ValueOptions NorthSTAR
Dallas County Service Delivery Area
SFY 2013 2nd Quarter
QUARTERLY QUALITY IMPROVEMENT ACTIVITY REPORT
ValueOptions Quality Management Department submits the Quarterly Quality Improvement Activity Report as specified in the State NorthStar Contract. This report addresses program activities for the second quarter (12/01/12-02/28/13) of the 2013 State fiscal year. The following areas will be addressed in this report:
· Status of Quality Management Work Plan
· Quality Improvement Activities
· Results of Quality Indicators
· Remedial/Corrective actions
· Assessment of Quality Management Program
QUALITY IMPROVEMENT PLAN /WORKPLAN
The Quality Management Committee met on December 11, 2012 and February 26, 2013 to review status of the QMUM Work Plan.
FOCUS STUDIES
The following QI Projects for 2013:
· Increasing Prescriber Engagement in NorthSTAR Mental Health consumers that are assigned to a MH Provider (SPN-Specialty Provider Network). The performance measures are to have a claim from an outpatient prescriber within 7 and 14 days of hospital discharge.
· Exploring other QI Projects for 2013 including the following:
o ICM Outcomes
o TRR Fidelity/Outcomes
o HHSC has requested we explore 2 Medication Adherence Measures in collaboration with one of the Medicaid Health Plans. One measure is related to Antidepressant Medication and the second measure is related to Medicaid enrollees with a diagnosis of Schizophrenia and adherence to Antipsychotic medication.
OTHER QUALITY IMPROVEMENT ACTIVITIES (RECOVERY):
QM and Clinical staffs at ValueOptions continue to participate in the coordination and planning for the Texas Recovery and Resiliency service design with DSHS. Children and Adult Curricula are the current focus of training and implementation planning. Participation by SPNs has been facilitated to ensure successful implementation of nationally recognized curriculum and programs set forth by DSHS. Regional training for Nurturing Parent was held at ValueOptions. Regional training for Supported Employment was conducted. Future trainings for other Evidence Base Practice programs were scheduled for this spring. Phone conferencing meetings with DSHS, ValueOptions and providers have been scheduled monthly and conducted for Wrap Around, Children’s Mental Health Fidelity, START Implementation, UM / Adult State-wide TRR Implementation, Supported Housing, Family Partner and NorthSTAR TRR Implementation. Documents under review include UM Guidelines, Curriculums and Fidelity Instruments.
REPORT ON STANDARD ACCESS Measures
The following provides a status update of certain access measures and a summary of any quality improvement activities related to each measure. Data was obtained from 12/1/2012-2/28/2013, except for the 7 and 30 day follow-up measures. This data was based on the time period of 8/1/2012/-11/30/2012 in order to allow adequate time for claims payment.
Reporting Measure / Data Source / Current Result / Limitations to Data Source / Initiation of any Quality Improvement Activities (provide summary) /Telephone response (ASA and Abandonment Rate) / Avaya Phone system data / Customer Service:
ASA: 16 sec
Abandonment Rate: 1.39 %
Clinical:
ASA: 24 sec
Abandonment Rate: 2.78 %
/ None / Customer Service and Clinical phone stats are within performance targets.
Timeliness of appointments w/in:
Routine: 14 calendar days
Urgent: 24 hrs.
Emergent:
Immediately / Member Complaints
Provider Relations Office-Site Audits / Access Complaints total = 2
2-Routine
0-Urgent
0-Emergent
Office Site Audits (Y=5)
100 %-Routine
Urgent
Emergent / No significant appointment access trends this quarter.
Data obtained from viewing appointment schedules and assessing provider’s appointment scheduling process may not be consistent with members’ experience. / Appointment access is monitored and reported through the complaint process as well as with office site audits.
Reporting Measure / Data Source / Current Result / Limitations to Data Source / Initiation of any Quality Improvement Activities (provide summary) /
Ambulatory Follow-Up to Hospitalization 7 days and 30 days MH / Claims / 40% 7 days
(581/1449)
58% 30 days
(758/1313) / Measures based on paid claims are subject to claims payment lag. / 7-day and 30-day follow-up were about the same as the previous quarter
30 Day Readmission MH / Authorizations / 12.5%
(195/1557) / 30-day Readmission MH was within the typical range.
30-Day Readmission Rate-CD / Authorizations / 8%
(80/1023) / 30-day Readmission CD was the same as the previous quarter.
CLINICAL AUDITS:
One SPN audit and one set of Chart Reviews for an Inpatient psychiatric facility were both conducted during 2nd quarter. The SPN Treatment Record Review audit received an overall passing score of 80% and a Corrective Action Plan was requested for specific elements within the audit such as individualized treatment plans, coordination of care with physical and behavioral health and clear documentation of support systems. Inpatient Chart Reviews were conducted on charts for adults and children to review quality of documentation and compliance with documentation standards. A Corrective Action Plan was completed for documentation of discharge plans, family therapy sessions and consistency amongst assessments.
The Care Coordination Study was also completed during first quarter. The purpose of this study was to increase Texas Health Steps participation and coordination of physical health needs with a primary care physician among NorthSTAR enrollees under the age of eighteen. A sample of ninety-five charts from eight specialty provider networks that serve children and adolescents was selected. The sample was limited to Medicaid clients since one of the review elements was to assess whether Texas Health Steps education was addressed.
Average outcomes from the 2012 study:
Identified Health Need is Met: 100%
PCP Identified: 96%
Annual Physical: 68%
THS Education: 85%
· The percent of charts with identified health needs met was 100 percent and the percent of primary care physicians identified was 96 percent.
· 100 percent of members who did not have a PCP identified received a PCP referral.
· 90 percent of the total sampled members had a physical within the past 2 years documented in their charts.
· Commonly reported health issues included asthma, allergies and stomach/GI issues.
· There was significant improvement in Texas Health Steps education since 2010, due in part to DSHS providing training at special provider network meetings to educate providers on Medicaid benefits, including Texas Health Steps.
· Data from the charts sampled reflected 20% of children and adolescents had a specific health need identified.
*In 2010, the methodology of this study was changed from provider-selected charts to a method of a randomized sample for more meaningful results.
Program Progress: There was marked improvement from the last study but there remain opportunities to continue to improve coordination of care between physical and behavioral health providers.
Continued action: The behavioral health organization will continue with provider audits and will continue to work with specialty provider network providers to develop best practice procedures to ensure that members are educated at regular intervals about physical health benefits available to them, and that documentation that this has been done is present in the medical record.
Program enhancements: Care Coordination Audits will be an ongoing activity with feedback to providers and to the Care Coordination Committee that includes the Medicaid and CHIP Health Plans for this population. The annual Treatment Record Review tools have also been updated to capture additional coordination of care elements. Texas HealthSteps will be invited to present to the Specialty Provider Network in 2013.
Specialty Provider Network Best Practices:
· Several SPNs chose to set aside one month in the year to make sure all families were educated on THS and other physical health benefits.
· Some SPNs have incorporated annual physicals and THS education into forms that are updated regularly such as medication visits, treatment plans or annual medical information update forms
· Several SPNs have developed a form to notify PCPs that members are receiving medications and behavioral health services
§ SPNs that have integrated care coordination elements into other routine documentation generally scored higher
RESULTS OF QUALITY INDICATORS
Telephone Access: Monitoring of call abandonment rates and answer yielded the following results for this quarter.
Clinical Calls:
Month / Number of Calls Received / Abandonment Rate < 5 % / Speed of Answer <30 sec.December 2012 / 1,518 / 2.70 % / 19 seconds ASA
January 2013 / 1,950 / 2.82 % / 27 seconds ASA
February 2013 / 1776 / 2.82 % / 26 seconds ASA
Clinical average speed of answer (ASA) was within target of within 30 seconds. The abandonment rate also met the 5 percent performance target for this quarter.
Enrollee/Provider Service Calls:
Month / Total Calls Received / Abandonment Rate < 5 % / Speed of Answer <30 secDecember 2012 / 6,886 / 1.13% / 13 second ASA
January 2013 / 8,539 / 2.00% / 19 second ASA
February 2013 / 8,253 / 1.04% / 15 second ASA
There were a total of 23, 678 calls received for this quarter, which was down from the previous report quarter (27,169 calls). The Customer Service average speed of answer (ASA) was 16 seconds for this reporting period, well within the target of 30 seconds. The abandonment rate was well within the 5 percent performance target for this quarter with an average of 1.39 %.
Medical Necessity Appeals: The following table presents information concerning medical necessity appeals for this quarter.
Month / Adverse Determinations / Level 1 Appeals / Level 1 Appeals Reversed / Level 2 Appeals / Level 2 AppealsReversed
Dec 2012 / 80 / 9 / 2 / 0 / n/a
Jan 2013 / 105 / 14 / 3 / 0 / n/a
Feb 2013 / 113 / 20 / 2 / 1 / 1
Adverse determination numbers trended up in.
Administrative Appeals:
Month / Level 1 Appeals Rec’d/Closed / Level 1 Appeals Reversed / Level 2 AppealsRec’d/Closed / Level 2 Appeals
Reversed
Dec 2012 / 60/74 / 22 / 2/8 / 2
Jan 2013 / 73/66 / 22 / 12/3 / 0
Feb 2013 / 87/76 / 27 / 6/11 / 1
Quarter Totals / 220/216 / 71 / 20/22 / 3
There were 220 Level 1 administrative appeals received for this reporting period, with 216 appeals that were closed. For Level II appeals, there were a total of 20 received and 22 closed for this reporting period. All Level I and Level II appeals were closed within 30 calendar days. Appeal type trends include timely filing, out of network providers, fee schedules, admin waivers, pre-certification/authorization issues, incorrect claims submission, member eligibility and Webcare denials.
Complaints/Grievances
Complaint volume in December 2012 (22) is the highest for this quarter while January (15) and February (8) are significantly lower. Overall, a total of 45 complaints were received for this quarter compared to 52 complaints received last quarter, indicating a downward trend. Quality Management continues to work closely with providers and other departments to resolve complaints in a timely manner.
Claims Data:
Dec 2012 / Jan 2013 / Feb 2013Mechanical Accuracy / 99.96% / 99.96% / N/A
Financial Accuracy / 99.00% / 99.75% / N/A
% Processed in 30 calendar days / 100.00% / 99.83% / N/A
Claims performance measures all were within contractual and regulatory standards. February claims data was not yet available.
Prevention, Education, & Outreach:
Numbers for December through February will be reported in the next quarterly report.
.
Provider Relations:
No formal trainings held during this reporting period. ProviderConnect training was held in the following quarter. SPN meetings and SPN Quality Committee meetings were held during this time period with a focus on TRR and CMBHS implementation. NorthSTAR providers and ValueOptions staff have been participating in the DSHS training programs and meetings related to TRR implementation.
Credentialing and Recredentialing
Indicator / Dec 2012 / Jan 2013 / Feb 2013# Initial Credentialed / 1 / 1 / 2
Average TAT Initial CR (in days) / 56 / 6 / 15
# Recredentialed / 6 / 1 / 6
Average TAT Recred (in days) / 23 / 17 / 15
% Recredentialed Files Completed within 36 month TAT / 100% / 100% / 100%
National Goals
Initial TAT – 25 days or less
Recredentialing Completed within 36 months – 96%
UM Average daily census table:
Month / Inpatient / Residential RehabilitationDec 2012 / 72.37 / 68.68
Jan 2013 / 80.6 / 67.29
Feb 2013 / 79.36 / 71.74
ASSESSMENT OF THE QUALITY MANAGEMENT PROGRAM
NorthSTAR ValueOptions QM Projects / TargetComplete 2012 QM/UM Program Evaluation / April 23, 2013
Complete 2013 QM/UM Program Descriptions and QM//UM Work Plan / April 23, 2013
QI Project: Improving Intensive Case Management (ICM) Clinical Outcomes / June 25, 2013
QI Project: Improving Access to Prescriber Appointments within 7 and 14 days after hospital discharge. / December 31, 2013
2012 Consumer Satisfaction Survey / August 27, 2013
Continue “Coordination of Care in Children” Project / December 31, 2013
Quarterly Quality 2nd Quarter Report
SFY 2013
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