End to End Clinical Process Flow Clinical Question & Answer Webinar August 14, 2015

Transcription

1 End to End Clinical Process Flow Clinical Question & Answer Webinar August 14, 2015

2 Agenda Introductions Brief Overview of the ASO Entry to Services Community Based Referrals ACT Referrals Referrals to Inpatient, CSU or BHCC Care Coordination Questions & Answers 2

3 Introductions Department of Behavioral Health and Developmental Disabilities Melissa Sperbeck, Deputy Chief of Staff John Quesenberry, Director of Decision Support and Information Management The Georgia Collaborative ASO Jason Bearden, CEO, GA Collaborative ASO Janet Gaspard, VP, Clinical Implementations Wendy Martinez, CEO, GCAL Jean Olshefsky, CPS, CARES, Director of Recovery and Advocacy, GA Collaborative ASO Sheri Smidhum, Director of Provider Relations, GA Collaborative ASO 3

4 The Georgia Collaborative ASO The right service In the right amount For the right individuals At the right time 4

5 Goals of the Collaborative Providing Easy Access to High Quality Care That Leads to a Life of Recovery and Independence Support recovery, resiliency and independence in community based service system Leverage technology through an integrated, customizable platform allowing all core functions to communicate (The CONNECTS platform) Coordination of previously disparate systems Improve state wide and provider specific outcomes and provider performance 5

6 End to End Processes: Entry to Services 6

7 Profile of Individual in Crisis Diagnosis: Schizoaffective Disorder Presenting History/Circumstances: History of Trauma Substance Abuse Mild Intellectual and Developmental Disabilities (IDD) Multiple inpatient admissions over life Limited natural supports Legal Involvement Resides in Albany in rural setting 7

8 Individual System Entry Points Inpatient or Emergency Department Mobile Crisis Law Enforcement Civil Commitment BHCC/CSU/OP clinic/walk in System of Care Supported by: 8

9 GCAL Licensed Clinician Individual Assessment System of Care Supported by: 9

10 GCAL Licensed Clinician Individual Triage Beacon Health Options - CONNECTS Data Integration & Sharing BHL MyGCAL Information Presentation BH, IDD and Medical Registration Eligibility Authorizations Service History Provider File Safety/Crisis Plan 10

11 GCAL Referral Options Inpatient, CSU or BHCC ACT Open Cases or Mobile Crisis Community Based Services 11

12 End to End Processes: Community Based Services Referrals Overview 12

13 GCAL Referral Options Inpatient, CSU or BHCC ACT Open Cases or Mobile Crisis Community Based Services 13

14 Non-Crisis Service Clinical Workflow and Process Provider submits individual registration and obtains CID via ProviderConnect (PC) or batch process CID and approved registration is obtained via PC or through 1 of four batch cycles daily Follow prescribed authorization spans and unit maximums on service class crosswalk when requesting authorization Utilizing CID, authorization request is submitted communicating medical necessity via PC or batch Continue on next slide All authorization requests should be individualized based on the individuals treatment needs and adhere to DBHDD policies

15 Non-Crisis Service Clinical Workflow and Process Continue from previous slide Clinical Care Manager (CCM) reviews request for medical necessity (Treatment plan may be requested) If medical necessity met and all collateral information provided, then authorization is given Discharge or complete concurrent auth. Request following process outlined If medical necessity is not met higher level of review will be completed If further collateral is needed to determine medical necessity CCM will contact facility. Response needed w/in 24 hours of request The ASO follows URAC standards for all turnaround times 15

16 Production Batch Cycle Times* Registration Working with IT, DBHDD and batch providers to identify the optimal time to run a weekend batch cycle. Exact time and day to be communicated in subsequent webinars

17 Batch Cycle Times Authorization and Discharge Working with IT, DBHDD and batch providers to identify the optimal time to run a weekend batch cycle. Exact time and day to be communicated in subsequent webinars

18 Authorization period Requirement: HP will not accept authorizations that have a duration longer than 365 days. Issue: Beacon s base system typically uses one PA number for the authorization period, adding services and extending dates on one PA number as concurrent authorizations are submitted and approved. This would have resulted in authorization periods longer than 365 days and subsequent denials by HP. 30 days PA days - PA days - PA 1 Initial Concurrent 1 Concurrent 2 18

19 Non Intensive Initial Authorization Process 10/1/15 12/18/15 Upgrade scheduled for Beacon s Q4 (12/19/15) CONNECTS release that will allow for update authorization functionality and 365 concurrent authorization for Non- Intensive Services. Interim Solution (Illustration 1): 10/1/15 12/18/15 All initial authorizations for Non-Intensive Outpatient services will be granted a 90 day authorization span. This will reduce the number of concurrent authorizations submitted prior to 12/19 Note: Max units will be adjusted accordingly to account for extended initial authorization period Illustration #1: 90 days PA days - PA 1 1 Authorization Ongoing Solution (Illustration 2): 12/19/15 forward All initial authorizations will for Non-Intensive Outpatient services will be granted a 30 day authorization span. 30 days Illustration #2: 365 days - PA 2 PA 1 2 Authorizations

20 End to End Processes: ACT Referrals 20

21 GCAL Referral Options Inpatient, CSU or BHCC ACT Open Cases or Mobile Crisis Community Based Services 21

22 GCAL ACT outreach and Engagement ACT on call staff are expected to return call to GCAL Agent within 15 mins of initial outreach GCAL Agent will contact ACT on call staff to engage via telephone and via the ACT dispatch monitor If crisis plan on file GCAL Agent will utilize Safety/Crisis Plan to engage individual ACT responder will meet individual in community and engage with individual utilizing the Safety/Crisis Plan and treatment plan ACT responder will notify GCAL via the ACT dispatch monitor board regarding individual disposition If individual needs higher level of care call must be placed to GCAL to coordinate linkage to CSU or Inpatient 22

23 Accessing ACT BHL Tools Type, or Copy and Paste the web address below into your Browser You can also pull the address from your Browser to your desktop 23

24 Click on GCAL WEB APPLICATIONS Click Here 24

25 Enter your User name ( address) and Password, click on Login Click Here 25

26 If you forget your password on the login screen click the Forgotten your password link. Click Here 26

27 If You Forget Your Password Click on the Forgotten your password? link on the Login page Click on link The New Password Generator box comes up enter your User Name (your address) and a new password will be ed to you. Enter User Name 27

28 Click on BHL Web Applications Menu Click Here 28

29 BHL Web Apps Menu ACT Board After Hours Contact Editor this application is used to inform GCAL of who to contact when your team is needed Assertive Community T/x After Hours Contact Editor Click here ACT Dispatch Monitor 29

30 GCAL ACT On-Call Staff Roster 30

31 GCAL ACT Dispatch Board 31

32 End to End Processes: Referral to Inpatient, CSU or BHCC 32

33 GCAL Referral Options Inpatient, CSU or BHCC ACT Open Cases or Mobile Crisis Community Based Services 33

34 Inpatient, CSU or BHCC Referral (Initial Auth) Inpatient, CSU or BHCC Initial Authorization Concurrent Authorization Discharge 34

35 Initial Authorization - Intensive Referral Process (SPOE/PPOE) All individuals presenting at ED placed on BHL Beds Inventory Status Board Individual remains on the SCB Referral Board until admitted or until referral is cancelled CSU w/in ED catchment has 2 timeframe to review and accept referral for admission If CSU w/in catchment declines referral then referral opens to all CSUs w/in DBHDD region for 4 hours If individual has primary MH* diagnosis and has not been accepted at 6 hour mark, they are placed on State Contracted Bed Referral Board (SCB) *Note: Individuals with primary AD diagnosis remain on CSU Referral Status Board until admitted to CSU or referral is cancelled * Note: State Hospital last resort of admittance for individuals with primary Dx of MH 35

36 Initial Authorization - Intensive Referral Intake Process GCAL works with ED to gather eligibility and clinical data GCAL uses data to create registration, obtain CID and create authorization GCAL send CID & Auth tracking number to Beacon though twice a day communication cycles Beacon returns approved Auth number to GCAL though twice a day communication cycles Note: All admissions originating from ED or mobile crisis requires no data entry by admitting provider Authorization tracking number and CID given to provider via secure and bed inventory status board GCAL places approved Auth # and CID on Beds Inventory Status board and s identified UM staff via secure Note: All other referral origination points will require admitting facility to complete brief registration and authorization to obtain CID and Auth number Initial registration and authorization granted: CSU = 7 business days SCB = 1 or 3 business days Admitting facility retrieves Auth # and CID to use for billing and concurrent authorization request 36

37 Beds Inventory Status Board Individual Editor Screen for Walk-ins, Internal Referrals and OTAs 37

38 Concurrent Decision Tree Intensive Services Last covered day of initial registration and authorization Discharge to Community base Services Request Additional Days at existing level of care Refer to external provider and transmit discharge Refer to internal resources transmit discharge. Must complete full registration and authorization Full Registration and Authorization Abbreviated Registration and Authorization Goto Concurrent Review Process (next slide) 38

39 Inpatient, CSU or BHCC Referral (Concurrent Auth) Inpatient, CSU or BHCC Initial Authorization Concurrent Authorization Discharge 39

40 Concurrent Review Process Intensive Services Document medical necessity for additional days on or before the last covered day* If medical necessity is not met higher level of review will be completed Communicate medical necessity to GA Collaborative via ProviderConnect or batch process Clinical Care Manager (CCM) reviews request for medical necessity (Treatment plan may be requested) If medical necessity met and all collateral information provided, then authorization is given If further collateral is needed to determine medical necessity CCM will contact facility. Response needed w/in 24 hours of request If medical necessity is met then authorization is given 40

41 Concurrent Review Treatment Plan Submission Process Concurrent Authorization Clinical Care Manager (CCM) reviews request for medical necessity (Treatment plan may be requested) I. Submit Treatment plan by attaching to concurrent authorization request via ProviderConnect. II. Fax Treatment Plan Routine OP Community Based Services Send completed Outpatient clinical information for initial or concurrent review Fax:

42 Contracted providers must develop: Treatment Plan Expectations individualized treatment plans that utilize assessment data Address the individual s current impairments related to the behavioral health diagnosis Actively include the individual and significant others, as appropriate, in the treatment planning process Living document spanning the longitudinal care and recovery of the individual accessing agency services 42

43 Treatment Plan Reviews Clinical Care Managers (CCMs) may request and review the treatment plans to assure that the following are included Measurable goals and objectives Use of relevant therapies Evidence of appropriate involvement of pertinent community agencies Discharge planning from the time of admission Documented active involvement of the individual and significant other as appropriate Providers are expected to document progress toward meeting goals and objectives in the treatment record to review and revise treatment plans as appropriate Treatment plans may be requested as part of the authorization process when conducting authorization reviews for specific services or in specific situations 43

44 Treatment Plan Basics A Quality Review Perspective 44

45 Treatment Plan Basics A Quality Review Perspective 45

46 Inpatient, CSU or BHCC Referral (Discharge) Inpatient, CSU or BHCC Initial Authorization Concurrent Authorization Discharge 46

47 CCM Review Criteria The following information may be requested and must be documented: Aftercare appointment Date of appointment Time of appointment specific to that individual Name of specific provider individual is to see Where the individual is to go for aftercare appointment Individual s contact information Phone number and address of where individual is being discharging Emergency contact information (family, support, social support available) Clinical information Date of Discharge Diagnosis at Discharge Medications with dosages Community resources referred 47

48 End to End Processes: Clinical Functions Care Coordination 48

49 Specialized Care Coordination Defined The Georgia Collaborative ASO s Specialized Care Coordination Program is: a community based program designed to monitor, support, and serve individuals within the behavioral health and developmental disability population uniquely targets individuals with the most complex care needs or during critical transition periods to best support care coordination with all community-based providers 49

50 Overview Targeted High Touch Certified Peer Specialist INTENSITY (TOUCH) HIGH Complex Care Coordination Community Transition Specialist Data Reporting and Analytics INTENSITY (TOUCH) LOW 50

51 Specialized Care Coordination Local in the Community Complex Care Coordinators (CCC) Certified Peer Specialist (CPS) Community Transition Specialist (CTS) 51

52 Community Transition Specialist (CTS) Care Coordination is targeted on TRANSITIONS OF CARE Community Transition Specialist Provides outreach and discharge appointment coordination to support the transition from a High Level of Care to a community based provider Engagement occurs within five and 30 days of discharge 52

53 Complex Care Coordination Care Coordination is targeted on COORDINATION OF CARE Complex Care Coordination Complex Care Coordination is the deployment of licensed clinicians that provide clinical oversight to vulnerable individuals with complex diagnostic histories and/or multiple hospitalizations. 53

54 Certified Peer Specialist (CPS) Certified Peer Specialist Certified Peer Specialists: Facilitate individuals building a self-directed Whole Health Action Management (WHAM) and Wellness Recovery Action Plan (WRAP) Support goal setting Develop problem-solving Assist their peers in skill building Show by example that long-term recovery is attainable 54

55 Certified Peer Specialist (CPS) Certified Peer Specialist Certified Peer Specialists: Facilitate individuals building a self-directed Whole Health Action Management (WHAM) and Wellness Recovery Action Plan (WRAP) Support goal setting Develop problem-solving Assist their peers in skill building Show by example that long-term recovery is attainable 55

56 Questions & Answers 56

57 Resources, Information and Training Information is available on our website at: This presentation will be posted to our website within 5 business days! Other Upcoming Trainings August 25, 2015: Quality Management Systems and Tools Webinars for BH and IDD August 26, 2015: Clinical Q&A Webinar September 9 & 10, 2015: Face-to-Face Clinical and Operational Provider Orientation Trainings (Macon and Atlanta). These trainings will have duplicate agenda s. Attendance at one location of your choice is recommended. 57

58 Thank you For Georgia Collaborative ASO general inquiry or questions please 58