Introduction to the New Routine Provider Monitoring Process

1. Introduction to the New Routine Provider Monitoring Process Presented by Mary T. Tripp Policy Unit Leader DHHS-DMH/DD/SAS Accountability Team Revised 3-4-14 Developed by the NC DHHS-LME/MCO-Provider Collaboration Workgroup February 2014

2. Focus of this Webinar • Streamlining Provider Monitoring • What’s New or Different • Accomplishments to Date • Continued Collaboration

3. Streamlining Provider Monitoring

4. 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

5. 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

6. We heard you!!

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

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

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

11. Routine Monitoring • Includes: • Routine Review • Post-Payment Review • State-funded and Medicaid-funded services • May be used together or separately.

12. Remember… Any of the monitoring or post-payment tools can be used at any time for targeted monitoring or investigations Incidents Complaints Quality of Care concerns

13. 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.

14. 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. 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

17. 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)

18. Semantics • 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.

19. Semantics • Health & Safety Review Tool for Unlicensed AFLs →Unlicensed AFL Review Tool • Health, Safety & Compliance Review Tool →Health, Safety and Compliance Review Tool for Initial Reviews

20. Semantics Facility (GS § 122C-3(14) • “….any person at one location whose primary purpose is to provide services for the care, treatment, habilitation, or rehabilitation of the mentally ill, the developmentally disabled or substance abusers”

21. What’s New or Different NC Provider Monitoring Process Gold Star Provider Monitoring

22. What’s New or Different Frequency: • Routine monitoring occurs on a 2-year cycle as opposed to annually.

23. What’s New or Different • The scoring and weighting of the review items has been revised.

24. What’s New or Different • Each of the following areas has a clearly defined sample size: • Incident Reporting • Restrictive Interventions • Complaints • FundsManagement • Medication Management

25. What’s New or Different • Plans of correction are used to address systemic issues rather than individual non-compliance items.

26. What’s New or Different • Unlicensed AFLs that are not under the waiver are reviewed every 2 years. • (Unlicensed AFLs under the Innovations Waiver are still required to be reviewed annually.)

27. What’s New or Different • The minimum overall passing score for routine monitoring increased to 85% from 75%.

28. What’s New of Different • The on-site Health, Safety & Compliance Review is done at implementation or when the program moves to a new location. • This review is not required if the service is located in a site that is licensed by DHSR.

29. What’s Been Accomplished? • Routine Provider Agency Tool reduced from 158 items to 18 items • 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

30. What’s Been Accomplished? • 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

31. What’s Been Accomplished? • Webinars have been taped as a follow-up to statewide training. • FAQs from training and the provider monitoring mailbox are posted on the Provider Monitoring web page for broad dissemination. • A confidential survey tool has been developed to obtain feedback from providers.

32. Provider Monitoring Survey • LME-MCO Compliance with Notification Guidelines • Professionalism of Review Team • Results of the Review/ Provider Performance

33. Parking Lot Issues

34. More to Do… This is a developing list of things to accomplish: • Will there be a standard monitoring report from the LME-MCOs? • Will there be a standard response to unsuccessful monitoring? • The role of national accreditation • Review and revise, as needed, the POC policy • Increase consistency and inter-rater reliability among reviewers • Advanced levels of Provider Monitoring development • Determine lead LME-MCO • More research needed on ability to do PPRs on TFC

35. Continued Collaboration

36. DHHS-LME/MCO-Provider Collaboration Workgroup Provider Organizations Janet Breeding, NC Providers Council Sally Cameron, PAC Celeste Dominguez, Benchmarks Caroline Fisher, Benchmarks Lakisha Marelli, Benchmarks Margaret Mason, NC Providers Council

37. Leslie Gerard, CenterPoint Beth Lackey, Partners Rhonda Little, Cardinal Innovations Eugene Naughton, CenterPoint Alison Rieber, Alliance Sherry Reece-Cota, Partners Carol Robertson, Sandhills Center Karen Salacki, Eastpointe Claudia Salgado, CenterPoint Onika Wilson, Cardinal Innovations DHHS-LME/MCO-Provider Collaboration Workgroup NC Council of Community Programs

38. Beverly Bell, DMA Cynthia Coe, DMH/DD/SAS Stephanie Gilliam, DHSR Vince Newton, DMH/DD/SAS Patrick Piggott, DMA Sandee Resnick, DMH/DD/SAS Nancy Rogers, DMH/DD/SAS Michael Schwartz, DMH/DD/SAS Adolph Simmons, DMA Glenda Stokes, DMH/DD/SAS Robin Sulfridge, DHSR Suzanne Thompson, DMH/DD/SAS Mary Tripp, DMH/DD/SAS PeiChi Wu, DMH/DD/SAS DHHS-LME/MCO-Provider Collaboration Workgroup DHHS Staff

39. Transparency The Key to Positive Outcomes and Accountability 39

40. Helpful Information • DMH/DD/SS Provider Monitoring link for tools, guidelines and updated information: http://www.ncdhhs.gov/mhddsas/providers/providermonitoring/index.htm • Records Management and Documentation Manual: http://www.ncdhhs.gov/mhddsas/statspublications/Manuals/rmdmanual-final.pdf • DMA Clinical Coverage Policies: http://www.ncdhhs.gov/dma/mp/ • DMH/DD/SAS Plan of Correction Policy and forms: http://www.ncdhhs.gov/mhddsas/providers/POC/ index.htm • DHSR Mental Health Licensure Section: http://www.ncdhhs.gov/dhsr/mhlcs/mhpage.html

41. Additional Information & Updates Additional background information about the DHHS Provider Monitoring Process can be found on the Provider Monitoring web page: http://www.ncdhhs.gov/mhddsas/providers/ providermonitoring/index.htm Check the Announcements page for new postings.

42. We want to hear from you!! 42

43. Questions Please send any questions or comments about the Provider Monitoring Tools or process to the following mailbox: provider.monitoring@dhhs.nc.gov Please put either “FEEDBACK” or “QUESTION” in the subject line!