An Introduction to Routine Monitoring of MH/IDD/SA Providers by LME-MCOs through Collaboration and Transparency

1. An Introduction to Routine Monitoring of MH/IDD/SA Providers by LME-MCOs through Collaboration and Transparency Presented by theNC DHHS-LME/MCO-Provider Collaboration WorkgroupFebruary 2014 Revised 2-26-14

2. Focus of this Workshop • The Impetus for Streamlining Provider Monitoring • An Introduction to the New Tools for Routine Monitoring of LIPs and Provider Agencies • Achieving Increased Accountability and Positive Outcomes Through Partnerships

3. What happened to Gold Star, and what led to this new way of monitoring? • Waiver Expansion • Continuous Quality Improvement • Reduce Administrative Burden on Providers and LME-MCOs per Session Law 2009-451 (SB 202) • Business Practices Sub-Committee of the LME-MCO & Provider Standardization Committee

4. We heard you!!

5. Streamlining Provider Monitoring

6. What happened to Gold Star, and what led to this new way of monitoring? • Decision made to stop using Gold Star as the name of the NC provider monitoring process. • Confusion between Gold Star, the process, and Gold Star, the highest level to be achieved. • Gold Star as a term remains as the highest level achievable.

7. What happened to Gold Star, and what led to this new way of monitoring?CONTINUED • A greatly streamlined, non-duplicative, standardized process needed for local monitoring. • The Provider Monitoring Workgroup expanded to include representatives from: • NC Council of Community Programs Business Practices Sub-Committee • NC Providers Council • Benchmarks • Professional Association Council

8. Stakeholder Groups • Benchmarks • N C Council of Community Programs • NC Providers Council • Professional Association Council 8

9. Professional Association Council • Addiction Professionals of NC • Licensed Professional Counselors Assoc. of NC • National Association of Social Workers-NC Chapter • NC Association for Marriage & Family Therapy • NC Counseling Association • NC Nurses Association • NC Psychiatric Association • NC Psychological Association • NC Society for Clinical Social Work 9

10. NC Council PAC Benchmarks Individuals & Families DMA DMH/DD/SAS NC Prov. Council DHSR LME-MCOs

11. What’s Been Accomplished? • Routine Provider Agency Tool reduced from 158 items to 18 • Agency Post-Payment tools were reduced from an average of 16 to an average of 12 items • LIP Review Tools (routine, office site and post- payment) went from 63 items to 49 • Focus is on rules related to systemic trends and quality of care • Elimination of duplication by using existing data such as review of IRIS reports, review of provider policies, submitted reports

12. Quality Providers = Quality Services = Best Possible Outcomes for Individuals and Families

13. Routine Monitoring of Provider Agencies • Occurs at a minimum of every two years • Includes use of a Routine Review Tool and a Post-Payment Review. They may be used together or separately. .

14. Remember… This is about Routine Monitoring only Any monitoring or post-payment tools can be used at any time for targeted monitoring or investigations Incidents Complaints Quality of Care concerns

15. Routine Monitoring of Provider Agencies Includes: • All GS §122C MH/IDD/SA services that are not licensed by DHSR (e.g., Supervised Living, Unlicensed AFLs). • All GS §122C MH/IDD/SA services that are licensed by DHSR, but are not surveyed annually (e.g., PSR, Day Treatment, ADVP-IDD, SAIOP, SACOT, etc.). See “Licensed MH/DD/SA Services and Frequency of Surveys Conducted by DHSR Mental Health Licensure and Certification Section” in the Provider Agency workbook.

16. No Monitoring by LME-MCOs The following services are referred to the appropriate licensing agency: • Therapeutic Foster Care (Licensed by DSS under GS §131D) • Hospitals (Licensed by DHSR Acute and Home Care Licensure Section) • ICF-IID -formerly ICF/MR- (Licensed by DHSR Mental Health Licensure Section)

17. Limited Monitoring by LME-MCOs • PRTF – Post-payment and reported health and safety issues • Licensed Residential Facilities – Post-payment and reported health and safety issues • Opioid Treatment – Post-payment and reported health and safety issues

18. The Who-What &When of the Review Tools • The Routine Review Tools are used with two provider types: • LIP Review Tool is used with LIPs in a solo or group practice where only outpatient / basic benefit services are provided. • Agency Review Tool is used with provider agencies that provide any service(s) other than outpatient services exclusively. 18

19. Historical Context • Agencies have a history of Routine Monitoring, i.e. endorsement, FEM, etc. • LIPs have typically only been monitored when there were concerns or issues. 19

20. Internal Quality Assurance • Routine Monitoring is …. • ….a New Experience for LIPs • ….will only involve review of documents needed to determine the met/not met/NA status for the review tool questions • ….less anxiety-provoking when providers (LIPs and agencies) use the tool as a pre-review self-assessment. 20

21. Routine Monitoring of Licensed Independent Practitioners (LIPs) • Two Components: • LIP Review Tool • LIP Post-Payment Review Tool • Other Specialized Tools • Office Site Review Tool • Service Plan Checklist

22. Routine Monitoring of Provider Agencies • Two Components: • Routine Tool • Post-Payment Review Tool • Other Specialized Tools • Unlicensed AFL Provider Review Tool • Health, Safety and Compliance Review Tool

23. Routine Monitoring of LIPs and Provider Agencies • Common Elements: • Rights Notification • Service Availability • Coordination of Care

24. Additional Element for LIPs • Storage of Records

25. Additional Elements for Provider Agencies • Incidents • Restrictive Interventions • Complaints • Protection of Property (as applicable) • Funds Management (as applicable) • Medication Review (as applicable)

26. Specialized Tools for LIPs • LIP Office Site Review Tool • Service Plan Checklist

27. Specialized Tools for Provider Agencies • Unlicensed AFL Review Tool • Health, Safety and Compliance Review Tool

28. Routine Review Tools For LIPs And Provider Agencies

29. How to Navigate the Excel Workbook andClinical Coverage Policies 29

30. Both the Routine Tool for LIPs and the Routine Tool for Agencies look at some of the same elements

31. Rights Notification

32. Item 1: There is evidence that the individual or LRP has been informed of their rights.10A NCAC 27D .0201. LIP and Agency Tool Sample is 10 events (solo LIP ), 30 service events (Agency/Group LIP Practice) Notification includes: • Rules to be followed and possible penalties. • How to obtain a copy of one’s service plan • Information received within 3 visits or 72 hours (for residential) • How to contact Disability Rights North Carolina • All areas above must be met to rate this item “Met”

33. Item 2: The individual has been informed of the right to consent to or to refuse treatment. 42 CFR 438.100 (Enrollee Rights), G.S. 122C-57(d); 10A NCAC 27D .0303 (c)LIP and Agency Tool Sample is same 10/30 service events as in Item 1 • Review documentation indicating the individual or LRP has been informed of the right to consent to or refuse treatment. • Signed consent must be present for each record in the sample to rate this item “Met”

34. Item 3: The individual is informed of right to treatment, including access to medical care and habilitation, regardless of age or degree of disability. G.S. 122C-51LIP and Agency Tool Sample is same 10/30 service events as in Item 1 • Must specifically inform, in writing, of right to Tx, including access to medical care and habilitation, regardless of age or disability. • Right to an individualized written treatment plan and right to access medical care. • All records in the sample must have the above to rate this item “Met.”

35. Item 4: The individual has been notified that release/ disclosure of information may only occur with a consent unless it is an emergency or for other exceptions. G.S. § 122C-55 or in 45 CFR 164.512 of HIPAA. 10A NCAC 26B .0205 LIP and Agency Tool Sample is same 10/30 service events as in Item 1 • Confidential information may not be released without written consent except in the case of an emergency. • Each element of the required notice listed in Statute must be explained in writing or verbally, but individual must sign that they have been explained. • Each record in the sample must have the above to rate this item “Met.”

36. Item 5: Authorizations to release information are specific to include [the items below]. 10A NCAC 26B .0202LIP and Agency Tool Sample is the same 10/30 service events as in Item 1 • Individual’s name • Name of facility releasing information • Name of individual(s), facility(ies) to whom information is released • Specific information to be released • Purpose of the release

37. Item 5: Authorizations to release information are specific to include [the items below]. 10A NCAC 26B .0202CONTINUED • Length of time consent is valid • Statement that consent can be revoked • Date consent signed • Must include a statement regarding the protection of HIV and SA information and disclosure requirements under 42 CFR Part 2 • Each record in the sample must include authorizations with all elements to rate this item “Met.”

38. Coordination of Care / Service Availability

39. Item 6: There is documentation that coordination of care is occurring between providers involved with the individual. CCPs 8A through 8P (8C 7.2.2 for LIPs)LIP Tool & Item 10 on Agency Tool Sample is same 10/30 service events as in Item 1 • Coordination of Care requirements vary per service definition • Evidence must be written • Common requirements include but are not limited to: case management; coordination with medical, psychiatric or other providers; coordination in crisis or discharge planning; participation in child & family teams • If individual does not agree to contacting other providers, refusal must be documented.

40. Item 7: Access to behavioral health crisis services is available 24/7/365 and provided directly by the agency or through written arrangements. – CCP 8A, 8C 7.4 LIP Tool& Item 11 on Agency Tool Sample is same 10/30 service events as in Item 1 • Providing 24/7/365 per service definition • Documentation will vary: first responder procedures and staffing logs, written arrangements with other entities for crisis services; notification to individuals of how to access services in a crisis

41. Storage of Records

42. Item 8: The LIP complies with HIPAA/Confidentiality requirements by ensuring privacy and secure storage of records. APSM 45-2 Chapter 2-7 through 2-9LIP Tool Review Policy Accessible only to authorized personnel Stored and transported securely Review Site Physical records stored securely Electronic records accessible only to authorized users Portable devices containing PHI are encrypted

43. End of the LIP Routine Monitoring Tool

44. The following slides are additional items on the Agency Tool Note: • The numbering of the items in this and subsequent sections reverts back to the Agency Tool

45. Incidents, Restrictive Intervention & Complaints

46. Item 6: Level I incidents were classified appropriately and reported in accordance with10A NCAC 27G .0602(3), 10A NCAC 27G .0103(b)(32) and 10A NCAC 27G .0604.Agency Tool Sample is 10 Level I Incident Reports • The reviewer is able to go back up to 1 year in order to obtain the sample. • Determine if each incident was classified appropriately • Incidents related to med errors, restrictive intervention or search and seizure must be included in Level I quarterly report. If not, technical assistance will be provided. • If NO incidents, item is rated “N/A.” • All incidents must be classified correctly to rate this item “Met.”

47. Item 7: For all Level II and Level III incidents reported, follow-up was conducted and recommendations were implemented in accordance with 10A NCAC 27G .0603 - .0604.Agency Tool Sample is 10 Level II and III Reports • Pre-site: Review incidents in IRIS to determine if follow-up completed and recommendations implemented. • On-site: Review provider documentation for follow-up and implementation of recommendations for outstanding Level IIs and IIIs. • Review incident log or list against IRIS to determine if all incidents were submitted. • Each incident must have been reported, follow-up occurred and recommendation implemented to rate this item “Met.”

48. Item 8: The agency's practice of restrictive interventions is in accordance with their agency policy and administrative rule. 10A NCAC 27E .0104.Agency Tool Sample is 10 Incidents of Restrictive Intervention Pre-site: • Review policy & procedure on Restrictive Intervention and determine if all elements of rule are included. • Each RI sampled must be in the submitted corresponding Quarterly Summary and in IRIS • On-site: Review RI log to ensure compliance with rule

49. Item 8: The agency's practice of restrictive interventions is in accordance with their agency policy and administrative rule. 10A NCAC 27E .0104. CONTINUED • Agency policy and procedure must meet requirements of rule; and • Each RI in sample must be conducted per policy and per elements in rule to rate this item “Met.” • This item requires 100% compliance as part of the assessment for Health & Safety

50. Item 9: The provider is responsive to complaints received per timelines in policy. 10A NCAC 27G .0201Agency Tool Sample is 10 Complaints • Pre-site: Review provider Complaint Policy & Procedure for addressing and resolving complaints/grievances (elements not in rule). There must be a defined procedure. • On-site: If there are not 10 reports, go back up to 1 year if needed. If still not 10, review the number found. • Policy & Procedure must be present and implemented in all complaints reviewed to rate this item “Met.”