DHS/DMH/The Collaborative Contractual Overview Presentation February 13, 2013 February 14, 2013 Scott Permentier, LSW, MBA, CCEP Chief Executive Officer

 Introductions  About the DHS/DMH, Administrative Service Organization and the Illinois Mental Health Collaborative for Access and Choice (The Collaborative)  Recovery and Resilience  Clinical Services/Medical  Compliance/Quality  Provider Relations

 Scott Permentier, Chief Executive Officer  Bryce Goff, Director of Recovery and Resilience  Pat Palmer, Director of Clinical Services  Todd Kasdan, MD, Director of Medical Services  Shawn Wilson, Director of Compliance  Aissa Bell, Director of Provider Relations

 As the state mental health authority, DHS/DMH is responsible for ensuring that those most in need have access to appropriate mental health services that comply with federal and state statutes and regulations  Ensure access for those most in need of mental health service  Ensure that services meet standards of quality relative to mental health services  Ensure prudent stewardship of taxpayer dollars  Establish all policies and procedures for the system of care

 The Illinois Mental Health Collaborative for Access and Choice is: ◦ A partnership between the DHS/DMH and ValueOptions to improve and advance mental health services ◦ An ASO created to help DMH make the best use of limited resources to serve people in need of mental health assistance ◦ Committed to the Recovery and Resilience of children and adults with mental illnesses

 A health solutions company designed to ensure that: ◦ The right services are provided ◦ In the right amount ◦ To the right person ◦ At the right time

 ValueOptions is the company contracted by DHS/DMH to provide ASO services  These services are provided under the name “Illinois Mental Health Collaborative for Access and Choice”

 The contract is set to expire June 30, 2015  There are two (2), one (1) year contract extensions that may be exercised by DHS/DMH that could continue the contract until June 30, 2017

 The Collaborative operates two (2) offices in IL: ◦ Chicago ◦ Springfield

 Clinical  Finance  Management Information Systems  Provider Relations  Quality Management  Recovery and Resilience

Patricia Palmer, LCSW, CADC, Clinical Director Callie R. Lacy, LCPC, Clinical Supervisor Sue Kapas, LCPC, Clinical Quality Assurance Advisor Todd H. Kasdan, MD, Medical Director Clinical Overview

The Utilization Management (UM) Program is the vehicle through which DHS/DMH ensures that individuals being served receive: ◦ The services best suited to support their recovery needs and preferences ◦ Cost effective services in the most appropriate treatment setting ◦ Services consistent with medical necessity criteria and evidence-based practices

By implementing the UM Program, DHS/DMH strives to achieve a balance between: ◦ The needs, preferences, and well-being of persons in need of mental health services ◦ Demonstrated medical necessity ◦ The availability of resources

 UM is dynamic and evolutionary  UM must be based on data  Individuals accessing services should meet a consistent threshold of medical necessity statewide  Authorization must be clinically focused and conducted by qualified staff

 The Medical Necessity Criteria (MNC) are published by IL DHS/DMH  These criteria should be used by providers to guide them in making consistent admission, continuing service, and termination of service decisions for each consumer  Providers must use these criteria consistently, regardless of whether or not DHS/DMH or its designee externally authorizes the service  Provider adherence to these criteria may be subject to post- payment review

 Assertive Community Treatment (ACT)  Community Support Team (CST)  Community Support Group (CSG)  Psychosocial Rehabilitation (PSR)  Therapy Counseling  Individual Care Grant (ICG)  Permanent Supportive Housing (PSH)  Including Williams Class members

 Region 1 Crisis Care  Inpatient CHIPS  Mental Health Crisis Residential  Substance Abuse Crisis Residential  Acute Community Care  Northwest Crisis Care  Inpatient CHIPS  Mental Health Crisis Residential  Acute Community Care

 Provider will contact the Collaborative to request services  Collaborative clinical care managers (CCMs) review submitted documents for adherence to Medical Necessity Criteria (MNC) via: ◦ Treatment Plan Goals ◦ Status Updates and Progress ◦ A rating scale  LOCUS Scoring for adults  Ohio Scales for Children/Adolescents  If the MNC are met for the service(s), the Collaborative CCM will enter an authorization

 If medical necessity IS established, request is authorized by CCM and communicated to the provider  If medical necessity is NOT established, the CCM contacts the provider to seek clarification and offer education/consultation regarding authorization criteria ◦ The Collaborative and the provider will reach mutual agreement with respect to next steps (e.g., additional information will be submitted for review, alternative service will be considered, etc.) ◦ If mutual agreement has NOT occurred and provider believes medical necessity is present, the CCM will forward information to a Collaborative Physician Advisor (PA) reviewer  PA reviews and either authorizes OR denies authorization

 In the case of a Clinical denial of authorization, a Reconsideration Request or Appeal (depending on the service/level of care) may be initiated  This review will be conducted by a Physician Advisor (PA – a physician licensed in the State of Illinois and board-certified in the specialty of psychiatry) Not the same PA who issued the original denial Not a subordinate of the PA who issued the original denial ◦ Review outcome  Either:  Overturn of the original denial decision  Upholding of the original denial decision

Reconsideration Requests and/or Appeals can be Clinical or Administrative in nature  Clinical ◦ Related to Medical Necessity Criteria  Administrative ◦ Administrative = based on reasons other than lack of medical necessity ◦ Examples of administrative denials  Consumer not eligible due to geographic residency  Diagnosis not present in eligible population universe  Service requested is not covered  Request is outside of timeframe

Bryce Goff Director, Recovery and Resilience Focus on Persons Served and Recovery

Concept of recovery includes: –Individuals with serious mental illnesses or serious emotional disorders can create a life of meaning and purpose Person-centered care - Focus on helping individuals achieve personal goals as opposed to merely managing symptoms Family support and involvement Providing hope as the cornerstone of recovery People who have mental illnesses: –Form a partnership with their providers –Have a voice in their care –Guide their treatment planning process –Use their strengths to achieve goals

 The Collaborative builds upon and works with the established DHS/DMH Recovery Services Development Group  The Collaborative draws on ValueOptions’ extensive experience in empowering consumers  On the national level: ◦ Clarence Jordan – ValueOptions’ Vice President for Recovery and Wellness  National recovery and consumer movement leader  Training and consultation for providers, service center employees, persons served  Facilitating integration of recovery and wellness principles throughout ValueOptions

 Certified Recovery Support Specialists (CRSS) at the Service Center level ◦ Director of Recovery in senior level position on management team ◦ Peer and Family Support Specialists  Facilitate consumer communications and education  Consultation and support to community and providers  Community training on recovery ◦ Providers ◦ Persons Served ◦ Family Members

 Involvement of persons with lived recovery experience in development and implementation of initiatives  Certified Recovery Support Specialists employed throughout the organization  Community education about mental illness and recovery

 Warm Line  Recovery and Empowerment Statewide Calls  Recovery Services Development Snapshots  CRSS Trainings and Provider Forums  Recovery and Empowerment Handbooks  Wellness Recovery Action Plan Training Support  Recovery Oriented Consultation to all Collaborative Departments

Compliance/Quality Management Shawn Wilson, CCEP Compliance/QA Departmental Director Bobbie Fracassi QM Specialist/Resolution Coordinator

 Maintain several QM functions to ensure quality of operations and regulation compliance  QM functions ensure VO contractual obligations are performed satisfactorily  Compliance function ensures operations meet all legal requirements (HIPAA/HITECH/mandated reporting, etc.)

 The Collaborative receives and processes consumer- and family-generated complaints regarding DMH service providers  Formalized process between ValueOptions and DMH  Process ensures all allegations are: ◦ Taken seriously ◦ Reviewed in an objective and timely manner ◦ Results are communicated to necessary entities

 Call : (866) and file your complaint or grievance with our Resolution Coordinator  Write to : Illinois Mental Health Collaborative Attn: Resolution Coordinator P.O. Box Chicago, IL 60606

Aissa Bell Director, Provider Relations Provider Relations (PR)

Aissa Bell Director Amy Montgomery Training Coordinator Chris McConkey Clinical Coordinator Chicago Liaisons 4 Springfield Liaisons 3

A. Training and Technical Assistance B. Provider Monitoring C. Management of the Collaborative Web Site D. Support of Provider Database Verification Maintenance

 Via webinar on a variety of subjects  On-site at the time of monitoring reviews in an effort to assist and guide providers with improving documentation practices  Individually as requested by the provider

 This contract year, the Collaborative is responsible for 5 different types of reviews:  PPR (Post-Payment Review)  Two Types: Standard Post-Payment Review, ICG Post Payment Review  Evaluates provider’s compliance with 11 specific Rule 132 items  Length of Review is 1-2 days depending on the number of claims reviewed  The number of claims depends upon the number of post- payment reviews the provider is receiving and the number of claims the provider has submitted during the billing period

 Billing period if reviewed last year: 60 days after last review up to date claims pulled.  Billing period if not reviewed last year: 12 months back and up to the date claims pulled.  DMH Contract Managers follow through on Plans of Improvement  Note: Same tools are used for both PPR and ICG PPR. If provider is receiving both types of Post-Payment Reviews, separate reports are left with provider for each type of review.

 ACT (Assertive Community Treatment)  Measures a provider’s delivery of ACT services to the fidelity model  Typical length is one full day per team being reviewed  With a few minor modifications, this scale is the Dartmouth Assertive Community Treatment Scale (DACTS) developed by Teague, Bond, and Drake (1998)  CST (Community Support Team)  Measure a provider’s delivery of CST services according to the definition and intent of the service  Typical length is one full day per team being reviewed  The review is conducted using a tool developed by a workgroup of DMH and the IL PR team

 Certification  Evaluates compliance of Rule 132 (a much broader review than PPR )  Typical length of review is three days.  Reviewers use DHS/BALC established tools  DHS/BALC office follows through with providers post-review  ICG Documentation Reviews  Reviews service documentation and focuses on the rehabilitative nature of services provided and coordination with other entities and includes a review of the provider’s policies and procedures related to elopement  Typically length is one day  The review is conducted using a tool developed by a workgroup of DMH, DHS C and A office and the IL Collaborative PR team  DHS/C and A office follows through with providers post-review

 In partnership with DHS/DMH and DHS/DORS, assistance with supported employment fidelity monitoring  Up to 33 provider programs

The purpose of provider database verification is to ensure that data in our system is accurate and up-to-date  Providers who are receiving a monitoring visit:  Receive an encrypted with an attached pre- populated PDV form documenting the provider’s information that is currently in our system. Providers make any corrections or changes and give to reviewers at the time of the monitoring visit  Providers who are NOT receiving a monitoring visit:  The Contract Manager will be contacting you to verify the information

 Today’s presentation will be available online at:  You can follow these steps:  Step 1: Go to  Step 2: Click on “Providers”  Step 3: Click on “Provider Information”  Step 4: Under Provider Trainings, click on this PowerPoint

Questions?