EXCELLUS BEHAVIORAL HEALTH POLICY

Transcription

1 EXCELLUS BEHAVIORAL HEALTH POLICY SUBJECT: BEHAVIORAL HEALTH ACCESS AND AVAILABILITY STANDARDS SECTION: QUALITY IMPROVEMENT POLICY NUMBER: BHQI-1 EFFECTIVE DATE: 3/99 Applies to all products administered by Excellus Health Plan Inc., except when changed by contract. Policy Statement: Access and availability will be maintained by the managed care organization (MCO) to the extent possible for 1) Urgent and Routine Care Appointments; 2) After Hours or Emergency Care, and; 3) Geographic Access to care. The MCO will ensure the availability of timely care in accordance with Federal Americans Disabilities Act. The MCO network will have the ability to provide culturally and linguistically competent care. Definitions: Behavioral Health Practitioners: The MCO has defined behavioral health practitioners as follows: psychiatrists, child psychiatrists, school psychologists, psychologists, social workers, community mental health centers and chemical dependency treatment centers. Access - The ability of the enrolled population to receive behavioral health care services or to make contact with the managed care organization. Access includes measures of preventive, routine, urgent, emergent, and telephone components. Availability - The ability of the enrolled population to receive health care from behavioral health practitioners within their described geographic area. Urban/Suburban County population greater than 1,000 persons per square mile Rural County population less than 1,000 persons per square mile (The definitions of urban/suburban and rural were adopted from the U.S. Census.) Routine visit - Can be defined as but not limited to: 1. a follow-up to a previous visit 2. a visit without presentation of a specific, acute illness 3. a planned periodic visit Page 1 of 6

2 Urgent: An urgent condition is a behavioral health condition manifesting itself by acute symptoms of sufficient severity that, in the assessment of a prudent lay person, possessing an average knowledge of medicine and health, could reasonably be expected to result in serious impairment of bodily functions, serious dysfunction of a bodily organ, body part, or mental ability, or any other condition that would place the health or safety of the Enrollee or another individual in serious jeopardy in the absence of medical or behavioral treatment. (Medicaid Managed Care Model Contract 1.31, page 11) Examples of conditions considered as urgent are: 1. The parents of Tom, a 15-year-old male, call saying he has had another fight with his brother, is threatening not to go to school and has plans of running away. Tom is being treated for ADHD and oppositional defiant disorder. The practitioner develops a contingency plan with the parents and speaks with Tom. An appointment is arranged for an urgent family meeting within the next 48 hours. 2. George, a 47 year old male, is being treated for major depression. He calls to say he feels paralyzed, has spent 30 minutes in the bathroom crying at work and that everything looks black. He is able to contract for safety and an urgent appointment is arranged for him to be seen within the next 48 hours. Emergent: An emergent condition is a behavioral health condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent lay person possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in: (I) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of the person of others in serious jeopardy: or (II) serious impairment to such person s bodily functions: or (III) serious dysfunction of any bodily organ or part of such person: or (IV) serous disfigurement of such person. (Medicaid Managed Care Model Contract 1.9, pages 8,9) Examples of conditions considered as emergent are: 1. (Non-life threatening example) Nina, a 54-year-old female, is being treated for bipolar disorder. She calls her practitioner at 2a.m. and her speech is accelerated, her thoughts disorganized and silly, she has not slept for three nights and spent the day at the beach talking to her husband s ashes. She is advised to go to the ED and the practitioner calls the ED with patient history. 2. (Life threatening example) The husband of Diane calls and stated that he found her sitting on the floor crying, speech slurred and an empty bottle of medication next to her. Diane has recurrent depression and has made multiple suicide attempts. She and her husband have a history of abusive verbal arguments. The husband is advised to call 911 and have Diane taken to the ED. The practitioner calls the ED with patient history. Clinically indicated - According to practitioner judgment Process: These access standards are relevant to the entire managed care enrolled population, including commercial, Medicare and Medicaid members. The MCO is considered compliant if the requirements below are met for at least 85% of the applicable population or if at least 85% of the applicable population indicate that they are satisfied with their access to care. Behavioral Health reports measured performance against the established standards on an annual basis. Page 2 of 6

3 Access Measure Timeliness of routine behavioral health appointments; Standard Routine care should be available within 10 business days Measurement Tool Appointment Availability Survey Timeliness of behavioral health urgent appointments; Urgent care should be available within 48 hours Appointment Availability Survey Timeliness of behavioral health emergency care; Timeliness of follow-up after inpatient hospitalization for a mental illness Access to the behavioral health specialist for life-threatening emergencies should be available immediately by telephone on a 24 hour/7 day a week basis Access to the behavioral health specialist for non-life-threatening emergencies should be available within 6 hours Follow-up care should be available within 7 calendar days following discharge Random After Hours Call Program Appointment Availability Survey Complaint analysis Provider Contract HEDIS measure Access and Availability Surveys I. Urgent and Routine Care Appointment Access A licensed Behavioral Health (BH) staff person performs the appointment availability survey with the practitioner or designee during all treatment record reviews (TRR) at practitioner sites. Access to urgent and routine care is considered one of the most important measurements of quality during a TRR.. A statistically significant sample must be available to adequately measure appointment availability in each respective region of Excellus Health Plan, Inc. Because a significant sample cannot always be realized for this measurement in a region where managed care enrollment is low per practitioner, the qualifying number of unique members a practitioner must have in order to be surveyed for this measure has been decreased to five per practitioner. This also ensures that an aggregate number of practitioners serving at least 50% of the Plan membership seeking behavioral health services were surveyed. The goal is an average compliance rate of 85% in each Plan. Interventions for Noncompliance The BH Wrap-up process following a TRR addresses any noncompliance with the above standard on a 1:1 basis when the survey is performed during an onsite TRR. A follow-up letter citing the issue of noncompliance with the appointment access and availability standards is sent to practitioners when the self-reported appointment availability survey is used, and the practitioner s office is not meeting the access standard. All results are tracked and trended Page 3 of 6

4 II. After Hours or Emergency Access Access to the behavioral health practitioners for urgent/emergent care should be available on a 24 hour/7 day a week basis. The BH After Hours Survey/Audit was developed to check the compliance of BH practitioners on our panel for immediate availability by telephone on a 24/7 basis for our members in need of emergent care. An option with direction of how to access the practitioner after normal business hours (9am - 5pm) for a clinical emergency must be available to the practitioners' established patients during the telephonic survey. The goal is an average compliance rate of 85% in each Plan. The telephonic answering options that are considered acceptable are as follows: a) Reaching the practitioner or a person with the ability to patch the call through to the practitioner (e.g., answering service) b) Reaching an answering machine or voice mail with instructions on how to contact the practitioner or his/her backup (e.g. cell phone or pager number, or the message is being call forwarded to the practitioner) c) For the Eastern Regions of Excellus, there has been found to be cell phone and beeper signal drop-out, so an additional option for these Regions has been considered (e.g., Reaching an answering machine or voice mail with instructions to call a Crisis Center, CPEP, or Lifeline. or some other entity will contact the BH practitioner) (This option is regionally specific for Behavioral Health (BH) practitioners participating with Excellus Health Plan in the Central New York, Central New York Southern Tier, and Utica Regions. This option is considered to be in compliance only when the practitioner has an agreement with the Crisis Center, CPEP, or Lifeline, or other entity whose number is given on the answering machine. The agreement must include the said entities having the BH practitioner's current phone, cell, or beeper number, and first making an attempt to reach the member's actively-treating BH practitioner or covering practitioner for triage purposes; and or notifying the practitioner as soon as possible concerning the phone contact or visit made with the member.) Interventions for Noncompliance Written communication will be sent to all practitioners surveyed. a) Practitioners receiving a passing score will receive a letter stating they have met the standard of care, and giving thanks for dedicated service to our members b) Practitioners that did not pass for the first time will receive a letter stating such and will also include the following: Identification of the noncompliance issue How to make a correction to be in compliance Contact phone numbers and web site address for assistance Page 4 of 6

5 c) Practitioners that did not pass for the second consecutive time will receive a certified letter, signed by the Medical Director of BH, stating such and include the following: Identification of the noncompliance issue How to make correction to be in compliance A statement that lets the practitioner know he/she is jeopardizing their placement on the panel if the issue of noncompliance continues Contact phone numbers and web site address for assistance d) Practitioners noncompliant for the third consecutive time will receive a phone call from BH to further determine the reason for continued noncompliance, and then will proceed as follows: If the practitioner chooses to resolve the issue of compliance, a certified letter signed by the Medical Director of BH, is sent outlining the phone conversation and verbal agreement, and the practitioner is surveyed again in 30 days from receipt of the letter If the practitioner chooses not to resolve the issue, or the compliance continues beyond the 30-day timeframe above, a certified letter is sent, stating that the practitioner has been noncompliant for the third consecutive time, and their file is being forwarded to the Corporate Credentialing Committee with a recommendation of termination from the panel The practitioner has the opportunity to appeal to the Corporate Credentialing Committee if terminated from the panel All results are tracked and trended III. Geographic Availability (Geo-Access): These availability standards are relevant to the entire managed care enrolled population, including commercial, Medicare and Medicaid members. The survey is conducted using mapping software, and the BH practitioner file and the membership file from each Plan. The MCO is considered non-compliant if the requirements below are not met for at least 85% of the population. Availability Measures Geographic distribution of behavioral health practitioners. Geographic distribution of behavioral health clinics Geographic distribution of chemical dependency clinics or programs Availability Standard Metropolitan/Urban = 3 specialists within 10 mile radius Rural/Suburban = 2 specialists within 30 mile radius 1 behavioral health clinic within a 30 mile radius 1 chemical dependency clinic or program within a 30 mile radius Availability Measurement Tool Geo Access report Page 5 of 6

6 Availability Measures Ratio of Psychiatrists to members Ratio of other BH Practitioners to members Availability Standard 1 : : 5000 Availability Measurement Tool Geo Access report Ad hoc reports Oversight: The Manager of Behavioral Health Quality and Compliance is responsible to provide oversight of access to the services and the MCO in collaboration with others. Policy Activity: Committee Approval: Excellus Behavioral Health Quality Committee: 2/3/99, 4/14/99, 3/14/01, 3/13/02, 7/11/02 Service Quality Committee: 6/12/03, 6/15/04, 7/19/05, 8/15/06 Quality Steering Committee: CNY 2/11/02, RA 2/13/02 Revised Dates: 3/99, 3/01, 2/02, 6/02, 6/03, 6/04, 7/05, 8/06 Reviewed Dates: 6/04, 7/05, 8/06 Original Source: 1998 MBHO Standards, MCO Policy QI-1 References: Page 6 of 6