The Clinical Practice Guideline & Treatment Record Review Presentation will begin shortly.

Clinical Practice Guideline & Treatment Record Review

Magellan Behavioral Health of Virginia

Quality Improvement Department

November 18, 2014

Clinical Practice Guideline (CPG) Treatment Record Review (TRR)

Overview

Overview

•What is a Treatment Record Review (TRR)

•How are records scored

•Possible outcomes of TRRs

•TRR Worksheet

•FAQs

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Treatment Record Reviews

Our Philosophy: In support of our commitment to quality care, we require that our providers maintain organized, well-documented member treatment records that reflect continuity of care for members. We expect that all aspects of treatment will be documented in a timely manner, including face to face encounters, telephone contacts, clinical findings and interventions.

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What are Treatment Record Reviews ?

Treatment Record Review (TRR) is a method used to evaluate care being provided to members and to identify opportunities for improvement that will assist providers with addressing the overall quality of care that members receive. For quality improvement purposes, Magellan reviews a random sample of treatment records from providers. We conduct routine TRRs to monitor network provider treatment record documentation and record keeping practices against Magellan standards. The TRR also allows us to measure network provider performance against important clinical process elements of Clinical Practice Guidelines (CPGs).

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The Treatment Record Review Tool

Routine treatment record reviews are conducted by a licensed clinician employed by Magellan who has been trained in the administration and scoring of the Treatment Record Review tool. The Treatment Record Review tool contains elements that Magellan will look for in the treatment record to ensure documentation meets Magellan’s standards and that our providers adhere to Magellan’s adopted Clinical Practice Guidelines (CPGs). Magellan’s Provider Handbook (www.magellanprovider.com) contains detailed information regarding Magellan’s requirements for documentation and record keeping, as well as the CPGs.

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Magellan Behavioral Health of Virginia’s Clinical Practice Guidelines

• Major Depressive Disorder

• Substance Use Disorders

• Schizophrenia

• Attention Deficit/Hyperactivity Disorder (ADHD)

(available at www.magellanprovider.com)

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What to do if your records are selected.

Your responsibilities are to: • Follow the detailed instructions provided if you are

selected for a review; • Make the requested records available for our review within 14

business days from the date of the request letter; and • Cooperate with Magellan in developing and carrying out a

quality improvement plan should opportunities for improvement be identified.

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Magellan’s Responsibilities

Magellan will:

• Provide detailed information prior to the review concerning the rationale and standards employed in the review process.

• Request the minimum necessary protected health information to perform treatment record reviews.

• Provide feedback and suggestions that can be implemented to improve the quality of treatment record documentation and care.

• Work closely with you in carrying out any identified opportunities for improvement.

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Feedback and Outcomes

The Provider will receive a score indicating the results of the Treatment Record Review. This will also include any suggested steps to be taken to improve quality of care and quality of treatment record documentation.

Scoring

Final Score Requirements

80-100 Minimal Deficiencies: no formal follow-up activity required; provider is requested to incorporate recommendations from the feedback report as a means to improve documentation practices.

70-79 Moderate Deficiencies: no formal follow-up activity required; provider is requested to submit an informal corrective action plan (CAP) within 30 days.

Below-69 Serious Deficiencies: the practitioner is required to submit a formal CAP, including, but not limited to, a plan to remedy deficiencies noted. All corrective actions must be completed within 30 days of the date of the letter. Review and approval of the CAP by Magellan is required. Magellan will follow up on the progress of the CAP, including, but not limited to an additional treatment record review to determine if the deficiencies have been corrected.

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Treatment Record Review Worksheet

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ASSESSMENT STANDARDS Yes No N/A EXPLANATIONS AND/OR COMMENTS

Section A: General Information

A1 Record is legible

A2 Consumer name or ID number noted on each page of record

A3 Entries are dated & signed by appropriately credentialed provider, including their professional degree

A4 Record contains relevant demographic information including address, employer, school, phone, emergency contact, marital status

Section A Score - (For each section, enter total number of “yes” Items and total number of “no” items in the columns to the right)

Section B: Consumer Rights and Confidentiality

B1 Signed treatment informed consent form or refusal documented

B2 Patient Bill of Rights signed or refusal documented

B3 Psychiatric advance directives or refusal documented

B4 Informed consent for medications signed or refusal documented

B5 Release(s) for communication with Primary Care Physician (PCP), other providers and involved parties are signed or member refusal documented

Section B Score

Treatment Record Review Worksheet

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ASSESSMENT STANDARDS Yes No N/A EXPLANATIONS AND/OR COMMENTS

Section C: Initial Evaluation

C1 Reason member is seeking services (presenting problem) & mental health status exam

C2 DSM IV diagnosis

C3 History & symptomatology consistent w/DSM IV criteria

C4 Psychiatric history

C5 Co-occurring (co-morbid) substance Induced disorder assessed

C6 Current and past suicide/danger risk assessed

C7 Assessment of Member strengths, skills, abilities, motivation, etc.

C8 Level of familial/supports assessed and involved as indicated

C9 Member identified areas for improvement/outcomes documented

C10 Medical History

C11 Exploration of allergies and adverse reactions

C12 All current medications with dosages

C13 Discussion of discharge planning/linkage

to next level of care

Section C Score

Treatment Record Review Worksheet

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ASSESSMENT STANDARDS Yes No N/A EXPLANATIONS AND/OR COMMENTS

Section D: Individualized Treatment Plan

D1 Individualized strengths based treatment plan is current

D2 Measurable goals/objectives documented

D3 Goals/objectives have timeframes for achievement

D4 Goals/objectives align with Member identified areas for improvement /outcomes

D5 Use of preventive/ancillary services including community & peer supports considered

Section D Score

Section E: Ongoing Treatment

E1 Documentation substantiates treatment at the current intensity of support (level of care)

E2 Progress toward measurable member identified goals & outcomes evidenced; If not, barriers are being addressed

E3 Clinical assessments and interventions evaluated at each visit

E4 Substance use assessment is current/ongoing

E5 Comprehensive suicide/risk assessment is current/ongoing

E6 Medications are current

E7 Documentation of Member compliance or non-compliance with medications is documented. If non-compliant, interventions considered

Treatment Record Review Worksheet

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ASSESSMENT STANDARDS Yes No N/A EXPLANATIONS AND/OR COMMENTS

Section E: Ongoing Treatment (continued)

E8 Evidence of treatment being provided in a culturally competent manner

E9 Family/support systems contacted

/involved as appropriate/feasible

E10 Ancillary/preventive services considered, used and coordinated as indicated

E11 Crisis plan documented

E12 Discharge planning/linkage to alternative treatment (level of care) leading to discharge occurring

Section E Score

Section F: Addendum for Special Populations

F1 Guardianship information noted

F2 Developmental history for children and adolescents

F3 If member has substance use disorder, is there evidence of Medication Assisted Treatment and/or discussion present

Section F Score

Section G: Record Storage

G1 Records are stored securely

G2 Only authorized personnel have access to records

G3 Staff receive periodic training in confidentiality of member information

G4 Treatment records are organized & stored to allow easy retrieval

Section G Score

Treatment Record Review Worksheet

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ASSESSMENT STANDARDS Yes No N/A EXPLANATIONS AND/OR COMMENTS

Section H: Coordination of Care

H1 Evidence of provider request of consumer for authorization for PCP communication

H2 Evidence consumer refused authorization for PCP communication

H3 PCP communication after initial assessment/evaluation

H4 Evidence of PCP communication at other significant points in treatment (e.g. Medication initiated, discontinued, or significantly altered. Significant changes in diagnosis or clinical status. At termination of treatment)

H5 Treatment record reflects continuity and coordination of care between primary behavioral health clinician and (note all that apply under comments): psychiatrist, treatment programs/institutions, other behavioral health providers, ancillary providers

Section H Score

Treatment Record Review Worksheet

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ASSESSMENT STANDARDS Yes No N/A EXPLANATIONS AND/OR COMMENTS

Section I: Medication Management I1 Medication flow sheet completed or

progress note includes documentation of current psychotropic medication, dosages, date(s) of dosage changes

I2 Allergies and adverse reactions, or no known allergies (NKA) or sensitivities, to foods, drugs and other substances are documented

I3 Documentation of member education regarding reason for the medication, benefits, risks, and side effects (includes effect of medication in women of childbearing age and to notify provider if becomes pregnant, if appropriate)

I4 Documentation of member verbalization of understanding of medication education

I5 Record reflects that DEA scheduled drugs are avoided in treatment of members with a history of substance abuse/dependency (if applicable)

Section I Score

Section J: Referral / Outreach

J1 Treatment record documents preventive services as appropriate, i.e., Relapse prevention; Stress management; Wellness programs; Lifestyle changes; Referrals to community resources

J2 Members who become homicidal, suicidal or unable to conduct activities of daily living are referred to appropriate level of care (if applicable)

Section I Score

Frequently Asked Questions (FAQs)

• What are the differences between Magellan Treatment Record Reviews and Department of Medical Assistance Services (DMAS) Audits?

Magellan Treatment Record Reviews are intended to provide feedback and assist with guiding care toward evidence-based practices for specific diagnoses. These reviews are meant to assist with identifying opportunities for improvement in both service provision and documentation.

• Will Magellan Reviews replace DMAS Audits?

Magellan’s Reviews are not Audits and will not replace any DMAS Audit process.

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FAQs Continued

• Do providers still need to give Members the Magellan Member’s Rights and Responsibilities Statement as well as the Department of Behavioral Health and Developmental Services (DBHDS) document?

Yes. The member is expected to receive Magellan’s Member’s Rights and Responsibilities Statement in addition to a copy of the DBHDS “Know Your Rights” document. Please be sure to document the date that the member is provided these items in your records. You can locate the document at https://www.magellanprovider.com, within the Magellan National Provider Handbook Appendices, Appendix D.

• How do providers meet the requirements for documenting Primary Care Physician (PCP) communication?

To show coordination of care between providers, documentation in the treatment record should include communication with the PCP at significant treatment stages (i.e. changes in medication, change in diagnosis, discharge, etc.). A letter asking a PCP for documentation of a yearly physical is not going to meet this requirement.

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Questions/Comments