Routine Monitoring of MH/IDD/SA Providers by LME-MCOs through Collaboration and Transparency

1. Routine Monitoring of MH/IDD/SA Providers by LME-MCOs through Collaboration and Transparency Presented by the NC DHHS-LME/MCO-Provider Collaboration Workgroup at the NC TIDE Spring Conference April 28, 2014

2. Presenters • Margaret Mason Chief Operating Officer HomeCare Management (N C Providers Council) • Carol Robertson Quality Management Director Sandhills Center LME-MCO (N C Council of Community Programs) • Mary T. Tripp Policy Unit Leader DHHS-DMH/DD/SAS Accountability Team

3. Focus of this Workshop • The Impetus for Streamlining Provider Monitoring • An Introduction to the New Tools for Routine Monitoring of LIPs and Provider Agencies • Achieving Increased Accountability and Positive Outcomes Through Partnerships

4. Part I – Morning Session • Streamlining Provider Monitoring • What’s New or Different • What’s Been Accomplished • An Overview of the Routine Monitoring Tools for LIPs and Provider Agencies

5. Streamlining Provider Monitoring

6. What happened to Gold Star, and what led to this new way of monitoring? • Waiver Expansion • Continuous Quality Improvement • Reduce Administrative Burden on Providers and LME-MCOs per Session Law 2009-451 (SB 202) • Business Practices Sub-Committee of the LME-MCO & Provider Standardization Committee

7. What happened to Gold Star, and what led to this new way of monitoring?CONTINUED • A greatly streamlined, non-duplicative, standardized process needed for local monitoring. • The Provider Monitoring Workgroup expanded to include representatives from: • NC Council of Community Programs Business Practices Sub-Committee • NC Providers Council • Benchmarks • Professional Association Council

8. We heard you!!

9. Stakeholder Groups • Benchmarks • N C Council of Community Programs • NC Providers Council • Professional Association Council

10. Professional Association Council • Addiction Professionals of NC • Licensed Professional Counselors Assoc. of NC • National Association of Social Workers-NC Chapter • NC Association for Marriage & Family Therapy • NC Counseling Association • NC Nurses Association • NC Psychiatric Association • NC Psychological Association • NC Society for Clinical Social Work

11. NC Council PAC Benchmarks Individuals & Families DMA DMH/DD/SAS NC Prov. Council DHSR LME-MCOs

12. Quality Providers = Quality Services = Best Possible Outcomes for Individuals and Families

13. The Who-What &When of the Review Tools • The Routine Review Tools are used with two provider types: • LIP Review Tool is used with LIPs in a solo or group practice where only outpatient / basic benefit services are provided. • Agency Review Tool is used with provider agencies that provide any service(s) other than outpatient services exclusively.

14. Routine Monitoring • Includes: • Routine Review • Post-Payment Review • May be used together or separately.

15. Remember… Any of the monitoring or post-payment tools can be used at any time for targeted monitoring or investigations Incidents Complaints Quality of Care concerns

16. Routine Monitoring of Provider Agencies Includes: • All GS §122C MH/IDD/SA services that are not licensed by DHSR (e.g., Supervised Living, Unlicensed AFLs). • All GS §122C MH/IDD/SA services that are licensed by DHSR, but are not surveyed annually (e.g., PSR, Day Treatment, ADVP-IDD, SAIOP, SACOT, etc.). See “Licensed MH/DD/SA Services and Frequency of Surveys Conducted by DHSR Mental Health Licensure and Certification Section” in the Provider Agency workbook.

17. No Monitoring by LME-MCOs The following services are referred to the appropriate licensing agency: • Therapeutic Foster Care (Licensed by DSS under GS §131D) • Hospitals (Licensed by DHSR Acute and Home Care Licensure Section) • ICF-IID -formerly ICF/MR- (Licensed by DHSR Mental Health Licensure Section)

18. Limited Monitoring by LME-MCOs • PRTF – Post-payment and reported health and safety issues • Licensed Residential Facilities – Post-payment and reported health and safety issues • Opioid Treatment – Post-payment and reported health and safety issues

19. Semantics • Decision made to stop using Gold Star as the name of the NC provider monitoring process. • Confusion between Gold Star, the process, and Gold Star, the highest level to be achieved. • Gold Star as a term remains as the highest level achievable.

20. What’s New or Different NC Provider Monitoring Process Gold Star Provider Monitoring

21. What’s New or Different Frequency: • Routine monitoring occurs on a 2-year cycle as opposed to annually

22. What’s New or Different • The scoring and weighting of the review items has been revised.

23. What’s New or Different • Each of the following areas has a clearly defined sample size: • Funds Management • Medication Management • Incident Reporting • Restrictive Interventions • Complaints

24. What’s New or Different • Plans of correction are used to address systemic issues rather than individual non-compliance items.

25. What’s New or Different • AFLs that are not under the waiver are reviewed every 2 years (previously those sites were reviewed based on the profile level. • (AFLs under the Innovations Waiver are still required to be reviewed annually).

26. What’s New or Different • The minimum overall passing score for routine monitoring increased to 85% from 75%.

27. What’s New of Different • The initial on-site Health and Safety Review is not required if the service is located in a site that is licensed by DHSR.

28. What’s Been Accomplished? • Routine Provider Agency Tool reduced from 158 items to 18 items • Agency Post-Payment tools were reduced from an average of 16 to an average of 12 items • LIP Review Tools (routine, office site and post- payment) went from 63 items to 49

29. What’s Been Accomplished? • Focus is on rules related to systemic trends and quality of care • Elimination of duplication by using existing data such as review of IRIS reports, review of provider policies, submitted reports

30. What’s Been Accomplished? • Tool has been developed to obtain feedback from providers via SurveyMax (to be implemented May 1, 2014). • Webinars are being taped as a follow-up to statewide training. • FAQs from training and provider monitoring mailbox are posted on the Provider Monitoring web page for broad dissemination.

31. Routine Review Tools For LIPs And Provider Agencies

32. Historical Context • Agencies have a history of Routine Monitoring, i.e. endorsement, FEM, etc. • LIPs have typically only been monitored when there were concerns or issues.

33. Internal Quality Assurance • Routine Monitoring is …. • ….a New Experience for LIPs • ….will only involve review of documents needed to determine the met/not met/NA status for the review tool questions • ….less anxiety-provoking when providers (LIPs and agencies) use the tool as a pre-review self-assessment.

34. Routine Monitoring of Licensed Independent Practitioners (LIPs) • Two Components: • LIP Review Tool • LIP Post-Payment Review Tool • Other Specialized Tools • Office Site Review Tool • Service Plan Checklist

35. Routine Monitoring of Provider Agencies • Two Components: • Routine Tool • Post-Payment Review Tool • Other Specialized Tools • Unlicensed AFL Provider Review Tool • Health, Safety and Compliance Review Tool

36. Routine Monitoring of LIPs and Provider Agencies • Common Elements: • Rights Notification • Service Availability • Coordination of Care

37. Additional Element for LIPs • Storage of Records

38. Additional Elements for Provider Agencies • Incidents • Restrictive Interventions • Complaints • Protection of Property (as applicable) • Funds Management (as applicable) • Medication Review (as applicable)

39. Specialized Tools for LIPs • LIP Office Site Review Tool • Service Plan Checklist

40. Specialized Tools for Provider Agencies • Unlicensed AFL Review Tool • Health, Safety and Compliance Review Tool

41. How to Navigate the Excel Workbook andClinical Coverage Policies

42. Both the Routine Tool for LIPs and the Routine Tool for Agencies look at some of the same elements

43. Rights Notification

44. Item 1: There is evidence that the individual or LRP has been informed of their rights.10A NCAC 27D .0201. LIP and Agency Tool Sample is 10 events (solo LIP ), 30 service events (Agency/Group LIP Practice) Notification includes: • Rules to be followed and possible penalties. • How to obtain a copy of one’s service plan • Information received within 3 visits or 72 hours (for residential) • How to contact Disability Rights North Carolina • All areas above must be met to rate this item “Met”

45. Item 2: The individual has been informed of the right to consent to or to refuse treatment. 42 CFR 438.100 (Enrollee Rights), G.S. 122C-57(d); 10A NCAC 27D .0303 (c)LIP and Agency Tool Sample is same 10/30 service events as in Item 1 • Review documentation indicating the individual or LRP has been informed of the right to consent to or refuse treatment. • Signed consent must be present for each record in the sample to rate this item “Met”

46. Item 3: The individual is informed of right to treatment, including access to medical care and habilitation, regardless of age or degree of disability. G.S. 122C-51LIP and Agency Tool Sample is same 10/30 service events as in Item 1 • Must specifically inform, in writing, of right to Tx, including access to medical care and habilitation, regardless of age or disability. • Right to an individualized written treatment plan and right to access medical care. • All records in the sample must have the above to rate this item “Met.”

47. Item 4: The individual has been notified that release/ disclosure of information may only occur with a consent unless it is an emergency or for other exceptions. G.S. § 122C-55 or in 45 CFR 164.512 of HIPAA. 10A NCAC 26B .0205 LIP and Agency Tool Sample is same 10/30 service events as in Item 1 • Confidential information may not be released without written consent except in the case of an emergency. • Each element of the required notice listed in Statute must be explained in writing or verbally, but individual must sign that they have been explained. • Each record in the sample must have the above to rate this item “Met.”

48. Item 5: Authorizations to release information are specific to include [the items below]. 10A NCAC 26B .0202LIP and Agency Tool Sample is the same 10/30 service events as in Item 1 • Individual’s name • Name of facility releasing information • Name of individual(s), facility(ies) to whom information is released • Specific information to be released • Purpose of the release

49. Item 5: Authorizations to release information are specific to include [the items below]. 10A NCAC 26B .0202CONTINUED • Length of time consent is valid • Statement that consent can be revoked • Date consent signed • Must include a statement regarding the protection of HIV and SA information and disclosure requirements under 42 CFR Part 2 • Each record in the sample must include authorizations with all elements to rate this item “Met.”

50. Coordination of Care / Service Availability