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Drug Medi-Cal Organized Delivery System QUALITY ASSURANCE REQUIREMENTS

Explore training on Quality Improvement requirements for DMC-ODS services. Learn key terminology and compliance standards for County Implementation Plans. Follow the evolution and accountability chain.

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Drug Medi-Cal Organized Delivery System QUALITY ASSURANCE REQUIREMENTS

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  1. Drug Medi-CalOrganized Delivery SystemQUALITY ASSURANCE REQUIREMENTS Presented by California Institute for Behavioral Health Solutions 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  2. A THREE PHASETRAINING SERIES Phase A • Introduction to 42 CFR Part 438 Quality Improvement (QI) requirements. • Addressing QI requirements in a County plan. Phase B • Practical implementation of organizational structure and operation of the QI Committee (QIC). Phase C • Practical implementation of the QI Program in general. • Developing quality standards, analyses, reports, formulating recommendations based on findings, implications for clinical documentation, reducing audit disallowances and other related issues. CIBHS; Prepared by Stan Taubman, PhD, LCSW

  3. Learning Objectives 1. Identify key terminology related to Quality Assurance, as used in the Department of Healthcare Services (DHCS) Special Terms and Conditions (STC’s). 2. Understand and describe the relationship between federal, state and county Quality Assurance requirements for Drug Medi-Cal Organized Delivery System (DMC-ODS) services. 3. Identify required components of a Quality Assurance Plan as a component of a County’s overall DMC-ODS Implementation Plan. 4. Identify issues for Phase B and Phase C training sessions. 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  4. Evolution of the DMC-ODS Waiver • Based on Sec. 1115 of the Social Security Act • “To ensure that a continuum of care is available to individuals with Substance Use Disorders.” • Federal implementation by CMS • “CMS (Centers for Medicare and Medicaid Services) is offering a new opportunity for Medicaid demonstration projects authorized under section 1115 to test Medicaid coverage of a full SUD treatment service array in the context of overall SUD service delivery system transformation, provided participating states meet specific requirements…” Source: CMS SMD # 15-003 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  5. Evolution of the DMC-ODS Waiver • California DHCS applied for, and received approval from CMS, to participate according to a set of conditions. • Approval was based on the DHCS Special Terms and Conditions, which then became the requirements for County participation. • Counties submit Implementation Plans to DHCS for approval, which then become the requirements for local programs to become part of the County Organized Delivery System. CIBHS; Prepared by Stan Taubman, PhD, LCSW

  6. Evolution of the DMC-ODS Waiver • The 43 CFR (Code of Federal Regulations) • sets the requirements for the… • California Special Terms and Conditions • which sets the requirements for the… • County Implementation Plans • Including their sections on Quality Assurance, which set the conditions for… • County and provider level Policies and Procedures CIBHS; Prepared by Stan Taubman, PhD, LCSW

  7. Organized Delivery Systems(ODS) are Managed Care Systems • Different than Fee For Service (FFS) systems where you’re paid when you provide a service visit. • The County assumes responsibility for meeting the medical necessity of all local Medi-Cal beneficiaries seeking services. CIBHS; Prepared by Stan Taubman, PhD, LCSW

  8. Public Accountability • Social model? Medical model? Harm reduction model? Abstinence-based model? • CMS and DHCS pays for professionally recognized approaches at the service delivery level, as long as there is accountability for: • Appropriate utilization • Quality of care • Outcome effectiveness CIBHS; Prepared by Stan Taubman, PhD, LCSW

  9. Public Accountability CHAIN OF ACCOUNTABILITY • FEDERAL HHS oversees… • CMS which oversees… • CALIFORNIA DHCS which oversees… • COUNTY DMC-ODS which oversees… • PROVIDER ORGANIZATIONS which oversee… • STAFF PRACTICES 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  10. Public Accountability The HHS National Quality Strategy A national plan to improve the delivery of health care services, with three goals: • Better Care • The basis for setting quality standards and using QA to monitor their achievement • Healthy People/Healthy Communities • The basis for Outcomes Studies in QA • Affordable Care • The basis for Utilization Management in QA 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  11. KEY TERMINOLOGY & ACRONYMS • QA - Quality Assurance • QI - Quality Improvement CIBHS; Prepared by Stan Taubman, PhD, LCSW

  12. KEY TERMINOLOGY & ACRONYMS • HHS – The Federal Department of Health and Human Services • CMS – Centers for Medicare and Medicaid Services, a division of HHS • DHCS – California Department of Health Care Services Prepared by Stan Taubman, PhD, LCSW

  13. KEY TERMINOLOGY & ACRONYMS • CFR – Code of Federal Regulations • “The State Plan” – The State’s federally approved written plan for implementing CFR requirements through the State’s various Counties • STC’s – The Special Terms and Conditions, contained in the State Plan, that must be addressed in a County’s plan for participation in the DMC-ODS program 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  14. KEY TERMINOLOGY & ACRONYMS • IP - Implementation Plan – refers to the County’s overall Implementation Plan for meeting terms of the DHCSSTC’s. • PIHP – Prepaid Inpatient Hospital Plan, a component of the IP. • IA – Interdepartmental Agreement (aka Interagency Agreement, aka Intergovernmental Agreement, aka the Managed Care Contract), a contract between State and County, based on the State’s acceptance of the County’s IP • “The Contract” – another term for the IA 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  15. KEY TERMINOLOGY & ACRONYMS • QIP – Quality Implementation Plan – the QA/QI focused portion of the county’s Implementation Plan • PIP – Performance Improvement Project – the term for a corrective action plan based on QA review findings; this term tends to be used in MH services • CAP – Corrective Action Plan – essentially the same as a Performance Improvement Project; this term tends to be used in DMC ODS documents • EQRO – External Quality Review Organization, a statewide entity that reviews QA and quality service performance of County programs; issues PIP’s and CAP’s when deficiencies are found 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  16. KEY TERMINOLOGY & ACRONYMS • MCO – Managed Care Organization, basically the county department that applied for, and is implementing the IP • MCP – Managed Care Plan, not a plan document but a term that refers to the MCO • ITP – Individual Treatment Plan, (aka Individualized Client Plan) the plan for an individual client’s services, including goals, objectives and planned interventions 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  17. KEY TERMINOLOGY & ACRONYMS • DMC-ODS – Drug Medi-Cal Organized Delivery System, the county entity with responsibility for implementing services that meet the requirements of the DMC ODS waiver • MHP – Mental Health Plan, the County entity with responsibility for implementing Medi-Cal mental health specialty services that meet the requirements of the mental health MC waiver 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  18. KEY TERMINOLOGY & ACRONYMS TWO TYPES OF “PLANS” Referring to Written Documents • The State Plan • A county’s DMC-ODS Implementation Plan • A county’s Quality Improvement Plan Referring to Organizations • The State Plan • Managed Care Plan (e.g. Kaiser-Permanente) • The Kern County Mental Health Plan • The Marin County Behavioral Health Plan CIBHS; Prepared by Stan Taubman, PhD, LCSW

  19. KEY TERMINOLOGY & ACRONYMS PLANS • State Plan • IP • IA • QIP / PIP • PIHP • MCP • ITP EXERCISE: Write a paragraph, using these acronyms, that explains the relationship among these various “plans.” 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  20. QIP REQUIREMENTS WHAT MUST BE ADDRESSED IN A COUNTY’S QUALITY IMPROVEMENT PLAN? 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  21. QIP REQUIREMENTS “The DMC-ODS is a Medi-Cal benefit in counties that choose to opt into and implement the pilot program. Any county that elects to opt into DMC-ODS services shall submit an implementation plan to the State for approval by DHCS and CMS pursuant to Attachment Z.” • STC Sec. 128. 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  22. QIP REQUIREMENTS ATTACHMENT Z • The county’s template for writing a county’s overall Implementation Plan, provided by DHCS as an attachment to the STC’s. • Attachment Z includes QA/QIP requirements. 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  23. ATTACHMENT Z • PART I: In this section a county makes commitments to accept specified responsibilities • PART II: In this section the county describes how those commitments will be fulfilled 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  24. ATTACHMENT Z QIP REQUIREMENTS PART I Each county’s QIC will review the following data at a minimum on a quarterly basis since EQR site reviews will begin after county implementation. These data elements will be incorporated into the EQRO protocol: • Number of days between referral/assessment and first DMC-ODS service/follow-up appointment • A 24/7 telephone access line with prevalent non-English language(s) • Access to translation services in the prevalent non-English language(s) • Data on approved or denied authorization requests CIBHS; Prepared by Stan Taubman, PhD, LCSW

  25. ATTACHMENT ZREQUIREMENTS Access to Services. In accordance with 42 CFR 438.206, describe how the County will assure the following: • Meet and require providers to meet standards for timely access to care and services, taking into account the urgency of need for services. • Require subcontracted providers to have hours of operation during which services are provided to Medi-Cal beneficiaries that are no less than the hours of operation during which the provider offers services to non-Medi-Cal patients. • Make services available to beneficiaries 24 hours a day, 7 days a week, when medically necessary. CIBHS; Prepared by Stan Taubman, PhD, LCSW

  26. ATTACHMENT ZQIC REQUIREMENTS ACCESS TO SERVICES (cont.) • Establish mechanisms to ensure that network providers comply with the timely access requirements. • Monitor network providers regularly to determine compliance with timely access requirements. • Take corrective action if there is a failure to comply with timely access requirements. 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  27. ATTACHMENT Z QIP REQUIREMENTS PART II: Sec. 12 Quality Assurance “Describe the County’s Quality Management and Quality Improvement programs.” The description must include… 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  28. ATTACHMENT Z QIP REQUIREMENTS …a description of the Quality Improvement (QI) Committee (or integration of DMC-ODS responsibilities into the existing MHP QI Committee). • Composition: Who will be “ex officio” members of the QIC? • Which member will be the Chairperson? • To whom does the Chairperson report? • How often will the QIC meet? 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  29. ATTACHMENT Z QIP REQUIREMENTS …a description of the QIC • Will the QIC establish practice standards? If so, how will they be developed? • What data sources will the QIC review to determine whether or not standards have been met? • To whom will review findings be reported? • Who will develop Corrective Action Plans? 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  30. ATTACHMENT Z QIP REQUIREMENTS …a description of the QIC …will address “monitoring of accessibility of services” 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  31. ATTACHMENT ZQIC REQUIREMENTS “The monitoring of accessibility of services outlined in the Quality Improvement Plan will at a minimum include: • Timeliness of first initial contact to face-to-face appointment • Frequency of follow-up appointments in accordance with individualized treatment plans • Timeliness of services of the first dose of NTP services • Access to after-hours care CIBHS; Prepared by Stan Taubman, PhD, LCSW

  32. ATTACHMENT ZQIC REQUIREMENTS • Responsiveness of the beneficiary access line • Strategies to reduce avoidable hospitalizations • Coordination of physical and mental health services with waiver services at the provider level • Assessment of the beneficiaries’ experiences, including complaints, grievances and appeals • Telephone access line and services in the prevalent non-English languages.”

  33. ATTACHMENT Z QIP REQUIREMENTS …a description of the QIC …will address “how beneficiary complaints data shall be collected, categorized and assessed for monitoring grievances and appeals.” CIBHS; Prepared by Stan Taubman, PhD, LCSW

  34. 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW GRIEVANCES & APPEALS • Each County shall have an internal grievance process that allows a beneficiary, or provider on behalf of the beneficiary, to challenge a denial of coverage of services or denial of payment for services by a participating County. DHCS will provide beneficiaries access to a state fair hearing process… • STC #128 (f)

  35. EXAMPLES OF QI COMMITTEE DESCRIPTIONS See handouts for examples of QI Committee descriptions in the DHCS approved plans from the counties of… • LA • Marin • Riverside Exercise: Write a brief description of your program’s QI Committee in a way that addresses the Attachment Z item calling for such a description. 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  36. ATTACHMENT Z QIP REQUIREMENTS ATTACHMENT Z, #13. Evidence Based Practices “How will the counties ensure that providers are implementing at least two of the identified evidence based practices? What action will the county take if the provider is found to be in non-compliance?” 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  37. EXAMPLES OF APPROACHES TO EVIDENCE BASED PRACTICES See handouts for examples of approaches to Evidence Based Practices in the DHCS approved plans from the counties of… • LA • Marin • Riverside Exercise: Write a brief description of your how your program might approach Evidence Based Practices in a way that addresses the Attachment Z issues. 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  38. SPECIAL ISSUES • QI programs can be combined with or kept separate from a county’s Mental Health QI Program • QI programs can be operated at the level of a county, but can also be operated on a regional basis across participating counties • Special conditions for Tribal and Indian Health Providers (see STC’s) 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

  39. NEXT STEPS For a comprehensive review of currently approved DMC-ODS Implementation Plans, including their Quality Improvement components, see… http://www.dhcs.ca.gov/provgovpart/Pages/County-Implementation-Plans-.aspx CIBHS; Prepared by Stan Taubman, PhD, LCSW

  40. QUESTIONS? RECOMMENDATIONS FOR FUTURE TRAINING TOPICS? 2017 CIBHS; Prepared by Stan Taubman, PhD, LCSW

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