The Connecticut Behavioral Health Partnership Quality Management Program Evaluation

Transcription

1 The Connecticut Behavioral Health Partnership 2010 Quality Management Program Evaluation

2 Table of Contents A. EXECUTIVE SUMMARY A. Overview of the QM Program page 3 B. Key Accomplishments of the CT BHP QM Program page 4 C. Key Accomplishments of the CT BHP UM Program page 4 B. EVALUATION OF OVERALL EFFECTIVENESS OF THE SERVICE CENTER QM PROGRAM A. Committee structure page 5 B. Adequacy of resources page 8 C. Practitioner involvement page 9 D. Leadership involvement page 9 F. Patient Safety page 10 C. EVALUATION OF 2009 CT BHP PROJECT PLAN page 11 D. ONGOING QM/UM GOALS AND OBJECTIVES TO BE CARRIED FORWARD FROM THE EVALUATION YEAR page 108 E. APPENDICES Appendix A Revised policy and procedure (Q316) Appendix B Data analysis summary for rate of disruption of newly placed foster care children with a history of behavioral healthcare treatment Appendix C Data analysis summary for MCO co-management QIA for identifying post partum depression and connecting members to treatment Appendix D Pediatric psychiatric hospital pay for performance initiative-state fiscal year (SFY) 2010 Appendix E Pediatric hospital performance initiative I Appendix F CT BHP state fiscal year (SFY) 2010 psychiatric residential treatment facility (PRTF) length of stay performance initiative Appendix G Hospital emergency department performance initiative-state fiscal year (SFY) 2010 Appendix H Emergency mobile psychiatric service performance initiative-state fiscal year (SFY)

3 I. EXECUTIVE SUMMARY The Department of Children and Families (DCF), the Department of Social Services (DSS), in conjunction with a legislatively mandated Oversight Council, have formed the Connecticut Behavioral Health Partnership (CT BHP) with ValueOptions serving as the Administrative Service Organization (ASO). The Partnership was initiated January 1, 2006 and serves as a redesign of the behavioral health service delivery system for low-income children and their parents. The program emphasizes families as partners in care planning, serves to enhance cultural competency within the service system, and strives to improve the quality and availability of community-based services and supports. The Partnership is a reform initiative designed to help children and parents with serious behavioral challenges remain in their homes and communities, through the use of targeted, individualized clinical and support services. The ultimate goal under the initiative is to allow children and parents to function independently, restore or maintain family integrity, improve family functioning, achieve a better quality of life, and avoid unnecessary hospital and institutional care. The (CT BHP) Quality Management (QM) Program was initiated with the implementation of the contract. The QM Program serves as the overarching structure to continuously evaluate the effectiveness of the ASO so as to ensure that the clinical and support services offered within the CT BHP live up to their promise for the youth and families served by the program. The QM Program identifies the key indicators that affect the operation and then monitors these indicators, analyzes the findings, identifies issues, trends and barriers, and then initiates actions to improve performance when necessary. On at least an annual basis, the QM Program is evaluated. The annual QM Program Evaluation provides an opportunity to examine completed and ongoing quality activities and to identify new opportunities for the coming year. The QM Program evaluation serves to assess the overall effectiveness of the QM Program including the effectiveness of the committee structure, the adequacy of the resources devoted to it, practitioner and leadership involvement, the strengths and accomplishments of the program with special focus on patient safety and risk assessment, and performance in quality of clinical care and service. Progress toward meeting the goals included on the previous year s project plan is also evaluated. A review of each of the goals is included within this evaluation along with a description of each goal and sub-goal, commentary regarding their completion status, and recommendations for whether to carry them over into the Quality Program for the following year. The results of this program evaluation together with the additional goals that reflect the strategic planning done collaboratively with DSS and DCF, will be used to formulate the 2010 Project Plan. During 2009, ValueOptions was awarded a three year extension on our contract. This extension, coupled with a significant decrease in staff turnover and maturing of service center staff, allowed us to focus on expanding programs and improving processes. During 2010, two significant events occurred. The service center moved from AIS to the Connect platform. This was a complicated project as the service center had developed many screens in AIS that were specific to the CT service center. In coordination with the national ValueOptions IT, Clinical, and Customer Service Departments, the local service center team devoted several months to the development and testing of the Connect system that successfully went live in November During the same time period, the service center bid on and won the contract for the remainder of the Medicaid behavioral health business in CT. The implementation of this new business will take place over the first quarter of 2011 and go live on April 1,

4 While these events were taking place, there was a simultaneous increase in membership of the HUSKY population. There was a 5.3% increase in total membership for youth between CY 09 (302,354) and CY 10 (318,319). For DCF, there was a spike in CY 09 (14,778) and then in CY 10 (12,405) the membership resumed numbers seen in previous years. On the other hand, the Non-DCF HUSKY population continued to increase year over year. Within the last year, there was a 5.2% increase in Non-DCF membership from 293,382 to 308,608 menbers. The Adult HUSKY membership continues to increase year over year; within the last year there was a 10.1% increase from 149,111 in CY 09 to 164,226 in CY 10. This increase in membership was smaller than the year before when the membership of HUSKY adults was 14.6%. The DCF adult membership peaked in CY 09 at 1,724 and then decreased by 15.5% in CY 10 (1,457). The Non-DCF HUSKY Adult membership increased by 10.2% within the last year from 147,889 to 162,968. Key accomplishments of CT BHP QM Program in 2010 include: Refresher trainings on formal and informal complaints which resulted in a more robust complaint identification process o The number of Formal Complaints increased by 42.9% between CY 09 and CY 10 and resumed figures seen in CY 07 and 08. During the Phone Redesign process, reporting anomalies were identified and reports were revised in order to better communicate performance Reviewed Exhibit E and updated reports based on recommendations Established new format for Quarterly/Annual analysis where by graphs are incorporated into the analysis for better reference Re-evaluated Adverse Incident protocols o Expanded criteria for submission in order to conduct real time review of cases Continued Provider, Analysis and Reporting (PARs) programs for child and adolescent Inpatient, PRTF, RTC, Emergency Departments and ECCs Continued Performance Incentive Programs for Pediatric Inpatient Hospitals, PRTF, ECC, and EMPS and added a performance incentive program for RTCs. Completed second cycle of the Pharmacy Data Analysis o Incorporated all the recommendation from the first cycle and reported on four 6 month blocks of data (Q1-2 08, Q3-4 08, Q and Q3-4 09) Key accomplishments of the CT BHP Utilization Management Program in 2010 include: Completely revamped the Phone System and the way that phone calls are triaged once they enter they system thereby addressing the issue of multiple call backs on the part of Providers o On first attempt, providers now speak to a clinician rather than scheduling callbacks o Phone statistics improved Migrated to a new IS platform for data collection - Care Connect both internally and externally for our Providers and Clients who enter requests for care Established a stronger Risk Management focus o High Risk cases are reviewed regularly with VO Doctors to ensure that appropriate care is being given and that the discharge plan is on track Established a By-Pass Program for IICAPS o Telephonic reviews for IICAPS providers whose utilization falls outside of established parameters Maintained a By-Pass Program for Inpatient services for both the adults and youth 4

5 Created a By-Pass Program for child/adolescent IOP and adult substance abuse IOP Established DCF-BHPD weekly calls in order to jointly facilitate planning and problem solving on cases ICMs were redeployed to DCF Regional Offices to work with BHPDs and ARG staff Maintained lower ALOS in inpatient despite the reduction in resources Based on PARS data, the length of stay for PRTFs decreased by 3.4% from CY 09. Maintained the decrease in the percent of days in discharge delay 19.4% Established reports specific to proactively identify members who are at risk of becoming discharge delayed Established weekly meeting with Riverview to review members referred, discharge plans and discharge delayed members. Achieved a service center pass rate for the IRR audit of 90.53% II. EVALUATION OF OVERALL EFFECTIVENESS OF THE CT BHP QM PROGRAM A. Committee structure The following QM committee structure is in place at the time of this evaluation. CT BHP Quality Management Committee (QMC) The QMC was established to provide oversight of the CT QM program. The QMC is co-chaired by the Medical Director and the Vice President (VP) of QM. The QMC reports both to the Senior Management Quality Management Steering Committee (SMQMSC) which is chaired by the Service Center VP/CEO, and to the ValueOptions Corporate Quality Council. During 2010, the membership of the QMC was comprised of representatives from all key departments within the Service Center. These include: CEO Medical Affairs Quality Clinical/Case Management including representation from the Intensive Care Management area Provider Analysis and Reporting IT/Reporting Customer Service Human Resources Finance The QMC met on a monthly basis at the beginning of the year and then moved to quarterly meetings as management was increasingly pulled to other required, often external meetings. As nearly 100% of the indicators on the QM Workplan were meeting and exceeding standards, the committee focused more on the Provider Analysis and Reporting (PARs) programs as well as the Performance Incentive programs. These programs continue to grow in scope and complexity and require ongoing strategic planning and review. Additionally, the Safety and Risk Management program received the attention of the committee as processes for identifying and managing high risk members were re-evaluated and enhanced. Quality of Care (QoC) Sub-Committee The QoC Sub-Committee reports to the QMC and is co-chaired by the Medical Director and the VP of QM. In addition to the co-chairs, the membership of the committee included: 5

6 QM Director QM Coordinator Intensive Care Management Team Leader Regional Network Manager The committee met weekly to review adverse incidents as well as quality of care and service issues identified by CT BHP staff, members, providers, and, on request, the Departments. The sub-committee reviewed all issues identified during the previous week and followed up on the results of actions and/or investigations previously identified by the committee. The subcommittee periodically reviewed the trends of specific facilities or programs. Additionally, the sub-committee identified new categories of QoC issues when necessary. During 2010, the focus of the committee has increasingly been on the review of the adverse incidents identified during clinical review of cases. While this committee reviews individual cases, the committee also identifies trends and opportunities for the improvement of internal processes. During 2010, the committee worked on improving the consistency with which high risk cases are identified, reviewed with Team Leads and Medical Directors, and followed by Intensive Care Managers following discharge to ensure appropriate follow-up care. 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 Director of PARs. Its members include: Regional Network Managers VP of QM QM Analysts Ad hoc: CEO, UM Director The primary focus of this committee is on the development of strategies for improving systems of care with particular focus on addressing issues generated by the PARs and Performance Incentive programs. The complexity of the PARs program has necessitated the formation of several workgroups off of the Network Management Sub-Committee including workgroups focusing specifically on the inpatient, ECC, RTC, and PRTF programs. The Network Management Sub-Committee then focuses on improving the consistency of strategies across the PARs program. This committee provides oversight of the five (5) Geo-Teams. The Geo- Teams include CT BHP staff, both clinical and administrative, who are involved with facilities and programs in specific geographic regions. These teams review PARs data and Performance Incentive program results and provide their perspective on the findings. The teams also strategize around interventions that would improve the performance of the facilities and programs in the region. The PARs Workgroup was established late in 2007 as the vehicle to oversee the development and implementation of the PARs initiatives. During 2009, the workgroup continued to meet weekly to assess profile monitors for each of the PARs programs, review data and recommendations from providers involved in the PARs programs, and to share the findings of the PARs programs with other departments. The workgroup is currently chaired by the VP of QM. Included in its membership are: Medical Affairs 6

7 Director of UM Director of IT/Reporting Regional Network Managers Quality Department Staff Provider Relations Ad hoc: CEO Utilization Management Sub-Committee The Utilization Management (UM) Sub-Committee was formally established It is chaired by the VP of Child and Family Clinical Operations. The committee meets monthly and primarily focuses on review of utilization data and the oversight of the UM and ICM Program. The focus of the committee during 2010 was on the oversight of the Bypass Programs for several levels of care as well as on improved oversight of outpatient services. During 2010, a project that retrospectively identified members under three (3) years of age who are on psychotropic meds was completed and presented to the MCO Subcommittee. The members of the committee include: Medical Director UM Director Director of Intensive Care Management and Peer Support Services VP of Quality Management QM Staff 7

8 Consumer and Family Advisory Sub-Committee The Consumer and Family Advisory Sub-Committee was established in 2006 and meets at least quarterly. It is chaired by the Director of Intensive Care Management and Peer Support Services and includes members, families of members, member advocates and CT BHP peer support staff. The Sub-committee provides the forum for the service center QM program to receive input from members and families. One example of their work in 2010, was the revision of the CT BHP Member Handbook. CT BHP Primary Care Physician Advisory Sub-Committee The Physician Advisory Sub-Committee was established in 2006 and meets quarterly. The group is comprised of physicians from both behavioral health and primary care and is cochaired by the CT BHP Medical Director and the Child Health and Development Institute of CT (CHDI). During 2010, the Physician Advisory Sub-Committee focused on strategies to improve the coordination of behavioral health care and primary care. A symposium on coordination of care was co-sponsored by CHDI and ValueOptions and featured a presentation by a pediatrician who has developed a screening tool for use with youth and/or their parents for the identification of behavioral health issues. The committee continues to work on the issue of improving communication between primary care and behavioral health providers. Assessment and Recommendations regarding QM Committee and Sub-Committee Effectiveness: As the committees moved away from oversight of the implementation of the CT BHP and towards projects designed to further CT system reform, there has been an increasing need to assess the resources necessary to implement those projects. As a result, additional levels of management of the CT BHP departments were added to assist in managing and operationalizing the projects. In the QM Department, this included the addition of a QM Director. These resources should help to support the maintenance of the committee structure and to manage the projects they undertake. D. Adequacy of resources The following chart is a summary of the positions currently included in the Quality Management Department, their credentials and the percentage of time devoted to quality improvement activities. Additionally, extra-departmental staff are listed with the percentage of their time devoted to quality activities. Title Credentials Percent of time per week devoted to QM VP Quality Management PhD 100% Director of QM LCSW 100% Director of PARs LMFT 100% Regional Network Managers (4 FTEs) Bachelors with experience and MA level 100% Network Coordinator Bachelors 100% 8

9 Quality Analyst (3 FTEs) 1 MBA and 2 Bachelors of Science 100% Appeals Coordinator II Bachelors of Arts 100% Complaint & Grievance Coordinator I High School Diploma 100% CEO/ VP Service Center Masters 30% Medical Director MD 50% VP of Child and Family MA 30% Clinical Operations Director of Customer and N/A 20% Provider Relations Director of Utilization LPC 20% Management Director of Community Support MA 20% During 2010, with the addition of new and more complex PARs and Performance Incentive programs as well as additional reporting responsibilities previously completed by another department, the resources dedicated to the QM Department were very stretched. As a result of the new contract, additional resources will be added during the first half of the year. E. Practitioner Involvement One of the strengths of the CT BHP QM Program is the active involvement of network practitioners in the program. Behavioral health practitioners representing different levels of care are integrally involved via the PARs program. They are instrumental in establishing measures and in setting goals for their performance. Providers are also involved in multiple QM Committees and Sub-Committees, including those that provide oversight of the Partnership at the highest level. Please see the 2011 CT BHP Program Description for details about those committees that involve providers. F. Leadership involvement Another significant strength of the QM program is the leadership involvement. The CEO and members of the senior management team are all active participants in the day to day operations of the QM Program. This active involvement provides a clear message to all CT BHP staff regarding the importance of their involvement in and support of the activities. The CEO brings her special expertise and experience in the development of the PARs and Performance Incentive programs. She participates in the PARs Workgroup and works closely with the Regional Network Management team to strategize and shape their projects. The Medical Director also plays an influential role in the Quality of Care Committee and the PARs Program. He is an active member of the QMC and provides input to the design of Quality Improvement Activities, particularly those involving clinical activities. He helps monitor utilization trends and contributes to the oversight of the appeals process. During 2010, he took the lead on designing and implementing the enhanced risk management program for the service center. 9

10 G. Patient Safety A strong focus of the service center during 2010 has been on patient safety and risk management. The oversight of adverse incidents and quality of care issues has been revised and strengthened. There has been increased focus on the identification of members who presented to emergency departments with high risk behaviors that resulted in serious self harm and the improvement of supervision and follow-up on these cases. 10

11 III. EVALUATION OF THE 2010 CT BHP QM PROJECT PLAN Goal 1: Review and approve the 2009 CT BHP QM/ UM Program Evaluation, 2010 QM Program Description and 2010 CT BHP QM Project Plan. (Contract reference: L3.1, L4 and L4.2.5) A-C. Activities and Findings that include trending and analysis of the measures to assess performance: The 2009 QM Program Evaluation, the 2010 QM Program Description, and the 2010 QM Program Project Plan were submitted to the Departments on March 31, Formal approval of the documents by the Departments was received on April 26, Recommendations for continuing sub-goal in 2011: This sub-goal should be continued in Goal 2: Ensure timely response and resolution of member/provider complaints and grievances. (Contract Reference Exhibit E; 20A-E) Description of Activities and Findings including trending and analysis of measures over time: A-B. Total number of complaints and grievances: Total Number of Complaints All Complaints In 2010, there were a total of 40 complaints and grievances received. Thirty-eight of those received in 2010 were also resolved and closed in There were two (2) complaints and grievances that were open at the end of Q4 10; they were subsequently closed in Q1 11. In comparison to 2009, this represents an increase of 42.9% in the total number of complaints and grievances received in The increase in complaints and grievances during 2010 is largely due to extensive retraining of staff within the service center and ensuring that complaints and grievances are entered into the system correctly. Following the training, it was determined early in 2010, that staff were 11

12 entering more complaints but not using the subset of complaint reason codes required by the departments to document the complaint correctly in the system. As a result, reports were not picking up all the complaints received within a quarter. During Q2 and Q3, we manually calculated the number of total complaints received in order to ensure accuracy. In addition, QM staff worked with the Service Center staff to correct choice of reason code errors. By Q4, all complaints received were correctly categorized in the system and reflected in the reports. In addition to correcting documentation errors, QM staff worked with IT to update the reports that are used to calculate the quarterly statistics for complaints and grievances. The report indicates Total Complaints Processed which is defined as all complaints and grievances that were touched during the timeframe (monthly or quarterly) including complaints received during the reporting period plus those remaining from the previous month/quarter. It is a discrete count of complaints in the system during the reporting period. Additionally, the report looks at the number of complaints resolved and then breaks it out by timeframes (within 30 days, days and greater than 45 days). Total Complaints Resolved between days are all complaints and grievances that necessitated a request of the member/provider for a one-time extension of 15 calendar days in order to complete the investigation and resolve the complaint. The extension is for the sole benefit of the complainant. The new report ends with Complaints Open at the end of reporting period (Current) which is the number of complaints and grievances open at the end of the reporting period and also the number of complaints and grievances open at the time the report was run. C-D. Total number of complaints and grievances broken out by member (child and adult) and provider complaints. Volume of Complaints by Source # of Complaints Provider Complaints Child Member Complaints Adult Member Complaints Of the 40 complaints and grievances received in 2010, five (5) were provider complaints, one (1) was a provider grievance, 18 were regarding child members, two (2) were child member grievances, and 14 were adult member complaints. The provider complaints were in reference to the Outpatient Registration Process, claims, benefits, and treatment practice issues. The adult member and child member complaints were in reference to benefits, inconvenient provider location, appointment wait time, treatment practice issue, being treated unfairly, and the authorization process. Of the 40 complaints received in 2010, there were three (3) grievances filed as a result of the complainant being dissatisfied with the complaint resolution. 12

13 E. Average number of days to resolution Timeliness of Complaint Resolution Average # of Days Average Days There were 40 Complaints and Grievances resolved in 2010; 37 were resolved within 30 days, 2 were resolved between 31 and 45 days due to needing additional time to investigate the complaint (the member was notified and a 15 day extension was requested), and 1 was resolved greater than 45 days. At the end of 2010, there were 2 Complaints/Grievances which remained open and were closed within Q1 11. The average resolution time increased to days in CY 10 as compared to last year when the average resolution time was days. This is in part due to the volume increasing as well as a new process being implemented whereby the complaints are reviewed weekly by a committee. While the committee review extends the resolution time, the participation of multiple departments in the investigation and resolution has resulted in the process being more thorough. Timeliness of Complaint resolution by Type of Complaint Average # of Days Provider Complaints Child Member Complaints Adult Member Complaints The increase in average number of days to resolve complaints is primarily accounted for by the substantial increase in the amount of time to resolve provider complaints (a 115.2% increase) as opposed to member complaints which has only increased by 6.2% for adult members and 18.3% for child members. 13

14 F. Percent of complaints resolved within 30 days There were 40 Complaints and Grievances resolved in 2010; 37 (92.5%) were resolved within 30 days, two (2) additional Complaints were resolved between 31 and 45 days due to needing additional time to investigate the Complaint. In both instances the member was notified, a 15 day extension was requested and then both Complaints were resolved within 45 days. One (1) Complaint was resolved in more than 45 days. This was due to QM staff not using scrub reports effectively to identify when the Complaint workflow process was not followed correctly. Once QM Staff became aware of the Complaint via the scrub report, 72 calendar days after it was received, the Complaint was resolved within 7 calendar days. 97.5% of the Complaints/Grievances received in 2010 were resolved within either 30 days or 45 days with a requested extension. This is a slight decrease from past years when 100% of Complaints/Grievances were resolved within the above mentioned timeframes. At the end of 2010, there were 2 Complaints/Grievances which remained open and were closed during Q1 11 within 30 days. G. Most frequent reasons for complaints Of the five (5) provider complaints received in 2010, the following reason codes described the nature of the complaint: One (1) complaint regarding benefits, One (1) complaint regarding claims, One (1) complaint concerning Value Options staff, One (1) complaint in reference to quality of care-provider treatment practice issue, One (1) complaint regarding WEB Registration Of the 14 adult member complaints received in 2010, the following reason codes describe the nature of the complaint: Ten (10) complaints in reference to quality of care-provider treatment practice issue, One (1) complaint regarding benefits, One (1) complaint regarding member request provider change due to inconvenient provider location, One (1) complaint in reference to appointment wait time, One (1) complaint regarding member being treated unfairly Of the 18 child member complaints received in 2010, the following reason codes describe the nature of the complaint: Nine (9) complaints in reference to quality of care-provider treatment practice issue, Four (4) complaints regarding benefits, One (1) complaint in reference to appointment wait time, One (1) complaint regarding WEB Registration, One (1) complaint in reference to referral appointment issue, One (1) complaint regarding member request provider change due to member being treated unfairly, One (1) complaint regarding member being treated unfairly 14

15 Recommendations for continuing sub-goal in 2011: This sub-goal continues to be applicable for 2011 and should be included in the 2011 Project Plan. Goal 3. Promote patient safety and minimize patient and organization risk from Adverse Incidents and Quality of Care and Service Issues (Contract Reference L.10.1) Activities and Findings that include trending and analysis of the measures to assess performance: A. Quality of Care (QoC) 1. Number of QoC issues identified; broken out by child and adult In 2010, there were 227 received and reviewed by the QOC Committee. This is a 19.8% decrease from 2009 (283). Out of 225, 95 were categorized by issue and further tracked by level of care. The remaining 130 were deemed not quality of care. 120 or 92.3% did not have enough evidence to support a QOC concern and 10 or 7.7% were unsubstantiated. Of the accepted QoC issues received, 4 were still in progress at the end of the year due to outstanding chart reviews. Of the accepted QoC issues received and categorized in 2010, 84 (94.5%) concerned the quality of the treatment of youth and the remaining 7 (7.7%) concerned individuals over 18 years old. The following chart displays the percentage of accepted QoC issues by Level of Care (LOC): Percentage of Quality of Care by Level of Care % of Cases 50% 45% 40% 32 35% 28 30% 25% 20% 15% % % 0% PRTF CARES IOP EMPS IICAPS ED GH OTP RTC IPD/IPF % of QOC 1.1% 2.2% 2.2% 3.3% 3.3% 4.4% 7.7% 9.9% 30.8% 35.2% Similar to 2008 and 2009, in 2010 the levels of care with the most quality of care issues associated were, by far, the RTC and Inpatient levels of care. 15

16 2. The QoCs issues categorized following the Committee review of the concern. Percentage of Quality of Care by Review Concern 100% 78 80% % of QOC 60% 40% 20% 0% Access to Care Provider Inappropriate/Unprof essional Behavior Attitude and Service % of QOC 0.0% 1.1% 1.1% 12.1% 85.7% 11 CT BHP Other Monitored Events Clincial Practice- Related Issues In 2010, the quality of care category with the highest volume continues to be issues related to clinical practice. In 2010, 85.7% of the QoCs issues identified were related to clinical practice issues. Within the category of Clinical Practice Related Issues, the most frequently occurring types of QoC issues across all levels of care were alleged: Sub Category % of QOC # of QOC Concerns of providers lack of supervision 15.4% 12 Failure to follow standard practice 15.4% 12 Inadequate discharge planning 14.1% 11 Failure to coordinate care 12.8% 10 Peer to Peer sexual relationship 7.7% 6 Incomplete information for effective UR process 6.4% 5 Failure to attempt to involve family in treatment 5.1% 4 16

17 When sorted by Level of Care (LOC), trends in quality of care issues identified by LOC are: Inpatient: RTC Category % of QOC # of QOC Inadequate discharge planning 18.8% 6 Failure to attempt to involve family in treatment 12.5% 4 Incomplete information for effective UR process 12.5% 4 Failure to coordinate care 9.4% 3 Failure to follow standard practice 9.4% 3 Failure to report required info to DCF (i.e. 136, Critical incident, abuse/neglect, med changes) 9.4% 3 Failure to follow DCF protocol 6.3% 2 % of QOC # of QOC Category Concerns of providers lack of supervision 32.1% 9 Failure to follow standard practice 21.4% 6 Peer to Peer sexual relationship 21.4% 6 Member substance abuse 10.7% 3 3. Trend Quality of Care issue by provider Percentage of Quality of Care by IPF/IPD Providers % of QOC 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Cornell Scott-Hill Health Hampstead Hospital Manchester Hospital Yale New Haven Hospital Riverview 2 2 Stonington St. Vincent's 3 3 Hartford Hospital % of QOC 3.1% 3.1% 3.1% 3.1% 6.3% 6.3% 9.4% 9.4% 12.5% 43.8% 4 Natchaug Hospital 14 St. Francis 17

18 During 2010, one inpatient hospital, St Francis, accounts for the largest percentage of identified quality of care issues. Fourteen quality of care issues were identified during 2010 with the majority of the QoC issues being related to Incomplete Information for Effective UR Process and Inadequate Discharge Planning. The issues were nearly all identified during the first quarter of the year and were reviewed with St. Francis during their quarterly Provider Analysis and Reporting (PARs) meeting. Percentage of Quality of Care by RTC Providers 25% 6 20% % of QOC 15% 10% % % Devereu x, MA Gray Lodge Harmon y Hill Hillcrest ITU Kidspea ce Northea st Center Waterfor d Country Whitney Devereu Wellsprin Academ x, FL g y Hillcrest/ Highpoin t Children' Mount s Center St. John of % of QOC 3.6% 3.6% 3.6% 3.6% 3.6% 3.6% 3.6% 3.6% 7.1% 7.1% 10.7% 10.7% 14.3% 21.4% Klingber g For RTCs, Klingberg and Children s Center of Hamden had the highest volume of quality of care issues, 6 and 4 respectively. For Klingberg, the majority of QoC issues were related to the providers lack of supervision, whereas for Children s Center of Hamden the majority of the QoC issues were related to member substance abuse. Following review by the committee, certain quality of care issues are shared with DCF staff. This is particularly true when it is uncertain whether DCF was notified of the issue or when it is unclear whether an investigation by DCF has been conducted. Annually, the concerns are trended and shared with the Departments in Clinical Operations. B. Adverse Incidents 1. Number of adverse incidents broken out by child and adult In 2010 there were 193 reported incidents. This is a 565.5% increase in reporting of adverse incidents from The substantial increase is due to Service Center trainings and increased attention being placed on monitoring risk events. Due to frequent contact with the hospitals, staff at the hospitals quickly learned what information CT BHP staff were requesting and subsequently provided that information more reliably. All 193 incidents were given a severity rating by the ValueOptions QualityConnect system; one (1) was deemed sentinel, four (4) were major, 82 were moderate and 106 were minimal risk. Of the 193 incidents, 95 (49.2%) involved youth and 98 (50.8%) involved adults. The one (1) sentinel event involved a youth and the four (4) major events involved 2 adults and 2 children. All incidents were reported to the departments or were determined to have already been reported to the departments by the facility or provider. 18

19 2. Most frequent types of Adverse Incidents identified: In 2010, the most frequent type (169) of reported adverse incidents involved self-inflicted harm (87.6%). Three (3) of the four major risk events involved self-inflicted harm and all of the members involved were admitted to an inpatient psychiatric hospital, typically following a medical stay to stabilize them. The next most frequent type during 2010 (five (5) incidents reported) were those that involved sexual behavior and injury. The one (1) sentinel event involved a youth and was typified as sexual behavior (alleged rape, of patient by patient). The remaining four (4) were deemed minimal risk. With respect to injury, all five (5) were deemed minimal risk. Other adverse incidents fell into categories such as elopement, violent or assaultive behaviors (non-lethal), unanticipated death, damage to property, and human rights violations. There were two (2) reported unanticipated deaths during 2010, one for an adult and one youth. CT BHP was notified of the adult who committed suicide during a retro review due to eligibility for inpatient care. The youth case involved a member who was attending a Partial Hospitalization Program and experienced medical complication while at the program. All incidents were reported to the departments or were determined to have already been reported to the departments by the facility or provider. 3. Trending of Adverse Incidents by provider With respect to trends in 2010, for Children s Center of Hamden (RTC) there were eight (8) incidents identified; seven (7) of which happened within the RTC. The eighth involved a RTC member while at the school on site. Of the incidents that were reported one (1) was deemed major, five (5) were considered moderate and two (2) were found to be minimal. Two (2) of the incidents were submitted due to elopement, one (1) was due to accusations of mistreatment/abuse, one (1) was due to injury from a fall and four (4) were due to self inflicted harm; suicide attempts. Following the reporting of all incidents it was confirmed by the facility that the Department of Children and Families had been contacted and was investigating as needed. Another facility with significant trends was Klingberg Family Center (RTC) which had five (5) incidents reported with an additional one (1) at the PRTF level of care. Of the incidents that were reported all were deemed minimal risk. One (1) of the incidents was submitted due to elopement, one (1) due to damage to property, one (1) for injury during restraint, another (1) due to injury, one (1) due to violent/assaultive behaviors and one (1) due to sexual behaviors (consensual, same age band). As mentioned above, following the reporting of all incidents it was confirmed by the facility that the Department of Children and Families had been contacted and was investigating as needed. Recommendations for continuing sub-goal in 2011: This sub-goal will be applicable for 2011 and should be included in the 2011 Project Plan. 19

20 Goal 4. Establish and maintain CT BHP-specific policies and procedures (P&Ps) in compliance with contractual obligations that govern all aspects of CT BHP operations. (Contract Reference E.3.1 and L.9) Activities and Findings: 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. During 2010, individual departments reviewed all of their policies and made revisions when necessary. Substantive revisions were made to several of the Quality Management P&Ps. Q316 Adverse Incidents, Critical Incidents, Significant Events and Sentinel Events were edited and submitted to DCF for review and final sign off. Additional revisions were made to the QM303 Medical Necessity Denials Notice of Action, QM308 Administrative Denials, QM305 Provider Appeals, QM309 Member Appeals, and QM306 Complaints and Grievances. See Appendix A for the revised P&P. Recommendations for continuing sub-goal in 2011: This sub-goal will be applicable for 2011 and should be included in the 2011 Project Plan. Goal 5. Establish and maintain training program that includes compliance with state regulatory requirements and HIPAA regulations (Contract Reference V.1 and V.3) Activities and Findings: A. Staff training on state regulatory requirements Staff training on state regulatory requirements is completed during orientation and then via periodic review in departmental staff meetings. This training has been conducted with 100% of new employees. The QM Department provided periodic updates on state and federal regulatory requirements during the year. B. Staff training on HIPAA privacy regulations The annual service center wide HIPAA training was conducted as usual during All service center staff completed the training. Human Resources monitors to ensure full compliance with this requirement. This training was later than usual this year in order for National VO to update the training module so that it incorporated the new rules related to HIPAA privacy regulations called HITECH (Health Information Technology for Economic and Clinical Health Act). Refresher trainings on basic information about PHI and what constitutes a HIPAA breach were conducted over the course of the year. In addition, quarterly audits were conducted of the service center staff to ensure compliance with the rules around protecting PHI. In 2010, there were eight (8) incidents where PHI was exchanged with an unintended party. Each instance was assessed with the assistance of National ValueOptions as to whether or not it was a violation or a breach and then the level of risk to the member was also assessed. Seven of these events were deemed to be violation and the eighth was considered a breach. The eight (8) instances fell into the following categories: 20

21 Privacy Violations: One involved sending an authorization letter to an incorrect provider. One involved a voice mail left for a provider for a member who was not at that facility. One involved clinical information being added for one member under another member s review. One involved an with an attachment which had non-secured PHI embedded within graphs. When the graphs within the Power Point were double clicked the data used to create the graphs was revealed which contained PHI (member name, id #, dates of admission to IICAPS and provider BHP id # s). The Departments were notified of this violation and a Corrective Action Plan was created: o Educate and train QM staff who create the graphs and instruct them to use a file naming convention that denotes PHI being included in the spreadsheet or PowerPoint and to keep member s PHI in separate files from materials that are sent externally for presentations. The determination that these incidents were privacy violations was based on the material being submitted to covered entities which are bound by the same Privacy Rules. In all cases, immediate actions were taken to retrieve the information or ensure that the information was destroyed if retrieval was not possible. In all cases, the Departments were notified of the HIPAA violations. Policy Violations: One involved a system issue where a provider was able to access all HUSKY members when doing a member search in AIS instead of that one particular member. Modifications were made to the system to block access to all members. One involved an sent encrypted but with information for the wrong member of an MCO. One involved an unencrypted which contained a spreadsheet with PHI to an innetwork hospital. The determination that these incidents were policy violations was based on ValueOptions policy not being followed which resulted in violation. In all cases, immediate actions were taken to retrieve the information or ensure that the information was destroyed if retrieval was not possible. In all cases, the Departments were notified of the HIPAA violations. Breach One involved an being sent to an unintended party external to ValueOptions. In error an external party was included in an distribution and the contained a member s name and Medicaid ID#. In spite of the being encrypted the external party was able to view the PHI. The unintended party immediately notified ValueOptions and confirmed that the was destroyed. National IT confirmed that the had been sent encrypted. The Departments were notified of this incident and ValueOptions assessment that this incident constituted as a breach and that member notification was needed. As well, a Corrective Action Plan was created: o Raise awareness of the risk associated with sending s without double checking the distribution list before hitting send. The Director of QM attends the Clinical staff meeting and reviews the regulations semi-annually. In addition, periodic reminders are mailed to all staff in the service center which include topics 21

22 such as the need to lock computers when staff walk away from their desk and HIPAA issues that can arise when faxing and ing. Privacy audits were conducted quarterly and feed back was provided to the various departments with respect to how staff was complying with the privacy regulations. Recommendations for continuing sub-goal in 2011: This sub-goal will be applicable for 2011 and should be included in the 2011 Project Plan. Goal 6. Ensure timely telephone access to CT BHP (Contract Reference Q.3) Activities and Findings that include trending and analysis of the measures to assess performance: During the first quarter of 2010, the decision was made to re-configure the telephone system and how calls come into the Call Center. Early consultations were held with ValueOptions national staff to determine next steps. This new process went live on June 14, 2010 and is consistent with other ValueOptions Service Centers. The re-design allows for a more streamlined process where by all provider calls are answered by Customer Service staff in order to confirm member eligibility and then transferred to Clinical staff to complete reviews. Call backs and appointments have been virtually eliminated. During this process, it was discovered that the previous calculations of the phone statistics were inaccurate; there has been an inflated count of the call volume. The inflated call volume resulted from calls being counted twice; once when answered by the receptionist and then again when the call was transferred to the clinical or customer service lines. Phone statistics were subsequently recalculated back to Q4 09; the earliest date for which phone data was stored by the system. The departments were notified of this finding and of the actions that were being taken by ValueOptions to obtain the corrected data. National ValueOptions staff were brought in to work on and program the revised reporting package. The reports are now generated by the QM Department. 22

23 Volume of Calls Volume of All Service Center Calls # of Calls Q4 '09 Q1 '10 Q2 '10 Q3 '10 Q4 '10 Crisis Customer Service Providers With the increasing membership, the total volume of calls coming into the service center continues to increase; the service center continues to receive a higher volume of provider calls as opposed to customer service calls within the past few quarters. The call volume from customer service increased from 7519 in Q4 09 to 8169 in Q4 10, an 8.6% increase. Q1 10 reports the highest number of provider calls to date (10326) and Q3 10 reports the highest number of crisis calls to date (91). Member and Provider Telephone Access A. Average speed to answer: Average number of seconds until call is answered by a live person Average Speed of Answer: Provider Calls 0:10 0:09 0:08 0:07 Avg Time 0:06 0:05 0:04 0:03 0:02 0:01 0:00 Q4 '09 Q1 '10 Q2 '10 Q3 '10 Q4 '10 CY '10 Providers 0:09 0:09 0:07 0:03 0:05 0:06 23

24 Average Speed of Answer: Member Calls 0:08 0:07 0:06 Avg Time 0:05 0:04 0:03 0:02 0:01 0:00 Q4 '09 Q1 '10 Q2 '10 Q3 '10 Q4 '10 CY '10 Customer Service 0:07 0:07 0:05 0:04 0:05 0:05 Crisis 0:06 0:06 0:04 0:02 0:02 0:03 The standard for the Average Speed of Answer is <30 seconds for both provider and customer service calls and <15 seconds for crisis calls. The service center was well within this standard for all calls within the quarters and continues to have a stable trend with average answer speeds. B. Abandonment Rate: Percentage of calls not answered before caller hangs up Call Abandonment Rate Average: All Calls 0.16% 0.14% 0.12% % of Calls 0.10% 0.08% 0.06% % 0.02% % Q4 '09 Q1 '10 Q2 '10 Q3 '10 Q4 '10 CY '10 Total Calls 0.13% 0.14% 0.07% 0.01% 0.01% 0.06% The standard for Call Abandonment Rate is <5% for all service center calls. The service center was well within this standard for all calls within the past quarters. The service center decreased the volume of calls abandoned by 95.7% from Q4 09 to Q

25 C. Percentage of calls placed on hold and average length of time on hold for Customer Service Percentage of Member Calls Placed on Hold % of Calls 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Q4 '09 Q1 '10 Q2 '10 Q3 '10 Q4 '10 CY '10 Customer Service 42.96% 43.59% 49.05% 59.13% 53.20% 51.29% Crisis 9.72% 7.25% 12.86% 14.29% 9.72% 11.26% From the beginning of 2010 we see that there has been a rise in the percentage of member calls placed on hold. However, in Q4 10, there was a decrease in both customer service and crisis calls being placed on hold (from 5.93% in Q3 10 to 4.57% in Q4 10). The volume of calls placed on hold is highly correlated with the volume of calls received. Average Hold Time of Member Calls 1:10 1:00 0:50 Avg Time 0:40 0:30 0:20 0:10 0:00 Q4 '09 Q1 '10 Q2 '10 Q3 '10 Q4 '10 CY '10 Customer Service 0:50 0:59 0:47 0:27 0:40 0:40 Crisis 0:19 0:27 0:24 0:33 0:17 0:25 The standard for average length of time that members are placed on hold is <3 minutes for customer service and <1 minute for crisis calls. In the reporting quarters, the service center is well within the standard and continues to have a stable trend. Q3 10 reports the shortest 25

26 average hold time to date for customer service calls (27 seconds) and Q4 10 reports the shortest to date average hold time for crisis calls (17 seconds). D. Percentage of Provider calls placed on hold and average length of time on hold for Clinical Services Percentage of Provider Calls Placed on Hold 100% 90% 80% % of Calls 70% 60% 50% 40% 30% % 10% 0% Q4 '09 Q1 '10 Q2 '10 Q3 '10 Q4 '10 CY '10 Providers 26.06% 26.52% 34.66% 83.89% 83.47% 56.13% The percentage of provider calls placed on hold has increased by 57.4% from Q4 09 to Q4 10. This large spike is due to the new triaging method, where calls are directed to the clinicians on first contact. This new method has also impacted the volume of provider calls placed on hold, which has increased by 23.2% from Q3 10 to Q4 10. The increase of percentage of provider calls being placed on hold is also related to the system conversion which took place in Q4 10. As clinical staff become more skilled in the use of the new system, their speed in completing reviews should improve resulting in fewer provider calls being placed on hold. Average Hold Time of Provider Answered Calls 1:10 1:00 0:50 Avg Time 0:40 0:30 0:20 0:10 0:00 Q4 '09 Q1 '10 Q2 '10 Q3 '10 Q4 '10 CY '10 Providers 0:34 0:34 0:40 0:45 0:59 0:44 26

27 The average length of time on hold was well within the standard of <5 minutes for the Clinical Department. However, the gradual increase in average hold times across the quarters is primarily due to the new triaging method as well as longer call times during the system conversion as clinicians become more familiar with the new clinical screens. As a result, providers are on hold for a bit longer, but are still able to reach a clinician to complete a review during the initial call. Average hold time for provider calls increased by 31.1% from Q3 10 to Q4 10. E. Average Length of Time of Call Average Length of Time on Call for All Calls 6:00 Avg Time 5:24 4:48 4:12 3:36 3:00 2:24 1:48 1:12 0:36 0:00 Q4 '09 Q1 '10 Q2 '10 Q3 '10 Q4 '10 CY '10 Total Calls 4:49 4:48 4:08 2:18 2:49 3:32 Overall, with the telephone system reconfiguration, there has been a significant decrease in the average length of time on calls throughout the second half of the year. The reason that the time on calls is shorter is because the measure is of the length of time on the portion of the call when it is first answered. Because all calls first go to Customer Service and then are either handled or triaged to the appropriate department, the clinical portion of the call that used to be included in this measure is no longer included. This results in the appearance of shorter average length of calls. In order to assess the average length of clinical calls, it is recommended that a new measure be initiated in Q3 10 reports the shortest average call length of time to date (2:18). The average length of time on calls for all calls has decreased by 41.5% from Q4 09 to Q4 10. However, from Q3 10 to Q4 10 there has been a 22.5% increase in average length of time on calls, which could be due to the increased volume of calls in Q4 10. Recommendations for continuing sub-goal in 2011: This sub-goal will be applicable for 2010 and should be included in the 2011 Project Plan. It is recommended that a new measure of the average length of clinical calls be added to the workplan. 27

28 Goal 7. Develop and implement Quality Improvement Activities (QIA) to address opportunities for improvement 7A. Child QIA: Decreasing the Rate of Disruption of Newly Placed Foster Care Children with a Hx of Behavioral Healthcare Treatment (Contract reference L.8) Activities and Findings that include trending and analysis of the measures to assess performance: Please refer to Appendix B for the data analysis and a summary (previously submitted) of the findings of this quality improvement activity. Recommendations for continuing sub-goal in 2011: This sub-goal will not be continued in A new quality improvement activity will be initiated in Currently under consideration with the departments is a project for 2011 concerning behavioral health services for members with developmental delays. A retrospective data analysis of utilization of services by this population as well as a literature review of best practices in the behavioral health treatment of this population will be conducted during the first half of 2011 A sub-goal regarding this QIA will be added to the 2011 QM Project Plan. 7B. Adult Study: MCO Co-Management Quality Improvement Activity on Improving the Identification of Post-Partum Depression and Connecting Members to Treatment Activities and Findings that include trending and analysis of the measures to assess performance: Please refer to Appendix C for the data analysis and a summary of the findings of this quality improvement activity. Recommendations for continuing sub-goal in 2011: This sub-goal will be continued in 2011 and should be included in the 2011 Project Plan. 28

29 7C. Reducing discharge delays for youth receiving inpatient behavioral health treatment (Contract reference: 2010 Performance Target 6) Activities and Findings that include trending and analysis of the measures to assess performance: The 2011 Performance Target related to discharge delay days was a maintenance measure based on 2009 discharge delay performance. Per performance target 6, the goal was to maintain discharge delay days at 20% or less of total inpatient days. Specifically, the percent of inpatient days in delay status was expected to total no more than 20% and acute average length of stay was to increase by no more than 3% in 2010 from the baseline established in Q3 and Q4 of 2008 (12.92 days). The total percent of discharge delay days for 2010 was 19.37% and the acute average length of stay for the year was days, indicating that the established target was met. 10B7: Percent of Inpatient Days Delayed All Children Excluding Riverview 30% 341 % of Days Delayed 25% 20% 15% 10% % 0% CY '08 Q1 '09 Q2 '09 Q3 '09 Q4 '09 CY '09 Q1 '10 Q2 '10 Q3 '10 Q4 '10 CY '10 Youth 25.2% 11.6% 15.1% 15.9% 17.5% 15.0% 16.6% 21.5% 22.7% 16.5% 19.4% The percent of inpatient psychiatric days spent by youth in discharge delay has increased from 2009 to The above graph illustrates the percent of days in each quarter that were discharge delayed. The percentages are based on all inpatient days used during the quarter, not on days associated with only discharged cases. The following grid displays actual performance during 2010 with regard to the number of discharge delay days during each quarter and the total for the year as well as the acute average length of stay for each quarter and the total for the year Q1 Q2 Q3 Q4 Total Discharge Delay Days ,862 Acute Average Length of Stay Days There are several hypotheses regarding the reasons that discharge delay increased during

30 1. During the second quarter of 2010, the eight CT hospitals that treat youth noted during their quarterly meeting that with CT BHP that they were struggling again with obtaining the cooperation of DCF staff to work with them on moving delayed children out of the hospital. They reported that the number of delay days was creeping up and even requested that their performance initiative for 2010 include only Q3 and Q4 10 in order to allow them time to recover from the loss of DCF participation in addressing discharge delay during Q2 10. DCF staff recommitted to the plan to assist hospitals with discharge delayed youth midway through During 2009, when there was great success in decreasing discharge delay, part of the success was accounted for by the focus of the PARs program on discharge delay days in the eight in-state hospitals treating youth in CT. On at least a quarterly basis, meetings with individual hospitals included in depth discussion of the percentage of cases and days in delay status. This activity served to focus the attention of the hospitals on the issue of discharge continued into 2010; both the clinical and the PARs teams were aware of the increase in discharge delay. However, while in-state discharge delay days increased by 21.2 % over the year, out of state discharge delay days increased by more than 100%. This issue was discovered in Q3 10 and addressed by dedicating case managers to the management of out of state inpatient facilities. Additionally, the rash of cases of youth stuck in EDs where the ED was recommending inpatient treatment in out of state hospitals with long lengths of stay and large numbers of delay days was addressed by meeting with those facilities and issuing denials of out of state treatment when appropriate. Further analysis of discharge delay for in-state versus out of state hospitals reveals other significant differences. For CY 2010, in-state average length of delay was 19.1 days, whereas out of state average length of delay was 44.2 days, representing a more than 100% difference between in-state and out of state. In-state hospitals represent a much higher volume of discharge delay cases and days than out of state hospitals, 72.4% of all discharge delay days and 85.1% of all discharge delay cases. However, the percentage of discharge delay days for out of state hospitals is 56.3%, whereas the percentage of discharge delay days for in-state hospitals is 20.1%. 3. Lastly, the loss of beds at Riverview Hospital had an impact on discharge delay. There were longer delays as youth waited for the remaining beds at Riverview. Additionally, as Riverview stays became a less likely discharge plan for members with complex needs, the clinical staff had to develop other plans for youth that might previously been treated at Riverview. As 2010 unfolded, the discharge delay efforts implemented in Q2 10 continued and resulted in significant change in both the discharge delay numbers as well as in the length of stay. As expected, discharge delay increased early in the year as the issues impacting the budget and services resulted in increased difficulty in moving children through the system. With renewed efforts and attention from providers and DCF the year ended on a positive note as the reduction to discharge delay days was notable (from 22.7% in Q3 to 16.5% in Q4). The following summarizes the key initiatives that we believe promoted movement from inpatient care to the community: On-site reviews continue at several inpatient programs but are more targeted for initial care planning, case conferencing and discharge planning meetings to better focus attention and resources on these areas. ICM clinicians have gone back on site for rounds and discharge planning at several hospitals to facilitate timely access to services. 30

31 The ICM clinicians have initiated weekly calls with BHPD s from DCF to facilitate planning and problem solving on cases of concern to either group. The ICM clinicians have begun onsite assistance in DCF Regional offices, to assist the BHPD and ARG staff in coordinating activities for discharge delay cases. Bypass Programs for the in state Child/Adolescent Inpatient providers has continued for Q4 10 The RVH team meets weekly to review members referred, discharge plans and discharge delayed members. Reports specific to proactively identify members who are at risk of becoming discharge delayed are utilized daily. Recommendations for continuing sub-goal in 2011: The goal for 2011 will be to maintain the percentage of inpatient days in delay status at 20% or less of total inpatient days. Acute average length of stay shall increase by no more than 3% in CY 2011 from the baseline established during Q3 and Q4 of CY 2008 of days. Goal 8. Monitor performance of Customer Service staff via audits of performance Activities and Findings that include trending and analysis of the measures to assess performance: A. Assess individual Customer Service staff (at least 5 cases per month) on performance in five (5) areas During 2010, the ValueOptions NICE system was utilized to conduct auditing of the Customer Service staff. The Team Lead and the Director of the Customer Service Department conducted the audits. The audit average for the department was 94.4% for Customer Service staff received feedback regarding their individual performance during supervision and the Customer Service team received feedback regarding overall department performance during staff meetings. 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 department. Audit results indicate that with the exception of misdirected calls (medical, dental, or vision) Customer Service staff routinely document every call received. Based on results from the NICE system, the scores for documentation were above the goal of 90%. Actual results for 2010 were 90.7%. Individual supervision, weekly staff meetings, and trainings were used to discuss the findings of the audits, particularly those areas where there were opportunities for improvement. The opportunity for improvement that was the focus of one initiative during the year was on the improvement of the documentation regarding complaints. As described above in Goal 2, on several occasions complaints were entered into the system that were not categorized within the required CT complaint categories. As a result, the reports did not pick up the complaint. Training on this issue was conducted and protocols and cheat sheets developed for use by the customer service staff. Performance on this issue improved during the second half of the year. A second opportunity for improvement came with the introduction of CareConnect in late The Customer Service Team initiated a collaborative effort between the clinical and customer 31

32 service department to facilitate the identification of members who need to speak with a clinician. Using the Risk Assessment Screening process built into CareConnect, customer service staff have improved the consistency of the identification of members with more urgent clinical needs who would benefit from speaking with a care manager. Education of the customer service staff as well as the clinical staff both individually and during team meetings focused on the review of appropriate call handling and documentation of these calls. Continued training, monitoring, and quality improvement activities will be offered to the team and other call center staff regarding this new initiative to ensure compliance in this area. Recommendations for continuing sub-goal in 2011 This sub-goal will be applicable for 2011 and should be included in the 2011 Project Plan. Goal 9. Review and approve the 2011 CT BHP UM Program Description Activities and Findings that include trending and analysis of the measures to assess performance: A. Annual development and review of the 2011 UM Program Description The 2011 UM Program Description was submitted to the state on November 1, 2010 and was subsequently approved. The 2011 UM Program Description has been updated to address the entire book of business and was be submitted for final approval on April 1, Recommendations for continuing sub-goal in 2011: This sub-goal will be applicable for 2011 and should be included in the 2011 Project Plan. 32

33 Goal 10. Monitor for under or over utilization of behavioral health services; identify barriers and opportunities Activities and Findings that include trending and analysis of the measures to assess performance: A. Inpatient Psych # of Admits, ALOS, Days/1000, & Admits/1000, Excluding Riverview and Riverview only Children Inpatient Average Inpatient Length of Stay Youth (0-18) Excluding Riverview Days DCF Non DCF Average Length of Stay (ALOS) is defined as total Length of Stay (LOS) including acute and discharge delay days. The above graph depicts the average length of stay for youth (children and adolescents) in the inpatient level of care for calendar years 2007, 2008, 2009 and 2010 by DCF and Non-DCF, excluding Riverview. The ALOS had presented a downward trend from 2007 to 2009 for both DCF and non-dcf children. For 2010, IPF admits continued to decrease slightly for non-dcf members, but there was a 13.7% increase in ALOS for DCF children. This increase in ALOS was directly related to the increase in discharge delay. The overall driver of the increase of discharge delay days was represented by the children in specialty hospitals out of state. These units are primarily associated with children with MR/PDD as a clinical profile. The stays associated with these children tend to be protracted with significant barriers to disposition. DCF member s ALOS has been consistently higher than non DCF member s ALOS (11.2 vs. 20.8). However, it should be noted that the ratio of DCF to Non- DCF ALOS was more than 2:1 in 2007 and 2008 but in 2009 and 2010, it is less than 2:1. 33

34 Inpatient Admissions/1000 Youth (0-18) Excluding Riverview Days DCF Non DCF In CY 2010, Inpatient Admissions/1000 decreased for DCF members following a steady increase between CY 2007 and This may be attributed to an increase in discharge delay days for CY 10; as discharge delay and length of stay increases, access to available beds decreases. Admissions have remained stable for Non DCF members across all four calendar years. Inpatient Days/1000 Youth (0-18) Excluding Riverview Days DCF Non DCF Inpatient Days/1000 increased slightly in 2010 for both DCF (2.4%) and for non-dcf (3.8%). Overall however, average length of stay decreased significantly for both DCF and Non DCF children from 21 days in 2007 to 14.8 days in This results in fewer inpatient days per 1000 children. 34

35 Riverview only Riverview Admissions/1000 Youth (0-18) Admissions DCF Non DCF With regard to the admissions per 1000, 2010 saw a slight decrease in DCF youth and no change for Non-DCF youth. Riverview lost beds at the end of 2009 and this is most likely what accounts for the decrease in admits per Riverview Days/1000 Youth (0-18) Days DCF Non DCF Days per 1000 children treated at Riverview have remained fairly flat compared to admits per 1000 which decreased slightly for DCF children. 35

36 Riverview Average Length of Stay Youth (0-18) Days DCF Non DCF Non-DCF children continue to stay in Riverview for shorter periods of time than DCF children. In 2010, Non-DCF ALOS continued to decrease slightly (7.1%) whereas DCF ALOS increased by 25.7 days (19.9%). However, current ALOS for DCF is still lower than in 2007 (difference of 11.8 days) and 2008 (difference of 35 days). # of Discharges CY 2008 CY 2009 Q1 '10 Q2 '10 Q3 '10 Q4 '10 CY 2010 Total # of Discharges Total # of Court Ordered Discharges % of Court Ordered Cases 51.3% 48.4% 50.0% 55.8% 61.7% 51.0% 54.8% % Non-Court Ordered Cases 48.7% 51.6% 50% 44.2% 38.3% 49.0% 45.2% ALOS Court Ordered Non-court Ordered Aggregate (Non-court Ordered & Court Ordered) In CY 10, at the suggestion of Riverview staff, additional reporting was added that breaks out Riverview ALOS by Court-Ordered vs. Non-Court Ordered sub-populations. While there has been some fluctuation both year to year and quarter to quarter, approximately 50% of youth admitted to Riverview are court ordered there. The differences in the ALOS between the two populations is substantial and throws into question the current practice of reporting aggregated ALOS. During 2010, there was very little change in the total number of youth discharged from Riverview yet there was a 10.9% increase in discharges for youth identified as Court Ordered. Court Ordered youth s ALOS remained stable between CY 09 and 10, while the Non-Court Ordered youth s ALOS increased by 31.1% from 2009 to In 2011, it is proposed that we update Riverview reports (4a1 and 4a2) to reflect this break out as it is currently being done manually. 36

37 Adults Inpatient Inpatient Average Length of Stay (IPF) HUSKY Adults (19+) Days ALOS During 2010, inpatient average length of stay decreased by 14.6%, the lowest ALOS since The Bypass Program, instituted in 2009, is still in place. The program involves allowing hospitals treating adults to bypass the first concurrent review providing that in the aggregate, they remain within proscribed length of stay parameters. CT BHP reserves the right to review high risk members at any time to ensure that discharge planning is appropriate. All parameters of the program are reviewed annually. The program will continue to be closely monitored to assess its efficacy, especially with regard to its impact on LOS for the adult population in the aggregate and by provider. The new parameters for this program have been announced and the providers notified that the duration of the initial authorization for those providers in the Bypass program will be five (5) days rather than six (6) days provided previously. The purpose of the change is to allow for a more robust conversation regarding the discharge planning for members returning to communities as well as those requiring more intensive downstream services. 37

38 Inpatient Admissions/1000 (IPF) HUSKY Adults (19+) Admissions Admits/ The number of adult HUSKY members with inpatient stays increased between 2009 and 2010 by 5.8%. While adult admissions/1000 had remained consistent since 2007, a slight drop occurred in 2010 (10%) that may be accounted for by the increase in membership. A data analysis completed early in 2010 showed that the new HUSKY adult members were less likely to be using behavioral health services. However, the number of admissions has increased by 24.8% since 2007 with the 38.8% increase in adult membership. Inpatient Days/1000 (IPF) HUSKY Adults (19+) Days Days/ Adult IPF days/1000 had increased between 2007 and 2009, but a slight decrease was noted for 2010 (6.7%) 38

39 B-C. Inpatient Psych Days in Discharge Delay vs. Acute Length of Stay Acute Portion of Non-Delayed Cases vs Acute Portion of Delayed Cases Youth (0-18) Excluding Riverview Days Non-Delayed Cases Delayed Cases The above graph represents the acute portion of the length of stay of children who were in delay status at some time during their stay compared to the acute portion of children never in delay status. From 2008 to 2010 there continues to be a significant discrepancy between the two populations. In 2010, the acute length of stay of the delayed children s stay is 9.56 days more than the acute portion of the non-delayed children. The acute portion for non-delayed children remained consistent from 2008 to 2009 but decreased slightly in 2010 by 6.4% or 0.74 days. The acute portion of the delayed children s stay increased by 12.6% or 2.3 days in 2010 after 13.3% drop in Children who experience a delay in discharge typically have a longer acute portion in their length of stay than children who experience no delay. The majority of children in discharge delay tend to be more complex and therefore have longer acute portions of their total lengths of stay. Most of the acute days associated in this particular year have been driven by complex cases in hospitals out of state. The complexity of the needs of these children and need for heightened coordination of these stays have resulted in the increase in the acute portion of a stay that ultimately results in a discharge delay for this population. 39

40 Acute ALOS vs Delayed ALOS of All Delayed Cases Youth (0-18) Excluding Riverview Days Acute Portion Delayed Portion Following a substantial drop in 2009, delayed average length of stay increased in 2010 by 5.7 days (31.8%). An increase of 2.28 days was also noted in acute average length of stay (12.6%) for delayed cases only. In order to further understand this phenomenon we have participated in a number of strategy meetings with stakeholders to support the efforts undertaken to resolve the issues of discharge delay. Focused meetings were held with DCF central office to analyze and understand the impact of the MR/PDD population. Additionally, meetings were held with DSS, DCF and DDS staff to evaluate the impact of OOS and MR/PDD cases, on discharge delay. A recent meeting was held with our state partners and DDS to begin to establish a dialogue focusing on the needs of the high risk, high impact MR/PDD population on the system. 40

41 Discharge Delay; Riverview Cases Acute Portion of Non Delayed Cases vs. Acute Portion of Delayed Cases; Youth (0-18) Riverview Only Days Non Delayed Cases Delayed Cases Consistent with all other inpatient hospitals, children who experience discharge delay have longer acute lengths of stay than in non-delayed cases. As seen previously in reporting on Riverview data, there is a distinct difference in the populations of court ordered vs. non court ordered children. These two distinct populations are driven by different needs and treatment responses based on the need for the admission. There is limited utility in aggregate data for this service. Acute ALOS vs Delayed ALOS of All Delayed Cases Youth (0-18) Riverview Only Days Acute Portion Delayed Portion

42 The acute ALOS portion of the delayed cases at Riverview has remained stable from 2008 to The ALOS of the delayed portion, however, increased in 2010 by 21.7%. As expected, we experienced an increase in discharge delay early in 2010 as the issues impacting the budget and services resulted in increase difficulty in moving children through the system. As 2010 unfolded, the discharge delay efforts implemented in early 2010 such as new meetings with the DCF BHPD s, increased ICM activity with Riverview continued and resulted in significant change in both the discharge delay numbers as well as in the overall length of stay. With renewed efforts and attention from the Riverview staff and DCF Area Offices, the year ended on a positive note as the reduction to discharge delay days was notable within the year quarters but is not reflected in the annual numbers. We expect that the efforts to mange the discharge delay days at Riverview ongoing will continue to show improvement. D. Inpatient Detox ALOS, Admits /1000 & Days/1000 Adults Inpatient Detox Average Length of Stay HUSKY Adults (19+) Days ALOS There has been an increase of 27.6% in the number of adults being detoxed in an inpatient setting. This may be accounted for by the increase in adult membership; within the last year there was a 10.1% increase. The average length of stay has stayed relatively consistent since 2007 with only a 0.1 day decrease in length of stay since

43 Inpatient Detox Admissions/1000 HUSKY Adults (19+) Admits/ Admits/ Adult Inpatient detox admissions/1000 has been flat since Though the number of detoxes has increased by 27.6%, this may be accounted for by the increase in membership. Inpatient Detox Days/1000 HUSKY Adults (19+) Days/ Days/ Adult Inpatient detox days/1000 has decreased slightly over the past two years. This is most likely accounted for by the increase in membership, especially since the ALOS has been flat. 43