Provider Performance Issues

The collaboration between Community Care and its provider network is a way for Community Care to ensure a successful partnership with providers. The purpose of this partnership is to improve the clinical and quality of care that is delivered to HealthChoices members. Comprehensive Provider Evaluations are a means by which Community Care monitors the quality of service provided to members. Some goals of Comprehensive Provider Evaluation Include:

• Ensuring that each provider is delivering best practice clinical and quality standards to members,
• Striving to continually improve the practice standards of the provider network,
• Utilizing both qualitative and quantitative measures to provide feedback to providers,
• Identifying areas for improvement,
• Ensuring a safe and healthy environment for members, and,
• Ensuring that providers practice within an environment conducive to recovery.

The Comprehensive Provider Evaluation includes identifying trends by tracking Provider Performance Issues (PPIs). If a trend is identified, Community Care may request that the provider submit a plan in order to improve member quality of care. In collaboration with network providers, Community Care has identified the following service and access indicators when tracking Provider Performance Issues. Provider Performance Issues and Community Care’s expectations are described below:

Aftercare providers schedule an appointment within 7 days of discharge

• Expectation: Receiving providers should provide routine aftercare appointment within 7 days of discharge, to include substance use disorder (SUD) appointments.

Appropriate treatment plan submitted

• Expectation: Treatment plans should be unique and individualized. Plans should reflect current information, specific measurable goals and objectives with target dates, discernible interventions, and a concrete discharge plan. The team’s input regarding goals, a connection to concerns outlined in the evaluation/prescription, along with the response to treatment should be in included. Providers are also encouraged to submit timely responses to requests for additional information to prevent unnecessary denials related to lack of information.

Assessment meets standards – specific to Intensive Behavioral Health Services (IBHS)

• Expectation: Assessments are expected to be face to face and completed within 15 days of the initiation of services and prior to completing an Individualized Treatment Plan by an individual qualified to provide behavior consultation services or mobile therapy services for individual or group services and also for individual and group evidence-based treatment (EBT) services; or within 30 days of the initiation of an Applied Behavior Analysis (ABA) EBT by an individual qualified to provide behavior analytic or Behavior Consultation-ABA; and completed in collaboration with the member or parent, legal guardian or caregiver of the child or youth, as appropriate. Assessment should contain all the required information and updates and is signed and dated.

Care Manager (CM) is invited to ISPT/Treatment Team meetings

• Expectations: Providers are expected to invite the CM to meetings at least 7 days prior to the meeting date/time for levels of care that require ISPT/Treatment Team Meetings, such as Residential Treatment Facilities and IBHS.

Discharge review is completed in a timely fashion

• Expectation: Discharge summaries must be received on or before the due date to be considered complete. All forms should be completed in entirety. All non-ambulatory levels of care, except SUD Sleep Over Partial Hospitalization (PHP) and Long-Term Structured Residential (LTSR) are due within one business day of discharge. All ambulatory levels of care, and SUD Sleep Over PHP and LTSR are due within 14 calendar days of discharge.

Discharging provider scheduled aftercare appointment within 7 days of discharge

• Expectation: Discharging Providers should schedule the aftercare appointment within 7 days of discharge. If the appointment cannot be scheduled related to network capacity Community Care should be notified. Discharging Providers are expected to engage in active discharge planning as part of transitioning, and appointments should be scheduled prior to discharge. Providers are expected to notify Community Care of the transition plan and any barriers to discharge. If co-occurring, both appointments should be scheduled in a timely manner.

Standards for service recommendation

• Expectation: This applies to written orders, psychological evaluations, psychiatric evaluations, and written orders. Service recommendations should be based on a face-to-face interaction by a qualified individual; have clinical information to support the recommendation; include a behavioral health diagnosis from the most recent edition of Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD); and address areas of functioning as outlined by best practice or regulations for the recommended level of care.

Other

• Expectation: Providers are expected to adhere to Provider Manual specifics and performance standards, follow administrative processes, communicate, and coordinate with treatment team, and ensure quality of care to members.

Provider adheres to industry standards

• Expectation: Providers are expected to adhere to industry standards and make transitions in identified timelines. For example, using ICD-10 codes, DSM 5 diagnoses, transitioning to ASAM, or IBHS.

Provider at capacity

• Expectation: Provider must notify Community Care when they can no longer take referrals (at capacity) by contacting the appropriate Community Care Provider Representative.

Provider attempts to coordinate care while member is still in treatment

• Expectation: Providers are expected to actively coordinate resources from admission through discharge. This includes formal and informal supports that increase the member’s likelihood of recovery and applies to all levels of care.

Provider ensures sufficient discharge planning

• Expectation: Providers should begin discharge planning on admission and address all appropriate areas of need. This applies to all levels of care and includes addressing specialized needs (SUD, trauma), other levels of care, and developing plans for transition.

Provider ensures submitted documentation is complete

• Expectation: Providers should submit documentation that is complete with all necessary information. This includes discharge summaries, treatment plans, safety plans, or packets.

Provider followed Care Plan developed by facility and care manager

• Expectation: Providers should follow through with discussed care plan interventions. This is defined by the specific individualized member care plan. The care plan outlines specific treatment indicators agreed upon between the provider, the member, Care Manager (CM), and other members of the treatment team. The plan can define specific administrative processes pertinent to coordination of care efforts. Providers are expected to adhere to plans as well as other administrative processes. Examples of information that must be provided in the care plan include aftercare planning, family sessions as part of treatment requirements, school input if services provided therein, and specific IBHS services to be implemented. This applies to all levels of care.

Provider informs members of the use of long-acting naltrexone as a MAT option

• Expectation: Providers should inform members of the use of long-acting naltrexone as a Medicated Assisted Treatment (MAT) option. This is applicable to all SUD residential levels of care.

Provider informs members of the use of naloxone as an emergency treatment of opioid overdose

• Expectation: Providers should inform members of the use of naloxone as an emergency treatment of opioid overdose when receiving residential SUD treatment for an opioid related disorder. This is applicable to all SUD residential levels of care.

Provider is prepared for clinical review and has all necessary information

• Expectation: Providers should provide necessary information to establish medical necessity criteria (including diagnoses) and demonstrate evidence of active and appropriate treatment; case management; discharge planning; and collaboration. This is not level of care specific and applies to all telephonic reviews and/or interagency/treatment team meetings.

Provider obtained authorization for members in the facility

• Expectation: Providers should obtain authorization for services in established timeframes. This applies to all levels of care and may or may not be accompanied by a Network Adherence Process (NAP).

Provider meets member’s cultural, religious, sexual orientation, gender identity, or communicative preferences

• Expectation: Providers should make every attempt to meet each member’s identified cultural, religious, communicative, sexual orientation, and/or gender identity preferences. This includes using identified names/pronouns, providing interpreters, or considering religious and cultural barriers to treatment approaches.

Provider reports out of home placement in designated timeframe

• Expectation: All ambulatory and community-based providers of children’s services should notify Community Care within 24 hours or the next business day of learning that a child or adolescent is relocating due to a child welfare or juvenile placement, prior to discharging the child or adolescent from care. Providers are expected to collaborate with Community Care to ensure continuity of care during the transition to a new treatment provider. Interagency/treatment team/CASSP meetings should be scheduled, as needed.

Provider reports accurate information

• Expectation: Providers should report accurate member information. This applies to all levels of care.

Timely reporting of incidents by provider

• Expectation: When a Significant Member Incident (SMI) occurs, the Provider is expected to report/submit an Unusual Incident Report (UIR) to Community Care. Reports for all incidents are due within 24 hours of the incident occurring, or within 24 hours of the provider learning of the incident. Significant Member Incidents should be reported through Community Care’s ePortal. Other acceptable methods would be to report via phone or fax in order to meet the requirement.

Timely submission of packets

• Expectation: For levels of care that require packet submission, it is Community Care’s expectation that packets be submitted in the timeframe designated for that level of care.