Article 16 Clinic Service Delivery System. An Overview

Transcription

1 Article 16 Clinic Service Delivery System An Overview The goal of the Article 16 Clinic of Lifespire is to make our services as accessible and Individual focused as possible. Our Clinic provides comprehensive clinical services to individuals with developmental disabilities, which serve to bolster the Individuals participation in the community. Lifespire is committed to the principle that all persons with disabilities are able to become contributing members of their families and communities thereby achieving a sense of self-worth and self-actualization. It is Lifespire s aim to provide individuals with developmental disabilities the special assistance and support necessary to achieve a level of functional behaviors and cognitive skills that enable them to maintain themselves in their community in the most included and independent manner possible. The focus of the Clinic is to increase access to efficient and cost-effective supports in the community and to empower people with developmental disabilities to exercise their rights and privileges as members of the communities of their choice. The Clinic also emphasizes supporting and expanding the range of social roles that people with developmental disabilities play in their communities. If services are to be rendered in an OPWDD certified residence or in a Day program, the process is initiated after the clinic receives a letter of invitation from the CEO or designee of the organization. Referrals for Services Source of referral (Medicaid Service Coordinator for all Waiver enrolled Individuals) must send complete referral package to the clinic. The referrals must come directly from the source and not through the contractors. The package must include: For all Individuals: Completed Clinic Referral Form. Letter from the Medicaid Service Coordinator outlining the current clinic services and the providers to ensure that there is no duplication of services (ISP Addendum). Signed Consent and Payment Authorization Form Legible Photocopy of Medicaid and/medicare/private Insurance card Updated Annual Physical Examination Report Current Medication Documents and Other Relevant Medical / Medication Information 1

2 Most Recent Psychological and Psychosocial Evaluation Report Most Recent Psychiatric, Speech, Occupational, Physical Therapy Reports (If Applicable). For Individuals who will receive services in their OPWDD-certified residence: Letter of consent/agreement from the CEO or Designee (For provision of clinical services in certified residences) Individualized Service Plan (ISP) outlining the identified clinical needs of the Individual that need to be served in the Individual s residence Intake Process Lifespire staff review a complete referral package. Intake coordinator interviews the Individual and other parties involved in the care of the Individual and completes the initial recommendation for evaluation based on the presenting problems / needs of the Individual. The Medical Director or Physician Designee evaluates the Individual and makes recommendations for discipline specific evaluations based on identified needs and presenting problems (If an initial script is not available with the referral package) Evaluations are completed by clinicians for all recommended services. The evaluations will outline the need for services, previous interventions and progress if any, diagnoses, proposed intervention strategies, prognostic indicators, duration, frequency, justification for in-home services (if applicable) and direction for clinical intervention. Once all recommended evaluations are completed, the designated Treatment Coordinator completes a Comprehensive Initial Service Plan for the Individual including all clinical recommendations to be presented to the Quality Assurance Committee. Services will not begin until the Service Plan is reviewed by the Quality Assurance Committee. Quality Assurance Review The Comprehensive Initial Service Plan and all other corresponding documents are reviewed by the Quality Assurance Committee. The committee consists of the Medical Director, Clinic Director, Treatment Coordinators, Psychologists, Clinicians, and other invited members who are involved in the care of the Individuals. The review is based on: The focus of proposed (ongoing) treatment and the identified diagnoses. The correlation of the identified need and proposed intervention strategies. For ongoing services, documentary evidence of progress or lack thereof. Services being offered (proposed) that may be duplicative in nature to that is being provided at the day program or with another discipline. 2

3 Appropriateness of the proposed frequency of services in addressing the severity of condition. Appropriate documentation for provision of services in the proposed setting. The committee makes its determination based on the above conditions. Admission to the clinic will be placed on pending status if additional documentation is required. The Treatment Coordinator will then inform all parties concerned (MSC, Residence Manager, Contracted Vendor, and Program Manager) about the QA decision and the service plan will be implemented effective the date specified in the QA report. The QA will review the Individual s ongoing services at least every three months (quarterly, semiannual and annual reviews) to assess the continued need for ongoing services and the progress achieved so far. Guidelines for Treatment Frequencies 1. Acute Rehabilitation 3 times a week. Acute diagnoses with short-term objectives that can be met in 30 days. Requires immediate and intensive treatment Maximum duration for acute stage is approximately ninety days. Examples of this case include surgery, acute onset of a new diagnosis, recent injury, psychiatric emergency, etc. Additional justification must be provided if frequency needs to be increased to 4 or 5 times a week. Active Restorative / Sub acute 2 times a week Chronic or sub acute diagnoses that have short term objectives that can be met in ninety days. If goals are not met within 90 days, treatment plan continuation of services thereof must be reviewed and approved on a quarterly basis by the QA committee Must demonstrate progress towards a short term goal over course of period reviewed. Long Term Progressive or Preventative- 1 time a week Chronic diagnoses that have a short term goal which is achievable within 180 days. Goals may be a combination of restorative and preventative intervention. 1 Frequencies and durations given are offered as broad outlines. Each case will be reviewed on its own merits in terms of the necessity, frequency and duration of ongoing treatment(s). 3

4 Long term progressive intervention must demonstrate sustained progress to continue services. Individuals requiring treatment to PREVENT decline in physical condition or current functioning level. Documentation must be provided that the Individual has a diagnosis in which the loss of skills is a likely outcome of the condition, e.g., multiple sclerosis. In such cases treatment may be long term. Whenever appropriate, treatment goals should be linked to their potential functional impact, e.g., Improved gait will result in increased mobility in the residence. The QA Committee reserves the right to request additional supporting documentation for any frequency or duration of treatment that is out of the norm for the focus of treatment. Treatment Review Meetings Semiannual and Annual Review meetings are scheduled by Lifespire Treatment Coordinators. The meetings are held in the settings where the services are provided. The Treatment Coordinators will inform the members of the treatment team about these meetings and clinicians or site compliance managers representing contracted vendors are required to attend annual meetings. The Treatment Coordinators will present the ongoing progress, current service plan, and the Quality Assurance committee recommendations at this meeting. The implementation date of the recommendations also will be communicated to the appropriate parties. The Medical Director or Physician Designee will also evaluate the continued need for services annually. Whenever notified, the Treatment Coordinators will also attend the Individualized Service Plan Meetings conducted by Medicaid Service Coordinators in order to discuss the needs and progress of the Individual. Appeal Process of Quality Assurance Review Decisions Individuals or their representatives (Medicaid Service Coordinator, Parent, and Guardian) may object to (appeal) any plan of services or proposed changes made by the Quality Assurance Committee. The following procedure must be followed in addressing the process of appealing such proposals or changes. Individual and/or the representative shall submit in writing why they disagree with the recommendations no later than ten days after the notice of recommendations for changes is initiated by the clinic. The clinical service plan will otherwise be implemented ten days after the recommendations are made if there is no appeal. The appeal, any supporting document from the objecting party, Individual records, and Quality Assurance recommendations are reviewed by a discipline specific reviewer (e.g. appeal on Psychology services reviewed by a licensed 4

5 Psychologist). The reviewer makes his/her recommendations to the Quality Assurance Committee within seven days of the receipt of the appeal. The Quality Assurance Committee will review the recommendations and either approve or disapprove the appealed changes within fourteen days of receipt of the appeal. The Treatment Coordinator will convey the decision of the Quality Assurance Committee to the objecting party within two days of the decision. Should the objecting party choose to further appeal the decision, the same must be communicated in writing to the DDRO Director and then to the Commissioner of OPWDD as per the regulatory clauses outlined in Individuals and/or their representatives are encouraged to obtain a second clinical opinion, either from Lifespire or from another clinic, with the goal of establishing the need for services. Services to the Individual will follow the service plan approved by the QAC until a final resolution to the appeals process is reached within the time line outlined above. Use of Technology for Service Documentation Each clinician will be provided with a GPS enabled ipadair so that the clinician can access the Internet and run a secure custom web based application which will document the services provided. The software will consist of two files and a number of pull down lists. The Individual Master Record contains pertinent Individual information such as name, Medicaid number, and diagnostic codes for each of the approved services and the approved frequencies for each of the approved services. Data in this file will also include the date of the physician s order, the date of the last Plan Review and the service site. The service documentation file will be populated by a combination of read only fields from the Individual Master Record and user (clinician) provided data. The user provided data will be the Individual name selected from a pull down list, the type of service provided, additional diagnostic codes, additional CPT codes, duration of service (rate code) and employee name. All data used to populate this file is either read only data from the Individual Master Record, Employee data from an Employee file or data selected from pull down lists. The data of service and the start time fields will be populated automatically and unalterably with the system date and time. Clinicians will not be able to enter the data of service, the service start time nor the service end time. Software edits When a clinician creates a service documentation record, the system will compare the date of the physician s order with the date of service and reject any transaction where the difference in dates exceeds one year. The system will also compare the plan review date with the date of 5

6 service and reject any transaction where the difference in dates exceeds seven months. The system will also check the balance of the services provided during the week within the date of service falls and reject any transaction which exceeds the approved frequency for that week. The system also checks the date of service compared to the system date and rejects any transaction where the difference is greater than 87 days. The billing software has its own error trapping which checks for the 90 day rule. Contemporaneous Progress Notes As a part of each record, there will be three tabs (General, Progress Notes, and Addendum) for each discipline. To make certain that the note is contemporaneous, when a progress notes tab is opened, it will be stamped with the system date. That date will be compared with the service date previously recorded by the system for that record. Should the difference between both dates exceed 48 hours, the clinician will not be able to save the record rendering the record nonbillable. If the difference in dates is within the specified parameters, the tab will be saved as read only thereby rendering it unalterable. If there are extenuating circumstances that prevented the clinician from entering notes within 48 hours, the addendum tab can be used to complete the note with written authorization from clinic administration. Since access is by user ID and password and the tabs are read only and unalterable, the progress note is considered electronically signed. Privacy Considerations Clinicians will not have access to Individual Master Records. The names of Individuals which will appear on the transaction record pull down will be only those Individuals at the particular site where the clinician is providing the service. The system will check for a match between the site identified in the Individual Master Record and the site indicated in the clinician s user record and display only those names where there is a match. All transactions will be reviewed by Clinic Administrators. The exception is the progress note which is read only and unalterable. When that review is completed, the Clinic s designated staff will close and approve the transactions for billing. Only after the Clinic has affirmed that the transactions are correct and proper for payment will an export file be created for the billing software. Quality Assurance Requirements 6

7 The Contractor must review all documents for content and quality before sending them to Lifespire. Site Compliance Managers must be assigned to all Lifespire sites. Site Compliance Managers are required to visits every site at least one every month to ensure that all aspects of service delivery meet regulatory compliance. Site visits must include file reviews as well as file updates. Reports of site visits must be sent to the Quality Assurance Specialist. All Clinicians are required to receive an in-service on Lifespire Policies and Procedures and Documentation Guidelines along with the generally approved Orientation process as outlined in the Contractor s Quality Assurance Program. All Clinicians are also required to attend special documentation/policy trainings that will be scheduled from time to time. Corrective Actions for all deficiencies identified by Lifespire staff must be sent back to Lifespire office before the specified date outlined in the correspondence. Contractors are required to inform Lifespire about all clinician absences, substitutions, scheduling changes etc. If a Contractor is unable to place/replace a therapist at a given site, Lifespire will permanently replace the Contractor with another or will advise the Source of referral to seek alternate means of service delivery. Any service change recommendation (discontinuing therapy, increasing or decreasing frequency, and change in treatment plan etc) must be brought immediately to the attention of Lifespire Treatment Coordinator. Services Available through the Clinic We currently offer Psychology, Social Work, OT, PT, Speech Therapy, and Nutritional Counseling through our clinic. Clinic administrators and quality assurance personnel are available for all service recipients to alleviate their concerns concerning service delivery. More information can be obtained by contacting the clinic at clinic@lifespire.org. 7