QUALITY ASSURANCE/QUALITY IMPROVEMENT PROGRAM EVALUATION

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QUALITY ASSURANCE/QUALITY IMPROVEMENT

PROGRAM EVALUATION

SFY: July 1

st

2014-June 30

th

2015

Report Completion Date: August 20, 2015 QIC Approval Date: September 1, 2015 Regulatory References: URAC Core v. 3.0 Standard 20

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EXECUTIVE SUMMARY

Partners Behavioral Health Management (Partners BHM) is dedicated to assuring that the highest quality services are rendered by those providers who receive oversight by Partners BHM. Partners BHM’s mission is as follows:

Our mission is to manage a publicly funded healthcare system which addresses the mental health, substance abuse and intellectual/developmental disabilities needs of citizens in our service area through a comprehensive network of community service providers. Partners BHM ensures access to appropriate and individualized treatment which results in positive outcomes and ensures good stewardship of public funds.

As the Local Management Entity (LME) and Managed Care Organization (MCO), Partners BHM oversees and manages consumer-centered local services for mental illness, intellectual and developmental disabilities and substance abuse. These services include, but may not be limited to, a 24 hour customer services call center, provider network and utilization management services. Partners BHM covers the economically and culturally diverse region of Burke, Catawba, Cleveland, Gaston, Iredell, Lincoln, Surry, and Yadkin counties of North Carolina. The Partners BHM Quality Assurance/Quality Improvement (QA/QI) Program helps to ensure that Partners BHM meets its regulatory and contractual responsibilities through continuous and systematic measurement and improvement of program systems and processes.

The QA/QI program is the vehicle through which Partners BHM analyzes and responds to data collected by its consumer health information system, claims data, operational performance monitoring and other program measurement processes. The objective of the QA/QI program is to systematically use performance information and data to drive improved consumer outcomes, training and support. The functional structure of the program not only guides and supports business decisions but creates a system of continual integrity and readiness for external review agents such as the Department of Health and Human Services (DHHS) Intra-departmental Monitoring Team (IMT), External Quality Review (EQR) Organization, national accrediting bodies and other agents. The clinical operation of the QA/QI program is overseen by the Chief Medical Officer, who is a board certified physician.

The Quality Improvement Committee (QIC), who is granted authority by the Partners BHM Board of Directors, meets no less than quarterly with the purpose of improving services by monitoring processes, implementing interventions, and evaluating the effectiveness of those intervention. It is also for guiding the QA/QI program including the annual review and approval of the QA/QI Plan and Program Description. The committee

membership includes senior clinical staff, management and staff representatives of the organization as well as representatives from the provider network and consumer/family members.

This report presents a summary of QA/QI program activities accomplished during the state fiscal year July 1, 2014 through June 30, 2015.

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Partners BHM Key Accomplishments SFY 2014-2015

 Partners BHM has met its strategic goal of ensuring stability as a managed care organization.

 Partners BHM met the Division of MH/DD/SAS contract Performance standard of 90% of the expected NCTOPPS Update forms are received within the required time frames for three of four quarters (1st Quarter, 3rd_{Quarter, and 4}th_{Quarter) SFY 2014-2015.}

 Partners BHM applied for and received re-certification as a Quality Improvement Organization (QIO)-like entity from the Centers of Medicare and Medicaid Services (CMS). The certification is good for 5 years and will expire January 2020.

 Partners BHM, in partnership with local providers, opened two Integrated Health Center (IHC) hubs during SFY 2014-2015, which provide consumers with access to same day services within 30 minutes or 30 miles of where they reside. Work is underway to open additional hubs in Iredell and Cleveland counties during SFY 2015-2016.

 Partners BHM achieved its strategic goal of increasing enrollee education contacts, with a total of 7807 contacts for the entire organization as of June 2015.

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ACCESS TO SERVICES

POPULATION CHARACTERISTICS

PERSONS SERVED

Medicaid 2013-2014 2014-2015

Unduplicated Count of Medicaid Members 132,256 149,106

% Members Receiving MH Services 6.2% 6.1%

% Receiving SA Services 1.1% 1.1%

% Members Receiving DD Services 1.6% 1.5%

*Data from MCO Monthly Report SFY 2014-2015

Uninsured (State/Block Grant Funding)

2013-2014

2014-2015

Estimated Number of Uninsured in Catchment Area 121,228 120,782

% Uninsured Receiving MH Services 2.2% 1.5%

% Uninsured Receiving SA Services 0.7% 0.7%

% Uninsured Receiving DD Services 0.6% 0.5%

*Data from MCO Monthly Report SFY 2014-2015

ACCESS TO CARE

Partners Behavioral Health Management (Partners BHM) has responsibilities in offering consumers 24/7/365 access to services. Partners BHM serves the residents of eight counties in North Carolina who need behavioral health services; during non-business hours, including weekends and holidays. Customer Services serves residents of other counties throughout North Carolina as defined in contractual relationships with other N.C. Local Management Entities. Partners BHM fulfills these responsibilities with a call-center operation. The Call-Center fields various calls and performs screening, triage and referral. Partners BHM Call-Call-Center does not perform health education, except in the context of screening, triage and referral when personnel are assisting the consumer with provider choice

Partners BHM strives to provide timely access to routine, urgent and emergent behavioral health care for its consumers. URAC Health Call Center guidelines and the Division of Health and Human Services (DHHS) contracts provide specific requirements for ensuring that timely appointments are provided to consumers.

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Emergent

Goal: 95% of Emergent calls are scheduled to be seen by a provider within two [2] hours (URAC Standard:

HCC 16)

*Data from Quarterly URAC Performance Dashboard SFY 2014-2015 Results & Analysis:



Partners BHM met the benchmark of 95% of Emergent calls are scheduled to be seen by a provider within two [2] hours for all four quarters of SFY 2014-2015.



The 100% scores for all quarters is an improvement from SFY 2013-2014 when Partners was below the benchmark for 1st_{and 2}nd_quarter.

Strategies for SFY 2015-2016:



Will continue to meet or exceed the 95% benchmark.

Urgent

Goal: 85% of Urgent calls are scheduled to be seen by a provider within 48 hours (URAC Standard: HCC

16)

*Data from Quarterly URAC Performance Dashboard SFY: 2014-2015 Results & Analysis:



Partners BHM met the benchmark 85% of Urgent calls are schedule to be seen by a provider within 48 hours for all quarters of SFY 2014-2015.



Although the overall compliance score did decrease slightly each quarter of the fiscal year, it still remained at or slightly above the benchmark.



100% 100% 100% 100%

90% 95% 100% 105%

1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun)

Emergent Calls Scheduled Within 2 Hours

Benchmark: 95%

% Calls Scheduled Benchmark

89.00% 86.15% _85.44% 85.30% 80.00% 85.00% 90.00%

Urgent Calls Scheduled Within 48 hours

Benchmark: 85%

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Routine

Goal: 85% of Routine calls are scheduled to be seen by a provider within fourteen [14] calendar days (URAC Standard: HCC 16)

* Data from Quarterly URAC Performance Dashboard SFY: 2014-2015 Results & Analysis:



Partners BHM exceeded the benchmark of 85% of Routine calls are scheduled to be seen by a provider within 14 days for all quarters of SFY 2014-2015.



The benchmark for Routine calls was also exceeded for all quarters of SFY: 2013-2014. Strategies for SFY 2015-2016:



TELEPHONE ACCESSIBILITY

Partners BHM has set specific objectives, based on URAC standards and contractual requirements, for telephone performance indicators and therefore measures actual performance against those objectives in real-time and on at least a monthly basis.

Partners BHM utilizes a sophisticated telephone system [ShoreTel] that includes call management reporting. Call management reporting is able to track and record individual and aggregate telephone data. Call

management reporting also provides Partners BHM staff with a variety of reports and historical data as well as providing the Customer Services Director with the ability to view “real time” departmental call activity on his/her PC desktop.

Abandonment Rate

Abandonment Rate (AR) is the percentage of calls offered to the automatic call distribution (ACD) system,

that are terminated by the caller prior to being answered by a live staff person. The abandonment rate is calculated separately for the Customer Services (CS) Call Center and Utilization Management (UM) department.

Goal: Customer Services and Utilization Management will maintain an abandonment rate of 5% or less. (URAC Standard: HCC 11c) 99.00% 99.39% 99.05% 99.60% 75.00% 80.00% 85.00% 90.00% 95.00% 100.00% 105.00%

Routine Calls Scheduled Within 14 Calendar Days

Benchmark: 85%

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*Data from Quarterly URAC Performance Dashboard SFY 2014-2015



Partners BHM has met the goal of maintaining abandonment rate of 5% or less for the Customer Services and Utilization Management call queues for SFY 2014-2015.



Will continue to maintain an abandonment rate of 5% or less.

Average Speed to Answer

Average Speed to Answer (ASA) is the average delay in minutes and seconds that inbound telephone calls

encounter waiting in the telephone queue before being answered by a live staff person. The average speed to answer is calculated separately for the Customer Services Call Center and Utilization Management department.

Goal: Customer Services and Utilization Management will maintain an average speed to answer of 30 seconds or less. (URAC Standard: HCC 11b)

0.0013% 0.0035% 0.0061% 0.0006% 0% 1% 2% 3% 4% 5% 6%

1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Mar)

Call Abandonment Rate- Customer Services

Benchmark: 5% or Less Benchmark % AR 0% 1% 0% 0% 0% 1% 2% 3% 4% 5% 6%

Call Abandonment Rate- Utilization Management

Benchmark: 5% or Less

% AR Benchmark

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*Data from Quarterly URAC Performance Dashboard SFY: 2014-2015



Partners BHM has met the goal of an average speed to answer of 30 seconds or less for both the Customer Services and Utilization Management call queues for SFY 2014-2015



Will continue to maintain an average speed to answer of 30 seconds or less.

Blockage Rate

Blockage Rate (BR) is the number of times a consumer calling into the Call Center experiences a busy

signal.

Goal: The Customer Services Call Center will maintain a blockage rate of 5% or less. (URAC Standard: HCC

11a)

*Data from Quarterly URAC Performance Dashboard SFY: 2014-2015

8 8 7.6 8

0 20 40

Se

co

nd

s

Average Speed To Answer- Customer Services

Benchmark: 30 Seconds or Less

ASA Benchmark 14 13 14 14 0 10 20 30 40

Se

co

nd

s

Average Speed To Answer- Utilization Management

Benchmark: 30 Seconds or Less

ASA Benchmark

0% 0% 0% 0%

0% 5% 10%

Blockage Rate

Benchmark: 5%

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Results & Analysis:



Partners BHM has met the goal of maintaining a blockage rate of 5% or less for SFY 2014-2015. Strategies for SFY 2015-2016:



Goal for 2015-2016 will be to maintain a blockage rate of 0%

Answering Service Factor

Answering Service Factor (ASF) is the percentage of calls offered to the automatic call distribution (ACD)

system that are answered by the Call Center.

Goal: The Customer Services Call Center will maintain an answering service factor of 95% or above. (DMH

Requirement)

*Data from Monthly Phone Performance Report (presented to QIC)



Partners BHM has met the goal of maintaining an answering service factor of 95% or above for SFY 2014-2015.



Will continue to maintain an answering service factor of 95% or above for SFY 2015-2016.

Telephone Service Factor

Telephone Service Factor (TSF) is the percentage of all calls answered by the Call Center that were

answered in 30 seconds or less.

Goal: The Customer Services Call Center will maintain a telephone service factor of 95% or above. (DMH

Requirement) 97% 98% 98% 97% 93% 94% 95% 96% 97% 98% 99%

Answering Service Factor

Benchmark: 95%

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*Data from Monthly Phone Performance Report (Presented to QIC) Results & Analysis:



Partners BHM met the goal of maintaining a telephone service factor of 95% or above for three of fourth quarters for SFY 2014-2015.



The telephone service factor was below 95% for the first quarter but was maintained at 97% for the rest of the fiscal year.



Will continue to maintain a telephone service factor of 95% or above for 2015-2016.

Live Call Response

All calls to the Call Center are to be answered “live” by a Customer Services Call Center staff person. The telephone call distribution system is designed to search for an available Call Center employee. In the unlikely event that there is no Call Center employee available to answer the call, the call will “roll over” to Customer Services support staff, Customer Services Supervisors or the Customer Services Director. The Customer Services Director and Supervisors monitor calls to ensure that the performance expectations of all calls answered live are met.

Goal: The Customer Services Call Center will maintain a live call response of 100% (URAC Standard: HCC

13a)

*Data from Monthly Phone Performance Report (presented to QIC)



Partners BHM has met the goal of maintaining a live call response of 100% for SFY 2014-2015. 91% 97% 97% _97% 85% 90% 95% 100%

1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar 4th Qtr (Apr-Jun)

Telephone Service Factor

Benchmark: 95% TSF Benchmark 100% 100% 100% 0% 50% 100% 150%

SFY 12-13 SFY 13-14 SFY 14-15

Live Call Responce for SFY 2014-2015

Benchmark: 100%

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

Will continue to maintain goal of a 100% live call response for 2015-2016



During SFY 2014-2015 Partners BHM entered into a delegation agreement with Smoky Mountain LME/MCO and CenterPoint Human Services to take any “over-flow” calls to ensure all calls are answered by a live person.

Clinical Staff Response Requirement

Goal: In the event the Call Center voicemail system is utilized, Customer Services staff are required to return the call within thirty [30] minutes of being received. (URAC Standard: HCC 13c)



The telephone system for the Call Center is designed for calls to “roll over” to the next available clinician in the queue if the initial clinician is on another call so no caller has to utilize the voicemail system.



Will continue to ensure voicemail will not be utilized for the call center

SERVICE AVAILABILITY

Partners BHM has developed and maintains a network of providers to serve citizens of Burke, Catawba,

Cleveland, Gaston, Iredell, Lincoln, Surry and Yadkin counties in North Carolina. The types of healthcare services offered within the Partners BHM network include those specialty services designed for the treatment of

individuals with mental health, developmental disability, and/or substance abuse services. The specific array of services offered within the provider network is set forth by the DHHS through the Division of Mental Health, Development Disability and Substance Abuse Services (DMH/DD/SAS) and the Division of Medical Assistance (DMA).

Partners BHM network consists of enough providers sufficient to provide adequate access to cover community capacity. This is assured by monitoring the availability of service providers, existence of waiting lists, availability of resources and overall need determined in part by the Partners BHM Gap Analysis/Community Needs

Assessment as well as intra-department communication.

0 0 0 0 0 5 10 15 20 25 30 35

M

inu

te

s

Call Center Voicemails Return in 30 Minutes or Less

Benchmark: 30 Minutes

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NETWORK COMPOSITION

Network Providers by Organization Type- SFY 2014=15

Type Totals

Agency/Integrated Care 5

Agencies 305

Hospitals 49

Licensed Independent Practitioners (LIP) and Professional Practice Groups 170

Facilities 10

*Data from Provider Information Report found on SQL Report Manager

CREDENTIALING AND RE-CREDENTIALING

Partners Behavioral Health Management (Partners BHM) is required to credential and re-credential all Applicants for participation in the closed Provider Network of Partners, including but not limited to Licensed Practitioners, Licensed Independent Practitioners, Agencies (including Group Practices and Licensed Facilities such as Psychiatric Residential Treatment Facilities) and Hospitals and/or Health Systems.

Primary source verification for Partners BHM is currently delegated to Smoky Mountain LME/MCO as part of the Western Regional Partnership between Partners, Smoky Mountain and CenterPoint, which was created to promote standardization in the credentialing process within the western region of North Carolina. The Delegate is responsible for processing all applications submitted by Applicants seeking to participate in Partners BHM’s Provider Network. The Delegate conducts the pre-screens, criminal records check, and all Primary Source Verifications on each Provider application prior to sending it back to Partners BHM for Credentialing Committee review and approval.

Credentialing Status for SFY 2014-2015

Initial Credentialing Re-credentialing

Agency 13 42

Licensed Independent Practitioner 514 123

*Data from Monthly Health Care Network Report (Presented to QIC) Goals:



Written notification of credentialing decision is sent within 10 business days of the credentialing determination 95% of the time. (URAC Standard: HNM-CR 13)



The delegated entity will maintain compliance with the standards outlined in the delegation agreement as evidenced by 95% or greater score for the delegation oversight audits completed by Partners BHM.

(Credentialing Delegation Contract Standard) The contractual standards include:

1. All initial or re-credentialing files shall have PSV completed within 30 days from receipt of a clean application, excluding delays caused by non-responsiveness from the primary sources and

any other factors clearly outside of Delegate’s control. 2. All applications must be presented to the applicable LME/MCO Credentialing Committee within

180 days of signed application attestation date, including any re-attestation permitted by URAC. 3. All applications must show that the following information was verified and/or current prior to

date of presentation to the LME/MCO Credentialing Committee, as applicable to the Provider type:

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a. Accreditation, b. License, c. DEA certificate, d. Board certification,

e. Criminal background check, f. OIG check, and

g. Healthcare Personnel Registry check.

Performance Results for Credentialing Program SFY 2014-2015

1st_Qtr. (Jul-Sep) 2nd _Qtr. (Oct-Dec) 3rd_Qtr. (Jan-Mar) 4th_Qtr. (Apr-Jun)

% of Written Notifications within 10 Business Days (Benchmark: 95%)

100% 100% 100% 98%

% Compliance of Delegated CVO Files with Delegation Agreement Standards (Benchmark: 95%)

93% 93% 98% 98%

*Data from Quarterly URAC Performance Dashboard Report SFY 2014-2015 Results & Analysis:



Partners BHM met the goal of having written credentialing notifications sent to the provider within 10 of the credentialing decision 95% of the time.



The delegated entity maintained compliance with the standards outlined in the delegation agreement as evidenced by 95% or greater score for the delegation oversight audits completed by Partners BHM for two of four quarters for SFY 2014-2015.



The quarters below the benchmark are when Medversant was still the delegated entity for primary source verification

Corrective Action Implemented:



Due to failing to meet the benchmark Medversant was required to credit Partners BHM three percent [3%] of the total monthly invoice fees in accordance to the delegation agreement.



Beginning 11/1/14 Partners BHM implemented a delegation agreement with Smoky Mountain LME/MCO to provide review of credentialing application review and primary source verification. Strategies for SFY 2015-2016:



Will ensure the delegated entity will maintain an audit score of 95% for all four quarters of 2015-2016.

NETWORK AVAILABILITY

Geo ACCESS Mapping

Partners BHM annually evaluates the location of Providers and types of services in its capacity study, and determines the need for additional Providers. A Provider mapping program is maintained which allows Partners to associate location of Providers in relation to where individuals live within the catchment area.

Goals:



Partners BHM will ensure there are inpatient providers within a 60 mile radius for 95% of Partners’ consumers. (URAC Standard HNM 1b)

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

Partners BHM will ensure there are outpatient providers within a 30 mile radius for 90% of Partners’ consumers. (URAC Standard HNM 1b)



Partners BHM met the benchmark of having inpatient providers within a 60 mile radius for 95% of Partners consumers



Partners BHM met the benchmark of having outpatient providers within a 30 mile radius for 90% of Partners consumers



Will continue to ensure there are an adequate number of providers in the network.

Needs Assessment Study

The Provider Capacity, Community Needs Assessment and Gaps Analysis 2015 was conducted by Total

Care Solutions LLC. It addresses the requirements of the North Carolina Department of Health and Human Services and builds upon the 2014 Needs Assessment and Gaps Analysis also conducted by Total Care Solution.

Progress in Addressing Priorities from 2014 Needs Assessment & Gaps Analysis



Partners BHM currently has two hubs operating in the catchment area. The Lincoln Wellness Center at McBee Street, the Hub in Lincoln County, is operating and is a collaboration between Alexander Youth Network, Monarch, Phoenix Counseling, and Support, Inc. The Hub in Burke County, called Burke Integrated Health, opened in May 2015 and features the integration of primary and behavioral healthcare. Burke Integrated Health is a result of the expanded services of A Caring Alternative, Burke Primary Care, Catawba Valley Behavioral Healthcare and The Cognitive Connection. Development efforts are underway in the remaining counties.



Partners BHM has worked to improve community re-entry for high need individuals being

discharged from adult care homes and state facilities. As of February 2015, 336 individuals in adult care homes are receiving In–Reach placement and coordination services. Additionally 150 people have been diverted from adult care homes. People in state hospitals are receiving In-Reach services, and three are currently in process. Twenty-four individuals are in supported housing and 36 individuals are in the transition process through the Transitions to Community Living (TCL) Initiative. Fifteen individuals are currently receiving care coordination after their transition to supported housing.



Partners BHM conducted a rate study in 2014 and developed rate setting models for several Medicaid and state funded services. As a result of the rate study, most service rates were increased. Along with the recently established provider performance measures that will go into effect July 1, 2015, we believe this will support providers to be more competitive in attracting qualified, professional staff, and will improve service outcomes.



Partners BHM has also streamlined the provider application and credentialing process, cleaned up and improved data that both providers and consumers can access, issued Request for Proposals (RFPs) for B3 services in the areas of peer support and respite and expanded B3 services for

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community guide, supported employment, individual support, and one time transition. Partners worked with providers to assess barriers and also developed mechanisms to improve access to Multi Systemic Treatment (MST) for consumers through the Utilization Management process and are assessing an alternative payment mechanism to continue expansion of this service through the eight country area.

Recommendations Continued from 2014 Needs Assessment

While most of the other recommendations from last year’s analysis have been actively addressed, the following recommendations will continue to receive attention and focus by Partners BHM in 2015:



Improve transportation options



Increase housing options



Facilitate more support groups for key constituencies



Case Management



Develop Provider Networks



Improve service integration with acute/primary care



Improve recovery-oriented systems of care for persons with substance abuse Newly Identified Needs/Gaps in 2015



Stigma and Drop-in Centers: While consumers who responded to the consumer survey were the most satisfied stakeholder group with current services, they did indicate a sense of embarrassment and stigma as the recipient of behavioral health services. They also identified a desire to have a safe place to go and “hang out” with peers who understand their situation and can provide support in a non-judgmental fashion.



Child and Adolescent Continuum of Care: Input from the provider focus group and an analysis of service utilization data indicate a need to strengthen the continuum for children and adolescents. The outpatient services make up 70% of the Medicaid services for children. Additional data indicates important evidence based practices such as Medicaid funded Multi-Systemic Therapy is potentially underutilized as evidenced by only .03% of children and .79% for adolescents receiving these services.



Supported Employment: An important barrier to services emphasized by community

members/stakeholders, family members/caregivers, and consumers is lack of employment. This is a difficult barrier to resolve due to the poverty issues identified in the demographic section of this report suggesting jobs may be difficult to obtain in many of the Partners BHM catchment counties. One of the associated barriers indicated in the survey was lack of insurance and inability to pay for medications and services likely due to lack of employment.

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CUSTOMER SATISFACTION

GRIEVANCE MANAGEMENT

Partners BHM provides and encourages any person or organization the right and ability to bring any complaint or grievance to the attention of Partners BHM in compliance with accreditation requirements; federal and state laws and regulations; state contracts; and any other controlling authorities. Grievances and complaints are accepted by all staff, in all forms and formats, including oral, written, and anonymous. Grievances will be processed formally or informally as appropriate. Partners BHM will comply with all regulatory expectations regarding timeframes for investigation, resolution and notification. Through appropriate committees and staffing, Partners BHM routinely tracks and analyzes complaint/grievance information to improve quality of care and service delivery

GRIEVANCE CATEGORIES



Abuse, Neglect and Exploitation: Any allegation regarding the abuse, neglect and/or exploitation of a child or adult as defined in APSM 95-2 (Client Rights Rules in Community Mental Health). Any suspicion must be immediately reported to the local Department of Social Services and reported into IRIS (as applicable).



Access to Services: Any complaint where an individual is reporting that he/she has had difficulty or not been able to obtain services



Administrative Issues: Any complaint regarding a Provider’s managerial or organizational issues, deadlines, payroll, staffing, facilities, etc.



Authorization/Payment Issues/Billing: Any complaint regarding the payment/financial arrangement, insurance, and/or billing practices regarding providers.



Basic Needs: Any complaint regarding the ability to obtain food, shelter, support, SSI, medication, transportation, etc.



Client Rights Issue: Any allegation regarding the violation of the rights of any consumer of mental health/developmental disabilities/substance abuse services. Clients Rights include the rights and privileges as defined in APSM 95-2 (Client Rights Rules in Community Mental Health)



Confidentiality/ HIPAA: Any breach of a consumer’s confidentiality and/or HIPAA regulations.



LME/MCO Functions: Any complaint regarding LME functions such as Governance/ Administration, Care Coordination, Utilization Management, Customer Services, etc.



Provider Choice: Any Complaint that a consumer or legally responsible person was not given information regarding available service providers.



Quality of Care: Any complaint regarding inappropriate and/or inadequate provision of services, customer services and services including medication issues regarding the administration or prescribing of medication, including the wrong time, side effects, overmedication, refills, etc.



Service Coordination Between Providers: Any complaint regarding the ability of providers to coordinate services in the best interest of the consumer.



Other: Indicates a complaint that has no designated category in Alpha system (i.e. disagreements with changes regarding Relative As Direct Support Employee (RADSE), changes in Innovations services, reduction in service hours

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SUMMARY OF GRIEVANCES

*Data from DMH/DD/SAS Quarterly Complaints Report SFY 2014-2015

Primary Nature of Complaint SFY 2014-2015

Abuse, Neglect, Exploitation 3 6 11 2

Access to Services (difficulty or inability to obtain services) 9 11 14 12

Administrative Issues by Provider 2 4 1 0

Basic Needs 0 0 3 2

Authorization/Payment/Billing (provider only) 1 4 4 4

Confidentiality/HIPAA 0 1 1 0

Consumer Rights 5 4 2 5

LME/MCO Functions 12 11 3 2

Provider Choice 1 0 0 1

Quality of Care by Providers 27 51 18 40

Service Coordination Between Providers 3 2 3 1

Other 1 0 2 7

*Data from DM/DD/SAS Quarterly Complaints Report SFY 2014-2015 Results & Analysis:



A total of 292 grievances were received during SFY 2014-2015.



The highest number of grievances occurred during the 2nd_{quarter with a total of 94 grievances.}



92% of the grievances received were made by or on behalf of a consumer.



Of the 292 grievances, 7.4% were categorized as abuse, neglect, or exploitation.



Of the 292 grievances, 45.9% were categorized as quality of care.

SUMMARY OF ACTIONS TAKEN

Grievance Investigation Data for SFY: 2014-2015

Grievances that resulted in an investigation 10 13 16 7

Grievances that did not result in an investigation 54 81 46 69 *Data from DM/DD/SAS Quarterly Complaints Report SFY 2014-2015

64 94 62 76 57 90 58 66 7 ₄ ₄ 10 0 20 40 60 80 100

1st Qtr (Jul-Sep) 2nd Qtr (Oct-Dec) 3rd Qtr (Jan-Mar) 4th Qtr (Apr-Jun) Total Grievances for SFY 2014-2015

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1st_Qtr. (Jul-Sep) 2nd _Qtr. (Oct-Dec) 3rd_Qtr. (Jan-Mar) 4th_Qtr. (Apr-Jun) Substantiated 1 1 2 0 Not Substantiated 3 4 3 0 Partially Substantiated 0 2 2 1

Not Resolved At Time of Quarterly Report 6 6 9 6

*Data from DM/DD/SAS Quarterly Complaints Report SFY 2014-2015

**Please note that a grievance not being resolved at the time of the quarterly report does not mean it was not resolved within the 30 day time frame. It is feasible that a grievance received during the latter half of the last month of a quarter may have a resolution date that falls within the next quarter.

Resolution for Grievances Not Requiring Investigation

Resolved by Working with Provider 29 51 18 26

Referral to Community Resource and/or Advocacy Group 0 0 0 0

Provided Information or Technical Assistance to Complainant 25 30 28 37

Referral to External Licensing or State Agency 0 0 0 4

Pending At Time of Quarterly Report 0 0 0 2

*Data from DM/DD/SAS Quarterly Complaints Report SFY 2014-2015

**Please note that a grievance not being resolved at the time of the quarterly report does not mean it was not resolved within the 30 day time frame. It is feasible that a grievance received during the latter half of the last month of a quarter may have a resolution date that falls within the next quarter Results & Analysis:



Of the 292 grievances received 46 (15.5%) resulted in an investigation.



Of the 46 grievance investigations 4 (8.7%) were substantiated.



Five of the 46 investigations (11%) resulted in recommendations to the provider.



Four of the 46 investigations (8.7%) resulted in the provider submitting a plan of correction.



Of the 250 non-investigations 49.6% were resolved by Partners BHM working with the provider.



Of the 250 non-investigations 48% were resolved by Partners BHM by providing information and or

technical assistance to the complainant.

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GRIEVANCE RESOLUTION TIME FRAMES

Goal: At least 90% of all grievances are resolved within 30 calendar days of receipt. (URAC Standard: Core 35d)

*Data from Quarterly URAC Performance Dashboard Report SFY 2014-2015 Results & Analysis:



Partners BHM exceeded the goal of resolving at least 90% of all grievances within 30 calendar days for all quarter of SFY 2014-2015.



Will continue to ensure that all grievances are resolved within 30 days.

PROVIDER DISPUTES

In order to respect providers’ rights while simultaneously protecting consumers, Partners Behavioral Health Management (Partners BHM) maintains a formal process consistent with its written agreements to address alleged violations of the agreement by participating providers. This “Dispute Resolution Process” is available to any participating provider who wishes to initiate it. However, only certain types of disputes are subject to the process. The types of disputes that are subject to the dispute resolution process are those:



Clinical Disputes: Involving professional competence or conduct issues.



Administrative Disputes: Involving administrative issues.

Provider Disputes for SFY 2014-2015

Clinical Disputes Administrative Disputes

# received for SFY 2014-15 7 25

# Disputes Resolved 7 25

# Unresolved 0 0

# In Process 0 0

*Data from Provider Network

100% 100% 100% 100% 85% 90% 95% 100% 105%

1st Quarter (Jul-Sep) 2nd Quarter (Oct-Dec) 3rd Quarter (Jan-Mar) 4th Quarter (Apr-Jun)

Grievances Resolved within 30 Day Time Frame

Benchmark: 90%

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Goal: Provider disputes are resolved within 30 days of the provider’s initiation of the dispute. (URAC Standard:

HNM 14e)

*Data from Monthly Health Care Network Report (Presented to QIC)



Partners BHM did not meet the time frame benchmark for provider dispute resolution in the month of May 2015.



Based on the information provided by Provider Network the main issue appears to be timely delivery of the dispute resolution request to the designated staff responsible for provider disputes.

Corrective Action Implemented:



Providers are now directed to email provider dispute resolution requests to the provider disputes email distribution list.



Provider Network has put measures in place to monitor the designated email address to ensure the 30 day time frame is met.

SATISFACTION SURVEYS

COMMUNITY RELATIONSHIP SURVEY

On October 27th_{, 2014 Partners BHM sent out the Community Relationship Survey to our partner agencies and} community stakeholders. This survey was designed to provide information on the level of satisfaction our partners and stakeholders have with Partners BHM and its role in the community. The survey was closed on November 10th_{, 2014. A total of 330 partners/stakeholders responded to this survey.}

Satisfaction with Partners BHM’s Management of Services

Answer Choices Responses

Very Satisfied or Satisfied 58%

Neither Satisfied or Dissatisfied 17%

Highly Dissatisfied or Dissatisfied 20%

Not Sure 5%

*Data from Community Relationship Survey Results

28 28 30 31 26 27 28 29 30 31 32

D

ay

s

Disputes Resolution Time Frames- SFY: 2014-15

Benchmark: 30 Days

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Page 21 Experience with Partners BHM Staff

Very Satisfied or Satisfied 80.5%

Neither Satisfied or Dissatisfied 9.5%

Highly Dissatisfied or Dissatisfied 10%

*Data from Community Relationship Survey Results Report

Do you feel that Partners is meeting its mission as outlined in the mission statement?

Yes 65.06%

No 20.48%

No Sure 14.46%

*Data from Community Relationship Survey ResultsReport



Partners received generally positive responses to the satisfaction of the community/stakeholders in regard to Partners BHM’s role in the community

CONSUMER PERCEPTION OF CARE SURVEY

The North Carolina Mental Health and Substance Abuse Consumer Perception of Care Survey provides information on the quality of care in each LME/MCO catchment area, based on the perceptions of individuals and families who have received Medicaid or state-funded mental health and/or substance abuse services. The NC Division of MH/DD/SAS and LME/MCOs gather this information annually through consumer surveys. Samples of adult consumers ages 18 years and over, youth ages 12 to 17 years, and families/parents of children under 12 years of age complete the confidential surveys, in English or Spanish, at their provider agencies during a specified time period each year. The 2014 survey was administered between June 30, 2014 and July 28, 2014.

Partners BHM Required Survey Sample Size & Actual Survey Respondents

Adult Survey Youth Survey Parent Survey

Required Sample Size 414 136 68

Number of Respondents 627 219 67

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Page 22 Combined 2014 Survey Results

Domain Adult Survey Results Youth Survey Results Parent Survey Results NC Aggregate Score Partners BHM Score NC Aggregate Score Partners BHM Score NC Aggregate Score Partners BHM Score Access 89% 91% 75% 78% 90% 93%

Quality/Appropriateness 93% 95% N/A N/A N/A N/A

General Satisfaction 91% 91% 81% 80% 92% 99%

Outcomes 74% 74% 66% 65% 68% 81%

Treatment Planning 84% 87% 71% 73% 93% 94%

Cultural sensitivity N/A N/A 91% 89% 98% 98%

Social Connectedness 74% 75% N/A N/A 87% 88%

Functioning 74% 72% N/A N/A 69% 80%

*Data from 2014 Consumer Perception of Care Survey Results Report Results & Analysis:

 For the Adult Survey, Partners BHM met or exceeded the State aggregate score for six of seven survey domains (Access, Quality/Appropriateness, General Satisfaction, Outcomes, Treatment Planning and Social Connectedness). Partners fell two percentage points below the State aggregate score for the Functioning domain.

 For the Youth Survey, Partners BHM met the State aggregate score for two of five survey domains (Access and Treatment Planning). Partners BHM fell one percentage point below the State aggregate score for the General Satisfaction domain and two percentage points below for the Treatment Planning and Cultural Sensitivity domains.

 For the Parent Survey, Partners BHM met or exceeded the State aggregate score for seven of seven survey domains.

PROVIDER SATISFACTION SURVEY

The 2014 DHHS Provider Satisfaction Survey was conducted on behalf of the North Carolina Department of Health and Human Services (DHHS), Division of Medical Assistance (DMA) by the Carolinas Center for Medical Excellence (CCME) of the providers participating in the 1915(b) (c) Medicaid Waiver program.

The purpose of the survey was to assess provider perceptions of the nine LME/MCOs in North Carolina. The results from this survey allowed DMA to assess the LME/MCOs ability in the following three areas:

1. Interacting with their network providers

2. Providing training and support to their providers

3. Providing Medicaid Waiver materials to help their providers strengthen their practice

The survey was initially sent out on August 20th_{, 2014 with an initial collection period from August 20}th_{, 2014} to August 26th_{, 2014 and a second collection period from August 27}th_{, 2014 to September 3}rd_{, 2014. The} survey was closed on September 4th_{, 2014.}

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A total of 411 providers who participate in Partners BHM’s provider network were invited to participate in the survey. A total of 173 surveys were collected for a response rate of 42.1%, which was the fourth highest response rate for the nine LME/MCOs.

2014 Provider Satisfaction Survey Results

Survey Question 2013 Score 2014 Score Comparison to 2013 Scores

LME/MCO Staff Accessible 68% 79.8% Exceeded

LME/MCO Staff Make Appropriate Referrals 53% 61.3% Exceeded

LME/MCO Staff Responsive to Provider Needs 70% 79.2% Exceeded

Customer Service Responsive to Stakeholders 53% 59% Exceeded

Provides Consistent & Accurate Claims Information 60% 70.5% Exceeded

Claims Training Meets Provider Needs. 61% 63% Exceeded

Claims Processing Timely & Accurate 68% 83.8% Exceeded

IT Training Informative & Meets Provider Need 60% 72.8% Exceeded Provider Network Meetings Informative & Helpful 56% 62.4% Exceeded

Provider Network Keeps Providers Informed 82% 80.9% Below

Provider Network Staff Knowledgeable 73% 75.7% Exceeded

Provider Council Adequately Addresses Provider Interests 49% 58.4% Exceeded

Overall Satisfaction With Provider Network 80% 78.6% Below

LME/MCO Investigations Are Fair & Thorough 46% 63% Exceeded

Requests For Corrective Action Plans Fair & Reasonable 44% 64.7% Exceeded Technical Assistance/Information Accurate & Helpful 68% 74.6% Exceeded Trainings Informative & Meet Provider Need 64% 66.5% Exceeded Authorizations Processed Within Required Time Frames 75% 82.1% Exceeded

Denials for Treatment/Services Are Explained 57% 66.5% Exceeded

Authorizations Are Accurate 75% 80.3% Exceeded

Satisfied With Appeals Process 38% 48% Exceeded

Partners BHM’s Website Is Useful Tool 65% 64.7% Met

Overall Satisfaction with Partners BHM 73% 80.3% Exceeded

*Pink highlight indicates Partner BHM below NC Aggregate Score for 2013 survey *Red highlight indicates Partners BHM below NC Aggregate Score for 2014 survey

*Green highlight indicates Partners BHM had highest LME/MCO score or tied with another LME/MCO for highest score for 2014 survey

CLIENT SATISFACTION SURVEY

The 2014 Client Satisfaction Survey was distributed to Partner BHM clients (DHHS, DMA) through Survey

Monkey on 8/11/14. The survey asks five key questions regarding Partner BHM’s contractual performance.

2014 Client Satisfaction Survey Results

Survey Question Yes No Not

Applicable

Has Partners BHM met DMH contract standards? 66.67% 0% 33.33%

Has Partners BHM met DMA contract standards? 66.67% 0% 33.33%

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Partners BHM Staff Responsive to client’s questions and/or needs?

100% 0% 0%

Overall Satisfaction With Partners BHM Contractual Performance Responses: 3

Extremely Pleased

Pleased Neutral Dissatisfied Extremely Dissatisfied Not Interacted with Partners BHM 0% 100% 0% 0% 0% 0%

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Page 25

CONSUMER SAFETY

ADVERSE INCIDENT REPORTING & REVIEW

Partners BHM seeks to ensure consumer safety and implements policies and procedures to ensure that staff understands how to manage consumer interactions or adverse incidents where consumers may be at risk. Additionally, Partners BHM tracks all reports of adverse incidents to ensure that interactions are handled appropriately and followed up in order to help ensure safety. Incident Review Committee (IRC) reviews and analyzes these reports to identify trends and opportunities for improvement.

DEFINITIONS OF ADVERSE INCIDENTS



Incident: An “incident,” as defined in 10A NCAC 27G .0103(b)(32), is “any happening which is not consistent with the routine operation of a facility or service or the routine care of a consumer and that is likely to lead to adverse effects upon a consumer.”



Level I: Includes any incident, as defined above, which does not meet the definition of a Level II or III incident. Level I incidents are events that, in isolated numbers, do not significantly threaten the health or safety of an individual, but could indicate systematic problems if they occur frequently.



Level II: Includes any incident, as defined in 10A NCAC 27G .0602, which involves a consumer death due to natural causes or terminal illness, or results in a threat to a consumer’s health or safety or a threat to the health or safety of others due to consumer behavior.



Level III: Includes any incident, as defined in 10A NCAC 27G .0602, that results in (1) a death, sexual assault or permanent physical or psychological impairment to a consumer, (2) a substantial risk of death, or permanent physical or psychological impairment to a consumer, (3) a death, sexual assault or permanent physical or psychological impairment caused by a consumer, (4) a substantial risk of death or permanent physical or psychological impairment caused by a consumer or (5) a threat caused by a consumer to a person's safety.

INCIDENT REPORTING DATA

Adverse Incident Reporting for SFY July 2014-June 2015

1st_Qtr. (Jul-Sep) 2nd_Qtr. (Oct-Dec) 3rd _Qtr. (Jan-Mar) 4th_Qtr. (Apr-Jun)

Level 2 Critical Incident Reports received 450 366 402 453

Level 3 Critical Incident Reports received 43 37 39 40

Level II and Level III Incidents that resulted in Partners BHM on-site investigation

7 4 8 2

Level II and Level III Incidents that resulted in DHSR Investigation

42 2 1 17

*Data from the Consumer Relations Monthly Operating Report, June 2015 Results and Analysis:

 There were a total of 1830 incident reports submitted into IRIS for Partners BHM consumers for SFY 2014-2015.

 91% of the incidents reported were Level II incidents.

 1% of the incidents reported resulted in Partners BHM on-site investigation.  3.4% of the incident reported resulted in DHSR investigation.

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INNOVATIONS WAIVER HEALTH & SAFETY MEASURES

Health & Safety Measures Reported Quarterly SFY 2014-2015

Performance Standard 1st_Qtr. (Jul-Sep) 2nd_Qtr. (Oct-Dec) 3rd _Qtr. (Jan-Mar) 4th_Qtr. (Apr-Jun)

% Incidents in which action was taken to protect the consumer

> 86% 87.76% 90.63% 100% 92.16% % Level II and Level III incidents reported within

required timeframes

> 86% 94.23% 94.12% 100% 82.35% % Incidents referred to the Division of Social

Services or the Division of Health Service Regulation.

<14% 0% 0.29% 0.73% 0.15%

% of Level II and Level III incidents that received required follow-up from Partners BHM

> 86% 100% 100% 94.34% 92.16% *Data from Innovations Waiver Performance Measures Report SFY: 2014-2015

Health & Safety Measures Reported Semi-Annually SFY 2014-2015

Performance Standard Semi-Annual Outcome (Jul-Dec) Semi-Annual Outcome (Jan-Jun)

% Individual Support Plans (ISP) that address strategies to address health and safety risks

>86% 100% 100%

*Data from Innovations Waiver Performance Measures Report SFY: 2014-2015 Results & Analysis:



Partners BHM met or exceeded the performance standard for all measures except for the Level II and Level III reports submission time frames during 4th_{quarter SFY 2014-2015.}



Documentation from the PBHM 2014-15 Innovations Waiver Overview Report indicates that one specific provider’s late report submissions caused Partners BHM to fall below the performance standard for 4th quarter. This provider also had late submissions during 4th_{quarter of SFY 2013-2014. This provider was} put on a plan of correction

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PERFORMANCE MEASURES

SERVICE UTILIZATION- TARGETED SERVICES

COMMUNITY PSYCHIATRIC HOSPITALIZATION

Inpatient Admission Statistics for SFY 2014-2015

Mental Health Admissions Medicaid Non-Medicaid

504 450 541 527

668 616 641 630

Substance Abuse Admissions Medicaid Non-Medicaid

31 40 28 28

68 72 59 41

*Data from MCO Monthly Monitoring Report SFY 2014-2015

Percentage of Readmissions in 30 Days for SFY 2014-2015

Mental Health Readmissions Medicaid Non-Medicaid

13% 17% 12% 13%

8% 6% 6% 5%

Substance Abuse Readmissions Medicaid Non-Medicaid

10% 3% 15% 15%

9% 10% 5% 11%

Average Length of Stay for Inpatient Admissions SFY 2014-2015

1st_Qtr. (Jul-Sep) 2nd_Qtr. (Oct-Dec) 3rd _Qtr. (Jan-Mar) 4th_Qtr. (Apr-Jun) Mental Health Medicaid Non-Medicaid 5.9 4.8 5.3 5.6 6.1 4.3 5.0 4.8 Substance Abuse Medicaid Non-Medicaid 4.2 4.0 4.4 4.0 4.4 3.4 4.4 4.0

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*Data from Executive Dashboard Report April 2015

**Bed day utilzation based on physical counts- not paid claims Results & Analysis:



The highest utilization of three-way hospital bed days occurred in October 2014.



The highest utilization of Non-Medicaid bed days occurred in August 2014.



The highest utilization of Medicaid bed occurred in August 2014.

CHILD/ADOLESCENT SERVICES

Goal: Maintain a bed day benchmark of 2400 or less.

**Bed day utilzation based on physical counts- not paid claims Results & Analysis:



Partners BHM has maintained a bed utilization of less than 2400 bed days.



The highest utilization of bed days occurred in December 2014.

Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 Mar 2015 Apr 2015 3-way hospital beds 1213 1487 1236 1605 1323 920 1273 1026 1343 1078 Non-Medicaid 215 631 476 491 275 393 258 538 401 325 Medicaid 1248 1122 1113 1267 1094 1084 1352 1182 1315 1405 0 200 400 600 800 1000 1200 1400 1600 1800

Inpatient Bed Utilization- July 2014-April 2015

1,514 1,592 1,607 _1,503 _1,546 1,645 _1,586 1,226 1,314 1,305 0 1,000 2,000 3,000 Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 Mar 2015 Apr 2015 N um be r o f B ed D ay s

Psychiatric Residential Treatment Facility Bed Day Utilization- Mediciad

Benchmark: 2400

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Multi-Systemic Therapy

*Data from Executive Dashboard Report April 2015 ** MST and IIH utilization trends based on paid claims data

*Data from Executive Dashboard Report April 2015 ** MST and IIH utilization trends based on paid claims data Results & Analysis:



There was no significant change in MST utilization during SFY 2014-2015.

Intensive In-Home

*Data from Executive Dashboard Report April 2015 ** MST and IIH utilization trends based on paid claims data

19 19 21 21 22 23 25 ₂₃ 25 ₂₃ 12 ₁₀ 6 14 11 ₁₀ 11 4 8 12 0 10 20 30 Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 Mar 2015 Apr 2015

Multi-Systemic Therapy(MST) Utilization -Medicaid

Unique consumers Medicaid New auths - Medicaid

1 1 1 1 0 0 0 0 1 1 0 0 0 0 0 1 2 3 4 5 Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 Mar 2015 Apr 2015

Multi-Systemic Therapy (MST) Utilization - Non-Medicaid

Unique consumers IPRS New auths - IPRS

388 ₃₇₂ ₃₆₉ ₃₇₉ ₃₇₂ ₃₆₉ ₃₇₆ ₃₇₆ 385 369 175 199 164 230 177 183 187 171 196 170 0 200 400 600 Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 Mar 2015 Apr 2015

Intensive In-Home Utilization- Medicaid

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*Data from Executive Dashboard Report April 2015 ** MST and IIH utilization trends based on paid claims data Results & Analysis:



There was not a significant change in Intensive In-Home utilization during SFY 2014-2015.

EMERGENCY DEPARTMENT (ED) UTILIZATION (MEDICAID ONLY)

**Due to 3 month lag in receiving ED information, date parameters for this graph are March 2014-February 2015 instead of using State Fiscal Year Results & Analysis:



Of the 3,276 emergency department admissions between March 2014 and February 2015 for individuals with a MH/DD/SA diagnosis 51% were admissions for active consumers.



Of the 3,276 emergency department admissions between March 2014 and February 2015 for individuals with a MH/DD/SA diagnosis 12.5% were readmissions within 30 days of discharge.

1 ₁ 1 3 5 ₅ 2 2 2 1 1 1 0 1 3 0 2 0 2 1 0 1 2 3 4 5 6 Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 Mar 2015 Apr 2015

Intensive In-Home Utilization- IPRS

Unique consumers IPRS New auths - IPRS

861 878 880 657 460 455 442 325 104 120 109 ₇₅ 0 200 400 600 800 1000

Mar 2014-May 2014 Jun 2014-Aug 2014 Sep 2014-Nov 2014 Dec 2014-Feb 2015

Emergency Department Admissions for March 2014-February 2015

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INTELLECTUAL DEVELOPMENTAL DISABILITY (IDD) SERVICE UTILIZATION

*Data from Executive Dashboard Report April 2015 Results & Analysis:



The actual monthly cost for IDD consumers was below the total PMPM rate during July 2014 to April 2015.



The average budget per consumer was below the PMPM rate for all months except January 2015. $0 $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 $6,000,000 $7,000,000 $8,000,000

July 2014 Aug 2014 Sept 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 Mar 2015 Apr 2015

IDD Per Member Per Month (PMPM) Utilization

Actual Monthly cost (paid claims only) Total PMPM

$0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000

Monthly Consumer Budget

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FINANCIAL PERFORMANCE

84.3% 88.8% 87.2% 86.8% 88.2% 88.0% 88.0% 87.3% 87.3% 84.8% 92.7% 98.9% 92.3% 94.1% 92.1% 90.3% 91.5% 92.3% _92.3% _92.8% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% 110.0%

Medical Expense Ratio

Medicaid MER IPRS MER 100% Line

$0 $50,000,000 $100,000,000 $150,000,000 $200,000,000 To tal Se rv ice C os t

Fiscal Year to Date Budget to Actual Comparison - Medicaid

Total FYTD Actual Total FYTD Budget

5,000,000 10,000,000 15,000,000 20,000,000 25,000,000 30,000,000 35,000,000 Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 Mar 2015 Apr 2015

Non-Medicaid Budget to Actual

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CLAIMS

Claims Data for SFY: 2014-2015

Clean Claims Received

Medicaid 499,995 483,914 489,256 507,172 Non-Medicaid 92,277 85,817 88,548 92,211 Average Number of Days for Processing

Medicaid 8 10 9 8

Non-Medicaid 7.5 9.1 8.6 8.3 Claims Denied

Medicaid 52,655 49,818 54,930 62,793 Non-Medicaid 10,548 8,649 8,243 15,100 Claim denials overturned due to Provider Appeals

(Medicaid Only)

0 0 0 0

Goal: 90% of all clean claims will be processed within 30 days. (DMA/DHHS Contract Standards)

*Data from Executive Dashboard Report April 2015 Results & Analysis:

 Partners BHM exceeded the goal of 90% of all clean claims processed within 30 days for all quarters of SFY 2014-2015.

 Partners BHM had no claim denials overturned due to provider appeal for all quarters of SFY to 2014-2015



Will continue to maintain claims processing goal.

100% 100% 100% 100% 100% 100% 100% 100% 85% 90% 95% 100% 105%

1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

Days to Pay Clean Claims

Benchmark: 90% Within 30 Days

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PROGRAM MEASURES

MH/SA CARE COORDINATION

Care Coordination is an administrative function within Partners BHM’s managed care system that is designed to be proactive in nature and ensure optimal care to at‐risk consumers in designated special healthcare needs populations. It is available to members in all three disability groups (Mental Health, Substance Abuse, and Intellectual/Developmental Disability). This section will only address MH/SA Care Coordination as elements of Intellectual/Developmental Disabilities are addressed in other sections of this report.

MH/SA CC activities include the identification, coordination and monitoring of, linkage to behavioral health treatment services, rehabilitative, and/or facilitative services and supports depending on the consumer’s individual needs and funding source.

Care Coordination Statistics for SFY 2014-2015

Note: these are new measures that were first reported in October 2014 1st_Qtr. (Jul-Sep) 2nd_Qtr. (Oct-Dec) 3rd _Qtr. (Jan-Mar) 4th_Qtr. (Apr-Jun)

Average Number of Adult MH/SA Consumers Receiving Care Coordintion Services During Quarter

Medicaid N/A 771 759 810

Non-Medicaid N/A 481 430 388 Average Number Child MH/SA Consumers Receiving

Care Coordintion Services During Quarter

Medicaid N/A 363 441 451

Non-Medicaid N/A 9 13 13

Goal: Ensure 85% of MH/SA inpatient readmissions are assigned to care coordintion (DMA/DMH Contract

Standard)

*Data from LME/MCO Monthly Monitoring Report SFY 2014-2015 Results & Analysis:



Partners BHM exceeded the goal of ensuring 85% of MH/SA inpatient readmissions are assigned to care coordination for all quarters of SFY 2014-2015.

100% 100% 98.7% 100% 0% 100% _97.4% 100% 0% 20% 40% 60% 80% 100% 120%

Percentage of MH/SA Readmissions Assigned to Care Coordination

Benchmark: 85%

QUALITY ASSURANCE/QUALITY IMPROVEMENT PROGRAM EVALUATION