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