. (Jul-Sep) 2 nd Qtr. (Oct-Dec) 3 rd Qtr. (Jan-Mar) 4 th Qtr. (Apr-Jun) New Cases Received Open Cases Carried Over from End of Prior Quarter Cases Closed Cases Substantiated Cases Remaining Open At End of Quarter *Data from Monthly Compliance Committee Reporting SFY -- HIPAA Privacy Monthly Activity Reporting The privacy violation trend identified by the HIPAA Privacy Officer was the mailing of consumer information to the incorrect address by Partners BHM staff. Barriers to Compliance: This is an on-going issue due to consumers moving frequently and current address not matching the Medicaid address in Alpha The addresses in Alpha come from the Global Eligibility System. These are the addresses consumers provide when they apply for Medicaid at DSS. In order to change the address a consumer would have contact DSS and provide them with the consumer s correct address. Corrective Action Implemented: DMA was contacted to obtain their viewpoint on this trend. DMA confirmed that if Partners BHM mails information to a consumer at their Medicaid address on file, Partners would not be in violation. If the consumer has not updated their address, any repercussions fall on them. Will continue to complete investigations and reporting as required. Goal: Ensure investigations of possible violations of HIPAA security rules are completed and reported in accordance with HIPAA Security rules, URAC standards and Partners BHM Policy. (Core 15c) HIPAA Security Activity SFY - 1 st Qtr. (Jul-Sep) 2 nd Qtr. (Oct-Dec) 3 rd Qtr. (Jan-Mar) 4 th Qtr. (Apr-Jun) New Cases Received Open Cases Carried Over from End of Prior Quarter Cases Closed Cases Substantiated Cases Remaining Open At End of Quarter Page 58

60 *Data from Monthly Compliance Committee Reporting SFY -- HIPAA Security Monthly Activity Reporting Failure to encrypt s containing PHI was the main trend identified for external cases. Failure to encrypt s containing PHI was also identified as a trend for cases involving Partners BHM staff. The main trend identified involving Partners BHM staff was the upload of documents and notes to the wrong consumer file in Alpha. Corrective Action Implemented: The HIPAA Security official for the providers involved in substantiated cases were notified of the violations so they could implement corrective action The applicable Partners BHM supervisors were notified of the violations. Re-training on HIPAA Security has been completed with staff involved in violations. The HIPAA Security Officer presented the on-going internal HIPAA issues during the May All Staff Meetings. The HIPAA Security Officer is working with provider network to start provider education regarding HIPAA Security rules. Will continue to complete investigations and reporting as required. HIPAA AUDITS In order to ensure Partners BHM staff are complying with State confidentiality rules, HIPAA privacy/security rules and URAC core standards, the HIPAA Privacy Officer and the HIPAA Security Officer complete walkthrough audits of staff workstations/offices in all Partners locations. Goal: Complete quarterly walk-through audits of staff workstations/offices to ensure compliance with confidentiality/hipaa rules. (Core 4) HIPAA Walk-Through Audits for Elkin, Hickory & Statesville 1 st Qtr. 2 nd Qtr. 3 rd Qtr. 4 th Qtr. (Jul-Sep) (Oct-Dec) (Jan-Mar) (Apr-Jun) Number of Audits Completed Number of Locations Number of Violations *Data from Monthly Compliance Committee Reporting SFY -- HIPAA Privacy Monthly Activity Reporting HIPAA Audits for New Hope & Court Drive Locations 1 st Qtr. (Jul-Sep) 2 nd Qtr. (Oct-Dec) 3 rd Qtr. (Jan-Mar) 4 th Qtr. (Apr-Jun) Number of Audits Number of Violations *Data from Monthly Compliance Committee Reporting SFY -- HIPAA Security Monthly Activity Reporting Page 59

61 One violation identified for December audits completed for New Hope Road and Court Drive locations. An employee left office door open with computer unlocked and office unattended. Employee was instructed on how to lock computer. Work order submitted to Facilities for lock on office door as there was no working lock on the door. Door lock has been installed. One violation identified for March audits completed for Court Drive location. Employee left office door open and the office unattended with documents not put away. Employee notified of findings and educated on the double lock rule for PHI. One violation identified for June audits completed for New Hope Road and Court Drive locations. A new employee s office door was left open with the office unattended. The employee s supervisor was notified of the incident and will inform the employee of the correct procedure for securing office space. Will continue with quarterly walk-through audits. Corrective action will be implemented as needed. BUSINESS CONTINUITY PLAN & DISASTER RECOVERY TESTING In order to ensure a strong infrastructure is maintained, Partners BHM completes business continuity plan and disaster recovery testing at least once every two years in accordance with Core 14(d). The goal is to complete testing of the Business Continuity plan during an eight-hour business day. The IT Department utilizes a checklist to document results of the testing. The checklist contains space to document corrective actions. Goal: Successful completion of disaster recovery testing at least once every two years. (Core 14d) The most recent disaster recovery test was successfully completed January 16, and was addressed in the evaluation. Disaster recovery testing is scheduled to take place in August and will be reported in the evaluation. Page 60