HealthChoices Capital Area Bedford/Somerset Franklin/Fulton
Quality Improvement/Utilization Management Program Evaluation Calendar Year 2013
Based on National Committee for Quality Assurance (NCQA) Managed Behavioral Healthcare Organizations (MBHO) Standards for Accreditation and Pa. Dept. of Public Welfare (DPW) Office of Mental Health and Substance Abuse Services (OMHSAS) Program Standards and Requirements.
This document contains proprietary information and may not be copied, duplicated, or distributed without the written authority of PerformCare
April 2014
QI/UM Annual Program Evaluation 2013 Page 1 of 205 Table of Contents Table of Contents ...... 2 Executive Summary...... 4 SECTION I ...... 8 Introduction ...... 8 SECTION II ...... 10 Components of the QI Program ...... 10 PerformCare Strategic CQI Initiatives ...... 11 SECTION III ...... 13 Overall Effectiveness of the QI Program ...... 13 SECTION IV...... 16 Activities of the QI/UM Program ...... 16 Program Structure ...... 16 Program Operations ...... 16 Inter-Rater Reliability ...... 16 CCM Documentation Audits and Live Call Monitoring of CCMs ...... 21 High-Risk or Enhanced Care Management directed at a reduction of readmissions ...... 27 Access and Availability ...... 31 Emergent, Urgent Access ...... 32 Routine Access ...... 32 Access to Initial Psychiatric Care ...... 34 Access to Best Practice (BHRS) Evaluations ...... 35 Access to Psychological Testing ...... 36 Access to BHRS ...... 37 Geographic Access to Providers ...... 44 New Service Development ...... 46 Appropriateness ...... 55 Utilization of Identified High-Volume and High-Risk Services ...... 55 Denials...... 58 Grievance Monitoring and Analysis ...... 62 Competency ...... 67 Credentialing Committee Actions and Recommendations ...... 67 Provider Profiling ...... 68 Provider Performance ...... 84 Co-occurring Competency ...... 91 Autism Competency for BHRS Providers ...... 92 Provider Education ...... 93 Treatment Record Review of High-Volume Providers...... 95 Consumer and Family Involvement ...... 99 Member Satisfaction Surveys ...... 99 Consumer / Family Satisfaction Team ...... 105 Continuity and Care Coordination ...... 106 30 Day Readmission Rates & SMI Only Readmission Rates in Mental Health Inpatient ...... 106 Ambulatory Follow-Up Rates after Hospitalization for Mental Illness ...... 109 Clinical Practice Guidelines ...... 115 Clinical Practice Guideline Measures ...... 118 DPW Physical Health-Behavioral Health (PH-BH) Joint QI Initiatives ...... 123 PH-BH Collaboration Efforts with Primary Care Physicians (PCPs) ...... 125 PH-MCO/BH-MCO Projects ...... 126 Pharmacy Initiatives ...... 128 Coordination Efforts with CYS, JPO, and Other Service Agencies ...... 129 School Coordination/Participation Report from ISPT ...... 131 Diversity and Cultural Competency ...... 134 Demographics, Penetration Rates, Top Diagnoses, and Percentage of Foreign-Language Speaking Members ...... 134 Disparities in Treatment ...... 138 Network Capacity of Spanish-Speaking Providers ...... 139 Cultural Competency Assessments of Provider Sites...... 140 QI/UM Annual Program Evaluation 2013 Page 2 of 205 Outcomes and Efficacy ...... 142 PerformCare Outcomes Monitoring ...... 142 Performance Outcomes Management System ...... 144 Community Outreach ...... 147 Member Education ...... 152 Prevention ...... 156 Domestic Violence, Smoking Cessation and Childhood Obesity ...... 160 Safety ...... 161 Quality of Care Council ...... 161 Monitoring of Critical Incidents ...... 165 Restraint Reduction ...... 168 Member Complaints ...... 172 Service Excellence ...... 178 Telephone Access and Service ...... 178 Timeliness of Routine Authorization Notices ...... 179 Claims Processing ...... 181 Administrative of Appeals ...... 184 Member Support Services ...... 187 Provider Satisfaction ...... 188 Provider Self-Service Features ...... 197 SECTION V Future Direction of the QI Program ...... 199 SECTION VI List of Tables and Figures ...... 200 APPENDIX F – PEPS Cross Reference ...... 204
QI/UM Annual Program Evaluation 2013 Page 3 of 205 Executive Summary
The Quality Improvement / Utilization Management (QI/UM) Program of PerformCare systematically monitors and evaluates the quality and safety of clinical care and the quality of service by PerformCare and network providers. Quality of care is defined as the degree to which health care services are consistent with current professional knowledge. This approach looks both outward to the provider network and inward to the provision of services by PerformCare to Members and providers.
The PerformCare QI/UM Program has been organized around ten Strategic Clinical Quality Improvement (CQI) Initiatives. These are listed below with highlights of the activities from the Calendar Year 2013: 1. Access Expanded capacity by developing alternative services for both adults and children. Worked to develop integrated service delivery models in Federally Qualified Health Centers to provide integrated PH/BH services throughout the network. Began implementation of use of the Child and Adolescent Needs and Strengths (CANS among the BHRS population as a reliable tool suitable for outcomes measure and decision-support when conducting evaluations. Developed numerous proposals for BHRS redesign of administrative processes and service alternatives. Met regularly with BHRS providers through the Account Executive structure within Network Operations to monitor initial access, service delivery and overall performance. Implemented real-time monitoring of service authorizations for BHRS (including FBA) to improve access. 2. Appropriateness Closely monitored service denial and grievance trends, achieving sustained improvement. Worked with BHRS providers on a quarterly basis to review comparative data in utilization and performance in order to improve access. Continued focus on improving communication between providers and evaluators and active adjustment in prescriptions as progress to goals is realized. Met regularly with FBMH providers to review comparative data and discuss variations in service delivery which are not supported with the fidelity of the FBMH model and/or best practice. Directed local discussion related to BHRS initial access to develop service strategies in partnership with counties and local providers. Participated in a workgroup with OMHSAS to develop Algorithms and proposed Outcomes reporting for BHR services. Improved technical assistance to providers related to initial BHRS treatment plans and conducting Functional Behavioral Assessments to guide forward progress in treatment planning. Supported the advancement of integrated care models, establishing a baseline competency for PerformCare specific to the CCISC – a Comprehensive, Continuous, Integrated System of Care model of service delivery. QI/UM Annual Program Evaluation 2013 Page 4 of 205 3. Competency Conducted 164 Quality Treatment Record Reviews in alignment with the triennial credentialing cycle; and, Increasing the average score in every level of care reviewed. Implemented treatment record reviews of BHRS exception services. 4. Consumer and Family Involvement Reviewed regular reports of CFST locally addressing areas of required action and identification of steps for improvement. As applicable, trend summaries were presented at QI/UM Committees and Credentialing Committee. ECHO Member Satisfaction Surveys are administered annually and results incorporated into the QI/UM Program. Participated in numerous of local community outreach initiatives across contracts. 5. Continuity and Care Coordination Continued actions identified in root cause analysis of follow up after hospitalization rates. Conducted root cause analysis of readmission rates in Dauphin, Lancaster and Franklin counties. Expanded case conferencing for clinical care managers to facilitate more active care management of complex cases which often lead to readmission. Conducted over 12,500 outreach calls to Members to verify follow up aftercare appointments to ensure proper transition from inpatient and implemented use of “Wellness” calls to increase Member engagement in securing outpatient treatment after discharge. Maintained compliance with quarterly reporting requirements, including the ongoing measurement of ambulatory follow-up rates after hospitalization and cost driver progress reporting. Completed performance improvement within required timeframes for all contracts on mental health measures and discontinued substance abuse measures per OMHSAS direction. Incorporated quarterly cost driver reporting of progress for MHIP, FBMH, BHRS, and RTF (according to contract). Continued efforts to support statewide initiatives related to Domestic Violence, Childhood Obesity and Smoking Cessation. Improved HEDIS measures for follow up after hospitalization services across the network in HEDIS 7-day. Increased both HEDIS and PA Specific 30 day measure results in the Capital contract. Improved inpatient readmission rates in Cumberland, Dauphin, Franklin, Lebanon, and Perry Counties. Focus on effective interventions with high-volume and high risk Members, improving active care management efforts and supportive outreach and follow up activities to this population. 6. Diversity and Cultural Competency Monitored penetration rates and treatment denials by race and county in order to prevent disparities in treatment. Monitored network capacity of Spanish-speaking providers, particularly in Lebanon, Lancaster and Dauphin counties where Member need exists. Monitored provider cultural competency assessments completed during credentialing site visits with an eye on incorporating LGBTQI.
QI/UM Annual Program Evaluation 2013 Page 5 of 205 Supported the ongoing development of consensus to enable more integrated, co-occurring treatment and participated in an assessment of PerformCare operations to support the initiative. 7. Outcomes and Efficacy Implemented use of the CANS in BHRS as a decision-support tool for evaluators. Completed the review of cost drivers identified for each contract to identify either best practices and/or opportunities for improvement; implemented interventions for progress. Worked on the development of expanded outcomes reporting functionality across all levels of care. Explore options for Pay for Performance measures to be implemented. Completed the development of quality rate setting practices for various levels of care (RTF completed; MH IP in process). 8. Prevention and Community Outreach Continued preventive behavioral health programs – Early Identification of ADHD and Improving Treatment Compliance for Adults with Depression Continued monitoring of multiple inpatient admissions and/or high volume Crisis Intervention usage as a potential quality of care concerns. Expanded the Member section of the PerformCare website to provide educational materials to Members about both physical and behavioral health issues in a Wellness Library. Improved the functionality and effectiveness of the Provider Advisory Committee. Refined Clinical Practice Guidelines measures to establish baselines in reporting. Enhanced Physical Health – Behavioral Health coordination efforts by participating in a performance improvement with a partnering PH-MCOs. Continued to explore data sharing projects with PH MCOs partners in support of Care Coordination. 9. Safety Monitored the submission of Critical Incident reporting, inclusive of all seclusion and restraint incidents through continued support of alternate reporting methods to include paper reporting, adoption of HCSIS, provider initiated report formats, and ProviderConnect. Conducted 810 Quality of Care Council reviews; incorporating a quarterly review of outliers such as high volume AWOL’s and/or restraints in RTF and Community Residential Rehabilitation (CRR HH). Implemented a Progressive Discipline process which effectively moves issues of performance and/or Member safety to Credentialing when not adequately addressed at another level. Monitored Complaint Analyses to trend by provider, by contract and network- wide for use at QI/UM and Credentialing Committee. Implement a process to monitor the use of restraints in levels of care other than RTF. 10. Service Excellence Telephone service access continued to exceed stringent performance goals. Continued to exceed the performance goal for timeliness of administrative appeal decision-making and notification.
QI/UM Annual Program Evaluation 2013 Page 6 of 205 Continued to offer the Member Handbook in Spanish, Braille, large print, and/or audiotape versions while reminding Members of interpretive / assistive services as needed when they are deaf or hard of hearing. Continued to support the functionality of e-Cura® ProviderConnect affording providers the opportunity to view authorizations and claims status, submit critical incident reports, capacity and FTE reporting on-line 24 hours a day, seven days a week. Implemented automated ISPT Scheduling process. Implemented electronic BHRS authorization process. Continue use of written QIA’s to guide Performance Improvement Projects as required by OMHSAS, IPRO and NCQA standards, allowing for identification of individual improvement projects within each contract. Satisfy the requirements outlined by the OMHSAS Program Evaluation Performance Summary (PEPS) Initiated a Transformation effort that will lead PerformCare to become a provider enhancing, value and quality enhancing organization in support of accessible and affordable, person-centered care.
All stakeholders, including Members, providers, counties, the Pennsylvania Department of Public Welfare, and PerformCare employees are encouraged to reference this QI/UM Program Annual Evaluation. PerformCare strives for transparency in its HealthChoices managed care operations. All Quality Improvement documents including this evaluation and the QI/UM Program Description are available upon request to any stakeholder.
Laurie A. Cross Director of Quality Improvement
QI/UM Annual Program Evaluation 2013 Page 7 of 205 SECTION I
Introduction
The Quality Improvement / Utilization Management (QI/UM) Program of PerformCare is evaluated annually to assess the effectiveness of the organization, to track progress in completion of QI/UM Program objectives, monitor the success of utilization management and to guide the development of the upcoming year’s QI/UM Program Description and QI/UM Work Plan. The scope of the QI/UM Program is intended to be comprehensive and integrative of all aspects of the organization. The QI/UM Program Description describes the structure and range of activities to be undertaken, and the QI/UM Work Plan outlines the specific indicators and timeframes for activities, data collection / measurement, and analysis. This annual QI/UM Program Evaluation report covers the Calendar Year 2013 for the PerformCare HealthChoices Program for the following counties with their respective oversight entities: Behavioral Health Services of Somerset and Bedford Counties, Inc. (BHSSBC) for Bedford and Somerset Counties Capital Area Behavioral Health Collaborative, Inc. (CABHC) for Cumberland, Dauphin, Lancaster, Lebanon and Perry Counties Tuscarora Managed Care Alliance (TMCA) for Franklin and Fulton counties.
Overall administration of the HealthChoices program occurs through the Pennsylvania Department of Public Welfare, Office of Mental Health and Substance Abuse Services (OMHSAS). Quality improvement, utilization management, and provider relations functions are based upon current National Committee for Quality Assurance (NCQA) accreditation standards as well as OMHSAS Program Standards and Requirements for Behavioral Health.
QI/UM Annual Program Evaluation 2013 Page 8 of 205 Table 1: 2013 Territory Enrollment
Bedford/ Franklin/ Total Month Capital Somerset Fulton Network Jan-13 144,859 16,716 18,462 180,037 Feb-13 145,895 16,844 18,651 181,390 Mar-13 145,470 16,960 18,732 181,162 Apr-13 145,996 16,974 18,861 181,831 May-13 145,927 17,019 18,933 181,879 Jun-13 146,129 17,028 18,970 182,127 Jul-13 145,509 17,027 18,930 181,466 Aug-13 146,049 16,935 18,899 181,883 Sep-13 145,429 16,864 18,934 181,227 Oct-13 146,153 16,845 19,075 182,073 Nov-13 147,102 16,930 19,155 183,187 Dec-13 146,135 16,974 19,168 182,277 Average 145,888 16,926 18,898 181,712 % of 1.60% 0.23% 1.54% 1.47% Increase
During the 2013 calendar year, the average monthly census by contract ranged from 16,926 to 145,888 resulting in a total network enrollment of 181,712; an increase of 1.47%. The percentage of increase was highest in the Capital contract with the increase at 1.60% followed by an increase of 1.54% in the Franklin/Fulton contract. A slight increase of .23% was also noted in the Bedford/Somerset contract.
QI/UM Annual Program Evaluation 2013 Page 9 of 205 SECTION II
Components of the QI Program
The PerformCare internal committee and reporting structure utilized during Calendar Year 2013 is reflected below. In order to ensure compliance with NCQA requirements, the Capital Area Quality Improvement/Utilization Management Committee serves as the lead QI/UM committee.
HealthChoices Committee Structure
AMH/PerformCare Board County Oversight Senior Management
QI/UM Capital
Credentialing Stakeholder Provider Advisory Committee Steering Committee Committee
Regional QI/UM Regional QI/UM Franklin/Fulton Bedford/Somerset
All Regional QIUM and Stakeholder Committees are considered Joint Committees of the Primary Contractor and PerformCare
QI/UM Annual Program Evaluation 2013 Page 10 of 205 For Calendar Year 2013 the PerformCare QI/UM Program continued with the identification of key initiatives of quality care and performance to drive the top-down Continuous Quality Improvement process, as described in QI/UM Program Descriptions and QI/UM Work Plans since 2003. To supplement this process, PerformCare has provided regional coverage in order to maintain a local presence with each individual HealthChoices contract. The intent is to strategically determine with stakeholders the most important quality areas of the organization and then organize the direction of the QI/UM Committee, the QI/UM Work Plan, and all subsequent QI/UM activities around these identified Strategic Quality Initiatives. The measurement of chosen indicators flows from a comprehensive philosophy and an organized approach. As needed, local areas of focus are addressed within regional work plans specific to each contract. In addition, Performance Objectives and Performance Improvement Projects are determined by contract. As a result, the 2013 QI/UM Program was organized around the following ten Strategic CQI Initiatives:
PerformCare Strategic CQI Initiatives
1. Access – The degree to which appropriate care and services are accessible and obtainable to meet the Member’s needs. 2. Appropriateness – The degree to which the care/services provided are relevant to the Member’s clinical needs, given the current state of knowledge & available resources. 3. Competency – The degree to which Providers and PerformCare associates adhere to professional and/or organizational standards of care and practice. 4. Consumer and Family Involvement – The degree to which Members and families of Members have an active role in PerformCare. 5. Continuity and Care Coordination – The degree to which needed healthcare services for a Member or specified population are coordinated across levels of care, across organizations, or across care of physical health and behavioral health. 6. Diversity and Cultural Competency – The degree to which Providers and PerformCare associates understand and demonstrate linguistic competency and show respect for differences among groups. 7. Outcomes and Efficacy – The degree to which a treatment or service improves health status. 8. Prevention and Community Outreach – The degree to which PerformCare services promote health, prevent deterioration of conditions, and educate the community. 9. Safety – The degree to which risks of adverse outcome are reduced for the Member and others, including the health care Provider. 10. Service Excellence – The degree to which PerformCare meets established service standards and produces Provider and Member satisfaction.
A primary focus for QI/UM activities is on high volume/high risk services and treatments for Mental Health Inpatient, Behavioral Health Rehabilitation Services (BHRS), and Residential Treatment Facilities. Consistent with HealthChoices requirements, activities addressed the collection of data and compliance with access standards for BHRS with actions taken for provider non-compliance. Attention is always paid to increasing Member awareness regarding the complaint and grievance process. During 2013, the continuous quality improvement focus was on improving reporting to
QI/UM Annual Program Evaluation 2013 Page 11 of 205 measure evidence based outcomes and conduct critical analysis; development of provider competencies in the areas of co-occurring disorders and autism; and the development of provider self-service features and administrative efficiencies.
Performance Improvement Projects (PIPS) focused on improving continuity of care through improving interventions to support follow up after inpatient hospitalization and related interventions. PerformCare strives to demonstrate sustained improvement over time, using ongoing measurements and interventions. PIPS have continued with favorable effects on health outcomes and Member satisfaction in both clinical and non-clinical care areas. Similarly, in review of Cost Drivers presented by OMHSAS, PerformCare has developed key clinical initiatives which are balanced and well-integrated to achieve the “Triple Aim” of improving the Member experience, improving the health of populations, and reducing the per capita cost of health care. Root cause, barrier and other types of critical analysis occur as needed to identify necessary areas of performance improvement and related initiatives.
These initiatives provide the focus for all QI/UM activities. Dimensions of Performance under each initiative are listed in the 2013 QI/UM Work Plan and outline the measures used to assess PerformCare performance. The QI/UM Program is also designed to be fully compliant with OMHSAS requirements and NCQA standard elements.
PerformCare’s strong performance is reflected in the organization having maintained Full Accreditation as a Managed Behavioral Healthcare Organization (MBHO) again on October 2, 2012. National Committee for Quality Assurance’s MBHO Accreditation evaluates how well a health plan manages all parts of its delivery system --hospitals, other providers and administrative services -- in order to continuously improve health care for its members. PerformCare maintains full NCQA Accreditation, scoring 95.67% out of 100. This accreditation is valid through October 2, 2015.
QI/UM Annual Program Evaluation 2013 Page 12 of 205 SECTION III
Overall Effectiveness of the QI Program
Resources for the QI/UM Program expanded during 2013 with the addition of an additional Psychologist Advisor with shared responsibility over Clinical and Quality Improvement functions. This position focuses on improved inter-rater reliability and integration among the departments. Current associates with direct involvement in the QI Program:
Medical Director: Cheryll Bowers-Stephens, M.D., M.B.A – Board Certified in Child and Adolescent Psychiatry, Board Certified in Neurology) Satyajit Mukherjee, MD – Board Certified in General and Geriatric Psychiatry Physician Advisors: Albert Sylvester, MD – Board Certified in General and Geriatric Psychiatry Jimmy Ibikunle’s, MD – Board Certified in Child and Adolescent Psychiatry Mayank Dalal, MD Board Certified in Forensic, General, and Child and Adolescent Psychiatry Director of Quality Improvement: Laurie Cross Capital QI/Clinical Manager Robert Nitschke Bedford/Somerset QI/Clinical Manager Allison Krause Franklin/Fulton QI/Clinical Manager Maria Bakner QM Manager: Jennifer Simonetti Complaint & Grievance Unit: Jennifer Hoffer Cassandra Neilson Katy Baum Michelle Posteraro Christie Minnick Psychologist Advisors: Jerri Maroney, Psy.D. Edward Toyer, Ph.D. Roger Beardmore, Psy.D. QM Manager: Shem Heller QM Project Manager: Bonnie Clark QM Project Manager: Genevieve Lupold QM Specialist: Melissa Reagan Rebecca Rager Andrea Kliss QI Coordinator: Colette Filliben
PerformCare continues to retain Prest & Associates, Inc., a Utilization Review Accreditation Commission-accredited independent review organization with a specialty in Psychiatry and Addictions Medicine for specialty consultation regarding quality of care issues and primarily for inpatient, residential treatment facility and partial hospitalization grievance participation.
QI/UM Annual Program Evaluation 2013 Page 13 of 205 PerformCare identified the following areas in last year’s Annual Program Evaluation as priorities, all of which were achieved as indicated:
1) Identified renewed clinical service areas for focus in Quality Improvement Initiatives to support Performance Improvement Projects as required by OMHSAS, IPRO and NCQA expectations. 2) Update measures for Performance Incentive Objectives by contract. 3) Improved HEDIS measures for follow up after hospitalization services for continued improvement throughout the network. 4) Improved access to psychiatric evaluations and continued expansion of telepsychiatry throughout the network. 5) Improved access to BHRS services throughout the network. 6) Satisfied the requirements outlined by the OMHSAS Program Evaluation Performance Summary (PEPS) – Care Management & Denials. 7) Continued to improve the functionality and effectiveness of Provider Advisory Committee as advisor to QI/UM Committees 8) Enhanced Physical Health – Behavioral Health coordination efforts and joint projects through use of pharmacy data, by maximizing alternatives to integrating data. 9) Participated in performance improvement initiatives with partnering PH MCOs in support of Care Coordination initiatives; specifically, a project related to Members with SMI in Emergency Rooms. 10) Finalized the development of Federally Qualified Health Centers to provide integrated PH/BH services throughout the network. 11) Focused effective interventions on active care management strategies for high-volume and high risk Members, improving outreach and follow up activities to this population. 12) Finalized the implementation of quality rate setting practices for RTF’s and MH IP). 13) Supported the continued advancement of CCISC – a Comprehensive, Continuous, Integrated System of Care model of service delivery as needed. 14) Encouraged the ongoing development of provider competencies to serve Members affected by autism and/or Members with co-occurring concerns. 15) Presented for consideration a treatment guideline for FBMHS. 16) Gained approval and implement strategies outlined in the BHRS re-design proposal(s). 17) Implemented the use of the CANS to support outcomes reporting for children’s services, specifically BHRS in parts of the network. 18) Renewed quality initiatives related to initial BHRS treatment planning and completion/use of Functional Behavioral Assessments. 19) Closely monitored the penetration of the Hispanic population to ensure the adequacy of services to those Members in the identified geographic areas of need. 20) Refined Inter-rater Reliability testing for clinical care managers and increase expectations for minimum scoring. 21) Expanded the source of clinical practice guidelines to incorporate more current practices, increase guidelines related to children’s services and publish guidelines related to schizophrenia. In addition, establish benchmarks based on research and accepted practice for all measures. 22) Implemented an initiative for improving discharge planning efforts in BHRS. 23) Established a process for measuring provider availability for routine services and set
QI/UM Annual Program Evaluation 2013 Page 14 of 205 minimum expectations in reporting. 24) Closely monitor the implementation of requirements for licensing of Behavioral Specialists to ensure minimal negative impact to Members in need of service. 25) Implemented live supervisory audits of CCM’s
Work has been done in the following areas; however continued focus will keep these initiatives a priority during 2014: Expand the use of provider profiling results to improve the quality of services and increase utilization as needed. Finalize Pay for Performance and/or Performance Based contracting initiatives for all contracts and implement. Improve inpatient readmission rates throughout the network.
QI/UM Annual Program Evaluation 2013 Page 15 of 205
SECTION IV
Activities of the QI/UM Program
The following is a description of QI/UM Program activities. Each Major Heading represents the ten Strategic CQI Initiatives (in addition to headings for Program Structure and Program Operations). Subheadings represent the Dimensions of Performance under each initiative.
Program Structure
QI/UM documents including the 2013 QI/UM Program Description and QI/UM Work Plan were developed and approved by the PerformCare QI/UM Committee for each contract, with subsequent submission and review by oversights (as applicable) and OMHSAS. All QI/UM Program Documents for PA Medicaid HealthChoices programs continue to follow a Calendar Year. The QI/UM Committee contributed to policy changes to strengthen progressive discipline and credentialing of providers, service authorizations to out-of-network providers, cultural competency, critical incident, administrative appeal and quality of care processes and improve fraud, waste, and abuse processes. New policies were improved and implemented to guide the delivery of peer support, TSS qualifications, CCM documentation and live call monitoring, and provider preventable conditions. PerformCare Senior Management responsible for departmental Policy and Procedure implementation also reviewed and approved the entire set of Policy and Procedures during 2013.
Program Operations
Activities of the QI/UM Program, including approval of the QI/UM Program Description, were reported annually to the PerformCare Board of Directors.
Corrective actions related to the clinical review of the Care Management portion of the 2012 Program Evaluation Performance Summary (PEPS) – standards #27 & 28 – as required by OMHSAS were completed during 2013. Corrective actions related to the Denial portion of the 2012 PEPS – standard 72 – were completed in 2013.
QI/UM Program informational summaries were updated and distributed to both Members and providers via newsletters & postings on the PerformCare website.
PerformCare has been given the opportunity to earn available funds above and beyond their administrative fee if stated objectives are met. These performance objectives are determined by each county oversight group and are specific to each contract. Refer to the appendices for contract specific detail.
Inter-Rater Reliability
The focus of the PerformCare utilization management activities is the continuous
QI Annual Program Evaluation 2013 Page 16 of 205
assessment and determination of medical necessity for behavioral health services in accordance with the approved medical necessity criteria. This assessment and determination is accomplished through the utilization management processes of preauthorization and concurrent review. The utilization management review process is designed to ensure that the type, intensity and duration of behavioral healthcare services requested and provided are medically necessary, clinically appropriate to the individual, delivered consistently and match the PerformCare Member’s behavioral health status and current needs.
In accordance with NCQA requirements, PerformCare conducts Inter-Rater Reliability (IRR) exercises to ensure and increase consistency in the application of Medical Necessity Criteria by Clinical Care Management staff (CCM) by minimizing variation in the application of guidelines. IRR exercises are conducted under the direction of PerformCare’s Chief Medical Officer and the results identify areas most in need of improvement and are used to guide the selection and development of staff education and training, clinical support, and the content of individual supervision for Clinical Care Managers as needed.
In order to ensure organization wide consistency in the application of Medical Necessity Criteria, Quality Improvement Staff (QIS) and Psychologist Advisors (PA) also participate in the IRR exercises and the data regarding their level of agreement is reviewed in a similar manner by QI supervisors and utilized to inform supervision and education for QI staff. Consistency in application between departments ensures expectations of providers are reliable and dependable in application of both quality initiatives and service authorization. Consistency among Psychologist Advisors ensures consistent direction in active care management strategies and consistent application of denials. The IRR results are also presented semi-annually to the network QI/UM Committees in accordance with PerformCare work plan.
One of the changes that had been recommended for 2013 involved increasing the target score from 60% or better to 80% or better. During the two previous years, almost 100% of average IRR rates had exceeded the expected level of 60%, with most results falling in the 70% – 75% range. Therefore, beginning in 2013, the following scale was used to assess the overall agreement:
1% - 20% 21% - 40% 41% - 60% 61% - 80% 81% - 100% Poor Slight Fair Substantial Excellent
Overall, the Inter-Rater Reliability methodology consists of the following steps:
1. Quarterly, cases are identified for review based on current initiatives regarding specific level(s) of care, informal feedback from Quality and Clinical Staff and the data from the previous quarter’s IRR exercise. Typically two children’s cases are selected from the Behavioral Health
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Rehabilitation (BHRS), Community Residential Rehabilitation Host Home (CRR-HH), Residential Treatment (RTF), or Family-Based Mental Health (FBMHS) levels of care and two adult cases are selected from the Mental Health Inpatient (MHIP), Substance Abuse Inpatient (SA) or Partial Hospitalization (PHP) levels of care. 2. The selected cases are reviewed by the Chief Medical Officer / Psychologist Advisor who then determines the appropriate level of care (using Appendix T for mental health treatment, ASAM criteria for adolescent drug and alcohol treatment, and PCPC criteria for drug and alcohol treatment of adults) and necessary follow-up activities by responding “yes” or “no” to standard questions which include: 1) Approve as requested? 2) Refer for a Physician Advisor for concern about safety, medication, dosing problems, and unreported abuse? 3) Substance abuse assessment/treatment clinically indicated? 4) Specialized referral for sexual abuse, sexual offender, eating disorder? 3. Cases are reviewed using the same medical necessity criteria identified above to determine the appropriate level of care and necessary follow-up activities by responding “yes” or “no” to the same questions noted above in step 2. 4. Response results are then compared to determine the concordance rate with that of the Chief Medical Officer / Psychologist Advisor. Percent agreement is computed for each individual rater and then aggregated across each level of care for each contract (i.e. Capital and NC). 5. The individual results are reviewed by the supervisor with the care managers and may result in education, further training, increased monitoring, or a performance improvement plan. 6. The Chief Medical Officer / Psychologist Advisor conducts a case review meeting to discuss the recommended level of care and necessary follow-up activities and leads group discussion, cross walking the specifics of the case to the identified Medical Necessity Criteria and generally accepted guidelines for treatment , support and follow-up activities. 7. The percent agreement data are graphed or charted and inspected visually to: 1) identify opportunities for increased clinical education pertaining to specific levels of care, 2) determine the need for increased support or individual supervision for specific CCM and/or 3) guide the selection of cases for the subsequent IRR exercises
During CY 2013, there were a total of 16 cases reviewed by both Capital and NC CCM. Data from the four IRR exercises conducted in 2013 are summarized separately for BHRS CCM and UR CCM by contract in the tables below. As noted above, the inter- rater reliability of each CCM is measured by agreement with Chief Medical Officer / Psychologist Advisor recommended responses.
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Table 2: IRR - Average Percent Agreement
CRR-HH BHRS FBMHS RTF Cap March -- -- 68% 80% Cap July -- 87% 69% -- Cap Sept 87% -- -- 86% Cap Nov -- 100% 88% --
NC March -- -- 77% 73% NC July -- 82% 73% -- NC Sept 95% -- -- 90% NC Nov -- 100% 85% --
Table 3: UR IRR – Average Percent Agreement
Inpatient SA Detox SA Rehab Cap March 78% -- 98% Cap July 82% -- 94% Cap Sept 77% -- 87% Cap Nov 79% -- 91%
NC March 71% -- 91% NC July 85% -- 88% NC Sept 80% -- 90% NC Nov 73% -- 88%
2013 Review: Overall, the results of testing for all levels of care have been improved over 2012 with the BHRS CCM, IRR data revealed substantial to excellent agreement with the Chief Medical Officer / Psychologist Advisor. The new target of 80% was hit or exceeded in 11 of the 16 tests for the combined Capital and North Central BHRS CCMs. The lowest levels of agreement were obtained for the FBMHS level of care. This is not unusual as the Medical Necessity Criteria used for this level of care tends to be less clear than for the other treatment modalities. These overall results were fairly consistent across the Capital and NC CCM.
Overall, for the UR CCM there was a higher level of agreement for SA Rehab than for Inpatient. The new target of 80% was met or exceeded in 11 of the 16 scores for the combined Capital and North Central UR CCMs.
A comparison of 2013 IRR results to 2012 results reveals increases in the agreement rates for most levels of care. The 2013 results for Capital’s FBMH were lower (by about 5 percentage points) as were the North Central results for Inpatient (although by less than 0.1 percentage points). Results in 2013 tended to have less variation than in the previous year; however significant improvement was noted during 2012 when Inpatient scores went from 57% to 92.6% for the Capital region and 53% to 87% for North Central. This
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contrasts to a range of 77% to 82% for Capital and 73% to 85% for North Central in 2013. This pattern was also seen in SA Rehab for the two years as well.
Table 4: IRR - Average Percent Agreement -Physician Advisors
CRR- BHRS FBMHS RTF Inpatient SA HH Rehab PA March -- -- 73% 40% 80% 87% PA July -- 100% 100% -- 80% 67% PA Sept 100% -- -- 80% 73% 53% PA Nov -- 95% 100% -- 60% 70%
This Program Evaluation marks the first inclusion of IRR data for Physician Advisors and Quality Improvement staff. Results were compared to those of Dr. Toyer for CRR HH, BHRS, and FBMHS and Dr. Mukherjee for RTF, IP, and SA Rehab. The results above range from a low of 40% (for RTF in March) to a high of 100% (in four test cases). The number of PAs participating in each test case varied from a low of one (for the two RTF cases) to a high of four (in three cases). Agreement improved during the year for two levels of care but actually fell for others. Scores that did not hit the new target of 80% were seen in tests for FBMH, RTF, Inpatient and SA Rehab. The scores reflected a need for subsequent discussion and training to increase consistency in interpreting Appendix T.
Table 5: IRR - Average Percent Agreement-QI
CRR- BHRS FBMHS RTF Inpatient SA HH Rehab QI April -- -- 90% 80% 65% 100% QI Aug -- 76% 80% -- 57% 60% QI Oct 96% -- -- 80% 87% 73% QI Dec -- 96% 80% -- 72% 90%
While Quality Improvement staff does not assess authorization requests for Medical Necessity, their expertise in applying Appendix T enhances their effectiveness in executing various QI initiatives. QI staff participates in trainings on the criteria for various levels of care and case conferencing reviews. The results above range from a low of 57% (for Inpatient in August) to a high of 100% (in SA Rehab in April). Scores indicating a need for improvement were evident for BHRS, Inpatient, and SA Rehab.
Another recommendation involved using individual test results (rather than just aggregate results) to identify the need for training. In 2013, Dr. Toyer initiated reviews of individual test scores in order to evaluate the performance of individual CCMs. Potential areas of discrepancy were highlighted during subsequent quarterly meetings in order to either clarify the item or provide clinical education. Dr. Toyer also collaborated with CCM supervisors regarding test results to support education and clarification during supervisory sessions with CCMs.
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2014 recommendations to be considered include:
Revise the report to reflect the scoring range categories that were previously recommended. Update the report displays to percentages rather than decimals to make the report easier for committee members to understand and discuss. Increase benchmark score to 81% - Excellent from 80% - Substantial Move to formal Kappa testing (utilizing SPSS software) as a measure in determining how well MNC is interpreted throughout clinical operations. Consult with an academic resource for advisement on improving the overall testing adding objectivity to questioning and randomization of case selection. Increase focus of education and training to CCMs on RTF, FB, and IP MNC. Refine testing of Physician Advisors to be separate according to Psychiatrist and Psychologist and related to the areas for which they are credentialed and require participation in quarterly testing by full Physician Advisor Panel. Review results of testing during supervision with Physician Advisors and identify training needs to increase consistency in interpretation of MNC. Adjust question 3 of IRR testing to say, “Assessment of need for co-occurring treatment when clinically indicated?” to address SA screening in a MH treatment service and MH screening in a SA treatment service. Adjust question 4 of IRR testing to say, “Referral to primary specialized outpatient (sexual abuse/sexual offender trauma, eating disorders).
CCM Documentation Audits and Live Call Monitoring of CCMs
During 2013, PerformCare worked to revise clinical monitoring tools to incorporate observations noted in the 2012 Triennial Care Management review conducted by OMHSAS and Mercer. In doing so, a live call monitoring process was developed to supplement clinical documentation audits.
Beginning in quarter 3 of 2013, the Clinical Department implemented use of Call Monitoring Audit Forms designed to monitor CCM compliance with established performance standards and contractual obligations as they are outlined in departmental goals and metrics. Performance goals, which have been determined by clinical management, are utilized to monitor individual CCM performance. Reviews are conducted quarterly by clinical supervisors in real time. Results are reviewed, in-depth, with each CCM during supervision. The results are included in the supervisory record, and are utilized to inform the need for staff training and ongoing skill development as trends are noted. A general review and possible revision of the tool will be conducted annually in order to accurately reflect current trends in behavioral health treatment and/or care management.
The audit tool is separated into 8 domains and can be scored as ‘1’ for compliance, ‘0’ for noncompliance, and ‘N/A’ if item is not applicable to the nature of the call (e.g., not relevant to the call). The table below highlights the number of calls that were monitored during 2013 and are separated by region. It is important to note that during the first two
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quarters the tool was being developed and piloted utilizing random CCM phone calls. As shown below, Capital monitored a significantly higher number of calls than North Central for the last two quarters of the year; however, this can be attributed to the staffing levels which are much lower in North Central.
Table 6: Total Audits per Quarter
Quarter 3 Quarter 4 Capital 36 28 North Central 2 4
Figure 1: Capital Comparison of Average Total Domain Score
Figure 2: North Central Comparison of Average Total Domain Score
Throughout operations the highest scores were within the Soft Skills domain which evaluates appropriate conversation skills, professionalism, friendliness, and effective
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listening skills. North Central domain scores remained rather consistent between the two quarters; while Capital scores had a larger discrepancy between the two quarters. The larger discrepancy found between quarters for Capital may be related to the decrease in completed audits from quarter three to quarter four.
Table 7: Capital Comparison of Average Total Domain Score
Domains Average Total Q3 Average Total Q4 Greeting 1.88 1.47 Handle Contact 1.28 1.08 UR Review/BHRS Meeting 3.34 2.26 QOC 0.17 0.05 Solution Information 1.8 1.47 Notification 0.4 0.7 Telephone Skills 0 0 End Call 1.68 1.32 Soft Skills 8.68 6.7
Table 8: North Central Comparison of Average Total Domain Score
Domains Average Total Q3 Average Total Q4 Greeting 2.5 2.75 Handle Contact 2 1.75 UR Review/BHRS Meeting 2 1 QOC N/A N/A Solution Information 0 1.5 Notification 1.5 0.75 Telephone Skills 1 0 End Call 0 2 Soft Skills 9 8.75
The average total score for each individual domain of the audit tool decreased from the third to the fourth quarter in almost every domain throughout clinical operations. Although the downward trend is not statistically significant, it should be noted; however, that there were many items scored as ‘Not Applicable’ in both quarters which may yield unreliable scoring. This would be an alternate explanation for the downward trend (e.g., more questions may have been rated as N/A in Quarter 4). Should this trend continue to be observed, it is recommended that the tool be revised to delete items that are consistently scored as not applicable.
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Figure 3: Care Managers Aggregate Scores for UR (MH IP/PHP & SA Detox/Rehab) and /BHRS (all Children’s LOCs)
Table 9: Aggregate Scores for UR (MH IP/PHP & SA Detox/Rehab) and /BHRS (all Children’s LOCs)
Aggregate Per Aggregate Per Items in Domain Item Q3 Item Q4 Discuss Evidence Based Practice referral options 34% 38% Explore member strengths 50% 38% Explore Community based Supports 50% 60% Ensure Treatment plan addressed quality of life issues 53% 40% Explore Co-Occurring issues 37% 28%
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Explore Trauma and abuse issues 44% 28% Ensure development of a Recovery/resiliency Prevention Plan 44% 31%
The above graph and table detail the scoring of audits completed in the third and fourth quarter of 2013. The highest domain score achieved was “exploring community based supports” for which 50% of CCMs were noted to have addressed in Q3 and 60% in Q4. The second highest domain score achieved was “ensuring treatment plan addresses quality of life issues” for which 53% of CCMs were noted to have addressed in Q3 and 40% in Q4. The lowest domain score achieved was in the area of “exploring co- occurring issues” for which 37% of CCMs were noted to have addressed in Q3 and 28% in Q4. The questions within this domain focus on recovery and resiliency, substance abuse screening, and trauma and abuse issues. In all cases, the focus will be to improve scores and by July 1, 2014, set a target benchmark to work toward.
Table 10: Average total score per Quarter
Quarter 3 Quarter 4 Capital 19.25 15.08 North Central 19.5 19.25
The table above highlights the average score of all individual audits per quarter in both regions. The highest possible score for the Live Call Monitoring tool is 35 and the average score for Q3 and Q4 for Capital is 19.25 and 15.08. The average score for the tool is similar for North Central CCMs in the third quarter with 19.5. On the other hand, North Central scored higher in the fourth quarter with 19.25 compared to Capital. To ensure improvement in CCM scores per quarter it is suggested clinical supervisors analyze the nature of the call with corresponding scores to determine if any specific trends exist that may account for the decrease in scores between quarters.
PerformCare also utilizes a process to review staff documentation in the Member medical record to ensure accuracy, completion and adherence with documentation requirements which include: 1.1. Demonstration of information review, including comparisons to previous diagnosis; evaluations; review of progress of treatment plan goals 1.2. Demonstration of the use of medical necessity criteria used in making decisions 1.3. Documented communication with providers about quality of care issues 1.4. Notification to the Chief Medical Officer regarding quality of care issues 1.5. Notification to Network Operations regarding procedural issues
The CCM Documentation Audit tool consists of two sections - The “Audit Tool” section which includes the domains of Assessment, Active Care Management, Coordination of Care, and Additional Items. Five time-points of the Members length of stay are available to be audited, including Initial Assessment, Continued Stay Reviews, as well as Discharge. Each time-point is scored on a 0-4 scale with ‘0’ as no documented evidence, ‘1’ minimal documented evidence, ‘2’ moderate documented evidence, ‘3’ nearly complete documented evidence, and ‘4’ complete documented evidence.
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The second section of the tool is the “Recovery Oriented Treatment Planning”. The tool assesses 5 areas that are a priority for clinical management for this member. These areas include Assessment Priority, Treatment Priority, Recovery/Resiliency Priority, and Other Priority Areas. Each priority domain has several items that can be selected based on relevance to the members’ clinical presentation.
Table 11: Total Audits Quarter 4
Quarter 4 Capital North Central BHRS UR BHRS UR 19 28 5 7
The CCM Documentation Audit tool was revised during 2013 in order to improve the review of cases to more accurate reflect work toward addressing the quality of treatment, quality of care concerns, appropriate discharge planning, and active care management.
Table 12: Average per Scoring Domain
Audit Tool Resiliency Score Total Score Capital BHRS CM 3.61 3.66 3.63 Capital UR 3.60 3.44 3.52 North Central BHRS 3.826 2.36 3.094 North Central UR 2.38 1.4 1.88
Throughout operations, use of the Audit Tool section was found to be an area of strength. The highest score achievable is a “4” in both sections of the tool. The Resiliency section of the tool elucidates needed improvement in clinical documentation on recovery orientated treatment planning, particularly for North Central CCMs.
In order to provide accurate, relevant, and meaningful data, 2014 recommendations to improve the format and structure of CCM Documentation Audits and Live Call Monitoring as follows:
Recognize the clinical importance of person-centered care and demonstrate active care management in documentation, paying specific attention to the promotion of recovery and the use of evidence based practices. Emphasize that providers utilize the Functional Behavior Analysis (FBA) in the development of a behavior and treatment plan to progress toward goals through psycho-education, per advisement from the Psychologist Advisor. Rely on the established Best Practice guideline directing the completion of FBAs for providers to reference during the development of a FBA. Identify a single and consistent item for assessing the assessment of drug and alcohol issues and the identification of co-occurring concerns throughout clinical operations.
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Continue with supervisory monitoring and consultation with CCM’s on a quarterly basis with feedback to CCMs upon completion of all audits for each quarter. Consider further revision to the tool to o Ensure that the questions are concise. As an example many items include two distinct questions in one question. This does not lend to effective inter-rater reliability. These should be further defined and differentiated, minimizing the use of ambiguous terminology within the item be further defined to reduce subjectivity. o Specify the tools to address calls audited by type and purpose (e.g., initial request, continuation of services, Member outreach) since not all questions are applicable to all types of call and many ‘Not Applicable’ items are being scored. o Evaluate the formula used for “Percentage Call Quality Score” as items not pertaining to the call result in a score of ‘n/a’. Development of scoring by type of call will eliminate the possibility of scoring an ‘N/A’ on an indicator in most instances The number of audits completed per CCM should be consistent in order to realize maximum reliability and validity of the data. Additionally, the overall number of CCM audits should be increased in order to provide meaningful feedback that will positively impact job performance. Training and education on Recovery Oriented Treatment Planning should occur throughout clinical operations to improve the ability to educate providers and Members in this area. It is recommended all audit results be reviewed by a clinical manager to improve the integrity of results and minimize the potential for clerical mistakes before final scoring is applied. Managers should ensure the accurate and consistent scoring of items under the End Call domain. This can be accomplished by developing an operational definition. It is recommended the identified supervisor completing the audit signs on the call in a timely manner in order to avoid using ‘N/A’ scores for the first few questions.
High-Risk or Enhanced Care Management directed at a reduction of readmissions
PerformCare provides Enhanced Care Management (ECM) for high risk Members. Dedicated Care Managers work closely with County contacts and community supports services to address the individual needs of the Members served by ECM. The Enhanced Care Management Report was presented to the QI/UM Committee on a bi-annual basis.
Members are identified for ECM by meeting one or more of these criteria: • Members with five or more inpatient admissions (mental health and/or substance abuse) in a twelve month period • Members identified by the County or PerformCare as needing ECM • Members admitted to Extended Acute Care (EAC) • Members discharged from State Hospitals
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The goals of ECM include: • Identification of high risk Members • Linkage of high risk Members with TCM • Development of more adequate discharge plans to impact IP readmission rates • Development of diversionary plans with TCM providers • Linkage of high risk Members to adequate community supports • Identification of, and increase in, natural and community supports
During monthly meetings a review of Member status serves to identify community supports and resources, develop action plans, and make decisions about adding or removing Members to ECM. These latter determinations are made based on recommendations from the County HR points of contact. Ongoing collaboration efforts will occur to continue linking High Risk Members with TCM. The data indicates that the average length of stay in ECM for all PerformCare contracts combined was 593 days, with variation noted by each individual contract.
Table 13: Members Served by Enhanced Care Management 2013
Members Members in % Members # of served in ECM with in ECM with ALOS Members County ECM 2013 TCM 2013 TCM 2013 in ECM Discharged Franklin/Fulton 53 35 66% 351 8 Capital 295 159 54% 907 101 Bedford/Somerset 33 17 52% 520 4 Total 381 211 57% 593 113
The following chart shows the percent of high risk Members identified with co-occurring disorders over the course of the reporting period. For all PerformCare contracts combined, the number has ranged from 46% to 56%. Percentage of high risk Members identified with co-occurring disorders fluctuated each reporting period for each individual contract. The ECM care managers continue to collaborate with the county representatives to connect these Members with other services and community supports to address all their treatment needs.
Figure 4: High Risk Members with Co-Occurring Disorders by Quarter
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High Risk Members with Co-occurring Disorders 100% 90%
80% 70% 60% 50% 40%
% of Members 30% 20% 10% 0% Dec-09 Jun-10 Dec-10 Jun-11 Dec-11 Jun-12 Dec-12 Jun-13 Dec-13 F/F 42% 45% 50% 36% 47% 47% 39% 45% 47% Capital 60% 61% 60% 56% 55% 57% 56% 56% 60% B/S 56% 62% 36% 42% 38% 33% 39% 56% 50% All contracts 53% 56% 49% 45% 47% 46% 45% 52% 52%
PerformCare tracks the Enhanced Care Manager’s activity through the number of phone calls, letters, secure emails, and meetings regarding HR Members each month. This activity includes ongoing discussion/identification of Members who would benefit from ECM. During 2013, ECMs continued to review HR Members who could potentially be discharged from ECM during monthly county/region phone calls. Generally speaking, if a HR Member has had no IP admissions over the course of a 6-month time period, it may be recommended that they be removed from ECM. Over the past year, several ECM Members have been removed from the ECM list per this process. This is an ongoing focus of discussion to reduce the number of HR Members to include only those Members who have been identified as needing or benefiting from ECM. TCM providers continue to be very responsive to the ECM program. Ongoing discussion is occurring to explore additional supports in these counties/regions for HR Members. Collaboration with PerformCare oversight entities, and MH and SA County Representatives continues in order to improve the identification of Members who would benefit from Enhanced Care Management.
During 2013, PerformCare implemented the Member Monitoring Program. The goal of this program is to identify and address the needs of Members in the early stages of involvement in the Behavioral Health System and prevent readmission. The following criteria for inclusion are as follows: Readmitted within 30 days as identified by the IP report Factors that increase risk of readmission including o homelessness o History of unsuccessful SA rehab admissions o 5 detox admissions that did not result in transfer to an appropriate step down.
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o non adherence with basic medical care for conditions such as diabetes, liver disease and COPD o newly diagnosed with SMI that includes psychosis o no natural supports Age 18 and older living independently or in an adult service setting such as a group home or personal care home
The CCM assesses the acuity of the Member’s need for frequency of contact according to a stratification process. In accordance with a four step protocol, the CCM will outreach to Members in the Program to assess stability, compliance with the treatment plan and to resolve any barriers to treatment or needs for community resources. Discharge criteria from the Member Monitoring Program are as follows: 3 months without SAIP or MHIP admission and stability in the community environment (i.e. with outpatient treatment and a support system).
Additionally during 2013, the High Profile Program, under the direction of a Psychologist Advisor, focuses on providing clinical guidance regarding the treatment of Members receiving high levels of BHR Services and at risk for out of home placement, was implemented. The criteria for inclusion are as follows: Children < 18 years old in BHRS High Cost (based on internal reporting) Recidivism ( 3 or more Mental Health Inpatient (MHIP)/year) State/Oversight monitoring Multiple children residing in same home w/services Behavioral-health/Physical-health needs Community Residential Rehabilitation (CRR)/Residential Treatment Facility (RTF) Step-down or risk of Out of Home placement Recommended by oversight/PerformCare staff CYS/JPO involvement
The Care Manager, Psychologist Advisor, Oversight representative and other applicable team members meet routinely to review Members receiving high levels of BHRS or at risk for out of home placement. The purpose of the meeting is to receive additional clinical direction and expertise on cases from Psychologist Advisor which may result in PA outreach to Evaluator to discuss future treatment recommendations, convening a CASSP or treatment team meeting facilitated by the CCM, and outreach to providers to discuss future treatment recommendations. Discharge Criteria is as follows: Member clinically stabilized Member no longer falling into high-cost reporting Member no longer requiring ongoing, intensive care management and follow-up due stabilization Member’s services have been secured upon discharge from CRR/RTF
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In the Capital contract, a Substance Abuse Enhanced Care Management was also implemented in 2013 by PerformCare. The Substance Abuse Active Care Management Program is designed to identify and intervene with Members who have a history of substance abuse treatment recidivism and co-occurring mental health, medical, or social issues. The criteria for inclusion are as follows: Recidivism in the same or higher level of care within 60 days of discharge History of leaving treatment AMA SMI populations with SA treatment Limited sober support system
The Clinical Care Manager maintains regular contact with Members in this Program, providing support and coordination of all services to meet the Member’s SA, MH, and Medical treatment needs by identifying community supports and resources, developing action plans. Discharge Criteria are as follows: 6 months without SAIP or MHIP admission and stability in the community environment (i.e. with outpatient treatment and support system).
Bedford/Somerset and Franklin/Fulton Counties continue to utilize a Field Clinical Care Manager (FCCM) in order to facilitate active care management within the region. Further, Bedford/Somerset also utilizes Local Care Management (LCM). This includes continually assessing treatment being received by Members and current needs, attending ISPT, CASSP, and treatment team meetings, and working collaboratively with the treatment team members in developing treatment recommendations based on behaviors, symptoms and Member progress. PerformCare continually enhances clinical services by implementing care management programs developed after an ongoing assessment of Member needs in order to better serve target populations. Some Care Management Programs are Contract specific and may not apply to all HealthChoices Contracts.
Despite our efforts, readmission rates within the PerformCare network continue to follow the increasing national trend. The impact of the increasing readmission rates also is more significant in more complex populations such as SMI and those with Co-occurring Substance Use and Mental Health issues. During 2014, PerformCare will refine care management processes to stratify the population in a manner which easily identifies individuals by their level of risk. The implementation of complex case management will allow for further specialization of caseloads to meet the needs of special diagnostic groupings represented in the Membership through population.
Access and Availability
Access can be defined as the degree to which appropriate care and services are accessible and obtainable to meet the Member’s needs. A Member’s needs can be assessed in terms of what is needed, when it is needed, and where it is needed. Availability can be defined in terms of capacity (i.e. a sufficient supply of provider staff to meet the demands of Members requiring services). A thorough analysis of Access and Availability therefore requires a review of the supply of specific types of services needed, the geographic location of the services (in terms of distance and travel time), and the time between the
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request for a specific service type and when it is delivered. PerformCare routinely measures these factors using established standards and targets. The following section analyzes Access in terms of what is needed and the timeliness of providing service when it is needed. A subsequent section will examine the availability of services based on geographic location (to assess the where component).
Emergent, Urgent Access
The need for Emergent and Urgent care is measure based upon a Member call to PerformCare to request a needed service. The standards used are an appointment with a provider within one hour for Emergent calls, within 24 hours for Urgent calls, and an offered appointment within seven calendar days for Routine services. This information is measured utilizing SSRS reporting which accesses eCura as the source of maintaining Member call information.
During 2013, a total of six (6) requests were recorded for Emergent care and all were for Members in the Capital region. The North Central region had none. Of the six emergent requests, all were offered an appointment within the one hour standard resulting in a network performance of 100%.
During the same period, the Capital region had 2 requests for Urgent care and the North Central regions had none. Of these, 2 were offered services within the 24 hour standard resulting in a network performance of 100%.
Direct requests by Members for Emergent or Urgent care tend to be relatively rare, as these situations are typically handled by Crisis Intervention units rather than PerformCare Member Services staff. PerformCare strives to achieve a target of handling 90% of Emergent and Urgent calls within the required standards of 1 hour and 24 hours respectively. PerformCare exceeded this target in 2013 and surpassed the 2012 Emergent performance of 66.67%. Likewise, PerformCare surpassed the 80% performance on Urgent care in 2012.
Although direct requests from Members for Emergent and Urgent care continue to be very rare, PerformCare will continue to monitor the availability of appointments offered and will strive to direct care within standard 100% of the time. Provider capacity will continue to be monitored, barriers to access will be identified, and additional providers will be credentialed into the network as needed.
Routine Access
The measure of routine access is defined as the percentage of initial outpatient appointments offered within 7 days of the request.
Routine Access measures the availability of initial outpatient appointments within seven days of the request. PerformCare monitors adherence to this measure through claims data in eCura. For the period of 1/1/2013 to 12/31/2013, access within the 7 day standard
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was: Bedford/Somerset - 65.23% Capital Region - 62.05% Franklin/Fulton - 73.54% Network - 63.25%
Figure 5: Routine Access within 7 days
Routine Access 90% 70% Interim Target 80% 70%
60% BS
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30% Network 20% Linear (Network) 10%
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PerformCare strives to achieve a target of offering appointments within seven days to 70% of requests for Routine Access. This measure includes outpatient Diagnostic Interviews (Masters level and Doctorate level).
Data for this measure is obtained by claims submitted for initial appointments. Claims for appointments offered within seven days of the request are to include the U7 modifier which results in a higher rate of reimbursement for the provider. PerformCare Account Executives review with outpatient providers, data for their Routine Access performance. When PerformCare data does not match provider data, the Account Executives attempt to identify factors contributing to the disparities and then resolve them. An unexpected negative impact on this measure occurred with some providers transitioning to electronic records who inadvertently omitted the U7 modifier from claims, resulting in under- reporting of in-standard appointments for both the provider and PerformCare until the problem was resolved. PerformCare also offers a financial incentive to providers who make appointments within seven days of inpatient discharge, recognizing the importance of maintaining continuity of care.
The Franklin-Fulton region out-performed the other contracts in the network and improved from 2012 (69.07% to 73.54%); however, an improving trend in network performance can be seen in the above graph as an overall network as well. This may be attributed to the mechanism described above for capturing the performance on Routine Access which is based on the use of a claims modifier to indicate when an initial
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appointment was offered within 7 days of the request. Outreach efforts to correct the ability to measure routine access is reflected in the increasing trend line above. PerformCare offers financial incentive to providers who use this modifier ---thus encouraging providers to offer appointments within the 7-day standard. In addition, efforts are currently underway to expand the measure to include outpatient Diagnostic Interviews conducted by Bachelor level staff as well. In review of the reasons why 7 day routine access is not met, the most common reason is Member choice in waiting for a specific provider. Second most common reason is that the Member was not available for the appointment offered within the 7 day timeframe.
To supplement this reporting, PerformCare requires quarterly reporting from mental health outpatient providers regarding the availability of therapy, medication management and psychiatric time. In addition, PerformCare is attempting to obtain corresponding availability reports from TCM, inpatient and partial hospitalization providers in order to validate the reported results of mental health outpatient providers. The combined results of this reporting will enable provider specific interventions to improve collaboration and improve access to routine care. Finally, providers who consistently miss the 70% are required to initiate corrective actions to improve performance.
PerformCare is currently developing an automated outpatient provider scorecard that will be shared with providers on a regular basis on order to monitor results and ensure progress on this measure. This initiative is part of the consolidated network Cost Driver for improving Ambulatory Follow-Up following MH Inpatient treatment. PerformCare will continue to monitor this measure and follow up with individual providers who do not meet the network standard. Feedback will continue to assist providers in addressing data or billing anomalies as well as capacity problems which may impact service availability. PerformCare will continue to explore opportunities to offer incentives to providers to improve the performance of this measure.
Access to Initial Psychiatric Care
PerformCare recognizes the importance of access to psychiatric evaluations in maintaining Members in the community and reducing readmissions to inpatient and/or unnecessary usage of emergency services. As such, access to psychiatric evaluations utilizes a 7-day standard. This measure is based on provider claims data. Performance data for the network during 2013 can be seen below.
Table 14: Psychiatric Evaluation Access: Percentage in 7-day Standard
County 0-17 18 Aggregate Bedford/Somerset 21.93% 12.86% 15.77% Capital 8.11% 11.65% 10.15% Franklin/Fulton 33.39% 31.17% 32.16% Network 13.03% 14.64% 13.96%
Figure 6: Psychiatric Evaluation Access – Percentage in 7 days
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Psychiatric Eval Access All Ages 45% 40% 35% 30% 25% BS
20% CA 15% FF 10% 5% NETWORK
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In 2013, all three contracts showed improvement on this measure for both adults and youths over the previous year with the Franklin-Fulton region significantly out-performed the other regions on this measure; however, an access rate of 13.96% is not desirable for the network. With a continuing goal of increasing access in this area, Fulton County has been designated as a Mental Health Professional Shortage area. In addition, application is pending with the Pennsylvania Department of Health to obtain the designation for Bedford/Somerset counties as well. Telepsychiatry is available throughout the networks with two providers initiating this service for the first time within the Franklin-Fulton region in 2013. Efforts to continue this expansion will extend into 2014.
PerformCare is presently facilitating the expansion of telepsychiatry throughout the network, partnering with Breakthrough as one option for providers to consider. PerformCare continues to monitor this measure and encourage providers to expand the availability of psychiatric evaluations.
Access to Best Practice (BHRS) Evaluations
Access to Best Practice (BHRS) Evaluations is measured using a 7-day standard and 30- day standard. These measures are based on provider claims data. Performance data for the network during 2013 can be seen below.
Table 15: 2013 Access to Best Performance Evaluations
Within 7 days Within 30 days Bedford/Somerset 56.63% 86.12% Capital 77.53% 91.58% Franklin/Fulton 69.03% 92.04% Network 74.38% 89.88%
Figure 7: Best Practice Evaluation – Percentage in 7 days
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Best Practice Eval--7 Day Access 100% 70% Target 90% 80% 70% 60% BS 50% CA 40% FF 30% NETWORK 20% 10% Linear (NETWORK)
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In 2013, all three contracts improved on the 30-day access to Best Practice Evaluations from 2012. Franklin-Fulton and Capital also improved on the 7-day measure. The graphs above show improving network trend lines during 2013. The network surpassed the 70% target for Best Practice Evaluations within 7 days.
The Bedford-Somerset region continues to use the Brief Treatment Model (BTM) in addition to traditional BHR services. This treatment intervention utilizes BSC or MT services without requiring a full Best Practice evaluation. This model can be used as a step-down from higher Levels of Care or as a step-up from lower Levels of Care when a more intensive intervention is appropriate. By not requiring an evaluation, these services can be initiated faster. In lieu of an evaluation, a Master’s level clinician can complete an assessment which must be approved and signed by a psychologist. In 2013, the Bedford- Somerset contract provided BTM BSC to 29 Members and BTM MT to 98 Members.
PerformCare continues efforts to reduce the over-reliance on BHRS as a treatment modality. In late 2013 (and at the direction of OMHSAS), PerformCare began to consolidate its Cost-Driver Projects across all contracts---one of which includes BHRS. Among the activities of this project is improving awareness of alternate treatment modalities (including Evidence-Based services). By reducing the volume of inappropriate requests for Best Practice Evaluations, the availability of evaluator time should improve and this in turn will reduce the wait-time for evaluations.
Access to Psychological Testing
Access to non-BHRS psychological evaluations and neuropsychological evaluations is currently measured using only the 7-day standard and this measure is based on provider claims data. Performance data for the network during 2013 can be seen below.
Table 16: Access to non-BHRS psychological and neuropsychological evaluations
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Within 7 days Bedford/Somerset 15.07% Capital 30.84% Franklin/Fulton 7.69% Network 28.86%
Figure 8: Access to non-BHRS psychological and neuropsychological evaluations
Psychological & Neuropsych Testing Within 7 Days 100% 90% 80% 70% 60% BS 50% CA 40% FF 30% 20% NETWORK 10%
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During 2013, a total of 525 evaluations were completed across the network. Of these, 384 were provided within standard, resulting in a performance of 26.86%. PerformCare will continue to monitor access and provide provider-specific feedback in order to improve performance.
Access to BHRS
Access to Behavior Specialist Consultant (BSC) services is measured using two standards. These include the traditional measure of 50 days from the evaluations and the newer measure of 30 days from the authorization. These measures are based on authorization and claims data. Performance data for the network during 2013 can be seen below.
Table 17: Access to Behavior Specialist Consultant (BSC) services
Within 50 days Within 30 days Bedford/Somerset 61.54% 94.87% Capital 52.38% 72.82% Franklin/Fulton 40% 66.67% Network 52.38% 74.46% Figure 9: Access to Behavior Specialist Consultant (BSC) services
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Initial BSC---50-Day 100%
80%
60% BS
40% CA FF 20% NETWORK
0%
Jan 13 Jan
Oct 13 Oct
Feb 13 Feb
July 13 July
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Sept 13 Sept June 13 June April 13 April Initial BSC---30-Day 100%
80%
60% BS 40% CA FF 20% NETWORK
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Sept 13 Sept June 13 June April 13 April
Initial access to BHR services is measured two ways: one uses the standard of 50 days from the evaluation and the other uses the standard of the 30 days from the authorization, with an ultimate goal of measuring 7 day routine access. The 50-day measure does not take into account situations where the start of services is delayed intentionally. The classic example of this is when the prescription calls for services to begin after the start of the school year. The 30-day measure provides a better indication of how well PerformCare and providers are doing with initiating services as intended. This is reflected in the comparison of the performance on the two measures. Through enhanced monitoring of authorization and regular follow up with providers to determine caseload assignment for newly authorized services, good progress was made toward improving access throughout the network during 2013; however, continued work in this area is needed. As such, PerformCare will move to closely monitoring access to BHRS in 7 days during 2014.
Historically, PerformCare monitored the initiation of BHR services primarily through the use of claims-based data. The obvious disadvantage in this is the lag time for claims to
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be submitted and entered into the system. In order to develop real-time capability in monitoring initial BHRS, PerformCare initiated weekly contacts with providers to review the status of each child authorized for services in the previous week. Begun in late 2013, this process has improved the effectiveness of monitoring by PerformCare, OMHSAS, and oversights.
In 2013, PerformCare began intensive monitoring and analysis of BSC capacity in light of new requirements for behavioral specialist licensure of individuals working with Members affected by Autism. To prepare for the full implementation of this requirement in 2014, PerformCare closely monitored the progress of providers to ensure staff completed the application and submission to the Pennsylvania State Licensing Board and reported regular progress updates to OMHSAS. By the end of 2013, due to the delays in processing, implementation of the new requirements was extended to May 26, 2014. It is expected that with this extension, PerformCare will be able to guarantee adequate services to these Members, having ensured all staff meet the additional licensing requirements. In rare instances, when this is not possible, Members will be transitioned to appropriately licensed staff. PerformCare will continue to monitor the availability of licensed BSC staff and share updated information with OMHSAS and oversights.
Continuing efforts to improve this service include initiatives identified in the BHRS Cost- Driver project which was consolidated in 2013. Among the activities and targets of this project are reductions in average length of stay, reductions in the number of Members requiring BHRS, improved awareness of alternate treatment modalities (including Evidence-Based services), and the use of the CANS assessment instrument (to improve decision-making when treatment is being recommended). These initiatives are intended to reduce an over-reliance on BHR services and thereby increase the availability of existing staff for new cases.
One of the areas currently under review involves mechanisms to incentivize BHRS providers for improving initial services. Also in late 2013, PerformCare introduced a new Outcomes report which can be used for analyzing the impact of multiple treatment modalities---including BHRS. Essentially, this report compares the aggregate use of services before and after a selected treatment---in order to determine if there is a pattern demonstrating a reduction in the use of higher levels of care following the treatment.
In January 2014, PerformCare began sharing provider-specific data on a limited basis during quarterly reviews in the Capital region. Feedback from multiple entities was used for refining and enhancing the report, as well as improving the presentation of the data. During 2014, PerformCare will execute changes as part of transformation to study existing processes, systems, and technologies to develop recommendations for improvements. A BHRS action plan has also been formulated to outline a timeline and plans for a number of initiatives. The plan will be shared with oversights, monitored and adjusted as needed. PerformCare will utilize regular meetings with BHRS providers which are already in place to inform them of impending changes and initiate changes accordingly throughout 2014.
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Access to Mobile Therapy (MT) services is measured using two standards. These include the traditional measure of 50 days from the evaluations and the newer measure of 30 days from the authorization. These measures are based on authorization and claims data. Performance data for the network during 2013 can be seen below.
Table 18: Access to Mobile Therapy
Within 50 days Within 30 days Bedford/Somerset 82.86% 90.91% Capital 49.60% 75.73% Franklin/Fulton 50% 83.33% Network 52.80% 77.61%
Figure 10: Access to Mobile Therapy
Initial MT---50-Day 100% 90% 80% 70% 60% BS 50% CA 40% 30% FF 20% NETWORK 10%
0%
Jan 13 Jan
Oct 13 Oct
Feb 13 Feb
July 13 July
Dec 13 Dec
Aug 13 Aug
Nov 13 Nov
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Sept 13 Sept June 13 June April 13 April Initial MT---30-Day 100%
80%
60% BS 40% CA FF 20% NETWORK
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In 2013, all three contracts showed improvement, on both measures, compared to the results from the previous year. As in 2012, Bedford-Somerset region led the network
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with the best performance on this measure. The interventions listed above in the BSC section also apply to MT (except activities relating to the licensing of BSC staff).
Access to Therapeutic Staff Support (TSS) services is measured using two standards. These include the traditional measure of 50 days from the evaluations and the newer measure of 30 days from the authorization. These measures are based on authorization and claims data. Performance data for the network during 2013 can be seen below.
Table 19: Access to Therapeutic Staff Support
Within 50 days Within 30 days Bedford/Somerset 60.00% 90.00% Capital 25.00% 32.65% Franklin/Fulton 00.00% 50.00% Network 26.67% 36.65%
Figure 11: Access to Therapeutic Staff Support
100% Initial TSS---50-Day
80%
60% BS 40% CA
20% FF NETWORK 0%
100% Initial TSS---30-Day
80%
60% BS 40% CA 20% FF NETWORK 0%
In 2013, improvements were noted in both the Bedford-Somerset and Capital contracts on both measures. While the Franklin-Fulton region saw percentage declines on both measures, it should be noted that the actual numbers of initial cases were extremely low.
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During the entire calendar year, there were only four cases with initial TSS.
Interventions listed above in the BSC section also apply to TSS (except for those activities relating to the licensure of BSC staff). Access to Functional Behavioral Analysis (FBA) services is measured using two standards. These include the traditional measure of 50 days from the evaluations and the newer measure of 30 days from the authorization. These measures are based on authorization and claims data. Performance data for the network during 2013 can be seen below.
Table 20: Access to Functional Behavioral Analysis
Within 50 days Within 30 days Bedford/Somerset 65.08% 86.89% Capital 21.02% 51.67% Franklin/Fulton 28.40% 56.25% Network 27.07% 56.43%
Figure 12: Access to Functional Behavioral Analysis
Initial FBA (Masters Level)---50-Day 100% 90% 80% 70% 60% BS 50% CA 40% FF 30% NETWORK 20% 10% 0%
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Initial FBA (Masters Level)---30-Day 100% 90% 80% 70% 60%
50% BS 40% 30% CA
20% FF 10% 0% NETWORK
All three contracts improved on the 50-day measure in 2013 but only the Capital region also improved on the 30-day measure. The other contracts however scored higher than the Capital region on the 30-day measure. The network continues to struggle with maintaining sufficient capacity for providing FBAs within the 50-day and 30-day standards. Providers report a competitive disadvantage in trying to recruit and retain licensed staff who would prefer working for school districts with regular schedules, benefits, and summers off. Current requirements prevent providers from recruiting recent Masters level graduates because they lack the necessary amount of experience.
As discussed in the BSC section, PerformCare continues to closely monitor provider capacity for delivering this service. Each child awaiting this service is tracked and weekly updates are obtained from providers. Providers are required to offer transfers to other providers for families awaiting services.
Access to Peer Support services following discharge from inpatient treatment is measured within spans of 30, 60, 90 180, and greater than 180 days. These measures are based on inpatient discharge data and claims data. Performance data for the network during 2013 can be seen below.
Table 21: Peer Support Access Following Inpatient
BS CA FF NETWORK Within 30 days 33.33% 24.32% 23.08% 25.00% Within 60 days 12.16% 7.69% 10.42% Within 90 days 10.81% 15.38% 10.42% Within 180 days 55.56% 35.14% 30.77% 36.46% Greater than 180 days 11.11% 17.57% 23.08% 17.71% Total Peer Admissions 9 74 13 96
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The total number of Peer Support admissions declined in Bedford/Somerset but rose in Capital and Franklin/Fulton with and overall increase from 485 Members in 2012 to 507 Members in 2013. Peer Support remains a service for which the demand exceeds the supply of staff. Providers continue to struggle with recruiting and maintaining staff. In 2013, each contract saw a decline in the percentage of Members accessing Peer Support within 30 days of discharge. The percentage of Peer admissions exceeding 180 days increased for each contract in 2013. PerformCare will continue to monitor access to this service and support providers in their efforts to recruit and retain staff.
Geographic Access to Providers
PerformCare uses a program called GeoAccess® which is the industry standard for producing reports on accessibility. All providers with a contract for a given county are included in the provider listing regardless of their location. The GeoAccess® program then plots provider addresses against actual member addresses to determine how many members have access within designated requirements. Pennsylvania HealthChoices and PA DOH require the following access standards to be met or an access waiver must be requested:
Ambulatory services – 2 in 20 miles (urban counties); 2 in 45 miles (rural counties) Inpatient services – 1 in 20 miles (urban counties); 1 in 45 miles (rural counties) The report identified compliance with the geographic access standards and contained specific Member vs. provider location data for all behavioral health services covered under PerformCare. Dauphin and Lancaster counties are defined as urban; Bedford, Cumberland, Franklin, Fulton, Lebanon, Perry, and Somerset Counties are defined as rural per OMHSAS definitions.
The chart below indicates, by service and county, what access waivers were requested for 2013. Exceptions were requested for any locations with less than 90% of the population of the county having access to services.
Table 22: 2013 Geographic Access to Providers
Service 2013 Exceptions Submitted MHIP – Adult N/A MHIP – Child Lancaster MH RTF Dauphin, Lancaster MH OP - Child N/A MH OP - Adult N/A MH Partial – Adult N/A MH Partial – Child N/A NH Detox – Adult/Child N/A Peer Support N/A NH Halfway – Adult Franklin NH Rehab – Child Franklin NH Rehab – Adult N/A
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D&A IP Detox – Adult Bedford, Cumberland, Dauphin, Franklin, Fulton, Lancaster, Lebanon, Perry, Somerset D&A IP Detox – Child Cumberland, Dauphin, Franklin, Fulton, Lancaster, Lebanon, Perry, D&A IP Rehab – Adult Bedford, Cumberland, Dauphin, Franklin, Fulton, Lancaster, Lebanon, Perry, Somerset D&A IP Rehab – Child Cumberland, Dauphin, Lancaster, Lebanon, Perry
Clozaril – Adult Franklin D&A OP – Adult N/A D&A OP – Child N/A Methadone Maintenance Cumberland, Dauphin, Franklin, Lancaster, Perry (Adult)
For all areas where exception requests were made, each contract continues to monitor the usage of the services; explore potential additions to the network; review service gaps with oversights, OMHSAS and Stakeholders; monitor access issues within QI/UM; and monitor possible complaints pertaining to each level of care. Other service development is addressed later in the report.
While access requirements for hospital-based detoxification and rehabilitation services were not met for all counties, the demand for these services appears to be low. PerformCare speculates that detox and rehab services are provided primarily in least restrictive, non-hospital settings. At this time, the demand for hospital-based detox and rehab continues to be insufficient to entice a provider to develop a new in-network program for these services.
Although the access requirements for Methadone Maintenance were not met for all counties, Members continue to be able to obtain this service, usually from the provider in closest proximity to their homes. Suboxone continues to be an alternative treatment for opioid addiction. No complaints from Members, their families, or advocates have been received regarding access to Methadone Maintenance.
For 2013, there were some changes in the requests for exceptions. Franklin County did not need to request a waiver for Adult NH Detox but did need to request one for Adult Clozaril Support due to a provider dropping out of the network. Franklin and Fulton Counties did not request a waiver for Child D&A IP Rehab. These exceptions present no negative impact to the network and do not prevent Members from accessing appropriate care.
Enhancements to the PerformCare’s Capital, Bedford-Somerset, and Franklin-Fulton contracts for 2013 include the addition of 54 new providers, 46 of which were individuals, 19 of those being psychiatrists. Eight (8) facilities were enrolled in 2013. There were no providers declined by the Credentialing Committee during 2013.
Any gaps in services within the PerformCare network were filled by the use of Out-Of- Network (OON) agreements. OON agreements during 2013 for counties with waivers include:
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MHIP – Child: 2 for Lancaster RTF: 1 for Dauphin County; 3 for Lancaster County Halfway House: None for Franklin County NH Rehab – Child: None for Franklin County D&A IP Detox – Adult: 1 for Somerset County D&A IP Detox – Child: None for the network D&A IP Rehab – Adult: Two for Somerset. D&A IP Rehab – Child: None for the network Methadone Maintenance: None for the network
Table 23: 2013 Provider Ratios
Contract Bedford/Somerset Capital Franklin/Fulton
2013 Provider Sites Member Count Provider Sites Member Count Provider Sites Member Count PT/PS - 08/110 - Psychiatric Outpatient Clinic includes licensed psychologist & psychiatrist (Facility/Organizational Providers) 160 16,844 477 145,487 124 18,933 Ratio: 1:105 1:305 1:153 Standard 1:1,000 Meets Meets Meets PT/PS - 08/184 - Outpatient D&A Clinic (Facility/Organizational Providers) 90 16,844 281 145,487 71 18,933 Ratio: 1:187 1:518 1:267 Standard 1:2,000 Meets Meets Meets PT/PS - 31/339 - Physician/ Psychiatrist (Individual Practitioner) 59 16,844 422 145,487 51 18,933 Ratio: 1:285 1:345 1:371 Standard 1:2,000 Meets Meets Meets PT/PS - 19/190 - Psychologist (Individual Practitioner) 110 16,844 271 145,487 94 18,933
Ratio: 1:153 1:537 1:201
Standard 1:2,000 Meets Meets Meets
During 2013, the provider ratios again met the standards for all contracts in all services reviewed. While all areas continued to meet the standard, slight improvements were seen in the ratios for Psychiatric Outpatient Clinic (Capital and Franklin-Fulton contracts), Outpatient D&A Clinic (Franklin-Fulton contract), Physician/Psychiatrist (Franklin- Fulton contract) and Psychologist (all three contracts).
New Service Development
New service development, particularly evidence based practices, can allow PerformCare to better match the unique treatment needs of the individual to the type of service that is
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needed, oftentimes preventing more restrictive or intrusive types of treatment, as well as develop effective outcome monitoring.
The overall objectives of PerformCare’s outcomes measurement is to develop indicators that assess the structure, process, and outcome of these evidence based programs. The following is a summary of the evidence based practices and new services that are currently implemented, or are under consideration.
Recovery Orientated Methadone (ROM) has been developed in the Bedford/Somerset area of the PerformCare network to improve the quality and monitoring of methadone services, explicitly focused on medication-assisted treatment for opioid dependence that includes the use of methadone. ROM also provides a conceptual framework that allows for intense focus on individual and family recovery and wellness. PerformCare is currently trending network capabilities in this area.
Table 24: ROM Outcomes - Bedford/Somerset (1/1/13 – 12/31/13)
Providers # of Co- High Age Phase of Treatment Mbrs occurring Risk 0 - 20 21 - 30 31-44 45 - 64 65+ 1 2 3 4 Alliance Medical 53 24 0 5 21 23 4 0 30 13 9 1 Services Pyramid 7 2 0 0 1 2 1 0 1 1 1 1 Healthcare Discovery House 4 3 0 0 4 3 0 0 2 1 3 1 Totals 64 29 0 5 26 28 5 0 33 15 13 3
PerformCare is continuing to develop outcomes to monitor Members and evaluate the program related to discharge type and improvements in quality of life. The Capital area contract has begun the planning process for implementation of ROM with White Deer Run in Lebanon.
Incredible Years is a community based, evidence based program that has been implemented in some regions. The Incredible Years was implemented to offset traditional BHR Services in the younger age group. The Incredible Years is a comprehensive treatment program for young children with early onset conduct problems. Because this program focuses on universal prevention and social competence, it can positively impact the developmental trajectory of children and families, and in some situations, can prevent the need for more intensive types of mental health treatment (e.g., BHRS OMHSAS determined the parent portion of the program is not compensable under Medical Assistance. In 2013, 38 Members received the Incredible Years through Nulton
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Diagnostic & Treatment Center. They are no longer providing this service and Alternative Community Resource Program (ACRP) is going to provide this service in 2014. Outcomes will need to be developed once the new provider begins providing services in this region in order to determine success of the program.
Parent Child Interactive Therapy (PCIT), an evidence based program, places an emphasis on improving the quality of the parent-child relationship and changing parent-child interaction patterns. PCIT was implemented to offset traditional BHR services for children. Parents are taught specific skills to establish a nurturing and secure relationship with their child and are also taught problem-solving skills to manage new problem behaviors as they arise. PerformCare and county partners will implement PCIT with one provider in the Bedford/Somerset region in early 2014. The Franklin/Fulton region implemented PCIT with two providers in late 2013. This treatment option will allow evidence based treatment to be provided and would allow an alternative to other more intrusive mental health treatments (e.g., BHRS), however it has not yet been implemented consistently (e.g., changing providers and varying levels of provider interest).
Functional Family Therapy (FFT) is another evidence based programs that some regions are implementing. FFT uses a co-therapist model and is developed to be a short-term intervention program. In general, FFT provides 12 sessions over a 3-4 month period. Services are conducted in both the clinic and home settings, and can also be provided in a variety of settings including schools, child welfare facilities, probation and parole offices/aftercare systems, and mental health facilities. According to the developers of FFT, this is “a strength-based model. At its core is a focus and assessment of those risk and protective factors that impact the adolescent and his or her environment, with specific attention paid both intrafamilial and extrafamilial factors, and how they present within and influence the therapeutic process”. PerformCare has implemented this treatment as a way to enhance the array of evidence based programs that are offered to our adolescent population. In 2013, 47 Members received treatment in Bedford and Somerset counties from Nulton Diagnostic & Treatment Center. PerformCare will rely on the outcomes reported through the EPIScenter to monitor the success of this program in 2014.
The CRR-HH-Intensive Treatment Program (CRR - ITP) program is a comprehensive community based service design that incorporates elements of the CRR - HH program, with added clinical elements, evidence based programs, and treatment standards. The CRR - ITP program places a strong emphasis on the strengths of the children, families, and communities they serve. The program goals and objectives are consistent with best practices guidelines outlined by the Department of Public Welfare and CASSP principles. CRR - ITP is a unique and individualized service that provides children and families the tools necessary to function appropriately in their natural home environment, lead healthy productive lives, and become outstanding citizens in their respective communities.
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PerformCare and county partners are currently collaborating on the continued development of this program. Although still being formulated, outcome information will likely include a standardized assessment (e.g., CANS) used via serial measurement. PerformCare implemented the CRR-ITP in June 2014 with 2 Providers, NHS and BAIR. PerformCare has developed an Outcomes dashboard to assist provider in using the CANS. There have been 9 admissions to CRR-ITP as of February 2014.
PerformCare and county partners are currently working with two FBMHS providers in the Franklin/Fulton contract to create two specialized FBMHS teams to treat problem sexual behaviors. Services will begin early in 2014. Outcomes will be closely monitored by regional staff and the PerformCare Psychologist Advisor. There will be a PA review for all referred Members, as well as regular meetings with PerformCare CCM’s to assess progress. Serial measurement will also be used in order to assist with outcome monitoring.
MST-Problem Sexual Behavior (MST-PSB) has also been implemented in the Capital region. MST-PSB provides quarterly reports to PerformCare that allow for the effective and efficient monitoring of outcomes, as well as level of care decisions at discharge. Information included in this quarterly report include client outcomes (e.g., placements; new charges), fidelity measures (e.g., consumer satisfaction; therapist adherence measure; supervisor adherence measure), as well as information regarding school information and functioning. In addition, monthly meetings are conducted with MST providers in order to address concerns and/or issues as they arise.
A short-term RTF model has also been developed and implemented whereby more intensive treatment is provided for a shorter duration, as compared to traditional RTF placements. The current short-term RTF program is using multiple outcome measures including serial measurement utilizing the CANS, consumer satisfaction, behavioral information that is tracked throughout the length of stay, number of restraints, Members leaving the premises, progression of Members through the level system, as well as school functioning.
BHSSBC and the Children’s Model Workgroup have joined together to implement WRAP for Kids as a pilot project in Bedford and Somerset Counties. According to the Copeland Center, “Wellness Recovery Action Plans (WRAP) is a self-management and recovery system developed by a group of people who had mental health difficulties and who were struggling to incorporate wellness tools and strategies into their lives. WRAP is designed to: Decrease and prevent intrusive or troubling feelings and behaviors; Increase personal empowerment; Improve quality of life; and Assist people in achieving their own life goals and dreams.” (http://copelandcenter.com/wellness-recovery-action-plan-wrap). BHSSBC and the Children’s Model Workgroup have utilized a multistep process in conducting a pilot program to examine using WRAP’s with children. The first phase
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involved members of the BHSSBC staff conducting presentations to providers, schools and stakeholders regarding WRAP for Kids. The second phase included training all interested parties in becoming WRAP facilitators. Forty-two professionals from Bedford/Somerset Counties were trained on how to implement the WRAP and eleven professionals were trained to be WRAP group facilitators. Another two-day WRAP Level I training occurred on 7/26/13 and 8/2/13. The WRAP for Kids Pilot Project was implemented with the Children’s Aid Home in 2013. The Children’s Aid Home PHP program and Nulton’s PHP program are offering WRAP for the population they serve. Twin Lakes Center is offering WRAP Groups to all the consumers in residential treatment (male and female).
The Crisis Bridge Program was implemented by Bedford and Somerset MHMR in April 2012 in cooperation with the Somerset Hospital in order to provide services to Members discharging from Somerset Hospital’s Mental Health Inpatient in the time between the discharge date and the date of the first appointment for routine follow up. It is known that the chance of readmission to the hospital increases with lack of follow up or participation in after care services. This service was developed to provide support to individuals during that lag time to increase the likelihood of follow up and decrease the likelihood of readmission. Outcomes were developed in order to measure the effectiveness of the program. Utilization of this service has been lower than expected. The below table shows utilization for this time period. 15 unique Members utilized this service in 2013. 11 of these Members utilized services within 7 days of discharge and 5 (33%) of these Members were readmitted. Follow up percentages during 2013 fluctuated and did not show consistent improvement as planned. The group of people responsible for monitoring this program met in November 2013 to review outcomes and to discuss any needed changes to the program. It was determined the program is worthwhile and would continue as implemented into 2014. Plans to continue to promote this service, despite the barriers, are ongoing with providers and Members.
Table 25: Crisis Bridge Utilization – Bedford/Somerset (1/1/13 – 12/31/13)
# of Male Female Co- High Age Mbrs occurring Risk 18-20 21 - 30 31-44 45 - 64 65+
Bedford/ 15 9 6 6 3 2 2 7 4 0 Somerset MHMR
Reinvestment Projects for the Capital Region are as follows:
Respite Care was implemented in all Capital Counties by Youth Advocate Program. It is now operational. Respite services offer short-term respite services to children, adolescents, and adults. The services provide temporary relief for caregivers by giving them a rest or break from caring for a child and/or adult with severe behavioral and/or emotional health concerns. Respite is offered as either In-Home or in the community. Respite workers supervise and interact with the
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individual family member while caretakers are able to take a break. Youth Advocate Program is the Respite Management Agency (RMA) for this program and has been able to contract with a number of additional providers to provide additional staff, as well as a few individuals who also provide these services.
The Specialized Transitional Support for Adolescents was implemented in all Capital Counties by The Jeremy Project in Dauphin County and NHS, Inc., the Stevens Center, in Cumberland and Perry County. This project was started with the goal of giving support to adolescents from the age of 14-22 years who are PerformCare Members. These Members all are at a point where there is a need to begin planning their transition from children to adult services. The transitional program is designed to focus on four basic target domains to assist these individuals in becoming successful adults, including: Education, Employment, Independent Living, and Community Involvement.
The Substance Abuse Supportive Housing was implemented for all Capital area counties by various providers. The program is currently operational. There are a number of individuals who, when completing non-hospital rehabilitation or halfway house services for the treatment of substance abuse issues, require some form of transitional housing to support their recovery. This may include individuals who are homeless or whose prior living situation would have undermined their recovery efforts. A local network of Recovery Houses has been developed to provide a living environment that reinforces recovery. In order to assist individuals who qualify, CABHC can provide scholarships to fund up to two months’ rent for a person to move into a Recovery House. CABHC began receiving scholarship applications in December 2007.
The Reinvestment Project Housing Initiative was implemented for all Capital area Counties and each County has its own housing initiative plan as presented to OMHSAS. The project in under development.
The Peer Operated D&A Recovery Center project is under development in all Capital area Counties. The goal of this project is to establish drug and alcohol recovery centers in the five counties. Services will target MA eligible adults (18 years or older) who are experiencing a substance abuse disorder. Peer Operated recovery Centers may have many attributes and services, but each will be developed based on geographical need and resource capacity and will be self- directed by its members. These recovery centers do not typically provide treatment and are not staffed by paid professionals. They are peer operated programs. It is intended to be a local consumer driven center that will provide peer support services, sober recreation activities, and/or community education. These programs are places where an individual working on their recovery from substance abuse can find a sympathetic ear, information about recovery and substance abuse services, and enjoy a safe and drug and alcohol free environment.
The D&A Adolescent OP Clinic is under development for all Capital area
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Counties. Under this initiative, each County will develop an Adolescent D&A OP Clinic, either embedded in an existing clinic or through the development of a new satellite site to an existing clinic. This in-plan service will enhance access to D&A services for our counties.
The MH-IP integrated Peer Specialist Services is under development for all Capital area Counties by Philhaven, PPI, LRMC, and HSH. It is the goal of this program to implement the development of Certified Peer Specialist (CPS) services that will be imbedded into four of our local MH IP units, including Philhaven, Pennsylvania Psychiatric Institute, Lancaster General Hospital, and Holy Spirit Hospital. The CPS will be active with the inpatient unit staff team to bring their recovery oriented perspective to the culture of the program. The CPS will also support and educate persons in treatment about the recovery philosophy as experienced through their own recovery, assure that the person has a strong partner in their treatment choices and most important, to assist in the discharge planning process, including limited follow up in the community after discharge.
The D&A Recovery Specialist Services project is operational through the RASE Project for all Capital area counties. Targets individuals in the five county area who are in need of one-on-one recovery coaching to assist them with overcoming the obstacles that otherwise may keep them from succeeding in the process of recovering from substance abuse. Recovery Specialists serve individuals who chronically relapse into abuse of substances and struggle to stay engaged in treatment and/or remain in sustained recovery. Program participants are matched with a Recovery Specialist who meets with them regularly and assists them in learning the skills necessary to live successfully and maintain their sobriety.
The Recovery House Development project is under development for all Capital area Counties. This project will fund eight new substance abuse recovery houses in the Counties through the purchase and/or renovation of selected homes. At least one of the homes will serve women and children. CABHC is facilitating a selection committee that will set the standards these programs will need to meet to be eligible for start-up funds.
The Evidence Based Projects are under development for all Capital Area Counties. Mental Health and Drug and Alcohol Outpatient Clinics are the primary treatment locations that members access services. This project seeks to enhance the quality of treatment by encouraging and expecting that Evidence Based Practices are embraced and delivered in these settings. To help reach this objective, this program was started to fund the certification of selected Outpatient Providers to gain the capacity to provide Dialectic Behavioral Therapy (DBT), Cognitive Behavioral Therapy (CBT), Parent-Child and Interaction Therapy (PCIT). DBT is a form of psychotherapy that was originally developed to treat people with Borderline Personality Disorder. It has also been used to treat patients with various mood disorders, including self-injury. Cognitive Behavioral Therapy is a therapeutic approach that aims to address maladaptive thinking that
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can result in such things as anxiety or phobias. Parent-Child Interactional Therapy aims to teach parents more effective means of changing their child's negative behaviors while working on developing the bond between parent and child through a form of play therapy. Early in 2012, CABHC finalized the selection process of providers for these services. An action plan was also outlined for the development of an EBT expansion.
The D&A Treatment Court RSS is under development for Cumberland and Perry Counties by the RASE Project. The goal of this project is to employ two part-time D&A Recovery Specialists to provide substance abuse recovery support services to participants in Cumberland County Specialty Courts. All D&A Recovery Specialists hired under this program will be expected to become certified as a Recovery Specialist through the PA Certification Board. The adults served will be individuals who have cycled in and out of D&A services and have demonstrated difficulty in engaging in their recovery through traditional treatment and supports. The target population may also include support for persons as a step down from inpatient treatment. Services provided will focus on life and recovery skills development that will be vital to the success of the individual in their recovery process.
The Adult Co-occurring OP Services project is under development for Dauphin County. This project is targeted towards Medical Assistance eligible adults (18 years or older) who are experiencing mental health and substance abuse disorders. These individuals would enter services either through a drug and alcohol intake or an assessment completed at a mental health outpatient clinic. Those who are being evaluated for drug and alcohol related issues will also be screened for mental health issues, and those coming into mental health outpatient facilities will answer questions related to drug and alcohol use. Based on these results, the individual may be a candidate for a co-occurring group (8 weeks long). These groups will run twice per week for 1.5 hours. The provider of these groups will need to have a dual license as both an outpatient mental health and drug and alcohol clinic. The individual may also be involved in individual treatment and psychiatric support during this time.
The Adult Acute Partial Hospitalization Project is under development for Dauphin County. This project is targeted to serve Medical Assistance eligible adults (18 years or older) who are in need partial hospitalization treatment for mental health disorders. This program (to be provided by a licensed acute partial hospitalization program) will provide services for individuals who are not in need of inpatient care, but whose needs are greater than can be provided by outpatient services. This project is expected to reduce inpatient mental health readmissions, improve psychiatric stability, and increase personal satisfaction for the individual members who participate in the program
The Mobile MH ID Behavioral Intervention project is under development for Dauphin County. The program will fund the creation of a Mental Health and
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Intellectual Disabilities team consisting of two professionals that will assist adults 21 years and older with a serious mental illness or intellectual disability. The team will include a Behavioral Specialist and a Registered Nurse who will work individuals and their families, or other support systems. This service will include a Functional Behavioral Assessment which will be used to develop a treatment plan for the individual, focusing on their behavioral issues/needs, interventions, and other related needs. All direct services conducted by this team are considered mobile because they are most often delivered in settings outside of an office (often in the home or community).
The Incredible Years is under development for Dauphin County. This evidence based practice is being implemented in Dauphin county in outpatient settings, particularly school based outpatient clinic settings and focuses on promoting resiliency in families and children (ages 2 to 12 years). The Incredible Years program consists of three components: A Parent Training Series, Teacher Training Series, and Dinosaur Child Training program which can be used in small groups or classrooms. The Parent Program will work on strengthening parental monitoring skills, teaching and strengthening positive discipline techniques, increasing parental confidence while encouraging increased parental involvement in school. The Teacher Training focuses on classroom management, encouraging positive social skills while reducing oppositional, aggression, or conduct based issues. The Dinosaur Training program helps children showing aggression or conduct issues to develop positive relationships with their peers. Dauphin County plans to implement the parent and child trainings, identifying other funds to cover the parent training portion of the program, which is not Medicaid eligible service.
The RTF Teleconferencing Project is under development in Dauphin County by CMU. This program allows the family of a child in a Residential Treatment Facility to participate in treatment and team meetings via a telecommunication system. This is utilized in cases where the Residential Treatment Facility their child is placed in makes participation difficult or impossible. The goal of this program is to decrease readmission through the support of increased parental participation in the treatment process. The teleconferencing is secured between two site locations. Dauphin County has established the Dauphin CMU as the county-specific secured site. It is located at 1100 South Cameron Street in Harrisburg PA. The CMU will also assist families in securing transportation to the site if they are encountering difficulty with accessing the teleconferencing service. The other secure site would be at the Residential Treatment Facility.
The Crisis Residential Program is under development in Lancaster County. The goal of the Crisis Residential Program (CRP) is to create a licensed residential program that will support people stabilizing their mental health symptoms through medication management, individual and group therapy, community service connections and other treatment supports. While CRP will not serve those persons who are presenting with solely a substance related disorder, it is also recognized that persons will present with co-occurring disorders. Because of this,
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the CRP will offer educational programming at the site and refer individuals to community based programs that addresses substance abuse disorders. The benefits to Lancaster County Health Choices members would be to decrease the number of people who require out of county placement for inpatient services, provide a community based service that has more flexibility in linking aftercare services with the person and would reduce readmission rates for people who are experiencing mental health crisis.
The Mobile CIS Expansion Project is under development in Lebanon County by Philhaven. This project will fund the addition of a full time employee to the Crisis Intervention Program of Philhaven. This employee will offer crisis intervention services in the community for high risk Members in order to support them within the community setting and reduce inpatient admissions.
Appropriateness
Utilization of Identified High-Volume and High-Risk Services
Identified high-volume and high-risk services continue to include the levels of care of Behavioral Health Rehabilitation Services (BHRS), Mental Health Inpatient , Community Support Services (includes Family Based Mental Health Services, Crisis, Peer Support, and TCM), Outpatient Mental Health and Residential Treatment Facility (RTF) services. These services are substantiated to be appropriate for regular monitoring as indicated in the chart below.
Figure 13: Allocation of Costs - 2013
Allocation of Costs - 2013 45% 40% 35% 30%
25% Bedford/Somerset 20% Capital 15% Franklin/Fulton 10% 5% 0% MH IP MH OP BHRS RTF - JCAHO/non-JCAHOCOMMUNITY SUPPORT
Table 26: Allocation Percent of Categories of Highest Cost Expenses
Quarter Bedford/Somerset Capital Franklin/Fulton Network MH IP 9.83% 17.36% 11.97% 16.19% MH OP 13.83% 13.92% 15.89% 14.09%
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BHRS 38.93% 31.27% 37.78% 32.56% RTF - JCAHO/non-JCAHO 6.33% 8.48% 9.10% 8.34% COMMUNITY SUPPORT 13.81% 12.34% 15.19% 12.73%
BHRS is consistently the largest cost category for all contracts. However, the percentage dropped from 36.01% in 2012 to 32.56% in 2013. This can be attributed to initiatives focused on BHRS which have evolved from redesign efforts and include the development of evidence based alternatives; increased active care management initiatives which focus on the transfer of skills to natural supports, thus reducing lengths of stay; increased monitoring of operations to identify efficiencies; and technical assistance on conducting functional behavioral assessments and incorporating the results of those assessments into treatment plans which includes objective and measurable goals. Other efforts in this area include the continued evaluation of providers’ level of competency to serve Members affected by Autism. During 2013, PerformCare closely monitored the implementation of newly imposed requirements for the licensing of Behavioral Specialists. This change could have significant impact on the number of clinicians available to provide some BHR services and is, therefore, being monitored closely.
BHRS Re-Design efforts continue and include a proposal to change the internal processing of initial BHRS and two service development proposals. One outlining an integrated outpatient program and another outlining a school based behavioral health program. Other efforts include a best practice evaluation efficacy program, a service description review initiative, a CANS algorithm and outcomes initiative, and an Early Intervention engagement initiative. Through the PerformCare Transformation Initiative, additional projects currently under development include automated provider scorecards and real-time reporting and close monitoring of Initial BHR services. PerformCare has implemented a network-wide protocol for provider Quality Improvement Plans relating to accessing initial BHR services.
With regard to the network-wide efforts on the use of the Child and Adolescent Needs and Strengths-Mental Health (CANS-MH) in order to positively impact the quality of care children and families in our network are receiving, PerformCare has worked to develop CCM expertise in use of the CANS by training and certifying the majority of clinical care managers; as well as to have provided trainings as requested for provider staff. In addition, two pilot studies were conducted among the BHRS population where results indicate that there is a small, but statistically significant, increase in caregiver and Member strengths identified during treatment episodes. This research also demonstrated a small to moderate, but statistically significant, positive correlation between total CANS-MH scores and the intensity of BHRS treatment that was recommended, which suggests that the CANS-MH has the potential to accurately identify service needs and/or treatment recommendations. Results also demonstrated that the CANS-MH total score was a statistically significant predictor of TSS prescription, providing support that the CANS-MH can accurately quantify service needs. Approximately 11.3% of the population demonstrated decreased CANS-MH scores and decreased intensity of TSS between the first and second assessments. Interestingly, 34% of participants were recommended less TSS, regardless of CANS-MH scores. As a result of the research,
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PerformCare and our partnering oversights, have selected the CANS-MH to be implemented in a systematic manner throughout our network to measure service outcomes by partnering with Community Data Roundtable (CDR). It is proposed that the CANS-MH will be utilized, initially, by all evaluators in the Bedford/Somerset and Capital regions as a means to provide immediate decision support information regarding the treatment recommendation that is rendered.
Mental Health Inpatient is the second highest cost category in the network with 16.19% of the expenses; however, within this level of care, there is wide variability between the contracts in the percent of the overall costs spent for Mental Health Inpatient services ranging from a high of 17.36% in the Capital region to a low of 9.83% in Bedford/Somerset. All contracts focused local initiatives on a higher than desired readmission rate in an effort to divert admissions and prevent readmission as the need for change was substantiated in root cause analyses conducted. Interventions were planned to address barriers identified as part of the Cost Driver initiative.
In 2013 PerformCare increased focus on follow-up after hospitalization, initiating Member Wellness calls in an effort to engage Members at the time of discharge from inpatient, increasing the likelihood of the Member to follow through with outpatient services to maintain continuity of care. In addition, technical assistance is being offered to improve the discharge planning of inpatient facilities and improving the orientation to recovery, recognizing the need for person-centered care. Root cause analysis focused on reducing readmissions identified the majority of Members readmitted to MHIP also had a co-occurring substance abuse issue. Therefore, a higher level – Member Monitoring was implemented, increasing care management to that population. New service development expanded the availability of Crisis Bridge programs in most counties as well as a Mobile Psych Nursing program. Peer support services are in the process of implementation to be positioned on inpatient units. It is anticipated that these Peer supports will develop relationships with the Member while in inpatient and they will follow the Member through discharge and seamlessly into outpatient treatment after discharge. Real-time reporting of discharges has been developed to replicate follow up reporting which allows for the more immediate notification to clinical management so that care management resources may be properly aligned.
During 2014, PerformCare will implement a “Strike Team” strategy which will position care managers on inpatient units, beginning with high volume inpatient facilities. Here, care managers will actively participate in treatment team meetings and discharge planning to improve the Member experience. In addition, plans are underway for the development of inpatient and outpatient provider scorecards which will be utilized by Account Executives to improve timely access to aftercare. The Enhanced Care Management program has been modified to more quickly identify co-occurring treatment needs and continues to demonstrate positive measurable outcomes with reductions in the number of subsequent hospitalizations following participation in the program.
Relatively little variation was seen in the percentages for Community Support among the contracts. There was a difference of less than 3 percentage points between the region
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with the highest percentage (Franklin/Fulton) and the lowest (Capital). This category includes Mental Health Crisis Intervention, FBMHS, Peer Support, and Mental Health Targeted Case Management and accounted for 12.73% of network costs. The network percentage devoted to this category declined from 13.05% in 2012. This can be partly attributed to initiatives focused on reducing utilization in Family Based Mental Health. The Enhanced Care Management Program influences the involvement of Targeted Case Management and Peer Support Services to avert Mental Health Inpatient Admissions.
The utilization of Mental Health Outpatient Services increased from 13.00% in 2012 to 14.09% in 2013. This increase in the use of lower levels of care is seen as a positive indicator of the effectiveness of treatment interventions. Efforts continue to reduce the reliance on higher and more intensive levels of care. The utilization of RTF services remained relatively flat for the network with a change of less than 0.2 percentage points from 2012. The QI/UM Committees continued to monitor these high cost, high risk services through reports presented to the Committee on a regular basis.
Denials
Service denials were monitored quarterly by the QI/UM Committee by Service Type, Denial Reason, and Denial Type and are shown below by percentage.
Figure 14: Denials by Service Type - 2013
Denials by Service Type - 2013 CRR-HH PHP 0% 1% SA REHAB RTF TESTING 3% BHRS 10% 2% OTHER 0% FBMHS MH-IP TESTING MH-IP RTF 9% CRR-HH PHP FBMHS SA REHAB 8% OTHER BHRS 67%
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BHR Services for children, consisting of TSS, BSC, MT, collectively represent the most frequent service category of denial, accounting for 68% of all denials. This is an increase from the 55% rate in 2012.
Testing which includes psychological evaluations, neuro-psychological testing and psychological testing experienced the second highest rate of denials. The denial rate increased from 9% in 2012 to 10% in 2013.
Mental Health Inpatient Services accounted for 9% of all denials, decreasing from 15% in 2012 which is a continuing trend from 2011.
Family Based Mental Health Services (FBMHS) accounted for 8% of all denials, a decrease from 13% in 2012.Denials in actual number are shown by contract in the table below.
Table 27: 2013 Denials by Service
2013 PerformCare Denials/Service B/S CAP F/F Total TSS 255 833 229 1317 BSC 147 363 101 611 MT 103 336 86 525 FBMHS 29 269 16 314 MH-IP 23 285 30 338 Psych Eval and Testing 63 275 29 367 RTF 5 47 26 78 CRR 3 38 10 51 BHRS Other (STAP, ASP, TAG, etc) 16 6 1 23 Partial 12 8 2 22 Substance Abuse Services 4 89 7 100 MH-OP 0 2 0 2 Other 4 5 0 9 Total 664 2556 537 3757
Figure 15: Denials per 10,000 Members per Quarter
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2012-2103 Denials per 10K Members per Quarter 100
80
60 B/S CAP 40
F/F Thousands 20 0 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013 Q3 2013 Q4 2013 Quarter/Year
Table 28: Denials per 10,000 Members per Quarter
Quarter B/S CAP F/F Quarter B/S CAP F/F Q1 2012 15 17 22 Q1 2013 39 21 38 Q2 2012 23 26 27 Q2 20123 63 35 54 Q3 2012 40 30 31 Q3 2013 47 27 40 Q4 2012 73 31 38 Q4 2013 80 30 63
As seen in the chart above, the Bedford/Somerset and Franklin/Fulton contracts saw an increasing trend in the denials per 10,000 members during in 2013.The Capital Area contract experienced a fluctuation in the denials per 10,000 across the two years but the overall trend was a slight increase in the denials with the most significant variance across the first three quarters of 2013. This was measured by calculating denials per 10,000 Members per quarter. Overall, PerformCare has seen the increase trend continue since 2011. This trend can be attributed to several changes implemented by PerformCare: o The PerformCare Physician Advisors continue to outreach to evaluators prescribing high level of BHRS and for extended periods to provide guidance in prescribing patterns. o Initial referrals for BHRS for non ASD children are being redirected to evidence-based, alternate treatment options, when appropriate. o Requests for TSS being made in the beginning of the school year have also provided the opportunity to address high utilization of TSS in the school and to reduce the reliance on this service in the school setting.
One of the key factors in managing BHRS is active care management involvement at the onset of entry into treatment. There was a focused effort to strengthen the active care management model to assure that Members receive the most clinically appropriate treatment in the most cost effective manner. Strategies to achieve this goal have been identified and are actively being implemented and others involve more long term initiatives that will eventually result in sustainable improvement.
PerformCare continues to enhance and refine our interdepartmental meeting structure to
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share information that is crucial to the success of these initiatives. Regular meetings consist of clinical updates, high profile case management, status of network performance and service development, financial reports and claims analysis, budget to actual projections, and quality/utilization activities. The meetings have created an additional venue to share information and data across our company. Feedback has been positive as these meetings have shown the direct relationship of between clinical operations and the overall trends.
Field Care Managers have provided local clinical presence which has increased more active participation in ISPT meetings focusing on a discussion of best practices with the team to encourage appropriate requests of services. The implementation care management staff, a clinical director and two local care managers, within the Bedford- Somerset has enhanced the services provided locally. Figure 16: Denials as a Percentage of Requests
2013 Denials as a Percentage of Requests
P 30% 26% e 25% 23% r 20% B/S c 13% 15% 12% 11% CAP e 10% F/F n 5% 5% t 1% a 0% Requests Requests Requests g for C & A for Adults for All e Members Members ages
Ratio of Denials to Requests
For all of the HealthChoices contracts, the ratio of denials to child/adolescent service requests averaged 15.2% for 2013, an increase from 11.4% for 2012 and the ratio for adult service requests averaged 1.2%, a slight increase from 1.0% in 2012. Overall, all ages with regard to the number of Members denied versus the number of requests averaged 6.2% in 2013, an increase from 4.5% in 2012. The increase in denials per requests rate is a trend that has continued since 2011.
The Cost Driver Activities developed and initiated in 2013 provided PerformCare the opportunity to take a new look at those services that are consistently experiencing costs above the HealthChoices average cost across all HC contracts. As a result of the cost driver activities and other care management strategies. PerformCare is taking a multi- level approach in addressing the identified cost drivers, including the expansion of the clinical care manager’s role in services, supplemental education for providers and PerformCare staff, improvement of discharge planning and collaboration with various levels of care, and continuation of the implementation of CANS throughout the provider network.
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Grievance Monitoring and Analysis
A grievance is a request for PerformCare to reconsider a denial decision concerning the medical necessity of a service. As such, the timely and appropriate resolution of grievances is carefully monitored by PerformCare and reviewed regularly by County Oversights and OMHSAS with strict adherence to the Program Standards and Requirements of the HealthChoices program. PerformCare places significant focus on the grievance process and considers this another opportunity to educate Members and their families, as well as providers and professionals among the systems of care such as CYS/JPO on appropriate service delivery expectations necessary to meet the needs of Members. The review of grievance data provides opportunity for lessons to be learned over time which have led to changes in the processing of grievances and collaborative changes with PerformCare Clinical Care Management. PerformCare continues to monitor various aspects of grievances with the percentage of grievances filed in comparison to the number of denials issued per month as a key indicator. The denial to grievance rate during 2013 was 26% for the Capital, Bedford/Somerset, and Franklin/Fulton contracts combined. This is the same as the denial to grievance rate as for 2012 which included the Capital, Bedford/Somerset, Franklin/Fulton, Blair, and Lycoming contracts.
Figure 17: Denial to Grievance Trends from 2008 to 2013
Denials to Greivances 2008 to 2013 30%
20% 26%
19% 18% 26% 10% 23% 20%
0% 2008 2009 2010 2011 2012 2013
*Data prior to 2013 includes Capital, Bedford/Somerset, Franklin/Fulton, Blair and Lycoming
A review of the actual number of level one grievances filed in 2013 (706) compared to 2012 (642) represents an increase of 64 more grievances filed in 2013 than 2012. This continued increase can still be attributed to opportunities identified for improvement in the application of medical necessity criteria which lead to the increase in denials which subsequently resulted in increase in the number of grievances.
As a measure of success in resolving Member satisfaction at the lowest level, PerformCare monitors the number of grievances which advance from Level 1 to Level II by contract.
Figure 18: Grievance Trends per 1000 Members 2013 -LI & LII
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Level I Grievances per 1000 Level II Grievances per 1000 Members Members 8.0 3.0 6.0 BS 2.0 BS 4.0 CA CA 1.0 2.0 FF FF 0.0 0.0 2009 2010 2011 2012 2013 2009 2010 2011 2012 2013
Initiatives to reduce the number of level II grievances include outreach and education to psychological evaluators and providers regarding the quality of evaluations and appropriateness of service requests and improved discussion during the level I grievance between the physician reviewer and Member/treatment team. The overall percentage of grievances moving to level II for all contracts had continued to decrease each year from an average of 25% in 2009, 18% in 2010, 10% in 2011. The percentage then rose to 22% in 2012 and in 2013 this percentage rose to 33%. The refinements in the application of medical necessity criteria noted above would also be attributed to the elevated level of grievances moving to level II. A multi-year comparison is presented below.
Figure 19: Percentage of Level I to Level II by contract – 2009 to 2013
% Level I moving to Level II by Contract 2010 through 2013 33% 35% 33% 30% 27% 25% 20% 17% 18% BS 14% 14% 15% 13% 12% 13% 12% CA 10% FF 5% 0% 0% 2010 2011 2012 2013
PerformCare staffs Psychologist Reviewers internally to more positively impact the outcome of grievances with the expectation of increased technical assistance regarding the local array of services and more of a focus on Member satisfaction, particularly in the children’s service area. When the volume of grievances cannot be supported by internal resources, external reviewers are contracted. Results are monitored by reviewer to identify training needs. In 2013, level I grievance decisions were upheld by external reviewers at a rate of 56% while internal reviewers upheld at a rate of 43%.
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Internal collaboration has been improved during 2013 conducting internal grievance case reviews, coordinating new information received during the grievances with clinical decision making, and enhancing communication between complaint and grievance staff and clinical care managers. During 2014, PerformCare will continue to increase CCM participation in ISPT meetings to further improve external communication to Members and their families. In addition, continued specialization of case loads, development of a complex case management component and other active care management strategies will provided additional opportunities to continue education in aspects of service requests which include the level of intrusiveness and intensive nature of service requests, the anticipated duration of the service requests, and the use of natural supports and community resources to support the Member and families.
In review of grievances by level of care and across contracts to determine trends, significant differences are evident although they are comparable to the ratio of Members served by contract. Overall during 2013, 69% of the grievances were for Capital Area Members, with 15% of the grievances filed in each Bedford/Somerset and Franklin/Fulton. The actual number of grievances per level of care and by contract is shown below.
Table 29: Grievances by LOC per contract 2013
LOC Bedford/ Somerset Capital Franklin/ Fulton Total BHRS 90 249 74 413 RTF 4 11 7 22 MH OP 1 8 0 9 MH IP 7 157 22 186 SA 0 23 3 26 FBMHS 5 35 44 PHP 3 0 1 4 RC/ICM 0 1 1 2 Total 110 484 112 706
The majority of level one grievances filed were for the BHRS (58%) with the second highest number of grievances for Mental Health Inpatient level of care (26%). This distribution remains consistent with the distribution from 2012. In the chart below you see the full distribution of level one grievances filed by level of care for 2013.
Figure 20: 2013 Grievances by Level of Care for Capital, Franklin/Fulton, and Bedford/Somerset contracts
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Grievances by Level Of Care 2013
1% 4% 2% BHRS FBMHS 26% RTF 58% MH IP MH PHP 3% SA 6% Other
Minor variations are noted in the overall number of level one grievances filed in 2013 with a slight increase in grievances related to BHRS and a slight decrease in those related to FBHMS and MH IP. Contributing factors noted in review of grievances include, long term/high prescription patterns in BHRS despite the level of utilization during the authorization period, misuse of the grievance process to earn continuation rights, a lack of appropriate discharge planning in inpatient and BHRS leading to Members staying in the service level longer, and inpatient facilities not utilizing diversionary plans when Members are seeking admission. To address these issues, PerformCare has: modified the concurrent review process to identify discharge dates in all levels of care and more firmly direct the forward progress of treatment toward discharge increased the number of doc to doc reviews between physician advisors and the attending physicians on the inpatient units at time of a new admission as well as during continued stay reviews continued case conferencing for Clinical Care Managers to review complex cases involving inpatient treatment, providing an opportunity for education and prepares them to better manage this level of care by incorporating active care management strategies.
PerformCare anticipates as education and feedback occur with network providers and evaluators, improved service requests should be submitted, reducing the overall rate of denial and subsequent filing of grievances.
PerformCare continues to monitor the outcome of grievances. With a focus on achieving Member and treatment team agreement with the physician reviewer at level I, more partial overturned decisions were made during 2013, reducing the overall number of denial decisions which were upheld. Both External and Fair Hearings have shown an increase in 2013. This is consistent with the increase in 2012 after a strong decline in these levels being filed during 2010 and 2011; however, this is likely due to the significant increases in denials overall. Through continued education and collaboration with systems of care and evaluators, PerformCare is strongly encouraging discussion around the appropriateness of services, the intent of the service and other service options to support the Member’s needs in order to impact the number of grievances moving to higher levels.
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Table 30: Grievance Outcome by Level 2010- 2013
Level III Level I 2010 2011 2012 2013 2010 2011 2012 2013 External upheld 124 92 323 409 upheld 6 5 1 21 overturned 112 57 109 144 overturned 3 0 4 11 withdrawn 109 64 157 153 withdrawn 1 2 5 5 Level II Fair Hearing upheld 35 25 56 106 upheld 1 1 2 6 overturned 18 6 22 78 overturned 1 1 4 9 withdrawn 5 4 20 31 withdrawn 2 4 2 6
Grievance outcomes per contract can be seen below with the increase in level II grievances filed in 2013 across contracts, despite ongoing efforts to implement initiatives to ensure more Member satisfaction at the level I grievance. It should be noted that there was an increase in denials and subsequent level I grievances filed in 2013. With a focus on providing the most effective interventions possible at level I, grievances that are overturned are internally reviewed to determine if changes need to be made to the grievance process.
The timely resolution of grievances is monitored and regulated by both HealthChoices Program Standards and the Department of Health. All grievances are to be resolved as the Member’s health and condition require, with an overall 30 day resolution time limit. PerformCare schedules grievances according to Member availability. As seen below, resolution compliance is noted for 2009 through 2013. Members have the opportunity to file a 14 day extension of level I grievances if they are unable to schedule the meeting or compile additional information within the 30 day timeframe.
Table 31: Grievance Resolution Compliance
Over # Over 30 % Over 30 Total 30 with with # Without % With % Within Records days Extensions Extensions Extensions Extensions Compliance 2009 843 45 45 100% 798 5% 95% 2010 345 6 6 100% 339 1.7% 98% 2011 204 2 2 100% 202 1% 99% 2012 589 22 22 100% 567 3.7% 96% 2013 672 39 38 97% 625 6% 96%
The average number of days it takes to resolve a level I grievance has increased to 21 days in 2013 from 17 days in 2012, but remains well within a timely manner for resolution.
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The trending of providers and evaluators to grievances continued during 2013, resulting in additional outreach to providers and prescribers to increase the quality of evaluations and service request information. Quarterly, these results were compiled; however no provider trends have been noted to date. Prescribers whose evaluations have led to a higher rate of denial and then subsequently to grievance have received follow up regarding the quality of the prescriptions. In 2014, PerformCare will continue to target these quality issues at the initiation of service request through provider and evaluator education and training with the goal of fewer denials leading to fewer grievances filed.
Competency
Credentialing Committee Actions and Recommendations
As a subcommittee of the QI/UM Committee, the Credentialing Committee is delegated responsibility for the credentialing and re-credentialing of both individual providers and organizations. The Credentialing Committee monitors the ongoing sanctions and complaints related to the provider network, as well as any progressive disciplinary actions of providers. The Credentialing Committee met monthly throughout the year and provided a report of actions and recommendations in each QI/UM Committee meeting. During 2013, there were 473 providers credentialed; of these 54 were initial files for 46 individuals and 8 facilities. Among the new individuals, 19 were new psychiatrists. During the same period, 400 providers were re-credentialing; of those 257 were individuals and 143 were facilities.
Table 32: Credentialing Actions by Contract – 2013
Bedford- Franklin- Contract Capital Network Somerset Fulton
Total Providers Credentialed 144 193 136 473 Total Initial Files 17 25 12 54 Initial Individuals 15 21 10 46 Initial Facilities 2 4 2 8 Total Re-Credentialed Files 121 162 117 400 Re-Credentialed Individuals 72 113 72 257 Re-Credentialed Facilities 49 49 45 143 New Psychiatrists 6 6 7 19
There were no providers declined by the Credentialing Committee in 2013. In addition, there were 71 individual providers terminated and 8 facilities terminated in 2013. No terminations were due to adverse actions. All were related to the relocation or change in work (i.e. retirement) OR were related to the discontinuation of contracts, elimination of service sites, or did not give cause.
Table 33: PerformCare Provider Turnover Rate 2013
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Total No. of Termed Total No. of In- Contract Turnover Rate Providers 2013 Network Providers Bedford-Somerset 45 441 10% Capital 62 654 9% Franklin-Fulton 48 448 11% Network Total 71 1543 5%
For Calendar year 2013, Network Development processed 510 out of network requests. Of those requests 82 were for MH IP, 228 were for MH OP, 75 for SA OP, 13 for SA IP, 21 for BHRS, 24 for Case Management, 12 for FBMH and 55 for “Other.” Several of these out of network arrangements enabled us to meet the individual needs of our Members in an identified service gap area as noted earlier in this report.
Table 34: Number of OON Requests by Contract
Total Out-of-Network Contract Requests 2013 Bedford-Somerset 136 Capital 245 Franklin-Fulton 47
In terms of the reason for request, 95 were requested to meet a Specialized Need; 297 were requested to ensure Continuity of Care; 77 were requested because a Member was Placed out of County; and 41were requested to accommodate a Need for Inpatient as the most prominent reasons for request.
An analysis was completed of “repeat” OON providers and those providers with a higher than average number of OON requests were identified. Provided there are no concerns, Account Executives will be conducting outreach to these providers to in an effort to invite them to join PerformCare’s provider network.
Throughout 2013 and into 2014, Network Operations staff has been working with Member Services Staff to revise the current Out-of-Network process. The goal is to reduce the delay in responding to OON requests by at least 75% (from 24 days to 6 days) and have the new process implemented during the first quarter of 2014. Process changes include modifications to the OON Letter of Agreement and elimination of the signature of OON providers; revision of the OON Contract Request Form & OON General Information Forms; development of draft Substance Abuse OON Form; revision of OON Workflow process supported by an electronic process.
Provider Profiling
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Provider Profiling remains an important provider-level quality improvement activity that is reviewed by the Credentialing Committee, Quality Improvement/Utilization Management (QI/UM) Committee, and subsequently available for reference by Clinical Care Managers (CCM). Provider Profiling reports are shared with all profiled providers. The Provider Profiling reports are generated by varied data sources including claims data, authorization data, and QI reports from the data period of 01/01/13 to 12/31/13.
Provider Profiling was completed for eleven high-volume levels of care during 2013. The profiled levels of care included Residential Treatment Facility (RTF), Behavioral Health Rehabilitation Services (BHRS), Mental Health Outpatient (MH OP), Mental Health Partial Hospitalization Program (MH PHP), Family Based Mental Health Services (FBMHS), Community Residential Rehabilitation Host Home (CRR HH), Mental Health Inpatient Services (MH IP), Substance Abuse Non-Hospital Detoxification Services (SA NH Detox), Substance Abuse Non-Hospital Halfway House (SA NH HH), Substance Abuse Non-Hospital Residential Rehabilitation 3B (SA NH 3B), and Substance Abuse Non-Hospital Residential Rehabilitation 3C (SA NH 3C). The results were compiled using data specific to each of the three contracts, and each level of care had a minimum criteria set for profiling, specific to performance data related to that level of care. It is important to note that all of the profiled providers are fully credentialed and considered in good standing with PerformCare. Provider Profiling reports are shared with all profiled providers.
All Profiling includes the following indicators:
Performance/Utilization Data which includes data specific to each level of care, such as average length of stay, percent utilization, percentage of delivered services, etc. Complaints and Quality of Care Concerns which include the number of Member complaints, the number quality of care issues, and the number of complaints and quality of care issues per 1000 Members. Member Complaint Outcomes Satisfaction which includes the percentage of Members satisfied with Outcomes related to Complaints filed. Critical Incidents which include the number of Critical Incident reports received by PerformCare, the number of reports resulting in Quality of Care or Safety Concerns, and the number of incident reports per 1000 Members. Administrative Compliance which includes the number of denied administrative appeals, the number of provider performance issues, and the number of each of these per 1000 Members. Co-occurring Competency which includes the competency score of each provider. Treatment Record Review Scores which include the provider score for the year.
Internal recommendations were made throughout the organization, indicating opportunities for Pay-for-Performance initiatives, quality rate setting indicators, opportunities for active care management and areas of focus in the development of provider toolkits for multiple levels of care. The results of each profiled indicator noted
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above are used for provider education and quality initiatives.
For the purpose of illustrating overall provider performance, the results of the Network’s performance/utilization indicators since 2010 are noted below. It should be noted that in June of 2013, the number of contracts that PerformCare held decreased from five to three, which most likely impacted the following Provider Profiling results.
RTF
The total number of Members receiving RTF services since 2010 has shown a steady decline. The average length of stay for RTF Members had also been declining since 2010 but rose slightly in 2013 from 301.54 days to 313.96 days. The number of inpatient (IP) admissions during treatment also rose slightly in 2013, from 50 to 61.. The number of restraints per 1000 Member days has held relatively steady since 2010, with a decrease in 2013 from 17.83 down to 15.65. This decrease in restraints is likely related to PerformCare’s restraint reduction initiatives, including continual and timely clinical review of Critical Incident Reports of restraint, monitoring of Members experiencing a high volume of restraints in the RTF setting, and providing educational Toolkits to RTF Providers. These initiatives will continue in 2014 in order to make an impact on the number of Member restraints reported per provider.
Figure 21: Provider Profiling RTF - 2013
RTF Total Members in Service RTF Average Length of Stay
600 400
500 300 400 300 200 200 100
100 NumberofDays
0 0 NumberofMembers 2010 2011 2012 2013 2010 2011 2012 2013 Calendar Year Calendar Year
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Inpatient Admissions During RTF Restraints per 1000 Member Days RTF Treatment
20 120 100 15 80 60 10 40 5 20
0 NumberofRestraints 0 2010 2011 2012 2013 2010 2011 2012 2013
NumberofInpatient Admissions Calendar Year Calendar Year
BHRS
The total number of Members receiving Mobile Therapy (MT), Behavioral Specialist Consultant (BSC) and Therapeutic Staff Support (TSS) services had been increasing since 2010, but in 2013 this number decreased from 12,103 to 9,563. The number of units per Member per month also showed a decrease in 2013. The percentage of services delivered increased in 2013, with MT having the largest increase among MT, BSC and TSS since 2012. Although the percentage of Members served with a PDD diagnosis had been decreasing since 2010, in 2013, this percentage increased by almost 4.5%. The number of IP and RTF admissions during BHRS treatment has shown a downward trend since 2010, with 431 IP/RTF admissions occurring in 2013. The percentage of services delivered within 50 days of the evaluation has shown a steady trend in 2010 and 2012, with a spike in 2011 and an increase in 2013. In 2013, the percentage of services delivered within 50 days of the evaluation increased from 35% to 45%. In order to encourage further increases, PerformCare will continue to educate providers on the importance of initiating services in a timely fashion. PerformCare will also encourage the development of agency policies that incorporate discharge planning discussions upon admission, as well as on a regular basis and to adopt and utilize evidence-based treatments. Extensive initiatives continue to be of focus in this service area as referenced previously within this report. PerformCare will also distribute resource guides for provider to disseminate to all internal staff in order to fully develop natural and community supports.
Figure 22: Provider Profiling BHRS Members - 2013
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Total Members in BHR Percentage of BHR Services Services Delivered within 50 Days of
MT, BSC, TSS Evaluation
15,000 60%
10,000 40% BSC 5,000 20%
MT Percentage
0 0% TSS NumberofMembers 2010 2011 2012 2013 2010 2011 2012 2013 Calendar Year Calendar Year
BHRS Units Per Member Per Percentage of BHR Services Month Delivered 250 70%
200 65%
150 60% BSC BSC 100 55%
MT MT Percentage
NumberofUnits 50 TSS 50% TSS 0 45% 2010 2011 2012 2013 2010 2011 2012 2013 Calendar Year Calendar Year
Percentage of BHRS Members Inpatient/RTF Admissions Served with PDD During BHR Services
70% 600
60% 500
50% 400 40% BSC 300 30% MT Percentage 200 20%
10% TSS 100 NumberofAdmissions 0% 0 2010 2011 2012 2013 2010 2011 2012 2013 Calendar Year Calendar Year
MH OP
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The total number of Members receiving MH OP services had increased since 2010 but decreased in 2013, most likely because of the decrease in PerformCare Membership due to the loss of two contracts. Although the compliance rate for offering services within 7 days decreased in 2011, it has been increasing since 2012, with 63% of all MH OP provider offering services within 7 days in 2013. PerformCare continues to encourage providers to establish an active treatment culture and focus, whereby current treatment goals are continually assessed and adjusted, and will encourage MH OP therapists to discuss discharge planning at each encounter with Members.
Figure 23: Provider Profiling MH OP - 2013
Total Members in Mental Compliance Rate for Offering
Health Outpatient Services Mental Health Outpatient
80,000 Services within 7 Days
60,000 65% 40,000 60% 20,000 55%
NumberofMembers 50% 0 ComplianceRate 2010 2011 2012 2013 2010 2011 2012 2013 Calendar Year Calendar Year
MH PHP
Members receiving MH PHP services has been decreasing since 2011 with a total of 1,670 Members receiving MH PHP services in 2013. The average length of stay has shown a decrease since 2010, with a slight increase from 2011 to 2012. The average length of stay decreased from 92.06 days in 2012 to 80.56 days in 2013. The number of IP and RTF admissions was showing an upward trend until 2012, when the number of admissions decreased slightly. The number of IP and RTF admissions has remained steady now for 2 years, around 105 IP/RTF admissions per provider per year. PerformCare will continue to provide active care management in order to ensure the best care for Members. PerformCare will encourage MH PHP providers and evaluators, primarily psychiatrists, to implement more structured training and supervision including CASSP, Life Domain format, Best Practice guidelines, and levels of care.
Figure 24: Provider Profiling MH PHP - 2013
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Total Members in Partial Hospital Services
2,000 1,500 1,000 500 0 2010 2011 2012 2013
NumberofMembers Calendar Year
Inpatient/RTF Admissions Partial Hospital Program During Partial Hospital Average Length of Stay
Treatment 140
120 120 100 100 80 80 60 60 40 40 20 Numberofdays 20 0 0
NumberofAdmissions 2010 2011 2012 2013 2010 2011 2012 2013 Calendar Year Calendar Year
FBMHS
The total number of unique Members receiving FBMHS has remained relatively steady throughout 2010, 2011 and 2012, with the number of unique Members receiving FBMHS decreasing substantially from 1,695 in 2012 to 1,212 in 2013. The utilization percentage and the percentage of team-delivered services both increased in 2013 and are the highest they have been in at least four years. In ensuring fidelity to the FBMH model, active care management is making the assurance that all services delivered are clinically indicated. PerformCare is presently reviewing the method of authorization, giving consideration to adjustments which would better support the completion of service within a 32 week period. Additionally, the units per Member per month decreased slightly from 63.01 in 2012 to 58.94 in 2013. Another noted decrease was related to the number of IP and RTF admissions during FBMHS treatment. In 2013, only 276 Members receiving FBMHS were admitted to the IP or RTF level of care, giving 2013 the lowest number of admission in at least four years. PerformCare will continue to provide active care management in order to keep the lines of communication open and effective and to ensure that FBMHS focus on discharge planning and development and utilization of natural supports/community resources with emphasis on establishing outpatient and/or medication management, as well as other less restrictive interventions.
Figure 25: Provider Profiling FBMHS - 2013
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Total Members in FBMH FBMHS Utilization
Services 58% 2,000 56% 54% % Utilization 1,500 52% 50% 1,000 48% 500 Percentage 46% 44% % Team 0 Delivered
NumberofMembers Services
2011 2012 2013 2010 2011 2012 2013 2010 Calendar Year Calendar Year
FBMHS Units Per Member Per Inpatient/RTF Admissions
Month During FBMHS
100 500 80 400 60 300 40 200 20 100
NumberofUnits 0 0
2010 2011 2012 2013 NumberofAdmissions 2010 2011 2012 2013 Calendar Year Calendar Year
CRR HH
The total number of Members in CRR HH level of care has steadily decreased since 2010, as have the average units paid per Member and the number of IP and RTF admissions during CRR HH treatment. While the overall number of Members in service (and corresponding units/days), tThe average length of stay has increased since 2010 with the length of stay in 2013 averaging 386 days. PerformCare will continue to assist providers with implementing more active discharge strategies to assist Members in transitioning to more natural settings and consolidate and renew efforts at identifying discharge resources earlier in treatment with actively involving these supports in treatment.
Figure 26: Provider Profiling CRR HH - 2013
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Total Members in CRR-HH Average Units Paid Community Residential per Member Rehabilitation - Host Home 175
Services 170 165 400 160 300 155 200 150 145
100 NumberofUnits 140 0 135
NumberofMembers 2010 2011 2012 2013 2010 2011 2012 2013 Calendar Year Calendar Year
CRR-HH Average Length of Stay
500
400 300 200
100 NumberofDays 0 2010 2011 2012 2013 Calendar Year
Inpatient/RTF Admissions During CRR-HH Treatment 80
70 60 50 40 30
20 Number of Admissions of Number 10 0 2010 2011 2012 2013 Calendar Year
MH IP
The total number of MH IP discharges has remained fairly steady since 2010. The total number of MH IP discharges has increased slightly every year since 2010 with the exception of 2013, where a decrease of 30 discharges was observed. The 30-day
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readmission rate has also remained fairly steady, with a decrease from 2011 to 2012, especially in the 0-17 age group, which was at the lowest rate it is had been since before 2009. In 2013, the 30-day readmission rate for Members ages 0-17 increased again and is closer to the readmission rate for Members over the age of 18. The average length of stay has remained between 10 and 11 days since 2010, with 2013 showing a slight decrease. . The follow-up rate within 7 days of discharge had been increasing from 2010 through 2012 but then decreased from 67% in 2012 to 46% in 2013. The largest decrease in follow-up rate within 7 days of discharge was observed in the 18+ age group. PerformCare will continue to work collaboratively with physical health services to ensure that Members receive the best care possible. PerformCare will also continue to effectively communicate with Members after discharge to ensure that follow up appointments are kept, thereby possibly avoiding a readmission to MH IP.
Figure 27: Provider Profiling MH IP - 2013
Mental Health Inpatient Total Mental Health Inpatient
Discharges 30 Day Readmission Rate
8,000 15% 6,000 10% 4,000 0-17 yrs 0-17 yrs 2,000 5% 18+ yrs 18+ yrs 0
Total ReadmissionRate 0% Total NumberofDischarges 2010201120122013 Calendar Year Calendar Year
Mental Health Inpatient Follow Up Rate Within 7 Days Average Length of Stay of 14 Mental Health Inpatient
12 Discharge 10 80% 8 0-17 yrs 60% 6 40% 0-17 yrs 4 18+ yrs
NumberofDays 20%
2 Total 18+ yrs Follow Follow Up Rate 0 0% Total 2010201120122013 2010201120122013 Calendar Year Calendar Year
SA NH Detox
The admissions to SA NH Detox services for the 18+ age group have been increasing steadily since 2010, with 1,620 total discharges being observed in 2013 . Although the 30-day readmission rate has increased slightly since 2011, rates in 2011 through 2013 are
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still lower than they were in 2010. The admissions to SA NH Detox services for the 0-17 age group have remained low, with zero readmissions from 2010 to 2013. The average length of stay has remained overall steady since 2010, with an upward trend in the 0-17 age group in 2013. The number of IP admissions during treatment has remained at under five per year since 2010 and in 2013; there were no IP admissions during SA NH Detox treatment. PerformCare will continue to work collaboratively with physical health plans, and to ensure that providers are competent in co-occurring disorders treatment.
Figure 28: Provider Profiling SA NH Detox - 2013
Substance Abuse - Detox Total Discharges 1800
1600 1400 1200 1000 0-17 yrs 800 600 18+ yrs 400 Total
NumberofDischarges 200 4 8 5 4 0 2010 2011 2012 2013 Calendar Year
Inpatient Admissions During
Substance Abuse - Detox Treatment
5 4 3 3 2 2 1 1 0
NumberofAdmissions 0 2010 2011 2012 2013 Calendar Year
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Substance Abuse - Detox 30 Day Readmission Rate 8%
7%
6% 5% 4% 0-17 yrs 3% 18+ yrs
ReadmissionRate 2% Total 1% 0.00% 0.00% 0.00% 0.00% 0% 2010 2011 2012 2013 Calendar Year
Substance Abuse - Detox Average Length of Stay 4.00 3.50
3.00 2.50 2.00 0-17 yrs 1.50 18+ yrs
NumberofDays 1.00 Total 0.50 0.00 2010 2011 2012 2013 Calendar Year
SA NH Halfway House
The number of Members receiving SA NH Halfway House services has shown an increase since 2010.The average length of stay for Members ages 18 and older has remained steady, however, the length of stay for Members ages 17 and younger has increased. The overall 30-day readmission rate increased from 1.08% in 2012 to 1.47% in 2013, however, has remained well under 2% since 2010. The number of IP admissions has remained steady in 2010, 2012 and 2013, after a spike in 2011. PerformCare will continue to work collaboratively with physical health plans, and to ensure that providers are competent in co-occurring disorders treatment.
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Figure 29: Provider Profiling SA NH Halfway House - 2013
Halfway House Total Discharges
500
400
300 0-17 yrs 200 18+ yrs 100 Total NumberofDischarges 3 0 3 2 0 2010 2011 2012 2013 Calendar Year
Inpatient Admissions During
Halfway House Treatment 15
10
5
0 NumberofAdmissions 2010 2011 2012 2013 Calendar Year
Halfway House Average Length of Stay 180.00 160.00
140.00 120.00 100.00 0-17 yrs 80.00 60.00 18+ yrs NumberofDays 40.00 Total 20.00 0.00 2010 2011 2012 2013 Calendar Year
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Halfway House 30 Day Readmission Rate 3.00%
2.50%
2.00%
1.50% 0-17 yrs
1.00% 18+ yrs
ReadmissionRate 0.50% Total 0.00% 0.00% 0.00% 0.00% 0.00% 2010 2011 2012 2013 Calendar Year
SA NH 3B Rehab
The number of Members receiving SA NH 3B Rehab services has been increasing since 2010. More specifically, Members ages 18 and older have been using the services more frequently and Members ages 17 and younger have been using the services less frequently. The 30 day readmission rate showed a decrease from 2010 to 2011 and has remained steady since then, with readmission rates staying below 5%. Although the average length of stay for the combined age groups has been increasing from 2010 through 2012, a slight decrease was observed in 2013 from 21.05 days to 20.71 days. The number of IP admissions during treatment has trended downward since 2010, with only one inpatient admission occurring during 2013. PerformCare will continue to work collaboratively with physical health plans, and to ensure that providers are competent in co-occurring disorders treatment.
Figure 30: Provider Profiling SA NH 3B Rehab - 2013
Substance Abuse Non-Hospital Residential Rehabilitation 3B
Total Discharges
3000 2500 2000 1500 0-17 1000 18+ 500 64 64 71 57 Total NumberofDischarges 0 2010 2011 2012 2013 Calendar Year
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Substance Abuse Non-Hospital Residential Rehabilitation 3B Average Length of Stay
40 30 20 0-17
10 18+ NumberDays of 0 Total 2010 2011 2012 2013 Calendar Year
Substance Abuse Non-Hospital Residential Rehabilitation 3B 30 Day Readmission Rate
8%
6%
4% 0-17
2% 18+
ReadmissionRate Total 0% 2010 2011 2012 2013 Calendar Year
Substance Abuse Non-Hospital Residential Rehabilitation 3B Inpatient Admissions During Treatment 14
12 10 8 6 4
NumberofAdmissions 2 0 2010 2011 2012 2013 Calendar Year
SA NH 3C Rehab
The number of Members receiving SA NH 3C Rehab services has been increasing for both age groups since 2010. Since 2011, the average length of stay has decreased. In 2013, the average length of stay of 73.36 days is the lowest it has been in four years. The 30 day readmission rate however, has shown an upward trend since 2012, with
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readmission rates for both age groups being higher in 2013 than they were in 2012. The number of IP admissions during treatment has decreased every year since 2010, with only one inpatient admission occurring in 2013. IP admissions during treatment have not exceeded five admissions per year from 2010 through 2013. PerformCare will continue to work collaboratively with physical health plans, and to ensure that providers are competent in co-occurring disorders treatment.
Figure 31: Provider Profiling SA NH 3C Rehab – 2013
Substance Abuse Non-Hospital Residential Rehabilitation 3C Total Discharges
800 600 400 0-17 yrs 200 18+ yrs 0 Total 2010 2011 2012 2013
Calendar Year NumberofDischarges
Substance Abuse Non-Hospital Residential Rehabilitation 3C Average Length of Stay
150
100 0-17 yrs 50 18+ yrs
NumberofDays 0 Total 2010 2011 2012 2013 Calendar Year
Substance Abuse Non-Hospital Residential Rehabilitation 3C 30 Day Readmission Rate
4.00%
3.00%
2.00% 0-17 yrs
1.00% 18+ yrs
ReadmissionRate 0.00% Total 2010 2011 2012 2013 Calendar Year
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Substance Abuse Non-Hospital Residential Rehabilitation 3C
Inpatient Admissions During Treatment 6
4
2
0 NumberofAdmissions 2010 2011 2012 2013 Calendar Year
Provider Performance
Provider Performance is a tool developed to identify and track performance issues for network providers. Currently, the Provider Performance report can provide information on by provider, site, contract, or county. Information can also be reported on a specific issue and/or a specific Member. The information is shared with PerformCare providers through individual interventions with Network Operations Account Executives (AE) and in regular meetings with providers in both the BHRS and FBMHS levels of care.
In 2013, PerformCare worked to develop a routine monitoring system with identified targets and an expectation to respond to low performing areas of operation during consecutive quarters in support of a progressive discipline policy. Providers throughout the PerformCare network objected and asserted the process was arbitrary and subjective. In review of the provider performance process, it was determined that there were inconsistencies in the application of the tool among care managers in the Capital and North Central contracts. Considerable time has been spent in review of the performance indicators noted for each level of care reviewed, linking each to a policy, procedure, NCQA standard, or HEDIS measure with thresholds for each performance category so that the data is objective. Upon completion, internal staff will be trained on the updated application of performance monitoring and providers will be informed of new targets and expectations for follow up. Higher level trend analysis can then be conducted to inform both the QI/UM Committees and Credentialing Committee of needed changes throughout the network.
2014 recommendations for improving the current use of Provider Performance tool include:
Establishing a consistent method and presentation format in which the Account Executives share this information with their assigned Providers. Developing a process by which Network Operations will be monitoring the follow-up Providers complete based on the number of Provider Performance issues identified. Refining the presentation of Provider Performance trend analysis presented
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through QI/UM committees and make recommendations for the contract/network to develop Technical Assistance to address noted deficiencies in the network as needed. Establishing a process by which the Credentialing Committee will review Provider Performance trend analysis on a quarterly basis and make recommendations for the contract/network to develop Technical Assistance to address noted deficiencies in the network as needed. Designate a Project Manager to champion the review of Provider Performance issues. This designated staff would be charged with coordinating all efforts related to improving Provider Performance. It is recommended that this staff be separate from the Quality of Care Council and/or staff that work directly with PerformCare’s Credentialing Committee to ensure that there is no bias or conflict of interest while following PerformCare’s progressive disciplinary policy.
In 2013 there were 9,311 Provider Performance issues associated with Members in the Capital contract, 1,758 were associated with Members in the Franklin/Fulton contract, and 1,248 were associated with Members in the Bedford/Somerset contract.
Figure 32: Total No of Provider Performance Issues by Contract
Figure 33: Provider Performance Issues by Contract and Level of Care - 2013
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Table 35: Provider Performance by Level of Care and Contract – 2013
Level of Care BS CA FF NETWORK BHRS 898 6110 1061 8069 FBMH 82 818 178 1078 RTF 67 318 112 497 MH IP 9 319 10 338 MH PHP 61 304 26 391 CRR HH 1 75 22 98
The following graphs provide a more detailed analysis of network-wide performance issues by level of care during 2013.
Figure 34: BHRS Provider Performance – Network - 2013
BHRS - 2013 Evaluation below standards
0% Inappropriate implementation of the treatment 1% 1% plan Provider did not assess for co-occuring treatment 0% 8% 0%0% 0% needs Provider did not collaborate with other treatment 27% 8% team members Provider did not complete discharge review within designated timeframes 18% Provider did not set up aftercare services/submit request for aftercare services as appropriate Discharging Provider did not 27% 10% Provider failed to respond to PerformCare
Provider submitted request with incomplete information Provider submitted request with incorrect information
The top noted areas of needed improvement in performance among BHRS providers include:
Provider submitted treatment packet or request after the due date. (27%) Provider submitted treatment plan lacking necessary information. (27%) Provider submitted request with incomplete information. (18%)
Significant improvement is noted in the submission of complete information having improved from 62% last year to only 45% (combined 27% and 18%) in 2013. It is anticipated that with the implementation of electronic packet submissions in December, 2013, this result will continue to improve throughout 2014.
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Figure 35: FBMHS Provider Performance – Network – 2013
FBMHS 2013 Evaluation below standards
Provider did not collaborate with other treating providers
Provider failed to respond to PerformCare request 1% 0% 1% Provider submitted request with incomplete 6% information 14% 9% Provider submitted request with incorrect 11% information
Provider did not set up aftercare 6% services/submit request for aftercare services as appropriate 51% Provider submitted treatment packet or request after the due date 1% Provider submitted treatment plan lacking necessary information.
Provider did not complete discharge review within designated timeframes
The top noted areas of needed improvement in performance among FBMH providers include:
Provider submitted treatment packet or request after the due date (51%) Provider submitted treatment plan lacking necessary information (14%) Provider submitted request with incomplete information (11%)
Providers continue to struggle to submit complete information in their service requests. It is the expectation of PerformCare that the release of a guiding document which clearly communicates expectations for this service, in the absence of a formal regulation, will improve the providers’ ability to meet expectations in the submission of treatment requests in the future.
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Figure 36: CRR-HH Provider Performance – Network – 2013
CRR - HH 2013 Evaluation below standards
Provider did not collaborate with 2% other treatment team members 1% 9% Provider failed to respond to PerformCare request 37% 14% Provider submitted late treatment 0% packet or request
Provider submitted request with incomplete information 5% 29% Provider submitted request with incorrect information
Provider submitted treatment packet 3% or request after the due date
Provider submitted treatment plan lacking necessary information.
Community Residential Rehabilitation – Host Home (CRR-HH) service providers where challenged with:
Provider submitted treatment plan lacking necessary information (37%) Provider submitted request with incomplete information (29%) Provider failed to response to PerformCare request (14%)
Providers have made some progress toward the submission of complete and accurate requests, improving from 70% in the previous year to 66% (37% and 29% combined) in 2013; however this is a needed area of continued improvement. Account Executives will continue to work with CRR HH providers in this area and CCM’s will continue to educate providers through active care management initiatives. During treatment record reviews and in conjunction with other quality initiatives, the QI Department will continue to education providers in refining administrative procedures which will positively impact their ability to submit complete requests in the future.
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Figure 37: MH PHP Provider Performance – Network – 2013
Discharging Provider did not set up after care MH PHP 2013 within 7 days of discharge Evaluation below standards
Inappropriate implementation of the treatment plan 3% 0% Provider did not assess for co-occuring treatment needs 1% 9% Provider did not collaborate with other treatment 1% 8% team members 0% 9% Provider did not complete discharge review within 1% designated timeframes 1% 2% Provider did not set up aftercare services/submit request for aftercare services as appropriate Provider failed to respond to PerformCare
Provider submitted request with incomplete information 20% Provider submitted request with inaccurate information Provider submitted treatment packet or request 42% after the due date Provider was not prepared with required information for clinical review 3% Provider submitted treatment plan lacking necessary information Provider was not prepared with required information for clinical review
Mental Health Partial Hospitalization Program providers are unique to this level of care and centered on inadequate discharge planning. Challenges include:
Provider failed to respond to PerformCare (42%) Provider did not complete discharge review within designated timeframes (20%) Provider was not prepared with required information for clinical review (9%) Provider did not set up aftercare services/submit request for aftercare services as appropriate (9%)
Efforts to improve discharge planning from this level of care are evident in the decline from 26% last year to 20% this year. This positive change can be attributed to increased attention to continuity of care, progression of care in recognizing symptom free periods, and timely initiation of discharge planning.
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Figure 38: MH IP Provider Performance – Network – 2013
Discharging Provider did not set up after care within 7 MH IP 2013 days of discharge Evaluation below standards
Inappropriate implementation of the treatment plan
2% 11% Provider did not assess for co-occuring treatment 20% needs 1% 13% Provider did not collaborate with other treatment 1% 0% team members 8% Provider did not complete discharge review within designated timeframes 22% 7% Provider did not set up aftercare services/submit 5% 10% request for aftercare services as appropriate
Provider failed to respond to PerformCare
Provider submitted request with incomplete information
Provider submitted request with inaccurate information
Provider submitted treatment plan lacking necessary information
Provider was not prepared with required information for clinical review
Mental Health Inpatient providers (MH IP), much like PHP had issues surrounding the various discharge processes. Provider failed to respond to PerformCare (22%) Provider was not prepared with required information for clinical review (20%) Evaluation below standards (13%)
Slight improvement is noted in the provider’s ability to be prepared with required information for clinical reviews in 2013. It is anticipated that significant improvement in this area will be noted in 2014 as a result of changes to streamline the initial assessment, continued stay and discharge reviews. Further, utilizing the concept of “Strike Teams”, PerformCare will work with high volume, inpatient facilities in an attempt to improve the patient experience, participating in treatment team meetings during inpatient, discharge planning, and will closely follow Members through to follow up care, post discharge. This on-site practice management modeling is expected to strengthen the relationship between PerformCare and providers, more clearly emphasize our expectations, and improve the continuity of care to our Members.
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Figure 39: RTF Provider Performance – Network – 2013
Evaluation below standards RTF 2013
Inappropriate implementation of the 1% 15% treatment plan 4% 1% Provider did not assess for co-occuring 36% 1% 0% treatment needs 0% Provider did not collaborate with other 13% treatment team members
Provider did not complete discharge review 8% 17% within designated timeframes
Provider did not set up aftercare 4% services/submit request for aftercare services as appropriate Provider failed to respond to PerformCare
Provider submitted request with incomplete information
Residential Treatment Facility (RTF) providers encountered performance issues in three key areas. Provider submitted treatment plan lacking necessary information (36%) Provider submitted request with incomplete information (17%) Evaluation below standards (15%)
Improvement is noted in treatment planning, improving from 47% in 2012 to 36% during this year. Continued support will be given in this area as needed throughout 2014.
Co-occurring Competency
PerformCare continues to support providers with becoming co-occurring capable, assisting providers with the complexities associated with members who have needs in both mental health and substance abuse treatment fields utilizing the Credentialing Addendum, Compass EZ™, CODECAT-EZ™ as 2013 Co-occurring Competency Tools.
In 2013, PerformCare required that all in network providers for FBMHS, CRR-HH, RTF, and MHIP submit a COC tool. In total, 126 tools were submitted to PerformCare. Results indicate that across the network, providers vary in their co-occurring capabilities. Some providers note having extensive screenings, specialized trainings for staff members, and continuous efforts to becoming co-occurring and complexity capable, while other providers report no intent to increase co-occurring capabilities. PerformCare has been a willing partner for those providers and regions invested in
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movement toward co-occurring/complexity capability. In 2012, PerformCare designated a co-occurring specialist who participates in all meetings within the network related to co-occurring issues and the CCISC (Comprehensive, Continuous, Integrated System of Care) model. Additionally, in 2013 PerformCare began having staff members complete the CODECAT-EZ™ to assess PerformCare staff competence in directing care in the CCISC environment.
The CCISC model, which has been embraced by some regions, is a model for implementing change throughout the entire system of care, utilizing existing resources efficiently, and promotes the use of evidence based/consensus based practices. PerformCare continues its partnership with oversights and providers in those regions participating in these movements, as evidenced by PerformCare staff completion of the CODECAT-EZ™ and involvement of the co-occurring specialist along with other PerformCare staff.
After expanding the COC Competency Assessment to FBMHS providers, PerformCare recognizes that the tool is most appropriate within facility-based treatment. Therefore, PerformCare will return to assessing only MHIP, RTF, CRR-HH, and PHP in 2014, but will continue to assess providers of other levels of care through the treatment record review process, and in interactions with care managers. Additionally, in keeping with the CCISC model, competency assessment scoring has been eliminated, creating additional challenges in demonstrating the value of this competency to PerformCare Members for consideration as they select a provider. PerformCare will also support providers of all levels of care through the care management process and participation in CCISC meetings in contracts where the model is endorsed. At the same time, PerformCare will support the continued development of co-occurring treatment throughout the network in an adaptable fashion to meet the needs of each local network.
Autism Competency for BHRS Providers
PerformCare continues to support providers with improving behavioral health treatment competency for members diagnosed with an Autism Spectrum Disorder. In 2013, PerformCare required that all network providers for BHRS submit an Autism Competency tool. In total, 38 tools were submitted to PerformCare. Results indicate a relatively consistent level of autism competency among PerformCare providers. Screening and Assessment was a strong focus area for a majority of providers. Providers’ scores reflect the ability to utilize evidence-based practices and to offer consistent methods to triage needs and determine appropriate services and intervention strategies. Program Environment and Safety is an area where larger volume providers scored well. Additionally, some providers indicated that they are currently developing their techniques to ensure Member safety during times of behavior and psychiatric crisis. Larger providers also seem to be better appointed to incorporate approaches such as SCERTS or TEACCH. Most providers indicated that they are trained in using PECS as needed with Members and some were able to use sign language and/or voice output communication aides as needed. One of the strongest areas for providers was the Coordination of Care. Nearly all providers, regardless of capacity, indicated that they coordinate with multi-
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disciplinary systems of care.
Areas of opportunities for all providers that have been identified through the Autism Competency tool include the agency providing community education on the impact of ASD and the fact that individuals affected by an ASD can be integral members of the community. Furthermore, providers do not report a significant utilization of Pivotal Response Training and implementation of social skills groups as an intervention strategy. PerformCare is currently focusing on several goal areas with providers, including: Frequent collaboration with providers whose overall score is below the benchmark (70%) Collaboration with providers whose safety scores are less than 95%. When Autism Competency Tool scores have decreased, written comments are submitted to the Quality Improvement department. This feedback provides the basis for ongoing collaboration and monitoring. Increasing the providers ability to coordinate and to communicate with physical health providers in order to positively impact care Improving the overall competency of our providers by continuing to providing feedback regarding FBA submissions.
In 2014, continued outreach will focus primarily on coordination of services, encouraging enhanced training opportunities for staff, increasing community involvement, and also the use of safe, empirically based management tools for Members impacted by an Autism Spectrum Disorder. PerformCare also offers a stipend to providers whose staff attends training in order to facilitate more competent care for those Members impacted by an Autism Spectrum Disorder.
Provider Education
In 2013, through the collaborative efforts of the Quality Improvement, Clinical and Network Operations Department, a total of 27 different topics were offered to various levels of care providers. PerformCare coordinated a two prong approach to meet the needs of the providers by offering general topics of interest and updates on recent changes in policies. Additionally, provider specific trainings of interest and requested topics by each contract were offered.
There were 7 topics presented to all providers which included a thorough overview and specific treatment recommendations for Members with ADHD and similarly for those Members with a Mood Disorder, a review of new CPT code changes, a FBA refresher, a review of Electronic ISPT Notifications and a Fraud, Waste and Abuse overview.
In conjunction with counties, oversights, and providers the topics of interest varied based on needs and demographic findings. Children and Adolescent Providers were offered trainings on Autism and Sexual Offending. Complex Adult Providers were educated on Intellectual Disorders. A breakdown, by contract area, of these trainings is provided below:
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Franklin and Fulton Counties . Cardiovascular Disease in the Serious Mentally Ill (TCM only) . Special Sex Offenders Treatment Approach . Juvenile Sex Offender Counseling Certificate . Mind and Body: The Need for Physical Health and Behavioral Health Collaboration . Annual CFST Training for Surveyors . ISPT and Provider Connect . FBMHS: Policy and Procedures . Eye Movement Desensitization and Reprocessing (EMDR)
Bedford and Somerset Counties: . Moving from Medical Model to a Recovery Oriented Collaborative Treatment . Recovery and Resiliency: Audit Focus . Parent-Child Interaction Treatment . Intro to CANS . CANS for Evaluators . Treatment Planning (all levels of care) . ISPT and Provider Connect . FBMHS: Policy and Procedures . Sex and Drugs
Cumberland, Dauphin, Perry, Lebanon and Lancaster Counties: . Cardiovascular Disease in the Serious Mentally Ill (TCM) . STAP: Policies and Procedures . Mind and Body: The Need for Physical Health and Behavioral Health Collaboration . CANS for Evaluators . OMHSAS Feedback on STAP and Planning for 2014
Throughout 2013, Quality Improvement initiatives directed meetings with BHRS providers and FBMHS providers on a regular basis to discuss current issues and provide technical support. These meetings looked at access, utilization, length of stay, caseloads and other measures of fidelity, in addition to administrative performance. Clinical and Network Operations staff as well as county staff often participated with Quality Improvement staff to educate providers on the expectations of service delivery.
Account Executives also provide onsite support and technical assistance as often as needed and often partner with the provider on claims issues, policies and processes, best practice standards, review of outcomes, and by directing the provider to available resources.
PerformCare continues to provide training reimbursement throughout the network for participation in trainings of the provider’s choice and encourages training related to Autism, Recovery, or Fraud/Waste/Abuse. Finally, providers continue to have access to the PerformCare website which was updated
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with the rebranding from CBHNP to PerformCare and which was expanded to support recovery and to offer Members the resources they need to manage their own care through the expansion of a variety of Wellness Resources which include materials related to Childhood Obesity and Smoking Cessation. At the same time, the Provider Portal was replace with iContact which offers a faster way for Providers and subscribers to get the latest news, updates, and information from PerformCare through the Network News system such as information related to:
Claims and Reimbursement Billing Updates Monthly Provider Bulletin Policy Changes/Updates State and Federal laws affecting plan providers
The e-Cura® ProviderConnect features were expanded to include automated ISPT scheduling and an electronic submission alternative was implemented to support the submission of BHRS authorization requests to improve business relationships. The eCura® ProviderConnect also continues to offer the ability to enter claims and critical incident reports as well as, look at authorizations, and submit information on capacity.
Input for 2014 training opportunities was requested from counties, oversights and providers and many suggestions were proposed. The training staff at PerformCare will meet the training needs for the network as issues arise and requests are made throughout the year. Currently, trainings in Trauma Informed Care for all providers including children, complex adults and substance abuse providers will be scheduled. Complex adult treatment issues training will be scheduled for those providers who may be working with Members who may have intellectual disabilities, brain injury, complex medical issues, personality disorders, or substance abuse issues. Other topics will include confidentiality in substance abuse, EMDR and sex offending. As in previous years, CANS, FBA, treatment planning, ICD 10 codes, and recovery and resiliency will be offered.
Treatment Record Review of High-Volume Providers
The Treatment Record Review (TRR) process is coordinated with the PerformCare Credentialing cycle, ensuring that record reviews are completed prior to approving an application for re-credentialing. The TRR process allows PerformCare to evaluate the quality of treatment and monitor provider progress, and includes provider education on topics such as treatment and service planning, documentation, discharge planning, and establishing treatment outcomes. Throughout the TRR process, PerformCare works collaboratively with the provider in order achieve the end result of improving the quality of care that PerformCare members receive. In addition, the results of the TRRs are presented to the Credentialing committee for review, allowing for more fully informed credentialing decisions.
In 2013, a performance goal of 75% (total score of review) was established. Any provider that did not achieve the performance goal was required to submit a Quality Improvement
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Plan (QIP). PerformCare monitors all QIP submissions and collaboratively works with the provider to ensure all areas of opportunity are addressed, and then continues to consult with the provider on a quarterly basis in order to assess progress. Annual on-site reviews continue until the provider achieves the performance goal of 75%.
For the Capital region, Family Based Mental Health Service (FBMHS) providers were held to more stringent performance criteria, as requested by consumers, stakeholders, and counties. As such, Capital area FBMHS providers must achieve, and maintain, a score of 90% or more, as determined by the on-site treatment record review. Annual reviews will occur for Capital FBMHS providers who do not meet the 90% performance goal. These performance standards also coincide and support revisions to the FBMHS policies and procedures and facilitate fidelity to the FBMHS model of treatment.
The network average comparisons for all levels of care, comparing 2013 average score to 2011 and 2012 are listed on the graph on the following page.
Figure 40: TRR Network Averages for Capital, Bed/So and Fr/FU Regions
TRR Network Averages for Capital, Bed/So and Fr/Fu Regions 100% 90%
80% 70% 60% 50% 40% 30% AverageScore 20% 10% 0% MH OP BHRS Crisis CRR-HH FBMH MH IP MH OP Non- PHP PSS RTF STAP clinic 2011 74% 70% 82% 64% 47% 69% 67% 76% 2012 79% 84% 77% 62% 65% 74% 73% 76% 79% 2013 87% 88% 84% 69% 77% 87% 82% 85% 81% 77%
*Blanks indicate that no TRR were conducted for that level of care (LOC) for the year noted
Analysis of the TRR network averages demonstrates an increase in all levels of care from 2011-2013, indicating that the TRR process has had a positive effect on improving the quality of clinical care that the PerformCare network provides.
In 2013, PerformCare completed a total of 97 TRRs in the Capital, Bedford/Somerset, and Franklin/Fulton regions. Six levels of care that had not received an on-site review in past years are included in these results. These six levels of care include Summer Therapeutic Activities Program (STAP), Intensive Family Services (IFS), Intensive Day Treatment (IDT), Family Focused/Solution Based Services (FFSB), Crisis Intervention (Crisis) and Enhanced Integrated Behavioral Services (EIBS).
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Several of the new levels of care reviewed were exception services (Intensive Family Services (IFS), Intensive Day Treatment (IDT), Family Focused/Solution Based Services (FFSB), and Enhanced Integrated Behavioral Services (EIBS). Of these exception services, only one (Intensive Family Services, provider Pressley Ridge) required a QIP.
Providers who score below the performance goal of 75% were required to submit a QIP within 30 days upon receipt of the review results letter. Contents of a QIP include an outline of measureable action steps for each indicator listed as an opportunity; delineates the staff person who will assume responsibility for implementation and completion of the indicator; identifies and overall “owner” of ensuring the QIP is completed, and clearly includes measurable data so that there is objective evidence of completion (e.g., measureable objectives for each action item). PerformCare monitors these QIPs on a quarterly basis and also collaboratively works with all providers in order to reduce barriers to completion, to assist with formatting goals and objectives, and also to discuss progress. For 2013, a total of 31 QIPs were required for various levels of care.
The following information provides more detailed information regarding 2013 TRR reviews, separated by region and level of care:
Table 36: 2013 TRR Reviews, Separated by Region and LOC
Network (Bed/So, Capital, and Fr/Fu Level of Care Bedford/ Somerset Capital Franklin/ Fulton regions) # TRR # QIP # TRR # QIP # TRR # QIP # TRR # QIP BHRS 5 0 3 0 5 0 13 0 Crisis 0 0 0 0 1 0 1 0 EIBS 0 0 1 0 0 0 1 0 FBMHS 1 0 14 3 2 0 17 3 FFSB 1 0 0 0 0 0 1 0 IDT 0 0 1 0 0 0 1 0 IFS 0 0 1 1 0 0 1 1 MH IP 7 5 10 8 6 5 23 18 MH OP 2 1 5 2 3 0 10 3 MH OP non- clinic 1 0 0 0 0 0 1 0 PHP 3 0 3 1 2 0 8 1 PSS 3 1 2 0 1 0 6 1 RTF 1 0 2 1 0 0 3 1 STAP 3 1 7 1 1 1 11 3 Totals 27 8 49 17 21 6 97 31
Below is a multi-year comparison that monitors provider submitted QIPs from 2011 through 2013. As you will note, in 2012 there was an increase in QIP submissions,
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which can be attributed to an increased performance goal, as well as the review of levels of care that may not have received an on-site review in prior years. In 2012, the Quality Improvement Department was able to expand the on-site review process to encompass approximately many levels of care that had either never received a review, or submitted self-audits. Although 2013 demonstrates a reduction in the number of QIPs required, there is still a need for continuous quality improvement efforts for all levels of care.
Table 37: 2013 TRR Reviews Resulting in a QIP
Number of TRR Number of QIPs Percentage of QIPs 2011 102 36 35% 2012 56 27 48% 2013 97 31 32%
Further analyses of the TRRs and QIPs highlights those levels of care most in need of continued intervention. These include MH IP and RTF. For the BHRS level of care, additional assistance such as monitoring of initial access, FBAs, and treatment planning technical assistance is also provided. PerformCare is currently drafting proposals that will provide active assistance and education to these levels of care in order to improve the quality of care that our members receive. Interventions that are currently being provided by PerformCare include technical assistance, education and assistance, and individual meetings with providers that score below the performance goal.
Figure 41: Percentage of TRR Requiring QIP by LOC
Percentage of TRR Requiring QIP by LOC 100% 90% 80% 70% 60% 50% 40%
Percentage 30% 20% 10% 0% MH OP BHRS (13 FBMHS (17 MH IP (23 MH OP (10 PHP (8 PSS (6 RTF (3 non-clinic reviews) reviews) reviews) reviews) reviews) reviews) reviews) (1 review) 2011 25% 17% 89% 100% 62% 56% 20% 2012 25% 40% 100% 78% 50% 38% 50% 29% 2013 0% 18% 78% 30% 0% 13% 17% 50%
*Denotes the number of providers which were reviewed by contract (i.e. a provider serving Members in two contracts would be noted as two reviews).
The Quality Improvement Department is continually improving the Treatment Record Review process in collaboration with network providers. PerformCare updates the TRR tools giving consideration to on input from oversights, providers, consumers,
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interdepartmental feedback, as well as other stakeholder requests. Revisions to the TRR tools reflect changes in the expectation for behavioral healthcare, the integration of physical health components, and other trends in the research.
During 2014, changes which will improve the TRR process include: Updates to enhance the focus and encourage providers to engage in appropriate discharge planning, such as including Included indicators on all tools that ensure providers are engaging in ongoing discussions regarding discharge planning, and ensuring providers are working with members/families to enhance the use of community/natural supports. Strengthening of the inter-rater reliability of reviewers. Updates to the TRR results letters in order to provide clear and concise feedback with multicounty results and scores for each individual indicator within a single letter to further emphasize areas of opportunity and focus. Previous year scores in the results letters for any providers who are currently working within a QIP, which allows for quick analysis regarding progress and continued areas of opportunity.
2014 recommendations include establishing a uniform QIP protocol be developed to delineate the QIP process for treatment record reviews and other process such as quality of care reviews and service access reviews. The protocol should address a progressive disciplinary procedure to be followed for providers who are unresponsive OR for providers whose scores require QIP in two consecutive years. Further expansion of he levels of care that receive on-site record reviews in order to fulfill our commitment to continuous quality improvement. Expansion should expand to Extended Acute Care (EAC), Mobile Mental Health Treatment (MMHT), and Music Therapy. Further, in keeping with the triennial credentialing cycle audit tools should be developed for exceptions services including Family Support Program (FSP), Juvenile Firesetter Assessment Consultation Treatment Service (JFACTS), After School Program (ASP), Specialized In Home Treatment (SPIN) and Juvenile Sex Offender Family Based Services. Finally, a phased in review of substance abuse services should begin with the review of Substance Abuse Outpatient treatment (SA OP) in the Franklin/Fulton region, at the request of oversights in that region. Depending on the results of these reviews, further expansion of review of substance abuse services should continue.
In preparation for 2015, tools will be further refined to direct the development of quality programs with a strong clinical focus; consideration of raising the performance goal from 75% to 80%; and improving the provider experience of the TRR by offering the choice of desk or on-site reviews, offering remote access to electronic health records for review, offering technical assistance after a review as requested, and accommodating provider’s requests when possible.
Consumer and Family Involvement
Member Satisfaction Surveys
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PerformCare conducts surveys annually to determine how well PerformCare is meeting Member and Provider needs, usingd Polk-Lepson Research Group, Inc.to complete both the member satisfaction and the provider satisfaction surveys in past years. As a result of the declining response rate for the Member Satisfaction Survey, the lack of timeliness in completing the survey distribution and collection and concern about the composition of the questions, PerformCare decided to terminate the contract with Polk-Lepson in 2012 after they completed the survey work for the year. A work group was formed to determine how to proceed with the member surveys. The work group decided to develop a survey tool and conduct a validity test of the survey questions. The work completed included a comparison of the current survey tools being used by the various county entities, a review of Appendix L requirements, and submission of the survey tool for review by the county oversight entities at the county level. This work prevented the completion of a Member Satisfaction Survey for services provided in calendar year 2012. The work group decided the most appropriate way to proceed with the survey was to conduct validity testing on a sample population (500) of adult and child members who received services in calendar year 2013. The survey tool was distributed by mail to PerformCare members in mid-January 2014. We followed up with the mailing by calling the members.
An overview of the results of the survey is presented here.
Member Satisfaction Surveys
The Member Survey tool used was developed by the work group and based on various resources including the Experience of Care and Health Outcomes Survey (ECHOTM), Managed Behavioral Health Organization version 3.0H, standard items plus additional supplemental items and the tools being used by Consumer Satisfaction Teams throughout the counties served by PerformCare. The survey was prepared in English and only one member surveyed indicated that English was a second language. A total of 500 surveys were mailed out and the distribution between adult and children was determined by the percentages of total number of eligible PerformCare members in each age category as well as the number of members per each contract. The table below shows the break out.
Age Group B/S CAP F/F Total 18 years and older 31 Surveys 237 Surveys 30 Surveys 298 Surveys (10.54%) (79.35%) (9.93%) (59.59%) 0-17 years 17 Surveys 165 Surveys 20 Surveys 202 Surveys (8.46%) (81.26%) (9.92%) (40.41%)
The participants were selected randomly from all eligible PerformCare members. The completed survey goal was 100 for a 20% completion rate. At the termination of data collection 77 surveys were completed, 47 were mailed in and 30 were completed by telephone, for an overall completion rate of 16.8%. This rate is significantly higher than those reported in 2012 and 2011. Adult and child/adolescent results are analyzed separately. A full statistical analysis of the survey results has not been completed. Therefore the following information is a summary of the results and not necessarily indicators of a complete and accurate trend analysis.
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The initial intent of this survey was validation of the survey tool as the questions have been revised and the exploration of effective ways to engage member participation in the survey process. At this time, PerformCare anticipates returning to the use of the ECHO survey tool and engaging a vendor to perform the survey tasks and analyses in for the calendar year 2014 survey process.
Topics investigated in the study include: • Ability to receive counseling or treatment as wanted • Counseling or treatment experiences • Information received • Evaluation of counseling or treatment • Experiences with company handling benefits for counseling or treatment • Evaluation of company handling benefits • Reasons for counseling or treatment • Member background information
The following is a summary of the 2013 results:
Adult Survey
PerformCare randomly selected the names and addresses of 298 adult Members who received services in 2013. The selection of the number per contract was based on the percentage of members per contract when compared the total membership. The survey instrument contained 73 satisfaction questions and used a six point response scale including a does not apply response. The survey also included six demographic questions and space for additional comments.
A total of 30 adult surveys were returned as undeliverable. At the termination of data collection, 44 completed surveys were submitted; 14 were completed by telephone and 30 were mailed back. Not counting the undeliverable surveys, this is a response rate of 17.7%. This is a significant increase from the response rates in 2009 (17%), 2011 (7.3%) and 2012 (9.1%), however, lower than in 2010 (24.0%).
Areas of continued improvement – Comparison of those satisfaction questions that correlate with the ECHO Survey tool used in previous years
Provider treated with dignity and respect 97.7% of respondents indicated satisfaction with being treated with dignity and respect by their providers This continues an overall upward trend of satisfaction since 2005 and represents an increase from 91.0% in 2012 Provider explained rights as patient 97.3% of respondents indicated satisfaction with being informed of their rights as a patient This continues an overall upward trend of satisfaction since 2008 and represents
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an increase from 91.5% in 2012 Provider treatment explanation 100% of respondents surveyed indicated satisfaction with the treatment explanation provided This continues an upward trend since 2011 and is a significant increase from 88% in 2012 Provider listened 100% of respondents surveyed indicated they were satisfied that the provider listened to them carefully This continues an upward trend since 2011 and is a significant increase from 88.5% in 2013
Adult Survey Conclusions
In general, Members were satisfied with the treatment they received with 64 of 73 (87.7%) questions rated as 85% or higher satisfaction; six questions were rated at 100% satisfaction and the satisfaction ratings for the other 58 questions were distributed between 85.4% to 97.7% satisfaction; and the satisfaction rating for the remaining eight (8) questions fell between 69.8% and 84.2 percent. The specific areas that should be targeted for further analysis are outlined below:
Satisfaction with Service Providers Availability of service providers 18.6% of respondents surveyed indicated they are not satisfied with the availability of service providers close to where they live This relates to NCQA measure: Availability of Practitioners and Providers (QI 4) Treatment received 17.5 % of respondents surveyed indicated they were not satisfied with the timeliness of the treatment received; this correlates to an Appendix L satisfaction measure and relates to NCQA measure: Accessibility of Services (QI-5) 19.5% of respondents surveyed indicated they disagree or strongly disagree that they are more satisfied with their life 20% of respondents surveyed indicated they disagree or strongly disagree that they are better able to deal with things when they go wrong Physical Health 30.2% of respondents surveyed indicated they disagree or strongly disagree that they are satisfied with their physical health This correlates to an Appendix L satisfaction measure Maintenance of Wellness and Mental Health 18.4% of respondents surveyed indicated they disagree or strongly disagree that they can maintain wellness and mental health stability This correlates to an Appendix L satisfaction measure Medical Assistance Transportation Program 28.9% of respondents surveyed indicated they disagree or strongly
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disagree that they are aware of the Medical Assistance Transportation Program This correlates to an Appendix L satisfaction measure
Satisfaction with PerformCare Availability of Clinical Care Management 15.8% of respondents surveyed indicated they are not satisfied with the availability of a Clinical Care Manager when they need to speak with one.
Child and Adolescent Surveys
PerformCare randomly selected the names and addresses of 202 Child and Adolescent Members who received services in 2013. The selection of the number per contract was based on the percentage of members per contract when compared the total membership. The survey instrument contained 77 satisfaction questions and used a six point response scale including a does not apply response. The survey also included twelve demographic questions and space for additional comments.
A total of 11 surveys were returned as undeliverable. At the termination of data collection, 33 completed surveys were submitted. Not counting the undeliverable surveys, this is a response rate of 17.3% and is a significant increase over those noted in 2012 (7.1%) and 2011 (7.8%).
Areas of continued iprovement – Comparison of those satisfaction questions that correlate with the ECHO Survey tool used in previous years
Provider treated with dignity and respect 93.9% of respondents indicated satisfaction with their family being treated with dignity and respect by their providers This continues an overall upward trend of satisfaction since 2010 and represents an increase from 91.7% in 2012 Provider explained rights as patient 97% of respondents indicated satisfaction with being informed of their child’s rights as a patient This is a significant increase from 86.3% in 2012 Provider treatment explanation 97% of respondents surveyed indicated satisfaction with the provider’s explanation of their child’s treatment This continues an upward trend since 2010 and is a moderate increase from 92.3% in 2012 Provider listened 93.9% of respondents surveyed indicated they were satisfied that the provider listened to them carefully This continues an upward trend since 2010 and is a moderate increase from 89.8% in 2013
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Child Survey Conclusions
The overall Member satisfaction with providers and PerformCare remains high with 71 of 77 (92.2%) questions rated as 85% or higher satisfaction; 10 questions were rated at 100% satisfaction and the satisfaction ratings for the other 61 questions were distributed between 85.7% to 96.6% satisfaction; and the satisfaction rating for the remaining six (6) questions fell between 78.6 and 84.8 percent. The specific areas that should be targeted for further analysis are outlined below:
Availability of services 15.2% of respondents surveyed indicated they disagreed or strongly disagreed that their child’s services were available at times that were convenient to their family This is an Appendix L satisfaction measure Pros and Cons of treatment options 19.4% of respondents surveyed indicated they disagreed or strongly disagreed that their child’s provider discussed the pros and cons of each treatment option, including potential side effects This correlates to an ECHO questions regarding the potential side effects which shows an increase in no responses from 2012 Provider adjustment of services 15.6% of respondents surveyed indicated they disagreed or strongly disagreed that their child’s provider adjusted services when they were not working for their child Provider assisted with informal sources 21.4% of respondents surveyed indicated they disagreed or strongly disagreed that their child’s provider helped to get support from informal sources Discharge discussions 15.4% of respondents surveyed indicated they disagreed or strongly disagreed that discussion about their child’s discharge occurred regularly throughout treatment Medical Assistance Transportation Program 18.5% of respondents surveyed indicated they disagree or strongly disagreed that they were aware of the Medical Assistance Transportation Program This correlates to an Appendix L satisfaction measure
2013 Initiatives
No new initiatives have been determined at this time. It is recommended that the 2013 survey results be further analyzed to determine the significance and impact of the lower satisfaction ratings. This analysis should include the impact these areas can have on the quality of care provided to members and a cross reference to the previously identified initiatives and recommended actions.
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2014 Initiative
The initiative for 2014 is to return to the use of the ECHO survey tool. This tool meets the NCQA standards and can be cross walked to satisfy Appendix L requirements for satisfaction surveys as well. There is also some flexibility in the use of the survey tool.
The survey work completed in 2013 suggests we can achieve better survey completion rates by using multiple avenues to engage PerformCare members in the survey process. Recommendation: 1. Research and analyze the various avenues of distribution and collection of survey materials 2. Research and document potential vendors for analysis of survey data 3. Determine sample size and content 4. Research and identify methods to engage Members participation in the survey process 5. Involve stakeholders in determining the appropriate survey structure
Consumer / Family Satisfaction Team
The HealthChoices CFST survey process acquires feedback from Members regarding service satisfaction. The process serves as a compliment to other survey practices such as the annual survey conducted by PerformCare. These Member and family satisfaction interviews provide an opportunity for early identification and resolution of problems related to service access, timeliness of service delivery, and appropriateness of services, as well as inclusion of recovery resiliency. During 2013, PerformCare received responses from the various county CFST entities, providing the opportunity to identify strengths, weaknesses, and areas where initiatives can have an impact on outcomes to benefit Members served. Across contracts, there are areas of service focus that are consistent in assessing Member satisfaction with PerformCare. This focus addresses Member satisfaction in obtaining the help they felt they needed in the past 12 months, whether they believed that they were given the chance to make treatment decisions for themselves, and what effect the treatment received has had on the quality of their life. The following summarizes 2013 activity related to each of these CFST processes, targeting the three aforementioned main components of Member satisfaction.
In the last 12 months, were you able to get the help you needed? Across contracts 79% of adult respondents surveyed reported that they were always satisfied and able to get the help they needed within the past 12 months. This represents a 1% decrease from 2012, when 80% of adult members surveyed reported that they were able to get the help they needed. Additionally, within all contracts 79% of guardians responding for Children/Adolescent services indicated that they were always satisfied and were able to obtain the assistance they needed for their child on a consistent basis with no problems in getting the help they needed for their children.
Were you given the chance to make treatment decisions? In the PerformCare provider network, 81% of adult members surveyed noted that they are always provided
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opportunities to make decisions in their treatment, which is an increase from the 72% noted in 2012. This reflects a Member driven treatment model and incorporates key components of Recovery/resiliency principles in actively serving Members. Further, 84% of guardians reporting for Children/Adolescent services stated they were always given a chance to make decisions about the mental health care their children received. This also reflects an increase from the 83% reported in 2012. This promotes parents and caregivers as the expert on their children and leads to more lasting behavioral changes and emotional wellness when offered this opportunity.
What effect has the treatment you received had on the quality of your life? The quality of my life is: The responses of the adult Members surveyed indicated that 75% of adult Members reported that the quality of their life was better as they have received treatment to address their presenting concerns, which is an increase from 2012 (57%). Of the parents/guardians surveyed regarding the services their child or adolescent received, 64% reported that their child or adolescent had an improved quality of life as a result of the services received. Again, an increase is noted for reported improvements in Members’ quality of life from 2012 (57 %). Although both the Adult Member Child/Adolescent surveys reflected significant positive movement in this area, numbers continue below the 90% benchmark. Further improvement can be made in this area to help Members and families view the services as they are receiving as improving their level of functioning.
Continuity and Care Coordination
30 Day Readmission Rates & SMI Only Readmission Rates in Mental Health Inpatient
Psychiatric Inpatient Care Recidivism (30 Day readmission) refers to inpatient admissions that occur within 30 days of discharge from a previous Inpatient Treatment. An excessive amount of readmissions in a county population may be an indication of quality of care issues. The office of Mental Health and Substance Abuse Services (OMHSAS) in 2007 established 10% as the benchmark for the readmission rate of all inpatient discharges in a given year. Ongoing monitoring of readmission rates are completed quarterly and a yearly joint Barrier Analysis of Readmission and Follow up After Hospitalization for Mental Health has been held over the past few years.
A comparison of 30 Day Readmission Rates over the last three years reveals that the efforts made to reduce the Readmission Rates have been mixed at best. Cumberland and Dauphin Counties have demonstrated a decrease in the rates over the three year period. The other seven counties show an overall increase in the rates over the period. The network average has experienced a slight change over the three years but shows a rate increase from 2012 to 2013.
Five of the nine counties (Cumberland, Dauphin, Franklin, Lebanon, Perry and Somerset) show a decrease in rates from the 2012; the largest decrease occurred in Somerset County. The other four counties experienced an increase in the readmission rate; the increases ranged from .32 percent (Perry County) to 9.49 percent (Fulton County). It is important to note that readmission rates are easily influenced by the low number of
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admissions for several counties including Bedford, Fulton, Perry and Somerset. Table 38: Year to Year Comparison of All Readmission Rates
COUNTY 2011 RATE 2012 RATE 2013 RATE Bedford 8.30% 5.90% 12.98% Cumberland 14.10% 12.50% 11.83% Dauphin 19.30% 17.00% 16.92% Franklin 13.20% 19.30% 15.03% Fulton 11.40% 4.30% 13.79% Lancaster 13.60% 12.30% 13.41% Lebanon 15.70% 20.50% 17.19% Perry 15.00% 18.00% 15.58% Somerset 13.10% 6.80% 13.96% Network 14.80% 14.10% 14.42%
Opportunities for improvement in 2013 continued to include a focus on improving discharge planning by addressing barriers to treatment prior to discharge, increasing treatment team collaboration, expanding the channels of communication with the Member’s inpatient and outpatient treatment teams and continuing the use of Follow-Up Specialists to encourage members to follow up with outpatient appointments and confirm participation in the appointments. Additionally, as part of the 2012 RCA, the Mental Health Bridge at Pennsylvania Psychiatric Institute (PPI) became a billable service through PerformCare for Dauphin County and Lancaster County while a Mental Health Bridge pilot program was implemented at Lancaster Regional Medical Center as well. These programs have the potential to reduce readmission rates and improve the follow up rates after inpatient hospitalization.
The graphs below illustrate the All Members and the SMI only readmission rates for 2013.
Table 39: 2013 Readmission Rates per County and Network
County All Readmission SMI Readmissions Bedford 12.98% 22.00% Cumberland 11.83% 17.82% Dauphin 16.92% 18.98% Franklin 15.03% 22.84% Fulton 13.79% 20.00% Lancaster 13.41% 22.64% Lebanon 17.19% 21.63% Perry 15.58% 18.75% Somerset 13.96% 20.19% Network 14.42% 20.54%
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Figure 42: 2013 Readmission Rates
2013 All Readmission 15.50% 14.87% 14.94% 15.00% 14.42% 14.50% 14.00% 13.64% 13.50% 13.00% 12.50% BS CA FF NETWORK
In-depth review of All Readmissions shows that all three contracts (Blair, Clinton, and Lycoming Counties are excluded from this 2013 evaluation) did not met the OMHSAS goal of 10% or less. The cumulative readmission rate for each of the three contract areas is below 15% with the Franklin/Fulton contract showing a rate decrease of 1.57% when compared with the 2012 all readmissions rate (16.51%). Bedford/Somerset and the Capital Area showed a readmission rate increase of 1.44 % and 2.29% respectively.
Figure 43: 2013 Readmissions with SMI
2013 Readmissions with SMI 23.00% 22.67% 22.50% 22.00% 21.50% 21.00% 20.78% 20.47% 20.54% 20.50% 20.00% 19.50% 19.00% BS CA FF NETWORK
Examination of the SMI readmission rates shows that all three contract rates and the network rate exceed the OMHSAS goal by greater than ten percent. A comparison of the 2013 individual contract rates with those of 2012, reveals a rate increase across all three contracts: Bedford/Somerset 8.58%, Capital Area 1.99% and Franklin/Fulton 6.88%. The nine counties did not meet the OMHSAS standard of 10 percent. The Dauphin, Franklin, and Perry county rates decreased when compared to the 2012 rates, while Bedford, Cumberland, Fulton, Lancaster, Lebanon, and Somerset county rates increased when compared to the 2012 rates. Bedford County showed the largest increase (12.38%) and
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Franklin County showed the largest decrease (7.34%). Again, it is important to note that readmission rates are easily influenced by the low number of admissions for several counties including Bedford, Fulton, Perry and Somerset.
PerformCare and its stakeholders will focus heavily on this area of network performance to identify opportunities to improve these readmission rates by examining what is working, what is not working, and also consider implementing initiatives that will make a positive impact, i.e., a significant decrease) on the rates. Some of the efforts already in process include the development of complex case management, increased Member monitoring (triggered by a single readmission), focuses on population based strategies, and the implementation of “Strike Teams” to conduct on-site practice management in order to improve treatment planning, Member engagement, and discharge planning during inpatient stays.
Ambulatory Follow-Up Rates after Hospitalization for Mental Illness
As the length of stay (LOS) of inpatient mental health hospitalization continues to decrease, follow-up care after discharge has become the cornerstone intervention in the efforts to reduce re-admissions to mental health inpatient programs (MHIP). Multiple studies have reported that Members who attend follow-up appointments have a decreased chance of being re-hospitalized when compared to those who do not follow-up with outpatient care. The 2013 QI Program established this measurement area as an ongoing Performance Improvement Project (PIP) as required by OMHSAS. This PIP also meets the requirements of the External Quality Review project that is overseen and validated by IPRO. In the Capital counties, this PIP was initiated in 2004 and continued into 2009. The North Central Counties initiated this PIP in 2009. OMHSAS determined that the initial PIP cycle was completed in 2009 and requested all counties to complete a Root Cause Analysis (RCA) with new action steps and measures. The new baseline for reporting purposes was established as 2008 and the first re-measurement year was established as 2010. In 2010, a second RCA which included all counties was requested of PerformCare for Num 1 and Num A only since rates failed to improve in 2009. New initiatives were gleaned from this RCA to increase the likelihood of Members attending an appointment within 7 days of discharge. PerformCare was requested to complete another RCA in 2012; this time focusing on HEDIS NUM 1, NUM 2 and PA Specific NUM B measures since these rates continued to show no improvement. New initiatives were developed and implemented in 2012-13. The follow-up measures were designed to be consistent with the national standard for follow-up measures available from the National Committee for Quality Assurance (NCQA) as part of the Healthcare Effectiveness Data and Information Set (HEDIS). Thus, measures obtained for PerformCare Members can be compared to both national Medicaid data from HEDIS and state HealthChoices data available from OMHSAS.
Four indicators are reported in this process:
Quality Indicator 1 (NUM 1): Follow-up after Hospitalization for Mental Illness within 7 days after discharge. (Calculation based on Industry Standard Codes). This indicator
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measures the percentage of discharges for Members 6 years and older who were hospitalized for treatment of selected mental health disorders, who were seen on an ambulatory basis or who were in day/night treatment with a mental health provider on the date of discharge up to 7 days after hospital discharge.
Quality Indicator 2 (NUM 2): Follow-up after Hospitalization for Mental Illness within 30 days after discharge. (Calculation based on Industry Standard Codes). This indicator measures the percentage of discharges for Members 6 years and older who were hospitalized for treatment of selected mental health disorders, who were seen on an ambulatory basis or who were in day/night treatment with a mental health provider on the date of discharge up to 30 days after hospital discharge.
Quality Indicator 3 (NUM A): Follow-up after Hospitalization for Mental Illness within 7 days after discharge. (Calculation based on Industry Standard Codes + PA local codes that are not able to be mapped to industry standard). This indicator measures the percentage of discharges for Members 6 years and older who were hospitalized for treatment of selected mental health disorders, who were seen on an ambulatory basis or who were in day/night treatment with a mental health provider on the date of discharge up to 7 days after hospital discharge.
Quality Indicator 4 (NUM B): Follow-up after Hospitalization for Mental Illness within 30 days after discharge. (Calculation based on Industry Standard Codes + PA local codes that are not able to be mapped to industry standard). This indicator measures the percentage of discharges for Members 6 years and older who were hospitalized for treatment of selected mental health disorders, who were seen on an ambulatory basis or who were in day/night treatment with a mental health provider on the date of discharge up to 30 days after hospital discharge.
The following table includes the 4 measurements noted above for all 9 counties over the past four years with a comparison to the HEDIS standards and the PA Specific standards.¹
Table 40: Follow-Up Rates 2009 to 2012
Perform-Care Perform-Care Perform-Care Perform-Care Rate 2009 Rate 2010 Rate 2011 Rate 2012 validated validated validated validated
NUM 1 (7-Day) Follow-Up Rates
Bedford 28.6% 36.8% 40.7% 38.9%
Cumberland 46.3% 42.1% 49.0% 46.1%
Dauphin 39.9% 35.1% 40.4% 44.2%
Franklin 39.5% 49.6% 49.2% 55.8%
Fulton 48.1% 46.4% 30.8% 57.9%
Lancaster 40.2% 40.8% 45.6% 44.5%
Lebanon 55.6% 48.6% 60.5% 55.2%
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Perry 42.2% 51.4% 34.5% 47.1%
Somerset 36.4% 38.4% 38.2% 49.4%
HEDIS Benchmark 2011 53.9%
NUM 2 (30-Day) Follow-Up Rates
Bedford 58.0% 66.3% 74.3% 72.2%
Cumberland 64.9% 68.0% 70.3% 71.7%
Dauphin 60.1% 57.8% 64.0% 68.1%
Franklin 73.5% 80.1% 82.7% 83.5%
Fulton 66.7% 75.0% 53.8% 78.9%
Lancaster 61.0% 60.4% 67.6% 69.5%
Lebanon 77.2% 74.6% 77.8% 79.2%
Perry 65.6% 70.0% 56.9% 71.4%
Somerset 61.4% 59.6% 64.6% 72.2%
HEDIS Benchmark 2011 74.6%
Perform-Care Perform-Care Perform-Care Perform-Care Rate 2009 Rate 2010 Rate 2011 Rate 2012 validated validated validated validated
NUM A (7-day) Follow-Up Rates (Including TCM and Peer Support)
Bedford 52.7% 55.8% 61.1% 61.1%
Cumberland 62.8% 55.4% 57.5% 57.9%
Dauphin 60.9% 58.4% 59.9% 64.1%
Franklin 54.2% 60.5% 64.6% 66.3%
Fulton 51.9% 53.6% 50.0% 63.2%
Lancaster 50.3% 48.5% 52.1% 54.3%
Lebanon 61.7% 57.8% 68.8% 62.0%
Perry 53.1% 51.4% 41.4% 52.9%
Somerset 50.6% 54.5% 51.7% 60.6% HEDIS Benchmark 2011 68.3%
NUM B (30-day) Follow-Up Rates (Including TCM & Peer Support
Bedford 77.7% 76.8% 85.8% 87.8%
Cumberland 78.1% 74.1% 75.7% 76.4%
Dauphin 76.1% 74.3% 76.6% 79.1%
Franklin 81.0% 83.5% 87.3% 88.4%
Fulton 70.4% 85.7% 65.4% 78.9%
Lancaster 67.7% 64.9% 71.7% 74.7%
Lebanon 81.8% 78.7% 83.5% 83.7%
Perry 71.9% 70.0% 63.8% 74.3%
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Somerset 71.0% 68.7% 72.5% 78.3%
HEDIS Benchmark 2011 82.6%
¹HEDIS Benchmark is a National Benchmark set at the 75th percentile of the national mean according to HEDIS 2010 Medicaid standards for NUM 1 and NUM 2 and 90th percentile for NUM A and NUM B as validated by IPRO ²The OMHSAS established benchmark (gold standard) is 90% for all four measures shown above
Summary
This snapshot of HEDIS measures over the four year time period of 2009 to 2012 clearly shows that PerformCare has improved, significantly in some counties, the County follow- up rates through the use of the PIP, QIA and RCA processes. PerformCare brought together a diverse group of stakeholders to identify barriers, identify appropriate corrective actions and implement these corrective actions. The partnership with providers throughout this process has helped to expedite the implementation of corrective actions and evaluate the results. Although progress has been made toward the attainment of HEDIS and PA Specific Benchmarks, PerformCare recognizes the need to continue to monitor these rates and to work towards identified benchmarks.
As shown in the above table, PerformCare and its network of providers did not meet the established HEDIS and PA Specific benchmark goals for all four measures in 2012. PerformCare’s noteworthy improvements include: 1) Fulton and Lebanon Counties achieved and exceeded the HEDIS benchmark for NUM1 and NUM 2 2) Franklin County achieved and exceeded the HEDIS benchmark for NUM2 3) Bedford, Franklin, and Lebanon Counties achieved or exceeded the PA Specific benchmark for NUM B 4) Dauphin, Franklin, Fulton, and Somerset Counties showed rate increases across all four measures.
The 2012 RCA interventions targeted discharge planning on the Mental Health inpatient unit, collaboration and communication within the Member’s treatment team, appropriate utilization of TCM, referrals to Peer Support Specialists, and in specific counties, the use of a Bridge Appointment to assist the Member in being seen within the 7 day standard. These interventions were instrumental in increasing the follow up rates during 2012 for NUM 1 (five out of nine counties), NUM 2 (eight out of nine counties), NUM A (six of the nine counties), and NUM B (nine of nine counties). Additionally, the four year data presented above reveals an overall increase in follow up rates across all three contracts. A graphic display of PerformCare’s progress with Follow up rates based upon validated rates over time is shown below.
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Figure 44: Network Validated Rates for 2012
Network Validated Rates 100.00% 90.00% 80.00%
70.00% 60.00% 2009 50.00% 2010 40.00%
Validated Rate 30.00% 2011 20.00% 2012 10.00% 0.00% NUM 1 NUM 2 NUM A NUM B HEDIS Measures
*Arrows above indicate the HEDIS and PA Specific Goals for 2011 as noted in the previous table
Note: Validated rates for 2013 will not be available until later in 2014 and will be reviewed in the 2014 Annual Report.
Quarterly Overview of 2013 Follow Up Rates
Despite the above described efforts, PerformCare found a continuation of rate fluctuation from quarter to quarter in 2013. The overall view of the three contract Follow Up rates during Quarters 1, 2, and 3 indicates that the HEDIS and PA Specific benchmarks were not achieved. It is important to note that the following rates are Quarterly results and not the rates for the full measurement year which tend to be higher. The year-end rates will be included in the 2014 Annual Report.
The following review and trending of progress in 2013 is shown by contract. Bedford-Somerset (BS) Territory – the B/S counties continued to struggle with meeting the HEDIS and PA Specific goals in the first three quarters of 2013. Only one (NUM 1) of the four measures demonstrated a rate increase over the three quarters. This rate increase was 5.3%; a significant increase over the three quarter period. The rates for the other three measures show decreases ranging from 1.2 % (NUM A) to 6.8% (NUM B). The HEDIS NUM 1 rate initially decreased from 39.40% in Quarter 1(Q1) to 38.50% (Q2) and then increased to 43.80 % in Quarter 3 (Q3); the HEDIS NUM 2 rate decreased from 75% (Q1) to 67.70% (Q2) and ended at 67.10% (Q3); the PA Specific NUM A showed the least change across the three quarters with an increase from 51.90% (Q1) to 52.30% (Q2) and decreased to 50.70% (Q3); and the PA Specific NUM B demonstrated the largest decrease from 80.80% (Q1) to 76.90% (Q2) and ended at 74% (Q3). The B/S territory started the year meeting and exceeding the benchmark for two (NUM 2 and
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NUM B) of the four 2012 measures but experienced a significant decrease in follow up rates throughout the three quarters.
Capital Area (CA) Territory – The trend across the three quarters of 2013 for the CA territory, the combined rate for the five counties, shows improvement for the HEDIS NUM 1 and NUM 2 and the PA-Specific NUM B indicators rates and a slight decrease for PA Specific NUM A. The HEDIS NUM 1 rate decreased slightly from 42.30% (Q1) to 42.08% (Q2) and then increased slightly to 43.84% (Q3); the HEDIS NUM 2 rate decreased from 62.30% (Q1) to 62.13 % (Q2) and increased to 68.62 (Q3); the PA- Specific NUM A rate decreased from 54.10 % (Q1) to 53.44 % (Q2) and increased to 54.05% (Q3) representing a slight decrease over three quarters; and the PA Specific NUM B rate decreased slight from 70% (Q1) to 69.99% (Q2) and increased to 74.17% (Q3). The Capital Territory has not met the recommended Benchmarks across all four measures.
Franklin-Fulton (FF) Territory – The F/F counties experienced rate increases across all four measures during the first three quarters of 2013 and demonstrated the most fluctuation in rates. Although the territory experienced an increase in each measure, the rates for quarter one appear to be significantly lower than the validated rates for 2012. The HEDIS NUM 1 rate maintained an increase across all three quarters and improved from 32.80% in the first quarter to 36.20 % (Q2) and ended at 42.31% (Q3) for an increase of 9.51%, the highest increase in the three territories; the HEDIS NUM 2 rate decreased from 65.60% (Q1) to 63.80% (Q2) and then increased to 71.79% (Q3); the PA Specific NUM A also maintained an increase across all three quarters and showed an improvement from 44.30% (Q1) to 50% (Q2) and ended at 51.28% (Q3); and the PA Specific NUM B rate showed the most fluctuation with a decrease from 73.80% (Q1) to 68.10% (Q2) and then an increase to 74.36 % (Q3). The F/F territory has not met the HEDIS or the PA Specific benchmarks in the first three quarters of 2013.
Figure 45: 2013 Follow-Up Rates – HEDIS
2013 NUM 1 2013 NUM 2 50.00% 80%
40.00% 60% 30.00% BS BS 40% 20.00% CA CA 20% 10.00% FF FF
0.00% 0% Q1 2013 Q2 2013 Q3 2013 Q1 2013 Q2 2013 Q3 2013
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Figure 46: 2013 Follow-Up Rates – PA Specific
2013 NUM A 2013 NUM B 60.00% 85.00% 50.00% 80.00% 40.00% BS 75.00% BS 30.00% CA 70.00% CA 20.00% FF FF 10.00% 65.00% 0.00% 60.00% Q1 2013 Q2 2013 Q3 2013 Q1 2013 Q2 2013 Q3 2013
PerformCare’s use of root cause analysis (RCA), performance improvement plans, and quality improvement activities has successfully improved the rates of follow up care since the original PIP implementation in 2002. The collaborative efforts of PerformCare and the various stakeholders resulted in significant improvement of the individual count rates but the county and the overall follow up rates still have not reached the benchmark standards established by OMHSAS. Additionally, the overall improvement in the rates appears to have plateaued over the last four years (2009 to 2012). OMHSAS has recognized this and is discontinuing the Ambulatory Follow-Up PIP in 2014, moving the focus to improving readmission rates. PerformCare recognizes the importance of timely follow-up treatment after inpatient, has established this as a priority, and will continue to develop initiatives to improve these rates.
Included in these initiatives are the following: 1. An OMHSAS Cost-Driver Initiative focused on Ambulatory Follow-Up Rates following inpatient treatment 2. Development of real-time reporting on Follow-Up 3. Data collection regarding Follow-Up Specialist contacts 4. Face-to-Face meetings with inpatient hospitals to improve discharge planning 5. Provider scorecards for discharging inpatient programs and receiving outpatient programs
NCQA recognizes follow-up after hospitalization as an important component of certification and continues to use the HEDIS measures as a gauge of managed behavioral health care organizations. Therefore, PerformCare will continue to monitor, analyze and work to improve the follow up after hospitalization rates within its established provider network in an effort to meet or exceed the HEDIS benchmark measures.
Clinical Practice Guidelines
The Quality Improvement/Utilization Management Committee (QI/UM) delegates responsibility for the evaluation of Clinical Practice Guidelines (CPG) to the Provider Advisory Committee (PAC). Seven Clinical Practice Guidelines had previously been
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evaluated and recommended as relevant for the PerformCare Provider Network, and one additional guideline was reviewed and recommended in 2013, bringing the total of recommended CPG’s to eight:
ADHD: Adopted American Academy of Pediatrics Clinical Practice Guideline: ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention Deficit Hyperactivity Disorder in children and adolescents (November 2011; Pediatrics 128(5):1007-1022, 2011). Available online at http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011- 2654.full.pdf o Update December 2013: No changes noted, re-adopted as currently referenced.
Bipolar Disorders. Adopted the American Psychiatric Association Practice Guideline for the Treatment of Patients with Bipolar Disorder (2nd Edition, April 2002). Available online from APA at http://www.psychiatryonline.com/pracGuide/pracGuideTopic_8.aspx. o Update December 2013: No changes noted, re-adopted as currently referenced, including the November 2005 Guideline Watch: http://www.psychiatryonline.com/content.aspx?aid=148430 o The reference includes the following statement: “This guideline is more than 5 years old and has not yet been updated to ensure that it reflects current knowledge and practice. In accordance with national standards, including those of the Agency for Healthcare Research and Quality ™ National Guideline Clearinghouse, this guideline can no longer be assumed to be current. A third edition of this guideline is in development. The November 2005 Guideline Watch associated with this guideline provides additional information that has become available since publication of the guideline, but it is not a formal update of the guideline.”
Bipolar Disorder in Children and Adolescents. Adopted the American Academy of Child and Adolescent Psychiatry Practice Parameter: Practice Parameter for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder. Available online from AACAP at http://www.disabilityscoop.com/2014/02/25/whats-so-funny-autism/19144/ o Update December 2013: Guideline adopted by Provider Advisory Committee during June 2013 meeting
Major Depressive Disorder. Adopted the American Psychiatric Association Practice Guideline for the Treatment of Patients with Major Depressive Disorder (3rd. Ed. October, 2010). Available online from APA at http://www.psychiatryonline.com/pracGuide/pracGuideTopic_7.aspx. o Update December 2013: No changes noted, re-adopted as currently referenced. No subsequent guideline watch has been published.
Oppositional Defiant Disorder. Adopted American Academy of Child and
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Adolescent Psychiatry Practice Parameter for the Assessment and Treatment of Children and Adolescents with Oppositional Defiant Disorder (January 2007). Available from AACAP at http://www.aacap.org/galleries/PracticeParameters/JAACAP_ODD_Jan_2007.pdf o Update December 2013: Guideline adopted by Provider Advisory Committee during June 2012 meeting
Psychiatric Evaluation of Adults. Adopted the American Psychiatric Association Practice Guideline for the Psychiatric Evaluation of Adults (2nd Edition, June 2006). Available online from APA at http://psychiatryonline.org/content.aspx?bookid=28§ionid=2021669 o Update December 2013: No changes noted, re-adopt as currently referenced. No subsequent guideline watch has been published
Schizophrenia. Adopted the American Psychiatric Association Practice Guideline for the Treatment of Patients with Schizophrenia, (Second Edition, February 2004). Available online from APA at http://www.psychiatryonline.com/pracGuide/pracGuideTopic_6.aspx o Update December 2013: No changes noted, re-adopted as currently referenced. o The reference includes the following statement: This guideline is more than 5 years old and has not yet been updated to ensure that it reflects current knowledge and practice. In accordance with national standards, including those of the Agency for Healthcare Research and Quality National Guideline Clearinghouse, this guideline can no longer be assumed to be current. The November 2009 Guideline Watch associated with this guideline provides additional information that has become available since publication of the guideline, but it is not a formal update of the guideline.
Substance Use Disorders. Adopted the American Psychiatric Association Practice Guideline For The Treatment Of Patients With Substance Use Disorders, (2nd Edition, August 2006). Available online from APA at http://www.psychiatryonline.com/pracGuide/pracGuideTopic_5.aspx. o Update December 2013: No changes noted, re-adopted as currently referenced, including the April 2007 Guideline Watch at http://www.psychiatryonline.com/content.aspx?aid=149073 o The reference includes the following statement “This guideline is more than 5 years old and has not yet been updated to ensure that it reflects current knowledge and practice. In accordance with national standards, including those of the Agency for Healthcare Research and Quality ™ National Guideline Clearinghouse, this guideline can no longer be assumed to be current. The April 2007 Guideline Watch associated with this guideline provides additional information that has become available since publication of the guideline, but it is not a formal update of the
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guideline.”
As noted above, all of the previously adopted Clinical Practice Guidelines were re- adopted by the PAC during the December 2013 meeting and the Practice Parameter for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder was reviewed and approved during the June 2013 meeting. There have been no new Guideline Watches added to any of the previously adopted practice guideline even though some are over 5 to 10 years old. The committee will continue to monitor the websites and information clearinghouses for information regarding updated guidelines and during 2014 the committee will continue to expand its search for more updated Practice Guidelines through other organizations (e.g. AACAP, American Academy of Pediatrics).
It was decided that all guidelines that are evaluated by PAC and considered helpful will continue to be made available as a reference to providers through the PerformCare Website in order to assist, guide and improve their practice.
Clinical Practice Guideline Measures
For the purposes of provider performance measurement as it relates to adherence to Clinical Practice Guidelines, specific measures related to the ADHD and Adult Bipolar Disorder CPG’s were developed and are routinely monitored by the committee through formal committee review at the March and September quarterly meetings. The following sources were identified to help guide the Guideline Measures currently reviewed by the committee:
Bipolar Disorders. The American Psychiatric Association Practice Guideline for the Treatment of Patients with Bipolar Disorder (2nd Edition, April 2002).
ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention Deficit Hyperactivity Disorder in children and adolescents. The American Academy of Pediatrics (November 2011; Pediatrics 128(5):1007-1022, 2011).
Updates to CPG Measures – 2013
During the 2013 year, the PAC continued to refine the CPG measures with the overarching goals of bringing the measures into close alignment with the approved practice guidelines and obtaining the most accurate and representative results. The committee was successful in updating CPG Measure #1 to reflect the most recently approved front line medications for ADHD and to more precisely determine the percentage of child members with a diagnosis of ADHD who are taking a front line medication. Due to changes in outpatient billing codes that occurred during the year, it is no longer possible to discriminate (from that data set) if an outpatient visit was for psychotherapy, medication management or a variety of other outpatient services. Thus, it is no longer possible to conduct the former CPG measure #2 analysis, which determines the percentage of members with ADHD diagnosis who had more than one medication
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management appointment. The data from this analysis therefore, cannot be presented here and will no longer be presented for bi-yearly review at PAC meetings. The Pharmacy and Therapeutics subcommittee will develop a 2nd ADHD analysis that will be available at the June 2014 meeting. The Bipolar CPG measure #1 was updated to reflect the most recently approved front line medications. Below are descriptions of the revised measures:
Measure 1: Percentage of members with an ADHD diagnosis who are prescribed at least one of first-line medication (as recommended by the guideline).
Identify all Members with ADHD diagnoses (314.01; 314.00; 314.9) in an identified 1-year period of time.
Exclude members from the analysis with the following diagnoses that would be a contraindication for front-line ADHD Medications: 307.23 - Tourette’s Disorder, 307.22 - Chronic Motor or Vocal Tic Disorder, 307.21 - Transient Tic Disorder, 307.20 - Tic Disorder, NOS, 304.40 - Amphetamine Dependence, 305.70 - Amphetamine Abuse, 304.20 - Cocaine Dependence, 305.60 - Cocaine Abuse, 304.80 - Polysubstance Dependence, 307.42 - Primary Insomnia, 307.1- Anorexia Nervosa
Exclude from the analysis members with TPL as pharmacy data are not available
For the same annual period, request pharmacy data from the PH-MCO for each identified Member for the following medications: methylphenidate; amphetamine; or other FDA-approved non-stimulants including: a. Adderall b. Adderall XR c. Concerta d. Daytrana e. Desoxyn f. Dexedrine g. Dextrostat h. Focalin i. Focalin XR j. Metadate CD k. Methylin l. Ritalin m. Ritalin SR n. Ritalin LA o. Strattera p. Vyvance
Determine the percentage of Members with ADHD diagnosis who are prescribed at least one of first-line medication options recommended by the guideline.
Measure 2: Percentage of members with a Bipolar Disorder diagnosis who are prescribed at least one of the first-line medication options (as recommended by the guideline),
Identify all Members with Bipolar Disorder diagnoses (296.4x; 296.5x; 296.6x; 296.7; 296.80; 296.89) in an identified 1-year period of time.
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For the same annual period, request pharmacy data from Gateway for each identified Member for the following medications: Lithium, valproate, divalproex, lamotrigine, carbamazepine, oxcarbazepine, olanzapine, risperidone, clozapine, ziprasidione, quetapine, aripiprazole, asenapine, paliperidone, fluoxetine/olanzapine combination (Symbyax), and lurasidone.
Determine the percentage of members with Bipolar Disorder diagnosis who are prescribed at least one of the first-line medication option recommended by the guideline.
Measure 3: Percentage of Members with a Bipolar Disorder diagnosis who have been treated for substance abuse or dependence.
Bipolar disorder with a co-morbid substance use disorder is a very common presentation, with individuals of both genders showing much higher rates of substance use than the general population. As a benchmark, the Epidemiologic Catchment Area (ECA) study found rates of alcohol abuse or dependence in 46% of patients with bipolar disorder compared to 13% for the general population. Comparable drug abuse and dependence figures are 41% and 6%, respectively.
Identify all Members with Bipolar Disorder diagnoses (296.4x; 296.5x; 296.6x; 296.7; 296.80; 296.89) who had at least one claim for any service in an identified 1-year period of time.
Identify secondary diagnoses of the following Substance-Related Disorders (303.90; 305.00; 304.40; 305.70; 304.30; 305.20; 304.20; 305.60; 304.50; 305.30; 304.60; 305.90; 304.00; 305.50; 304.60; 305.90; 304.10; 305.40; 304.80; 304.90; 305.90) and/or Substance Abuse treatment authorization within the same annual time period within the same annual time period.
Comparative Data
Presented below are the data for each of the three CPG Measures for which data analyses have been fully reviewed and revised for calendar years 2011, 2012, and 2013. In general, data remain quite stable across time. During the April 2013 PAC meeting the following benchmarks, based on Clinical Practice Guidelines or prevalence data presented in published research were approved and no changes have been recommended to the current benchmarks so they will be retained for 2014. Measure Proposed Benchmark 1) ADHD and Front Line Medication 80% 3) Bipolar and Front Line Medication 80% 4) Bipolar and SA Treatment 50%
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Figure 47: CPG Measures
CPG Measure #1: Percentage of Members with ADHD Diagnosis and Front Line Medication Prescribed
70
60
50
40 2011
30 2012 2013 20
10
0
Percentprescribed medication frontline 0-5 years 6-11 years 12-18 years
CPG Measure #2: Percentage of Members with Bipolar Diagnosis and Front Line Medication Prescribed
100 90 80 70 60 50 40 30 20 10 0
Percentage PrescribedFrontMed Line 2011 2012 2013
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CPG Measure #3: Percentage of Members with Bipolar Diagnosis and Substance Abuse Treatment 100 90 80 70 60 50 40
Treatment 30 20 10 0
Percentage withSubstance Abuse 2011 2012 2013
As noted, all CPG data have been remarkably stable over the past three years with evidence of a slightly decreasing trend in the percentage of Members with a Bipolar diagnosis who are prescribed a front-line medication. None of the analyses produced results that meet the current benchmarks, however due to the amount of time that was invested in the refinement of the actual CPG measure analyses during 2013, very little progress was made in further analyzing potential drivers for low performance on these measures. This will be a focus of the PAC in 2014.
Recommendations for 2014
1) PAC to refine and approve on additional ADHD CPG measure and two Schizophrenia CPG measures During the 2013 Calendar year, a number of refinements and enhancements were made to the current Bipolar and ADHD CPG measures and these measures have been approved for continued use in 2014. However, NCQA standards now require the review of two CPG measures for three different CPGs. Therefore, in order to meet NCQA requirements the PAC / Pharmacy and Therapeutics Subcommittee will develop and implement one additional ADHD CPG measure (to replace the one that was discontinued due to billing code changes) and develop and implement two additional CPG measures for Schizophrenia.
2) PAC to review and approve a Substance Use Disorder Clinical Practice Guideline and Develop CPG associated measures Based on the group discussion, including the statement that TIP 42 (Substance Abuse Treatment for Persons with Co-Occuring Disorders) was currently being utilized in some parts of the network, TIP 42 was selected by the Committee for review. This will be presented and reviewed by the committee during the June 2014 meeting.
3) PAC to address network performance below benchmarks Once all of the CPG measures are developed and implemented, the PAC will begin to
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analyze potential drivers for performance that does not meet benchmark standards. The Pharmacy and Therapeutics subcommittee will lead root cause analyses to identify potentially powerful drivers for substandard performance on CPG measures and work with the PAC and QI/UM committee to develop initiatives focused on improving network understanding of clinical practice guidelines and adherence to CPG measure standards.
DPW Physical Health-Behavioral Health (PH-BH) Joint QI Initiatives
Recognizing the importance of integrated care and the benefit to Members in improving overall health and extending their lifespan, PerformCare participates in a number of coordinated efforts, the most prominent of which include:
PH/BH Education - TCM trainings on Cardiovascular Disease in the SMI population were completed in 2013. Consumer/Family/Provider PHBH trainings were completed as part of the Cumberland and Dauphin County Recovery Conference and for Franklin County Providers. PHBH training is scheduled for Bedford and Somerset Providers in March of 2014. Further discussion concerning the value of additional TCM trainings will be completed in February 2014. Mobile Psychiatric Nursing - This is utilized for follow up after discharge and with Members with complex needs. Current Providers of this service are established in Lancaster and Dauphin County. Behavioral Healthcare Corporation in Lancaster provides service to Lancaster, Lebanon, Dauphin, Cumberland and Perry Counties. Northwestern Health System is initiating a new service for Dauphin, Cumberland and Perry Counties in 2014 which will expand choice and improve access. Mobile Psychiatric Nursing services were provided to 162 Members (2012)and in 2013 the number of members served increased to 189 Members. Perinatal Program - Specialized case management is offered to any women who are currently pregnant or Members who have recently delivered and are experiencing postpartum depression. The ultimate goal is to prevent postpartum depression or lessen. Potential sources of referral include Members, utilization review care management or community providers. Case Management assistance includes telephonic outreach to the Member throughout the pregnancy up to two months postpartum. Members are provided with referrals and assistance with connecting to a behavioral health or substance abuse provider if needed. Additionally, Members are encouraged to connect with their physical health plan and assisted with a warm transfer or a phone number depending on the Member’s preference. An assessment measuring the Member’s needs is completed upon admission to the program. Dates of obstetrical appointments are obtained to ensure the Member is receiving medical care and community resources are suggested if needed. Members who are experiencing their first pregnancy receive a book called Nine Months to Get Ready which guides them through each trimester. This is a voluntary program and Members have the right to decline. In 2013, 51 pregnant and 5 postpartum Members were identified as program candidates. Fourteen (14) perinatal women and one postpartum Member agreed to participate in the program. Unfortunately not all Members participate through the two month postpartum goal which makes other measurable outcomes difficult. The majority of referrals to the program were Members in Dauphin and Lancaster County with 20 Members from each. Cumberland County had 5 referrals,
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Lebanon County 4, Franklin County 3, Somerset County 1, and Perry County 1. Current data indicates 5 women delivered healthy babies and there were no known abortions or fetal demise in 2013. Wellness and Health Education - PerformCare has maintained a section of updated materials related to Domestic Violence, Childhood Obesity and Smoking Cessation. Additionally, online resources titled Self-Management Tools are offered for a comprehensive approach to multiple health topics from sleep to stress. A new tool on How to Talk to Your Psychiatrist was also added in 2013. Tools will be placed on the website periodically throughout the year. The Adult Wellness Toolkit, created in 2012, is based on the 8 dimensions of Wellness and continues to be a good resource for PerformCare Members. Member education is also provided through the Member Newsletter and is addressed in section K2 of this report. Consumer input was obtained twice in 2013 on the website and topics of interest and their input will be incorporated in to the Self-Management tools section throughout 2014.
Peer Support Services (PSS) are also measured on 3 out of the 4 measurements which noted improvement.
Table 41: Peer Support Services
PSS INDICATOR 2012 2013 Is there a release of information for PCP signed by the member at the initiation of service? 93% 100% Is communication with PCP at start of services documented? 65% 100% Is communication with PCP at discharge documented? 16% 80%
Federally Qualified Health Center FQHC has incorporated both physical health and behavioral health staff to address the Member’s needs in a holistic approach. Currently in the provider network, six FQHC have successfully co-located including South East Lancaster Clinic (SELHS), which has a full-time psychologist on-site through a partnership with Catholic Charities. Another SELHS site has a CRNP on-site and in 2014 will have a full-time Spanish-Speaking LCSW through a partnership with Community Services Group. Hamilton Health Center in Dauphin County currently has 2 full-time social workers on-site and has established a partnership with Philhaven for additional services. Sadler Health Center in Cumberland County has a full-time LCSW on-site and services Members from Perry County also. Keystone Rural Health Center in Franklin County employees a licensed therapist and a psychiatrist to perform behavioral health treatment. In Fulton County, the FQHC TriState does not provide Behavioral Health Services. Tri-State does however have a letter of agreement with True North, a licensed mental health outpatient facility. True North also embeds a crisis worker at TriState twice a month to provide information and referral to patients there. Of note, TrueNorth will also become a certified smoking cessation treatment facility in 2014.
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Bedford and Somerset Counties have a small number of Members who are treated at Primary Network an FQHC in Blair County. Efforts are also underway to collocate behavioral health services in Hyndman Health Center, the FQHC within Bedford/Somerset Counties.
Combined in the five Capital Counties, Franklin, Fulton, Bedford and Somerset Counties, approximately 400 Members age 0-17 are treated for behavioral health issues at a FQHC. Members ages 18 and over number approximately 1005. The specific numbers per county are as follows:
Table 42: Members Receiving Behavioral Health Services in FQHC - 2013
Age Group Capital 5 Franklin & Fulton Bedford & Somerset 0-17yrs 89 292 19 18 > 329 645 31
Clearly, Franklin and Fulton Counties have a larger percentage of Members utilizing treatment at a FQHC more than any other county. Bedford/Somerset Counties will be working with Hyndman Health Center in 2014 to establish a link with a behavioral health provider who can embed staff in the health center.
CareConnections - Lancaster General Hospital (LGH) has started their CareConnections program recently for management of Members with a mental health diagnosis as well as complex and unmanaged physical health issues. They are also utilizing a Brief Treatment Model which PerformCare is in the process of credentialing. Additionally, PerformCare is working with LGH to establish data transfers with Member authorizations and connections to PerformCare Care Management.
NHS Proposal - Northwestern Health System is establishing a program designed for adults (18 years and older) with SMI and complex care needs. Their approach is a Behavioral Health Home Model (Co-location of PCP in MH OP clinic in Harrisburg). This is a team approach which includes Nurse Navigators and Peer Supports, as well as communication and collaboration with both the BH MCO and PH MCO.
PH-BH Collaboration Efforts with Primary Care Physicians (PCPs)
PerformCare promotes collaboration among physical health and behavioral health providers in a variety of ways, most notably are the treatment record reviews where provider documentation is measured. Additionally, child services require a yearly physical be conducted.
An additional PH-BH coordination project involves treatment record reviews. Annually records are monitored and scored in several areas including PCP coordination at time of admission and discharge, a list of allergies, and a list of medical conditions. Two statewide obesity initiatives are also scored which includes a current physical in the chart
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and if the treatment respects weight and food concerns regardless of behavioral/mental health concern (i.e. not using food as a reward, suggesting active versus sedentary activities, etc.). These measures are included in audits for most levels of care including BHR (Behavioral Health Rehabilitation) services, FBMHS (Family Based Mental Health Services), MH OP (Mental Health Outpatient), PHP (Partial Hospitalization Program), RTF (Residential Treatment Facility) and CRR (Community Residential Rehabilitation)- Host Homes. Record Reviews are ongoing for 2014. The following scores are based on the record reviews for 2013 and the specific measurements include: 1. Does the chart contain a current physical (or document the request for one)? 2. Does treatment respect weight and food concerns regardless of behavioral/mental health concern? (i.e. not using food as a reward, suggesting active versus sedentary activities) 3. Is there documentation regarding coordination with the PCP at the time of admission? 4. Is there documentation of coordination with the PCP at the time of discharge?
Table 43: PH-BH Collaboration Results from Treatment Record Review
MH OP MH OP RTF CRR HH Clinic NonClinic BHRS FBMHS PHP MH IP TTTS
INDICATOR 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013 2012 2013 1 N/A 94% 91% 100% (NO 30% 58% 100% 100% 84% 92% 80% 99% 85% 70% 0% 99% 100% 100% 2 N/A 100% 91% 100% (NO 95% 100% 100% 100% 97% 100% 80% 86% 98% 100% 100% 99% 100% 100% N/A 3 12% 100% 100% (NO 49% 67% 100% 100% 75% 80% 84% 91% N/A N/A N/A N/A 100% 100% N/A 4 14% 33% 73% (NO 21% 16% 0% N/A 33% 36% 71% 46% N/A N/A N/A N/A 0% 0%
There are some improvements noted in in MH OP, BHRS and FBMHS but there is still need for improvement in RTF and Partial Hospitalization Programs. Providers continue to be educated by Quality Improvement Specialists on the need to actively meet the goals for these measures.
PH-MCO/BH-MCO Projects
Aetna Better Health Project
In the fall of 2011, Aetna approached PerformCare to collaborate on a Performance Improvement Project (PIP) to reduce physical and behavioral health admissions for Members with serious mental illness (SMI) through managed care organization coordination. The PIP required the following three measurements:
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Table 44: Reduction of Physical Health/Behavioral Health Admissions PIP
2010 2012 Percent Measure Goal Rate Rate change 1. Total mental and physical health inpatient utilization per 1000 member months for 42.06 37.56 (10.70%) 39.95 members with a SMI 2. Percentage of Aetna Better Health members with SMI, living in counties common with 54.69% 51.90% (5.1%) 52.42 PerformCare, who utilized the emergency room for any reason 3. Percentage of members with SMI, common with Aetna Better Health, who had an outpatient 88.16% 84.75% (3.87%) 88.75 visit with a BH provider
The final rates will be re-measured in April of 2014 with final recommendations based on the percent changes and if goals were obtained. Aetna has shown interest in moving to a collaborative project with PerformCare with a focus on a special population to be determined. The first meeting to discuss possibilities will be in March of 2014.
Preliminary activities to improve the rates above included training Aetna’s Case Mangers on basic behavioral health definitions, defining SMI, risk factors associated with the SMI population and why collaboration is necessary. In turn, Aetna trained PerformCare Care Managers on typical physical health issues managed by Aetna nurses and where and how collaboration can occur. Each managed care company was responsible for making an impact on the measurements, which for PerformCare these activities coincided with activities being completed for the Follow- up PIP. Similar metrics are inherent in active care management practices throughout the PerformCare network. Examples below: 1. Increasing the utilization of FQHCs, tele-psychiatry and bridge appointments. 2. Improving discharge planning with mental health inpatient facilities. 3. Improving availability of outpatient therapy and psychiatry time. 4. Improving member linkage to Targeted Case Managers 5. Improving linkage to Enhanced Care Management if member does not have a TCM 6. Improve member engagement through reminder calls and case management by Member Services Specialist 7. Decrease transportation barriers in reminder calls by the Follow Up Specialist 8. Increase utilization of Peer Support Services
Additional PH MCO Interest Both Gateway Physical Health and AmeriHealth Caritas have shown interest in joint collaboration projects. Meetings for 2014 with both entities are currently being scheduled. Possible joint pilots preliminarily discussed have been perinatal depression, members with cardiovascular disease and depression, and a focus on members who are utilizing Suboxone.
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Pharmacy Initiatives
Current pharmacy data is available internally through our Sidekick Application and can be reviewed per Member. Care Managers can access this information during utilization reviews for the purposes of determining medication compliance. Pharmacy data was also utilized for a Root Cause Analysis for Readmissions in Dauphin County.
An additional pharmacy project, initiated in 2012 and completed in 2013, was the monitoring of Members prescribed Suboxone or Methadone and receiving an Opioid, Benzodiazepine or Hypnotic/Sedative simultaneously. In the beginning of 2013, Methadone and Suboxone prescribers in clinic settings were sent a letter with the names of Members who were filling prescriptions that could be potentially fatal in conjunction with their Methadone or Suboxone. The letter outlined PerformCare’s concerns and recognized that many members have complex illnesses and treatment is based on a case by case scenario. However, PerformCare recognizes the prescribing of Opioids, Benzodiazepines or Sedatives/Hypnotics to treat a mental illness for a person with an addiction is counterproductive and is not best practice. Additionally, the letter addressed three specific areas of concern. The first concern noted that current literature addresses the use of multiple drugs as potentially fatal because the risk of side effects increases as Members receive additional medications. Second, untreated or inadequately treated mental health disorders can clearly interfere with addiction treatment and should be addressed upon admission to their program. Finally, a cognitive-behavioral approach for anxiety or an antidepressant should also be considered because long term use of Benzodiazepines for the treatment of anxiety is not an evidenced-based intervention; providers were encouraged to refer the Member for mental health treatment for their anxiety or depression.
PerformCare is currently reviewing a new NCQA requirement which requires three Clinical measurement activities which may include pharmacy data. A Pharmacy and Therapeutic Committee was formed in February 2013 to discuss and review current literature findings and best practices which may involve pharmaceutical treatment. For example, psychotropic prescribing for children and adolescents in foster care or the increase in use of stimulants in the adult Medicaid population, may be areas of interest. The Committee will actively pursue pharmacy data analysis in 2014 and will report findings in the Quality Improvement/Utilization Management meeting.
Current pharmacy data is available internally through our Sidekick Application and can be reviewed per Member. Care Managers can access this information during utilization reviews for the purposes of determining medication compliance. Pharmacy data was also utilized for a Root Cause Analysis for Readmissions in Dauphin County.
An additional pharmacy project, initiated in 2012 and completed in 2013, was the monitoring of Members prescribed Suboxone or Methadone and receiving an Opioid, Benzodiazepine or Hypnotic/Sedative simultaneously. In the beginning of 2013, Methadone and Suboxone prescribers in clinic settings were sent a letter with the names
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of Members who were filling prescriptions that could be potentially fatal in conjunction with their Methadone or Suboxone. The letter outlined PerformCare’s concerns and recognized that many members have complex illnesses and treatment is based on a case by case scenario. However, PerformCare recognizes the prescribing of Opioids, Benzodiazepines or Sedatives/Hypnotics to treat a mental illness for a person with an addiction is counterproductive and is not best practice. Additionally, the letter addressed three specific areas of concern. The first concern noted that current literature addresses the use of multiple drugs as potentially fatal because the risk of side effects increases as Members receive additional medications. Second, untreated or inadequately treated mental health disorders can clearly interfere with addiction treatment and should be addressed upon admission to their program. Finally, a cognitive-behavioral approach for anxiety or an antidepressant should also be considered because long term use of Benzodiazepines for the treatment of anxiety is not an evidenced-based intervention; providers were encouraged to refer the Member for mental health treatment for their anxiety or depression.
PerformCare is currently reviewing a new NCQA requirement requiring three Clinical measurement activities which may include pharmacy data. A Pharmacy and Therapeutic Committee was formed in February 2013 to discuss and review current literature findings and best practices which may involve pharmaceutical treatment. For example, psychotropic prescribing for children and adolescents in foster care or the increase in use of stimulants in the adult Medicaid population, may be areas of interest. The Committee will actively pursue pharmacy data analysis in 2014 and will report findings in the Quality Improvement/Utilization Management meeting.
Coordination Efforts with CYS, JPO, and Other Service Agencies
Periodic summaries are provided to the Quality Improvement / Utilization Management Committee (QI/UM) describing coordination efforts with CYS, JPO, and other service agencies by PerformCare. In 2013, coordination efforts with CYS, JPO, and other service agencies focused on the following areas for the various contracts. The Dauphin County interagency (MH, JPO, CY, CMU) RTF Reform Committee ended based on successful reduction of RTF PerformCare Clinical representatives participate in Dauphin County ASD/ID Committee to review community treatment and services, as well as and coordination of care to decrease the use of out of home treatment for members with ASD and ID or MH and ID. The Committee includes Dauphin County MH ID, CMU MH and ID Case Management, as well as some Dauphin County school districts. PeformCare Clinical representatives participate in Dauphin County interagency supervisors meeting (MH, JPO, CY, CMU) which focus is interagency collaboration, communication and understanding of mutual processes. PerformCare Clinical department representatives continue to participate in Integrated Children’s Services Meetings (MH, JPO, CYS) in Cumberland County, as well as Perry County.
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PerformCare outreach efforts to the school districts to measure level of interest in having PerformCare conduct a presentation on how to access mental health services through PerformCare revealed little interest. There was little success in 2013 with outreach mailings at the beginning of the school year, thus subsequent attempts to speak with school representatives while in the field and outreach calls were also attempted. PerformCare scheduling staff will be making outreach calls to schools and the Supervisor will be going in the field to provide presentations. Additionally, another outreach mailing will be attempted in the spring to see a better response is elicited. The Franklin/Fulton Counties PerformCare Regional office program Manager, participates in meetings between CYS, JPO, TMCA, and PerformCare to discuss any systems issues or concerns with specific high profile cases. Ongoing ad hoc meetings and communication occurs as needed regarding cases of systems issues. PerformCare Program Manager and Field Clinical Care Manager participate in case review meetings every 60 days with Fulton County CYS and JPO. All PerformCare Members involved with CYS and JPO are discussed to ensure all Members’ service needs are being met, to ensure coordination and collaboration between service agencies, and to eliminate any potential gaps in services. PerformCare Program Manager and North Central Clinical Care Manager Supervisor participate in the MH/ID Coordination meetings on a monthly basis. Other participants include Franklin/Fulton CASSP Coordinator, TMCA, Franklin/Fulton MH/ID, Franklin/Fulton Program Specialists, and Service Assess Management. Participants in the work group work to ensure proper collaboration and coordination occurs amongst the Inter-Agency Team members. The group is currently reviewing the Dual Diagnosis Emerging Best Practice Document issued by Mercer and the Emerging Practice Manual for Dual Diagnosis Treatment and Supports issued by the Department of Public Welfare. During 2013, the group developed a scorecard in which the Franklin/Fulton region was scored on all areas outlined in the DPW document. Areas of opportunity were identified and the group will develop goals and initiatives for focus in 2014. Interventions will be identified to assist the region in improving in areas lacking with the end goal to improve coordination systems. PerformCare Franklin/Fulton region, in collaboration with Franklin and Fulton CYS and JPO, identified a need for the addition of services geared towards working with Juvenile Sexual Offenders and children and adolescents who are exhibiting sexualized behavior. A JSO certification training was offered within the region and attendees included PerformCare QI and Clinical staff, MH-OP therapists, Franklin and Fulton County CYS, Franklin County JPO, TCM, FBMHS providers, and an RTF provider. JPO and CYS are currently participating in ongoing work group meetings held on a monthly basis. The PerformCare Franklin/Fulton regional office Program Manager and Account Executive participate in the Fulton County Family Partnership, a non-profit human service agency that provides support, education, and resources to families in Fulton County as well as a forum for county Health, Human Service, Government, Education representatives and consumers. The Fulton County Family Partnership meetings occur monthly and bring together decision makers
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from health and human service organizations, local government, businesses, schools, judicial system/law enforcement, and local residents. The PerformCare Franklin/Fulton regional office Program Manager participates in the Franklin County Link to Aging and Disability Resources Community Partner meetings as scheduled. CYS and JPO participate in the monthly Bedford/Somerset regional Children’s Model Workgroup and have input into all activities related to Children’s Services discussed at that meeting. JPO and CYS collaboration also occurs through ongoing participation with in the Criminal Justice Advisory Board within the Bedford/Somerset region.
Coordination efforts with CYS, JPO, and other service agencies will continue throughout 2014. As a part of the current PerformCare transformation process, coordination efforts with the above mentioned agencies has been identified as an area in which PerformCare would like to improve. Throughout internal discussions within PerformCare and with other service providers, it has been noted that difficulties ensuring coordination and collaboration with other service entities exist. Often service providers are not aware of the service array that is included in the PerformCare network nor are they fully aware of how to access services for Members. Minimal marketing materials exist at this time that would aid in educating other service providers on PerformCare, services available, how to access services, etc. Marketing materials will be developed in 2014 geared towards improving communication and collaboration with other service providers and will include one page documents detailing a specific topic (i.e., How to access services, Information about PerformCare, services available which will be broken out by specialized services offered and will list all service providers within a specific region, etc.).
School Coordination/Participation Report from ISPT
School coordination/participation in ISPT meetings is presented to the QI/UM Committee on a bi-annual basis. For the 2013 calendar year, school participation in ISPT meetings fluctuated on a monthly basis across all contracts. Schools participated in ISPT meetings in person, via speaker phone, and/or via school feedback/input. Percentage of school participation in ISPT meetings within the Bedford/Somerset region fluctuated from a low of 54.55% to a high of 95.65%. Within the Capital contract, percentage of school participation in ISPT meetings fluctuated from a low of 32.41% to a high of 95.21%. Percentage of school participation in ISPT meetings within the Franklin/Fulton region fluctuated from a low of 29.41% to 95.00%.
Overall, school participation in ISPT meetings showed an overall increase in the later part of 2013. Throughout 2014, PerformCare will continue to educate providers and families on the importance of school participation in ISPT meetings especially when services are to be provided within the school setting.
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Table 45: ISPT Meetings-School Participation - 2013
ttended ttended ttended
articipation
nvites nvites nvites
I A P I A I A Participation Bedford/Somerset Capital Franklin/Fulton Jan-13 33 24 72.73% 239 89 37.24% 19 8 42.11% Feb-13 25 16 64.00% 216 70 32.41% 17 5 29.41% Mar-13 22 12 54.55% 202 66 32.67% 16 6 37.50% Apr-13 43 31 72.09% 210 137 65.24% 35 30 85.71% May-13 50 40 80.00% 171 141 82.46% 40 26 65.00% Jun-13 24 20 83.33% 117 87 74.36% 27 18 66.67% Jul-13 26 24 92.31% 105 76 72.38% 29 25 86.21% Aug-13 23 19 82.61% 148 106 71.62% 24 22 91.67% Sep-13 40 34 85.00% 161 131 81.37% 45 39 86.67% Oct-13 38 34 89.47% 167 159 95.21% 45 40 88.89% Nov-13 40 33 82.50% 247 210 85.02% 40 38 95.00% Dec-13 23 22 95.65% 170 161 94.71% 34 32 94.12%
Figure 48: % School Participation - 2013
% School Participation 100.00%
80.00%
60.00% BS 40.00% Cap 20.00% FF
0.00%
PerformCare Clinical staff participates in the Dauphin County ASD/ID Committee to review community treatment and services, as well as coordination of care to decrease the use of out of home treatment for members with ASD and ID or MH and ID. The Committee includes Dauphin County MH ID, CMU MH and ID Case Management, as well as several Dauphin County school districts.
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The Bedford-Somerset School Workgroup was formed in 2013, consisting of representatives from BHSSBC, PerformCare, and a CASSP Coordinator from both Bedford and Somerset Counties. The workgroup established several goals. First, a presentation was developed for each school district based on the school district’s expressed interests in certain topic areas. Some of the topic areas included: Orientation to Health Choices Behavioral health required services Prior authorization services Orientation to PerformCare Benefits of health choices How to access services C&G information Trends in children’s services CANS information Evidence Based Programs WRAP ISPT meetings CASSP
Representatives from the workgroup gave presentations to all school districts in Bedford County and to guidance counselors and nurses in Somerset County. The meetings were collaborative and addressed specific topic areas important to the school districts. “Navigating the System” folders were distributed at these meetings as well containing essential information regarding available providers and how to move through the behavioral managed care system. The schools were encouraged to share these with the families the work with. The workgroup will continue throughout 2014. Currently future planning is on hold due to requested revisions to the Navigating the System folder by OMHSAS. There is a new workgroup formed to address those revisions and once complete, the new Navigating the System folders can be distributed to schools and planning can resume on 2014 targets and goals will be established at that time.
The Franklin/Fulton Counties regional office met with the Lincoln Intermediate Unit in March 2013 in order to discuss issues in regards to coordination of BHR Services and educational services provided by the LIU and to facilitate ongoing collaboration and coordination between PerformCare and the LIU. Ongoing coordination with local school districts to assist with facilitating improved communication between BHRS providers and the school district occurred throughout 2013. As a result, several BHRS providers met with the school districts and have regularly scheduled meetings to discussion service delivery, collaboration, and coordination.
The Franklin/Fulton region, in conjunction with Tuscarora Managed Care Alliance as well as, Franklin/Fulton MH/ID and Drug and Alcohol agencies, has initiated a planning committee for a School-Based OP Summit to be held in 2014. Areas identified by the group that are in need of improvement will be addressed during the Summit. The goal of the Summit is to promote education on available school-based services, improve collaboration between PerformCare, service providers, and school entities.
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In the Capital region, school coordination efforts for 2014 will focus on: Increasing school awareness of resource alternatives to BHRS (especially evidence-based treatments and natural supports Increasing school participation in ISPT meetings and increased school feedback Increasing the collaboration of school staff in treatment planning and the transfer of skills Ongoing refinement in the expectations of school staff concerning the role of BHRS staff, treatment, and duration of treatment
Coordination efforts with schools will continue throughout 2014 across all contracts. As a part of the current PerformCare internal transformation process, coordination efforts with the school districts has been identified as an area in which PerformCare would like to improve. Throughout internal discussions within PerformCare and with other service providers, it has been noted that difficulties ensuring coordination and collaboration with other service entities exist. Often, service providers are not aware of the service array that is included in the PerformCare network nor are they fully aware of how to access services for Members. Minimal marketing materials exist at this time that would aid in educating other service providers on PerformCare, services available, how to access services, etc. Marketing materials will be developed in 2014 geared towards improving communication and collaboration with other service providers and will include one page documents detailing a specific topic, such as, how to access services, and specialized services which may be offered. Additionally, efforts will continue to promote increased collaboration and coordination between service providers and school entities, especially in light of the overall increase in usage of School-based OP services within all contracts.
Diversity and Cultural Competency
Demographics, Penetration Rates, Top Diagnoses, and Percentage of Foreign-Language Speaking Members
The demographics and top diagnoses of PerformCare HealthChoices membership were analyzed by each QI/UM Committee to assist in planning for QI initiatives, prevention efforts, and to help ensure the appropriateness of existing programs and future direction of the QI program. Enrollee demographics, penetration rates, diagnoses and languages are evaluated semi-annually. Some highlights from 2013 are summarized and can be seen in the following tables:
Penetration Rates
There are multiple methods of calculating penetration rates. PerformCare calculated monthly penetration and used the following methodology. The unique Members receiving services was determined by open treatment authorizations per month. The Enrollment is based on Members that were eligible to receive HealthChoices funding per month.
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Table 46: Network Penetration Rates - 2013
Unique Members Treatment Month Enrollment Receiving Penetration Services Rate Jan-13 180,037 23,176 12.87% Feb-13 181,390 23,280 12.83% Mar-13 181,162 22,968 12.68% Apr-13 181,831 23,529 12.94% May-13 181,879 23,577 12.96% Jun-13 182,127 21,562 11.84% Jul-13 181,466 21,416 11.80% Aug-13 181,883 21,293 11.71% Sep-13 181,227 21,392 11.80% Oct-13 182,073 22,764 12.50% Nov-13 183,187 21,775 11.89% Dec-13 182,277 20,553 11.28%
PerformCare penetration rates fluctuated through 2013. There was a low of 11.28% in December 2013 and a high of 12.96% in May 2013. In addition, there was a low of 9.19% in December 2012 and a high of 11.77% in January 2012. Overall, PerformCare penetration was higher in 2013 when compared to 2012.
Gender, Ethnicity, and Age Summary The demographic makeup of Members served by the network is depicted in the following tables.
The PerformCare Network was serving 182,277 unique Members enrolled in the HealthChoices program as of December, 2013. Of these, 55.63% were female and 44.37% were male. These numbers are consistent with 2012 data. In regards to age, 52.64% were children or adolescents, an increase from 51.53% in 2012. 5.94% were between the ages of 18 and 20 years old, a slight decrease from 6.09% in 2012; 37.12% were between 21 and 65 years old, a slight decrease from 38.03% in 2012. 4.30% were over the age of 65, a decrease from 4.35% in 2012. Ethnicity data indicates 62.43% of all HealthChoices Members were Caucasian, a decrease from 67.63% in 2012 while 19.66% were in the “other” population, an increase from 16.30% in 2012 and 15.16% were African American, an increase from13.73% in 2012. The ethnicity data indicates low percentages of Asian and North American enrollees.
Top 5 Diagnoses
Top diagnoses of enrollees were reviewed for calendar year 2013 for the network. The top 5 diagnostic categories for the 2013 are seen below.
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Table 47: Top 5 Diagnostic Categories - 2013
Age Diagnosis Code 314.01 ADHD, Combined Type 299.80 Pervasive Developmental Disorder 313.81 Oppositional Defiant Disorder < 18 296.90 Mood Disorder, NOS 309.4 Adjustment Disorder With Mixed Disturbance of Emotions and Conduct
311 Depressive Disorder NOS 304.00 Opioid Dependence Unspecified >18 296.32 Major Depressive Disorder, Recurrent, Moderate 296.90 Mood Disorder NOS 296.80 Bipolar Disorder NOS
The network results show no change in Top Diagnoses when compared to 2012 results in the less than 18 years old category. There was a slight change in the top 5 diagnoses among adult Members. Mood Disorder is fourth in 2013, after being third in 2012. Major Depressive Disorder, Recurrent, Moderate was third spot in 2013, compared with being fourth in 2012. The results indicate the focus of chosen Prevention Programs and Clinical Practice Guidelines remain consistent with the top diagnoses through the PerformCare HealthChoices area. The top diagnosis for individuals under 18 remains ADHD, Combined Type while the top diagnosis for individuals over 18 remains Depression, NOS.
PerformCare offers two preventative programs to address the Top Diagnoses for each age group. These programs address Attention Deficit Hyperactivity Disorder (ADHD) and Depression. PerformCare provides the ADHD Early Identification Program to parents of children turning six years of age.
The ADHD Early Identification Program consists of a four-page educational module in newsletter format, entitled Understanding Your Child’s Behavior. The contents of the module are designed to assist parents in identifying age-appropriate behaviors and to raise awareness about the signs and symptoms of ADHD. The module also includes an easy-to-score one-page screening tool based on the diagnostic criteria for ADHD contained in the DSM-IV. The tool is designed to help parents identify if their child could benefit from a professional evaluation for ADHD. A post card survey asking parents for feedback about the Program is also included. The goals of the Program are to: . Educate parents about age-appropriate skills and behaviors . Increase awareness of parents about behaviors that could be indicative of ADHD . Improve the rate of early detection of ADHD . Help children identified as a risk for ADHD receive a professional evaluation
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PerformCare distributes educational materials about depression to adult members who have a newly diagnosed depressive spectrum disorder diagnosis. The treatment compliance program for Depression consists of three four-page educational modules in newsletter format, entitled Depression; Making the Most of Treatment; and Recovery and Treatment. The contents of the modules are designed to assist members in understanding treatment in order to improve treatment compliance, particularly medication compliance.
Members receive an initial letter describing the program and providing information about how to opt out of the program including a confidential toll-free number to call. The first module is sent two weeks later and it assists members in understanding the causes, symptoms, and treatment depression and what to expect when starting medications and beginning therapy. The second module is sent four weeks after the first one and provides more information about antidepressant medications including side effects. The third module, sent four weeks after the second one, explains what to expect during recovery, ending therapy, and offers ways to prevent recurrence.
Each of the modules includes a cover letter that provides information about how to opt out of the program. The third module includes a program evaluation survey that members are encouraged to complete in a postage-paid envelope. The survey addresses member- reported usefulness of the education materials.
The goals of the program are to improve treatment compliance that should: . For an individual patient, reduce the length of symptomatic period . For the population, reduce the prevalence of major depressive disorder
PerformCare is in the process of eliminating the above depression program in favor of developing a new Depression Prevention Program which will include assessment and education in 2014.
PerformCare has also adopted Clinical Practice Guidelines to address these diagnoses. The Clinical Practice Guidelines were discussed earlier in this report. ADHD 1-Percentage of Members with ADHD diagnosis prescribed a front line ADHD medication ADHD 2-Percentage of Members with ADHD diagnosis and more than 1 medication check Bipolar 1-Percentage of Members with Bipolar Diagnosis and prescribed a front line Bipolar medication Bipolar 2-Percentage of Members with Bipolar Diagnosis and Substance Abuse Treatment The percentage of youth with Bipolar disorder who are currently taking a front line medication (new) The Percentage of youth with Bipolar Disorder who attend more than one medication management appointment during the year (new)
Language Summary
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The table below shows the various languages spoken by the enrolled Members by county of residence as of 2/25/2014. Member materials (e.g., handbook) are required to be provided if a 5% threshold is met.
Table 48: Language Summary - 2013
Predominant Language Languages >5% Spoken Threshold County English Spanish Bedford 99.93% Somerset 99.93% Cumberland 98.67% Dauphin 94.94% Lancaster 93.68% 5.53% Lebanon 91.59% 8.12% Perry 99.84% Franklin 96.95% Fulton 99.73%
Across the PerformCare HealthChoices area, there has been little variability in the languages spoken by Members in service. English represents the vast majority of languages spoken in the network. This remains unchanged when compared to 2012 with the exception of a decline in the percentage of Spanish speaking Members in Lancaster and Lebanon Counties. 6.38%% spoke Spanish in 2012 and 5.53% spoke Spanish in 2013 in Lancaster County. 9.15% spoke Spanish in 2012 and 8.12% spoke Spanish in 2013 in Lebanon County. Lancaster and Lebanon Counties continue to show a Spanish population of greater than 5%, therefore Member materials such as the Member handbook, Prevention Program information, Denial Letters, Grievance Letters, etc. are made available in Spanish translation for all counties.
Disparities in Treatment
PerformCare strives to provide effective and equitable, quality care which is responsive to the diverse cultural health beliefs and practices of our Membership. To accomplish this, Penetration and Denial Rates by Race and County are monitored for trends that may indicate healthcare disparities. Health care disparities are differences in access and use of health care services by various populations. Racial/cultural differences in either penetration rates or denial rates are a potential indicator of a health care disparity regarding access.
Data was gathered for 2013 and across the network the White population penetration rate was 2.21% and the African American population penetration rate was 1.71%. Additionally, the Asian population penetration rate was .53%, the North American Indian population was 2.28%. The Other population penetration rate was 1.76%. Although the North American Indian population statistically had the highest penetration rate, this population was excluded from the analysis due to low numbers. The territory denial
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percentage by race was 2.01%. With regard to ethnicity, the penetration of Hispanic population was 1.77% and non-Hispanic 2.05% with 2.63% unspecified.
Table 49: Penetration/Denials by Race and Ethnicity – 2013
Percent Race Penetration Denial Percentage By Race North American Indian 2.28% .51% African American 1.71% .39% Asian .53% .35% Native Hawaiian or Other Pacific Islander White 2.21% .29% Other* 1.76% .27% Territory 2.01% .30% * The Other category includes the Hispanic population.
Percent Ethnicity Penetration Denial Percentage By Race Hispanic 1.77% .24% Non-Hispanic 2.05% .31% Unspecified 2.63% .25%
There are no significant disparities in the denial percentage by race for the Other and Caucasian populations, each with a denial percentage lower than the territory denial percentage ranging from .27% to .51% and within ethnicity, a range of .24% to .31%.
Recommendations
The Caucasian population accessed services in high numbers when compared to other populations. The Other category of population includes the Hispanic population and had the second highest penetration rate (1.76%); however, further distinction must be made in order to separate race from ethnicity in order to adequately explore. Further, the linguistic needs of various populations need to be reviewed to ensure they do not create a barrier for Members in pursuing treatment.
PerformCare will work during 2014 toward achieving National Distinction in Cultural Diversity from NCQA. Preparation for this distinction will strengthen our cultural competency by developing approaches in responsiveness to the culture of various societal groups. This growth will improve our ability to communicate with Members according to their linguistic needs (i.e., preferred language and health literacy) in a way that is easy for them to understand and act upon.
Network Capacity of Spanish-Speaking Providers
To determine the capacity of Spanish-speaking providers, semi-annual tracking and reporting by the Network Operations Department were developed for the QI/UM
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Committee. The report includes a review of Providers, services, and languages spoken. There are numerous combinations of sites/services and 70 unique languages spoken.
Of 355 providers at 587 sites throughout the network, 379 sites staff a total of 510 individuals who speak a language other than English. Of those, 175 (29.8%) offer access to Spanish speaking staff. Of those, 34 (9.6%) sites are physically located within Lebanon and Lancaster County where the highest penetration of Spanish-speaking Members reside.
While there were no complaints or serious issues which were identified internally, it was recommended that the Network Operations Department continue to work on improved mechanisms to both identify network providers with Spanish-speaking capacity and update the eCura™ information system on an ongoing basis for accurate referrals by Member Services associates in order to more quickly match Members in need to adequate resources.
Cultural Competency Assessments of Provider Sites
As part of the credentialing and/or re-credentialing process, providers (both facilities and individuals) are asked to respond to questions regarding cultural competency. Questions include topics such as the process to address phone calls from Spanish speaking clients, the process for communicating with persons with various ethnic backgrounds, who are blind, deaf or hard of hearing, or who may be of various lifestyles. Questions also ask for accommodations for specific requests for treatment assignment to clinicians of certain backgrounds and whether or not the organization is welcoming to persons of all backgrounds.
The following table shows providers responses to cultural competency surveys conducted during 2013.
Table 50: Cultural Competency Assessment January 2013 – December 2013
Sites with Sites without Accommodations Accommodations - "Y" - "N" Overall Process For Phone Calls 85 63 57.4% Calls More Than 3 X Per Month 44 104 29.7% TTD_TTY_or_PA_Relay_Available 59 89 39.9% Staff Trained to use TTD_TTY Rel 58 90 39.2% One or More TTD_TTY Relay Per Month 24 124 16.2% Amplification Device Available 30 118 20.3% PC Pen Available 141 7 95.3% Respond to Variety of Languages 67 81 45.3% Able to Accomodate Requests 85 63 57.4%
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Staff Represents Community 127 21 85.8% Staff Fluent in other Languages 74 74 50.0%
Of note, 29. 7% of providers report receiving more than three phone calls per month from foreign language speaking clients, an increase from 29.1% in 2012. Also, 16.2% of providers report one or more TTD/TTY relay calls per month, an increase from 10.7% in 2012. Moreover, 20.3% of providers report an amplification device is available if needed, an increase from 17.0% in 2012 while 95.3% of providers report a Personal Computer Pen is available, an increase from 92.7% in 2012. It is also noted that 45.3% of providers indicate they can respond to a variety of languages, an increase from 33.64% in 2012 while 57.4% of providers indicate the ability to respond to requests, a decrease from 60.2% in 2012 and 85.8% indicate the staff represents the culture of the community, a decrease from 87.2% in 2011. Finally, 50.0% of providers report fluency in languages other than English, an increase from 41.5% in 2012.
An increasing percentage of providers reported they receive more than three phone calls per month from foreign language speaking clients. In addition, the providers reported an increasing percentage of providers reporting staff fluent in languages other than English. Similarly, providers reported an increasing percentage relating to the ability to respond to a variety of languages. This information solidifies the need for PerformCare to continually seek providers with the ability to serve Members speaking a variety of languages in the counties where this type of diversity exists, such as Lebanon County and Lancaster County.
PerformCare has identified Cultural Competency of Provider Sites as a targeted area for improvement. The focus will include improvement in the accuracy of measurement data, improved competence with existing measures, and expansion of the competencies being measured.
The current process of gathering data regarding cultural competency is obtained through the credentialing and re-credentialing process. This means the data is not necessarily up to date. As with any data, it is subject to change and may require research in order to verify the current information. As a result of the Transformation process, PerformCare is exploring ways in which the Cultural Competency information can be obtained more frequently, potentially four times per year, in order to make the data more current. In addition, plans are under way to revise the reporting capabilities to produce more usable reports in order to assist a Member or provider. Also in development is the expansion of an existing outcomes report to include race, ethnicity and language information which will allow us to analyze data accordingly. This may be useful for Care Management to make informed decisions related to specific provider recommendations when needed.
Finally, there is clearly a need for culturally competent medical care and prevention services that are specific to this population. It is known that “social inequality is often associated with poorer health status, and sexual orientation has been associated with multiple health threats. Members of the LGBT community are at increased risk for a number of health threats when compared to their heterosexual peers. Differences in
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sexual behavior account for some of these disparities, but others are associated with social and structural inequities, such as the stigma and discrimination that LGBT populations experience (Centers for Disease Control)”
Research has also shown that Members of the LGBT community are at greater risk of mental health issues along with co-occurring conditions. For example, homosexual men are at greater risk of Major Depression during childhood, Bipolar Disorder, and Generalized Anxiety Disorder in childhood. They are also at greater risk of drug use and suicide and are more likely to have attempted suicide and to have completed suicide when compared to the male population in general (Centers for Disease Control).
Due to the importance of meeting the mental health needs of the LGBT population recommendations, resource materials, and available trainings are expected to be shared with providers in anticipation of a revised competency tool better suited to capture this population’s needs.
Centers for Disease Control. About LGBT Health. Lesbian, Gay, Bisexual and Transgender Health. Retrieved from: http://www.cdc.gov/lgbthealth/about.htm
Outcomes and Efficacy
PerformCare Outcomes Monitoring
Quality monitoring activity is performed through a variety of measurement methods and tools such as telephone performance reports, medical record review, claims and other administrative data, provider and network performance profiling, complaints and grievances, outcomes assessment, and Member satisfaction surveying. The outcomes program employs techniques used within the health services research field such as sampling methods, statistical modeling and analysis, use of large data sets, and graphical display, which are all validated in the literature. A quality improvement work plan is used to identify key outcomes measurements for each department. The work plan structure includes information about what is being measured, the purpose of the measurement and targeted outcomes, responsible parties, reporting frequency, and the data source.
The overall objectives of PerformCare’s outcomes measurement is to develop indicators that assess the structure, process, and outcome of various levels of care, specifically the quality of the behavioral health treatment that is being provided to Members. Behavioral health care quality monitoring utilizes various clinical indicators, best practice guidelines, assessment tools, on-site audits, and provider training and education in order to improve the quality of behavioral health treatment. These indicators form the basis for quality improvement initiatives and prioritization within PerformCare, ultimately positively impacting our network providers. Initiatives and training efforts are also focused on adopting evidence-based treatments that, in general, provide superior mental health outcomes.
PerformCare utilizes a data analytic platform that meets full compliance with reporting requirements in the HealthChoices contract and allows for outcome data to be collected
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(e.g., Performance Outcomes Management System (POMS) data) as required by the Department of Public Welfare. The POMS database serves as the basis for producing performance measures and indicators by provider. These indicators are used to continuously evaluate and improve the effectiveness of PerformCare initiatives, provider performance, and also allow PerformCare to achieve a variety of systems-level outcomes. POMS information provides relevant information that allows PerformCare to fulfill its mission of implementing continuous quality improvement activities. PerformCare incorporates POMS measurements into our Quality Improvement/ Utilization management (QI/UM) review process, allowing early identification of trends.
In collaboration with multiple system partners, PerformCare is implementing the use of the Child and Adolescent Needs and Strengths (CANS) to positively impact the quality of care children are receiving in our network. After conducting preliminary research using this measure with a BHRS population, PerformCare determined that there is a small, but again statistically significant, increase in caregiver and Member strengths identified during treatment episodes. This research also demonstrated a small to moderate, but statistically significant, positive correlation between total CANS scores and the intensity of BHRS treatment that was recommended. This suggests that the CANS has the potential to accurately identify service needs and/or treatment recommendations. PerformCare and several stakeholders have partnered with Community Data Roundtable (CDR) and have created a local version of the CANS. This project will allow PerformCare to standardize the symptoms and behaviors that are reported and then match the type of treatment that is the best fit to the presenting symptomatology. The information gathered by the CANS will be developed into algorithms that “match” the current clinical presentation to the most effective treatment. This will offer the psychological evaluator immediate decision support and also provide the most appropriate treatment to the Member in the least restrictive setting.
Several counties are utilizing a Crisis Bridge Program that supports Members after discharge from an intensive level of care, such as a psychiatric hospitalization, by “bridging” them to community supports and outpatient treatment providers. The Crisis Bridge Program also assists Members in following discharge plans, and will provide information and assistance to connect the Member with an outpatient provider. PerformCare conducts bi-annual review of the Bridge Programs to evaluate the effectiveness in meeting quality improvement goals such as (1) improve Ambulatory Follow-up, (2) decrease Mental Health Inpatient Re-admissions, (3) engagement of Members involved in Crisis and Mental Health Inpatient services with Outpatient services such as Outpatient, Partial Hospitalization Program, Targeted Case Management Services, and Peer Support Services, and (4) Monitor Members who are complex and have high utilization of Crisis and /or Mental Health Inpatient Services.
In addition, PerformCare uses Performance Improvement Projects (PIPs) and Cost-Driver projects to incorporate the findings of quality assurance measurements, which are applied to achieve continuous improvement, as well as remove barriers to effective performance. PIPs and Cost-Driver projects identify clinical and non-clinical areas of focus and are designed to develop programs that achieve sustained and significant improvement. All of
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the initiatives and programs that PerformCare develops focus on the positive impact that the Member will experience, as well as on Member satisfaction. Projects include measurement of performance (e.g., provider performance; provider profiling, provider scorecards, etc.), employing validated research methodology to explore trends (both positive and negative), and development of appropriate data collection methods. PIPs and Cost-Driver analyses also offer a comparison of provider performance and PerformCare expectations. This assists in establishing benchmark performance objectives as well as identifying and analyzing the root causes of identified issues. This then supports PerformCare in the development and implementation of system interventions, evaluation of improvement activities, and ongoing evaluation of effectiveness of such processes and interactions.
A number of innovations, enhancements, and refinements are in progress and will be implemented in 2014. In fact, one of the recommendations stemming from PerformCare’s Transformation workgroups is a revision to the process used to generate POMS scoring. Previously, PerformCare completed scoring based on information supplied by providers. The new recommendation calls for providers to complete the POMS scoring and is expected to result in more accurate scoring.
PerformCare has developed a new Outcome Report that will assist the Quality Improvement Department to determine the effectiveness of treatment, both before and after the treatment has been provided. This type of outcome reporting will allow PerformCare to infer the effectiveness of treatment by determining if there is a subsequent reduction in the need for behavioral health treatment. At the current time, stakeholders (e.g., counties; oversights; consumers) are reviewing the report and providing feedback.
Effective in 2014, the Ambulatory Follow-Up PIP will be modified to include the monitoring of Readmission Rates. Another change for 2014 is the consolidation of Cost- Driver projects. Previously, each contract had region-specific Cost-Driver plans. At the direction of OMHSAS, PerformCare has consolidated these projects to include network- wide initiatives. In addition to improving efficiency, these projects will involve improvements to various levels of care (e.g., MH-IP; BHRS; FBMHS).
Performance Outcomes Management System
PerformCare’s eCura® system enables full compliance with reporting requirements in the HealthChoices contract. PerformCare is able to collect Performance Outcomes Management System (POMS) data as required by the Department of Public Welfare. The POMS database serves as the basis for producing performance measures/indicators. These indicators are used to continuously evaluate and improve the effectiveness of PerformCare, achieve a variety of systems-level outcomes and implement continuous quality improvement activities. PerformCare incorporates POMS measurements into our QI/UM process. On a semi-annual basis, the QI/UM Committees review performance indicators in order to identify any negative trending.
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The average monthly member enrollment for calendar year 2013 was 217,535 for the three contracts (Bedford/Somerset, Capital, and Franklin/Fulton). The total number of member responses for both the Living Status and the Vocational/Education Status was 39,523 in 2013. The total number of member responses for Living Status and Vocational/Educational Status was 45,440 in calendar year 2012; a decrease of 5,917 responses (13%).
Figure 49: POMS – Living Status - 2013
Living Status
100%
90%
80%
70%
60%
50%
40% Percentage ofMembers 30%
20%
10%
0% B/S CAP F/F 99 = Unknown 2 12 75 = Homeless 15 541 13 75 = C & A Homeless 1 3 74 = Restrictive Setting 2 96 12 74 = C & A in Restrictive Setting 10 38 1 73 = Supervised Setting 14 187 5 73 = C & A in Supervised Setting 4 46 3 72 = Living Dependently 12 131 9 72 = C & A Living Dependently 32 346 67 71 = Family Setting 974 7957 719 71 = C & A in Family Setting 1924 14925 1988 70 = Living Independently 664 7968 784 70 = C & A Alone 1 16 1
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The majority of reporting PerformCare Members reported their Living Status for calendar year 2013 as living in a family setting (Adults – 9650; C&A 18837) or living independently (Adult – 9416). The number of Members living in a restricted or supervised living arrangement is a small percentage of the reporting Members (Adults 0.8%; C&A 0.3%). When compared with the calendar year 2012 data there is a slight increase, 47% to 47.6% in C&A members and a 4.3% increase (20.1% to 24.4%) in Adult members living in a family setting; and a 3% decrease, 26.8 to 23.8%, in Adult members living independently. Based on DPW’s goal of establishing and maintaining independent living for our members this decrease in independent living status may indicate the beginning of a negative trend.
Figure 50: POMS – Vocational/Educational Status - 2013
Vocational/Educational Status 100%
90%
80%
70%
60%
50%
40%
Percentage ofMembers 30%
20%
10%
0% B/S CAP F/F 99 = Unknown 0 45 2 74 = No Activity 615 5724 529 74 = C & A No Activity 5 21 1 73 = Meaningful Activity 236 4283 398 73 = C & A Meaningful Activity 62 767 139 72 = Work Program 4 33 0 72 = C & A Work Program 0 10 0 71 = Training/Education 801 6545 601 71 = C & A Training/Education 1916 14608 1924 70 = Competitive Employment 15 207 6 70 = C & A Competitive Employment 1 23 2
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Almost half (46.7 %; 18,448 members) of the reporting Children and Adolescents Members across the three contracts reported being in either an educational setting or receiving job training services during calendar year 2013. Over twenty percent (20.1%; 7947 members) of the reporting Adult Members reported being involved in a training or educational type program while 17.3 % (6868 members) reported no activity and 12.4%; (4,917 members) engaged in a meaningful activity during the year. When compared to the calendar 2012 data there is a slight increase (46.0%), less than one percent, in the C&A Members in an educational setting or receiving job training; an almost one percent increase in Adult members in an educational setting or receiving job training (16.4%); and 1.6% decrease in Adults members engaged in no meaningful activity (15.7%).
In 2013 PerformCare began work on the modification and enhancement of POMS data reporting by retooling the report to more accurately capture real time information. This work has been incorporated into the PerformCare transformation plan under the lead of Member Services.
Based on the comparison of the average monthly enrollment numbers with the data results provided above, there is a significant amount of POMS data that is not being effectively collected. As we move forward with modification and enhancement of POMS data reporting in 2014 we will need to develop and implement a more effective way of gathering and compiling POMS data reporting data. At the same time we will continue to work on the trend analysis of the collected data. PerformCare will continue to monitor the Living Status and Vocational/Educational Status for negative trends.
Community Outreach
PerformCare’s Manager of Consumer & Family Affairs, Program Managers, and Quality Care Managers provide periodic summaries to the Quality Improvement / Utilization Management Committee (QI/UM) regarding community outreach efforts. Participation in community events, outreach and educational programming is largely influenced by stakeholder input and recommendation. In 2013, Community Relations efforts focused on the following areas for the various contracts.
Advisory Committees- PerformCare Manager of Consumer & Family Affairs, Consumer & Family Affairs Specialists, Regional Program Managers, and Quality Improvement staff participated in a number of advisory committees which include the following:
Adult Advisory Committee – OMHSAS (Retained on Adult Advisory Committee) HealthChoices Advisory Meeting- MAXIMUS – Harrisburg/Temple Family Service Partnership Board – Cumberland/Perry RCPA MH Committee Medical Assistance Advisory Committee meeting Health Education Advisory Committee (HEAC) - AmeriHealth Caritas
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Systems Improvement Committee – Consumer Satisfaction Services/CABHC – Capital Region Adolescent Mental Health Workshop Committee – United Way for the Capital Region – Cumberland/Perry/Dauphin Health Equities Council – AHMFC Health Education Advisory Committee (HEAC) - AHMFC PA Parent Family Professional Council Meetings- Cumberland and Dauphin counties Children’s Task Force (Meeting) - Dauphin County Dauphin Children’s Mental Health Day event planning- MH Awareness/Anti Stigma event in May 2013 Project Homeless Connect (Dauphin) event in August/September 2013 Drug and Alcohol Task Force (Cumberland/Perry) in September 2013 SAMHSA Monitoring Meeting (OMHSAS) Franklin County Link to Aging and Disability Resources Community Partner meeting Fulton County Family Partnership monthly meetings Health and Welfare Council – Somerset County
Community Support Program Meetings - The CSP is a coalition of mental health consumers, family member and professionals working to help with adults with serious mental illnesses and co-occurring disorders live successfully in the community. CSP meetings typically occur once a month and PerformCare’s involvement in various ways across counties included: Regular attendance at CSP meetings held in Cumberland/Perry, Dauphin, Lancaster, Lebanon by the PerformCare’s Manager of Consumer & Family Affairs. Regular attendance by the Franklin/Fulton regional office Program Manager and/or Quality Care Manager at CSP meetings held in Franklin and Fulton Counties. Providing managed care updates, assist with the planning of the CSP Annual Wellness Conference, provide training and speakers at the Wellness Conference, assist with the planning of the Annual Walk the Walk event in both Franklin and Fulton County CSP meetings. Helping recruit Consumer and Family participants for the CSP Meeting. Participation in CSP planning committees to provide support for conferences facilitated by the CSP. Dauphin/Cumberland CSP MH Recovery Conference. Supported and attended Lancaster CSP’s Recovery Picnic.
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PerformCare’s Member Newsletter offered articles encouraging participation in local CSPs. Contact information and meeting times was provided for each HealthChoices County.
Community Events/Activities - PerformCare participated in a number of community activities/events and conferences through the year to continue providing ongoing outreach, education, and to maintain a presence within the communities we serve. The list of community events/activities/conferences include: PerformCare attended both the Franklin and Fulton County “Walk the Walk” events and PeformCare assisted in the development and planning for the event. PerformCare attended the Brightside Community Health and Fitness Fair in March 2013. In March 2013, PerformCare attended the Middletown SD Transition Fair, the Palmyra School District Resource Fair, the Resource Fair Early Intervention CAIU, and the Healthy Kids Day in Lebanon County. During April 2013, PerformCare attended the Logan’s Walk/Run, the Edge of Autism (Tommy Foundation), the NHS Autism School Crafts Fair, the Northern Dauphin Area Special Needs Resource Fair, and the Film Sponsorship: US of Autism PerformCare attended the Adolescent MH Workshops With United Way and Providers (MH Stigma, MH Stigma in Latino Communities/Working with Spanish Speaking Families) during the months of April/October/November PerformCare attended the Capital Area Mental Health Summit, the Boscov’s Autism Event in Dauphin County, the Parent Youth Professional Forum, the Children’s Mental Health Awareness Fair (Wesley AME Church Harrisburg), the Mental Health Awareness Day (Former Harrisburg State Hospital Grounds), and the Messiah College Career Day during May 2013 In June 2013, PerformCare attended the Recovery Picnic (Lancaster CSP), the CSP Conference (Cumberland/Perry/Dauphin), the SACA Fair (Lancaster), and the Peace Street Event at Youth Advocate Program. PerformCare attended the Cultural Diversity Event (Lebanon) and the New Story Back Pack Event/NS Harrisburg School during August 2013. During September 2013, PerformCare participated in the Project Homeless Connect (Dauphin), the Autism Fair in Franklin County, and the Human Service Fair/Expo in FF Counties. In October 2013, PerformCare attended the Faces of Recovery (Cumberland/Perry). Somerset County Human Services Fair Somerset County Student Assistance Program Meeting
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The results of C/FST surveys are reviewed with consumers/families across all contracts. Results of the survey are reviewed at Stakeholder meetings for input. Follow up is done with Individuals/Families when they express concerns during surveys. Contacts are made to the Individual/Family Member to discuss their concerns in-depth and provide needed assistance or further follow-up in an attempt to increase satisfaction with Providers and with PerformCare. If the individual/family member is still unsatisfied after provider follow-up, PerformCare will assist the family with filing a formal complaint for additional investigation. Other specific County outreach related to surveys includes: PerformCare has been attending MHA advisory board meetings on a quarterly basis in Franklin/Fulton. In Franklin/Fulton region, PerformCare Program Manager and Quality Care Manager provided a presentation for the C/FST surveyors regarding the Complaint and Grievance process, services available within the region, and ways to access mental health services as part of the annual surveyor re- training. Participation in the Capital Area Systems Improvement Committee – Consumer Satisfaction surveys.
Committee’s and other Group Involvement - PerformCare is very involved in several committees’ and other groups with emphasis on community outreach such as the following: Participation in conferences includes Cross-Systems Mapping and Taking Action for Change Conferences What it Means to Grow Old (PA Aging BH Coalition, Online Resources to Support Mental Health (Webinar), Gaudenzia Women and Children’s Conference, Pennsylvania Association of Psychosocial Rehabilitation Services (PAPSRS), Dauphin/Cumberland CSP MH Recovery Conference, Companion/Poverty Culture (Philhaven Series), Health Equities Conference, and the PAASWW Conference. Participation in Advocates for a Drug-Free Tomorrow to discuss outreach activities for the purpose of educating the community regarding drug use misconceptions, prevention, and how to access resources. Head Start Mental Health Advisory Committee with a focus on services for children in Head Start. Head Start – Somerset County
Presentations and Informational Outreach - PerformCare provides several presentations and informational outreach in the community and offers advocacy or assistance with PerformCare or HealthChoices issues. In 2013, C/FAS were able to provide advocacy/support by offering resources/support, assistance with complaints and grievances, assistance in issues with providers, as well as assisting providers. This assistance was primarily provided to either Members/Consumers, Parents/Family members, Providers, and Advocates. C/FAS were PerformCare’s primary contacts for support of community events or support group activities, requests for presentations or information about PerformCare as well as assistance to families moving into PerformCare counties.
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Additional presentations and informational outreach includes: PIN Lancaster- Education, Updates, and Q&A on BHRS (Newsletter article) No Longer Alone Ministries (Lancaster County)- Caring 4 Your Recovering Loved One Aurora Club West (Outreach planning/opportunities) Aurora Club East: Planning/Participation with HOPE Troupe Recovery Insights (Lancaster County) - C&G Overview and Navigation Patch N Match – Educational Outreach “Cultural Considerations” Autism Society of America (Greater Harrisburg Chapter)- Presentation on changes to BHRS, BSC, STAP/Q&A Autism Connect/Autism Stand (Facilitated presentation at HEAC Wellness meeting) Autism Connection Planning Group - Elizabethtown Language Issues and Access – Lancaster IU 13, Spanish American Civic Association: Accessing Services. Continuing Dialogue Resource Expo (Trinity Lutheran Church Carlisle – Special Kids Network) The Tommy Foundation – Lancaster Parent (ASD) Support Estados Unidos- PerformCare and HealthChoices/Language Issues (Latino Hispanic American Center Harrisburg. Bethany Adoption Services – Lancaster Offices Root-Cause Analysis Workgroup (with SSC Reps) Franklin/Fulton Autism Society of America – Franklin County Post Hospitalization Barrier Analysis (workgroup Bienaventuranza/Spanish Speaking Asperger’s Support Group
In 2013, Additional types of Consumer/family/community connections (including emails) included:
Calls for support of community events or support group activity Requests for presentations Requests for information about PerformCare Information concerning changes to HealthChoices (i.e. Budget, BHRS, Health Exchanges) Advocacy/support calls
In summary, community outreach efforts have been successful and include a wide range of community events, outreach, and educational programming within the network. A lot of these efforts are based on consumer/family input which allows the opportunity to remain close to matters most important to the community. In order to continue this success, efforts to obtain and maintain Member, community, and family participation will
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be important. However, transportation for some Members and families to community events has been a bit of an obstacle to achieving more success. Therefore, it may be necessary to focus on identifying resources that can assist with transportation that may positively impact community outreach efforts through increased participation.
Member Education
PerformCare provides a variety of education to PerformCare Members through several different channels of distribution such as emails, newsletters, meetings, and informational presentations.
In 2013, PerformCare distributed two newsletters (also available in Spanish) to Members which were included in the Member section of the PerformCare website. Newsletter content is influenced significantly by the input and recommendations of the Stakeholder Steering Committee. The newsletter was created to inform Members of the latest news and information about their behavioral health services, PerformCare, and in behavioral HealthChoices. Informational topics included in the newsletters were:
Spring/Summer 2013 Newsletter How to make the most of your doctor visit. Community Support Programs. How do I get help when I am unhappy with my care? For Teens: Is your relationship healthy? Winter 2013 Newsletter Participating in your doctor visit. We need and want your involvement - PerformCare committee involvement. New information on the PerformCare website – Wellness education. We can come to talk with your group – informational presentations about PerformCare, HealthChoices Behavioral Health program and various available services. Mental Illness: Violence and Stigma Myths and Realities. Rethinking Drinking. Special Edition 2013: CBHNP name change to PerformCare: Mental Illness Awareness Week New Chief Medical Officer Check Out PAautism.org Resources PAautism.org Drive Out Suicide Recovery Month 2013 The Importance of Updating Your Information
PerformCare provides periodic summaries to the Quality Improvement / Utilization Management Committee (QI/UM) regarding Stakeholder Steering Committee (SSC) activity. These SSC meetings provide education and give members the opportunity to ask questions regarding PerformCare, behavioral HealthChoices and the service system.
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Participants are afforded the chance to interact with others from the community that may be experiencing a similar situation. SSC participants are responsible to take information back to club Houses, Drop in Centers, Partial programs, and to their communities.
The Stakeholder Steering Committee (SSC) continues to actively seek improvement in attendance from all counties and to provide topics of interest in hopes to promote participation. Attempts to improve attendance include emails, newsletters, flyers, and direct appeals via community outreach and participation in community events.
PerformCare reviews and provides education about Quality Improvement/Utilization Management (QI/UM) work plans with the SCC. This helps keep the Committee informed of current initiatives that are worked on throughout the year and the opportunity to provide any feedback, suggestions, or ask questions.
Through the year there have been several topics discussed during the SSC meeting to both educate as well as provide opportunities for involvement and discussion. The following are educational items or presentations discussed at various SSC meetings: A presentation on Member Information by Tony House, PerformCare Consumer and Family Affairs Manager A presentation entitled “ I Am The Evidence” by Barry Munch, MHA CSP BHRS Improvements and BS Licensure Parent Child Interaction Therapy (PCIT) as a new service in the Franklin/Fulton region Review of C/FST and I/FST surveys and an informational presentation on the Shippensburg Evaluation Project Phase II Findings by Dr. James Griffith TMCA annual report overview C/FST and I/FST survey updates Several Bedford/Somerset Stakeholder Steering Committee Members began sharing their stories of recovery in local churches and planned to continue speaking in other area churches and at community events. Somerset Psych Rehab presented a discussion on a second “Photo Voice” project. Psych rehab staff members gave updates on attending a workshop hosted by a psych rehab from Phillipsburg including the use of “Six-Word Memoirs” to describe themselves as a picture is displayed and the six words are typed at the top of the picture. Consumers from Psych Rehab gave updates on arranging trips through Tableland every month. A trip was arranged in July to the Galleria in Johnstown. Transportation continues to be a barrier. The Mental Health Advance Directives Training was held Sept. 24 in Somerset and Oct. 15 in Bedford. The training was for staff and consumers. As part of the training in the afternoon, the staff at Psych Rehab met with the consumers to assist them in developing a MHAD. Somerset Psych Rehab participated in a community Halloween contest and entered a scarecrow.
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Psych Rehab Honors Banquet on 9/26/13 to honor members who attended for two years and have reached their goals. Over 70 Members attended. A nine week Wellness Challenge began during the week of 9/16/13. The challenge was not only for eating well and exercising, but for anything related to wellness. Somerset Psych Rehab Leadership Workshop every Friday Somerset Psych Rehab has a Facebook page on the internet that is a public service announcement about stigma and is working on having this announcement on U- tube. Somerset Psych Rehab had an open house in October 2013. Members participated in a racing poll. Bedford Psych Rehab planning of an Honors Banquet and a Photo Voice project in late August 2013 was discussed. Bedford CSP moved to the HOPES Center and they had a booth at the Bedford County Fall Foliage festival. The Bedford Psych Rehab began a Pay it Forward Workshop and initiated good deeds in the community throughout 2013. They also began a Biggest Loser contest that focuses on overall wellness, and members are participating in a football poll. Regrouping/Budget Concerns/Presentations SSC participants in the Capital region discussed “Why Members no show for follow-up appointments and proper discharge planning from Inpatient stays.” Within the Capital region, SSC members were oriented to the QI-UM Committee meeting. Members then began attending meetings regularly and provide a report to the SSC on pertinent information from the QI-UM meeting. Year-end review and Celebration
Member outreach efforts continue to grow. These outreach efforts are in large part due to recommendations made by the SSC. The SSC continues to participate in educational efforts as well as help in the dissemination of educational information. PerformCare, with the cooperation and feedback from various Consumers, Consumer Groups, Family members, Advocates and Providers, recognizes the barriers that exist to quality Consumer/Family participation on Committees. During 2013, the following obstacles to Consumer participation on Stakeholder Committees were identified: Transportation (reliable) to get to meetings Experiences from the past: o Being stranded after a meeting o Disrespected at a meeting o Being treated as a token (counted for number’s sake but not listened to) o Not feeling safe at a meeting (feeling attacked for their ideas and facilitator not stepping in) Orientation of the meeting is often not Consumer/Family friendly – technical and fast paced and no assistance with understanding what’s going on
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o We actually oriented four Members to the QI/UM meeting here in Capital. One Member created a acronyms sheet so newbies could understand what people were talking about! Condescension felt at meetings Lack of compensation for their time (sign of disrespect) Fear (when compensation is offered) that amount paid may impact their benefits Not seeing results or changes made when recommendations are offered Fear Worry they won’t know enough Stigma issues Concern if they will be heard Location of meetings can be an obstacle Abrasive personalities at meetings (again back to the safety issue) Lack of refreshments Length of meetings Boring topics that are not of interest Inability to make the agenda – the organization does this and we have to go along with it.
To address some of these obstacles, the following plan has been proposed and is currently being implemented in an effort to bring more voices to the table. Below is an outline the plan:
Outreaches and Informational Sessions will be conducted to inform the communities we serve as well as our Membership (and their families) about opportunities for Stakeholder involvement and how to become involved. At that time, club houses, social rehab centers, partial hospitalization programs -- wherever it is our Members are located -- would be approached and informational programs offered and implemented. Recruitment would occur at each opportunity that presented itself during community programming/presentations. Organizing Local Stakeholder Groups/Meetings that would convene at accessible locations within the five county area served by PerformCare. These groups will meet quarterly and receive training and education regarding topics such as HealthChoices, PerformCare, services, Member rights and responsibilities, self- advocacy, the Complaint and Grievance process. Current stakeholder participants will be invited to participate in organizing, training and eventually leading local stakeholder meetings. Through the development of an “Ambassador” program, PerformCare will launch a recruiting effort to increase Member participation in all aspects of operations. Representatives from these local meetings/groups will be invited to represent their Local Group at the Stakeholder Steering Committee. They can also communicate ideas, issues, concerns, etc. if they prefer. Educating new committee members about the purpose of the committee on which they have agreed to serve. Educating committee members about Health Choices.
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Equipping committee members to share information with others. Conveniently located facilities will be sought to hold meetings. Potential participants will be informed of the availability of compensation for time and travel to and from meetings.
In order for Member outreach efforts to continue to grow, it will be important to continue to promote active participation from SSC Members and identify additional resources that can be used to further develop Member education across the network throughout 2014.
Prevention
Early Identification of Attention Deficit Hyperactivity Disorder (ADHD) PerformCare offers a preventive behavioral health program designed to assist parents in identifying age-appropriate behaviors and to raise awareness about the signs and symptoms of ADHD. The educational material is sent to the parents/guardians of all HealthChoices Members turning age six quarterly. The ADHD Early Identification Program consists of a four-page educational module in newsletter format, entitled Understanding Your Child’s Behavior, and an easy to score one page screening tool based on the diagnostic criteria for ADHD contained in the DSM 5. The goals of the Program are to: . Educate parents about age-appropriate skills and behaviors . Increase awareness of parents about behaviors that could be indicative of ADHD . Improve the rate of early detection of ADHD . Help children identified as a risk for ADHD receive a professional evaluation
Table 51: ADHD Mailing Results – 2013
Counties Total Total Returned #/% Total #/% of Mailed (Undeliverable) Delivered Survey Returned Capital 5,500 231 5269 /95.8% 65/1.2%
Franklin/Fulton & 1660 48 1612/97.1% 21/1.3% Bedford/Somerset* *1st Quarter data only includes Blair, Lycoming and Clinton Counties
In 2013, in the Capital Counties there is a slight increase in mail distributed from the previous year of 4,940. This may be due in part to an increase in MA enrollment. Only 65 parents returned their survey which is a slight decrease from the previous year. PerformCare also measures quarterly how effective the prevention program is through a Member survey which is attached to the educational material. For the ADHD Program, five items are measured on a “1” (worst) to “4” (best) scale. The most recent data available for comparison is the 4th quarter of 2013. Below are the measurable outcomes which yielded similar rates to previous quarters. Overwhelmingly the majority of Members who return the survey responded positively to the literature.
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Basic Skills and Abilities (Item 1) – how helpful is the program in describing the basic skills and abilities that children need in order to do well at home and in school. Average item Rating = 3.63 with 100% positive ratings (score of 4 or 3).
Problem Recognition (Item 2) – how informative the materials were in describing how to recognize problems their child may experience. Average item Rating =3.75, with 100% positive ratings.
ADHD Information (Item 3) – how helpful the materials were in providing them with a basic understanding of ADHD and its symptoms. Average item Rating = 3.75, with 100% positive ratings. . ADHD Identification (Item 4) – how helpful the screening tool was. Average item Rating = 3.56, with 100% positive ratings.
Directing Further Action (Item 5) – how much the information helped them understand what they could do about difficulties their child may experience. Average item Rating = 3.50, with 100% positive ratings.
In 2013 for the North Central Counties, this is the first full year of data, Franklin and Fulton Counties sent out on average 190 mailings per quarter. Bedford and Somerset Counties mailed on average 125 per quarter. The Total Delivered rate is slightly higher than the Capital County Total Delivered rate. The survey return rate is similar to the Capital Area. The following survey responses for the North Central Counties are as follows:
Basic Skills and Abilities (Item 1) – how helpful is the program in describing the basic skills and abilities that children need in order to do well at home and in school. Average item = 3.00, with 100% positive ratings (score of 4 or 3).
Problem Recognition (Item 2) – how informative the materials were in describing how to recognize problems their child may experience. Average item =3.00, with 100% positive ratings.
ADHD Information (Item 3) – how helpful the materials were in providing them with a basic understanding of ADHD and its symptoms. Average item = 4.00, with 100% positive ratings. . ADHD Identification (Item 4) – how helpful the screening tool was. Median Score = 4.00, with 100% positive ratings.
Directing Further Action (Item 5) – how much the information helped them understand what they could do about difficulties their child may experience. Average item = 3.00, with 100% positive ratings.
The Early Identification of Attention Deficit Hyperactivity Disorder appears to be a fairly
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successful program and the Quality Improvement Project Manager will continue to distribute educational material and aggregate, analyze and report the data as required. Further discussion is warranted to review possible ways to improve survey return rates and the impact this program may have on the initiation of treatment if the parent identifies that their child could benefit from a psychiatric evaluation.
Improving Treatment Compliance for Adults with Depression PerformCare offers a second preventive health program which focuses on Members between the ages of 18 and 64 who have recently been diagnosed with Major Depressive Disorder and are currently treated with psychotherapy and/or an antidepressant medication. A series of three educational newsletters are sent to the Members over a 3 month period of time. This program is designed to improve clinical outcomes for this subset of individuals by educating the Members about depressive symptoms, available treatments, and the course of recovery. The Members are encouraged to become engaged in treatment by reviewing the critical aspects of their own role in their treatment process. The overarching goals of this program are to improve compliance and to reduce the length of a symptomatic period.
Together with provider support, PerformCare hopes to assist Members who are receiving treatment for MDD, become informed consumers of mental health care and actively involved in their own treatment. The educational materials provided can assist Members to understand the importance of communicating openly with their providers and thereby increase treatment compliance since treatment compliance is a critical component of effective therapy with the ultimate goal of the Member stabilizing their depression in a timely manner.
PerformCare reviews quarterly survey responses returned by the Members. The survey measures how effective the prevention program materials are by asking the Member to complete a twenty question survey. The material is measured for helpfulness and if the newsletter details have improved their knowledge base. The most recent data available for this report measures from October of 2012 through September of 2013.
Table 52: Report Measures from October of 2012 through September of 2013
Counties Total Total Returned #/% Total #/% of Mailed (Undeliverable) Delivered Survey or Opted out Returned Capital 2,524 352 2,172/86.1% 79/3.6%
Franklin/Fulton & 1088 113 975/90% 51/5.2% Bedford/Somerset* *All seven NC counties are included in the data for the first six months.
In the Capital Counties, 2,524 modules were sent to newly diagnosed Members. This is a moderate increase from 1,884 the previous year. The undeliverable and opted out rates are similar to previous years. Unfortunately, only 79 Members returned their survey which is a 3.6% returned rate. This is slightly lower than previous years but similar to the
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typical response rate to educational materials. In the North Central Counties, literature was sent to all seven counties from the inclusive dates of October 2012 to February of 2013 however, educational materials continued the remainder of the timeframe reported for the following counties, Franklin, Fulton, Bedford and Somerset. This is the first full year of data for analysis and comparisons cannot be made, however the total delivered and the survey return rates are slightly higher than the Capital Counties. On average, the total modules sent for the Franklin and Fulton Counties per month was 30, and the total modules sent for Bedford and Somerset was 35.
The Likert Scale was utilized wherein; a score of 1 to 4 was assigned to a question with a score of “4” being the most helpful and a score of “1” the least helpful. The following 7 questions are a small part of the survey results from the same time period noted above. Overall, most Members found the materials to be helpful or somewhat helpful. The tables below provide the Average Item Ratings for seven measures.
Table 53: Capital
Average Rate Measurement 3.31 Found the information associated with symptoms of depression helpful. 3.19 Increased their knowledge about antidepressant medication. 3.26 Increased their knowledge of coping skills. 3.03 Helped them discuss their side effects with their physician. 3.10 Helped them continue on their medications even as they experienced side effects. 3.25 Helped them communicate better with their family and friends about depression. 3.45 Information overall (the 3 newsletters) was helpful
Table 54: North Central
Average Rate Measurement 3.17 Found the information associated with symptoms of depression helpful. 2.92 Increased their knowledge about antidepressant medication. 3.09 Increased their knowledge of coping skills. 3.49 Helped them discuss their side effects with their physician. 3.27 Helped them continue on their medications even as they experienced side effects. 2.85 Helped them communicate better with their family and friends about depression. 3.41 Information overall (the 3 newsletters) was helpful
Based on the total survey results, this prevention program appears to have an impact on some of our Members. Comments provided by the surveyors for the most part are positive and in fact some ask for additional information. The goals for this project appear
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to be met for this year. However, during 2014, PerformCare will be presenting updated prevention programs which will provide a screening tool and educational material. This is more in line with NCQA requirements of ensuring programs are preventing or promoting self-assessment and seeking treatment. Depression material will still remain available to all Members by placing materials on the website.
Domestic Violence, Smoking Cessation and Childhood Obesity
PerformCare provides updated educational information on three topics, Domestic Violence, Smoking Cessation and Childhood Obesity. The ultimate goal of this educational information is to reduce or prevent further violence, decrease the number of Members who smoke and reduce the number of children rated as obese. This educational information is displayed on the PerformCare Member and Provider Website under Self- Management Tools section.
In 2013, PerformCare added four Domestic Violence articles on Abuse in Later Life, Teaching Boys Respect, Domestic Violence and How to Get Help, and STD’s and Domestic Abuse. These articles are also available in Spanish. Additionally, two articles and the link to a new website were added to the library which addresses Childhood Obesity. The two articles are Shape your Family’s Habit, and Everyday Physical Activity Tips. The new website link accesses BAM! Body and Mind a page on the official Web site of the Centers for Disease Control and Prevention (CDC). It is a public domain Web site, which means PerformCare may link to CDC.gov at no cost and without specific permission. CDC.gov provides direct access to important health and safety topics, scientific articles, data and statistics, tools and resources, and over 900 topics in the CDC.gov A-Z Index. The BAM! Body and Mind format and articles are written for children and adolescents.
In 2012 PerformCare added a new section on the website devoted to smoking cessation. This section includes an explanation on the Member’s smoking cessation benefit, resources available and 12 articles supporting this initiative. Articles range from Smoking Cessation in Pregnant Women to Sticking to Quitting. Additional articles addressing smoking and heart disease, smoking and diabetes, and smoking and cancer were placed on the PerformCare website in 2013. These articles are also available in Spanish. On the Provider side of the website, besides the articles mentioned above, additional resources are available such as OMHSAS latest report on smoking and articles from the American Lung Association. In addition, smoking cessation is addressed with pregnant women who agree to specialized case management.
Recommendations for 2014 include, continued education via the PerformCare website, reminding providers to assess for tobacco use upon admission to treatment and to gauge readiness for change, and PerformCare’s continued involvement with the American Lung Association Task Force. Additionally, Smoking Cessation benefits will be addressed in a Member Letter at the beginning of the year. Last, smoking cessation and available smoking cessation benefits will be address through complex case management. The PerformCare Physical Health Behavioral Health Collaboration Team will develop
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strategies and possibly partner with a Physical Health Managed Care Organization on how to address smoking with shared Members, childhood obesity and domestic violence.
Safety
Quality of Care Council
The Quality of Care Council (QOCC), consisting of the Chief Medical Officer (or Physician/Psychologist Advisor designee), Clinical Manager (or designee), Director of Quality Improvement (or designee) and Director of Network Operations (or designee) is led by a Quality Management Project Manager (QMPM) in the review of identified quality of care concerns requiring further investigation, referral, or follow-up. The council reviews potential quality of care concerns identified through daily operations. The role of the council is to gather information to resolve issues at the lowest possible level while giving the assurance of Member safety at all times. Quality of care and Member safety issues are identified through Clinical contacts, Member and Provider Complaints, Critical Incident Reports, Quality Treatment Record Reviews or any other area of operation. Throughout 2013, the QMPM gathered information related to the concern, consulted with the inter-disciplinary group which makes up the QOCC and conducted follow-up via telephonic or written clarification, reviewed clinical records, conducted provider meetings, and acted as the lead for Non- Routine Site Visits. During 2013, the transition was made to assigning a level to each referral that was submitted to QOCC for review. The level (Non-Event, 1-4) helps standardize what follow-up will be completed with the Provider. In addition, recommendations may also be made to suspend referrals for a period of 30-days when there are significant safety concerns related to the treatment a Member is receiving. In the event of suspension, consultation is made with PerformCare’s Chief Medical officer. When quality of care concerns are resolved, a referral may be made to the Special Investigation Unit for review and consideration of allegations of Fraud, Waste or Abuse. Additionally, referrals may be made to the Credentialing Committee for review and consideration of issues related to provider licensure and/or contract compliance.
During 2013, the Quality of Care Council reviewed 810 referrals. Of these referrals, 738 were opened and reviewed by the committee. There were 72 referrals that were not opened for reasons as follows: duplicate referrals, referrals that could be addressed through the Provider Performance process, or referrals related to agencies that PerformCare does not have the jurisdiction to investigate. If a referral was rejected from QOCC, it was redirected to an appropriate department for follow up as needed.
Of the 810 referrals, 76.3% were reviewed through the Capital Contract and 23.7% were reviewed through the Bedford-Somerset and Franklin-Fulton Contracts. The number of referrals remains consistent with the ratio of Member enrollment by contract. The distribution of the accepted referrals across contracts is reflected in the following graph with one exception. Twenty-one referrals affected multiple contracts and are, therefore, not reflected in the graph below.
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Figure 51: Number of Quality of Care Referrals by Contract - 2013
A review of referrals made by level of care reveals the greatest volume for Members receiving services in a Residential Treatment Facility (RTF). The complex needs of the individuals served in this level of care can explain the volume. There was only a slight decrease in the number of referrals related to Members receiving services in an RTF. RTF represented 36% of all QOCC referrals in 2012 and decreased to 35% in 2013. The next greatest volume is related to Members receiving Behavioral Health Rehabilitative Services (BHRS). There was a slight increase in the percentage of referrals received for BHRS between 2012 and 2013. BHRS represented 17% of all referrals in 2012 and 19% of all referrals for 2013. Based on this increase, in 2014, PerformCare will look at providing additional Technical Assistance and Training to BHRS Providers. The third greatest volume of referrals is related to Mental Health Inpatient where appropriate discharge planning and coordination of care with outpatient services continues to be an area of needed improvement and focus. There was also a slight decrease in the number of QOCC referrals related to Members receiving MH Inpatient (MH IP) services. In 2012, MH IP represented 13% of all QOCC referrals and this was reduced to 9% in 2013.
Figure 52: Quality of Care Concerns by Level of Care - 2013
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During 2013, the majority of follow-up was conducted verbally. This remains consistent between 2012 and 2013. Verbal follow-up can include having a phone conference with a Provider to request more information to review a potential concern or educating the Provider on an issue. The next largest category was related to an internal review of the referral. Upon receipt of a referral, an internal review may reveal that the issue resolved appropriately before coming to QOCC. In those instances, the event is accounted for as a Level 1 event. In the event an issue is referred and is determined to be inappropriate for review (i.e. does not qualify as a Member Safety or Treatment Quality concern), it is considered a non-event and is not included in reporting/trending for QOCC. The third largest category is related to written follow up. Written follow up may include; asking for more information related to the concern, requesting a Plan to Prevent Reoccurrence, requesting a Quality Improvement Plan, or providing education to the Provider. Written follow can be conducted after verbal follow up is found to be unsuccessful or it can be conducted when repeat referrals are noted and previous attempts to correct the issue have been unsuccessful.
Per the PerformCare Progressive Disciplinary Actions for Providers Policy, a referral can be made to the Credentialing Committee due to one or more of the following: 1.1.When efforts to resolve a quality concern at a lower level via QOCC and provider education efforts are unsuccessful; 1.2.When attempts to review a quality of care concern are compromised or not supported by the provider in the return of requested information; 1.3.When QOCC review identifies a situation that could result in harm to Member; 1.4. When a provider repeatedly fails to follow PerformCare administrative procedures after multiple counseling sessions and documented education about the concern.
In compliance with this policy, six referrals were made to the Credentialing Committee for consideration in 2013. Five referrals were related to unsuccessful efforts at a lower level; one referral was compromised by the provider’s response to requested information; three referrals were related to situations of potential harm to a Member, and one referral was related to a provider repeatedly failing to follow procedures. Each referral was accepted by the Credentialing Committee and the recommendations made by QOCC were followed by the Credentialing Committee.
In 2013, 126 referrals were made to the Special Investigation Unit for further review of allegations of Fraud, Waste or Abuse. 76 of those referrals were reviewed at some level by the Quality of Care Council. The remaining referrals were made by members of the QI department as issues were detected through either treatment record review or complaint and grievance. 36 referrals were received noting an allegation of staff to Member abuse. All were involving children and in each instance, assurance was given that ChildLine was notified. Verbal report of disposition was received on all cases and referral was made directly to the Bureau of Program Integrity without referring first to the Special Investigation Unit.
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Figure 53: Quality of Care Follow up Actions - 2013
The primary focus of QOCC is to ensure Member Safety and improve the Treatment Quality of services to our Members; however, in order to ensure proper referral to SIU and Credentialing, additional categories reported include Allegation of Fraud/Waste/ Abuse, Failure to Follow Policy/Procedure, and Referral from Critical Incident Reports. In review of referrals by primary incident type, the greatest numbers of referrals come from Critical Incident Reports (CIR), and are most commonly related to Members reported as being out of site (AWOL) or Member allegations of abuse by staff. This is consistent with the above noted level of care of RTF being the most prominent level of care for which we handled referrals.
Due to the increase in referrals related to allegations of abuse against staff, QOCC will begin to monitor the total number of referrals by provider on a monthly basis to compare against the number of restraints reported to direct appropriate follow-up with providers. Issues related to Member death, medication errors, fire/law events, injury/illness of a Member, seclusion, suicide attempts, and issues which are not required to be reported, such as reports of mental health inpatient admissions, peer to peer aggression, and self- injurious behaviors are related to treatment quality; however, the majority of referrals in this area are related to information missing from treatment plans, lack of discharge planning, and poor coordination of care.
Throughout 2014, Members of the Quality of Care Council will continue to review all referrals to ensure that follow-up can be completed as outlined in QI-004. As referrals that are not appropriate for QOCC continue to be rejected and redirected, Members of the QOCC will be able to spend more time conducting high level follow-up and analysis with referrals that are safety concerns and/or significant treatment quality concerns.
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Figure 54: Quality of Care Concerns by Type of Incident - 2013
In 2014, QOCC further definition of primary incident Categories will be provided. For example, Member Safety, sub-categories will include elopement, self-harm, and physical aggression. Treatment Quality will lack of treatment planning, lack of discharge planning and poor coordination of care. This will allow for a higher level of trend analysis to occur.
Furthermore, in 2014 the internal reporting and tracking of Critical Incident Reports will be expanded to further define each required reporting category listed in PR-008. For example, restraints will detail physical, chemical or mechanical and allegations of abuse will detail staff to Member, peer-to-peer, or family. In addition to managing the review and disposition of all referrals, QOCC conducts a quarterly review of outliers in key areas. Those key areas include: Multiple inpatient admissions High volume crisis contacts Chronic restraints (RTF) – by provider and Member High volume AWOL (RTF & CRR HH)
With regard to the high level crisis and inpatient services, clinical care managers have the opportunity to increase the level of care management offered to positively impact the Member experience. With regard to high volume restraints and AWOLs, providers have the opportunity to review current operations against existing policy in the area of need identified and consider modifications in policy and/or practice to improve the operational area.
Monitoring of Critical Incidents
With immediate Member safety our primary concern at the time of restraint, Quality Improvement staff perform a clinical reviews of reports received to the status of the
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Member. The review includes discussion of safety concerns and review alternative treatment strategies with providers and notification is made to the Member’s Clinical Care Manager for further review. If safety concerns remain, after initial review, referral is made to the Quality of Care Council for further review. This is common practice for reports of injury that require treatment greater than first aid due to physical restraint. Referrals are also made to the Quality of Care Council if a Member makes an allegation of abuse against staff after a restraint has occurred.
The reporting of critical incidents by providers is an important ongoing monitoring tool to assess network and case-specific Member safety issues. Categories of reportable Critical Incidents include: Death of a Member. Suicide attempt. Medication error. Any event requiring the services of the fire department, or law enforcement agency. Abuse or alleged abuse involving a Member. Any injury or illness (non-psychiatric) of a Member requiring medical treatment more intensive than first aid. A Member who is out of contact with staff for more than 24 hours without prior arrangement, or a Member who is in immediate jeopardy because he/she is missing for any period of time. Any fire, disaster, flood, earthquake, tornado, explosion, or unusual occurrence that necessitates the temporary shelter in place or relocation of residents. Seclusion. Restraint. Other incident identified by Providers as Critical, Adverse or Unusual.
Areas of focus for 2013 included clear documentation of safety issues that required the use of restraint, de-escalation and other treatment techniques used to avoid restraint, medical assessment of Members following a restraint with indication of whether the Member was injured, and debriefing of the Member following the restraint as a preventative measure to be used in ongoing treatment planning.
A total of 6,179 Critical Incident Reports were submitted by providers in 2013 across the Capital, Bedford/Somerset, and Franklin/Fulton contracts. It should be noted that one Critical Incident Report can involve more than one category below.
Table 55: Critical Incident Reports and Categories 2013
Critical Incident Category Count Death of a Member 90 * Suicide attempt 41 Medication error 16 Any event requiring the services of the fire department, or law enforcement 505 agency Abuse or alleged abuse involving a Member 751
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Any injury or illness (non-psychiatric) of a Member requiring medical 316 treatment more intensive than first aid A Member who is out of contact with staff for more than 24 hours without 201 prior arrangement, or a Member who is in immediate jeopardy because he/she is missing for any period of time Any fire, disaster, flood, earthquake, tornado, explosion, or unusual 11 occurrence that necessitates the temporary shelter in place or relocation of residents
Restraint Episodes 2,038 Seclusion Episodes 63 Other incident identified by Providers as Critical, Adverse or Unusual 2,700 *The number of Member deaths for which a critical incident report is received may vary from the number of Member deaths which are investigated as potential quality of care concerns. Information may be observed in local newspapers or may be reported by counties and/or oversights. In review, we may find the Member to not be in any active services and therefore, have no provider with which to pursue a critical incident report.
The number of reported cases of abuse or alleged abuse involving a Member continued to increase in 2013. The number of incidents related to injury or illness of a Member requiring medical treatment (non-psychiatric) also increased. The increases are attributed to more comprehensive reporting to by all providers which is strongly encouraged and closely monitored during care management contacts with providers. In addition, Account Executives routine encouragement of providers to submit incident reports aid in more comprehensive review and trending of incidents which can inform the need for interventions to improve the safety of Members.
Among levels of care, RTF has the highest number of incident reports submitted with 28% of all incident reports submitted. Inpatient is second with 25% of incident reports submitted followed by BHRS with 20% of the incident reports submitted. Among the RTF level of care, the highest reported category was for restraints with 53% of incident reports submitted falling into this category. For the Inpatient level of care, the highest reported category was for restraints with 22% of all incidents reported falling into this category. For the BHRS level of care, 56% of the reported incidents fell into the ‘other” category.”
In 2013, there was a decrease in restraint episodes by 506 restraints across the Capital, Franklin/Fulton, and Bedford/Somerset contracts as compared to 2012. In 2013, ongoing attention was paid to restraint reduction, specifically in the RTF level of care in an effort to promote Member safety and the use of less intrusive de-escalation techniques and to encourage restraint reduction. Ongoing monitoring of Member’s who experience 5 or more restraints in any given month continue to occur. Providers are requested to respond in writing as to the plan to address cases with multiple restraints in an effort to reduce or eliminate restraints for the identified Member. To address restraints in a timelier manner, incident reports are closely monitored for current increasing trends in restraints or behaviors that could lead to restraints. When a trend is identified, the Clinical Care Manager assigned to the Member is notified of this trend for follow up. When a concern is noted with a provider (antecedents to a restraint, length of restraint, reason for restraint), a call is placed to the provider to discuss the restraints and possible
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alternatives. Further concerns regarding Member safety in terms of restraints are referred to the Quality of Care Committee for review.
PerformCare continues to have a high number of critical incident reports submitted for the “other” category. This category is frequently used by providers to report Inpatient Hospitalizations, self-injurious behaviors, Member aggression toward others, etc. Ongoing reporting revisions will occur in 2014 to quantify the main report types within the “other” category in order to provide more meaningful reporting and monitoring for this category.
All Critical Incident reports are reviewed within 48 hours of receipt for Member safety. If there is a Member safety concerns, immediate contact occurs with the provider to address these safety concern. In addition there is immediate outreach to the assigned CCM for further follow up. The PerformCare Incident Report reviewer contacts the Provider to ensure that a safety plan is in place if this is not evident from reviewing the critical incident report. If there are quality of care concerns that arise from the review of the critical incident report, a referral is made to the Quality of Care Council for further follow up with the provider.
PerformCare will also launch a campaign to promote the use of ProviderConnect, an electronic, self-service feature for the submission of incident reporting to improve efficiency in reporting for both providers and PerformCare staff.
1,227 of the restraints reported were for Members in service in RTF. Of those, the overwhelming majority of restraints were reported by: Hoffman Homes 356 KidsPeace National Centers, Inc. 290
Restraints reported in levels of care other than RTF are most prominent in the following areas:
MHIP – 404, up from 299 in the previous year BHRS – 329, up from 224 in the previous year PHP – 58, down from 96 in the previous year
An area of focus for 2014 will be the refinement of incident report categories for clearer reporting and analysis in areas such as the type of restraint used and types of abuse - peer to peer, staff to Member, and family will be added. Additionally, the “other” category will detail self-harm, peer aggression and admission to inpatient when it is reported. Reporting will begin to differentiate by provider and by level of care. These refinements will assist in the analysis of critical incident reports. Restraint reduction efforts as described above will also continue in 2014 in addition, PerformCare will continue to promote the use of trauma informed, evidence based practices.
Restraint Reduction
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In support of Department of Public Welfare philosophy related to Strategies and Practices to Eliminate the Use of Unnecessary Restraints and Prohibiting the Use of Prone Restraints, PerformCare closely follows published bulletins to monitor the use of restraints throughout the network but specifically within residential treatment programs and promote best practice initiatives, particularly the effective management of problematic behaviors in an environment free of violence and coercion. Embracing this concept, PerformCare focuses on restraint reduction efforts as a clinical initiative to reduce the risk of serious injury, emotional harm and trauma to children that could occur when restrictive procedures are utilized, eliminating the use of prone restraints; improving the review of restraints to address immediate safety concerns and ensure ongoing monitoring of Member safety. To support these efforts, providers are encouraged to implement trauma informed care initiatives and reduce the overall number of restraints to PerformCare Members. PerformCare emphasizes the use of preventive measures to circumvent behavioral escalation and the importance of offering multiple debriefing opportunities to both Members and staff. Both of these factors can facilitate more effective treatment, decrease the trauma that is often associated with physical restraints, and allow the Member to actively identify preventative strategies that can facilitate more active recovery.
Noted strategies to reduce restraints of focus in 2013 include continual and timely clinical review of Critical Incident Reports of restraint, monitoring of Member’s experiencing a high volume of restraints in the RTF setting, and participating in restraint reduction workgroups. Furthermore, PerformCare continues to encourage Providers to institute the Sanctuary Model (if applicable), and provide training on Functional Behavioral Assessments. Finally, PerformCare is available to Providers as needed to discuss individual Members treatment and offer support and suggestions in how to reduce the number of restraints for individual Members at all Levels of Care.
High Volume Restraint Monitoring
When reports of five or more restraints are received within a quarter, providers are asked to address how they will reduce the use of restraints in the Members treatment. This may include updates to the Safety Plan/treatment plan or be an overall plan regarding the Members treatment. This plan is then reviewed by the QI department and the Member’s Clinical Care Manager with feedback given to the provider. In 2013, the thresholds related to High Volume of restraints in the RTF setting were modified. Throughout 2013, for any Member who received 10 or more restraints in a quarter a written response is developed by the Provider and the Quality Improvement department alerted the Member’s Clinical Care Manager in order for a treatment team meeting to occur.
During 2013, the number of unique Members in RTF restrained decreased from a total of 203 Members in 2012 to 136, contributing to an overall decrease in the number of restraint episodes from 1334 episodes in 2012 to 919 in 2013.
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Figure 55: RTF Restraint Analysis – 2010 to 2013
In review of the number of individual Members involved in multiple restraints over time, overall improvement is demonstrated over time since 2010 with the number of Members restrained 10 or more times during the year declining from 2012 to 2013.
Figure 56: Members in Multiple Restraints – Multi-year
Reduction in % of Members Restrained
35%
30%
25%
20% 2010
15% 2011 2012 10% 2013
5% PercentofMembers Restrained 0% +10 6-10 Number of Restraints
The number of days with restraints across the network continued to be reduced from 1135 in 2012 to 919 in 2013. From 2012 to 2013, the percentage of Members restrained also decreased from 47.21% to 38.75%.
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Figure 57: Total Days in Restraint – Multi-year
# of Days in Restraint 1400
1200
1000
800
600
400 Days in Restraints in Days
200
0 2010 2011 2012 2013 Calendar Year
In 2013, there were a total of 2,525 restraints overall across all levels of care. Despite the overwhelming majority of restraints occurring in RTF and MH IP, PERFORMCARE recognizes the importance of monitoring restraints in any level of care. A breakdown of the number of restraints with the percentage of distribution is reflected below.
Figure 58: Percentage of Restraints by Level of Care - 2013
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Table 56: Restraints by Level of Care - 2013
Level of Care # RTF 919 MH IP 349 BHRS 253 MH Partial 41 SA Non-Hospital 5 SA Inpatient 4 FBMH 2 Grand Total 1625
As illustrated in the graph above the highest level of restraints are associated with Member’s in the RTF level of care. PerformCare continued to focus on RTF Providers throughout 2013 by monitoring the number of restraints by Member, and by encouraging the use of the Sanctuary Model during Treatment Record Reviews. Throughout 2013 efforts were expanded to focus on the use of restraints throughout all levels of care, offering education and outreach to providers as needed.
In 2013, PerformCare’s participation in Provider workgroups has expanded as QI and Clinical staff now participates in a workgroup that looks at the use of mechanical restraints on Mental Health Inpatient units. In 2014, PerformCare will continue to monitor which Providers are working on completing Sanctuary training and/or operating under the model. In addition, PerformCare will continue to participate in various RTF Restraint Reduction workgroups hosted by Providers and upon invitation.
During 2014, PerformCare will increase restraint monitoring throughout all Levels of Care, continuing to focus on a target of “reduction”. In addition, PerformCare will review restraint data by provider and Member, paying specific attention to the number of injuries which occur during a restraint. This information will be reviewed in conjunction with the number of allegations of abuse made against staff at each Provider.
Member Complaints
A complaint is a dispute or objection regarding a participating health care provider or the coverage, operations, or management policies of PerformCare. When Provider quality of care issues were present in a complaint outcome, the complaint was forwarded to the Quality of Care Council for further follow up with the Provider. When a policy or procedural issue was present in a complaint outcome, the complaint was forwarded to a PerformCare Account Executive for follow up with the Provider. Complaint outcomes which required follow up were monitored and tracked through to completion when provider quality of care issues rose above normal follow up requirements.
Throughout 2013, each of the QI/UM Committees, the Credentialing Committee and the Corporate Compliance Committee were provided quarterly complaint analysis reports
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regarding the number of complaints by level of care and complaint descriptor; a rolling 12 month trend in the number of complaints filed per month; and the top provider complaint targets.
In review of Member complaints for 2013, there were 84 filed among the 3 contracts of Capital, Franklin/Fulton, and Bedford/Somerset. This represents an increase of 5 complaints filed from 2012 for these three contracts. The Capital contract had the highest number of Member complaints with 74%, followed by the Franklin/Fulton contract with 18% and the Bedford/ Somerset contract with 8%. Complaint volume by contract is consistent with the Membership of each contract. BHRS continues to be the target of the highest complaint volume, consistent with previous years, with 41% (34) of all complaints filed. Of those, 65% (22) were from Members in the Capital contract with 20% (7) from Franklin/Fulton Members and only 15% (5) from Bedford/Somerset Members. Overall, this represents an 8% increase in the number of BHRS complaints filed from the previous program year. BHRS complaints continue to express concerns related to a lack of staffing, to treatment which is not helpful to services being inappropriate. PerformCare has trended these issues for the past four years, and a common theme in most complaints reveals a lack of communication to the Member or family about service issues. This continues to be an area that is addressed in all Provider and Member meetings and reports. During 2013, active care management strategies enhanced both Member and provider education opportunities through increased participation in ISPT meetings. Further, education to evaluators and focus on appropriate service levels, use of evidence based practices and use of community supports to support person-centered, recovery oriented services has been a focus throughout the organization. Mental Health Outpatient (MH OP) is the second highest level of care, representing 29% of complaints filed due to concerns with discharge and aftercare planning, and parents/guardians reporting lack of communication about treatment issues. PerformCare will closely monitor the increasing trends in MHOP complaints in order to conduct outreach to providers with education and training to ensure quality of service provision.
Figure 59: Complaints by Level of Care for 2012 vs 2013
Complaints by level of care 2012 vs. 2013 50% 40% 30% 20% 10% 0% BHRS RTF PHP MH IP MH OP SA 2012 34% 8% 5% 19% 17% 4% 2013 41% 2% 9% 12% 27% 5%
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Figure 60: Complaint Descriptors for 2013
Complaints by Descriptor 2013
1% 4% 1% 1% 8% 4% 1% Treatment Inappropriate Inquiries not answered timely Provider billed Member Dissatisfied with Treatment Unethical, Inappropriate Behavior
80% Provider Staff Rude Gives Incorrect/Incomplete Information Other
In review of complaints by provider, several providers present as having a higher volume of complaints. All of these providers are among the largest volume providers in the PerformCare Network and all of them offer multiple services to the network.
Figure 61: High Volume Complaint Descriptors 2013
Complaint Descriptors for High Volume Providers 18 16 14 12 10 Gives Incorrect/Incomplete Information 8 Other 6 Treatment Not Helpful 4 2 Provider Staff Rude 0 Dissatisfied with Treatment Received
In review of complaints per 1000 Members by contract, complaint volume is fairly consistent with a decrease in the Capital and Franklin/Fulton contracts in 2013 and a slight increase (from zero) in the Bedford/Somerset contract in 2013.
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Table 57: Distribution of Complaints by Contract
Bedford/Somerset Capital Franklin/Fulton T. W Ponessa and Associates Philhaven PPI The Meadows Psychiatric Center NHS
Information is regularly communicated to Members about the complaint process through community outreach by PerformCare as a Member driven mechanism to resolve provider issues. Significant provider outreach and education continues to be conducted through all complaints filed. In 2013, there were two level two complaints filed, one of which is currently pending as an external complaint was filed.
PerformCare was named in 6 complaints filed during 2013 or 7%. This is an increase in number by 1 from 2012. Two of these complaints was regarding rude staff behavior, one was regarding wrong information presented at a grievance, one was regarding poor communication, one was regarding failure to credential a music therapist, and one alleging a refusal to pay for TCM to accompany Member to OP appointments.
Complaint resolutions are monitored in order to track and trend PerformCare follow up with providers. A provider may have a high number of complaints, but required few to no follow up from the complaint resolution. Therefore, PerformCare began to monitor the number of complaints requiring follow up regardless of the number of complaints filed. Of the 84 Level I complaints filed in 2013, 56 (67%) required some level of follow up. This represents an increase from 49% in 2012. Five complaints required CCM follow up; 34 were referred to Network Operations to conduct follow up; and 20 referrals were made to the Chief Medical Officer for additional investigation due to severe quality of care concerns. It should be noted that in one Member complaint, both the Medical Director and Network Op follow up were recommended to address both quality of care issues and to conduct necessary provider outreach and education concerns and in two complaint outcomes both Network Operations and CCM follow up were recommended.
Timely resolution of complaints as well as satisfaction at level I continue to be carefully monitored. PerformCare consistently has a low number of level II complaints filed, noting high satisfaction from the level I process. In program year 2013, only two level I complaints moved to level II.
While complaints are required to be resolved within a 30 day timeframe from date filed, Members are allowed to file a 14 day extension if they feel their concern cannot be resolved appropriately within the 30 days. Of the 84 complaints resolved in 2013, 16 requested an extension resulting in not being resolved within 30 days. Two complaints were not resolved within 30 days without an extension. Without risking Member satisfaction with the resolution of complaints, PerformCare will attempt to improve the number of requests resolved within 30 days during 2014.
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Table 58: Extensions Filed and Resolution Compliance for 2013 – Network
Number % Over over 30 30 Days Total Over With with # Without % With % Within Records 30 days Extensions Extensions Extensions Extensions Compliance 2009 137 21 21 100% 116 15% 85% 2010 118 7 7 100% 111 6% 94% 2011 148 12 12 100% 136 6% 92% 2012 93 14 14 100% 79 15% 85% 2013 77 18 16 89% 59 21% 79% Note: 2009-2012 data includes complaints filed for Lycoming/Clinton and Blair contracts as well.
A comparison of 2009 through 2013 data regarding the average number of days PerformCare resolves complaints shows the average number of days has increased in 2013. This has been attributed to the complexity of the concerns being presented in complaints which require more documentation from the provider in order to appropriately investigate the issue noted in the complaint. PerformCare continues to focus on resolving complaints in a manner that provides the Member with timely resolution.
PerformCare strives for an average resolution time of 20 calendar days. This requirement increases demands on providers to increase their response time to PerformCare and allowing for a quicker, yet thorough resolution of the issues on the Member’s behalf. While we did see a decrease in the average resolution time from 2009 moving forward, the goal of 20 days for average resolution had not been met and in 2013, resolution time continued to rise. PerformCare attributes this to the identification of additional concerns found in the complaint investigation not noted in the original complaint issues, requiring repeated requests for additional documentation, prolonging the time it takes to resolve the complaint. In two instances, complaints were resolved in 31 and 32 days without an extension being completed.
Table 59: Average Resolution Time for 2009 to 2013
Average Number of Days Year Total Resolved to Resolve 2009 137 26 2010 118 22 2011 148 23 2012 93 27 2013 77 29 Note: 2009-2012 data includes complaints filed for Lycoming/Clinton and Blair contract as well. 2013 data only for Capital, Bedford/Somerset and Franklin/Fulton
Of the 84 level 1 complaints filed in 2013, 5 (6%) Member’s indicated dissatisfaction with the complaint outcome. Ninety four percent reported satisfaction with the complaint
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outcome. This slight decline in satisfaction is hypothesized to be related to Member desired outcomes that were outside of PerformCare’s control (i.e. having a specific staff person fired, reinstating services that were terminated).
Figure 62: Member Complaint and Satisfaction Outcomes 2010-2013
Member Satisfaction 2010 through 2013 110% 100% 90% 80% 97% 98% 70% 96% 94% 60% 50% 2010 2011 2012 2013
Provider Complaints
PerformCare has a process that allows in network providers to file complaints against PerformCare as well as other in network providers. These concerns are tracked and trended and also combined with Members complaints in order to view a more global picture of provider concerns, as well as internal PerformCare concerns. Past provider complaints against PerformCare processes have resulted in changes to these processes for more effective coordination between PerformCare and the provider network. This process is looked upon as an opportunity to make a positive impact on PerformCare processes for the betterment of Member treatment and provider relations. In 2013, PerformCare was named in one provider complaint filed. This is consistent with one provider complaint against PerformCare filed in 2011. Additionally, the overall number of provider complaints has declined steadily over the years as is demonstrated in the table below.
Table 60: Provider Complaints per Contract 2009 to 2013
2009 2010 2011 2012 2013 Total filed 12 9 5 3 1 Bedford/Somerset 1 (PC) 1 (PC) 0 1 (PC) 0 Blair 1 (PC) 0 0 0 n/a Capital 8 (2 PC) 4 1 (PC) 1 0 Franklin/Fulton 1 4 (2 PC) 3 1 1 Lycoming/Clinton 1 0 1 0 n/a
Summary and 2014 focus
Focus in 2014 will be on reducing the number of complaints across the provider network
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with a focus on providing education to BHRS providers regarding common complaint categories across the network. Another focus in 2014 will be to decrease the number of days for complaint resolution without compromising Member satisfaction and to increase the number of complaints resolves within 30 days. To increase Member satisfaction with complaint outcome, it will be important for complaint coordinators to discuss more clearly with Members the desired complaint outcome when complaint information is received to discuss if the resolution that is being sought is in line with a resolution that PerformCare can provide. Continued focus in 2014 will also be in tracking of complaint trends and follow up that occurs from the complaint outcome to identify if any provider trends can be determined and education can be provided to reduce the number of complaints.
Service Excellence
Telephone Access and Service
Telephone access is measured by the call abandonment rate and the percentage of calls answered within 30 seconds. PerformCare’s internal performance goals are more stringent than regulatory and accreditation requirements. The performance goal for Calls Answered within 30 Seconds was increased to > 97%. With a new telephone system installation in February, some statistical information was not captured during that month but the overall average for all other months was 99.50%. PerformCare was able to maintain the high standard of performance goals 97.67% of the time, even during the transition to a new telephone system. The Performance goal for Call Abandonment was reduced to < 2%. An average of 2.38% was maintained during 63% of the 2013 period. As the year progressed, along with the learning curve with the new system, the call abandonment rates returned to meeting the targeted goal. . Table 61: HealthChoices Member Telephone Service Statistics - Percentage Answered in 30 Seconds and Call Abandonment Rates
Total Abandoned Abandonment Calls ans % of calls Call center calls calls rate <=30s ans <=30s Capital HC Members 22005 456 2.07% 20106 93.30% North Central Members 4789 122 2.55% 4100 87.85% Grand Total 26794 578 2.16% 24206 92.33%
PerformCare has maintained a high Member call volume in 2013, responding to a call volume of 26,794 calls during the year. Overall performance remains consistent over the past seven years, while 2013 data showed higher abandonment rates due to the new telephone system transition. The percentage of Calls Answered in Less Than 30 Seconds remained well above the goal of > 97% so the desired performance standard was achieved. Although the Member abandonment rates were higher than the desired target in the early part of the 2013, as the year progressed the performance percentages returned to maintain percentages closer to the set goal.
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In 2013, the PerformCare HealthChoices Provider Line responded to 127,295 calls. Although performance exceeded most goal expectations, as a key component and indicator of quality service to Members and other parties, telephone access will continue to be monitored and reported during 2014.
Table 62: HealthChoices Provider Telephone Service Statistics - Percentage Answered in 30 Seconds and Call Abandonment Rates
Total Abandoned Abandonment Calls ans % of calls ans Call center calls calls rate <=30s <=30s HealthChoices Providers 127295 837 0.66% 96419 99.45% Grand Total 127295 837 0.66% 96419 99.45%
A minimum of one chart per month is audited for each HealthChoices MSS. The audit assesses for adherence to PerformCare’s clinical documentation standards. For MSS within their Introductory Period or on Corrective Action with PerformCare, at least two charts are audited monthly. Scoring is assigned as Unacceptable (scored 84.9% or below); Development Opportunity (scored 85%-89.9%); “Satisfactory” (scored 90%- 94.9%); and “Excellent” (scored 95% and above). Audits are scores at 125 points for the Initial Assessment Event and 100 points for the Clinical Contact event with some critical items noted in each audit. Bonus points are awarded to documentation exceeding expectations. Scoring results for 2013 are as follows.
Table 63: MSS Documentation Audit Results - 2013
Q1 Q2 Q3 Q4 Unacceptable 0 0 0 0 Development 0 0 0 0 Opportunity Satisfactory 2 0 1 1 Excellent 19 22 19 20 Total Charts 68 67 65 66 Total MSS 21 22 20 21
Timeliness of Routine Authorization Notices
A global measure of authorization timeliness was instituted to monitor the turnaround time for BHRS requests. The QI/UM Committee reviewed authorization timeliness on a quarterly basis. To monitor authorization turnaround time, the date of the authorization request is compared to the date that the Medical Necessity Criteria is determined.
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Figure 63: % of Timeliness of MNC determinations for BHRS Services within Goal Standard - 2013
Timeliness of MNC Determinations for BHRS Service 2013 100.50% 100.00% 99.50% 99.00% 98.50% 98.00% 97.50% 97.00% 96.50% 96.00% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
The number of authorizations generated within two business days from the time it was received barely fluctuated throughout all months in 2013. The 2013 overall performance for the entire PerformCare Network consistently displayed a very high success rate, with an overall annual average of 99.12%. August reached 100% of the turnaround time goal while December, the lowest month of 2013, showed 97.63%. The months with the highest number of BHRS requests for authorizations were May, June and December respectively. July, August and September had the least requests.
Figure 64: Comparison of MNC Requests to MNC Determinations by Contract - 2013
Comparison of MNC Determinations Meeting Deadline to all MNC Requests 8000 7000 6000
5000 MNC Determinations 4000 Meeting Deadline 3000 All MNC Requests for BHRS 2000 1000 0 BS CAP FF
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While the Capital region submitted the most BHRS authorization requests, over 7,000, Franklin/Fulton counties submitted the least, totaling 910 requests. Although the number of requests varied greatly per county, the highest standard of a 2 day turn around goal was met by each contract. Bedford/Somerset counties reached 98.65% of the 2 day MNC determination goal. The Capital region yielded a 98.69% determination rate and Franklin/Fulton counties had a 99.23% rate. All BHRS service requests and their MNC determination dates will continue to be monitored to ensure that these high standards continue to be met for the benefit of our Members as well as our Provider Network.
Claims Processing
During 2013, the PerformCare Network average days to adjudication experienced a gradual increase over the first seven months, peaked in July, and then gradually decreased over the last five months of the year. The region with the lowest average of adjudication days was Bedford/Somerset and highest average of days belonged to Franklin/Fulton. The average days to claims adjudication for the network was 18.72 days which had increased from last year’s 13.55 days. PerformCare’s established goals of processing 98% of all claims with a 45 day period and 100% within a 90 day period were reached. Generally, the increase of average days to claims adjudication corresponds with the volume increase of claims submission for each month. This was consistent in all PerformCare regions, along with the network.
Figure 65: Average Days to Claims Adjudication – PerformCare Network - 2013
Average Days to Claims Adjudication - 2013
35
30 BS 25 CAP 20 FF 15 NETWORK
10
5
0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Average Days to Claims Adjudication
The network results indicate that average days to claims adjudication are overall within the 30 day target for 2013. PerformCare will continue to monitor average days to claims adjudication through QI/UM on a routine basis in order to identify trends and implement future interventions, if necessary. PerformCare has released an RFP with the purpose of
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employing a clearinghouse with higher quality management standards which will benefit our Provider Network and ultimately our Members.
The volume, rate of claims denial, and reasons for claims denials are monitored quarterly by the PerformCare QI/UM Committee. One primary focus is on claims volume and reasons for claims denials which can significantly impact administrative appeals (see next section). The second primary focus is to monitor the highest categories of claims denial reasons, which for this year included reasons such as duplicate claims, invalid MPI/SLC/NPI/no Contract, Provider billing errors and untimely submissions. During 2012, the most common reasons for claims denials included no authorization, duplicate claims and untimely filing. These areas have remained problematic for providers as they experience administrative authorization and billing management problems, often due to the Provider’s internal staff turnover. Interventions by PerformCare to assist in this area to reduce claims denials include network and organizational provider education, notification to high-volume providers of denial reports, and monitoring network performance in these areas. A comparison of the overall claims volume to the overall percentage of claims denials is evidenced in the chart below. The network shows the last two years with similar percentages of total claims denied.
Figure 66: Percentages of Total Claims Denials by Contract - 2013
Percentages of Total Claims Denials by Contract - 2013 14% 12% 10% BS 8% CAP 6% FF 4% Network 2% 0% 2007 2008 2009 2010 2011 2012 2013
Some specific reasons for claims denials may include issues that are beyond the control of the provider such as Members’ retroactive eligibility issues, while other reasons for claims denials may be a failure on the part of the Provider which may include a failure to request authorization, duplicate billing, incorrect and/or insufficient information (such as a missing EOB) and the untimeliness of submissions. A comparison showing the Provider’s most common denial reasons and the total number and percentages of those denied claims to the total claims submissions of the network are listed below. Duplicate claims, provider billing errors, incorrect MPI/NPI identifiers and untimely claims were the four most common reasons, respectively, for all claim denials in 2013. No authorization ranked only sixth among the most common denial reasons this year within the Provider Network. The chart below explains the totals and percentages of each
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specific claims denial reasons and the graph shows the network’s combined percentages of the four most common claims denial reasons.
Table 64: Totals and Percentages of Specific Claim Denials 2013
# of Total % of # of # of Provider # of Claims % of % of Provider % of Duplicate No Billing Untimely for Duplicate No Billing Untimely Month Claims Auths Errors Claims 2013 Claims Auths Errors Claims Jan 2,064 807 1,409 988 86,999 2.37% 0.93% 1.62% 1.14% Feb 1,936 842 2,563 1,305 94,126 2.06% 0.89% 2.72% 1.39% Mar 2,987 704 1,638 835 96,506 3.10% 0.73% 1.70% 0.87% Apr 4,596 659 1,578 1,001 108,818 4.22% 0.61% 1.45% 0.92% May 3,037 529 1,735 1,282 107,939 2.81% 0.49% 1.61% 1.19% Jun 2,071 673 991 681 91,818 2.26% 0.73% 1.08% 0.74% Jul 1,744 807 6,377 965 86,738 2.01% 0.93% 7.35% 1.11% Aug 3,616 926 4,816 1,092 97,639 3.70% 0.95% 4.93% 1.12% Sep 1,698 497 1,939 900 83,652 2.03% 0.59% 2.32% 1.08% Oct 2,072 593 1,266 1,771 109,450 1.89% 0.54% 1.16% 1.62% Nov 2,365 470 749 1,095 92,743 2.55% 0.51% 0.81% 1.18% Dec 1,089 420 783 993 84,155 1.29% 0.50% 0.93% 1.18%
Figure 67: Percentages of Common Claims Denial Reasons by Contract - 2013
Percentage of Common Reasons of Claims Denials to Total Claims - 2013 14% 12% 10% BS 8% CA 6% FF 4% 2% Network 0% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
The increase noted above in the month of July can be attributed to delays which occurred during systems upgade when server migration was occurring. Since 2011, PerformCare worked to comply with CMS final rule adopting updated standards for electronic healthcare and pharmacy transactions originally adopted under the Administrative Simplification subtitle of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) by adopting ANSI version 5010 for all covered entities. Notification was made
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to all providers that all covered entities who submit electronic transactions would be required to comply. The requirement for compliance includes Clearing Houses, Service Bureaus, Software Vendors, Individual Providers, Provider Groups, County Consolidated Community Reporting and Managed Care Organizations. PerformCare was fully compliant with the ruling as of 1/1/2012.
A paper claims submission process as well as a web-based claim form submission process remains an available option for providers. While related processes were not changed, PerformCare has also established an Emdeon Payer ID, and has contracted with Emdeon, an electronic data interchange (EDI) services leader in healthcare, who was already used by many PerformCare providers. Emdeon provides EDI services based on individual needs, and trades with all major clearinghouses, giving flexibility to providers for testing and submitting claims. PerformCare has also contracted with ACS for preliminary processing of paper claims. Success in the paper claims submission process is dependent upon proper submission of claims to include a registered National Provider Identifier (NPI) for both the rendering and billing providers. In addition, extensive work has been done with providers to assist them in properly coding the diagnosis and place of service for each service billed and improved percentage of clean claims submission from providers.
PerformCare continues to offer ePayment services at no charge to providers in the PerformCare network. This includes an easier, web-based registration and provider preference selection process for electronic funds transfer (EFT) services, provider preferences on receiving electronic remittance advice via paper, electronic PDF or in the postable 835 format. A provider training position has been created within PerformCare which will specifically serve our network of providers by offering training on topics including claims processing. Training will be offered on-site visits, webinars and group sessions at the PerformCare location to assist providers with billing challenges in efforts to prevent unnecessary claims denials.
Administrative of Appeals
In medical necessity decisions, service or authorization denials follow the grievance process (see section Grievance Monitoring and Analysis under Appropriateness above). Administrative denials are claim payments or authorization denials for requests that are not approved because they do not meet contractual or administrative requirements. Administrative denials are not denied based on medical necessity criteria. PerformCare has established policy and procedure for requested reviews of administrative denials by providers. Reversal of administrative denials are regarded as an exception and are not routinely approved without compelling evidence that the Provider did not follow protocol due to legitimate special circumstances as determined by PerformCare. PerformCare evaluates all such requests and takes into consideration factors which caused the procedural error as well as remedies in place to prevent future occurrences. The timeliness and outcomes of such administrative appeals have been tracked and monitored as our standard is to complete the resolution of such retrospective reviews within 30 days.
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Figure 68: Total # of Administrative Appeals for Network Over Past Eleven Years
Total # of Administrative Appeals for Network Over Past Eleven Years 8000
6000
4000
2000
0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
While 2008 saw the highest number of submitted administrative appeals previously, there has been a significant trending increase since 2009. This notable trend was influenced by a few large providers who had experienced sizable billing challenges related to high rates of internal staff turnover.
Figure 69: Total # of Administrative Appeals and Determinations by Contract - 2013
Total # of Admin Appeals and Determinations by County 2000 1800 1600 1400 1200 BS 1000 CA 800 FF 600 Network 400 200 0 Rejections Approvals Denials
The greatest number of administrative appeals was submitted for members in Lancaster, Dauphin and Franklin counties, respectively. The counties that submitted the least amount of appeals were Bedford, Perry and Fulton, which corresponds to the number of their respective enrollments.
In 2013, 52% of the processed administrative appeals were approved for claims payment, 34% were denied and 15% were rejected due to inappropriate submissions. The greatest numbers of approved appeals were among the MH OP, BHRS and PHP levels of care. Combined, these levels of care comprised 79% of all approved appeals. The greatest
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numbers of denied appeals were among the MH OP, PHP and BHRS levels of care, while Peer Support, ECT, Labs and Detox were the levels of care with the least denials, rating only a combined total of .4%. The greatest numbers of rejected appeals were among the Crisis, MH OP and BHRS levels of care which composed 66% of the rejections while Labs, ECT and Peer Support had the least submissions with a combined tally of only .2%. In these instances, providers have the opportunity to exhaust claims and/or authorization processes before utilizing the appeals process.
Figure 70: Administrative Appeals by LOC - 2013
Approvals by LOC Denials by LOC Crisis SA BHRS 0% RTF 8% CM RTF CM Psych 7% SA BHRS 8% 7% Crisis 2% 6% CRR-HH Rehab Psych 10% 7% 15% 2% 8% Rehab CRR- 0% ECT PHP HH 0% 8% 7% PHP FBMHS 20% 1% Peer MH OP Labs FBMHS 37% Support Peer Labs 8% 0% 8% MH OP MH IP Support MH IP 8% 8% 8% 0% 7%
In 2013, 98% percent of the administrative appeals submitted were completed within the 30-day standard, while 2% percent were completed outside the 30-day standard. While the volume of submitted appeals increased substantially, the percentage of achieving the performance goal remained consistently high. The performance goal set by the QI Committee was for a minimum of 95% of administrative appeals to be completed within 30 days and it was successfully attained. Improving the timeliness of the administrative appeal determinations was a specific goal and remains a Service Quality Improvement Activity (QIA).
Figure 71: Timeliness of Admin Appeal Decisions/Notifications Average Days to Resolution - 2013
Average Days to Resolution Goal: 100% in less than 30 days
25 20 15 10 5 0 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13
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In summary, we have learned that the administrative appeals process is utilized most frequently by our providers who have experienced significant staff turnover rates and newly implemented systems issues. While the appeals process will always be necessary for claims denials related to retroactivated membership eligibility and the challenges that sometimes accompany the implementation of new electronic billing systems, the most commonly identified reason for appeal submissions is related to the high volume of staff turnover among our Provider Network. To resolve this issue, a quarterly reporting schedule has been established which identifies the providers who have experienced four or more failures in following PerformCare procedures within a 3 month period. The Account Executives of the Provider Relations Department then outreach to those identified Providers and offer further education and training specifically tailored to prevent similar future occurences and to continue to nurture successful and mutually beneficial relationships among our Provider Network to ensure the best care for our Members.
Member Support Services
MSS Quality Audits are completed to establish a standard pattern of documentation that encompasses accuracy, timeliness, accessibility, legibility and completeness. The goal is to evaluate for quality assurance, coaching, training and operational improvements. Each MSS works with all PerformCare HealthChoices contracts.
A random sample of Member Service Specialist’s documentation is reviewed by the MSS Supervisor, while the MSS Supervisor’s documentation is reviewed by the Manager of Member Services. A MSS audit tool is used to evaluator the associate’s performance. Those MSS still in their introductory period or having performance concerns are audited two times per month, while those MSS who have successfully completed their introductory period are audited three times per quarter.
During monthly supervisions the Supervisors/Manager will review the audits and identify reasons for errors as well as discuss and develop plans to prevent these errors from recurring in the future. They will coach on the significance of the documentation audit questions and relevance of each question to provide a holistic understanding of the documentation audit tool.
The goal for each MSS associate is to achieve a quarterly average score of 95% on audits. The audit tool identifies four categories of scoring: Excellent - 95%+ Satisfactory - 90-94.9% Development Opportunity - 85-89.9% Unsatisfactory - below 85%
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Table 65: MSS Audit results by quarter and aggregate for 2013
Quarter 1 Quarter 2 Quarter 3 Quarter 4 Unsatisfactory 0 0 0 0 Development Opportunity 0 0 0 0 Satisfactory 2 0 1 1 Excellent 19 22 19 20 # of Audits 68 67 65 66 # of Staff 21 22 20 21 # at 100% 7 8 8 8
In 2013, it’s clear that Members Service Specialists maintained excellent scores in documentation with only a slight decrease from 95.5% to 95.2% in overall scores for the year. Additionally, it is noted that that 37% of staff consistently scored 100% results across the four quarters.
Provider Satisfaction
The Provider Survey tool is the CHCS (Center for Health Care Strategies) Clinical and Administrative Provider Satisfaction Survey with 38 items for clinical staff and 15 items for administrative staff. The areas investigated in the survey are:
Clinical Administrative Service Authorization Service Authorization Quality Claims Provider Relations Complaints and Grievances Member Services / Care Management Provider Relations Overall Satisfaction Overall Satisfaction
In 2013, the survey process and reports on findings were completed by PerformCare’s Quality Improvement Department. The QI Department mailed the surveys to the providers, received the completed surveys, and collected, entered and analyzed the survey responses. In years prior to 2013, Polk-Lepson Research Group, Inc. had completed the survey process and reports on findings. The information is presented with detail by area of internal operations. Survey results beginning in 2008 include responses from all regions of operations. Reports prior to 2008 reflect results for the five county Capital Area contract only. The findings are reviewed by the Quality Improvement Department to develop a report summary that outlines quality improvement initiative recommendations for review and final approval by the Quality Improvement / Utilization Management Committees.
PerformCare randomly selected 1,321 HealthChoices (HC) providers to participate in the survey. A total of 98 surveys were returned as undeliverable. By the termination of data
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collection, 164 surveys were completed for a response rate of 12.4%, which is higher than the 9.4% response rate realized last year. The responses by region are 116 Capital, 36 Bedford/Somerset, 16 Franklin/Fulton
Clinical Satisfaction Ratings – Overall 86.9% in 2013
Overall satisfaction of clinical providers with PerformCare is 86.9% with 21.5% being very satisfied and 52.3 % being satisfied; a decrease of 4.0% from the overall satisfaction rating of 90.9% in 2012. Overall satisfaction was rated by 65.2 % of the respondents (107 of 164) compared to 71.5 % (88 of 123) in 2012, a decrease of 6.3 percent. The 2013 overall satisfaction rate is lower than the ratings in previous years (2006 to 2011) which ranged between 88.2% and 95.7% overall satisfaction.
Of the 37 clinical attributes evaluated, 18.9% of the attributes had Satisfied Ratings of 96% or higher; 45.9% had ratings between 91% and 95%; 18.9% with Satisfied Ratings between 86% and 90%; and 16.3% with Satisfied Ratings between 80% and 85%. In total 100% of the Satisfied Ratings met or exceeded the 80% satisfaction level with over 60% meeting or exceeding the 91% satisfied level. These ratings indicate a high level of clinical provider satisfaction with PerformCare.
Administrative Satisfaction Ratings – Overall 87.0% in 2013
The overall satisfaction of administrative providers with PerformCare is 87.0% a decrease from a 90.5% rating in 2012. Overall satisfaction was rated by only 60.9% of the respondents (100 of 164). Despite the lower overall rating, over half of the 14 administrative attributes (64.3%) received Satisfied Ratings between 91% and 95.5%. The remainder of other administrative attributes is in the 85% to 90% range. Overall, 9 of the 14 Satisfaction Ratings for individual attributes have improved since last year.
Observations
Overall satisfaction of clinical and administrative providers remains high, over 86% satisfied. This year, 2013, marks the eighth year of maintaining an overall satisfaction rating of over 86 percent. This eight year trend also shows a general decline in the provider Satisfaction Rating. The Satisfied Rating of the individual attributes remained high this year; clinical attributes met or exceeded the 81% Satisfied Rating with the majority exceeding 90% and the administrative attributes met or exceeded the 85% Satisfied Rating with the majority exceeding 90%. The 2013 Satisfied Ratings continue an eight year trend of scoring 80% or greater ratings amongst all clinical and administrative attributes.
Clinical • The Satisfied Ratings for the clinical attributes met or exceeded 90% in 63.2% of the attributes. All the clinical attributes received a satisfaction rating greater than 80%. Eight of the evaluated attributes showed an improvement in Satisfied Ratings of at least one percent with a maximum rating improvement of 4.9%
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(89.1 to 94.0); twenty-one of the evaluated attributes showed a decrease of at least one percent with a maximum decrease of 8.8% (93.6 to 84.8); and eight of the evaluated attributes showed a change of less than one percent (0.3 percent to 0.8 percent). The percentage of attributes meeting or exceeding the 90% satisfaction rating decreased from 84% in 2012; this appears to be a longitudinal decrease.
• Over the years, the ratings of the Service Authorization attributes have been relatively steady, with the exception of appropriateness of medical necessity criteria, which has shown a 13.1% decrease since last year. An examination of this attribute over the time period of 2006 to 2013 reveals a trend. The satisfaction rating increases over a three year period and then a decrease, a significant decrease in 2013, occurs in the fourth year.
• Small fluctuations have occurred in the Quality attributes. Here, the Satisfied Ratings approximate 80% or higher. The attribute with the downward trend from last year, clarity of documentation requirements, has decreased from 87.2% to 80.4%, which is the lowest score reported in the survey. Conversely, coordination with physical health plans has improved by nearly 5% since last year from 89.1% to 94.0%.
• Six of the twelve Provider Relations attributes have shown an increase in satisfaction with the most significant increase (around 4%) in the availability of on-going training opportunities and the usefulness of on-going training opportunities. The helpfulness of provider relations staff continues to increase from the previous two years 91.5% to 94.9%. The provider forums for feedback/problem solving attribute continues the four year trend of decreased satisfaction; this year’s decrease is four percent and is the largest decrease over the four years. All Provider Relations attributes have scores of 84% or higher.
• In the Member Services area, all attributes have scores of 84% or higher with four of the eleven attributes showing an increase in satisfaction ratings. Access of second opinion in review of authorization experienced the greatest increase, 2.7 percent. Several of the attributes have shown a negative trend since last year, especially the attributes related to the consistency of response by staff, a decrease of 5.7%, and the application of medical necessity criteria, a decrease of 8.8%.
Administrative • The Satisfied Ratings for the administrative attributes have shown a variety of change since last year. While none of these attributes had ratings of 96% or above, 60% were in the 90% to 95% range. All attributes scored 85% or higher. Nine of the eleven attributes experienced an increase in the satisfaction ratings, ranging from a 1.3% to 6.9% increase. The decrease in the Satisfied Ratings ranged from 0.3% to 6.3 % (Credentialing process).
• The Service Authorization attribute, clarity of pre-certification policies, has shown a 3.6% increase since last year.
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• The Claims attributes show an increase across three of the five attributes with the most significant increases for timeliness of payment receipt (6.9%) and accuracy of response to claims questions (6.8%). The Satisfied Ratings decrease experienced in the two other attributes were not significant – 0.3 and 1.3 percent. The five claims attributes scored above the 85% Satisfied Rating.
• Under Complaints & Grievances, both attributes have increased Satisfied Ratings from last year and continue to show a significant upward trend over the last three years (2011 to 2013). The two attribute scores were above 92% Satisfied Rating.
• The Provider Relations attributes have remained relatively unchanged since 2012 with five out of the six attributes changing less than 2 percent. The exception to this stability is the credentialing process attribute, which showed a 6.3% decrease from 92.6% to 86.3%. The six provider relations attributes scored above 86% in the Satisfied Ratings.
Longitudinal Comparisons
Increases and decreases from the 2012 Satisfied Ratings related to Clinical Satisfaction Ratings are noted below. Based on this information, areas for potential initiatives can be identified from the following, with options to identify/ implement initiatives or monitor for future trends. Based on other factors such as state initiatives, company initiatives and other defined outcomes, there may be specific areas with large variances from 2012 to 2013 or continuous changes across the annual periods which may warrant initiatives, even though the regression review indicates there are general fluctuations.
Clinical:
Satisfaction Rate Increases 1. Availability of physician review for authorization +0.7% from 91.9% to 92.6% 2. Availability of ER services +0.7% from 97.3% to 98.0% 3. Coordination with physical health plans +4.9% from 89.1% to 94.0% 4. Courtesy of provider relations staff +2.0% from 96.7% to 98.7% 5. Helpfulness of provider relations staff +1.6% from 93.3% to 94.9% 6. Level of knowledge of provider relations staff +1.2% from 92.2% to 93.4% 7. Availability of ongoing training opportunities +3.9% from 89.9% to 93.8% 8. Usefulness of ongoing training opportunities +4.0% from 89.8% to 93.8% 9. Clarity of quality management goals +0.6% from 90.7% to 91.3% 10. Helpfulness of member services staff +0.8% from 96.2% to 97.0% 11. Courtesy of clinical care managers staff +0.4% from 98.1% to 98.5% 12. Helpfulness of clinical care managers staff +2.2% from 93.3% to 95.5% 13. Access of second opinion review of authorization +2.7% from 90.2% to 92.9% request
Satisfaction Rate Decreases 1. Clinical – Overall Satisfaction -4.0% from 90.9% to 86.9% 2. Timeliness of authorizations -2.7% from 94.0% to 91.3% 3. Ease of authorization -4.0% from 90.5% to 86.5% 4. Appropriateness of medical necessity criteria -13.1% from 94.4% to 81.3%
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5. Accuracy of authorizations -4.0% from 90.4% to 86.4% 6. Availability of services for mental illness/substance -0.3% from 92.9% to 92.6% abuse 7. Availability of clinical care manager -1.5% from 92.6% to 91.1% 8. Cultural competency -0.3% from 96.6% to 96.3% 9. Availability of children’s services -3.3% from 88.2% to 84.9% 10. Assistance coordinating services for difficult -5.2% from 91.4% to 86.2% patients 11. Clarity of documentation requirements -6.8% from 87.2% to 80.4% 12. Adequacy of confidentiality policy -1.4% from 100.0% to 98.6% 13. Timeliness of calls answered – provider relations -4.5% from 94.3% to 89.8% 14. Usefulness of provider manual -3.8% from 95.0% to 91.2% 15. Notification of changes in policies and procedures -0.3% from 90.7% to 90.4% 16. Credentialing process -6.6% from 95.7% to 89.1% 17. Clarity of provider performance specifications -3.4% from 90.9% to 87.5% 18. Provider forums for feedback/problem solving -4.0% from 88.3% to 84.3% 19. Timeliness of calls answered – member services -1.7% from 94.3% to 92.6% 20. Courtesy of member service staff -0.3% from 98.1% to 97.8% 21. Coordination of transportation -1.0% from 95.7% to 94.7% 22. Consistency of responses by staff -5.7% from 90.1% to 84.4% 23. Application of level of care criteria by clinical -5.8% from 95.7% to 89.9% care managers 24. Application of medical necessity guidelines -8.8% from 93.6% to 84.8% 25. Clinical care manager turnover -5.9% from 98.6% to 92.7%
Administrative:
Satisfaction rate increases 1. Clarity of pre-certification process +3.6% from 91.9% to 95.5% 2. Timeliness of payment receipt +6.9% from 81.5% to 88.4% 3. Accuracy of response to claims questions +6.8% from 87.1% to 93.9% 4. Timeliness of response to claims inquiries +0.9% from 90.5% to 91.4% 5. Timeliness of complaint resolution +1.3% from 90.9% to 92.2% 6. Timeliness of grievance resolution +3.7% from 90.6% to 94.3% 7. Availability of ongoing training opportunities +1.6% from 93.3% to 94.9% 8. Notification of changes in policies +0.6% from 90.9% to 91.5% 9. Clarity of QM/QA goals +1.8% from 90.1% to 91.9%
Satisfaction Rate decreases 1. Administrative – Overall Satisfaction -3.5% from 90.5% to 87.0% 2. Consistency of payment with fee schedule -0.3% from 92.5% to 92.2% 3. Timeliness of claims complaints resolution -1.3% from 86.9% to 85.6% 4. Credentialing process -6.3% from 92.6% to 86.3% 5. Clarity of provider performance specifications -1.3% from 90.3% to 89.0% 6. Providing forums for feedback/problem solving -1.9% from 88.8% to 86.9%
Regional Variances
Several of the attributes scored similarly across contracts. However, quite a few significant differences were noted, and these items are presented below. Overall, the Franklin/Fulton Contract reported the most positive results, with the Capital contract and the Out of Network providers reporting similarly positive ratings. Bedford/Somerset consistently reported more negative results for each attribute.
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Table 66: Regional Variances – Clinical
Clinical Bedford/ Franklin/ Out of Capital Somerset Fulton Network Ease of authorization 64.7% 83.7% 100% 92% Level of assistance provided by PerformCare coordinating services 61.5% 89.2% 100% 88.3% for difficult/complex patients Clarity of documentation 52.9% 80.8% 87.5% 85.9% requirements Clarity of provider performance 76.5% 79.2% 100% 95.2% specifications Clarity of PerformCare quality 70.6% 94.9% 100% 93.8% management goals Provider forums for 76.5% 80.6% 100% 87.1% feedback/problem solving Courtesy of clinical care managers 100% 97.9% 75.0% 100% staff Coordination of transportation 60.0% 91.7% 100% 100% Consistency of responses by staff 57.1% 82.5% 100% 90.6% Application of level of care criteria 61.5% 93.9% 100% 93.2% by clinical care managers Application of medical necessity 53.8% 84.4% 100% 91.1% guidelines Clinical care management turnover 63.6% 96.3% 100% 97.6% rate Overall satisfaction with 89.1% 64.3% 91.4% 100% PerformCare
Table 67: Regional Variances – Administrative
Administrative Bedford/ Franklin/F Out of Capital Somerset ulton Network Timeliness of claims complaints 80.0% 81.0% 100% 88.5% resolution Credentialing process 76.9% 75.6% 100% 94.7% Clarity of provider performance 75.0% 82.2% 100% 96.7% specifications Clarity of PerformCare QM/QA 93.2% 70.6% 97.6% 100% goals Provider forums for 71.4% 81.3% 100% 96.2% feedback/problem solving Overall satisfaction with 64.3% 94.1% 100% 87.2% PeformCare ¹The attributes listed in this table are taken verbatim from the survey tool
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Summary of Quality Initiatives
The following areas of concern have been the focus of intervention for several years due to their low scoring and/or downward trend.
Table 68: Availability of children’s services
2007 2008 2009 2010 2011 2012 2013 89.3% 84.9% 91.7% 87.9% 84.5% 88.2% 84.9%
Previous efforts focused on clarifying internal operations which might give the perception that services were unavailable. Interventions included: the development of instructions for the submission of authorization requests; supplementing the review of initial request for BHR services with a focused quality audit of initial treatment plans by the Quality Improvement Department offering feedback to providers; development of a standard treatment plan training offered across varied levels of care and required for providers which identified needs; implementing a clinical supervisor level review of all requests for additional information for Members affected by Autism to maintain consistency in review; continued development of an “unmatched treatments” approach to service reimbursement which would eliminate the requirement to obtain an authorization prior to delivering some levels of service; refining the inter-rater reliability of treatment plan and functional behavioral analysis reviews among CCMs and QI staff who conduct treatment record reviews and other audits to eliminate mixed messages to providers; refinement of Physician/Psychologist Advisor consults with providers to obtain additional information and/or discuss the quality of evaluations to be positive, collaborative and assistive rather than burdensome.
2013 results continue to indicate a decrease in this area. Recommended Action: PerformCare will continue to monitor the satisfaction of providers. PerformCare will expand educational opportunities to inform providers on the process of how to access services for children they are serving. Primary initiatives to address this area of performance include the implementation of automated ISPT scheduling for providers through eCura, ProviderConnect and implementation of an automated process for the submission of BHRS requests both of which were implemented during 2013.
Table 69: Ease of authorization
2007 2008 2009 2010 2011 2012 2013 92.6% 86.6% 86.7% 86.4% 88.6% 90.5% 86.5%
PerformCare continues to utilize the unmatched treatment authorization process for
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specific levels of care. Providers are given full clearance to provide certain levels of care to PerformCare Members and submit claims without having prior authorization.
2013 results show a decrease from last year. Recommended Action: PerformCare will monitor this rating and offer provider education through PerformCare Account Executives to ensure that providers are aware of authorization processes. PerformCare will review the authorization process for specialized outpatient giving consideration to reducing unnecessary administrative expectations. This area will be improved in the next annual update to the provider manual. PerformCare will review expectations for arrival notification on inpatient; as well as to review expectations to document the need for inpatient, again giving consideration to reducing unnecessary administrative expectations.
Table 70: Assistance coordinating services for patients with complex needs
2007 2008 2009 2010 2011 2012 2013 86.8% 83.3% 92.9% 84.2% 85.0% 91.4% 86.2%
Previous efforts have focused on improving the Enhanced Care Management program, improving Follow up Specialist activities and increasing the opportunity for Providers to address specific barriers to treatment. In addition, this topic is included in provider trainings and Level of Care (LOC) meetings. In September 2013, follow up activities were increased to ensure that Members were attending after care appointments to ensure continuity of treatment.
PerformCare has added additional Enhanced Care Management and Field Care Managers to increase our ability to actively manage member care, including coordination with the Special Needs Units of the Physical Health Plans. In addition, Local Care Management also exists is some areas of the network. The continuation of case conferencing led by the Chief Medical Officer, provides a forum for case discussions and care manager education regarding the treatment of Members with complex behavioral and physical needs.
PerformCare continues to offer technical assistance to providers in strengthening treatment plans and functional behavioral assessments (FBA) to direct the care of children with complex needs being served through BHRS. These reviews have been an effective method that allows PerformCare to collaborate with network providers in providing education and assistance and provides an opportunity to join treatment plans and FBA Summary information in a way that improves overall treatment efforts. Similarly, the continued assessment of both co-occurring and autism competencies has strengthened the Network and better prepared our providers to improve the quality and manner in which care is offered.
Provider tool kits have also been initiated for several levels of care. Each communication provides a brief, informative topic that supplements PerformCare’s efforts toward continuous quality improvement. Topics have included trauma informed care, recovery practices, substance abuse assessment, safe behavioral management, objective measures,
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and evidence based practices.
PerformCare Psychologist Advisors facilitated several provider trainings that allowed for discussion and collaboration regarding implementation of these standards. The Child and Adolescent Needs and Strengths (CANS) is a standardized tool that facilitates active and accurate communication of information. PerformCare is currently exploring the use of the CANS as a decision support tool that treatment teams can utilize in order to facilitate treatment planning and strengths based programming.
Overall, the 2013 results indicate a decline since 2012. Recommended Action: Continue to enhance, refine and develop active care management strategies and provide technical assistance as needed as best practice strategies are implemented. Guide providers to allow FBA’s to inform the treatment plan and modify goals accordingly. Fully implement CANS initiatives to guide decision-making related to BHR service delivery. Formalize development of a Complex Care Management initiative to better meet the needs of Members with complex needs.
2013 Findings:
The following indicators resulted in regression of 8% or more:
Appropriateness of medical necessity criteria down 13.1% 81.3% Application of medical necessity guidelines down 8.8% 84.8%
The appropriateness of criteria and application of guidelines are critical to the provision of appropriate behavioral health services. PerformCare provides technical assistance and training to providers to help them understand the appropriateness of MNC as well as the application of MNC. The PerformCare Network providers, 25 of 134 respondents (18.7%), reported dissatisfaction with the appropriateness of medical necessity criteria; the provider Satisfied Rating was below 80% for all three contracts. The PerformCare providers, 16 of 105 respondents (15.2%), reported dissatisfaction with the application of medical necessity guidelines; the Bedford/Somerset provider Satisfied Rating was 61.5% and the Capital Area and the Franklin Fulton area provider Satisfied Ratings were greater than 93%. The wide variance in this rating is attributed to local efforts to positively impact the continuum of care in Bedford/Somerset through the development of evidence based alternatives which are more appropriately suited to meet the needs of Members is specific diagnostic categories. The end result of this change positively impacts the Member experience in treatment so it is important to continue to work with providers to understand the need for change.
Initiatives: 1. Appropriateness and application of MNC Criteria A. Compare results to the results of a local satisfaction survey to gain a greater understanding of the underlying issues which lead to provider dissatisfaction in this area.
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B. Improve provider satisfaction with the appropriateness and application of MNC criteria through the use of specific interventions which target the areas of dissatisfaction. C. Recommended Action: Research the cause of provider dissatisfaction; engage providers, specifically targeting those territories with the lowest Satisfied Rating, in discussion of MNC Criteria, and develop interventions focused on improving provider satisfaction based on input from providers and other stakeholders.
2. Bedford/Somerset Provider Satisfaction A. Conduct research to understand the cause(s) of the low Satisfied Ratings for the Bedford/Somerset territory providers. B. Given the low volume of response from providers identified to be affiliated with the Bedford/Somerset contract, it should be determined if these results are representative of the region through comparative review of local survey results. C. Recommended Action: Research any cause(s) noted above via a root cause analysis (RCA) of Bedford/Somerset provider dissatisfaction, engage providers and other stakeholders in discussions around the identified cause(s), and develop interventions focused on improving provider satisfaction
Provider Self-Service Features eCura® ProviderConnect is a web-based application with e-business functionally which gives providers the opportunity to view claims status, view authorizations status and check provider site location information 24 hours a day, seven days a week. Features include: electronic critical incident reporting electronic capacity reporting for BHRS and FBMHS electronic FTE reporting for BHRS and FBMHS electronic change requests for e-Cura® ProviderConnect. electronic remittance advices
The implementation of a registration free process for most outpatient services eliminated the need for providers to submit an authorization request for service is in process. Providers were given full clearance to provide certain levels of care to PerformCare eligible Members and submit claims without having prior authorization. Safeguards have been established to ensure appropriate service levels remain in place.
Services implemented to date include: Targeted Case Management Mental Health Crisis Intervention Mental Health Outpatient
Provider Relations has expanded capacity to allow providers to use the Council for Affordable Quality HealthCare (CAQH) credentialing process for efficiency.
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Providers who utilize the PerformCare Website and icontact have access to an online training calendar and all communications sent by PerformCare. These communications are categorized by service and/or topic area and searchable.
Providers can view provider “tool kit” through the PerformCare Web-site. Tool kits offer resources which may enhance the service area such as various substance abuse screening tools, restraint initiatives, education materials useful to prescribers, etc.
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SECTION V Future Direction of the QI Program
For Calendar Year 2014, the Quality Improvement Program of PerformCare will be organized around the established CQI Strategic Initiatives as described in the QI/UM Program Description and the QI/UM Work Plan. Additional monitoring or measurement areas have been added to the QI/UM Work Plan, reflecting the needs of the Counties or HealthChoices quality improvement activities and initiatives as planned by OMHSAS. The following specific areas are identified as new or revised QI program priorities for Calendar Year 2014: 1) Identify renewed clinical service areas for focus in Quality Improvement Initiatives to support Performance Improvement Projects as required by OMHSAS, IPRO and NCQA expectations. 2) Realize 100% of Performance Incentives from each contract 3) Improve HEDIS measures for follow up after hospitalization services to ensure optimal continuity of care. 4) Improve inpatient readmission rates throughout the network. 5) Implement use of at least two new HEDIS measures; one of which will be Initiation and Engagement of SA. 6) Improve service access in the areas of a) psychiatric evaluations b) BHRS (TSS, MT, BSC, FBA) 7) Establish a reliable process for measuring provider availability for routine services and set minimum expectations in reporting. 8) Implement clinical initiatives to improve the coordination of behavioral healthcare and medical care (new 2014 NCQA standards) through enhanced Physical Health – Behavioral Health coordination efforts. 9) Implement a population based, complex case management (new 2014 NCQA standards) system to focus effective, active care management strategies on high- volume and high risk Members, improving outreach and follow up activities to this population. 10) Implement a minimum of two behavioral health screening programs (new 2014 NCQA standard) – one of which addresses the needs of Members with co-occurring mental health and substance abuse disorders. 11) Improve the provider network by a) Supporting the continued advancement of integrated systems of care; b) Encouraging the ongoing development of provider competencies to serve Members affected by autism and/or Members with co-occurring concerns. c) Implementing use of provider score cards to give current and useful feedback on performance and provide technical assistance on improving areas of need as applicable. d) Initiating terminations from the network when indicated, utilizing the progressive discipline policy. e) Developing and implementing a viable Pay for Performance and/or Performance Based contracting initiative. 12) Implement the use of the CANS to support evaluation decision-making and outcomes reporting for children’s services, specifically BHRS.
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13) Improve the collection of cultural and linguistic data to improve our ability to assess the capabilities of the provider network and more closely monitor the penetration the population, eliminate disparities in treatment and ensure the adequacy of services in identified geographic areas of need. 14) Closely monitor the implementation of requirements for licensing of Behavioral Specialists to ensure minimal negative impact to Members in need of service. 15) Continue to improve the functionality of the Provider Advisory Committee and sub- committees established to address Pharmacy and Therapeutics, Provider Education, and Clinical Practice/Treatment Guidelines. 16) Gain approvals to implement strategies outlined in BHRS re-design proposal(s).
SECTION VI List of Tables and Figures
Table Descriptions Page # Table 1: 2012 Territory Enrollment 9 Table 2: IRR - Average Percent Agreement 19 Table 3: UR IRR – Average Percent Agreement 19 Table 4: IRR - Average Percent Agreement -Physician Advisors 20 Table 5: IRR - Average Percent Agreement -QI 20 Table 6: Total Audits per Quarter 22
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Table 7: Capital Comparison of Average Total Domain Score 23 Table 8: North Central Comparison of Average Total Domain Score 23 Table 9: Capital Aggregate Scores for UR (MH IP/PHP & SA Detox/Rehab) and 24 /BHRS (all Children’s LOCs) Table 10: Average total score per Quarter 25 Table 11: Total Audits Quarter 4 26 Table 12: Average per Scoring Domain 26 Table 13: Members Served by Enhanced Care Management 2013 28 Table 14: Psychiatric Eval Access: Percentage in 7-day Standard 34 Table 15: 2013 Access to Best Performance Evaluations 35 Table 16: Access to non-BHRS psychological and neuropsychological evaluations 37 Table 17: Access to Behavior Specialist Consultant (BSC) services 37 Table 18: Access to Mobile Therapy 40 Table 19: Access to Therapeutic Staff Support 41 Table 20: Access to Functional Behavioral Analysis 42 Table 21: Peer Support Access Following Inpatient 43 Table 22: 2013 Geographic Access to Providers 44 Table 23: 2013 Provider Ratios 46 Table 24: ROM Outcomes - Bedford/Somerset (1/1/13 – 12/31/13) 47 Table 25: Crisis Bridge Utilization – Bedford/Somerset (1/1/13 – 12/31/13) 50 Table 26: Allocation Percent of Categories of Highest Cost Expenses 55 Table 27: 2013 Denials by Service 59 Table 28: Denials per 10,000 Members per Quarter 60 Table 29: Grievances by LOC per contract 2013 64 Table 30: Grievance Outcome by Level 2010- 2013 65 Table 31: Grievance Resolution Compliance 66 Table 32: Credentialing Actions by Contract – 2013 67 Table 33: PerformCare Provider Turnover Rate 2013 67 Table 34: Number of OON Requests by Contract 68 Table 35: Provider Performance by Level of Care and Contract – 2013 85 Table 36: 2013 TRR Reviews, Separated by Region and LOC 96 Table 37: 2013 TRR Reviews Resulting in a QIP 97 Table 38: Year to Year Comparison of All Readmission Rates 106 Table 39: 2013 Readmission Rates per County and Network 106 Table 40: Follow-Up Rates 2009 to 2012 109 Table 41: Peer Support Services 123 Table 42: Members Receiving Behavioral Health Services in FQHC - 2013 124 Table 43: PH-BH Collaboration Results from Treatment Record Review 125 Table 44: Reduction of Physical Health/Behavioral Health Admissions PIP 126 Table 45: ISPT Meetings-School Participation - 2013 131 Table 46: Network Penetration Rates - 2013 134 Table 47: Top 5 Diagnostic Categories - 2013 135 Table 48: Language Summary - 2013 137 Table 49: Penetration/Denials by Race and Ethnicity – 2013 138 Table 50: Cultural Competency Assessment January 2013 – December 2013 139
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Table 51: ADHD Mailing Results – 2013 155 Table 52: Report Measures from October of 2012 through September of 2013 157 Table 53: Capital 158 Table 54: North Central 158 Table 55: Critical Incident Reports and Categories 2013 165 Table 56: Restraints by Level of Care - 2013 171 Table 57: Distribution of Complaints by Contract 174 Table 58: Extensions Filed and Resolution Compliance for 2013 – Network 175 Table 59: Average Resolution Time for 2009 to 2013 175 Table 60: Provider Complaints per Contract 2009 to 2013 176 Table 61: HealthChoices Member Telephone Service Statistics - Percentage 177 Answered in 30 Seconds and Call Abandonment Rates Table 62: HealthChoices Provider Telephone Service Statistics - Percentage 178 Answered in 30 Seconds and Call Abandonment Rates Table 63: MSS Documentation Audit Results - 2013 178 Table 64: Totals and Percentages of Specific Claim Denials 2013 182 Table 65: MSS Audit results by quarter and aggregate for 2013 187 Table 66: Regional Variances – Clinical 192 Table 67: Regional Variances - Administrative 193 Table 68: Availability of children’s services 193 Table 69: Ease of authorization 193 Table 70: Assistance coordinating services for patients with complex needs 194
Figure Descriptions Page # Figure 1: Capital Comparison of Average Total Domain Score 22 Figure 2: North Central Comparison of Average Total Domain Score 22 Figure 3: Capital Care Managers Aggregate Scores for UR (MH IP/PHP & SA 24 Detox/Rehab) and /BHRS (all Children’s LOCs) Figure 4: High Risk Members with Co-Occurring Disorders by Quarter 29 Figure 5: Routine Access within 7 days 33 Figure 6: Psychiatric Evaluation Access – Percentage in 7 days 35 Figure 7: Best Practice Evaluation – Percentage in 7 days 36 Figure 8: Access to non-BHRS psychological and neuropsychological evaluations 37 Figure 9: Access to Behavior Specialist Consultant (BSC) services 38 Figure 10: Access to Mobile Therapy 40 Figure 11: Access to Therapeutic Staff Support 41 Figure 12: Access to Functional Behavioral Analysis 42 Figure 13: Allocation of Costs - 2013 55 Figure 14: Denials by Service Type - 2013 58 Figure 15: Denials per 10,000 Members per Quarter 59 Figure 16: Denials as a Percentage of Requests 61 Figure 17: Denial to Grievance Trends from 2008 to 2013 62 Figure 18: Grievance Trends per 1000 Members 2013 -LI & LII 62 Figure 19: Percentage of Level I to Level II by contract – 2009 to 2013 63
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Figure 20: 2013 Grievances by Level of Care for Capital, Franklin/Fulton, and 64 Bedford/Somerset contracts Figure 21: Provider Profiling RTF - 2013 70 Figure 22: Provider Profiling BHRS Members - 2013 71 Figure 23: Provider Profiling MH OP - 2013 72 Figure 24: Provider Profiling MH PHP - 2013 73 Figure 25: Provider Profiling FBMHS - 2013 74 Figure 26: Provider Profiling CRR HH - 2013 75 Figure 27: Provider Profiling MH IP - 2013 76 Figure 28: Provider Profiling SA NH Detox - 2013 77 Figure 29: Provider Profiling SA NH Halfway House - 2013 79 Figure 30: Provider Profiling SA NH 3B Rehab - 2013 80 Figure 31: Provider Profiling SA NH 3C Rehab - 2013 82 Figure 32: Total No of Provider Performance Issues by Contract 84 Figure 33: Provider Performance Issues by Contract and Level of Care - 2013 84 Figure 34: BHRS Provider Performance – Network - 2013 85 Figure 35: FBMHS Provider Performance – Network – 2013 86 Figure 36: CRR-HH Provider Performance – Network – 2013 87 Figure 37: MH PHP Provider Performance – Network – 2013 88 Figure 38: MH IP Provider Performance – Network – 2013 89 Figure 39: RTF Provider Performance – Network – 2013 90 Figure 40: TRR Network Averages for Capital, Bed/So and Fr/FU Regions 95 Figure 41: Percentage of TRR Requiring QIP by LOC 97 Figure 42: 2013 Readmission Rates 107 Figure 43: 2013 Readmissions with SMI 107 Figure 44: Network Validated Rates for 2012 112 Figure 45: 2013 Follow-Up Rates – HEDIS 113 Figure 46: 2013 Follow-Up Rates – PA Specific 114 Figure 47: CPG Measures 120 Figure 48: % School Participation - 2013 131 Figure 49: POMS – Living Status - 2013 144 Figure 50: POMS – Vocational/ Educational Status – 2013 145 Figure 51: Number of Quality of Care Referrals by Contract - 2013 161 Figure 52: Quality of Care Concerns by Level of Care - 2013 161 Figure 53: Quality of Care Follow up Actions - 2013 163 Figure 54: Quality of Care Concerns by Type of Incident - 2013 164 Figure 55: RTF Restraint Analysis – Multi-year 169 Figure 56: Members in Multiple Restraints – Multi-year 169 Figure 57: Total Days in Restraint – Multi-year 170 Figure 58: Percentage of Restraints by Level of Care - 2013 170 Figure 59: Complaints by Level of Care for 2012 vs 2013 172 Figure 60: Complaint Descriptors for 2013 173 Figure 61: High Volume Complaint Descriptors 2013 173 Figure 62: Member Complaint and Satisfaction Outcomes 2010-2013 176 Figure 63: % of Timeliness of MNC determinations for BHRS Services within Goal 179
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Standard - 2013 Figure 64: Comparison of MNC Requests to MNC Determinations by Contract - 179 2013 Figure 65: Average Days to Claims Adjudication – PerformCare Network - 2013 180 Figure 66: Percentages of Total Claims Denials by Contract - 2013 181 Figure 67: Percentages of Common Claims Denial Reasons by Contract - 2013 182 Figure 68: Total # of Administrative Appeals for Network Over Past Eleven Years 184 Figure 69: Total # of Administrative Appeals and Determinations by Contract - 2013 185 Figure 70: Administrative Appeals by LOC - 2013 185 Figure 71: Timeliness of Admin Appeal Decisions/Notifications 185 Average Days to Resolution - 2013
APPENDIX F – PEPS Cross Reference
Item # Report Name PEPS Page Standard I. PH/BH Coordination 92.1 124 – 127 II. Access to Services – Urgent, Emergent, Routine 93.1 32 III. Access to Services – Initial Psychiatric 93.1 34 IV. Access to Services – BHRS Initial (Best Practice Evaluations) 93.1 35 V. Access to Services – BHRS Service Access 93.1 37 VI. Provider Network Adequacy (GeoAccess®) 93.1 44
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Out of Network Arrangements 67 Spanish Speaking/Cultural Competency 138 VII. Penetration Rates 93.1 133 VIII. Inter-Rater Reliability 93.2 16 IX. Complaint, Grievance and Fair Hearing 93.3 61, 171 X. Treatment Outcomes* 93.4 BHRS 155 Follow up After Hospitalization 168 Readmission Rates 105 XI. Consumer and Provider Satisfaction 100.1 C/FST Survey 104 Member & Provider Surveys 98, 182 XII. Over / Under Utilization** 98.2 55 XIII. Adverse Incidents 99.2 164 XIV. Coordination with Other Service Agencies and Schools* 98.3 128 – 132 XV. Treatment Record Review and Summary 99.1 94 XVI. Provider Profiling 99.5 68 XVII. Performance Improvement Plans (PIPS) 93.4 155, 108 XVIII. Telephone Access 98.1 177 *Also refer to Consumer and Provider Satisfaction results and Treatment Record Review section
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