Quality Improvement Program Description

Transcription

1 ABH 2013 Quality Improvement Program Description, Work Plan, and Evaluation 1 Appendix A Quality Improvement Program Description

2 ABH 2013 Quality Improvement Program Description, Work Plan, and Evaluation 2 Table of Contents Overview... 3 Program Structure... 3 Quality Improvement Projects... 5 Oversight of QI Activities by the Quality Management Committee... 8 QMC Roles, and Involvement of Representatives Objectives for Serving a Culturally and Linguistically Diverse Consumership Objectives for Serving Consumers with Complex Health Needs... 14

3 ABH 2013 Quality Improvement Program Description, Work Plan, and Evaluation 3 OVERVIEW The Quality Improvement Program at Access Behavioral Health (ABH) provides a formal mechanism whereby ABH can systematically and objectively monitor, evaluate, improve, and impact the quality, efficiency, safety, and effectiveness of care to our consumers. Through this process ABH is able to identify and focus on opportunities for improving the quality of clinical service delivery by our network of providers. The Quality Improvement program approach enables ABH to focus on opportunities for improving clinical care to our consumers, service quality, consumer safety, and customer satisfaction. The Quality Improvement plan helps ensure accountability of staff and network providers for the quality of care and services provided to ABH consumers. Access Behavioral Health maintains a network of contracted behavioral healthcare providers. The Quality Improvement Department governs the quality assessment and improvement activities of our network providers and spans the system to any function that impacts the quality of service delivered to our consumers. The ABH QI Department accomplishes this governance via internal and external monitoring of care management, utilization management, the development and maintenance of a provider network, consumer safety, and monitoring of clinical services to ensure that all consumers receive the highest quality care and service. PROGRAM STRUCTURE The Quality Improvement (QI) program is the operational structure of all ABH activities, including Quality, Care Management, Claims, Network Management and Contracting, and Reporting and Information Systems. The Quality Improvement program provides the organizational framework whereby all information and data is collected, organized, trended, and analyzed for overall system effectiveness. ABH uses a variety of monitoring systems, both qualitative and quantitative, for providing continuous quality improvement. The activities described in this plan involve all ABH staff as well as the network providers that serve ABH consumers, creating a comprehensive plan with ownership by all. The scope of the ABH QI Program is integrated with clinical and non-clinical services provided to ABH consumers; the program work plan is reviewed annually and revised according to changing needs and conditions of the behavioral health services system. The program is designed to monitor, evaluate, and continually improve the care and services to all ABH consumers and encompasses services delivered in both outpatient and inpatient settings. The methodology of the QI Program and activities includes elements of performance goals and objectives, data sources, data collection, trending and tracking of data related to performance measures, consumer satisfaction, patient safety, interventions, and services.

4 ABH 2013 Quality Improvement Program Description, Work Plan, and Evaluation 4 ABH integrates quality improvement into all functional areas. Participation in the QI program is required of all contracted network providers. All staff, practitioners and consumers are asked to participate in the quality management process through satisfaction surveys, committee meetings, and corrective action plans which are implemented as part of the overall quality plan whenever opportunities are identified. The primary goals of the Quality Management program are to ensure safe, quality, timely, and effective behavioral health services to our consumers. Improvement in these areas are measured using Health Plan Effectiveness Data Information Set (HEIDIS) information, internal quality studies, and other health outcomes data. To support ABH s mission, additional goals and areas of focus include: Ensure that reporting measures are met. Ensure a high level of HEIDIS Performance. Consistently monitor and enhance behavioral health strategies based upon clinical practice guidelines instituted by ABH and distributed to network providers. Monitor consumer and provider satisfaction to identify areas of need and opportunities for growth. Ensure that behavioral health services are culturally and linguistically diverse as required to meet the needs of our membership. Promote joint collaboration among providers in addressing safety, diversity, and outcomes. Identify consumers who require Complex Case Management through review of utilization and claims data. Ensure that a safety net of clinical services and/or effective care coordination exists to meet the needs of consumers with complex health needs. Provide objective and systematic monitoring and evaluation of the quality of care of services Monitoring to ensure that policies, procedures, laws, state and federal rules, and accepted standards of practice are maintained throughout the network Ensure that contract requirements for Quality Assessment and Performance Improvement standards are met

5 ABH 2013 Quality Improvement Program Description, Work Plan, and Evaluation 5 Assess performance and promote best practice implementation and change practice where areas of concern are identified through the monitoring and evaluation or feedback processes Pursue opportunities to continuously improve care and service provision through the incorporation of continuous quality improvement principles Utilize risk management data to attempt to anticipate potentially negative outcomes and proactively address their prevention Provide a structure for the sharing of information and the collaboration of knowledgeable parties in the improvement efforts of the organization. Ensure patient safety via monitoring, incident reviews, grievance resolution, utilization review, records reviews. Ensure a provider network with sufficiency to meet members' behavioral health service needs in all applicable levels of credentialing and specialties; including culturally, linguistically, geographically, and those with complex health needs. Ensure that timely access to services and geographic access to services fully meets or exceeds standards. ABH uses a variety of oversight and reporting systems, both qualitative and quantitative, for providing continuous quality improvement. These performance and measurement activities, described in this plan, involve all ABH staff as well as the network providers that serve ABH consumers, creating a comprehensive plan with ownership by all. QUALITY IMPROVEMENT PROJECTS ABH oversees overall system effectiveness, positive member experience, quality of clinical care, quality of service, and safety of clinical care though the following Quality Performance Projects and Activities: Performance Improvement Projects Intervention(s) Targeted Goals Measurement Period Call Center Monitoring A rolling YTD monthly average of less than 5% of all calls to the Quarterly

6 ABH 2013 Quality Improvement Program Description, Work Plan, and Evaluation 6 ABH Call Center Follow-up Within 7 Days Study Monitoring Interventions increase the rate of followup after acute care discharge for a mental health diagnosis. Annual Readmission Study Monitoring Determine risk factors for readmission in 30 days; Determine the adequacy of the system of care for clients who are at risk for readmission in 30 days; Reduce readmissions to inpatient care within 30 days by 3% per year Quarterly Trauma Informed Care System-wide Implementation (nonclinical) Steering Committee Activities To improve Organizational Readiness to implement Trauma Informed Care across the circuit Annual

7 ABH 2013 Quality Improvement Program Description, Work Plan, and Evaluation 7 Care Coordination Monitoring 100% of records indicate the client was assessed for physical health; Quarterly 100% of records where the member had a complex medical condition the record reflects coordination of mental health/medical care Quality Improvement Activities Tools Measurement Period Customer Satisfaction Press-Ganey Survey Overall 85% Satisfaction Rate Annual Incidents Provider Reporting, Review, and Corrective Action 100% of Corrective Actions will be implemented Ongoing Grievances System for receipt of grievances, review, and Provider Corrective Actions Grievances will be resolved within 90 Days Ongoing

8 ABH 2013 Quality Improvement Program Description, Work Plan, and Evaluation 8 Provider Monitoring Onsite and Desktop Reviews; Risk Assessments 100% of Provider will receive an annual Risk Assessment; 100% of Providers will receive either an onsite or desktop review annually At minimum Annually Care Management Review Patient Surveys Satisfaction rate of 5 on all surveys Ongoing OVERSIGHT OF QI ACTIVITIES BY THE QUALITY MANAGEMENT COMMITTEE The Quality Management Committee (QMC) is the governing body of the ABH QI Program and is responsible for oversight of the Quality Improvement program, along with its subcommittees. The QMC is responsible for ensuring the quality improvement processes outlined in this plan are implemented and monitored. QMC also serves as an advisory group and communication forum for all ABH Quality Improvement components and sub-committees. The QMC exists to establish, coordinate, review and monitor the operational activities of ABH including, quality management and improvement, utilization management, provider management, and other areas of operation. The QMC reviews and approves the QI description, work plan, and annual evaluation. The Quality Management Committee meets quarterly. Ad hoc meetings may be called if necessary. The Director of Quality Management and Improvement is responsible for conducting the meeting. Quality Management Committee Members include: Medical Director (designated Behavioral Health Care Practitioner) Director of Access Behavioral Health Director of Quality Management & Improvement Director of Care Management

9 ABH 2013 Quality Improvement Program Description, Work Plan, and Evaluation 9 Director of Network Management Quality Specialist(s) Care Management Staff Provider Representative(s) Claims Department Representative Consumer Representative Call Center Representative Information System Representative The authority to implement the ABH Quality Improvement Program plan is held by the QMC. The ABH Medical Director is the designated behavioral health staff member and senior consumer staff designated to oversee all components of the QI plan. The QMC is assigned oversight responsibilities to all ABH quality improvement efforts. ABH is accountable to the QMC, where quarterly reports, pertinent reports, data analysis, and recommendations or actions are put forth for consideration. This process allows ABH to routinely monitor the activities and effectiveness of the Quality Improvement program. This monitoring includes, but is not limited to: Reviewing data and reports to identify trends that may require corrective action Ensuring practitioner participation in the QI process Monitoring the implementation and effectiveness of corrective actions Determining the need for ad hoc committees Reporting conclusions and actions as appropriate to meet the goals of ABH QI. The Quality Management Committee (QMC) has responsibility for oversight of ABH s QI activities. The QMC is the decision making body ultimately responsible for implementation, coordination, and integration of all QI activities for ABH. The QMC is comprised of all departments and committees of ABH which work together as a whole to achieve program goals and objectives. The QMC s focus is on key quality outcome areas designed to improve overall system effectiveness of service delivery to ABH consumers. All components operate as a whole to create the ABH Quality Program. Each component and subcommittee operates to achieve specific objectives and processes that are operationalized through the ABH QI Program. The QMC

10 ABH 2013 Quality Improvement Program Description, Work Plan, and Evaluation 10 provides direction to all components and committees and ensures coordination between all activities of the ABH QI framework. The QMC meets at least quarterly to accomplish the goals and oversee, coordinate, implement, evaluate, and modify the overall ABH QI Work Plan. The Quality Management Committee consists of Program Components and related subcommittees if applicable are as follows: Program Component Main Activities and Responsibilities Quality Management Compliance with HEDIS Performance measures. Annual QI Work Plan Annual QI Plan Evaluation Provider Monitoring System Improvement & Effectiveness Credentialing Patient Safety Care Management Utilization Review and Management to Care Management Care Coordination Continuity of Care Network Management & Reporting Contracting Track Contracting Performance Data Improve data collection & data quality IS Data Collection Data Reporting

11 ABH 2013 Quality Improvement Program Description, Work Plan, and Evaluation 11 Claims Timely Claims Payment Claims Processing SubCommittees of QMC: Credentialing: Oversees Provider Network Credentialing Activity. Member Safety and Experience Clinical Issues Contracts Performance: Oversees tracking and trending of data for system improvement. Ad Hoc: Committees to track and trend issues as needed. QMC ROLES, AND INVOLVEMENT OF REPRESENTATIVES The QMC consists of the following voting consumers: The Director of Access Behavioral Health Care is responsible for the overall operations of Access Behavioral Health. The Director of Access Behavioral Health Care ensures that the ABH network has the capacity and capability of meeting the needs of our consumers. The ABH Medical Director is the designated Behavioral Health Care Practitioner who provides supervision and oversight to the Quality Improvement program, the Quality Management Committee, and all sub-committees. The Medical/Clinical Director reports to the Director of Access Behavioral Health Care. The Medical/Clinical director oversees the utilization review functions for the Care Management Department and the ABH Utilization Management Plan. The Medical/Clinical Director provides support and consultation to ABH and provider staff. The Director of Quality Management and Improvement is the senior level quality staff person responsible for and with the authority to manage the Quality Management Operations Plan. This role reports directly to the Director of Access Behavioral Health Care. The Director of Quality Management and Improvement coordinates the Quality Management Committee, compliance and quality monitoring activities, and other activities related to quality management of the ABH network.

12 ABH 2013 Quality Improvement Program Description, Work Plan, and Evaluation 12 The Director of Network Management and Reporting reports directly to the Director of Access Behavioral Health Care. The Director of Network Management and Reporting is responsible for ensuring that the reporting needs of the Quality Management program and the care Management program are met. The Director of network Management and Reporting collects data from a variety of sources and outs it into a meaningful format for review and analysis. The Director of Care Management is responsible for the functions and operations of the Care Management Department. This position reports directly to the Director of Access Behavioral Health Care. The Director of Care Management oversees the utilization review, utilization management and claims authorization processes for ABH. The Director of Care Management works closely with the Medical/Clinical Director in coordination of care and outreach to primary care physicians. Provider Representative(s) is responsible for aiding the network in participation in the ABH QI plan. Claims Representative: Staff responsible for processing claims and reporting on any issues or concerns identified. Information Systems Representative: Team representative(s) responsible for key outcome performance tracking systems/software, data reports and other issues as identified. Consumer Representative: Member that is a current/past recipient of behavioral health services. Call Center Representative: Responsible for reporting on all call center activities and reports. QI Specialist/Incident Coordinator: Tracks, trends incidents from the district. Reviews any pertinent issues or trends. Reviews internal quality assurance activities to include Care management department record reviews, enrollee satisfaction with services. ABH Care Coordinator: Network care coordination activities. ABH Office Manager: Completes and distributes minutes. Minutes are recorded at each meeting using a standardized format which includes topic, discussion, recommendations, follow up, and applicable graphs or associated reports. Follow up items become topics for the next meeting. All minutes are maintained in a confidential manner. The minutes are reviewed and approved at the beginning of the subsequent meeting with any changes or corrections noted. The meetings are led by the Director of Quality Management and Improvement.

13 ABH 2013 Quality Improvement Program Description, Work Plan, and Evaluation 13 OBJECTIVES FOR SERVING A CULTURALLY AND LINGUISTICALLY DIVERSE CONSUMERSHIP Access Behavioral Health addresses the cultural and linguistic needs of its members through a broad plan of outreach and education. The outreach plan is designed to educate recipients and providers about available culturally and linguistically diverse services and how to access them. The outreach plan also encourages potential recipients to inquire about services available. Access Behavioral Health provides outreach information that encourages plan consumers and other eligible recipients to seek assistance when needed, informs and educates the general population about the plan, and provides potentially eligible individuals information about enrollment in the plan. Access Behavioral Health offers educational programs that encourage preventive care as an integral part of mental health care. Access Behavioral Health provides educational programs to providers on the benefits of the program, how to assist consumers in accessing services, and education on behavioral health care treatment topics. Specific objectives include: Monitor for disparities in clinical areas; Client interviews and record reviews to understand differences in care provided; Conduct patient-focused interventions with culturally competent outreach materials that focus on race/ethnicity/language; Reduce specific health disparities when identified; Provide information and training to network providers to support culturally competent communication.

14 ABH 2013 Quality Improvement Program Description, Work Plan, and Evaluation 14 OBJECTIVES FOR SERVING CONSUMERS WITH COMPLEX HEALTH NEEDS Coordination and Continuity of Care is a function of both the Quality Improvement Department and the Care Management Department. The QI Program supports the importance of coordination of care among practitioners and providers, and strives to ensure that this process is streamlined and effective and measures activities implemented to improve coordination. Objectives ABH uses to ensure coordination of care for consumers with complex health needs includes: Provide education and training to providers on the importance of communication with other health care providers regarding the care of ABH consumers Educate ABH consumers on the importance of providing pertinent information to other health care providers that they are seeing besides a behavioral health provider. Conduct regular record reviews to assess provider communication with other health care providers Collaborate with other health care providers via the ABH Complex Case Management Policy and Procedure Ensure that members with complex health needs receive appropriate services Collaborate with staff of contracted providers to encourage coordination with medical providers END OF DOCUMENT