2014 Quality Management Program Highlights

Transcription

1 2014 Quality Management Program Highlights March

2 Table of Contents Quality Management Program Overview Quality Committees. 5 Data Monitoring... 6 QM/UM Plan Highlights.. 7 Access to and Availability of Care 8 Denial and Appeals Decision Timelines... 9 Monitoring Quality of Care Incident Reporting Preventive Health Highlights.. 13 Quality Management Program Goals Contact Us

3 Quality Management Program: Overview The Value Behavioral Health of Pennsylvania, Inc. (VBH-PA) Quality Management (QM) Program serves as a unifying structure for all HealthChoices quality management activities across all behavioral health services provided to members in thirteen western Pennsylvania counties. VBH-PA recognizes a responsibility to demonstrate a solid commitment to superior clinical quality and service that is consumer-focused, clinically appropriate, cost effective, data-driven, and culturally competent. This is achieved through our company-wide, systematic, and well coordinated QM Program that involves input from and coordination with all stakeholders including clients, members, providers, functional areas, and clinical staff. 3

4 Overview Each year, VBH-PA develops a comprehensive QM/UM Program Work Plan that includes a detailed set of goals and the actions necessary to achieve our goals. Measures of almost every aspect of our operation are developed and maintained. The collection of data for each measure is begun after a consistent data collection methodology has been established. This approach allows VBH-PA to track and trend progress towards achieving our goals. VBH-PA also prepares an annual QM Program Evaluation to assess the overall effectiveness of the QM Program, the strengths and accomplishments of the program, our performance across a set of clinical care and service quality initiatives, and adherence to HealthChoices standards. Based on the evaluation results, VBH-PA revises the QM Program Description annually to reflect the full scope of the Quality Program. In this 2014 Quality Management Program Summary, you will find information on our QM Program Evaluation results for 2014, as well as a description of our QM Program, including highlights of our QM Work Plan goals for

5 Quality Committees VBH-PA maintains a robust quality committee structure to aid in the oversight and implementation of its QM Program. We work in close partnership with our network participating providers, members/consumers, families, counties, oversight entities, and OMHSAS to continually improve the quality of care and services provided to our members. VBH-PA Quality Management has established Quality Management Committees (QMCs) for each Pennsylvania contract. Composition of the committees includes, at a minimum, the following representatives: Provider Representatives [Mental Health (MH) and Drug and Alcohol (D&A)] Consumer/Family Representatives County Representatives (at least one from each county) VBH-PA Clinical Representative VBH-PA QM Director and Quality Staff Department of Provider Relations Contractual Oversight Representative The Committees meet regularly throughout the year to review monitoring reports and updates on current activities underway. 5

6 2014 QM Program Evaluation: Data Monitoring As part of the Quality Management Program and Evaluation, we track our progress in meeting our goals. Some of the data VBH-PA monitors include: Utilization trends and patterns Risk management for critical incidents, complaints, and quality of care Preventative behavioral health services Evaluation of the quality effectiveness of internal processes Assessment of satisfaction from members and providers Evaluation of quality and performance of the provider network Coordination with primary healthcare Status updates on state-wide performance improvement projects 6

7 QM/UM Plan Highlights Member Satisfaction VBH-PA assesses member satisfaction through Consumer/Family Satisfaction Team surveys and also through an independent telephonic survey through Fact Finders, Inc. In 2014, overall member satisfaction with VBH-PA was rated 96% from over Provider Satisfaction 6,000 CFST surveys and 97% from 1,000 member Fact Finders surveys VBH-PA contracts with Fact Finders, Inc. to survey providers annually and utilizes the feedback to monitor our performance and identify potential areas for improvement in provider satisfaction. In 2014, overall provider satisfaction with VBH-PA was 96% 7

8 Access to and Availability of Care VBH-PA evaluates members access to behavioral health services and care through provider capacity reporting, geo access, member satisfaction, call monitoring, and exception waivers. Our performance standard for emergent care is one hour, urgent care within 24 hours, and routine care within seven days for most services. We answered our 800 numbers for 17,391 member calls with an average speed of 15 seconds We responded to 58,532 calls on our provider lines with an average speed of answer of 29.5 seconds 8

9 Denial and Appeals Decision Timelines VBH-PA maintains ongoing systems for tracking and monitoring compliance with applicable timelines for all levels of care managed. The 2014 results were as follows: Request Type VBH-PA Timeline for Resolution Percent Processed Timely Peer Review 1 Hr/24 Hrs 100% Grievance Level I 30 Days 100% GLI Resolution Letters 5 Days 99.7% Grievance Level II 30 Days 99.7% GLII Resolution Letters 5 Days 99.4% 9

10 2014 QM Program Evaluation: Monitoring Quality of Care 10

11 Monitoring Quality of Care Quality of care and service issues and trends are those that decrease the likelihood of desired health outcomes and that are inconsistent with current professional knowledge of behavioral health. VBH-PA has a defined procedure for the identification, investigation, resolution, and monitoring of behavioral health quality of care and service issues and trends including Critical Incidents, Quality of Care Committee Referrals, and Complaints. 11

12 Incident Reporting There are various types of events that qualify as critical incidents. More severe or high risk incidents meet criteria for adverse events and are investigated and presented to the Quality Management Committee for recommendations. All incidents are tracked and trended in the Quality Department. There were 1,492 reported critical incidents in Of these, 301 met adverse criteria for full investigation and resolution Adverse Incidents PHP 5% Case Management 4% Home Based 7% Other Residential 9% D&A 12% RTF 23% Inpatient / ER 14% Outpatient 26% 12

13 Performance Improvement Project Successful Transitions from Inpatient Care to Ambulatory Care A 3 year project ( ) of all Pennsylvania Medicaid BH MCOs that will focus on members hospitalized with a MH or SA diagnosis. The topic was selected by OMHSAS. The 4 performance measures are: Reducing behavioral health readmissions (30 Days) Reducing substance abuse readmissions (30 Days) Improving medication adherence to antipsychotic medications for individuals with schizophrenia Components of discharge management planning In 2014, VBH-PA submitted a written proposal which included a barrier analysis, proposed interventions, performance indicators, and a desktop procedure for conducting the onsite chart reviews of discharge planning. Selection of the Inpatient Providers for the onsite chart review process was also completed. 13

14 Quality Management Program Goals Each year, VBH-PA formulates a QM/UM Program Work Plan that includes goals and actions that are necessary to achieve those goals. Monitors of almost every aspect of our operation are developed and maintained. The following are highlights of VBH-PA program goals for 2015: Performance Improvement Project for readmissions and follow-up after hospitalization Risk Management for Quality of Care and Critical Incidents Investigation and resolution of member complaints Increase Coordination of Care Measure satisfaction with members and providers and target opportunities for improvement Treatment Outcomes Provider Profiling for Inpatient Mental Health, BHRS, and Independent Prescribers Enhance collaboration across PH and BH Identify internal improvement opportunities 14

15 Contact Us If you have any questions or are interested in more information about our Quality Management Program, please contact: VBH-PA Quality Department (TTY: ) Value Behavioral Health of Pennsylvania, Inc. 520 Pleasant Valley Road Trafford, PA