QUALITY IMPROVEMENT PLAN AND PROGRAM DESCRIPTION FY

Transcription

1 QUALITY IMPROVEMENT PLAN AND PROGRAM DESCRIPTION FY Global Quality Improvement Committee Approved: July 19, 2016 Board of Directors Approval: August 23, 2016

2 Table of Contents Organizational Overview... 5 Governance... 6 Eastpointe s Board of Directors... 6 Executive Committee... 6 Finance Committee... 6 Nominating and Governance Committee... 7 Human Rights Committee... 7 Board Policy Committee... 8 Consumer and Family Advisory Committee (CFAC)... 8 Quality Management Program Overview... 9 Continuous Quality Improvement Quality Management Resources Analytics Department Quality Assurance/ Medicaid Contract Manager Quality Improvement Grievance and Appeals Department Medical Records/Data Management Quality Management Objectives Committee Structure Executive Team Leadership Team Global Quality Improvement Committee (GQIC) Systems Performance Review Committee (SPRC) Clinical Advisory Committee (CAC) Provider Network Council Credentialing Committee Cultural Competence Advisory Committee Safety Committee Eastpointe Organizational Overview 1

3 Communication Committee Policy and Procedure Committee Alpha Call Workgroup Fatality Review Committee Corporate Compliance Committee Quality of Care Committee (QOC) Reports Committee Regulatory Compliance Committee Outlier Workgroup Reconsideration Committee Global Quality Improvement Reporting Structure Departmental Collaboration Clinical Operations Department Medical Director/Senior Clinical Staff Member Call Center Innovations Care Coordination Mental Health/Substance Abuse (MH/SA) Transition to Community Living (TCL)/Housing Department Special Populations Utilization Management (UM) Business Operations Information Technology Financial Services Funding Services Human Resources External Operations Network Management Provider Monitoring Communication Provider Contracting Community Relations Regulations and Compliance Corporate Compliance Department Program Integrity (PI) Training Facility Management Eastpointe Organizational Overview 2

4 Performance/Quality Improvement Projects PIP/QIP Workflow Fiscal Year 2016 Current PIP/QIP Decrease state psychiatric hospital 30 day readmissions for high risk members Increase data reporting from providers regarding member/enrollee attendance to routine follow-up Timely Access to Care: Increase percentage of members who received a face to face service within 48 hours Initiation and Engagement: Increase continuity of Care Decrease Emergency Department (ED) Re-admission Rate: Pending approval by DMA Improve Encounter Claims Processing: Pending approval by DMA Future PIP/QIP for FY Transition to Community Living (TCL) Dashboard: Increase TCL Measures Increase appointment availability for members Increase NC TOPPS Interviews by providers It is expected that this document is a living document and should be updated and reported as changes and progress occurs. Eastpointe Organizational Overview 3

5 You can t manage what you don t measure W. Edward Deming Eastpointe Organizational Overview 4

6 Organizational Overview Our Mission Eastpointe works together with individuals, families, providers, and communities to achieve valued outcomes in our behavioral healthcare system. Executive Summary Eastpointe Local Management Entity/Managed Care Organization (LME/MCO) serves the eastern North Carolina counties of Bladen, Columbus, Duplin, Edgecombe, Greene, Lenoir, Nash, Robeson, Sampson, Scotland, Wayne and Wilson. The twelve county area has a total of 7, square miles, with a total population of 825,451 individuals and is located in the far eastern section of the State of North Carolina. During fiscal year 2015, Eastpointe served 39,072 Medicaid recipients or about 54% in the service area which averaged 199,699 individuals per month. Eastpointe began operations as a Managed Care Organization on January 1, 2013, to manage publicly-funded behavioral healthcare services under the 1915(b) (c) Medicaid Waiver to individuals with Mental Health and Substance Abuse needs and Intellectual Developmental Disabilities (MH/IDD/SAS). This includes coordination, facilitating and monitoring provision of state, federal and Medicaid funded services. The organization is overseen by a Board of Directors with membership as defined in N.C G.S 122C. The twelve counties that make up the catchment area are racially and ethnically diverse. A demographic analysis of the population by race based on 2015 Census reports for counties in the Eastpointe catchment area indicates that 49.9% or (411,838) are Caucasian, 10.2% are Hispanic/Latino or (84,254) 34.1% or (281,291) are African-American, 7.6% or (62,498) are Native American/Alaskan Native. The organization has the second largest Medicaid population statewide. The largest Native American populations reside in Robeson (51,663) and Scotland (4,095) counties. 1 Eastpointe Needs and Gaps Assessment (2015), p. 1 Eastpointe Organizational Overview 5

7 Governance Eastpointe s Board of Directors Administrative oversight for Eastpointe LME/MCO is provided by the Board of Directors which functions as the governing body of all service programs. Current N.C. General Statute 122C requires the Board to have no fewer than eleven (11) and no more than 21 voting members. In conjunction with Eastpointe LME/MCO, The Board of Directors engages in comprehensive planning, budgeting, implementing and monitoring of community based mental health, intellectual development disabilities and substance abuse services (MH/IDD/SA). The Board meets in compliance with N.C.G.S 122c and more frequently if indicated. The Board has five standing committees: Executive, Finance, Human Rights, Nominating and Governance and Board Policy Committees. The Consumer and Family Advisory Committee (CFAC) advise the area authority area on planning and management of local public mental health, developmental disability and substance abuse services. The Area Director/Chief Executive Officer serves as an ex-officio member of all Standing Committees. Minutes of the Board meetings are posted on the Eastpointe website after they are approved by the Board. Executive Committee The Executive Committee is responsible for responding to the need for emergency session between regular Board meetings. The Executive Committee is composed of the Board Chair, Vice Chair and the Chair of CFAC. Finance Committee The Finance Committee has the responsibility of reviewing and making recommendations to the Board regarding financial issues that affect the organization. The committee is comprised of three (3) members of the Board. Committee members have expertise in budgeting and fiscal control. The committee meets at least six times per year. The Finance Committee has the responsibility for reviewing and making recommendations to the Board on the following issues: LME/MCO s annual financial and compliance audit All budget amendments Monitor all building and construction projects LME/MCO s annual operating budget Quarterly Financial Statements Eastpointe Governance 6

8 Nominating and Governance Committee The Nominating and Governance Committee identifies qualified individuals to become Board members consistent with criteria approved by the Board and applicable law. This committee develops and recommends corporate governance guidelines applicable to the organization. Additionally, the committee reviews and reassess adequacy of such guidelines periodically and recommends proposed changes to the board. The responsibilities of The Nominating and Governance Committee are: Oversee the evaluation of the Board and management of Eastpointe LME/MCO Periodically review the criteria for selection of new directors to serve on the Board and recommend proposed changes to the Board for approval, consistent With applicable law Evaluate candidates for board membership Periodically review and make recommendations regarding composition, size, Purpose and structure of each of the Board s committees Human Rights Committee The Human Rights Committee (HRC) is a subcommittee of Eastpointe s Board of Directors. This committee ensures compliance with federal and state rules governing client rights for enrollees receiving services throughout the LME/MCO network. The purpose of the committee is to oversee the protection of enrollee rights and to provide feedback and recommendations for system improvements. The Committee is comprised of 15 members across the LME/MCO who are either direct enrollees of services or family members representing Mental Health (MH), Intellectual Developmental Disabilities (I/DD) and Substance Abuse Services (SAS). Eastpointe staff serves as liaisons to the committee and are non-voting members. The purpose of the Human Rights Committee is to: Maintain ultimate responsibility for the assurance of human rights protection Review incident reports pertaining to seclusion, restrain and isolation timeout Review data regarding member grievances Review alleged violations of the rights of individuals or groups, including alleged abuse, neglect or exploitation Review concerns regarding the use of restrictive procedures Review the failure to provide needed services through Eastpointe Review grievances regarding incidents which occur within a contract agency after the governing body of the agency has reviewed the incident Eastpointe Governance 7

9 Board Policy Committee Eastpointe develops policies and procedures that promote effective and efficient operation of the organization according to Federal and State regulations and URAC Standards. The Policy Committee reviews all new policies to ensure they meet all requirements that will govern management of the LME/MCO. The Committee is comprised of 4 members of the Board. Appointment is made by the Board of Directors. The committee is responsible for review of all policy statements before going to the Board of Directors for final approval. A master list of all policies and procedures is maintained and updated at least annually. Consumer and Family Advisory Committee (CFAC) The CFAC committee is a self-directed and self-governing organization that advises the Board of Directors on the planning and management of the LME/MCO. The purpose of the committee is to ensure meaningful participation by Enrollees and families in enhancing the development and delivery of MH/IDD/SAS services within Eastpointe s network. Composition of membership reflects equitable representation from each disability, one family member and one consumer from each disability group across the catchment area. Membership represents the race and ethnicity of the community when possible. A few responsibilities include: Review, offer comment, and monitor the implementation of the local business plan. Identify service gaps and underserved populations. Make recommendations regarding the service array and monitor the development of additional services. Review and comment on the area authority or county program budget. Participate in all quality improvement measures and performance indicators. Submit to the state Consumer and Family Advisory Committee findings and recommendations regarding ways to improve the delivery of mental health, intellectual/developmental disabilities, and substance abuse services. Eastpointe 8

10 Quality Management Program Overview Eastpointe Quality Management (QM) Program fosters an environment that Quality is everyone s responsibility, by implementing W.E. Deming s philosophy that opportunities create chances for improvement and create interventions. The purpose of the Quality Management Program is to systematically monitor and evaluate access, appropriateness, safety and effectiveness of care utilizing a multidimensional approach. The program focuses on health and safety, protection of rights, achievement of outcomes, accountability and strives to continually improve the system of care. The Quality Management Program aims to continuously improve all aspects of healthcare delivery through monitoring and analyzing data, modifying practices and developing initiatives to measure and improve services provided by the organization. Specifically, the QM Program includes, but is not limited to the following responsibilities and monitoring of key performance measures: Effectiveness of Care Measures Access to Services Payment Denials Out of Network Services Member/Enrollee and Provider Satisfaction Use of Services Health Plan Stability Plan Descriptive Information Health and Safety Complaints The Quality Management Plan/Program Description (QMPD) outlines objectives, activities and the process by which the agency monitors and evaluates services, integrates quality improvement activities throughout the organization and promotes collaboration through inter-departmental representation on teams and committees. The plan describes how the Quality Management Program ensures Federal; State and URAC requirements are met to create qualitative outcomes for the population served. The plan is approved by the Board of Directors. The effectiveness of the Quality Management Program is reviewed and updated annually by the Global Quality Improvement Committee (GQIC). The prior year s program activities are summarized and incorporated into the following years QM Program Description and Work Plan. Progress toward performance/quality improvement goals are evaluated quarterly. Eastpointe Quality Management Program Overview 9

11 Continuous Quality Improvement The Center for Medicaid/Medicare (CMS) Quality Framework serves as the foundation of Eastpointe s Quality Management program. The Program focuses on the seven dimensions of continuous quality improvement: participant access, participant centered service planning and delivery, provider capacity, participant safeguards, participant rights and responsibilities, participant outcomes and satisfaction and system performance. Figure 1 Enrollee Access - Eastpointe provides information to assist individuals with obtaining access to service. Member Call Center operates 24 hours per day, 7 days per week, and 365 days per year to ensure members have access to services. Interpreter services, information regarding availability of non-emergency transportation and referral to community resources are available. Community Relations Department disseminates educational resources for members/enrollees regarding access to care, transportation services and a variety of MH/IDD/SAS topics. System Performance - Standardized monitoring tools, over and underutilization, submission of required data, quality of care reviews and complaint logs are a few methods used to measure provider performance. Eastpointe s Cultural Competency Advisory Committee is responsible for ensuring that culturally and linguistically appropriate services (CLAS) are delivered throughout the organization and provider network. Eastpointe Continuous Quality Improvement 10

12 Enrollee Centered Service Planning and Delivery Eastpointe ensures services and supports are implemented in accordance with the unique needs of the member/enrollee by completion of a Person Centered Plan (PCP) or Individual Support Plan (ISP). System of Care (SOC) is responsible for ensuring collaboration between a network of community based services to meet the needs of the child. Eastpointe collaborates with multiple community agencies such as Community Care North Carolina (CCNC), Department of Juvenile Justice (DJJ) and Department of Social Services (DSS) to facilitate service planning to ensure service provision. Eastpointe is involved with local hospitals and manages three-way psychiatric inpatient bed contracts for individuals who are considered indigent. Provider Capacity and Capabilities Eastpointe ensures that there are sufficient providers within the community by monitoring the need for services, surveying the community, and completing the annual needs assessment. Data on new and terminated providers are reviewed quarterly during GQIC. Enrollee Safeguards Eastpointe has several processes to ensure health and safety of members and quality of care. Provider Monitoring review Level II and III incidents to ensure health and safety of individuals served. If the provider response raises concern, an onsite visit may occur. Quality of Care Concerns regarding health and safety are addressed immediately and may include referrals to DSS, Department of Health Service Regulation (DHSR) or Care Coordination. Enrollee Rights and Responsibilities When an individual initiates services through Member Call Center, a statement of rights and responsibilities is mailed to them. Members have the right to make recommendations regarding enrollee rights and responsibilities policy. Enrollees also have the opportunity to voice complaints and file appeals about providers or other aspect of the organizations operations. Enrollee Outcomes and Satisfaction Eastpointe monitors the network of providers through annual member/enrollee satisfaction surveys, monitoring activities, mystery shopping/first responder capacity and incident reporting. Eastpointe also ensures compliance of the provider network, and monitoring via the North Carolina Treatment Outcomes and Program Performance System (NC-TOPPS) software program services are measured for outcomes. Eastpointe Continuous Quality Improvement 11

13 The CMS Quality Framework is woven across the organization through design, discovery, remediation and improvement. These four components drive the operation and management of the QM Program and contribute to its continued success. Design The QM Program Description, work plan, annual review of policies and procedures and establishment of benchmarks illustrate the structure and process for how the program is designed. Multiple inter-departmental and external advisory committees have been established to be in compliance with state, federal and accrediting bodies. All Eastpointe staff receives training on policies and procedures annually, and are able to access these documents through the intranet and receive updates when revised. Discovery As part of the Discovery phase for continuous quality improvement, monitoring is conducted throughout the organization. Several committees are responsible for the on-going monitoring of these measures and report routinely to the GQIC. Eastpointe s Quality Improvement monitoring includes, but is not limited to the following: Customer Service Accessibility - Monitors how quickly individuals access staff to address their needs (i.e., Telephone Statistics, such as Average Speed of Answer, and Abandonment rate). Provider Network Accessibility & Availability- Monitors the availability of providers to meet the needs of the population and the accessibility of those providers to treat members on an emergent, urgent, and routine basis.(new and term providers) Utilization Metrics- Denial and Appeal Data- to monitor (i.e., percentage of cases denied, appeal overturn rate). Staff Documentation Audits- Monitors staff compliance with policies and documenting activities appropriately. (I.e. Call Center, UM, MH/SA Care Coordination, Transition to Community Living (TCL) IDD: Individual Support Plans (ISP), Complaints). Complaints Monitors complaints regarding service delivery. Complaint data is analyzed to identify trends and also review response timeliness. Participant and Provider Satisfaction Survey Results- Monitors member/enrollee and provider satisfaction with service delivery annually. Eastpointe Continuous Quality Improvement 12

14 Remediation: The Global Quality Improvement Committee is responsible for approving benchmarks for quality assurance initiatives and processes. When discovered, that a benchmark has not been achieved for two consecutive quarters, the remediation phase begins. Improvement Designing and implementing the corrective action plan begins the Improvement phase of continuous quality improvement. The Eastpointe designated staff or committee implements and evaluates Quality/Performance Improvement Projects (QIP/PIP) utilizing the Plan, Do, Study, Act(PDSA) improvement model to achieve the needed performance improvement following the below course to manage the QIP and ensure goals are met and maintained. Figure 2 Eastpointe Continuous Quality Improvement 13

15 The design, discovery and remediation phases establish the processes and data necessary for the GQIC to identify monitor and select a PIP/QIP to address the critical dimensions of care delivery and outcomes for the improvement phase. Designing and implementing the corrective action plan begins the improvement phase of continuous quality improvement. If a department fails to meet the performance standard for two consecutive quarters, a Corrective Action Plan (CAP) will be implemented and presented to the GQIC for review. When the implementation of a CAP does not resolve the specific issue(s) a PIP/QIP will be implemented. The Global Quality Improvement Committee and PIP/QIP workgroups implement and evaluates quality/performance improvement projects utilizing the Plan, Do, Study, Act (PDSA) Improvement Model to achieve improvement. The following diagram illustrates the PIP/QIP process to ensure goals are met and maintained. Act Plan the next cycle PLAN Define the objective, questions and predictions. Answer the questions (who? what? where? when?) Data collection to answer the questions STUDY Complete the analysis of the data. Compare data to the predictions. Summarize what was learned DO Carry out the plan Collect the data Begin analysis of the data Figure 3 Eastpointe Continuous Quality Improvement 14

16 Quality Management Resources The Quality Management (QM) Department encompasses the Analytic Department, Quality Assurance, Quality Improvement, Grievance and Appeals and Medical Records Management. These departments are embedded throughout the organization and ensure quality principles are executed. The QM Department provides resources necessary to support the day to day operations of the division. The Chief of Quality Management oversees the department, with collaboration and guidance from the Medical Director. The Medical Director serves as chair of the GQIC and is involved in all clinical (PIP/QIP) initiatives. Analytics Department The Analytics Department is responsible for designing, operationalizing and maintaining an effective, efficient operation of the organization. The department is responsible for managing data analytics and is accountable for oversight to any manner of external reports to ensure cohesive, accurate, consistent reporting. The department initializes internal analytics, to include, but not limited to operational scorecards; QIP related outcomes. Responsible for supporting the operational reporting needs of: Claims, Clinical Management, Access, Finance, Grievance and Appeals, Information Technology, Provider Network, Quality Assurance, Quality Improvement, Regulatory/Corporate Compliance, growth and other key functions. Quality Assurance/ Medicaid Contract Manager The Quality Assurance Department is responsible and accountable for developing, implementing and maintaining quality throughout the agency to meet state and federal mandates. This department works across departments to ensure regulatory compliance and the integrity of policies and procedures are carried out in a timely and consistent manner. The Medicaid Contract Manager acts as the liaison between the state and the LME/MCO to ensure compliance with the waiver contract. Quality Improvement The Quality Improvement unit is linked to all programs/departments through structured monitoring activities which support organizational wide goals of continuous improvement in all services and processes, while ensuring compliance to state and federals laws, regulatory and accreditation standards. Under the direction of the Medial Director, the department is responsible for coordination and oversight of Quality of Care Committee, which includes follow -up and referral for members/enrollees of Eastpointe. Eastpointe Quality Management Resources 15

17 Grievance and Appeals Department The Grievance and Appeals Department manages the grievance and appeals processes for enrollee/members and providers. Eastpointe believes There is no wrong door to file a complaint. Therefore, all staff is trained in assisting complainants with grievances. The department responds to complaints and questions from enrollees, providers and stakeholders. The department facilitates enrollee/member involvement and plays an integral role in the Appeals Process. The department assists enrollees/members with filing appeals when needed. Complainant appeals are reviewed and resolved by an Ad-Hoc Committee within 28 days from receipt. Provider Disputes are reviewed and processed by the Reconsideration Committee within 60 days. Medical Records/Data Management Medical Records/Data Management is responsible for maintaining enrollee medical records, files and statistics. The Department ensures all medical records are released according to Health Insurance Portability and Accountability Act (HIPAA) guidelines and compliant with relevant regulations and standards. Staff is responsible for entering Member Enrollment, Client Update Requests and Discharge forms. The department is also responsible for submission of North Carolina Support Needs Assessment Profile (NC-SNAP) and maintenance of Client Data Warehouse (CDW). Technical assistance is provided to Network Operations Providers to ensure clinical records meet requirements of the Records Management and Documentation Manual. The department assumes responsibilities for member records when the provider has gone out of business. Grievance & Appeals Quality Assurance Quality Management Medical Records Analytics Quality Improvement Figure 4 Eastpointe Quality Management Resources 16

18 Quality Management Objectives The overall objective of the Quality Management Program (QM) is designed to implement state, federal regulations and national accreditation standards. The following describes how Eastpointe intends to comply with these standards. Meet or exceed CMS, DMA, DHHS, defined minimum performance levels on standardized quality measures annually QM Review Specialists conduct quarterly audits, assess for trends and data accuracy while working in collaboration with Department Directors and various committees. QM Review Specialists review medical records, grievance and claims data to determine the organization s level of performance and/or compliance. The QM Department has implemented processes for monitoring internal performance in all functional areas: Authorization Time Frames Access to Care Standards Review of Appeals, Medical Necessity Denials quarterly Review of NC TOPPS updates daily Quarterly Audits: MH/SA Care Coordination Member Call Center Documentation Appeals/Medical Necessity Denials Innovations Services Grievance and Appeals Data Develop and implement Performance/Quality Improvement Projects Performance/Quality Improvement Projects (PIPS/QIPS) are initiated in response to identified problems, gaps, performance issues, accreditation requirements and or other performance initiatives. QM Review Specialists are assigned to projects to gather, analyze and process data related to the projects. Updates on performance/quality improvement initiative are shared with GQIC and staff quarterly. Implemented methods to detect over and underutilization of services Over and underutilization of services impact services provided to members/enrollees. Keeping abreast of service utilization surrounding high cost/high risk is crucial to the success of the organization. The QI department distributes Eligibility of Benefits (EOB) surveys on a quarterly basis to determine if services billed for were delivered to members. If discrepancies are discovered, results are forwarded to Program Integrity (PI). Results are reported to the GQIC quarterly. During FY 2016, Data Analytics identified trends from paid claims data. Trends identified were overutilization of services, billing practices, high utilization of same diagnosis and service. Results were forwarded to Program Integrity. Eastpointe Quality Management Objectives 17

19 Eastpointe s Utilization Management (UM) Department utilizes clinical care criteria related to best practices on current treatment protocols and national standards. The UM Department analyzes and trends utilization data to identify normal and special cause variations that impact patterns of utilization. Eastpointe established ranges for utilization of services and examines utilization patterns outside the established criteria ranges at an individual, provider, and at the aggregate system level. Penetration rates, inpatient recidivism, bed days per 1,000, emergency department (ED) visits and outpatient utilization is a few key measures analyzed for under and over utilization and identification of problem areas. Utilization data is discussed and analyzed for trends during System Performance Review and the Clinical/ Finance Committee. Clinical case reviews are also conducted to identify barriers to access, discharge from higher levels of care and/or gaps in service continuum. Mental Health and Substance Abuse (MH/SA) Care Coordination identify and track high-cost and/or high-risk members/enrollees through inpatient admission reports generated by UM and Member Call Center within 24 hours. All members/enrollees admitted into Care Coordination receive an Intensity of Need (ION) rating based on number of psychiatric admissions, ED visits and other criteria. The QI Department conducts quarterly reviews of MH/SA Care Coordination internal processes. The audit ensures follow up activities were conducted, use of person centered/recovery/oriented language and available resources for medication adherence. Assess the quality and appropriateness of care furnished to member/enrollees Eastpointe's philosophy correlates with Division of Medicaid Assistance (DMA) expectations to ensure quality and appropriateness of care provided to enrollees. Development of a provider network comprised of the most qualified providers, coordination of care for individuals identified as high risk/high cost and collaboration with Community Care of North Carolina (CCNC) is a few ways the organization ensures timely, appropriate and cost efficient services. The QI Department conducts record reviews of Innovations cases to ensure oversight of plan implementation and service delivery on a quarterly basis. MH/SA Care Coordination audits are conducted quarterly to ensure coordination for members/enrollees discharged from state facilities or who have received inpatient admission or facility based crisis. The department also facilitates the weekly Quality of Care Committee (QOC) which reviews cases of concerns originating from various departments throughout the organization. Provider Monitoring and I/DD Care Coordinators monitor back-up staffing plans to assess appropriateness of care furnished to members. Any situation identified as health and welfare issues are addressed immediately with the employer, representative and/or agency of choice. A plan of correction is required if the failure to provide back-up staffing presents a health and safety concern. Eastpointe Quality Management Objectives 18

20 During FY 2016, the QI Department developed and disseminated a survey to evaluate effectiveness of care coordination in local community and state hospitals. Survey results indicated a lack of community resources for individuals being discharged and more collaboration needed to occur among hospital staff and care coordinators to assist with discharge planning. The survey was instrumental in securing a new position in the Care Coordination Department which serves as a liaison to one of the local hospitals, initiated weekly contacts with emergency rooms in the catchment area and incorporated more face to face meetings. Enrollee progress and experience is also monitored through NC Treatment Outcomes and Program Performance System (NC-TOPPS). Quality Improvement (QI) Staff work together with providers to ensure complete and accurate reporting of member/enrollee progress and outcomes. QI Staff conducts daily reviews of the NC-TOPPS System for updates needed. An reminder or phone call to providers may occur regarding updates due or out of compliance issues. QI Staff overseeing NC TOPPS has been instrumental in ensuring Eastpointe met and/or exceeded the State Performance Standard for FY Eastpointe values the satisfaction of enrollees/member, families and stakeholders. Eastpointe measures enrollee satisfaction which includes annual Perception of Care surveys, complaints and mystery shopping. The goal of these initiatives is to gather feedback on how various Eastpointe departments perform during random and anonymous monitoring. This system is used to pinpoint the need for additional training of staff. Eastpointe utilizes these tools to monitor provider customer service. Measure performance of Network Providers An important part of Eastpointe s role as a MCO is to monitor the performance of providers in the network. Provider performance is measured in a variety of ways to include but not limited to monitoring health and safety of members, rights protections, and adherence to Best Practice Standards, review of incident reports, quality of care reviews, member satisfaction surveys, first responder capacity surveys and compliance with data submission requirements. The organization monitors providers use of service funds, investigates complaints and incidents. Perception of Care Surveys are conducted annually to provide information on the quality of care based on the perceptions of individuals and families who have received Medicaid and State Funded mental health and /or substance use services. Results of the survey are shared with CFAC, Human Rights and GQIC committees. Data from FY2015 Perception of Care Survey showed satisfaction in all areas, with the exception of family survey treatment planning. Eastpointe fell 4 percentage points (89%) below the state total (93%) in this domain. A large majority of respondents (89%) agreed their first service was offered in a time frame that meets their needs. Eastpointe Quality Management Objectives 19

21 Provide Performance Feedback to Providers Eastpointe believes creating a partnership through open dialogue with providers will improve outcomes and quality of life for members/enrollees. Performance feedback is shared with providers through provider meetings, forums and training sessions. Eastpointe disseminates critical and time sensitive information through communication bulletins and Provider Listserv. Provider Network Operations are assigned to specific providers to act as contact to respond to individual needs. All providers in the network receive a profile review at least every three (3) years. The Provider Monitoring Unit maintains a master schedule of profile review dues dates. At the conclusion of the review, a briefing of the outcome is provided. Copies of the results are mailed within 30 days to the provider. Quality Improvement (QI) utilizes data from surveys to identify opportunities for improvement, implements interventions as appropriate or evaluate the need for new or revised policies. Surveys are posted on the website to obtain feedback from members, providers and employees. The Department collects the surveys and presents the information to GQIC, Human Rights and CFAC committees. Quarterly and annual evaluations are also shared within the Provider Council and posted on Eastpointe's website for review. The Quality Improvement Department in collaboration with Network Operations administered a survey to collect data regarding member wait times and staff availability in walk in crisis clinics. Outcome of the survey revealed average wait time for walk in appointments is two hours which meets DMA contract requirements and licensed staff is available during first and second visit. Develop and adopt clinically appropriate practice parameters and protocols Eastpointe uses established medical necessity criteria, clinical decision support tools and level of care tools that serve as the basis for consistent and clinically appropriate service authorization decisions for all levels of mental health, substance abuse and intellectual/developmental disability services. The UM and Member Call Center consistently adhere to adopted clinical practice guidelines. Inter-rater reliability Procedure (IRR) is a process that has been implemented by both departments to assure consistency in the application of departmental, state, federal and URAC guidelines. Studies are conducted every 3 months or as needed based upon staff level of expertise and results of prior reviews. Periodic inter-rater reliability studies are conducted and reviewed by Medical Director as part of Eastpointe s continuous quality improvement philosophy. Eastpointe Quality Management Objectives 20

22 Departmental and individual staff performance improvement plans are implemented if individual inter-rater reliability is below established benchmarks. In addition, the QI Department performs reviews to ensure compliance with established procedures. The Clinical Advisory Committee (CAC) comprised of Provider Agencies, Licensed Independent Practitioners (LIP) and Hospitals is one method the organization ensures practice guidelines are shared among a consensus of professionals. Practice guidelines are reviewed and updated periodically by the committee and in accordance with changes and developments in clinical research. The organization has developed processes to ensure that UM decisions, enrollee education decisions, coverage of services and all other decisions are consistent with practice guidelines. When areas of concern are identified, a discussion of clinical standards and the expectations are held. Providers are supported with clinical protocols and guidelines to enable them to meet the established standards, and recommendations for actions to correct the deficiencies. Evaluation of Access to Care for Members/Enrollees Eastpointe evaluates the adequacy of the provider community regarding issues such as cultural and linguistic competency of existing provider, provisions of evidenced based practices and treatment and availability of community services to address housing and employment issues. The organization has implemented several processes to ensure that medically necessary services are delivered in a timely and appropriate manner. Eastpointe utilizes GEO Access Map which determines the location of providers in relation to where members live within the catchment area, and focus on areas that need recruitment. The network capacity report measures the number and type of active members/enrollees and providers served by category in the catchment area. Eastpointe recognizes that timely access to care is critical to protect both health and safety and ensure positive outcomes. Eastpointe operates a 24 hour, Member Call Center to link individuals to services in the 12 county areas through a toll free crisis line. Members are screened and triaged by a licensed clinician who determines if the individual meets criteria for emergent, urgent, or routine care. The triage level determines scheduling and is as follows: Emergent-2 hours (Life-Threatening Emergent-Immediate) Urgent- 48 Hours Routine-14 calendar days ( DMA Contract) Eastpointe Quality Management Objectives 21

23 All appointments are followed up to ensure the member/enrollee has been seen and linked to services. During FY2015, percent of members who attended urgent appointments and percent of provider who report follow up appointments was captured to measure access to care/services. Timely response to the needs of members and linkage ensured member safety. During FY 2016, the QI Department in collaboration with Member Call Center developed a survey to identify barriers for reasons appointments missed. The phone survey was administered to individuals deemed to need urgent care that failed to attend or rescheduled the appointment. Survey results revealed transportation, changed mind and forgot appointment was the top three reasons individuals failed to attend appointments. Survey feedback evoked discussion to develop incentives for providers who are willing to offer transportation and provide assessments on weekends and after hours. Provider Sufficiency A goal of Provider Network is to ensure adequate appointments available to members/enrollees to meet the standard. Eastpointe providers are held to the following standard in regards to Appointment Wait Time for Urgent Referrals: for scheduled appointments, members are not to wait more than one hour; for walk-in appointments no later than two hours. The Need Assessment is conducted on an annual basis. The assessment evaluates access to services offered throughout the network and includes input from consumer, family and stakeholder regarding needs and gaps in the catchment area. The report also included progress from needs identified during last year report and strategies to address the gap. During FY 2015, Eastpointe focused on several areas to increase the number of Medicaid and uninsured populations. Conversion to the Alpha System on May 1, 2015 Expansion of Facility Based Crisis (FBC) the southern part of the catchment area Plans to open a Level IV Behavioral Outpatient Walk in Unit Increase knowledge about access; placed billboards throughout the catchment area and launched Facebook page. Released an Request for Proposal(RFP) for tenancy support 2 Eastpointe Needs and Gaps Assessment (2014) pgs Eastpointe Quality Management Objectives 22

24 Committee Structure As a part of the Continuous Quality Improvement Process, Eastpointe has established multiple cross functional and external advisory committees that report to the Global Quality Improvement Committee (GQIC). All committees maintain meeting minutes of activities and tasks, which are reviewed and approved quarterly by the GQIC. The committees serve as feedback loop to the organization and ensure that contractual requirements are met. Committee representation includes Eastpointe staff, stakeholders and provider network. The organization recognizes that partnering with members, stakeholders and providers to find solutions will strengthen the service delivery system. Executive Team The Executive Team is responsible for the overall management of the organization. The team is charged with making informed decisions for the LME/MCO that govern monitoring the provision of public services, and promotes effective and efficient operation of the organization that complies with state and federal requirements to safeguard the organization, member/enrollees, Board of Directors and staff. The Executive Team review and approve all revised procedures as well as internal forms. The team is comprised of Chief Executive Officer (CEO), Medical Director, Chiefs of Clinical Operations, External Operations, Quality Management, Regulation and Compliance and Business Operations. The committee meets on a weekly basis. Leadership Team The purpose of the Leadership Team is to facilitate communication surrounding issues that affect the organization. Membership is comprised of Division Directors of the LME/MCO. The committee discusses current operations, reviews performance outcomes and distributes information throughout the organization. The members of this committee are responsible for implementing and monitoring goals within the organization. The committee meets at least quarterly face to face or telephonically. Eastpointe Committee Structure 23

25 Global Quality Improvement Committee (GQIC) The Global Quality Improvement Committee (GQIC) identifies and addresses opportunities for improvement of organizational operations and the local service system. The committee is granted authority by Eastpointe s Executive Team. The committee meets at least quarterly with the purpose of monitoring the organizations and provider performance, analyzing reports and data, recommending continuous quality improvement projects and evaluating the effectiveness of the continuous quality projects and interventions). The committee maintains minutes of all meetings, which are approved by the GQIC and posted on the website. The committee is cross functional and membership includes management representatives from each area of the organization, network providers and the CFAC chair. The Board of Directors provides oversight through review of routine reports from the Executive Team. The GQIC provides staff with oversight and guidance on quality management priorities and projects. The Medical Director serves as chair of the committee. The committee reports at least quarterly to the Eastpointe Board concerning quality management activities. The (GQIC) is accountable to the Executive Team. This committee interacts with other committees as a guide for setting goals and objectives for the program. The responsibilities of the committee are: Monitor and document key performance measures that is quantifiable and used to establish acceptable levels of performance, including a baseline and at least annual remeasurement Approves and selected Quality/Performance Improvement Projects and monitor for progress Provide guidance to staff on QM priorities and projects Approve Corrective Action Plans (CAP) to improve or correct identified problems or meet acceptable levels of performance Reviews and update the QM Program Description and QM Work Plan annually Receive and incorporate input from participating providers Evaluates the effectiveness of the Quality management program at least annually Provide structure and oversight of subcommittees Eastpointe Global Quality Improvement Committee (GQIC) 24

26 Systems Performance Review Committee (SPRC) The System Performance Review Committee evaluates the utilization of services with the goals that member/enrollees receive the appropriate level of services within reasonable time frame. The committee reviews key performance indicators related to over and underutilization, penetration rates, inpatient admissions and bed days per 1,000 consumers, emergency departments visits per 100 consumers and outpatient utilization. The committee reviews monthly Medicaid report, key performance indicators related to Effectiveness of Care, Use of Services and Access/Availability. This committee reviews individual cases and oversees high risk/high cost members/enrollees. The committee is chaired by the Medical Director and consists of Clinical Operations, Network Operations and Quality Management Departments. The committee meets on a semi-annual basis. Plans are to combine this committee and the Outliers workgroup. Clinical Advisory Committee (CAC) The purpose of the Clinical Advisory Committee is to work collaboratively to review evidencebased practices, identify training needs, evaluate utilization in relation to clinical guidelines and assist with the development of community standards of care. The committee is chaired by the MCO Medical Director. The Clinical Advisory Committee is comprised of Licensed Network providers and Eastpointe clinical staff representing various disciplines and disabilities from Eastpointe s network providers and practitioners. The committee reviews and approves all clinical criteria, scripts and tools annually. The committee meets quarterly. Provider Network Council The Provider Network Council advises Eastpointe on communication, policy development, initiatives, projects and the impact of state responsible for monitoring and trending data from the provider network. The committee also assists in the development of plans to address concerns from the provider network and Eastpointe. Membership consists of current active, contracted partners in the Eastpointe Provider Network. Provider membership represents all three member demographics (Adult Mental Health, Child Mental Health, Developmental Disabilities, and Substance Abuse). The Group is one of the key operational committees of Eastpointe and, as such, has responsibilities to Network Providers in representing their interests and challenges, to members and family members and to Eastpointe in responding to standards, key indicators, initiatives and requirements. The Director of Network Operations or their designee will serve as liaison to the Provider Council. The committee meets on a monthly basis. Eastpointe Global Quality Improvement Committee (GQIC) 25

27 Credentialing Committee The Credentialing Committee (CC) is tasked with assuring that licensed independent practitioners meet standards for entrance into the Managed Care Organization (MCO). Eastpointe Medical Director serves as Chair. The CC is comprised of providers enrolled in the Eastpointe network as well as licensed staff employed by Eastpointe who represent various licensing guilds and disability groups. The CC reviews licensure, sanctions, criminal background checks, and other relevant documents to determine if the applicant meets Eastpointe standards. If the applicant meets those standards, then the applicant is privileged to enter or remain in the Eastpointe network and a contract is executed. The committee meets at least quarterly or more frequently at the discretion of the chairperson. Cultural Competence Advisory Committee The Cultural Competency Advisory Committee in collaboration with network providers and the community address issues related to the ever expanding diverse populations for enrollees and staff in the provision of competent services. The purpose of the committee is to develop, implement and monitor agency and network provider s practices and procedures to ensure services and supports are culturally competent by striving to incorporate each individual s culture and heritage. The Committee is responsible for ensuring that Culturally and Linguistically Appropriate Services (CLAS) are delivered through the establishment, implementation and maintenance of the Cultural Competence Plan, as documented in this written Program Description the CCAC conducts an annual literature review to identify benchmarks that may be used to set quantifiable goals for the program. The Committee consists of Eastpointe staff members, CFAC representatives, underserved populations, professional/community organizations, and network provider representatives. The committee meets as often as necessary, but at least every six (6) months. Safety Committee The Safety committee is charged with the responsibility of implementing Eastpointe s Safety Plan, Policies and Procedures related to safety, and for all safety issues/concerns within the agency regarding facilities and staff. Representation from each site is included within this committee. Subcommittees have been established for each site under the supervision of the safety manager. The committee meets on a quarterly basis or as needed. Major responsibilities of the committee are as follows: 1. Complete annual and ongoing safety inspections per location 2. Review of Safety Plan Goals Eastpointe Global Quality Improvement Committee (GQIC) 26

28 Communication Committee The Communication Committee is charged with reviewing member/enrollee literature before dissemination. The purpose of this committee is to ensure that information represented in these materials is accurately and clearly communicated to members/enrollees. The goals of the committee are to: Review enrollee/member education materials for adherence to Medicaid contract requirements and adherence to the Federal Plain Language Guidelines. Safeguard against misrepresentation in communication materials through review and approval process. Policy and Procedure Committee The Policy and Procedure (P&P) Committee reviews all new policies, retiring policies, and new or revised procedures to ensure that the P&Ps submitted by staff meet all the requirements of the Policy and Procedure Development Policy. The committee meets on a monthly basis or as needed. Functions of this committee include: Ensure all elements/formats are met. Investigate duplicate possible duplication of policies and procedures Ensure all P&Ps submitted are tracked through the entire process. Initiate the need for new policies and procedures. Alpha Call Workgroup The purpose of the workgroup is to address any significant issues/concerns related to system conversion or policy change that will affect the operational software across multiple departments. The committee is cross functional and includes representatives from all departments that interact with the agency operational software. The committee meets twice monthly. Fatality Review Committee The responsibility of the Fatality Review Committee is to ensure that all deaths of members are reported and reviewed for compliance with all applicable death reporting regulations. The committee meets at least quarterly to review and discuss concerns, trends and any follow up actions that are needed for death reporting. Eastpointe Global Quality Improvement Committee (GQIC) 27

29 Corporate Compliance Committee The Corporate Compliance Committee is responsible for on-going review of the organizations Corporate Compliance Plan, coordination of area wide corporate compliance and program integrity activities both internal and external. Functions of this Committee include, but are not limited to review reports of potential fraud and/or abuse and internal investigations. The committee meets monthly and is chaired by the Corporate Compliance Officer. Responsibilities of Committee Members: To be or become adequately knowledgeable of the department functions and responsibilities in order to represent department s perspective on the issues at hand. This may include research and/or consulting with the Department Director and other staff. To regularly report to the member s department on the activities, decisions and actions of the Compliance Committee which directly affect the department s activities. Quality of Care (QOC) The Quality of Care (QOC) reviews clinical and practice issues that are identified by various departments throughout the organization. The committee is comprised of Medical Director, Associate Medical Director, Chief of Clinical Operations, Chief of Quality Management, Director of Provider Monitoring, Director of QI, UM Director and QM Review Specialists. The referrals are made to various departments within the organization. The QOC meets weekly or as needed to discuss cases of concern. The committee identifies patterns of over/under utilization by services and providers. Reports Call The Reports Call is charged with reviewing both DMA 1915-B Waiver and DMH/DD/SAS LME-MCO Performance Measures to ensure technical specifications are followed when reporting performance measures. The committees purpose is to ensure consistency, reduce duplication and establish uniformity when reporting. The committee reviews and validates data, assigns new reports and ensures reports meet North Carolina LME/MCO Performance Measurement and Reporting Guide. The committee meets monthly or as needed. Eastpointe Global Quality Improvement Committee (GQIC) 28

30 Regulatory Compliance Committee The Regulatory Compliance Committee ensures Eastpointe s compliance with applicable laws and regulations. The committee tracks applicable laws and regulations in the jurisdiction where Eastpointe conducts business. The committee is comprised of Waiver contract Manager, Communications Officer and Director of Corporate Compliance. The Committee reviews monthly any changes in regulation, new communication and establishes work teams as needed to respond to changes. Outlier Workgroup The Outlier Workgroup was initiated in 2016 after several measures on the monthly Medicaid Report were identified as outliers. The purpose of the group is to review measures deemed as outliers or not meeting statewide totals and identify opportunities for improvement. The group is cross functional and meets on a monthly basis. Updates on progress are provided during quarterly IMT calls. Plans are to merge this committee with Systems Performance Review Committee during FY Reconsideration Committee The Reconsideration Committee serves as an appeals committee to review disputed adverse actions related to administrative or competency and professional conduct appeals that are unresolved based on opinion of the Providers. Membership consists of Medical Director or designee, Chiefs of Clinical Operations and Quality Management Director of Grievance and Appeals. The committee meets on an as needed basis. Eastpointe Global Quality Improvement Committee (GQIC) 29

31 Global Quality Improvement Reporting Structure Eastpointe 30

32 Departmental Collaboration Clinical Operations Department Clinical Operations provides leadership to the Member Call Center, Utilization Management, MH/SA Care Coordination, I/DD Care Coordination, Special Populations and Transition to Community Living (TCL). The Senior Clinical Staff Person/Medical Director provides clinical oversight, leadership in quality management of clinical issues, and clinical consultation. Medical Director/Senior Clinical Staff The Medical Director serves as the Senior Clinical staff. The Senior Clinical Staff person provides guidance to the clinical operational aspects of programs and oversight to the Quality Management Division. This individual chairs the Clinical Advisory Committee (CAC) and is responsible for the oversight of clinical decision-making aspects of the program and has periodic consultation with practitioners in the field. The Senior Clinical Staff is also responsible to ensure the organization utilizes qualified clinicians who are accountable to the organization for decisions affecting participants. The senior clinical staff person is a board certified psychiatrist, M.D. or D.O. and holds a current, unrestricted clinical license. If the license is restricted, Eastpointe ensures job functions of this individual do not violate the restrictions imposed by the state licensure board. The Senior Clinical Staff person has a postgraduate experience in direct patient care and possesses the qualifications to perform clinical oversight of Eastpointe services. The Senior Clinical Staff person participates in the GQIC and all clinical QIP workgroups. The Senior Clinical Staff Person is responsible for the oversight of all clinical aspects of activities performed by delegated entities and ensures that only well-qualified individuals carry out the delegated functions. The senior clinical staff person also ensures the organizational objective to have qualified clinicians accountable to the organization for decisions affecting members. Member Call Center Eastpointe s Member Call Center provides one of the core functions of the LME/MCO. Routine reports such as telephone average speed to answer (ASA), abandonment rate (ABR), blockage rate and service levels, enrollee inquiries and grievances, and enrollee satisfaction reports are shared with GQIC on a quarterly or annual basis. QI Department conducts quarterly audits to ensure accountability and adherence to state and URAC standards. Eastpointe Departmental Collaboration 31

33 Innovations Care Coordination Care Coordination is an administrative function of the LME/MCO. Intellectual Developmental Disability (I/DD) Care Coordination is provided for all enrollees in the Innovations Waiver and to individuals who are on the Innovations Waiver Registry of Unmet Needs. I/DD Care Coordination are responsible for developing the Individual Service Plan and budgets for Innovations Waiver enrollees. The QM Department monitors Innovations Slot Tracking Report monthly, conducts quarterly reviews of internal processes related to services (ISP reviews, Health and Safety, Innovations Waiver Performance Measure audits) and compiles data for state required reporting. Mental Health/Substance Abuse (MH/SA) MH/SA Care Coordination is provided to enrollees identified as high risk, high cost, special healthcare, or referred by CCNC from Quadrant II (high behavioral needs, low medical needs) and Quadrant IV (high behavioral, high medical needs). MH/SA Care Coordination monitor behavioral health hospital admissions and discharges; collaborate and consult with providers and participate in discharge and ongoing treatment planning as needed to ensure enrollees are receiving services that meet their needs. Quality Improvement (QI) conducts quarterly reviews to ensure timely follow-up after discharge from inpatient care, tracks Medicaid and State community hospitalization and emergency department utilization monthly. During FY 2016, MH/SA audit tool was revised to incorporate measures that assessed service quality such as engagement of service and medication adherence. Transition to Community Living (TCL)/Housing Department The TCL/Housing Department collaborates with other stakeholders to develop and oversee housing resources available to members. The Department links members/enrollees to appropriate services and community supports while providing support during and for a period of time following transition. The Analytics Department identifies the number of individuals receiving Assertive Community Treatment (ACT) and Individual Placement Support (IPS-SE) services monthly. During FY 15-16, the QM Department collaborated with TCL Staff and developed a web based form for supported Employment providers to submit information electronically. Information submitted is compared to NC TOPPS data to validate provider specific outcomes. Quarterly audits are also conducted to ensure discharged related measures are followed per Department of Justice (DOJ) settlement guidelines. During FY16, QI collaborated with TCL Department to develop strategies to address performance outcomes not meeting state baseline requirements on the Transitions to Community Living Dashboard. Eastpointe Departmental Collaboration 32

34 Special Populations Special Population Services assists with the development and oversight of activities impacting special populations (i.e. Traumatic Brain Injury (TBI), Military Personnel, deaf services, etc.) The department is supported by the Special Populations Specialist. Eastpointe collects information during screening, triage and referral process on individuals who have suffered traumatic brain injuries. The Member Call Center also incorporated salutations to acknowledge individuals and family members who are veterans or actively serving. The QM Department reviews and validates the TBI report quarterly and submits to the designated entity. Figure 6 Utilization Management (UM) Eastpointe UM Department reviews and approves authorization requests on State and Medicaid funded services. A Quality Review Specialist is assigned to the department to facilitate crossagency reporting and analysis of data. Quarterly audits ore conducted on Medical Necessity Denials and Appeals. Total number of authorizations received, percent processed in 14 days and number of authorizations requests processed in required time frames are reviewed monthly. Penetration rates, inpatient admissions and emergency department visits data are analyzed and discussed during Systems Performance Review Committee (SPRC). UM Staff refers clinical and practice concerns identified during review of clinical information to the Quality of Care Committee to ensure appropriate treatment. Eastpointe Departmental Collaboration 33

35 Business Operations As part of the GQIC, the Financial Operations Department manages the financial resources of the organization. The department provides oversight of Facility Maintenance, Medicaid Contract Management, Information Technology (IT) and Financial Operations. The Chief of Business Operations leads these divisions. Information Technology The Information Technology (IT) Department is responsible for ensuring that all network and software systems are maintained. Housed within Business Operations, IT collects, maintains and analyzes information necessary for organization management that provides for data integrity, provides a plan for storage maintenance and destruction of data, and provides a plan for interoperability. A systems Business Continuity plan is in place that identifies which system to maintain in outages, how business continuity is maintained given various lengths of time that information systems are not functioning or accessible, is tested yearly and responds promptly to detected problems and takes corrective action as needed. Eastpointe operations and activities are accomplished in a primarily electronic environment. However, when paper or oral personal health information (PHI) or individually-identifiable health information (IIHI) is generated, Eastpointe has various mechanisms in place to protect that information as well. Eastpointe has developed standards for securing PHI and IIHI and maintaining all security standards necessary to protect it. Report writing is a crucial area for ensuring data integrity and consistency. The IT Department maintains a Data Manager and Report Writers who develop reports in collaboration with the end user. The report writers work closely with QM and various other departments to assure compliance with state guidelines. A monthly Reports Meeting is held to discuss progress of reports development which includes various departments from Clinical, External Operations and Quality Management. All reports are submitted to Data Analytics for second level validation before forwarded to the end user. Financial Services Financial Operations manages the financial resources of the organization, including claims and reimbursement. The department is oversees the accounts payable, payroll, general ledger and contracts management. Financial Services is charged with ensuring that all Eastpointe expenditures are accurately paid in a timely manner. Eastpointe Business Operations 34

36 Funding Services The reimbursement function of the MCO/LME is one of the most critical and visible elements of the organization. The essence of the section is the processing of IPRS and Medicaid reimbursement claims. The department is responsible for processing claims submitted by providers. During FY 2015, QI Department began conducting random audits of 3% of all claims submitted to ensure timely filing, verify diagnosis and reimbursement rate is processed accurately. The findings are summarized and shared with Departmental Director and Chief of Business Operations. In May 2016, at the recommendation of Division of Medicaid Assistance (DMA), a Quality/Performance Improvement Project was initiated to improve Medicaid encounter processing. Human Resources The Human Resources Department manages the personnel activities of the organization. The department is responsible for recruiting and hiring new employees, overseeing employee benefits and compensation packages. The Department is responsible for maintaining the official, current organization chart of the LME/MCO. Eastpointe Business Operations 35