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Alliance Behavioral Healthcare 1

Quality Management Plan and Program Description FY 2012-2013

Alliance Behavioral Healthcare Managed Care Organization

QUALITY MANAGEMENT PLAN AND PROGRAM DESCRIPTION FISCAL YEAR 2013-2014

Alliance Behavioral Healthcare Managing Behavioral Health & Developmental Disability Services |

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ACKNOWLEDGEMENTS

The Quality Management Department staff of Alliance Behavioral Healthcare would like to thank all other staff, the Quality Management Committee, Board of Directors, Consumer and Family Advisory Committee, providers, and other stakeholders who assisted with developing this plan for FY2013-2014.


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ALLIANCE BEHAVIORAL HEALTHCARE MANAGED CARE ORGANIZATION (MCO) QUALITY MANAGEMENT PLAN AND PROGRAM DESCRIPTION FISCAL YEAR 2011-2012

1. BACKGROUND ....................................................................................................................................... 4

2. PURPOSE ............................................................................................................................................... 4

3. MISSION AND PHILOSOPHY .................................................................................................................. 4

4. SCOPE AND ROLE OF THE QUALITY MANAGEMENT PROGRAM .......................................................... 5

5. ORGANIZATIONAL STRUCTURE AND RESPONSIBILIES .......................................................................... 6

Continuous Quality Improvement Leadership Team .......................................................................... 10

6. Quality Improvement Model .............................................................................................................. 14

7. QUALITY MANAGEMENT PLAN AND PROGRAM DESCRIPTION .......................................................... 16

8. QUALITY MANAGEMENT ACTIVITIES .................................................................................................. 19

A. Risk Management (Enrollee Safety) ................................................................................................ 20

B. Coordination with Primary Care ..................................................................................................... 21

C. Evaluation of the Effectiveness of Services .................................................................................... 22

D. Evaluation of the Quality and Effectiveness of Internal Processes ................................................. 25

E. Evaluation of the Quality and Performance of the Provider Network ........................................... 28

F. Reporting of Suspected/Substantiated Fraud and Abuse ............................................................... 30

G. Clinical Records Content, Retention and Storage ........................................................................... 31

9. CONFIDENTIALITY ............................................................................................................................... 31

10. EVALUATION AND UPDATE PROCESS ................................................................................................. 32

Attachments

Attachment A: Matrix of Reports ............................................................................................................... 33

Attachment B: Quality Improvement Projects for FY2012 ........................................................................ 37

Attachment C: FY 2010 – 2013 Strategic Plan, Updated for 2011 (edits in red italics) .............................. 39


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1. BACKGROUND

Alliance Behavioral Healthcare (TDC) Local Management Entity (MCO) currently manages a state Medicaid behavioral health contract for Durham County, and CAP and I/DD Medicaid for 20 counties in North Carolina. If awarded waiver capabilities in October 2011, TDC will also manage Medicaid behavioral health and developmental disability services for 2 additional counties—Cumberland and Johnston. In addition, TDC will be managing State funding for the 3 county region in addition to Durham County funds allocated for behavioral health and developmental disabilities for the citizens of Durham County in need. This plan will provide detailed information for Alliance Behavioral Healthcare MCO. Demographics: County Total Population Medicaid Lives* Durham 271,580 35,296 Cumberland 324,225 51,272 Johnston 173,600 25,519 Total 769,405 112,087

* Does not include birth to age 2

2. PURPOSE

The purpose of this Quality Management Plan and Program Description is to provide a systematic method for continuously improving the quality, efficiency, and effectiveness of the services managed by TDC for enrollees served. This plan also encompasses internal quality and effectiveness of all MCO internal processes.

3. MISSION AND PHILOSOPHY

The Vision TDC holds is to: We are a community with energy and momentum that embraces people with disabilities as equal partners and valued citizens. When citizens with disabilities reach their full potential the entire community benefits. The Mission of TDC is to: We pursue a community effort dedicated to supporting the lives of citizens affected by mental illness, developmental disabilities, and substance abuse by assuring a collaborative, accessible, responsive and efficient system of services and supports.


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An overlying philosophy of Alliance Behavioral Healthcare is to be an organization whose management focuses on its responsibility to maintain a fiscally sound agency, but will never permit the focus to undermine its responsibility to the delivery of exceptional care to those in need. Our Customers TDC upholds the highest integrity for the staff, enrollees, families, providers, and all other stakeholders to ensure that enrollees receive:

• Access to high quality clinical and human services • Best practice programs and innovative ideas to shape and trend services, outcomes, and

community needs • The highest level of customer service to address needs

4. SCOPE AND ROLE OF THE QUALITY MANAGEMENT PROGRAM

Alliance Behavioral Healthcare (TDC) through its Quality Management Program (QMP) promotes objective and systematic measurement, monitoring and evaluation of services and implements quality improvement activities based upon the findings. The purpose of quality management activities is to ensure the provision of quality services rendered by those providers who receive oversight by TDC and therefore applies to governance, management, clinical, administrative, and support functions that affect desired enrollee outcomes. While the Quality Management Department (QM) implements, maintains, and documents evidence of an ongoing QMP throughout Alliance Behavioral Healthcare MCO, quality management serves as a core function of all TDC departments and as a defined expectation per provider contracts and service agreements. Internal quality management is included as a core function of this QMP as well. Quality Management Program Reporting TDC utilizes a Quality Management Committee (QMC) structure to regularly report activities, studies, findings, compliance with performance indicators, and the results of corrective action plans to the counties, TDC’s Continuous Quality Improvement Leadership Team (CQIT), the Consumer and Family Advisory Committee (CFAC), and Board of Directors. The organization of all committees is described beginning on page 6 under the “Organizational Structure and Responsibilities” heading and on page 10 under “Subcommittees of the CQIT.” Corrective Action Planning The QMC will take appropriate corrective actions whenever substandard care and services, or opportunities to improve care and services, are identified. The CQIT examines and processes all data from the CQIT sub-committees for first level review and recommendations. The performance review process begins with data collection, which in turn drives the quality management activities that define baselines and performance benchmarks. If data reveal that processes or outcomes are not acceptable, appropriate resources and actions are identified


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with a corrective action plan taken first to the CQIT, and then to the QMC. Corrective Action Plans may include; changes to processes within TDC’s internal structure and/or provider agencies; staff, provider and/or enrollee/family member education; creation of specific quality improvement task groups; and other measures as deemed necessary. The QMC oversees implementation of corrective action plans related to quality management. Additional data are collected and trended, with monitoring of improvements until the issue has been resolved and/or corrected. The individuals responsible and the types of corrective action will vary depending upon what is required. Corrective actions and follow-up are continuous.

5. ORGANIZATIONAL STRUCTURE AND RESPONSIBILIES

Alliance Behavioral Healthcare MCO has ultimate responsibility for assuring a comprehensive and integrated Quality Management Program. TDC assumes responsibility for assuring that the Quality Management Program is implemented and maintained. TDC’s board of directors oversees TDC’s Quality Management activities, which are delegated to the Quality Management Committees. Quality Management Committee activities are reported to the board at least quarterly. Responsibilities at the MCO Level TDC’s Quality Management program infrastructure is designed to allow top-down direction and bottom-up participation, thereby ensuring optimal enrollee outcomes. The Quality Management reporting structure involves active participation and communication among staff members at MCO offices, all access points, enrollees, family members and providers. Potential and existing problems are to be identified with opportunities for improvement offered as solutions. Other responsibilities include ensuring all policies and procedures meet regulatory and accreditation requirements. Committees and sub-committees are structured to facilitate the effectiveness of TDC’s Quality Management Program. The following reporting structure is used:

State DMH/DM

BOCC

CFAC

TDC Board

Global Quality Management Committee

CQI Leadership Team (CQI)

Human Rights

Finance Committee

Exec Committee


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Quality Management Committee (QMC) Authority and Composition: The QMC is the standing committee that is granted authority for Quality Management by the MCO. The QMC reports to the MCO Board of Directors which derives from General Statute 122C-117 and reports to the County Commissioners. The Board Chairperson appoints the Quality Management Committee consisting of five voting members whereof three are Board members and two are members of the Consumer and Family Advisory Committee (CFAC). Other non-voting members include at least one MCO employee and one provider representative. The MCO employees typically assigned are the Director of the Quality Management (QM) Department who has the responsibility for overall operation of the Quality Management Program, the MCO Medical Director, and the Human Services Planner/Evaluators. The QMC meets at least quarterly and provides ongoing reporting to the Area Board. The Committee approves annual Quality Improvement Projects, monitors progress in meeting Quality Improvement goals, and provides guidance to staff on QM priorities and projects. Further, the Committee evaluates the effectiveness of the QM Program and reviews and updates the QM Plan annually. The QMC is responsible for the following:

• Ultimate accountability for the Quality Management Program • Providing feedback and input to improve organizational performance • Determining if services are within TDC’s resource capabilities • Assuring policy and procedure development and maintenance • Delegates authority to the CQIT for overall review and implementation of various

activities including, but not limited to: o Developing, implementing, and revising policies and procedures o Evaluating agency and services quality improvement activities o Identifying trends to improve quality of services o Evaluating TDC MCO’s performance at all levels of operation o Ensuring TDC meets established benchmarks/outcomes

Responsibilities of the QMC Chairperson(s) The Chairpersons of the QMC are responsible for presiding over the meetings of the QMC, and for assuring that the QMC complies with the requirements specified in the TDC Quality Management Work Plan. QM Committee Member Terms One half of the initial positions will serve a one-year term. Thereafter, all terms will be for two years excluding MCO staff assignments. Committee members are expected to show a knowledge and commitment to service quality, evaluation and incentive-based quality

UM Committee CCMT Corporate Compliance

IT Committee

Clinical Advisory Committee PAC

Credentialing Committee


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improvement. Committee members are expected to attend at least 80% of meetings and to actively engage in sub-committee involvement as needed. Excused absences are allowed and committee members shall notify the QM Committee Chair and TDC staff if an absence is expected. The QM Committee Chair determines the appropriate involvement of members and will confer with committee members if absence becomes an issue. Meeting Times and Minutes The Committee meets at least quarterly at a regularly scheduled date and time. The Director of QM or designee will provide an agenda for each meeting to the Quality Management Committee Chairperson for review and dissemination to other members of the committee. Minutes will be taken at each meeting by a designated QM staff and sent to the chairperson for review. QMC agendas and minutes will be kept electronically on the QM Drive and hard copies will become part of the Area Board Packet. The minutes will be redacted to protect enrollee and provider confidentiality, and will be made available for review on TDC’s website. Definition of Quorum For the purpose of conducting business, a quorum will consist of half of the voting members. Members who are not able to attend QMC meetings in person may participate by conference telephone calls, which will be pre-arranged by the QM Director and/or designee. In the event that a quorum is not reached, an informal meeting takes place. Subcommittees The QMC may designate subcommittees as necessary to assure the efficient operation of the QM Program. Urgent Issues Issues that arise prior to the regularly scheduled meetings and need immediate attention will be reviewed by TDC’s QM Director, and/or the Medical Director and the QMC Chair to determine if an ad hoc meeting is needed or if the matter can wait for the next scheduled meeting. Ad hoc meetings can be by conference call, email exchange or in person. Role of Participating Network Providers Participating providers are informed about quality improvement program efforts via the provider manual, provider forums, TDC’s website, and training sessions. Providers participate on various committees including the Quality Management Committee, Clinical Advisory Group, and the Provider Advisory Committee (these committees are described in more detail under “other committees and functions”). Through these committees, participating providers:

• Advise TDC on all issues associated with the provider network • Provide peer review and feedback on proposed practice guidelines, clinical quality

indicators, technology issues, and any critical issues regarding policies and procedures • Review quality improvement activities and make recommendations for improvements


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Role of Members and their Families TDC values are reflected in our belief that people should be viewed as active participants in their treatment and recovery. Member and their family’s involvement and membership in the Quality Management Committee provide an opportunity for constructive input in TDC’s quality improvement process. Enrollee and family advocates are members of several TDC committees: The Quality Management Committee, the Human Rights Committee, the Clinical Advisory Group, CFAC, the Cultural Competence Committee, and other sub-committees and work groups, such as the strategic planning workgroup. Role of Quality Management Staff TDC leadership ensures adequate resources are available for implementation of the Quality Management Plan and Program Description and Department operations. The staffing pattern is continuously evaluated based upon the evolving needs of the agency. Role of TDC Medical Director

• Responsible for the overall operation of the QM Department and quality related waiver programs

• Oversees the development of clinical practice standards, policies, procedures, and performance

• Ensures the review and resolution of quality of care concerns • Oversees the grievance process related to service denials and clinical practice • Provides consistent input into the development, implementation and review of the

internal Quality Management via the QM Director • Oversees the quality of behavioral health and developmental disability services

Role of the Quality Management Director

• Oversees and ensures the operations of TDC’s Quality Management Program meet required goals and objectives, as defined by the Quality Management Committee and as outlined in the annual Quality Management Plan and Program Description

• Serves as the chair of TDC’s Continuous Quality Improvement Leadership Team • Co-chairs the Clinical Care Management Team (CCMT) with TDC’s Medical Director • Provides QM input into inter-departmental operations on a daily basis • Oversees the accreditation processes and maintains appropriate agency accreditation • Responsible for day-to-day operations of the QMP • Ensure coordination of quality management activities with internal MCO departments

and refers potential fraud/abuse and confidentiality violations to the MCO Corporate Compliance Director

Roles of Quality Management Staff


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• Prepare monitoring reports including analysis of data, significant trends and any drill down information as appropriate

• Serve as project leads for various studies, developing data collection tools, collecting and analyzing data, writing reports and presenting updates to stakeholders

• Review provider QM plans for accuracy and efficiency • Serve as QM contacts on other TDC committees, and some outside committees, such as

the Partnership for Children Evaluation Committee • Participate in strategic planning • Process all grievances and quality of care concerns • Serve as technical consultants to TDC staff regarding quality improvement projects and

evaluation/research activities • Work closely with IT staff to streamline reports generated from Avatar and other

databases • Work with State Division of Mental Health, Developmental Disabilities and Substance

Abuse Services (DMH/DD/SAS), the Division of Medical Assistance (DMA), Division of Health Services Regulation (DHSR), and Division of Social Services (DSS)

• Provide training on various QM and program evaluation techniques, practices and tools

Continuous Quality Improvement Leadership Team (CQIT) The CQIT Leadership Team is the internal review venue for the examination and review of all data for the MCO. This committee is composed of the Area Director, Deputy Area Director, Medical Director, Director of Corporate Compliance, Director of Utilization Management, Director of Care Coordination, Director of Customer Service, Director of Contracts Management, Director of Finance, Director of IT, and Director of Quality Management. The Director of QM and Medical Director Co-Chair CQIT meetings. Agendas and minutes are recorded. The CQIT meets at least bi-monthly to review clinical and provider network performance data. The CQIT is responsible for the development, implementation and evaluation of the TDC Quality Management Plan, monitoring of quality improvement goals and activities and identifying opportunities for improvement within TDC and the provider network. This committee examines data and information for further distribution and action, both internally and externally. Information reviewed with strategies for improvement and/or changes is then taken to the Board Quality Management Committee for additional review, feedback, recommendations and approval mechanisms. Committees that come under the CQIT Committee and which data flows from and to CQIT (indicated in the chart on page 6): Subcommittees of the CQIT: Corporate Compliance Committee (CCC) - This committee reviews and evaluates organizational and network achievement on indicators designed to monitor compliance to applicable state and federal regulations. Committee membership includes representatives of Contracts Management, Customer Service, Quality, Research & Development, Care Management and


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Utilization Management Departments. It is chaired by the Corporate Compliance Officer and reports matters of significant non-compliance such as fraud and abuse to the Continuous Quality Improvement Leadership Team. This committee meets at least monthly. Clinical Care Management Team (CCMT) – This committee meets at least monthly to enhance lateral communication for all TDC clinical functions. A major responsibility of the committee involves reviewing deaths serving as a mortality/morbidity committee and conducting root cause analyses related to death and other serious incidents; the clinical oversight of UM/UR/Access center; assures that authorizations and clinical reviews are conducted properly; oversees problem cases of denials and appeals; identifies Best Practice to include in Clinical Guidelines; and monitors clinical data including high risk/high cost enrollees. The committee also reviews cases of concern referred to TDC or elicited by TDC staff, conducts case conference for complex clinical cases, provides group clinical supervision for clinical department heads, encourages and ensures care coordination to improve quality of care and exercises clinical oversight of licensed supervisory staff within TDC. This committee is chaired by the Medical Director. Utilization Management Committee (UMC) - This committee evaluates the utilization of services with the goal of ensuring that each enrollee receives the correct services, in the right amount and in the most appropriate time frames to achieve the best outcomes. This is a collaborative, dynamic process by which over or under utilization of services can be detected, monitored and corrected. The committee serves as a vehicle to communicate and coordinate quality improvement efforts to and with the CQIT. It is chaired by the UM Director and Co-Chaired by the Medical Director. Community Systems Improvement Committee (CSI) - The primary charge of this committee is to review program related data, identify and address service gaps, explore trends and make policy recommendations based upon this information. In addition, the CSI Committee examines the clinical implications of ongoing state and federal funding reductions on the services that are provided within the community and makes recommendations on how to address these issues from a clinical perspective. All significant findings and recommendations are sent to CQIT. The CSI Committee is chaired by the Director of UM/STR and meets once per month. Cultural competence issues and data are reviewed in this committee. Credentialing Committee – Meets monthly with a primary charge of the Credentialing Committee is to provide a venue for credentialing, re-credentialing, ongoing monitoring, and determining actions related to provider credentials (such as termination of provider participation agreements) for providers serving enrollees in the catchment area and are deemed to be credentialed by TDC. All TDC network clinicians and facilities are subject to TDC’s Credentialing Plan, Provider Participation Agreement, and the Provider Network Manual, and any and all amendments. The Medical Director and/or Designee chairs the Credentialing


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Committee, with membership consisting of the Medical Director, UM Director, Finance Director, Corporate Compliance Officer, and other staff as determined by TDC’s Director. Information Technology (IT) Committee – The IT Committee serves as a mechanism to continually address internal and external information technology issues and processes. Common discussion items regard data integrity monitoring, findings of the monitoring, work-around to be streamlined, communication with providers and community partners, and problem-solving. The IT Committee has an integral role in the IT Strategic Plan. The IT Director chairs the committee with representation from all major departments and units within the organization. This committee meets at least monthly. Clinical Advisory Committee (CAC) – This group consists of external medical and clinical directors of provider agencies in the continuum of care. Meetings are chaired by TDC’s Medical Director and co-chaired by the Director of Clinical Operations. The group meets at least quarterly to discuss medical appropriateness of treatment, treatment issues that have been identified by TDC’s committee process and/or by staff, medication adherence, and other health issues determined to be performance criteria such as BMI, medications and adverse reactions in certain populations such as the elderly and so forth. Provider Advisory Committee (PAC) – This committee meets monthly and serves as a venue for leadership of provider agencies to discuss concerns and to strategize with TDC on improvements to the continuum of care. This committee provides a voice for providers with TDC and is chaired by TDC’s CEO and co-chaired by the Deputy Director. Data Sources TDC uses the NetSmart Avatar system for care management, utilization review, screening/triage/referral, care coordination, customer service, encounter data, quality of care input, and other aspects of operational services. The data sources available and used for quality improvement and evaluation measurement include claims, authorization data, Person-Centered Plans, surveys, call center data, GeoAccess reports, provider profile data, focus groups, structured interviews, and state provided data on contract performance indicators. Excel and SPSS software are used for tracking inter-rater reliability, determining appropriate sampling and other statistical analyses and reporting. Integration of Quality Management within the MCO Each department of the MCO has a report manager (sometimes more than one) who works in tandem with QM Department staff to ensure quality measures and issues are identified at each level within the agency. While the CQIC and its subcommittees review data and processes, each MCO department utilizes data on a daily basis to conduct day-to-day operations and to improve upon and streamline workload, performance, processes, technology, and reporting.


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A. Quality Management and Governing Boards TDC is responsible for reporting quality management information up to TDC’s Board of Directors. This occurs by the QMC reporting out minutes and data from the previous QMC meeting(s), and other data reports presented to TDC’s board by QM staff.

B. Quality Management and Clinical Operations

The integration of Quality Management and Clinical Operations (utilization management and care management) is assured by representation on key committees including QMC, CAG, CCMT, UM, and CSI, as well as the integrated meeting structure including other counties in the catchment area. These structures support the integration of clinical quality management activities and indicators. Clinical indicators have been established to measure the effectiveness of practice guidelines, over and under utilization, and the timeliness of appointment referrals per URAC, Medicaid and State regulations and contracts. Regular inter-rater reliability studies are conducted on care managers to assure quality of treatment authorizations being made. The results of these quality activities are shared with the QMC for evaluation and recommendations. In addition, Quality Management Department staff are assigned to the UM and Care Coordination Departments to facilitate cross-agency reporting and analysis of data.

C. Quality Management and Care Coordination Care Coordination is an important aspect of managing care of enrollees served. QM staff has been designated to integrate with Care Coordination as a major component of the work performed. Details of work accomplished are documented in staff work plans, and include but are not limited to serving as the point person for data collection, tracking and trending of the following:

o Hospital admissions and readmissions o Emergency room admissions o Crisis Facility admissions and readmissions o Discharge planning practices data o Community data such as homeless individuals and incarcerated enrollees o Data indicating when and where enrollees receive assessments for treatment o Direct and regular contact with the CCNC liaisons o Trending data related to high utilizers of the system of care

Data pertaining to the above are evaluated and discussed via the committee processes, beginning with the designated Care Coordination/System of Care committee. Data pertaining to clinical outcomes are presented to the CCMT, UM, CQIT, and QM Committees. Performance indicators designated for Care Coordination are determined by consensus of the boards of directors via the committee process.

D. Quality Management and Network Management


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The integration of Quality Management and Network Management occurs with cross-representation on key committees such as internal management team and workgroup meetings. Provider quality reviews and performance data are evaluated by the CCMT, which includes the Provider Network Operations, Clinical Operations, and QM, and Customer Service Directors, and/or designees. Provider profiles are reviewed and discussed at the Provider Advisory Committee, which includes provider network representatives.

E. Quality Management and Member Rights

TDC utilizes members and family participation in the Quality Management Program in various ways, including membership on the QM Committee. Data are collected, reviewed and analyzed regarding grievances, incidents and other compliance issues that may impede enrollees’ rights. The TDC Human Rights Committee is chaired by a enrollee representative with board and CFAC membership.

F. Quality Management and Information Technology Accurate and timely data are vital to a successful quality management program. TDC’s QM Program is data driven, and interfaces with TDC’s IT Department to assure report development, data integrity and accurate reporting. QM staff serves on the IT Committee to assure communication and accuracy of data requests and to discuss issues with data processes.

6. Quality Improvement Model

TDC is committed to the ideal that quality management is visible and consistently sets benchmarks that will exceed required performance standards and to meet or exceed industry benchmarks to show improvement on both systemic and individual levels. TDC’s QM Program complies with the American Accreditation HealthCare Commission/URAC. TDC’s quality initiatives are designed to eliminate barriers that inhibit provider and agency performance. TDC operates under the culture of the quality improvement cycle proposed by D. Edwards Deming who was a major proponent of quality management1. Deming created a “cycle” of Plan, Do, Check, Act, which is used today as Plan, Do, Study, Act and is depicted in the graph below:


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By implementing a continuous quality improvement model, TDC uses data to identify opportunities for improvement and to create interventions. The Centers for Medicaid and Medicare Services (CMS) use a somewhat similar model for community-based services with a philosophy of Design (providing structure and planning), Discovery (reviewing data and monitoring), Remediation (making corrections and changes), and Improvement (evaluating changes to complete the feedback loop). TDC strives to emulate the CMS model to ensure that the QM process yields increased satisfaction and better outcomes for all stakeholders. 1Fisher, C., Barfield, J., Li, J., & Mehta, R. (2005). Retesting a model of the Deming Management Method. Missouri University of Science & Technology Staff and Provider Training TDC QM Department staff provides ongoing quality management training to providers, enrollees, and staff. Training is available regionally and on-site for provider or enrollee and family member groups upon request. Further training needs are identified through the annual gaps and needs analysis, strategic planning and provider/enrollee surveys. Annual training for TDC employees includes, but is not limited to training regarding:

• Confidentiality (includes HIPAA and 42CFR) • Conflict of Interest • State, Medicaid and regulatory requirements (URAC) • Organizational structure • Policies and procedures • Best practices • Contractual requirements

PLAN

ACT DO

STUDY

Enrollees and other

Stakeholders


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• Enrollee safety • Quality-related topics such as writing a QM plan

QM Department Staff Structure:

7. QUALITY MANAGEMENT PLAN AND PROGRAM DESCRIPTION

Each year, TDC will develop a Quality Management Work Plan which is based on goals and objectives related to TDC’s Strategic Plan and established benchmarks/threshold data. This Work Plan will reflect the ongoing quality improvement initiatives implemented in the previous year, and will be developed as a direct result of our annual summary of QI activities. The reports indicated in the following objectives are listed in the Reports Matrix in Attachment A. It is understood that satellite sites determined by the Medicaid Waiver are included in all operations related to Quality Management and this Plan. Goal 1: Develop and implement a FY2012-2013 Quality Management Work Plan that reflects the quality improvement initiatives identified via an analysis of FY2011 QM activities

Objective 1.1: The FY2011 Annual Report will be submitted to the QMC by the October 2011 meeting.

Objective 1.2: A draft of the FY2012-2013 Quality Management Work Plan will be

Medical Director

Research Assistant

Grievance Coordinators -5

QM Director

Quality Review Mgr

Data Manager

Research Asst NC-TOPPS

Quality Reviewers - 3

Data Analysts - 4

QM Business Analyst


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submitted to TDC’s QMC for input in order to be approved at the August 2011 meeting.

Goal 2: Continue monitoring of the State DMH/DD/SAS Performance Contract Requirements and Indicators Objective 2.1: Monitor the indicators that are not being met and strategize on activities

that could impact improvement. Objective 2.2: Work with TDC’s committee structure to develop interventions to

improve on indicators not being met. Objective 2.3: Report on the status of the indicators each quarter to the CQIT, QMC and

the board of directors. Goal 3: Conduct an annual needs/gaps assessment that is integrated with the strategic plan

Objective 3.1: Conduct a needs/gaps assessment by March of 2012 that includes Innovations services capacity in addition to other services managed by TDC.

Objective 3.2: Integrate results of the needs/gaps assessment with the current strategic plan by working with other TDC and partner agency staff and Network Operations.

Objective 3.3: Revise TDC’s Dashboard per the changes to the Strategic Plan by August 2011.

Objective 3.4: Report results of TDC’s Dashboard each quarter to the CQIT, QMC and The boards of directors.

Goal 4: Continue monitoring procedures for the evaluation of the effectiveness of services Objective 4.1: Continue the procedures for monitoring the authorization and appeals

processes on a monthly basis. Objective 4.2: Continue the procedures for monitoring treatment outcomes via NC-

TOPPS on a quarterly basis. Objective 4.3: Continue to monitor hospital admission and readmission monthly.

Report quarterly and end of fiscal year. Objective 4.4: Continue to monitor enrollee satisfaction with access to services with

monthly calls to enrollees (sample) and an annual survey. Objective 4.5: Continue to monitor enrollee quality of life as part of the annual

satisfaction survey. Objective 4.6: Analyze the outcomes data for the state funded contracts to determine

efficacy of the programs.


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Goal 5: Continue monitoring procedures for the evaluation of the quality and effectiveness of internal processes

Objective 5.1: Continue the procedures for monitoring telephone access standards and responsiveness on a monthly basis. Report quarterly.

Objective 5.2: Continue the procedures for responsiveness and accuracy of TDC staff to ensure provider satisfaction. Provider satisfaction survey will be conducted annually.

Objective 5.3: Continue monitoring of under and over utilization patterns and trends on a monthly basis. Report quarterly.

Objective 5.4: Continue monitoring grievances, including by level of care and category. Report Quarterly.

Objective 5.5: Continue monitoring of quality of care concerns monthly. Report quarterly.

Objective 5.6: Clinical operations staff will participate in the inter-rater reliability studies. Findings reported quarterly.

Objective 5.7: Monitor and report the timeliness of referral decisions monthly. Report quarterly.

Objective 5.8: Continue mystery caller studies quarterly of screening, triage and referral staff.

Goal 6: Evaluate the quality and performance of the provider network Objective 6.1: Develop a provider report card for enhanced service providers. The

Clinical Advisory Committee, Provider Advisory Committee, Network Operations staff, and QM staff will develop the criteria for the report card by December 2011.

Objective 6.2: Analyze provider report cards and develop corrective action plans by June 2012.

Objective 6.3: Report aggregate results of provider network data annually. Objective 6.4: Continue first responder assessments of the provider network annually. Objective 6.4: Work in conjunction with provider network operations to target specific

outcomes for the provider network not already captured in current data reporting.

Goal 7: Continue trending of suspected/substantiated fraud, abuse, and neglect Objective 7.1: Continue trending data from fraud and abuse reports. Report quarterly. Objective 7.2: Continue trending plans of correction for non-compliance with standards,

regulations and procedures. Report quarterly. Objective 7.3: Continue reporting on monitoring visits and trending data. Report

quarterly.


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Goal 8: Develop studies and quality/program improvement MCO initiatives for FY2012

Objective 8.1: Conduct a quality improvement project to address readmission rates of adults utilizing Alliance Behavioral Healthcare Access crisis facility with the provision of targeted discharge planning and care coordination.

Objective 8.2: Conduct a quality improvement project to address recidivism of youth utilizing Alliance Behavioral Healthcare Access crisis facility with the provision of targeted discharge planning and care coordination.

Objective 8.3: Conduct a quality improvement project to address retention of adults with substance abuse disorders in outpatient services. The goal is to improve the percentage of adults who show for 4 or more consecutive visits for treatment (from third quarter results of FY2011).

Objective 8.4: Finalize quality improvement projects from FY2011 with reports provided by September of 2011.

Goal 9: Target individual quality improvement initiatives

Objective 9.1: Identify and review baseline data regarding state performance contract Indicators for each county.

Objective 9.2: Establish outcomes and strategies to meet the outcomes for indicators not being met.

Objective 9.3: Conduct a needs assessment/gap analysis if one has not been done in the past year.

Objective 9.4: Addend TDC’s strategic plan objectives and benchmarks to include both counties.

Goal 10: Evaluate and update TDC’s Quality Management Work Plan Objective 10.1: Complete the annual summary of the FY2011-2012 QM Plan by

September 2011. Objective 10.2: Complete the annual 2013-2014 Work Plan by June 30, 2012.

8. QUALITY MANAGEMENT ACTIVITIES

Continuous quality improvement occurs within the context of various planned QM activities. All quality management activities are governed by the analysis of individuals and families served by the provider network. A comprehensive gaps/needs analysis has been conducted


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over the FY2011-2012 contract year. With the advent of TDC undertaking Medicaid utilization management for Durham in September of 2010, and CAP MR/IDD utilization management of 20 counties in January of 2011, additional QM activities have been identified for this next fiscal year. Following are the major categories identified as needing more focused attention and the QM activities to address them:

A. Risk Management (Enrollee Safety) TDC’s QMC will monitor high risk cases (defined as individuals involved in the highest volume of emergent events, i.e., emergency room visits, hospitalizations, and crisis center admissions). Critical incidents and quality of care concerns are included in the risk management category. 1. High Volume/High Risk Cases

TDC’s QM Department monitors monthly the utilization of emergent events by cost and by number of distinct enrollees. The aggregate reports are presented to QMC quarterly. TDC’s Community Engagement and System Development Department manages high volume and high risk cases via focused care coordination on special populations. Annually a report will be completed that includes the individuals who are followed for co-morbidity and medically complex issues as well.

2. Quality of Care Concerns

Quality of Care issues will be reviewed by the Clinical Care Management Team and Clinical Advisory Committee. These committees are chaired by TDC’s Medical Director and comprised of internal staff (CCMT) and external members (CAC) from providers in the catchment area. Issues are referred for review by UM staff, QM staff, Customer Services, and/or Corporate Compliance. CCMT and CAC make recommendations to improve quality of care and monitors corrective action plans via the Corporate Compliance Committee. Cases are reviewed and prepared for committee action by TDC’s QM Department, which also presents a quarterly overview of CCMT activities to the QMC.

3. Critical Incidents

The standards utilized by TDC regarding critical incidents are described in TDC’s policy and procedure manual. Data from incident reports are aggregated by the QM Department. The aggregated data will include the number of incidents and type by quarter, and trends in incident type. Data on specific incidents are considered confidential and are maintained internally as an integral aspect of risk management. Quarterly, the QM Department will review all reported incidents from the previous


21


quarter by member and by provider for trends in reporting or in the number of incidents. Emergent or urgent incidents are handled by the UM Department as they become aware of an issue via the authorization process. If Customer Service takes a call regarding a member in crisis, a licensed clinician will take the call and coordinate care at that time. Providers for whom four or more incidents have been reported will be reviewed individually from a care management perspective to determine if further analysis is indicated clinically. This may include medical record reviews, claims data review, review of person-centered plans, and clinical/social issues that may be impacting care. A risk analysis will be completed by the QM Department and when findings have merit, will be reviewed at the QMC. Providers will be reviewed against their own established reporting baseline regarding number of incidents. Since providers vary significantly in the number of members served and in their commitment to report all incidents, potential trends will be reviewed by provider volume, the type of incidents being reported and whether distinct members are involved in multiple incidents. These data will be reviewed and an analysis completed to determine if the provider should be reviewed by the Human Rights Committee, and subsequently, the QMC. The QMC will identify opportunities for improvement in treatment outcomes. The QM Department will oversee implementation of corrective action plans, and will continually monitor performance standards in order to determine if and when improvement is achieved.

B. Coordination with Primary Care TDC is in the process of designing a system of service management that emphasizes communication and coordination between all participants in the enrollee’s health and behavioral health care delivery systems. TDC has worked with the Duke operated Durham Community Health Network to develop agreements on the provision and coordination of services to enrollees. Issues included in these agreements include referral and communication protocols, medication management, transition plans, overall treatment management, service provision for special needs populations, and enrollee education issues. 1. Coordination and Interaction with TDC’s Quality Management Activities

Monthly coordination meetings occur with Duke University Hospital and TDC Care Coordinators when issues of mutual concern regarding members are identified.


22


TDC’s Medical Director or designee will participate as an active member and act as a liaison regarding behavioral health pharmacy and clinical guidelines. Via CCMT trends in coordination with primary care will be reported and discussed with action items. These will be reported to the CQIT and quarterly to the QMC.

2. Coordination of Care with the Primary Care Physician TDC’s Care Coordination staff will ensure there is evidence of a release of information in order to collaborate with primary care physicians related to connection with health and behavioral health issues. The QM Department will continue to collect data via NC-TOPPS regarding satisfaction with physical health and report any substandard results to the QMC. Data will be aggregated semi-annually. TDC’s care managers will ensure major physical health needs are coordinated with Care Coordination staff on a case by case basis.

C. Evaluation of the Effectiveness of Services The Quality Management Committee will evaluate the effectiveness of services provided to enrollees and families using the methodologies described below. The QMC will recommend appropriate corrective actions whenever substandard care and services, or opportunities to improve care and services, are identified. When the data indicate that structures, processes or outcomes have fallen outside an acceptable threshold, the appropriate responsible resources will be identified and a corrective action plan is developed by QM Department staff and submitted to the QMC. The QMC will review implementation of corrective action plans and continue to make recommendations until the issue or concern is resolved. The following domains and methodologies will be included: 1. Access to Services

Alliance Behavioral Healthcare’s standards for access to services are described in the policy and procedures manual, and in the Access to Services Policy and Procedure. The Quality Management Committee will review access to services using the following methodologies:


23


a. TDC utilizes annual satisfaction data as well as Screening, Triage, and Referral (STR) and Utilization Management (UM) data on the following:

• Percentage of enrollees and families reporting that the time of service was convenient

• Percentage of enrollees and families reporting they were able to get their initial appointment within 7 days

• Percentage of enrollees and families who do not feel that the distance to their provider is a problem

• Percentage of enrollees and families reporting that their provider is conveniently located

• Percentage of enrollees and families reporting that their first appointment was timely

b. Prevalence rates, which are defined as rates of eligible members accessing behavioral health and developmental disability services will be reported to the QMC quarterly.

2. Authorization/Utilization Management and Appeals

TDC’s standards for service authorization/utilization management and the appeals process are described in the UM Process and Clinical Guidelines Policies and Procedures. The QMC will review service authorizations and appeals via the following methodologies on at least a quarterly basis:

• Number of peer reviews, number of denials/reductions, by county, service type, and level of care

• Number of enrollee and provider appeals, by a county, and level of care • Rate of resolution of denials/reductions and appeals, within prescribed

timeframes, by county, and level of care • Hearings (if applicable)

3. Treatment Outcomes and Clinical Quality Improvement Activities

TDC’s QM Department will monitor treatment outcomes through the methodologies described below. However, note that the research activities described are subject to special confidentiality restrictions for drug and alcohol abusers, as defined in by the U.S. Department of Health and Human Services (42 CFR, Part 2), and the activities will not occur where these restrictions apply and/or if releases of information and consent are not provided.


24


TDC will evaluate the following domains in order to measure treatment outcomes:

• Reduction of Symptoms. In accordance with the methodology developed by the Mental Health Statistics Improvement Program (MHSIP), use of selected items from the SF-36 and the Symptom Distress Scale are recommended as the basis for measuring reduction in symptoms and improvement in health status for the adult and child/adolescent population. These items are contained in the annual enrollee and family member satisfaction survey and in NC-TOPPS.

• Follow-up after Inpatient Psychiatric Admission. TDC will monitor the rate of follow-up by providers as reported in the State Performance Contract Community Systems Improvement report on a quarterly basis. The targeted annual improvement is to have more than 75% of individuals discharged from psychiatric hospitals to have a follow-up appointment within 7 days of discharge.

• Readmission Rates. TDC will provide reports on a quarterly basis to the QMC showing readmission rates within an acute level of care during the following intervals: 0-7 days, 8-30 days, and within 90 days. Readmission data will be reported on a monthly basis to the CCMT, and will be stratified by inpatient psychiatric and Durham Center Access crisis facility, by age group.

• Outcome/Evaluation Studies:

Improving Recovery Environments. The NC-TOPPS program is not ideal at this time to review and analyze recovery related outcomes of individuals with severe and persistent mental illness. The Recovery Oriented Systems Indicators Measure (ROSI) has been standardized and allowed to be used in public domain. TDC has not measured recovery specific outcomes of the population served in over two years, and therefore will conduct a study with this measure with the Critical Access Behavioral Health Agencies (CABHAs) serving enrollees in Durham, Cumberland and Johnston counties. Data will be analyzed and reported to the QMC in the spring of 2012 that will provide insight regarding the recovery environments among the CABHAs.

Recovery Readiness for Behavioral Health Staff. Recovery awareness and readiness among behavioral health providers is crucial to helping enrollees reach their full potential of wellness. The CABHA staff will be requested to complete the Recovery Knowledge Inventory (RKI), developed by the Yale Program for


25


Recovery and Community Health, in order to assess if additional training and provision of other tools for practitioners is needed. Data will be collected and analyzed in the fall of 2011, with a full report of findings presented to the CAC, CCMT, PAC and QMC in the spring of 2012.

Durham Center Access Crisis Facility Quality of Care. An assessment of key indicators to quality of care will be conducted during the fiscal year to assess family involvement, coordination of outpatient follow-up, and medication rationale documentation for all enrollees discharged in 2010. Improvement strategies will be developed from the findings with a report to the CAC, CCMT, PAC, and QMC in late spring of 2012.

D. Evaluation of the Quality and Effectiveness of Internal Processes All internal policies and procedures will be reviewed annually and revisions made as warranted.

1. Telephone Access Standards and Responsiveness

TDC’s standards for telephone access are described in the Policy and Procedures Manual. The procedures for monitoring telephone access are described below:

• Total number of calls • Total number of calls answered • Total number of calls abandoned • Average speed to answer • Average hold time • Average abandonment delay • Average speed to answer • Overall abandonment rate • Average length of call

2. Responsiveness and Accuracy of Member and Provider Services

The TDC QM Director will oversee separate enrollee and provider satisfaction surveys annually in order to assess the responsiveness and accuracy of enrollee services. Enrollee and provider comments, both negative and positive, will be


26


incorporated into the analysis. Findings of the surveys will be reported to the CQIT, CFAC, and QMC annually.

3. Overall Utilization Patterns and Trends

The QM Department will create reports for monthly and quarterly reporting on accessibility, productivity, and cost effectiveness. The reports will include the following statistics as a minimum:

• Enrollee volume by county • Enrollee volume per age, gender, race, diagnosis • Volume by level of care • Annual percent change • Utilization rates by service and rate per thousand • Comparison of authorization rates to actual services utilized

4. Grievance Tracking Process

TDC’s standards for processing grievance grievances are described in the Grievance and Investigation Management Policy and Procedure, and in the enrollee and provider services manuals/documents. The procedures for monitoring the processing of grievances are described below:

All grievances will be entered, routed, monitored, and reported from TDC’s internal Avatar data system. Tracking numbers are assigned that are used to identify the grievance in the database. The grievances are concurrently entered in the Avatar system. QM Department staff conduct review of the grievances on a monthly basis with a report to the Corporate Compliance Committee monthly and to CQIT, Human Rights, and QMC quarterly.

Elements reported are (at a minimum):

• The number of grievances received, by type • The number of grievances resolved • The number of grievances processed with the required timelines • The number of grievances by level of care • Grievance notification letters processed within the required timelines • Grievances that resulted in an investigation by Compliance Staff

5. Peer Review and Appeals Tracking Process


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All peer review and appeal activity will be entered, monitored and reported via Avatar. These processes are coordinated daily by the UM Director to assure accordance with timeliness guidelines. TDC QM staff will prepare a quarterly report identifying peer review and appeal activities as listed below:

• The number of authorizations approved, denied, and reductions of care • The number of peer reviews conducted • The result of the peer reviews • The number of reviews processed within required time frames • The number of appeals received, resolved and processed within the

required time frames • The number of appeals referred to the state and/or Office of

Administrative Hearings

6. Inter-rater Reliability

One element of TDC’s QM Department is to be able to demonstrate to members and stakeholders that utilization management decisions are made in a fair, impartial, and consistent manner so that the best interest of the enrollees is served. TDC has adopted policies and procedures as well as Medical necessity Criteria that is based on scientific evidence and stakeholder input. TDC will be appraising the consistency with which all staff that makes clinical decisions applies the guidelines and criteria through inter-rater reliability studies. These will be conducted monthly and reported to UM monthly, CQIT and QMC quarterly.

No person may participate in the review and evaluation of any case or clinical activities in which he or she has been professionally involved or where judgment may be compromised. Utilization Management decision making is based solely on the clinical appropriateness of the care and services needed. TDC does not incentivize individuals engaged in utilization review for issuing denials of coverage or service, or for rendering decisions that result in underutilization. Psychiatrists, psychologists, and other behavioral health professionals who carry out care management or peer review activity must be free from conflict of interest when reviewing the work of providers. This also means that clinical staff, including peer reviewers, must not review the work of any health care facility or entity where they have active staff privileges and treat enrollees or from which they derive any income.


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E. Evaluation of the Quality and Performance of the Provider Network 1. Provider Profiling

TDC will use a comprehensive provider profiling system to focus on the assessment of care delivery and patterns and trends in care, rather than on individual occurrences of care. The provider profiling system serves as a quality management tool designed to support administrative and clinical processes. One major data source for provider profiling and enrollee outcomes is the North Carolina Treatment Outcomes Program Performance System (NC-TOPPS). Data from NC-TOPPS will be utilized to determine and analyze trends in enrollee outcomes related to self-sufficiency (employment, education, substance use, school performance, and quality of life). When the data indicate that structures, processes or outcomes have fallen outside an acceptable threshold, the appropriate responsible resources are identified and a corrective action plan is developed. The TDC Corporate Compliance Department develops and oversees implementation of the corrective action plans, and monitors performance standards in order to determine if and when improvement is achieved.

The TDC Corporate Compliance Committee is comprised of representatives from Senior Management, Network Operations, Clinical Operations, and Quality Management staff. The CCC meets to review outlier data based on indicators that are one or more standard deviations from the mean. If warranted, action plans are developed and progress toward resolution is monitored.

All reports will be submitted to the TDC CEO, CQIT, and QMC. Additionally, report cards are disseminated to the appropriate network providers. Provider profiling information will be reported on the following levels of care for FY2012-2013, subsequent to claims lag:

• CABHAs • ACT Teams • Community Support Teams • Psychosocial Rehabilitation • Substance Abuse Intensive Outpatient Programs • Substance Abuse Comprehensive Outpatient Treatment • Developmental Disability Services

2. Coordination with Other Service Agencies and Schools

Appropriate and timely coordination of services among inpatient and outpatient behavioral health agencies, practitioners, ancillary providers, consultants, juvenile justice, criminal justice, social services, schools and other pertinent agencies


29


enhances the likelihood of successful treatment outcomes for enrollees. Communication among these entities allows for appropriate and timely interventions on the part of the responsible agency, resolution of problems during the early phases of treatment, and adequate discharge and transition planning. It is the combination of these factors, added to the treatment services provided by the clinician and the active participation of the enrollee that allow for successful resolution of the issues related to enrollee’s care needs.

TDC monitors the coordination of services via a System of Care database that is integrated with the internal Avatar system.

3. Network Management

TDC strives to assure that its provider network offers the full array of services to enrollees. The TDC UM Utilization Review Criteria and Accessibility of Services policies and procedures reflect guidelines used.

The TDC Provider Network Operation Director and/or designee will present a written quarterly report to the CQIT and QMC indicating:

• Results of routine and on-site monitoring • The network provider capacity and gaps report • Changes in the provider network including new provider and provider

implementations • Evidence-based and culturally competent practices • New program implementations • Prevention Education and Outreach Activities Report • Authorized out-of-network and out-of-area providers • Exception Report (GeoAccess) • GEOAccess to be updated annually • Provider choice confirmation • Training needs

4. Quality of Service Management Planning by Providers

TDC’s Monitoring of Providers Policy and Procedure describes monitoring services. The Corporate Compliance Unit currently monitors providers based on the Frequency and Extent of Monitoring (FEM) tool. Based on findings from the FY2011-2012 monitoring report, activities will be targeted and a sample of clinical records will be audited to determine if levels of care are followed appropriately. Also included in the provider clinical record audit process is a review of compliance with treatment guidelines for ADHD, Major Depression, Bipolar Disorder and


30


Schizophrenia, as well as fidelity to best practice services, such as ACTT and CST. Scores for treatment guidelines are included in the report card sent to providers and monitored in aggregate formats for needed performance improvement plans.

5. Provider Satisfaction Survey Data

Satisfaction survey data regarding providers is reviewed annually in order to compare year to year trends to identify areas that have improved and any areas that may required a new action plans. Providers, members and staff offer input into the questions and information needed from providers regarding TDC’s management and service continuum in order to have more meaningful data. The Quality Management Director shares provider survey data with each TDC Department Manager, develops strategies and follows-up on the strategies at determined points in time. Data are also reported out to the provider community via various mechanisms and committees and to TDC’s Board of Directors.

F. Reporting of Suspected/Substantiated Fraud and Abuse TDC’s policy and procedures for reporting of fraud and abuse are contained in the Information Systems Policies and Procedures and in Claims Fraud Policy and Procedures. These policies and procedures incorporate the following items:

• Definitions of fraud and abuse • Accountable staff/function • Reporting requirements of staff and providers • Time frames • Integration with Quality Management

Internal staff training is conducted annually by the Corporate Compliance Unit.

A report will be written quarterly by Corporate Compliance and presented to the Corporate Compliance Committee, CQIT and QMC. Following are the items to be included:

• All allegations of fraud and/or abuse, by type of event, redactd to protect confidentiality

• All substantiated instances of fraud and abuse • Analysis of any trends/patterns • Actions taken and improvement implemented

The Corporate Compliance Committee will take appropriate corrective actions whenever substandard care and services, or opportunities to improve care and services, are identified.


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G. Clinical Records Content, Retention and Storage Records Management is handled by the Corporate Compliance Department. TDC’s policies and procedures for clinical records content, retention, and storage are contained in the Confidentiality Policy and Procedure. Additionally, TDC will adhere to the detailed requirements for HIPAA compliance. TDC will take the following physical and procedural steps to ensure the confidentiality of enrollee records:

Physical Security:

• TDC stores all clinical history information in secured files 24 hours per day, seven days per week, with limited access

• TDC staff will not discuss enrollee personal behavioral and other health information with unauthorized personnel

• All claims are stored in files with limited access • When data/documents are to be destroyed Compliance staff follow the

policy and procedures related to this component

Information Systems Security:

TDC will ensure the integrity and confidentiality of all data in accordance with federal and state laws regarding HIPAA and 42 CFR. TDC’s MIS system uses physical controls, data segregation and password protection. Each individual staff has a log-on and confidential password for each level of access. All passwords are protected and do not show up on the screen.

Staff Training:

All staff are required to take HIPAA Confidentiality training upon initiation of employment and annually thereafter. This training is conducted by the Corporate Compliance Officer and/or designee and indicated on the TDC Master Training Plan.

9. CONFIDENTIALITY

All documentation that is created as a result of the TDC QM Program is confidential, and will be maintained in compliance with applicable legal requirements. Such documentation includes, but is not limited to, QMC minutes, quality management data and reports, records of clinical care and services, and administrative records and reports. All participants in QMC meetings, including both QMC members and guests, will sign a statement attesting to the foregoing as they become a member of the committee. Each fiscal year a new confidentiality statement will be signed by QMC members. New guests will also sign a confidentiality agreement at the first meeting attended.


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10. EVALUATION AND UPDATE PROCESS

The TDC Quality Management Work Plan is continuously evaluated and updated, in order to determine the overall effectiveness of the Quality Management Program. The evaluation will result in an annual written report which includes:

• A description of completed QM activities • Ongoing QM activities • Trending of measures to assess performance in the quality of clinical care

and quality of service delivery • An analysis of whether there have been demonstrated improvements per

TDC’s Strategic Plan

The results of the QM annual evaluation are reported to the CQIT, TDC Management, QMC and the board of directors.

Alliance Behavioral Healthcare Managing Behavioral Health & Developmental Disability Services | 33

Quality Management Work Plan and Program Description FY 2012-2013

Attachment A: Matrix of Reports

ALLIANCE BEHAVIORAL HEALTHCARE COMMITTEE REPORTS MATRIX - REVISED July 2011

COMMITTEE Report # Require

d by: REPORT STAFF

DATE PRESENTED TO

THIS COMMIT

TEE

Date for CQIT to Review

DATE SUBMITTED TO Board COMMITTEE

DATE GOES

TO BOARD

DATE GOES

TO STATE QMC

Human Rights CFAC

Finance

Corporate Compliance (C) Chairperson: Monica P. Purpose & Tasks: Responsible for ensuring TDC, its employees, and contractors are acting in accordance with laws, regulations, ordinances, and rules. Tasks include: develop compliance-related policies, standards, procedures for TDC; develop & implement training for staff about requirements; audit and monitor application of requirements; develop & implement process for internal reporting and investigation of inappropriate activities; develop & implement disciplinary actions to address non-compliance.

QM Staff Rep: Lena and Melissa. Other Staff as needed.

Participants: Provider Relations, QM Director, Customer Service Director, Contracts Director, Care Coordination Director, and Deputy Director

To be Reported June 2011 PR-02-C

State 9.2.2, 5.5

Provider Monitoring Results (all elements in 5.5) Monica P. Quarterly Quarterly Quarterly N/A Quarterly

Reported Sept 2010 QM-02-O/C

State 9.2.1 Grievances-Quarterly Trends Melissa Quarterly Quarterly Quarterly

Quarterly N/A Quarterly

Reported Sept 2010 QM-13-C State 9.2.1

Incident Reports-Quarterly Trends Melissa Quarterly Quarterly Quarterly

Quarterly N/A Quarterly

Reported Sept 2010 QM-09-C State 9.3 NC-TOPPS Compliance Hilda Quarterly Quarterly N/A N/A N/A N/A

To be Reported July 2011 QM-10-C State 5.5 First Responder Report Hilda Semi-Annually

semi-Annually

Semi-Annually N/A N/A

Reported Sept 2010 QM-18-C State 9.2.2 Plans of Correction Trends Melissa Quarterly Quarterly Quarterly N/A N/A

Reported April, May 2011 IT-1-C URAC IT Data Integrity Report IT Quarterly Quarterly N/A N/A N/A N/A

Management Team (M) Chairperson Ellen/Rob

Purpose & Tasks: To provide an opportunity for participants to report on important activities within their Units and to discuss issues that directly (or potentially) impact other Units. QM Staff Rep: Lena

Participants: Managers from each unit, Director of Communications, Executive Secretary, Quality Assurance Specialist

Planned for July 2011 AD-07-M TDC Management Report Rob/Susan Quarterly Quarterly N/A N/A N/A

Planned for July 2011 FIN-02-M State 9.2.3 Claims (Administrative) Kelly Quarterly Quarterly N/A Quarterly Quarterly

Planned for July 2011 QM-11-M URAC Provider Satisfaction Melissa Annually Annually N/A Annually Annually Planned for July/August 2011

QM-05-M/O

State 9.2.1 Enrollee Satisfaction Hilda

Semi-Annually

Semi-Annually

Semi-Annually

Semi-Annually

Semi-Annually



COMMITTEE Report # Require

d by: REPORT STAFF

DATE PRESENTED TO

THIS COMMIT

TEE



DATE GOES

TO BOARD

DATE GOES

TO STATE QMC

Human Rights CFAC

Finance

Reported in 2010 QM-14-M State 5.1 Strategic Plan Lena/Tina Every 3 years

Every 3 years

Every 3 years

Every 3 years

Every 3 years

Every 3 years

To Report June 2011 QM-15-M State 5.1 Needs & Gap Analysis Update (includes stakeholder survey) Tina/Lena Annually Mar/Apr Annually Annually Apr/May July

RPT 4/1/2009 (Planned for July 2011) AD-06-O TDC Climate Survey Lena

Every 2 years

Every 2 years N/A N/A

RPT 1/1/2010 (Planned for July 2011) TR-01-O TDC CFAC Survey Hilda Annually Annually Annualy N/A

March 2010 Last Report AD-03-H CARF Health & Safety Report Doug Annually Annually Annually N/A N/A

Community Systems Improvement (S) Chairperson: Sean Purpose & Tasks: Review programmatic data and enrollee outcomes, identify and address service gaps, explore trends and make policy recommendations based upon this information, review and approve RFPs from PDAC Committee, examine the clinical implications of ongoing state and federal funding reductions/increases and make recommendations on how to address these issues from a clinical perspective. QM Staff Rep: Tina

Participants: Specialists, QM Director, Care Coordination Director, Customer Service Director, Contracts Director, Evaluator

To Be Revised July 2011 SOC-01-S TDC Care Review Reports Kenitra Quarterly Quarterly N/A N/A

Presented Nov 2010 QM-02-S State 9.2.1, 2 DD Reports Hilda Quarterly Quarterly


Presented Jun-10, Jan 2011 QM-04-S

State 9.2.1, 2 Adult MH Reports Tina Quarterly Quarterly


RPTD July 2010, Jan, Mar 2011 QM-03-S

State 9.2.1, 2 SA Reports Tina Quarterly Quarterly


RPTD July 2010, Jan, Mar 2011 SOC-02-S

State 9.2.1, 2 Child MH Reports Tina Quarterly Quarterly


RPTD July 2010, Jan, Mar 2011 SOC-07-S

State 7.3.5 Housing Initiative Reports

Stephanie W./Tina Quarterly Quarterly


Presented July 2010 TR-02-S State 9.2.2 Training reports Carla Annually Annually Annually N/A N/A

To Be Developed June 2011 PD-02-S

State 9.2.2 Technical Assistance Reports

Program Development Quarterly

semi-Annually


To Be Developed June 2010 QM-15-M State 5.1

Needs Assessment: Cultural/Linguistic Competency Results Tina Annually Annually Annually Annually N/A

Presented Mar 2011 QM-01-S

State 9.2.2 (EBPs) Area Board Dashboard Report Tina/Lena

Semi-Annually Jan/Aug

Semi-Annually Feb/Sep N/A

Presented Jun-10, Nov-10 QM-16-S State 9.2.3 Durham Assessment Team Tina Quarterly Quarterly




COMMITTEE Report # Required

by: REPORT STAFF

DATE PRESENTED TO

THIS COMMIT

TEE



DATE GOES

TO BOARD

DATE GOES

TO STATE QMC

Human Rights CFAC

Finance

Program Development Advisory Committee (P) Chairperson: Terry

Purpose: Review and provide input on all Requests for Proposal. QM Staff Rep: Tina

Participants: Specialists, representatives from CFAC with experience in all three disability areas

All reports are sent to the CSI Committee PRN

Utilization Management/Utilization Review (U) Chairpersons:

Sean & Dr. Tanas Purpose & Tasks: Insure compliance with relevant Medicaid, State and URAC standards, analyze

its performance against key indicators, examine important trends and issues that can be extrapolated from utilization review data (service trends, use of high cost services, and explore request patterns among providers), and to approve the state funded enrollee benefits package and review all North Carolina Division of Medical Assistance Clinical Coverage policies relevant to service. QM Staff Rep: Tina

Participants: MCO UM Managers, Provider Relations Representative, IT representative, Director of Quality Management or designee, Customer Services representative and the MCO Finance Director

Presented Aug 2010 CC-03-O

State 9.2.3, URAC Call Center/STR Results Sean S./Tina Monthly Quarterly Quarterly N/A N/A

Presented Aug 2010 QM-07-U Medicaid Inter-Rater Reliability Tina Monthly Quarterly N/A N/A

Presented Jul 2010, Jan 2011 UM-01-U

Medicaid, URAC, State 9.2.3

Authorizations/UM (Hospital/Crisis vs. Non-Hospital); Turnaround Time Tina Monthly Quarterly Quarterly N/A Monthly

Report in June 2011 UM-06-U State 9.2.3 High Cost Tina Monthly Quarterly Semi-Annual N/A Quarterly

Report in June 2011 UM-03-U/CMT URAC

PCP Reviews-will start in Feb 2011 Tina/Lena Monthly Quarterly

Semi-Annual N/A N/A

To Be Developed June 2010 PR-04-U State 9.2.2

Needs Assessment: Service Capacity Results (providers by service, waitlists) Tina

Semi-Annual

Semi-Annual

Semi-Annual N/A N/A

Report in June 2011 Medicaid, URAC UR appeals Lena Monthly Quarterly

Report in June 2011 Medicaid, URAC Adverse letter audit Lena Monthly Quarterly

Presented Oct 2010 UM-04-O State 9.2.3

Quarterly Access & Prevalence Rates (State) Tina Quarterly Quarterly Quarterly Quarterly Quarterly

Report in July 2011 QM-08-O State 9.4 Mystery Caller Melissa Semi-Annually Annually Annually N/A Annually



COMMITTEE Report # Required

by: REPORT STAFF

DATE PRESENTED TO

THIS COMMIT

TEE



DATE GOES

TO BOARD

DATE GOES

TO STATE QMC

Human Rights CFAC

Finance

Budget and Finance Committee (F) Chairperson: Kelly

Purpose & Tasks: QM Staff Rep: Lena Participants:

Presented Jan 2011 FIN-04-F State Balance Sheet Kelly Monthly N/A N/A Quarterly Monthly N/A To be Reported in July/Aug 2011 State Annual Budget

Annually Annually Annually

Clinical Care Management Team (CM) Chairperson: Dr. Tanas Purpose & Tasks: Clinical supervision and group discussion with TDC Medical Director of any challenging clinical situations that come to our attention, monitor clinical services provided by the Durham County network of Providers, works side by side with other efforts at TDC to improve effectiveness and enrollee outcome, coordinate its clinical protocols within the agency, improve efficiency, reduce duplication and ensure a focus on meeting performance standards of UM, DHHS and URAC. QM Staff Rep: Lena

Participants: UM Director, QM Director, Care Coordination Director, Customer Service Director, Specialists, QM Specialist, Contracts Director, Contracts & UM staff, Quality Assurance Director

To Be Developed July 2011

SOC-06-CMT State 7.2 Care Coordination Kenitra Quarterly Quarterly

Semi-Annual N/A Monthly

Presented June 2010, Jan 2011

QM-08-U/CMT

State 9.2.1 Durham Mobile Crisis Team Lena Quarterly Quarterly Quarterly Quarterly N/A


PD-01-U/CMT

State 9.2.1 Durham Center Access (DCA) Lena Quarterly Quarterly Quarterly Quarterly N/A

To Be Reported June 2011

SOC-03-CMT

State 9.2.1 High Risk Enrollee Data Kenitra Quarterly Quarterly Quarterly Quarterly N/A

Presented Jan 2011 QM-17-CMT

State 9.2.1

Hospital Trends ED vs. Non-ED Lena Quarterly Quarterly Quarterly Quarterly N/A


QM-04-CMT

State 9.2.1 Hospital Admissions Lena Quarterly Quarterly Quarterly N/A N/A


QM-05-CMT

State 9.2.1 Hospital Re-Admissions Lena Quarterly Quarterly Quarterly N/A N/A


QM-08-CMT

State 9.2.1 Psychiatric Walk-In Service Lena Quarterly Quarterly Quarterly N/A

Bi-Annual

Presented Jan 2011 QM-19-CMT TDC Emergency Department Report Lena

Semi-Annual

Semi-Annual

Semi-Annual Annually N/A

To be Reported July/August 2011

QM-09-CMT

State 9.2.4

Evidence of health exam in last 15 months Lena Annually Annually Annually N/A N/A



Attachment B: Quality Improvement Projects for FY2012

Project Name Project Description Data Source(s) Duration Resources Needed

Notes TDC Staff Recommendation

Durham Center Access (DCA) Repeat Admissions Analysis

Concern: Lack of focused discharge planning for enrollees discharged from DCA. There is a high readmission rate among enrollees who do not have an established provider. What the Data show: Approximately 40% of individuals leaving DCA do not have an established provider. QI Project: Implement a focus on discharge planning via the care coordination unit of TDC to ensure individuals discharged are connected to a provider and that the enrollees show for their appointments (by phone call reminders and working with the provider to make contacts). Goal/Desired Outcome: At least 80% of individuals discharged from DCA will have an established provider. At least 70% of individuals discharged from DCA are seen by a provider within 7 days.

Discharge planning notes of individuals discharged from DCA.

July 1, 2011 through December 31, 2011 of enhanced discharge planning from DCA.

Care Coordination staff. QM Staff to implement data tracking, analysis and reporting of findings.

Data will be collected from Care Coordination staff to track enrollees and report status in January of 2012.

Recommended by QM Committee

Repeat Admissions to DCA of Children and Youth

Concern: Admissions of children and youth to the DCA facility continue to rise. Reviews of the preliminary data indicate that many youth are repeaters to DCA. All children and youth should have active providers that prevent triggers for crisis events. What the Data Show: Approximately 35% of youth presenting at DCA are not connected to a provider. During Jan-Dec of 2010, 16% (20 of 122) of youth were readmitted to DCA and of those, 9 still did not have a provider even after being admitted to DCA before. QI Project: Implement a focus on discharge planning via the care coordination unit of TDC to ensure individuals discharged are connected to a provider and that the enrollees show for their

DCA Authorization Data and Claims

July 1, 2011 through December 3, 2011 of enhanced discharge planning from DCA

Care Coordination staff. QM Staff to implement data tracking, analysis and reporting of findings.

Data will be collected from Care Coordination staff to track enrollees and report status in January of 2012.

Recommended by QM Committee



Project Name Project Description Data Source(s) Duration Resources Needed

Notes TDC Staff Recommendation

appointments (by phone call reminders and working with the provider to make contacts). Goal/Desired Outcome: There will be a 50% decrease in child/youth readmissions to DCA between July 1 and December 31, 2011.

Retention of Individuals in Substance Abuse Treatment

Concern: More enrollees with SA issues should remain in treatment. The rate of crisis events at DCA and Duke ED continue to be high among people with SA diagnoses. What the Data Show: Only 53% of SA enrollees come to 4 visits in the first 45 days. Proposed project: Implement a focused effort for providers of SA services to stay connected to the enrollees. Increase TDC’s care coordination role to call providers regarding enrollees who show in NC-TOPPS as not staying connected (at least 4 visits within 45 days). Goal/Desired Outcome: Increase the percent of SA enrollees going to at least 4 visits within the first 45 days.

Paid Claims Provider Reports Substance

Abuse Study

July 1, 2011 to December 31, 2011

Care Coordination staff, providers and QM staff

Recommended by QM Committee.



Attachment C: FY 2010 – 2013 Strategic Plan, Updated for 2011 (edits in red italics)

GOAL 1: ALLIANCE BEHAVIORAL HEALTHCARE MCO ADOPTS EXEMPLARY PRACTICES IN MANAGING CARE FOR ENROLLEES AS A COMPREHENSIVE BEHAVIORAL HEALTHCARE ORGANIZATION. OBJECTIVES BENCHMARKS STRATEGIES STATUS 1.1: Engage in exemplary practices to improve quality of providers and the MCO.

1.1A (1): Review and assess current compliance procedures, policies, forms, and committee membership by March 2011. 1.1A (2): Implement recommendations for changes from the assessment by June 30, 2011.

1.1A: Review and strengthen Corporate Compliance program.

1.1A (1): Met. 1.1A (2): In process, to be completed by August 2011.

1.1B (1): Update FEM scores for CABHA certified providers by August 10, 2010. 1.1B (2): New Provider Monitoring Tool & Policy implemented by September 1, 2010. 1.1B (3): Meet state benchmark for monitoring providers by June 30, 2011.

1.1B: Provider monitoring is standardized and complies with state requirements.

1.1B (1): Met. 1.1B (2): Met. 1.1B (3): On target to meet goal.

1.1C: TDC will create a plan to train providers, stakeholders, and MCO staff based on needs identified in Strategic Plan and continuous input from community by June 30, 2011.

1.1C: Ensure providers and MCO staff receive high quality training to improve services to enrollees and their natural supports.

1.1C: In process.

1.1D (1): Required reports created by September 20, 2010 and pulled on regular basis. 1.1D (2): Medicaid data analyzed on monthly basis starting in September 2010.

1.1D: TDC regularly analyze Medicaid UR funding and services data to improve quality.

1.1D (1): Met. 1.1D (2): Met, data analyzed on a monthly basis.

1.1E (1): TDC to become accredited for Health UM & Core standards by URAC by January 1, 2011.

1.1E: TDC will implement improved business practices through national accreditation (UM & Core Health Standards by URAC).

1.1E (1): Met, Alliance Behavioral Healthcare is URAC accredited under UM & Core standards.

1.1F (1): TDC to become URAC accredited for Health Call Center and Network Administration by January 2012.

1.1F: TDC will implement improved business practices through national accreditation (Call Center & Network Administration by URAC).

1.1F (1): Alliance Behavioral Healthcare will apply for Call Center accreditation in July 2011. Network Admin pended, discussion with TDC leadership.



OBJECTIVES BENCHMARKS STRATEGIES STATUS 1.1: Engage in exemplary practices to improve quality of providers and the MCO.

1.1G: TDC will have fully operational & automated IT system to support reports and databases by June 30, 2011.

1.1G: TDC will implement improved business practices to include a fully operational & automated IT system for managing authorizations, service decisions, and claims adjudication.

1.1G: In process, IT Strategic Plan created in June 2011.

1.1H: Final expenditures will not over spend or under spend budgets by more than $500,000 each fiscal year.

1.1H: TDC will ensure that budgets are spent according to priorities set by TDC’s Finance Committee and Board of Directors.

1.1H: In process, on target to meet goal.

1.1I (1): TDC identify partners and prepare application for Medicaid waiver by May 20, 2011. 1.1I (2): If Waiver designation is awarded, TDC and its partners will implement plan for Waiver by January 2013.

1.1I: TDC meet all standards and requirements to operate a Medicaid Waiver by January 2013.

1.1I (1): Application was submitted on time, Cumberland and Johnston MCOs identified as partners. 1.1I (2): TDC will be notified August 1 if Waiver designation is awarded.

1.1J (1): 50% of state funded outpatient providers will use evidence-based and evidence-informed practices by June 30, 2012; % will increase to 75% by June 30, 2013. 1.1J (2): IPRS benefit packages will incorporate outreach and best known management practices for all disability areas by July 1, 2013.

1.1J: Increase use of evidence-based and best practices for ALL disability services.

1.1J (1): 57% of enrollees participate in evidence-based services. 1.1J (2): New objective, will be implemented in FY 12.

1.2: Increase enrollee and family engagement in services.

1.2A: Study of transportation needs conducted by June 30, 2011.

1.2A: Collaborate with public transportation to address needs of enrollees.

1.2A: Geo-map created to plot locations of providers and bus routes; will add enrollees.

1.2B (1): The engagement of services by all disability groups will, at the minimum, meet State standards by June 30, 2011.

1.2B-D: TDC will ensure higher levels of engagement into services are achieved for all disability groups.

1.2B (1): Met



OBJECTIVES BENCHMARKS STRATEGIES STATUS 1.2: Increase enrollee and family engagement in services.

1.2C (1): The engagement rate for all disability services will exceed the state average by a minimum of 10% by June 30, 2013.


1.2C (1): Goals/3rd Q data: MH: 45%/42%, in process. DD: 69%/63%, in process. SA: 66%/70%, met.

1.2D (1): Approximately 40 – 45% of enrollees in state-funded substance abuse outpatient remain in service for longer than 90 days. Increase % of enrollees who stay for more than 90 days to 55% by June 30, 2013.


1.2D (1): Not met, QIP in FY 12 to increase retention in substance abuse services.

1.2E (1): TDC will have partnered with at least 1 agency to expand family support by June 30, 2012. 1.2E (2): SOC will recruit and train family members and recipient of services to serve on Care Review Team by December 31, 2011.

1.2E: Develop plan to create or expand parent/ family support services.

1.2E (1): Objective to be implemented in FY 12. 1.2E (2): Objective to be implemented in FY 12.

1.2F: TDC will have partnered with NAMI, Duke Psychiatry, or other agency to provide 2 medication trainings by June 30, 2012.

1.2F: Develop plan to educate enrollees and family members on psychotropic medications.

1.2F: Objective to be implemented in FY 12.

1.3: Establish meaningful and measurable outcomes for providers.

1.3A: TDC will develop an evaluation plan for the agency that includes meaningful and measurable outcomes by June 30, 2010.

1.3A: TDC’s Evaluation Plan will create purposeful Benchmarks and MCO/Provider Outcomes.

1.3A: Met.

1.3B (1): Establish baseline data for provider performance by June 30, 2011. 1.3B (2): By June 30, 2012, improve provider performance from baseline.

1.3B: Evaluate impact of services across public systems in order to improve care for enrollees.

1.3B (1): Data is being compiled and report will be completed by August 2011. 1.3B (2): Objective to be implemented in FY 12.



GOAL 2: IMPROVE QUALITY OF LIFE AND OUTCOMES FOR ENROLLEES AND THEIR FAMILIES/NATURAL SUPPORTS. OBJECTIVES BENCHMARKS STRATEGIES STATUS 2.1: Ensure services are based on individuals’ and family’s needs.

2.1A (1): Per a review of sampling PCPs, establish baseline data for appropriateness of PCPs by June 30, 2011. 2.1A (2): By June 30, 2012 there will be a 30% improvement in documentation per established baseline data. 2.1A (3): TDC will provide or sponsor training related to effective person-centered planning.

2.1A: TDC will ensure that services are based on individual enrollee and family needs via Person-Centered Planning adherence among provider agencies, prioritizing those agencies serving individuals with developmental disabilities.

2.1A (1): Making progress, 40 PCPs have been reviewed. 2.1A (2): Objective to be implemented in FY 12. 2.1A (3): New objective, to be implemented in FY 12.

2.1B (1): TDC’s Cultural Competency Committee will determine a mission and vision for the community and providers by August 31, 2010 June 30, 2011. 2.1C (1): Representatives from at least 20% of providers attend cultural competency training by June 30, 2011. 2.1B (2): TDC will incorporate culturally competent goals, objectives and outcomes for providers and the MCO by June 30, 2011.

2.1B: Incorporate cultural competent definitions, goals, objectives and outcomes with providers and the MCO.

2.1B (1): Met. 2.1B (2): Not met, need to identify strategies with CESD.

2.1C (1): TDC will assess its internal cultural competency and the competency of providers in its network by June 30, 2012. 2.1C (2): TDC will address concerns in internal cultural competency and the competency of providers in its network by June 30, 2013.

2.1 C: Identify and address barriers to delivering culturally competent services

2.1C (1): New objective, to be implemented in FY 12. 2.1C (2): New objective, to be implemented in FY 13.

2.1D (1): Complete high-risk study by August 1, 2011. 2.1D (2): Increase timely engagement of community services after hospital discharge by June 30, 2011. 2.1D (3): Increase diversion from state hospitals by December 31, 2011.

2.1D: Develop individualized services for vulnerable populations involved with multiple systems (high-risk, homeless, transition-age youth, and individuals involved with criminal and juvenile justice).

2.1D (1): Making progress, on target to be completed by August 1. 2.1D (2): Not met. 3rdQ engagement fell to 50% (ADATC) and 51% (psychiatric hospitals). 2.1D (3): Objective to be fully implemented in FY 12.



OBJECTIVES BENCHMARKS STRATEGIES STATUS 2.1: Ensure services are based on individuals’ and family’s needs.

2.1E: Implement Family Psychoeducation toolkit in 2 agencies and expand Family-to-Family programs by June 30, 2012.

2.1E: Provide ongoing connection of families to other community and natural supports.

2.1E: Objective to be implemented in FY 12.

2.1F (1): Expand self-advocacy education such as WRAP, enrollee rights fact sheets, and family blogs by June 30, 2013. 2.1F (2): Support Durham Center’s CFAC.

2.1F: Encourage enrollees and CFAC self-advocacy.

2.1F (1): Objective to be implemented in FY 13. 2.1F (2): TDC continues to support CFAC.

2.2: Provide mechanisms for enrollee (including CFAC), family and provider satisfaction.

2.2A (1): TDC will conduct satisfaction surveys of enrollees, providers, families and other stakeholders at least annually. 2.2A (2): Satisfaction rates among all stakeholder groups will be a minimum of 85% overall.

2.2A: TDC will ensure enrollee, provider, family and stakeholder satisfaction is monitored.

2.2A (1): Surveys administered to enrollees, providers, and CFAC in FY 11. 2.2A (2): Met

2.3: Increase community education in an effort to reduce stigma.

2.3A (1): TDC will create a plan to increase education offered to community members by December 31, 2010. 2.3A (2): TDC will implement the plan by June 30, 2011. 2.3A (3): TDC will collect baseline data via community polling regarding perceptions of individuals with disabilities by June 30, 2011. 2.3A (4): Poll will be repeated, to measure perception change, in April 2013.

2.3A: Create plan, using multiple media sources, to reduce stigma via increased community education.

2.3A (1): Met. 2.3A (2): In process. 2.3A (3): Not met, to be discussed with QMC. 2.3A (4): Not met, to be discussed with QMC.

GOAL 3: DEVELOP ARRAY OF HIGH QUALITY SERVICES AND SUPPORTS. OBJECTIVES BENCHMARKS STRATEGIES STATUS 3.1: Ensure services are available to intervene early with young children.

3.1A (1): TDC will work collaboratively with stakeholders to identify needs and gaps in services by June 30, 2011. 3.1A (2): Develop services as needed for young children by June 30, 2013.

3.1A: Identify needs of very young children with emotional disturbance.

3.1A (1): Progress made, more resources needed for population. 3.1A (2): Objective to be implemented in FY 13.



OBJECTIVES BENCHMARKS STRATEGIES STATUS 3.2: Partner with primary care and other agencies to promote treatment and integration of all services to serve the whole person.

3.2A: TDC will have at least 2 contracted providers that have integrated primary and behavioral health by June 30, 2011.

3.2A: Create a consortium of providers that are interested in integrating primary and behavioral health (MH/DD/SA) care, by June 30, 2011.

3.2A: Met – DCA developed primary care satellite in partnership with Lincoln Community Health, BAART staff co-located at Lincoln.

3.2B: Provide training to 80 professionals in primary healthcare by Dec. 31, 2010.

3.2B: Increase awareness of behavioral healthcare resources among professionals in primary healthcare.

3.2B: Met. 40 professionals attended training in September 2010. Served as model for other trainings around state.

3.2C (1): Co-located DCHN position filled by September 1, 2010.

3.2C: Improve coordination of behavioral and primary health care for enrollees.

3.2C (1): Met.

3.2D (1): DCHN Liaison identifies and provides care coordination to individuals in “Quadrant 4” (severe mental & physical illnesses) by June 30, 2011. 3.2D (2): 25% reduction in hospitalizations of highest risk enrollees (“Quadrant 4”) by June 30, 2013.

3.2D: Reduce hospitalizations of enrollees with complex physical and mental health problems.

3.2D (1): In process. 3.2D (2): In process.

3.3: Partner with community agencies to facilitate expansion of quality services to fill identified gaps.

3.3A (1): TDC will identify specific gaps in trauma-focused care by June 30, 2011. 3.3A (2): TDC will develop a plan and identified funding by June 30, 2012.

3.3A: TDC will identify specific gaps and funding to fill gaps in trauma-focused care.

3.3A (1): Met. Identified TF-CBT, services for offenders, gender-specific, more training, individual therapy. Provided training on TF-CBT. 3.3A (2): Objective to be implemented in FY 12.

3.3B (1): TDC will identify specific gaps in by June 30, 2011. 3.3B (2): TDC will develop a plan and identified funding by June 30, 2012.

3.3B: TDC will identify specific gaps and funding to fill gaps in a new integrated MH/DD service and MH/SA services for criminal justice population.

3.3B (1): Met. Need to increase capacity for youth (MH/DD) crisis services and training. 3.3B (2): Objective to be implemented in FY 12.



OBJECTIVES BENCHMARKS STRATEGIES STATUS 3.3: Partner with community agencies to facilitate expansion of quality services to fill identified gaps.

3.3C (1): Study & implement plan to address transition-aged youth who need independent living by June 30, 2016. 3.3C (2): Decrease % of youthful enrollees missing school due to suspension and expulsion by June 30, 2016.

3.3C: Evaluate needs for transition-age youth.

3.3C (1): To be implemented by end of FY 16. 3.3C (2): To be implemented by end of FY 16.

3.3D (1): Study current substance abuse prevention services in community to identify needs by June 30, 2013. 3.3D (2): If gaps exist, create plan to address needs.

3.3D: Evaluate needs for substance abuse prevention services and create plan to expand, if needed.

3.3D (1): New objective, to be implemented by end of FY 13. 3.3D (2): New objective, to be implemented by end of FY 13.

3.4: Collaborate with other public/ private agencies to expand employment opportunities for enrollees.

3.4A (1): Durham Center & SOC host forum for private businesses by June 30, 2012. 3.4A (2): By June 30, 2013, increase % of enrollees with employment, based on Quality of Life surveys and/or NCTOPPS, by 10%.

3.4A: Educate employers on benefits of hiring individuals with disabilities.

3.4A (1): To be implemented by end of FY 12. 3.4A (2): To be implemented by end of FY 13.

3.5: Develop array of crisis services for youth.

3.5A (1): TDC will develop scope of work by June 30, 2011. 3.5A (2): TDC will complete RFP for services by December 31, 2011. 3.5A (3): Contracted provider will start offering services by July 1, 2012.

3.5A: Develop plan and identify funding to create inpatient beds for youth by June 30, 2011.

3.5A (1): Developed proposal in August 2010, waiting for approval and funding. 3.5A (2): To be implemented in FY 12. 3.5A (3): To be implemented in FY 12.

3.5B (1): TDC will use existing data sources to evaluate effectiveness of current services by June 30, 2011.

3.5B: TDC will evaluate current array of crisis services and identify gaps.

3.5B (1): Making progress, final analysis to be completed in August 2011.



OBJECTIVES BENCHMARKS STRATEGIES STATUS 3.6: Ensure enrollees have access to safe, stable and affordable housing in the Durham community.

3.6A (1): Establish baseline percentage of enrollees who report, on Quality of Life survey, that they have accessible, safe, stable and affordable housing in the community by June 30, 2011. 3.6A (2): Increase, by 20%, enrollees who have safe and affordable housing by June 30, 2013. 3.6A (3): Annually decrease the percentage of homeless individuals who report a behavioral health or developmental disability in Point in Time Count data by 5%. 3.6A (4): Increase the percentage of affordable and accessible housing units available for individuals with disabilities by 20% by June 30, 2011. 3.6A (5): An additional 100 homeless individuals will receive outreach services by June 30, 2011. 3.6A (6): Serve an additional 10% of enrollees through ILI assistance by June 30, 2011.

3.6A: Increase access to affordable, permanent housing for enrollees experiencing or most at risk of homelessness.

3.6A (1): In process. 3.6A (2): To be implemented by end of FY 13. 3.6A (3): In process, next count in January 2012. 3.6A (4): Status to be reported in August 2011. 3.6A (5): Status to be reported in August 2011. 3.6A (6): Status to be reported in August 2011.

3.6B (1): Offer SOAR (disability income) training to 15 direct care staff by June 30, 2011. 3.6B (2): Increase % of eligible enrollees who receive SSI, SSDI, or VA benefits by 20% by June 30, 2012.

3.6B: Prevent homelessness of individuals with behavioral health and/or developmental disabilities and their families.

3.6B (1): Training in April 2011, 20 attended; another training in November 2011. Durham first county in NC to be Gold Certified by SOAR. 3.6B (2): To be implemented in FY 12.

3.7: Expand short-term housing options for enrollees early in their recovery to improve health and stability.

3.7A (1): Establish baseline for average length of stay for Transitional Living and increase by 20% by June 30, 2011.

3.7A: Increase average length of stay in substance abuse Transitional Living programs.

3.7A (1): Met. Baseline is 23 days. By 2nd Q, length of stay increased 22% to 28.1 days.

3.7B (1): Establish baseline for average length of rental assistance and increase by 20% by June 30, 2012.

3.7B: Increase average length of rental assistance for enrollees.

3.7B (1): In process.



3.7: Expand short-term housing options for enrollees early in their recovery to improve health and stability.

3.7C (1): Establish baseline data of high risk enrollees by June 30, 2011. 3.7C (2): Reduce percentage of high risk enrollees being discharged into homelessness by 20% by June 30, 2012.

3.7C: Reduce % of high risk enrollees who are discharged from crisis services into homelessness.

3.7C (1): Status to be reported in August 2011. 3.7C (2): Status to be reported in August 2011.

3.7D (1): Create plan, including identifying funding, to expand residential services by June 30, 2013.

3.7D: Expand substance abuse residential treatment services.

3.7D (1): New objective; to be implemented by end of FY 13.

3.8: Increase community and enrollee awareness of housing resources

3.8A: The # of direct care staff attending the housing education seminars will increase 20% by June 30, 2012.

3.8A: Increase attendance at bi-monthly trainers for providers.

3.8A: In process.

3.8B: Fact sheet created by December 31, 2010 and widely distributed to TDC staff, stakeholders, and providers by January 30, 2011.

3.8B: Create a public fact sheet on housing resources for enrollees.

3.8B: Met.

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