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Annual QM and UM Program Evaluation

2015

B e a c o n H e a l t h O p t i o n s – A n n u a l Q M & U M E v a l u a t i o n

This review of the findings of Annual QM & UM Program was conducted by Beacon Health Options under the auspices of the CT Behavioral Health Partnership. The opinions, conclusions, and recommendations contained herein are solely those of Beacon Health Options and may not represent those of DSS, DMHAS, and DCF. By Lynne Ringer, LCSW with Ann Phelan and Robert W. Plant, Ph.D., Erika Sharillo, Heidi Pugliese, Lindsay Betzendahl, Yvonne Jones, Jackie Stupakevich, Scott Greco, Jessica Dubey, Nancy Ninesling, Kerri Miller as well as the entire Quality, Clinical and Reporting Departments.


Table of Contents

I. EXECUTIVE SUMMARY ...................................................................................... 5

A. Overview of the Quality Management (QM) Program ........................................ 7

B. Key Accomplishments of the QM Program ........................................................ 8

C. Overview of the Utilization Management (UM) Program .................................... 9

D. Key Accomplishments of the UM Program ........................................................ 9

II. EVALUATION OF THE OVERALL EFFECTIVENESS OF THE QM PROGRAM STRUCTURE ......................................................................................................10

A. QM Committee Structure and Effectiveness of Structure ..................................10

B. Adequacy of Resources ...................................................................................14

C. Practitioner Involvement ...................................................................................16

D. Leadership Involvement ...................................................................................16

E. Patient Safety ...................................................................................................17

III. EVALUATION OF THE OVERALL EFFECTIVENESS OF THE UM PROGRAM STRUCTURE ......................................................................................................17

A. UM Committee Structure and Effectiveness of Structure ..................................17

B. Adequacy of Resources ...................................................................................18

C. Practitioner Involvement ...................................................................................18

D. Leadership Involvement ...................................................................................18

E. Patient Safety ...................................................................................................19

IV. EVALUATION OF THE 2015 QM & UM PROJECT PLAN ...................................20

Goal 1: Review and Approve 2014 Beacon Health Options QM Program Evaluation, 2015 Beacon QM Program Description, 2015 Beacon UM Program Description and 2015 Beacon QM & UM Project Plan ........................................................................20

Goal 2: Establish and maintain BEACON, CT-specific policies and procedures (P&Ps) in compliance with contractual obligations that govern all aspects of BEACON, CT operations. ................................................................................................................20

Goal 3: Establish and maintain a training program for BEACON, CT Staff. ..............21

Goal 4: Ensure Utilization/Care Management Department compliance with established UM standards. ........................................................................................25

Goal 5: Monitor consistency of application of UM Criteria (IRR) and adequacy of documentation. .........................................................................................................29

Goal 6: Ensure timely telephone access to CT BHP Engagement Center. ................31

Goal 7: Ensure timely response and resolution of member/provider complaints and grievances.................................................................................................................36

Goal 8: Monitor performance of Customer Service staff via audits of performance. ...40

Goal 9: Assess provider network adequacy...............................................................41


Goal 10: Health literacy, cultural and linguistic competency ......................................42

Goal 11: Reduce emergency department (ED) discharge delays. .............................44

Goal 12: Maintain and Establish additional Bypass/Outlier Management Programs. .46

Goal 13: Monitor for under- or over-utilization of Behavioral Health Services; identify barriers and opportunities. .........................................................................................53

Goal 14: Monitor Timeliness of UM Decisions, authorization information being available to providers and claims payer; identify barriers and opportunities...............54

Goal 15: Monitor Medical Necessity and Administrative Denials; identify barriers and opportunities. ............................................................................................................59

Goal 16: Monitor Timeliness of Appeal Decisions; identify barriers and opportunities. ..................................................................................................................................63

Goal 17: Develop methodology and reporting of Medication Adherence for antidepressant and antipsychotic medications categories. ........................................68

Goal 18: Ensure consistent application of activities to maintain and/or improve the rate of ambulatory follow up services after inpatient admission. ................................76

Goal 19: Promote patient safety and minimize patient and organization risk from quality of care/service concerns and adverse incidents. ............................................77

Goal 20: Monitor integration of coordination of care with medical, dental and transportation ASO as well as ABH and other partners; identify barriers and opportunities. ............................................................................................................83

Goal 21: Maintain the Quality Improvement Activities: Provider Analysis and Reporting Programs ..................................................................................................85

Goal 22: Monitor and Improve Quality of ASD Provider Charts .................................94

V. ONGOING QM & UM GOALS TO BE CARRIED FORWARD FROM THE EVALUATION YEAR-2015 ..................................................................................95

VI. SUMMARY OF APPENDIX .................................................................................97


I. EXECUTIVE SUMMARY

Beacon Health Options’ Connecticut Engagement Center continues to serves as the

behavioral health administrative service organization (ASO) for the Connecticut Behavioral

Health Partnership (CT BHP) and manages the behavior health care for over 900,000 Medicaid

members. The CT BHP is a partnership between the Department of Social Services (DSS),

Department of Children and Families (DCF) and Department of Mental Health and Addiction

Services (DMHAS). The Connecticut Engagement Center’s expected role is to be the primary

vehicle for organizing and integrating clinical management processes across the payer streams,

supporting access to community-services, promoting practice improvement, assuring the

delivery of quality services and preventing unnecessary institutional care. Additionally, the

Connecticut Engagement Center is expected to enhance communication and collaboration

within the behavioral health delivery system, assess network adequacy on an ongoing basis,

improve the overall delivery system and provide integrated services supporting health and

recovery by working with the Departments to recruit and retain both traditional and non-

traditional providers.

The Medicaid membership continued to increase between 2014 and 2015 but the

increase was not a great as the previous year (9.5% 2014 to 2015 and 10.8% 2013 to 2014).

Please note: The membership numbers sited above will not add to the total youth and adult

numbers as members change both eligibility categories and age groups over the year.

The Medicaid population analysis that was completed as a part of the Performance

Targets using CY 2014 Medicaid claims data found the following for adult members: Gender. In CY 2014, fifty-seven percent (57%) of the Total Adult Medicaid population

were female, and forty-three percent (43%) were male. The gender composition was the same for members with BH Non-ED/Non-IP, possibly reflecting gender health equity for the lower levels of care. This finding is discrepant from earlier analyses of gender disparity and it will be

Eligibility Category2015 Total

MembershipYouth (0-17) Adults (18+)

Family Single 586,074 348,483 250,776

Family Dual 7,466 12 7,454

HUSKY B 26,989 25,663 2,096

DCF Limited Benefit (D05) 424 424 -

Aged, Blind and Disabled (ABD) Single 33,970 174 33,804

ABD Dual 61,076 - 61,076

Long Term Care (LTC) Single 2,412 - 2,412

LTC Dual 21,850 - 21,850

Medicaid Low Income Adults (MLIA) 271,897 142 271,774

Total Membership 967,054 362,376 618,752


important to tease out if this is due to differing methodologies or real changes in utilization. Among members with SMI, females were slightly overrepresented (61%) and males slightly underrepresented (39%).

Age. The Adult Medicaid population (average age = 37 years old) was slightly younger

than the BH Service Non ED/Non IP cohort (average age = 39 years old), as well as members with an SMI diagnosis (average age = 41 years old).

Race/Ethnicity. The proportions of Caucasian, African American, and Hispanic

members that utilized BH Non-ED/Non-IP were similar to the Total Adult Medicaid Population (Caucasian, 52%; Hispanic, 26%; African American 18%), possibly reflecting fewer ethnicity disparities for lower levels of care overall. This finding is discrepant from earlier analyses of racial and ethnic disparity (Plant, 2016) and it will be important to tease out if this is due to differing methodologies or real changes in utilization. Among members with an SMI diagnosis, there were slightly more Caucasian members (58%) and fewer African American members (14%), but the same proportion of Hispanic members (26%).

Eligibility. There were more members in the Total Adult Medicaid Population with Husky

A (46%), in comparison to the BH Non-ED/Non-IP (Husky A, 40%). Moreover, there were fewer members in the Total Adult Medicaid Population with Husky C (7%), in comparison to the BH Non-ED/Non-IP (Husky C, 12%). These differences were more pronounced in comparison to members with an SMI (Husky C, 23%; HUSKY A, 27%). Across these cohorts, almost half of members had HUSKY D MLIA at some point within CY 2014 (Total Adult Medicaid members, 46%; BH Non-ED/Non-IP, 48%; SMI, 48%).

Homelessness. Conservatively, 4% of the Total Adult Medicaid Population and 6% of

members that utilized BH Non-ED/Non-IP were homeless at any point during CY 2014, rising to 9% among members with an SMI diagnosis. This represents a significant challenge to individuals, as well as communities and the system-of-care.

And for youth, the following: Gender. In CY 2014, approximately half of the Total Youth Medicaid population were

female (49%) and approximately half were male (51%). Medicaid Youth ages 3-12 and ages 13-17 mirrored the overall Total Youth Medicaid population, and youth with DCF involvement* in both age groups were also similar in gender composition. In contrast, females were slightly underrepresented among BH Service Utilizers Non-ED/Non-IP, with 43% female and 57% male. This underrepresentation was more pronounced among the Developmental Disability (DD) and Autism Spectrum Disorder (ASD) cohorts, and male youth comprised the majority of members in both the DD (68%) and ASD (79%) cohorts.

Age. The Total Youth Medicaid Population and the Youth with DCF Involvement

(average age = 10 years old) cohorts were slightly younger than the BH Service Non-ED/Non-IP cohort (average age = 11 years old).

*Note: “DCF-involvement” includes any youth under eighteen who is involved with the Department of Children and Families through any of its mandates. This includes youth committed to DCF through child welfare or juvenile justice, and those dually committed. It also includes youth for whom the Department has no legal authority, but for whom DCF provides assistance through its Voluntary Services, Family with Service Needs and In-Home Child Welfare programs.


Race/Ethnicity. Caucasian youth comprised the majority of both the Total Youth Medicaid Population (44%) and BH Service Utilizers Non-ED/Non-IP (47%) while Hispanic youth made up the second highest membership group in both cohorts (Total Youth Medicaid Population, 34%; BH Service Utilizers Non-ED/Non-IP, 36%). African American youth were slightly underrepresented among the BH Service Utilizers Non-ED/Non-IP (15%) compared with the Total Youth Medicaid population (17%).

Caucasian Youth made up a higher proportion of members with Autism Spectrum

Disorder (54%) when compared to Developmental Disability (41%) or the Total Youth Medicaid Population (44%). Hispanic Youth were disproportionately overrepresented among members with DD (40%) and underrepresented among members with ASD (30%) compared to the Total Youth Medicaid Population (34%). African American Youth were somewhat underrepresented among those with Developmental Disability (15%) or Autism Spectrum Disorder (12%) compared to the Total Youth Medicaid Population (17%). Asian, Multiracial and Other make up the lowest membership across both cohorts.

Eligibility & Homelessness. Nearly all members in the Total Youth Medicaid population

had Husky A Eligibility (95%). Unfortunately, obstacles in the Eligibility data continue to challenge the accurate reporting of homelessness. It would be important to consider possible solutions to this barrier, to be able to measure and track this key social determinant, and address the adverse impact of homelessness and housing instability on youth, and the impact on their health and well-being.

DCF Involvement. DCF Involvement includes any youth under eighteen who is involved

with the Department of Children and Families through any of its mandates. This includes youth committed to DCF through child welfare or juvenile justice, and those dually committed. It also includes youth for whom the Department has no legal authority, but for whom DCF provides assistance through its Voluntary Services, Family with Service Needs and In-Home Child Welfare programs. DCF Involved youth represent 3.5% of the Total Youth Medicaid Population, and are disproportionately overrepresented among the BH Service Utilizer Non-ED/Non-IP cohort (10%), as well as the ASD (10%) and DD (8%) cohorts. Among youth with DCF Involvement, most were DCF Committed (92%), and the rate of Voluntary DCF Involvement was highest among the DD (11%) and ASD (27%) cohorts in comparison to the Total Youth Medicaid Population (6%). However, the majority of youth among the BH Service Utilizer Non-ED/Non-IP cohort are not DCF Involved (90%).

A. Overview of the Quality Management (QM) Program The Quality Management (QM) Program was initiated with the implementation of the

original contract in 2006. The QM Program serves as the overarching structure to evaluate

continuously the effectiveness of the Connecticut Engagement Center as the ASO for the CT

BHP and to ensure that the clinical and support services offered within the engagement center

live up to their promise for the youth, families and adults served by the program. The QM

Program identifies the key performance indicators across functional areas within the

engagement center that affect the operation and develops the QM/UM project plan for the

coming year. Over the course of the year, the indicators are monitored, findings and trends are

analyzed, barriers identified, and then actions initiated to improve performance when necessary.


The methods and processes used to evaluate the quality of health care services are

undergoing rapid change in response to demands for greater accountability and use of “big”

data. With the resulting increase in the complexity of data integration efforts, statistical analysis

techniques, real time reporting, and incorporation of standardized quality measures; the IT,

software, and staffing resources across the agency will need to be adjusted to meet these

increasing demands. The Clinical, Quality, IT, and Reporting Departments are all in the process

of reviewing the composition and competencies of existing staff in light of anticipated future

challenges. In order to maintain an effective and efficient Quality and Utilization Management

Program, staffing will need to keep pace with new technologies and industry expectations.

The engagement center’s annual Quality/Utilization Management program evaluation

assesses the overall effectiveness of the QM Program including the effectiveness of the

committee structure, the adequacy of the resources devoted to it, practitioner and leadership

involvement, the strengths and accomplishments of the program with special focus on patient

safety and risk assessment, and performance related to clinical care and service. Progress

toward the previous year’s project plan goals is also evaluated. A review of each of the goals is

included within this evaluation along with a description of each goal and sub-goal, commentary

regarding their completion status, and recommendations for whether to carry them over into the

project plan for the following year. The results of this program evaluation, together with the

additional goals that reflect the strategic planning done collaboratively with DSS, DMHAS and

DCF will be used to formulate the 2016 Project Plan.

B. Key Accomplishments of the QM Program

Developed and implemented new IICAPS PAR program with performance

thresholds and benchmarks.

Developed new PRTF data with focus on overstay cases, changes in overstay

reasons, and changes in DCF status.

Moved Child and Adolescent Inpatient and Adult Inpatient dashboards to a digital

interactive format via Tableau Software.

Developed and implemented Home Health bypass program.

Continued support of Community Care Teams and CCT planning efforts at

numerous hospitals across the state.

Began holding PAR-type meetings with inpatient detox providers across the state

to build relationships and share data.

Moved the Quarterly Reports to a semi-annual submission and continued to

improve the formatting and presentation by moving the reports into Tableau for

more interactive data visualization.

Completed third round of ECC surveys for providers that had lost their ECC

designation and communicated all the results with providers.

Completed Intensive Outpatient (IOP) retrospective chart review with the 34

identified IOP providers and presented results to the Operations Subcommittee

of the Behavioral Health Oversight Council. Results were also included in the


IOP Clinical Study and contributed to the recommendations for improving the IOP

network.

C. Overview of the Utilization Management (UM) Program Clinical excellence and the highest business ethics are at the forefront of Beacon'

operations. Beacon recognizes a responsibility to demonstrate a solid commitment to superior

clinical quality service that is member focused, clinically appropriate, cost effective, data-driven,

and culturally competent. This is achieved through a companywide, systematic, and coordinated

UM Program that involves input from and coordination with all stakeholders, including clients,

members, providers, business units, departments, functional areas, and clinical staff. We work

in a matrix environment. We share responsibility to achieve a common goal.

Beacon, in concert with the Connecticut Behavioral Health Partnership, has established

a Case Management (CM)/Intensive/Integrated Care Management (ICM) program designed to

assist children and adults who reside in the state of Connecticut and who have the most

complex care needs. These members are typically assessed to be at the highest risk within the

health population for negative clinical outcomes related to mental health/substance abuse

issues and co-morbid medical issues. The primary goals of the CM/ICM programs are to help

individuals maintain community tenure, regain optimal health, improve life functioning capability

and promote recovery and resiliency. Beacon’ CM/ICM Program works closely with the Medical

ASO to create an integrated model meeting member’s behavioral health and medical needs.

Value Options remains devoted to ensuring that those entrusted to our care receive the best

behavioral health services possible.

D. Key Accomplishments of the UM Program

The clinical department achieved 96.4% passing score on the annual IRR with an

average score of 91.47%

The Adult Intensive Care Managers (ICM) continue to facilitate and participate in

Community Care Team (CCT) meetings in the 5 hospitals involved with the

Frequent Visitor performance target

Implementation of the Risk Indicator Score with providers regarding discharge

plans

Enhancement of the connect to care process to proactively outreach to members

with a risk indicator prior to and after the follow up appointment

Implementation of Beacon Health Options health alert appointment reminders for

those members with a completed discharge form from IP level of care

Continued participation in weekly co-management meetings with Community

Health Network (CHN), the medical ASO, to effectively coordinate care for those

HUSKY members who experience medical and behavioral health needs

Clinical Care Managers are participating in onsite rounds in an effort to support

member discharge planning


Bypass targets were reassessed based on standard deviation of the statewide

averages and 90% completion rate of discharge form within two business days

Quarterly meetings with Advanced Behavioral Health (ABH) continue for strategy

in addition to CCT meetings for increased identification and referrals as well as

collaboration of the HUSKY D population

March 2015 all HLOC were able to complete prior authorization and concurrent

reviews via Provider Connect

II. EVALUATION OF THE OVERALL EFFECTIVENESS OF THE QM

PROGRAM STRUCTURE

A. QM Committee Structure and Effectiveness of Structure The following QM committee and sub-committee structure is in place at the time of this

evaluation:

Quality Management Committee (QMC)

The QMC was established to provide oversight of the Connecticut Engagement Center

QM program. The QMC is chaired by the Senior Vice President (VP) of Quality and Innovation.

The QMC reports to the both the Latham Service Center and to the Beacon Health Options

Corporate Quality Committee (CQC). Additionally, the committee is guided by the Senior

Management Quality Management Steering Committee (also known as CORE) which is

attended by representatives of the Departments as well as Beacon Health Options senior

leadership.

The membership of the QMC includes representatives from all departments within the

engagement center including the leadership of the engagement center. Included are:

Chief Executive Officer (CEO)

Chief Medical Director or designee

Senior VP of Quality & Innovation

Chief of Research and Outcomes

Assistant VP of Quality Management

Assistant VP of Analytics and Innovation

Assistant VP of Performance Improvement and Implementation

Director of Provider Analysis and Reporting (PAR)

Director of Data Management and Analysis

Director of Project Management

QM & Reporting Staff

SVP of Clinical Operations and Recovery

VP of Member and Provider Support


Assistant VP of Utilization Management

Assistant VP of Clinical Services

Assistant VP of Community Support

Customer Service Director

Director of Compliance

Human Resources Director

Finance Director

IT Director

Provider Relations Director

Director of Peer Services

The QMC met quarterly during 2015 and reviewed the findings from the various

performance targets that were being done related to the emergency departments, inpatient

detoxification and home health, prior to the findings being shared externally. In addition, the

QMC reviewed performance on the performance standards.

Quality of Care Sub-Committee

The Quality of Care Sub-Committee reports to the QMC and is co-chaired by the Chief

Medical Director and the Assistant VP of Quality Management. In addition to the co-chairs, the

membership of the committee includes:

Senior VP of Quality and Innovation (ad hoc)

Quality Specialists II

Clinical Supervisor

Network Development Specialist

Regional Network Manager

Director of Peer Services

The Quality of Care sub-committee continued to meet weekly to review potential quality

of care and service concerns and adverse incidents identified by Beacon staff, members,

providers, and, on request, the Departments. The sub-committee reviewed all concerns

identified during the previous week and followed up on the results of actions and/or

investigations previously identified by the committee. The sub-committee reviewed semi-

annually trends of specific providers and practitioners.

In 2015, the subcommittee struggled to keep up with the increased number of concerns

and incidents (see Goal 19 below). The QM staff worked to develop processes to improve the

efficiency of the meeting and only presented cases that had been fully investigated and were

ready for evaluation by the subcommittee. The agenda went from 18 pages at the beginning of

2015 to 6 pages at the beginning of 2016.

Additionally, there was some turnover in the membership of the subcommittee and

binders were created for every subcommittee member that included relevant documentation,

process notes and definitions to assist in consistent knowledge of the subcommittee processes


and roles and responsibilities of the members. Another significant change for the subcommittee

was the hiring of a new Chief Medical Director. Dr. Sherrie Sharp became an active participant

in the subcommittee and provided significant contribution to the review of the care that was

being provided to members.

Regional Network Management Sub-Committee and Provider Analysis and Reporting (PARs) Workgroup

The Network Management Sub-Committee meets monthly and reports to the QMC. The

sub-committee is co-chaired by the Director of Provider Analysis and Reporting (PAR) and

Assistant VP of Quality Management. Its members include:

Regional Network Managers

Senior VP of Quality and Innovation (Adhoc)

QM Analysts

Utilization Management Director (Ad Hoc)

Director of Clinical Services (Ad Hoc)

CEO (Ad Hoc)

Medical Directors (Ad Hoc)

The primary focus of this sub-committee continues to be reviewing PAR profiles to

identify patterns and trends in the data, developing strategies for the PAR meetings and

strategizing ways to improve systems of care, with particular focus on addressing issues

generated in conversations with providers during PAR meetings. In addition, the sub-committee

reviews progress made in the Performance Targets relative to the systems issues and PAR

data. For example, we have reviewed results of the Inpatient Performance Target, as it informs

the trends in data that we see in the Inpatient PAR profiles. When new data measures are

developed, this sub-committee reviews the methodology so that the RNMs have a clear

understanding of what the measure represents and can accurately explain it to the

providers. During 2015, in addition to reviewing PAR profiles on a regular basis, this sub-

committee reviewed enhancements to the PRTF PAR program, and participated in the

development of the IICAPS PAR program.

This sub-committee continues to provide oversight of the six (6) Geo-Teams. The Geo-

Teams include Beacon staff members from all key functional areas who are involved with

facilities and programs in specific geographic regions. These teams reviewed PAR data, denial

and appeals data and discussed strategies to address concerns specific to the geographic

regions. The Geo-Teams members also provide their perspective on the findings, and develop

strategies for improving the performance of the facilities and programs in the region. Regional

issues are discussed at PAR meetings to share strategies and to identify issues that appear in

multiple regions.


In 2015, the sub-committee strategized around the ongoing development of the

Community Care Teams (CCT) and developing plans for at least partial transition of the CCTs

to the hospitals. We also strategized about the provider workgroup meetings and identifying

subjects for discussions or presentations at those meetings. The level of care specific provider

workgroups continue to identify best practices, work on developing new indicators and fine tune

existing measures.

Consumer and Family Advisory Sub-Committee

The Consumer and Family Advisory Sub-Committee was established in 2006 and meets

monthly. In 2015, the sub-committee was co-chaired by a Community Peer Services Director

and a parent consumer. The committee membership includes:

Peer Support staff

Director of Clinical Services (Ad Hoc)

Families of consumers

Member advocates

Consumers

Providers

Community Representatives

During the early part of 2015, the subcommittee moved forward with planning a

consumer driven conference based on the work of the smaller workgroups in 2014. Several

consumers from the subcommittee joined the planning workgroup, assisted in the development

of the conference and reported back to the subcommittee progress that was being made on the

conference. The iCAN conference occurred on September 10, 2015 and received high praises

from DSS. With more planning time in 2016, the subcommittee members will co-lead

workgroups in the development of next year’s conference.

Assessment and Recommendations of QM Committee Structure and Effectiveness:

The QM committee structure was successful in ensuring active participation and

communication among key functional areas at the Connecticut Engagement Center, CT BHP

provider network and members. The committee membership included representation from all

key functional areas within the engagement center. Several of the subcommittees were

reinvigorated and became more effective in promoting improvement of the provider and member

experience. This structure continues to not only be vital to developing projects, but is also

necessary in developing improvement initiatives with interventions that have a greater likelihood

of success. This structure also lends itself to a more robust evaluation of the impact of

improvement efforts.


B. Adequacy of Resources The following chart is a summary of the positions that support the Quality Management

program with credentials and percentages of time devoted to the quality management activities:

After all the changes that were made in 2014, 2015 was a year of a bit more stability for

the QM department. As new programs continued to be developed in the engagement center, a

new need was identified, which was to have a position to assist with implementations and

ensuring that programs were established with appropriate processes put in place at the

Quality Management Staff by

TitleCredentials

Percent of time per

week devoted to QM

SVP of Quality and Innovation Doctorate level 100%

Chief of Research and

Outcomes Doctorate level 100%

Assistant VP of QM Master's level 100%

Assistant VP of Analytics and

Innovation Doctorate level 100%

Director of PAR JD 100%

Regional Network Managers

(8 FTEs) Master's level 100%

Quality Analysts - Team Lead Master's level 100%

Quality Analysts (8 FTEs) Master's level 100%

Statistician Doctorate level 20%

QM Coordinator -

Complaints/Appeals (3 FTEs)

Bachelor and Master's

level 100%

Contract Monitor Associate level 100%

QM Specialists II - Auditor (2

FTEs)

Master's level/Licensed

clinicians 100%

AVP of Performance

Improvement and

Implementation Master's level 100%

Director of Data Management

and Analysis Master's level 100%

Reporting Manager Extensive experience 100%

BI Developers Bachelor level 100%

Business Analysts Bachelor level 100%

Program Analysts

Bachelor and Master's

level 100%

Director of Project

Management Master's level 100%

Project Manager Master's level 100%


beginning of a project, in order to ensure success. The position would also engage in process

and performance improvement for existing projects. During the restructuring that occurred in

August and September, the new position of AVP of Performance Improvement and

Implementation was proposed and accepted. With the addition of the new AVP, Project

Management moved under this position as this section of QM was often heavily involved with

the implementations.

Another change that occurred in the QM department was the reduction in the Regional

Network Management (RNM) staff as Performance Improvement Center (PIC) for the

Therapeutic Group Home was defunded and the Care Management Entity (CME) contract was

obtained. It was decided that three (3) of the RNM positions associated with the PIC would be

reassigned to the CME as Network of Care Managers (NCMs). Both the RNMs and NCMs work

closely in continuing to develop the network and identify regional trends.

In the fall of 2015, the Reporting Department was carved out of the Quality Department

with direct reporting to the VP of Corporate BI and Analytics at Beacon National. This change

was made to align with the Beacon Corporate organizational structure. The Quality and

Reporting Departments continue to work closely together and collaborate on data development

and quality improvement activities. As the volume, scope, and complexity of the quality

improvement projects and processes have increased, management has identified the need for

additional quality improvement staff to meet requirements and expectations. In particular, the

need has been identified for an additional subject matter expert and sole contributor who could

assist with project design, oversight, and reporting.

While there was some turnover within the denials and appeals group, the movement was

due to professional growth. With the change in staff, came an initial increase in errors in

processing denials and appeals timely. This was addressed with an increase in training around

timeframes and processes set up to assist in the tracking of the time. Despite the increase in

the number of medical necessity denial and appeals there was adequate resources in this

section of QM.

Additionally, the QM program is supported by members on the staff that are not

specifically in the QM department and they are as follows:


It has been vital to have the quality mindset infused across the entire organization, which allows for process improvements to occur on an on-going basis and shared responsibility around ensuring that the member experience is the best that it can be.

C. Practitioner Involvement

Network providers continue to be actively involved in the QM program through the

Quality, Access and Policy subcommittee of the Oversight Council. Providers have given

feedback on the performance target projects as well as the clinical studies. The provider

network continues to be involved in the development of PARs programs through workgroups

and the PARs provider meetings. Providers continue to be a valuable component to the

ongoing development of the QM program.

D. Leadership Involvement The leadership within the CT engagement center continues to value quality as

evidenced by the additional changes that were made within QM department as well as across

the engagement center in 2015. With the change in Chief Medical Director came greater

involvement from the leadership in ensuring the quality of both the clinical and administrative

services and practices with a focus on member access and safety.

Engagement Center Staff

Outside of the QM

Department by Title

CredentialsPercent of time per

week devoted to QM

Director of Compliance Bachelor level 50%

CEO/VP Service Center Master level 20%

Chief Medical

Director/Medical Directors MD 40%

SVP of Recovery & Clinical

Operations Master level 30%

AVP Utilization Management Master level 20%

AVP of Community Support Master level 20%

AVP of Clinical Services RN 20%

VP of Consumer and Provider

Support Master level 20%

Customer Service Director Extensive experience 20%

Provider Relations Director Master level 20%

Dirctor of Peer Services Master level 20%

IT Director Bachelor level 20%


E. Patient Safety The engagement center continues to be committed to ensuring that patient safety is

promoted throughout the organization. Efforts are made to minimize patient risk from adverse

incidents, quality of care or service. Adult members continue to present with the highest risk

and efforts are being made via the performance targets in attempts to address some of the risk

by assisting members in connecting to care post hospital stays.

III. EVALUATION OF THE OVERALL EFFECTIVENESS OF THE UM PROGRAM STRUCTURE

A. UM Committee Structure and Effectiveness of Structure

Utilization Management Sub-Committee

The Utilization Management Sub-Committee is charged with the general oversight of CT

BHP engagement center UM activities. The Utilization Management Sub-Committee meets

weekly and reports to the Quality Management Committee. The sub-committee is co-chaired by

the Utilization Management Director and the Chief Medical Director. In addition to the co-chairs,

the membership of the committee included:

Associate Medical Director - Adults

Associate Medical Director - Children

AVP of Utilization Management

AVP of Integration Services

Clinical Supervisors

Assistant VP of Quality Management

QM Quality Analyst Staff

Provider Relations staff

The goal is to understand the clinical landscape and work as a group to find better ways

to positively impact the system through data. Functions include reviewing and approving

Connecticut engagement center-specific policies and procedures pertaining to the UM process,

oversight of the referral and triage function, developing and monitoring UM and Medical

Management utilization data reports and indicators such as Hospital Census reports, days/1000,

admits/1000, Discharge Delay data, as well as length of stay, turnaround time completion rates

and monitoring of UM staff performance against contract indicators. Representatives from this

committee attend the Senior Management Committee. The UM Committee reports to the Senior

Management Quality Steering Committee. The committee develops new reports that support

innovative UM strategies, as well as evaluates the utility of current reports including the Bypass

Program reports. UM strategies and interventions are consistently being reviewed for

effectiveness and reliability.


Assessment and Recommendations of UM Committee Structure and Effectiveness:

The UM Committee continues to meet weekly to review current reports and request

additional reports to gain a better understanding of next steps in UM strategy. During 2015

some areas of focus for the UM Committee were Bypass target (ALOS, Readmission rates,

Discharge form completion), enhancements to the Bypass program, implementation of the risk

score, revisions of the turnaround time reports to capture web pended and telephonic measures

in one document for streamlining, implementation of electronic health alerts and Provider

meeting/training schedules. All implementations were successful and some interventions such

as risk score outreach have been adopted in others areas such as connect to care due to

positive outcomes. The UM Committee will continue to meet weekly and monitor the impact of

Bypass enhancements on clinical department resources and the impact of risk scores, health

alerts and connect to care activities impact on percentage of members successfully connected

to aftercare. Committee attendees will continue to invite additional department staff as

needed.

B. Adequacy of Resources

The UM program resources are reported in the UM program description. There were two

position changes in the clinical department to allow for Adult and Child ICM Supervisors. All

Supervisor positions were filled by years end. There was some turnover within the clinical

department as a result of internal promotions, external promotions and desire for more direct

care. All positions have been filled with the exception of one CCM position that will remain

vacant. The Clinical Care Managers continue to expand their role beyond standard UM practice

and participate in facility rounds, co-manage complex cases through ongoing collaboration with

ABH/CHN/Logisticare and arrange case conferences as indicated.

C. Practitioner Involvement

There is active involvement by CT providers/practitioners in UM activities. Individual

provider meetings occur frequently and include: onsite rounds, clinical documentation trainings,

Medication Assisted treatment initiative discussions, member specific care planning meetings.

The UM program often partners with member of the Quality team to engage providers in PAR

discussions and Inpatient Provider meetings to discuss different UM initiatives. Providers are

also involved in multiple UM/QM Committees and Sub-Committees, including those that provide

oversight of the Partnership at the highest level.

D. Leadership Involvement

The CEO and members of the Senior Management team are all active participants in the

operations of the UM Program. The active involvement of Senior Leaders provides a clear

message to all Beacon staff regarding the importance of their daily activities while also providing

sound clinical and professional leadership. The SVP of Clinical Operations and Recovery


attends each weekly staff meeting and provides ongoing updates on initiatives and performance

targets. Clinical managers also take time to explain how each clinician’s individual contributions

influence and change the behavioral health delivery system in CT.

E. Patient Safety

During utilization review activities the clinician assesses any potential risk or safety

concern and collaborates with the treating provider on planned treatment interventions,

measures for progress to reduce risk to self or others. Internally staff notify Clinical and Quality

Leadership when any concerns are identified regarding a member’s safety to self or others and

these concerns are reviewed weekly by the Quality of Care subcommittee to ensure discharges

plans are adequate and specific to each member’s needs. This committee is comprised of staff

from Medical Affairs, QM and the UM departments, upon case review it may be determined that

additional outreach is required from a Clinician, Peer Specialist or Clinical Liaison to either the

provider, member or both.


IV. EVALUATION OF THE 2015 QM & UM PROJECT PLAN

Goal 1: Review and Approve 2014 Beacon Health Options QM Program Evaluation, 2015 Beacon QM Program Description, 2015 Beacon UM Program Description and 2015 Beacon QM & UM Project Plan

Description of activities and findings that include trending and analysis of the measures to

assess performance over time:

The 2014 QM & UM Program Evaluation was submitted to the Departments on April 1,

2015 and resubmitted on May 28, 2015 following feedback from the Departments. An

addendum to Goal 12 - Adult Utilization was submitted on May 28, 2015 with the resubmission.

Final approval was obtained on June 11, 2015.

The 2015 QM Program Description was submitted to the Departments on April 1, 2015

and resubmitted on May 28, 2015 following feedback from the Departments. Final approval was

obtained on June 11, 2015.

The 2015 UM Program Description was submitted to the Departments on April 1, 2015

and resubmitted on May 28, 2015 following feedback from the Departments. Final approval was

obtained on June 11, 2015.

The 2015 QM/UM Project Plan was submitted on April 1, 2014 and resubmitted on May

28, 2015 following feedback from the Departments. Final approval was obtained on June 11,

2015.

Recommendations for continuing goal in 2016: This goal continues to be applicable for 2016

and should be included in the 2016 Project Plan.

Goal 2: Establish and maintain BEACON, CT-specific policies and procedures (P&Ps) in compliance with contractual obligations that govern all aspects of BEACON, CT operations.



Beacon Health Options CT utilizes National Beacon Health Options Policy and

Procedures except in cases where exceptions are needed to meet local contractual

requirements. At least annually, all policies and procedures (including attachments) will be

reviewed, revised or retired.

In 2015, legacy ValueOptions and legacy Beacon policy and procedures were reviewed

and merged into Beacon Health Options policy and procedures. A full review of current CT


specific Policy and Produces will be completed in 2016. Changes will be made based on

updated contract language or if a national policy and procedure can be used as a replacement

to a CT specific policy and procedure.

Recommendations for continuing goal in 2016: This goal continues to be applicable for 2016 and should be included in the 2016 Project Plan.

Goal 3: Establish and maintain a training program for BEACON, CT Staff.



A. Staff training on state regulatory requirements

Staff training on federal and state regulatory requirements was conducted with our new

employees during new hire orientation and periodically throughout the year in departmental staff

and ad-hoc meetings. The Compliance Department completed 68 face to face training sessions

and sent 20 electronic training alerts to staff in 2015. During the month of November, the

engagement center participated in Corporate Compliance and Ethics Week. Daily activities

were designed to highlight the importance of compliance and ethics in the workplace.

B. Staff training on HIPAA/HITECH/42 CFR Privacy regulations

The CT Engagement Center staff completed the annual companywide 2015 HIPAA

training. National Human Resources Department monitored the process to ensure full

compliance with this requirement. Refresher trainings on basic information about PHI, what

constitutes a HIPAA violation and how to report a HIPAA violation were conducted over the

course of the year.

During 2015, there were 9 audits conducted of the engagement center staff to ensure

compliance with the rules around protecting PHI. Additionally, all documents containing PHI

were reviewed by a member of Senior Management prior to mailing to verify that the member

information in the letter matches the address on the envelope.

The local and national compliance staff continued to monitor all violations closely. Each

violation reported during 2015 was thoroughly investigated and placed into one of the categories

listed below.

There were 2 privacy breaches during 2015. There were 104 policy and regulatory

(privacy) violations which equate to .0020% of the 62,724 authorizations issued during 2015.

Two (2) – Privacy Breaches:

o Two (2) - An unauthorized individual received a letter containing PHI mailed to

the wrong address. The breaches were reviewed by the Connecticut Department


of Social Service who agreed with our recommendation to notify the clients as

the unauthorized individual were not bound by HIPAA or any other federal or

state laws to keep the information received confidential. Notifications were sent

to the members.

Eighty-One (81) – Policy Violations:

o Sixty-On (61) - Instances of incorrect information being entered into a member’s

record set; there was no disclosure of PHI.

o Six (6) – Authorizations were created for the wrong provider; an authorization

letter was not generated.

o Four (4) - Authorization was created for the wrong member; an authorization

letter was not generated.

o Three (3) - Emails sent unencrypted to the intended party (Low risk as email

went to intended party).

o One (1) – Emails sent encrypted to an unintended party (Low risk as email was

sent to State Partner instead of a Beacon Health Options employee).

o One (1) – PHI released to provider without documenting Release of Information

on file.

o One (1) – No Designated Record Set request form on file.

o One (1) – Staff member misplaced work bag containing laptop. The bag and

laptop were found without incident.

o One (1) – PHI emailed to wrong provider.

o One (1) – Employee attempted to access daughter’s medical record (employee

terminated per policy).

o One (1) – Member Identification Number was left in conference room after

meeting.

Twenty-Three (23) – Privacy (Regulatory) Violations:

o Sixteen (16) - Authorizations were created for the wrong provider by Clinical

Department or Central Night Service and an authorization letter was generated.

o Three (3) – No Release of Information on file. (no risk to member; staff did not

confirm provider had ROI on file for member when discussing members history

with provider).

o Two (2) –PHI entered/uploaded under wrong member.

o One (1) – Authorizations were created for the wrong member and an

authorization letter was generated.

o One (1) – PHI released to wrong provider.


C. Staff training on Denials and Appeals In 2015, denials and appeals trainings were conducted for clinical staff as well as

customer service staff and were held in May and then again in November for the clinical staff

and December for the customer service staff. The clinical denial trainings were specific to

operationalize how and when to enter denials in the system. The appeals portion of the

trainings focused on the timeliness of providers appealing and how members can appeal as

well. Customer services staff received the appeals training so that they could better handle

member and provider questions about appeals. Monthly trainings regarding denials and

appeals continued in 2015 for new staff and more seasoned staff were encouraged to join as

training needs were identified by clinical supervisors.

D. Staff training on Complaints, Quality of care and Adverse Incidents In 2015, the semi-annual trainings for complaints, quality of care and adverse incidents

were combined into one training for staff because often complaints and quality of care overlap

and are difficult to differentiate. The trainings were conducted in April 2015 and then scheduled

for the end of the year, but then due to staff vacations the decision was made to reschedule for

the beginning of 2016. Next year, the second training of the year will be scheduled to occur

prior to Thanksgiving so that it does not conflict with the holidays and vacations.

The training was presented to clinical, customer service and peer staff so all of the

department that interface with members and providers may hear about concerns. Monthly

trainings continued the second Wednesday of the month for new staff as a part of the new hire

training series. More seasoned staff were also encouraged to attend if a refresher was needed

at alternative times of the year. Trainings focused on identification of concerns and also the

operational piece of what to do once identified. Reminders specific to the process of submitting

concerns were made during clinical staff meetings at the end of the year when the training

needed to be moved.

E. Staff training regarding State Partners' Departments and specific populations and

programs

Trainings for specific populations and programs were held throughout 2015. Initially,

special program overviews and trainings were completed by our advocacy subcontracts for CT

Hearing Voices Network and Focus on Recovery-United, Inc. (FOR-U) and continued with

coordination between the Beacon CT Academy and Clinical Department to offer special

population trainings on a number of topics. (Biology of Addiction, Family Engagement

Techniques, Medication Assisted Treatment and trainings on Autism Spectrum Disorder

Services). Provider Relations assisted DMHAS with the development and distribution of an

internal survey for Beacon staff that assessed staff’s current DMHAS knowledge and identified

additional areas of interest. Those results then shaped the content for a DMHAS

Programs/Services Overview. DMHAS also presented a training to Beacon staff on their

Community Services Division. These trainings provided a broad overview of the DMHAS


programs as well as the special populations which they serve. Specific program areas

discussed were Young Adult Services, Local Mental Health Authorities, Behavioral Health

Homes, Grant funded programing, Opioid Agonist Treatment Protocol, the SOTA and

Community Bridges Peer Program. Additional trainings included overviews from the

Department of Developmental Services (DDS) and Advanced Behavioral Health (ABH). Lastly,

the overview of CT’s Behavioral Health Home Initiative was rescheduled for 2016. In 2016,

trainings on Medication Assisted Treatment will continue and our hope is to collaborate with

DCF and DSS on overview presentations for the Beacon staff.

F. Staff enrichment trainings through the CT Academy The CT Academy was established in 2013 as an internal committee to provide training

and development opportunities for all employees at Beacon. The CT Academy provided 54

unique trainings in 2015 plus some of the trainings were repeated to ensure that as many

people as possible could attend. 189 employees attended the various trainings that were

offered. Nine hours of face to face Continuing Education Credits were offered to licensed

clinicians for their professional development. Other training opportunities ranged from trainings

relating to professional development and emerging leaders, to support regarding software

applications.

G. Peer staff annual trainings

Ongoing trainings for all Peer Staff have been identified and will continue for the next

year.

On an annual basis, we evaluate trainings for core competencies for the peer and care coordinator staff. This aligns with Beacon National’s overall mission and vision, as well as local


Performance Targets and specific program needs (i.e. ASD, adult and family peer staff). Further exploration of core competencies for the peer role are to be reviewed during the course of 2016. Additionally, a new Yale University academic partnership will review national peer standards, documentation, and peer supervision. Based on competency scores from 2015 performance appraisals, the CT Academy will evaluate the ongoing need for additional trainings related to peer competencies. The trainings below have been identified and will continue for the next year.



Goal 4: Ensure Utilization/Care Management Department compliance with established UM standards.



A. Clinical training plan is complete as defined in the program description

All new Beacon staff participate in general new hire orientation. The clinical department

maintains a new hire checklist approved by the State to monitor trainings and training needs of

staff. Continuing education for clinical staff is provided by the clinical department on a weekly

basis, in addition to the CT Academy trainings provided to the engagement center.

Documentation of training is retained and provided to Clinical Leadership for monitoring of

attendance. Beacon maintains a training site within a shared documents site which all

employees utilize to register for trainings and view upcoming trainings.

The following trainings were provided to the clinical department during the course of

2015: 1. Compassion Fatigue (2 hours) 1/4/15

2. Clinical Jeopardy 1/6 & 1/8/15

3. How to Manage Conflict and Confrontation 1/12/15

4. Integrated Medicine & Health Care Reform 1/15 & 1/20/15

5. Child ICM Overview 1/29/15

6. Communicating for Success- Part 1 1/29/15

7. Refiring in All Areas of Your Life 1/29/15

8. Health Promoter Session 1 2/3 & 2/5/15

9. Fundamentals of Data Analysis and Statistics for Healthcare Professionals 2/6/15

10. Communicating for Success- Part 2 2/19/15

11. Public Speaking 101 2/12 & 2/26/15


12. Compassion Fatigue 3/15/15

13. Training on new HLOC forms 3/10 & 3/12/15

14. Compassion Fatigue Training 3/13/15

15. Cultural Competency 3/17 & 3/19/15

16. Improv for Business 3/19/15

17. Positive Communication Strategies to Use with Families Raising Children with ASD 3/20/15

18. OneNote Workshop 3/23/15

19. Health Promoter Session 2 3/24 & 3/26/15

20. Microsoft Excel Webinar: PivotTables & PivotCharts 3/25/15

21. Logisticare overview 3/31 & 4/2/15

22. Co- Management 3/31 & 4/2/15

23. Improving Engagement and Consumer Response 4/7/15

24. Crisis call refresher 4/14 & 4/16/15

25. 5 Dysfunctions of a team 4/14/15

26. EMDR 4/21 & 4/23/15

27. Toad Data Point 4/22/15

28. National Training on Alcohol Use Disorders 4/22 & 4/29/15

29. Denials 4/28 & 4/30/15

30. Death by Meeting 5/5/15

31. The biology of Addiction (2 hours) 5/8/15

32. Turning Point CT 5/8/15

33. Review of new audit tools 5/14 & 5/16/15

34. Romas and Beefsteaks and Pears 5/20/15

35. ABA 101 5/19 & 5/21/15

36. Provider Connect 5/26 & 5/28/15

37. Implementation Science 101 5/29/15

38. Overview of Autism spectrum disorders 6/9 & 6/11/15

39. From Homeless to Healthy 6/10/15

40. Relias Overview (how to do online trainings) 6/16 & 6/18/15


41. PowerPoint 101 6/18/15

42. Desk Yoga 6/17/15

43. Cognitive Behavioral Intervention for Trauma in Schools (CBITS) 6/22/15

44. Microsoft Applications 101 6/22/15

45. Difficult Conversations 6/26/15

46. Negotiation and Influence Training 6/29/15

47. Presentation Skills 101 6/29/15

48. SCA 6/30 & 7/2/15

49. Enhanced Care Clinics overview 7/7 & 7/9/15

50. Reflexology 101 7/8/15

51. ECT 7/21 & 7/23/15

52. The Science of Managing Remote Employees 7/23/15

53. Difficult conversations 7/28/15

54. What We Don’t Appreciate About Appreciation 7/28 & 7/30/15

55. Enhancing Care Management Skills 8/11 & 8/13/15

56. The Anonymous People 8/18/15

57. Autism 101 and Treatment Options 8/20/15

58. Excel Basics 8/25 & 8/27/15

59. ABA 101 8/26/15

60. Customer Service 101 8/26/15

61. Smart Board 101 8/27/15

62. Open Forum 8/18 & 8/20/15

63. Run, Walk, Move 9/1/15

64. Rules for Editing an Authorization Line 9/8 & 9/10/15

65. Microsoft Outlook 9/15 & 9/17/15

66. Death by Meeting Follow-Up Session 9/15/15

67. Universal Precautions 9/22 & 9/24/15


69. Assessing Family Support 9/24/15


70. EMPS presentation by Wheeler Clinic 9/29 & 10/1/15

71. Behavioral Health and Value Based Care 10/6/15

72. IRR 10/13 & 10/15/15

73. Eating Disorders from Soup to Nuts 10/20 & 10/22/15

74. Identifying and Working with Parents with Cognitive Limitations (6 hours) 10/22/15


76. Breast Cancer Awareness Lunch and Learn 10/22/15

77. Achieving Successful Outcomes with BH Care Coordination 10/20/15

78. Changing the Outcome Suicide Risk Management 10/20/15

79. CCAR 10/27 & 10/29/15

80. Leadership and Influence 10/29/15

81. Denials and Appeals 11/10 & 11/12/15

82. Grappling with Grammar Punctuation and AP Style 11/17/15

83. Spectrum 11/17 & 11/19/15

84. Opioid Addiction Crisis Presentation 11/19/15

85. DMHAS presentation on the Managed Services Division 11/24/15

86. Arm Knitting 12/2/15

87. Life on the Autism Spectrum: My Story (Sara S.) 12/3/15

88. Motivational Interviewing (2 hours) 12/15 & 12/17/15

Beacon will continue to offer weekly training opportunities for the clinical department

staff. Clinicians participate in the identification of topics for training/refreshers relating to internal

workflows and enhancements to all roles within the clinical department. For CT Academy

trainings formal surveys are completed to assess the overall effectiveness of the training and

trainer. Feedback is shared with the facilitator and appropriate adjustments made. Many

trainings are offered twice a week to allow for phone coverage and flexibility. Overall, trainings

were well attended and something new is learned in each training even by our most seasoned

staff.

Recommendations for continuing goal in 2016: This goal continues to be applicable for

2016 and should be included in the 2016 Project Plan.


Goal 5: Monitor consistency of application of UM Criteria (IRR) and adequacy of documentation.



A. Percent compliance rate with clinical inter-rater reliability audit

Annually, CT Engagement Center participates in the company wide IRR audit. This IRR

audit consisted of 27 clinical vignettes, each of which the clinicians must determine the

appropriate level of care. For the past year, 96.4% of our clinical staff passed the IRR

examination, with an average score of 91.47%. The average score was lower than last year,

which was 92.96%. The two Clinicians who did not pass have been placed on corrective action

plans with the expectation that level of care guidelines were carefully reviewed and that they

would retake and pass the IRR. Both Clinicians function as Intensive Care Managers and do

not routinely review or determine level of care as their efforts are spent managing complex

cases and collaborating with providers on accessing services to support discharge plans back to

communities.

In order to continue to ensure consistency with clinical decisions, clinicians meet weekly

for clinical rounds and clinical training. Supervisors provided both weekly individual supervision

as well as group supervision.

B. Assess adequacy and accuracy of clinical documentation

As mentioned in last year’s program evaluation, findings from the Q4 2014 audits were

shared with staff in early Q1 2015. In preparation for completing web-pended inpatient

psychiatric precert audits, the UM supervisors shared opportunities for improvement with their

staff during their group supervision times. Following this supervisions, staff improved in the

area of Professional Performance. The clinical supervisors completed their assigned staff’s

audits on their own and met with QM Specialist who had also completed the audit, we discussed

our scores and resolved any discrepancies.

Due to the migration from phone-based to web-based reviews and due to the high

performance on web-pended precerts, we developed an audit tool for use with web-pended

concurrent reviews. In both Q2 & Q3 2015, we audited inpatient psychiatric concurrent reviews.

During these quarters, we talked more about consulting around or making referrals for co-

management. In Q2, the areas needing improvement were noted to be treatment plans, doctor

consults and mandatory doctor consults. The Q3 data showed that the treatment plan standard

was much improved and the areas of doctor consults and mandatory doctor consults were

somewhat improved. We saw a 1% increase in the average score between Q2 (96.9%) and Q3

(97.9%).


2012 2013 2014 2015

Quarterly Data

Percent with 90% or better

Average Score


Average Score


Average Score


Average Score

Q1 93.0% 95.7% 97.1% 96.3% 97.0% 98.2% 95.0% 95.8%

Q2 97.6% 97.2% 100.0% 97.3% 100.0% 97.1% 94.0% 96.9%

Q3 97.6% 97.5% 100.0% 96.7% 97.0% 98.3% 100.0% 97.9%

Q4 96.9% 96.1% 100.0% 97.5% 93.0% 96.2% 100.0% 98.0%

Due to high levels of performance on the audits for the inpatient psychiatric level of care,

in Q4 2015, we began auditing a new level of care - inpatient detoxification precerts. We

developed a tool and tested it on several reviews prior to finalizing it for use. We focused on

reviews for freestanding detox facilities but also conducted a small number of medically

managed hospital-based detox reviews.

While most of the clinical staff were audited on this new level of care, the child ICMs

were audited on inpatient psychiatric concurrent reviews. For the ICMs, we identified three

areas needing improvement, psychotropic medications, doctor consults and mandatory doctor

consults. We hope to see improvement in these areas next quarter. 100% of the Child ICMs

scored 90% or better with an aAverage score of 97.1%. These scores remain consistent with

the scores from Q2 & Q3 2015. As the roles of the Adult ICMs continued to change, they were

excluded from review based documentation audits beginning in Q2 2015. Adult ICMs were

spending more time in the field, working with members as part of the ICM/Peer intervention.

They were no longer responsible for completing member authorizations. Discussion began at

the end of the year around developing a new audit tool for Adult ICMs due to the unique nature

of their work.

As mentioned in last year’s evaluation, in Q4 2014, we began completing audits for the

home health team. During Q1 2015, we continued with home health audits on web-pended

concurrent reviews for Medication Administration services. The identified opportunities for

improvement were medication, frequency of services, professional performance and timeliness

of completion. In Q2 2015, due to staffing constraints, we were unable to complete audits for the

home health team but they resumed in Q3 & Q4. We worked closely with the supervisor of this

team to refine the home health tool and expectations.

In Q3, timeliness of completion was an area that had improved from Q1. There were

several remaining areas requiring improvement- presenting problem, medication, frequency of

services, clinical criteria and medical necessity, units authorized and professional performance.

Although the majority of the 6 person team scored quite well, the percentage with 90% or better

was low due to one individual’s scores. This staff member was placed on weekly audits.


In Q4, the areas of medication, clinical criteria and medical necessity, units authorized

and professional performance had improved. The remaining areas needing slight improvement

were presenting problem and frequency of services.

2014 2015

Quarterly Data


Average Score

Percent with 90% or better Average Score

Q1 - - 100.0% 96.3%

Q2 - - - -

Q3 - - 83.0% 94.7%

Q4 100.0% 98.5% 100.0% 100.0%

Each quarter, we completed a collaborative inter-rater reliability (IRR) process with the

clinical supervisors and QM staff for each level of care we were auditing. During this quarterly

review, we evaluated the results from the previous quarter’s staff audits, discussed opportunities

for improvement, discussed our scores from two previously completed audits from the level of

care and type of review we planned to audit the following quarter. We discussed any changes

to the standards, expectations, business rules and made a plan for sharing opportunities for

improvement with staff prior to starting the next quarter’s audits. For staff members who did not

score 90% or better on their quarterly audits, they were dropped to weekly audits with more

intensive supervision. Most individuals were able to resume quarterly audits after three weeks

of more intensive supervision and auditing.

Note: See QM Program Description Appendix for audit tools



Goal 6: Ensure timely telephone access to CT BHP Engagement Center.




Total Volume of Calls

In 2015, our call volume decreased by 23.5% with approximately 28,000 fewer calls from

CY 2014. This decrease was due, primarily, to the shift from call-based requests to web-pended

inquiries by providers. Our highest call volume occurred in Q1 ‘15 (26, 283) and continued to

trend downward over the course of the year. An 18.7% decrease occurred between Q1 2015

(26.283) to the lowest number of calls for the year in Q4 ‘15 (21,364). Member and crisis calls

rates remained relatively constant through the calendar year with slight increases seen from Q1

’15 through Q3’15. Provider calls, as expected, steadily decreased from Q1 ’15 (19,665) to the

lowest number for the year in Q4 ‘15 (14,200).

A. Average Speed of Answer

Overall, the average speed continued to increase very slightly for crisis, member and

provider calls during 2015. This slight increase may be attributed to an increased turnover in

customer service reps due to several promotions as well as Clinical liaisons and Peer Support

staff being transitioned from phone responsibilities as their other responsibilities increased. An


equivalent of 2 FTEs were removed from supporting Customer Service staff in answering the

phones. The average answer speed continues to be well below the expected performance

standards of 30 seconds for provider and non-crisis member calls and 15 seconds for member

crisis calls.

B. Percent of Calls Answered within Service Level (15 sec. & 30 sec.)

This measure tracks the speed in which a call is answered from the moment it is received

within the call center. Since 2011, there has been a steady decline in the percentage of calls

answered within the service level agreement of 15 seconds for member crisis calls and 30

seconds for provider and non-crisis member calls. This measure continues to be well above the

expected performance standard of greater than or equal to 90% of all calls received within the

service levels.


C. Abandonment Rate

The call abandonment rate continued to increase in 2015 due largely to the increase in

new staff from the high turnover in 2015. Despite the increase, the rate remains well below the

performance standard of less than or equal to 5%.

D. Percentage of Calls Place on Hold (Provider, Member & Member-Crisis)


The percentage of provider, member and crisis calls placed on hold remains consistent with

previous years.

E. Average Length of Hold Time (Provider, Member & Member-Crisis)

The average hold time for provider calls continues to trend up in 2015, while the hold

time for crisis and non-crisis member calls has increased only slightly from 2014.




Goal 7: Ensure timely response and resolution of member/provider complaints and

grievances.



A – D. Total Number of Complaints and Grievances

A 10.6% decline in total volume of complaints received by the QM department occurred

from 2014 (198) to 2015 (177). Annual volume by complainant type remained consistent with

previous years. Adult members accounted for the majority of total complaints received at 63.3%

(112 of 177). Providers, 20.9% (37 of 177), and youth members, 15.8% (28 of 177), made up

the remainder of all complaints received.

Of the one hundred and seventy-seven (177) complaints received in 2015, two

complaints were escalated to grievances by the complainants who were not satisfied with the

initial outcomes of the complaints. Our highest influx of complaints was seen during the second

and fourth quarters in 2015. Staff reminder trainings around complaint and grievance processing

continue to occur in the second and fourth quarters which may account for the increase seen.

With improved tracking and trending procedures implemented and bi-annual complaint &

grievance trainings for staff occurring within the Engagement Center, it is expected that this

volume will be relatively consistent over the coming year.


Total Number of Complaints and Grievances, specific to ASD

While there were no complaints during the first half of 2015 specific to Autism Spectrum

Disorder treatment services, there was a complaint received from a mother on behalf of her

child, who has been identified for autism spectrum disorder services. The complaint was

regarding an outpatient provider and the alleged unprofessionalism of an intern. There were

four total complaints specific to Autism Spectrum Disorder (ASD) services received during the

last half of 2015. One complaint was forwarded on and handled as a quality of care concern.

The other three complaints were regarding one specific ASD provider and concerns with their

quality of care, discharge planning, use of restraints, and termination of services. Beacon

Health Options will continue to track these complaints.

E. Average Number of Days to Resolution

The average handle time to resolve a complaint/grievance increased slightly in 2015 to

23 days versus the low seen in 2014 of 20 days. An increase to 23 days in the average handle

time began within the second quarter of 2015 and remained consistent throughout the

remainder of the year. Resolution time continues to remain well within the expected

performance standard of less than or equal to 30 days.

To ensure that complaints were resolved quickly and effectively, all complaints were

reviewed weekly by the Assistant VP of QM and efforts to resolve the issues were acted upon

immediately. Beacon Health Options staff continue to work collaboratively with DSS around

specific concerns as they are identified.

Provider -

Adult Member -

Youth Member 4

CY2015

Autism Spectrum Services

Complaints & Grievances


F. Percent of Complaints Resolved within Expected Timeframes (30 days or 45 with an approved extension)

In 2015, one hundred and seventy-eight (178) were resolved with one complaint being

received at the end of 2014 and resolved after the start of the New Year. This is 7.3% reduction

from the total amount of complaints resolved in 2014 (192). One hundred and sixty-two

complaints were (162) were resolved in 30 days of receipt – 91%. A total of sixteen (16)

complaints were resolved within 31-45 days with the appropriate permission granted by the

complainant – 9%. No complaints were resolved greater than 45 days during 2015.

G. Most Frequent Reasons for Complaints/Grievances

2011 2012 2013 2014 2015

Complaint with VO

staff/process 7 8 27 23 14

Provider 5 3 21 18 9

Adult Member - 2 4 2 5

Youth Member 2 3 2 3 -

Clinical Issues 26 41 43 49 32

Provider - - 1 3 3

Adult Member 14 32 33 36 25

Youth Member 12 9 9 10 4

Access Issues 3 11 10 41 58

Provider 1 1 2 7 6


Youth Member 2 - 3 5 10

Reimbursement/Billing/Clai

ms Issues 1 13 3 29 16

Provider 1 9 - 1 1

Adult Member - 3 - 23 12

Youth Member - 1 3 5 3

Benefit Issues 8 3 14 7 2

Provider 3 2 2 2 1

Adult Member 5 1 12 1 -

Youth Member - - - 4 1

Annual Number of Complaints/Grievances by Reason


Complaints regarding Beacon Health Options performance in 2015 were largely received

from providers. These provider complaints peaked in 2013 (21), and have now come down,

significantly, in 2015 (9). The majority of the concerns were related to a perceived lack of

courtesy and requests for authorizations that were delayed, misplaced, or partially approved.

Issues related to staff performance were addressed immediately by supervisors/managers and

Beacon Health Options continues to track system issues and aims to proactively address

service needs based on provider demand.

In 2015, there was a notable increase in the number of complaints received from

members regarding access issues including, but not limited to, making provider appointments,

accessing medical records, refilling prescriptions, and receiving callbacks from providers. For

(continued)

2011 2012 2013 2014 2015

Annual Number of Complaints/Grievances by Reason

Provider Network

Accuracy/Incorrect Referrals 1 3 3 0 4

Provider - - - - -

Adult Member 1 3 3 - 3

Youth Member - - - - 1

Transportation Issues 0 4 8 35 18

Provider - 1 3 19 8


Youth Member - 1 2 8 1

Authorization Issues 31 17 3 1 -

Provider 31 17 1 1 -

Adult Member - - 1 - -

Youth Member - - 1 - -

Provider Attitude/Behavior 6 0 29 13 15

Provider - - - 1 1

Adult Member 2 - 24 10 10

Youth Member 4 - 5 2 4

Quality of Practioner's Office 0 0 2 0 1

Provider - - - - -

Adult Member - - 2 - 1

Youth Member - - - - -

Quality of Care Issues

(New Q2 '15 ) 0 0 0 0 16

Provider - - - - 3

Adult Member - - - - 7

Youth Member - - - - 6

Non-covered Services

(New Q3 '15 ) 0 0 0 0 1

Provider - - - - -

Adult Member - - - - 1

Youth Member - - - - -


issues regarding access to records, provider callbacks and prescription refills, the QM

department worked with the individual providers to determine the validity of the inquiry and best

possible resolution for the members.



Goal 8: Monitor performance of Customer Service staff via audits of performance.



A. Assess individual Customer Service staff (at least 5 cases per month) on performance in

5 areas (Call Opening, HIPAA Requirements, Issue Definition, Problem Solving/Utilizing

Tools/Decision Making and Hold/Transfer Techniques)

During 2015, the Beacon Health Options NICE recording system was utilized to conduct

call auditing of the Customer Service staff. The designated Customer Service auditor lead

conducted these audits. The audit average for the department for call audits conducted in 2015

was 98.98%. Customer Service staff received feedback, routinely, regarding their individual

performance as call audits were conducted; and overall department performance during staff

meetings.

Additional resources include live call observation by supervisor, continued review of call

center/customer service job aids/workflows, and interdepartmental interface meetings to keep

call center triage team up to date with most current information and operations. In addition to

the CT Academy trainings that include personal and professional development tools, Customer

Service staff also participated in clinical trainings to broaden their knowledge base around

working in a utilization review setting.

B. Assess adequacy and accuracy of documentation of content of call.

The Customer Service Department conducts audits of the accuracy of the

documentation that results from calls into the department. Audit results indicate that with the

exception of misdirected calls (medical, dental or vision) Customer Service staff routinely

document every call received. Based on results from the NICE system, the scores for

documentation were above the goal of 90%. Actual results for calls that were audited in 2015

were 99.01%. Call documentation audits provide opportunities for improvement in the quality of

the documentation in member records regarding the content of the call. Call documentation

audit feedback is discussed with Customer Service Staff in coordination with routine call audit

findings and shared individually; and overall department performance during staff meetings.




Goal 9: Assess provider network adequacy



A. Identify providers who are not accepting new Medicaid referrals and place them in No

Referral status.

The process used for identifying providers not accepting new referrals is based on direct

report by providers as well as on member experience and direct feedback from CT BHP

Network Managers, Peer Specialists and Customer Service Representatives. Providers are

instructed to notify the CT BHP when, for any reason, they are not accepting new referrals. At

the time of the notification, providers are placed in “no referral status,” and removed from the

website used by members seeking treatment for outpatient services. Through daily system

inquiries and emails, CT BHP staff informs Provider Relations when they are informed providers

are not accepting referrals or when provider demographic/contact information needs updating.

Provider Relations will outreach to provider, confirm updated information and referral status and

make updates to the ReferralConnect system.

In order to assess the accuracy of the data elements processed from the provider

add/change reports a quarterly audit was conducted again in 2015. The results of the quarterly

audit for 2015 continues to be well above the 98% threshold, which was the goal established

when the Provider File Audit was part of Performance Target 1.

Quarter Results (%) # or records # correct records # of errors

Q1 2015 99.71% 339 338 1

Q2 2015 100.00% 339 339 0

Q3 2015 99.41% 339 337 2

Q4 2015 99.41% 339 337 2

Q1 2014 100.00% 339 339 0

Q2 2014 100.00% 339 339 0

Q3 2014 99.41% 339 337 2

Q4 2014 99.71% 339 338 1

B. Develop the network where inadequacies exist.

In addition to the outreach and enrollment efforts that the Provider Relations/Network

Operations Departments maintain on a daily/weekly basis: weekly provider add/change reports,

staff referrals and member requests, targeted network development projects focused on Autism

Spectrum Disorder (ASD) providers, Medication Assisted Treatment (MAT) providers and a

smaller initiative to expand the current network of Acquired Brain Injury (ABI) waiver providers.


Acquired Brain Injury: Provider Relations developed and distributed a survey to over 300

psychologists and psychologist group practices enrolled in the CT Medical Assistance Program

(CMAP) network to identify interest and increase the network of providers that are willing to offer

ABI related services. Survey and outreach efforts resulted in 43 respondents in which

credentialing and additional information was provided.

Medication Assisted Treatment: A two fold provider outreach to expand the current MAT

network began with the distribution of electronic and hardcopy surveys and secondly, with

telephonic outreach to all CT CMAP MDs and APRNs. Telephonic outreach to over 800

MD/APRN individual and group practices was completed and over 65 providers expressed

interest in providing Medication Assisted Treatment or requested additional information.

Educational materials were developed and distributed to those providers and follow up calls,

trainings and assistance will continue throughout 2016.

ASD Services: Provider Relations/Network Operations began the year by outreach efforts to

more than 260 providers including DCF ASD providers, DDS Credentialed providers and

Identified ASD providers through certification boards, provider lists and member/staff referrals.

Electronic surveys, hardcopy mailings and telephonic outreach was utilized to educate providers

on covered services, the CMAP enrollment process, DDS credentialing process and general

education on the program and how services were authorized. Education and outreach efforts

continue on a weekly basis and will continue throughout 2016.

C. Network adequacy reports specific to ASD services.

Provider Relations/Network Operations provides a weekly update report for the

participants in the weekly ASD meetings which includes state partners, CT BHP staff and DDS

staff. Reports include information on call volume, enrollment status of ASD providers and

providers that are in the process of CMAP enrollment as well as a current listing of ASD network

providers and the types of services they provide. The network of ASD providers has grown from

a starting total of six providers to 25 providers with nine providers in the process of enrollment.

See the December 11, 2015 presentation on CT BHP Network Adequacy for more details.

Recommendations for continuing goal in 2016:

This goal continues to be applicable for 2016 and should be included in the 2016 Project Plan.

Goal 10: Health literacy, cultural and linguistic competency




A. Assess organizational health literacy, cultural and linguistic competency

As a part of the CONNECT grant and the Care Management Entity contract, the

Connecticut Engagement Center has been invited by the Department of Children and Families

to participate in the implementation of the enhanced National Culturally and Linguistically

Appropriate Services (CLAS) standards. These standards were designed to make services

more responsive to the individual needs of members, specifically members of racial, ethnic and

linguistic minority population groups. We felt this was an important initiative to embark on in

order to ensure that the engagement center was engaging individuals from racially, ethnically

and linguistically diverse backgrounds. It was also expected that by doing so it would improve

the health and satisfaction levels of the entire organization.

The initial phase of the implementation was establishing commitment from senior

leadership, which occurred in mid-December. The next steps that will occur in 2016, will be to

conduct a comprehensive assessment of the organization whereby employees at all levels were

invited to participate in a survey. This assessment will identify any inequities and push to

eliminate any barriers through responsive governance, culturally competent practice, flexible

communication, and community engagement and accountability. A multisource analysis will

result from the assessment, identifying strengths and weaknesses. From the assessment, a

work plan will be developed and goals will be prioritized.

B. Assessing and enhancing the means of identification of disparities in treatment of the

Medicaid population

A comprehensive assessment of the Medicaid population was initiated in 2015 (See

Health Equity and Inequity in the Connecticut Medicaid Behavioral Health Service System

submitted on February 2, 2016) by the Connecticut Engagement Center. This clinical study

identified both equities and inequities in the behavioral health care for Medicaid members in

Connecticut and included recommendations for improvement.

C. Assess provider network adequacy to meet needs of cultural diverse population

It was determined that assessing the Medicaid provider network in order to ascertain if

the network was adequate in its ability to meet the diverse needs of the Medicaid population

was challenging and not accomplished in 2015. The CT Engagement Center will continue to

attempt to determine how this goal can be met in 2016. Beacon is working with DCF via the

CONNECT grant as mentioned above and it is anticipated that more will be done in this area in

2016.

This activity for Goal 10 should be modified to read, continue to evaluate ability to

assess provider network adequacy to meet the needs of the culturally diverse Medicaid

population.




Goal 11: Reduce emergency department (ED) discharge delays.



A - B. Number and average length of time of youth are delayed in the ED

The total yearly number of youth stuck in the ED has decreased from 2013 to 2015 by

37.3% (1,164 to 730). The average length of time youth were delayed in the ED has remained

the same averaging 1.64 days from 2013 to 2015.

ED Stuck ALOS ED Stuck ALOS ED Stuck ALOS ED Stuck ALOS ED Stuck ALOS

Q1 192 1.80 315 1.49 307 1.41 391 1.82 264 1.90

Q2 292 1.73 287 1.59 366 1.61 393 1.65 221 1.97

Q3 166 1.26 149 1.28 159 1.40 101 1.55 75 1.39

Q4 183 1.48 215 1.53 332 1.52 211 1.64 161 1.22

Year 833 1.60 966 1.49 1,164 1.50 1,096 1.70 721 1.72

2011 2012 2013Youth (0-17)

2014 2015

Youth Delayed in the Emergency Department CY 2011-CY 2015


Seasonality continues to be evident as quarter three of each year remains the lowest

average length of stay and volume of youth delayed in the ED.

C. Frequency Distribution of ED Delayed Youth

As indicated on the frequency distribution above, the number and percentage of youth staying 3+days decreased between 2014 (231) and 2015 (135).


Beacon Intensive Care Managers continue to call each ED daily to offer care

coordination for any HUSKY member present in the ED. Regional meetings have been initiated

to improve collaboration between area providers and regional emergency departments. The

New Haven area has begun this process to improve connection to care and collaboration with

its area E.Ds. Daily Rapid Response interventions continue with two high volume emergency

departments. Representatives from DCF, Emergency Mobile Psychiatric Services (EMPS), the

hospital EDs and Beacon meet monthly to discuss issues, barriers and the status of the Rapid

Response model. The Rapid Response model focuses on the collaboration among community,

State agencies and Beacon staff to provide emergency departments support and case

management for children “stuck” in emergency departments.



Goal 12: Maintain and Establish additional Bypass/Outlier Management Programs.



A. Evaluate on-going effectiveness of the Bypass/Outlier management programs.

Adult Inpatient Bypass Program

The inpatient bypass program continued in 2015. The three measures used to evaluate

a hospital’s participation in the bypass program remained consistent with the previous year:

average length of stay (ALOS), 7-day readmission rate, and 2-day discharge form completion

rate. However, the targets identified to determine which providers would be eligible for

participation in the bypass program were reevaluated in November 2015. The targets, and the

evaluation period, were based on 12 months of data (Q3 ’14 through Q2 ’15, or FY 2015) for

average length of stay and 7-day readmission rates, and the most recent 6 months (Q1 and Q2

’15) for the 2-day discharge form completion rate measure. Currently, being in the bypass

program grants the provider access to submit reviews and obtain a 7-day authorization.


As noted in the 2014 QM/UM Evaluation, providers were reassessed for bypass in April

of 2015 based on performance in Q3 and Q4 ’14. The targets for the three measures remained

unchanged (based on CY 2013 data). At that point, 11 of the 22 adult providers (50%) met the

criteria for the bypass program. In April, the statewide ALOS for the measurement period was

8.02 days with a target of 9.04 days or less. The statewide 7-day readmission rate was 4.33%

with a target of 6.00% or less, and the 2-day discharge form completion rate was 84.37% with a

target of 90% or greater. All measures for the adult bypass program include members ages 18

and older.

Previous bypass targets were based on 2013 data, so during the November 2015

reevaluation period it was decided to review the target values. As mentioned, the evaluation


period and the new targets were based on a full year’s worth of data from Q3 ’14 through Q2 ’15

(FY 2015).

The ALOS measure includes all discharges during the evaluation period, excluding dual

eligible, LTC Single, and TEMP members, as well as discharges with an ALOS of 0 days or

greater than 100 days. The statewide ALOS for Q3 ’14 through Q2 ‘15 (FY 2015) was 7.97

days, which was a 0.62% reduction from Q3 and Q4 ’14. Given the continued reduction in

ALOS, the target was adjusted from 9.04 days to 8.20 days or less. Across all 22 providers,

ALOS ranged from 4.98 days (Bristol Hospital) to 10.48 days (Waterbury Hospital), a 5.5 day

spread. Of the 11 providers who were previously on the bypass, 81.8% (N=9) met the new

ALOS target. However, out of all 22 adult providers, only 5 (22.7%) exceeded the ALOS target,

ranging from 9.17 days to 10.48 days. Two of which were unable to participate in the bypass

solely due to exceeding the ALOS target (Stamford Hospital and the Hospital of Central

Connecticut).

The 7-day readmission rate measure includes all readmissions to an inpatient

psychiatric or inpatient detoxification facility that occur two or more days after the member

discharges from the hospital. Discharges that follow-up to a state facility and members with LTC

Single and Dual are also excluded. The statewide 7-day readmission rate was 4.90%, which

was an increase of 0.57 percentage points from the previous measurement period. Of the 11

providers previously on the bypass 10 continued to meet the readmission target. In fact, 81.8%

(N=18) of providers met the readmission rate target. The 7-day readmission rate range was

from 2.51% (Charlotte Hungerford Hospital) to 7.67% (Bristol Hospital). Given the fact that

statewide readmission rates have slightly increased for the past two evaluation periods, the

target remained the same at 6.00% or less. However, the majority (59%, N=13) of providers

were actually well below the target at 5% or less. Only four providers (18.2%) did not meet the

7-day readmission rate target, an increase of one provider from the previous evaluation period.

The range for those that exceeded the target was from 6.42% to 7.67%. Three providers

(13.6%) met the ALOS and discharge form completion targets, but were unable to participate in

the bypass because they did not meet the 7-day readmission target.

The 2-day discharge form completion rate measure includes all discharges from the

inpatient unit excluding members who are dually eligible. The statewide 2-day discharge form

completion rate was 88.20%, an increase of 3.83 percentage points from the previous

evaluation period. The target for this measure remained the same at 90% or greater. This

measure requires that providers submit a discharge form within two days following the patient’s

discharge (excluding weekends). All 11 providers who were previously in the bypass continued

to meet this measure. Across all 22 providers, discharge form completion rates ranged from

57.93% (Yale New Haven Hospital) to 99.72% (Hartford Hospital). Only three providers did not

meet the target for this measure, ranging from 57.93% to 75.90%. A significant improvement

from the previous period when seven facilities did not meet this target. Additionally, two

providers (9%) were unable to participate in the bypass program solely due to performance on

this measure, whereas previously there were five providers who were denied because of this


measure alone. This highlights the significant improvement in hospitals completing these

discharge forms in a timely manner, which enhances Beacon’s ability to aid in the connect-to-

care and outreach processes for members.

In summary, 12 providers met all three measures and, as a result, were granted bypass

status. All providers were informed of their status in November 2015 during a statewide inpatient

workgroup meeting at CT BHP. This was an increase of one provider from the previous

measurement period, showing the improvement in the provider network. As mentioned there

were 9 providers who were able to continue in bypass status. Two providers lost their status

(Stamford Hospital due to their ALOS and Waterbury Hospital due to both their ALOS and

readmission rate), and three providers were able to come into the bypass program (Griffin

Hospital, Bridgeport Hospital and Norwalk Hospital). There were eight facilities that remained

out of the bypass program. Of the 10 total hospitals that were not granted bypass status in

November, the majority failed to meet only one out of the three measures (N=7). Three

providers (Vincent’s Medical Center, Waterbury Hospital, and Yale New Haven Hospital) did not

meet two of the three measures.

Pediatric Inpatient Hospital Bypass

As with the adult providers, the targets for each of the three measures were reevaluated

based on data from Q3 ’14 through Q2 ’15 (FY 2015). All measures for the pediatric bypass

program are for members ages 17 and younger. Currently, being in the bypass program grants

the provider access to submit reviews and obtain a 7-day authorization. During the April 2015

reevaluation, three of the seven pediatric providers met the bypass program criteria (42.9%). At

that time, the statewide ALOS was 11.52 days with a target of 13.36 days or less. The statewide

7-day readmission rate was 2.92% with a target of 5.00% or less, and the 2-day discharge form

completion rate was 92.08% with a target of 90% or greater. The four facilities that did not meet

the bypass criteria each failed to meet the target for one of the three measures.

The ALOS measure includes all discharges during the evaluation period, excluding dual

eligible, LTC Single, and TEMP members, as well as discharges with an ALOS of 0 days or

greater than 100 days. The statewide ALOS for Q3 ’14 through Q2 ‘15 was 11.17 days, which

was a 3.0% reduction from Q3 and Q4 ’14. The ALOS target was consequently adjusted from

13.36 days to 12.0 days or less. Across the seven providers, ALOS ranged from 8.99 days to

14.50 days, a 5.5 day spread. Of the three providers who were previously on the bypass, 100%

(N=3) met the new ALOS target. In fact, only one provider (14.3%) exceeded the ALOS target

with an ALOS of 14.5 days (Yale New Haven Hospital) and was denied entry into the bypass

program solely due to missing the target on this measure. The second highest ALOS was 11.54

days, which indicates that the newly adjusted ALOS is within reach for the vast majority (85.7%)

of providers and shows overall improvement in this measure.

The 7-day readmission measure includes all readmissions to an inpatient psychiatric

facility that occur two or more days after the member discharges from the hospital. Discharges


that follow-up to a state facility, and members with LTC Single and dual eligibility are also

excluded. The statewide 7-day readmission rate for Q3 ’14 through Q2 ’15 was 3.16%, which

was an increase of 0.24 percentage points from the previous measurement period. All three

providers previously on the bypass continued to meet the readmission target. In fact, 100%

(N=7) of the pediatric providers met the readmission rate target. The 7-day readmission rate

range was from 1.44% (St. Francis Hospital) to 4.36% (St. Vincent’s Medical Center). Given that

statewide readmission rates have slightly increased the past two evaluation periods, the target

remained unchanged at 5.00% or less. However, the majority (85.7%, N=6) of providers had

rates below 4%.

The 2-day discharge form completion rate measure includes all discharges from the

inpatient unit excluding members who are dually eligible. The statewide 2-day discharge form

completion rate was 93.79%, an increase of 1.71 percentage points from the previous

evaluation period. The target for this measure remained the same at 90% or greater. As

mentioned previously, this measure requires that providers submit a discharge form within two

days following the patient’s discharge (excluding weekends). All providers who were previously

in the bypass program continued to meet this measure. Across all seven providers, discharge

form completion rates ranged from 85.19% (Yale New Haven Hospital) to 100% (Manchester

Memorial Hospital). Only one provider did not meet the target for this measure with a rate of

85.19%. This was an improvement from the previous period when two facilities did not meet this

target. One provider was unable to participate in the bypass program solely due to performance

on this measure, whereas previously there were two providers who were denied because of this

measure alone.

In summary, five providers met all three measures and, as a result, were granted bypass

status. All providers were informed of their status in November 2015 during a statewide inpatient

workgroup meeting at CT BHP. This was an increase of two providers from the previous

measurement period. As mentioned earlier, there were three providers who were able to

continue in the bypass program. While no providers lost their status, two remained out of the

program (Hartford Hospital and Yale New Haven Hospital) and two providers were able to come

into the bypass program (Manchester Memorial Hospital and St. Vincent’s Medical Center).


Bypass Program 2016 Recommendations

During the November 2015 bypass status assessment, CT BHP also made a shift by

moving the bypass reports to Tableau, an interactive data analytics and visualization software.

By interacting with the data, clinical and quality staff were able to determine the potential results

of a more frequent evaluation of bypass status, rather than only semiannually.

Multiple meetings were held internally with CT BHP staff from various departments to

discuss the possibility of moving to a quarterly assessment of bypass status with more regular,

and timely, communication to providers on their interim progress, using more up-to-date data.

During this process, CT BHP reviewed the Q3 ’15 data for both the adult and pediatric bypass

programs using the same targets identified in November 2015. At that time, it was decided to

allow providers who had made progress, and met all three targets, to come into the bypass

program. Two adult facilities (Johnson Memorial Hospital and State of CT – John Dempsey

Hospital) and one pediatric facility (Hartford Hospital) joined the bypass program on February 1,

2016. No facilities were taken off the bypass at that time despite some facilities not meeting

targets.

For the next evaluation period in March of 2016, CT BHP has recommended that

providers be evaluated on the bypass measures every three months based on the last full

quarter’s worth of data. In March, providers will be evaluated based on Q4 ’15 data. Because

the data shows there can be variability from quarter to quarter, CT BHP will designate hospitals


who do not meet the target, but were previously on the bypass, as “not meeting targets”. While

bypass status won’t change, the provider will have two additional quarters to make adjustments

as necessary and hopefully meet the targets.

Furthermore, the expectation is, with the move to Tableau, CT BHP staff can alert

providers in the middle of a measurement quarter of their current status. This should allow

providers to adjust practices when needed and develop strategies in “real-time”, rather than

being informed about their progress well past the end of the measurement period. It is

anticipated that this change will also keep attention on the bypass measures and encourage

providers to continue to engage in quality improvement activities.

Home Health Bypass Program

The Home Health Bypass Program became effective on October 1, 2015. There was an

all provider PAR meeting held September 30, 2016 at which providers were informed about the

Home Health Bypass Program. 22 agencies were eligible for the Bypass Program and 10

agencies qualified to be on the Bypass which meant they automatically qualified for extended

authorizations. The data used was based on claims data from Q1 ’15. The eligibility metrics

utilized to determine criteria for participation in the Bypass program were:

Establishment of an annually determined minimum volume of members treated during

the previous calendar year – 40 or more, a BID rate that is no greater than the annually

determined number of standard deviations from the pre-established target, a QD rate that is no

greater than the annually determined number of standard deviations from the pre-established

target, an ED rate that is no greater than the annually determined number of standard

deviations from the pre-established target and verification that the provider has no current

corrective action plans related to quality of care.

For the Q1 ’15 program, although providers were informed of the eligibility metrics, only

the three following metrics were applied to determine who qualified for the bypass program, with

the understanding that the other metrics could be applied eventually. The three metrics are:

1. A minimum of 40 members treated during Q1 ’15

2. A BID rate that falls within .5 Standard Deviations of the BID Target rate of 15%

3. No current corrective action plans exist related to quality of care associated with the

targeted Home Health agencies treating CT BHP members

As a part of the implementation process of helping providers understand the bypass

program, of the 22 eligible agencies, the Regional Network Manager met with 17 of the

agencies in 2015. She will meet with the remaining five in 2016.




Goal 13: Monitor for under- or over-utilization of Behavioral Health Services; identify

barriers and opportunities.



A – M See Appendix A - D for PDF and Tableau for both Adult and Youth Utilization

N Develop claims-based metrics for 10 F-G if claims extract is available thru DSS.

Claims-based measures of PHP, IOP and EDT Admits/1000 and Units (Visits)/1000

were not developed during 2015. Methodology associated with identifying an episode of care of

IOP developed for the Clinical Study could be utilized to develop these measures in 2016.

O Ongoing evaluation of use of Data Warehouse Meeting to provide oversight of claims-

based reporting, the integration of DMHAS data and to identify changes in DSS claims data


During 2015, the Data Warehouse Meeting occurred weekly and primarily focused on 1)

the development of methodology for new measures included in the 2015 Performance Targets,

2) the establishment of consistent workflows and procedures for the transfer of DMHAS

encounter data to Beacon Health Options for integration with Medicaid claims data and 3) the

enhancement of understanding of the content and processes used by DMHAS staff to collect

utilization and assessment data from providers. During the year, the membership of the Data

Warehouse Meeting was expanded to include additional DMHAS staff to accomplish these

goals.



Goal 14: Monitor Timeliness of UM Decisions, authorization information being available

to providers and claims payer; identify barriers and opportunities.



The turnaround time reports were revamped in 2015 due to more requests moving to

web-based submission. In July, the process was started to determine how to evaluate web-

based submissions. The reports were updated to include logic that evaluated both the

telephonic and the web-pended request and then combined the results so that performance on

this measure could be evaluated across all requests. This process identified were performance

was falling below expectations and enabled greater discussion and solutions to be identified.

The overall turnaround time (TAT) for initial and concurrent reviews, for both higher and

lower levels of care, was well within the set standard for this evaluation period.

o Initial Reviews: 98.98% completed within the target time (32,565 of 32,901)

o Concurrent Reviews: 98.25% completed within the target time (27,563 of 28,054)

A. Initial Decisions re: authorizations for acute levels of care (LOC) (Psych/Gen Hosp IP, IP

Detox, Intermediate duration acute psychiatric care, PHP, Psych Res and crisis

stabilization) Communication within 60 minutes.

98.99% of initial decisions for acute higher level of care authorizations were

communicated within the target timeframes (32,344 of 32,673).

B. Initial decisions re authorizations for non-acute LOC (lower level of care) within 2 BD of

request.

96.98% of initial decisions for non-acute lower level of care authorization were



Initial decisions re authorizations for non-acute LOC (LLOC) within 4 BD of request.

89.67% of initial decisions for non-acute lower level of care authorization were

communicated within the target timeframes (4,566 of 5,092). The reason for not meeting the

95% performance standard is because the months of January, February, March, November,

and December were all below 95% for web-pended requests, which resulted in an overall web-

pend compliance rate of 89.50%. Telephonic requests achieved an overall 98.06% for the year,

but only comprised of 2% of the total number of requests (103 of 5,092).

C. Initial decision for Psych/Gen Hospital IP, offer an appointment for peer to peer review

within 60 min of completion of CM review

93.83% of initial decisions for general hospital and inpatient psych authorizations that

required a peer to peer review were completed within the target timeframe (76 of 81). The

reason for not meeting the 95% performance standard is because the months of February,

August, and December were all below 95% for web-pended requests, which resulted in an

overall web-pend compliance rate of 94.00%. Telephonic requests achieved an overall 96.77%

for the year, but only comprised about 38% of the total number of requests (31 of 81).

D. Initial Decision for IP Detox, offer appointment for peer to peer review within 120 min of

completion of CM review.

97.62% of initial decisions for inpatient detox authorizations that required a peer to peer

review ere completed within the target timeframe (123 of 126).

E. Initial Decision for other HLOC, offer appointment for peer to peer review within 1

business day of completion of CM review.

100% of initial decisions for other higher level of care authorizations that required a peer

to peer review were completed within the target timeframe (21 of 21).

F. Initial Decision for other non-acute (LLOC), offer appointment for peer to peer review

within 2 business day of completion of CM review.

88.53% of initial decisions for lower level of care authorizations that required a peer to

peer review were completed within the target timeframe (247 of 279). The reason for not

meeting the 95% performance standard is because the months of February, April, May, June,

August, September, October, and November were all below 95% for web-pended requests,

which resulted in an overall web-pend compliance rate of 88.41%. Telephonic requests

achieved an overall 100% for the year, but only comprised about 1% of the total number of

requests (3 of 279).


Initial Decision for other non-acute (LLOC), offer appointment for peer to peer review

within 4 business day of completion of CM review.

38.18% of initial decisions for lower level of care authorizations that required a peer to

peer review were completed within the target timeframe (21 of 55). The reason for not meeting

the 95% performance standard is because all 12 months were all below 95% for web-pended

requests, which resulted in an overall web-pend compliance rate of 35.85%. Telephonic

requests achieved an overall 100% for the year, but only comprised about 4% of the total

number of requests (2 of 55).

G. Concurrent decisions re: authorizations for acute LOC (Psych/Gen Hosp IP, IP Detox,

Intermediate duration acute psychiatric care, PHP, Psych Res and crisis stabilization)

Communication within 60 min on date auth expires.

98.26% of concurrent decisions for acute higher level of care authorizations were

communicated within the target timeframe (27,435 of 27,921).

H. Concurrent decisions re authorizations for non-acute LOC (LLOC) within 2 BDs of

request.

99.16% of concurrent decisions for non-acute higher level of care authorizations were


Concurrent decisions re authorizations for non-acute LOC (LLOC) within 4 BDs of

request.

87.10% of concurrent decisions for non-acute higher level of care authorizations were

communicated within the target timeframes (26,199 of 30,078). The reason for not meeting the

95% performance standard is because the months of January, February, March, October,

November, and December were all below 95% for web-pended requests, which resulted in an

overall web-pend compliance rate of 86.88%. Telephonic requests achieved an overall 100%

for the year, but only comprised about 2% of the total number of requests (519 of 30,078).

I. Concurrent decision for Psych/Gen Psych IP, offer an appointment for peer to peer

review within 60 min of completion of CM review

94.23% of concurrent decisions for general hospital and inpatient psych authorizations

that required a peer to peer review were completed within the target timeframe (49 of 52). The

reason for not meeting the 95% performance standard is because the months of February,

March, and April were all below 95% for web-pended requests, which resulted in an overall

web-pend compliance rate of 93.62%. Telephonic requests achieved an overall 100% for the

year, but only comprised about 10% of the total number of requests (5 of 52).


J. Concurrent decision for IP Detox, offer appointment for peer to peer review within 120

min of completion of CM review.

94.87% of concurrent decisions for inpatient detox authorizations that required a peer to

peer review were completed within the target timeframe (74 of 78). The reason for not meeting

the 95% performance standard is because the months of July, August, and October were all

below 95% for web-pended requests, which resulted in an overall web-pend compliance rate of

92.31%. Telephonic requests achieved an overall 97.44% for the year, but only comprised of

50% of the total number of requests (39 of 78).

K. Concurrent decision for other HLOC, offer appointment for peer to peer review within 1

business day of completion of CM review.

100% of concurrent decisions for other higher level of care authorizations that required a

peer to peer review were completed within the target timeframe (3 of 3).

L. Concurrent decision for other non-acute (LLOC), offer appointment for peer to peer

review within 2 BDs of completion of CM review.

94.77% of concurrent decisions for lower level of care authorizations that required a peer

to peer review were completed within the target timeframe (326 of 344). The reason for not

meeting the 95% performance standard is because the months of February, march, April, May,

July, August, September, and December were all below 95% for web-pended requests, which

resulted in an overall web-pend compliance rate of 83.02%. Telephonic requests achieved an

overall 100% for the year, while comprising of 69% of the total number of requests (238 of 344).

Concurrent decision for other non-acute (LLOC), offer appointment for peer to peer

review within 4 BDs of completion of CM review.

52.17% of concurrent decisions for lower level of care authorizations that required a peer

to peer review were completed within the target timeframe (84 of 161). The reason for not

meeting the 95% performance standard is because all 12 months were all below 95% for web-

pended requests, which resulted in an overall web-pend compliance rate of 34.75%.

Telephonic requests achieved an overall 100% for the year, but only comprised about 27% of

the total number of requests (43 of 161).

In order to address the low performance and in anticipation of receiving all the Standard

Benefit requests, a proposal is going to be presented to the State requesting to expand the

turnaround time for home health reviews from 4 business days to 7 business days, limiting the

requests that require clinical attention to skilled nursing, medication administration, and high

utilization of any of the home health services. Additionally, increase the staffing in this section

of the department based on efficiencies in other areas. Also the trend in failing to meet

benchmarks for TATs associated with web pended registrations will be reviewed by the Clinical


and Quality departments to identify if there is a need for workflow or other process

improvements.

M. 98% of all authorization decisions result in an appropriate letter based on quarterly audit.

In order to monitor performance of this item and ensure that providers were able to view

authorization letters within 2 business days, a quarterly audit was conducted of a sample of

authorizations from each level of care in Provider Connect. For 2015: 381 authorizations were

audited over the course of the four quarters and found that only one (1) letter was not available

in the appropriate timeframe - 99.74% for the year.

After further investigation of the one letter, that was not available, it was determined that

a new process around the creation of the authorization was needed for members that gain

eligibility during a hospital stay.

N. 98% of all batch extracts of authorization notifications created will be delivered to the

vendor, who creates and mails letters, within 2 business days.

In 2015, batch extracts of authorization notifications continued to occur daily and

produced letters both to the On-Demand system for providers to view in Provider Connect and

to the vendor for creation and mailing of the letters to out of state providers. Results for 2015

were consistent with previous years and are as follows:

Q1 – 99.98%

Q2 – 99.99%

Q3 – 99.93%

Q4 – 99.97%

O. Timeliness in passing authorization data to fiscal agent; timeliness in correcting

authorization info errors.

In 2015, 100% of the authorization files (264) were delivered to the fiscal agent within

the expected timeframe of prior to the start of the business day following production of the

authorization file. There were 700 authorization errors corrected in 2015, of which 692 were

corrected within the expected 2 business days, which resulted in 98.86% of authorization errors

being corrected timely and meeting the expectation of 98%. Although 700 errors is an increase

2015

No. Auths

Checked

No.

w/Letter %

Q1 89 89 100

Q2 95 95 100

Q3 95 95 100

Q4 102 101 99.01


over the errors in 2014 (571), more authorizations were created so the percent of valid

authorization only decrease very slightly from 99.92% in 2014 to 99.91% in 2015.

P. Accuracy in passing authorization data to fiscal agent, and accuracy in importing units

used data from fiscal agent.

In 2015, 805,953 authorizations processed with 700 authorization errors. These errors

range from invalid detail status change, to PA overlaps with existing PA and changing of from

and through dates of service on an existing authorization. This resulted in an error rate of .09%

which is below the threshold of 2%. In addition, the accuracy in importing units used data from

the fiscal agent was completed at 99.92%, again meeting the expectations of 98%.



Goal 15: Monitor Medical Necessity and Administrative Denials; identify barriers and

opportunities.



A. Total Number of Administrative Denials Issued

After increasing in 2014, the number of administrative denials issued to providers

decreased by 4.9% in 2015. The decrease was driven by the administrative denials issued to

providers of adult members and accounted for by the decrease in denials issued to inpatient


psych and detox providers. Adult member eligibility issues seemed to have a significant impact

on providers’ ability to register services timely. Outpatient and intensive outpatient continues to

be the most frequent level of care that is administratively denied for both adults and youth.

Total Number of Administrative Denials Issued, specifically for ASD services

There were no administrative denials issued in 2015 for ASD services. The use of

administrative denials will be explored at the beginning of 2106 in order to shape providers’

behavior around timely submission of requests and updates. Providers will be informed of the

new process prior to the denials being issued and potentially providers will be given a trial

period before the denials will impact payments.

Most frequent reason

Denials issued to providers treating adult member for not following the expectations

regarding registration and prior authorization increased in 2015, after decreasing in 2014.

Denials for concurrent reviews and requests that should have been made to the medical ASO

(home health), decreased in 2015 after reaching a high in 2014. Denials issued to home health

providers for not submitting an updated 485 and clinical material, increased significantly in 2015

due to.

Administrative Reasons Adult CY '12 Adult CY '13 Adult CY '14 Adult CY '15

Registration or Prior authorization procedures were not followed 751 1,052 936 1,025

Concurrent review procedures were not followed 970 1,185 1,270 963

Services requested were not a covered service ("one to one" authorizations) - - 3 1

Service request should be made with medical ASO 739 203 255 157

Intermediate care bed not a covered service at this facility - - 16 9

Provider was not Medicaid approved 3 - 2 -

There was a delay in treatment 1 1 - -

ValueOptions did not receive the required document (485) from the provider - - 92 219

Provider failed to submit an updated treatment request according to ValueOptions required procedures - - 22 52

Non-Authorized-Benefit Limits Exceeded - - 12 10

Total 2,464 2,441 2,608 2,436

Administrative Denials

Administrative Reasons Youth CY '12 Youth CY '13 Youth CY '14 Youth CY '15

Registration or Prior authorization procedures were not followed 292 241 226 310

Concurrent review procedures were not followed 311 302 280 204

Services requested were not a covered service ("one to one"

authorizations) 7 - 1 14

Service request should be made with medical ASO 4 2 2 2

There was a delay in treatment 1 - - -

ValueOptions did not receive the required document (485) from the

provider 2 -

Total 615 545 511 530

Administrative Denials


Denials for youth providers, followed similar trends with the adult providers, an increase

in denials due to not following the prior authorization procedures and a decreased in denials due

to not following concurrent review procedures.

B – C. Total Number of Medical Necessity Denials and Partial Denials

The denial for medical necessity increased in 2015 by 50.4 % to the highest number

reported to date. The largest increase was seen in the psychological testing denials on behalf

of youth members. Beacon hired 4 Psychologists at the end of 2014 to review the psychological

testing requests and by 2015, they were fully trained and reviewing the requests more closely

and issuing denials as needed. Their impact on psychological testing requests was felt by both

adult and youth members.

Total Number of Medical Necessity Denials, specifically for ASD services

There was one medical necessity denial issued for ASD services in 2015 due to the

services requested not being medically necessary and symptoms could be more appropriately

treated with cognitive behavioral therapy in an outpatient setting.


Most frequent reason

Consistent with previous years, most denials in 2015, both full and partial, were issued

due to services not being clinically appropriate in terms of type, frequency, timing, site, extent

and duration and considered effective for the individual’s illness, injury, or disease.

D. Number and percentage of NOAs and Denials Issued within 3 business days of decision.

In CY 2015, 3785 out of 3787 (99.9%) total NOAs and denials were sent out and met the

TAT standard of within 3 business days of decision.

Medical Necessity Reasons Adult CY '12 Adult CY '13 Adult CY '14 Adult CY '15

Not enough information 2

Full Denial: Services were not consistent with generally-accepted standards of medical practice that are defined

as standards that based on (a) credible scientific evidence published in peer-reviewed medical literature that is

generally recognized by the relevant medical community, (b) recommendations of a physician-specialty society,

(c) the views of physicians practicing in relevant clinical areas, and (d) any other relevant factors39 23 12 -

Partial Denial: Services were not consistent with generally-accepted standards of medical practice that are

defined as standards that based on (a) credible scientific evidence published in peer-reviewed medical literature

that is generally recognized by the relevant medical community, (b) recommendations of a physician-specialty

society, (c) the views of physicians practicing in relevant clinical areas, and (d) any other relevant factors- 2 2 1

Full Denial: Services were not clinically appropriate in terms of type, frequency, timing, site, extent and duration

and considered effective for the individual’s illness, injury or disease 256 548 473 450

Partial Denial: Services were not clinically appropriate in terms of type, frequency, timing, site, extent and

duration and considered effective for the individual’s illness, injury or disease - 43 23 124

Services were primarily for the convenience of the individual, the individual’s health care provider or other health

care providers - - - 1

Services were more costly than an alternative service or sequence of services at least as likely to produce

equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the individual’s illness, injury or

disease 4 1 - -

Services were not based on an assessment of the individual and his/her medical condition - - - -

Total 299 617 510 578

Medical Necessity Denials

Medical Necessity Reasons Youth CY '12 Youth CY '13 Youth CY '14 Youth CY '15

Full Denial: Services were not consistent with generally-accepted

standards of medical practice that are defined as standards that

based on (a) credible scientific evidence published in peer-reviewed

medical literature that is generally recognized by the relevant

medical community, (b) recommendations of a physician-specialty

society, (c) the views of physicians practicing in relevant clinical

areas, and (d) any other relevant factors 1 1

Full Denial: Services were not clinically appropriate in terms of type,

frequency, timing, site, extent and duration and considered effective

for the individual’s illness, injury or disease 25 49 32 71

Partial Denial: Services were not clinically appropriate in terms of

type, frequency, timing, site, extent and duration and considered

effective for the individual’s illness, injury or disease 1 3 171

Services were primarily for the convenience of the individual, the

individual’s health care provider or other health care providers - - 1

Services were more costly than an alternative service or sequence of

services at least as likely to produce equivalent therapeutic or

diagnostic results as to the diagnosis or treatment of the individual’s

illness, injury or disease 1 -

Total 27 50 36 243

Medical Necessity Denials




Goal 16: Monitor Timeliness of Appeal Decisions; identify barriers and opportunities.



Member Medical Necessity Appeals

A & E. Number of Member-Level I Appeals – Routine & Expedited

There were five more member appeals in 2015 than the previous year with the increase

being seen in both expedited as well as routine appeals.

B. & F. Number and Percent Resolved within Expected Turnaround Times

As mentioned above there were five (5) expedited member appeals in 2015 and 100%

were resolved timely. Additionally, the 10 routine appeals were completed 100% of time within

expected timeframes.

C. & G. Number and Percent of Member-Level I Appeals Overturned – Routine & Expedited

Of the five (5) expedited member appeals, two (2) were overturned and they were both

for adult members. Of the 10 routine member appeals, one (1) was overturned for a youth

member.

H.–J. Expedited from the ED

There were no member appeals expedited from the ED in 2015.

Appeal Type CY '12 CY '13 CY '14 CY '15

# of Resolved

Expedited

Appeals 5 9 3 5

# of Resolved

Routine Appeals 3 14 7 10

Total 8 23 10 15

Resolved Member-Level I Appeals


K. Number of Member-Level II Appeals

There continues to be a low number of member level II appeals and the number in 2015

(6) was consistent with the number resolved in 2014. The majority of the appeals are upheld

due to the member not showing for the administrative hearing that was held at the DSS offices.

L. Number and Percent of Member-Level II Appeals Overturned

As seen above, there was only one member level II appeal overturned in 2015 by the

DSS administrative hearing officer.

Provider Medical Necessity Appeals

M. Number of Provider-Level I Appeals

In 2015, there was a 73% increase in the number of medical necessity appeals due to

the substantial increase in denials, as mentioned above in Goal 15. The increase for appeals

on behalf of adult members was 63%, whereas the increase for the youth was more sizable.

Providers for adult members were appealing primarily for inpatient detox, home health and

inpatient psych, and the providers for youth were appealing for psychological testing.

CY '13 CY '14 CY '15

Upheld 16 6 4

Overturned 1 0 1

Withdrawn 3 0 1

Resolved Member - Level II Appeals


N. Number and Percent of Provider-Level I Appeals Overturned

The number and percent of appeals that are overturned in 2015 decreased and returned

to more typical numbers seen in previous years after reaching an unusually high number and

percentage in 2014.

O. Number and Percent Resolved within Expected Turnaround Times

Of the 182 provider level I appeals that were resolved in 2015, 175 (96.15%) were

resolved timely. Due to the turnover in QM staff and staff at the National level and having newly

trained staff, some of the appeals were resolved within two days instead of the expected one

day.

P. Number of Provider-Level II Appeals


As expected, the number of provider level II appeals increased for adults due to the

overturn rate going down as mentioned above and more providers exercising their appeal rights

in light of denials being upheld on level I appeals.

Q. Number and Percent of Provider-Level II Appeals Overturned

Of the 40 provider level II appeals, three (3) were overturned and they were all appeals

on behalf of adult members.

R. Number and Percent Resolved within Expected Turnaround Times

In 2015, 39 (97.5%) out of the 40 provider level II appeals were resolved timely.

S. Number of Administrative Appeals

As seen on the medical necessity side, administrative appeals increased (11.4%) as well

and was also due to the increase in administrative denials. The increase was primarily driven

by the increase seen for adult members (14.4%).


T. Number and Percent of Administrative Appeals Overturned

In 2015, there was an increase in the number of appeals that were overturned and that

increase was seen progressively over the course of the year, particularly during the last half of

the year. The top three reasons for overturning denials were due to provider errors, eligibility

notification, and Beacon Health Options processing errors. The majority of the provider errors

were made by home health providers not submitting the correct 485 at the time of the request.

Providers were given the opportunity to submit the correct 485 at the time of the appeal as long

as they were within the 21 days of the authorization expiring and the denial was overturned.

Regarding overturning due to eligibility notification, providers demonstrated that they were

belatedly being notified of Medicaid eligibility. It is anticipated that this reason will be used

slightly less frequently in 2016 due to increasing the time, from 30 to 60 days, in which providers

have to submit a retrospective chart following updates to eligibility. This change went into effect

in October so the impact should be seen in Q1 2016. When Beacon errors were identified on

appeal, supervisors were informed and training opportunities were pinpointed.

U. Number and Percent Resolved within Expected Turnaround Times

As mentioned above, there were 985 administrative appeals resolved in 2015 and 984

(99.90%) were resolved timely.




Goal 17: Develop methodology and reporting of Medication Adherence for

antidepressant and antipsychotic medications categories.



A. Results of pharmacy analysis - Medication Adherence for antidepressant and

antipsychotic medications categories

During 2012, psychotherapeutic agents were among the top five therapeutic classes of

prescribed drugs purchased by adults 18 and older (Roemer, 2015).

In 2014, among the adult CT Medicaid population (ages 18+):

19.0% of all Medicaid adults filled at least one prescription for an antidepressant and

6.7% filled at least one prescription for an antipsychotic.

40.1% of Behavioral Health (BH) service users who did not use BH ED or BH inpatient

services filled at least one prescription for an antidepressant and 14.9% filled at least

one prescription for an antipsychotic.

74.3% of Medicaid adults with at least one BH hospitalization in an acute care hospital

filled at least one prescription for an antidepressant and 71.3% filled at least one

prescription for an antipsychotic.

In 2014, among the youth CT Medicaid population (ages 3-17):

3.1% of Medicaid youth filled at least one prescription for an antidepressant and 2.4%

filled at least one prescription for an antipsychotic.

11.4% of BH service users who did not use BH ED or BH inpatient services filled at least

one prescription for an antidepressant and 8.8% filled at least one prescription for an

antipsychotic.

59.0% of Medicaid youth with at least one BH hospitalization in an acute care hospital

filled at least one prescription for an antidepressant and 61.8% filled at least one

prescription for an antipsychotic.

Martin, Wiley-Exley & Richards et al., (2009) defined medication adherence as “the

extent to which an individual’s behavior coincides with medical advice.” For nearly two decades

it has been clearly understood that adherence to antipsychotic medication by individuals with

schizophrenia and to antidepressants by individuals with major depression was a key factor in

preventing relapse and psychiatric hospitalization or re-hospitalization (Dencker & Liberman,

1995; Olfson, Marcus, Tedeschi & Wan, 2006).

For measurement of adherence to a class of medications, Martin et al. recommended

the use of “proportion of days covered” (PDC). The PDC measure entails a determination for

each day in the measurement period of whether the individual had one or more dispensed drugs

in the class (any antipsychotic or any antidepressant) in their possession. The number of

possession days is divided by the total days in the measurement period to obtain the PDC. By


using the PDC measure, the shortcomings associated with an earlier measure, the Medication

Possession Ratio, are avoided.

Finally, it is important to briefly explain the rationale for the diagnostic restrictions placed

on the measures of medication adherence of antipsychotics and antidepressants. Neither of

these two drug classes are used to treat a single condition. Antidepressants are used to treat

multiple conditions apart from major depression such as anxiety, sleep disturbance, smoking

cessation, OCD, PTSD, etc. Similarly, antipsychotics are used to treat multiple conditions apart

from schizophrenia including agitation in adults with dementia, psychotic symptoms associated

with major depression, youth with disruptive mood dysregulation or youth with sleep

disturbances resulting from the stimulants used to treat ADHD.

In all of the examples of other diagnoses treated by these two drug classes, treatment is

not necessarily expected to continue over long periods of time. Including all individuals being

treated with an antipsychotic or an antidepressant in a measure of medication adherence would

result in the inclusion of individuals who were never expected to remain on the medication for a

prolonged period of time. Inclusion of those individuals would distort any measures of

medication adherence. As a result, the application of medication adherence measures typically

requires that the measure only be applied to a single drug class being used to treat a single

chronic illness that requires ongoing treatment for a prolonged period of time.

Medication Adherence of Adults with Schizophrenia Treated with Antipsychotics

The methodology used for obtaining the rates of medication adherence included in this

section were based upon the HEDIS measure, Adherence to Antipsychotic Medications for

Individuals with Schizophrenia. The measure is defined in the HEDIS 2015 Technical

Specifications for Health Plans, Volume 2, by the National Committee of Quality Assurance

(NCQA) as:

“The percentage of members 19-64 years of age during the measurement year (2014) with

schizophrenia who were dispensed and remained on an antipsychotic medication for at least

80% of their treatment period.”

Once the measure was programmed according to the HEDIS specifications, rather than

reporting only the percentage of members who remained on an antipsychotic for at least 80% of

their treatment period, we additionally reported on the percentage of the treatment period that all

of the members identified in the denominator remained on an antipsychotic medication. Finally,

the members in the denominator were divided into those with and without a BH inpatient stay in

order to examine the differences in the medication adherence rates of those two subgroups.

Findings

During 2014, a total of 3,350 adults between the ages of 18 and 64 were eligible for the

measure.


Of those adults, 2,094 (62.51%) remained on an antipsychotic medication for at least

80% of their treatment period.

The HEDIS Medicaid National Average for this measure was 60.07%. CT adults fell

above the National Average, and between the 50th (60.68%) and 66.6th (65.37%) percentiles.

The HEDIS Medicaid New England Average for this measure was 60.24%. CT adults

fell above the regional average and between the 50th (57.79%) and 66.6th (64.67%) percentiles.

Comparisons of those who had an inpatient stay to those without an inpatient stay

A total of 1,167 (34.84%) of the 3,350 adults eligible for the measure had at least one

BH inpatient stay during 2014.

Of those 1,167 adults with an inpatient stay, 545 (46.7%) remained on an antipsychotic

medication for at least 80% of their treatment period.

Of the 2,183 adults without an inpatient stay, 1,549 (70.96%) remained on an

antipsychotic medication for at least 80% of their treatment period.

Adults with an inpatient stay had a significantly lower rate of remaining on an

antipsychotic medication for at least 80% of their treatment period (Chi-Square=p<0.0001).

Remaining on an antipsychotic medication for a larger portion of the treatment period appears to

decrease the likelihood of a hospitalization.

The following graph displays the entire eligible population broken into quartiles and

provides the percent of individuals within each of the quartiles who had a BH inpatient stay.


More than 50% of the adult schizophrenics who remained on an antipsychotic for <64%

of their treatment period had at least one BH inpatient stay. As the proportion of days covered

by an antipsychotic increased, the percentage of adults hospitalized decreased. However, it

should be noted that even though the number of adults included in each of the quartiles is

approximately equal, the range of proportion of days covered becomes increasingly narrow,

particularly for Quartiles 3 and 4. Even when adults with schizophrenia remain on an

antipsychotic medication for 90 to 97.99% of the days in their treatment period, nearly 27% are

hospitalized. It is not until the PDC rate reaches 98 to 100% that the hospitalization rate falls

below 20%.

Medication Adherence of Adults with Major Depression Treated with

Antidepressants

The methodology used for obtaining the rates of medication adherence included in this

section were based upon the HEDIS measure, Antidepressant Medication Management. The

measure is defined in the HEDIS 2015 Technical Specifications for Health Plans, Volume 2, by

the National Committee of Quality Assurance (NCQA) as:

“The percentage of members 18 years of age and older who were treated with antidepressant

medication, had a diagnosis of major depression and who remained on an antidepressant

medication treatment. Two rates are reported.

Effective Acute Phase Treatment. The percentage of members who remained on an

antidepressant medication for at least 84 days (12 weeks) during the 114-day period following

the IPSD.

Effective Continuation Phase Treatment. The percentage of members who remained on

an antidepressant medication for at least 180 days (6 months) during the 231-day period

following the IPSD.”

Once the measures were programmed according to the HEDIS specifications described

below, rather than only reporting the HEDIS rates for these two measures, there is additional

reporting on:

The percentage of the treatment period that youth members ages 6-17 treated with

antidepressant medication, had a diagnosis of major depression and who remained on

an antidepressant medication for the same time periods described for adults.

The percentage of the treatment period that all of the youth and adult members

identified in each of the two measure denominators remained on an antidepressant

medication.

Finally, the adult and youth members in each of the two measures were divided into those

with and without a BH inpatient stay in order to examine the differences in the medication

adherence rates of those two subgroups.


Findings

During 2014, a total of 10,968 adults 18 years and older were eligible for the measure.

Of those 10,968 adults, 5,377 (49.02%) remained on an antidepressant medication for at least

84 days of the 114-day period (Acute Phase) following the earliest prescription dispensing date

for an antidepressant medication during the intake period (IPSD). This is a significantly lower

rate than that achieved by youth (53.34%) (Chi-Square=p<0.01)

Of those 10,968 adults, 3383 (30.84%) remained on an antidepressant medication for at

least 180 days of the 231-day (Continuation Phase) following the earliest prescription

dispensing date for an antidepressant medication during the intake period (IPSD). This was a

non-significantly lower rate than that achieved by youth ages 6 to 17 (31.01%).

The HEDIS Medicaid National Average for the Acute Phase measure was 52.3%. CT

Medicaid adults fell below the HEDIS Medicaid National Average at 49.02%, and between the

33.3rd (48.11%) and 50th (50.54%) percentiles.

The HEDIS Medicaid National Average for the Continuation Phase measure was

37.06%. CT Medicaid adults fell considerably below the National Average at 30.84%, and

between the 10th (27.44%) and the 25th percentile (30.99%).

The HEDIS Medicaid New England Average for the Acute Phase measure was 51.11%.

CT

Medicaid adults fell below the regional average at 49.02% and close to the 50th percentile

(49.85%).

The HEDIS Medicaid New England Average for the Continuation Phase measure was

36.16%. CT Medicaid adults fell considerably below the regional average at 30.84% and

between the 10th (30.02%) and 25th (31.4%) percentiles.

Comparisons of those who had an inpatient stay to those without an inpatient stay

A total of 1,167 (10.64%) of the 10,968 adults with major depression eligible for the

measure had at least one BH inpatient stay during 2014. When compared to the proportion of

the adult schizophrenics with an inpatient stay that were eligible for the antipsychotic medication

adherence measure, a much smaller proportion of adults diagnosed with major depression and

who received antidepressants had a BH hospitalization.

Of those 1,167 adults with an inpatient stay, 517 (44.30%) remained on an

antidepressant medication for at least 84 days of the 114 acute phase days of their treatment

period.



period.


Adults with an inpatient stay were significantly less likely to remain on an antidepressant

medication for at least 84 of the 114 day acute phase days of their treatment period (Chi-

Square=p<0.001). While this finding reached a relatively high level of significance, this measure

may not distinguish between adults who will or will not require hospitalization or re-

hospitalization. The differences in the rates of adherence with antipsychotics for adults were

much wider between those with and without an inpatient stay.

Of those 1,167 adults with an inpatient stay, 354 (30.33%) remained on an

antidepressant medication for at least 180 days of the 231 continuation phase days of their

treatment period.



treatment period.

Adults with an inpatient stay had a non-significantly slightly lower rate of remaining on

an antidepressant medication for at least 180 days of the 231 continuation phase days of

their treatment period than adults without an inpatient stay.

The failure to find the expected higher rate of medication adherence among adults treated

for major depression on an outpatient basis led to several hypotheses for the finding:

1. The low rate of admission to the hospital for the adults diagnosed with major depression

suggests that outpatient providers may be “over-diagnosing” major depression. Adults

with less serious symptomatology might have been less motivated to remain on an

antidepressant.

2. Timely access to an outpatient prescriber may be more difficult for adults with less

severe symptoms than for adults with a recent hospitalization.

3. The specialties of the prescribers are currently unknown. It is possible that more adults

without an inpatient stay are receiving antidepressants from their PCP and that there is

less oversight of their adherence by non-behavioral health prescribers.

Adult Recommendations

1. While CT fell above the HEDIS national and regional average for the percentage of

adults who remained on an antipsychotic medication for at least 80% of their treatment

period, there is significant room for improvement.

2. Particularly poor continued adherence with antipsychotics by adults leaving the hospital

suggests that connection to care with a prescriber needs to be more accentuated during

discharge planning.

3. Some of the BH outpatient clinics, including ECCs, continue to have requirements that

impede access to prescribers. While there have been conversations with those clinics

regarding those policies, there have been no stringent actions taken. Consideration

should be given to imposing more stringent requirements for timely initial access to

prescribers as well as to follow-up appointments, particularly for adults discharged from

the hospital.


4. Hospitals need to improve the timeliness and adequacy of their communication with

receiving outpatient providers. The dosages of medications of members leaving the

hospital are frequently still being titrated; communication between the attending

physician and the receiving prescriber is critical.

5. The current measure of connection to care includes connection to any type of BH follow-

up care. Consideration should be given to breaking this measure out to enable

assessment of timeliness of connection to the prescriber as well as to the receiving

therapist.

6. The extremely high rate of diagnosis of major depression coupled with the lack of a

difference between the antidepressants medication adherence rate for adults with and

without an inpatient stay suggests that the diagnosis of major depression may be inflated

in the adult Medicaid population receiving outpatient services. Further review of the

frequency of use of antidepressants among the Medicaid population in other states

should be considered.

7. The drop of nearly 20 percentage points between the rate of remaining on

antidepressants during the acute phase to the rate during the continuation phase is

concerning and raised important questions about access to prescribers, antidepressant

prescribing patterns as well as the accuracy of diagnosis of major depression. The

issues that are responsible for this finding need to be further investigated, possibly via

Focus Groups with prescribers as well as members, in order to learn more about the

barriers encountered in remaining on medication.

Medication Adherence of Youth with Major Depression Treated with

Antidepressants

Please note: The HEDIS measure for Antidepressant Medication Management does not

include the youth population. While the results in this section were based, with the exception of

the age criteria, on the specifications for that measure, there are no national or regional HEDIS

results for comparison for youth.

Youth Findings

During 2014, a total of 1,393 youth between the ages of 6 and 17 years old met the

criteria for the measure.

Of those 1,393 youth, 743 (53.34%) remained on an antidepressant medication for at

least 84 days of the 114-day period (Acute Phase) following the earliest prescription dispensing

date for an antidepressant medication during the intake period (IPSD). This was a significantly

higher rate than that achieved by adults (49.02%) (Chi-Square=p<0.01)

Of those 1,393 youth, 449 (32.23%) remained on an antidepressant medication for at

least 180 days of the 231-day (Continuation Phase) following the earliest prescription

dispensing date for an antidepressant medication during the intake period (IPSD). Adults

achieved a non-significantly lower rate of 30.84% on this same measure.


Comparisons of youth with a BH inpatient stay with those without an inpatient stay

A total of 281 (20.17%) of the 1,393 youth with major depression who met the criteria for

the measure had at least one BH inpatient stay during 2014.

Of those 281 youth with an inpatient stay, 157 (55.87%) remained on an antidepressant

medication for at least 84 days of the 114 acute phase days of their treatment period.

Of the 1,112 youth without an inpatient stay, 586 (52.70%) remained on an


period.

Youth with an inpatient stay had a non-significantly higher rate of remaining on an

antidepressant medication for at least 84 of the 114 acute phase days of their treatment

period than youth without an inpatient stay.

Of those 281 youth with an inpatient stay, 96 (34.16%) remained on an antidepressant

medication for at least 180 days of the 231 continuation phase days of their treatment period.

Of the 1,112 youth without an inpatient stay, 353 (31.74%) remained on an


treatment period.

Youth with an inpatient stay had a non-significantly higher rate of remaining on an

antidepressant medication for at least 180 days of the 231 continuation phase days of

their treatment period than youth without an inpatient stay.

The hypothesis going into this project was that youth with major depression and a BH

inpatient stay would have lower rates of adherence with antidepressant medication than youth

without an inpatient stay. Although there were no statistically significant differences between

youth with and without an inpatient stay for either of the rates of adherence, the youth with an

inpatient stay had higher rates of adherence. In comparison, adults with an inpatient stay had

lower rates of adherence. However, while the findings for the adults were in the predicted

direction, the differences may not be enough for this measure to predict hospitalization or re-

hospitalization.

The lack of findings to support the expected higher rate of medication adherence among

youth treated for major depression on an outpatient basis led to the following hypotheses for the

actual findings:

1. The assumption is that the youth included in this data analysis were un-emancipated.

Parents who were concerned enough about the mood of their child to obtain BH

inpatient treatment would probably also have been more likely to ensure that their child

continued to take their medication on discharge.

2. Youth with an inpatient stay may have been more likely to receive closer ongoing

oversight of their antidepressant medication by a BH prescriber while at least some of


the youth treated by outpatient prescribers may be receiving their prescriptions from

non-BH prescribers.

Youth Recommendations

1. Some BH outpatient clinics, including ECCs, continue to have requirements that impede

member access to prescribers. While there have been conversations with those clinics

regarding those policies, there have been no stringent actions taken. Consideration

should be given to imposing more stringent requirements for timely initial access to

prescribers as well as to follow-up appointments with prescribers, particularly for youth

discharged from the hospital.

2. Hospitals need to improve the timeliness and adequacy of their communication with

receiving outpatient prescribers. The dosages of medications of members leaving the

hospital are frequently still being titrated; communication between the attending

physician and the receiving prescriber is critical.

3. The current measure of connection to care includes connection to any type of BH follow-

up care. Consideration should be given to breaking this measure out to enable

assessment of timeliness of connection to the prescriber as well as to the receiving

therapist.

4. The drop of more than 20 percentage points between the rate of remaining on

antidepressants during the acute phase to the rate during the continuation phase is

concerning and raised important questions about access to prescribers, antidepressant

prescribing patterns as well as the accuracy of diagnosis of major depression. The

issues that are responsible for this finding need to be further investigated, possibly via

Focus Groups with prescribers as well as members, in order to learn more about the

barriers encountered in remaining on antidepressant medication.



Goal 18: Ensure consistent application of activities to maintain and/or improve the rate

of ambulatory follow up services after inpatient admission.



A. Report on methods to ensure linkage of target population to aftercare

Connect to Care efforts are completed by the Clinical Liaison (CL) team members once

a discharge is entered into Provider Connect or Care Connect indicating that a member has

been discharged from Inpatient Psych, Inpatient Detox-Hospital and Inpatient Detox-

Freestanding levels of care. The CL reviews the indicated discharge plan, triggers an automated

health alert, outreaches telephonically to the member prior to the appointment and if no contact


is made the CL will outreach telephonically after the scheduled appointment. The CL inquires if

the appointment was kept and if not offers to support the member in connecting with a provider

and scheduling a new aftercare appointment. If no contact is made the CL will send a connect

to care letter to the member that provides contact information and offers CT BHP services and

support in accessing behavioral health services. At 30 days the CL reviews the member’s

record to see if a new authorization is on file indicating connection to care or if an existing

authorization reflects additional units used for tracking and reporting purposes.

B. Performance of aftercare linkage efforts

Connection to Care rates are reported monthly and reflect the previous month’s

percentage of attending follow up care appointments within 30 days of discharge. This report

excludes members who are not able to be followed for connection to care due to discharge

plans that involve services not authorized by Medicaid such as residential rehabilitation services

for HUSKY C and D members and other nontraditional services identified as the primary

aftercare follow up plan (Recovery/Sober/Supportive housing).

C. Review linkage efforts and interventions for improvement

During the course of 2015 several procedural changes were made to enhance outcomes

of the Connect to Care process. The first was moving away from provider outreach and

focusing more on member contact and confirmation of appointment adherence. This was a

result of provider concerns about disclosing member attendance and refusal to confirm if an

appointment was kept or missed. With the implementation of the Risk Indicator Score we began

outreaching to these identified members prior to the scheduled appointment and found when we

were able to connect the member indicated barriers to attending that appointment such as

transportation that Beacon could assist with and increase the likelihood of attendance. We then

made this the standard procedure for all members not just those with a risk score. Going

forward Beacon will continue to meet with Inpatient Detox-Hospital providers to educate and

train on entering discharges into Provider Connect and how that initiates the Connect to Care

process by Beacon. Provider webinars are scheduled for calendar year 2016 in order to

support these efforts.



Goal 19: Promote patient safety and minimize patient and organization risk from quality

of care/service concerns and adverse incidents.



A. Number of quality of care/service concerns identified (by child and adult members)


In 2015, the QM department received a total of 309 potential quality of care and service

concerns to further investigate in order to determine whether or not there was an actual quality

of care concern. 309 is a 33.8% increase in the number received in 2014, when the QM

department processed 231 potential quality of care concerns. The number received in 2015 is

consistent with the number received in 2013. The number of concerns related to youth nearly

doubled in 2015 from 37 in 2014 to 66 in 2015. The number of concerns related to adults also

increased by 25.3%. The increase in the number of concerns is partly due to the greater

stability in the clinical staff and having more experienced staff. Additionally, there was an

increase in the number of concerns that were identified by the medical staff during consults for

long lengths of hospital stays as well as hospital detoxifications, which Beacon began managing

in March of 2015. All of the concerns were reviewed by a licensed clinician and elevated to the

Assistant VP of Quality Management, if immediate interventions were necessary for reasons of

member safety. All submissions were investigated via review of the Beacon record, provider

medical record, policy review or outreach to the provider. Findings were brought to the Quality

of Care sub-committee for review and determination as to whether or not the concerns was an

actual quality of care/service and what appropriate actions needed to be taken as follow up.

Number by Category – Founded or Unable to Determine

Potential Quality of

Care/Service Received CY '11 CY '12 CY '13 CY '14 CY '15

Youth 121 76 50 37 66

Adult 62 101 261 194 243

No Member Attached - 17 - - -

Total 183 194 311 231 309

Categorization of Concerns

that were Deemed Quality

of Care/Service or Unable to

Determine CY '12 CY '13 CY '14 CY '15

Access to Care 4 2 1 3

Attitude and Service 1 3

Clinical Practice 69 96 74 79

Other Monitored Events 5 1 6 0

Provider

Inappropriate/Unprofession

al Behavior 2 4 2 2

Total 80 103 84 87


The concerns that were either determined to be founded or where it was unable to

determine if there was a concern based on the investigation were categorized by type. Despite

the increase mentioned above in the total concerns submitted, the number of founded/unable to

determine remained the same as last year. The increase was therefore accounted for by an

increase in unfounded concerns, which may be as a result of both increased investigation and

staff over reporting. As with past years, the most frequent type of concern was related to clinical

practice, which included concerns such as the adequacy of assessment, failure to follow

practice guidelines, and pre-mature discharges.

B. Number of adverse incidents (by child and adult)

The number of adverse incidents submitted to QM continued to increase in 2015. The

percent increase between 2014 and 2015 was 14% whereas the increase in the previous year

was only 5%. This more sizable increase in 2015 can be accounted for by again the stability of

the staff as well as increased communication with CHN and increased contact with more high

risk members via the ICM/Peer intervention in the ED and Inpatient Detox hospitals for the full

year. The growth in membership may also have been a contributing factor in the higher

numbers of adverse incidents.


Number by Incident Type

As with previous years, the highest number of incidents were related to self-inflicted

harm by members. There was an increase in the number of reported deaths which is attributed

to our increased involvement with members through the ICM/Peer intervention and CCTs where

notification of such events would be shared. This intervention works closely with members who

often had more complex medical issues in addition to complex behavioral health needs.

Trends by provider

In 2015, trends were determined using both quality of care and adverse incidents where

the member was involved with a provider at the time of the incident or shortly before. The

concerns that were used for trending were incidents with a finding of either unable to determine

based on our investigation or where there was a founded concern with a provider. When

concerning trends were identified, the Quality of Care subcommittee developed action steps,

which often involved various departments working together to support the provider in practice

changes in order to provide improved care.

The following provider trends were identified and addressed in 2015:

Bristol Hospital (Inpatient/Detox/ED) had an increase in the number of potential quality of

care and adverse incidents in Q1/Q2 2015. There were 11 concerns reported of which four (4)

ended up being founded following the investigation, two (2) we were unable to determine during

the investigation and five (5) were determined to be unfounded. Several concerns were

identified to be related to the Bristol Hospital assessment and treatment of higher risk members.

Specifically, concern with Bristol ED and their lack of engagement in the Bristol Hospital CCT.

The Quality of Care subcommittee decided that Bristol Hospital inpatient would be identified as

a provider that would be investigated further on future potential concerns by conducting a

medical record review and investigation for any potential quality of care concerns occurring in

Adverse Incident Category CY '11 CY '12 CY '13 CY '14 CY '15

Property Damage - - - - 1

Serious Adverse Reaction to Treatment - - - - 1

Medication or Treatment Errors - 3 - 1 4

Other Occurrences - - 1 2 3

Unanticipated Death 1 5 6 14 20

Elopements 1 - 1 2 -

Human Rights Violations 1 - - - -

Violent/Assaultive Behavior (non leathal) 5 4 2 5 5

Injuries (Accidents): Urgent or Emergent 7 4 2 1 3

Sexual Behavior 10 8 2 2 4

Self Inflicted Harm 226 252 228 661 745

Total 251 276 242 688 786


the next two quarters. Additionally, Dr. Sharp, Beacon Chief Medical Director attended the

PARs meeting at Bristol Hospital with the RNM and discussed potential concerns and

encourage the improvement of ED participation in the CCT.

The number of potential quality of care and adverse incidents associated with Bristol

Hospital remained the same in Q3/Q4 2015 but there were no founded concerns, five (5) that

we were unable to determine despite increased investigation and medical records review and

six (6) were deemed unfounded concerns. Additionally, the RNM involved in the CCT reported

that there was a change in staffing at Bristol Hospital, which resulted in an improvement of ED

participation in the CCT.

During the first half of 2015, Community Health Resources (CHR) continued to be one of

outpatient providers associated with the highest number of adverse incidents (13) and potential

quality of care (1) across all programs. The majority of the adverse incidents were related to

adult members who made a serious suicide attempt, which resulted in a psychiatric

hospitalization and had an open outpatient authorization for CHR in the Beacon system. This

high number is not completely unexpected due to CHR being a high volume provider for

Medicaid members. CHR Manchester had been identified in Q3/Q4 2014 based on the number

of concerns received as a provider to investigate more thoroughly when concerns were received

in 2015. Following chart reviews of CHR Manchester in Q1/Q2 2015, it was identified that this

location did not often send progress notes when a medical record was requested, however did

include treatment plans. It is unclear if CHR Manchester continues to update treatment plans

for members not actively engaged in treatment. Additionally, documentation was lacking

detailed information. Of the 14 concerns submitted during the first half of 2015, two (2) were

founded, 10 were unable to be determined and two (2) were unfounded.

During the last half of the year, Community Health Resources continued to have a large

number of concerns (16), with the majority being related to the Manchester (7) and Enfield (6)

sites. In the majority of the cases, we were unable to determine if there was an actual quality of

care so we will continue to monitor these programs and request medical records and complete a

thorough investigation.

A potential trend also developed at Harford Hospital during the first half of 2015 with five

(5) incidents associated with Hartford Hospital youth inpatient unit. Dr. Narad and Region 4

clinical team identified some concerns with Hartford Hospital youth inpatient unit over past two

quarters including a longer length of stay and potential concerns about discharge planning.

Trends were discussed in Geo-team with Region 4 and it was reported that rounds with Hartford

Hospital had been re-established in order to address the issue in real time. Additionally,

Hartford Hospital hired additional staff and changed processes to address concerns of

discharge planning.

The concerns with the youth inpatient unit decreased in the last half of 2015 but

concerns with the adult unit increased and this trend was the most concerning. There were a


total of 14 concerns associated with Harford Hospital’s various levels of care in Q3/Q4 2015,

with the majority (9) being associated with the adult inpatient unit. Half of the concerns were

related to the clinical practice (adequacy of assessment, delay in treatment, inadequate

discharge planning, and failure to follow practice guidelines) and the other half were unable to

determine. We will continue to monitor this program and request medical records and complete

a thorough investigation on concerns received in 2016.

St. Vincent’s Medical Center had eight (8) associated quality of care incidents that were

trended in Q1/Q2 2015, with seven (7) incidents associated with the Bridgeport adult inpatient

location. We monitored this location more closely during the last half of 2015 and by the end of

the year, concerns had reduced with only four (4) being received during Q3 and Q4.

Stonington Institute PHP/IOP continued to be of concern and IOP chart reviews were

done on site in July 2015 as a follow up to a review conducted in November 2014. Concerns

regarding the documentation and treatment being provided continued to be identified despite

quality improvement plans that should have addressed the issues. Group notes do not

adequately indicate the members’ participation in the groups and how the group was addressing

the members’ treatment plans. Members with high risk presentations were not consistently

being monitored and evaluated to ensure that risk was being addressed. Following the chart

review in July, it was evident that a revisit would need to occur in the early part of 2016. This

plan is being reevaluated in light of a comprehensive review that conducted on 10 PHP records

that were requested based on a potential quality of care concern in September 2015. These

records highlighted the continued concerns:

Lack of evidence of timely initial psychiatric evaluations and inconsistent evidence that

members are seen appropriately for follow up visits for medication monitoring and/or

adjustments.

Lack of evidence that these high risk/at-risk behaviors are monitored and assessed in

treatment.

Lack of evidence of coordination for medical or aftercare services with medical or other

behavioral health providers.

At this point, more significant changes needs to occur with Stonington Institute and it

does not appear that chart reviews are the means to effect such change.

An ASD provider trended with several potential quality of care concerns associated with

the practice, so charts were requested for all the members being seen by the provider. A chart

review was conducted and it was identified that the provider needed some education about best

practices around record keeping and crisis planning. Education was provided via learning

collaboratives that were provided to ASD providers. A follow up chart review will be conducted

in April of 2016, allowing the provider time to establish the appropriate documentation.


Catholic Charities – Institute for Hispanic Families outpatient was also identified as

having potential concerns following the final ECC chart survey, which was conducted in early

June 2015. Following the survey, it was decided that an additional on-site chart review would

be conducted, joining DCF licensing when they would be on-site doing their bi-annual licensing

review. Similar concerns were identified by both Beacon and DCF during the review of the

records. The concerns were related to high turnover in clinical staff and the lack of follow up

with members when clinicians left the agency. Evidence was also lacking of coordination of

care with previous behavioral health providers or medical providers. In addition, it was unclear if

members were being appropriately referred and assessed for medication. The provider created

a quality improvement plan and worked closely with DCF to improve their performance.



Goal 20: Monitor integration of coordination of care with medical, dental and

transportation ASO as well as ABH and other partners; identify barriers and

opportunities.



A. Number of Referrals of cases from medical ASO, ABH and other partners

• 357 referrals were made/recommended by Beacon to ABH

• 2,693 cases were referred for Inpatient or ED co-management since April 2015

• 71 cases were involved in community based co-management with CHN

• 0 cases were co-managed with the Dental ASO however ongoing contact is kept

between Beacon and CTDHP

B. In cooperation with CHN, develop and implement monthly Medical ASO Operations

Committee

Beacon has developed, implemented and participated in bi-monthly meetings with CHN

to discuss, revise and update shared workflows. This meeting has been reduced to monthly or

as needed due to workflow adherence and a greater understanding of which ASO should

authorize medical admissions when detoxification is primary or secondary reason for admission.

This activity has been successfully completed and should not continue in 2016.

C. Develop and implement training Medical ASO and their UM staff regarding BEACON, CT

coordination of care activities.


Beacon participates in monthly community based co-management meetings with CHN

ICMs and provides ongoing education and support to that team in understanding behavioral

health coordination of care. Additionally Beacon staff participate weekly on the hospital watch

list to lend behavioral health expertise and guidance for next steps in care coordination and

member engagement. Going forward Beacon will participate in bi-weekly meetings with the

IPCM and IDCM teams from CHN for collaboration on co-managed cases.

This activity has been successfully completed and should not continue in 2016.

D. Implement monthly meetings with designated CHN staff to review any co-managed

cases.

Monthly meetings to review any community based co-managed cases with CHN

continue to occur and will be enhanced by the addition of bi-weekly inpatient co-managed

meetings weekly with IPCM and IDCM teams from CHN. Beacon will continue to participate in

the weekly hospital watch-list as requested by CHN for support on cases that may not require

formal co-management.

E. Implement monthly meetings with designated ABH staff to review any co-managed

cases.

Meetings with ABH have continued to occur on a bi-monthly basis to discuss strategies

as to how to best work with the HUSKY D population without duplication of services. CCT

meetings have been an ongoing forum for co-managed cases to be discussed and create plans

and interventions while identifying who will be the lead agency working with the member.

Beacon also shared Detox data relating to readmission rates and length of stay by benefit

package to strategize around collaboration with detox providers to increase utilization of ABH

services and reduce rapid readmissions. Beacon continues to provide a daily census to

DMHAS that ABH utilizes to identify candidates for case management in addition to daily

encouragement by Beacon staff to providers to refer members to ABH for services.

F. Implement report to track referrals, linkage to care, and co-managed cases

The lead Beacon co-management clinician tracks all incoming referrals for community

based co-management, outgoing referrals (to CHN) for co-management and referrals that are

declined due to meeting criteria for an alternative ICM program. In April 2015 Beacon began

reporting the number of hospital/ED co-managed cases by region per week and then per month

on the clinical dashboard. This report will be enhanced to have a yearly total and include the

community based co-managed cases. Cases are closed when members are appropriately

engaged in services or are unresponsive to outreach efforts.

Recommendations for continuing goal in 2016: Activities A, D, E, & F continue to be applicable

for 2016 and should be included in the 2016 Project Plan.


Goal 21: Maintain the Quality Improvement Activities: Provider Analysis and Reporting

Programs



During 2015, Beacon Health Options CT continued to use the Provider Analysis and

Reporting (PAR) programs as a strategy to reform the behavioral health system of care in CT

with the goal of improving the quality and efficiency of the service system.

During 2015, the following PAR programs were in existence:

1. Child and Adolescent Inpatient Hospital

2. Psychiatric Residential Treatment Facilities (PRTFs)

3. Adult Inpatient Hospitals

4. Home Health

5. Therapeutic Group Homes

6. Enhanced Care Clinics (ECCs) for Youth and Adults

7. Intensive In-home Child and Adolescent Psychiatric Services (IICAPS)

One PAR program, Therapeutic Group Homes, was discontinued during the year and one

new PAR program, Intensive In-home Child and Adolescent Psychiatric Services (IICAPS), was

started.

Each of these programs is evaluated below.

Child and Adolescent Inpatient Hospitalization PAR Program

The Child and Adolescent Inpatient Provider Analysis and Reporting (PAR) Program has

been successfully maintained since its implementation in 2007. Regional Network Managers

(RNMs) have been reviewing quarterly data with individual pediatric hospital providers,

discussing system challenges and strengths, identifying best practices, and developing

collaborative strategic plans to improve the quality and access to care for young Medicaid

members since 2008. While many standard measures, such as average length of stay, and

overall philosophies of the PAR program have remained consistent over the years, the program

continues to evolve with the changing needs of the hospital providers, the child and adolescent

population, and the behavioral health system.

During the course of 2015, the RNMs continued to meet with the child and adolescent

hospitals to evaluate and monitor certain standard measures including average length of stay,

discharge delay rates, and readmission rates. Trends observed across the state include higher

acuity level of youth and difficulty connecting to appropriate services in the community after


discharge. Some hospitals cited lengthy waitlists for IICAPs and using EMPS for bridging.

RNMs scheduled additional meetings as necessary to discuss and strategize regarding follow-

up on items identified during individual PAR meetings. For example, a monthly clinical

operations meeting with Beacon and Hartford Hospital was begun in the spring of 2015 to

address unusually high length of stay at Hartford Hospital.

While individual hospital rates vary, the statewide average length of stay has declined

considerably since the inception of the program. In 2014, the ALOS was 11.4 days. In 2015,

the rate decreased again, to 11.09 days, the lowest since the inception of this PAR program.

Despite the average length of stay continuing to decline, the 7-day readmission has stayed

relatively flat, going from 3.63% in 2014 to 3.61% in 2015. The 30-day readmission rate has

increased slightly, from 13.31% in 2014 to 14.52% in 2015.

In addition to regular meetings with individual hospitals, the PAR program also supports

a workgroup comprised of all the pediatric hospital providers. The workgroup meets to

collaboratively share data, discuss best practices, and strategize about challenges and

addressing system changes. The workgroup met once in 2015. The primary subject was the

update to the bypass program. Providers were notified of their updated bypass status and we

explained the new bypass methodology.

A presentation on recent inpatient discharge delay data was given to the pediatric

providers. The data spanned two full years and highlighted the steady increase in delayed

discharges over the first three quarters of 2015. There had been an increase in youth waiting for

Solnit Inpatient compared to the previous year. In fact, at the time of the workgroup, the number

of youth that had been delayed waiting for Solnit inpatient in 2015 had already surpassed the

total youth who had waited for that service in 2014. The average days on delay for youth waiting

for Solnit inpatient, PRTF, and Solnit PRTF were also discussed.

Additionally, hospitals were provided information on recent PRTF updates and

qualification for referrals. A 1-page handout was provided explaining the criteria for PRTF

referrals including the expected length of stay, treatment modalities, family expectations, and

information on the facilities in the state providing this level of care such as bed capacity,

location, and age ranges accepted. A similar update to the new S-FIT program was also given

to providers. Criteria for referrals and the scope of service was discussed with the hospital

providers.

During 2015 the dashboard for this PAR program was moved to Tableau, allowing for

real-time filtering of data to better support discussions in the PAR meetings. This has led to

deeper conversations about issues that the hospitals may be experiencing. For example,

member-level detail, including length of stay, acute days, delay days, and what the child is

waiting, for can be pulled up by merely hovering in the right spot. Similarly, we can look at data

with outliers included or excluded, as appropriate to the conversation. In addition, bypass status


and data measures were added to the dashboard, so that we can look at current status as well

as historical trends.

The Inpatient Child and Adolescent PAR program will continue during CY 2016 with a

continued emphasis on reducing discharge delay, reducing length of stay and better connecting

members to care at discharge from the hospital.

Adult Psychiatric Inpatient PAR Program

The adult inpatient PAR program has continued to operate in a similar manner as the

previous year. Data was provided to the adult inpatient psychiatric unit leadership for acute

care hospitals throughout the state at least twice during the year. The dashboard was used in

most instances to share length of stay and readmission data. Discussions were also held to

determine the greatest challenges for these hospitals, highlighting most often the wait for state

beds and homelessness. Where hospitals complained about difficulty connecting members to

the next level of care, we continued to encourage utilization of the CCT process.

As noted above with respect to the child and adolescent PAR program, in 2015 the

dashboard for the adult inpatient PAR program was moved to Tableau. Because Tableau

allows us to present the data differently and to customize the display according to the concerns

expressed by the hospital, this has led to deeper conversations about issues that the hospitals

may be experiencing. As was done with the pediatric version, bypass status and data

measures were added to the dashboard.

During 2015 the RNMs began to schedule meetings with inpatient detox units. By the

end of the year, initial meetings had been held and data provided to many inpatient detox

providers, and RNMs will build upon this base going into 2016 with the goal of holding semi-

annual meetings. Several hospitals which had a small number of inpatient detoxes were not

interested in having such meetings. Where meetings have been held, the conversations

revealed that discharge planning and connecting to care post-discharge present significant

challenges. Follow up meetings on discharge planning and connecting to care will continue into

2016.

A statewide provider meeting for adult and child and adolescent inpatient providers was

held on November 12, 2015. There were two main presentations. The first concerned the new

version of the bypass program. Providers were notified of their bypass status and we discussed

the new methodology for determining bypass status. The second presentation was about the

newly developed risk scores for members who were at high risk of not connecting to care after

discharge. There appeared to be great interest in this subject. Providers asked many questions

about how the risk scores were determined and how the process would be rolled out. We will

continue to engage with providers about utilizing the risk scores in 2016.


Over the course of the Adult IP PAR program, there has been no significant

improvement in the average length of stay (ALOS). In Quarter 4 2011 the ALOS was 7.9 days.

During 2015 the quarterly ALOS was as follows:

Q1 8.24 days

Q2 7.74 days

Q3 7.87 days

Q4 7.90 days

There has been, and continues to be, significant variability among the hospitals.

Quarter High ALOS Low ALOS

Q1 2015 St Vincent’s 11.05 Midstate 4.68

Q2 2015 Midstate 11.31 Johnson Mem 4.14

Q3 2015 Stamford 10.8 Norwalk 4.2

Q4 2015 Danbury 12.5 Norwalk 4.37

The RNMs, therefore, will continue to work with the hospitals to identify best practices

and regional challenges and barriers. We have started to track adults waiting in inpatient

settings for DMHAS-controlled state beds, as this appears to be a significant barrier to

discharge. We should consider adding this measure to the PAR profile. We also suggest

reporting on the 18-to-26 year old cohort separately from the rest of the adult population to

determine if there are significant differences in utilization.

The Adult Psychiatric Inpatient Hospital PAR program will continue during CY 2016.

Psychiatric Residential Treatment Facilities (PRTF) PAR Program

The Psychiatric Residential Treatment Facility (PRTF) Program began in 2008 in

response to the need for a more efficient referral process to PRTF level of care. Since the

inception of the PRTF program, the average length of stay has decreased by 49% (338 days to

172.1 days.) During 2015 the ALOS for the first 2 quarters was 181.8 days and 172.1 days for

the last 2 quarters. The decrease in ALOS has led to greater availability of PRTF beds and, at

times, an increase in admissions.

PRTF data includes the following measures: number of discharges, average length of

stay, percentage of members in overstay status, percentage of days spent in overstay status,

overstay reasons in real time, discharge level of care, as well as a comparison between the

number of inpatient stays and inpatient days in the six-month periods before and after the PRTF

stay. During 2015, in response to requests for additional data from DCF, we also looked at

overstay cases broken out by DCF status (Non DCF involvement, DCF voluntary and DCF

committed) as well as changes in DCF status while at the PRTF. This information was further


broken out by DCF region. While these changes have not been added to the PRTF PAR profile

per se, they have been programmed in Tableau and can be supplied as a supplement to the

PAR profile.

The 2015 PRTF Program goals and objectives focused on improving care transitions

with increased family engagement and cross-continuum collaboration with providers at other

levels of care. Providers continued to express the need to augment their family engagement

efforts. They also noted the increased acuity of the children referred to them. The Beacon

RNM continues to attend the monthly team planning meetings at each PRTF to gain more

information about systems issues that PRTFs face.

Major themes identified in both the PAR meetings and the monthly team meetings

include increased acuity of the youth, family engagement and strategies for maintaining the

youth in the community after discharge from the PRTF. In addition, providers identified an

increasing concern with families (both biological and foster care) who change their minds about

taking the youth back upon discharge. This has led to increased overstay days.

The RNM met with the TFC contract holder from DCF to discuss increasing

communication and collaboration, including the ability of the foster family to work with the PRTF

prior to the youth’s discharge to increase the likelihood that the youth will remain with the family

and reduce admissions to a higher level of care.

Working with DCF and Clinical, we created and disseminated “one pagers” about the

PRTFs including referral criteria, expected length of stay, and expectations regarding family

work and engagement. One version was created for hospital staff and one version was created

for family members of youth referred to PRTF.

The Psychiatric Residential Treatment Facility PAR program will continue during CY

2016, with the same program goals and objectives, but additional measures requested by DCF

may be added to the profile.

Home Health PAR Program

In 2015 CT BHP continued to support the movement towards recovery for members

receiving Home Health services with the goals of increasing the autonomy and self-sufficiency

by decreasing the unnecessary utilization of medication administration. The themes that had

informed our interactions with providers in 2014 continued in 2015. Those themes were:

Barriers in transition and medication issues

Addressing access issues

Nurse delegation

Participation in Community Care Teams (CCTs)


The focus of the Home Health PAR program, however, shifted in 2015. This was in part due

to the sense that the PAR providers with whom we had traditionally met were now well educated

about the data for the measures that we use to inform them about their performance and the

sense that the data over time was not dramatically different enough to warrant continuous

meetings. To that end, the focus of the Home Health program in mid-2015 shifted to

establishing and implementing a Bypass program. In addition, HHA prompting was approved by

the state in an effort to continue to support providers in providing medication administration.

Home Health Aide (HHA) Prompting was approved by the state and became effective on

October 1, 2015. It was offered as a way of helping to support home health providers deliver

medication administration for qualified Medicaid members without the use of a registered nurse

but rather the use of a home health aide to remind members to take their medication. This was

shared with providers at a meeting for all providers held at CT BHP on September 30, 2015.

In subsequent meetings held with providers eligible for the Bypass, the general

consensus from providers was that HHA would be easier to implement than nurse delegation

and most providers were open to it although were very much in the exploratory phase of figuring

out how to integrate and implement this within their existing framework in the Fall of 2015.

As mentioned above, the Home Health Bypass program and HHA prompting were

introduced at a Home Health Provider workgroup meeting on September 30, 2015.

A modified version of the Home Health PAR program will continue in CY 2016. We will

continue to monitor the PAR performance measures on a quarterly basis and will identify

providers whose performance warrants discussion. For those providers, PAR meetings will be

held to address the changes in the trends reflected in the data. In addition, we will monitor

performance on the Bypass eligibility measures, and will schedule meetings with providers to

discuss their performance on an “as needed” basis. Provider workgroup meetings will continue

to be held as appropriate.

Enhanced Care Clinic (ECC) PAR Program

The Enhanced Care Clinic (ECC) PAR program followed a unique progression when

compared to other CT BHP PAR programs. In the case of the ECCs, providers received

incentive payments prior to demonstrating that they could meet the expectations of their

agreement for the following:

1. Centralized telephonic access to appointments

2. Timely access to care including:

a. Routine appointments offered within 14 days 95% of the time

b. Urgent appointments offered within 48 hours 95% of the time

c. Emergency evaluations within 2 hours of arrival at the ECC 95% of the time


d. Psychiatric evaluations within 2 weeks of evaluation when the need for

psychiatric evaluation was identified

e. Extended clinic hours

3. A signed Memorandum of Understanding (MOU) with PCPs or Pediatricians in their

areas providing consultation and timely access to those providers so that they may in

turn provide psychopharmacologic treatment to HUSKY members within their practices.

4. Screening for co-occurring disorders

ECCs have remained well above the 95% access standard for Routine appointments for the

entire year, with an annual rate of 99.58% for 2015. Urgent evaluations similarly have

maintained above the 95% access standard for the year, with an annual rate of 98.28%. In Q4

’15 ECCs dropped below the 95% standard for Emergent cases, with a rate of 92%. For

quarters 1 through 3, however, they were at 100%, resulting in an annual rate of 98.35%.

It is interesting to note that the volume of ECC registrations in 2015 was the lowest it has been

since 2011. ECC registration climbed from 13,484 in 2011 to 17,548 in 2012, and peaking at

19,041 in 2013. Registration volume fell slightly in 2014 to 18,493, with a more significant

decline to 16,193 in 2015.

As previously reported, surveys of all ECCs were conducted beginning in 2012. Early in

2015, several appeals from ECC providers who had not passed the survey were still

pending. Decisions were made on those appeals and, as a result, the following providers lost

their ECC status in 2015: Catholic Charities – Institute for Hispanic Families, Rushford Center

and McCall Foundation.

Throughout 2015 RNMs continued quarterly contact with ECC providers to provide data

details and assisted providers with developing and implementing corrective action plans as

needed. Quarterly mystery shopper calls continued to be placed, with three ECCs receiving

calls each quarter. Here is a summary of Mystery Shopper activity in 2015:

Q1 2 providers passed; 1 did not, but passed when called in again in Q2.

Q2 All providers passed.

Q3 1 provider passed; 2 did not, but passed when called again in Q4.

Q4 2 providers passed; 1 did not and will be called again in Q1 2016.

Since its inception the ECC program has significantly improved the initial access to

outpatient care for children, adolescents and their families. Maintenance of the program is

believed to be essential to maintaining the gains regarding access, coordination with primary

care and co-occurring competence.

The ECC PAR program will continue in CY 2016.


Therapeutic Group Home PAR Program

Under the auspices of the Performance Improvement Center (PIC), the PAR program for

Therapeutic Group Homes (TGHs) continued during the first quarter of 2015 and for the first

month of the second quarter. During that period the RNMs, along with DCF congregate care

staff, held PAR meetings with the TGH providers, bringing out data from Q3 2014. The data

included the following measures: occupancy rate, length of stay frequency distribution;

provider-specific event rates including suicide attempts, AWOLs, arrests, police calls and

restraints; monthly treatment hours; monthly family visits; emergency department (ED) visits of

youth in care; hospitalizations of youth in care; monthly treatment plan progress report (MTPPR)

completion rate; ED visits within 30 and 90 days of discharge; transfers and readmissions to a

TGH within 30, 90 and 180 days of discharge; and admissions to a higher level of care within

30, 90 and 180 days of discharge. RNMs, in collaboration with DCF staff, also worked with

TGH providers to develop Focused Improvement Plans to address issues identified as needing

improvement.

In the spring of 2015 in his biennial budget, however, Governor Malloy proposed

eliminating funding for the PIC. Shortly thereafter, the decision was made to end the PIC and

redeploy the PIC resources. The TGH PAR program, therefore, was discontinued.

Intensive In-home Child and Adolescent Psychiatric Services (IICAPS) PAR Program

Building upon work done by Beacon Health Options and the Yale Child Study Center in

prior years, in 2015 the CT BHP took a significant step forward by developing and implementing

a Provider Analysis and Reporting (PAR) program for IICAPS providers. In collaboration with

Yale, Beacon created an initial version of the provider profiles and shared it with IICAPS

providers at a statewide meeting of the IICAPS network on March 2, 2015. The concept of a

PAR program was presented to the providers, along with examples of other successful PAR

programs that previously had been implemented. The initial version of the profile contained the

following measures:

7, 14 and 30-Day Connections to Care (CTC);

Psychotropic medication refills at 30 and 45 days post-discharge

Percentage of members that were not hospitalized in the 60 days post-IICAPS

Number of gaps in service lasting 21 days or more during an IICAPS episode of care by

provider

Following the statewide meeting the Beacon Regional Network Managers held regional

break-out sessions to review individual provider performance, identify best practices, barriers to

care and gaps within the service system for each region.

Based upon the information elicited from the IICAPS providers, Beacon and Yale agreed

to make the following changes to the provider profile:


Extend the measure that captures the percentage of youth who do not have an inpatient

admission after IICAPS discharge to 90 and 180 days post discharge

Eliminate the 7-day CTC in favor of the 14-day CTC

Add a CTC rate for connections made 30 days prior to IICAPS discharge

Eliminate the 30-Day Psychotropic Medication Refill measure in favor of the 45-Day

measure

Eliminate the 21-day or greater gaps in service measure

Develop site specific vs. agency specific profiles

Provide 14- and 30-day CTC rates by DCF region

For all measures show rates for completers vs. non-completers

Administer each measure every 6 months vs. quarterly given the small number of

observations for certain programs/sites and in order to improve the practical utility

A new version of the provider profiles incorporating these changes was developed. In

addition, Beacon and Yale agreed to establish thresholds and benchmarks for provider

performance for three selected measures.

The profiles were shared with providers at the next statewide meeting of the IICAPS

network, held on November 30, 2015. The concept of the thresholds and benchmarks was

introduced to providers along with expectations for provider performance. Once again,

following the statewide meeting, regional breakout sessions were held to review the profiles and

discuss developments in the network and identify best practices and barriers to care.

As a result of these conversations, we have developed a set of recommendations

regarding the IICAPS level of care, including facilitating regional connect-to-care meetings,

continuing the IICAPS PAR program for 2016, developing a one-page fact sheet on IICAPS to

share with community providers and pediatricians, publishing a provider bulletin to clarify billing

practices for care coordination for purposes of transition to the next level of care and holding

focus groups with family members to elicit their feedback on their experiences with IICAPS

treatment.

Going forward, the RNMs will hold PAR meetings with IICAPS providers on a semi-

annual basis. They will work with providers to assess progress towards meeting the thresholds

and benchmarks, identifying best practices and challenges on a statewide and regional basis.

RNMs will also hold connect-to-care meetings with IICAPS providers and providers at other

levels of care to facilitate transitions from IICAPS.

The IICAPS PAR program will continue in CY 2016.




Goal 22: Monitor and Improve Quality of ASD Provider Charts



A. Number of charts reviewed based on a statistically significant sampling methodology

During the implementation phase of the new ASD services classes in 2015, a chart

review tool was discussed, created and vetted by CT BHP and State Partners. The chart review

tool was based off of the current Medicaid ASD documentation regulations, National Behavior

Analyst Certification Board documentation guidelines and clinical best practices. Utilizing this

tool, charts reviews were piloted with two ASD providers who received complaints from member

families. The chart review tool will be presented to the ASD Provider Network prior to reviews

beginning at a future date.

B. Number of charts reviewed that need additional clinical information

Of the eleven charts reviewed from the pilot review with one ASD provider, additional

clinical information was required for each member’s file. Further ASD provider chart reviews will

begin at a future date.

C. Number of charts reviewed that resulted in a corrective action plan from provider

One ASD provider participated in a chart review which consisted of eleven total records.

This pilot review did result in a formal corrective action plan toward the end of 2015.

D. Number of charts reviewed that are satisfactory in clinical quality

Not applicable as the chart review tool continues to be finalized with State Partners and

CT BHP. Reviews will take place at a future date.




V. ONGOING QM & UM GOALS TO BE CARRIED FORWARD FROM

THE EVALUATION YEAR-2015

1. Review and approve the 2015 Connecticut Engagement Center QM Program

Evaluation, 2016 QM Program Description, 2016 UM Program Description and 2016

QM/UM Project Plan.

2. Establish and Maintain Connecticut Engagement Center Specific Policies and

Procedures (P&Ps) in Compliance with Contractual Obligations that Govern all Aspects

of Engagement Center's Operations.

3. Establish and Maintain a Training Program for Staff

4. Ensure Utilization/Care Management Department Compliance with Established UM

Standards

5. Monitor Consistency of Application of UM Criteria (IRR) and Adequacy of Documentation

6. Ensure Timely Telephone Access to Connecticut Engagement Center

7. Ensure Timely Response and Resolution of Complaints and Grievances

8. Monitor Performance of Customer Service Staff via Audits of Performance

9. Assess Provider Network Adequacy

10. Health Literacy, Cultural and Linguistic Competency

11. Reduce Emergency Department (ED) Discharge Delays

12. Maintain and Establish Additional Bypass/Outlier Management Programs

13. Monitor for Under- or Over-Utilization of Behavioral Health Services; identify barriers and

opportunities

14. Monitor Timeliness of UM Decisions, Authorization Information being Available to

Providers and Claims Payer; identify barriers and opportunities

15. Monitor Medical Necessity and Administrative Denials; identify barriers and opportunities

16. Monitor Timeliness of Appeal Decisions; identify barriers and opportunities


17. Report and Monitor Medication Adherence for Antidepressant and Antipsychotic

Medications Categories

18. Ensure Consistent Application of Activities to Maintain and/or Improve the Rate of

Ambulatory Follow-Up Services after Inpatient Admissions

19. Promote Patient Safety and Minimize Patient and Organization Risk from Quality of

Care/Service Concerns and Adverse Incidents

20. Monitor Integration of Coordination of Care with Medical, Dental and Transportation ASO

as well as ABH and other Partners; identify barriers and opportunities

21. Maintain the Quality Improvement Activities: Provider Analysis and Reporting Programs

22. Monitor and Improve When Necessary the Quality of ASD Provider Charts


VI. SUMMARY OF APPENDIX

A. Adult Annual Utilization Report 2015 - Tableau B. Adult Annual Utilization Report 2015 – PDF C. Youth Annual Utilization Report 2015 – Tableau D. Youth Annual Utilization Report 2015 - PDF

annual qm and um program evaluation · b e a c o n h e a l t h o p t i o n s – a n n u a l q m...

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