What is a Significant Member Incident?
A Significant Member Incident (SMI) is an unexpected and undesirable incident that has an adverse impact on the outcome of care.
What are the reporting timelines?
Incidents must be reported to Community Care within 24 hours* of the incident occurring or within 24 hours of the provider learning of the incident.
What form do I use to report?
A provider may use its own reporting form or complete the online form and fax to the Community Care office according to the member’s county of eligibility (see list of fax numbers by county/Community Care office).
Does this replace having to report incidents to my county?
No, Community Care's Significant Member Incident (SMI) reporting process does not take the place of the reporting process a provider has established with its county.
Where can I find more information on this topic of Significant Member Incident's (SMI)?
The SMI reporting process can be found in the Provider Manual.
Will you come to my office and perform chart audits/record reviews?
Community Care performs chart audits/record reviews regularly on providers at various levels of care. If your facility/site is selected, you will be notified by Community Care and a mutually agreed upon time will be arranged for this process. You will be given feedback on the review including strengths noted and areas for improvement; at times, you may be asked to develop and implement a "quality improvement plan" if certain quality indicators fall below an acceptable threshold. Community Care may also request a chart audit/record review in order to follow up on any quality concern that may arise such as a Significant Member Incident or issues in a Member Complaint.
How quickly do I have to give an appointment for members requesting services?
Community Care follows the access standards promulgated by the Department of Human Services (DHS). For life threatening needs, care must be delivered immediately; for non-life threatening within 1 hour; for urgent needs within 24 hours; and for routine care within 7 calendar days. Community Care measures provider adherence to these standards.
Do I have to cooperate with Consumer/Family Satisfaction Teams (C/FST)?
Yes, you have to cooperate with providing comfortable, private space and making individuals available to the teams when they ask. C/FST results are an important way to get feedback from members on their care. When you become a provider in the Community Care network, your contract obligations include this.
How do I know how I am doing as a Community Care provider?
You are given feedback on your care delivery in a variety of ways. For example, you will be given feedback through the following processes: provider benchmarking on specific quality indicators, member complaints, significant member incidents, denials, grievances, record reviews, and utilization factors such as average length of stay, authorization, and discharge functions. We believe that excelling in HealthChoices requires a collaboration between you and Community Care and we look forward to working with you in such a team approach.
What activities are being measured in the Quality Department?
There are a variety of activities being monitored and measured within the department. We follow the continuous quality improvement (CQI) process and always look for areas to improve and then follow through with measurement and review until the process has been completed. You will get detailed information about our various activities via the provider manual and newsletters, as well as by visiting our website. We also invite providers to be participants on our Quality and Care Management Committee to directly work on processes in tandem with members, the counties, Office of Mental Health and Substance Abuse Services (OMHSAS), and Community Care. If you would like to participate in these meetings and are committed to attending routinely please contact Community Care and ask for a Quality Representative.