Annual QM and UM Program Evaluation

Transcription

1 2016 Annual QM and UM Program Evaluation

2 This review of the findings of Annual QM & UM Program was conducted by Beacon Health Options under the auspices of the CT Behavioral Health Partnership. The opinions, conclusions, and recommendations contained herein are solely those of Beacon Health Options and may not represent those of DSS, DMHAS, and DCF. By Lynne Ringer with Ann Phelan and Robert W. Plant, Dr. Sherrie Sharp, Erika Sharillo, Heidi Pugliese, Jennifer Krom, Lindsay Betzendahl, Yvonne Jones, Jackie Stupakevich, Laurie Van der Heide, Jessica Dubey, Erica Clough as well as the entire Quality, Clinical and Reporting Departments. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 2

3 Table of Contents I. EXECUTIVE SUMMARY... 5 A. Overview of the Quality Management (QM) Program... 8 B. Key Accomplishments of the QM Program... 9 C. Overview of the Utilization Management (UM) Program...10 D. Key Accomplishments of the UM Program...11 II. EVALUATION OF THE OVERALL EFFECTIVENESS OF THE QM PROGRAM STRUCTURE...12 A. QM Committee Structure and Effectiveness of Structure...12 B. Adequacy of Resources...16 C. Practitioner Involvement...18 D. Leadership Involvement...19 E. Patient Safety...19 III. EVALUATION OF THE OVERALL EFFECTIVENESS OF THE UM PROGRAM STRUCTURE...19 A. UM Committee Structure and Effectiveness of Structure...19 B. Adequacy of Resources...20 C. Practitioner Involvement...20 D. Leadership Involvement...21 E. Patient Safety...21 IV. EVALUATION OF THE 2016 QM & UM PROJECT PLAN...22 Goal 1: Review and approve the 2015 Connecticut Engagement Center QM UM Program Evaluation, 2016 QM Program Description, 2016 UM Program Description and 2016 QM UM Project Plan Goal 2: Establish and maintain BEACON, CT-specific policies and procedures (P&Ps) in compliance with contractual obligations that govern all aspects of BEACON, CT operations Goal 3: Establish and Maintain a Training Program for Staff...23 Goal 4: Ensure Utilization/Care Management Department Compliance with Established UM Standards...27 Goal 5: Monitor consistency of application of UM Criteria (IRR) and adequacy of documentation Goal 6: Ensure Timely Telephone Access to Connecticut Engagement Center...31 Goal 7: Ensure Timely Response and Resolution of Complaints and Grievances...35 Goal 8: Monitor performance of Customer Service staff via audits of performance Goal 9: Assess Provider Network Adequacy...40 Goal 10: Health Literacy, Cultural and Linguistic Competency...44 B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 3

4 Goal 11: Reduce Emergency Department Discharge Delay...48 Goal 12: Maintain and Establish Additional Bypass/Outlier Management Programs..49 Goal 13: Monitor for Under- or Over-Utilization of Behavioral Health Services; Identify Barriers and Opportunities...60 Goal 14: Monitor Timeliness of UM Decisions...63 Goal 15: Monitor Medical Necessity and Administrative Denials; Identify Barriers and Opportunities...68 Goal 16: Monitor Timeliness of Appeal Decisions; Identify Barriers and Opportunities...69 Goal 17: Report and Monitor Medication Adherence for Antidepressant and Antipsychotic Medications Categories...69 Goal 18: Ensure Consistent Application of Activities to Maintain and/or Improve the Rate of Ambulatory Follow-Up Services after Inpatient Admissions...73 Goal 19: Promote Patient Safety and Minimize Patient and Organization Risk from Adverse Incidents and Quality of Care/Service Concerns...74 Goal 20: Monitor Integration of Coordination of Care with Medical, Dental and Transportation ASO as well as ABH and other Partners; identify barriers and opportunities...78 Goal 21: Maintain the Quality Improvement Activities: Provider Analysis and Reporting Programs...79 Goal 22: Monitor and Improve when Necessary the Quality of ASD Provider Charts 90 V. ONGOING QM & UM GOALS TO BE CARRIED FORWARD FROM THE EVALUATION YEAR VI. SUMMARY OF APPENDIX...95 B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 4

5 I. EXECUTIVE SUMMARY The Beacon Health Options (Beacon) Connecticut Engagement Center continues to serve as the behavioral health administrative service organization (ASO) for the Connecticut Behavioral Health Partnership (CT BHP) and manages the behavior health care for over 950,000 Medicaid members. The CT BHP is a partnership among the Department of Social Services (DSS), Department of Children and Families (DCF) and Department of Mental Health and Addiction Services (DMHAS). Beacon s expected role is to be the primary vehicle for organizing and integrating clinical management processes across the payer streams, supporting access to community-services, promoting practice improvement, assuring the delivery of quality services and preventing unnecessary institutional care. Additionally, Beacon is expected to enhance communication and collaboration within the behavioral health delivery system, assess network adequacy on an ongoing basis, improve the overall delivery system and provide integrated services supporting health and recovery by working with the Departments to recruit and retain both traditional and non-traditional providers. The Total Medicaid membership (with duals) for CY 2016 declined by 1.74%. This is the first annual decline in membership since Eligibility Category 2016 Total Membership Youth (0-17) Adults (18+) Family Single 578, , ,790 Family Dual 8, ,154 HUSKY B 27,817 26,459 2,269 DCF Limited Benefit (D05) Aged, Blind and Disabled (ABD) Single 31, ,409 ABD Dual 60,929-60,929 Long Term Care (LTC) Single 2,516-2,516 LTC Dual 21,201-21,201 Medicaid Low Income Adults (MLIA) 270, ,824 Total Membership 955, , ,454 Please Note: The membership numbers sited just above will not add to the total youth and adult numbers as members change both eligibility categories and age groups over the year. The counts for unique membership include all members that were eligible at any time during the reporting period. This method of counting members is quite distinct from the method used by DSS to report on membership. DSS reports the average daily membership across a reporting period to communicate the number of individuals that are typically eligible for Medicaid on any particular day. The Beacon method identifies how many members we had the potential to work with during a reporting period. In general, the DSS numbers will be lower than those reported by Beacon. The adult membership continues to be comprised largely by two benefit groups, HUSKY D (MLIA) and HUSKY A (Family Single). While these two groups had essentially the same number of members at the end of CY 2014, MLIA became the larger group during CY 2015 and B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 5

6 continued to have about 26,000 more members throughout CY After increasing each year since 2012 this was the first year that membership declined for both groups. Three of the HUSKY C benefit groups (ABD/Other Single, LTC Single, LTC Dual) have decreased in size each year since The Youth Members without Duals decreased in CY 2016; the first annual decrease in the last five years. Youth Members without Duals represents 36.6% of the total Medicaid membership for CY The Medicaid population analysis that was completed using CY 2015 Medicaid eligibility and claims data found the following demographic information for adult members: Gender. In CY 2015, fifty-six percent (56%) of the Total Adult Medicaid population were female, and forty-four percent (44%) were male. The gender composition was the same for members with BH Service Non-ED/Non-IP, possibly reflecting gender health equity for the lower levels of care. This finding is discrepant from earlier analyses of gender disparity and it will be important to tease out if this is due to differing methodologies or real changes in utilization. Among members with Serious Mental Illness (SMI), females were slightly overrepresented (62%) and males slightly underrepresented (38%). In contrast, for members with opioid-related disorders males (61%) were disproportionately over represented, and females (39%) were disproportionately underrepresented. Age. The Adult Medicaid population (average age = 38 years old) was similar to the BH Service Non ED/Non IP cohort (average age = 39 years old), as well as members with an SMI diagnosis (average age = 39 years old) and members with an opioid-related disorder (average age = 38). Race/Ethnicity. The proportions of White, Black, and Hispanic members that utilized BH Service Non-ED/Non-IP were similar to the Total Adult Medicaid Population (White, 52%; Hispanic, 26%; Black 17%), possibly reflecting fewer ethnicity disparities for lower levels of care overall. This finding is discrepant from earlier analyses of racial and ethnic disparity (Plant, 2016) and it will be important to tease out if this is due to differing methodologies or real changes in utilization. Among members with an SMI diagnosis, there were slightly disproportionately more White members (62%) and fewer Black members (13%). Hispanic members were slightly under represented (23%). The biggest differences were observed when comparing the total Medicaid population to members with an opioid-related disorder. White members accounted for 71% of this population, followed by Hispanic members (19%) and Black members (9%). Eligibility. There were more members in the Total Adult Medicaid Population with HUSKY A (44%), in comparison to the BH Service Non-ED/Non-IP (HUSKY A, 38%). Moreover, there were fewer members in the Total Adult Medicaid Population with HUSKY C (6%), in comparison to the BH Service Non-ED/Non-IP (HUSKY C, 10%), or for members with an SMI (HUSKY C, 15%; HUSKY A, 33%). Across these cohorts, approximately half of members had HUSKY D B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 6

7 MLIA in CY 2015 (Total Adult Medicaid members, 50%; BH Non-ED/Non-IP, 52%; SMI, 52%), but this rate was higher for members with an opioid-related disorder (Husky D MLIA 70% HUSKY A 21% HUSKY C 9%). Homelessness. Conservatively, 4% of the Total Adult Medicaid Population and 6% of members in the BH Service Non-ED/Non-IP cohort were homeless at some point during CY 2015, rising to 9% among members with an SMI diagnosis, and 16% among members with opioid use disorders. This represents a significant challenge to individuals, as well as communities and the system-of-care. And for youth members, the following demographic information was found: Gender. In CY 2015, approximately half of the Total Youth Medicaid population were female (49%) and approximately half were male (51%). Medicaid Youth ages 3-12 and ages mirrored the overall Total Youth Medicaid population, and youth with DCF involvement* in both age groups were also similar in gender composition. In contrast, females were slightly underrepresented among BH Service Utilizers Non-ED/Non-IP, with 44% female and 56% male. This underrepresentation was more pronounced among the Developmental Disability (DD) and Autism Spectrum Disorder (ASD) cohorts, and male youth comprised the majority of members in both the DD (69%) and ASD (80%) cohorts. Age. The Total Youth Medicaid Population and the Youth with DCF Involvement (average age = 10 years old) cohorts were slightly younger than the BH Service Non-ED/Non-IP cohort (average age = 11 years old). Race/Ethnicity. White youth comprised the majority of both the Total Youth Medicaid Population (43%) and BH Service Utilizers Non-ED/Non-IP (45%), while Hispanic youth made up the second highest membership group in both cohorts (Total Youth Medicaid Population, 35%; BH Service Utilizers Non-ED/Non-IP, 37%). Black youth were slightly underrepresented among the BH Service Utilizers Non-ED/Non-IP (14%) compared with the Total Youth Medicaid population (16%). White youth made up a higher proportion of members with Autism Spectrum Disorder (50%) when compared to Developmental Disability (45%) or the Total Youth Medicaid Population (43%). Hispanic Youth were slightly disproportionately overrepresented among members with DD (37%) and slightly underrepresented among members with ASD (32%) compared to the Total Youth Medicaid Population (35%). Black youth were somewhat underrepresented among those with DD (13%) or ASD (13%) compared to the Total Youth Medicaid Population (16%). Asian, Multiracial and Other make up the lowest membership across both cohorts. *Note: DCF-involvement includes any youth under eighteen who is involved with the Department of Children and Families through any of its mandates. This includes youth committed to DCF through child welfare or juvenile justice, and those dually committed. It also includes youth for whom the Department has no legal authority, but for whom DCF provides assistance through its Voluntary Services, Family with Service Needs and In-Home Child Welfare programs. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 7

8 Eligibility & Homelessness. Nearly all members in the Total Youth Medicaid population had HUSKY A Eligibility (94%). Unfortunately, obstacles in the Eligibility data continue to challenge the accurate reporting of homelessness. It would be important to consider possible solutions to this barrier, to be able to measure and track this key social determinant, and address the adverse impact of homelessness and housing instability on youth, and the impact on their health and well-being. DCF Involvement. DCF Involvement includes any youth under eighteen who are involved with the DCF through any of its mandates. This includes youth committed to DCF through child welfare or juvenile justice, and those dually committed. It also includes youth for whom the Department has no legal authority, but for whom DCF provides assistance through its Voluntary Services, Family with Service Needs and In-Home Child Welfare programs. DCF Involved youth represent 3% of the Total Youth Medicaid Population, and are disproportionately overrepresented among the BH Service Utilizer Non-ED/Non-IP cohort (9%), as well as the ASD (9%) and DD (8%) cohorts. Among youth with DCF Involvement, most were DCF Committed (94%), and the rate of Voluntary DCF Involvement was highest among the DD (12%) and ASD (21%) cohorts in comparison to the Total Youth Medicaid Population (5%). However, the majority of youth among the BH Service Utilizer Non-ED/Non-IP cohort are not DCF Involved (91%). A. Overview of the Quality Management (QM) Program The Beacon Quality Management Program focuses on improving the performance and quality of Beacon s internal operations (turn-around times, speed to answer, compliance, utilization management standards, etc.) and the external services and system of care (the full continuum of services as well as transitions between levels of care as indicated by rates of connect to care, follow-up, readmissions, etc.) that Beacon is charged with managing as the ASO for Behavioral Services under Medicaid. Internally we are focused on meeting or exceeding established benchmarks for performance and improving internal processes and procedures to meet both the letter and intent of the various standards. As the following narrative confirms, we have consistently met or exceeded nearly all contracted benchmarks and have instituted investigations and improvement plans in the small number of cases where our performance has fallen short. The consistently high level of performance demonstrated requires ongoing efforts as the systems, rules, and methods adapt to current circumstances. The consistently high level of performance in this area of practice underlies and supports our ability to effectively work with external partners including providers, members, advocates, funders and other stakeholders. As the organization has gotten larger and more complex, the challenges of continual monitoring, feedback, and collaboration across departments in order to meet standards have grown. Next year we will be working to streamline the aggregation, analysis, and reporting of results to sustain high performance, while paying extra attention to the small number of standards that we fail to meet for limited periods of time. It may also be useful to critically reevaluate the value proposition of B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 8

9 some of the processes and standards and consider shifting resources to other activities that promise a higher return on investment (outcome systems, outlier management, value based payments, etc.) In our quality oversight of the child and adult systems of care, the work has been growing in scope of practice and complexity/sophistication of approach. For example, the adult inpatient PAR programs have expanded to include medical and freestanding detox providers and we are utilizing advanced analytics to identify the population targeted under the NGA intervention and to evaluate outcomes. We have also begun to incorporate the principles of implementation science and performance management systems into programs being implemented across the engagement center. Our capacity to do this has been enhanced by the restructuring of staff resources to bring in the right expertise, and strategic affiliations with academic centers such as the Beacon-Yale Academic Partnership. We expect to continue to enhance and expand these efforts as we further the integration of the Tableau data visualization platform to enhance the accessibility of our data by funders, providers, and other stakeholder groups. A primary goal is to enhance the timeliness of data reporting to support improved intervention efforts. We also hope to use knowledge gained through financial mapping projects and PMPM calculations to enhance our capacity to conduct analyses to support value based payment projects. In the future, we hope to utilize our growing analytic capacity to incorporate risk adjustment and predictive models into the feedback provided to providers. Finally, we wish to continue and expand our focus on issues of equity and disparity in the BH service system by further analysis of all service and member data broken out by age, gender, and race/ethnicity. B. Key Accomplishments of the QM Program Reallocated resources and created two new positions - Senior Research Scientist and Director of Analytics & Innovation Established an academic partnership with Yale University, which included the addition of 0.5 FTE to support research and report writing Behavioral Health Homes (BHH) Director Hired a new BHH Director through a subcontract with ABH. Regional Network Managers (RNMs) began meeting with the freestanding detox providers and sharing data Collaborated with the Connecticut Hospital Association (CHA) and held a forum dedicated to raising awareness of ED utilization by youth Assisted hospitals across CT in expanding the number of Collaborative Care Teams Expanded the PRTF PAR program to include Solnit Center Assisted in the expansion of the Enhanced Care Clinics (ECCs) with the addition of four (4) new providers and seven (7) sites in the Regions 1 and 5 Started conducting Mystery Shopper calls to the ECCs in Spanish RNMs held Connect2Care regional meetings with various levels of care including the IICAPs providers Reintroduced spotlighting of provider best practices during provider workgroup meetings B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 9

10 In February, supported a state-wide Home Health meeting with all the stakeholders, which was followed up by smaller meetings with providers to share provider specific data Re-introduced HEDIS FUH measure to the providers, in particular to the IPF providers Working on additional HEDIS measures - APC and Opioid were new (SAA and IET delivered) Spectrum was rolled out for providers within the Behavioral Health Homes Claims based member level data Increased use of Tableau as a data visualization platform - Behavioral Health Home dashboards, and semi-annual utilization reports o Moved Denials and Appeals dashboards into Tableau o Underwent a rapid start of Tableau server Submission of Health Equity study February approved clinical study - health equity adopted by BHPOC and health equity lens adopted for all reports going forward including the semi-annual reports Developed expertise in financial mapping and financial claims added financial components to the dashboard Received a grant award from DCF to assist them in creating financial maps for both mental health and substance use services for children and adolescents (IMPACCT & CONNECT). Created the adult and youth inpatient story compiling all our knowledge to date about the membership that uses the emergency departments and inpatient hospitals. Presentations and posters at several national conferences including at the National Council for Behavioral Health and the 29 th Annual Research and Policy Conference on Child, Adolescent, and Young Adult Behavioral Health DCF Conference - We Help Kids Get Better Tableau presentation of Youth story Completed Behavioral Health Home Chart Reviews for each of the Local Mental Health Authorities (LMHAs) Completed Inpatient Detoxification-Medically Monitored retrospective chart reviews with seven (7) detox providers. Assisted in presenting results to detox providers and developed next steps around establishing collaborative meetings between the detox providers and lower levels of care providers (Methadone Maintenance) C. Overview of the Utilization Management (UM) Program Clinical excellence and the highest business ethics are at the forefront of Beacon' operations. Beacon recognizes a responsibility to demonstrate a solid commitment to superior clinical quality service that is member focused, clinically appropriate, cost effective, data-driven, and culturally competent. This is achieved through a companywide, systematic, and coordinated UM Program that involves input from and coordination with all stakeholders, including clients, members, providers, business units, departments, functional areas, and clinical staff. We work in a matrix environment. We share responsibility to achieve a common goal. Beacon, in concert with the Connecticut Behavioral Health Partnership, has established a Case Management (CM)/Intensive/Integrated Care Management (ICM) program designed to assist B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 10

11 children and adults who reside in the state of Connecticut and who have the most complex care needs. These members are typically assessed to be at the highest risk within the health population for negative clinical outcomes related to mental health/substance abuse issues and co-morbid medical issues. The primary goals of the CM/ICM programs are to help individuals maintain community tenure, regain optimal health, improve life functioning capability and promote recovery and resiliency. Beacon s CM/ICM Program works closely with the Medical ASO to create an integrated model meeting member s behavioral health and medical needs. Beacon remains devoted to ensuring that those entrusted to our care receive the best behavioral health services possible. D. Key Accomplishments of the UM Program The Clinical Department achieved a 91.29% passing score on the annual IRR The Adult Intensive Care Managers and Peer Specialists have successfully transitioned from the Frequent Visitor Initiative to working with the High need/high cost population Inpatient Hospital Bypass performance continues to be evaluated and updated on a quarterly basis while monthly data is provided to the hospitals Developed and implemented IICAPS PAR program with performance thresholds and benchmarks. Developed the PRTF data with focus on overstay cases, changes in overstay reasons, and changes in DCF status. Moved Child and Adolescent Inpatient and Adult Inpatient dashboards to a digital interactive format via Tableau Software. Continued to develop and implement the Home Health bypass program. Held provider and statewide Home Health meetings to discuss performance thresholds and benchmarks. Introduced the HHA Medication prompting code option into Home Health utilization management. Utilization of HHA Medication prompting increased during The state wide Home Health BID (twice a day) medication administration rate was reduced to 12.3% in The 2016 Discharge delay rate for youth was 8.98%. Continued support of Community Care Teams and CCT planning efforts at numerous hospitals across the state. Held meetings with inpatient detox providers across the state to continue to build relationships and share data. Improved the formatting and presentation of the semi-annual reports using the Tableau for more interactive data visualization. Clinical Liaisons continue to engage in connect to care activities and proactively outreach to members with a discharge form prior to and after the follow up appointment Continuation of Beacon health alert appointment reminders for those members with a completed discharge form from IP level of care B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 11

12 II. Continued participation in weekly co-management meetings with Community Health Network (CHN), the medical ASO, to effectively coordinate care for those HUSKY members who experience medical and behavioral health needs Hospital Bypass performance continues to be evaluated and updated on a quarterly basis EVALUATION OF THE OVERALL EFFECTIVENESS OF THE QM PROGRAM STRUCTURE A. QM Committee Structure and Effectiveness of Structure The following QM committee and sub-committee structure is in place at the time of this evaluation: Quality Management Committee (QMC) The QMC was established to provide oversight of the Connecticut Engagement Center QM program. The QMC is chaired by the Senior Vice President (VP) of Quality and Innovation. The QMC reports to the both the Latham Service Center and to the Beacon Health Options Corporate Quality Committee (CQC). Additionally, the committee is guided by the Senior Management Quality Management Steering Committee (also known as CORE) which is attended by representatives of the Departments as well as Beacon Health Options senior leadership. The membership of the QMC includes representatives from all departments within the engagement center including the leadership of the engagement center. Included are: Chief Executive Officer (CEO) Chief Medical Director or designee Senior VP of Quality & Innovation Chief of Research and Outcomes Assistant VP of Quality Management Assistant VP of Analytics and Innovation Assistant VP of Performance Improvement and Implementation Director of Provider Analysis and Reporting (PAR) Director of Data Management and Analysis Director of Project Management QM & Reporting Staff Senior VP of Clinical Operations and Recovery Assistant VP of Utilization Management Assistant VP of Clinical Services VP of Member and Provider Support Customer Service Director Director of Compliance B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 12

13 Human Resources Director Finance Director IT Director Provider Relations Director Director of Peer Services The QMC met quarterly during 2016 and reviewed the findings from the semi-annual reports and various performance targets that were being done related to the NGA project, adult and youth inpatient story and home health, prior to the findings being shared external to Beacon. In addition, the QMC reviewed performance on the performance standards. Quality of Care Sub-Committee The Quality of Care Sub-Committee reports to the QMC and is co-chaired by the Chief Medical Director and the Assistant VP of Quality Management. In addition to the co-chairs, the membership of the committee includes: Senior VP of Quality and Innovation (ad hoc) Quality Specialists II Clinical Supervisor Regional Network Manager Director of Peer Services Network Development Specialist The Quality of Care sub-committee began the year meeting weekly but by mid-year it was clear that based on the number of adverse incident and quality of care concerns that needed to be reviewed by the committee, it was no longer necessary to meet weekly and moved to meeting every other week. The committee continued to review all the concerns that were investigated by the QM Specialists and made a determination as to whether or not the concerns were founded, unable to determine or unfounded. For the founded concerns, next steps were identified which included informing the State and/or working with the provider directly to address the concern. Additionally, the committee reviewed the semi-annual trends of specific provider and practitioner concerns in order to elevate concerns to the State or modify how concerns are investigated if a specific trend was starting to develop. The membership of the sub-committee changed over the year with the Network Development Specialist discontinuing attendance as the Provider Relations (PR) department was impacted by the reduction in force due to the budget. The attendance of the Regional Network Manager was also impacted as the current person filling the role was elevated to a different position and the ability to backfill was limited due to the reduction in the number of RNMs. This position will be filled once the RNM team fills current vacancies in B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 13

14 Regional Network Management Sub-Committee and Provider Analysis and Reporting (PARs) Workgroup The Network Management Sub-Committee meets weekly and reports to the QMC. The subcommittee is chaired by the AVP of Performance Improvement and Implementation. Its members include: Director of Systems Improvement and Strategy Regional Network Managers AVP of Performance Improvement and Implementation Medical Directors Senior VP of Quality and Innovation (Ad Hoc) AVP of Utilization Management (Ad Hoc) AVP of Clinical Services (Ad Hoc) AVP of Quality Management (Ad Hoc) Chief of Research and Evaluation (Ad hoc) QM Analysts (Ad Hoc) The primary focus of this sub-committee continued to be reviewing PAR profiles to identify patterns and trends in the data, developing strategies for the PAR meetings and strategizing ways to improve systems of care, with particular focus on addressing issues generated in conversations with providers during PAR meetings. When new data measures were developed, this sub-committee reviewed the methodology so that the RNMs had a clear understanding of what the measure represented and could accurately explain it to the providers. During 2016, in addition to reviewing PAR profiles on a regular basis, this sub-committee reviewed enhancements to the PAR Profiles such as the IICAPS PAR and Inpatient PAR. This sub-committee continued to provide oversight of the Geo-Teams. The Geo-Teams include Beacon staff members from all key functional areas who are involved with facilities and programs in specific geographic regions. These teams reviewed PAR data, denial and appeals data and discussed strategies to address concerns specific to the geographic regions. The Geo- Teams members also provided their perspective on the findings, and developed strategies for improving the performance of the facilities and programs in the region. Regional issues were discussed at PAR meetings to share strategies and to identify issues that appear in multiple regions. In 2016, the sub-committee strategized around the ongoing development of the Community Care Teams (CCT) and developing plans for transition of the management of the CCTs to the hospitals or provider participants. We also strategized about the provider workgroup meetings and identifying subjects for discussions or presentations at those meetings. The level of care specific provider workgroups continued to identify best practices, work on developing new indicators, and the fine tuning of existing measures. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 14

15 Consumer and Family Advisory Sub-Committee The Consumer & Family Advisory Council (CFAC), formerly known as the Consumer & Family Advisory Sub-Committee meets monthly and is a Connecticut Medicaid consumer and family driven committee that is culturally competent and diverse. In 2016, the CFAC was co-chaired by the Director of Customer Service and two consumers/parents. The committee membership includes: Director of Clinical Services (Ad Hoc) Consumers Families Member advocates Behavioral health providers Peer Support staff Community Representatives CFAC acts as advisor to the Departments and Beacon Health Options (Beacon) to improve on best practices for behavioral health services (mental health and addiction services) for Connecticut Medicaid HUSKY Health members. The vision of CFAC is a true partnership between consumers, families, and service providers as it relates to the service delivery of mental health and addiction services that will result in a more positive and meaningful outcome for individuals and families living with behavioral health matters In January of 2016, the Consumer & Family Advisory Council received training, hosted by the CT Network of Care Transformation initiative. The training focused on parents and families understanding the power of their voice in helping to impact the system of behavioral health care in a positive direction. Skills that were focused on include system collaboration, community engagement, effective provider and family communication, and partnerships. In March, 2016 the Consumer & Family Advisory Council began the preparation and planning for the 2016 ican Conference. The second year of the ican Conference would expand to include breakout sessions. The presentation/agenda included the following topics: o Young Adults Making a Difference (Young adults in recovery) o Juvenile Justice (2 nd Chance Society) o Eliminating Racial Disparities (Culturally and Linguistically Appropriate Services standards) o Family Engagement Action Team (Family engagement) o Inpatient Detox to Medication Assisted Recovery (Adult recovery success stories) o Building Stronger Families (Workshop translated from Spanish to English language) B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 15

16 In October, 2016, the Consumer & Family Advisory Council hosted a joint meeting to include the Behavioral Health Partnership Oversight Council (BHPOC) and all subcommittees reporting to the BHPOC. The focus of the joint meeting was to inform all partners of the BHPOC structure and where we want to go in the future as a joint entity. In October, 2016, we formed the Joint Workgroup which includes representation from the DCF, DSS, DMHAS, CFAC consumers, BHPOC subcommittee, consumer/provider agencies, and Beacon. The workgroup was charged to focus on information sharing statewide addressing system of care related initiatives for behavioral health services. In November, 2016, Consumer & Family Advisory Council proposed adding two additional workgroups to the existing workgroup objectives to include: o Focus on transitioning youth and young adults o Council recruitment and orientation. In November and December 2016, Consumer & Family Advisory Council reviewed and revised the CFAC Brochure to aid in recruitment and By-Laws to outline the guidelines and commitment to the council. Assessment and Recommendations of QM Committee Structure and Effectiveness: The QM committee structure continued to be effective at ensuring that there was input into the ongoing development of the QM program from across the organization, key functional areas and from members and providers as well. The structure also increased efficiencies and eliminated duplicative efforts. B. Adequacy of Resources The following chart is a summary of the positions that support the Quality Management program with credentials and percentages of time devoted to the quality management activities: B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 16

17 Quality Management Staff by Percent of time per Credentials Title week devoted to QM SVP of Quality and Innovation Doctorate level 100% Chief of Research and Outcomes Doctorate level 100% Senior Research Scientist Doctorate level 100% Assistant VP of QM Master's level 100% Assistant VP of Analytics and Innovation Doctorate level 100% Director of Analytics & Innovation Master's level 100% Assistant VP of Performance Improvement and Implementation Master's level 100% Director of PAR JD 100% Regional Network Managers (8 FTEs) Master's level 100% Quality Analysts - Team Lead Master's level 100% Quality Analysts (8 FTEs) Master's level 100% Statistician Doctorate level 50% QM Coordinator - Complaints/Appeals (3 FTEs) High School diploma and experience & Master's level 100% Contract Monitor Associate level 100% QM Specialists I (1 FTEs) Bachelor level QM Specialists II - Auditor (2 FTEs) Master's level/licensed clinicians 100% Director of Data Management and Analysis Master's level 100% Reporting Manager Extensive experience 100% BI Developers Bachelor level 100% Program Analysts Bachelor and Master's level 100% Director of Project Management Master's level 100% Project Manager Master's level 100% In the spring of 2016, we were informed of by the State that our CT BHP base contract would be reduced, which lead to a reduction in staff and the QM department was heavily impacted. Several of the losses were absorbed by terminating positions that had not been filled but in a B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 17

18 couple of incidents staff positions were reduced. Two members of the quality analyst staff, one member of the denials and appeals team and the project manager positions were eliminated at the end of July. This had a large impact on the morale over the summer but all were able to remain focused, complete projects in a timely manner and maintain performance standards. The reduction in force impacted the Quality Specialist II staffing, where the FTEs associated with the CT BHP base contract went from 2 FTE to 1.5 FTE. Fortunately, we were able to retrain both of the existing staff by filling the.5 FTE on Behavioral Health Home contract. Additionally, these above noted changes gave the department the opportunity to reevaluate priorities and ensure that the staffing met the needs to address the priorities. Additionally, the QM program is supported by members on the staff that are not specifically in the QM department and they are as follows: Engagement Center Staff Outside of the QM Department by Title The process of training the entire organization to incorporate Quality tenets into all processes has been an important component of our success, which allows for process improvements to occur on an on-going basis with shared responsibility regarding ensuring that the member experience is the best that it can be. C. Practitioner Involvement Credentials Percent of time per week devoted to QM Director of Compliance Bachelor level 50% CEO/VP Service Center Master's level 20% Chief Medical Director/Medical Directors MD 40% SVP of Recovery & Clinical Operations Master's level 30% AVP Utilization Management Master's level 20% AVP of Clinical Services Master's level RN 20% VP of Consumer and Provider Support Master's level 20% Customer Service Director Extensive experience 20% Provider Relations Director Master's level 20% Dirctor of Peer Services Master's level 20% IT Director Bachelor level 20% Network providers remain actively involved in the QM program through both the Child and Adult Quality, Access and Policy subcommittee of the Oversight Council. Providers have given B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 18

19 feedback on clinical initiative, interventions as well as the clinical studies. In addition, the provider network continues to shape and develop the PARs programs and the data that is shared through the provider workgroups and the provider PARs meetings. Providers continue to be vital to the ongoing development of the QM program. D. Leadership Involvement The leadership within the CT engagement center remained committed to development of the QM program and ensuring that quality was maintained at the highest level as evidenced by the additional changes that were made in staffing within QM department in The Chief Medical Director continues to have involvement in the oversight of quality of the provider network and continues to work with the Departments to move that agenda forward. E. Patient Safety The engagement center remains committed to ensuring that patient safety is promoted throughout the organization. Efforts are made to minimize patient risk from adverse incidents, quality of care or service. Adult members continue to present with the highest risk and efforts are being made via clinical interventions with both Peers and ICMs to address some of the risk by assisting members in connecting to care post hospital stays. III. EVALUATION OF THE OVERALL EFFECTIVENESS OF THE UM PROGRAM STRUCTURE A. UM Committee Structure and Effectiveness of Structure Utilization Management Sub-Committee The Utilization Management Sub-Committee is charged with the general oversight of CT BHP engagement center UM activities. The Utilization Management Sub-Committee meets weekly and reports to the Quality Management Committee. The sub-committee is co-chaired by the SVP of and Clinical Operations and Recovery (or her/his designee) and the Chief Medical Director. In addition to the co-chairs, the membership of the committee included: AVP of Utilization Management AVP of Integration Services Clinical Supervisors Assistant VP of Quality Management QM Quality Analyst Staff Provider Relations staff The goal is to understand the clinical landscape and work as a group to find better ways to positively impact the system through data. Functions include reviewing and approving B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 19

20 Connecticut engagement center-specific policies and procedures pertaining to the UM process, oversight of the referral and triage function, developing and monitoring UM and Medical Management utilization data reports and indicators such as Hospital Census reports, days/1000, admits/1000, Discharge Delay data, as well as length of stay, turnaround time completion rates and monitoring of UM staff performance against contract indicators. Representatives from this committee attend the Senior Management Committee. The UM Committee reports to the Senior Management Quality Steering Committee. The committee develops new reports that support innovative UM strategies, as well as evaluates the utility of current reports including the Bypass Program reports. UM strategies and interventions are consistently being reviewed for effectiveness and reliability. Assessment and Recommendations of UM Committee Structure and Effectiveness: The UM Committee continues to meet weekly to review current reports and request additional reports to gain a better understanding of next steps in UM strategy. During 2016 some areas of focus for the UM Committee were Evaluation of IP Hospital Bypass targets (ALOS, Readmission rates, Discharge form completion), potential enhancements to the Bypass program, Adjusted length of stay report which captures members on overstay awaiting a state bed, assessment of Freestanding ALOS and frequency distribution to understand rates of AMA and new protocols, incorporating the DMHAS access line as a referral source, monitoring IP Psych Bypass registration reports to ensure compliance with TATs, and strategizing around sharing best practices statewide. The UM Committee will continue to meet weekly and monitor the impact of Bypass enhancements on clinical department resources and identify a new Bypass target, continue to monitor health alerts and connect to care activities impact on percentage of members successfully connected to aftercare as well as continuing to monitor ALOS, readmission rates and TAT compliance. Committee attendees will continue to invite additional department staff as needed. B. Adequacy of Resources During the course of the past year there was a reduction of two Clinical Supervisor Positions leaving a total of six (6) Clinical Supervisors. Additionally, there was a reduction in CCM staffing however with the Inpatient Hospital Bypass allowing for a registration process vs clinical review all TATs standards continue to be met and exceeded. The Clinical Care Managers continue to expand their role beyond standard UM practice and participate in case conferences, co-manage complex cases through ongoing collaboration with ABH/CHN/Logisticare, engage in Peer Advisor facilitated rounds and facilitate alternative discharge planning discussions when indicated. C. Practitioner Involvement There is active involvement by CT providers/practitioners in UM activities. Individual provider meetings occur frequently and include: onsite Provider meetings, clinical documentation B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 20

21 trainings, Medication Assisted treatment initiative discussions, member specific care planning meetings and semiannual Inpatient Hospital provider meetings. The UM program team partners with members of the Quality team to engage providers in PAR discussions and Inpatient provider meetings to discuss different UM initiatives and to gather feedback on what data or information would be of value to the providers. Providers are also involved in multiple UM/QM Committees and Sub-Committees, including those that provide oversight of the Partnership at the highest level. D. Leadership Involvement The CEO and members of the Senior Management team are all active participants in the operations of the UM Program. The active involvement of Senior Leaders provides a clear message to all Beacon staff regarding the importance of their daily activities while also providing sound clinical and professional leadership. The SVP of Clinical Operations and Recovery attends each Clinical staff meeting and provides ongoing updates on initiatives and performance targets. Clinical managers also take time to explain how each clinician s individual contributions influence and change the behavioral health delivery system in CT. E. Patient Safety During utilization review activities the clinician assesses any potential risk or safety concern and collaborates with the treating provider on planned treatment interventions and measures for progress to reduce risk to self or others. Internally, staff notify Clinical and Quality Leadership when any concerns are identified regarding a member s safety to self or others and these concerns are reviewed weekly by the Quality of Care subcommittee to ensure discharges plans are adequate and specific to each member s needs. This committee is comprised of staff from Medical Affairs, QM and the UM departments, upon case review it may be determined that additional outreach is required from a Clinician, Peer Specialist, Clinical Liaison or AVP to either the provider, member or both. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 21

22 IV. EVALUATION OF THE 2016 QM & UM PROJECT PLAN Goal 1: Review and approve the 2015 Connecticut Engagement Center QM UM Program Evaluation, 2016 QM Program Description, 2016 UM Program Description and 2016 QM UM Project Plan. Description of activities and findings that include trending and analysis of the measures to assess performance over time: A. QM UM Program Evaluation The 2015 QM UM Program Evaluation was submitted to the Departments on April 1, 2016 and approved on May 12, B. QM Program Description The 2016 QM Program Description was submitted to the Departments on April 1, 2016 and approved on May 12, C. UM Program Description The 2016 UM Program Description was submitted to the Departments on April 1, 2016 and resubmitted on May 27, 2016 and then again on June 22, 2016 following feedback from the Departments. Final approval was obtained on July 7, D. QM UM Project Plan The 2016 QM UM Project Plan was submitted on April 1, 2016 and approved on May 12, Recommendations for continuing goal in 2017: This goal continues to be applicable for 2017 and should be included in the 2017 Project Plan. Goal 2: Establish and maintain BEACON, CT-specific policies and procedures (P&Ps) in compliance with contractual obligations that govern all aspects of BEACON, CT operations. Description of activities and findings that include trending and analysis of the measures to assess performance over time: A. All CT-BHP-specific Clinical, Quality, Customer Service and Provider Relations P&Ps are reviewed and revised as necessary but no less than annually. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 22

23 Beacon Health Options CT utilizes National Beacon Health Options Policy and Procedures except in cases where exceptions are needed to meet local contractual requirements. At least annually, all policies and procedures (including attachments) will be reviewed, revised or retired. Recommendations for continuing goal in 2017: This goal continues to be applicable for 2017 and should be included in the 2017 Project Plan. Goal 3: Establish and Maintain a Training Program for Staff Description of activities and findings that include trending and analysis of the measures to assess performance over time: A. Staff training on state regulatory requirements Staff training on federal and state regulatory requirements was conducted with our new employees during new hire orientation and periodically throughout the year in departmental staff and ad-hoc meetings. The Compliance Department completed 43 face to face training sessions and sent 12 electronic training alerts to staff. In May, all employees completed the required annual compliance training and attestations. Employee s demonstrated comprehensive understanding of the material by obtaining 100% passage rate on the post tests for all of the following: CMS Compliance Training: Part 1: Medicare Parts C & D Fraud, Waste and Abuse (FWA) Training CMS Compliance Training: Part 2: Medicare Parts C & D Compliance Training Code of Conduct General Privacy Training During the month of November, the engagement center participated in Corporate Compliance and Ethics Week. Daily activities were designed to highlight the importance of compliance and ethics in the workplace. B. Staff training on HIPAA/HITECH/42 CFR Privacy regulations The CT Engagement Center staff completed the annual companywide 2016 HIPAA training. National Compliance monitored the process to ensure full compliance with this requirement. Refresher trainings on basic information about PHI, what constitutes a HIPAA violation and how to report a HIPAA violation were conducted over the course of the year. Compliance completes audits of the engagement center staff to ensure compliance with the rules around protecting PHI. Additionally, all documents containing PHI were reviewed by a member of Senior Management prior to mailing to verify that the member information in the letter matches the address on the envelope. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 23

24 The local and national compliance staff continued to monitor all violations closely. Each violation reported during 2016 was thoroughly investigated and placed into one of the categories listed below. There were no privacy breaches during There were 67 policy and regulatory (privacy) violations which equate to.090% of the 73,648 authorizations issued during Fifty-One (51) Policy Violations: Thirty-Six (36) Instances of incorrect information being entered into a member s record set; there was no disclosure of PHI. Four (4) Authorizations were created for the wrong provider; an authorization letter was not generated. Four (4) s sent unencrypted to the intended party (Low risk as went to intended party). Four (4) s sent encrypted to an unintended party (Low risk as was sent to a covered entity). One (1) No Release of Information on file (Low risk as member s name was released to a covered entity) One (1) Letter mailed to wrong member address. Letter was returned unopened to Beacon Health Options One (1) Authorization completed in the live environment instead of testing. No authorization letter was generated. Sixteen (16) Privacy (Regulatory) Violations: Five (5) Encrypted sent to unintended party (recipient was a covered entity) containing member PHI Four (4) Authorizations were created for the wrong provider and an authorization letter was generated. Four (4) No Release of Information on file. (no risk to member; staff did not confirm provider had ROI on file for member when discussing member s history with provider). One (1) Authorization created for wrong member. An authorization letter was generated. One (1) Authorization created in the live environment instead of testing. An authorization letter was generated. One (1) Unencrypted sent to intended party C. Staff training on Denials and Appeals Denials and Appeals 5/24 & 5/26/2016 Jen Day & Quality Denials and Appeals 12/13 & 12/15/2016 Jen Day & Quality B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 24

25 Denials and Appeals trainings were provided on the above noted dates for all CT Engagement Center staff who are involved in the process including Clinical Care Managers, Intensive Case Managers and Medical Directors. Clinical Liaisons and Customer Service Representatives attended for a refresher on understanding the appeals process. Staff from the Clinical Department and the Quality Department were involved in planning and presenting to the CT Engagement Center. The Clinical portion of the training focused largely on the language used with providers during the assessment of Level of Care through the peer to peer process, and ultimately, the determination. Contractual turnaround times were covered as well as documentation of the second level review. The need to assist the provider and member in identifying referrals for the level of care recommended was stressed. Lastly, the clinician s requirement to inform the provider of the medical denial and appeal rights was covered. The Quality portion of the training focused primarily on describing and educating the teams on appeal rights and responsibilities when a denial or Notice of Action (NOA) is issued to a provider or member. The instruction was guided via a PowerPoint presentation created by the Quality Department. Descriptions of the differences between administrative denials versus denials due to a lack of medical necessity were explained to the attendees. Turnaround times for both types of appeals were discussed with the group and it was heavily stressed that these rights and responsibilities apply to every denial that is issued in the Engagement Center. An overview of applicable forms necessary for the processing of medical necessity/noa appeals was shown to the group and the sessions concluded with an opportunity for the associates to ask questions. It is recommended that the Clinical and Quality teams work towards separating out the administrative and medical necessity denial & appeals trainings to better focus on the unique differences between both types and to help facilitate more focused questions and understanding. D. Staff training on Complaints, Quality of care and Adverse Incidents The combined training of complaint, quality of care and adverse incidents continued to be effective and allowed for good discussion about the differences and how to categorize the concerns as they are identified or made by members. The training was held on March 1 st and 3 rd and was open to the entire engagement center. Additional training was provided in September 1, 2016 to the Customer Service staff, when the Beacon P&Ps were updated and the informal complaint (complaints were the member wished to remain anonymous) as a separate process was sunset. Now all complaints are managed via one process. An additional training was scheduled for the end of the year but postponed when updates were made to the Beacon Adverse Incident and Quality of Care policy & procedure that first needed to be fully reviewed by the Quality of Care Subcommittee before being presented to the staff. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 25

26 Trainings for the new staff continued to be held monthly on the second Wednesday of the month. Seasoned staff continued to be encouraged to attend if a refresher was needed over the course of the year. Trainings focused on identification of concerns and also the operational piece of how to submit the concerns to Quality for review and processing. E. Staff training regarding State Partners' Departments and specific populations and programs The Clinical and Provider Relations department worked with the Departments to provide several trainings over the course of Additionally, trainings were identified that addressed specific populations and programs. See Appendix A: Clinical Trainings 2016 for a complete list of the trainings that were provided. F. Staff enrichment trainings through the Beacon CT Academy The Beacon CT Academy subcommittee is made up of various individuals across the engagement center who are invested in work force development. The committee meets twice a month to discuss training needs of the engagement center and works to identify trainings that can meet the needs. In 2016, trainings covered six (6) primary domains: CEU, Clinical, Clinical Webinar, Professional Development, Software Training, Wellness Committee. Twenty-seven (27) different trainings were provided. Several of the trainings were repeated so that staff could attend and the day to day work not be disrupted. See Appendix A: Beacon CT Academy Trainings 2016 for a complete list of the trainings that were provided. G. Peer staff annual trainings The trainings below have been identified for all peer staff and will continue for the next year Name of Training Occurrence Length Presenters/Trainers Focus CCAR Recovery Coach Ongoing 5 days CCAR Substance abuse/recovery principles Compassion Fatigue June hours Beacon Staff Overview of impact that trauma can have on well being Connect Training Every Tuesday/Thursday 1 hour Beacon Staff System training Cultural Competency September hour VO Academy Overview of culturally competent practices and policies Motivational Interviewing Peer Specialist Certification December days J. Fader, PhD Bukky Kolawole, PhD MI techniques and practical applications Ongoing 80 hours Advocacy Unlimited Recovery Support Specialist Certification Universal Precautions Ongoing 1 hour/video Beacon RN Staff Hand washing/infectious disease overview Working in the Community Feb hour Beacon Staff Safety in the community B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 26

27 Trainings for peer staff are evaluated on an ongoing basis each year. All trainings continue to align with Beacon National s overall mission and vision, as well as local performance targets and program needs. Working in the Community was developed by peer and clinical staff and added to the above schedule to address training needs related to safety/taking precautions while working in the community. This need was identified by front line staff, and was well received based upon training evaluations. Additionally, there are other trainings that are being considered at the National level for peers, including Mental Health First Aide (MHFA). This and other trainings may be added during the course of the coming year as appropriate. Additional trainings that were provided: Starting in March of 2016, Tableau Desktop users participated in a biweekly Tableau User Group lead by the Director of Analytics and Innovation. The focus of the group was to teach users new Tableau skills, problem solve as a group around data visualization best practices and data manipulation or calculations, share successes and new discoveries, and promote available training resources. In December of 2016, the Tableau Desktop users all received formal training from an outside vendor either attending a beginner level or intermediate/advanced level training. Throughout the year, various trainings were held with other Tableau Reader users to ensure people were adequately educated to maneuver and explore data visualizations and dashboards produced in Tableau. We have included SAS EG online training through sas.com as part of our on-boarding training process for new Quality Data Analysts and key staff, including the new Senior Research Scientist and staff associated with the Beacon-Yale Academic Partnership, and Kate Powers participated in a SAS EG Administration course as well. At this point, all Analysts use SAS EG on a daily basis, and have increasingly moved away from Excel as their default tool. This shift has likely contributed to increased accuracy, efficiency, and accountability due to the datasecurity and programming features in SAS EG. Tableau training was extended to the RNM Team, as the Director of Analytics and Innovation has provided extensive training in the use of dashboards created in Tableau, that RNMs use frequently in their work with providers, as well as extensive collaborations to continuously improve and refine the dashboards in response to RNM and provider feedback. Recommendations for continuing goal in 2017: This goal continues to be applicable for 2017 and should be included in the 2017 Project Plan. Goal 4: Ensure Utilization/Care Management Department Compliance with Established UM Standards B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 27

28 Description of activities and findings that include trending and analysis of the measures to assess performance over time: All new Beacon staff participate in general new hire orientation. The clinical department maintains a new hire checklist approved by the State to monitor trainings and training needs of staff. Continuing education for clinical staff is provided by the clinical department on a weekly basis, in addition to the CT Academy trainings provided to the engagement center. Documentation of training is retained and provided to Clinical Leadership for monitoring of attendance. Beacon maintains a training site within a shared documents site which all employees utilize to register for trainings and view upcoming trainings. Beacon will continue to offer weekly training opportunities for the clinical department staff. Clinicians participate in the identification of topics for training/refreshers relating to internal workflows and enhancements to all roles within the clinical department. For CT Academy trainings formal surveys are completed to assess the overall effectiveness of the training and trainer. Feedback is shared with the facilitator and appropriate adjustments made. Many trainings are offered twice a week to allow for phone coverage and flexibility. Overall, trainings were well attended and something new is learned in each training even by our most seasoned staff. Recommendations for continuing goal in 2017: This goal continues to be applicable for 2017 and should be included in the 2017 Project Plan. Goal 5: Monitor consistency of application of UM Criteria (IRR) and adequacy of documentation. Description of activities and findings that include trending and analysis of the measures to assess performance over time: A. Percent compliance rate with clinical Inter-Rater Reliability audit Annually, CT Engagement Center participates in the company wide IRR audit. This IRR audit consisted of 20 clinical vignettes, each of which the clinicians must determine the appropriate level of care. For the past year, 92.31% of our clinical staff passed the IRR examination, with an average score of 91.29%. The four Clinicians who did not pass have been placed on corrective action plans with the expectation that level of care guidelines were carefully reviewed. hey would retake and pass the IRR. Three of the four Clinicians function as Intensive Care Managers and do not routinely review or determine level of care as their efforts are spent managing complex cases and collaborating with providers on accessing services to support discharge plans back to communities. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 28

29 In order to continue to ensure consistency with clinical decisions, clinicians meet weekly for clinical rounds and clinical training. Supervisors provided both weekly individual supervision as well as group supervision. B. Assess adequacy and accuracy of clinical documentation. Clinical documentation audits continued in 2016 on a quarterly basis to assess the adequacy and accuracy of documentation. Inpatient detox Percent with Percent with Percent with Percent with Quarterly Data 90% or better Average Score 90% or better Average Score 90% or better Average Score 90% or better Average Score Q1 97.1% 96.3% 97.0% 98.2% 95.0% 95.8% 100.0% 99.0% Q % 97.3% 100.0% 97.1% 94.0% 96.9% 100.0% 100.0% Q % 96.7% 97.0% 98.3% 100.0% 97.9% 100.0% 99.0% Q % 97.5% 93.0% 96.2% 100.0% 98.0% For Q1 of 2016, the inpatient detox level of care was audited. The average scores for this level of care for clinical case managers were 99% with all staff scoring above 90% for this quarter. There was additional improvement to a perfect average of 100% (Q2) and then to 99% (Q3) in these quarters. In Q1 the areas of focus were the following: substance use symptom complex, detoxification medication documentation, discharge plan being reviewed, and internal referrals to ABH or other being made. Supervisors were able to review the areas of focus to improve the measures. By Q2 all areas had improved and were 95% and above, except for detoxification medications being documented which was at 70%. However, by Q3, this area had improved as well to 88%. In Q3 the internal referral portion dropped to 60%. This was quickly addressed by supervisors with their staff to improve the measure. It should be noted, however, that the overall average score still remained high with a score of 99%. As a result of the high levels of performance in this level of care, a new level of care was selected for auditing in Q4, which was inpatient psychiatric admissions. Upon completion of this level of care audits, a perfect score of 100% was seen. This included both child and adult admissions. Compared to last year s evaluation, Q4 2015, the scores have remained consistent. Moving forward, in the upcoming year, we will continue to audit the inpatient psychiatric level of care to be sure this remains consistent with staffing changes. (See Appendix C: IPD Web-pended Precertification Audit Scoring Sheet) B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 29

30 ICM child 2016 Percent with Quarterly Data 90% or better Average Score Q1 86.0% 96.0% Q % 99.0% Q3 86.0% 97.0% Q4 **100% **100% **includes adult and child psych admissions Although included in the above audit for Q4, child ICMs were also audited for the first three quarters. In Q1, the average score was at 96% with 86% of staff scoring at 90% or better. The areas of focus in this quarter were the treatment plan being reviewed, clinical criteria and medical necessity being met, as well as mandatory supervisor or doctor consult. During Q1, these areas ranged from 71-75%. Supervisors, therefore, addressed with their staff and this improved by Q2 with all scores exceeding 86%, except for the supervisor or doctor consult area. Supervisors therefore continued to address this with staff in group supervision and a marked improvement was seen. The score for this measure increased to 100% in Q3. In Q2, 100% of staff scored above 90% on their audits. In Q3 this scored dropped a bit to 86% of staff scoring above 90% which may have been related to staffing issues at that time. By Q4, 100% of staff were again scoring above 90%. (See Appendix D: IPF Web-pended Concurrent Audit Scoring Sheet) Home health Quarterly Data Percent with 90% or better Average Score Percent with 90% or better Average Score Q % 96.3% 100.0% 98.0% Q % 100.0% Q3 83.0% 94.7% 100.0% 100.0% % 100.0% Q % % The home health team reviews were also audited in This has proven to be a strong team with all staff scoring above 90% consistently throughout the year. The average score in Q1 was 98% which was the lowest for the entire year. Beyond this, the score was a perfect 100% across the board. This was also consistent with the score for Q4 of 2016 which was an average of 100%. In looking deeper into the data, an area of focus was ensuring that the medications were being consistently listed on the 485 as well as medical necessity being met for the service being authorized. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 30

31 In Q2 of 2016, we began to audit the ICM/Peer Intervention teams for the first time. The purpose of this was to first identify a baseline of how staff were performing and whether or not the tool was appropriate to measure the intervention and the associated documentation. (See Appendix E: Home Health Audit Scoring Sheet) Data ICM/Peer 2016 Percent Quarterly with 90% or better Score Q1 n/a n/a Average Q2 50.0% 89.0% Q3 n/a n/a Q4 n/a n/a Fifty percent of the staff scored over 90% on their audits. The overall average was a total of 89%. For the three teams who did not meet expectations, additional audits were conducted. The first team passed with over 90%, but the two remaining did not and therefore 5 additional audits were completed. The average continued to average at below the standard of 90% for each. Therefore, the team of supervisors and quality came together to discuss and support what was provided to the teams to increase the adequacy of their documentation. When the intervention changed in the Fall, a new tool was created to reflect the changes in workflow within the ICM and Peer teams and to be more conducive to measuring the work being completed. Moving forward, this tool will be used for this team, which is expected to improve documentation of the outcomes. Supervisors within the department have been working with their staff to improve in the areas of completing SF-12 assessments on an initial and monthly basis as well as closing out cases appropriately. (See Appendix F & G: Adult ICM Peer Intervention Audit Tool) Recommendations for continuing goal in 2017: This goal continues to be applicable for 2017 and should be included in the 2017 Project Plan. Goal 6: Ensure Timely Telephone Access to Connecticut Engagement Center Description of activities and findings that include trending and analysis of the measures to assess performance over time: B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 31

32 Total number of Calls: In CY 2016, the total number of calls continued to decrease and following the trend that has been seen for the last three years. All call types decreased between CY 2015 and 2016 with the provider calls decreasing the most significantly at 28.7% and the non-crisis member calls experiencing the smallest decrease of 6.5%. Provider calls continue to decrease as more and more requests for authorization can be made on ProviderConnect, the web-based interface. Autism Spectrum Disorder Treatment Services Annual Call Volume CY 2015 CY 2016 Member* 2,063 2,033 Provider TotalCalls 2,210 2,434 The number of calls related to Autism Services increased between CY 2015 and The increase was in the number of provider calls, which increased substantially. *Incl. calls from both English and non-english speakers. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 32

33 A. Average Speed to answer: Average number of seconds until call is answered by a live person. The average speed of answer increased by a second in CY 16 for member calls both crisis and non-crisis calls. On the other hand, for provider calls the average speed of answer decreased by two seconds. B. Percent of Calls Answered with Service Level (15 & 30 seconds) B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 33

34 The percent of calls answered with the service level increased slightly in 2016 due to the greater stability in the staffing within Customer Service and the overall call volume decreasing. C. Abandonment Rate: % of calls NOT answered before caller hangs up The call abandonment rate remains within the expected performance standard and decreased to rates seen in the past when there was more stability in the staffing. D. Average length of time on hold for Clinical, Customer Service and Member Crisis calls The average hold time continues to increase but remains within the expected performance standards of 1 minute for crisis calls, 3 minutes for member, and 5 minutes for provider. Recommendation for continuing goal in 2017: This goal continues to be applicable for 2017 and should be included in the 2017 Project Plan. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 34

35 Goal 7: Ensure Timely Response and Resolution of Complaints and Grievances Description of activities and findings that include trending and analysis of the measures to assess performance over time: A - D. Total Number of Complaints and Grievances The total number of complaints received by the QM department in 2016 (173) was consistent with last year (177). Additionally, the number received by complainant type remained consistent with previous years. Adult members accounted for the majority of total complaints received at 69% (120 of 173). Youth members, 16% (28 of 173), and providers, 14% (25 of 173), made up the remainder of complaints received. Our highest influx of complaints was seen during the second and third quarters in Of the 173 complaints received in 2016, 20 complaints were escalated to grievances by the complainants who were not satisfied with the initial outcomes of the complaints. This is an increase from the two (2) that were elevated to grievances last year. In half of the grievances, members were disputing the provider s response to the complaint and wanted further follow up. In the remaining grievances, the complainant just wanted further follow up on their complaint. With improved tracking and trending procedures implemented and bi-annual (Q2 & Q4) complaint & grievance trainings for staff occurring within the Engagement Center, it is expected that this volume will be relatively consistent over the coming year. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 35

36 Total Number of Complaints and Grievances, specific to ASD Autism Spectrum Services Complaints & Grievances CY2015 CY2016 Provider - - Adult Member - - Youth Member 4 7 While there were no complaints specific to Autism Spectrum Disorder treatment services during the first quarter of There were seven (7) complaints received in the Q2 and Q4 of There were four (4) complaints specific to Autism Spectrum Disorder (ASD) services received during the 2 nd quarter of 2016 and three (3) complaints received in Q4 of E. Average Number of Days to Resolution The average handle time to resolve a complaint/grievance increased slightly in 2016 to 28.8 days versus the 23.1 days in The increase to 28.8 days in the average handle time began within the third quarter of 2016 and remained consistent throughout the remainder of the year. Resolution time continues to remain within the expected performance standard of less than or equal to 30 days. Of note, in Q4 six (6) complaints were resolved in greater than 45 days. The complaints were related to discrimination concerns by multiple providers submitted by 2 members with five (5) being submitted by one member and one complaint being submitted by her partner. Unfortunately, there was a delay in determining who would be handling and investigating these type of concerns. Once it was identified that the complainant needed to file their concerns with a different State agency and/or Federal agency, they were informed immediately. To ensure that complaints were resolved quickly and effectively, all complaints were reviewed weekly by the Assistant VP of QM and efforts to resolve the issues were acted upon B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 36

37 immediately. Beacon Health Options staff continue to work collaboratively with DSS around specific concerns as they are identified. F. Percent of Complaints Resolved within Expected Timeframes In 2016, 174 complaints were resolved with 129 resolved within 30 days of receipt 74% and 39 complaints were resolved within days with the appropriate permission granted by the complainant 22%. 96.5% of the complaints were resolved within the expected timeframes. G. Most Frequent Complaint Reasons B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 37

38 In 2016, the number of complaints received from members regarding access issues decreased slightly which included, but was not limited to, making provider appointments, accessing medical records, refilling prescriptions, being discharged from care due to missed appointments and receiving callbacks from providers. For issues regarding access to records, provider callbacks and prescription refills, the QM department worked with the individual providers to determine the validity of the inquiry and best possible resolution for the members. The number of complaints received from members related to clinical issues remained high in Many of the complaints (19) were related to concerns about medication - under, over medicated, type of meds, not getting medication they wanted. Several (5) were related to treatment issues and the type of treatment they received. An additional four (4) were concerns related to diagnoses that were given. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 38

39 Complaints regarding Beacon s performance in 2016 were largely received from providers. The majority of the concerns were related to a perceived lack of courtesy and requests for authorizations that were delayed, misplaced, or partially approved. Issues related to staff performance were addressed immediately by supervisors/managers and Beacon continues to track system issues and aims to proactively address service needs based on provider demand. Most Frequent Complaints Reasons specific to ASD The nature of the ASD complaints were related to lack of follow up by the Peer staff (1) and the remainder were related to provider and the qualifications or nature of the service being provided. One complaint was received from a provider related to concern with a parent. Recommendations for continuing goal in 2017: This goal continues to be applicable for 2017 and should be included in the 2017 Project Plan. Goal 8: Monitor performance of Customer Service staff via audits of performance. Description of activities and findings that include trending and analysis of the measures to assess performance over time: A. Assess individual Customer Service staff (at least 5 cases per month) on performance in five areas (Call Opening, HIPAA Requirements, Issue Definition, Problem Solving/Utilizing Tools/Decision Making and Hold/Transfer Techniques) During 2016, the Beacon s NICE recording system was utilized to conduct call auditing of the Customer Service Staff. The designated Customer Service auditor lead conducted audits for the first half of 2016, and the national Beacon auditing team conducted audits for the second half of The audit average for the department for call audits conducted in 2016 was 99.26%. Customer service staff received feedback, routinely, regarding their individual performance as call audits were conducted; and overall department performance during staff meetings. Additional resources included live call observation by supervisor, continued review of call center/customer service job aids/workflows, and interdepartmental interface meetings to keep the call center Triage team up to date with most current information and operations. Connecticut Customer Service staff also received additional training from the National Beacon call auditing team to support further efficiencies and optimal service. B. Assess adequacy and accuracy of documentation of content of call. The Customer Service Department conducts audits of the accuracy of the documentation that results from calls into the Customer Service department. Audit results indicate that with the exception of misdirected calls (medical, dental or vision) Customer Service staff routinely B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 39

40 document every call received. Actual results for calls that were audited in 2016 were 99.89%. Call documentation audits provide opportunities for improvement in the quality of the documentation in member records regarding the content of the call. Call documentation audit feedback is discussed with Customer Service Staff in coordination with routine call audit findings and shared individually; and overall department performance is reviewed during staff meetings. Recommendations for continuing goal in 2017: This goal continues to be applicable for 2017 and should be included in the 2017 Project Plan. Goal 9: Assess Provider Network Adequacy Description of activities and findings that include trending and analysis of the measures to assess performance over time: A. Identify providers who are not accepting new Medicaid referrals and place them in No Referral status In order to assess the accuracy of the data elements processed from the provider add/change reports a quarterly audit was conducted again in The results of the quarterly audit for 2016 continues to be well above the 98% threshold, which was the goal established when the Provider File Audit was part of Performance Target 1. Quarter Results (%) # of records # correct records # of errors Q % Q % Q % Q % B. Assessment of network adequacy In 2016, in preparation for a presentation to the Medicaid Assistance Program Oversight Committee (MAPOC) that was subsequently cancelled, a series of reports on Geo-Access and BH Provider Density Ratios were developed. The following is a summary of the findings. Geo-Access Geo-Access Standards: Urban: 46.8% of Medicaid population One provider within 15 miles Suburban: 39.7% of Medicaid population One provider within 25 miles Rural: 13.5% of Medicaid population One provider within 45 miles B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 40

41 Methodology: 1. Measure geo-access for adults and youth separately 2. Included members from all eligibility categories for intermediate level of care services 3. Excluded members with dual eligibility for outpatient services 4. Included providers who were accepting referrals and those who had been authorized to treat at least two members in the previous year. Findings: Adults: Met 100% geo-access standards for access to the following types of treatment for MH o IOP, o Outpatient treatment in ECCs and facilities, o Outpatient treatment with Masters and Doctoral level individual practitioners and group practices, and Prescribers Met 100% geo-access standards for access to the following types of treatment for SUD o IOP o Methadone o Outpatient SUD services in ECCs and Facilities Failed to meet 100% Urban (91%) and Suburban (98%) access standards in Fairfield County for ECCs Youth: Met 100% geo-access standards for access to the following types of treatment for MH o IOP, o Outpatient treatment in ECCs and facilities, o Outpatient treatment with Masters and Doctoral level individual practitioners and group practices, and Prescribers Met 100% geo-access standards for access to the following types of treatment for SUD o Outpatient SUD services in ECCs and Facilities Failed to meet 100% Urban (76%) access standards in Fairfield County and New Haven counties for IOP SUD Urban ECC with SUD services was below standard in New London county but had more than adequate services through local SUD facilities Density Ratios B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 41

42 Up until recently, the measurement of network adequacy has focused on geo-access. While geo-access measures whether there is a network provider within pre-determined distances from the members, it does not take into account whether there are enough providers to serve the needs of the population in the area. While work in the area of establishing density ratio methodology has focused on primary care providers, there are currently no accepted industry-wide provider density ratios for Medicaid Behavioral Health. Furthermore, there are challenges associated with determining how to count the providers in an area. Individual BH practitioners often have multiple offices and/or work in multiple agencies. There is no detailed information available about the percentage of their time spent in each site. CMS has established methodology for assessing provider to beneficiary ratios based on a minimum provider to beneficiary ratio and market share in the county. Those ratios are only available for Psychiatry. However, we can assume that the Medicare population utilizers fewer Psychiatric services than the Medicaid population, so that the minimum number of providers required is probably an underestimate of actual need for the CT Medicaid population. Beacon Health Options has set national standards for number of providers per 1000 members that are primarily used for Commercial business. BH Prescriber (Psychiatrist or APRN): 0.3/1000 members BH Psychotherapists: 1.0/1000 When these standards were applied to the CT Medicaid population, all standards were met for every CT county. In order to adjust the commercial standards to meet the needs of the Medicaid population and to attempt to correct for the duplication in counts of therapists and prescribers when multiple sites of practice are considered, the following standards were applied to the membership of each CT county: BH Prescriber (Psychiatrist or APRN): 1.2/1000 members BH Psychotherapists: 3.0/1000 B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 42

43 Adult Findings: Youth Findings: CT County Member Count Prescriber Count Prescriber: 1.2/1000 CT County Member Count Prescriber Count Prescriber: 1.2/1000 Psychotherapist Count Psychotherapists: 3.0/1000 FAIRFIELD 85, HARTFORD 110, LITCHFIELD 17, MIDDLESEX 13, NEW HAVEN 110, NEW LONDON 29, TOLLAND 9, WINDHAM 14, Psycho- Therapist Count When the revised density standards are applied to the CT adult and youth populations, the ratio of psychotherapists to both adults and youth are met. The density standards for prescribers are met in 2 of the 8 counties for adults and in 4 of the 8 counties for youth. The methodology and the results of the application of this methodology to the CT Medicaid population should be reviewed by the MAPOC committee in order to determine next steps. C. Development of the network based on results of analysis results Psychotherapists: 3.0/1000 FAIRFIELD 69, HARTFORD 76, LITCHFIELD 11, MIDDLESEX 8, NEW HAVEN 77, NEW LONDON 20, TOLLAND 6, WINDHAM 10, See deliverable submitted on January 31, 2017 for Performance Target #3: Medication Assisted Treatment for the efforts that were made in 2016 to increase the provider network to include those who are able to provide medication assisted treatment to members with substance use disorders. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 43

44 D. Network adequacy reports specific to ASD services Provider Relations/Network Operations and Quality Management provide a monthly update report for the ASD Director which includes information on authorization volume by service class, demographics of members admitted into services, peer and care coordination activities, expenditures, number of currently enrolled practices and providers, enrollment status of ASD providers and providers that are in the process of CMAP enrollment as well as a current map showing the location of ASD network providers and members currently waiting for a provider to begin services. The network of ASD providers has grown considerably in CY As of January 1, 2016, there were 62 individual providers across 36 unique practices providing ASD services. By January 1, 2017, the network increased to 86 individual providers across 56 unique practices. The individual provider network increased by 39% and the practices increased by 56%. In July 2016, Beacon took over the responsibility of qualifying Medicaid providers to provide ASD services. This process includes collecting documentation that supports the individual s credentials, education, and experience in working with individuals on the autism spectrum, reviewing sample work and the resume of potential providers who hold a Board Certification in Behavior Analysis or who are Licensed Clinicians, as well as reviewing general liability insurance and completing a State Police background check. Once providers receive confirmation that Beacon has qualified them as an ASD provider, they then submit information to CMAP for processing. Recommendations for continuing goal in 2017: This goal continues to be applicable for 2017 and should be included in the 2017 Project Plan. Goal 10: Health Literacy, Cultural and Linguistic Competency Description of activities and findings that include trending and analysis of the measures to assess performance over time: A. Assess organizational health literacy, cultural and linguistic competency As a part of the CONNECT grant and the Care Management Entity contract, the Connecticut Engagement Center has been invited by the Department of Children and Families to participate in the implementation of the enhanced National Culturally and Linguistically Appropriate Services (CLAS) standards. These standards were designed to make services more responsive to the individual needs of members, specifically members of racial, ethnic and linguistic minority population groups. We felt this was an important initiative to embark on in order to ensure that the engagement center was engaging individuals from racially, ethnically and linguistically diverse backgrounds. It was also expected that by doing so it would improve the health and satisfaction levels of the entire organization. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 44

45 There was a comprehensive cultural and linguistic survey distributed to all service center staff. The survey results informed steps related to identifying goals for improvement, ongoing assessment and implementation of a work plan. The work plan serves as a tool to improve responsive governance, culturally competent practice, flexible communication, community engagement and accountability. The work plan identified three of the CLAS standards goal to begin work immediately. CLAS standard 2: Advance and sustain governance and leadership that Promotes CLAS and Health Equity; Measurable indicators include adding policies to new hire orientation packets and bi-annual cultural trainings available to all staff within the next four to twelve months. CLAS Standard 3 Recruit, Promote, and Support a Diverse Governance, Leadership, and Workforce; Measurable indicators included increasing diverse staff recruitment by reviewing current hiring practices and tools, and to utilize multi-lingual staff more appropriately within the next six to eight months. CLAS Standard 4: Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis; Measurable indicators included offering bi-annual cultural competency/humility trainings for all staff and encourage participation, 50% of all staff participation is year one goal and will increase each year. Continue to promote and educate all staff about cultural and linguistic workgroup and practices. On July 18, 2016, Section 1557 Nondiscrimination in Health Program and Activities went into effect and was rolled out in stages. This rule prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs or activities. The regulation is enforced by the Office for Civil Rights (OCR). Section 1557 went into effect for Beacon Health Options (Beacon) and our federally funded clients. Beacon was compliant with accommodations for members with disabilities online, in person and over the phone offering; qualified sign language, interpreters, captioning, large print materials, screen reader software, text telephones (TTY), video remote interpreting services. During Q4 16 Beacon developed and implemented the Notice Against Discrimination (Notice) for member facing materials. The staff in the Connecticut Service Center were trained Section 1557 and the requirement of the Notice being included in significant member communications. The Notice includes the process for member grievance process if they feel discriminated against. All written materials for members from Beacon are accompanied by a notice in all threshold languages (babel card) notifying members of the availability of interpreting, translating services and is available on the Beacon website. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 45

46 B. Assessing and enhancing the means of identification of disparities in treatment of the Medicaid population After the submission of the Health Equity Clinical Study in early 2016, CT BHP continued to enhance the methods by which we identified and reviewed health disparities through the Medicaid population in Connecticut. In an effort to deliver the results of the Clinical Study, tables were generated in Tableau and presented at various forums to show the impact of health equity. These tables showed (see below) the impact of the disproportionality rates for each demographic group across various measures. The table summarized much of the Clinical Study in such a way that the impact of rate variances was extremely visible. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 46

47 In April 2016, a 1-pager on the Health Equity Clinical Study was also completed to further summarize the findings and recommendations. One of the major deliverables that reviews both membership and utilization has been the Semiannual reports. It was here that we worked to add in a health equity lens to the overall analysis within the youth and adult utilization reports. In September 2016, CT BHP delivered the first semiannual report with a health equity lens. The following categories were added: age groups, gender, and racial/ethnic groups. This broadened the ability to analyze the membership growth or decline of certain subpopulations, to further learn about what demographic groups make up the various benefit groups and DCF groups for youth, and to understand utilization patterns of demographic groups across all levels of care. Resulting from the success of the insights gained from the demographics with the Semiannual Utilization reports, demographic information was also added into the Inpatient PAR Dashboards. Many requested data reports now include demographic information, such as the quarterly S-FIT and the quarterly inpatient reports given to DCF, and the practice has become more common as CT BHP works to meet the continued requests of stakeholders to understand the impact of health equity on the Medicaid population. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 47

48 C. Assess Provider Network Adequacy to meet needs of cultural diverse population Assessing the provider network for adequacy of whether or not it meets the needs of the cultural diverse Medicaid population continues to be challenging based on the data that Beacon receives on the eligibility file from DSS. Beacon receives primary language on the file so is able to address linguistic needs but cultural is not identified. Typically, assessment of the provider network adequacy is determined via the annual member survey, but this was sunset in 2012 due to other priorities. Engaging the Consumer and Family Advisory Council in the conversation about how to assess will be done in 2017, particularly as this Council integrates into the sub-committees of the BHP OC, which is prioritizing health disparities. The CT Engagement Center will continue to evaluate how to assess in Recommendations for continuing goal in 2017: This goal continues to be applicable for 2017 and should be included in the 2017 Project Plan. Goal 11: Reduce Emergency Department Discharge Delay Description of activities and findings that include trending and analysis of the measures to assess performance over time: A - B. Number and average length of time of youth are delayed in the ED Description of activities and findings that include trending and analysis of the measures to assess performance over time: A - B. Number and average length of time of youth are delayed in the ED Youth Delayed in the Emergency Department CY CY 2016 Youth ( 0-17) ED overstay ALOS ED Overstay ALOS ED Overstay ALOS ED Overstay ALOS ED Overstay ALOS ED Overstay ALOS Q Q Q Q Year , , The total yearly number of youth in overstay Emergency Departments has decreased from 2013 to 2016 by 26.03% (1,164 to 861). The average time youth were delayed in the Emergency Department has slightly increased from 2013 to 2016 (1.5 days to 1.96 days). B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 48

49 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 January February March April May June July August September October November December CY Number of Youth ED Stuck Non DCF DCF Grand Total The Non-DCF volume of youth in ED overstay has been consistently higher than the DCF volume of youth in overstay. In 2016, there were a total of 861 youth who were in overstay status in the emergency department. Of those 861 youth, 259 were DCF involved and 602 were Non-DCF involved. This indicates the Non-DCF youth were the primary driver of the increased ALOS. There continues to be seasonal variation as the highest overall volumes for the past three years are recorded in the months of March, April and May. Recommendations for continuing goal in 2017: This goal continues to be applicable for 2017 and should be included in the 2017 Project Plan. Goal 12: Maintain and Establish Additional Bypass/Outlier Management Programs Description of activities and findings that include trending and analysis of the measures to assess performance over time: A. Evaluate on-going effectiveness of the Bypass/Outlier management programs Inpatient Bypass Program Criteria The inpatient bypass program continued in The three measures used to evaluate a hospital s participation in the bypass program remained consistent with the previous year: average length of stay (ALOS), 7-day readmission rate, and 2-day discharge form completion rate. The targets identified for each of these measures also remained consistent with Being in the bypass program grants the provider access to submit reviews and obtain a 7-day authorization. Additionally, in Quarter 2, inpatient providers in the bypass program were given B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 49

50 the ability to obtain an automatic registration for the requested services similar to some other levels of care. The ALOS measure includes all discharges during the evaluation period, excluding dual eligible, LTC Single, and TEMP members, as well as discharges with an ALOS of 0 days or greater than 100 days. The ALOS target for adults ages 18+ remained unchanged throughout all of 2016 at 8.2 days or less. The ALOS target for youth ages 17 and younger was 12.0 days or less. The 7-day readmission rate measure includes all readmissions to an inpatient psychiatric or inpatient detoxification facility that occur two or more days after the member discharges from the hospital. Discharges with a follow-up to a state facility and members with LTC Single and Dual were also excluded. The 7-day readmission target for adults remained unchanged throughout all of 2016 at 6% or less, and the youth target was 5% or less. The 2-day discharge form completion rate measure includes all discharges from the inpatient unit excluding members who are dually eligible. The discharge form completion target remained unchanged throughout all of 2016 at 90% or greater for both adults and youth. As noted in the 2015 QM/UM Evaluation, CT BHP recommended that providers be evaluated on the bypass measures every three months based on the last full quarter s worth of data. As mentioned in the prior QM/UM Evaluation, hospitals who do not meet the target, but were previously on the bypass, are identified as not meeting targets. Since data is available closer to real-time, providers can actively make changes to address any issues contributing to not meeting the measures. Hence, providers have two additional quarters to make adjustments as necessary and hopefully meet the targets. Adult Inpatient Hospital Bypass In March 2016, providers were evaluated based on Q4 15 data. At that point there were 14 providers on the bypass and seven were off the bypass program. During the March evaluation, eight of the providers previously meeting all three measures, did not meet one or more targets and fell into the not meeting targets category, leaving six providers that met all three measures (28.6%). All seven of the providers previously not on the bypass, continued to remain off the bypass. No providers came off the bypass program given the new criteria to come out of the program. Two providers did not meet the ALOS target, five did not meet the readmission target, and five did not meet the discharge form completion target (some providers did not meet two measures). The Statewide ALOS for Q4 15 was 7.71, the 7-day readmission rate was 6.53%, and the discharge form completion rate was 90.43%. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 50

51 After this initial quarterly evaluation, it was clear that information related to a provider s data was required as soon as it was available to allow providers to adjust practices when needed and develop strategies in real-time, rather than being informed about their progress well past the end of the measurement period. This led to the development of a timeline by which to communicate data updates to the providers. It was determined that within approximately three weeks of the data running, providers would be informed of their bypass status at the end of the quarter, or of an update mid-measurement quarter of their current status. As a result of this timeline adjustment, the next bypass evaluation was completed in April and providers were evaluated on Q1 16 data (graph below). The Statewide ALOS was 8.37 days, 7- day readmission rate was 4.41%, and the discharge form completion rate was 95.39%. Compared to the previously evaluated quarter, ALOS increased by 0.66 days, 7-day readmissions decreased by 2.21 percentage points, and the discharge form completion rate increased by almost 5 percentage points. Overall, providers improved from the previous evaluation. Of the six providers previously meeting the bypass measures, four continued to meet all measures and two fell into the not meeting targets category. Of the previous eight providers not meeting targets, six were able B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 51

52 to meet all targets and continue in bypass status. There were two, Danbury Hospital and Harford Hospital, that fell into the not meeting targets (2) status due to a high ALOS, and they were given notice they had one remaining quarter to meet all measures or they would no longer be able to participate in the bypass program. Of the remaining seven providers who were not on the bypass, one provider (Manchester Memorial Hospital) met the targets and became on the bypass as of May 2, In summary, there was a net gain of one provider coming into the bypass increasing the total who met all three measures to 11 (52%), though 15 remained in the program and six remained off the bypass. CT BHP monitored both Danbury and Hartford Hospital closely over the next quarter, providing them with monthly updates to their data. Providers were evaluated again in August 2016 on Q2 16 data (graph below). The Statewide ALOS was 8.11 days, 7-day readmission rate was 6.40%, and the discharge form completion rate was 98.94%. Compared to the previously evaluated quarter, ALOS increased by 0.66 days, 7-day readmissions increased by almost 2 percentage points, and the discharge form completion rate increased by 3.55 percentage point, a significant improvement. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 52

53 At this evaluation, one hospital (Hartford Hospital) was taken out of the bypass program due to failing to meet the measures for three consecutive quarters. Hartford Hospital missed both the ALOS and readmission measure for this quarter. This was the first hospital to lose their bypass status. Two other hospitals that were at risk (St. Francis and Danbury) both met all three measures and remained in the program. Norwalk Hospital was the only hospital that was not meeting targets (2) due to readmission rates and was closely monitored during the following quarter. Five hospitals who were in the bypass did not meet the targets and also were monitored in the following quarter. In total, 8 out of 21 hospitals (38%) met all three bypass measures. Hospitals were reviewed one final time in November 2016 based on the Q3 16 data. The Statewide ALOS was 8.48 days, 7-day readmission rate was 5.33%, and the discharge form completion rate was 99.5%. Compared to the previously evaluated quarter, ALOS increased by 0.37 days, 7-day readmissions decreased by approximately one percentage point, and the discharge form completion rate increased by 0.56 percentage points to the highest rate ever for the adult inpatient hospitals. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 53

54 At this time there was great variability in the adult hospital providers for the ALOS and 7-day readmission measure. All hospitals met the discharge form completion target. Out of the 21 adult hospitals, only eight met all three measures (38%). Of the eight providers who had met all the targets last quarter, five met the targets again and three went into not meeting targets status. Of those hospitals that were recently not meeting the targets, two met all the targets and three did not, thus resulting in not meeting targets (2) status. These three facilities, Griffin, State of CT-John Dempsey, and Bridgeport Hospital, were all monitored closely with RNM and Clinical support. All three did not meet the readmission target and Griffin Hospital also did not meet the ALOS target. Lastly, Norwalk Hospital did not meet the targets for the third consecutive quarter and was informed that they no longer would be offered bypass status, while Bristol Hospital was able to join the bypass program by meeting all measures. In summary, over the course of the year with the new bypass program, two hospitals (Hartford Hospital and Norwalk Hospital) came off the bypass program and two hospitals that started the year not on the bypass (Bristol Hospital and Manchester Memorial Hospital) came into the program due to meeting all of the measures. Of the initial seven hospitals that were not on the bypass at the beginning of the year, five continued to not meet the targets throughout the B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 54

55 course of the year (Hospital of Central CT, Stamford Hospital, St. Vincent s Hospital, Waterbury Hospital, and Yale New Haven Hospital). The end of the year resulted in the same overall count as the beginning of the year with 14 hospitals on the bypass (66.7%) and seven hospitals off the bypass (33.3%). Six of the 14 on the bypass had not met the measures for one or two quarters and active efforts to support improving their measures have been taking place. Pediatric Inpatient Hospital Bypass In March 2016, providers were evaluated based on Q4 15 data. At that point all seven (100%) pediatric hospitals were in bypass program. During the March evaluation, three of the providers previously meeting all three measures, did not meet one or more targets and fell into the not meeting targets category, leaving four providers that met all three measures (57%). No providers came off the bypass program given the new criteria to come out of the program. All three providers that did not meet all three targets, Manchester Memorial, Natchaug, and Yale New Haven Hospital did not meet the 7-day readmission rate. Natchaug also closely exceeded the ALOS target. All seven providers met the discharge form completion target. The Statewide ALOS for Q4 15 was 10.19, the 7-day readmission rate was 4.35%, and the discharge form completion rate was 95.50%; all measures Statewide met the targets. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 55

56 As with the adult program, after this initial quarterly evaluation, it was clear that information related to a provider s data was required as soon as it was available to allow providers to adjust practices when needed and develop strategies in real-time, rather than being informed about their progress well past the end of the measurement period. This led to the development of a timeline by which to communicate data updates to the providers. It was determined that within approximately three weeks of the data running, providers would be informed of their bypass status at the end of the quarter, or of an update mid-measurement quarter of their current status. As a result of this timeline adjustment, the next bypass evaluation was completed in April and providers were evaluated on Q1 16 data (graph below). The Statewide pediatric ALOS was days, 7-day readmission rate was 5.63%, and the discharge form completion rate was 97.28%. Compared to the previously evaluated quarter, ALOS increased by 0.79 days, 7-day readmissions increased by 1.28 percentage points, and the discharge form completion rate increased by 1.79 percentage points. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 56

57 Overall, providers fared worse than the previous evaluation. Six of the seven hospitals did not meet all three measures. Of the four providers previously meeting the bypass measures, only St. Vincent s Hospital continued to meet the targets out of the seven hospitals (14%). Three hospitals fell into the not meeting targets category (Hartford, St. Francis, and Waterbury) all due to exceeding the ALOS target. The three hospitals that had not met the targets the previous quarter, continued to not meet the targets and fell into not meeting targets (2) status (Manchester, Yale, and Natchaug) all due to exceeding the 7-day readmission target. These three providers were alerted that they had one additional quarter to meet the targets or they would not be offered participation in the bypass program. In summary, six providers did not meet the targets three due to a high ALOS and three due to high readmission rates. Providers were evaluated again in August 2016 on Q2 16 data (graph below). The Statewide ALOS was days, 7-day readmission rate was 4.25%, and the discharge form completion rate was 98.50%. Compared to the previously evaluated quarter, ALOS increased by 0.70 days, 7-day readmissions decreased by 1.38 percentage points, and the discharge form completion rate increased by 1.21 percentage points. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 57

58 At this evaluation, of the three hospitals at risk to lose their bypass status, two hospitals continued to not meet the measures (Natchaug Hospital and Yale New Haven Hospital) and were taken out of the bypass program due to failing to meet the measures for three consecutive quarters. The remaining hospital, Manchester, met all three measures and was not longer at risk. Natchaug and Yale were the first hospitals to lose their bypass status. Natchaug Hospital missed both the ALOS and readmission measure for this quarter. Yale New Haven Hospital did not meet the readmission target by only 0.03%. It should be noted that due to a refresh in the data, Yale later did meet the readmission target and was brought back into the bypass program. A decision was later made that if a provider misses a rate by less than a tenth of a point, the Quality and Clinical teams would review the data and the subsequent decision. Of the three hospitals that previously were not meeting the targets, all three continued to not meet the targets. St. Vincent s continued to meet all three targets. In summary, two hospitals met the targets (Manchester and St. Vincent s), three were in not meeting targets (2) status, and two came out of the bypass program due to not meeting the targets for three consecutive quarters. The end result was 28.6% (2 of 7) of the hospitals met all targets, but 71% (5 of 7) remained in the bypass program. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 58

59 Hospitals were reviewed one final time in November 2016 based on the Q3 16 data (graph below). The Statewide ALOS was days, 7-day readmission rate was 3.39%, and the discharge form completion rate was 99.05%. Compared to the previously evaluated quarter, ALOS was stable (only decreasing by 0.07 days), 7-day readmissions decreased by 0.86 of a percentage point, and the discharge form completion rate increased by 0.55 percentage points to the highest rate ever for the youth inpatient hospitals. For the evaluation of Q3 16 data, the pediatric hospitals showed improvements as a whole. Five of the seven hospitals (71%) met all three measures and remained in the bypass. Yale New Haven Hospital and Hartford Hospital, both remained off the bypass due to continuing to not meet the measures. Both providers did not meet the ALOS target, but met the other two targets. In summary, over the course of the year with the new bypass program there was a net loss of two providers from the pediatric bypass program since all providers started the year in the program. However, as mentioned earlier, Yale New Haven Hospital was given back bypass status in late November 2016 as a result of an adjustment made to their Q2 16 data. At the end B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 59

60 of the year, therefore, only Natchaug Hospital was not in the program. The next review was then completed in January of 2017 based on Q4 16 data. Bypass Program 2016 Recommendations As anticipated, the shift to Tableau and a timelier analysis of the bypass measures has allowed CT BHP to be informed of the hospitals progress on the bypass measures monthly. This allows both the Quality and Clinical Departments to discuss these results with the hospitals during the quarter they will be evaluated on. Further data exploration has been able to take place to identify possible causes and interventions to improve rates. For the next year, CT BHP has recommended that providers continue to be evaluated quarterly with as needed monthly updates. The access to real-time data and more frequent evaluations has improved hospitals awareness of these metrics and many hospitals are closely monitoring the numbers to ensure they continue to remain in the bypass program. As per discussions with providers, CT BHP recommends continued analysis of the methodology by which the ALOS bypass measure is evaluated. Currently only lengths of stay of 100 or more days are removed from the measure and identified as outliers. Many providers have expressed concern that, especially for adult members, an outlier length of stay is much lower than 100 days. Identifying a more statistical calculation of an outlier by which to identify the cut off for the ALOS measure is recommended. Recommendations for continuing goal in 2017: This goal continues to be applicable for 2017 and should be included in the 2017 Project Plan. Goal 13: Monitor for Under- or Over-Utilization of Behavioral Health Services; Identify Barriers and Opportunities Description of activities and findings that include trending and analysis of the measures to assess performance over time: A-L. See Exhibit E deliverable on March 1, 2017 for Adult and Youth Semi-Annual Utilization CY 2016 Report via Tableau Server M. Develop claims-based metrics for 13 F-G if claims extract is available thru DSS The DSS claims extract is consistently made available to Beacon Health Options. As a result, the following claims and DMHAS-based utilization metrics are currently under development and will be finalized by the end of CY 2017 as part of the CT Behavioral Health Dashboard project. The claims-based reporting of these measures will allow Beacon to report Admits and Days/1000 as well as Average Length of Stay (ALOS), when applicable and Per Member/Per Month expenditures. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 60

61 1. Free-Standing Detox 2. State Detox Utilization (CMHC, Greater Bridgeport and Capitol Region) 3. CVH Detox 4. Inpatient Medical Detox 5. State Inpatient Psych (CVH) 6. DMHAS Residential Rehabilitation 7. Adult MH Group Homes 8. SUD Residential Rehab for Youth 9. Behavioral Health Emergency Department 10. Community-based Psychiatric Residential Treatment 11. Intensive Outpatient (IOP) 12. Partial Hospitalization (PHP) 13. IICAPS 14. All Other In-Home services 15. Home Health 16. Outpatient Services 17. ASD Services N. Ongoing evaluation of use of Data Warehouse Meeting to provide oversight of claims-based reporting, the integration of DMHAS data and to identify changes in DSS claims data The Data Warehouse Meeting has continued to convene weekly when there are agenda items that need to be addressed. During 2016, the group expanded to include additional DMHAS, DSS and DCF staff as well as the Beacon Medical Director and Senior Vice President of Clinical Operations on an ad hoc basis. The new ad hoc members brought additional expertise to the group and allowed improvements to be made regarding the timing and workflow for the DMHAS data exchange, the development of the CMS High Dose Opioid measure, the CT BH Dashboard contents and display in Tableau, and the methodology of the National Governors Association High Need/High Cost initiative. During 2016, in order to focus on the performance target entitled Emerging Adults, one meeting per month was devoted to the development of the methodology for that initiative and then review of the findings of the initiative. DCF staff who have worked for many years with the DMHAS Young Adult Services staff participated monthly and shared their knowledge, recommendations and data to enhance the initiative. The project concerns the enhancement of the identification of high need youth who are transitioning to adult services as they age out of DCF services or of the youth BH service system. O. Develop a system dashboard that will monitor key indicators of the quality, efficiency, and effectiveness of the CT Medicaid Behavioral Health Service System B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 61

62 Over the past five years, multiple utilization, quality and outcome measures have been developed, programmed, reported and analyzed by the CT Behavioral Health Partnership (CT BHP). Many of those measures were associated with complex performance targets. As challenging as those initiatives were however, an even bigger challenge has been how to communicate the information contained in them more succinctly to the State Partners, the Behavioral Health Oversight Committee and the broader CT stakeholder community. Those audiences each require the delivery of the findings in different levels of detail that allows them to answer questions they have about the quality, efficiency and effectiveness of BH services in CT as well as of the performance of the CT BHP. As a result, one of the most significant undertakings of 2016 that will continue into 2017, was the development of the CT Medicaid BH Dashboard. The dashboard development project is in lieu of the contractually required clinical quality improvement initiatives during 2016 and The acquisition of Tableau software was key to the progress made over the past year in the ability of Beacon Health Options to display complex data in a way that is accessible to a variety of audiences. Tableau dashboards are interactive and allow the user to begin with the most aggregated display of the data and then, if desired, use filters to drill down to answer increasingly detailed questions about the findings. All of the measures included in the BH Dashboard are, after being programmed and quality checked, being constructed in Tableau. The first iteration of the BH Dashboard will include sections that display Quality, Utilization and Expenditure measures. Quality Measures: This section of the dashboard includes a display of: 1. Medicaid Membership 2. HEDIS measures including a. Follow-Up after Hospitalization for Mental Illness b. Initiation and Engagement of Alcohol and Other Drug Dependence Treatment c. Antidepressant Medication Management d. Adherence to Antipsychotic Medications for Individuals with Schizophrenia e. Use of Multiple Concurrent Antipsychotics in Children and Adolescents 3. CMS measure on Use of Opioids at High Dosage in Persons without Cancer 4. CMS measure on Use of Opioids from Multiple Providers in Persons without Cancer 5. Non-HEDIS Measures: a. Connect to Care within 7 and 30 Days following BH ED, IP Psych, IP Hospital Detox, Free-Standing Detox, State Hospital Detox, and State Hospital Psychiatric Stays b. Readmission within 7 and 30 Days following BH ED, IP Psych, IP Hospital Detox, Free-Standing Detox, State Hospital Detox, and State Hospital Psychiatric Stays c. Percent of BH ED Visits Accounted for by Frequent Visitors to the BH ED B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 62

63 Utilization Measures This section includes ALOS (when applicable), Admits/1000 and Days (Visits)/1000 Utilization Measures of: 1. Inpatient Psychiatric Stays 2. State Hospital Psychiatric Stays 3. Inpatient SUD Stays (Free-Standing Detox, Inpatient Medical Detox and State Hospital Detox) 4. Residential and Group Home Stays 5. BH ED Visits 6. Community-Based PRTF 7. Intermediate Levels of Care (IOP, PHP) 8. In-Home Services (IICAPS, All Ohers) 9. Home Health 10. Community-Based BH Services 11. ASD Services Expenditures by Level of Care (Per Member/Per Month) This section includes PMPM for the following Levels of Care 1. Acute Inpatient Psychiatric services 2. Youth State Hospital 3. Free-Standing Detox 4. Inpatient Medical Detox 5. IOP 6. PHP 7. IICAPS 8. Home Health 9. Community-Based BH Services As dashboards for the measures are completed, they are reviewed in the Data Warehouse Committee. The recommendations of that group are then incorporated into the dashboard. Finally, the dashboard is reviewed in CORE and then submitted to the State Partners. Recommendations for continuing goal in 2017: Activity item N can be sunset in 2017 as there is no longer a need to evaluate the need of Data Warehouse but the remainder of the activities continue to be applicable for 2017 and should be included in the 2017 Project Plan. Goal 14: Monitor Timeliness of UM Decisions Description of activities and findings that include trending and analysis of the measures to assess performance over time: B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 63

64 In 2016 the turnaround time reports were edited to reflect changes in the underlying time frames for completion of initial and concurrent reviews. There were two changes: 1) for web pended reviews, removal of the one-hour standard after all information is received; 2) extending the Home Health Agency Services standard to 7 days from 4 days The overall turnaround time for both initial and concurrent reviews, for both higher and lower levels of care, were well within the 95% standard. Initial Reviews: 99.29% (40,937 out of ) Concurrent Reviews: 99.12% (77,721 out of 78,414) A. Initial Decisions re: authorizations for acute levels of care (LOC) (Psych/Gen Hosp IP, IP Detox, Intermediate duration acute psychiatric care, PHP, Psych Res and crisis stabilization) Communication within 60 minutes % of initial decisions for acute level of care authorizations were communicated within the target timeframe (27,875 of 27,963). B. Initial decision for Psych/Gen Hosp IP, offer an appointment for peer to peer review within 60 min of completion of CM review 90.91% of initial decisions for general hospital and inpatient psych authorizations that required a peer to peer review were completed within the target time frame (20 of 22). There were eight telephonic reviews that were denied in CY2016; two of them did not meet the turnaround time standard. Please note that, given the small number of cases for the year, 21 of 22 would need to meet the standard to achieve 95%; 20 met the standard. C. Initial Decision for IP Detox, offer appointment for peer to peer review within 120 min of completion of CM review % of initial decisions for inpatient detox authorizations that required a peer to peer review were completed within the target timeframe (41 of 41). D. Initial Decision for other HLOC, offer appointment for peer to peer review within 1 business day of completion of CM review. 100% of initial decisions for other higher level of care authorizations that required a peer to peer review were completed within the target timeframe (22 of 22). E. Initial decisions re authorizations for non-acute LOC (LLOC) within 2 & 4/7 business days of request. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 64

65 2 business days: 98.76% of initial decisions for non-acute lower level of care authorizations were communicated within the target timeframe (6,762 of 6,847). 4/7 business days: 98.31% of initial decisions for non-acute lower level of care authorizations were communicated within the target timeframe (5,995 of 6,098). F. Initial Decision for non-acute (LLOC), offer appointment for peer to peer review within 2 & 4/7 business days of completion of CM review. 2 business days: 93.68% of initial decisions for lower level of care authorizations that required a peer to peer review were completed within the target timeframe (163 of 174). The reason for not meeting the 95% performance standard was because the months of March, June, July, and December were all below 95% for web-pended requests, which resulted in an overall web-pend compliance rate of 93.64%. Telephonic requests achieved an overall 100% for the year, but comprised less than 1% of the total number of requests (1 of 174). 4/7 business days: 91.94% of initial decisions for lower level of care authorizations that required a peer to peer review were completed within the target timeframe (57 of 62). The reason for not meeting the 95% performance standard was because January and February were below 95% for web-pended requests, which resulted in an overall web-pend compliance rate of 91.23%. All other months met this standard at 100%. Telephonic requests achieved an overall 100% for the year, but only comprised about 9% of the total number of requests (5 of 62). G. Concurrent decisions re: authorizations for acute LOC (Psych/Gen Hosp IP, IP Detox, Intermediate duration acute psychiatric care, PHP, Psych Res and crisis stabilization) Communication within 60 min on date auth expires % of concurrent decisions for acute higher level of care authorizations were communicated within the target timeframe (26,796 of 26,915). H. Concurrent decision for Psych/Gen Psych IP, offer an appointment for peer to peer review within 60 min of completion of CM review % of concurrent decisions for general hospital and inpatient psych authorizations that required a peer to peer review were completed within the target timeframe (48 of 50). I. Concurrent decision for IP Detox, offer appointment for peer to peer review within 120 min of completion of CM review % of concurrent decisions for inpatient detox authorizations that required a peer to peer review were completed within the target timeframe (19 of 20). B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 65

66 J. Concurrent decision for other HLOC, offer appointment for peer to peer review within 1 business day of completion of CM review. 100% of concurrent decisions for other higher level of care authorizations that required a peer to peer review were completed within the target timeframe (15 of15). K. Concurrent decisions re authorizations for non-acute LOC (LLOC) within 2 & 4/7 business days of request. 2 business days: 99.53% of concurrent decisions for non-acute higher level of care authorizations were communicated within the target timeframes (22,992 of 23,100). 4/7 business days: 98.43% of concurrent decisions for non-acute higher level of care authorizations were communicated within the target timeframes (27,484 of 27,923). L. Concurrent decision for non-acute (LLOC), offer appointment for peer to peer review within 2 & 4/7 business days of completion of CM review. 2 business days: 94.88% of concurrent decisions for lower level of care authorizations that required a peer to peer review were completed within the target timeframe (185 of 195). The reason for not meeting the 95% performance standard was because the months of June, July, November, and December were below 95% for web-pended requests, which resulted in an overall web-pend compliance rate of 94.85%. Telephonic requests achieved an overall 100% for the year, while comprising less than 1% of the total number of requests (1 of 195). 4/7 business days: 92.55% of concurrent decisions for lower level of care authorizations that required a peer to peer review were completed within the target timeframe (174 of 188). The reason for not meeting the 95% performance standard is because the months of January, May, and August were all below 95% for web-pended requests, which resulted in an overall webpend compliance rate of 92.43%. Telephonic requests achieved an overall 100% for the year, but only comprised about 1.6% of the total number of requests (3 of 188). M. 98% of all authorization decisions result in an appropriate letter based on quarterly audit. In order to monitor performance of this item and ensure that providers were able to view authorization letters within 2 business days, a quarterly audit was conducted of a sample of authorizations from each level of care in ProviderConnect. For 2016: 431 authorizations were audited over the course of the four quarters and found that only one (1) letter was not available in the appropriate timeframe % for the year. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 66

67 2016 # Auths Checked # w/letter % Q Q Q Q One letter was not available for the particular authorization due to the admission date occurring prior to member s eligibility start date. A new authorization was created to cover the dates of the admission for which the member was eligible and it was confirmed that the letter was available to the provider. N. Timeliness in passing authorization data to fiscal agent; timeliness in correcting authorization info errors. In 2016, 263 of the 264 (99.62%) authorization files created were delivered to the fiscal agent within the expected timeframe of prior to the start of the business day following production of the authorization file. The number of authorization errors increase significantly in 2016 due to the Hospital Outpatient Reform project. ERRORS RESOLVED RESOLVED WITHIN TAT % RESOLVED WITHIN TAT Q % Q % Q3 3,463 1, % Q % YEARLY TOTALS 4,748 2, % Authorization errors increased in Q2 due to HPE implementing new error reasons that were discussed with CT BHP in 2015 but never finalized. CT BHP was not notified by HPE of the effective date of implementing the new error reasons and the errors started to appear on the error reports on May 4, 2016 through May 11, The new error reasons were: Units submitted incorrect, Inpatient stay overlap exists (due to RCC list), and PA overlaps with existing PA. Discussions were held with HPE and a decision was made by HPE to reverse the edits. This was done on approximately May 13, Given that error corrections could not be made until the edits were reversed, the approximately 110 errors were not completed within the 2-day TAT. Authorization errors increased dramatically at the end of Q2 and into Q3 due to the Hospital Outpatient Reform project. The change to the procedure code suffix was put into place early (in error) effective on June 24, 2016 and continuing through June 28, This change meant that B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 67

68 authorizations created on June 24, 2016 through June 28, 2016 that included June dates of service as well as those continuing into July and going forward contained the incorrect suffix for June dates. For example, an authorization created on June 24, 2016 with levels of care included in the Hospital Outpatient Reform project included a suffix of C for both June and July dates of service. June should have had a suffix of Y and July dates going forward should have had a C suffix. Errors occurred when changes were made to the authorizations (date extensions, backdates, voids, or additional units being added) after this change was reversed on June 28, 2016 because the suffix could not be changed. The total number of errors attributed to this was New authorizations had to be created to cover the authorizations with the June dates. When this change was reversed, it also meant that authorizations created for July dates of service now contained the incorrect suffix and those needed to be recreated once the suffix change was implemented on July 29, 2016 in order for providers to be paid. The primary error reason that applied to these errors was Procedure code cannot change. In addition, when new authorizations were created many members had incurred eligibility changes that included benefits terminating prior to the authorization end date. This required the termination date from the member s policy to be lifted in order for the authorizations to pass to HPE. This caused 1183 eligibility errors on authorizations. If the errors reasons attributed both to the May issues as well as the Hospital Outpatient Reform project were excluded, the total number of errors that did not meet the TAT for calendar year 2016 was five (5). This would have resulted in a 99.64% compliance for the 2-day turnaround time requirement. O. Accuracy in passing authorization data to fiscal agent, and accuracy in importing units used data from fiscal agent. In 2016, 841,350 authorizations processed with 4,748 authorization errors. This resulted in an error rate of.56%, which is an increase over previous years but still below the threshold of 2%. In addition, the accuracy in importing units used data from the fiscal agent was completed at 99.92%, again meeting the expectations of 98%. Recommendations for continuing goal in 2017: This goal continues to be applicable for 2017 and should be included in the 2017 Project Plan. Goal 15: Monitor Medical Necessity and Administrative Denials; Identify Barriers and Opportunities Description of activities and findings that include trending and analysis of the measures to assess performance over time: A-C. See Exhibit E deliverable on March 1, 2017 for Denials and Appeals CY 2016 Report via Tableau Server B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 68

69 Recommendations for continuing goal in 2017: This goal continues to be applicable for 2017 and should be included in the 2017 Project Plan. Goal 16: Monitor Timeliness of Appeal Decisions; Identify Barriers and Opportunities Description of activities and findings that include trending and analysis of the measures to assess performance over time: A-R. See Exhibit E deliverable on March 1, 2017 for Denials and Appeals CY 2016 Report via Tableau Server Recommendations for continuing goal in 2017: This goal continues to be applicable for 2017 and should be included in the 2017 Project Plan. Goal 17: Report and Monitor Medication Adherence for Antidepressant and Antipsychotic Medications Categories Description of activities and findings that include trending and analysis of the measures to assess performance over time: In 2015, among the adult CT Medicaid population (ages 18+): 18.7% of all Medicaid adults filled at least one prescription for an antidepressant and 6.7% filled at least one prescription for an antipsychotic. Both of these rates are consistent with those calculated for % of Behavioral Health (BH) service users who did not use BH ED or BH inpatient services filled at least one prescription for an antidepressant and 14.2% filled at least one prescription for an antipsychotic. Both of these rates decreased from 2014 to % (from 74.3% in 2014) of Medicaid adults with at least one BH hospitalization in an acute care hospital filled at least one prescription for an antidepressant and 58.5% (from 71.3% in 2014) filled at least one prescription for an antipsychotic. Both decreases in rates are significant (Chi-Square=p<0.001). One explanation for the decrease in rates is the change in methodology this year for identifying inpatient stays. This year, new HEDIS methodology for identifying behavioral health inpatient stays was utilized that includes all stays in hospitals with a primary MH or SUD diagnosis. Some of the stays included took place on hospital units other than psychiatric units. This new methodology resulted in identifying nearly 50% more inpatient stays in 2015 than in Consequently, the denominators (number of BH inpatient stays) for the rates of filling prescriptions for antidepressants and antipsychotics after discharge is inflated in comparison with B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 69

70 In 2015, among the youth CT Medicaid population (ages 3-17): 3.2% of Medicaid youth filled at least one prescription for an antidepressant and 2.3% filled at least one prescription for an antipsychotic. These rates are nearly identical to those of % of BH service users who did not use BH ED or BH inpatient services filled at least one prescription for an antidepressant and 7.5% filled at least one prescription for an antipsychotic. Both of these rates decreased from 2014 to % of Medicaid youth with at least one BH hospitalization in an acute care hospital filled at least one prescription for an antidepressant and 65.8% filled at least one prescription for an antipsychotic. Both of these rates increased. The new HEDIS methodology for identifying inpatient stays did not impact the youth population counts to the extent that it did the adult population. Medication Adherence of Adults with Schizophrenia Treated with Antipsychotics The methodology used for obtaining the rates of medication adherence included in this section were based upon the HEDIS measure, Adherence to Antipsychotic Medications for Individuals with Schizophrenia. The measure is defined in the HEDIS 2016 Technical Specifications for Health Plans, Volume 2, by the National Committee of Quality Assurance (NCQA) as: The percentage of members years of age during the measurement year (2014) with schizophrenia who were dispensed and remained on an antipsychotic medication for at least 80% of their treatment period. Findings During 2015, a total of 3,832 adults between the ages of 19 and 64 were eligible for the measure. Of those adults, 2,716 (70.9%) remained on an antipsychotic medication for at least 80% of their treatment period. This was a significant improvement from 2014 s rate of 62.5% (Chi- Square=p<0.001). Furthermore, a higher percentage of adults remained on their antipsychotic medication for >90% of their treatment period in 2015 (61.5%) than in 2014 (49.4%). As research has clearly shown that adherence to antipsychotic medications for individuals with schizophrenia results in fewer hospitalizations, this is a very positive finding. The HEDIS Medicaid National Average for this measure was 58.0%. CT adults fell above the National Average, and slightly below the 90th percentile. The HEDIS Medicaid New England Average for this measure was 61.9%. CT adults fell above the regional average and between the 75 th and 90 th percentiles. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 70

71 Highlights of Findings Regarding Demographic Differences The percentage of members on antipsychotics for 80% or more days in their treatment period increased with age. The 19 to 24-year- old adults had the lowest percentage of days covered rate (63.0%) while the 55 to 64- year-old adults had the highest rate (79.6%). Members identified as White or Asian had higher rates of adherence to antipsychotic medication than Blacks or Hispanics. Females had higher rates of adherence than males. HUSKY C members had higher rates of adherence than HUSKY A or D members. Members with a BH inpatient stay had lower rates of adherence than members without an inpatient stay. Medication Adherence of Adults with Major Depression Treated with Antidepressants The methodology used for obtaining the rates of medication adherence included in this section were based upon the HEDIS measure, Antidepressant Medication Management. The measure is defined in the HEDIS 2016 Technical Specifications for Health Plans, Volume 2, by the National Committee of Quality Assurance (NCQA) as: The percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment. Two rates are reported. Effective Acute Phase Treatment. The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks) during the 114-day period following the IPSD. Effective Continuation Phase Treatment. The percentage of members who remained on an antidepressant medication for at least 180 days (6 months) during the 231-day period following the IPSD. Once the measures were run according to the HEDIS specifications described below, rather than only reporting the HEDIS rates for these two measures, there is additional reporting on: The percentage of the treatment period that youth members ages 6-17 treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication for the same time periods described for adults. The percentage of the treatment period that all of the youth and adult members identified in each of the two measure denominators remained on an antidepressant medication. B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 71

72 Findings During 2015, a total of 12,690 adults 18 years and older were eligible for the measure. Of those 12,690 adults, 6,388 (50.3%) remained on an antidepressant medication for at least 84 days of the 114-day period (Acute Phase) following the earliest prescription dispensing date for an antidepressant medication during the intake period (IPSD). This is a significantly higher rate than that achieved in 2014 (49.0%) (Chi-Square=p<0.05) Of those 12,690 adults, 3383 (32.3%) remained on an antidepressant medication for at least 180 days of the 231-day (Continuation Phase) following the earliest prescription dispensing date for an antidepressant medication during the intake period (IPSD). This is a significantly higher rate than that achieved in 2014 (30.8%) (Chi-Square=p<0.05) The HEDIS Medicaid National Average for the Acute Phase measure was 54.5%. CT Medicaid adults fell below the HEDIS Medicaid National Average at 50.3%, and between the 33.3 rd and 50 th percentiles. The HEDIS Medicaid National Average for the Continuation Phase measure was 39.5%. CT Medicaid adults fell considerably below the National Average at 32.3%, and between the 10 th and 25 th percentile. The HEDIS Medicaid New England Average for the Acute Phase measure was 53.3%. CT Medicaid adults fell below the regional average at 50.3% and just above the 25 th percentile for the region. The HEDIS Medicaid New England Average for the Continuation Phase measure was 37.6%. CT Medicaid adults fell considerably below the regional average at 32.3% and between the 33 rd and 50 th percentiles. Highlights of Findings Regarding Demographic Differences With the exception of adults 65 and over, the percentage of members who remained on an antidepressant medication during the Acute and Continuation Phases increased with age. Members identified as White or Asian had higher rates of remaining on their antidepressants during both the Acute and Continuation Phases of treatment of depression than did Blacks or Hispanics. Females had higher rates of adherence than males, particularly during the Acute Phase of treatment. HUSKY D adults had the highest rates of adherence during both phases of treatment. Adults with a BH inpatient stay had lower rates during both phase of treatment B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 72

73 Please Note: The display of the findings of the HEDIS measures was improved this year by using Tableau. All of the findings noted above can be visualized in the Tableau version of the measures. Recommendations for continuing goal in 2017: This goal continues to be applicable for 2017 and should be included in the 2017 Project Plan. Goal 18: Ensure Consistent Application of Activities to Maintain and/or Improve the Rate of Ambulatory Follow-Up Services after Inpatient Admissions Description of activities and findings that include trending and analysis of the measures to assess performance over time: A. Report on methods to ensure linkage of target population to aftercare The Connect to Care process is initiated by the Clinical Liaison (CL) team members once a discharge is entered into ProviderConnect or CareConnect indicating that a member has been discharged from Inpatient Psychiatric, Inpatient Detox-Hospital and Inpatient Detox- Freestanding levels of care. The CL reviews the indicated discharge plan and triggers an automated Beacon health alert to the member s telephone number or address, reminding them to attend their scheduled appointment at least 2 days prior to the appointment. If a member left this level of care Against Medical Advice (AMA), the CL will call the member as soon as possible to support the member in connecting to services. In addition to the health alert, the CL outreaches telephonically to the member at least 2 days prior to the scheduled appointment to ask if there are any barriers to attending the appointment. They offer support with these barriers and/or offer to reschedule the appointment with the member if the member would like to be seen sooner or at another agency. After the scheduled appointment, the CL makes one final call to inquire if the member attended the appointment, and if not, offers to support the member in connecting with a provider and scheduling a new aftercare appointment. If no contact is made with the member during the above calls, then the CL will send a connect to care letter to the member that provides contact information and offers CT BHP services and support in accessing behavioral health services. At 30 days post-discharge from the inpatient level of care, the CL reviews the member s record to see if a new authorization is on file indicating connection to care or if an existing authorization reflects additional units used for tracking and reporting purposes. This Connect to Care process can be repeated multiple times for each member depending on their frequency of readmission to inpatient levels of care. B. Performance of aftercare linkage efforts Connect to Care rates are reported monthly and reflect the previous month s percentage of member s who attended follow-up care appointments within 30 days of discharge from the inpatient level of care. This report excludes members who are not able to be followed for B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 73

74 connection to care due to discharge plans that involve services not authorized by Medicaid, such as residential rehabilitation services for HUSKY C and D members and other nontraditional services identified as the primary aftercare follow-up plan (Recovery/Sober/Supportive housing). We are in the early stages of comparing the HEDIS data to Beacon s Connect to Care data to see if we can glean any further information that might be helpful for the providers who offer aftercare services. C. Review linkage efforts and interventions for improvement During the course of 2016, Beacon offered several provider webinars focused on entering discharge reviews on ProviderConnect. A CL was present during the webinar and offered firsthand experience about the importance of a discharge plan being entered into the discharge review. On many occasions, the Clinical Care Managers and CLs take time to educate the providers about the importance of the discharge plan for the specific reason of being able to initiate the Connect to Care process. During several provider meetings in the community, the Regional Network Managers and Clinical Supervisors or AVPs emphasized the importance of entering the discharge plan as well. Beacon will continue this effort with the individual providers who need to be trained on entering discharges into ProviderConnect and how that initiates the Connect to Care process by Beacon. Recommendations for continuing goal in 2017: This goal continues to be applicable for 2017 and should be included in the 2017 Project Plan. Goal 19: Promote Patient Safety and Minimize Patient and Organization Risk from Adverse Incidents and Quality of Care/Service Concerns Description of activities and findings that include trending and analysis of the measures to assess performance over time: A. Number of Adverse Incidents (by child and adult) B e a c o n H e a l t h O p t i o n s A n n u a l Q M & U M E v a l u a t i o n Page 74