- Sandhills Center

advertisement
Sandhills Center
LME-MCO
Quality Management
Committee
Executive Summary
January-March 2015
Quality Management Committee
Executive Summary
Time Period Covered January – March 2015

The Quality Management Committee (QMC) met face-to-face three times for
regular meetings during the 3rd quarter of this fiscal year, and had 67 (a
significant increase from last quarter) reviews for approval of policies, procedures
and other documents. There were 32 additional procedures and seven (7)other
notification documents reviewed though the expedited process, making the total
106 for the quarter. The Executive Summary includes Quality Management
Program activities that systematically monitor the quality and effectiveness of
Sandhills Center's internal systems, as well as ensuring the provision of high
quality services delivered by the Provider Network to Members. The Quality
Management Program's design helps ensure adherence to the Sandhills Center
mission to develop, manage and assure that persons in need have access to quality
mental health, intellectual/developmental disabilities and substance abuse
services.

Quality Improvement Projects (QIPs): There are eight active Quality
Improvement Projects. One will be presented for closure in April 2015. Please
see the attached QIPs beginning on page 15 for a brief description of current
QIPs.

3rd Quarter Routine and Post-payment Reports: This includes agencies and
LIPS, Health and safety reviews and unlicensed AFL reviews.
There were a
total of 180 reviews this quarter in this category. Additionally 60 Plans of
Correction reviews were completed with 31 requiring the final 20 day review for
completion.
Analysis: The questions most frequently failed for agencies were documentation
did not meet the requirements of the service definition and staff supervision plans
were not implemented as written. The questions most frequently failed for LIPs
related to documentation and appropriate service plans.
Interventions: Documentation training was held in March and will be held again
in April. QM was slated to present highlights of documentation requirements at
the February Provider Forum, which was canceled due to weather, but will
present in May.
Full report is attached beginning on page 37.
2

Investigation Reviews:
During the 3rd quarter, a total of 92 investigations were completed; 24 were based
on incident reports; 24 were based on quality of care concerns; 41were based on
complaints and three (3) were based on Network sanctions. This is an increase of
11 reviews from the 2nd quarter.
In addition, 100 reviews were completed as a follow up to 60 day approved plans
of corrections from previous monitoring. Of these 100, 31 sites required an
additional 20 day review to verify the implementation of the approved plan of
correction.



24 based on incident reports include suicide attempts, suicides and allegations of
abuse by staff or some type of aggressive behavior. Six (6) of these were onsite,
18 desktop review of records and one (1) required a plan of correction.
24 based on quality of care, documentation, services not true to the model or staff
not qualified were some of the reasons for review. Seventeen (17) were onsite,
seven (7) desktop review of records, with 11 plans of corrections requested.
41 based on complaints included 20 onsite reviews and 21 desktop, five (5)
required a plan of correction.
Investigative reviews play an intricate role in the quality management of
providers. As the data shows, providers continue to require plans of corrections,
with the highest number following quality of care concern reviews. These issues
were related to documentation, staying true to the model, and duplication of
services.
Interventions include provider training on documentation, and tracking, by quality
management, the providers who attended the trainings and comparing monitoring
scores to determine trends in monitoring deficiencies.

Focus Reviews
The focus review relating to SAIOP/SACOT is in the final stages. Plans of
Correction have been requested and responded to and payment concerns have
been referred to Finance.
A new focus review has been started relating to ACTT providers, team size and
composition. Staff records have been requested from those providers billing
within the past year. If the team size and qualifications are not according to state
standards, the agency will be referred to Network for further actions. If the team
size is appropriate and staff is qualified, medical records will be reviewed for
fidelity to the model of ACTT services.

Appeals: During the 3rd quarter, no appeals related to complaint resolution,
provider disputes or utilization management were brought to the QMC for review.
3

Executive Summaries (beginning on page 19) were reviewed from the following
programs:
 Care Management/Utilization Management
 Health Network and Network Leadership Council
 Customer Services

Reports: The following reports were reviewed by the QM Committee and QM
Program Committees, as well as stakeholders, Consumer and Family Advisory
Committee [CFAC], Client Rights Committee, Network Leadership Council
[NLC], LME Management Team, and the Board of Directors:
 Routine and Investigative Monitoring reports
 Level II and III Incident Reports
 Quarterly Complaint Reports

Incidents: 433 incidents were reported in the 3rd quarter compared to 395 the
previous quarter. 97 providers submitted reports from 160 different sites, of these
98 25 are CABHAs and 56 are out of network agencies.
 Consumer behavior accounted for 61.6% increase from last quarter
 Consumer injury was the next highest at 13.2%
 18 attempted suicides, 11 eleven adults, 7 under age of 18, highest
number in Guilford County; most commonly received service is ACTT
and most common method was overdose.
There were 0 suicides this
quarter.
 Allegations of abuse, neglect and exploitation decreased from the previous
quarter. All physical and sexual abuse was reported to the appropriate
DSS and DHSR if occurred in a licensed facility. The Health Care
Registry was also notified if a staff member is accused of abuse, neglect or
exploitation.
The largest number of incidents reported occurred in Guilford County (247),
followed by out of catchment providers (56) and Moore and Randolph counties
(24 each).

Critical Incident Subcommittee Quarterly Report (CIR): The committee met
monthly and reviewed a total of 49 incidents (these are also included in the larger
Level II-III report), this is the same number as in the previous quarter. The CIR
Committee reviewed fifteen (15) suicide attempts during the 3rd quarter, which is
an increase of 6 from the previous quarter. There were no suicides this quarter.
Due to the increasing number of suicide attempts, Customer services and the
training coordinator will work on developing and scheduling a suicide prevention
training. QM will develop flow charts showing what was found in review of the
incidents, what actions were taken and what will be done to educate providers.
QM and Customer Services Director will develop a monitoring tool for suicide
prevention and present to CLT in April for approval and use. Additionally QM is
tracking attendance at provider trainings to see if any correlations between
attendance and the number of incidents/quality of care concerns.
4
The CIR committee also reviewed five (5) Incident Reports of Allegations of
Abuse, Neglect and/or Exploitation during the 3rd quarter, which was a decrease.

Complaints: Quarterly Reports for January to March indicate 78 complaints were
received, an increase of 24 from the previous quarter.
Fifty nine (59) complaints were against providers, five (5) were provider against
LME-MCO, and nine (9) consumer against LME-MCO and two (2)) were
classified as other but against the LME-MCO.
The highest categories of complaints were quality of care by providers- 39 (50%)
The highest number of complaints was made on behalf of adult mental health
consumers. All were resolved within the required time frames and no consumer
suffered physical or psychological effects. Guilford County (our largest county)
had the highest number of complaints. This is consistent with previous quarters.
Moore County had the 2nd highest number of investigated complaints
A total of 44 complaints were investigated by either a desk top chart review (24)
or an onsite review (20). Five (5) of the complaints were substantiated, five (5)
were partially substantiated and four (4) required plans of corrections. Thirty four
(34) complaints were resolved with technical assistance.
Nine (9) complaints were referred to DHSR, one (1) to DSS and two (2) to
another LME-MCO
Complaints increased again from the previous quarter. However, the issue of
abuse, neglect and exploitation remained low and quality of care remained the
largest issue in the type of complaints received. The population most affected
still remains adult mental health consumers in residential setting or receiving
outpatient services,
Access to and Monitoring of Services: The Program QM Committees reviewed
the identified performance indicators during the quarter. No issues regarding
access and availability were brought to the QM Committee for review.

Policies, Procedures, Posting or Correspondence Approval Requests
Expedited January 2015
Information Management Data Integrity
Core 13a
P&P Maintenance, Review & Approval
Core 3a
Included additional
information re data
integrity and IT claims
audit process
Revised to streamline
process for annual review
Expedited February 2015
5
ACTT Provider Letter
Talking points - Bulletin J 110
2015 Community Needs Assessment
Accounts Payable-Electronic Funds Transfer
FIN 2c
Notifies ACTT providers of
special project
Talking points when staff
visit community hospitals
Survey for
providers/community/staff
Changes in software
system
Expedited March 2015
Care Management/Utilization Management
Plan 2014-2015
Access & availability of Care Coordination
Staff
Care Coordination Interventions for MH/SA
Members (Discharged from IP & LTC)
CC 4a
CC 12a
Changes made per Mercer
recommendations
Language changes
Added additional method
of follow-up with
members
Added wording re nonopioid individuals
Language changes re
software system
Added elements
documentation in member
electronic record
Included information
about high risk, high need
members
Minor language changes
Criteria for & Id of MH/SA Member
Participation fo CC
Inter-rater Reliability for MH/SA CC
CC 5a
MH/SA Care Coordination Documentation
Requirements
CC8a
MH/SA Care Coordination for Acute Care
Members
CC11a
Care Coordination Intervention Used for
Children Adm. To PRTF
Care Coordination Intervention for Minors
in Residential Placements Beyond a 6
month period
CC 17a
CC 18a
Language changes re IT
system to MCO software
system
Care Coordination Interventions for
Members with 1st Time Crisis Utilization
Non Engaged in Treatment with a
Behavioral Health Provider
CC20a
Changed payor to payer
MH/SA Care Coordination of Integrated
Care
CC 14a
MH/SA Care Coordination Supervision
CC 1a
Levels of Care Coordination Provided to
MH/SA Care Coordination Members
CC 22a
Purpose for MH/SA Care Coordination
CC 2a
CC Network Task Force will
meet at the request of SHC
Medical Director
Typographical error
corrected
Changes to duration,
frequency and tasks
associated with each level
of Care Coordination
Included statement re
opioid and no-opioid
dependent members, 1st
time crisis users and DD
inmates
CC 13a
6
IT Business Continuity & Disaster Recovery
Plan Manual
Core 14b
State Funded (IPRS) Provider Manual
Medicaid Provider Manual
Scope of Services (Medicaid)
N NM 1a
Scope of Services (IPRS)
N NM 1a
Provider Network Access & Availability
Medicaid
Provider Network Access & Availability IPRS
N NM 2a
Provider Selection Criteria
N NM 3
Participating Provider Representation
N NM 5a
Participating Provider Relations Program
(Medicaid)
Participating Provider Relations Program
(IPRS)
Participating Provider Written Agreements,
Exclusions & Inclusions (Medicaid)
Participating Provider Written Agreements,
Exclusions & Inclusions (IPRS)
Participating Provider Suspension
Mechanism for Consumer Safety
Contract Process
N NM 6a
Provision of Innovations Waiver Services by
Relative/Legal Guardian (Medicaid)
Emergency Enrollment Network Providers
with forms
Out of Network Client Specific
Agreements/Contracts & Provider Payment
Agreements (Medicaid)
N NM 21a
Reclaiming Futures
N NM 2a
N NM 6a
N NM 7a, 8a, 9a
N NM 7a, 8a, 9a
N NM 17a
N NM 20a
N NM 22a
N NM 23a
Minor wording changes;
staff changes, language to
Great Plains, routing
instructions and
emergency contact listing
Language changes and
updated to reflect current
processes
Language changes and
updated to reflect current
processes
Changes to reflect current
processes
Changes to reflect current
processes
Changes to reflect current
processes
Changes to reflect current
processes
Changes to reflect current
processes
Changes to reflect current
processes
Changes to reflect current
processes
Changes to reflect current
processes
Changes to reflect current
processes
Changes to reflect current
processes
Changes to reflect current
processes
Changes to reflect current
processes
Changes to reflect current
processes
Changes to reflect current
processes
Changes to reflect current
processes
Request for review of
Reclaiming Futures
Directory.
Approved at Regular QMC meetings
January 27, 2015
7
Workplace Safety
HR 44, 44a
Policy/Procedure
OSHA
20, 20a`
Deleted as material is
included in HR 44,44a
Customer Services Supervision
CS 10a
Education and Training for Enrollees
CS 11a
Advance Directives
CS 14a
834 (State Funded) DMH Recipient Eligibility
Update Report
Clinical Decision Support Tool Update
Requirements
Clinical Staff Response Requirements
CS 18, 18a
Handling of Triage Calls
HCC 14a
Clinical Triage Dispositions
HCC 16a
Non-Automated Communication
Documentation
Member Eligibility & Enrollment
HCC 19a
Cash Management Policy
FIN 2
1/12 Provider Payment Process
FIN 3a
State & Federal Grant Settlement
FIN 4c
Checkwrite Balance Report
FIN 3g-3
Updated with software
language changes
Updated with software
language changes
Updated with software
language changes
Updated with software
language changes
Updated with software
language changes
Updated with software
language changes
Updated with software
language changes
Updated with software
language changes
Updated with software
language changes
Updated with software
language changes
Reflects current practices
pertaining to payroll
transfer
Reflects implementation of
Great Plains process
Reflects implementation of
Great Plains process
Retire- no longer needed
Provider Advancement
FIN 3x
Medicaid Timely Payment
FIN 3D
Revoking Authorizations
HIM 20
Retention of Member Records
HIM 19a
Investigative Process
PI 1a
February 25, 2015
HCC 8a
HCC 13a
HCC 19b
Per Mercer
recommendation-build
cushion on repayments
Reflects implementation of
Great Plains process
Revised to allow written
communication
SHC is an MCO and
maintains records in
accordance with State
Records Retention
Schedule
Language/grammar
changes per Mercer
8
recommendation
Verification of Services Billed
PI 2a
Recovery of Overpayments
PI 3a
RAT-STATS
PI 5a
Internal Investigations
PI 8a
Prepayment Claims Review Initial Notice
Letter
Internal Monitoring
QM 1a
Quality of Care
QM 4a
Inter-Departmental Coordination
Core 5a
Non-Contract Provider Monitoring
QM 29a
Provider Performance Profile Review
QM 30a
Provider Investigations
QM 31a
Developing & Monitoring Quality
Improvement Projects
Organizational Structure and Documents
QM 32a
Consumer Satisfaction
Core 39a
Review Criteria Requirements
HUM 1a
Initial Clinical Reviewer Resources
HUM 11a
Initial Clinical Reviewer Non-Certifications
HUM 12a
Initial Clinical Review Process
HUM 13a
Core 1a & 2a
Language/grammar
changes per Mercer
recommendation
Language/grammar
changes per Mercer
recommendation
Language/grammar
changes per Mercer
recommendation
Language/grammar
changes per Mercer
recommendation
Language/grammar
changes per Mercer
recommendation
Change in frequency of
monitoring
Includes PI director in QOC
referral process
Changes in frequency of
monthly meeting dates
Deletes language
referencing use of DGGS
worksheets
Deletes information about
levels and adds sentence
about referral for
sanctions
Language changes, process
for investigation and
responsible for collection
of complaint information
Change in frequency of
reporting to Global CQIC
Language and additions to
ensure current process
Revisions provided by staff
from QM, CS and Network
Operations
Language changes
Changes in frequency of
supervision
Added documentation
requirements per Mercer
recommendation
Deleted next review date
9
Concurrent Review Timeframes
HUM 21a
Certification Decision Notice & Tracking
HUM 22a
Continued Certification Decision
Requirements
Prospective Review Patient Safety
HUM 23a
Prospective & Concurrent Review
Determinations
HUM 30a
Retrospective Review Determinations
HUM 31a
Lack of Information Policy & Procedures
HUM 32a
Non Certification Appeal Process (Medicaid
& IPRS)
HUM 33a
Standard Appeals Process Timeframe
HUM 39a
Added clinical scenarios to
necessitate a QOC referral
per Mercer
recommendation
Deleted sentence
referencing
documentation on clinical
review form
Added information for
submission for review
Added information re
Unable to Process
Changed appeal request
process to completion
online
Title change
Written Notice of Upheld Non-Certifications
HUM 40a
Title change
Certification Submission & Review Process
HUM 42a
CM/UM Clinical Staff IRR Monitoring
HUM 43a
Provider Credentialing Plan
Medicaid & State Funded
NCR 1-18a & NM 3a
Practitioner & Facility Credentialing
N CR 1&4
Credentialing Committee
N CR 3
Credentialing Application
N CR 5
Credentialing Communication Mechanisms
NCR 8
Consumer Safety Credentialing Investigation
NCR 10
Deleted information about
missing information and
early request for appeal
submission
Changes in frequency of
consultation w/Medical
Director and auditing of
decisions
Multiple language
changes, deletions and
additions
Multiple language
changes, deletions and
additions
Multiple language
changes, deletions and
additions
Multiple language
changes, deletions and
additions
Multiple language
changes, deletions and
additions
Multiple language
changes, deletions and
additions
HUM 26a
Deleted reference to next
review date in system
Deleted anticipated review
date
Deleted next review point
10
Credentialing Application Review Policy
NCR 11
Credentialing Timeframe
NCR 12
Credentialing Determination Notification
NCR 13
Participating Provider Credentials
Monitoring
NCR 14
Multiple language
changes, deletions and
additions
Multiple language
changes, deletions and
additions
Multiple language
changes, deletions and
additions
Multiple language
changes, deletions and
additions
March 24, 2015
Accounts Payable Invoice Payment Process
FIN 32g
For deletion
HR 32a
Payroll Process
HR 38a
HR Software Management System
New HR Policy
Entering Applicants into the SHC Software
Management System
New HR Procedure
Entering New Hires into the SHC Software
Management System
New HR Procedure
Maintaining staff accidents & workers
compensation in the SHC Software
Management System
Maintaining staff training in the SHC
Software Management System
New HR Procedure
Recruiting and setting up a vacancy in the
SHC Software Management System
New HR Procedure
Setting up workflow management in active
directory for SHC Software Management
System
Terminating employees in the SHC Software
Management System
New HR Procedure
Criteria for & Identification of I/DD Member
Participation for Care Coordination
I/DD Decision Support Assessment
I/DD CC5, 5a
New HR Procedure
New HR Procedure
I/DD CC 10a
Documents process
w/Great Plains
Procedure no longer
followed
Procedures written to
include new HR Software
Management System
Procedures written to
include new HR Software
Management System
Procedures written to
include new HR Software
Management System
Procedures written to
include new HR Software
Management System
Procedures written to
include new HR Software
Management System
Procedures written to
include new HR Software
Management System
Procedures written to
include new HR Software
Management System
Procedures written to
include new HR Software
Management System
Procedures written to
include new HR Software
Management System
Language change from ICFMR to ICF IID
Language
changes/frequency of
updates
11
ICF-IID Deinstitutionalization Planning
I/DD CC 12, 12a
Language changes
Level of Care Criteria (ICF-II)
I/DD CC 15, 15a
Language changes
TCLI Access & Availability
New Policy &
Procedure
Assigning Care Coordination Staff to TCLI
Cases
New Policy &
Procedure
Purpose of TCLI Unit
New Policy &
Procedure
Accessing & Processing Gift Cards Needed
for Transition Year Stability Resources
(TYSR)
Payment Process for TYSR
New Policy &
Procedure
Case Activity Documentation Requirements
New Policy &
Procedure
Criteria for & Identification of TCLI Member
Participation
New Policy &
Procedure
Criteria for Completion of Root Cause
Analyses
New Policy &
Procedure
Interface with External Stakeholders in the
Transition Process
New Policy &
Procedure
Monitoring of Transition Services &
Stakeholder Follow-Along
New Policy &
Procedure
Developed per
recommendation of
Mercer
Developed per
recommendation of
Mercer
Developed per
recommendation of
Mercer
Developed per
recommendation of
Mercer
Developed per
recommendation of
Mercer
Developed per
recommendation of
Mercer
Developed per
recommendation of
Mercer
Developed per
recommendation of
Mercer
Developed per
recommendation of
Mercer
Developed per
recommendation of
Mercer
New Policy &
Procedure
The QMC recommended approval of the above policies, procedures, and other
documents, following approval by the respective Program Committees, IT,
Finance and Quality Management Departments.

Delegation Contracts: The QMC received Delegation of Function Reports for
PREST. One issue was identified and resolved. PREST is meeting contract
expectations.

CM/UM Appeals: During the 3rd quarter, there were 47 Medicaid appeals and
one (1) State dollar appeal, an increase of two Medicaid appeals from last quarter
and a decrease of five state dollar appeals.

Community Care of North Carolina:
Sandhills Center initiated a process that improves efficiencies and collaboration
with the CCNC networks in the service area. The Sandhills Center CCNC
12
Taskforce now meets monthly with all three networks jointly via teleconference.
The restructured meetings have proven to facilitate standardization and
transparency regarding both entities’ efforts.
Sandhills Center shares information with the CCNC networks regarding its
integrated care project involving local pediatrics, hospitals, public health, and
behavioral health providers that have integrated care as part of their practices. The
CCNC networks have been invited to participate in the initiative by providing
access to health systems data that might be pertinent to the study.
Sandhills Center continues to work with CCNC around SBIRT. More specifically,
Sandhills Center and Community Care of the Sandhills partner, offering technical
support and monitoring the work of the selected providers. The initiative recently
expanded to include MH/SA trainings relevant to substance abuse issues. The
target population for these trainings include the faith based community and the
native American community. Trainings are also being made available to providers
not currently involved with SBIRT but who might have involvement with the
integrated care initiative in the future.

Quality of Care 3rd Quarter Summary January-March 2015:
Fifty-six (56) Quality of Care concerns (an increase of six (6) from last quarter)
were received this quarter. Forty-four (44) were accepted for review (an increase
of 8) and twelve (12) were not accepted, a decrease of two (2).
Eighteen (18) Quality of Care concerns accepted (41%) were related to
documentation ( a slight decrease from last quarter); 12 of these had letters sent to
Medical Directors/Clinical Directors; two (2) agencies had two (2) letters each
and one (1) Clinical Director had three (3) letters--two (2) different agencies).
Nine (9) Medical Directors/Clinical Directors letters were mailed in the previous
quarter.
Nine (9) Quality of Care concerns accepted (20%) were related to services not
true to the model.
Seven (7) of 12 QOC concerns not accepted (58%) were related to duplication of
services and five (5) of those were referred to Program Integrity.
There were 47 different providers; four (4) agencies with two (2) referrals each
reported; three (3) agencies with three referrals each; however one of these
providers had referrals from different sites.
Referral Sources continue to come from CM/UM (50%), Care Coordination
(21.5%), Customer Services (12.5%), QM and other sources (16%).
13
Documentation concerns still remain the highest number of concerns. Provider
training occurred in March and overflow sessions are scheduled for April. A
presentation relating to service specific documentation, planned for the Feb
Provider Forum, was cancelled due to weather but will be presented in May.

Internal Monitoring Quarterly Report:
Brief overview by department below.
CM/UM: Twenty-eight denial letters were reviewed; one had language that
indicated provider asked for too much time, but agreed to review monthly. This
is more administrative then clinical.. There were no overturned appeals this
quarter. High cost/high utilization reviews were reviewed by QM staff to ensure
individualized decisions were being made member-specific. Services reviewed
were PRTF, IIH, ACTT, In Home Skill Building and no issues noted.
Network: Sanctions are discussed in both Network and QM Committees
monthly; no issues were noted in compliance with policies and procedures. There
were eight (8) sanctions this quarter with one (1) dispute.
Call Center: Random sample of STRs were reviewed for clinically appropriate
disposition; no issues noted.
Care Coordination: Issues still remain with compliance with policies and
procedures. MH/SA/and I/DD issues with timely documentation of notes were
identified. DOJ and I/DD Non Waiver reviews were also completed, with the
same issues identified. However, the number of errors and/or staff with errors is
decreasing. The numbers consistently decrease each quarter. New to the review
this quarter for I/DD care coordinators was the review of ISPs. Results were
sent to supervisors for education and training.
Finance:
Reviews completed this quarter by QM staff found no deficiencies.
QM: Errors in the QM database were discussed with Managers and corrected.
HR: To be discussed in CFRM when issues occur.
Communication Department: A Training Plan was developed prior to requiring
input from CMT; however, input for trainings during this quarter was obtained
from other SHC staff.
IT: Reports are to be presented at QMC each quarter.
Respectfully submitted by:
______________________________________
Carol Robertson, Quality Management Director
__________________
Date
14
Quality Improvement Projects
Utilization Management
Decrease the number of Unable to Process Service Requests
To meet Health Utilization Management standards outlined by URAC, this project has been
implemented to decrease the number of administrative denials received by providers that impede
the process of members getting services timely. In December with the beginning of the Medicaid
Waiver 1,591 UM/UR requests were received and processed. During that time there were 394
(24.76%) administrative denials issued. 266 of these were MH/SA and 128 were I/DD. For
MH/SA, 130 requests were not processed at the provider’s request and 78 not processed due to
missing documents; for I/DD 82 were not processed due to incorrect units/time frame for service
and 46 were not processed at provider request. The goals of this project are to provider training
and technical assistance to providers to decrease number of denial by 20%; reduce the percentage
of Innovations services administrative denials to less than 17% and to reduce the number of
consumers’ authorizations receiving 3 or more administrative denials to less than 10.
During the 3rd quarter 2014-2015, 10,165 requests were received; of these 793 were unable to
process for a 7.8% request rate.
Mental Health/Substance Abuse providers were issued 636 of the 793 (80.2%) unable to process
request. I/DD Innovations providers were issued 157 of 793 (19.8%) administrative denials.
The Unable to Process request rate is below the target of 17.5% for the third consecutive quarter
since the implementation of Alpha and marks the lowest quarter since the start of this QIP. The
training and technical assistance for all providers will continue until goal is met or exceeded for
three consecutive quarters. Recommendation to close will be made at the April Quality
Management Committee meeting.
QIP in its entirety is attached.
Increase Percentage of Authorized Service Used by Providers
Initiated to closely monitor and increase the percentage of authorized services used by providers.
During their work, the UM staff observed a trend of providers requesting authorizations for
outpatient services and then not using the majority of the units authorized. The outpatient code
most requested is Individual Psychotherapy (90837). The numbers of units requested for Oct.Dec. 2013 were 10,227. The service takes place in an office or outpatient facility setting and
lasts approximately 60 minutes, face to face with the patient. The outpatient group therapy
service is most requested as Group Therapy (90853). The number of units requested for Oct.Dec. 2013 quarter for this code was 6,605. When comparing providers, the UM staff observed a
wide range in the percentage of units used. The purpose of this project is to assist providers in
increasing the percentage of authorized units used for the service codes 90837 and 90853.
15
Base line measurement was second quarter FY2013-2014. During this quarter, 120 providers
billed Individual Psychotherapy (90837). The overall percentage of authorized units eventually
billed was 23.8% (2,438 of 10,227 units authorized). Of the 120 providers only 17 providers
(14%) are billing more than 50% of the authorized units. During this quarter, 33 providers billed
Group Therapy (90853). The overall percentage of authorized units eventually billed was 19%
(3,690 of 16,832 units authorized). Of the 33 providers, only four (4) providers (12.12%) billed
more than 50% of the authorized units
Both consumers and providers are impacted by this project. This project fits with the HUM
module Version 7.0 and is designed to measure the increased utilization of services codes
referenced. The project is clinical in nature and the study question is: Will targeted training and
support tools assist community providers in increasing utilization of number of units authorized?
Third quarter 2014-2015 time frame reported was for 2nd quarter 2014-2015 data; 53.2% of
authorized units for 90837 were used; 45.2% of providers used at least 50% of the units
authorized; 29.1% of authorized units for 90853 were used; 11.4% of providers used at least
50% of units authorized. For both codes there is improvement in utilization.
QIP in its entirety is attached.
Increase the number of members authorized for Psychosocial Rehabilitation Services
(PSR) with correct diagnosis or sufficient clinical information
This QIP was approved January 27, 2015 and was initiated to closely monitor and decrease the
number of consumers approved for PSR with an incorrect diagnosis or insufficient clinical
information. Both consumers and providers are impacted by this project This project is clinical
in nature and the study question is: Will targeted training and support tools assist CM/UM
Managers and community providers in ensuring members appropriate for PSR get authorized for
services..
Baseline measurement was April 1-Sept 30-2014. 44% of services were authorized with a
diagnosis that was not clinically appropriate or the clinical information submitted did not justify
the approval of the service or stated differently 56% were authorized appropriately. The goal is
to increase the percentage of members authorized appropriately for PRS to 85%.
For the 2nd quarter measurement 55% were approved appropriately based on diagnosis and
clinical information submitted. This is a list decrease from the baseline.
Health Network
Increase tracking for the Receipt of North Carolina Treatment Outcomes Program
Performance System (NC-TOPPS) Interviews
NC-TOPPS is a web-based system in which providers enter data based on face-to-faceinterviews conducted with members, initially and at periodic intervals during the time services
16
are rendered. This is a mandatory and contractual requirement for mental health and substance
abuse services (MH/SA) members ages six and older. Data collected from interviews is
designed to assist in evaluating the effectiveness of treatment, access, and member’s satisfaction
with services. Historically, SHC has ranged an average 22% below the state standard of 90%.
SHC ensures that all network providers of publicly-funded MH/SA services in its catchment area
meet the requirements of NC-TOPPS tools and protocols by tracking receipt of data, providing
quarterly training as well as technical assistance. However, data suggests that these methods
have not proven effective and a more intensive approach is needed to increase compliance. In
addition, SHC has not fully utilized its authority based on contractual agreements to impose
possible consequences
Sandhills Center has achieved the State Performance Standards of 90% and above for three
consecutive quarters. This QIP will be presented to Network and QMC for closure at the April
meetings.
QIP in its entirety is attached.
Decrease the length of time it takes for providers to return their signed contracts and/or
contract amendments to Network
Currently Sandhills Center has 617 Medicaid-only network providers, comprised of agencies and
solo Licensed Independent Practitioners. Quantitative data from the Contracts’ unit indicates that
44% of Medicaid providers did not return their signed contracts within 60 days of mailing.
URAC standard N-NM 7 requires that the LME/MCO has written agreements with all
participating providers. To meet this standard a quality improvement project was initiated to
closely monitor and track the length of time it is taking network providers to return their signed
contracts and/or signed amendment to the Network Development unit for final processing and
execution. A contract is executed when it is signed by all parties to the contract.
A contract is initiated after the provider has been credentialed and after SHC Board approval.
The contract with attachments is mailed to the provider, with directions on how to process and
where to return two (2) signed original contract packets. The date the contract is sent to the
provider is entered on a routing/tracking log. Upon return to Network Development, the signed
contract packets are reviewed for completeness and complete packets are tracked and routed to
the SHC Finance Director and CEO for signature. Dates are tracked at each instance. Upon
execution, a fully signed original contract is mailed to the provider; an original is filed at the
SHC, and a scanned copy is saved electronically.
Third Quarter 2014-2015 review indicated that 92% of Medicaid providers returned their signed
contracts/amendments within 60 days. The goal is to reach 85% of providers returning their
contacts. This is the first quarter, the goal has been met.
QIP in its entirety is attached.
17
Health Call Center
Improve member’s access to care by ensuring follow through with routine and urgent
scheduled appointments – Individuals triaged are given an appointment based on the clinical
acuity of their situation. Reporting to the Division of Mental Health, Developmental Disabilities
and Substance Abuse services, regarding members’ access to routine and urgent care, is
mandatory. SHC has consistently failed to meet the statewide performance standard (Urgent:
82%, Routine: 71%) for the past three quarters, which indicates the need for improvement.
Research supports that effectively engaging individuals at the onset diminish risk of further
deterioration, relapse and hospital readmission. Individuals who call SHC’s toll-free line Access
lines are triaged and given an appointment based on the clinical acuity of their situation; urgent
(appointment scheduled within 48 hours) or routine (appointment scheduled within 14 days). The
overall objective for this project is to reduce the number of cancellations and No-shows for
urgent and routine appointments. The goal is to increase the performance measures for Access to
Care-Urgent to 84%, and Access to Care-Routine to 73%. Data is compiled and analyzed
monthly, utilizing Sandhills Center Avatar PM Screening Triage and Referral Report (STR900).
Strategies are implemented to assure the correct categorization of members (urgent or routine)
during the process. Health Call Center staff assists callers with addressing potential barriers that
may interfere with the individual’s ability to keep scheduled appointment. In addition, staff
offers possible alternatives and/or resources.
Measure for 3rd quarter 2014-2015:
Urgent STRs 73% kept appointment. Goal is 84%, state standard 82%. Goals not met.
Routine STRs 58% kept appointment (42% no show). Goal is 75%, state standard 75%. Goals
not met.
QIP in its entirety is attached.
New QIP sent to DMA for approval:
Improving access to behavioral health information and services for Hispanic members by
improving content available to members of this population seeking such services.
QIP was approved by DMA in January 2015 and is attached. No measurements are available at
this time.
18
Utilization Management Committee
Executive Summary
Committee Chair: Sabrina Russell-Holloman, LCSW
Date of Summary: 4/16/2015
Meeting Date: February 23, 2015
Date of Summary to QM Committee: 4/16/2015
Committee progress towards purpose and objectives











2014-2015 Quality Improvement Projects: Review of previous quarter data for
Unable to Process QIP, QIP for Outpatient Therapy Utilization and PSR QIP.
Ongoing participation on Alpha User Group for standardization of clinical
processes.
Continue to maintain over 85% consistency standard for IRR.
Prepared desktop and record selection for EQR.
Ongoing meetings with Medical Director and Care Coordination Director to discuss
plan for Mental Health/ Intellectual Developmental Disability high risk/high need
members.
UM participated in training on Due Process related to Innovations.
UM assisted in selection of provider for ACTT RFP.
UM participated in an update meeting with B-3 providers to address concerns
related to authorization and service delivery.
UM initiated random audit of outpatient unmanaged sessions with the assistance of
Program Integrity staff.
UM met with SHC training staff to highlight need for training with PSR providers
and Outpatient providers referring to PSR.
UM staff trained on use of CCNC Provider Portal and CMT to aid in managing
care of members.
Significant Reports and Data Reviewed Certification Tracking reports
 Unable to Process report(for QIP data)
 Outpatient Treatment Utilization (for QIP data)
 PSR Utilization report(for QIP data)
 Summary Count of Requests by Status report
 IPRS and Medicaid Request Completion Timelines report
 PREST Delegation monitoring reports reviewed
 Inter Rater Reliability
 Peer Review tracking report
 Summary Count of requests by Care Manager
19
Committee Highlights
Top Significant Accomplishments
Identified Accomplishment
PREST IRR Completion
2012-2013 QI Projects
Policy and Procedures
Staff Training
Provider Communication/Training
Factors That Supported Success
IRR conducted in December 2014. Results were
100% consistency with PREST physicians.
The Unable to Process QIP remains below
the target of 17.5% for the third consecutive
quarter since the implementation of Alpha
and marks the lowest quarter since the start
of this QIP. The monitoring of Unable to
Process service requests will continue
however UM will be recommending closure
of this QIP. The QIP related to Increasing
the Percentage of Authorized Services Used
by Providers reflects an increase in
utilization for both 90837 and 90853, in
terms of authorized units used and the
fourth increase in percentage of providers
utilizing at least 50% of authorized units for
90837. The percentage of providers utilizing
at least 50% of authorized units for 90853
decreased slightly from the previous quarter.
The QIP related to increasing the number of
members authorized for PSR with the
correct diagnosis and clinical information
decreased from the baseline measurement of
56% authorized appropriately to 55%.
Completed yearly review of UM Policy and
Procedures. Updates made based on Mercer
recommendations.
CM/UM staff participated in training related to
Due Process, Comprehensive Clinical
Assessment, Person Centered Planning, and
Understanding Substance Use Disorders from a
Trauma Perspective and Ethical Decision
Making in Behavioral Health.
Met with SHC training staff to discuss need for
PSR training and training for Outpatient
providers referring to PSR. UM participated in a
meeting with B-3 Providers to address concerns
related to authorization and service delivery.
20
Management Reports for Medicaid
book of business
Continue to review Summary Count of
Requests by Status report. This report
allows us to report to Management team
authorizations received, approved,
reduced and unable to process weekly.
These reports will also be used to report
monthly to DMA.
Continue to review Summary Count of
Request by Status report. This report will
be used to report total number of IPRS
authorizations received, approved and
unable to process monthly. This report
will also be used to report monthly to
DMH.
Management Reports for IPRS book
of business
Other Notable Accomplishments
Identified Accomplishment
Factors That Supported Success
Staffing of the CM/UM
Department
UM Department is recruiting for a CM/UM
reviewer to manage adult outpatient and
enhanced services.
Adherence with contract
requirements.
Include Quality Management issues
as identified within CM/UM.
UM Department has maintained a 99%
standard for reviewing routine and
expedited requests within contract
timeframes.
Referrals are made on an ongoing basis as
issues arise within the CM/UM Department via
the agency wide capability to submit Quality of
Care Concerns and/or Care Coordination
referrals in addition to Complaints/Grievances.
Issues identified with overutilization of family
therapy. Ongoing meeting with Quality
Management and Program Integrity to discuss
issues related to service delivery and billing.
Identified Areas of Need and Possible Solutions
Item/Area of Need Identified
Reports to project utilization of
services.
Recommended Solutions
UM met with Business Intelligence staff to
highlight need and request assistance.
Additional Comments:
Add any additional comments if needed. None
Prepared by:
Sabrina Russell-Holloman, LCSW Utilization Management Director
CM/UM Committee Chair
Approved by: _______________________________________________________________
QM Committee Chair/Regulatory Compliance Officer
21
Health Network
Executive Summary
Committee Chair:
Bonita Porter, LCSW Date of Summary: April 10, 2015
Summary Prepared by: Bonita H. Porter, Provider Network Director
Monthly Meeting Date: Second Tuesday each month
Date of Summary to QM Committee: April 28, 2015
Committee progress towards purpose and objectives

Review of reports to monitor issues and trends related to provider network composition,
credentialing, re-credentialing, accreditation, network access/gaps, training, monitoring
results, incident reports and provider complaints. Develop/implement strategies to
address issues as indicated.

Review of provider compliance of contract and credentialing requirements, to determined
execution of corrective action and/or sanctions.

8 Sanctions this Quarter with 2 Disputes

Network has two (2) Active QI Projects and will Request to terminate one and add a new
one effective the 4th quarter.
Request to terminate NC TOPPS QIP due to meeting the 90% state standard for three
consecutive quarters.
Decrease the length of time it takes for providers to return their signed contracts and/or
contract amendments to Network Development.

Network credentialing department continue to provide monthly monitoring duties to
contact providers to remind them of NC-TOPPS responsibilities.

Per the URAC standards, Network Credentialing has implemented the Re-Credentialing
Process.
Significant Reports and Data Reviewed
January 2015
Reports and Policy & Procedures Presented:

Contracts QIP: The percentage of contracts returned within sixty (60) days was 76.09%.
Outreach continues to be made via sending emails, making calls and sending out letters.
22


Provider Payment Agreement: Revisions approved
QM: Documentation expectations and overview scheduled for February Provider Forum.
Sanction(s):
3 Sanctions
0 Disputes
Discussion:


Re-Credentialing: Approximately 200 letters were mailed for providers expiring in June
2015
B 3 Service Allocation/claims report: Review of paid claims and utilization of services
February 2015
Reports and Policy & Procedures Presented:




Effectiveness of Communication Plan: Revisions approved
December PHD Q&A’s: Approved
NC 11: Credentialing Application Review Policy revised to change “provisional” to
associate per CB #J116: Approved
Re-Credentialing Letter revision: Approved
Discussion:


Re-Credentialing Letters: one hundred thirty nine (139) certified letters mailed reminding
providers of their upcoming re-credentialing. February 100% returned out of that group
started off with six (6) but two (2) to terminate; March 73%; April 75%; May 56% and
June those letter were mailed in January 2015 and we are at 11%. Total of five hundred
ninety six (596) have been mailed out to providers.
ACTT RFP: 4 Provider Applications Received
Sanction(s):
2 Sanction
1 Disputes
March 2015
Reports and Policy & Procedures Presented:




QM Reports
Quality of Care reports have declined
B 3: Peer Support services have increased significantly
ACTT RFP was awarded to Daymark Recovery
February PHD: Approved
23
Sanction(s)
3 Sanctions
0 Disputes
Discussion

Re-Credentialing Update:
Re-Credentialing status as of March 3, 2015 without the MD approval: February: 100% returned;
March: 87% returned; April: 75% returned.
Dr. Carraway requested one point of contact with Network in oversight of QOC/MD approval report.

Gaps/ Needs Discussion: Care Coordination requested evaluation of providers that served sexually
aggressive youth and crisis assessment for mental health and IDD for child/youth.

Provider Network Request: Clarification that outpatient provider submits clear clinical justification and
supporting documentation for network consideration.
Committee Highlights
Top Significant Accomplishments
Identified Accomplishment
Re-Credentialing Mailing Notification:
Timely mailing and consistent process
ACTT Needs in Lee, Moore and
Montgomery Counties
B3 Services implemented:
Respite, Community Guide, Peer Support,
SE/MH, SE/IDD, Personal Care, Physician
Consult
NC TOPPS: Have met state performance
standard of 90% for Three consecutive quarters.
Will request to terminate this QIP.
Factors That Supported Success
Documented MD initial credentialing information that
thoroughly assisted in the re-credentialing process.
ACTT RFP released and provider awarder contract
Network support and collaboration with SHC
departments and community stakeholders/providers
Coordination with QM Department and Credentialing
monitoring and reminders to providers.
Identified Areas of Need and Possible Solutions
Item/Area of Need Identified
Recommended Solutions

Sanction and dispute process
Review and revision of procedure and sanction grid.
Procedure QM 36a

100% Execution of contracts
Continue to enhance the contract process via the QIP
Goals

Re-Credentialing and Shaping the Network:
Providers who haven’t billed. But decline to
voluntarily terminate or amend their
contract.
Prepared by:


Establish billing requirement and/or evaluate current
contract requirements.
Data reports that identify actual needs per
catchment zip code
_________________________________
Committee Chair
Approved by: __________________________________
QM Committee Chair
24
Network Leadership Council (NLC) Executive Summary
Date of Summary:
Committee Chair:
Co-Chair:
Summary Prepared by:
Monthly Meeting Dates:
Date of Summary to QM
Committee:




April 1, 2015
Jan Herring, Vice-President of Operations with RHA Health
Services, Inc
Bonita Porter, Director of Network Operations with SHC
Alexis Wright/Tana K. Wirtz, Network Development
January - March 2015
4/28/15
Committee Progress Towards Purpose and Objectives
Membership is maintained to reflect composition of provider network.
Input is encouraged via email reminders of meetings, copies of agendas, handouts and the
ability to participate via conference call. A quorum was represented at each meeting.
Reviewed reports and data on provider related performance and quality management
activities and provided input/recommendations.
Provided input regarding the SHC Training Plan, NLC Self-Assessment Results, and
NLC Orientation Overview.
January 8, 2015 Meeting Significant Reports and Data Presented
Nominees for Vacant Positions
 Pamela Parker, PhD, MS, LMFT
 MaryAnn McCrary, LCSW
Care Coordination Update
 Dorinda Robinson stated they continue to meet every month with CCNC (Community
Care of North Carolina) partners in the three (3) different networks. December’s meeting
was cancelled.
 Martha Rogers and Robin Kapp met with the Provider Portal Network Administrator on
January 7, 2015 of CCPGM and they received Train the Trainer Training.
 The Integrated Care Project, spearheaded by Dr. Carraway at SHC, has a multidisciplinary taskforce and met January 7, 2015.
 Robeson Healthcare have identified 3 SBIRT sites. Currently 2 sites are operational.
CFAC Update
 Stakeholder’s breakfast was held in Lillington on November 24, 2014. The next
stakeholder’s breakfast will be at First Health, Pinehurst in conference room A and will
start at 8:30.
 CFAC has not met since November, 2014 and the next meeting will be January 20, 2015.
25
Customer Service Update
 Reports due in January were: Quarterly Report for Access, Block Grant Semi Annual,
Work First and Quality Management.
 A new Quality Improvement Project, to improve access for Spanish speaking population,
was approved before the New Year. The purpose is to improve our Spanish language
content on the website along with written material.
UM Update
 UM continues to process about 4,000 Medicaid authorizations and 1,500 IPRS
authorizations a month.
 UM continues to meet performance standards with DMA and DMH; 100% compliant
with routine authorizations processed within 14 days; 100% compliant with urgent
request within 72 hours; averaging 13 Medicaid appeals a month and 2 IPRS appeals.
 UM reports an increase in B3 services and new members are being served with those
services.
LME-MCO December 2014 Report Operations (Reviewed by Anthony Ward)
There was an increase in Medicaid Eligible; this has been a trend over the
last 6 to 9 months and may be due to the Affordable Care Act.
The Call Center continues to meet all the bench marks associated with
Speed to Answer, Blockage Rate and Abandonment Rate; 95% of the calls
Health Call
being answered within 30 seconds.
Center
Sabrina R. noted CM/Utilization is meeting all standards. Anthony W.
Health Utilization called attention to the “Unable to Process/Administrative Denials”; 9.7% is
the lowest it’s been since starting the Waiver.
Management
The number of providers is 860 and holding. Network has started the recredentialing process. The network consists of LIPs, Hospitals, Agencies,
Clinicians within Agencies and Other Provider Types. There were no
Sanctions or Disputes for the month of November.
Health Network
Anthony W. noted that consumers re-admitted to hospitals are getting
connected to Care Coordination and getting linked with a provider prior to
Care
discharge.
Coordination
100% of complaints against SHC and Providers were resolved within 30
Quality
days.
Management
Anthony W. noted claims have held constant during Oct. and Nov. The
Claims
average # of days to process claims increased due to hospitals submitting
Processing
paper within 30 day timeframe as required.
Medicaid Eligible



Nov. 20 & 21 were the dates of the Mercer visit and consisted of the Clinical Operations,
IT and Administration Operations.
The transition to the ALPHA system in the spring 2014 brought a more standardized
approach to the process.
For Network there was discussion on re-credentialing: how files are stored, what
information is stored in the files and the monitoring that has to be done each month.
26


SHC has been operating as a Waiver for two years while understanding that the next
business step is to analyze how to use our data.
Mercer suggested corrective action and best practice recommendations to adopt. We are
waiting for their final report.
Quality Management
 10 Quality Care Concerns were accepted for December, 50% due to documentation
issues.
 The overall QOC reviews were submitted for Independent Psychiatric Review.
 In February 2015 at the provider forum we will focus on documentation with the
providers.
Provider Network
 Bonita Porter reported on the re-credentialing process; the third set of letters for those
credentialed in May 2012 were mailed on January 7, 2015, there were about 300. Any
re-credentialing applications not received within the allotted time frame will receive a
final letter. Anthony W reported once out of the network providers cannot re-enter the
network due to the network being closed.
 A new RFP for ACTT is posted on SHC website and sent out via email for Moore,
Montgomery and Lee Counties. There will be a question and answer session in West End
on Monday Jan. 12, 2015 at 1:00 pm in building one and in Greensboro on Jan. 13, 2015
at 2:30 pm.
 The Global CQI meeting sent out an email that SHC is going to do a Blanket Waiver for
the QM11 for providers who do not wish to submit Quarterly Incident Reports.
 Anthony W. reported at the next session they will discuss1. Medicaid Reform-how that looks moving forward across the State;
2. Medicaid Expansion-whether that is something the State is going to consider and
3. Structure of Medicaid in the State
Upcoming Meetings:
 The next monthly meeting is scheduled for February 12, 2015.
February 12, 2015 Meeting Significant Reports and Data Presented
Nominees for Vacant Positions
 Theodus Roach, LCSW, ACSW
CFAC Update
 Statewide CFAC is on February 20, 2015 and three (3) members will be attending.
 The Moore County Stakeholders Breakfast was on January 30, 2015; twenty seven (27)
people in attendance and 4 out of the 27 were Psychiatrics
 CFAC is recruiting for two (2) new members: one in Guilford County in Mental Health
and one in Randolph County in IDD.
27

The next stakeholder’s breakfast will be in Hoke County on February 27, 2015 at First
Health Hoke Campus in Raeford.
Customer Service Update (See January Report Below)
UM Update
 UM is continuing to remain in compliance in meeting the routine and urgent request.
 UM is continuing to recruit for two (2) reviewer positions for urgent request and adult
service requests.
 New QIP specifically related to Psychosocial Rehabilitation Services. UM has seen some
over utilization with Psychosocial Rehabilitation and billing issues.
Quality Management Update (See January Report Below)
CCNC Update
 Dr. Carraway and Carol Robertson will be meeting February 13, 2015 with the local
Behavioral Health Providers Partnership.
 Center for Behavioral Health is assisting with the rollout of the B3 Psychiatric Consult
Service.
LME/MCO January Report (Reviewed by Anthony Ward)
Medicaid
Eligible
Health Call
Center
Health
Utilization
Management
Health
Network

November 2014 – 162, 169 and December 2014 - 153, 534

Number of calls received: November 2014: 2,328; December 2014:
2,483
 Average Speed to Answer is thirty (30) seconds or less: November
2014: 5.0 seconds; December, 2014: 5.0 seconds
 Blockage Rate is five (5) seconds: November 2014: 1.42%; December
2014: 1.21%
 Abandonment Rate is five (5) seconds: November 2014: 0.82%;
December 2014: 1.24%
 % of calls answered within 30 seconds: November 2014: 99.9%;
December 2014: 99.9%
 All bench marks have been met within the required time frames.
Number of Unable to Process/Administrative Denials Issued
 9.7% in November 2014and 11.6% in December 2014
Number of Providers in Network
 860 Providers in November 2014; 857 Providers in December 2014
Number of Provider Sanctions Imposed
 0 Provider Sanctions in November 2014; 4 Provider Sanctions in
December 2014
28
Quality
Management
Claims
Processing
Financial
Claims Trends
Number of Complaints Against MCO Received
 4 in November 2014; 1 in December 2014
Number of Complaints Against Providers Received
 13 in November 2014; 11 in December 2014
Number of Complaints Resolved within 30 Days
 100% resolved in November 2014; 100% resolved in December 2014
Total Number of Claims Denied
 3.2% in November 2014 and 3.6% in December 2014
Number of Total Claims Pended or In Process
 0.5% in November 2014 and 0.0% in December 2014
Review categories:
 Revenue, Expenses, Year to Year Comparison (Revenue Source),
Year to Year Comparison (Expense Category), New Allocations from
State, SHC Medicaid Alpha Denials.
Provider Network



QIP for decreasing the length of time it takes for providers to return their signed contracts
and/or contract amendments to Network Development:
 September 30, 2014: 70% of Medicaid providers returned their signed
contracts/amendments within 60 days (includes those within 60 day range)
 December 31, 2014: 76.09% of Medicaid providers returned their signed
contracts/amendments within 60 days (includes those within 60 day range).
In order to officially close the NC TOPPS QIP, Network has to have two (2) QIPs open at
all times.
Community Needs Assessment Survey was dispersed to providers present at meeting.
March 12, 2015 Meeting Significant Reports and Data Presented
Vacancy Updates
 Due to Theodus Roach not being able to attend NLC in person, it was recommended to
re-open the vacancy to providers.
Quality of Care Documentation Trends
 The services provided are not true to the model and there are missing components of
service definition; Anne Gable has organized documentation training and Lisa Bunting
will be the trainer.
 Substance Abuse providers have received plan of corrections on Substance Abuse
documentation following reviews. Carol R. stated they are getting ready to start an ACTT
project which may bring more plans of corrections on documentation.
CFAC
 Statewide CFAC Conference was held on February 20, 2015 in Wilson. They would like
to have a Statewide CFAC meeting at least twice a year, some suggested to have it four
(4) times a year.
29
The Hoke County Stakeholders Breakfast was held on February 27, 2015 and only twelve
(12) in attendances due to the weather. The next Breakfast will be held in Anson County
on March 27, 2015 at the Lockhart Center in Wadesboro.
 CFAC is still recruiting for two (2) members; one for Guilford County with Mental
Health and the other in Randolph County for IDD. February CFAC meeting was
cancelled due to the weather.
Customer Service
 Gene McRae reported they continue to meet all the standards for access that are required.
 EQRO visit is scheduled for the end of April.
 Customer Service has developed a text message to send to consumers to remind them of
their appointments and hopefully this will cut down on the missed appointments.
 Developing posters with SHC’s 800 number and information for outreach.
UM Update
 Remains in compliance with the performance standards.
 Hired a new reviewer that will be starting on Monday March 16, 2015; 1 vacancy
remains.
 Sabrina H. stated based on their efforts they have been monitoring and providing more
oversight regarding the PSR request and we are seeing an increase in our adult appeals
but overall appeals have been down.
Community Care of NC Update
 SHC has met monthly with the three (3) CCNC Networks for several years. Dr. Carraway
made a decision to consolidate the meeting and we have had two (2) meeting with all
three (3) CCNC networks at one time.
LME/MCO February Report (Reviewed by Anthony Ward)
Decrease in January (presenting an issue with NC TRACKS)
Medicaid
Eligible

Average Speed to Answer thirty (30) seconds or less :
Health Call
December-5.0 sec; January 5.0 sec.
Center

Blockage Rate 5% or less: December-2.21%; January 1.77%

Abandonment Rate 5% or less: December-1.24%; January
1.17%

% of calls answered within 30 seconds (95% or more):
December-99.9%; January 98.8%
Health

Number of unable to process/administrative denials issued
Utilization
December-11.6%; January-10.9%
Management

% of Standard Requests Processed within 14 days (95% or
more)
December-100%; January-100%

% of Expedited Requests Processed within 3 days (within 72
hrs.)
December-100%; January-100%
30
Health
Network
Care
Coordination
Quality
Management
Claims
Processing

Client Specific Contract (out of network providers):December58; January-58

Number of providers for re-credentialing: December-3,875;
January-3,950
Sanctions December-4; January-3 (due to: requested information not
being returned or a signed contract not returned, insurance information
has lapsed)

Number of Provider Disputes Received: December-0; January0
 Number of Admissions to Community Psychiatric Inpatient:
December-147; January 61

% of Readmissions Assigned to Care Coordination:December100%; January-100%

Number of Complaints Against MCO Received: December-1;
January-1

Number of complaints Against Providers Received:
December-11; January-17

Complaints 90% has to be process within 30 days: December100%; January-100%
Per Anthony W. denial is very low and the last report that he saw was the
lowest in the State.

Number of Total claims Denied: December-3.6%; January4.0%

Number of Total Claims Pended or In process: December0.0%; January-0.0%

% of Claims Processed within 30 days (90% of claims have to
be processed within 30 days or less)
December-100%; January-100%

Average Number of Days Processing: December-11; January10
Identified Accomplishment
All URAC, DMA, and DHHS standards
were met for: time to answer,
abandonment rate, and calls answered
within 30 second or less.
Factors That Supported Success
Customer Service Department and staff commitment to maintaining
standards and serving members.
Utilization Management is consistently
meeting performance standards for DMA
and DMH at 100%.
Addressed staffing issues to manage the oversight of targeted
services and processing of standard and expedited requests.
Increased monitoring to prevent over utilization of services.
Claims Processing are the lowest in the
state. 90% or more of claims have been
processed in 30 days or less.
Clean claims are being paid in a timely manner.
31
Health Network has facilitated an
increase in the number of providers
returning contracts within 60 days.
Quality Management met
standards for processing and
resolving complaints within 30
days. Standard is 90% and SHC met
at 100% for December – February.
Item/Area of Need Identified
Identifying providers that have incomplete contracts and initiating
contact through email, postal mail, and phone calls to facilitate the
return of contracts.
Issues with provider documentation
continue to be a QI concern. Services are
not true to model and are missing
components of service definition.
Organization of training and review of other services to identify
service areas where documentation training is needed.
High numbers of appointments are being
missed.
QM and staff commitment to meeting compliance standards.
Recommended Solutions
Call center is developing a text message to remind consumers of
appointments. They are also developing a poster with SHC’s 800
number and outreach information.
Additional Comments:
Prepared by:
__________________________________
Committee Chair
Approved by: __________________________________
QM Committee Chair
32
Customer Service Committee
Executive Summary
Date of Summary to QM Committee: 4/20/15
Quarterly Customer Service Committee Meeting Date: 2/11/15
Committee progress towards purpose and objectives




















Reviewed QIP: Improving Consumer Timely Access to Care by ensuring follow through with
routine and urgent scheduled appointments. 12/31/14 data:
Urgent 78% kept appointment, State Standard = 84%. Routine = 73 % State Standard 75 %.
Reviewed QIP: Improvement in the consistency and uniformity of risk assessment and intensity
of need determination of members with routine care needs during the clinical screening, triage
and referral process assessment and intensity of need determination of members with routine care
needs during the clinical screening, triage and referral process. Goals were met and it was
recommended the QIP be closed.
Implementing new QIP Improving access to behavioral health services for non-English speaking
members through faster linkage to language translation services.
10/1/14-12/31/14: Avg. time to answer phone: 5 seconds, well within standard of 30 seconds.
10/1/14-12/31/14: Abandon call percentage: 1.06 % (standard < 5.00 %).
10/1/14-12/31/14: Blocked/Dropped calls @ 1.42 %. Standard is less than 5 %.
10/1/14-12/31/14: Most calls (99.96 %) are being answered within 30 seconds
Customer Service Handbook (both Spanish and English versions) revisions have been approved by DMA, CS
Committee and QM Committee. They are in the process of being printed. They have been posted on the SHC
Website.
Reviewed Quarterly complaint report Oct , Nov, Dec 2014
Reviewed and approved minor revisions to the following P & P removing language that is no longer needed and
added language to coincide with the new phone system.
1) HCC 8a Procedure Clinical Decision Support Tool Update Requirements
2) HCC 13 Procedure Clinical Staff Response Requirements
3) HCC 14a Procedure Handling of Triaged Calls
4) HCC 16a Procedure Clinical Triaged Dispositions
5) HCC 19a Procedure Non Automated Communication Documentation
Reviewed HCC Reports for 2nd Quarter (October- December) Fiscal Year 2014-2015
1769 Medicaid, 8285 STRs Total, 16 Emergent, 41 Urgent, 82 Routine. There were no outliers to be reviewed
by Dr. Carraway.
Reviewed Inter-rater Reliability Report: Date of Report: 01/14/15, Period covered: 10/01/14-12/31/14.Results:
Number of STRs Reviewed: 26, Inter-Rater Reliability: 85%, 22 of the 26 STRs passed with a rating of 85% or
better in inter-rater reliability, Average of IRR agreement: 90%.
Reviewed Cardinal Innovations Roll Over Report: Health Call Center –October- December 2014: Volume: Oct
2014- 13, Nov 2014- 14 Dec 2014- 11; Average Time to answer (seconds): Oct 2014 .01, Nov 2014 .02 Dec
2014 .01, Abandoned calls: Oct 2014 7.1%, Nov 2014 0%, Dec 2014 8.3%, calls answered within 30 seconds:
Oct 2014 100%, Nov 2014 100%, Dec 100% Call Abandonments rate in October and December 2014 was
above standard limit (5%)- a corrective action plan was implemented by Cardinal Innovations. Clinical Triage
and referral phone rollover service meets all URAC, DMA, and DHHS access standards for this quarter.
Reviewed Call Center Performance October, November, December 2014
33

Month:
October

Volume:
3,056
2,338
2,883

Abandoned calls:
37=1.2%
30=.8%
35 =1.16%

Time to answer:

Calls answered within 30 seconds:

Summary: Call Center is meeting all URAC, DMA, and DHHS standards for access for this period.
5.0 seconds
99.9%
November
December
5.0 seconds
99.9%
5.0 seconds
98.8%
Significant Reports and Data Reviewed
Reviewed and analyzed data from the following reports:
 Call Log Summary – (Nov, Dec, Jan, 2014/2015)
 Summary of SHC access Data – (Nov, Dec, Jan, 2014/2015)
 Summary of Cardinal Innovations Data – (Nov, Dec, Jan, 2014/2015)
 HCC – Emergent Call Case Review – (Nov, Dec, Jan, 2014/2015)
 Number of STR’s by Where Referred After Triage and Provider Agency Referred to
(Nov, Dec, Jan, 2014/2015).
 Reviewed and updated task logs. No new tasks
 Reviewed QIP’s monthly – (Nov-Dec, 2014).
 Reviewed Cardinal Innovations primary rollover performance.
 Reviewed quarterly complaint reports for Oct Nov Dec 2014.
Committee Highlights
Accomplishments
Identified Accomplishment
No Complaint Appeals were received
this quarter.
Analyzing of Cardinal Innovations Call
Center data continues.
Continued to monitor new QIP of:
Improvement in the consistency and
uniformity of risk assessment and
intensity of need determination of
members with routine care needs during
the clinical screening, triage and referral
process.
Factors That Supported Success
As evidenced by Complaint Appeal Tracking
forms.
Occurring and reported to Member Services
Committee. This is an ongoing task. Primary
rollover agreement in place.
Approved by Committee. Monitoring data.
Recommendation for closure.
34
Monthly review of where CTR’s are
Continued monthly review.
referred to.
Continued task of reviewing non-URAC P &Reporting
P in
documentation now more accurate.
Preparation for EQRO impending visit.
Reviewed monthly reporting of the
Quality of Data regarding phone call logs Occurring monthly.
Reviewed call log data. All within state
Well within DMA and URAC standards.
standards.
Customer Service Handbook has been
They have been posted on the SHC Website and
revised as per Mercer recommendations
copies are in the process of being printed for
regarding “Special Populations”.
distribution. (Both English and Spanish versions).
Implemented new QIP: Improving access
to behavioral health services for nonCS Committee, QM Committee and DMA
English speaking members through faster approved.
linkage to language translation services.
Identified Areas of Need and Possible Solutions
Item/Area of Need Identified
Recommended Solutions
Continue Quarterly reviews of
Cardinal Innovations Call Center data
Analyze and address trends noted.
Ongoing monitoring of QIP projects.
Discontinuation of QIP Projects that have been
met and adding projects as needed. Monitor closed
QIP projects for 1 year.
Continue to monitor URAC Standard
Performance Indicators and contract
standards.
Develop and monitor new Customer
Service call structure as changes occur.
Handbook Review ongoing.
All required monthly reports to be completed on an
ongoing basis.
Required to meet DMA access standards.
Required to meet DMA access standards.
Additional Comments: None.
Prepared by: Gene McRae Customer Service Director and Mike Markoff, Customer
Service Coordinator.
Approved by:
35
Sandhills Center LME-MCO
Quarterly Routine Monitoring Report
3rd Quarter FY 14-15 January -- March
Brief Description of the Report:
The report shows the Provider Routine Monitoring results for the third quarter of fiscal year
2014-2015. This reflects Routine Monitoring process, to include reviews of agencies, Licensed
Independent Practitioners (LIPS), post-payment reviews, Health & Safety reviews, as well as
annual and initial reviews of unlicensed Alternative Family Living (AFL) sites.
Summary Results:
A total of 180 Routine Monitoring reviews were completed this quarter. This represents an
increase of 45 reviews from the previous quarter. The types and totals are listed below:
Forty-seven (47) monitoring reviews were conducted during this quarter of unlicensed AFL sites.
Fifty-eight (58) Health & Safety reviews were conducted as part of the provider monitoring
process. These reviews occurred at individual provider sites across the state. Although
Sandhills Center has a closed network, Health & Safety reviews are conducted when a provider
moves to a new location or a provider is brought into the network due to a gap in an existing
service.
A total of 75 Routine Reviews were completed this quarter. Twenty-six (26) provider agencies
and 49 Post-Payment reviews of residential or out-of-catchment sites were conducted.
Plans of Correction reviews:
Sixty-day (60) Plan of Correction reviews of previously monitored agencies and LIPS were also
conducted during this quarter. One hundred (100) reviews were conducted. This follow-up
review is scheduled to verify implementation of the approved Plan of Correction submitted for a
previously conducted review.
If implementation of the Plan of Correction cannot be verified at this time, the provider receives
notice a final follow-up review is scheduled in 20 days. All corrections are to be completed by
this time or the provider is referred for possible sanctions. During this quarter, 31 final follow-up
reviews were conducted. No provider agencies were referred to Network Management for
sanctions due to failure to implement the Plan of Correction.
Investigative Reviews:
There were three (3) Sanctions reviews, as well as 24 Incident Reports which required an
investigative review. There were 41 complaints that required an investigation. There were 24
Quality of Care reviews conducted. The total investigative reviews are 92.
36
Total reviews conducted 403 during this quarter. During the 2nd quarter FY 14-15 there were a
total of 337 reviews conducted.
Monitoring questions scored not met of 50% or more
Providers—Routine and Post Payment
Documentation indicates requirements of the service definition/rule were met 17%
Staff supervision plan implemented as written 34%
Licensed Independent Practitioners
Authorizations to release all required information 20%
CCA support the level of care 20%
Service note individualized specific to the date of service 20%
Referral from an approved source prior to the date of service 20%
Informed of the right to treatment 20%
Documentation reflect the specific service billed 25%
Valid service order for the service billed 25%
Documentation reflect treatment for the duration of the service billed 30%
Service documentation include an assessment of progress toward goals 35%
Service note relate to the goal(s) listed in the service plan 35%
Documentation signed by the person who delivered the service 35%
Documentation of coordination of care 35%
Appropriate service plan current for the date of service 50%
Appropriate service plan which identifies the type of service billed 50%
Trending review results across months and quarters continue to show
documentation in various categories is largest area of non-compliance.
Interventions implemented are: discussions with GCQI and NLC. Presentations
at Network Forum showing highest areas of non-compliance and provider
trainings scheduled for March and April of 2015. Provider attendance at
training will be tracked and reviewed in comparison with QM monitoring
results. Additionally in the May Provider Forum, required documentation
highlights from each service definition will be presented.
37
Sandhills Center LME-MCO 3rd Quarter FY 14-15
Monitoring Report Total Reviews
120
100
Number of Reviews
100
80
58
60
47
41
40
24
24
26
49
31
20
3
0
Sandhills Center LME-MCO 3rd Quarter Total
Monitoring Report Total Reviews FY 14-15
420
403
Number of Reviews
400
390
380
360
340
337
320
300
Total Reviews 1st quarter
Total Reviews 2nd quarter
Total Reviews 3rd quarter
Reviews as of 3rd quarter FY 14-15
38
Sandhills Center LME-MCO 3rd Quarter FY 14-15 Monitoring
Report Plan of Correction Required
70
0
Unlicensed AFL
Health & Safety
35%
35%
Service documentation include an
assessment of progress toward goals
Service note relate to the goal(s) listed in
the service plan
Documentation signed by the person who
delivered the service
Documentation of coordination of care
Authorizations to release all required
information
CCA support the level of care
Service note individualized specific to the
date of service
Referral from an approved source prior to
the date of service
Informed of the right to treatment
Valid service order for the service billed
20%
Documentation reflect the specific service
billed
20%
Documentation indicate requirements of
the service definition/rule were met
Staff supervision plan implemented as
written
20%
17%
20%
25%
20%
25%
Documentation reflect treatment for the
duration of the service billed
35%
Appropriate service plan which identifies
the type of service billed
50%
Appropriate service plan current for the
date of service
10%
35%
30%
Licensed Independent Practitioners
Agencies
30%
34%
40%
Total POC
Required
Routine
8
Post-Payment
7
10
50%
0%
14
20
50%
20%
59
60
50
40
30
30
Sandhills Center LME-MCO 3rd Quarter Total Most Questions Not Met FY 14-15
60%
39
Sandhills Center LME-MCO 3rd Quarter FY 14-15 Monitoring
Report 60 day Plan of Correction Reviews Completed
120
100
100
80
60
44
40
28
20
2
3
5
Health &
Safety
Unlicensed
AFL
Complaint
7
11
0
Incident Report Quality of Care Post-Payment
Routine
Total
Sandhills Center LME-MCO 3rd Quarter FY 14-15 Monitoring
Report 20 day Plan of Correction Reviews Completed
35
31
30
25
21
20
15
10
5
1
2
3
4
0
Incident Report
Quality of Care
Complaint
Routine
Post-Payment
Total
40
QOC 3rd Quarter Summary
Jan-March 2015
Fifty-six (56) Quality of Care concerns (an increase of six (6) from last quarter)
were received this quarter. Forty-four (44) were accepted for review (an increase
of 8) and twelve (12) were not accepted, a decrease of two (2).
Eighteen (18) Quality of Care concerns accepted (41%) were related to
documentation ( a slight decrease from last quarter); 12 of these had letters sent to
Medical Directors/Clinical Directors; two (2) agencies had two (2) letters each
and one (1) Clinical Director had three (3) letters--two (2) different agencies).
Nine (9) Medical Directors/Clinical Directors letters were mailed in the previous
quarter.
Nine (9) Quality of Care concerns accepted (20%) were related to services not
true to the model.
Seven (7) of 12 QOC concerns not accepted (58%) were related to duplication of
services and five (5) of those were referred to Program Integrity.
There were 47 different providers; four (4) agencies with two (2) referrals each
reported; three (3) agencies with three referrals each; however one of these
providers had referrals from different sites.
Referral Sources continue to come from CM/UM (50%), Care Coordination
(21.5%), Customer Services (12.5%), QM and other sources (16%).
Documentation concerns still remain the highest number of concerns. Provider
training occurred in March and overflow sessions are scheduled for April. A
presentation relating to service specific documentation, planned for the Feb
Provider Forum, was cancelled due to weather but will be presented in May.
Sandhills Center LME-MCO Quality of Care Referrals 3rd
Quarter 1/1/15-3/31/15
60
56
50
50
40
QOC Referrals
44
36
QOC Accepted
30
QOC requiring letter
to Medical Directors
20
12
10
9
0
2nd Quarter FY 14-15
3rd Quarter FY 14-15
Sandhills Center LME-MCO Quality of Care Referrals Referral
Source 3rd Quarter
1/1/15-3/31/15
80%
70%
70%
CM/UM
60%
50%
50%
Care
Coordination
40%
30%
20%
21.50%
12%
10%
10%
12.50%
0%
2nd Quarter FY 14-15
3rd Quarter FY 14-15
Customer
Servcies
Sandhills Center Level II and III Quarterly Incident Report
3rd Quarter Fiscal Year 2014-2015: January—March
Numbers by Level of Incident:
Level II
416
Level III
17
Total
433
The total number of Incidents Reports in the previous (2nd quarter of Fiscal Year 2014-2015 (395)
represented the number of Incident Reports submitted for the 9 county MCO. This quarter
reflects an increase by 38 in the number of Incident Reports submitted.
There were a total of 97 Providers submitting Level II and III Incident Reports this quarter,
representing 160 different sites. Of the 97 Providers submitting reports, 25 are CABHA certified
agencies and 56 Providers are Out of Network agencies.
Count for Each Type of Incident:
● Consumer Behavior-267 or 61.66% of the total reports
● Allegations of Abuse, Neglect, Exploitation- 40 or 9.24% of the total reports
● Restrictive Interventions- 33 or 7.62% of the total reports
● Consumer Injury- 57 or 13.16% of the total reports
● Consumer Death- 11 or 2.54% of the total reports
● Suspension, Expulsion- 19 or 4.39% of the total reports
● Medication Error- 6 or 1.39% of the total reports
Highest Number of Reports for a Single
Consumer
26 (all unplanned absence)
Unduplicated Count of Consumers
302
Consumer Behavior:
Number by Type and
Level
Unplanned Absence
Aggressive/Destructive
Behavior
Other
Illegal Acts
Suicide Attempts
Diversion of drugs
Inappropriate Sexual
Behavior
Total
Level II
Level III
Total
115
1
116
55
36
37
18
1
0
0
2
0
0
55
36
39
18
1
2
264
0
3
2
267
The total number of reports categorized as Consumer Behavior represents 61.66% of the total
reports submitted this quarter. The total number of reports for Consumer Behavior represents an
increase from the number reported during the previous quarter by 51 of the total.
Attempted Suicide:
Total Attempted Suicides: 18
Child: 7
Adult: 11
Male: 3*
Female: 12
* 1 male consumer had three suicide attempts; this consumer is in a residential setting and
continues to receive additional staff to monitor his behavior as well as additional therapy
* 1 male consumer had two suicide attempts; this consumer is an ACTT consumer. The ACTT
team has limited the amount of medication he will have on hand and will deliver medication more
frequently, as well as more intense monitoring of consumer.
County
Guilford
Lee
Mecklenburg
11
1
1
Montgomery
Richmond
Wake
3
1
1
Service (may have more than one service)
Supervised Living
1
ICF Res
3
IIH
2
OPT
4
TFC
2
ACTT
7
Method (may have more than one method)
Choke
1
Cutting
5
1
Over
dose
10
Ingest non-food item
In Road
2
Location
Community
1
ICF
School for the deaf
1
Home
Group Home
2
3
11
Intervention (may have more than one intervention)
Additional assessments
1
OPT
Update crisis plan
1
Higher level of care
Safety Plan
1
Monitor closely/additional staff
Limit medication packs
2
2
5
10
Attempted Suicide continued:
Diagnosis (may have more than one diagnosis)
Borderline Personality D/O
Intermittent Explosive Disorder
Bipolar I D/O
Generalized Anxiety D/O
Cannabis Abuse
Depressive D/O NOS
Cocaine Dependence
1
1
1
1
1
2
2
Mood D/O NOS
ODD
Major Depressive D/O Recurrent
Moderate Mental Retardation
Alcohol Abuse
ADHD, Predominately Hyperactive-Impulsive Type
Schizophrenia
2
3
3
3
3
3
6
The total number of suicide attempts increased in the third quarter from 7 in the second quarter to
18 in the third quarter. Sandhills Center LME-MCO will continue to track suicide attempts to be
able to detect trends.
Allegations of Abuse, Neglect, Exploitation
Number by Type and
Level II
Level
Abuse:
-Physical
14
-Sexual
1
-Verbal
5
-Emotional
0
Neglect
11
Misappropriation of
0
Consumer Property
Exploitation
1
Diversion of drugs
1
Total
33
Level III
Total
0
6
0
0
1
0
14
7
5
0
12
0
0
0
7
1
1
40
The number of allegations of abuse, neglect, and exploitation represents approximately 9.24% of
the total reports submitted this quarter. There was a slight decrease in total number of reports in
this category from the last quarter. Physical abuse remained the same with approximately 35%
for both quarters. Allegation of Neglect incident reports decreased from 4.05% of the total reports
last quarter to 2.77% of the total reports this quarter.
The Incident Reports submitted include 21 allegations of physical and sexual abuse. These
allegations were made against the following:
 Staff: 8 reports. This is a decrease from last quarter of 11
o 7 Group Home Staff
o 1 ACTT
 Family: 7
 Boy Friend: 1
 Consumer: 5
11 allegations of neglect were reported this quarter. 16 were submitted last quarter.
 12 of the 21 reports were submitted by residential providers.
All allegations were referred to the appropriate Department of Social Services. Reports were also
made to DHSR as necessary for those licensed facilities with allegations against staff. The NC
Health Care Registry (HCPR) is to be notified by the provider in the event a staff member is
accused of abuse, neglect, or exploitation. The results of their investigations are not shared with
the MCO.
Restrictive Interventions:
Number by Type and Level
Restraint -Standing
Restraint-Sitting
3 person face up
Total Restrictive Interventions
Level II
18
14
1
33
Level III
0
0
0
The total number of restrictive interventions this quarter represents a decrease from the previous
quarter. These reports reflect unplanned interventions, indicating the use of a restrictive
intervention was not included in the consumer’s Person Centered Plan.
In reviewing the reports submitted, it was noted 29 of the 33 occurred in residential settings. This
continues the trend seen in previous quarters.
Consumer Injury:
Number by Type and
Level
Fall
Behavioral Outburst
Assault
Fire
Unknown
Other
Vehicle Accident
Seizure
Self-Injurious
Pica
Medical
Total
Level II
Level III
Total
16
5
3
0
3
14
1
1
8
1
1
53
2
0
1
0
0
0
1
0
0
0
0
4
18
5
4
0
3
14
2
1
8
1
1
57
This category has seen a continual fluctuation in numbers reported in recent quarters however,
there has been an increase this quarter. Reports will be monitored for trends.
Consumer Death:
Number by Type and Level
Unknown Cause
Suicide
Homicide/Violence
Accident
Terminal Illness/Natural Cause
Total
Level II
Level III
0
0
0
0
8
8
3
0
0
0
0
3
Copies of the Death Certificate and Medical Examiner’s Report, when applicable, have been
requested for all Death Due to Unknown Cause Incident Reports. Reports submitted as Death
Due to Unknown cause remain listed in this category until a copy of the Death Certificate is
submitted in IRIS by the Provider. After receipt of the Incident Report the level of the incident
may change.
Suspension, Expulsion, Fire:
Number by Type and Level
Suspension
Expulsion
Fire
Total
Level II
7
12
0
19
Level III
0
0
0
0
Level II
3
0
0
3
0
6
Level III
0
0
0
0
0
0
Medication Error:
Number by Type and Level
Refusal
Wrong Dose
Wrong Time
Missed Dose
Wrong Medication
Total
Incidents involving medication errors are to be reported to a physician or pharmacist. This
individual determines if the error was potentially life threatening or likely to cause permanent
impairment. A Level I Incident Report is to be completed by the provider for any error that does
not threaten the individual’s health or safety, as determined by the physician or pharmacist
notified of the error.
Number of incident reports by county.
Anson
9
Harnett
12
Hoke
22
Moore
24
Richmond
15
Randolph
24
Lee
12
Montgomery
12
Guilford
247
Out of Catchment
56
Total
433
Sandhills Center LME-MCO 1st through 3rd Quarter FY 14-15
Incident Reports
440
433
430
420
420
410
400
395
390
380
370
July-Sept 2014
Oct-Dec 2014
Jan-March 2015
Sandhills Center LME-MCO Third Quarter
Incident Report by County
FY 14-15
500
433
450
400
350
300
247
250
200
150
100
56
50
9
12
12
12
15
22
24
24
0
48
Sandhills Center LME-MCO 3rd Quarter FY 14-15 Consumer
Behavior Incident Reports
300
267
250
200
150
116
100
50
1
18
2
55
39
36
0
Sandhills Center LME-MCO 3rd Quarter FY 14-15 Allegations of
Abuse, Neglect & Exploitation Incident Reports
45
40
40
35
30
25
20
15
12
10
5
5
1
1
Exploitation
Diversion of
drugs
14
7
0
Verbal
Sexual
Neglect
Physical
Total
49
Sandhills Center LME-MCO 3rd Quarter FY 14-15 Restrictive
Interventions Incident Reports
35
33
30
25
20
18
14
15
10
5
1
0
3 person face up
Restraint-Sitting
Restraint -Standing
Total Restrictive Interventions
Sandhills Center LME-MCO 3rd Quarter FY 14-15 Consumer Injury
Incident Reports
57
60
50
40
30
18
20
14
8
10
1
1
1
2
3
4
5
0
50
Sandhills Center LME-MCO Complaints Investigated 3rd Quarter FY 14-15 1/1/15-3/31/15
Complaints Investigated
Total Complaints: 78
 Total Complaints resolved by technical assistance: 34
 Total Complaints Investigated desk top review: 24
 Total Complaints Investigated on site review: 20
Substantiated: 5
Partially Substantiated: 5
Not Substantiated: 34
Requiring a POC: 4
Not requiring a POC: 40
Total Types of Complaints Investigated
Confidentiality/HIPAA 1
Provider Choice1
Abuse, Neglect, Exploitation 2
Access to Services
3
Authorization/Payment/Billing 6
LME/MCO Functions 6
Quality of Services
25
Number of Providers
Provider (SHC) with 13 investigated complaints: 1
Providers with 3 investigated complaints: 1
Providers with 2 investigated complaints: 2
Providers with 1 investigated complaints: 24
Number of total providers: 28
Number of Complaint referred:
Number of Complaints referred to an external agency
 DHSR: 9
 DSS: 1
Number of Complaints referred to another LME-MCO: 2
County of Investigated Complaints
Hoke: 1
Lee: 1
Randolph: 2
Anson: 3
ONN (Out of Network): 3
Richmond:
5
Moore: 14
Guilford: 15
51
Sandhills Center LME-MCO Complaints Investigated 3rd Quarter
FY 14-15
50
44
45
40
40
34
35
30
24
25
20
20
15
10
5
5
Substantiated
Partially
Substantiated
4
5
0
Complaints
Complaints
Investigated on site Investigated desk
review:
top review
Complaints
Investigated
Not Substantiated
Requiring a POC Not requiring a POC
Sandhills Center LME-MCO 3rd Quarter FY 14-15 Types of
Investigated Complaints
30
25
25
20
15
10
6
5
1
1
2
6
3
0
52
Sandhills Center LME-MCO 3rd Quarter FY 14-15
Providers Investigated Complaints
30
28
24
25
20
15
10
5
1
0
2
1
Provider (SHC) with 13
Providers with 3
Providers with 2
Providers with 1
investigated complaints investigated complaints investigated complaints investigated complaints
Number of total
providers
Sandhills Center LME-MCO 3rd Quarter FY 14-15 Investigated
Complaints by County
16
15
14
14
12
10
8
6
5
4
3
3
Anson
ONN (Out of
Network)
2
2
0
1
1
Hoke
Lee
Randolph
Richmond
Moore
Guilford
53
Quarterly Complaints Report
This report summarizes all complaints received during the
quarter by the Local Management Entity - Managed Care
Organization (LME-MCO) indicated below.
The numbers reported do not include information requests,
compliments, referrals or Medicaid Appeals.
LME-MCO:
Sandhills Center
State Fiscal Year:
2014-2015
Quarter:
3rd Quarter (Jan - Mar)
Date Report Submitted:
All
Complaints
Medicaid
NonMedicaid
61
52
9
17
13
4
78
65
13
Section 1 - Summary of Complaints Made
1. Total Number of Complaints Received By LME-MCO
During the Quarter:
a. Total Number of Complaints By or On Behalf of a
Consumer ……………………………
b. Total Number of Complaints Not By or On Behalf of a
Consumer ………………………
c. Total
2. Person Making Complaint Is:
a. Anonymous
………………………………………………………………………
……………
b. Consumer
………………………………………………………………………
……………..
c. Consumer Advocate/Representative/Attorney
…………………………………………….
d. DMH/DD/SAS
………………………………………………………………………
…………
e. DMA
………………………………………………………………………
……………………
f. Family Member
………………………………………………………………………
………..
g. Parent/Guardian
………………………………………………………………………
………
h. Provider
………………………………………………………………………
………………..
List each complaint in only one
category
10
10
0
21
16
5
4
4
0
0
0
0
0
0
0
4
2
2
18
14
4
10
9
1
54
i. LME/ MCO Staff
…………………………………………………………………….…
………
j. Other
………………………………………………………………………
……………………
k. Total (Must = Total # of Complaints in 1.c.)
………………………………………………
1
1
0
10
9
1
78
65
13
3. Age of Consumer On Whose Behalf Complaint is Being
Made:
a. Child (Ages 0-17)
………………………………………………………………………
……..
b. Adult (Ages 18 and Older)
…………………………………………………………………..
c. Unknown Age
………………………………………………………………………
…………
d. Total (Must = Total # of Complaints in 1.a.)
…………………………………………..…
List each complaint in only one
category
4. Gender of Consumer On Whose Behalf Complaint is
Being Made:
a. Male
………………………………………………………………………
……………………
b. Female
………………………………………………………………………
…………………
c. Unknown Gender
………………………………………………………………………
……..
d. Total (Must = Total # of Complaints in 1.a.)
………………………………………………
List each complaint in only one
category
5. Disability of Consumer On Whose Behalf Complaint is
Being Made:
a. Mental Health Only
………………………………………………………………………
……
b. Intellectual/ Developmental Disabilities Only
………………………………………………
c. Substance Abuse Only
………………………………………………………………………
d. Multi-Disability
………………………………………………………………………
………..
e. Unknown Disability
………………………………………………………………………
…..
f. N/A
………………………………………………………………………
………………………
g. Total (Must = Total # of Complaints in 1.a.)
……………………………………………..
List each complaint in only one
category
6. Race/Ethnicity of Consumer On Whose Behalf
Complaint is Being Made:
List each complaint in only one
category
17
16
1
44
36
8
0
0
0
61
52
9
36
29
7
25
23
2
0
0
0
61
52
9
37
31
6
16
16
0
4
3
1
3
2
1
0
0
0
1
0
1
61
52
9
55
a. Hispanic/ Latino
………………………………………………………………………
……….
b. African American
………………………………………………………………………
………
c. Caucasian
………………………………………………………………………
………………
d. Native American
………………………………………………………………………
……….
e. Native Hawaiian or Pacific Islander
………………………………………………………….
f. Asian
………………………………………………………………………
…………………….
g. Unknown/ Not Specified
………………………………………………………………………
h. Multi-racial
………………………………………………………………………
……………..
i. Other
………………………………………………………………………
…………………….
j. Total (Must = Total # of Complaints in 1.a.)
………………………………………………
7. Primary Nature of Complaint (person is dissatisfied
with ~ ):
a. Abuse, Neglect, Exploitation
…………………………………………………………………
b. Access to Services - Difficulty or Inability to obtain
services …………………………….
c. Administrative Issues by Provider
……………………………………………………………
d. Basic Needs
………………………………………………………………………
……………
e. Authorization/ Payment/ Billing - Provider Only
…………………………………………….
f. Confidentiality/ HIPAA
………………………………………………………………………
…
g. Client Rights
………………………………………………………………………
……….…..
h. LME-MCO Functions
………………………………………………………………………
….
i. Provider Choice
………………………………………………………………………
…………
j. Quality of Care by Providers
…………………………………………………………………..
k. Service Coordination Between Providers
……………………………………………………
l. Other
………………………………………………………………………
…………………….
0
0
0
28
26
2
30
25
5
1
1
0
0
0
0
0
0
0
0
0
0
2
0
2
0
0
0
61
52
9
List each complaint in only one
category
7
7
0
10
8
2
1
0
1
0
0
0
6
6
0
1
1
0
0
0
0
8
8
0
1
1
0
39
30
9
4
4
0
1
0
1
56
m. Total (Must = the Total # of Complaints in 1.c.)
………………………………………..
8. Complaint Involves The Following Service(s):
a. Adult Day Vocational Program
………………………………………………………………
b. Ambulatory Detoxification
……………………………………………………………………
c. Assertive Community Treatment Team
…………………………………………………….
d. Child and Adolescent Day Treatment
………………………………………………………
e. Clinical Intake
………………………………………………………………………
…………
f. Community Guide (MCO Only)
………………………………………………………………
g. Community Support Team
…………………………………………………………………..
h. Crisis Services
………………………………………………………………………
…………
i. Developmental Therapies
……………………………………………………………………..
j. Diagnostic Assessment
………………………………………………………………………
k. Drop-In Center
………………………………………………………………………
…………
l. Facility-Based Crisis Program
……………………………………………………………….
m. IDD Care Coordination
………………………………………………………………………..
n. Innovation Services
………………………………………………………………………
……
o. Intensive In-Home Services
…………………………………………………………………..
p. Long Term Vocational Supports
……………………………………………………………..
q. Mobile Crisis Management
…………………………………………………………………..
r. Medically Supervised or ADATC Detoxification/Crisis
Stabilization ……………………..
s. Medication Administration
……………………………………………………………………
t. MH/SA Care Coordination
…………………………………………………………………….
u. MH/SA Targeted Case management
………………………………………………………..
v. Multisystemic Therapy (MST)
………………………………………………………………..
w. Non-Hospital Medical Detoxification
………………………………………………………..
x. Opioid Treatment
………………………………………………………………………
………
y. Outpatient Services
………………………………………………………………………
78
65
13
An individual complaint may involve >1
service
0
0
0
0
0
0
7
6
1
3
3
0
0
0
0
0
0
0
0
0
0
1
0
1
0
0
0
1
1
0
0
0
0
0
0
0
9
9
0
9
9
0
3
3
0
0
0
0
0
0
0
0
0
0
4
4
0
1
1
0
0
0
0
2
2
0
0
0
0
1
1
0
13
7
6
57
……
z. Partial Hospitalization
………………………………………………………………………
…
aa. Peer Support Services
………………………………………………………………………
ab. Peer Support Services (B-3 MCO only)
…………………………………………………..
ac. Psychosocial Rehabilitation
………………………………………………………………..
ad. Psychological Evaluation
……………………………………………………………………
ae. Psychiatric Services
………………………………………………………………………
…
af. Residential Services
………………………………………………………………………
….
ag. Respite
………………………………………………………………………
………………..
ah. Respite Services (B-3 MCO Only)
…………………………………………………………
ai. Screening, Triage and Referral
………………………………………………………………
aj. Sheltered Workshop
………………………………………………………………………
….
ak. Substance Abuse Intensive Outpatient Program
…………………………………………
al. Substance Abuse Comprehensive Outpatient Treatment
Program ……………………..
am. Substance Abuse Non-Medical Community Residential
Treatment …………………..
an. Substance Abuse Medically Monitored Community
Residential Treatment …………..
ao. Substance Abuse Halfway House
………………………………………………………….
ap. Social Setting Detoxification
………………………………………………………………..
aq. Supported Employment
……………………………………………………………………..
ar. Unknown/ Not Known
………………………………………………………………………..
as. Not Service Related
………………………………………………………………………
…
at. Other
………………………………………………………………………
…………………..
au. Total (Must be ≥ to the Total # of Complaints in 1.c.)
………………………………….
0
0
0
0
0
0
0
0
0
6
6
0
0
0
0
0
0
0
11
8
3
0
0
0
0
0
0
0
0
0
0
0
0
1
1
0
1
1
0
0
0
0
0
0
0
0
0
0
2
2
0
0
0
0
3
3
0
0
0
0
1
0
1
79
67
12
9. Residential Is An Issue In The Complaint: (from 8.af.)
…………………………………
11
8
3
10. Identify Residential Service Type For Each Complaint
Included in 9:
a. Own Home
List each complaint in only one
category
0
0
0
58
………………………………………………………………………
……………..
b. Parents/ Guardian’s Home
……………………………………………………………………
c. Supervised Living 5600 A (Adult with Mental Health
Concerns …………………………..
d. Supervised Living 5600 B (Minor with
Intellectual/Developmental Disabilities) …………
e. Supervised Living 5600 C (Adult with Intellectual
/Developmental Disabilities) …………
f. Supervised Living 5600 D (Minor with Substance Abuse
Concerns) ……………………..
g. Supervised Living 5600 E (Adult with Substance Abuse
Concerns) …………………….
h. Supervised Living 5600 F (Alternative Family Living) Licensed …………………………
i. Supervised Living 5600 F (Alternative Family Living) Unlicensed ………………………
j. Therapeutic Foster Care
………………………………………………………………………
k. Psychiatric Residential Therapeutic Facility (PRTF): InState …………………………..
l. Psychiatric Residential Therapeutic Facility (PRTF): Outof-State within 40 miles …….
m. Psychiatric Residential Therapeutic Facility (PRTF): Outof-State outside 40 miles …
n. MH Apartments- Supervised
…………………………………………………………………
o. Family Care Home
………………………………………………………………………
……
p. Level III Group Home
………………………………………………………………………
….
q. Level IV Group Home
………………………………………………………………………
…
r. SA Halfway House
………………………………………………………………………
…….
s. Other
………………………………………………………………………
……………………
t. Total (Must = Total # of Residential Service in 9.)
………………………………………..
11. Total Number of Complaints in which a Consumer was
involved in DOJ: ………
0
0
0
0
0
0
0
0
0
2
2
0
0
0
0
1
1
0
1
1
0
0
0
0
1
1
0
2
2
0
0
0
0
0
0
0
1
0
1
0
0
0
1
1
0
0
0
0
0
0
0
2
0
2
11
8
3
2
1
1
44
40
4
34
25
9
78
65
13
Section 2- Summary of Actions Taken and Final
Disposition
12. Investigations:
a. Total Number of Complaints that Resulted in an
Investigation ………………………….
b. Total Number of Complaints that Did Not Result in an
Investigation ……………………
c. Total (Must = Total # of Complaints in 1.c.)
………………………………………………
59
Note: Investigation includes any investigation by DHSR, DSS, DMH/DD/SAS or LME/ MCO, including
Provider Monitoring and/or Client Rights Investigations.
13. Total Number of Investigations That Were:
a. Substantiated
………………………………………………………………………
………….
b. Not Substantiated
………………………………………………………………………
…….
c. Partially Substantiated
……………………………………………………………………….
d. Not Resolved at time of Report
………………………………………………………………
e. Total (Must =Total # of Investigated Complaints in 12.a.)
……………………………….
Include only investigated complaints
14. Total Number of Investigations That:
Include only investigated complaints
a. Required no Further Action
b. Resulted in Recommendations Only
……………………………………………………….
c. Resulted in a Corrective Action Plan
……………………………………………………….
d. Were Not Resolved at time of Report
………………………………………………………
e. Resulted in Other Actions
…………………………………………………………………..
f. Total (Must = Total # of Investigated Complaints in 12.a.)
………………………………
15. Total Number of Complaints Not Investigated that
Were:
a. Resolved By Working with Provider
………………………………………………………..
b. Resolved By Referral to Community Resource and/ or
Advocacy Group ………………
c. Resolved by Providing Information or Technical
Assistance to Complainant ………….
d. Resolved By Referring to an External Licensing or State
Agency ………………………
e. Referred to Another LME/ MCO for resolution
…………………………………………….
f. Resolved By Mediating With Parties
………………………………………………………..
g. Pending at The Time of Report
………………………………………………………………
h. Total (Must = Total # of Not Investigated Complaints in
12.b.) …………………………
16. Total Number of Complaints that were:
a. Resolved
………………………………………………………………………
……………….
b. Partially Resolved
………………………………………………………………………
…….
c. Unresolved
5
5
0
34
30
4
5
5
0
0
0
0
44
40
4
40
36
4
0
0
0
4
4
0
0
0
0
0
0
0
44
40
4
Include only complaints not
investigated
3
3
0
0
0
0
20
14
6
9
7
2
2
1
1
0
0
0
0
0
0
34
25
9
Include all complaints
78
65
13
0
0
0
0
0
0
60
………………………………………………………………………
…………….
d. Total (Must =Total # of Complaints in 1.c.)
……………………………………………….
17. Total Number of Final Dispositions:
a. Made by LME-MCO (no referral to a state agency)
……………………………………….
b. Referred to DSS
………………………………………………………………………
……….
c. Referred to DHSR
………………………………………………………………………
……..
d. Referred to DMH/DD/SAS
……………………………………………………………………
e. Referred to DMA (including Program Integrity)
…………………………………………….
f. Referred to Licensing Boards
………………………………………………………………..
g. Pending at the time of the report
……………………………………………………………
h. Total (Must = Total # of Complaints in 1.c.)
………………………………………………
18. Total Number of Working Days from Receipt by LMEMCO to Completion:
a. 0-30 Days
………………………………………………………………………
………………
b. 31-60 Days
………………………………………………………………………
…………….
c. 61-90 Days
………………………………………………………………………
…………….
d. 91-120 Days
………………………………………………………………………
…………..
e. Over 120 Days
………………………………………………………………………
………..
f. Pending at the time of the report
……………………………………………………………
g. Total (Must = The Total # of Complaints in 1.c.)
…………………………………………
19. Number of Complaints over 30 days that were
Reported to the LME-MCO and Investigated by an Agency
Other Than LME-MCO (e.g. DHSR, DSS, etc.) ……….
78
65
13
Include all complaints
68
55
13
1
1
0
9
9
0
0
0
0
0
0
0
0
0
0
0
0
0
78
65
13
Include all complaints
78
65
13
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
78
65
13
0
0
0
All Children
Medicaid
30
0
Section 3 - Special Reporting
20. Total # of Children Currently in PRTFs:
a. In-state
NonMedicaid
30
61
b. Out-of-State inside 40 mile radius
c. Out-of-State outside of 40 mile radius
d. Total (Must = The Total # of Children Currently in
PRTFs)
Section 4 - Update On Information Reported In Prior Quarter(s)
Reason for Update)
Name of Person Completing Report:
………………………………………………………..
Title:
………………………………………………………………………
………………………..
Phone:
………………………………………………………………………
……………………..
Email:
………………………………………………………………………
………………………
14
0
14
0
0
0
44
0
44
(Indicate SFY and Quarter and
Mary Kidd
Complaints and Incident Manager
910-673-7418
maryk@sandhillscenter.org
SFY2015 Report Submission Schedule
SFY / Quarter
2015 Q1
2015 Q2
2015 Q3
2015 Q4
Report
Quarter
Data
Period
LME-MCO
Report
Submission
Date*
Same as
November
Report
15, 2014
Quarter
Same as
Oct to Dec
February 15,
Report
2014
2015
Quarter
Same as
Jan to Mar
May 15,
Report
2015
2015
Quarter
Same as
Apr to Jun
August 15,
Report
2015
2015
Quarter
* DMH/DD/SAS Complaint Form and DMA
forms
Jul to Sep
2014
Direct Questions To:
DMH/DD/SAS Customer Service and Community Rights
Team
Phone: 919-715-3197
FAX: 919-733-4962
Email: dmh.advocacy@dhhs.nc.gov
Submit Reports To:
DMH/DD/SAS: dmh.advocacy@dhhs.nc.gov
DMA: adolph.simmons@dhhs.nc.gov
62
QUALITY IMPROVEMENT PROJECTS – Full Reports
CARE MANAGEMENT/UTILIZATION MANAGEMENT
Name of Project: (Core 20 (g), Core 23 (b)
Decreasing the number of Unable to Process of Service Requests.
Description and Background [Core 19, 20, 21]
To meet the Health Utilization Management standards outlined by URAC, a quality improvement project was initiated to closely monitor and reduce the number
of Unable to Process service requests issued to network providers.
Sandhills Center has had a URAC accredited Utilization Management/Utilization Review Unit for three years. The Unit includes UM/UR responsibilities for all
Medicaid and State funded services with local providers with whom we directly contract. Our Network providers are familiar with the UM/UR process and with
the elements required to receive a certification for service. The Sandhills Center publishes a Utilization Management Master Grid as well as a Benefit Plan for
State Funded Services that provides a framework for providers indicating the services appropriate for consumers with given needs and the number of units
appropriate for a given timeframe.
The Utilization Management Program follows an established process which identifies, in detail, in making review determinations when information essential to
making a review determination is not forthcoming. When there is insufficient information to conduct a review, specific timeframes are followed, a resolution will
be determined within these timeframes, and an unable to process certification is made due to lack of information.
During December 2012 (when Sandhills added the Medicaid book of business), the UM/UR Unit processed 1,591 authorizations. Qualitative data from the Unit
indicates one of the difficulties faced by the Unit and by local service providers requesting authorizations is receiving all necessary information from local
providers to make an authorization decision.
The request for authorization begins with member and provider eligibility. Once this is established, services are reviewed for medical necessity and clinical
appropriateness. To determine medical necessity and clinical appropriateness, specific materials and documents are collected and reviewed. These items are
submitted electronically and are reviewed by Master Level Licensed Initial Clinical Reviewers.
Materials and documents collected and reviewed for prospective and concurrent service requests include but are not limited to:
Service Authorization Request (SAR)
63
Person Centered Plan (PCP)
Comprehensive Clinical Assessment (CCA)
Level of Care (LOC) form
Individualized Support Plan (ISP)
Unable to Process service requests are based on administrative issues and are processed by Utilization Management Staff (UM Staff). Unable to Process service
requests are not related to medical necessity and are based on the Network provider’s failure to submit the above documents within specified timeframes based
on the service request type: prospective, concurrent or retrospective.
Describe the population affected by the Quality Improvement Project [Core 21(b)(i)(ii)(iii)(g)(h), Core 24(a),(b)]
Both consumers and local network providers are impacted by this quality improvement project. Child and adult consumers of mental health, developmental
disability and substance abuse services are impacted by not having necessary services denied for administrative reasons and network providers are impacted by
having less Unable to Process service requests issued.
Selection Process [Core 19(b), Core 20(g), Core 21 (a)(b)(i),(ii),(iii)(c)(d)(e)(f) and Core 23(a)]
The Health Utilization Management Unit’s need to adhere to timelines for processing of service requests reduced the amount of time local providers had for
submission of documents. This reduced time for providers to submit necessary information had the potential to lead to increased Unable to Process service
requests. To reduce the number of Unable to Process service requests, this project was selected. Reports will be developed to closely monitor the UM/UR Unit’s
performance with the standard. These reports are measured over time to gauge increased timeliness of completing UM/UR requests.
Relation to Modules under Review [Core 21 (a)(b)(i),(ii),(iii), Core 24(a)(b)]
This quality improvement project fits with the Health Utilization Management module, Version 7.0. This project is designed to measure the decreased number of
Unable to Process service requests across all three disability groups.
Date approved by the Quality Management Committee
[Core 20(g)]
February 27, 2013
Date of meeting minutes reflecting approval by Quality
Management Committee [Core 20(d)]
February 27, 2013
Time Frames [Core 23(c)]
64
February 2013 – Formulated Quality Improvement Project to address level of Unable to Process service requests.
February 2013 – Developed a report to analyze trends in Unable to Process service requests, this report will track which providers are receiving Unable to
Process service requests.
January 2013 – Collected baseline data from December 2012
Spring 2013 – Service providers that frequently receive Unable to Process service request (over 3 in a quarter) will be asked to attend training for Unable to
Process service requests.
February 2013 – Ongoing monitoring of Unable to Process service requests.
Focus of Project [Core 24(a)(b)]
Clinical – Will targeted training and support tools assist community providers
in decreasing the number of Unable to Process service requests received?
Name of Senior Clinical Staff Person Involved [Core 24 (b)]
Dr. Anthony Carraway, Sandhills Center Medical Director
Baseline Measurement [Core 21(d)]
The baseline measurement for this project was December 2012 when Sandhills Center began managing Medicaid services under the 1915(b)/(c) waiver. During
that month 1,591 UM/UR requests were received and processed. During that time period there were 394 Unable to Process service requests issued, 24.76%
Unable to Process service request rate. Mental Health/Substance Abuse providers were issued 266 of 394 (68%) Unable to Process service requests. Of that total,
130 service requests were not processed at the provider’s request and 78 were not processed due to missing required documents. I/DD Innovations providers
were issued 128 of 394 (32%) Unable to Process service requests. Of that total, 82 were not processed due to incorrect units/timeframe for service and 46 were
not processed at the provider’s request. Of concern, 25 (6.3%) consumers’ authorizations received 3 or more Unable to Process service requests.
Data Collection [Core 21(a),(b),(c) and Core 23(a)]
Quarterly data is collected regarding Unable to Process service requests. This report extracts data from the provider portal, the authorization request software
program used by local network providers, and the SHC Managed Care Software system, the software used by the Utilization Management/Utilization Review
staff. The report parameters remain constant each time the data is pulled, with the exception of the date range selected. The unchanged report parameters will
allow the Utilization Management Director an opportunity to analyze the data over time extracting similar information for each month or quarter. Data will be
collected and reviewed monthly.
Measurable Goal(s) toward improvement [Core 23(a)]
Provide training and technical assistance to providers to decrease the number of Unable to Process service requests issued by 20%.
Reduce the percentage of Innovations’ services receiving Unable to Process service requests to less than 17.5%
Reduce the number of consumers’ authorizations receiving 3 or more Unable to Process service requests to less than 10.
65
Projected Timeframe to Achieve Goals [Core 23(c)]
December 31, 2013 or until the UM/UR Unit achieves 3 consecutive quarters of meeting the stated goal.
Initial Interventions/Action Plans [Core 23 (b)(e)(f)]
Barriers Identified and Intervention/Action Taken
Customized report created to monitor the number and reason for Unable to Process service requests.
Training/technical assistance session scheduled with UM/UR Staff to explain the new goals and allow providers an
opportunity to ask questions about the project.
UM staff to identify primary reasons for Unable to Process service requests in order to provide technical assistance to
providers.
Ongoing training and technical assistance to network providers giving feedback on requests submitted and suggestions for
improving required authorization elements.
Ongoing monitoring of Unable to Process service requests.
Date Implemented
March 2013
March – June 2013
March – April 2013
April – December 2013
February – December 2013
Periodic Measurements at least annually [Core 23(d)] and re-measurement for changes or improvements to baseline [Core
23(e)]
Date of Measurement Result of Measurement
Date Reported to QM
Committee
April 29, 2013
The January 1, 2013 – March 31, 2013 data indicates a total of 6,230 authorization
May 28, 2013
requests were received and processed for that timeframe. During that time period
there were 1,064 Unable to Process service requests issued, a 17.1% Unable to
Process service request rate.
During the quarter, Mental Health/Substance Abuse providers were issued 867 of
1,064 (81.5%) Unable to Process service requests. Of that total, 190 (21.9%)
service requests were not processed at the provider’s request and 91 (10.5%) were
not processed due to missing required documents.
During the quarter, I/DD Innovations providers were issued 197 of 1,064 (18.5%)
Unable to Process service requests. Of that total, 126 (63.9%) were not processed
due to incorrect units/timeframe for service and 39 (19.8%) were not processed at
66
the provider’s request.
The number of consumers receiving 3 or more Unable to Process service requests
increased to 133 (12.5%) of the total processed.
QMC comments based on results of 1st measurement [Core 20(f)
& Core 20(h)]
July 3, 2013
This Unable to Process service request rate is a decrease from the 24.76%
baseline rate. Additionally, for both MH/SA and IDD authorizations, the
percentage Unable to Process for the earlier identified reasons decreased.
During the quarter, the number and percentage of consumers receiving 3 or
more Unable to Process service requests increased.
The April 1, 2013 – June 30, 2013 data indicates a total of 15,620 authorization
July 30, 2013
requests were received and processed for that timeframe. During that time period
there were 4,310 Unable to Process service requests issued, a 27.5% Unable to
Process service request rate.
During the quarter, Mental Health/Substance Abuse providers were issued 2,796 of
4,310 (64.8%) Unable to Process service requests. Of that total, 825 (29.5%)
service requests were not processed at the provider’s request and 309 (11.0%) were
not processed due to missing required documents.
During the quarter, I/DD Innovations providers were issued 1,514 of 4,310
(35.12%) Unable to Process service requests. Of that total, 929 (61.3%) were not
processed due to incorrect units/timeframe for service and 195 (12.8%) were not
processed at the provider’s request.
The number of consumers receiving 3 or more Unable to Process service requests
were 338 (7.8%) of the total processed.
This Unable to Process service request rate is an increase from the 24.76%
baseline rate. The increase is primarily driven by the addition of Guilford
County to the 1915 (b)/(c) Medicaid waiver on April 1. The same strategies
implemented for the original 8 county area are and will continue to be used in
Guilford County to reduce the Unable to Process service request rate.
Preliminary data seems to indicate the strategies are working as the Unable to
Process service request rate for June 2013 was 18.02%, a significant decrease
from the quarterly percentage.
67
During the quarter, the number of consumers receiving 3 or more Unable to
Process service requests increased (again primarily attributed to the increase
with the addition of Guilford County) while the overall percentage decreased
to 7.8%. This represents a decrease from last quarter and a slight increase
from the baseline percentage.
Periodic Measurements at least annually [Core 23(d)] and re-measurement for changes or improvements to baseline [Core
23(e)]
Date of Measurement
Result of Measurement
Date Reported to QM
Committee
October 16, 2013
The July 1, 2013 – September 30, 2013 data indicates a total of 15,689
October 22, 2013
authorization requests were received and processed for that timeframe. During that
time period there were 2,961 Unable to Process service requests issued, an 18.87%
Unable to Process service request rate.
During the quarter, Mental Health/Substance Abuse providers were issued 2,191 of
2,961 (73.9%) Unable to Process service requests. Of that total, 769 (35.0%)
service requests were not processed at the provider’s request and 252 (11.5%) were
not processed due to missing required documents.
During the quarter, I/DD Innovations providers were issued 770 of 2,961 (26.0%)
Unable to Process service requests. Of that total, 312 (40.5%) were not processed
due to incorrect units/timeframe for service and 186 (24.1%) were not processed at
the provider’s request.
The number of consumers receiving 3 or more Unable to Process service requests
were 253 (8.54%) of the total processed.
This Unable to Process service request rate is a decrease from the 24.76%
baseline rate and is a decrease from last quarter’s rate of 27.5%.
The data seems to indicate the strategies initially used in the December 1,
2012 8 county implementation of the 1915 (b)/(c) Waiver are working for
the April 1, 2013 implementation in Guilford County. As we approaching
our target, but not yet below the target of 17.5%, these strategies will
continue.
68
January 2014
During the quarter, the number of consumers receiving 3 or more Unable to
Process service requests decreased to 253 while the while the overall
percentage decreased to 8.5%. This percentage increase is likely primarily
attributable to the significant decrease in total Unable to Process service
requests (a decrease of 1,349 denials).
The October 2013 – December 2013 data indicates a total of 13,895 authorization
January 28, 2014
requests were received and processed for that timeframe. During that time period
there were 2,222 Unable to Process service requests issues, a 15.99% Unable to
Process service request rate.
During the quarter, Mental Health/Substance Abuse providers were issued 1,735 of
2,222 (78.1%) Unable to Process service requests. I/DD Innovations providers
were issued 487 of 2,222 (21.9%) Unable to Process service requests.
The Unable to Process service request rate continues to decline and, for the first quarter, is below the target of 17.5%. The
strategies being employed by the Utilization Management staff will continue in an effort to meet the project’s overall goal of 3
consecutive quarters with a decreased Unable to Process service request rate.
April 2014
The Utilization Management Committee reviewed the goal of processing less than 3 Unable to Process service requests per
member and recommends discontinuing this goal. The goal was set on data from only one month, rather than the quarterly data
reviewed during the project, and is believed not to be realistic given the increased number of members receiving authorization
currently.
The January 2014 – March 2014 data indicates a total of 12,355 authorization
April 22, 2014
requests were received and processed for that timeframe. During that time period
there were 1,891 Unable to Process service request issues, a 15.31% Unable to
Process service request rate.
During the quarter, Mental Health/Substance Abuse providers were issued 1,501 of
1,891 (79.4%) Unable to Process service requests. I/DD Innovations providers were
issued 390 of 1,891 (20.6%) Unable to Process service requests.
Quality Management Committee discussed the recent change to Alpha MCS
The Unable to Process service requests rate is below the target of 17.5% for
as the new system for authorizations and discussed the thought that the change the second consecutive quarter and is lower than previous quarters. The
would likely increase the number of Unable To Process authorizations
strategies being employed by the Utilization Management staff will continue
significantly until providers became familiar with the new system.
in an effort to meet the project’s overall goal of 3 consecutive quarters with a
decreased Unable to Process service request rate.
Utilization Management staff met with I/DD Coordinators March 2014 and
69
July 2014
October 2014
reviewed common themes for Unable to Process service requests.
Supervisors agreed to work with staff to reduce the number of Unable to
Process service requests issued for I/DD Innovations.
The April 2014 – June 30, 2014 data indicates a total of 11,127 authorization
July 22, 2014
requests were received and processed for that timeframe. During that time period
there were 2,299 Unable to Process service request issues, a 20.66% Unable to
Process service request rate.
During the quarter, Mental Health/Substance Abuse providers were issued 1,850 of
2,299 (80.5%) Unable to Process service requests. I/DD Innovations providers were
issued 449 of 2,299 (19.5%) Unable to Process service requests.
The Unable to Process service request rate is above the target of 17.5% but is
significantly less than the 27.5% rate experienced last year during the same
quarter. Contributing to the 5% increase from last quarter is the April change
from NetSmart to Alpha MCS. The training and technical assistance offered
to providers prior to the transition and the number of providers using the
same IT platform for other MCOs is likely to reduce the number within the
next two or three quarters.
The July 2014 – September 2014 data indicates a total of 12,370 authorization
October 28, 2014
requests were received and processed for that timeframe. During that time period
there were 1,826 Unable to Process service request issues, a 14.8% Unable to
Process service request rate.
During the quarter, Mental Health/Substance Abuse providers were issued 1,513 of
1,826 (82.9%) Unable to Process service requests. I/DD Innovations providers were
issued 313 of 1,826 (17.1%) Unable to Process service requests.
The Unable to Process service requests rate has returned below the target of
17.5% since the implementation of Alpha and marks the lowest quarter since
the start of this QIP. The training and technical assistance, both for MH/SA
and IDD providers will continue with the goal of continuing to meet or
exceed the announced goal.
January 5, 2015
The October 2014 –December 2014 data indicates a total of 12, 738 authorization
requests were received and processed for that timeframe. During that time period
there were 1,266 Unable to Process service request issued, a 9.9% Unable to Process
service request rate.
January 27, 2015
70
April 1, 2015
During this quarter, Mental Health/Substance Abuse providers were issued 1,020 of
1,266 (80.5%) Unable to Process service requests. I/DD Innovations providers were
issued 246 of 1,266 (19.5%) Unable to Process service requests.
The Unable to Process service requests rate continued below the target of
17.5% for the second consecutive quarter since the implementation of Alpha
and marks the lowest quarter since the start of this QIP. The monitoring of
Unable to Process service requests will continue for at least one more quarter
to achieve 3 or more consecutive quarters below the target of 17.5%
The January 1, 2015 – March 31, 2015 data indicates a total of 10,165 authorization
April 28, 2015
requests were received and processed for that timeframe. During that time period
there were 793 Unable to Process service request issued, a 7.8%% Unable to Process
service request rate.
During this quarter, Mental Health/Substance Abuse providers were issued 636 of 793
(80.2%) Unable to Process service requests. I/DD Innovations providers were issued
157 of 793 (19.8%) Unable to Process service requests.
The Unable to Process service requests rate continued below the target of
17.5% for the third consecutive quarter since the implementation of Alpha
and marks the lowest quarter since the start of this QIP. The monitoring of
this performance is recommended to continue with a recommendation to
formally end this QIP given the performance.
Conducts an analysis if performance goals are not met [Core 23(f)]
Barriers Identified and Actions Taken
71
CARE MANAGEMENT/UTILIZATION MANAGEMENT
Name of Project: (Core 20 (g), Core 23 (b)
Increasing Percentage of Authorized Services Used by Providers.
Description and Background [Core 19, 20, 21]
This quality improvement project was initiated to closely monitor and increase the percentage of authorized services used by providers. Sandhills Center has had
a Utilization Management/Utilization Review Unit for over 10 years. The UM Unit is responsible for authorizing State funded and Medicaid services for those
consumers seeking service through the public mental health system with no other payer source. The services available for authorization are those services
included in the North Carolina Department of Health and Human Services (DHHS) Integrated Payment and Reporting System (IPRS) service array and the
Medicaid Clinical Coverage Policies. The State requires that we use the service definitions and medical necessity criteria outlined in the Mental Health,
Developmental Disability and Substance Abuse State Funded Service Definitions and the Medicaid Clinical Coverage Policies to make these decisions.
The UM Managers are responsible for reviewing each service definition based on the disability area with new staff and, thereafter, as needed. The definitions are
reviewed to provide the UM Care Manager with an overview of the definition, how the service is intended to be provided, the skills the consumer is intended to
gain, the medical necessity criteria, the requirement for a service order, the continuation/utilization review criteria, the discharge criteria, the service maintenance
criteria, appropriate service codes and the documentation requirements. The UM Managers also review any updates in clinical policy from the Division of
Medical Assistance with the UM Care Managers regarding changes in the State service definitions. In addition to the North Carolina Medicaid Service
Definitions, UM staff also utilize the American Society of Addictive Medicine (ASAM) criteria as well as the LOCUS/CAOLCUS Level of Care Utilization
System criteria.
During their work, the UM/UR staff observed a trend of providers requesting authorization for outpatient services and then not using the majority of the units
authorized. The outpatient individual therapy service that is most requested is Individual Psychotherapy (90837). The numbers of units requested for the October
– December 2013 quarter were 10,227. The service takes place in an office or outpatient facility setting which lasts approximately 60 minutes face-to-face with
patient. The outpatient group therapy service that is most requested is Group Therapy (90853). The numbers of units requested for the October – December 2013
quarter were 6,605. When comparing providers, the UM/UR staff observed a wide range in the percentage of units used. The purpose of this project is to assist
providers in increasing the percentage of authorized units used for service code 90837 and 90853.
Describe the population affected by the Quality Improvement Project [Core 21(b)(i)(ii)(iii)(g)(h), Core 24(a),(b)]
Both consumers and local network providers are impacted by this quality improvement project. Adult and child consumers of mental health and substance abuse
72
services are impacted by not receiving the services that have been medically authorized. Local network providers are impacted by being unable to provide
services that have been authorized as medically necessary.
Selection Process [Core 19(b), Core 20(g), Core 21 (a)(b)(i),(ii),(iii)(c)(d)(e)(f) and Core 23(a)]
The Health Utilization Management/Utilization Review unit observed a trend of unused outpatient units. A report was developed to show the number of units
authorized and the percentage of those units used by the provider for a specific service. The report highlighted a low usage rate for the service of Individual
Psychotherapy (90837) and Group Therapy (90853). The utilization of service codes 90837 and 90853 will be closely monitored for increases in use as the
providers received technical assistance. The reports will allow a measurement over time to gauge increased utilization of the service codes identified.
Relation to Modules under Review [Core 21 (a)(b)(i),(ii),(iii), Core 24(a)(b)]
This quality improvement project fits with the Health Utilization Management module, Version 7.0. This project is designed to measure the increased
utilization of service codes 90837 and 90853.
Date approved by the Quality Management Committee
[Core 20(g)]
April 22, 2014
Date of meeting minutes reflecting approval by Quality
Management Committee [Core 20(d)]
April 22, 2014
Time Frames [Core 23(c)]
March 2014 – Formulated Quality Improvement Project to address low utilization rate of services.
March 2014 – Developed a report to analyze trends in service code utilization.
March 2014 – Collected baseline data from 2nd quarter FY 2013-2014.
Ongoing – monitoring of service utilization and technical assistance to providers.
July 2014 – Updated QIP and data based on transition to Alpha MCS
July 2014 (and forward) – monitoring of service utilization and technical assistance to providers.
Focus of Project [Core 24(a)(b)]
Clinical – Will targeted training and support tools assist community providers
Name of Senior Clinical Staff Person Involved [Core 24 (b)]
Dr. Anthony Carraway, Sandhills Center Medical Director
73
in increasing utilization of the number of units authorized?
Baseline Measurement [Core 21(d)]
The baseline measurement for this project was October 1, 2013 – December 31, 2013. During this quarter, 120 providers/sites billed Individual Psychotherapy
(90837). The overall percentage of authorized units billed was 23.8% (2,438 of 10,227 units authorized). Of the 120 providers only 17 providers (14%) are
billing more than 50% of the authorized units. During the same quarter, 33 providers/sites billed Group Therapy (90853). The overall percentage of authorized
units eventually billed was 19.0% (3,690 of 16,832 units authorized). Of the 33 providers, only 4 providers/sites (12.12%) billed more than 50% of the
authorized units.
Data Collection [Core 21(a),(b),(c) and Core 23(a)]
Quarterly data is collected regarding the number of units authorized and the percentage of those units used by the provider. This report extracts data from the
SHC Managed Care Software system. The report parameters remain constant each time the data is pulled, with the exception of the date range selected. The
unchanged report parameters will allow the Utilization Management Director an opportunity to analyze the data over time extracting similar information for each
month or quarter. Data will be collected and reviewed monthly.
Measurable Goal(s) toward improvement [Core 23(a)]
Increase the percentage of authorized units of service code 90837 used by providers to 33%, an increase of 10%.
Increase the percentage of providers/sites using at least 50% of authorized 90837 units to 20%, an increase of 6%
Increase the percentage of authorized units of service code 90853 used by providers to 25%, an increase of 6%
Increase the percentage of providers/sites using at least 50% of authorized 90853 units to 17%, an increase of 5%.
Projected Timeframe to Achieve Goals [Core 23(c)]
74
Sept 2015 or until the UM/UR Unit achieves 3 consecutive quarters of meeting the stated goal.
Initial Interventions/Action Plans [Core 23 (b)(e)(f)]
Barriers Identified and Intervention/Action Taken
Customized report created to monitor the number of units authorized and used by providers.
Training/technical assistance session scheduled with UM/UR Staff to explain the new goal and allow providers an
opportunity to ask questions about the project
SHC increased unmanaged outpatient therapy sessions to 24 units for Medicaid and IPRS.
Update of customized report to monitor authorization data based on transition to Alpha MCS and incorporation of provider
site information
UM staff to identify primary reasons for low utilization rates in order to provide technical assistance to providers.
UM staff to identify providers with higher utilization and determine strategies used by those providers to increase
utilization. These strategies will be shared with the providers who have the lower utilization.
SHC implemented a 10% rate increase for outpatient therapy services.
UM staff communication to providers in writing as well as during a NC Council presentation outlining the goal of
increasing outpatient therapy as a means of ensuring members receive services from licensed professionals.
Ongoing monitoring of units authorized and percentage of units used by providers.
Date Implemented
March 2014
April 2014
April 2014
July 2014
August 2014
August/September 2014
October 2014
December 2014
March, 2014– Sept 2015
Periodic Measurements at least annually [Core 23(d)] and re-measurement for changes or improvements to baseline [Core
23(e)]
Date of Measurement Result of Measurement
Date Reported to QM
Committee
July 8, 2014
The data for January 1 – March 31, 2014 for 90837 indicates 3,136 of July 22, 2014
12,336 (25.4%) authorized units were used; 9 of the 92 (9.78%)
providers authorized for 90837 during that time frame used at least
75
50% of the units authorized.
The data for January 1 – March 31, 2014 for 90853 indicates 4,013 of
18,151 (15.1%) authorized units were used; 0 of the 25 (00.0%)
providers authorized for 90853 during that time frame used at least
50% of the units authorized.
October 3, 2014
Given the transition to Alpha MCS and the incorporation of
provider site locations with that transition, revisions are
recommended to the project’s measurable goals. The
incorporation of provider sites add specificity that will be
helpful in identifying provider/sites with stronger performance
in providing outpatient services. The project did not see
significant gains during this transition period. It is
recommended UM staff continue reviewing performance of
providers during this transition and note providers with strong
performance.
October 28, 2014
The data for April 1 – June 30, 2014 for 90837 indicates 7,368 of
20,085 (36.7%) authorized units were used; 29 of the 121 (23.9%)
providers authorized for 90837 during that time frame used at least
50% of the units authorized.
The data for April 1 – June 30, 2014 for 90853 indicates 2,021 of
9,921 (20.4%) authorized units were used; 4 of the 37 (10.8%)
providers authorized for 90853 during that time frame used at least
50% of the units authorized.
QMC comments based on results of 2nd measurement [Core
20(f) & Core 20(h)
For the quarter, 90837 exceeded both the percentage used target
of 33% and the percentage of provider sites using 50% units
authorized target of 20%.
76
For the quarter, 90853 did not meet the stated goal of 25% units
used or the goal of 17% using 50% or more of authorized units.
Both 90837 and 90853 utilization show gains from the previous
quarter. UM staff will continue reviewing utilization, noting
those providers sites with strong performance to identify
successful strategies to increase overall performance.
January 5, 2015
The data for July 1 – September 30, 2014 for 90837 indicates 11,872 of
23,590 (50.3%) authorized units were used; 55 of the 130 (42.3%)
providers authorized for 90837 during that time frame used at least 50% of
the units authorized.
January 27, 2015
The data for July 1 – September 30, 2014 for 90853 indicates 2,381 of
8,434 (28.2%) authorized units were used; 6 of the 38 (15.8%) providers
authorized for 90853 during that time frame used at least 50% of the units
authorized.
The most recent measurement marks the third increase in utilization
for both 90837 and 90853, both in terms of authorized units used and
percentage of providers utilizing at least 50% of authorized units.
For the quarter, 90837 exceeded both the percentage used target of
33% and the percentage of provider sites using 50% units authorized
target of 20%.
For the quarter, 90853 exceeded the percentage used target of 25% but
fell just short of the goal of 17% using 50% or more of authorized
units.
Given the increases shown in utilization, UM staff will continue the
current performance enhancement strategies into the next quarter.
UM staff communicated with the Integrated Care Providers as well as
77
with Outpatient providers at the North Carolina Council of
Community Programs fall training regarding SHC efforts to increase
utilization of outpatient services. This communication included
highlighting the increase in unmanaged sessions, increasing the rate
for outpatient therapy and encouraging the use of the highest trained
professionals in the service delivery.
April 1, 2015
The data for October 1 – December 31, 2014 for 90837 indicates 12,957 of
24,365 (53.2%) authorized units were used; 61 of the 135 (45.2%)
providers/sites authorized for 90837 during that time frame used at least
50% of the units authorized.
April 28, 2015
The data for October 1 – December 31, 2014 for 90853 indicates 2,226 of
7,660 (29.1%) authorized units were used; 4 of the 35 (11.4%)
providers/sites authorized for 90853 during that time frame used at least
50% of the units authorized.
The most recent measurement marks the fourth increase in utilization
for both 90837 and 90853, in terms of authorized units used and the
fourth increase in percentage of providers utilizing at least 50% of
authorized units for 90837. The percentage of providers utilizing at
least 50% of authorized units for 90853 decreased slightly from the
previous quarter.
For the quarter, 90837 exceeded both the percentage used target of
33% and the percentage of provider sites using 50% units authorized
target of 20%.
For the quarter, 90853 exceeded the percentage used target of 25% but
fell short of the goal of 17% using 50% or more of authorized units.
Given the decrease in providers using at least 50% or more of
authorized units for 90853, UM will continue their work identifying
strategies of stronger performing providers/sites to share those
78
strategies with less performing providers/sites.
Periodic Measurements at least annually [Core 23(d)] and re-measurement for changes or improvements to baseline [Core
23(e)]
Date of Measurement
Result of Measurement
Date Reported to QM
Committee
Summarize the results acheived utilizing statistical methodologies
Date results submitted to QMC
QMC comments based on results of 3rd measurement[Core 20(f)
& Core 20(h)
Date of 4th
Measurement
Interventions/Actions implemented based on results of 3rd
measurement [Core 21(f)]
Summarize the results acheived utilizing statistical methodologies
QMC comments based on results of 4th measurement [Core
20(f) & Core 20(h)]
Date results submitted to QMC
Interventions/Actions implemented based on results of 4th
measurement [Core 21(f)]
Conducts an analysis if performance goals are not met [Core 23(f)]
Barriers Identified and Actions Taken
79
CARE MANAGEMENT/UTILIZATION MANAGEMENT
Name of Project: (Core 20 (g), Core 23 (b)
Increase the number of members authorized for Psychosocial Rehabilitation Services with correct diagnosis or sufficient clinical information.
Description and Background [Core 19, 20, 21]
This quality improvement project was initiated to closely monitor and decrease the number of members approved for Psychosocial Rehabilitation Services with
an incorrect diagnosis or insufficient clinical information. Sandhills Center has had a Utilization Management/Utilization Review Unit for over 10 years. The
UM Unit is responsible for authorizing State funded and Medicaid services for those consumers seeking service through the public mental health system with no
other payer source. The services available for authorization are those services included in the North Carolina Department of Health and Human Services (DHHS)
Integrated Payment and Reporting System (IPRS) service array and the Medicaid Clinical Coverage Policies. The State requires that we use the service
definitions and medical necessity criteria outlined in the Mental Health, Developmental Disability and Substance Abuse State Funded Service Definitions and the
Medicaid Clinical Coverage Policies to make these decisions.
The UM Managers are responsible for reviewing each service definition based on the disability area with new staff and, thereafter, as needed. The definitions are
reviewed to provide the UM Care Manager with an overview of the definition, how the service is intended to be provided, the skills the consumer is intended to
gain, the medical necessity criteria, the requirement for a service order, the continuation/utilization review criteria, the discharge criteria, the service maintenance
criteria, appropriate service codes and the documentation requirements. The UM Managers also review any updates in clinical policy from the Division of
Medical Assistance with the UM Care Managers regarding changes in the State service definitions. In addition to the North Carolina Medicaid Service
Definitions, UM staff also utilizes the American Society of Addictive Medicine (ASAM) criteria as well as the LOCUS/CAOLCUS Level of Care Utilization
System criteria.
A Psychosocial Rehabilitation (PSR) service is designed to help adults with psychiatric disabilities increase their functioning so that they can be successful and
satisfied in the environments of their choice with the least amount of ongoing professional intervention. This service includes interventions that address the
functional problems associated with complex or complicated conditions related to mental illness. These interventions are strength-based and focused on
promoting recovery, symptom stability, increased coping skills and achievement of the highest level of functioning in the community.
During their work, the UM/UR managers observed a trend of providers requesting authorization for Psychosocial Rehabilitation services for members with
incorrect diagnosis or insufficient clinical information. They also found the UM Care Managers were approving the service requests with the incorrect diagnosis
or insufficient clinical information. The purpose of this project is to decrease the number of members authorized for Psychosocial Rehabilitation Services with
incorrect diagnosis or insufficient clinical information.
80
Describe the population affected by the Quality Improvement Project [Core 21(b)(i)(ii)(iii)(g)(h), Core 24(a),(b)]
Both consumers and local network providers are impacted by this quality improvement project. Adult consumers of mental health services are impacted by not
receiving the appropriate service based on their diagnosis and needs. Local network providers are impacted by requesting and being approved for services that
are not clinically appropriate for the member.
Selection Process [Core 19(b), Core 20(g), Core 21 (a)(b)(i),(ii),(iii)(c)(d)(e)(f) and Core 23(a)]
The Health Utilization Management/Utilization Review unit observed a trend of members being authorized inappropriately for Psychosocial Rehabilitation
Services. A report was developed to allow UM Managers an opportunity to review a sample of members authorized for Psychosocial Rehabilitation Services for
appropriateness. The report will allow the UM/UR managers to gauge appropriateness of authorization of this service over time.
Relation to Modules under Review [Core 21 (a)(b)(i),(ii),(iii), Core 24(a)(b)]
This quality improvement project fits with the Health Utilization Management module, Version 7.0. This project is designed to measure the appropriateness of
authorization of Psychosocial Rehabilitation Services.
Date approved by the Quality Management Committee
[Core 20(g)]
January 27, 2015
Date of meeting minutes reflecting approval by Quality
Management Committee [Core 20(d)]
January 27, 2015
Time Frames [Core 23(c)]
October 2014– Formulated Quality Improvement Project to address appropriateness of authorization of Psychosocial Rehabilitation Services.
October 2014 – Implemented training with UM/UR Care Managers regarding appropriate authorization of Psychosocial Rehabilitation Services.
January 2015 – Collected baseline data from April 2014 to September 2014.
June 2015- Provided training to network providers on Psychosocial Rehabilitation Services-appropriate diagnoses for the service and clinical information
submitted.
81
Ongoing – monitoring of service utilization and technical assistance to providers.
Focus of Project [Core 24(a)(b)]
Clinical – Will targeted training and support tools assist UM/UR Care
Managers and community providers in ensuring members appropriate for
Psychosocial Rehabilitation Services get authorized for services?
Name of Senior Clinical Staff Person Involved [Core 24 (b)]
Dr. Anthony Carraway, Sandhills Center Medical Director
Baseline Measurement [Core 21(d)]
The baseline measurement for this project was April 1, 2014 to September 30, 2014. During this timeframe, there were 1,194 authorizations submitted for
Psychosocial Rehabilitation. Of the 1,194 authorizations submitted, 646 authorizations were approved. A sample of 10% of approved Psychosocial
Rehabilitation Service authorizations were reviewed by UM/UR managers for appropriateness based on the diagnosis and clinical information submitted by the
network provider. During this review, the UM/UR managers found that 28(44%) were authorized with a diagnosis that was not clinically appropriate or the
clinical information submitted did not justify approval of Psychosocial Rehabilitation Services, or stated differently, 56% were authorized appropriately.
Data Collection [Core 21(a),(b),(c) and Core 23(a)]
Quarterly data is collected regarding the number of members authorized for Psychosocial Rehabilitation Services and the percentage of those authorized
appropriately based on the diagnosis given by the network provider. This report extracts data from the SHC Managed Care Software system. The report
parameters remain constant each time the data is pulled, with the exception of the date range selected. The unchanged report parameters will allow the
Utilization Management Director an opportunity to analyze the data over time extracting similar information for each month or quarter. Data will be collected
and reviewed monthly.
Measurable Goal(s) toward improvement [Core 23(a)]
Increase the percentage of members authorized appropriately for Psychosocial Rehabilitation Services based on diagnosis and clinical information submitted by
the provider to 85%.
Projected Timeframe to Achieve Goals [Core 23(c)]
82
October 2015 or until the UM/UR Unit achieves 3 consecutive quarters of meeting the stated goal.
Initial Interventions/Action Plans [Core 23 (b)(e)(f)]
Barriers Identified and Intervention/Action Taken
Customized report created to monitor the number of members authorized for Psychosocial Rehabilitation Services.
Training/technical assistance session scheduled with UM/UR Staff.
SHC provided training to network providers on Psychosocial Rehabilitation Services-appropriate diagnoses for the service
was covered.
Ongoing monitoring of members authorized for Psychosocial Rehabilitation Services based on diagnosis and clinical
information submitted.
Date Implemented
January 2015
October 2014-January 2015
March 2015
February 2015-October 2015
.
Periodic Measurements at least annually [Core 23(d)] and re-measurement for changes or improvements to baseline [Core
23(e)]
Date of Measurement Result of Measurement
Date Reported to QM
Committee
The
October
2014
to
December
2014
data
indicates
that
of
a
10%
April 28, 2015
April 2015
random sample of approved PSR authorizations (80 authorizations),
that 44 or 55% were approved appropriately based on the diagnosis
and clinical information submitted.
This update indicates a slight decrease in the appropriateness of
83
those approved for PSR services. The UM managers will
continue to train and educate staff on appropriate diagnosis and
clinical presentation of members for PSR services.
QMC comments based on results of 2nd measurement [Core
20(f) & Core 20(h)
Periodic Measurements at least annually [Core 23(d)] and re-measurement for changes or improvements to baseline [Core
23(e)]
Date of Measurement
Result of Measurement
Date Reported to QM
Committee
Summarize the results acheived utilizing statistical methodologies
Date results submitted to QMC
QMC comments based on results of 3rd measurement[Core 20(f)
& Core 20(h)
Date of 4th
Measurement
Interventions/Actions implemented based on results of 3rd
measurement [Core 21(f)]
Summarize the results acheived utilizing statistical methodologies
QMC comments based on results of 4th measurement [Core
20(f) & Core 20(h)]
Date results submitted to QMC
Interventions/Actions implemented based on results of 4th
measurement [Core 21(f)]
Conducts an analysis if performance goals are not met [Core 23(f)]
84
HEALTH NETWORK
Name of Project: (Core 20 (g), Core 23 (b)
Increase tracking for the Receipt of North Carolina Treatment Outcomes Program Performance System
(NC-TOPPS) Interviews.
Description and Background [Core 19, 20, 21]
The NC-TOPPS is a web-based system in which providers enter data based on face-to-face-interviews conducted with members initially and at
periodic intervals during the time services are rendered. This is required for mental health and substance abuse (MH/SA) members ages six and
older. Data collected from ininterviews is designed to assist in evaluating effectiveness of treatment, access, and member’s satisfaction with
services. Information obtained from interviews is entered into NC-TOPPS system by the Qualified Professional (QP) of the member’s primary
agency and may be utilized in the development and subsequent revisions of the Individualized Support Plan (ISP). NC-TOPPS allows members to
query information on providers across the state and to track their progress in treatment using NC-TOPPS Individual Reports. It also gives
providers the opportunity to share and discuss individual reports with members. Between 2009 and 2012 receipt of NC-TOPPS interviews from
providers in a timely manner by Sandhills Center for MH, DD & SAS (SHC) ranged on average 22% below the state standard of 90%.
SHC ensures that all network providers of publicly funded MH/SA services in its catchment area meet the requirements of NC-TOPPS tools and
protocols by providing quarterly training as well as technical assistance. However, data suggests that these methods have not proven effective and
a more intensive approach is needed to increase compliance. In addition, SHC has not fully utilized its authority based on contractual agreements
to impose possible consequences. The overall outcome desired by SHC taking this proactive approach to addressing deficiency is to promote
consumer participation in the treatment planning process and enable providers to utilize data obtained from the system in the development and
revision of MH/SA plan of care, thereby improving consumer’s quality of care.
In January 2012 through April 2012, the Legislative Research Commission’s Committee on In-Home and Community Based Mental Health
Services for Youth held meetings and were tasked with the development and implementation of a program for youth for MH providers. The
purpose of the program is to establish reimbursement and regulatory flexibility for providers that demonstrate beneficial outcomes. As part of this
discussion, the Committee is interested in looking at child and adolescent outcome data already collected in the NC-TOPPS system. Aggregate
data compiled from NC-TOPPS Initial interviews for juveniles regarding barriers to entering treatment (July 2011 – December 2011) indicate
13.10% (highest for the state) for the catchment area in the category of Active MH symptoms, another factor that further highlights the impact on
consumers and the usefulness of SHC network providers completing NC-TOPPS in a timely manner.
85
Describe the population affected by the Quality Improvement Project [Core 21(b)(i)(ii)(iii)(g)(h), Core 24(a),(b)]
All members in catchment area ages 6 and above who have been formally admitted to SHC and are assigned a member health record number, and
began receiving qualified mental health/substance abuse services (see attached NC–TOPPS Service Codes Criteria, Appendix A).
Selection Process [Core 19(b), Core 20(g), Core 21 (a)(b)(i),(ii),(iii)(c)(d)(e)(f) and Core 23(a)]
SHC is currently out of compliance per contract requirement regarding NC-TOPPS Performance Measure. Based on quarterly reports, SHC
network providers have not achieved North Carolina standard of 90%. In addition, aggregate data compiled for involved child/adolescents
regarding barriers to entering treatment suggest a high percentage for the SHC catchment area in comparison to other local management entities.
Relation to Modules under Review [Core 21 (a)(b)(i),(ii),(iii), Core 24(a)(b)]
This project accommodates the Health Network module, Version 7.0. This project is designed to increase provider’s compliance with NC-TOPPS
interviews which in turn will assist them in measuring the quality of care and impact on member’s lives.
Date approved by the Quality Management Committee
[Core 20(g)]
Date of meeting minutes reflecting approval by Quality
Management Committee [Core 20(d)]
April 25, 2012
Time Frames [Core 23(c)]
April 25, 2012
April 25, 2012 – March 31, 2014 or until three (3) consecutive State Performance Standards of 90% and above are achieved.
Focus of Project [Core 24(a)(b)]
Non-Clinical. The focus of this project is to determine whether
increased oversight and tracking of NC-TOPPS provides timely data
and information that will result in improvement in compliance with
timely submission of NC-TOPPS by community providers. The State
performance standard is 90% and we have not met that standard.
Baseline Measurement [Core 21(d)]
Name of Senior Clinical Staff Person Involved [Core 24 (b)]
N/A – Non- Clinical
The baseline, 65.7%, was established using the Compliance Report by Provider Agency, 3rd quarter results 2012 for performance measure
(Timeliness; Percent of Expected Assessments Received On-Time). This percentage indicates SHC compliance for the period. The report reflects
aggregate data compiled from the 1st quarter (July - September 2011; data collected is time-lagged two quarters) for measure. A total of 1088
interviews were to be received for this timeframe, and of that total 715 were received on time.
86
Data Collection [Core 21(a),(b),(c) and Core 23(a)]
Quarterly review and analysis of the Compliance Report by Provider Agency for the Performance Measure (Timeliness; Percent of Expected
Assessments Received On-Time). Monthly update and review; formal presentation of findings quarterly by Director and/or designee to Quality
Management Committee. The data will be analyzed as follows:
N: Total number of NC-TOPPS interviews not returned by providers in a timely manner
D: Total number of NC-TOPPS Expected number of Update Interviews
Measurable Goal(s) toward improvement [Core 23(a)]
Improvement in the timeliness rating for the NC-TOPPS Assessments from 65.7% to 90%, percentage point increase of 24.3%
Projected Timeframe to Achieve Goals [Core 23(c)]
March, 31, 2014
Initial Interventions/Action Plans [Core 23 (b)(e)(f)]
Barriers Identified and Intervention/Action Taken
1. System upgrade rendered NC-TOPPS inaccessible for several providers/Provider training held to assist
providers with the upgraded system (data collected is time lagged two quarters, evidence of action 2012).
2. High rate of attrition for provider staff, particularly QP/Quarterly training or as needed on NC-TOPPS
provided by SHC.
3. Historically low provider compliance with mandatory timelines with minimal or no consequences
employed/Quarterly Informational sessions/forums held by SHC for providers outlining the importance of
timeliness and potential sanctions for lack of adherence.
4. Providers consistently fail to meet mandatory reporting timelines/Revised Compliance letter for timeliness
of submission to include potential sanctions for non-compliance and notification of SHC Chief Clinical
Officer/Medical Director.
5. Providers need to be more informed regarding benefits for members/providers associated with utilizing NCTOPPS / DHHS NC-TOPPS Project Manager discussed the importance of data collection and timeliness at
the Quarterly Service Provider Meeting.
Date Implemented
April 2012
On-going
April 2012 – ongoing
June 2012
August 2012
87
6. Monitoring Specialists site visits to providers found out of compliance.
September 2012
Periodic Measurements at least annually [Core 23(d)] and re-measurement for changes or improvements to baseline [Core 23(e)]
Date Reported to QMC
Date of Measurement
Result of Measurement
Data from NC-TOPPS SFY 2012 Update Compliance by Provider Agency Report from
April 25th, 2012
1st Date of
1st Quarter FY 2009-2010 to 2nd Quarter FY 2011-2012 indicates a historical low
Measurement
April 2012
compliance rate for SHC provider’s timeliness in submitting NC-TOPPS. Analysis from
the NC-TOPPS Report indicates an average of 62.47% for this time period. Further data
to be reviewed once the 3rd Quarter compliance rates are received from NC-TOPPS in
Raleigh.
QMC comments based on results of 1st measurement [Core 20(f) & Core
20 (h)]
Quality Improvement Project presented to QMC; project approved
Interventions/Actions implemented based on results of 1st
measurement [Core 21(f)]
Review and monitor updates, apply strategies
Periodic Measurements at least annually [Core 23(d)] and re-measurement for changes or improvements to baseline [Core 23(e)]
88
Date Reported to QMC
Date of Measurement
Result of Measurement
Previous quarter compliance report reviewed to analyze providers out of compliance for
May 22nd, 2012
2nd Date of
more than one quarter. Developed list of providers out of compliance. Due to time lag two
Measurement
May 2012
quarters, 3rd quarter results unavailable at this time.
QMC comments based on results of 1st measurement [Core 20(f) &
Interventions/Actions implemented based on results of 1st measurement
Core 20 (h)]
[Core 21(f)]
QMC updated on project and findings.
Recommended analysis of 3rd Quarter Report when received. Current
Compliance letter to be modified. Draft letter to be submitted to QMC
in June.
Periodic Measurements at least annually [Core 23(d)] and re-measurement for changes or improvements to baseline [Core 23(e)]
Date Reported to QMC
Date of Measurement
Result of Measurement
rd
Review and analysis of the 3 quarter SFY 2012, NC-TOPPS Report, Timeliness of
June 26th, 2012
3rd Date of
Interviews Performance Measure - 1088 interviews were expected; however, 373 (34%)
Measurement
June 2012
were not received on time. Fifty (50) providers with a rating of <90% received notification
via modified Compliance letter.
QMC comments based on results of 1st measurement [Core 20(f) &
Interventions/Actions implemented based on results of 1st measurement
Core 20 (h)]
[Core 21(f)]
QMC updated on project and effectiveness of strategies.
Continue to review and monitor data.
Periodic Measurements at least annually [Core 23(d)] and re-measurement for changes or improvements to baseline [Core 23(e)]
Date Reported to QMC
Date of Measurement
Result of Measurement
th
Review
and
analysis
of
the
4
quarter
SFY
2012
NC-TOPPS
Report
Timeliness
of
July 24th, 2012
4th Date of
Interviews - 903 interviews were expected for this measure. A total of 195 (22%) were
Measurement
July 2012
not received in a timely manner. Compliance letters were forwarded to 31 agencies with a
rating of <90% on the measure; goal met for the 4th quarter.
89
NC-TOPPS Timeliness QIP 2012-2013
100.0%
90.0%
90.0%
90.0%
78.4%
80.0%
70.0% 65.7%
QIP Measure
60.0%
QIP Goal
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
3rd
4th
Quarter Quarter
QMC comments based on results of 1st measurement [Core 20(f) & Core
20 (h)]
QMC updated on project and informed that the established goal for the
project, 75%, was achieved for the 4th quarter reporting period.
Improvement reflects a significant increase from the baseline and can be
attributed to interventions implemented thus far; however, SHC still
remains 11.6% below the state standard.
Interventions/Actions implemented based on results of 1st
measurement [Core 21(f)]
Continue to review data, utilize strategies, but to explore options/
interventions to sustain performance and move toward incrementally
to attaining state standard level of performance.
Periodic Measurements at least annually [Core 23(d)] and re-measurement for changes or improvements to baseline [Core 23(e)]
Date Reported to QMC
Date of Measurement
Result of Measurement
No new data to report.
August 28th, 2012
5th Date of
Measurement
90
August 2012
QMC comments based on results of 1st measurement [Core 20(f) &
Core 20 (h)]
QMC updated on project and continued interventions
Interventions/Actions implemented based on results of 1st measurement
[Core 21(f)]
Continue to review data and employ interventions
Periodic Measurements at least annually [Core 23(d)] and re-measurement for changes or improvements to baseline [Core 23(e)]
Date Reported to QMC
Date of Measurement
Result of Measurement
Sandhills Center elected to take a more proactive approach to addressing issues of
September 25th, 2012
6th Date of
compliance and error reduction regarding the NC TOPPS Timeliness of Interviews
Measurement
September 2012
measures. Data from the SFY 2012 Update Compliance Report by Provider Agency Third
and Fourth Quarter Report indicate fifteen (15) SHC providers out of compliance. In
response to findings and current project the NC-TOPPS Member File Review Check Sheet
was developed from a collaborative effort from various departments. The Check Sheet is
designed to a) readily assess records for compliance, and b) as a mechanism to identify
barriers, compile data and decrease errors in completing NC-TOPPS. It was determined
that SHC Monitoring Specialists, whose job responsibilities consist of monitoring
providers in accordance with current rules, regulations, statutes and other regulatory
requirements; provide technical assistance as needed, and generate reports based on
findings, were best qualified to conduct reviews. Network providers were notified via
certified mail and/or email of non-compliance and upcoming site visits scheduled.
QMC comments based on results of 1st measurement [Core 20(f) &
Interventions/Actions implemented based on results of 1st measurement
Core 20 (h)]
[Core 21(f)]
QMC updated on project and continued interventions
Continue to review data and employ interventions
Conducts an analysis if performance goals are not met [Core 23(f)] – Barriers Identified & Actions Taken
Time Frame
Performance Analysis
Update
October-December 2012
Review and analysis of the 1st quarter SFY 2013, NC -TOPPS Report, Timeliness of Interviews 02/07/2013
Performance Measures – 990 interviews was expected; 932 interviews received reflecting a 94.1%.
Interviews received ON-Time 679, reflecting 68.6%. Fifty-five (55) providers with a rating <90%
received notification via modified Compliance letter.
91
January-March 2013
April-June 2013
July-September 2013
Review and analysis of the 2nd quarter SFY 2013, NC – TOPPS Report, Timeliness of Interviews
Performance Measures – 964 interviews was expected; 920 interviews received reflecting a 95.4%.
Interviews received On – Time 855, reflecting 88.7%. A 20% increase from the previous quarters
is noted this quarter
Twenty-five providers with a rating <90% received notification via modified Compliance letter. A
decrease from last quarter.
Review and analysis of the 3rd quarter SFY 2013, NC – TOPPS Report, Timeliness of Interviews
05/13/2013
Performance Measures – 1,813 interviews was expected; 1,632 interviews received reflecting a
90.0%. Interviews Received On – Time 1361, reflecting 75.1%.
Sixty-four providers with a rating < 90% received notification via a modified compliance letter. An
increase from last quarter. During the month of May 2013, it was recommended during QMC that
Network Committee look at implementing sanctions to providers with contracts who fail to meet
contract requirements. Network Committee approved to revise compliance letter June 2013 with the
focus on sanctions.
Review and analysis of the 4th quarter (Based on Initials Submitted October –December 2012) 10/10/2013
SFY 2013, NC –TOPPS Report, Timeliness of Interviews Performance Measures – 1,604
interviews was expected; 1,441 interviews received reflecting a 89.8%. Interviews Received on –
Time 1,255, reflecting 78.2%. Sixty providers with rating < 90 % received notification via a
compliance letter. Network Committee compared the 3rd and 4th quarter reports to focus on
effectiveness of current sanction (compliance notifications and requested POCs). It is the goal for
SHC to meet the State Performance Standard of 90% and above for conducting interviews on time.
Network Committee recommended effective 10/10/13: Credentialing Specialist assigned to
providers who fail to meet the State Performance Standard of 90% will conduct phone calls and
email correspondence to remind them of the consequences if no improvement is seen. Sanctions
may be applied and could lead to termination of SHC contract. Notes from all correspondences will
be placed in the provider file.
92
October-December 2013
Review and analysis of the 1st Quarter Report (Based on Initials Submitted January – March 01/14/2014
2013) SFY 2014, NC – TOPPS Report, Timeliness of Interviews Performance Measures – 1,435
interviews was expected; 1,273 interviews received reflecting an 88.7%. Interviews received
on–time 1,190, reflecting 82.9%. One Hundred Twelve (112) provider sites were identified as out
of compliance for not meeting the required State Performance Standard of 90% and above for
conducting interviews on time.
Review and analysis of the 2nd Quarter Report (Based on Initials Submitted April –June 2013)
SFY 2014, NC – TOPPS Report, Timeliness of Interviews Performance Measures – 1,579
interviews were expected; 1, 436 interviews received reflecting
90.9 %. Interviews received on-time 1,326 reflecting an 84.0%. One Hundred Eight (108)
provider sites were identified as out of compliance for not meeting the required State Performance
Standard of 90% and above for conducting interviews on time. Credentialing Specialist continue to
join work efforts with QM department by conducting phone calls and forwarding emails as a
reminder of the consequences if no improvement is seen. Sanctions may be applied and could lead
to termination of SHC contract.
SHC SFY 2013 NC TOPPS
Timeliness of Interviews Performance Measures
Expected
Received
1st Qtr. Jan-Mar 2013
89%
83%
2nd Qtr. Apr-Jun 2013
91%
84%
3rd Qtr. Jul-Sep 2013
97%
94%
4th Qtr. Oct-Dec 2013
97%
91%
93
100%
95%
90%
Expected
Received
85%
80%
75%
Jan.-Mar.
Apr.-Jun.
Jul.-Sept.
Oct.-Dec.
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
Conducts an analysis if performance goals are not met [Core 23(f)] – Barriers Identified & Actions Taken
Time Frame
Performance Analysis
Update
rd
January-March 2014
Review and analysis of the 3 Quarter Report (Based on Initials Submitted July – September 04/17/2014
2013) SFY 2014, NC- TOPPS Report, Timeliness of Interviews Performance Measures – 1,545
interviews was expected; 1,506 interviews received reflecting 97.5%. Interviews received ontime 1,458 reflecting 94.4%. Eighty-two (82) provider sites were identified as out of compliance
for not meeting the required State Performance Standard of 90% and above for conducting
interviews on time. Network Management’s Credentialing Specialist will continue to join work
efforts with Quality Management and Program Integrity Departments by conducting phone calls
and forwarding emails as a reminder of consequences if no improvement is seen. This has been a
significant improvement for SHC this quarter.
April-June 2014
On this date July 7, 2014 Network Management was informed by the NC – TOPPS Help Desk 07/07/2014
representative that the analysis for the SFY 2014 Update Compliance by Provider Agency 4 th
Quarter Report (Based on Initials Submitted October – December 2013) will be compiled at the
end of July 2014 and released to LME/MCOs early August 2014. Network Management’s
Credentialing Specialist will continue to join work efforts with Quality Management and Program
94
July-August 2014
September 2014
January 12, 2015
Integrity Departments by conducting phone calls to providers and forwarding emails as reminders
of the importance to complete their NC- TOPPS in a timely manner. Providers have been informed
and are aware of consequences of not improving could result into sanctions and possible
termination of contract.
Review and analysis of the 4th Quarter Report (Based on Initials Submitted October –December 08/06/2014
2013) SF 2014, NC –TOPPS Report, Timeliness of Interviews Performance Measures – 1,513
interviews was expected; 1,469 interviews received reflecting 97.1%. Interviews received ontime 1,380 reflecting 91.2%.Twenty-nine (29) provider sites were identified as out of compliance
for not meeting the required State Performance Standard of 90% and above for conducting
interviews on time. Network Management’s Credentialing Specialist will continue to join work
efforts with Quality Management and Program Integrity Departments by conducting phone calls
and forwarding emails as a reminder of consequences if no improvement is seen. SHC met the State
Performance Standard of 90% and above this quarter and last quarter. Please see attached the SHC
SFY 2013 NC-TOPPS Timeliness of Interviews Performance Measure dated 8/4/2014.
Network Management has not received an analysis for the NC-TOPPS 1st Quarter Report to present 10/28/2014
to the October Quality Management meeting. Network Management’s Credentialing Specialist
continues to join work efforts with Quality Management and Program Integrity Departments by
conducting phone calls to providers and forwarding emails as a reminder of consequences if no
improvement is seen. SHC has met the State Performance Standard of 90% and above for two (2)
consecutive quarters. If SHC accomplishes the same results next reporting period we will achieve
the goal for this QIP. It will then be place on the monitoring phase.
Network Management has not received an analysis for the NC-TOPPS 1st Quarter Report to present 1/27/ 2015
to the January Quality Management meeting. The Network Manager conducted a follow-up call and
left a message on 1/12/15 for the NC-TOPPS contact person to provide feedback about the LMEMCO Update Compliance Report. Contact was made with QM staff designated to work on weekly
NC-TOPPS monitoring. She unaware of the Quarterly Compliance Provider Report and works with
the weekly monitoring. However, the weekly reports are continuing to show much improvement,
but there is no way of calculating a percentage at this time. Network Management’s Credentialing
Specialist continues to join work efforts with Quality Management and Program Integrity
Departments by conducting phone calls and forwarding emails as a reminder of consequences if no
improvement is seen. SHC is waiting for the next Quarterly Provider Compliance Report to ensure
that three (3) consecutive months have occurred to meet the State Performance Standard of 90%
and above.
95
February 10, 2015
Review and analysis of the 2nd Quarter Report (Based on Initials Submitted April-June 2014) 4/14/2015
SFY 2015, NC-TOPPS Report, Timeliness of Interviews Performance Measures- 1,227 interviews
was expected: 1,202 interviews received reflecting 98.0%. Interviews received on-time 1,175
reflecting 95.8%. Eighteen (18) provider sites were identified as out of compliance for not meeting
the required State Performance Standard of 90% and above for conducting interviews on time.
Network Management’s Credentialing Specialist will continue to join work efforts with Quality
Management and Program Integrity Departments by conducting phone calls and forwarding emails
as a reminder of consequences as a monitoring requirement for the next year. Sandhills Center has
achieved the State Performance Standards of 90% and above three (3) consecutive quarters.
This QIP will be recommended to Network and Quality Management Committees for
approval to close.
96
HEALTH NETWORK
Name of Project: (Core 20 (g), Core 23 (b)
Decrease the length of time it takes for providers to return their signed contracts and/or contract amendments to Network
Development.
Description and Background [Core 19, 20, 21]
Currently the Sandhills Center has 617 Medicaid-only network providers, comprising agencies and solo Licensed Independent
Practitioners. Quantitative data from the Network Development unit indicate that 56% of Medicaid providers returned (or 44% of
Medicaid providers did not return) their signed contracts during the first six months after mailing. URAC standard N-NM 7 requires
that the LME/MCO have written agreements with all participating providers. To meet this standard a quality improvement project was
initiated to closely monitor and track the length of time it is taking network providers to return their signed contracts and/or signed
amendment to the Network Development unit for final processing and execution by Sandhills Center. A contract is executed when it is
signed by all parties to the contract.
A contract is initiated after the provider has been credentialed and after SHC Board approval. The contract with attachments is mailed
to the provider with directions on how to process and where to return two (2) signed original contract packets. The date the contract is
sent to the provider is entered on to a routing/tracking log. Upon return to Network Development, the signed contract packets are
reviewed for completeness and complete packets are tracked and then routed to the SHC Finance Director and CEO for signature.
Dates are tracked at each instance. Upon execution, a fully signed original contract is mailed to the provider; an original is filed at the
SHC, and a scanned copy is saved electronically.
Describe the population affected by the Quality Improvement Project [Core 21(b)(i)(ii)(iii)(g)(h), Core 24(a),(b)]
SHC administrative staff, network providers and consumers are impacted by this quality improvement project. Both parties to the
contract are negatively impacted by not having an executed contract to review for accountability and payment terms. Consumers are
negatively impacted by being served by providers who do not understand or meet the expectations and obligations of service delivery,
as detailed in the written agreement. Provider payments are delayed, and budget projections become uncertain.
Selection Process [Core 19(b), Core 20(g), Core 21 (a)(b)(i),(ii),(iii)(c)(d)(e)(f) and Core 23(a)]
Data reviewed indicated that contracts and/or contract amendments are not being executed in a timely manner. To reduce the length of
time it takes to get contracts executed, this project was selected. The following will be closely monitored: date the contract or contract
97
amendment was sent to the provider, date returned from provider and sent to Finance Director and CEO for execution, and date
executed contract sent to provider.
Relation to Modules under Review [Core 21 (a)(b)(i),(ii),(iii), Core 24(a)(b)]
This quality improvement project aligns with URAC N-NM 7, in that the LME/MCO shall have written agreements with all
participating providers. This project is designed to measure the decreased length of time it takes for a network provider to return a
signed contract or contract amendment.
Date approved by the Quality Management Committee
Date of meeting minutes reflecting approval by Quality
[Core 20(g)]
Management Committee [Core 20(d)]
April 22, 2014
April 22, 2014
Time Frames [Core 23(c)]
 January and February 2014- Collected baseline data from 1st two quarters of FY 13-14
 January and February 2014 – Revised existing desk instructions to send written reminders to providers who have not returned
their signed contracts in timely fashion
 February 2014 – Formulated Quality Improvement Project to decrease the amount of time to get contracts executed
 Spring 2014 – Network providers who fail to return their signed contracts within 60 days of mailing will be sent a certified
letter, informing them that they must return their signed contract or provider will be subject to sanctions up to and including
termination of the contract as a provider in the Sandhills Center network.
 Beginning July 1, 2014 and each year thereafter, track dates on which providers return executed contracts/amendments and
measure against prior year’s performance.
 On-going monitoring of quality improvement project
Focus of Project [Core 24(a)(b)]
Name of Senior Clinical Staff Person Involved [Core 24 (b)]
Administrative – Will written reminders sent to providers
Bonita Porter, Network Operations Director
decrease the length of time it takes for providers to return their
signed contracts and/or contract amendments to the Sandhills
Center?
Baseline Measurement [Core 21(d)]
During fiscal year 13-14, 56% of Medicaid-only providers returned (or 44% of Medicaid-only providers did not return) their signed
98
contracts during the first half of the fiscal year. For FY 14-15 and future years, data will be measured against the quantitative standard
of 85% contracts returned within 60 days.
Data Collection [Core 21(a),(b),(c) and Core 23(a)]
Quarterly data is collected regarding receipt of signed contract packets or amendments from network providers. This data is tracked
from the above described contract routing log. Reports will be issued each quarter for all contacts/amendments sent to providers more
than 60 days earlier.
Measurable Goal(s) toward improvement [Core 23(a)]
85% of Medicaid-only providers will return their signed contracts within 60 days of mailing.
Projected Timeframe to Achieve Goals [Core 23(c)]
February 2014 through September 30, 2015.
Initial Interventions/Action Plans [Core 23 (b)(e)(f)]
Barriers Identified and Intervention/Action Taken
The provider will be sent an e-mail reminding them that their contract has not yet been received by
Sandhills Center
The provider will receive either a phone call or e-mail reminder.
The provider will be sent a certified letter indicating that provider will be subject to sanctions, up to
and including termination of the contract as a provider in the Sandhills Center Network, if signed
contract is not received by the Contracts Unit within sixty (60) days of the date that the contract was
sent to provider.
The provider will be sent a certified letter indicating that their contract has been terminated, payments
will be suspended. The letter will include an explanation of the provider’s appeal rights.
Date Implemented
Three (3) weeks (21 days)
after mailing contract
Five (5) weeks (40 days)
after mailing contract
Seven (7) weeks (49 days)
after mailing contract.
Sixty (60) days after
mailing contract.
99
February 2014 – June 30,
2015
On-going monitoring of contract receipt
Periodic Measurements at least annually [Core 23(d)] and re-measurement for changes or improvements to baseline [Core
23(e)]
Date of Measurement Result of Measurement
Date Reported to QM
Committee
Date of 1st
Summarize the results achieved utilizing statistical methodologies.
measurement (not the If an initial project improvement measurement has not occurred, then
baseline measurement) when will it be conducted?
June 30, 2014
25% of Medicaid-only providers returned their signed
contracts/amendments within 60 days
QMC comments based on results of 1st measurement [Core
20(f) & Core 20(h)]
None noted.
Date of 2nd
measurement (not the
baseline measurement)
September 30, 2014
July 22, 2014
Interventions/Actions implemented based on results of 1st
measurement [Core 21(f)]
Emails and telephone reminders were made to providers who
had not returned their signed contracts/amendments pursuant to
time frames identified above.
Summarize the results achieved utilizing statistical methodologies.
70% of Medicaid providers returned their signed
contracts/amendments within 60 days (includes those within 60 day
range)
To be reported to QM committee on
October 28, 2014.
100
QMC comments based on results of 2nd measurement [Core
20(f) & Core 20(h)
Interventions/Actions implemented based on results of 2nd
measurement [Core 21(f)]
Emails and telephone reminders were sent to providers who had
not returned their signed contracts/amendments pursuant to the
time frames identified above.
Periodic Measurements at least annually [Core 23(d)] and re-measurement for changes or improvements to baseline [Core
23(e)]
Date of Measurement
Result of Measurement
Date Reported to QM
Committee
rd
Date of 3
Summarize the results achieved utilizing statistical methodologies.
measurement
Need date reported to QM
December 31, 2014
76.09% of Medicaid providers returned their signed
contracts/amendments within 60 days (includes those within 60 day
range)
To be reported to QM committee
on
(insert date)
QMC comments based on results of 3rd measurement[Core 20(f)
& Core 20(h)
Interventions/Actions implemented based on results of 3rd
measurement [Core 21(f)]
The percentage of contracts/amendments returned within 60 days
continues to improve.
Emails and telephone reminders were sent to providers who had
not returned their signed contracts/amendments pursuant to the
time frames identified above. In addition, providers received a
certified letter on or about 49 days and then 60 days after
mailing.
Date of 4th
Measurement
March 31, 2015
We have fine-tuned our methodology to have a better cohort. This
shows that 92% of Medicaid providers returned their signed
contracts/amendments within 60 days (includes those with 60-day
range.)
Date results submitted to QMC
101
QMC comments based on results of 4th measurement [Core 20(f) Interventions/Actions implemented based on results of 4th
& Core 20(h)]
measurement [Core 21(f)]
The percentage of contracts/amendments returned within 60 days
continues to improve.
Emails and telephone reminders were sent to providers who had
not returned their signed contracts/amendments pursuant to the
time frames identified above. In addition, providers received a
certified letter on or about 49 days and then 60 days after
mailing. Providers still failing to return their contracts were
presented to Network Committee with recommendation that
provider receive sanction letter. Certified sanction letter was sent
to the provider with notice that their contract had been
terminated and providing information on how to appeal the
decision.
Conducts an analysis if performance goals are not met [Core 23(f)]
Barriers Identified and Actions Taken
102
HEALTH NETWORK
Name of Project: (Core 20 (g), Core 23 (b)
Enhance Network Provider Directory. Improve the accuracy of provider information in the Network Provider Directory.
Description and Background [Core 19, 20, 21]
Sandhills Center is committed to ensuring that members have timely and easy access to behavioral health services and that network
providers have the availability to meet the needs of members based on intensity of need criteria. One means of accomplishing this
access and availability goal is to maintain accurate, current information about provider contact information, services and locations in
the Provider Directory. The Directory is posted on the Sandhills Center website and is used internally by Sandhills staff and externally
by members and community stakeholders.
On March 31, 2014, Sandhills Center transitioned the software system containing provider information from AVATAR to a new
software system known as Alpha. A benefit of the new system was that, unlike AVATAR, Alpha links provider services to specific
service locations. In addition, Alpha has the ability to track therapists and age-disability and other target populations, evidence based
treatment practices, specialties and language. The ability to track this information helps to remove members’ barriers to services and
improves Sandhills Center’s ability to make appropriate referrals to network providers. If additional options are needed, Network
Operations will work closely with Sandhills Center IT Department to request modifications to the Alpha software.
Describe the population affected by the Quality Improvement Project [Core 21(b)(i)(ii)(iii)(g)(h), Core 24(a),(b)]
Sandhills Center employees, Network Providers, members and stakeholders.
Selection Process [Core 19(b), Core 20(g), Core 21 (a)(b)(i),(ii),(iii)(c)(d)(e)(f) and Core 23(a)]
A review of the State Provider Satisfaction Survey, local needs assessment survey, complaints and quality of care concerns received
by the Quality Management department of the Sandhills Center, and feedback from Sandhills Center staff, including Call Center and
Care Coordination , indicate that the Provider Directory does not always have current, accurate information, including but not limited
to incorrect provider contact information, site specific addresses and phone numbers, and services no longer being provided at specific
locations.
Relation to Modules under Review [Core 21 (a)(b)(i),(ii),(iii), Core 24(a)(b)]
This quality improvement project aligns with URAC N-NM 2 in that the LME/MCO shall monitor access and availability of providers
103
to provide care to members. This project is designed to improve the accuracy of provider data maintained in the Provider Directory.
Date approved by the Quality Management Committee
[Core 20(g)]
TBD on April 28th, 2015
Date of meeting minutes reflecting approval by Quality
Management Committee [Core 20(d)]
Time Frames [Core 23(c)]
April 14th, 2015 – October 31st, 2016 With modifications needed in Alpha for specialties, age, disabilities, evidence based treatment
practices and language; we are starting at 0% in those areas. Our goal is to increase improvement up to 90%.
Focus of Project [Core 24(a)(b)]
Name of Senior Clinical Staff Person Involved [Core 24 (b)]
Improve the accuracy of provider information in the Network Bonita Porter, Health Network Operations Director
Provider Directory.
Baseline Measurement [Core 21(d)]
In an effort to establish a baseline, each Credentialing Specialist has an assigned provider roster. The Credentialing Specialists have
identified themselves as the Account Manager in Alpha (100%).
Currently, we have an estimated 856 providers in the Network. Alpha has approximately 3,800+ providers in the Network (agencies,
solo practitioners and licensed independent therapists linked to agencies). Each Credentialing Specialist will perform a monthly
random audit of fifteen (15) providers from their assigned caseload. The Credentialing Specialist will compare data in Alpha against
information in the provider file and verify to ensure that provider contact information, site(s), & service information are current. As
files are reviewed for re-credentialing, monthly we will report accurate data in the system.
Current baseline for aligning providers with age-disability and other target populations, evidence based treatment practices, specialties
and language - 0%. Network Operations will work closely with the IT Department to request modifications to the Alpha software as
needed to include the addition of drop down boxes and additional choices in current drop down boxes for data entry to meet the needs
of the QIP.
Provider data issues identified & reported by Sandhills Center staff, members, providers, random audits & re-credentialing will be
104
1
reported to the provider’s assigned Credentialing Specialist for review and will be corrected in Alpha as necessary. The monthly
random audit of assigned providers will indicate percentage of data that is found to be accurate.
Our baseline will consist of four phases to be completed.
 The Network Manager along with the Network Reports Manager will submit IT requests for drop down boxes & additional
choices to be added for specialties, age disabilities & other target populations, evidence based treatment practices and
languages
 The Credentialing Specialist will ensure all serving counties are identified.
 The Credentialing Specialist will ensure that all information is correct during internal audits, initial audits re-credentialing &
provider change request(s) and as identified by staff & members.

The Network Manager along with the Network Reports Manager will submit IT requests for drop-down boxes to be added for
specialties and modifications to Alpha for facility license and other requirements that support the provider directory.
Data Collection [Core 21(a),(b),(c) and Core 23(a)]
The data will be reviewed and entered on an on-going basis. Each Credentialing Specialist will randomly audit fifteen (15) of their
assigned case load for accuracy.
Measurable Goal(s) toward improvement [Core 23(a)]
With modifications needed in Alpha for specialties, age, disabilities, evidence based treatment practices and language, we are starting
at 0% in those areas. Our goal is to increase improvement up to 90%.
Current information will be entered into Alpha for 100% of the providers audited each month. 100% of the provider data issues
reported by Sandhills Center staff, members and providers will be reported to the provider’s assigned Credentialing Specialist for
review and will be corrected in Alpha as necessary.
Projected Timeframe to Achieve Goals [Core 23(c)]
18 months (October 31, 2016).
105
2
Initial Interventions/Action Plans [Core 23 (b)(e)(f)]
Barriers Identified and Intervention/Action Taken
Request for IT support for modifications in Alpha.
Training of new Credentialing Specialist
Manually pulling and checking files for specialties – files are not electronic
Date Implemented
April 14, 2015
April 30, 2015
April 14, 2014
Periodic Measurements at least annually [Core 23(d)] and re-measurement for changes or improvements to baseline [Core
23(e)]
Date of Measurement Result of Measurement
Date Reported to QM
Committee
April 14, 2015
Introduction if new Quality Improvement Project of enhancing the
Provider Network Directory. Monthly report of findings will be
presented to Network Committee, and quarterly to QMC.
The date of the 1st measurement to be conducted will be dependent
upon the modifications to Alpha.
QMC comments based on results of 1st measurement [Core 20(f) Interventions/Actions implemented based on results of 1st
& Core 20(h)]
measurement [Core 21(f)]
Date of 2nd
measurement
Summarize the results acheived utilizing statistical methodologies
Date results submitted to QMC
106
QMC comments based on results of 2nd measurement [Core
20(f) & Core 20(h)
Interventions/Actions implemented based on results of 2nd
measurement [Core 21(f)]
Periodic Measurements at least annually [Core 23(d)] and re-measurement for changes or improvements to baseline [Core
23(e)]
Date of Measurement
Result of Measurement
Date Reported to QM
Committee
Date of 3rd
Summarize the results acheived utilizing statistical methodologies
Date results submitted to QMC
Measurement
QMC comments based on results of 3rd measurement[Core 20(f)
& Core 20(h)
Date of 4th
Measurement
Interventions/Actions implemented based on results of 3rd
measurement [Core 21(f)]
Summarize the results acheived utilizing statistical methodologies
Date results submitted to QMC
Conducts an analysis if performance goals are not met [Core 23(f)]
Barriers Identified and Actions Taken
107
CUSTOMER SERVICES
Name of Project: (Core 20 (g), Core 23 (b)
Improving access to behavioral health information and services for Hispanic members by improving content available to members of this
population seeking such services.
Description and Background [Core 19, 20, 21]
The Hispanic/Latino population in North Carolina began growing in the early 1990’s and has grown an average of 13.5% per year. The Sandhills
Center services area counties have the following Hispanic/Latino populations: Harnett-11.7%, Hoke- 12.2%, Lee- 19.9%, Montgomery- 12%,
Randolph-10.9%. Moore, Anson, Guilford, and Richmond counties have a Hispanic/Latino population of 7.5% or less.
This population has special needs in accessing behavioral health services including :

Language barriers- this is a primary barrier, reading levels and availability of information must meet the population where they are.

Lack of familiarity with community resources and how to access them- information must be available in non-traditional sites (churches,
community centers) to be utilized.

Cultural beliefs- regarding mental health, intellectual developmental disabilities, and substance abuse issues may stigmatize those who
need or seek assistance. Culturally-informed assessment and treatment services increase the acceptance of professional assistance.

The stresses of immigration and acculturation- can lead to increased need for behavioral health services. Pressure to adopt values of the
new culture can make Hispanic/Latino youth especially vulnerable to depression and emotional distress. Factors of poverty,
discrimination, and inequality add this potent mix of stressors.
Sandhills Center manages the behavioral health services for the Medicaid population in a nine (9) county area. The Medicaid population for those
nine counties is 138,572 (2013). Of that number, 23,605 (11.80%) report as Hispanic/Latino. During 2013-14, 1,982 (5.88%) Hispanic/Latino
enrollees received a Medicaid behavioral health service. In contrast, the number for other Racial/Ethnic categories receiving services are; White=
20.19%, Black/African American= 14.80%, American Indian= 17.39%. These numbers demonstrate that the Hispanic/Latino population is
108
underrepresented in Medicaid enrollees receiving behavioral health services.
Sandhills CenterLME-MCO already offers a range of Spanish translations of materials for members, these include;

Member Handbook (English and Spanish versions)

Spanish language information on the Sandhills Center website

Translator services for callers to the 1-800 access line

Client rights pocket guide

Informational brochure

Business cards (includes 1-800 number)

A Spanish language version of the new enrollee education letter mailed within two weeks of enrollment
Describe the population affected by the Quality Improvement Project [Core 21(b)(i)(ii)(iii)(g)(h), Core 24(a),(b)]
The population affected by this project is Medicaid-funded Hispanic recipients seeking behavioral health information or services from
the Sandhills Center LME-MCO network.
Selection Process [Core 19(b), Core 20(g), Core 21 (a)(b)(i),(ii),(iii)(c)(d)(e)(f) and Core 23(a)]
This project was selected after a review of the Sandhills Center MCO 2013-2014 Provider capacity, Community Needs Assessment, and Gaps
Analysis Report.
This report reflects an under representation of Hispanic/Latino Medicaid clients receiving behavioral health services (chart, page 10: Ethnic
109
Categories Reported for Medicaid Enrollees that Received a MH/IDD/SAS Service).
During 2013-14, 1,982 (5.88%) Hispanic/Latino enrollees received a Medicaid behavioral health service. In contrast, the number for other
Racial/Ethnic categories receiving services are; White= 20.19%, Black/African American= 14.80%, American Indian= 17.39%. These numbers
demonstrate that the Hispanic/Latino population is underrepresented as compared to other racial/ethnic groups.
Relation to Modules under Review [Core 21 (a)(b)(i),(ii),(iii), Core 24(a)(b)]
HCC-10,11- Telephone performance monitoring and thresholds
HCC-13- Clinical staff response requirements
Core 27- Staff training
Core 28- Staff operational tools and supports
Core 34- Access to services
Date approved by the Quality Management Committee
[Core 20(g)]
Date of meeting minutes reflecting approval by Quality
Management Committee [Core 20(d)]
1/27/15
Time Frames [Core 23(c)]
February 1, 2015- January 30, 2016
1/27/15
Focus of Project [Core 24(a)(b)]
Will improved Spanish language content, staff training, and
outreach increase the number of Hispanic and Latino Medicaid
members receiving behavioral health services?
Baseline Measurement [Core 21(d)]
Anthony Carraway, MD, Medical Director/Chief Clinical Officer
This project was selected after a review of the Sandhills Center MCO 2013-2014 Provider capacity, Community Needs Assessment, and Gaps
Analysis Report. This report reflects an under representation of Hispanic/Latino Medicaid clients receiving behavioral health services (chart, page
10: Ethnic Categories Reported for Medicaid Enrollees that Received a MH/IDD/SAS Service). Hispanic/Latino Medicaid members received
services at a much lower rate than other racial/ethnic categories. During 2013-14, 1,982 (5.88%) Hispanic/Latino enrollees received a Medicaid
service. The number for other Medicaid Racial/Ethnic categories receiving services are; White= 20.19%, Black/African American= 14.80%,
110
American Indian= 17.39%. These numbers demonstrate that the Hispanic/Latino population is underrepresented in Medicaid enrollees receiving
behavioral health services.
The Hispanic population for the Sandhills Center service area is 10.04% of the total population (11.80% of the Medicaid population). Mental
health, developmental disabilities, and substance use disorders affect all racial/ethnic populations at an equal rate. Therefore, it is anticipated
that the need for behavioral health services in the Hispanic/Latino population should be about the same rate as other racial/ethnic populations.
Many Hispanic/Latinos with behavioral health needs do not turn to the resources in the community but instead rely on their extended family,
churches, or traditional healers. Tradition and cultural values play a role in this, but so does lack of information and awareness or community
services. This gap in information leads to thousands of Hispanic/Latinos going without professional assistance.
Since Hispanic/Latino enrollees face barriers to accessing behavioral health services including language, knowledge of resources, cultural beliefs
and values, there is a need for a special, focused effort to increase their access to these services.
Data Collection [Core 21(a),(b),(c) and Core 23(a)]
To measure the effectiveness of the interventions the following measurements will be made:
 The use of services by Hispanic/Latino will be measured by enrollment of members identified as Hispanic/Latino on the
Global Eligibility File (GEF). This report will be run two times per month to obtain data on new enrollees.
 Calls to the 1-800 access line where the caller identifies Hispanic/Latino as the ethnicity (calls per month).
 Use of language Spanish translation services by callers to the 800 line (requests per month).
 Number of visits to the Sandhills Center website when the visitor clicks on the Spanish language button (visits per month).
Measurable Goal(s) toward improvement [Core 23(a)]
The goals for this project are:

The number and percentage of Hispanic/Latino Medicaid enrollees receiving services will increase by 10% to 6.5% (as compared to 2013
data).
111



Callers identifying as Hispanic/Latino requesting information or services through the 1-800 access line will increase by 10% (as compared
to 4th quarter 2013-14) .
Visitors accessing the website and clicking on the Spanish language button will increase by 5% (over 4th quarter 2013-14).
Spanish language materials distributed to crisis providers and outpatient sites will be increased by 20% (over 4th quarter 2013-14).

Sandhills Center website Spanish language content will be increased by 20% (over existing content).
Projected Timeframe to Achieve Goals [Core 23(c)]
February 1, 2015- January 30, 2016 (one year).
Initial Interventions/Action Plans [Core 23 (b)(e)(f)]
Barriers Identified and Intervention/Action Taken
Barrier: There is a lack of culturally appropriate Spanish language informational materials available
at Sandhills Center network provider sites and the Sandhills Center website.
Date Implemented
4/1/15
Intervention: Review Sandhills Center website for Spanish content, reading level, and cultural
appropriateness. Update and improve where necessary.
Barrier: There is a lack of culturally appropriate Spanish language informational materials available at
Sandhills Center network provider sites and the Sandhills Center website.
Intervention: Spanish language materials will be reviewed for readability level and cultural
appropriateness and distributed to Sandhills Center crisis sites and outpatient services sites
Barrier: There is a lack of knowledge and skill for Call Center clinicians in the area of
Hispanic/Latino cultural competency, particularly in the area of Hispanic/Latino cultural beliefs and
values regarding behavioral health issues.
4/1/15
4/9/15
112
Intervention: Call Center clinical staff will receive cultural competency training on Hispanic/Latino
culture and values and beliefs regarding behavioral health issues.
Intervention: Identify network providers with enhanced capability to serve Hispanic/Latino enrollees
4/15/15
and provide additional written materials to them and ensure they are on the electronic scheduler for
appointments.
Additionally, collaboration with the CCNC and specialty medical services (esp. pediatrics) around
outreach, referrals, and care coordination for the Hispanic/Latino population.
Intervention: Work with Hispanic member(s) of the Consumer and Family Advisory Committee
6/1/15
(CFAC). To identify key sites in the Hispanic/Latino community to place behavioral health information
and strategies to engage Hispanic/Latino community stakeholders in outreach to persons in need of
behavioral health information and services.
113
Periodic Measurements at least annually [Core 23(d)] and re-measurement for changes or improvements to baseline [Core
23(e)]
Date of
Result of Measurement
Date Reported to QM
Measurement
Committee
Improving access to behavioral health information and services for
Hispanic Members
4/15/15
25
4/28/15
22
20
14
15
Language Line
10
New Enrollees
5
0
1st Quarter
2nd
Quarter
3rd Quarter 4th Quarter


Spanish translator requests since 2/1/15 = 14 callers
Client education letters to new enrollees (Spanish) = 22


New Call Center posters developed and distributed
Cultural awareness (behavioral health) training for Call Center clinical
staff done.
New (Spanish) version of handbook posted on website and in hard
copy.
List of providers with Spanish language capability developed and
distributed to Call Center staff.


114
QMC comments based on results of 1st measurement [Core 20(f) &
Core 20(h)]
Date of 2nd
measurement
Interventions/Actions implemented based on results of 1st
measurement [Core 21(f)]
Summarize the results acheived utilizing statistical methodologies
QMC comments based on results of 2nd measurement [Core 20(f) &
Core 20(h)
Date results submitted to
QMC
Interventions/Actions implemented based on results of 2nd
measurement [Core 21(f)]
Periodic Measurements at least annually [Core 23(d)] and re-measurement for changes or improvements to baseline [Core
23(e)]
Date of Measurement
Result of Measurement
Date Reported to QM
Committee
Date of 3rd
Summarize the results acheived utilizing statistical methodologies
Date results submitted to QMC
Measurement
QMC comments based on results of 3rd measurement[Core 20(f)
& Core 20(h)
Date of 4th
Measurement
Interventions/Actions implemented based on results of 3rd
measurement [Core 21(f)]
Summarize the results acheived utilizing statistical methodologies
QMC comments based on results of 4th measurement [Core
20(f) & Core 20(h)]
Date results submitted to QMC
Interventions/Actions implemented based on results of 4th
measurement [Core 21(f)]
Conducts an analysis if performance goals are not met [Core 23(f)]
Barriers Identified and Actions Taken
115
CUSTOMER SERVICES
Name of Project: (Core 20 (g), Core 23 (b)
Improve member’s access to care by ensuring follow through with routine and urgent scheduled appointments.
Description and Background [Core 22]
Improve the percentage of clients who attend/keep the appointment they are given after calling the toll free line and receiving a
Clinical Screening, and an appointment for services based on the triaged acuity level- urgent (within 48 hours) and routine (within 14
days).
Reducing the number of cancellations and no shows in this population is the overall goal of this project.
Describe the population affected by the Quality Improvement Project [Core 21(b)(i)(ii)(iii)(g)(h), Core 24(a),(b)]
All individuals who call Sandhills Center for MH, DD & SAS toll-free line and are triaged as either urgent (appointment scheduled
within 48 hours) or routine (appointment scheduled within 14 days).
Selection Process [Core 20(g), Core 21 (a)(b),(iii)(c)(d)(e)(f) and Core 23(a)]
Individuals triaged are given an appointment based on the clinical acuity of their situation. Mandatory reporting is required to the
Division of Mental Health, Developmental Disabilities and Substance Abuse services re: members in SHC catchment area access to
routine and urgent care. SHC has consistently failed to meet the State’s standard for the past three quarters which indicate a need for
improvement in these areas. Research supports that effectively engaging individuals at the onset diminish risk of further deterioration,
relapse and hospital readmission.
Relation to Modules under Review [Core 21(b)(i), Core 24(a)(b)]
Core 19: Regulatory compliance. This tracking and service access monitoring is required by Sandhills Center’s contract with
NCDMH. Core 25: Access to and monitoring of services. Tracking and monitoring of services is part of service monitoring for
effectiveness required for this high-risk member group. Core 29: Quality Management: Improving life outcomes for this member
group is the goal of this project.
116
Date approved by the Quality Management Committee
[Core 20(g)]
June 26, 2012
Time Frames [Core 23(c)]
July 1, 2012-January 31, 2013
Date of meeting minutes reflecting approval by Quality
Management Committee [Core 20(d)]
June 26, 2012
Focus of Project [Core 24(a)(b)]
Will accurate triage, barrier removal, and follow up calls increase
the number and percentage of members who keep their
assessment appointment?
Name of Senior Clinical Staff Person Involved [Core 24 (b)]
Anthony Carraway, MD
Baseline Measurement [Core 21(d)]
Sandhills Center is required to report client access information to the Division of MH,I/DD, and SAS. This information is complied in
the Community Systems Progress Indicator (CSPI) quarterly report. The State standard for Access to Care is Urgent: 82%, Routine:
71%. In the past three (3) quarters Sandhills Center has not met both standards.
 2011 4th quarter- Urgent- 73% Routine- 76% > one met
 2012 1st quarter- Urgent-76% Routine- 74% > one met
 2012 2nd quarter- Urgent- 77% Routine- 70% > none met
 2012 3rd quarter – Urgent- 76% Routine- 64% >none met
These numbers demonstrate a need to improve this area of access for client care. Keeping the initial appointment is the first step to
engagement in services. Clients who do not become engaged in services are at high risk to deteriorate and need a higher level of care.
Data Collection [Core 21(a),(b),(c) and Core 23(a)]
The Division of Health and Human Services of North Carolina set Statewide goals for the service system annually that reflect current
needs, priorities and available resources and attainable achievement standards for the year. The goal or performance standard-Access
to Routine/Urgent Care is based on recent Statewide averages. Mandatory reporting is required from all Statewide Local Management
Entities- Managed Care Organizations. Information is compiled, reviewed quarterly and measures are adjusted accordingly.
117
Currently, the performance measure for Access to Care Statewide is 71%-Routine and 82%-Urgent. The goal for SHC for the
measure is 84% Urgent and 73% Routine. Data will be compiled and analyzed on a monthly basis by using Sandhills Center Avatar
PM accessing STR (Screening Triage and Referral) Reports (Report # STR900). The monthly percentages are calculated by the
following equation:
“Number For Which Care was Provided Within Request”
“Total Number of STRs for Severity”
The above measure does not include “Number Offered But Declined Appointment Within Request.” This category includes
consumers that were offered one or more appointments at reasonable times within the target time frame but either: declined the offered
appointment for personal convenience or necessity and requested an appointment outside the target time frame, or were initially
scheduled for an appointment within the target time frame but later rescheduled it to a date/time outside the target time frame.
Measurable Goal(s) toward improvement [Core 23(a)]
Increase performance measures for the following: Access to Care-Urgent: 84%; Access to Care-Routine 73%.
Projected Timeframe to Achieve Goals [Core 23(c)]
July1, 2012 – January 31, 2013
Initial Interventions/Action Plans [Core 23 (b)(e)(f)]
Barriers Identified and Intervention/Action Taken
The initial interventions to be taken are; assure that the client is accurately categorized as Urgent or
Routine, during the clinical screening inquire about potential barriers or other issues that may interfere
with the client keeping the appointment (transportation, directions, child care, etc.) and offer possible
alternatives or resources.
List the 2nd interventions/action plan taken to improve performance.
List the 3rd interventions/actions taken to improve performance
Date Implemented
July 1, 2012
Date intervention/action
implemented
Date intervention/action
implemented
118
List the 4th interventions/actions taken to improve performance
List the 5th interventions/actions taken to improve performance
List the 6th interventions/actions taken to improve performance
List the 7th interventions/actions taken to improve performance
Date intervention/action
implemented
Date intervention/action
implemented
Date intervention/action
implemented
Date intervention/action
implemented
List the 8th interventions/actions taken to improve performance
December 2013- Call Center Staff retrained in:
Use of risk criteria
Practice in assigning risk level to cases
Disposition of cases
Date intervention/action
implemented
12/2013
List the 9th interventions/actions taken to improve performance
Date intervention/action
implemented
119
Download