DMC-ODS IMPLEMENTATION PLAN SUBSTANCE USE TREATMENT … · DMC-ODS IMPLEMENTATION PLAN SUBSTANCE...

SANTA CLARA COUNTY – MEDI-CAL WAIVER IMPLEMENTATION PLAN- DECEMBER 2016-FINAL

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DMC-ODS IMPLEMENTATION PLAN SUBSTANCE USE TREATMENT SYSTEM 2016 Prepared By: Kakoli Banerjee, Ph.D. Director, Research & Outcome Measurement

Substance Use Treatment System Behavioral Health Services Department Santa Clara County Version: December 2016-FINAL


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Document Update History

Version Date Content/changes

August 29 First draft with: -Introduction -System of Care -Provisional summary tables for System of Care, Business Operations, Quality Management -Detailed tables for System of Care

September 9 Revisions: -Revised provisional summary tables for System of Care -Business Operations section added

October 11 Revisions: -System of care section-updated with reference to Section 30 of the IGA (Contractor Specific Requirements) -Revised detailed tables for System of Care-based on review at EG -Revised summary business operations table -Quality Management section added

November 11 Revisions: -QI Section added -Treatment services updated from Section 30 of the IGA

December 6 Revisions: -All implementation status information has been removed from this document. Implementation status will be monitored in EXCEL during waiver meetings. -This document is intended as a reference only from this point onward.


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NOTE TO USERS: Please note that the information in SUTS ODS-DMC Waiver Implementation document is based on the SUTS proposal and the most recent versions of IGA general and contractor-specific sections (as of December 2016). This document is intended as a guide for staff as they develop detailed work plans to implement specific provisions of the ODS-DMC plan. Some proposals may become redundant or obsolete as implementation progresses. This implementation document will not be updated as these developments occur. Workgroups will document how their work diverges from the original waiver proposal and these changes will be reflected in policies, procedures, protocols and other working documents.


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SECTION I INTRODUCTION TO THE DMC-ODS IMPLEMENTATION PLAN


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Medi-Cal Waiver Plan Implementation

The Santa Clara County Substance Use Treatment Services (SCC SUTS) Waiver plan, submitted to DHCS, described a fully articulated Organized Delivery System that encompassed several ASAM levels of care and service components required to provide high quality substance use treatment for clients. The Medi-Cal Waiver plan was submitted to DHCS in February 2016 and was approved by DHCS in June 2016. Once SCC SUTS enters into an Intergovernmental agreement (IGA) with the state, it will be required to comply with a range of state and federal regulations (primarily CFR 438) that govern administration of a managed care plan. In effect, SUTS will need to transform itself into a health plan administrator, while maintaining its direct service capability.

The formal acceptance by DHCS of Santa Clara County Substance Use Treatment Services (SUTS) Medi-Cal Waiver plan effectively transforms it into a Managed Care Plan for Medi-Cal beneficiaries. While the core service modalities will be familiar to providers and staff, the delivery of these services will have to change to meet the requirements of a Medi-Cal Managed Care plan. Section 1.E. of the Exhibit A of the Intergovernmental Agreement (IGA) between DHCS and SCC SUTS states that:

“The Drug Medi-Cal Organized Delivery System (DMC-ODS) is a Medi-Cal benefit provided by, and within this county (Contractor), through a county operated PIHP as defined in 42 CFR438.2.” (A PIHP stands for Prepaid Inpatient Hospital Plan and is defined by 42 CFR438.2.)

In order for the current SUTS system to operate as a Medi-Cal system and meet the requirements of the

intergovernmental contract with DHCS, work groups will be convened to create and implement the necessary changes to the System of Care. The purpose of this implementation plan is to provide a high level overview of the main administrative and system changes that will be required to create a fully-functioning Medi-Cal system for substance abuse treatment services in SCC. Summary: Key anticipated changes under the SUTS Medi-Cal Waiver plan

The changes in services and practices proposed in the IGA and the SUTS proposal are summarized in this section. In the rest of this document, the Medi-Cal waiver project will be referred to as the DMC-ODS (Drug Medi-Cal Organized Delivery System) and SUTS as MCP (Managed Care Plan). The major changes are summarized below:


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SUTS System of Care will shift from one that has historically served unsponsored clients to one in which insured (mainly Medi-Cal) beneficiaries will make up a larger share of clients. Consequently, services will need to be provided according to 42 CFR 438. Clients will become beneficiaries with specific set of entitlements regarding the quality and quantity of services, registering grievances and timely access to services.

o The expansion of the eligible beneficiary population is less consequential for SCC SUTS because it has for many years served the safety net population with county general funds, particularly, single low-income county residents. The client profile is not expected to change dramatically although a higher percentage will have a payor, mainly Medi-Cal, and fewer clients will be unsponsored.

SUTS will need to develop new administrative units and expand existing administrative units to manage a health plan for Medi-Cal beneficiaries. Thus, SUTS will have two distinctive identities: direct service provider and a health plan administrator.

New levels of care will be added to the present continuum, which will permit the system to more effectively match clients with the appropriate level.

o Under the Medi-Cal waiver, it will necessary to ensure that evidence-based practices are being uniformly followed uniformly followed across the system of care.

In contrast to the present, virtually all services rendered by SUTS across county and contract clinics will have a payor for reimbursement. Over time, the proportion of services without a payor will shrink, as more and more clients become insured.

o The standards for documenting services will be required to meet the requisite standards of accuracy and completeness in order to maximize reimbursement for services.

o Services that are not currently reimbursed by Medi-Cal will be wholly or partially reimbursed under the waiver plan. Residential treatment, case management and recovery services will be reimbursed by Drug Medi-Cal. (Note: Board and care for residential services will not be reimbursed by Medi-Cal).

The system of care will be subjected to greater scrutiny regarding system performance in areas such as access to care, appropriate placement, and client engagement, authorization for services particularly residential services, overall quality of care, cost effectiveness or value and client satisfaction.

o A Quality Improvement/Assurance plan will be used to set standards and monitor system performance with a view to making rapid improvements in client services.

o The system of care’s practices will be reviewed by an external body – the EQRO (Externality Quality Review Organization).


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o Additionally, the state will evaluate SUT’s Medi-Cal waiver program as a demonstration project. The program evaluation will be conducted by UCLA. The program evaluation will focus on access, quality, and cost and client satisfaction.

Implementation plan

This implementation plan gathers together the requirements for implementing the DMC-ODS plan for Santa Clara County SUTS and offers a general timeline for tasks, based on the requirements at project ‘go-live.’ The DMC-ODS plan is based on SCC SUTS proposal to DHCS and the DHCS contract provisions. The former is concerned primarily with describing expanded treatment services, including additional ASAM levels of care, access to treatment, and quality improvement plan. The IGA has two sections: Sections 1 through 29 cover mandated services and practice guidelines, requirements for service delivery in accordance with 42 CFR 438, compliance, and quality standards and Section 30 covers the contractor (county)-specific services that each opt-in county has proposed.

The objectives this implementation plan are to provide a high level ‘roadmap’ to guide the work of implementation

teams:

To provide a high-level description of the key services and administrative functions required to implement the Medical waiver plan:

o The implementation plan describes: (a) key proposals of the SUTS Medi-Cal waiver proposal, (b) the key provisions of the DHCS contract with SCC SUTS, and (c) a general assessment of the implementation status, division involvement and deadline for implementation. Changes in services and management are shown by the type of operation affected – access, client flow, treatment services, business operations, quality improvement, etc.

o A goal of the implementation plan is to provide a ‘master list’ of tasks required to implement the DMC-ODS.

To serve as a guidance for implementation for SUTS divisions. The focus of this implementation plan is to describe what needs to be accomplished in order to build the Organized Delivery System.

o An implementation plan differs from a work plan or project plan in terms of content, detail and specific tasks. A work plan is designed to accomplish the tasks/proposals described in this document. In other words, an implementation plan is concerned with ‘what’ needs to be accomplished and a work plan is concerned with ‘how’ a specific requirement is implemented.


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Organization of the implementation plan

The implementation plan is organized into three main sections: System of Care, Business Operations and Quality Improvement. It should be noted that this grouping is not intended to reflect the SUTS organizational structure and most implementation tasks require the participation of several units within SUTS. For example, some activities under System of Care may fall under division directors responsible for adult services, youth services, medication assisted treatment and quality improvement. Similarly, some tasks included under Business Operations will require input from all division directors.

Each section has several sub-sections each devoted to a specific aspect of the system of care such as levels of care,

access, authorization and so forth. Each sub-section contains a summary of the SCC Waiver plan or the appropriate section of the contract. The plan summary describes key new proposals that are to be implemented as part of the waiver. Each section also includes a table that contains the following:

Requirements Divisions/Units affected Action Required Recommended Workgroup Complete by date

Tables 1 through 3 highlight the major requirements and their sources, the divisions involved, and the deadline for completion.


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Table I. System of Care Implementation under DMC-ODS & Responsible Divisions/Units - High Level Summary

REQUIREMENTS Source/ Rationale

Divisions/units Completion by

System of Care

Access to treatment

Beneficiary access line IGA S 2; SUTS # 3

Gateway, QI, ASOC, YSOC

Go-Live (3/1/2017)

Beneficiary handbook IGA 14 & 18 QI Go-Live (3/1/2017)

Access to services IGA 2.2; SUTS 8

QI Year 1

Timely access IGA 2.3; SUTS 3 & 8

Gateway, QI, ASOC, YSOC

Referrals to treatment SUTS # 8; 30 Gateway, QI, Go-Live (3/1/2017)

Treatment services

Availability of services (network adequacy)

IGA 2.1; SUTS 8

ASOC, YSOC, Admin Year 1

Adequate capacity and standards IGA 2.4; SUTS 8

ASOC, YSOC, Admin Go-Live (3/1/2017)

Establishment of medical necessity IGA 1.1 (B) 2 QI, ASOC, YSOC Go-Live (3/1/2017)

Assessment IGA 1.2 (B); SUTS 2

QI, ASOC, YSOC

Authorization of services- residential programs

IGA 2.6; SUTS 19

QI Go-Live (3/1/2017)

Client transfers within SoC IGA 2.5 (B); 30; SUTS 2

QI Go-Live (3/1/2017)

Coordination & continuity of care IGA 2.5; SUTS 5 & 6

QI, ASOC, YSOC Go-Live (3/1/2017)


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Treatment Services-new LOC Residential LOC SUTS 4;IGA 8,

30 QI, ASOC, YSOC Year 1

OP LOC SUTS 4; IGA 6 & 7, 30

QI, ASOC, YSOC Year 1

Treatment Services-new Modality Recovery Services components IGA 11 & 27

(D) 30;SUTS 4 QI, ASOC, YSOC Year 1

Case management IGA 9 30; SUTS 4

QI, ASOC, YSOC Year 1

Physician consultation IGA 10 30;SUTS 4

QI, ASOC, YSOC, MAT Year 1

Evidence-based practices/practice guidelines

IGA 26; IGA 19 (B) 3; SUTS 12

QI, ASOC, YSOC, MAT Year 1

Training IGA 23.3 ; SUTS 9

ASOC, YSOC, MAT, Admin

Year 1

Tele-health services IGA (under tx svcs) SUTS 16

ASOC, YSOC, MAT, Admin

Year 2

Coordination with Physical Health SUTS 6 ASOC, YSOC, MAT Year 1

Coordination with Mental Health IGA 9, 24 (A) 6; SUTS 5

ASOC, YSOC, Year 1

Compliance with PSN Guidelines 2015

IGA 27 (C) MAT In place

See Section on System of Care (II) for more detailed implementation tables.


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Table 2. Business operations impacted by DMC-ODS –Summary

REQUIREMENTS Source/Rationale Divisions/units Completion by

Finance

Financing-payment for services IGA 1.3 A Admin Go-Live (3/1/2017)

Rate setting IGA 1.3 B Admin Go-Live (3/1/2017)

Quarterly Federal Financial mgmt. Report (QFFMR)

IGA 23.2 Section G Admin Year 1

Year-end Cost Settlement Reports IGA 23.2 Section H Admin Year 1

State Monitoring & financial audits IGA 23 A Admin Year 1

Contracts(Changes in boilerplate)

Provider selection & certification (some provisions fall under certification)

IGA 3 Admin Year 1

Subcontracts IGA 19 Admin Year 1

Additional provisions Admin Year 1

Formation and purpose Admin Year 1

Contract Monitoring

Non-DMC/SAPT (Salary restrictions) IGA 27 A Admin Year 1

Monthly monitoring IGA 23.4 Sections A & B IGA 20 G

Admin Year 1

MOU with Health Plans SCC SUTS Plan-15; 42 CFR 438

Admin Go-Live (3/1/2017)

Compliance & state monitoring

SUDS Compliance Division IGA 23.5 QI; Admin Go-Live (3/1/2017)

Beneficiary problem resolution process (Grievance procedure)

IGA 18 QI; Admin Go-Live (3/1/2017)

Advance Directives IGA 21 E QI; Admin Go-Live (3/1/2017)

Program Integrity Requirements IGA 20 A-F QI; Admin

Confidentiality Requirements IGA 21 A, B QI; Admin Go-Live (3/1/2017)

Record Retention IGA 23.6 QI; Admin Year 1

Policies & procedures QI, ASOC, YSOC, Year 1


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MAT

Claim submission & monitoring

DMC claims & reports IGA 3 (E); 20 H Admin Go-Live (3/1/2017)

Beneficiary liability for payment IGA 4.1 Admin Go-Live (3/1/2017)

Recovery from other sources or providers

IGA 4 Admin Year 1

Financial audits (state monitoring) IGA 23 B, C Admin Year 1

Certification

DMC certification & enrollment IGA 3.1; 3.2 Admin Go-Live (3/1/2017)

Certification of individual providers Admin Go-Live (3/1/2017)

Beneficiary relationship

Beneficiary brochure & provider list IGA 14 & 18 QI; Admin Go-Live (3/1/2017)


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Table 3. Quality Improvement, Utilization & Monitoring Operations Impacted by DMC-ODS –Summary

Source/Rationale Divisions/units Completion by

Quality Improvement, Utilization & Monitoring

Quality Management Plan

Written description of QI plan consistent with 438.240; & annual updates

IGA 22 A & C; SUTS 11 QI Go-Live (3/1/2017)

Annual submission –DHCS measures & 438.240

IGA 22 C; SUTS 11 QI;ROM Year 1

Triennial review IGA 22 E QI;ROM Year 1

Monitoring expectations IGA 22 F- L; SUTS 11 QI;ROM Year 1

Quality Improvement Program

Monitoring accessibility of services IGA 24 A; SUTS 2 QI; ROM Year 1

Monitoring delivery system IGA 24 B; QI; ROM Year 1

Convening a QI Cmte to review tx svcs IGA 24 C QI; ROM Year 1

Minimum data for reviewing IGA 24 D QI; ROM Year 1

QI program operation includes licensed staff

IGA 24 E QI Year 1

Demonstrate involvement of practitioners, beneficiaries & family members

IGA 24 F QI Year 1

Maintain a minimum of two PIPs that meet the DHCS contract criteria

IGA 24 G, H, I , J ASOC, YSOC, QI, ADMIN, ROM

Year 1

QM Work plan IGA 22 M QI Year 1

Contractor Monitoring (EQRO)

EQRO monitoring plan IGA 23.1 A QI; ROM Year 1

Annual utilization review of DMC providers

IGA 23.1 B QI Year 1

Compliance with DMC-ODS IGA 23.1 C, E, F Compliance; Admin; QI

Year 1


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Timely DATAR submissions (see below)

IGA 23.1 D QI Go-Live (3/1/2017)

Identification of provider-preventable conditions (PPCs)

IGA 23.1 G Admin; Compliance; QI

Year 1

Reporting Requirements

Submission to DHCS data on beneficiaries, providers

IGA 23.2 A QI; ROM Year 1

CalOMS PV IGA 23.2 B QI; Prevention Go-Live (3/1/2017)

CalOMS for treatment IGA 23.2 C QI Go-Live (3/1/2017)

DATAR reporting IGA 23.2 E QI Go-Live (3/1/2017)

Referrals for Charitable Choice IGA 23.2 F QI; ROM Year 1

Utilization Management Program

UM program responsibilities align with IGA

IGA 25 QI Go-Live (3/1/2017)

Documented system for collecting, maintaining & evaluating accessibility to care and waitlist information

IGA 25 QI Go-Live (3/1/2017)


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SECTION II SYSTEM OF CARE: IMPLEMENTATION REQUIREMENTS


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System of Care section covers all major program areas that will be affected by the Medi-Cal Waiver Plan (MWP). MWP describes the operations of the SUTS Managed Care Plan (MCP), and describes how beneficiaries will be served under the plan. Virtually all part of the System of Care will be affected by the MCP implementation. The contract with DHCS, referred to as the Intergovernmental Agreement (henceforth IGA) in this document, describes the terms of the agreement including required components and compliance with 42 CFR 438. Sections 1 through 29 cover requirements that apply to all opt-in counties and Section 30 describes county- specific services. Section 30 renders SUTS program proposals into contract language. As a result, SUTS becomes contractually obligated to provide all services approved by DHCS.

The System of Care section covers: 2.1 Access to treatment 2.2 System of Care 2.3 Evidence-based practices and practice guidelines 2.4 Training 2.5 Tele-health options 2.6 Coordination with Physical Health 2.7 Coordination with Mental Health 2.8 Compliance with 2015 PSN guidelines

2.1 Access to treatment

Access to Treatment discusses the SUTS MCP proposal regarding the Beneficiary Access Line and Access to services to which beneficiaries are entitled.

The SUTS MCP requirements describe how beneficiaries enter the system of care, whether access procedures meet the

minimum requirements under IGA, access to different service modalities, and how the network proposes to maintain capacity to serve the anticipated number of Medi-Cal beneficiaries during the waiver period (ending in 2020). The state contract specifies the responsibilities of the MCP toward beneficiaries and the rights of beneficiaries to receive information about the content of the plan, grievance procedures and fair hearing. Section 30 refers to specifically to services proposed by SCC SUTS. The key tasks in the Client Access plan which includes Beneficiary Access Line and Access sections in the MWP and Sections 14 & 18 in the IGA) are summarized in Table 2.1.


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IGA 30: Beneficiary (Client) Access The IGA contains specific requirements related to beneficiary access to services. Changes in the system policy and

procdures may be needed to comply with the access provisions in the IGA such as expanding the hours of services, and creating mechanisms for dealing with urgent cases.

Gateway will function as the primary portal for entering services.

Beneficiary access line: SUTS will provide a toll-free 24/7 number for beneficiaries to access services and/or referral for outpatient screening, triage, residential and detoxification services. Section 30 B 2

Access to urgent and after hours care: Under the timely access provision (IGA 2.3), the MCP will be required to

provide medically necessary services 24 hours a day, 7 days a week. ‘The Gateway Call Center staff shall conduct a brief substance use and risk screening to determine an initial Level

of Care (LOC) placement. A comprehensive ASAM assessment shall subsequently be conducted at the treatment site. All provider sites shall be assessment sites. Thus, a beneficiary may be admitted to the LOC to which they were referred to by Gateway, or be moved to a higher or lower LOC’. Section 30 B 2

‘In-custody beneficiaries shall have access to two dedicated phone lines in the jails that connect directly to the Gateway Call Center at no cost to in-custody callers. In-custody callers shall receive the same standards of service as other callers to the Gateway Call Center.’ Section 30 B 2

Language capability: All relevant information about access to treatment and treatment services must be provided in a county’s threshold languages. Oral interpretation will need to be provided to speakers of threshold languages to access treatment services.

Hours of operation: Hours of operation for DMC clients must be the same as those available for other clients Screening: See Access and assessment (see above)


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Referral to treatment: (Section 30 B 3-Language extracted directly from SUTS waiver proposal) Referrals for service are made in four different ways: 1) appointment-based referrals; 2) post-authorization referrals; 3) care coordination referrals determined by the Quality Improvement Coordinators (QICs); and 4) same day intake or walk-in referrals.

a) Appointment-based referrals:

i. Treatment providers shall allow beneficiaries to schedule their admission into treatment.

ii. Treatment providers shall attempt to reschedule “no shows” to the initial appointment.

b) Post-authorization referrals: i. A post-authorization site is located at agencies that require the ability to directly screen and refer

beneficiaries to treatment providers. Post-authorization locations include specific courts, a centralized facility for serving criminal justice beneficiaries, and withdrawal management services providers.

ii. Beneficiaries shall access post-authorization sites as walk-ins or referrals from the courts or other agencies, such as the Probation Department. The post-authorization site shall then directly refer the beneficiary to treatment.

iii. Beneficiaries with special needs or that present with special circumstances, such as high use of treatment services, shall be reviewed by the QICs and placed in an appropriate LOC. Beneficiaries with special needs shall be referred to the Quality Improvement Division by the Gateway Call Center and Mental Health Department. Beneficiaries identified as high users enter the system of care via Care Coordination service through the Quality Improvement and Data Standards (QIDS) Division.

c) Same-day referrals:

i. When beneficiaries call the residential placement coordinator (after their Gateway Call Center

screening), the residential placement coordinator shall offer the beneficiary a bed for intake that same day (if capacity permits) to reduce early terminations.


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ii. Same-day access in outpatient shall include a scheduled rotation of “on-call” outpatient providers. Beneficiaries referred by the Gateway Call Center to an “on-call” outpatient treatment provider shall be offered an intake/assessment appointment on the same day.

d) Youth and MAT System Referrals

i. This basic referral process detailed above shall be in the Youth and MAT systems with some variations

required by the specific needs of the target populations.

ii. Beneficiaries can enter the youth system directly through the QIC who manages the treatment referrals for youth and transitional aged youth (up to 26 years), or from a third party such as the Probation Department, Social Services Department, juvenile justice system, community based organizations, high schools, parents and family members.

iii. Referrals for youth outpatient services shall be distributed to the appropriate county or community provider, based on the transportation needs, geographic needs, and gang affiliation.

iv. Referrals to the youth system shall receive individualized assistance through the post-authorization referral coordinator or will be channeled directly through the Gateway Call Center.

v. Beneficiaries shall be screened and referred to MAT through the Gateway Call Center. Adult beneficiaries shall be screened for eligibility appropriateness for MAT and referred to one of methadone clinics depending on the beneficiary’s place of residence.

Location & Staff conducting ASAM assessments Section 30 B 4

Intake is the first session at all treatment sites across the system of care.

An in-depth LOC assessment shall be conducted with each beneficiary using the American Society of Addiction Medicine’s (ASAM) Criteria at each treatment site.

The ASAM 6-dimensional (DIM) assessment shall be conducted by licensed, licensed-waivered, or state certified AOD counselors working under the direction of the clinic’s Licensed Practitioner of the Healing


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Arts (LPHAs).

LPHA staff shall review and sign all placement decisions that meet the medical necessity criteria.

When a beneficiary needs a LOC not currently available in the System, such as partial hospitalization or medically monitored Intensive Inpatient Treatment, they shall be referred to the most appropriate level available or given community referrals to those services.

Timeliness of access: Under Section 2.3, the MCP will be required to:

Maintain continuous availability and accessibility of covered services Initiate needed services with ‘reasonable promptness’ Authorize services in accordance with medical necessity criteria specified in Title 22. 51303:

Authorize ‘residential services within 24 of prior authorization of request be submitted by provider’ Use ASAM and DSM criteria to evaluate beneficiary’s need for treatment services Have written policies and procedures for initial and subsequent authorizations, review of all

authorizations, and timelines for authorization Section 30 C requirements include:

For new referrals, appointments shall be made five days a week during normal business hours. Outpatient providers shall be open Monday through Friday from 8 AM to 6 PM. Evening outpatient services

will be provided. The Contractor shall provide beneficiaries with entry to treatment seven days a week when medically

necessary. The Contractor shall ensure a maximum of fourteen days between referral (including from the Gateway

Call Center) and first appointment for a face-to-face visit, which is the standard for outpatient placements.

All outpatient treatment agencies shall provide at least four face-to-face treatment sessions within the first thirty days of admission.

Detoxification services shall be available seven days a week. Beneficiaries that need afterhours care shall be referred to an on call clinician for immediate clinical

disposition and/or care coordination. Beneficiaries with an urgent condition shall receive services or attention from Care Coordination staff

within 24 hours. Residential providers shall take weekend admissions and evening admissions for beneficiary convenience


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Beneficiary brochure: Under the IGA, the MCP will be responsible for creating a beneficiary brochure that will be

provided to beneficiaries upon enrollment. (See Business Operations for details) Table 2.1 BENEFICIARY ACCESS PLAN IMPLEMENTATION SUMMARY (Section 2.1)

Requirement Divisions Action required Workgroup Complete by:

Beneficiary access line Gateway Implement the after-hours contact process Mgmt. Go-Live (3/1/2017)

Point of access HHS None Access Wkgrp

Year 1

Hours of operation- access to urgent & after hours care

ASOC/YSOC/MAT

Implement access to 7 days a week with 24 hours as a goal.

Access Go-Live (3/1/2017)

Language capability and threshold languages & hearing impaired access

ASOC/YSOC/MAT

Implement hearing impaired access method

Access Go-Live (3/1/2017)

Screening Gateway None Review In place

Referral process Gateway,QI None Review In place

Timeliness of face to face visits

ASOC/YSOC/MAT/QIDS

Implement plan for 4 services in 30 days and initial tx service within 14 days of referral from call-center

QI Go-Live (3/1/2017)

Integrated call –center referral routing

Integrated Call Center

Create & test protocol for screening & routing Medi-Cal clients

Access Year 1

Beneficiary brochure QI, Admin Create beneficiary brochure BB workgroup

Go-Live (3/1/2017)

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2.2 Treatment services The framework for the ODS is based on the Continuum of Care that has been operating for nearly two decades. Key

features of the Continuum of Care will continue to operate as it has in the past, with appropriate modifications. This section covers:


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Treatment services (ASAM Levels) Availability of services and network adequacy as timely access to screening Establishing medical necessity, ASAM assessment, re-assessments, Residential treatment authorization, Care coordination & client transfers within the System of Care

Overall system functioning: The Santa Clara County ODS will maintain its population-focused delivery approach, consisting of three distinctive

and interrelated delivery systems: the Adult System of Care (ASOC), the Youth System of Care (YSOC) and Medication Assisted Treatment (MAT).

Medical necessity throughout the system will continue to be established by current DMC [51341.1(a) & (h)] regulations and updated versions, except in the case of MAT for which additional requirements must be met. The use of ASAM Criteria for treatment placement will become mandatory in the DMC-ODS.

The present continuum of care will be expanded for both youth and adults. The key tasks related to Treatment Services are summarized in Table 2.3.

IGA Section 30 G-Treatment services-Section 30 G - R: SUTS is contractually obligated to services described below.

Early Intervention (ASAM Level 0.5) o The Contractor shall provide early intervention services in the manner described in Section 5 of Exhibit A,

Attachment I.

Outpatient Services (ASAM Level 1) o ASAM Level 1 services provided to youth and adults, and age-appropriate treatment shall be provided to each

beneficiary o A client’s case will be kept open for up to one year in order to maintain continuity of care in both YSOC and

ASOC. Services to incarcerated persons will not be reimbursed by DMC.

Intensive Outpatient Services (ASAM Level 2.1) o ASAM Level 2.1 shall provide adult outpatient services for between 9 to 19 hours per week and between 6

and 19 hours per week for youth and young adults. Beneficiaries may be stepped down to ASAM Level 1 or up to residential services


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Residential Treatment Services to be provided

o Clinically Managed Low-Intensity Residential Services (ASAM Level 3.1) o Clinically Managed Population-Specific High-Intensity Residential Services (ASAM Level 3.3) o Clinically Managed High-Intensity Residential Services (ASAM Level 3.5)

Three levels of ASAM residential services shall be available to adults. Level 3.1 shall be available to adults in the first-year and ASAM Levels 3.3 and 3.5 in the second-year.

The youth residential system shall provide ASAM Level 3.1 for residential treatment. The Youth System shall offer Residential Level 3.5 in the second-year.

Perinatal residential treatment for women and their children under age 5, shall be provided at ASAM Level 3.5. This program shall comply with the Perinatal Services Network Guidelines.

Medically Monitored Intensive Inpatient Services –

o Adult/High Intensity Inpatient Services – Adolescent/Medically Managed Intensive Inpatient Services (Adult & Adolescent) (ASAM Level 3.7 and 4.0) (Level 3.7 and 4.0 residential services are not billable under the DMC-ODS system.)

o The Contractor shall establish an MOU with a local provider to provide ASAM 3.7 and 4.0 services. Beneficiaries shall receive services from these providers until they can be discharged to a lower LOC provided by the SCCBHD network.

Case Management o On-site staff at all ASAM Levels of Care for youth and adults shall offer case management services.

o Services shall include, but will not be limited to, linking beneficiaries to other levels of care for substance

use treatment, primary care, mental health, vocational, legal and housing resources, as well as case consultation services.

o Case management services shall be provided by licensed or credentialed staff persons.


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o Case management services shall be integrated with the treatment plan.

o The Youth System of Care shall utilize a clinical/rehabilitation approach to case management in which the therapist provides both therapy and case management.

o In the adult system, the primary treatment counselor/therapist may also provide case management services.

o When the case manager is not the primary treatment provider, he/she shall work closely with the primary counselor to support the treatment plan.

Specific tasks such as transportation, assistance completing applications, or accompanying the beneficiary for appointments and other tasks shall be assigned to a community-worker or peer mentor.

Adult system community-workers and peer mentors shall work under the direction of the credentialed or licensed counselor to provide a range of services, depending on a beneficiary’s needs.

Physician Consultation

o The DMC provider’s physician/s will be able to consult for complex cases with addiction medicine specialists at the established physician consultation rate.

o Physician consultation may include; medication selection, dosing, side effect management, adherence, drug-drug interactions, or LOC considerations.

Recovery Services

o Beneficiaries shall be offered this service if they have relapsed. o Recovery services shall address ASAM 6 DIM o Recovery Services shall be available for adult beneficiaries with a SUD in remission but exhibit a high risk for

relapse potential on ASAM DIMs 3 to 6. o Recovery Services shall be available for beneficiaries after completing the course of treatment if they are

struggling with triggers, they relapse, or as a preventive measure. o Services may be provided face-to-face or by telephone and may include, but are not limited to, Wellness

Recovery Action Plan (WRAP) groups, Continuous Recovery Monitoring (CRM), drop-in support groups, and relapse prevention groups.

o Youth and young adults who are eligible for the early recovery services shall be either vulnerable to future substance use problems or at immediate risk for meeting the criteria for a SUD.


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Withdrawal Management o ASAM Level 3.2 shall be available to adult beneficiaries who meet the necessary ASAM criteria. o The components of withdrawal management services shall include intake and observation (Clinical Institute

Withdrawal Assessment/CIWA). o At discharge from ASAM Level 3.2, beneficiaries shall be referred to either residential or outpatient services,

based on an assessment of individual needs.

Opioid (Narcotic) Treatment Program Services o Beneficiaries referred to the MAT program shall be screened for eligibility. Both adults and youths shall

receive MAT services if they meet the criteria for admission. o MAT services shall be provided in clinics licensed and accredited by Commission on Accreditation of

Rehabilitating Facilities (CARF) and staffed by board certified physicians specializing in Addiction Medicine, and licensed master’s level clinicians or certified counselors.

o MAT shall offer medications (e.g., methadone, naloxone, disulfiram, Suboxone and Vivitrol), counseling, case management, medical consultation, confidential human immunodeficiency virus (HIV) and tuberculosis (TB) testing and counseling to beneficiaries who meet the medical necessity criteria.

o MAT prescriptions shall be provided through the patient’s local or county pharmacies. o Beneficiaries referred to methadone shall meet the admission and medical necessity criteria established by

the California Code of Regulations (CCR) Title 9 and Federal regulations.

Beneficiaries who meet admission criteria shall be admitted within 72 hours of the intake appointment. o Admission to the Suboxone program shall require an evaluation by a program physician to establish medical

necessity.

Induction phase shall occur during the first week of treatment and involve onsite treatment and monitoring. Individuals will be required to keep a follow up appointment for refilling their prescription. Individuals can be referred to counseling in accordance with State and Federal regulations.

Youth shall be referred to Suboxone services.

Assessment using ASAM criteria shall be used to determine whether youth are eligible for Suboxone treatment (diagnosis of opioid dependence or opioid use disorder is given, at least a one-year history of opioid dependence, and parental permission and involvement).


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Additional Medication Assisted Treatment

o As stated in Section 30(A) of Exhibit A, Attachment I, SUTS has elected to provide additional MAT services o Vivitrol treatment shall be available to out-patient beneficiaries at all MAT clinics. o Patients may refer themselves for Vivitrol treatment, but admission shall require an assessment by a licensed

physician to determine whether the medication is appropriate for a beneficiary. o Vivitrol shall be administered to volunteers from Substance Use Treatment System (SUTS) treatment programs

with alcohol and/or opiate dependency upon consent to treatment. o The Vivitrol Treatment Program shall provide monthly assessments, reassessments, and medical services

including evaluations, monthly injections follow up visits, and counseling.

Partial Hospitalization

o As stated in Section 30(A) of Exhibit A, Attachment I, SUTS has elected to provide Partial Hospitalization services as a Contractor specific service.

o Partial hospitalization (ASAM Level 2.5) shall be available to beneficiaries with unstable medical and psychiatric problems in the second year.

o A minimum of 20 or more hours of service per week shall be provided in Level 2.5.

o Beneficiaries shall have access to medical, psychological, psychiatric and toxicology services through consultation or referral.

o Psychiatric and other medical consultation will be available within 8 hours by phone and within 48 hours in- person.

o Emergency services will be available 7 days a week and 24 hours a day o Beneficiaries may live in a residential facility, such as transitional housing with 24-hour supervision.

Transitional Housing

o SUTS will provide Transitional Housing services o SUTS shall make available Transitional Housing Units (THUs) to beneficiaries who are homeless, at risk for

homelessness or living in unstable housing that may affect their recovery. o At-risk beneficiaries that have been placed in outpatient treatment shall be offered THUs for the duration of

treatment.


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o THUs shall be provided by vendors that have contracts with SUTS. THU vendors shall comply with the THU policies and procedures developed by SUTS.

o The housing vendors shall work closely with the treatment providers. o Beneficiaries shall be required to pay up to 35 percent of their income for THU services. Beneficiaries with food

stamps are expected to use these benefits to partially cover their food costs. o The costs associated with THUs shall not be reimbursed through the DMC-ODS Waiver; therefore, SUTS shall use

other funding sources to pay for THU costs. (See Table 2.2 for a summary of ASAM levels that will be offered under the waiver)


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Table 2.2. Required and optional treatment services by System of Care component- Santa Clara County Medi-Cal Waiver Demonstration

ASAM LEVEL YSOC ASOC MAT PSAP

Required services (in bold font)

Withdrawal Management

3.2 Clinically managed Residential detoxification services

X X X

Levels 1-WM, 2 –WM, 3.7 WM, 4 WM

Residential treatment (any level)

3.1 Clinically managed low intensity residential services

X X X X

3.3 Clinically managed medium intensity residential services

NA X X X

3.5 Clinically managed medium/high intensity residential services

2nd year X X X

Outpatient Services

1.0 Outpatient services X X X X

2.1 Intensive outpatient treatment X X

2.5 Partial Hospitalization – Day Treatment

X

OTS Level 1-Narcotic Treatment Program

X

Recovery Services X X

Case management X X X X

Physician consultation 1st yr. 1st yr. 1st yr. X Source: SUTS Proposal to DHCS – Accepted June 2016


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Proposed: Availability of services (network adequacy) The adequacy of the current network to provide services to Medi-Cal beneficiaries was assessed, based on projections of current utilization levels.

It was determined that the current network of care has adequate capacity to handle on an annual basis: o 6400 outpatient admissions o 1800 residential admissions o 900 detoxification admissions o 600 MAT admissions

The current capacity can be further extended with better management of residential beds as the first resort

with an expansion of bed capacity as an option if a significant increase in demand occurs. IGA: Availability of services (network adequacy)

The requirements for providing services to beneficiaries are covered in a number of sections of the IGA as shown below.

In the IGA, MCPs are required to “ensure the availability and accessibility of adequate numbers of facilities, service locations, service sites, and professional, allied and supportive personnel to provide medically necessary services, and ensure the authorization of services for urgent conditions.” (IGA 1 E)

Covered services are required to be provided as Prepaid Inpatient Hospital Plan (PIHP). (IGA 1.2 A) The MCP is required to possess sufficient capacity to provide medically necessary services to beneficiaries as described

in IGA 2.1 A: o All services covered under the IGA should be available to beneficiaries o The MCP is required to document the following:

Anticipated number of Medi-Cal eligible beneficiaries Expected level of services utilization Expected utilization of services based on need Number of network providers not accepting new beneficiaries Geographical distribution of providers Services not available in network and coverage of out of network service for beneficiaries


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Proposed: Adequate capacity & standards See above section for a discussion of system capacity.

Standards: SCC SUTS has operated a system of care for two decades and developed standards for service delivery for its system of care. SUTS system of care complies with many of the IGA standards requirements, and will revise or create policies to conform to IGA requirements. (See IGA: Adequate capacity & standards) IGA: Adequate capacity & standards

IGA addresses the need to have a system that is “sufficient in number, mix, and geographic distribution to meet the needs of the anticipated number of beneficiaries in the service area.” The expected standards for service delivery and administration appear in different sections as shown below in Table 2.3.

Table 2.3 IGA standards for treatment, data and quality improvement

Domain IGA - Standard

Treatment standards Coordination of care will be provided in accordance with 42 CFR 438.208

Treatment plan will comply with state QA and UR standards

Residential authorization will meet decision standards

Residential programs will meet IGA standards of operation

MCP shall require members of its network to comply with all relevant sections of Titles 9, 21 and 22, and DMC Certification Standards and Standards for Drug Treatment Programs

DMC certified providers’ certification will be reviewed every 5 years

MCP will require the provider network members to have written P & Ps to monitor compliance with written procedures and held accountable for audit results from DHCS

MCP will be monitored by DHCS for quantity of work or services, quality of services, and compliance with the IGA

MCP will perform work in compliance with the relevant HIPAA provisions and will not “change any definition, data condition or use of data element or segment as proscribed in the federal HHS Transaction Standard Regulation

Data standards MCP will adhere to state and federal data standards, and certify to submitting accurate data

CalOMS Prevention data shall comply with CalOMS Pv Data Quality Standards; new providers will receive appropriate training before entering data

MCP shall comply with CalOMS Tx Data Compliance Standards related to data content, quality completeness, reporting frequency, reporting deadlines and reporting method


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MCP’s provider network will adopt CLAS (Cultural and Linguistically Appropriate Standards)

Quality management MCP network providers will accomplish treatment outcomes based on current standards of practice

IGA: Establishment of Medical Necessity

Establishment of Medical Necessity: SCC SUTS will comply with the IGA requirements for establishing medical necessity, which is described below. IGA requires the MCP establish medical necessity for potential beneficiaries before authorizing DMC reimbursable services. (See Section 1.1 B) The requirements for establishing medical necessity include:

o A face to face interview with an LPHA o For adults above 21 years,

At least one diagnosis from the DSM for Substance-related and Addictive Disorders Meeting the ASAM criteria definition of medical necessity

o For individuals under 21 years, Estimation of the risk of developing a SUD Meeting ASAM adolescent treatment criteria

o For ongoing services, LPHAs and medical Directors need to reevaluate an individual’s medical necessity at least every six months.

Proposed: Assessments & reassessments

The content of this section is based largely on the Client Flow section in the SUTS DMC-ODS proposal. It focusses on client flow through the System of Care, specifically ASAM assessments, admissions to recommended level of care, frequency of re-assessments, transition through the levels of care, role of case managers in care coordination, and timelines for movement between levels of care. These are discussed below:

ASAM assessment: The ASAM 6-dimensional assessment will continue to be used for placement decisions. ASAM assessments will be conducted by licensed, licensed-Waivered, or state certified AOD counselors working under the direction of clinic LPHAs. Under ODS rules, LPHA staff will need to review and sign all placement decision in cases of medical necessity.

The current practice of providing a full ASAM assessment at the first treatment modality will also continue.


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QIDS will also review authorization for detoxification and residential services. New protocols will need to be developed for walk-in clients, who presumably will not have been screened by staff at the call-center or a post-authorization site.

Admissions to recommended level of care: The procedures for referring clients to a level of care will continue to

be the same under ODS. Relevant sections from the SUTS ODS proposal are shown below.

o At the initial level of care, a clinician shall conduct a comprehensive ASAM assessment to confirm that the level of care is appropriate for the client’s condition. The decision about placement at a particular level of care shall be made by a licensed or credentialed clinician in both the adult and youth Systems of Care. If the clinician determines that a client’s needs would be better served at a different provider site or a different Level of Care, the clinician shall make arrangements to refer the client to the proper placement.

o When a client requires a Level of Care not currently available in the System, such as partial hospitalization or

medically monitored Intensive Inpatient Treatment, they shall be referred to the most appropriate level available within the network or offered community referrals.

Frequency of reassessments: ASAM assessments will be conducted after a client is admitted to a treatment

modality. Reassessments will also occur at regular intervals throughout the treatment episode to establish the validity of the Level of Care placement. An ASAM assessment will be required for extension of treatment and residential authorization.

IGA: Assessments & reassessments In the IGA, MCPs will be required to use ASAM for placement into the appropriate level of care.

Once medical necessity is established, which means that a DSM diagnosis is available, the level of care placement is to be determined using the ASAM. (IGA 1B.2)

Individuals must meet the ASAM criteria definition of medical necessity for services based on the ASAM criteria (IGA 1B.2)

Proposed: Authorization for Residential Services The SUTS ODS proposal covers primarily the protocol for residential treatment authorization, while the IGA provides the regulatory framework for residential treatment. (For other modalities, see next section on Movement through System of Care)


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Initial authorization for residential treatment shall be provided for 45 days Extensions will be granted to additional 45 days

IGA: Authorization for Residential Services The general requirements for authorization are covered in Section 2.2 B. Authorization for Residential Services is covered in Section 2.6. (Note: Authorization for services other than residential services is not currently required). The generic requirements include:

Authorization decisions are expected to be timely (within 14 days of the initial request for service) with an extension of an additional 14 days

An expedited authorization decision (within 3 working days of the initial request for service) is required in cases where the standard timeframe could jeopardize a beneficiary’s health. An extension of up to 14 working days is permissible.

Written procedures for initial and continuing authorization for residential treatment are required DHCS designated residential providers must have the capacity to deliver care in accordance with ASAM treatment

criteria Adult beneficiaries (above 21 years) are eligible receive up to 2 continuous short-term residential within 365 days,

(short term residential defined as a stay of 90 days or less) Adult beneficiaries are entitled to one 30 day extension per 365 days Youth beneficiaries (under 21 years) are eligible for continuous residential treatment for a maximum of 30 days Youth beneficiaries are entitled to one 30 day extension per 365 days Perinatal beneficiaries are eligible for a longer length of stay in residential treatment when medical necessity can

be established Denial of residential services, when medical necessity has been established, must be documented in writing

Proposed: Client transfers with System of Care

Initial services for residential, outpatient, MAT and detoxification services shall be authorized for the standard periods currently in use in the System of Care. See Table 2.3 for initial stays and extensions by modality.

All providers in the Adult System and residential providers in the Youth System will continue to seek authorization from QICs to continue treatment beyond these benchmarks for all treatment modalities.

These benchmarks shall be applied to outpatient treatment in the Youth System as part of the Medi-Cal Waiver demonstration project.


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Transition through the levels of care (client transfers with CoC): Current procedures for routine and non-routine

movement of clients through the System of Care shall continue under ODS. The same criteria shall be used to make

decisions about routine and non-routine client movement under ODS.

Timelines for movement between levels of care: The system benchmarks for lengths of stay for each modality shall

remain the same as it is in the System of Care today, as indicated in table 2.4.

Table 2.3. System benchmarks for standard lengths of stay by modality and system of care

Adult Youth

Withdrawal management 5-7 days N.A.

Intensive Outpatient 90 days ~ 42 days

Outpatient 60-90 days ~ 90 days

Residential 35-45 days 30 days

Transitional housing 90 days N.A.

Lengths of stay will need to be developed for the two new levels of residential and partial hospitalization for the

adult system. In addition, length of stay for recovery services and case management will need to be determined.

IGA: Client transfers with System of Care

The IGA expectations regarding client movement are described in Section 2.5 B (Care Coordination within DMC-ODS

levels of care).

SUTS shall develop a system of seamless transition between levels of care without disruptions in service.

SUTS shall ensure that beneficiaries will have access to recovery support services after discharge.

Proposed: Coordination & continuity of care

(See also next section on coordination for mental health and physical health services)

Role of QICs in care coordination: QICs shall continue to be responsible for overseeing client transfers within the

system under the ODS. QICs shall continue to:

Transfer clients


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Authorize extensions of stay in treatment

Trouble-shoot solutions for specific client problems and other client-related issues that arise during treatment

Care coordination function shall be expanded to cover out-of- network referrals for services

IGA: Coordination & continuity of care

The expectations for coordination and continuity of care are described in Section 2.5 A. SUTS will be required to provide care coordination in compliance with 42 CFR 438.

SUTS shall care coordinate referrals to ambulatory care, inpatient and other services that beneficiaries are entitled to receive

SUTS shall provide care in compliance with state and federal privacy laws


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Table 2.4 System of Care Implementation SUMMARY (Section 2.2)

Requirements Divisions Action required Workgroup Complete by:

NEW LOCs

2.5 Partial Hospitalization

ASOC, QI, IP Create a new level of care OP workgrp Go-Live (3/1/2017)

3.3 Residential ASOC, QI,IP Create a new level of care Res workgrp Go-Live (3/1/2017)

3.5 Residential YSOC,ASOC, QI,IP

Create a new level of care Res workgrp Go-Live (3/1/2017)

Recovery Services YSOC,ASOC, QI,IP

Create a new level of care RS workgrp Year 1

Case management YSOC, ASOC, QI,IP

Align current CM with IGA guidelines

CM workgrp Go-Live (3/1/2017)

Physician consultation MAT None Complete Go-Live (3/1/2017)

NETWORK ADEQUACY

Anticipated number of Medi-Cal clients

HHS, ROM,QIDS Estimate the annual number of new enrollees

TBD Year 1

System capacity ASOC;YSOC/MAT None NA Year 1

ADEQUATE CAPACITY/ STANDARDS

Tracking standards-Tx QIDS, ROM Create & evaluate tracking measures for tx

TBD Year 1

Tracking standards-data QIDS, ROM Create & evaluate tracking measures for tx

TBD Year 1

Tracking standards-QM QIDS, ROM Create & evaluate tracking measures for tx

TBD Year 1


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Table 2.4 System of Care Implementation SUMMARY (Section 2.2)

Requirements Divisions Action required Workgroup Complete by:

MEDICAL NECESSITY

Protocol YSOC, ASOC, QI,IP Create protocol for medical necessity based on IGA requirements

SL (Access) Go-Live (3/1/2017)

Documentation YSOC, ASOC, QI,IP Written version of the above SL (Access) Go-Live (3/1/2017)

ASSESSMENTS/ REASSESSMENTS

Initial assessment (Intake) YSOC, ASOC, QI,IP P & P QI Go-Live (3/1/2017)

Admission to recommended level of care

YSOC, ASOC, QI,IP P & P QI Go-Live (3/1/2017)

Frequency - re-assessments YSOC, ASOC, QI,IP P & P QI Go-Live (3/1/2017)

RESIDENTIAL AUTHORIZATION

Protocol YSOC, ASOC, QI,IP Protocol for residential treatment authorization, and methodology for tracking authorizations

Res placement Go-Live (3/1/2017)

Documentation YSOC, ASOC, QI,IP Written version of the above Res placement Go-Live (3/1/2017)

CLIENT TRANSFERS

Routine transitions QI None Complete Go-Live (3/1/2017)

Non-routine transitions QI None Complete Go-Live (3/1/2017)

CCORDINATION/ CONTINUITY OF CARE

Care coordination referrals QI None Complete Go-Live (3/1/2017)


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2.3 Evidence-based practices and practice guidelines Proposed: Evidence-based practices & guidelines Clinicians in the Adult System of Care and MAT are trained in Motivational Interviewing, Seeking Safety, Breaking Barriers, Framework for Recovery, Gorski’s Relapse Prevention and 12 Step Facilitation.

During the first year of the Waiver, SUTS shall provide additional training in Evidence Based Practices. As part of the ODS implementation, SUTS shall require contract providers to attest that they are providing at least

two EBPs in their treatment program. Compliance with EBPs shall be monitored with annual audits. Methods for monitoring shall include though not be

limited to: o Standard paper-based audit tools o Review of randomly selected treatment sessions by QIDS staff. A pilot project may be initiated to develop a

standard protocol for coding audiotaped sessions and evaluating fidelity to the EBP.

Practice guidelines: SUTS shall monitor practice guidelines related to co-occurring capability in the System of Care. All programs in the System of Care shall be expected to become co-occurring capable, as determined by the Dual Diagnosis Capability in Addiction Treatment (DDCAT) score of 3 or above.

MAT programs shall be assessed for co-occurring capability, using the DDCAT tool. IGA: Evidence-based practices & guidelines In the IGA, requirements related to Evidence-Based practices (EBPs) are covered in Section 19 B.3 and Practice Guidelines in Section 26. Evidence-based practices:

At least two EBPs shall be provided by each provider for each service modality SUTS shall monitor provision of EBPs in each service modality Five EBPs are required: Motivational Interviewing, Cognitive- behavioral Therapy, Relapse Prevention, Trauma-

Informed Treatment and Psycho-education. Practice Guidelines;

SUTS shall adopt practice guidelines in accordance with 42 CFR 438.236 Practice Guidelines under the Measurement & Improvement Standards. Practice guidelines must comply with the following conditions:


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o Shall be based on valid and reliable clinical evidence or consensus among experts in the field o Shall consider the needs of beneficiaries o Shall be adopted in consultation with contracting health care professionals o Shall be reviewed and updated periodically o Shall be circulated among providers in the network o UM, beneficiary education, services coverage shall consistent with the guidelines

2.4 Training Proposed: Training

Training for participating agencies: ASAM training shall be provided as usual. Additional training shall be provided for at least some of the following practices.

COD symptoms and diagnoses

Motivational interviewing

Breaking Barriers

Framework for Recovery

Seeking Safety

12 Step Facilitation Therapy

Matrix model

Thinking for a Change

Anger Management

Helping Women Recover

Healing the Trauma

Living in Balance

Seven Challenges

Family therapies

CBT

Relapse Prevention

Trainings shall be offered each month, with topics rotating throughout the year based on need. As noted, Motivational Interviewing shall be offered twice a year, with a minimum of three other EBP trainings offered annually for all Behavioral Health County and Contract Providers.


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Treatment providers shall be required to provide at least two Evidence-based Practices (EBPs) such as Seeking Safety and the Matrix model in each treatment modality

IGA: Training requirements Training requirements are referenced throughout the document and apply to training of all specialties in the System of Care from clinicians to data collection staff to the compliance officer.

Nonprofessional staff shall be provided with on-site orientation and training prior to performing assigned duties Professional and non-professional staff shall have appropriate experience and training at the time of hiring Department shall consider the number and types of providers (including training level) required to meet the

demand for services Department shall ensure effective training for compliance officers at SUTS and providers Contractor shall participate in CalOMS-Tx informational meetings, trainings and conference calls Contractor shall ensure that all subcontractors receive training on the requirements of Title 22 and DMC

requirements at least once a year. Proof of attendance at trainings shall be required. Contractors shall require subcontractors to be trained in ASAM criteria prior to providing services Contractor shall ensure that providers and staff conducting ASAM assessments are required to complete 2 e-

trainings modules – ASAM Multidimensional Assessment & From Assessment to Service Planning and Level of Care It is recommended that other (non-clinical) staff take “Introduction to the ASAM Criteria”

2.5 Tele-health services plan Proposed: Tele-health services

SUTS services shall provide via tele-health media during the second or third year of the DMC ODS waiver project. As

the Behavioral Health Services Department is located within Santa Clara County’s Health & Hospital System, policies and procedures must be aligned with the technological capacity and requirements of the county system. A working committee composed of representatives from the Santa Clara County Compliance Office and County Counsel’s Office has been reviewing procedures for tele-health modalities to ensure that all programs comply with confidentiality and other relevant regulations.


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IGA: Tele-health services DHCS recognizes tele-health services as viable means for delivering services in substance use treatment programs. The requirements for using tele-health as mode of delivering services are scattered throughout the IGA. The key requirements are noted below.

Medical necessity may be determined via a tele-health interview or a face-to-face (Section 1.1 B(2)) Outpatient services and Intensive Outpatient services may be provided in person, by telephone or tele-health media

(Section 6 (C) and 7 (C)) Case management services may be provided face-to-face, by telephone or tele-health media (Section 9 B (5)) Recovery services may be provided face-to-face, by telephone or tele-health media (Section 11 C (3))

2.6 Coordination with Physical Health Proposed: Coordination with Physical Health Current practices related to clients’ physical health needs will continue. The linkages between SUTS and the medical care system proposed in the waiver plan will need to be reviewed for compliance with IGA requirements.

Health screens conducted at admission will continue Clients shall continue to receive services from the department’s full-time psychiatrist for stabilization medication

and referrals to the ambulatory care system for follow-up care. Youth system clients shall continue to work with on-and off-site physicians, and have access to the program’s

Medical Director, contracted physician and on-site medical staff. o Under the DMC-ODS, program’s physician shall work with the clinician to coordinate care with the client’s

PCP

MAT shall continue its current practices which includes developing a care plan based on laboratory results, physical exam and the ASAM bio-psychosocial assessment

For the perinatal program, pregnant clients shall be referred to obstetrician/gynecologist, if they do not already have one; MAT physicians shall initiate linkage with obstetricians/gynecologists in the SCVHHS

IGA: Coordination with Physical Health Under the ODS, the MCP is expected to put into place procedures and the necessary agreements to link clients to medical specialists. (See Section 2.5 (5))

MCP shall ensure that enrollees with special health care needs have access to specialists


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MCP shall ensure that each beneficiary has an ongoing source of primary care, appropriate to his or her needs, including special health care needs. SUTS shall ensure that beneficiaries are assessed by appropriate health care professionals

Under the DMC-ODS, treatment plan must developed by the PCP and beneficiary, approved by the entity and in accordance with applicable state quality assurance and utilization review standards

MCP shall ensure that women have direct access to a women’s health specialist, where necessary 2.7 Coordination with Mental Health Proposed: Coordination with Mental Health

Coordination with mental health services shall involve:

o Developing a common entry portal into behavioral health services, as part of the integration between Mental

Health and Substance Use Treatment

Clients shall continue to be referred to Mental Health services by assessors in locations where the two

departments operate as an integrated team such as the Behavioral Health Team at the Re-Entry

Center

Youth shall continue to access Mental Health services from school sites or through the specialty

Substance Use Treatment Referral Coordinator call number

IGA: Coordination with Mental Health Coordination with other health services such as Mental Health is discussed throughout the IGA.

Case management services shall cover coordination with mental health services. Section 9 B (5). Coordination between substance use and mental health services shall be monitored in accordance with Section 24 A (6).

2.8 Compliance with 2015 PSN guidelines Proposed: Compliance with 2015 PSN guidelines

SUTS has been operating a perinatal program for many years. The perinatal program has updated its policies and procedures to comply with the most recently revised PSN guidelines (2015).

IGA: Compliance with 2015 PSN guidelines The requirements related to compliance with PSN guidelines are covered in section 27 (C).


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Table 2.5 SYSTEM OF CARE IMPLEMENTATION SUMMARY (Sections 2.3-2.9)

Requirements Divisions Action required Workgroup Completed

by:

EBPs & GUIDELINES YSOC, ASOC, MAT Develop a list of EBPS, expectations by modality and method of verification

TBD Year 1

TRAINING YSOC, ASOC, MAT List of trainings and frequency; method of verification

TBD Year 1

TELEHEALTH SERVICES YSOC, ASOC, MAT Create a HIPAA & 42 CFR compatible protocol for delivering telehealth services

TBD Year 2

COORDINATION W/ PHYSICAL HLTH

YSOC, ASOC, QI,IP, MH

Protocol for referrals to medical providers; written agreements with VMC

TBD Year 1

COORDINATION W/ MENTAL HLTH

YSOC, ASOC, QI,IP, MH

Protocol for referrals to MH service providers; written agreements with MH

TBD Year 1

COMPLIANCE W/PSN GUIDELINES

MAT None NA NA


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SECTION III BUSINESS OPERATIONS


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The SUTS DMC-ODS proposal to DHCS included only those operational details required by the RFA. As the IGA serves as the contract between SUTS (the Managed Care Plan) and DHCS, the implementation of the Business Operations focusses on IGA requirements. The business operations section of IGA describes the responsibilities of the MCP, financial reporting requirements, contracting with provider network and meeting beneficiary needs. The areas covered in this section Include:

3.1 Finance 3.2 Contracts 3.3 Contract monitoring 3.4 MOU with Health Plans 3.5 Compliance & monitoring 3.6 Claim submission and monitoring 3.7 Certification 3.8 Beneficiary relations 3.9 Updates to P & P

3.1 IGA: Finance Financing requirements are covered in Sections 1.3, 23.2 and 23 (A) of the IGA. The requirements have been gathered together and summarized below.

Payment for services: The requirements shal be reviewed and procedures revised to ensure that: o Allowable expenditures for services are certified o A CPE (Certified Public Expenditure) protocol based on the DHCS process to determine expenditures is put

into place (or revised if one already exists) o A beneficiary with other health coverage (OHC) is billed first or has on record a denial letter from the OHC

Note: Until the IGA is signed, services will only be reimbursed under the state plan Rate setting:

o MCP’s proposed rates for services other than (OTP/NTP) to DHCS have been approved. These rates may be adjusted in the future.

A covered service will be reimbursed only at this rate. o OTP/NTP rates are set separately by a workgroup and:

MCP must reimburse OTP/NTP services at these rates OTP/NTP providers must submit financial data annually and report to DHCS An annual cost settlement does not apply to NTP/OTP services


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DHCS Monitoring Reviews & Financial Audits o MCP shall be monitored for compliance with the service provision requirements stated in the IGA and may

involve: Inspection/audits of services Review of management systems and procedures Review of books and records Beneficiary enrollment/disenrollment procedures Grievances and appeals process (See section on compliance for more detail) Violations of conditions for FFP

QFFMR: o MCP is required to submit a Quarterly Federal Financial Management Report (QFFMR) to report SAPTBG

quarterly expenditures Year-end cost settlement reports

o MCP shall submit to DHCS year-end cost settlement paperwork. There current process, which SUTS has been following for many years, will continue. Specific documents required include:

Year-end claim for reimbursement DMC Cost report for IOP for perinatal and non-perinatal beneficiaries DMC Cost report for OPDF group counseling for perinatal and non-perinatal beneficiaries DMC Cost report for OPDF individual counseling for perinatal and non-perinatal beneficiaries DMC Cost report for residential treatment for perinatal beneficiaries DMC Cost report for NTP for perinatal and non-perinatal beneficiaries

3.2 Contracts Proposed: Contracts SUTS MCP proposes to follow Santa Clara County’s contracting and appeals process, as summarized below:

Selection of provider contracting process

o All county departments shall follow the Board of Supervisors policy, Chapter 5 -on soliciting and contracting.

(See Attachment IX for Board of Supervisors policy)

Length of term of contract o Services shall be re-bid every 5 years through a competitive procurement process that involves publishing

Request for Proposals (RFP). Contract awards from RFPs shall be renewed every fiscal year and will remain


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in effect for a maximum of 5 years. Under specific circumstances, the Board of Supervisors may allow a contract to be extended beyond the prescribed period.

Local appeals process o County policy (Section 5.6.5.3 Protest Process) offers contractors with the opportunity to protest a contract-

related decision. This protest procedure is described in the RFP and it allows non-selected contractors to appeal a decision process to appeal.

Options for continuing service for beneficiaries if a particular contractor is not selected o If current DMC providers are not awarded a DMC-ODS contract, the county will ensure that beneficiaries are

referred to other DMC-ODS contract providers that provide comparable services. IGA: Contracts

IGA requirements for contracts are covered in Sections 3 (D), 19 and 28, which cover provider selection and certification, subcontracts, and formation and purpose. Note that this section covers both (a) contract between SUTS and the state (DHCS) and (b) SUTS and its provider network (subcontractors).

Under Section 3, there are several provisions that become SUTS responsibility: o MCP will need to ensure that policies and procedures for selection, retention, credentialing and re-

credentialing of providers are in place; and that they do not discriminate against providers that serve high risk populations; equal application of procedures to all entities regardless of whether they are public or private. For additional provisions, see Sections 3 D and E.

o MCP shall contract only with providers who have been enrolled with DHCS, designated limited risk in the prior year and has a signed Medicaid provider agreement with DHCS (3 F)

o MCP may contract with individual LPHAs to provide DMC-ODS services (3 G) o MCP shall comply with 42 CFR 438 provisions related to selection of providers and expectations related to

contractor selection, appeals, services, reimbursement. o If MCP does not render a decision within 30 days of a provider filing a protest (contesting a selection), the

provider can appeal directly to DHCS. Subcontracts are covered in Section 19 of the IGA, which describes the requirements for the contractual agreement

between the MCP and its provider network. 3.3 Contract monitoring This section covers the MCP’s responsibilities related to monitoring contracts with its sub-contractors (the provider network) and complying with DHCS requirements. The provisions related to contract monitoring and compliance overlap, and


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it will be necessary to determine the appropriate division of labor between the Compliance Office (to be created) and the plan administration. Proposed: Contract monitoring

SUTS MCP shall comply with the requirements related to contract monitoring IGA: Contract monitoring-responsibilities related to monitoring subcontractors

MCP shall ensure that: o Subcontractors follow all relevant regulations as identified in Section 28 b (1) a through j o Comply with 42 CFR 438.236(b) adoption of practice guidelines o List of debarred individuals and agencies on the OIG list of Excluded individuals/entities & Medi-Cal suspended

and ineligible list will be monitored o Contract rules are followed o Fraud and abuse will be monitored and reported

The MCP is also responsible for monitoring contracts with subcontracts with respect to: o Quality of services -Section 28.1 A (b) o Audits Section - 28.1 A (d) o Addressing barriers to treatment (geographic, cultural, ethnic, linguistic, disability, etc. Section 28.1 (B) o SUTS MCP will be required to monitor compliance with restrictions on salaries of sub-contractors o Monthly monitoring of active participation in the DMC program and notification to DHCS of changes in

subcontractor certification items such as change in ownership 3.4 MOU with Health Plans

SUTS MCP is currently developing a Memo of Understanding (MOU), and the required policies and procedures with the two Medi-Cal Managed Care Plans in Santa Clara County: Valley Health Plan and Santa Clara County Family Health Plan. The MOU will outline mechanisms for sharing information and coordination of service delivery. Note: MCP must comply with the IGA requirements for MOU and other health plans. IGA: MOU with other health plans_ In the IGA, the contents of MOU with health plans are covered mainly in section 2.5 Coordination and Continuity of Care. The key provisions of an MOU with a Medi-Cal managed care plan include:

Notification to DHCS if MCP is unable to enter into an MOU or maintain an MOU with a Medi-Cal managed care


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Mechanisms for monitoring effectiveness of the MOU with physical health plans Ensuring that each beneficiary has a PCP Ensuring coordination of services provided by another plan and sharing data about beneficiaries A mechanism to make specialist services available to beneficiaries with special healthcare needs Ensuring that the treatment plan reflects the need for specialist care and consultation with the provider of specialist

services Ensuring that women beneficiaries have access to a women’s health specialist

Additionally, subsection C lists specific provisions related to the MOU – shown below:

‘Contractor shall enter into a memorandum of understanding (MOU) with any Medi-Cal managed care plan that enrolls beneficiaries served by the DMC-ODS. This requirement can be met through an amendment to the Specialty Mental Health Managed Care Plan MOU’.

The following elements in the MOU should be implemented at the point of care to ensure clinical integration between DMC-ODS and managed care providers:

Comprehensive substance use, physical, and mental health screening, including ASAM Level 0.5 SBIRT services; Beneficiary engagement and participation in an integrated care program as needed; Shared development of care plans by the beneficiary, caregivers and all providers; Collaborative treatment planning with managed care; Delineation of case management responsibilities; A process for resolving disputes between the county and the Medi-Cal managed care plan that includes a means for

beneficiaries to receive medically necessary services while the dispute is being resolved; Availability of clinical consultation, including consultation on medications; Care coordination and effective communication among providers including procedures for exchanges of medical

information; Navigation support for patients and caregivers; and Facilitation and tracking of referrals between systems including bidirectional referral protocol.


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3.5 Compliance Proposed: Compliance

SUTS MCP will comply with all relevant regulations. IGA: Compliance

Several sections of the IGA deal with compliance with specific regulations such as HIPAA, grievance and fair hearing policies, etc. This section focuses on the regulations specific to the MCP which are covered in Sections 17, 18 and 20. Section 17 covers the main areas of compliance as shown in the list below. Current Policies & Procedures related to grievance, fair hearing and appeals are shown in section 18 (see table 3.2-in the Beneficiary Brochure section). Current Policies & Procedures related to grievance, fair hearing and appeals need to be reviewed and updated for consistency with 42 CFR 438.404(c). The compliance requirements in the new DMC contract need to be compared against the existing DMC contract. It is likely that most of these requirements will not be new, although IGA requirements may contain updates to recent changes in federal and state regulations.

The SUTS MCP is required to establish a compliance office and designate a compliance officer to monitor compliance.

Areas covered in Section 17: o Additional Intergovernmental Agreement Restrictions o Nullification of DMC Treatment Program SUD services (if applicable) o Hatch Act o No Unlawful Use or Unlawful Use Messages Regarding Drugs o Noncompliance with Reporting Requirements o Limitation on Use of Funds for Promotion of Legalization of Controlled Substances o Restriction on Distribution of Sterile Needles o Health Insurance Portability and Accountability Act (HIPAA) of 1996 o Nondiscrimination and Institutional Safeguards for Religious Providers o Counselor Certification o Cultural and Linguistic Proficiency o Intravenous Drug Use (IVDU) Treatment

o Tuberculosis Treatment o Trafficking Victims Protection Act of 2000

o Tribal Communities and Organizations o Participation of County Alcohol and Drug Program Administrators Association of California and California


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Behavioral Health Director’s Association of California. o Restrictions on Grantee Lobbying – Appropriations Act Section 503 o Nondiscrimination in Employment and Services o Federal Law Requirements: o State Law Requirements: o Investigations and Confidentiality of Administrative Actions

3.6 Claim submission and monitoring The requirements related to claims submission and the MCP’s responsibilities for monitoring the claims process are described mainly in IGA sections: 3, 4, 20 and 23. The majority of the requirements related directly to claims submission are discussed in Section 20 (H) entitled DMC Claims and Reports. The key requirements from several sections are gathered together under IGA requirements. See Section 23 for references to additional regulations related to billing and claims submissions, specifically MCP’s responsibilities in the event of inaccurate claims. See also section 1.3 Financing for details on Payment for Services and Rate Setting. Proposed: Claims submission & monitoring

SUTS MCP will comply with all requirements related to claims submission and monitoring. IGA: Claims submission & monitoring

MCP shall submit claims in compliance with the DHCS DMC Provider Billing manual MCP and provider network shall verify a beneficiary’s eligibility prior to providing a covered service Additional requirements are shown below (Verbatim from IGA-Section 20):

o Contractor shall submit to DHCS the “Certified Expenditure” form reflecting either: 1) the approved amount of the 837P claim file, after the claims have been adjudicated; or 2) the claimed amount identified on the 837P claim file, which could account for both approved and denied claims.

o DMC service claims shall be submitted electronically in a Health Insurance Portability and Accountability Act (HIPAA) compliant format (837P). All adjudicated claim information must be retrieved by the Contractor via an 835 HIPAA compliant format (Health Care Claim Payment/Advice).

o The following forms shall be prepared as needed and retained by the provider for review by State staff: Multiple Billing Override Certification (MC 6700), Document 2K Good Cause Certification (6065A), Document 2L(a) Good Cause Certification (6065B), Document 2L(b)


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o In the absence of good cause documented on the Good Cause Certification (6065A or 6065B) form, claims that are not submitted within 30 days of the end of the month of service shall be denied.

Certified Public Expenditure (CPE) County Administration (Section 23) o Separate from direct service claims as identified in #2 above, the Contractor may submit an invoice for administrative

costs for administering the DMC program on a quarterly basis.

Contractor shall attest that DMC claims submitted to DHCS have been subject to review and verification process for accuracy and legitimacy. (45 CFR 430.30, 433.32, 433.51). Contractor shall not knowingly submit claims for services rendered to any beneficiary after the beneficiary’s date of death, or from uncertified or decertified providers.

Contractor shall comply with the requirements mandating provider identification of provider-preventable conditions as a condition of payment, as well as the prohibition against payment for provider-preventable conditions as set

forth in 42 CFR 434.6(a)(12) and 42 CFR 447.26. MCP also has additional responsibilities related to recovering payments from other sources (See Section 4-Recovery from Other

Sources):

o The Contractor shall recover the value of covered services rendered to beneficiaries whenever the beneficiaries are

covered for the same services, either fully or partially, under any other state or federal medical care program or under other contractual or legal entitlement including, but not limited to, a private group…..

o The monies recovered are retained by the Contractor o The Contractor shall maintain accurate records of monies recovered from other sources.

o Nothing in this section supersedes the Contractor's obligation to follow federal requirements for claiming FFP for services provided to beneficiaries with other coverage under this Intergovernmental Agreement

3.7 Certification Proposed: Certification

SUTS MCP shall comply with all requirements related to certification. IGA: Certification The requirements related to certification are covered in IGA sections 3.1 and 3.2. Some of the provisions related to requirements will also appear in the sub-section on contracts.

SUTS MCP sub-contractors (provider network) will need to be licensed, registered, DMC-certified and/or “approved in accordance with applicable laws and regulations” in order to provide services

Sub-contractors shall be required to comply with the following:


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o Drug Medi-Cal Certification Standards for Substance Abuse Clinics (Document 2E); o Title 22, CCR, Sections 51341.1, 51490.1, and 51516.1, (Document 2C); o Standards for Drug Treatment Programs (October 21, 1981) (Document 2F); o Title 9, CCR, Division 4, Chapter 4, Subchapter 1, Sections 10000, et seq.; and o Title 21, CFR Part 1300, et seq., Title 42, CFR, Part 8;

o Title 22, CCR, Division 3, Chapter 3, sections 51000 et. seq. 3.8 Beneficiary relations Proposed: Beneficiary relations

SUTS MCP shall comply with all requirements related to beneficiary relations. A workgroup has been convened to produce a beneficiary brochure, which each beneficiary is entitled to receive. IGA: Beneficiary relations

The main components included in this sub-section include the beneficiary brochure and a provider list for beneficiaries. The key provisions are covered in IGA section 14 and selected components of section 18. IGA section 18 covers Beneficiary Problem Resolution Processes and only relevant parts of this section need to be included in the beneficiary brochure. Section 18 also falls under the general purview of compliance. The content areas for the beneficiary brochure are shown in Table 3.2

The content of the beneficiary brochure is described in IGA Section 14-, Beneficiary Brochure and Provider List.

The contents of the beneficiary brochure must include, but need not be limited to, the 13 required elements from Section 14 (see list below).

In addition, relevant sections of IGA Section 18- Beneficiary Problem Resolution Processes- must be included so

beneficiaries have information about their rights regarding fair hearing, grievance and appeal processes, expedited fair hearing and the contents of the Notice of Action (NOA). (For more information, see section on Compliance).


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Table 3.2 Required elements for Beneficiary Brochure

Required elements Relevant sections

IGA Section 14 IGA Section 18

Enrollment notice & other information in specified format

General provisions

Automatic Enrollment Fair hearing

Information about enrollment Notice to Beneficiaries

Provider information, cost sharing, etc. Grievance process

Accessing services Appeal Process

Providers with Threshold languages Expedited Appeal

Oral interpretation Beneficiary Problem Resolution Processes Established by providers

Grievance and fair hearing Fair Hearing

Provision of copy of booklet Expedited Fair Hearing

Inclusion of toll-free numbers Continuation of Services Pending Fair Hearing Decision

Provider directory Provision of NOA

Changes in scope of service Contents of NOA

Notification of termination Consistent with 42 CFR 438.404(c)

Effectuation of reversed appeal resolutions

3.9. Updating Policies & Procedures This section serves as the ‘catch-all’ part of the document, the purpose of which is to: (a) bring attention to specific policy requirements and (b) the need to revise current policies and procedures to reflect IGA requirements. Proposed: Record Retention SUTS MCP shall comply with all DMC regulations related to record retention. SUTS MCP follows Santa Clara County policies with respect to record retention and protection. SCC record retention policies exceed the minimum required under the IGA. IGA: Record Retention SUTS responsibilities related to record retention are covered in Section 23.6. SUTS MCP responsibilities include:

Ensuring that sub-contractors comply with the minimum period for which records must be retained by statute


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Triggering a CAP in the event of non-compliance, and resolution will require a series of steps detailed in the CAP. o Sub-contractors must be informed that failure to submit a CAP and implement the CAP may lead to funds

being withheld

Table 3.3. Business operations - DMC_ODS plan-Summary

Business Operations/Plan Administration

Divisions Action Required Workgroup Complete by

Finance

Financing-payment for services Admin Review NA Year 1

Rate setting Admin Review NA Go-Live (3/1/2017)

Quarterly Federal Financial Mgmt. Report (QFFMR)

Admin Review NA Year 1

Year-end Cost Settlement Reports


State Monitoring & financial audits


Contracts(Changes in boilerplate)

Provider selection & certification? (some provisions fall under certification)

Admin Review & modify Business Ops manual Year 1

Subcontracts Admin Review & modify Business Ops manual Year 1

Additional provisions Admin Review & modify Business Ops manual Year 1

Formation and purpose Admin Review & modify Business Ops manual Year 1

Contract Monitoring

Non-DMC/SAPT Admin/QI Review & create new P & P

Contract monitoring workgroup

Year 1

Monthly monitoring Admin/QI Review & create new P & P

Contract monitoring workgroup

Year 1


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Table 3.3. Business operations - DMC_ODS plan-Summary

Business Operations/Plan Administration

Divisions Action Required Workgroup Complete by

MOU with Health Plans Admin/QI Create MOU Contract monitoring workgroup

Year 1

Compliance SUDS Compliance Division Admin/QI Create compliance

office Compliance workgroup Year 1

Beneficiary problem resolution process (Grievance procedure)

Admin/QI Review current P & P & update

Compliance workgroup Go-Live (3/1/2017)

Advance Directives Admin/QI New P & P Compliance workgroup Year 1 Program Integrity Requirements Admin/QI New P & P Compliance workgroup Year 1 Confidentiality Requirements All Review current P & P

& update Compliance workgroup (3/1/2017)

Record Retention All Review current P & P & update

Compliance workgroup Year 1

Policies & procedures All Review current P & P & update

Compliance workgroup Year 1

Claims submission/monitoring DMC claims & reports Admin Review & update Claims workgroup (3/1/2017) Beneficiary liability for payment Admin Review & update Claims workgroup (3/1/2017) Recovery from other sources or providers

Admin Need to develop a plan Claims workgroup (3/1/2017)

Financial audits (state monitoring) Admin Review & update Claims workgroup Year 1 Certification DMC certification & enrollment Admin Review & update TBD Year 1 Certification of individual providers?

? Needs discussion TBD (3/1/2017)

Beneficiary relationship Beneficiary brochure & provider list

Admin/QI In process BB workgroup (3/1/2017)


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SECTION IV- QUALITY MANAGEMENT


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A Medicaid (Medi-Cal in California) managed care plan is expected to develop and implement a Quality Improvement (QI) plan. The main purpose of the QI plan is to demonstrate that: (a) beneficiaries are able to access treatment in a timely fashion, and (b) they receive high quality treatment that produce beneficial outcomes. The QI plan may be regarded as guidance for improving treatment practices to produce good outcomes for beneficiaries. The SUTS MCP will come under scrutiny during the waiver implementation period from a number of different entities-DHCS, EQRO (External Quality Review Organization) and UCLA. UCLA has been contracted by DHCS to evaluate the substance use treatment waiver implementation in California. This section covers the quality improvement plan described in the waiver proposal to DHCS and key IGA requirements related to quality improvement, quality monitoring and utilization management in Medi-Cal Managed Care Plans (MCP). References to quality improvement, quality monitoring and utilization management appear in different sections of the IGA, but the majority are gathered under Sections 22, 23, 24 and 25. A separate document – The Strategic Data Plan - covers the data requirements and data gathering strategy related to the ODS-DMC waiver. The key requirements for quality improvement for the MCP include:

4.1 Quality management plan 4.2 Quality improvement program 4.3 Contractor monitoring (EQRO) 4.4 Reporting requirements 4.5 Utilization management

The IGA makes a distinction between Quality Management, covered in Section 22 and Quality Improvement, covered

mainly in Section 24. The Quality Management Program (QM) refers primarily to the structure and processes that produce desirable treatment outcomes. The Quality Improvement (QI) section focuses on the metrics that the MCP needs to create, monitor and report to the relevant oversight entities. 4.1 Quality Management plan Proposed: Quality Management (QM) Program The SUTS QI plan is designed to meet the requirements covered in Section 22 B, which requires the MCP to have a QI program description, components, responsibilities of staff and performance measurements. The QIDS will continue to manage the System of Care by (a) overseeing placements, (b) managing transfers within the system, (c) troubleshooting care


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coordination issues raised by contract and county providers and (d) conducting quality assurance tasks such as DMC audits, clinical chart audits, and monitoring data quality and integrity.

Quality improvement staff will continue to perform these functions: system audits, client grievance monitoring and regular reports from the department’s electronic health record. However, client complaint and grievance procedures needs to be modified to align with Part 438 of 42 CFR. Memoranda of understanding with health plans will cover procedures for handling and resolving denial of service and payment-related complaints. Some routine office functions associated with handling denial of services will be moved to the Business Office. The SUTS Quality improvement plan calls for expanding the list of measures used to monitor system functioning. These measures are organized into ‘output’ and ‘input’ measures. The Quality Improvement plan calls for gathering data on five different ‘output’ domains: (i) access to services, (ii) engagement in services, (iii) client outcomes, (iv)care coordination, and (v) communications between and within key partners. Verbatim from Section 11 (Quality Assurance)-Final Waiver proposal

Access to services is divided by service modality; there are three outpatient access measures, three residential

treatment access measures, two Medication Assisted Treatment access measures and one Intensive Outpatient access

measure. Access measures focus primarily on wait-times, intervals between key clinical events such as intake, first

treatment session and completion of treatment plan, utilization rates and re-admissions. (See table 4.1)

For engagement, three separate sets of measures are proposed: one set for outpatient, intensive outpatient and

Medication Assisted Treatment; a second set for residential treatment and Partial Hospitalization; the third, for utilization of

the continuum of care: (See Table 4.2)

For outpatient, intensive outpatient and MAT, the engagement is measured as the percent of clients with 4 services

provided in the first 30 days of admission, number and type of treatment services, and customer services Key

Performance Indices (which are yet to be determined).

o In addition, the QI team will monitor the interval between admission and the next clinical appointment (at or

below 5 days post-admission).

o For MAT, measures will include percent receiving same day dosing (upon admission), when consistent with

medical evaluation and state and federal regulations.


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For Residential Treatment and Partial Hospitalization, engagement is measured as the percent of clients who receive

an intake, assessment or a treatment plan within 14 days of admission, number of treatment services, and Customer

Service Key Performance Indicators (which are yet to be determined)

For the continuum of care, engagement is measured as the percent of client who use the step down components of

the Continuum of Care.

Table 4.1. Quality Improvement Measures for Access

Measures – system

functioning

Metrics Data Requirements

ACCESS

Access to treatment system

Responsiveness of beneficiary access line: time to

call response, dropped and abandoned calls

CISCO telephone routing system

Outpatient treatment Date of Screening to First Offered Appt.

Date of Screening to initial appointment (intake) at the appropriate LOC

reporting requirement in DMC – ODS Waiver 1115

% of clients with 3 additional AOD services in first 30 days from the date of intake (4 in 30 metric, including intake as 1st service.

reporting requirement of Quality Measures (CMS letter July 27, 2015)

Residential treatment Date of Screening to First Placement attempt

Date of first Placement attempt to date of Intake (Intakes should occur 24/7)

Goal is to a 10% maximum vacancy rate

MAT Date of Screening to Induction

Date of Walk-in appt to Induction

IOP from Res Or other transfer

Date referral is received by provider to IOP Intake


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Table 4.2. Quality Improvement Measures for Engagement

Measures – system functioning

Metrics Data Requirements

Engagement

OP/IOP/AMT 4/30 Includes Intake and Assessment, TX Plan, TX Service(s),

Strategic Data Plan

Treatment services Strategic Data Plan

Customer service key performance indices

Strategic Data Plan

Residential and PHP

Intake, Assessment and TX Plan by 9 days

Strategic Data Plan

Treatment services Strategic Data Plan

Customer service key performance indices

Strategic Data Plan

Continuum of care

% clients utilizing multiple step down

components of the COC

Strategic Data Plan

For client outcomes, value rather than volume of services will be measured. Frequency of data collection for client

outcomes is under discussion. A preliminary set of client outcome measures based on the SAMHSA National Outcome Measures

(NOMs) is being considered for implementation. (See Table 4.3) The Research and Outcome Measurement will assist in

adapting and testing the NOMs.

In addition, a second option under discussion involves developing an outcome tool, based on the ASAM 6 dimensions.

The final outcome measure set would need to complement the system’s Practice Standards that includes both clinician and

client measurements of outcome. Post-discharge data collection is currently conducted only for grant-funded projects, and

expanding these efforts to the larger system will depend on identified funding.


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Table 4.3. Client Outcomes – based on SAMHSA’s National Outcome Measures

Domain Outcome Indicator

Abstinence Abstinence from substance use

at end of episode

Comparison of substance use at

beginning and end of treatment

episode

Criminal

justice

Decreased criminal justice

involvement

Arrests 30 days prior to admission

versus 30 days prior to discharge

from treatment episode

Housing

stability

Increased stability in housing Housing status 30 days prior to

admission versus 30 days prior to

discharge from treatment

episode

Social

connectedness

Increased social

support/connectedness

To be determined

Perception of

care

Client perception of value of

care

Client treatment perception

instrument under development

Metrics for care coordination will be developed during the second year of the Waiver demonstration. Measures will

involve identifying specific populations within the System of Care such as frequent utilizers of high intensity services and

effectiveness of care coordination practices to improve treatment outcomes for this group. (See Attachment III “High

utilizer”)

The last set of measures involves communication within (intra-system), Mental Health and Physical Medicine. At

present, the System of Care’s treatment continuum relies on written, faxed and electronic communications to inform county

staff, treatment providers and others about a client’s status. The new Quality Improvement plan calls for establishing formal

tracking of different system communication and utilization processes. Communication tracking will provide Quality

Improvement staff with an organized method to identify gaps in communication within the system. A list of the

communications forms that will be used for tracking and measuring the effectiveness of communications are shown below.

(See Table 4.4)


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Table 4.4. Quality Improvement Division: Type and purpose communications

Communication Purpose Type

Continuum of Care Authorizations, Transitions in LOC Document stored

Treatment Status Report Communications with CJS Document stored

QICs on –call log System troubleshooting Document stored

Clinical Supervision Mtg Regular meeting with clinical

supervisors

Meeting

Criminal justice Mtg Regular meeting with CJS Meeting

Medi-Cal Collaborative Regular meeting with providers re

DMC

Meeting

DWC /QI weekly meeting Regular meeting with DWC Meeting

Drug TX Court weekly

meeting

Regular meeting with Drug Tx

Court

Meeting

IP meeting Meeting

THU providers meeting Regular meeting with THU

providers

Meeting

Quality Assurance ‘inputs’

Quality Improvement metrics proposed in the previous section are directly tied to the processes the Quality

Improvement Department uses to monitor the system, authorize extensions of lengths of stay in residential and transitional

housing units, and the quality of client services. These activities constitute system ‘inputs,’ which refer to standards used by

the Quality Improvement Department to conduct its day-to-day work. We describe each ‘input’ activity separately below.

Audits: Audits are currently conducted annually to assess the extent to which the system complies with the standard

operational protocols as part of contractual obligations. Two types of audits are relevant to this discussion: (1) Clinical Chart

Audits which include both the annual DMC audit and the system Clinical Performance Measures audit, and (2) Programmatic


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audits which look primarily at contractual and system-wide provider operational requirements. Elements of expected program

performance, such as the interfaces with psychiatry and primary care, are included in these audits.

The purpose of the audit of MHD coordination for services is to assess coordination of care. This feedback may be used to assess the effectiveness of client services, identify care management issues and improve service delivery. The documentation in the Health Record is audited for the items shown in Table 4.5.

Table 4.5. Items for Audit for MHD Coordination

Item Item description

A Psychiatrist or Primary Care Physician (PCP) prescribing medications for problems noted in Dimension #3

B Evidence of coordination between providers and the prescriber based on the beneficiary’s need

C For moderate to severe ASAM dimension 3 assessment, care coordination with the PCP included in the treatment goals and documented in the treatment plan

D Evidence for beneficiary declining to consent to care coordination between behavioral health provider & PCP (in progress note)

PCP communication with other providers is currently audited mainly for the contract with the county-run health plan.

The audit involves reviewing documentation in the Health record. Specifically, the review examines whether: (i) the PCP’s

name was documented, (ii) whether there was evidence of care coordination between PCP and other providers based on

beneficiary need, (iii) whether moderate to severe assessment of ASAM Dimension 2 (Physical Health) was documented, and

coordination with PCP noted in the treatment plan and treatment goals, and (iv) whether the beneficiary’s consent or

refusal to coordinate with PCP was documented in the progress note and evidence for motivational enhancement

interventions was recorded.

System monitoring: A significant proportion of Quality Improvement efforts focuses on maintaining client flow through

the System of Care, and customizing care based on individual clients’ needs, as determined by ASAM criteria. In the System

of Care, ‘flow’ metrics are monitored routinely for detoxification services, residential and outpatient lengths of stay.


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Detoxification service stays over 7 days will be monitored through reports submitted by service providers. QICs will

follow up with detoxification service providers when significant deviations in the length of stay occur. In the future,

‘avoidable admissions’ to detoxification services will also be monitored.

Residential stays over 45 days will also monitored as extensions will require formal authorization from the Quality

Improvement Department. In the future, ‘avoidable admissions’ to residential treatment will also be monitored.

Stays in outpatient treatment in excess of 180 days and intensive outpatient stays over 90 days will be monitored.

Outpatient providers are required submit justification for extensions beyond 90 days. Typically, outpatient length of

stay is monitored with a standard report, which triggers action by the Quality Improvement Department when

unusually lengthy stays are found. Quality Improvement staff willalso routinely monitor client ‘no shows’, which

providers are required to record in the electronic health record.

IGA: Quality Management (QM) Program (Section 22) Components of the QM program

Definition of the QM’s Program structure & elements Assignment of responsibility to staff Identification of quantitative performance measures Identification and prioritization of areas for improvement

Annual review

Reports of DHCS standard measures from relevant sections of 438.204 Submission of data to DHCS to enable it to evaluate MCP performance Reviews and updates to the QM plan

Triennial review

DHCS review of QI plan and monitoring activities: Monitoring activities cover:

o Service delivery system o Beneficiary protections o Access to services o Authorization for services o Compliance with regulatory & contractual requirements


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o Beneficiary records reviews DHCS review of compliance with requirement to monitor service capacity

o (Out of compliance finding triggers POC (Plan of Correction) due within 60 days of the receipt of the final report).

QM program monitoring requirements (See Section 22)

Monitoring of the following activities: o Beneficiary outcomes o System outcomes o Utilization management o Utilization review o Provider appeals o Credentialing o Resolution of beneficiary grievances

Care coordination o Ensuring continuity and coordination of care with physical health o Ensuring continuity and coordination of care with human services agencies o Evaluating effectiveness of MOU with physical health care plan

Mechanisms to monitor services over- and under-utilization of services Evaluating the following annually:

o Beneficiary satisfaction and feedback to providers o Beneficiary grievances, appeals and fair hearings o Changes in providers

Monitoring safety and effectiveness of medication practices Implementing mechanisms to address meaningful clinical issues at a system-wide level Implementing timely interventions for quality of care

Content of QM work plan

Evidence that monitoring activities cover at least the following: o Review of beneficiary grievances, appeals, expedited appeals, fair hearings, expedited fair hearings, provider

appeals, clinical records o PIPs that contribute to meaningful changes in beneficiary care o Descriptions of completed and in process QM activities


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o Mechanisms to improve service access including 24- telephone number, timeliness of appointments, timeliness of appointments for urgent conditions, etc.

o Compliance with requirements for cultural competence 4.2 Quality improvement program In the IGA, the required contents of the quality management plan are discussed in Section 24, which contains the key provisions of 42 CFR 438.240. Proposed: Quality Improvement plan (See above) IGA: Quality Improvement plan

IGA Section 24 covers the key 438 requirements that are required to be included in a quality improvement plan. The key components include plans to monitor services accessibility, the overall system of services delivery, treatment services, compliance with EQRO, active involvement of providers and at least two Performance Improvement Plans (PIPs).

QI plan requirements o QI must have involvement of at least one licensed staff o QI plan must include active participation by providers, beneficiaries and family members in the design and

execution of the QI program Monitoring of accessibility of services will include (at a minimum) : (Verbatim section 24 (N)

o Timeliness of first initial contact to face-to-face appointment “frequency of follow-up appointments in accordance with individualized treatment plans”

o Timeliness of services of the first dose of NTP services o Access to after-hours care o Responsiveness of the beneficiary access line o Strategies to reduce avoidable hospitalizations o Coordination of physical and mental health services with waiver services at the provider level o Assessment of the beneficiaries’ experiences o Telephone access line and services in the prevalent non-English languages.

Monitoring service delivery system for: o Improving services to beneficiaries o Meeting beneficiary needs


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Convening a QI committee to: o Recommend policy decisions o Review and evaluate the results of QI activities including PIP o Initiate QI actions o Review quarterly the following data elements:

o Number of days to first DMC-ODS service at appropriate level of care after referral o Existence of a 24/7 telephone access line with prevalent non-English language(s) o Access to DMC-ODS services with translation services in the prevalent languages

Maintaining two active PIPs which have specific objectives, and are conducted in a ‘reasonable time period’ so as to inform practice on an annual basis:

o Performance measurement using objective quality indicators o System interventions to achieve quality improvement o Evaluation of effectiveness of interventions o Plans for sustaining improvements

4.3 Contractor monitoring (EQRO) Proposed: Contractor monitoring (EQRO) The MCP will comply with requirements related to External Quality Review Organization, as specified in 42 CFR Part 438. Proposed: Contractor monitoring (EQRO)

EQRO site reviews will begin after implementation Data elements that are incorporated into the EQRO protocol include:

o The number of days between referral and first DMC-ODS service o 24/7 telephone access line with prevalent non-English languages (threshold languages) o Access to DMC-ODS services with translation services in the prevalent languages

Additional measures are being developed by EQRO for ODS-DMC 4.4 Reporting requirements Proposed: Reporting requirements

The MCP will comply with requirements related to reports, as specified in IGA section.


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IGA: Reporting Requirements The requirements around reporting are described in Section 23.2. SUTS MCP is contractually obligated to submit required data and reports to DHCS as identified in Exhibit A, Attachment I or Reporting requirement Matrix for Counties.

SCC must submit documentation in a specified format that: o Demonstrates that the range of services is adequate for the anticipated number of beneficiaries in the area o Demonstrates that the mix of providers geographically dispersed and is large enough to meet the needs of the

beneficiaries in the area o Documents changes in services, benefits, geographic service areas, payments or enrollment of a new population

CalOMs Prevention o Section B 1 through 6 covers existing CalOMs prevention data requirements

CalOMs Tx o Section C 1 through 9 covers existing CalOMS Tx data requirements

Other CalOMS Prev & Tx data provisions o Section D 1 through 3 covers approaches to reporting and resolving problems with data transmission within the

required deadline DATAR

o Section E 1 through 6 covers the requirements related to DATAR reporting Charitable choice

o SCC will be required to record and report the number of referrals necessitated by religious objections to other substance use providers, in a format and at the frequency prescribed by DHCS.

Other reporting requirements o Quarterly Federal Financial Management Reports (G) and Year-End Cost Settlement Reports (H) are discussed in

the Business Operations section Penalties for failure to report

o Failure to do so may result in DHCS withholding funds until the reports are made available. (Section 17 E) o A Notice of deficiency will be sent out with a deadline for submission and a request for a CAP.


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4.5 Utilization management Proposed: Utilization management Within SUTS, the responsibility for Utilization Management (UM) and coordination of client movement through the System of Care falls under the QI Division. Under the waiver, QI Division will continue to be responsible for tracking assessments, admissions to the appropriate level of care, residential treatment authorization and transitions between levels of care are managed.

Location and staff conducting ASAM assessments

Intake shall be the first session at all treatment sites across the system of care.

A level of care assessment shall be conducted with each client using the American Society of Addiction Medicine’s (ASAM) Criteria at each treatment site. The ASAM 6-dimensional assessment shall be conducted by licensed, licensed-Waivered, or state certified AOD counselors working under the direction of clinic LPHAs.

LPHA staff shall review and sign all placement decisions that meet the medical necessity criteria.

The final decision about placement at a particular level of care shall be made by a licensed or credentialed clinician in both the adult and youth Systems of Care. If a clinician determines that the client’s individual needs would be better served at a different provider site or a different Level of Care, then the clinician must make arrangements to place the client into the appropriate modality.

Transition between levels of care

Movement within the continuum of care is classified into two types: routine and non-routine movements.

o Routine movement: Providers shall be responsible for moving clients between providers (direct referral),

which occurs when clients are discharged from a higher level of care to a lower level of care. Direct

referrals shall be the normal practice when a client wishes to switch providers within the same level of

care.

o Non-routine movement: Provider shall consultation with and seek authorization from QICs to move a

client to a higher Level of Care (e.g. outpatient to residential). ASAM 6 DIM and LOC Criteria shall be used

to determine whether the move should be authorized.

Care Coordination shall be offered by the Quality Improvement staff in special instances where there are :


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o Provider-client issues, client-specific needs, or other unique circumstances. This function includes successful

transitions of clients that have been designated as “high utilizers,” and in cases where clients need to be

upgraded back to a higher level of care.

o QIDS staff shall manage such clients to ensure appropriate placement in treatment and assessment of case

management services necessary to address the individual needs of this population. In all these instances,

transfers shall require prior consultation with and authorization by Quality Improvement Coordinators.

Admissions to the recommended level of care o A client shall be referred to an initial level of care by the Call-Center or a post-authorization site, or a QIC (in

the case of youth residential referrals). At the initial level of care, a clinician shall conduct a comprehensive ASAM assessment to confirm that the level of care is matched to the client’s treatment need. (Note: Medication Assisted Treatment system follows a different procedure for transfers in compliance with State Title 9 regulations).

o Clients requiring a Level of Care not currently available in the System, such as partial hospitalization or medically monitored Intensive Inpatient Treatment, shall be referred to an appropriate level of care or to a community partner.

Frequency of assessments

o Clients will be assessed as often as necessary, although the system shall require an assessment every 30 days using the ALOC.

o Clients who return to the system following a break in treatment (discharge) shall require a re-assessment before they are placed in a level of care.

The Quality Improvement Department shall authorize extensions of stay in residential treatment and transitional

housing for outpatient clients. IGA: Utilization management The MCP’s responsibilities related to Utilization Management (UM) are described in Section 25 of the IGA. The UM Program is required to assure that beneficiaries have access to appropriate services.

Monitoring responsibilities include: o Timely access to services including waitlists, number of days between the referral/initial request to the first

DMC-ODS service o Medical necessity established for beneficiaries


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o Services provided at the appropriate level of care o Interventions that are tailored to the diagnosis and level of care

Maintaining integrity with respect to UM o Entity responsible for UM shall not have the incentive to deny, limit or discontinue medically necessary services

Table 4.6. Quality Improvement, Utilization & Monitoring Operations Impacted by DMC-ODS -Summary

Divisions/units Action Required Workgroup Complete by

Quality Improvement, Utilization & Monitoring

Quality Management Plan

Written description of QI plan consistent with 438.240; & annual updates

QI Create a QI plan QI Plan workgroup Go-Live (3/1/2017)

Annual submission –DHCS measures & 438.240

QI;ROM Covered under the Strategic Data Plan (SDP)

Staff Year 1

Triennial review QI;ROM Review & Compliance Staff Year 1

Monitoring expectations QI;ROM Compliance SUTS Year 1

Quality Improvement Program

Monitoring accessibility of services

QI; ROM Covered under the Strategic Data Plan (SDP)

Staff Year 1

Monitoring delivery system QI; ROM Covered under the Strategic Data Plan (SDP)

Staff Year 1

Convening a QI Cmte to review tx svcs

QI Select committee members and convene meetings

NA Year 1

QI program operation includes licensed staff

QI None NA Year 1

Demonstrate involvement of practitioners, beneficiaries & family members

QI Review-QI committee sign-in sheets

NA Year 1

Maintain a minimum of two PIPs ASOC, YSOC, Need to select two PIPS Workgrps will be assigned following

Year 1


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that meet the DHCS contract criteria

QI, ADMIN, ROM for presentation to yrly EQRO

selection of PIP

QM Work plan QI Create a Work Plan Staff Year 1

Contractor Monitoring (EQRO)

EQRO monitoring plan QI; ROM Covered under the Strategic Data Plan (SDP)

Staff Year 1

Annual utilization review of DMC providers

QI Review by QIDS & dessemination to providers

Staff Year 1

Compliance with DMC-ODS Compliance; Admin; QI

Need to create a compliance plan

Year 1

Timely DATAR submissions (see below)

QI None NA Operational

Identification of provider-preventable conditions (PPCs)

Admin; Compliance; QI

NA NA Year 1

Reporting Requirements

Submission to DHCS data on beneficiaries, providers

QI; ROM Covered under the Strategic Data Plan (SDP)

Staff Year 1

CalOMS PV QI; Prevention None NA Operational

CalOMS for treatment QI None NA Operational

DATAR reporting QI None NA Operational

Referrals for Charitable Choice QI; ROM Follow P & P estd by BO NA Year 1

Utilization Management Program

UM program responsibilities align with IGA

QI Finalize authorization workflow

Staff Go-Live (3/1/2017)

Documented system for collecting, maintaining & evaluating accessibility to care and waitlist information

QI Data analysis of QI metrics for access

Residential integration/Utilization management/QI

Go-Live (3/1/2017)


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SELECTED GLOSSSARY

Acronym

ASAM American Society of Addiction Medicine

LOC Level of Care

DMC-ODS Drug Medi-Cal Organized Delivery System

IGA Inter-governmental Agreement (also known as STC)

STC Standard Terms and Conditions

SCC SUTS Santa Clara County Substance Use Treatment System

CFR Code of Federal Regulations

MCP Managed Care Plan

DHCS Department of Health Care Services (California)

ASOC Adult System of Care (Santa Clara County)

YSOC Youth System of Care (Santa Clara County)

QIDS Quality Improvement & Data Standards

MAT Medication Assisted Treatment

AMT Addiction Medicine Therapy (Santa Clara County)

SoC System of Care

CoC Continuum of Care

OP Outpatient services

THU Transitional Housing Unit (Santa Clara County)

ROM Research & Outcome Measurement Unit

EQRO External Quality Review Organization

PIP Performance Improvement Project (EQRO related)

CaLOMS California Outcome Measurement System

UM Utilization Management

PSN Perinatal Services Network

SUDS Substance Use Disorder

HHS Health & Hospital System (Santa Clara County)

BHSD Behavioral Health Services Department (Santa Clara County)


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LPHA Licensed Practitioner of Healing Arts

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