Professional Development & Training Series: Behavioral Health Quality 2017. 6. 19.¢  Quality Management

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    Title

    1

    Professional Development & Training Series:

    Behavioral Health Quality Assurance (BHQA) Staff

    Workshop #4: Short-Doyle Medi-Cal Rehabilitation Option &

    Targeted Case Management Manual (1993):

    June 2017

    San Francisco Department of Public Health

    Behavioral Health Services

    Quality Management

    Clinical Documentation Improvement Program (CDIP)

    Staff contact: Joseph A Turner, PhD (joe.turner@sfdph.org)

  • Handouts

     Build a binder for workshop materials:

     Powerpoint: steal these slides for your training!

     CDIP SDMC Rehab/TCM Manual Excerpts: a must-

    have reference for a true QA professional

     Bonus Info: Kaiser Family Foundation Report

    (Rehab Option) + DHCS Information Notices Tool

    Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/8/2017 2

  • Recap on the Series

     Problem: People Do Not Understand…

     Quality assurance…

     Managed care…

     BHQA staff deserve education, training & support:

     Workshop 1: don’t have to memorize CCR Title 9, but…

     Workshop 2: don’t have to our Medicaid State Plan, but …

     Workshop 3: don’t have to memorize MHP Boilerplate, but…

     Workshop 4: you don’t have to memorize the Short-Doyle

    Medi-Cal Rehab Option/TCM Manual, but…

    Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 6/8/2017 3

  • Jargon Check: Quality Assurance

    4

    …retrospective

    comparison against

    a standard

    …real-time

    investigation of

    processes

    …organized

    system to monitor

    & improve quality

    6/8/2017Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org)

  • 5

    Recap on the Series

    6/8/2017

    Federal

    State

    County

    Provider

    Workshop #1 Workshop #2 Workshop #3 Workshop #4 Workshop #5

    State Plan

    CCR Title 9 Boilerplate

    Contract

    1994

    SDMC

    Manual

    Medi-Cal

    Certification

    Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org)

  • 6

    Recap: Workshop #1

    “CCR Title 9”

    (a regulation)

    Blueprint (build a County Mental Health Plan)

    Rules (operate a County Mental Health Plan)

    You build a publicly funded managed care

    Medicaid program by following blueprints & rules!

  • Recap: Workshop #1

    7

    The 27 Regulatory “Titles” of the California Code of Regulations (CCR)

    Title 1: General Provisions Title 15: Crime Prevention & Corrections

    Title 2: Administration Title 16: Professional & Vocational Regulations

    Title 3: Food & Agriculture Title 17: Public Health

    Title 4: Business Regulations Title 18: Public Revenues

    Title 5: Education Title 19: Public Safety

    Title 7: Harbors & Navigation Title 20: Public Utilities & Energy

    Title 8: Industrial Relations Title 21: Public Works

    Title 9: Rehabilitative & Developmental Services Title 22: Social Security

    Title 10: Investment Title 23: Waters

    Title 11: Law Title 24: Building Standards Code

    Title 12: Military & Veterans Affairs Title 25: Housing & Community Development

    Title 13: Motor Vehicles Title 26: Toxics

    Title 14: Natural Resources Title 27: Environmental Protection

    Regulations =

    BLUEPRINTS &

    RULES

    6/19/2017Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org)

  • 8

    Switching Gears…

    If CCR Title 9 functions as

    “blueprints and rules” for SMHS…

    …what were the blueprints and rules for CCR Title 9?

    …what preceded CCR Title 9?

    6/8/2017Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org)

  •  Tracking Down Jargon

     How to understand “service necessity”

     How to understand “case management brokerage”

     Connecting with History and Context

     How to understand County “Carve Out”

     What did Medi-Cal look like before?

    Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 9

    Backstory on the SDMC-

    Rehab Option/TCM Manual

  •  Manuals & Page-by-Page Updates

     Guidance published in “manuals” that get updated over

    time—only specific pages get updated

    Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 10

    Backstory on the SDMC-

    Rehab Option/TCM Manual

  •  SDMC Rehab Option TCM Manual

     CDIP tried to obtain all the pages (original and

    updated)…

     Partially successful

     CDIP marked up the document to show:

     original language that was updated,

     updates from July 1995 and

     updates from October 1995 Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 11

    Backstory on the SDMC-

    Rehab Option/TCM Manual

  •  Frankensteinian monster?

    Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 12

    Backstory on the SDMC-

    Rehab Option/TCM Manual

  •  Don’t let perfection be the enemy of good!

    Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 13

    Backstory on the SDMC-

    Rehab Option/TCM Manual

    Cover sheet

    explains how

    CDIP created

    our local copy of

    the manual

  • Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 14

    Structure of the

    SDMC-Rehab Option/TCM Manual SECTION TITLE (Compact)

    1

    Introduction

    Acknowledgements

    Philosophy

    2

    Service Definitions *

    Planned Services*

    Unplanned Services*

    Targeted Case Management*

    Comparison of Service Functions*

    Lockouts, Overrides, Computer Edits, and Other Limitations

    Staffing Qualifications for Service Delivery and Documentation

    3 Medical and Service Necessity *

    4

    Coordinated Services Summary*

    Personnel Description-Coordinated Services*

    Quality Management System-Coordinated Services *

    Documentation Standards-Coordinated Services*

    5 Short-Doyle/Medi-Cal Traditional Quality Assurance and Utilization Review

    Requirements for Rehabilitation and Case Management/Brokerage* 6 Inpatient Hospital UR Requirements 7 Provider Certification Standards* 8 Definitions* 9 Index

    * selected pages are

    included in

    workshop

    handout

    get the full

    copy @CDIP

    website

  •  Expansion of Billable Services

     Moving from Clinic Option to Rehab Option

     Expansion of “Case Management/Brokerage”

     Quality Assurance & Utilization Review

    Models

     “Traditional” vs. “Coordinated Services”

    Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 15

    SDMC-Rehab Option/TCM

    Manual: Key Concepts

  •  The “necessity”

     Medical vs. service necessity

     The domains of impairment

     Derived from the Community Functioning Evaluation

    (CfE)

    Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 16

    SDMC-Rehab Option/TCM

    Manual: Key Concepts

  • Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 17

    Expanding Services-

    M-Caid Rehab vs. Clinic Option*

    Service Clinic Option Rehab Option

    Inpatient Psych Hospital yes yes

    Psych Health Facility no yes

    Adult Residential no yes

    Adult Crisis Residential no yes

    Day Treatment no yes

    Mental Health Services ish yes

    Crisis Stabilization no yes

    Case Management only client client or sig other

    *see page 2-43 of Manual to see table

  •  Rehab vs. Clinic Option Flexibility

     More types of services (beyond inpatient and limited

    outpatient)

     More types of service providers (beyond

    MD/PhD/LCSW)

     More locations for services (beyond the clinic walls)

    Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 18

    Expanding Services-

    M-Caid Rehab vs. Clinic Option

  •  Formal “Case Management”

     Elements of Targeted Case Management:

     Assessing, planning, brokering, monitoring

     Rehabilitation Option services include

    services that are “case management-like”

     Managing/monitoring Medicaid planned services (e.g., Plan

    Development; Assessment of case management needs)

    Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 19

    Expanding Services-

    Rehab + TCM

  •  Limits of Rehab Option Services

     “…activities geared toward gaining access to and

    monitoring non-Medicaid services are not reimbursable

    under the rehabilitation option”

     “California has chosen to include linkage to both Medicaid

    and non-Medicaid services under a Case

    Management/Brokerage service function…billed as

    Targeted Case Management…rather than Rehabilitation

    Option.

    Staff Contact: Joseph A Turner, PhD (joe.turner@sfdph.org) 20