Environmental Scan of MLTSS Quality Requirements in MCO Contracts

• The Medical Director/CMO is a state licensed physician who:
  • Is actively involved in all major clinical and QM components of the contract.
  • Oversees the QM/PI program monitoring and evaluation activities.
  • Serves as chair to quality oversight committees.
• The QM Coordinator is a state-licensed RN, physician or physician's assistant or is a CPHQ by the NAHQ and/or CHCQM by the American Board of Quality Assurance and Utilization Review Providers. The QM Coordinator must have experience in QM and QI. The primary functions of the QM Coordinator position are to:
  • Ensure individual and systemic quality of care.
  • Integrate quality throughout the organization.
  • Implement process improvement.
  • Resolve, track and trend quality of care grievances.
  • Ensure a credentialed provider network.
• The Performance/QI Coordinator has a minimum qualification as a CPHQ or CHCQM or comparable education and experience in data and outcomes measurement. The primary functions of the Performance/QI Coordinator are to:
  • Focus organizational efforts on improving clinical quality performance measures.
  • Develop and implement PIPs.
  • Utilize data to develop intervention strategies to improve outcomes.
  • Report QI/performance outcome.

The MCO must ensure that the QM/QI Unit within the organizational structure is separate and distinct from any other units or departments (e.g., Medical Management or Case Management units).

• Acknowledgement letter to the originator of the concern.
• Documentation of all steps utilized during the investigation and resolution process.
• Follow-up with the member to assist in ensuring immediate health care needs are met.
• Closure/resolution letter that provides sufficient detail to ensure that the member has an understanding of the resolution of their issue, any responsibilities they have in ensuring all covered, medically necessary care needs are met, and an MCO contact name/telephone number to call for assistance or to express any unresolved concerns.
• Documentation of implemented corrective action plan(s) or action(s) taken to resolve the concern.
• Analysis of the effectiveness of the interventions taken.

• Measurement of performance using objective quality indicators.
• Implementation of system interventions to achieve improvement in quality.
• Evaluation of the effectiveness of the interventions.
• Planning and initiation of activities for increasing or sustaining improvement.

PIPs are mandated but MCOs may select additional projects based on opportunities for improvement identified by internal data and information. Each PIP must be completed in a reasonable time period so as to generally allow information on the success of PIPs in the aggregate to produce new information on quality of care every year. MCO must submit PIP baseline, re-measurement and final reports to the state.

• Number of HCBS members x 2.0.
• Number of ALF members x 1.6.
• Number of ACO members x 1.0.
• Plus number of NF members x 0.8.

MCOs may assign a weighted value lower than those outlined.

• Measure and report to the state its performance using standard measures required by the state by CMS.
• Submit to the state data specified by the state that enables the state to measure the MCO's performance.

• Development and implementation of the quality strategy.
• Interface and support of the EQRO.
• Development of the MCO's annual written quality strategy (including objectives, scope, specific activities, and methodologies for continuous tracking, provide review and focus on health outcomes).
• Monitoring of the quality of care that MCO members receive and the review of all potential quality of care problems.
• Oversight of the development and implementation of continuous assessment and improvement of the quality of care provided to members.
• Clinical or health service areas to be monitored.
• Specification of quality indicators that are objective, measurable, and based on current knowledge and clinical experience for priority areas selected by the state and MCO.
• HEDIS standard.
• MCO's QM committee.

The MCO also must have a QM Committee that assists the coordinator in carrying out the quality strategy. The MCO must have policies and procedures that clearly define the roles, functions, and responsibilities of the QM committee and medical director. The Committee will have oversight responsibility and input on all QM activities.

• Unexpected death of a member.
• Suspected physical, mental or sexual abuse and/or neglect of a member.
• Theft or financial exploitation of a member.
• Severe injury sustained by a member.
• Medication error involving a member.
• Inappropriate/unprofessional conduct by a provider involving a member.

MCOs regularly identify, track, review and report (within 24 hours) CIs to the state. MCOs review and analyze CIs to identify and address potential and actual quality of care and/or health and safety issues. MCOs require providers involved in a CI to conduct an investigation and submit a report within the timeframe specified by the MCO. MCOs shall review provider reports and follow-up as necessary to ensure that an appropriate investigation was conducted and corrective actions were implemented within applicable timeframes. MCOs submit monthly reports to the state regarding all CIs.

• Grievance rate by medical nature of grievance.
• Number of provider complaints by nature of complaint and resolution.
• Number of families or caregivers of enrolled children with special health care needs from whom MCO has received a written complaint regarding accessibility or quality of services specified in the child's care plan.
• Number of appeals by medical nature of appeal and outcome.
• Analysis that identifies trends and/or patterns for administrative use and review including any corrective action taken as a result of the analysis.

• Access to care, quality of care, cost effectiveness, and effect of case management.
• The MCO's QA procedures, implementation of the procedures, and the quality of care provided.
• Consumer satisfaction surveys.

MCOs must identify, collect and provide any data or medical records to be reviewed by the independent assessors as requested. The monitoring and evaluation of MCOs will be conducted through periodic review of:

• Data and/or narrative reports describing clinical and related information on health services and outcomes of health care for the enrolled populations.
• Evaluation of encounters.
• On-site visits and inspection of facilities.
• Staff and member interviews.
• Appointment scheduling logs, ER logs, denial of services, and other areas that will indicate quality of care delivered to members.
• Medical records review of all quality strategy procedures, reports, and recommendation and corrective actions.
• Staff and provider qualifications.
• Grievance procedures and resolutions.
• Requests for transfer between PCPs within contractor's network.

• 1:120 for NF members.
• 1:60 for members receiving HCBS (own home or assisted living).
• 1:30 for members receiving services under the MFP program.

• At least every 180 days for a member in an institutional setting (this includes members receiving hospice services and those in uncertified institutional settings).
• At least every 90 days for a member receiving HCBS.
• At least every 90 days for a member residing in an alternative residential setting.
• At least every 90 days for a community-based member receiving acute care services only.

Acute care service monitoring for these members may be conducted on-site, via telephone or by certified letter. However, an on-site visit with the member must be completed at least once a year. MCOs may develop standards for more frequent monitoring visits of specific types of members/placements at their discretion but may not determine members to need less frequent visits.

• Investigate and resolve access and cultural sensitivity issues identified by the MCO, state, providers, advocate organizations, and members.
• Monitor MCO formal and informal grievances with the grievance personnel to look at trends or major areas of concern.
• Coordinate with schools, community agencies and state agencies providing services to members.
• Recommend policy and procedural changes to MCO management including those needed to ensure/improve member access to care and quality of care.
• Function as a primary contact for member advocacy groups and work with these groups to identify and correct member access barriers.
• Participate in local community organizations to acquire knowledge and insight regarding the special health care needs of members.
• Analyze systems functions through meetings with staff.
• Provide training and educational materials for MCO staff and providers to enhance their understanding of the values and practices of all cultures with which the MCOs interact.
• Provide input to MCOs on how provider changes affect access and quality/ continuity of care, and develop plans to minimize potential problems.
• Review all informational material to be distributed to members.
• Assist members and authorized representatives obtain medical records.

• Closure of subcontracted facilities due to license violations.
• Contractor or subcontractor financial concerns/difficulties.
• Loss or destruction of enrollee records.
• Compromise of data integrity.
• Fire or natural disasters.
• Critical issues or adverse incidents that affect the health, safety, and welfare of enrollees.

In the incident log, the MCO shall include a brief summary of the problem(s) and proposed corrective action plans and timeframes for implementation within a reasonable time after the incident is reported.

• 1 PIP must be a statewide collaborative PIP coordinated by the EQRO.
• 1 PIP must address deficiencies identified by the MCO through monitoring, performance measure results, member satisfaction surveys, or other similar means.
• Populations selected for study under the PIP must be specific to the enrollees in the MCO.

• Licensed Medical Director to oversee the quality of care furnished by the MCO and to ensure care is provided by qualified medical personnel. The Medical Director shall address any potential quality of care problems and direct quality activities. The Medical Director shall work closely with the State Medical Director and participate in quarterly state meetings, Provider Advisory Board meetings and any committee meetings relating to the programs when requested by the state.
• QM coordinator/director responsible for all QI activities. This person shall be a licensed physician or RN.
• Grievance coordinator to oversee all member grievance system activities. This person shall also be responsible for the provider complaints, grievance and appeals system. The MCO may choose to delegate this function to the provider services manager.
• Compliance officer responsible for all fraud and abuse detection activities, including the fraud and abuse compliance plan.

• Number of grievances and appeals by type.
• Type of assistance provided.
• Administrative disposition of the case.
• Overturn rates.
• Percent of grievances and appeals that did not meet timeliness requirements.
• Ratio of grievances and appeals per 100 members.
• Listing of unresolved appeals originally filed in previous quarters.

• Rate of acute hospital admissions.
• Rate of preventable hospital admissions (e.g., pneumonia, COPD, CHF, dehydration and urinary tract infection).
• Rate of NF admissions.
• Members discharged from a NF.
• Members residing in NFs.
• Rate of chronic hospital admission.

The contract specifies the following care coordination performance measures:

• New members who have met with their service coordinator.
• New members received an assessment and had a care plan developed.

The MCO must use the following performance standards to monitor the success of program implementation and must improve its performance measure outcomes from year to year. The state will set and provide the MCO with the performance standards annually on the following 3 levels:

• Minimum--Minimal expected level of performance.
• Goal--A reachable standard for a given performance measure.
• Benchmark--Ultimate standard to achieve.

The MCO must show demonstrable and sustained improvements toward meeting the state set performance standards. The state will require corrective action plans and may impose sanctions on the MCOs that do not meet the minimum performance standards and do not show significant improvement.

• Collaborate with the EQRO to assess the quality of care and services provided to members and identify opportunities for health plan improvement.
• Provide all requested program-related documents and data to the EQRO.
• Submit any corrective action plan(s) that address identified issues requiring improvement, correction or resolution to the state and the EQRO.

The EQRO will perform an annual independent review of the quality outcomes, timeliness of, and access to, services provided by the MCO that includes:

• Validation of PIPs.
• Validation of HEDIS performance measures required by the state.
• A review to determine the MCO's compliance with standards established by the state which requires a state quality strategy relating to access to care, structure and operations and quality assessment and improvement.

The EQRO will also perform the following optional activities:

• Administration and reporting the results of the CAHPS^® 3.OH Consumer Survey. The survey will be conducted annually, administered to an NCQA-certified sample of members enrolled in each MCO and analyzed using NCQA guidelines. The EQRO will provide an overall report of survey results to the state.
• Administration and reporting of the results of the provider satisfaction survey. The EQRO will assist the state in developing a survey tool to gauge PCPs' and specialists' satisfaction in areas such as how providers feel about managed care, how satisfied providers are with reimbursement, and how providers perceive the impact of health plan UM on their ability to provide quality care. The EQRO will provide the state with a report of findings including the raw data broken down by island. If the health plan scores low in certain areas, the state will require that the health plan initiate corrective action plans to resolve these areas of concern. The results of the provider survey will also be made available to providers.

• For non-NF LOC members, service coordinators may have up to 750 members (1:750). The assumption is that service coordinators will devote approximately 2.5 hours annually to each member in this category (1,880 hours/750 members = 2.5 hours).
• For NF LOC members residing in the community, service coordinators may have up to 50 members (1:50). The assumption is that service coordinators will devote approximately 37.6 hours annually to each member in this category (1,880 hours/50 members = 37.6 hours).
• For NF LOC members residing in an institutional setting, service coordinators may have up to 120 members (1:120). The assumption is that service coordinators will devote approximately 15.7 hours annually to each member in this category (1,880 hours/120 members = 15.7 hours).
• For members choosing self-direction, service coordinators may have up to 40 members (1:40). The assumption is that service coordinators will devote approximately 47 hours annually to each member in this category (1,880 hours/40 members = 47 hours).

If a mixed caseload is assigned to a care coordinator, the following formula shall be used in determining the service coordinator's mixed caseload:

• Number of non-NF LOC members X 2.5 hours +
• Number of NF LOC members residing in the community X 37.6 hours +
• Number of NF LOC members residing in an institutional setting X 15.7 hours +
• Number of members choosing self-direction X 47 hours = 1,880 hours or less.

• Increases the number of members receiving personal assistance services.
• Increases the number of members receiving HCBS per the annual thresholds.
• Increases its HCBS provider network.
• Does not have a waiting list.

• Evidence of the MCO's ability to expand capacity for personal assistance services.
• Evidence of the MCO's ability to expand capacity for HCBS.

The MCO shall annually report the need for assistance with ADLs for all members, by age and gender, and place of residence. This data will be collected in accordance with the MDS, and will include the number of members per 1,000 needing limited assistance and number of members per 1,000 needing extensive or total assistance with mobility, transfer, dressing, eating, toilet use, personal hygiene, or bathing. Each year, the MCO must submit a QAPIP description to the state which includes program goals, objectives, work plan, timetables for implementation and accomplishments. The report must include the previous year's QAPIP report along with UM program and evaluation reports. The MCO must also submit annually a QAPIP Evaluation, which details the activities during the previous year, analysis of the strengths and areas of improvement, a discussion of incorporating the strengths into the MCO's practices and a corrective action for each area of improvement. Semi-annually, the MCO must report performance measure statistics according to state requirements. On an annual basis, the MCO must report an evaluation of the performance measure activity from the previous calendar year. The MCO must submit the following reports related to LTSS utilization:

• Long-Term Care Services Report, which include performance measures on transfers to and from NF and community settings, acute care hospital administrations, access to ER services and those receiving supports through HCBS and institutional setting.
• Personal Assistance Services Report, which include names of members assessed to need personal assistance services and those assessed who are receiving the service.
• HCBS Report, which include members assessed to need HCBS and those assessed who are receiving the service.

• Age 19 and older.
• Non-Medicare eligible older adults and adults with disabilities receiving Medicaid (case numbers beginning with 01, 91, 02, 92, 03, 93) including all HCBS waiver enrollees.

• Be submitted to the state in writing and approved in writing by the state.
• Provide for prompt resolution.
• Assure the participation of individuals with authority to require corrective action.

MCOs must have a Grievance Committee for reviewing Grievances registered by its enrollees and enrollees must be represented on the Grievance Committee. At a minimum, the following elements must be included in the Grievance process:

• Informal process to handle grievances internally.
• Formally structured grievance system compliant with federal regulations, including an expedited process.
• Formally structured grievance committee that includes an enrollee.
• Final decision can be appealed to the department.
• Summary of grievances, responses and decisions submitted to the state quarterly.
• Enrollee can appoint someone to represent them throughout the grievance process.

The MCO shall have a full-time Compliance Officer who shall oversee the MCO's compliance plan and the complaint, grievance and fair hearing process, and ensure and verify that fraud and abuse is reported in accordance with the federal guidelines.

• 50:1 High risk enrollees identified as needing intensive Care Management services.
• 250:1 Moderate risk enrollees identified as needing supportive Care Management services.

• Conducting outreach and education about the development and purposes of the enrollee Care Plan.
• Assigning a Care Coordinator who has experience most appropriate to support enrollee.
• Using motivational interviewing techniques.
• Explaining alternative care options.
• Educating enrollee and caregivers about available resources.
• Developing an enrollee Care Plan.
• Providing the enrollee with a copy of the enrollee Care Plan.
• Coaching the enrollee to have constructive conversations with the enrollee's PCP.

If an enrollee is receiving medical care or treatment as an inpatient in an acute care hospital on the effective date of enrollment, the MCO is required to assume responsibility for the management of such care and shall be liable for all claims for covered services from that date. For hospital stays that would otherwise be reimbursed under the Medicaid Program on a per diem basis, the MCO's liability shall begin on the effective date of enrollment. Notwithstanding the foregoing, for hospital stays that would otherwise be reimbursed under the Medicaid Program on a DRG basis, the MCO will have no liability for the hospital stay.

• HRQ;
• Predictive Modeling and CORE;
• Surveillance Data.

• Maintenance in or movement to community living.
• Number of hospitalizations and length of hospital stay.
• Falls resulting in hospitalizations.
• Behavior resulting in injury to self or others.
• Enrollee non-compliance of services.
• Medical errors resulting in hospitalizations.
• Occurrences of pressure ulcers, weight loss, and infections.

• Children with autism;
• Children and adults with DD;
• People ages 16-64 with PD;
• Medically fragile children ages 0-22 dependent on intensive medical technology (TA);
• People ages 16-64 with TBI;
• People 65 and older who are functionally eligible for NF (FE);
• Children who are SED.

Per 2012 state legislation, HCBS for individuals with IDD are not to be provided under a managed care system until January 1, 2014. A pilot demonstration program will be developed for this population between January 1, 2013 and January 1, 2014.

• Management and integration of health care through primary provider/other means.
• Provision of systems to assure referrals for medically necessary, specialty, secondary and tertiary care and a person or entity formally designated as primarily responsible for coordinating the health care services furnished to the enrollee.
• Provision of systems to assure provision of care in emergency situations, including an educational process to help assure that members know where and how to obtain medically necessary care in emergency situations.
• Monitoring coordination of care among PCPs, specialists, behavioral health providers, and long-term care providers.
• Maintaining performance-based outcomes in NFs for care coordination including case management.
• Performing age and gender specific preventive health care management services in accordance with current best practices, having mechanisms to assess the quality and appropriateness of services furnished, and provide appropriate referral and scheduling assistance.
• Monitoring members with ongoing medical or behavioral health conditions.
• Identifying members using emergency department services inappropriately to assist in scheduling follow-up care with PCPs and/or appropriate specialists to improve continuity of care and establish a medical home.
• Maintaining and operating a formalized hospital and/or institutional discharge planning program.
• Coordinating hospital and/or institutional discharge planning that includes post-discharge care, as appropriate.
• Maintaining an internal tracking system that identifies the current preventive services screening status and pending preventive services screening due dates for each member.

There are also special requirements for care coordination for members with complex needs. The state intends to procure services that promote patient-centered care and improve health outcomes for the entire population, but particularly for high risk, high service utilizes and other high cost individuals with complex needs.

• Information provided to beneficiaries;
• Grievances;
• Timely access;
• Coordination/continuity;
• Quality of care.

The data are used to monitor the above topics by obtaining information from the members, resolving issues, identifying and addressing trends. If deficiencies are noted the MCO must perform corrective action until compliance is met. A grievance may be received by telephone, voice mail, e-mail, written communication or by a person. The MCO is responsible for documenting, investigating and resolving all grievances in a courteous and prompt manner. The MCOs shall establish an internal grievance and appeal process to identify record, investigate, resolve and report grievances. The grievance process must be in full compliance with all applicable state and federal laws and shall not supplant, delay, or hinder the fair hearing/appeal process. MCOs must provide a system to track and document all grievances. The grievance tracking system shall provide operational and management information at various levels, show resolution, measure and track timeframes, allow referrals to other entities and allow inquiry into multiple fields. MCOs shall also develop a database extract file that can be imported into the state fiscal agent's grievance database.

• Children with autism;
• Children and adults with DD;
• People ages 16-64 with PD;
• Medically fragile children age 0-22 dependent on intensive medical technology (TA);
• People ages 16-64 with TBI;
• People 65 and older who are functionally eligible for NFs (FE);
• Children who are SED.

Similar HCBS waiver performance measures in the domains of access, eligibility, POC development, choice, health and welfare, financial accountability and customer satisfaction are required for each of the populations. Additionally, LTSS-specific performance measures include the following:

• Percentage of members reporting their physical health as good within 1 standard deviation of the mean.
• Percentage of members reporting they are connected to the people who support them the most within 1 standard deviation of the mean.
• Percentage of members reporting they are doing what they want for their work within 1 standard deviation of the mean.
• Percentage of adults with an SPMI who report having a place to live that is comfortable for them.
• Percentage of re-admissions at 30 days, 90 days and 1 year from last discharge from:
  • State MH hospitals, alternatives to state MH hospitals, and Medicaid-funded community hospital psychiatric inpatient programs for children and youth;
  • State MH hospitals and Medicaid-funded community hospital inpatient programs for adults;
  • NFs for MH;
  • Psychiatric residential treatment facilities.
• Average Length of Stay for youth admitted to psychiatric residential treatment facility will be 100 days or lower.
• The MCO will ensure providers offer timely initial appointments. 85% of members will be offered an initial appointment within 10 calendar days.
• The MCO will maintain the following access standards for screening for institutional care:
  • Post-stabilization 1 hour within 1 hour from initial contact to arrival of provider in an ER;
  • Emergent immediate within 1 hour urgent 24 hours from referral.
• The MCO will ensure that 95% of appeals are resolved as expeditiously as the member's health condition requires.

• Provide the state with an independent assessment of the quality of care delivered to members.
• Resolve identified problems or contribute to improving the care of all members.
• Measure MCO compliance with contract requirements.

MCOs are required to provide full co-operation with the EQRO to assure quality and accessibility of health care in the appropriate setting to members including the validation of PIPs and performance measures.

• Total cholesterol level;
• HDL cholesterol level;
• LDL cholesterol level;
• TC/HDL ratio;
• Triglycerides;
• Glucose level;
• Blood pressure check;
• Waist circumference measurement;
• Height measurement;
• BMI calculation;
• Depression screening;
• Identification of allergy history;
• Medication use discussion;
• Complete age-appropriate EPSDT screenings.

Information collected shall also include demographic information and current health and behavioral health status to determine the need for care management, behavioral health services, or any other health or community services.

• Timely claims processing;
• Encounter data submission;
• Credentialing;
• Grievances;
• Appeals;
• Customer Service.

Different measures from service data are used for years 2 and 3. MCOs who believe they can exceed the acceptable benchmark standard will be provided an opportunity to create and present additional performance targets and appropriate incentives. The state hopes to add measures which focus on patient outcomes, health and functional status. The state is particularly interested in measures which address smoking cessation and obesity rates. Any plan for additional incentives must be submitted by the MCO and the state reserves the right to accept, reject, or modify any additional incentive plan proposed by an MCO. Measures related to the HCBS waiver for individuals with IDD will be developed by the state with MCO input and will be allowed to have an additional year of benchmarking.

• SCO Director--Oversees all activities by the SCO and its subcontractors, including but not limited to, coordinating with the SCO's QM director, medical director, geriatrician, and behavioral health clinician.
• QM Director--An identified senior level director to oversee all QM and performance improvement activities.
• Medical Director--A licensed medical director with geriatric expertise and experience in community and institutional long-term care who will be responsible for establishing medical protocols and practice guidelines to support the program.
• Geriatrician--A licensed geriatrician who will be responsible for establishing and monitoring the implementation and administration of geriatric management protocols to support a geriatric model of practice.
• Behavioral Health Clinician--A qualified behavioral health clinician, with expertise in geriatric service, who will be responsible for establishing behavioral health protocols and specialized support to PCPs and PCTs.

• Mechanisms for detecting under utilization and over utilization of services.
• Resource utilization of services, including specialty and ancillary services.
• Clinical performance measures on structure, process, and outcomes of care.
• IDT performance, including resolution of SP disagreements.
• Enrollee experience and perceptions of service delivery.
• Timely access.

• Enrollee may file an internal appeal within 60 days of the receipt of the written denial notice. Enrollee must exhaust internal appeal processes before they go to external appeal by the CMS Independent Review Entity. An enrollee may also request and external review by the State Board of Hearings.
• On a monthly basis, the SCO must report the number and types of complaints filed by enrollees specifying how and in what timeframes they were resolved. The MCO must cooperate with the state to implement improvements based on the findings of these reports.
• The SCO must report the number, types, and resolutions of appeals filed, including, for external appeals, whether the external review was by the CMS Independent Review Entity or by the State Board of Hearings.

• Individualized POC.
• Generating or receiving referrals and recording and tracking the results of referrals.
• Providing or arranging for second opinions.
• Sharing clinical and individualized POC information.
• Determining conditions and circumstances under which specialty services will be provided.
• Tracking and coordination of enrollee transfers from 1 setting to another.
• Obtaining and sharing individual medical and care planning information among the enrollee's caregivers in the provider network.

• Quality and performance indicators including:
  • Information on enrollee satisfaction;
  • Availability, accessibility, and acceptability of services;
  • Information on health outcomes and other performance measures.
• Information about enrollee appeals and their disposition.
• Member experience of care.

The SCO must conduct 1 survey or focus group with each of the following groups:

• Non-English speaking enrollees to assess their experience with the contractor's ability to accommodate their needs.
• Persons with PD to assess their experience with the SCOs ability to meet their needs.
• Enrollees from a minority ethnic group served by the SCO to assess their experience with the SCO's ability to provide culturally sensitive care and support to family members and caregivers of enrollees.
• Family members and significant caregivers of enrollees to assess the SCO's ability to support family members and significant others.

• Clinical data including specific HEDIS measures and state specific measures regarding preventive medicine, acute and chronic disease, and enrollees diagnosed with dementia.
• Complaints and appeals.
• Disenrollment rate.
• Annual report of voluntary enrollment rate and reasons.
• Annual reports on rates of preventable hospitalizations, admissions and discharges from nursing homes facilities.
• Community health service utilization in units and per 1,000 enrollees for services such as personal care, hospice and adult day care.

• As a member of the PCT, participate in Initial and Ongoing Assessments of the health and functional status of enrollees.
• Arrange, coordinate and authorize the provision of appropriate community long-term care and social support services.
• Monitor the appropriate provision and functional outcomes of community long-term care services.
• Track the appropriate provision and functional outcomes of community long-term care services.

• Minimize unnecessary or inappropriate hospital admissions.
• Ensure that enrollees who are admitted to an institution receive the Interdisciplinary Discharge Planning and implementation processes that begin at the point of admission to the hospital or NF.
• Provide cancer screening services, and the provision of appropriate follow-up services.
• Provide DM activities (for enrollees identified with CHF, COPD, diabetes).
• Manage the care for enrollees identified with dementia.
• Prevent, identify, and treat alcohol abuse.
• Prevent and treat abuse and neglect of enrollees and report incidents and actions taken.

• Suicide;
• Non-suicide death;
• Emergency Medical treatment due to Injury or Medication Error;
• Hospitalization due to Injury or Medication Error;
• Arrest of Consumer.

CIs must be reported within 60 days after the end of the month in which the event occurred, except for suicide. If 90 calendar days have elapsed without a determination of cause of death, the PIHP must submit a "best judgment" determination of whether the death was a suicide. PIHPs must notify the state immediately of deaths that occur as a result of a suspected staff member action or inaction, or any death that is the subject of a recipient rights, licensing, or police investigation. Reports must be submitted electronically within 48 hours of either the death, or the PIHP's receipt of notification of the death, or the PIHP's receipt of notification that a rights, licensing, and/or police investigation has commenced. The PIHP or its delegate is responsible for implementing the process of the review and follow-up of sentinel events (not specified in the contract) and other CIs and events that put people at risk of harm. The PIHP or its delegate has 3 business days after a CI occurs to determine if it is a sentinel event. If the CI is classified as a sentinel event, the PIHP or its delegate has 2 business days to commence a root cause analysis of the event. Persons involved in the review of sentinel events must have the appropriate credentials. Mortality Reviews--All unexpected deaths (suicides, homicides, deaths experienced by person having an undiagnosed condition, accidental deaths, deaths where there is suspicion of abuse or neglect) must be reviewed. The review includes:

• Screens of individual deaths with standard information (e.g., coroner's report, death certificate).
• Involvement of medical personnel in the mortality reviews.
• Documentation of the mortality review process, findings, and recommendations.
• Use of mortality information to address quality of care.
• Aggregation of mortality data over time to identify possible trends.

Risk Event Management--The PIHP must have a process for analyzing additional critical events that put individuals at risk of harm. This analysis is used to determine what action needs to be taken to remediate the problem or situation and to prevent the occurrence of additional events and incidents. The state will request documentation of this process when performing site visits. These events include:

• Actions taken by individuals who receive services that cause harm to themselves.
• Actions taken by individuals who receive services that cause harm to others.
• 2 or more unscheduled admissions to a medical hospital within a 12-month period.

Restrictive Interventions--On a quarterly basis, the PIHP is required to review data from a Behavior Treatment Review Committee (part of the local MH agency) where intrusive or restrictive techniques have been approved for use with beneficiaries and where physical management or 911 calls to law enforcement has been used in an emergency behavioral crisis. Only the techniques permitted by the Technical Requirement for Behavior Treatment Plan Review Committees and that have been approved during person-centered planning by the beneficiary or his/her guardian, may be used with beneficiaries. Data must include:

• Dates and numbers of interventions used.
• Settings (e.g., individual's home or work) where behaviors and interventions occurred.
• Observations about any events, settings, or factors that may have triggered the behavior.
• Behaviors that initiated the techniques.
• Documentation of the analysis performed to determine the cause of the behaviors that precipitated the intervention.
• Description of positive behavioral supports used.
• Behaviors that resulted in termination of the interventions.
• Length of time of each intervention.
• Staff development and training and supervisory guidance to reduce the use of these interventions.
• Review and modification or development of the individual's behavior plan.

The purpose of the Behavior Treatment Review Committee is to review and approve/disapprove any plans that propose to use restrictive or intrusive interventions with individuals served by the public MH system who exhibit seriously aggressive, self-injurious or other challenging behaviors that place the individual or others at imminent risk of physical harm.

• Percent of all Medicaid adult and children beneficiaries receiving a pre-admissions screening for psychiatric inpatient care for whom the disposition was completed within 3 hours. Standard = 95% in 3 hours.
• Percent of new Medicaid beneficiaries receiving a face-to-face meeting with a professional within 14 calendar days of a non-emergency request for service (MI adults, MI children, DD adults, DD children, and Medicaid SA). Standard = 95% in 14 days.
• Percent of new persons starting any needed ongoing service within 14 days of a non-emergent assessment with a professional (MI adults, MI children, DD adults, DD children, and Medicaid SA). Standard = 95% in 14 days.
• Percent of discharges from a psychiatric inpatient unit who are seen for follow-up care within 7 days. (All children and all adults (MI, DD) and all Medicaid SA (sub-acute detox discharges.)
• Percent of Medicaid recipients having received PIHP managed services (MI adults, MI children, DD adults, DD children, and SA).

ADEQUACY/APPROPRIATENESS PERFORMANCE MEASURES

• Percent of HSW enrollees during the quarter with encounters in data warehouse who are receiving at least 1 HSW service per month that is not supports coordination.

EFFICIENCY PERFORMANCE MEASURES

• Percent of total expenditures spent on managed care administrative functions for PIHPs.

OUTCOMES PERFORMANCE MEASURES

• Percent of adult Medicaid beneficiaries with mental illness and the percent of adult Medicaid beneficiaries with DD served by PIHPs who are in competitive employment.
• Percent of adult Medicaid beneficiaries with mental illness and the percent of adult Medicaid beneficiaries with DD served by PIHPs who earn state minimum wage or more from employment activities (competitive, self-employment, or sheltered workshop).
• Percent of MI/DD children and adults readmitted to an inpatient psychiatric unit within 30 days of discharge. Standard = 15% or less within 30 days.
• Annual number of substantiated recipient rights complaints per thousand Medicaid beneficiaries with MI and with DD served, in the categories of Abuse I and II, and Neglect I and II.
• Percent of adults with DD served, who live in a private residence alone, or with spouse or non-relative.
• Percent of adults with serious mental illness served, who live in a private residence alone, or with spouse or non-relative.
• Percent of children with DD (not including children in the Children's Waiver Program) in the quarter who receive at least 1 service each month other than case management and respite.

PASRR-RELATED PERFORMANCE MEASURE

• PIHPs must also meet a standard of 100% whereby people who meet the OBRA Level II Assessment criteria for specialized MH services for people residing in nursing homes, as determined by MDCH shall receive PIHP managed MH services.

ADDITIONAL PERFORMANCE MEASURES

• An increased number of Medicaid children (birth through age 17 years) with SUD per 1,000 in the PIHP service area who are provided Medicaid SA specialty services and supports.
• An increased number of Medicaid adults (age 18 and older) with SUD per 1,000 in the PIHP service area who are provided Medicaid SA specialty services and supports.
• An increased percentage in FY 2011 Medicaid expenditures over the base year of FY 2006 Medicaid expenditures for children and adults with SUD.

For the following measures, each PIHP must negotiate its individual performance targets. A baseline for FY 2006 will be established. For FY 2008 no sanctions will be imposed for failure to reach target. In future years, P4P will be imposed, with the details of the P4P arrangement negotiated between state and the PIHP and included in subsequent contract amendments.

• An increased number of Medicaid children per 1,000 Medicaid-eligible children in the PIHP service area who are provided Medicaid MH specialty services and supports.
• For children with SED and DD/SED co-occurring conditions, an increased number of Medicaid children per 1,000 Medicaid-eligible children in the PIHP service area who are provided Medicaid MH specialty services and supports.
• For children with DD, an increased number of Medicaid children per 1,000 Medicaid-eligible children in the PIHP service area who receive MH specialty services and supports.

• Number of enrollees engaged in meaningful employment.
• Number of enrollees served that are living in a private residence not owned by the PIHP or the contracted provider, either alone or with spouse or non-relative.
• Number of enrollees discharged from a SA detox unit and seen for follow-up within 7 days.

In order to be eligible for the award, a PIHP must not have received a non-compliance score for any site review dimension in their site review report.

• The MCO shall adopt a uniform credentialing and re-credentialing process and comply with that process consistent with state regulations and current NCQA "Standards and Guidelines for the Accreditation of Health Plans".
• For organizational providers, including NFs, hospitals, and Medicare certified home health care agencies, the MCO shall adopt a uniform credentialing and re-credentialing process and comply with that process consistent with state regulations.

• A document describing how case management is being provided for community and nursing home members by county and population group including whether it is provided through contracts with local agencies or tribes, clinic or provider care systems, community agencies, health plan staff or other arrangements or through a combination of such arrangements.
• The most recent SNP model of care as submitted to CMS.
• Lists and descriptions of entities providing Care Coordination and Case Management contractors, duties of such entities or subcontractors, contracting and delegation arrangements.
• A description of Care Coordination and/or Case Management screening and assessment tools, timelines and follow-up processes.
• A description of use of protocols for management of chronic conditions including procedures for communication with clinics and physicians.
• A description of use of Nurse Practitioners in the care of NF residents if applicable.
• A description of the MCO's oversight and training of subcontractors and Care Coordinators/Case Managers, qualifications and caseloads/ratios of Care Coordinators/Case Managers.
• Changes and updated descriptions provided annually.

• Collect data on enrollee and provider characteristics, and on services furnished to enrollees.
• Ensure that data received from providers is accurate and complete by:
  • Verifying the accuracy and timeliness of reported data;
  • Screening or editing the data for completeness, logic, and consistency;
  • Collecting service information in standardized formats to the extent feasible and appropriate.
• Make all collected data available to the state and CMS upon request.

• Assure compliance with Medicare and Medicaid requirements.
• Preserve enrollees' access to all appropriate levels of Medicare and Medicaid appeals.
• To the extent possible, integrate both processes to make the system easier to navigate for the MSHO enrollee.
• MCO must maintain and make available upon request by the state its records of all Grievances, DTRs, Appeals and state Fair Hearings to include the following reports:
  • Quarterly electronic report of all oral and written Grievances;
  • Quarterly DTR of Service Notice report;
  • Quarterly electronic report of all oral and written Appeals.

The Grievance System must meet requirements of state statutes. Any proposed changes to the Grievance System must be approved by the state prior to implementation.

• Meeting with the EQRO and responding to questions.
• Providing requested medical records and other data in the requested format.
• Providing copies of MCO policies and procedures, and other records, reports and/or data necessary for the external review.

To avoid duplication, the state may use information collected from Medicare or private accreditation reviews in place of a Medicaid review by the state, its agent, or EQRO. The MCO may request an exemption to the EQRO requirements from the state if the MCO meets federal requirements and is approved by the state and CMS. The state shall allow the MCO to review a final draft copy of the EQRO Annual Technical Report prior to the date of publication. The MCO shall provide the state any written comments about the report, including comments on its scientific soundness or statistical validity, within 30 days of receipt of the final draft report. The state will include a summary of the MCO's written comments in the final publication of the report and may limit the MCO's comments to the report's scientific soundness and/or statistical validity. The MCO is required to effectively address recommendations for improving the quality of health care services made by EQRO in the Annual Technical Report for obligations under the contract.

• Non-English speaking or need for translation.
• Case-mix.
• Need for high intensity acute Care Coordination.
• MH status.
• Travel time.
• Lack of family or informal supports.

• Specific provider measures.
• Completion of and submission to state of the Care Plan audit.
• Timely completion of initial health risk screening or assessments.

In addition, the MCO is required to cooperate with the state to develop and implement a P4P model for chronic disease care. The state pays the incentive payments to the MCO based on criteria established by the state. The MCOs pay the state's program administrator (private vendor) the same incentive reward payment. The program administrator then distributes the appropriate payment to the eligible MCOs based on their performance. In order to receive the annual reward, the MCO contracted clinic or medical group must have achieved optimal chronic disease care for a designated percentage of its patients, as determined by the Program Administrator. The P4P projects are limited to diabetes care and coronary/vascular disease care.

• Is in good standing with state and federal regulatory bodies.
• Has been reviewed and approved by an accrediting body.

The MCO must also develop and implement standards of participation that demonstrate the provider is in compliance with provider participation requirements under federal law and regulations if the provider has not been approved by an accrediting body. The state and the MCO shall mutually agree to a single primary source verification entity to be used by the MCO and its subcontractors in its provider credentialing process. All MCOs shall use 1 standardized credentialing form. The state shall have the right to mandate a standard credentialing application.

• Utilize the report formats provided by the state and provide monthly analysis report findings.
• Utilize critical indicator monitoring for early identification and interventions of quality of care and/or health and safety issues.
• Analyze the data including the identification of any significant trends.
• Address negative trends in the analysis and develop appropriate CQI initiatives.
• Conduct annual provider reviews of all network providers on data collected on medication management to identify harmful practices.

• Acute and long-term health and social service delivery and coordination.
• Scope of the objectives, projects, or activities planned, timeframes and data indicators for tracking performance.
• PIPs, plans and activities consistent with federal and state laws and regulations.
• At least 1 member safety indicator.
• Institute QM/QI policies and procedures that emphasize and promote wellness and prevention, DM of chronic illnesses, and complex service coordination.

The MCO must also submit an annual program evaluation of overall effectiveness to demonstrate improvements in the quality of clinical care and service to its members that includes the following:

• Goals, objectives and structure, and that result in CQI for members.
• Description of ongoing and completed QI activities.
• Trending of measures to assess performance in quality of clinical care and service.
• An analysis of whether or not there have been demonstrable improvements in the quality of clinical care and service.
• Incorporation of findings of overall effectiveness in the development of the following year's plan.
• Protocols for working with school age members.
• Member and network provider satisfaction surveys and other relevant member and family/caregiver surveys.
• DM protocols.
• Continuity and coordination of services.
• Tracking and trending of member and provider grievances for early identification and resolution of systems' issues and potential trends.
• Service coordination protocols that reflect their comprehensive needs and SP priorities, including coordination and integration of home and community-based waiver services.
• Provide quality oversight of ALFs.

• Monitor the plan reporting obligations and ensure that the required reports are accurate and submitted in a timely manner.
• Develop written policies, procedures and standards of conduct that articulate the plan commitment to adhere to all applicable federal and state standards.
• Conduct appropriate staff training activities in an atmosphere of open communication.
• Establish provisions for internal monitoring and auditing.
• Have provisions for prompt responses to detected offenses with provisions for corrective action initiatives where appropriate.

The MCO must establish a review committee(s) to:

• Evaluate data collected pertaining to quality indicators, performance standards, and client satisfaction.
• Make recommendations to the board regarding the process and outcomes of the QA and performance improvement program.
• Provide input related to processes to evaluate ethical decision-making including end-of-life issues.

Policies and procedures of the review committee should:

• Define qualifications of individuals participating on the committee(s).
• Include a method for identifying, selecting and reviewing data and information to be used in the QA and performance improvement program.
• Integrate the findings of the grievance and appeals process.
• Define a process for recommending appropriate action to resolve problems identified as part of QA and improvement activities including:
  • Providing feedback to appropriate staff and subcontractors for monitoring effectiveness of corrective actions taken, for reporting QA/PI findings to the board on at least an annual basis.
  • Incorporating review of the care delivery process to include appropriate clinical professionals and paraprofessionals as well as non-clinical staff as appropriate.

• That the credentials of affiliated professionals or other health care providers will be reviewed directly by the MCO or the credentialing process of the provider will be reviewed and approved by the MCO and the MCO must audit the credentialing process on an ongoing basis.
• How the provider shall participate in the MCO's QA, service authorization and grievance and appeals processes, and the monitoring and evaluation of the MCO's plan.

• Timeliness of receipt of covered services.
• Quality indicators that are objective, measurable and related to the entire range of services provided by the MCO and which focus on potential clinical problem areas (high volume service, high risk diagnoses or adverse outcomes).

The methodology should assure that all care settings (e.g., day center, nursing home and in-home settings) will be included in the scope of the QA and performance improvement program.

• Establish, maintain and comply with written procedures and a comprehensive grievance system for:
  • Services that are a Medicare only benefit;
  • Services that are covered under both Medicare and Medicaid.
• The grievance system must meet requirements of state statutes.
• Any proposed changes to the grievance system must be approved by the state prior to implementation.

The MCO must report the following with regard to its grievance system:

• Quarterly summary of all complaints and action appeals.
• Quarterly report on the total number of complaints and action appeals that have been unresolved for more than 45 days.
• Quarterly summary of all grievance and appeals received.
• Quarterly report on the total number of grievance or appeals that have been unresolved for more than 30 days.

• Length of time to respond to requests for referrals.
• Timeliness of receipt of covered services.
• Timeliness of implementation of care plan.
• Telephone consultation to assist enrollees in obtaining health information and urgent care on a 24 hour basis.

Quality indicators that are objective, measurable and related to the entire range of services provided by the MCO and focus on potential clinical problem areas (high volume service, high risk diagnoses or adverse outcomes). The methodology should assure that all care settings (e.g., day center, nursing home and in-home settings) will be included in the scope of the QA and performance improvement program.

• Eligibility for nursing home LOC at the time of enrollment.
• At the time of enrollment, ability of returning to or remaining in their home and/or community without jeopardy to their health and/or safety, based upon criteria provided by the state.
• Expectation that applicant requires at least service and care management for at least 120 days from the effective date of enrollment.

• Establish mechanisms to ensure that providers comply with the timely access requirements appointment availability and appointment wait times.
• Monitor providers regularly to determine compliance.
• Take corrective action if a provider fails to comply.

LME-MCOs shall measure the performance of providers and conduct peer review activities such as identification of practices that do not meet plan standards, recommendation of appropriate action to correct deficiencies and monitoring of corrective action by providers. LME-MCOs shall also measure provider performance through medical record audits, provide performance feedback to providers, including detailed discussions of clinical standards and the expectations of LME-MCO; develop and adopt clinically appropriate practice parameters and protocols/guidelines and provide LME-MCO's providers enough information about the protocols/guidelines to enable them to meet the established standards.

• Be available 24 hours per day, 7 days per week, to perform telephone assessments and crisis intervention.
• Determine which behavioral health services are medically necessary.
• Perform quality monitoring of the behavioral health services provided to enrollees.
• Coordinate and monitor behavioral health hospital and institutional admissions and discharges including discharge planning.
• Ensure the coordination of care with each enrollee's primary care and behavioral health providers.

• Be approved in writing by the state.
• Provide for prompt resolution of enrollee grievances and appeals.
• Assure the participation of individuals with the authority to require LME-MCO to take corrective action when appropriate.

In addition LME-MCOs shall:

• Use grievance and appeal data for QI and shall report enrollee grievances and appeals to the state by number, type, and outcome by no later than 45 calendar days after the end of each quarter of the state fiscal year.
• Attend state training on the enrollee appeal process.
• Use state standardized letters to notify recipients of their rights to appeal.
• Provide quarterly report on grievance and appeals.

• Medicaid:
  • Finance Management;
  • Behavioral Health, Clinical Policies and Programs;
  • QEHO;
  • Waiver Development;
  • Budget Management;
  • Program integrity;
  • IT.
• DMH/DD/SAS:
  • Best Practice;
  • Financial Operations;
  • LME System Performance Team;
  • QM;
  • Accountability;
  • Advocacy and Customer Service;
  • IT.
• LME-MCO:
  • Management;
  • Finance;
  • Information System;
  • Operations (Access, Network, Waiver Implementation);
  • Quality.
• State:
  • Office of the Controller;
  • Office of Budget and Analysis.

• Health and safety.
• Choice.
• Quality of the SP.
• Provider remediation, compliance, standards, enrollment and capacity.
• LOC process and instrument.
• Slot transfer and tracking.

The following measures are specific to individuals with a primary diagnosis of MI or SA. Effectiveness of care measures:

• Follow-up after hospitalization for mental illness (HEDIS).
• 30 day readmission rates for MH hospitalization.
• 30 day readmission rates for SA hospitalization.
• Ambulatory follow-up within 7 and 30 calendar days of hospital discharge for SA therapy.
• Ambulatory follow-up within 7 and 30 calendar days of discharge for MH.

Access and Availability:

• Initiation and engagement of alcohol and other drug dependence treatment (HEDIS).
• Call answer timeliness (HEDIS).
• Call abandonment (HEDIS).
• Number and percent of requests for authorization that were denied by LME-MCO.
• Number and percent of services rendered by an out of network provider.

Use of Services:

• MH Utilization--Inpatient discharges and average length of stay (HEDIS).
• MH Utilization--Percentage of members receiving inpatient, day/night care, ambulatory and other support services (HEDIS).
• Chemical Dependence Utilization--Inpatient discharges and average length of stay (HEDIS).
• Chemical Dependency Utilization--Percentage of members of receiving inpatient, day/night care, ambulatory and other support services.
• Integrated Care--For adults, reports the percentage of enrollees who had an ambulatory or preventative care visit during the measurement year. For children and adolescents, reports the percentage that had a visit with a PCP.

LME-MCOs are required to implement a total of 3 PIPs over the 2 years of the contract. During year 1, the LME-MCO shall implement 2 PIPS, 1 clinical and 1 non-clinical. Appropriate topics for PIPs include:

• Primary, secondary and/or tertiary prevention of acute mental illness conditions.
• Primary, secondary and/or tertiary prevention of chronic mental illness conditions.
• Care of acute mental illness conditions.
• Recovery/outcome measures.
• Care of chronic mental illness conditions.
• High volume services.
• High risk services.
• Continuity and coordination of care.
• Availability, accessibility, and cultural competency of services.
• Quality of provider/patient encounters.
• Appeals and grievances.

• Determining LME-MCO compliance with federal Medicaid managed care regulations.
• Validation of performance measures produced by LME-MCOs.
• Validation of PIPs undertaken by LME-MCOs.

CMS-published protocols shall be utilized by the EQRO. In addition, based on the availability of encounter data, the EQRO shall conduct encounter data validation per the CMS protocols. The LME-MCO is required to address the EQRO findings.

• If behavioral health needs are predominant, the LME-MCO is responsible for care coordination.
• If physical health needs are more pressing then CCNC is to provide care coordination.

The LME-MCO shall ensure the coordination of care with each enrollee's PCP/Health Home. The LME-MCO shall encourage, support and facilitate communication between PCPs and behavioral health providers regarding medical management, shared roles in the care and crisis plan, exchange of clinically relevant information, annual exams, coordination of services, case consultation and problem solving as well as identification of medical home for persons determined to have need. (The LME-MCO shall conduct at least 1 coordination meeting per month). The LME-MCO shall also ensure acute care coordination through the following mechanisms:

• LME-MCOs have the responsibility to provide feedback to the referring source on all referrals.
• LME-MCOs shall conduct at least 1 meeting per month to facilitate communication.
• LME-MCOs shall provide follow-up activities to:
  • High risk enrollees who do not appear for scheduled appointments;
  • Enrollees for whom a crisis service has been provided as the first service to facilitate engagement with ongoing care;
  • Individuals discharged from 24 hour care.

LME-MCOs shall ensure that each enrollee's privacy is protected in accordance with state and federal law.

• Developing mechanisms for collecting and evaluating information, identifying problems, formulating recommendations, disseminating information.
• Implementing corrective actions and evaluating the effectiveness of action taken.
• Reviewing annually and making recommendations concerning the formulation, revision or implementation of the policies governing the scope of services offered, practice guidelines, medical supervision, ISPs, crisis intervention care, clinical records, personnel qualifications and program evaluation.
• Providing technical advice regarding professional questions and individual service problems.
• Participating in program evaluation including annual evaluation of the MCO's performance.
• Assisting in maintaining liaison with professional groups and health providers in the community.
• Participating in the development and ongoing review of written policies, procedures, and standards of patient care and QM.
• Reviewing the adequacy and effectiveness of QM and utilization activities on a quarterly basis.
• Developing mechanisms for evaluating responsiveness of the complaint and grievance processes and for collecting and analyzing information about voluntary disenrollments.

• Establish ongoing mechanisms to monitor provider compliance with the state's standard for timely access to care and services as specified.
• Monitor the performance of its providers on an ongoing basis, conducting formal review of each provider at least annually and if any deficiencies or areas of improvement are identified, take corrective action or require the provider to take corrective action to detect both under utilization and over utilization of services and to assess the quality and appropriateness of care furnished to all participants.

• Fewer episodes of :
  • Law enforcement involvement;
  • Psychiatric inpatient and ER hospitalizations;
  • MH crisis interventions.
• Increase in percentages of participants with jobs or volunteer opportunities.
• Participant satisfaction and quality of life indicators.
• Percentages of:
  • Complaints received and resolved;
  • Grievances received and resolved.

• Based on valid and reliable clinical evidence or a consensus of health care professionals in the particular field.
• Adopted in consultation with contracting health care professionals.
• Reviewed and updated periodically as appropriate.

Practice guidelines must be approved by the state before being implemented. Guidelines must be shared with all affected providers and upon request, with participants and applicants.

• Number of participant deaths.
• Number of complaints received and resolved.
• Number of grievances received and resolved.
• Services furnished to participants.

• MCOs develop and implement an abuse/neglect plan that includes protocols for preventing, identifying, and reporting suspected abuse, neglect, and exploitation of members; a plan for educating and training providers, subcontractors, care coordinators, and other MCO staff regarding the protocols; and a plan for training members, representatives, and caregivers regarding identification and reporting of suspected abuse and/or neglect.
• MCOs are required to develop and implement a CI reporting and management system for incidents that occur in a home and community-based long-term care service delivery settings.
• MCOs are required to identify and track CIs and will review and analyze CIs to identify and address potential and actual quality of care and/or health and safety issues. The MCO will regularly review the number and types of incidents and findings from investigations; identify trends and patterns; identify opportunities for improvement; and develop and implement strategies to reduce the occurrence of incidents and improve the quality of CHOICES HCBS.
• MCOs require its staff and contract CHOICES HCBS providers to report, respond to, and document CIs as specified by the state.

Reports: MCOs submit:

• Quarterly CHOICES HCBS CIs Report (MFP participants will be identified).
• Quarterly Behavioral Health Adverse Occurrences Report that provides information, by month regarding specified measures, which will include the number of adverse occurrences, date of occurrence, type of adverse occurrence, location, provider name; and action taken by facility/provider.

• State/designee (or CMS) annually monitors the operation of MCO for compliance with the provisions of contract and applicable federal and state laws and regulations.
• Monitoring activities will include inspection of MCO's facilities, auditing and/or review of all records developed under the Agreement including periodic medical audits, appeals, enrollments, disenrollments, termination of providers, utilization and financial records, reviewing management systems and procedures developed under this Agreement and review of any other areas or materials relevant to or pertaining to this Agreement.
• State emphasizes case record validation because of the importance of having accurate service utilization data for program management, utilization review and evaluation purpose.
• State prepares a report of its findings and recommendations and will require MCOs to develop corrective action plans as appropriate.

• MCO is required to have sufficient full-time clinical and support staff to conduct daily business including administration, accounting and finance, fraud and abuse, UM including prior authorizations, MCO case management, DM, care coordination, QM/QI, member education and outreach, appeal system resolution, member services, provider services, provider relations, claims processing, and reporting.
• MCO is responsible for ensuring that all employees, agents, subcontractors, providers or anyone acting for or on behalf of MCO, are legally authorized to render services under applicable state law.
• Fiscal Intermediary is responsible for ensuring that consumer-directed workers are qualified to provide services in accordance with state requirements.
• MCO is responsible for conducting background checks in accordance with state law and policy and ensuring that all employees, agents, subcontractors, providers or anyone acting for or on behalf of the MCO conducts background checks in accordance with state law and policy. Background checks will include a check of the state's Abuse Registry, Felony Offender Registry, National and State Sexual Offender Registry, and LEIE. The FI will be responsible for conducting background checks on its staff, its subcontractors, and consumer-directed workers.

• Assessing a member's physical, behavioral, functional, and psychosocial needs.
• Identifying the physical health, behavioral health and long-term care services and other social support services and assistance (e.g., housing or income assistance) that are necessary to meet identified needs.
• Ensuring timely access to and provision, coordination and monitoring of physical health, behavioral health, and long-term care services needed to help the member maintain or improve his or her physical or behavioral health status or functional abilities and maximize independence.
• Facilitating access to other social support services and assistance needed in order to ensure the member's health, safety and welfare, and as applicable, to delay or prevent the need for more expensive institutional placement.

• Upon successful transition to the community of each MFP demonstration participant up to and including the MCO's established benchmark for the calendar year--a one-time payment of $1,000.
• If a member has been enrolled in more than 1 MCO during the 90-day minimum stay in a Qualified Institution established under ADA, the incentive payment shall be awarded to the MCO in which the person is enrolled at transition to the community and enrollment into MFP. Upon successful transition to the community of each MFP demonstration participant that exceeds the MCO's established benchmark for the calendar year--a one-time payment of $2,000.
• If a member has been enrolled in more than 1 MCO during the 90-day minimum stay in a Qualified Institution established under ADA, the incentive payment shall be awarded to the MCO in which the person is enrolled at transition to the community and enrollment into MFP.
• Upon each MFP demonstration participant's completion of community living for the full 365-day demonstration participation period without readmission to a NF (excluding short-term SNF stays solely for purposes of receiving post-hospital short-term rehabilitative services covered by Medicare), a one-time payment of $5,000.
• If a member has been enrolled in more than 1 MCO during the 365-day participation period in MFP, a pro-rated portion of the incentive payment shall be awarded to each MCO based on the number of days the member was enrolled in each plan. Only days included in the 365-day participation period shall be counted and not any days during which MFP participation was suspended during an inpatient facility stay.
• Additionally, payments are provided dependent upon the MCOs ability to achieve MFP Program Benchmarks, which address:
  • Number of individuals in each target group in successfully transitioning from an inpatient facility to a qualified residence.
  • Percentage of Medicaid spending for qualified home and community-based long-term care services.
  • Number and percentage of individuals who are elderly and adults with PD receiving Medicaid-reimbursed long-term care services in home and community-based (versus institutional) settings.
  • Number of unduplicated licensed CBRAs contracted with MCOs statewide to provide HCBS in the CHOICES program during each year of the demonstration. Number of persons receiving Medicaid-reimbursed HCBS participating in consumer direction for some or all services.

• Identify instances and/or patterns of non-compliance.
• Determine and analyze the reasons for non-compliance.
• Identify and implement actions to correct instances of non-compliance.
• Address patterns of non-compliance.
• Identify and implement QI activities to improve performance and ensure compliance going forward.

The MCO will submit additional reports as follows:

• Quality of care activities will be monitored through information obtained in a quarterly CHOICES Care Coordination Report and through activities performed by the Quality Oversight Division of TennCare.
• Quarterly 24/7 Nurse Triage Line Report that lists the total calls received by the 24/7 nurse triage line, including the number of calls from CHOICES members, including the ultimate disposition of the call.
• Quarterly CHOICES Care Coordination Report, in a format specified by TennCare that includes, information on care coordination staffing, enrollment and care coordination contacts, ongoing assessment, care planning and service initiation, and self-directed health care task.
• MCO will identify and immediately respond to problems and issues, service gaps, and complaints or concerns regarding the quality of care rendered by providers, workers, or care coordination staff.
• Member services and provider services phone line reports.

MCOS are also required to submit the following LTSS-related reports including:

• Status of transitioning CHOICES member report.
• CHOICES NF diversion activities report.
• CHOICES NF-to-community transition report.
• CHOICES HCBS late and missed visits report.
• CHOICES consumer direction of eligible CHOICES HCBS report.
• CHOICES care coordination report.
• Monthly CHOICES caseload and staffing ratio report.
• Quarterly MFP participants report.

• Rate of in-patient admissions and re-admissions of CM members.
• Rate of ER utilization by CM members.
• Percent of member satisfaction specific to CM.
• Contact providers and workers on a periodic basis and coordinate with providers and workers to collaboratively address issues regarding member service delivery and to maximize community placement strategies.

• Developing PCP and provider-specific reports that include a multi-dimensional assessment of a PCP or provider's performance using clinical, administrative, and member satisfaction indicators of care that are accurate, measurable, and relevant to the enrolled population.
• Establishing PCP, provider, group, service area or regional benchmarks for areas profiled, where applicable.
• Providing feedback to individual PCPs and providers regarding the results of their performance and the overall performance of the provider network.

Network Adequacy--MCOs are required to systematically and regularly verify that covered services furnished by providers are available and accessible to members in compliance with established appointment wait time standards and within established geographical standard for covered services furnished by PCPs. The MCO must enforce access and other network standards required by the contract and take appropriate action with providers whose performance is determined by the MCO to be out-of-compliance.

• Percent members with good access to service coordination.
• Percent increase in members that receive personal attendant and/or respite services through the consumer-directed services delivery model.
• Number of members entering NF.
• Number of waiver clients returning to community services.

• 5% risk--The state will place each MCO at risk for 5% of the Capitation Payment(s). If the MCO meets the performance expectations they will receive up to 100% of the risk reserve.
• Quality Challenge Award--If 1 or more MCOs are unable to earn the full amount of the performance-based at risk portion of the Capitation Rate, the state will reallocate all or part of the funds through the MCOs Program's Quality Challenge Award. The state will use these funds to reward MCOs that demonstrate superior clinical quality, service delivery, access to care, and/or member satisfaction. The state will determine the number of MCOs that will receive these funds annually based on the amount of the funds to be reallocated.
• Additionally, there are programs based on inpatient and nursing home utilization. These MCOs must achieve a 22% reduction in projected FFS Hospital Inpatient Stay costs, for the Medicaid-only population, through the implementation of the STAR+PLUS model. MCOs achieving savings beyond 22% will be eligible for the STAR+PLUS Shared Savings Award and will be at risk for savings less than 22%.
• NF Utilization Dis-incentive--The state will compare the annual rate of nursing home admissions for enrollees to determine if there is a statistically significant increase in admissions. Those admitted and discharged within 120 days are excluded.
• Additional Incentives and Dis-incentives--The state will evaluate all performance-based incentives and dis-incentive methodologies annually and in consultation with the MCOs. The state may then modify the methodologies as-needed in an effort to motivate, recognize, and reward MCO for performance.

• A MH professional with substantial involvement in the implementation of mental health care aspects of the QAPIP.
• A chemical dependency professional with substantial involvement in the implementation of chemical dependency health care aspects of the QAPIP.
• A geriatric specialist with substantial involvement in the implementation of the long-term care aspects of the QAPIP.

• The MCO's medical director or other designated physician's shall have direct responsibility and participation in the credentialing process.
• The MCO must have a designated Credentialing Committee to oversee credentialing process.
• Identification of the type of providers that are credentialed and re-credentialed.
• Verification sources used to make credentialing decisions, including any evidence of provider sanction.
• Prohibition against employment or contracting with providers excluded from participation in federal health care programs under federal law.

The MCO must also have a process for re-credentialing providers at least every 36 months through information verified from primary sources. The MCO must also have a system for monitoring sanctions or limitations on licensure, complaints and quality issues or information from identified adverse events and provide evidence of action, as appropriate based on state-defined methods or criteria.

• Collect, analyze, integrate, and report data. The system must provide information on areas including but not limited to, utilization, grievance and appeals, and terminations of enrollment for other than loss of Medicaid eligibility.
• Ensure data received from providers is accurate and complete by:
  • Verifying the accuracy and timeliness of reported data;
  • Screening the data for completeness, logic, and consistency;
  • Collecting service information on standardized formats to the extent feasible and appropriate.

The MCO shall make all collected data available to the state and CMS upon request.

• Antidepression medication management.
• Follow-up after hospitalization for mental Illness.
• Drugs to be avoided in the elderly.
• Falls.
• Number of screens conducted on a quarterly basis.
• Quality of preparation offered to patients for post-hospital care.

• Personal care;
• Environmental modification;
• PERS installation and service;
• Adult day care;
• Home-delivered meals;
• Home health aide;
• Skilled nursing;
• Client training;
• Specialized medical equipment and supplies;
• Nurse delegation (in-home);
• Adult family home;
• Enhanced residential care;
• Community transition services;
• Assisted living.

In addition, The MCO must track and report service days paid for all WMIP enrollees to licensed boarding homes that have an Assisted Living contract with the state.

• Appropriate risk assessments are performed on a timely basis.
• Members participate in the preparation of the care plan and are provided opportunities to review and accept it.
• MCPs address all participants' assessed needs (including health and safety risk factors) and outcomes.
• MCPs are updated and revised in accordance with the applicable standards for timeliness and when warranted by changes in the members' needs and outcomes.
• Services are delivered in accordance with the type, scope, amount, and frequency specified in the MCP.
• Members are afforded choice among covered services and providers.

• Achievement of member outcomes.
• Performance indicators for internal use that are relevant and timely for QM purposes.
• Interpretation of the indicators to care managers and providers.

• Whether the reported incident occurred and the facts of the reported incident.
• The type and extent of harm experienced by the member.
• Any actions that were taken to protect the member and to halt or ameliorate the harm.
• Whether reasonable actions by the provider or others with responsibility for the well-being of the member would have prevented the incident.
• Whether any changes in the MCO's or provider's policies or practices might prevent occurrence of similar incidents in the future.

MCOs are required to have an ongoing program of collecting information about adverse events, monitoring for patterns or trends, and using that information in the QM program. MCOs are required to compile and submit quarterly report to the state on information related to its identification of and response to CIs, the date the MCO incident analysis was completed and a brief description of any policies or standard practices that have been or will be changed or adopted to prevent similar incidents in the future.

• Monitor and detect under utilization and over utilization of services.
• Assess the quality and appropriateness of care furnished to members.
• Have appropriate health professionals reviewing the provision of health services.
• Provide for systematic data collection of performance and results.
• Provide for making needed changes.

• Revision of a care plan or any of its elements for correction, if found to be incomplete or unsatisfactory.
• Corrective action within a timeframe to be specified in the notice, if the effect on the member is determined to be serious.
• Additional review to determine the extent and causes of the noted problems.
• Action to correct systemic problems that are found to be affecting additional members.

• Needs, strengths and outcomes.
• Resources, informal supports and community connections.
• Close family members and friends.
• Ongoing conditions or other risk factors that require a course of treatment or regular care monitoring.
• Preferences for the way in which the services and supports will be delivered.

Care management also includes assistance in filing grievances and appeals, maintaining eligibility, accessing community resources and obtaining advocacy services.

• Copies of newspaper or magazine articles about the MCO that appeared during the quarter.
• CI response reports.
• Appeal and grievance summary and logs.
• Provider appeals log.

MCOs are required to maintain documentation of the following activities:

• Annual QM work plan and its approval by the governing board.
• Monitoring the quality of assessments and MCPs.
• Monitoring the completeness and accuracy of completed functional screens.
• Member satisfaction surveys.
• Provider surveys.
• Response to CIs.
• Monitoring adverse events, including appeals and grievances that were resolved as requested by the members.
• Monitoring access to providers and verifying that the services were actually provided.
• PIPs.
• Results of the annual evaluation of the QM program.