Behavioral Health Quality Review Nicole Griep Director of Quality Assurance
Agenda Introductions Brief Overview of the ASO Quality Review Process Focused Outcomes Q&A 2
Introductions Department of Behavioral Health and Developmental Disabilities Melissa Sperbeck, Deputy Chief of Staff Dr. Chris Gault, Director of Performance Management and Quality Improvement Monica Parker, Director, Division of Behavioral Health The Georgia Collaborative ASO Jason Bearden, CEO, GA Collaborative ASO Mona Allen, VP of Quality, GA Collaborative ASO Nicole Griep, Director, Quality Assurance, GA Collaborative ASO 3
The Georgia Collaborative ASO The right service In the right amount For the right individuals At the right time 4
Goals of the Collaborative Providing Easy Access to High Quality Care That Leads to a Life of Recovery and Independence Support recovery, resiliency and independence in community based service system Leverage technology through an integrated, customizable platform allowing all core functions to communicate (The CONNECTS platform) Coordination of previously disparate systems Improve state wide and provider specific outcomes and provider performance 5
The Quality Review Process 6
Review Tool: Four Scored Sections Billing Validation 25% Compliance with Service Guidelines 25% Overall Score 100% Focused Outcome Areas 25% Assessment & Tx Planning 25% 7
Review Tool: Two Non-Scored Sections Individual Interview Staff Interview Rights Choice Whole Health Focused Outcome Areas Safety Person Centered Practices Community 8
Overview of Review Process When possible, reviews will be conducted in tandem with other entities (IDD, CSU, ACT, etc.) Number of Records - Similar number of historical records reviewed Frequency of Reviews Every provider will have a review within the next fiscal year However, the recurring frequency will ultimately depend on performance Reviews will begin August 2015 9
Overview of Review Process Notification Standard 2 week notification via email Ad hoc/no notice reviews will also be conducted at the direction of DBHDD 48 hours to verify receipt of notification Email - @valueoptions.com Upon arrival, an Entrance Interview will be conducted Record Delivery to Reviewers Same record delivery timeframe as foundation (2 hours for on-site/electronic records; 4:00 delivery for those records at other DBHDD approved locations) 10
Scored Section #1: Assessment & Treatment Planning 25% of Total Score Combination of Assessment and Treatment Planning Examples of Questions: Consumer meets Core Customer Criteria Medical screening is present The Treatment Plan: Individual s own language Choices and preferences Wellness goals, whole health Co-occurring health conditions (SA, physical health) 11
Scored Section #2 Compliance with Service Guidelines 25% of Total Score Programmatic review of services provided within each record based on DBHDD Service Guidelines For example: Case Management Services: At least 50% of services are delivered face to face ACT: One contact per month addresses symptom assessment and medication management Progress notes contain documentation of progress (or lack thereof) Interventions related to treatment plan Progress notes document individual response to interventions 12
Scored Section #3: Billing Validation 25% of Total Score Validated $ vs. Invalidated $ (Billing Validation) Up to 10 claims per record reviewed Eligibility Missing order, individual does not meet admission criteria Performance Standards Diversionary activities, content does not match service definition, supports units billed, etc. Quantitative Date of service, signature, location, credential, billing codes, etc. 13
Scored Section #4: Focused Outcome Areas 25% of Total Score Rights Whole Health Safety Choice Focused Outcome Areas Community Person Centered Practices 14
Scored Section #4: Focused Outcome Areas (continued) Whole Health Ongoing physical health assessments, medication education and risks, etc. Safety Documentation of safety/crisis plans, medication side effects, etc. Person Centered Practices Access to individualized services, documentation that the individual is a participant in planning/modifying services, etc. 15
Scored Section #4: Focused Outcome Areas (continued) Community Documentation of transition planning, employment, volunteer activities, church and civic membership, school attendance, etc. Choice Documentation demonstrates an individual s known preferences are followed, how the person is provided with options of supports and services including dates, time frames, and location, etc. Rights Documentation supports individuals are informed about their rights and responsibilities, at onset of services, at least annually, if barriers are identified, documentation demonstrates that alternatives are explored, etc. 16
Non - Scored Sections: Individual and Staff Interview Similar to the Focused Outcome Areas, the Individual and Staff Interviews are comprised of six different areas Rights Choice Whole Health Focused Outcome Areas Community Safety Person Centered Practices 17
Non - Scored Section #1: Individual Interview Individual Interview 5 Individual Interviews conducted during the review process Providers will select individuals for interview Once notification of Review is received, providers can begin identifying individuals to participate in the interviews Reviewers may select an additional 2-3 individuals based on the records reviewed May be conducted telephonically 18
Non - Scored Section #1: Individual Interview (continued) Whole Health Physical health-related needs have been addressed, primary care physician within the last year, individual is managing his/her own health, aware of diagnosis & medications, etc. Safety Safety-related needs have been addressed, individual is aware of or recognizes what constitutes abuse, neglect, exploitation, knows who to go to if a safety concern arises, etc. Rights Individual feels they are treated with dignity and respect, rights are explained in language that is understandable, individual feels services/supports can change as requested, etc. 19
Non - Scored Section #1: Individual Interview (continued) Choice Individual is satisfied with services, options/choices are provided, etc. Person Centered Practices Preferences related to independent living are being pursued, involved in treatment planning, monitor his/her progress, etc. Community Life Community involvement, social roles, employment, etc. 20
Non - Scored Section #2: Staff Interview Staff Interview 5 staff interviews conducted during the review process Reviewers will select staff for interview Providers can select up to 2-3 additional staff for interview Once notification of Review is received, providers can begin identifying staff to participate in the interviews May be conducted telephonically 21
Non - Scored Section #2: Staff Interview (continued) Whole Health Staff are educated on individual s diagnoses, medications, coordination of care, etc. Safety Staff are aware of crisis/safety plans, crisis hotlines, have received safety-related trainings, etc. Rights Staff are trained on how to avoid rights restrictions, aware of cultural practices and beliefs related to rights and exercising those rights, etc. 22
Non - Scored Section #2: Staff Interview (continued) Choice Staff present options to individuals regarding services and supports, competitive employment, aware of complaint and grievance policy, etc. Person Centered Practices Staff is able to identify individual s treatment goals and/or objectives related to service being provided, describe individual s strengths, reviews progress, etc. Community Life Education on community connections, activities, access to community involvement, etc. 23
The Review Process Upon completion of a Review, an Exit Interview will be conducted with tentative scores Written Summary of Findings will be sent via email within 30 days Appeals Process Technical Assistance Review Tools will be posted on the Georgia Collaborative Website by the end of July 2015 http://georgiacollaborative.com/ 24
Thank you For Georgia Collaborative ASO general inquiry or questions please email: GACollaborative@beaconhealthoptions.com 25