quality improvement plan and program description · quality improvement plan and program...

QUALITY IMPROVEMENT

PLAN AND PROGRAM

DESCRIPTION

J.W. SIMMONS BOARD CHAIR

FY2019

Board of Directors Approved: August 28, 2018

Eastpointe | 1

Table of Contents

Organizational Overview ........................................................................................................................... 4

Organizational Structure ........................................................................................................................... 5

Eastpointe’s Board of Directors................................................................................................................. 5

Quality Management Program Overview ................................................................................................. 6

Continuous Quality Improvement ............................................................................................................. 7

Quality Management Process Model ......................................................................................................... 8

Quality Management Resources ................................................................................................................ 9

Analytics Department ........................................................................................................................... 9

Quality Assurance/ Medicaid Contract Manager .................................................................................. 9

Quality Improvement ............................................................................................................................ 9

Grievance and Appeals Department ................................................................................................... 10

Medical Records/Data Management ................................................................................................... 10

Quality Management Goals/Objectives .................................................................................................. 11

Committee Structure ................................................................................................................................ 15

Executive Team ....................................................................................................................................... 16

Leadership Team ..................................................................................................................................... 16

Global Quality Improvement Committee (GQIC) ................................................................................. 17

Clinical Advisory Committee (CAC) ................................................................................................. 18

Policy and Procedure Committee ........................................................................................................ 18

Quality of Care (QOC) ........................................................................................................................ 18

Outlier Workgroup .............................................................................................................................. 18

Global Quality Improvement Reporting Structure .............................................................................. 19

Departmental Collaboration .................................................................................................................... 20

Clinical Operations Department ............................................................................................................. 20

Medical Director/Senior Clinical Staff ............................................................................................... 20

Member Call Center ............................................................................................................................ 20

Innovations Care Coordination ........................................................................................................... 21

Mental Health/Substance Abuse (MH/SA) ......................................................................................... 21

Transition to Community Living (TCL)/Housing Department ........................................................... 21

Utilization Management (UM) .............................................................................................. 21

Eastpointe | 2

Business Operations .................................................................................................................. 22

Information Technology ........................................................................................................ 22

Financial Services .................................................................................................................. 23

Funding Services ................................................................................................................... 23

Human Resources .................................................................................................................. 23

External Operations .................................................................................................................. 24

Network Management ........................................................................................................... 24

Provider Monitoring .............................................................................................................. 24

Communication ..................................................................................................................... 25

Regulations and Compliance ........................................................................................................ 26

Corporate Compliance Department ............................................................................................ 26

Program Integrity (PI) ........................................................................................................... 26

Training ................................................................................................................................. 26

Facility Management ............................................................................................................. 27

Community Relations ............................................................................................................ 27

Performance/Quality Improvement Projects ........................................................................... 28

PIP/QIP Workflow...................................................................................................................... 30

............................................................................................................................................... 30

It is expected that this document is a “living document” and should be updated and reported as

changes and progress occur

Eastpointe | 3

Crafting a quality culture always comes down to process improvement

Kari Miller (2013

Eastpointe | Organizational Overview 4

Organizational Overview

Our Mission Eastpointe works together with individuals, families, providers, and communities to achieve

valued outcomes in our behavioral healthcare system.

Executive Summary

Eastpointe Local Managed Entity/Managed Care Organization (LME/MCO) provides access to

Medicaid and State Behavioral Health, Substance Use and Intellectual Developmental

disabilities services covering Bladen, Duplin, Edgecombe, Greene, Lenoir, Robeson, Sampson,

Scotland, Wayne and Wilson Counties. Eastpointe LME/MCO is responsible for managing,

coordinating, facilitating and monitoring the provision of services for 173,365 Medicaid funded

and 94,973 state funded individuals in Northeast North Carolina. A nineteen-member board of

directors oversees Eastpointe’s operation.

In January 2013, Eastpointe evolved from a LME to a Managed Care Organization(MCO)

operating under 1915b/c Medicaid Waivers. Since inception, Eastpointe has partnered with

providers and stakeholders to ensure members and families receive the medical, behavioral and

social support they need.

In March 2018, Eastpointe was granted full re-accreditation for (3) three years with URAC in

three modules to include Health Call Center, Health Network and Health Utilization

Management.

Eastpointe LME/MCO has developed and implemented a Quality Management (QM)program

that monitors clinical and administrative functions within the organization to improve all aspects

of service delivery. The program is integral to the organization’s day to day operations and

strives to nurture an internal quality improvement culture.

The Quality Management Program encompasses Eastpointe’s Local Business plan, outlining the

organization’s intent to meet state standard laws and rules for ensuring quality mental health,

developmental disabilities and substance use services and evaluate program effectiveness.

This plan describes the Quality Management framework for developing and improving processes

and is guided by policy and reflects the agency’s mission statement to achieve valued outcomes.

Eastpointe | Organizational Structure 5

Organizational Structure

Eastpointe’s Board of Directors Administrative oversight for Eastpointe LME/MCO is provided by the Board of Directors which

functions as the governing body of all service programs. Current North Carolina General Statute

122C-118.1 requires the Board to have no fewer than eleven (11) and no more than 21 voting

members. In conjunction with Eastpointe LME/MCO, the Board of Directors engages in

comprehensive planning, budgeting, implementing and monitoring of community based Mental

Health, Intellectual Development Disabilities and Substance Use Services (MH/IDD/SU). With

representatives from each of our ten counties in our service area, the board helps ensures that all

members receive the care they deserve.

The Board has five standing committees:

• Executive Committee

• Finance Committee

• Human Rights Committee

• Nominating and Governance Committee

• Board Policy Committee

In addition, The Consumer and Family Advisory Committee (CFAC) advises the area authority

on planning and management of local public mental health, developmental disability and

substance abuse services. The Area Director/Chief Executive Officer(CEO) serves as an

ex-officio member of all Standing Committees. Minutes of the Board meetings are posted on the

Eastpointe website after they are approved by the Board.

Eastpointe | Quality Management Program Overview 6

Quality Management Program Overview

Eastpointe LME/MCO formulates and implements a formal quality improvement program with

clearly defined goals, structure, scope and methodology directed at improving the quality of

healthcare delivered to enrollees/members. (EQRO IV A.1). The purpose of the Quality

Management (QM) Program is to systematically monitor the quality and effectiveness of internal

systems to ensure state, federal and accreditation body standards are executed. The Quality

Management Program aims to continuously improve all aspects of healthcare delivery through

analyzing data, quality reviews to ensure compliance with policies and state standard, follow up

to stakeholder complaints and developing initiatives to measure and improve services provided

by the organization. Specifically, the QM Program includes, but is not limited to the following

responsibilities and monitoring of key performance measures:

• Effectiveness of Care Measures

• Access to Services

• Payment Denials

• Member/Enrollee and Provider Satisfaction

• Use of Services

• Health and Safety

• Complaints

The Quality Management Plan/Program Description (QMPD) outlines objectives, activities and

the process by which the agency monitors and evaluates services, integrates quality improvement

activities throughout the organization and promotes collaboration through inter-departmental

representation on teams and committees. The plan describes how the Quality Management

Program ensures Federal, State and URAC requirements are met to create qualitative outcomes

for the population served. The plan is approved annually by the Board of Directors.

The Annual Evaluation (a written summary and assessment of the effectiveness of the Quality

Management Program) and QM Work Plan (specifies Quality Management activities for the

upcoming year) are reviewed and approved by the Executive Team. The prior year’s program

activities are summarized and incorporated into the QM Program Description and Work Plan.

Progress toward performance/quality improvement goals are evaluated quarterly and reported to

the Global Quality Review Committee.

Eastpointe | Continuous Quality Improvement 7

Continuous Quality Improvement The Center for Medicaid/Medicare (CMS) Quality Framework serves as the foundation of

Eastpointe’s Quality Management program. The functions of the Quality framework are design,

discovery, remediation and continuous improvement are woven across the organization. The goal

of the program is to attain better outcomes and improve quality of services for

members/enrollees.

These four components drive the operation and management of the QM Program and contribute

to its continued success. Design: The QM Program Description, Work plan, policies and procedures illustrate the

structure and process for how the program is designed. Written policies and procedures guide

and detail how all QM functions will be extended throughout the organization.

Discovery- As part of the discovery phase, the QI Department conducts organization wide audits

on Claims, UM Appeals, Complaints and Care Coordination activities. Quarterly audits ensure

policies and procedures are implemented while identifying other deficiencies. Multiple sources

of data from medical record reviews, paid claims, grievances, utilization review and member

satisfaction surveys are analyzed. Analysis of data from these systems provide useful

information on patterns and trends of utilization. This function identifies opportunities for

improvement and potential health care delivery problems. (EQRO IV A.3).

Remediation: The Global Quality Improvement Committee is responsible for setting and

approving benchmarks for quality improvement projects. When discovered, that a benchmark

has not been achieved for two consecutive quarters, a Corrective Action Plan(CAP) is

implemented, the remediation phase begins. Designing and implementing the corrective action

plan begins the Improvement phase of continuous quality improvement.

Continuous Improvement: Eastpointe designated staff or committee implements and evaluate

Quality/Performance Improvement Projects (QIP/PIP) utilizing various data from surveys,

complaints and performance measures leads to continuous improvement.

Eastpointe | Quality Management Process Model 8

Quality Management Process Model The QM Department operates under the philosophy of W. Edwards Deming Plan, Do, Study, Act

(PDSA) Model to continuously improve organizational process. The Global Quality

Improvement Committee and Quality Improvement Project(QIP) Workgroups implements and

evaluates improvement projects utilizing the PDSA model to achieve improvement. The

following diagram illustrates the cycle of the PDSA process to ensure goals are met and

maintained.

Eastpointe’s continuous quality improvement philosophy correlates with the PDSA cycle

in identifying opportunities for existing processes.

• Carry out the plan

•Document any problems encountered and observations

•Gather Data

•Fully analyze data

•Compare data to predictions

•Examine learning

•Set goals

•Predict what will happen

•Plan the cycle(who, where, what and how)

•Decide what data to gather

•What changes need to be made to the next cycle?

•If no changes, roll out improvement.

ACT PLAN

DOSTUDY

Eastpointe | Quality Management Resources 9

Quality Management Resources The Quality Management (QM) Department has an active presence throughout the organization.

Encompassing Analytics, Quality Improvement, Grievance and Appeals and Medical Records

Management, these departments are embedded throughout the organization and ensure quality

principles are executed. The QM Department provides resources necessary to support the day to

day operations of the division. The Chief of Quality Management oversees the division, with

collaboration and guidance from the Medical Director. The Medical Director serves as chair of

the GQIC and is involved in all clinical (PIP/QIP) initiatives.

Analytics Department

The Analytics Department is responsible for designing, operationalizing and maintaining an

operation of the organization. The department is responsible for managing data analytics and is

accountable for oversight to any manner of external reports to ensure cohesive, accurate,

consistent reporting. The department initializes internal analysis, to include, but not limited to

operational scorecards, QIP related outcomes and performance measures. The department is

responsible for supporting the operational reporting needs of: Clinical Operations, External

Operations, Business Operations, Quality Management, Regulatory/Corporate Compliance,

growth and other key functions.

Waiver Contract Manager

The Waiver Contract Manager is accountable for developing, implementing and maintaining

quality throughout the agency to meet state and federal mandates as well as accreditation

standards. This department works across departments to ensure regulatory compliance and the

integrity of policies and procedures are carried out in a timely and consistent manner. This is

evidenced by multiple annual state audits as well as accreditation reviews and renewals. Plans of

Correction, legislative requests and inquiries, and all other reporting requirements are tracked

and submitted to the state by the Waiver Contract Manager. The Waiver Contract Manager

serves as the liaison between the state and the LME/MCO to ensure compliance with the waiver

contract

Quality Improvement

The Quality Improvement unit is linked to all programs/departments through structured

monitoring activities. The Department supports organizational wide goals of continuous

improvement in all services and processes, while ensuring compliance to state and federal laws,

regulatory and accreditation standards. Under the direction of the Director of Quality

Improvement, the department is responsible for coordination and oversight of Quality of Care

Committee, which include follow-up and referral for members/enrollees of Eastpointe.

Eastpointe | Quality Management Resources 10

Grievance and Appeals Department

The Grievance and Appeals Department manages the grievance and appeals processes for

enrollee/members and providers. Eastpointe believes “There is no “wrong door” to file a

complaint. Therefore, all staff are trained in assisting complainants with grievances. The

department responds to complaints and questions from enrollees, providers and stakeholders.

Complaints are resolved within 30 calendar days from receipt. Complainant appeals are reviewed

and resolved by an Ad-Hoc Committee within 28 days from receipt. The department facilitates

enrollee/member involvement and plays an integral role in the Appeals Process for adverse

decisions by Utilization Management. The department assists enrollees/members with filing

appeals when needed. Provider Disputes are reviewed and processed by the Reconsideration

Committee within 60 days.

Medical Records/Data Management

Medical Records/Data Management is responsible for maintaining enrollee medical records, files

and statistics. The Department ensures all medical records are released according to Health

Insurance Portability and Accountability Act (HIPAA) guidelines and compliance with relevant

regulations and standards. Staff are responsible for entering Member Enrollment, Client Update

Requests and Discharge forms. The Department is also responsible for submission of North

Carolina Support Needs Assessment Profile (NC-SNAP) and maintenance of Client Data

Warehouse (CDW). Technical assistance is provided to Network Operations Providers to ensure

clinical records meet requirements of the Records Management and Documentation Manual. The

Department assumes custody of member records when the provider has gone out of business.

Waiver Contract

Management

Grievance&

Appeals

Quality

Assurance

Analytics

Quality Improvement

Medical

Records

Eastpointe | Quality Management Goals/Objectives 11

Quality Management Goals/Objectives The overall objective of the Quality Management Program (QM) is designed to implement state

and federal regulations along national accreditation standards. The following describes how

Eastpointe intends to comply with these standards. The goals and objectives correspond with

work plan and the strategic plan.

Goal# 1. Meet or exceed CMS, DMA, DHHS, defined minimum performance levels on

standardized quality measures both quarterly and annually.

Quality Assurance audits are conducted on a monthly and quarterly basis. QM Review

Specialists review medical records, grievance and appeals, claims data to determine the

organization’s level of performance and/or compliance. The QM Department has implemented

processes for monitoring internal performance in the following areas:

• Member Call Center: Access to Care Standards

• Utilization Management:Review of Appeals and Medical Necessity Denials

• Mental Health Care Coordination: Discharge and Follow up timeframes

• Innovations: Level of Care, service provision

• Transition to Community Living: Follow up visit

• Grievance and Appeals: Timeframes

• Claims Audits: Accuracy and processing

During FY2019, DMA and DMH established new performance measures standards that include

financial penalty known as ‘Super Measures”. The three (3) measures chosen by DMA address

each of the disability groups mental health, developmentally disability and substance use

(MH/DD/SU), while the DMH measures concentrate on MH, SU and TCLI measure. A cross

functional workgroup was established by Analytics to implement strategies to meet these

standards. The group meets monthly.

Goal # 2. Develop and implement Performance/Quality Improvement Projects for FY2019

Performance/Quality Improvement Projects (PIPS/QIPS) are initiated in response to identified

problems, gaps, performance issues, accreditation requirements and or other performance

initiatives. QM Review Specialists are assigned to projects to gather, analyze and process data

related to the projects. Updates on performance/quality improvement initiative are shared with

GQIC and staff quarterly. (EQRO IV.A.7)

Goal #3. Implement methods to detect over and under-utilization of services

Over and under-utilization of services impact services provided to members/enrollees. During

FY 2019, Data Analytics established a workgroup to address over and underutilization patterns

and trends.


Eastpointe’s Utilization Management (UM) Department applies clinical care criteria related to

best practices on current treatment protocols and national standards. The UM Department

analyzes and trends utilization data to identify normal and special cause variations that impact

patterns of utilization and health care delivery. Eastpointe has established ranges for utilization

of services and examines utilization patterns outside the established criteria ranges at an

individual, provider, and at the aggregate system level.

Penetration rates, inpatient recidivism, bed days per 1,000, emergency department (ED) visits

and outpatient utilization is a few key measures analyzed for under and over-utilization and

identification of problem areas.

Data Analytics in collaboration with Mental Health and Substance Abuse (MH/SA) Care

Coordination identify and track high-cost and/or high-risk members/enrollees through inpatient

admission reports. Data Analytics facilitates a work team to review and analyze utilization data

as identified. The QI Department conducts quarterly reviews of MH/SA Care Coordination

internal processes. The audit ensures follow up activities were conducted, use of person

centered/recovery/oriented language and available resources for medication adherence.

Goal # 4. Assess the quality and appropriateness of care furnished to members/enrollees

The QI Department conducts record reviews of Innovations cases to ensure oversight of plan

implementation and service delivery on a quarterly basis. MH/SA Care Coordination audits are

conducted quarterly to ensure coordination for members/enrollees discharged from state facilities

or who have received inpatient admission or facility-based crisis. The department also facilitates

the weekly Quality of Care Committee (QOC) which reviews cases of concerns originating from

various departments throughout the organization.

Innovations Back-up staffing plans are monitored by Provider Monitoring to assess

appropriateness of care furnished to members. A plan of correction is required if the failure to

provide back-up staffing presents a health and safety concern. The QI Department compiles the

aggregate data and summarizes findings for submission to Department of Health and Human

Services(DHHS).

Enrollee progress and experience is also monitored through NC Treatment Outcomes and

Program Performance System (NC-TOPPS). Quality Improvement (QI) Staff work together

with providers to ensure complete and accurate reporting of member/enrollee progress and

outcomes. QI staff conduct daily reviews of the NC-TOPPS System for updates needed. An

email reminder or phone call to providers may occur regarding updates due or out of compliance

issues.

The Transition and the Quality Management Department collaborate to assess the quality of

member’s being referred for housing placement, patterns of service utilizations and measures

from the DHHS Dashboard. Quarterly audits are also conducted to ensure discharged related

measures are followed per Department of Justice (DOJ) settlement guidelines.


Goal #5. Measure Performance of Network Providers

Eastpointe MCO monitors its providers through various methods. These processes measure

service quality and ensure standards of care are followed:

• Health and Safety Reviews

• Review of Level II and III Incident Reports

• Focused/Targeting Monitoring

• Complaint Reviews

• Post Payment Clinical Reviews

Perception of Care Surveys are conducted annually to assess consumer satisfaction and

perceptions of quality and outcome of publicly funded Mental Health(MH) and Substance Use

(SU) services. Results of the survey are reviewed by Data Analytics and shared with CFAC,

Human Rights, GQIC Committee and Provider Network. Previous year’s results are compared,

and an action plan is developed to address systematic issues identified. (EQRO IV.A.4)

Monitoring provider submission of NC TOPPS interviews is one method of monitoring provider

performance. Quality Improvement Department compares paid claims data to NC-TOPPS

submission to ensure interviews are completed according to guidelines. In the event, an interview

has not been completed, QM Staff will contact the provider. During FY2018, almost fifty percent

(50%) of providers are submitting

Goal # 6. Provide Performance Feedback to Providers

Eastpointe believes creating a partnership through open dialogue with providers will improve

outcomes and quality of life for members/enrollees. Performance feedback is shared with

providers through provider meetings, forums and training sessions. Eastpointe disseminates

critical and time sensitive information through communication bulletins and provider listserv.

Annually the Division of Medical Assistance Contracts with a third part to complete satisfaction

surveys. The annual surveys are completed on both adult and child members as well as

providers within the Eastpointe network. Once the results are received, Data Analytics

Department completes a comparison of Eastpointe’s results from the previous year and the

statewide average. The results of those surveys are shared with the Provider Network, Provider

Council, CFAC, GQIC and other Stakeholders as well as posted on the website. An action plan is

developed to address areas of concern. Updates to the plan occurs quarterly. (EQRO IV.A.5&6)

Goal #7. Develop and adopt clinically appropriate practice parameters and protocols

Eastpointe uses established medical necessity criteria, clinical decision support and level of care

tools that serve as the basis for consistent and clinically appropriate service authorization

decisions for all levels of mental health, substance abuse and intellectual/developmental

disability services. The UM and Member Call Center consistently adhere to adopted clinical

practice guidelines.


Eastpointe adopted Clinical Practice Guidelines with national and/or professional standards for

providers to utilize when submitting requests for review. The guidelines are located on

Eastpointe’s website for review.

Consistent medical necessity determinations decisions are accomplished through quarterly inter-

rater reliability studies. Staff responses are measured against the responses of the Medical

Director. Scores below the benchmark indicate a need for retraining and /or increased individual

supervision and monitoring of staff decisions.

Eastpointe maintains a Clinical Advisory Committee (CAC), comprised of Provider Agencies,

Licensed Independent Practitioners (LIP) and Hospitals. This committee ensures practice

guidelines are shared among a consensus of professionals. Practice guidelines are reviewed and

updated annually and/or periodically by the committee and in accordance with changes and

developments in clinical research.

During FY2019, a cross-functional workgroup consisting of External Operations, Regulations

and Compliance, Clinical Operations, Quality Management and Medical Director

was established. The purpose of the group was to create a process and workflow to assess

provider compliance with clinical practice guidelines adopted by Eastpointe LME/MCO.

Annually, two adopted clinical practice guidelines will be reviewed to ensure practitioner

adherence. Recommendations will be made by the Clinical Advisory Committee. Feedback and

technical assistance will be provided as needed to provider agencies. (EQRO IV.A.2)

Goal #8 Evaluation of Access to Care for Members/Enrollees

Eastpointe evaluates the adequacy of the provider community regarding issues such as cultural

and linguistic competency of existing providers, provisions of evidenced based practices and

treatment and availability of community services to address housing and employment issues. The

organization has implemented several processes to ensure that medically necessary services are

delivered in a timely and appropriate manner.

Eastpointe utilizes GEO Access Mapping which determines the location of providers based on

the state guidelines of 30/45 miles from a member’s home to service location. The network

capacity report measures the number and type of active members/enrollees and providers served

by category in the catchment area.

Eastpointe recognizes timely access to care is critical to protect both health and safety and ensure

positive outcomes. Monitoring Call Center and UM metrics is one of the most effective methods

for evaluating member access. These metrics as well as quarterly Access to Care Report (ATC)

are discussed and reviewed on a quarterly basis during GQIC meetings. An active QIP is also in

place to ensure members receive timely access to care. Eastpointe operates a 24-hour member

call center to link individuals to services within the ten-county area through a toll-free crisis line.


Goal #9. Provider Sufficiency

A goal of Provider Network is to ensure adequate appointments available to members/enrollees

to meet the standard. Members are informed of the availability and how to access Crisis Services

in Eastpointe’s area through advertisement, distribution of brochures to the local community,

welcome letters from Eastpointe, enrollee handbook, community collaborative meetings, and

Eastpointe website. Eastpointe providers are held to state standards regarding wait time for

emergent, urgent and routine appointments.

The Needs and Gaps Assessment is conducted annually. The assessment evaluates access to

services offered throughout the network and includes input from consumer, stakeholders, family

and stakeholder regarding needs and gaps in the catchment area. The report also includes

progress identified during last year’s report and strategies to address the gaps.

During FY2018 Network Development Plan addressed following services gaps identified during

the previous year’s assessment. The plan addresses needed capacity in such areas as opioid

usage, community wellness model, transportation opportunities and other noted areas.

Eastpointe | Committee Structure 16

Committee Structure As a part of the Continuous Quality Improvement Process, Eastpointe has established multiple

cross functional and external advisory committees that report to the Global Quality Improvement

Committee (GQIC). All committees maintain meeting minutes of activities and tasks, which are

reviewed and approved quarterly by the GQIC. The committees serve as feedback loop to the

organization and ensure that contractual requirements are met. Committee representation

includes Eastpointe staff, stakeholders and provider network. The organization recognizes that

partnering with members, stakeholders and providers to find solutions will strengthen the service

delivery system.

Executive Team

The Executive Team is responsible for the overall management of the organization. The team is

charged with making informed decisions for the LME/MCO that govern monitoring the

provision of public services and promotes effective and efficient operation of the organization

that complies with state and federal requirements to safeguard the organization,

member/enrollees, Board of Directors and staff. The Executive Team review and approve all

revised procedures as well as internal forms. The team is comprised of Chief Executive Officer

(CEO), Medical Director, Chiefs of Clinical Operations, External Operations, Quality

Management, Regulation and Compliance and Business Operations. The committee meets on a

weekly basis.

Leadership Team

The purpose of the Leadership Team is to facilitate communication surrounding issues that affect

the organization. Membership is comprised of Department Directors and managers of the

LME/MCO. The committee discusses current operations, reviews performance outcomes and

distributes information throughout the organization. The members of this committee are

responsible for implementing and monitoring goals within the organization. The committee

meets at least monthly.

Eastpointe | Global Quality Improvement Committee (GQIC) 17

Global Quality Improvement Committee (GQIC) The Global Quality Improvement Committee (GQIC) identifies and addresses opportunities for

improvement of organizational operations and the local service system. The committee is granted

authority by Eastpointe’s Executive Team. The committee meets at least quarterly with the

purpose of monitoring the organizations and provider performance, analyzing reports and data,

recommending continuous quality improvement projects and evaluating the effectiveness of the

continuous quality projects and interventions. The committee maintains minutes of all GQIC

meetings including committee findings, recommendations, and actions. The GQIC minutes are,

approved by the committee GQIC and posted on the Eastpointe website. The committee is cross

functional, and membership includes management representatives from each area of the

organization, network providers and the CFAC chair. The Board of Directors provides oversight

through review of routine reports from the Executive Team. The GQIC provides staff with

guidance and technical assistance on quality management priorities and projects. The Medical

Director serves as chair of the committee. The committee reports to the Eastpointe Board

concerning quality management activities.

The (GQIC) receives oversight from the Executive Team. This committee interacts with other

committees as a guide for setting goals and objectives for the program. The responsibilities of the

committee are:

• Monitor and document key performance measures that is quantifiable and used to

establish acceptable levels of performance, including a baseline and at least annual re-

measurement

• Approves and selects Quality/Performance Improvement Projects pertinent to the member

population or as required by contract and monitors for progress

• Provide guidance to staff on QM priorities and projects

• Approve Corrective Action Plans (CAP) to improve or correct identified problems or meet

acceptable levels of performance

• Receive and incorporates input from participating providers

• Evaluates the effectiveness of the Quality Management Program at least annually

• Provide structure and oversight of Outliers workgroup, Quality Improvement workgroups,

Policy and Procedure and Clinical Advisory Committees


Clinical Advisory Committee (CAC) The purpose of the Clinical Advisory Committee is to work collaboratively to review evidence-

based practices, identify training needs, evaluate utilization in relation to clinical guidelines and

assist with the development of community standards of care. The committee is chaired by the

MCO Medical Director. The Clinical Advisory Committee is comprised of Licensed Network

providers and Eastpointe clinical staff representing various disciplines and disabilities from

Eastpointe’s network providers and practitioners. The committee reviews and approves all

clinical criteria, scripts and tools annually. The committee meets quarterly.

Policy and Procedure Committee

The purpose of the PPC is to ensure that the organization incorporates state, federal regulatory

rules and Utilization Review Accreditation Commission (URAC) standards within the agency

policies and procedures.

The PPC is a subcommittee of the Global Quality Improvement Committee (GQIC) and is

responsible to ensure that Eastpointe:

1. Maintains and complies with written policies and documented procedures the govern core

business processes of its operations related to the scope of the accrediting body (URAC).

2. Maintains the ability to produce a master list of all such policies and procedures.

3. Reviews written policies and documented procedures no less than annually and revises as

necessary

4. Includes the following on the master list and on all written policies and documented

procedures:

a) Effective dates, review dates, including the date of the most recent revision, and

b) Identification of approval authority

Quality of Care (QOC)

The Quality of Care (QOC) reviews clinical and practice issues that are identified by various

departments throughout the organization. The committee is comprised of Medical Director,

Chief of Clinical Operations, Chief of Quality Management, Directors of Provider Monitoring,

Quality Improvement, Utilization Management, Program Integrity, MH/SA Care Coordination,

Innovation, Transition to Community Living(TCLI) and QM Review Specialists. Referrals are

made to various departments within and outside of the organization. QOC meets weekly or as

needed to discuss cases of concern.

Outlier Workgroup

The Outlier Workgroup reviews measures deemed as outliers or not meeting statewide totals

from the monthly Medicaid report and identify opportunities for improvement. The workgroup

reviews state hospital bed day utilization and high risk/high cost members. The group is cross

functional and meets monthly. Updates on progress are provided during quarterly IMT calls.


Global Quality Improvement Committee

Executive Team

Policy

and

Procedure Committee

Clinical Advisory

Committee

Quality Improvement Workgroups

Outliers Workgroup

Global Quality Improvement Reporting Structure

Eastpointe | Departmental Collaboration 20

Departmental Collaboration

Clinical Operations Department

Clinical Operations provides leadership to the Member Call Center, Utilization Management,

MH/SA Care Coordination, I/DD Care Coordination and Transition to Community Living(TCL).

The Senior Clinical Staff Person/Medical Director provides clinical oversight, leadership in

quality management of clinical issues and clinical consultation.

Medical Director/Senior Clinical Staff

The Medical Director serves as the Senior Clinical staff. who is a board-certified psychiatrist,

Doctor of Osteopathic (D.O) and holds a current, unrestricted clinical license. The Senior

Clinical Staff person provides guidance to the clinical operational aspects of programs and

oversight to the Quality Management Division. The Medical Director chairs the Clinical

Advisory Committee (CAC), is responsible for the oversight of clinical decision-making aspects

of the program and has periodic consultation with practitioners in the field. The Senior Clinical

Staff is also responsible to ensure the organization utilizes qualified clinicians who are

accountable to the organization for decisions affecting participants. If the license is restricted,

Eastpointe ensures job functions of this individual do not violate the restrictions imposed by the

state licensure board. The Senior Clinical Staff person has a postgraduate experience in direct

patient care and possesses the qualifications to perform clinical oversight of Eastpointe services.

The Senior Clinical Staff person participates in the GQIC and all clinical PIP/QIP workgroups.

The Senior Clinical Staff Person is responsible for the oversight of all clinical aspects of

activities performed by delegated entities and ensures that only well-qualified individuals carry

out the delegated functions.

Member Call Center

Eastpointe’s Member Call Center provides one of the core functions of the LME/MCO. Routine

reports such as telephone average speed to answer (ASA), abandonment rate (ABR), blockage

rate and service levels, and call statistics reports are shared with GQIC on a quarterly basis. QI

Department conducts quarterly audits to ensure accountability and adherence to state and URAC

standards and tracks.


Innovations Care Coordination

Care Coordination is an administrative function of the LME/MCO. Intellectual Developmental

Disability (I/DD) Care Coordination is provided for all enrollees in the Innovations Waiver and

to individuals who are on the Innovations Waiver Registry of Unmet Needs. I/DD Care

Coordination are responsible for developing the Individual Service Plan and budgets for

Innovations Waiver enrollees. The QI Department monitors Innovations Slot Tracking Report

monthly, conducts quarterly reviews of internal processes related to services (ISP reviews,

Health and Safety, Innovations Waiver Performance Measure audits) and compiles data for state

required reporting. During FY2018, Analytics Department collaborated with the department to

create a more efficient way of tracking member eligibility via smartsheet.

Mental Health/Substance Abuse (MH/SA)

MH/SA Care Coordination is provided to enrollees identified as high risk, high cost, special

healthcare, or referred by CCNC from Quadrant II (high behavioral needs, low medical needs)

and Quadrant IV (high behavioral, high medical needs). MH/SA Care Coordination monitors

behavioral health hospital admissions and discharges; collaborate and consult with providers and

participate in discharge and ongoing treatment planning as needed to ensure enrollees are

receiving services that meet their needs. Quality Improvement (QI) conducts quarterly reviews to

ensure timely follow-up after discharge from inpatient care, tracks Medicaid and State

community hospitalization and emergency department utilization and high risk/high cost

monthly.

Transition to Community Living (TCL)/Housing Department

The TCL/Housing Department collaborates with other stakeholders to develop and oversee

housing resources available to members. The Department links members/enrollees to appropriate

services and community supports while providing support during and for a period following

transition. The Analytics Department identifies the number of individuals receiving Assertive

Community Treatment (ACT) and Individual Placement Support (IPS-SE) services monthly.

Utilization Management (UM)

Eastpointe UM Department reviews and approves authorization requests on State and Medicaid

funded services. A Quality Review Specialist is assigned to the department to facilitate cross-

agency reporting and analysis of data. Quarterly audits ore conducted on Medical Necessity

Denials and Appeals. Total number of authorizations received, percent processed in 14 days and

number of authorizations requests processed in required time frames are reviewed monthly.

Penetration rates, inpatient admissions and emergency department visits data are analyzed and

discussed during Outliers Workgroup monthly. UM staff refers clinical and practice concerns

identified during review of clinical information to the Quality of Care Committee to ensure

appropriate treatment.


Business Operations

As part of the GQIC, the Financial Operations Department manages the financial resources of

the organization. The department provides oversight of Human Resources, Information

Management Systems and Financial Operations. The Chief of Business Operations leads these

divisions.

Information Technology

The Information Technology (IT) Department is responsible for ensuring that all network and

software systems are maintained. Housed within Business Operations, IT collects, maintains and

analyzes information necessary for organization management that provides for data integrity,

provides a plan for storage maintenance and destruction of data, and provides a plan for

interoperability.

A systems Business Continuity plan is in place that identifies which system to maintain in

outages, how business continuity is maintained given various lengths of time that information

systems are not functioning or accessible, is tested yearly and responds promptly to detected

problems and takes corrective action as needed.

Eastpointe operations and activities are accomplished in a primarily electronic environment.

However, when paper or oral Protected Health Information (PHI) or individually-identifiable

health information (IIHI) is generated, Eastpointe has various mechanisms in place to protect that

information as well.

Report writing is a crucial area for ensuring data integrity and consistency. The IT Department

maintains a Data Manager and Report Writers who develop reports in collaboration with the end

user. The report writers work closely with QM and various other departments to assure

compliance with state guidelines. A Reports Workgroup is held to discuss progress of reports

development which includes various departments from Clinical, External Operations and Quality

Management. All reports are submitted to Data Analytics for second level validation before

forwarded to the end user. A current quality improvement project is in place to address

encounter claims submission.


Financial Services

Financial Operations manages the financial resources of the organization, including claims and

reimbursement. The Finance department oversees the accounts payable, payroll, general ledger

and contracts management. Financial Services is charged with ensuring that all Eastpointe

expenditures are accurately paid in a timely manner.

Funding Services

The reimbursement function of the MCO/LME is one of the most critical and visible elements of

the organization. The essence of the section is the processing of IPRS and Medicaid

reimbursement claims. The department is responsible for processing claims submitted by

providers.

QI Department conducts random audits of 3% of all claims submitted to ensure timely filing,

verify diagnosis and reimbursement rate is processed accurately. The findings are summarized

and shared with Departmental Director and Chief of Business Operations.

Human Resources

The Human Resources Department manages the personnel activities of the organization. The

department is responsible for recruiting and hiring new employees, overseeing employee benefits

and compensation packages. The Department is responsible for maintaining the official, current

organization chart of the LME/MCO.


External Operations

Eastpointe’s External Operations Department is responsible for developing and managing the

provider network. The department is responsible for the following functions: Network

Operations, Provider Monitoring and Contracts. The Chief of External Operations supervises the

division with oversight by the Medical Director. Quality Management and External Operation

collaborate on several projects and committees within the organization including the annual

Needs and Gaps assessment.

Network Management

Network Management develops and oversees the Provider Network of services for adults and

children with Mental Health, Intellectual/Developmental Disabilities, and/or Substance Abuse.

The Department provides necessary information to the Provider Network to ensure rules and

regulations are met. Network Operations encompasses the following responsibilities:

• Assist with the development of managing provider contracts

• Maintain database of Provider Network by service type and specialty and

• Conduct continuous needs assessment to identify gaps in services.

• Recruit provider with demonstrated competencies to meet the service needs of

members and families

• Coordination of needed trainings

In conjunction with QI, the department measures provider network access and availability and

reports the results to the Global Quality Improvement Committee (GQIC). During FY 2018,

Network Operations collaborated with QI Department to develop a Credentialing Audit Tool.

The QI Department will complete documentation reviews of credentialing and re-credentialing

checklist to ensure all required standards of licensure, legal standing and performance are met

prior to submission to Medversant.

Provider Monitoring

Provider Monitoring performs monitoring activities to ensure that required standards of care and

LME/MCO practice guidelines followed by providers. The Department monitors health and

safety of members, rights protections and quality of care. Provider Monitoring is charged with

conducting compliance reviews and audits of medical records, administrative files, physical

environment, and other areas of service including cultural competency reviews. During FY2019,

Provider Monitoring and Quality Management will collaborate to develop a post block grant

audit tool to review internal and external processes.

Back up Staffing incident reports are submitted and reviewed by Provider Monitoring

Department to ensure that any issues that affect the members health and safety are addressed and

appropriate follow up occurs. During FY2018, QI Department assumed the task of compiling the

Innovations incident reporting for failure to provide back-up staffing

Eastpointe | 25

Communication

Communications assists in the review and assessment of communication and marketing

materials, documents, presentations and manages all media contacts. The Communications

Officer serves as chair of the Communications Committee and is responsible for maintaining the

organizations Communication Materials Log. The department in conjunction with the Quality

Department tracks applicable laws and regulations. During FY2018, oversight of the

Communication Committee was transitioned to the Grievance and Appeals Department.

Provider Contracting

Provider Contract develops contracts for in and out of network providers. The department assists

with provider set up in the claim software system as well as set up for member specific and

agency specific rates.

Eastpointe | 26

Regulations and Compliance

The Regulations and Compliance Department is responsible for implementing and monitoring

the organizations compliance as required by federal and state laws, regulations and

administrative procedures. The Chief of Regulations and Compliance supervises the division.

The Regulations/Compliance Department is comprised of the following functions.

Corporate Compliance Department

Corporate Compliance Department oversees the implementation of Eastpointe’s Corporate

Compliance Program whose mission is to prevent financial waste, fraud, abuse and other

wrongdoings within the company. During FY2018, QI Department began monitoring

departmental risk assessment and mitigation efforts. Outcome of monitoring revealed

departments fulfilled all policies and procedures and contractual standards.

Program Integrity (PI)

The Program Integrity Unit ensures compliance, efficiency and accountability of funded services

by detecting and preventing fraud, waste and program abuse. The unit receives complaints from

members, families, other providers, former employees of providers, community stakeholders and

through federal and state referrals. The unit identifies patterns of fraud and abuse through the Fraud

and Abuse Management System (FAMS). The Analytics Department works closely with the

department to collect and capture data for suspected fraud Throughout the year QI Department,

partners with PI to develop and disseminate several targeted surveys to enrollees to detect fraud

and abuse of services.

Training

The Training Department plays an integral role in new employee orientation by ensuring staff

receive appropriate training before assuming assigned roles and responsibilities. The department

collaborates with Departmental Chiefs, Directors and Supervisors to review, update and approve

all trainings to ensure they are current, appropriate and accessible for staff. Housed within, the

Geriatric/Adult Mental Health Specialty Teams (GAST) provides consultation, education,

training and technical assistance to caregivers and community facilities serving geriatric adults.

Additionally, in collaboration with other Eastpointe departments, this unit coordinates needed

training for the provider network.

Eastpointe | 27

Facility Management

Facility Maintenance oversees the physical sites operated by the Eastpointe MCO. This

department is responsible for performing routine building maintenance and overall safety within

the organization. A QI staff serve as liaison to the Safety Committee.

Community Relations

The Community Relations Department has the privilege of being the “Face of Eastpointe. With

a Community Relations Specialists assigned to each of Eastpointe’s ten counties, they are a

visible, active member of their assigned community. Education, Prevention, Awareness and

Outreach describes the focus of the Community Relations Department. Educating community

Stakeholders on how to access services and helping them understand the ever so changing world

of Mental Health is an on-going effort. Decreasing stigma through the utilization of research

based Anti-Stigma campaigns, a monthly educational series in each county and developing

collaborative partnerships including community, members and staff are all efforts of the

Community Relations Department. The Crisis Collaborative in our catchment area was

developed and led by the Community Relations department and is in line with DHHS’s Crisis

Solution Initiative. They also work closely with our internal departments such as Care

Coordination with the Crisis Collaborative in efforts to reduce recidivism rates. The Community

Relations department also shares substance abuse, suicide prevention and advocacy information

regularly in their communities. The annual Behavioral Health Disaster Response Plan is

developed and maintained by the Community Relations Department and we have staff

representation on our local, regional and state disaster related committees.

Eastpointe | Performance/Quality Improvement Projects 28

Performance/Quality Improvement Projects Eastpointe identifies aspects of care and service that indicate areas of concern through

continuous data collection and analysis from multiple sources that focus on clinical and non-

clinical issues. When an area of concern is identified, topics are systematically selected and

prioritized to achieve the greatest practical benefit for enrollees. The Performance/Quality

Improvement Projects (PIP/QIP) selected must achieve demonstrable and sustained improvement

in significant aspects of care and are expected to have a favorable effect on mental health

outcomes and enrollee satisfaction. Additionally, at least one of the selected PIP/QIPS per

program must address enrollee safety for the population served

For URAC accreditation, Eastpointe maintains at least two active PIP/QIPs that address

opportunities for either error reduction or performance improvement in place related to the

services covered by accreditation of Utilization Management, Provider Network, and Call Center

services.

The North Carolina Division of Mental Health, Developmental Disability and Substance Abuse

Services (NC MH/IDD/SAS) and Division of Medicaid (DMA) require a minimum of three

performance improvement projects. During year one of the contract, a minimum of two

performance improvement projects were developed which focus on clinical and non-clinical

areas. During year two of the contract, at least one additional performance improvement project

shall be developed; for a total of three performance improvement projects. The PIP/QIPS

selected to fulfill the state requirements may also fulfill URAC requirements. All projects

separately track Medicaid or State Funded populations. Summaries of these findings will be

reported to the Board of Directors and CFAC.

The GQIC is responsible for the approval of PIP/QIP within the organization. The GQIC reviews

data from various committees, takes appropriate action when deficiencies or opportunities to

improve care and services are identified and makes recommendations accordingly. The GQIC

uses the following criteria to determine and prioritize PIP/QIPs:

• The impact of the project on the member/enrollee, Provider Network,

and/ or LME/MCO

• Safety Concerns for the member/enrollee, provider network and /or the LME

• Ability/Control to make the change required in the QIP

• Possible liability/cost/penalty and risk to the agency

• The resources that are available to assist with the project

Eastpointe | Performance/Quality Improvement Projects 29

Performance/Quality Improvement Project (PIP/QIP) topics will be determined jointly by

Eastpointe and DMA from the list of clinical and non-clinical focus areas listed below:

• Primary, secondary and/or tertiary prevention of acute/chronic mental

illness conditions

• Care of Acute chronic/mental illness conditions

• Recovery/outcome measures

• High-volume High-risk /services

• Continuity and Coordination of care

• Availability, Accessibility, and Cultural Competency of services

• Quality of provider/patient encounters; or

• Appeals and Grievance

• TCL Measures

Eastpointe must be able to sustain any observed improvements for at least one year after the

performance is first achieved. Sustained improvement is documented through the continued

measurement of quality indicators for at least one year after the performance improvement

project is completed.

The QM Department utilizes inter-departmental workgroups and stakeholder participation which

are responsible for the coordination, implementation and on-going monitoring of their Quality

Improvement. These workgroups meet as least quarterly to monitor progress of the project and

ensure consistency with URAC, DHHS and DMA requirements. Benchmarks for each project

are set based upon past performance data, measurable goals currently accepted standards or

available national data. The Medical Director serve on all PIP/QIP workgroups to ensure clinical

expertise and judgment. A Quality Review Specialist is assigned to each workgroup and is

responsible for gathering and analyzing data (along with Departmental Director and the

Analytics team) and meeting schedules. Progress and findings of the projects are reported both

quarterly and annually to the Global Quality Improvement Committee and Eastpointe employees.

The PIP/QIP workgroup is responsible for gathering, documenting, and reporting to the GQIC

all the following factors for each selected Quality Improvement Project: (EQRO IV.A.7)

• Establish a measurable goal

• Design and implement strategies to improve performance

• Establish projected time frames for meeting goal

• Persons responsible for project

• Re-measure level of performance at least annually

• Document changes or improvements relative to the baseline measurement

• Conduct an analysis if the performance goals are not met

Eastpointe | PIP/QIP Workflow 30

PIP/QIP Workflow

Reference: Q-6.18 Quality Management Program and Q-6.19 Performance/Quality Improvement Projects

Benchmark Regained

START

Stakeholder Provider Council CFAC Quality Improvement

Quarterly Audit

Benchmark

met

quarterly

Quarterly

No Yes

Present to Dept. & GQIC

No

QI notifies

Dept. & Chief

Can Singular

Corrective Action

Occur?

Plan

occurred

Yes

Implement Corrective

Action

QIP/PIP

No

Approved

by GQIC Yes No Implement

& Monitor Quarterly

Discovery Phase

Remediation

Phase Improvement

Phase

Eastpointe | PIP/QIP Workflow 31

SITES

Beulaville

514 East Main Street

Beulaville, NC 28518

Rocky Mount

500 Nash Medical Arts Mall

Rocky Mount, NC 27804

Kinston

2901 North Herritage Street, Suite A & C

2902-B N Herritage Street Poole Building

Kinston, NC 28501

Lumberton

450 Country Club Road

Lumberton, NC 28360

quality improvement plan and program description · quality improvement plan and program...

Documents