Environmental Scan of MLTSS Quality Requirements in MCO Contracts. Appendix H. Michigan Medicaid Managed Specialty Supports and Services

09/01/2013

  Element     Description/Notes  
State and Lead Agency Michigan Department of Community Health (MDCH)
Program Medicaid Managed Specialty Supports and Services Concurrent 1915(b)/(c) Waiver Program
Inception 1998: 1915(b)--serving persons with mental illness and DD.
2002: 1915(c)--provides additional services (private duty nursing and goods/services); for subgroup of DD population.
Year LTSS Added An LTSS program from inception.
Medicaid Authority 1915(b) Specialty Services Waiver.
1915(c) HSW.
# Enrolled 172,527
Data Source: Section 404(1): Community Mental Health Services Support Programs Report, May 31, 2013.
Group Enrolled Persons with mental illness, persons with DD and dually diagnosed.
  1. MCO Quality Management Infrastructure
a. Staffing requirements for quality oversight/reporting.

PIHPs are the MCO entities in Michigan. They are required to have a comprehensive managed care program that includes QI and utilization review. PIHPs must have an operational QAPIP accountable to a Community Mental Health Services Program Board of Directors. A designated senior official of the PIHP is responsible for the QAPIP implementation.

b. Staffing and processes for provider monitoring and associated reporting requirements.

Contracts entered into by the PIHPs must address QA/QI systems.

The PIHP is required to conduct annual monitoring of its provider network and subcontractors.

c. Staffing and processes for care coordinator monitoring and associated reporting requirements.

None specified.

d. IT requirements in support of quality monitoring and reporting.

Contract requires PIHPs to have a MIS that has capability to track grievances and complaints, quality indicator reporting and information on program participant access and satisfaction.

e. CI investigation processes and associated reporting requirements.

PIHPs must report 5 CIs to the state via the state's CI reporting site on the state's website:

  • 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.

f. Mechanisms for monitoring receipt of community LTSS and associated reporting requirements.

PIHPs are required to verify that services reimbursed by Medicaid were furnished to enrollees by a provider. The PIHP's verification methodology must be approved by the state. The PIHP must annually submit its findings from this process and include in its report any follow-up actions that were taken as a result of the findings.

g. Mechanisms for handling complaints/grievances/appeals, and associated reporting requirements.

None specified.

h. Other.

Emergency and After-Hours Access to Services--PIHPs are required to provide emergency and after-hours access to services for persons experiencing a MH emergency.

  1. LTSS Performance Measures Requirements
PIHPs are required to submit uniform data elements for performance measures that constitute the Michigan Mission-Based Performance Indicator System, focused on the following 4 categories:

ACCESS PERFORMANCE MEASURES

  • 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.
  1. PIP Requirements
Each PIHP must engage in at least 2 PIPs during the waiver renewal period.
  1. EQRO Requirements
The state arranges for an annual, external independent review of the quality outcomes, timeliness and access to covered services provided by PIHP. The PIHP must develop and implement performance improvement goals, objectives and activities in response to the external review findings. The state may also require separate submission of an improvement plan-specific to the findings of the external review.
  1. Care Coordination Requirements
None specified.
  1. Ombudsman (Function) Requirements
None specified.
  1. Quality-Related Financial Incentives
A first and second place monetary award will be presented to a PIHP who has shown a relative improvement over the last fiscal year in the following areas:
  • 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.

  1. Experience of Care/ Satisfaction Feedback Requirements
PIHPs are required to conduct periodic quantitative (e.g., surveys) and qualitative (e.g., focus groups) assessments of member experiences with its services. These assessments must be representative of the persons served and the services and supports offered. The assessments must address the issues of the quality, availability, and accessibility of care. The PIHP must submit a report on an annual consumer satisfaction in August each year. More specifically, for persons with mental illness, the PIHP is required to use the MHSIP Youth and Family Survey and to conduct this survey in May of each year. Programs that the PIHP serves will be selected by the QIC* to receive the survey based on volume of units, expenditures, complaints and state site review information.

*The QIC is comprised of consumers, advocates, provider organizations, PIHPs and Community Mental Health Service Programs.

  1. LTSS Quality Review
None specified.
  1. Other
Non-monetary Incentives--Should a PIHP show full compliance within a particular area or 2 full cycle site reviews, the state site review team will skip the next full review unless the state has other information that brings the PIHP's compliance into question.
  1. Other
Non-monetary Sanctions--PIHPs are required to submit a plan of correction that addresses each review dimension for which there was a finding of partial or non-compliance. If a PIHP receives a repeat citation on a site review dimension, the state site review team may increase the size of the clinical record review sample for that dimension for the next site review and/or require the program to re-undergo state approval to operate.
  1. Other
Financial Sanctions--The PIHP contract specifies that financial sanctions may be imposed to address repeated or substantial breaches, or reflect a pattern of non-compliance or substantial poor performance on performance indicator standard, repeated site review non-compliance, substantial inappropriate denial of services, or substantial or repeated health and/or safety violations.
CI = critical incident
DD = developmental disability
EQRO = external quality review organization
HSW = Habilitation Supports Waiver
IT = information technology

LTSS = long-term services and supports
MCO = managed care organization
MDCH = Michigan Department of Community Health
MH = mental health
MHSIP = Mental Health Statistics Improvement Program

MI = mentally ill
MIS = Management Information System
OBRA = Omnibus Budget Reconciliation Act
P4P = pay-for-performance
PIHP = Pre-paid Inpatient Health Plan

PIP = performance improvement project
QA = quality assurance
QAPIP = Quality Assessment and Performance Improvement Plan
QI = quality improvement
QIC = Quality Improvement Council

SA = substance abuse
SED = serious emotional disturbance
SUD = substance use disorder

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