New Program Manager Quality Improvement

Orientation

For County and Contracted

Behavioral Health Service Providers

of the County of San Diego

Congratulations on becoming a Program Manager!

This presentation offers a brief overview of several important topics related to program management and quality improvement in the County of San Diego’s System of Behavioral Health are.

It is an orientation and does not take the place of the various provider manuals that will be discussed. Please be familiar with the manuals and have them readily available for use in your program.

Orientation Topics

This orientation will cover the following areas:

Working with San Diego County Behavioral Health Services (SDCBHS)

Federal and State Statutes and Regulations Documentation and Uniform Clinical Records Staff Requirements Highlights from the Organizational Provider Operations Handbook Quality Improvement Programs Client Satisfaction Surveys Client Grievances and Rights Confidentiality

Working with County Behavioral Health Services

Not a day at the beach but still a wonderful opportunity to help those in need of behavioral health services

Working with Behavioral Health Services:

Program Managers must be aware of: Requirements for following Federal and State

statutes and regulations and all County polices.

Federal statutes and regulations include: Code of Federal Regulations, Title 42 HIPAA Title VI, Civil Rights Act of 1964 Federal Managed Care Regulations

California State Statutes

State Laws include the: Business and Profession Code Civil Code Education Code Health and Safety Code Welfare and Institutions Code (W&I)

Lanterman Petris Short Act

An Example of Statutes you need to be familiar with: Found in W&I code, Division 5, part 1 LPS concerns the involuntary civil commitment to a

mental health institution in the State of California. The act set the precedent for modern mental health commitment procedures in the United States. It was co-authored by California State Assemblyman Frank Lanterman (R) and California State Senators Nicholas C. Petris (D) and Alan Short (D), and signed into law in 1967 by Governor Ronald Reagan.

California State Regulations

Titles 2, 5, 9, 15, 16 and 22 The most critical is Title 9 which:

Establishes Local Mental Health Director, and Mental Health Board

Sets standards for service requirements and documentation standards

Identifies staff qualifications and requirements Defines criteria for reimbursement of services Establishes clients rights and problem resolution processes Defines Medical Necessity Criteria

What is Title 9?

Title 9 is a California Code of Regulations (CCR) that determines requirements for services and Medi-Cal reimbursement for specialty mental health services.

Updates to Title 9 are sent out periodically through California Department of Health Care (DHCS) Letters and Notices which can be found on the DHCS website.

For a copy of Title 9 please visit the website for the California Department of Health Care Services at http//www.dhcs.ca.gov

Working with San Diego County Mental Health Services

Program Managers should also be aware of the following County authorities:

Behavioral Health Administration (Mental Health and Alcohol and Drug Services) Local Behavioral Health Director is Alfredo Aguirre

Health and Human Services Agency (HHSA) HHSA Director is Nick Macchione

San Diego County (The County) CAO is Helen N. Robbins-Meyer

Rehabilitation Option and Targeted Case Management Topics not covered by Title 9 that Program

Managers may need to be aware of may be covered in the Rehabilitation Option and Targeted Case Management Manual

The manual includes Service Definitions Lockouts Staffing qualifications

The manual has mostly been replaced by Title 9 The Rehab Option Manual can be found on the

DHCS Website at http//www.dhcs.ca.gov, under Mental Health Letters, Letter #95-04

Quick List of Abbreviations: SDCBHS-San Diego County Behavioral Health Services EPU- Emergency Psychiatric Unit (Adults and Older Adults) ESU- Emergency Screening Unit (Children and Adolescents) SDCPH- San Diego County Psychiatric Hospital QI- Quality Improvement MHSD- Mental Health Service Division MHP- Mental Health Plan MHSA- Mental Health Services Act Substance Use Disorders (SUD) Services

Where to find information:

Services such as Assessments, Client Plans, and Collaterals are all defined in Title 9 – see Article 2, sections 1810.200 through 1810.254

Program and Billing requirements in Title 9 – see Article 3, sections 1810.302 through 1810.374.

What else do you need to know?

Contractors: One of the best places to find information about

what is required is to read and be familiar with your contract.

Contact your COTR County:

Contact your Chief or the Regional Program Coordinator

Target Population: Kids, Transitional Age Youth, Adults and Older Adults

Target Population

Who do we serve: Persons with Medi-Cal Persons with no insurance Low income individuals who may have other

3rd party insurance such as Medicare Persons receiving services must meet

medical necessity criteria as noted in Title 9

Medical Necessity Summary: Title 9 “in its own words…”

“ The medical record must indicate the client has an included diagnosis and/or is demonstrating emotional/behavioral symptoms sufficient enough to impair normal functioning, and that interventions were applied to produce therapeutic change.”

Among it’s many statutes, Title 9 defines Medical Necessity for mental health services:

First there must be an Included Diagnosis: This diagnosis must be present in documentation.

The primary diagnosis must be an included diagnosis listed in Title 9, Chapter 11.

“Excluded Diagnosis” (those not on the list of included diagnoses from Title 9) may be entered as a secondary diagnosis.

What are the “Included Diagnoses” ?Look up Section 1810.210 of Title 9 for the complete list :

•Somatoform Disorders•Factitious Disorders•Dissociative Disorders•Paraphilias•Gender Identity Disorders•Eating Disorders•Impulse Control Disorders Not

Elsewhere Classified•Adjustment Disorders•Personality Disorders, excluding

Antisocial Personality Disorder•Medication-Induced Movement

Disorders (related to other included diagnoses)

•Pervasive Developmental Disorders, except Autistic

Disorders•Disruptive Behavior and Attention Deficit Disorders•Feeding and Eating Disorders of Infancy and Early Childhood•Elimination Disorders•Other Disorders of Infancy, Childhood, or Adolescence•Schizophrenia and other Psychotic Disorders•Mood Disorders•Anxiety Disorders

Substance abuse/dependence disorders are NOT a part of Title 9 Included Diagnoses.

Can we provide services to clients with a co-occurring disorder? How do we document the service?

A co-occurring disorder may be a secondary diagnosis, but a Title 9 included diagnosis must ALWAYS be a primary diagnosis. For clients with co-occurring disorders, documentation must include how any substance-related interventions or treatment are directed towards the improvement of specific mental health issues.

Title 9 Medical Necessity Continued

Second there must a significant Impairment:

A client’s functioning is impaired by the symptoms of their diagnosis, or

There is a probability of significant impairment or deterioration in an important area of life functioning, or

for children, there is a probability that the client will not progress developmentally as individually appropriate.

Title 9 Medical Necessityo Third the Intervention is expected to improve the

clients functioning and impairment:

The intervention(s) are specifically focused to address the condition identified in the impairment criteria.

Intervention(s) will accomplish at least one of the following: Impairment will be significantly diminished, For client’s stabilized by treatment, the intervention will prevent

significant deterioration in an important area of life functioning, For children the intervention(s) will allow the client to progress

developmentally as individually appropriate.

The client’s condition will NOT be responsive to physical healthcare treatment.

Utilization Review ProcessMental Health Services has developed standards for

Utilization Review and/or Utilization Management(UR/UM).

The processes vary for: Adults and Older Adults System Children and Adolescents

Program Managers are responsible for ensuring that their programs are following the UR/UM Standards. Please check with your COTR or RPC to ensure you have the latest information or refer to the Organizational Provider Operations Handbook (OPOH)

Documentation Standards

Learning About Documentation Standards

Familiarity with Documentation Standards is a critical function of all Program Managers as services are billed to the State and federal government- so all documentation must adhere to minimum standards to reduce the risk of audit problems.

Title 9 requires that Medical Necessity is well documented in the clinical record.

Where do new program managers and clinical staff turn for information on documentation?

The Documentation and Uniform Clinical Record Manual and Documentation Training!

The Documentation and Uniform Clinical Record Manual

This manual is the complete guide to documentation in the County of San Diego mental health system.

It is the resource for information on forms, documentation timelines and documentation standards.

Only forms from the manual (or those created by QI) should be used. Exceptions to the Manual must be approved by the QI Unit.

Documentation Training

Currently, a new process for documentation training is being developed by the QI Unit

Training modules will be available via the internet

The training modules will be available any time your staff needs them!

Documentation Training

Each module will cover one of the following:

What is Title 9 and Medical Necessity? Documentation Basics Assessments Client Plan Progress Notes Discharge Summary Recoupments

Electronic Health Record

SDCBHS has of implemented the Electronic Health Record (EHR) through the Anasazi application

While we are in the transition period program managers need to be aware that auditors or reviewers may ask for hard or printed copies of records.

Processes as programs need to be modified to adhere to standards for the EHR

Staff Requirement Highlights

Staff Requirements

In order for staff to provide services, several criteria must be met:

Clinical Staff must have an NPI (National Provider Identifier ) number.

The NPI is a unique identification number for covered health care providers.

The NPI is a HIPAA requirement

Requirements for Programs that May Serve Clients with Medicare

Programs are required to have approved Medicare Provider Numbers known as  PTAN for Psychiatrist, LCSW, Licensed Psychologist and Nurse Practitioners

Programs must have Medicare eligible providers to provide services

CMS 855 I and CMS 855R are required to be completed and submitted to the Medicare Intermediary  Noridian

Staff Requirements

For questions on how to obtain an NPI, you can:

Phone:  1-800-465-3203 or TTY 1-800-692-2326

E-mail:  customerservice@npienumerator.com

Mail:NPI EnumeratorP.O. Box 6059  Fargo, ND  58108-6059

Staff Requirements Staff must also have access to the County’s Management

Information System (MIS), which is called Anasazi and must also have an Anasazi Staff ID

To gain access to Anasazi, staff must:

Complete the training modules on the Anasazi Forms (Demographic, Diagnosis, Treatment Session/Assignment, Individual and Group Service Records Forms).

An “ARF” (Anasazi Request Form) must be completed by the program manager and sent to the MIS unit to receive staff Anasazi ID and Anasazi Password (Program Managers are also responsible to notify the MIS unit when staff terminates, so they no longer have access to Anasazi.)

Staff Requirements

Staff must also attend Anasazi training sessions as they apply to their job function:

For example, clinical staff will learn how to enter Behavioral Health Assessments (BHAs), Client Plans and Progress Notes into Anasazi

Regular Anasazi training sessions are available for new administrative staff

Staff RequirementsClinical staff that can provide mental health services:

1. Physician2. Licensed Psychologist (or licensed waivered Psychologist 3. Licensed Clinical Social Worker (or registered ASW)4. Marriage and Family Therapist (or registered IMF)5. Registered Nurse6. Licensed Professional Clinical Counselor (LPCC)7. Mental Health Rehabilitation Specialist (MHRS)

It is a Program Managers responsibility to ensure that all staff are licensed, registered or waivered or receive appropriate co-signature on documentation

Staff- Needing a Waiver

Each CA licensed psychologist candidate and/or LCSWs or MFTs from out of state must obtain a license waiver.

Psychologists are waivered for 5 years Out of state Waivers are only effective for three years

Staff- Other important info. LCSW and MFT candidates must remain registered with

his/her licensing board until such time the candidate is licensed.

For LCSW/MFT candidates, no waiver is needed, nor can one be obtained; the only exception pertains to license-ready candidates recruited from out of state.

Trainees (clinicians who are pre-Master’s degree) may provide mental health services as long as they receive appropriate supervision and have their work co-signed based on requirements found in the Uniform Clinical Record Manual (UCRM)

Other MIS Unit Requirements

Program Managers must inform MIS Unit of all new staff and most importantly of staff terminations. It is critical that MIS Unit be informed of any staff who have left or been terminated from their positions so that we can immediately remove their access to the system.

Program Managers must ensure that staff are not sharing Anasazi staff IDs.

A “Must Read” for new Program Managers. . .

Organizational Provider Operations Handbook (OPOH)

The current Version is found on the OptumHealth Web-site

www.optumhealthsandiego.com

OPOH Highlights

This is a guide for all program managers with information needed for running your program.

It contains specific requirements for a program.

This handbook provides references and referrals for further assistance.

Each chapter will provide you with valuable information so, let’s get started.

OPOH Highlights

Chapters in the Handbook:• Systems of Care• Compliance and Confidentiality• Accessing Services• Providing Specialty Mental Health

Services• Interface with Physical Health Care• Beneficiary Rights & Issue Resolution

OPOH Highlights

Chapters in the Handbook (continued): Quality Improvement Program Cultural Competence Management Information System Provider Contracting Provider Issue Resolution Practice Guidelines Staff Qualifications and Supervision Data Requirements

OPOH Highlights

Chapters in the Handbook (continued):

Training/Technical Assistance Quick Reference Mental Health Services Act – MHSA List of Appendices

MIS Manuals

• With the implementation of the County’s new Management Information System (MIS), two important manuals were developed:

• Management Information System (MIS) Anasazi User Manual

• Financial Eligibility and Billing Procedures

• Both manuals are available at https://www.optumhealthsandiego.com

Financial Manual

Each program is responsible to have a copy of the Financial Eligibility and Billing Procedures – Organizational Providers Manual

The manual is available online at https://www.optumhealthsandiego.com

Financial Manual

A Financial Eligibility and Billing Procedures – Organizational Providers Manual has been developed

It provides detailed instructions for completion of financial eligibility and billing processes including entry of third party coverage and financial reviews (UMDAP), billing and recording of payments.

Anasazi User Manual

Describes the services codes to be entered into the Anasazi system

If you have questions please contact the OptumHelp Desk at 1-800-834-3792.

The (OPOH)details Important QI Requirements

Internal Quality Improvement Controls and Activities Medical Record Quality Management & Short-Doyle Medi-Cal Requirements Staff Signature Logs Medi-Cal Recoupment and Appeals Process Medication Monitoring Accessibility of Services/Wait Times Client and Performance Outcomes Reporting Serious Incidents

The following slides provide a brief overview for each of these topics

Quality Management & Short-Doyle Medi-Cal Requirements

Programs will be monitored for quality and compliance by BHS Quality Improvement staff.

Monitoring occurs at least annually. This includes medical record reviews as well as site certifications and recertifications

QI unit will monitor trends and/or patterns.

Medical Record

Programs are required to use the Anasazi EHR or current forms found in the Uniform Clinical Record Manual as needed.

All records must be maintained in a secure location, filed in a prescribed order, and be retrievable for audits by QI, DHCS or other entities

Medi-Cal Recoupment and Appeals Process

If a provider disagrees with a recoupment, there is a 2 level process for appealing (found in the OPOH under Quality Improvement Program).

Included is a description of the process with timelines for first and second level appeals.

Staff Signature Logs

A Signature Log is list of all current staff providing direct services, their licensure, job title, and a copy of their typical signature.

All organizational providers are required to maintain an accurate and current staff signature log.

Logs must reflect any changes in staff licensure, degree, job title, name, or signature.

Logs shall be made available at request of QI or DMH during reviews, visits, etc.

Medi-Cal Recoupment and Appeals Process

Billings will be disallowed that do not meet documentation standards in the Uniform Clinical Record Manual.

Per the current California State DMH Reasons for Recoupment of FFP Dollars, MHP is obligated to disallow Medi-Cal claims under: Medical necessity Client plan Progress notes

Site Reviews

Types of site Reviews include: Medi-Cal certification and recertification

The protocol for these reviews is available at the OptumHealth website.

Medication Monitoring

All providers with programs prescribing medications are required to have a medication monitoring system.

Results of medication monitoring activities are reported to QI Unit.

QI Unit evaluates for trends.

Refer to OPOH, Quality Improvement Program Section for Medication Monitoring process.

Reporting Serious Incidents

Providers are required to report serious incidents involving clients in active treatment or who were discharged within past 30 days.

Required reports shall be sent to BHS Quality Management Team

Provider shall also notify appropriate authorities. The forms for reporting are found at https://www.optumhealthsandiego.com

Reporting Serious Incidents

Serious incidents are classified in two levels (See OPOH for definition)

Level One – most severe Shall be reported telephonically to County Quality

Improvement Unit immediately (619-563-2781) Written report must be faxed to QI unit within 72 hours

Level Two – less severe Telephonically notify QI Unit within 24 hours Written report shall be faxed within 72 hours

Unusual Occurrences

An unusual occurrence is an incident that may indicate potential risk/exposure for the program, client, or community.

When one occurs, appropriate agencies are to be notified within specified timeline and format.

Providers are required to notify their COTR within 24 hours when an unusual occurrence occurs.

Accessibility of Services/Wait Times

Request for Services log must be maintained by all Outpatient Programs.

Ensure that clients receive services in a timely manner – emergent, urgent, routine.

How do clients access services at your clinic – orientation group, walk-in or scheduled appointment?

Wait Time – What is it?

A measure of system efficiency , the amount of time clients have to wait to receive mental health services.

Wait time is reported monthly to QI

Wait Time, cont.

Wait times are monitored by the Performance Improvement Team (PIT) of County Quality Improvement

For further information, consult your OPOH and/or your COTR.

Mandated State Survey

State surveys occur during a two week time period twice a year.

Surveys are to be completed by all outpatient providers, including case management.

Surveys include client satisfaction surveys.

HSRC/CASRC are responsible for handling the survey process.

Client Outcomes

Programs must follow the current guidelines for administrating client outcome tools.

Please check with your COTR if you need more information

See the Optum web site information on adult outcomes at :https://www.optumhealthsandiego.com

or CASRC for Children’s outcomes at http://casrc.org/projects/soce/des.html

Provider Transfer Requests

If a client requests a change in providers it must be documented in the Monthly Status Report (MSR) or

Quarterly Status Report ( QSR) under the Provider Transfer Requests tab

When In Doubt

For more information regarding QI information, refer to the Quality Improvement Program chapter in your OPOH at: https://www.optumhealthsandiego.com

Serving Clients

The final section of this orientation relates to the client issues of:

Client Grievances Beneficiary Rights HIPAA Regulations

Beneficiary rights

Clients have the right to: Be treated with personal respect and respect

for their dignity and privacy. Receive information on available treatment

options and alternatives presented in a manner they understand.

Participate in decisions about their mental health care.

Beneficiary rights

Receive informing materials about the services covered by the Mental Health Plan (MHP).

Request and receive a copy of their medical records and request they be amended or corrected.

Be free from any form of restraint or seclusion as specified in federal rules.

Write an Advance Directive covering their mental health care.

Refuse treatment

Client Concerns & Grievances Clients are encouraged to direct their concerns, complaints

or suggestions to program staff or management, orally or in writing. These are to be reported in the MSR/QSR as a suggestion on the Suggestion & Transfer tab.

Providers shall inform all clients about their right to file a grievance with one of the MHP’s contacted advocacy organizations if the client has an expression of dissatisfaction about any matter, is uncomfortable approaching program staff, or the dissatisfaction has not been successfully resolved at the program.

Grievance and Appeal information must be readily available for clients to access without the need for request. Each provider site shall have posters, brochures, and grievance/appeal forms in threshold languages, and addressed envelopes available to clients, displayed in a prominent place.

Client Grievances If clients are not able to resolve their concern at the program

level, or want to appeal a decision that limits care, they should be assisted to contact one of the agencies listed below.

For problems with inpatient or 24-hour residential services, call

the Jewish Family Service (JFS) Patient Advocacy Program at 800.479.2233.

For problems with outpatient and any other type of mental health service, call the Consumer Center for Health Education and Advocacy (CCHEA) toll-free at 877.734.3258.

Clients complaints or grievances

There can be absolutely no retribution or retaliation against a client or family member who has filed a complaint or grievance against a program or staff

HIPAA Regulations

Handling/Transporting Medical Record Documents outside Certified Clinics

Medical Record Laptop which contains client information

(see OPOH on Compliance and Confidentiality)

Confidentiality Breaches New state laws and regulations effective January 1, 2009.

HITECH will require notification to patients “without reasonable delay” but no later than 60 days after discovery of a privacy breach. (See Compliance and Confidentiality)

Monthly and QuarterlyStatus Reports (MSRs/QSRs)

MSRs/QSRs are required from each program, county or contract by the 15th of month

Required by COTRs For more info contact COTRs or their

designated analyst

Check for Updates:

All emails, FAQs, Handbook Updates and other written communication will be uploaded onto the Optum Website for ease of access

A list of all communications will also be available to check for any updates you may have missed.

For further information:

• The County QI Unit: For documentation and other QI questions, E-mail: QIMatters.hhsa@sdcounty.ca.gov

• See https://www.optumhealthsandiego.com • for copies of the “Management Information System (MIS) Anasazi

User Manual” and the “Financial Eligibility and Billing Procedures.”

• The Optum Helpdesk: (800) 834-3792. For questions related to using Anasazi (the MIS), or assistance accessing their Public Sector Website.

• The BHS Fiscal Billing Unit: (619) 338-2612. For assistance with financial questions.

Thank you for your participation in this New Program Manager Orientation!

Who to contact:

QI Director- Tabatha Lang at (619) 563-2741 QI Manager- Steve Jones at (619) 563-2747 QI Supervisors-

Trang Tran at (619) 584-5082 Debbie MacDougall at (619) 563-2774