Quality of Care Data Collection Process Update

1. Quality of Care Data Collection Process Update Division of Medical Assistance and Division of Mental Health, Developmental Disabilities and Substance Abuse Services September 12, 2011

2. Training Agenda • Introduction • Background • Review of QOC Procedure • Data Elements/Tool • Data Flow • Independent Assessments • Q & A

3. Background • Utilization Review vendors have been sending reports on Cases of Concerns and Complex Cases seen in authorization requests to PI and DMA per contract • Concerns were sent to the LMEs for follow up • The need for a more streamlined feedback loop was identified • Reporting and follow up processes have been developed to ensure quality of care to Medicaid behavioral health recipients

4. QOC Procedures • Quality of Care (QOC) concerns are clinical and practice issues identified by UR vendors during authorization requests for Medicaid funded behavioral health services • The contract between NC UR vendors and DMA states clinical and practice issues identified by a UR vendor are to be reported to DMA on a regular basis

5. QOC Procedures • 3 types of QOC concerns • Type 1: Safety Concerns • Type 2: Complexity of Care Concerns • Type 3: Incorrect Clinical Request Concerns • Only Type 1 and Type 2 Concerns will be addressed in this data collection process

6. Type 1: Safety Concerns • Include abuse, neglect, or reported risk of suicide or harm to others without follow up by provider • UR vendor must immediately notify LME contact and send information in monthly report to DMA/QOC committee • LME must meet appropriate timeframes in responding to issue • Investigate immediate risks within 24 hours • Resolve concern within 15 calendar days • Provide resolution report within 30 calendar days

7. Type 2: Complexity of Care Concerns • Include inappropriate treatment and lack of appropriate referrals • UR vendor must notify LME of concern within 15 calendar days and send this information in monthly report to DMA/QOC committee • LME must meet appropriate timeframes in responding to issue • Investigate immediate risks within 24 hours • Begin case review within 30 calendar days • Resolve concern within 60 calendar days • Provide resolution report within 90 calendar days

8. Data Elements • Data elements on the form are based on the elements contained on the QOC Care Review Notification form • Use of the excel form is optional • Use of data elements and format is not optional • Different components of the form are to be filled out by different entities (UR vendor, LME, DHHS staff)

9. Data Flow • UR vendors complete the UR vendor portion of the QOC form for each calendar month and send it to the QOC email address by the 15th of the following month • DMH staff will compile the data and will send each LME and the DMH LME Team representative a backup copy of the data for the responsible LME.

10. Data Flow Continued • Each LME will complete the LME response portion of the form for each calendar month and send it to the QOC email address by the 15th of the following month • Each LME will send the UR Vendors the LME portion of the form for the cases that UR vendor is responsible for by the 15th of each month. Please note that cases will have varying resolution times within the timeframes for Safety (Type 1) and Complexity of Care (Type 2) concerns.

11. Data Flow Continued • The QOC committee will review the data and cases on a monthly basis. • DMH staff will document the QOC follow up on the form. ☼Please note that UR vendors will continue to submit the case summary to the LME, DMA Program Integrity and the DMA staff currently receiving the QOC concerns.

12. Pilot Program • Data collection was piloted with 4 LMEs beginning July 1, 2011 • Data collection will go statewide on October 1, 2011

13. Lessons Learned • UR Vendors must continue to send the QOC summary to the LMEs. • UR vendors send the data and the QOC Summaries to DMA.QOC@lists.ncmail.net via ZixMail. • DHHS will send the data to the LMEs. • QOC and Independent Assessments are two different processes!

14. New Material

15. Type 3 QOC Concerns • QOC Committee to define benchmarks for authorization denial rates • State’s Medicaid UR vendors shall provide data re: providers denial rates • QOC Committee will contact the LME • LME to • conduct a clinical chart review • report back within 45 days

16. Type 3 Clinical Chart Review • Quality of the clinical assessment • Based on the assessment, review the PCP to determine: • Level of care is appropriate • Appropriate referrals have been made • For services • For additional evaluations/assessments • To informal supports • Services ordered are • In accordance with (IAW) DMA Clinical Policy 8A • in accordance with PCP guidelines • consistent with best practice guidelines

17. Type 3 Clinical Chart Review • LME determines disposition of review • Technical assistance to the provider • Require a Plan of Correction • Refer for further monitoring/investigation • LME Targeted Monitoring • DMA Program Integrity • DMHDDSAS Accountability • DHSR Mental Health Licensure • DSS Licensure • Withdraw endorsement • Results of the review are reported to DMA Program Integrity for tracking

18. Independent Assessment Law Session Law 2010-31, Section 10.36 • Subsection (a) • requires that an initial assessment or continuing need reassessment be completed for Medicaid recipients…prior to the delivery of an enhanced mental health service • Subsection (b) • if the cost savings are not realized in implementing Subsection (a), the DHHS shall additionally require targeted independent assessments • In both cases, the assessor shall recommend the type and amount of service to be delivered based upon the needs and condition of the recipient

19. Independent Assessment Law • Subsection (a) • Covered by current practice • DMA Clinical Coverage Policy 8A • comprehensive assessment of an individual’s needs • determination of medical necessity prior to service delivery • Subsection (b) • Level of Care Review

20. Level of Care Review • Medicaid recipients identified by the UR vendor & referred to LME Care Coordination • Criteria: individuals receiving services beyond benchmark identified or for whom services are requested to continue beyond benchmark • ACTT - 18 months • PSR - 18 months • IIH - 6 months • Day Tx - 6 months • MH/SA TCM - 7 months • Out of home placement - 12 months • Out of state placement - initial submission; 12 months

21. Level of Care Review • LME Care Coordination review • Has the individual had an assessment within the past 6 months? • If yes, then licensed LME staff shall review the assessment • If no, determine type of assessment indicated & refer • Review of existing assessment • Recommendations NOT been implemented • All recommendations implemented

22. With Existing Assessment • Recommendations NOT been implemented • LME staff shall assist the recipient in obtaining all necessary referrals • All recommendations implemented • LME staff shall review documentation to determine whether current services meet the needs of the individual • If services continue to be clinically indicated, LME staff shall assist the current provider and the recipient in reviewing the PCP to determine whether the interventions are meeting the needs of the recipient. • If revisions to the PCP are indicated, they shall be completed utilizing the person centered planning process and/or the Child and Family Team. • If LME staff determines that there is a question whether the services are clinically indicated, LME staff shall refer for additional independent assessment.

23. Independent Assessment • Medication evaluation • completed by a psychiatrist who specializes in the age/disability of the Medicaid recipient • completed as soon as clinically indicated (based upon immediacy of need), but no later than 28 calendar days of the identification of the need for the evaluation • Full clinical assessment • must be a Comprehensive Clinical Assessment • completed (evaluation and the report) as soon as possible but no later than within 30 calendar days of the identification of the need for an independent assessment.

24. Provider Responsibilities • Assessing provider • disposition shall include the recommended type and amount MH/DD/SA services (frequency and intensity) and identify other referrals necessary • copy of the assessment to the current provider • Copy to LME involved in the referral • discuss the findings of the assessment with the LME, the current provider and the recipient.

25. Provider Responsibilities • Current provider • address all recommendations in the disposition of the assessment • assist the consumer in following up on all necessary referrals • If referral outside the current provider agency is necessary for any of the recommendations in the assessment, provider choice guidelines shall be followed.

26. Level of Care Review • LME determines disposition of review for the agency • Arrange the recommended assessment • Technical assistance to the provider • Require a Plan of Correction • Refer for further monitoring/investigation • LME Targeted Monitoring • DMA Program Integrity • DMHDDSAS Accountability • DHSR Mental Health Licensure • DSS Licensure • Withdraw endorsement • Results of the review are reported to DMA Program Integrity for tracking

27. Level of Care Review • Medicaid recipients identified by the UR vendor & referred to LME Care Coordination • Criteria: individuals receiving services beyond benchmark identified or for whom services are requested to continue beyond benchmark • ACTT - 18 months • PSR - 18 months • IIH - 6 months • Day Tx - 6 months • MH/SA TCM - 7 months • Out of home placement - 12 months • Out of state placement - initial submission; 12 months

28. Questions ?

29. DMH/DD/SAS Quality of Care website http://www.ncdhhs.gov/mhddsas/statspublications/presentations.htm