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Quality Management

Quality Management

The key focus of the Behavioral Health Quality and Compliance Program is to monitor, evaluate, develop and implement quality improvement activities that contribute to the corporate mission of improving the quality of life in the communities in which it serves. We work collaboratively with the Behavioral Health provider/practitioner communities in our service area by supporting access to the most appropriate and highest quality Behavioral Health care services for members. The program strives to achieve best practice performance in areas of patient wellness, chronic and acute care management, and member satisfaction with care and services, thus improving outcomes and the overall health status of the population. On an annual basis, the goals and objectives are reviewed and redefined based on the Behavioral Health Program Evaluation.

Access and Availability of Care

The Behavioral Health Department monitors access and availability per request and in accordance with the New York State Department of Health (NYSDOH) and the National Committee for Quality Assurance (NCQA), with the purpose of ensuring timely access to Behavioral Health care.

These access standards are relevant to the entire managed care enrolled population, including commercial, Medicare and Medicaid members.

Access Measure Standards Measurement Tool

Timeliness of routine Behavioral Health appointments

Should be available within 10 business days

Appointment Availability Survey

Timeliness of Behavioral Health urgent appointments

Should be available within 48 hours

Appointment Availability Survey

Timeliness of Behavioral Health emergency care

In life-threatening emergencies, a Behavioral Health specialist should be accessible immediately by telephone, 24 hours a day, 7 days a week.

In non-life-threatening emergencies, a Behavioral Health specialist should be accessible within 6 hours

Random After Hours Call Program

Appointment Availability Survey

Complaint analysis

Provider Contract

Timeliness of follow-up after inpatient hospitalization for a mental illness

Should be available within 7 calendar days  following discharge

HEDIS® measure *

* HEDIS, the Health Plan Employer Data and Information Set, is a set of standardized performance measures designed to provide purchasers and consumers with information to reliably compare the performance of managed health care plans. HEDIS is sponsored, supported and maintained by the National Committee for Quality Assurance.

After-Hours Coverage

Behavioral Health practitioners are required to provide necessary telephone availability to members 24 hours a day, seven days a week to triage telephone calls from established patients or patients’ family members. Practitioners must also arrange for complete backup coverage from other participating clinician(s) when unable to provide covered services to established patients.

Health Plan members must be able to:

  • Reach the practitioner or a person with the ability to patch the call through to the practitioner (i.e., answering service); or
  • Reach an answering machine with instructions on how to contact the practitioner or his/her backup (i.e., message with number for home, cell phone or beeper).

If a call forwarding message is used, the practitioner must state that the call is being forwarded to the practitioner’s contact number. Practitioners’ contact information should be primary in the message, before listing additional information. Additionally, callers should be referred to call 911 only in case of a life threatening emergency.

Continuity and the Coordination of Care

We work to maintain continuity and coordination of general medical care with the Behavioral Health care that members receive. The goal is for members to receive seamless, continuous, and appropriate care, and to strengthen system-wide continuity between medical and Behavioral Health care.

The Behavioral Health Department monitors the BH practitioners' exchange of information with PCPs, other Behavioral Health caregivers and consultants, ancillary providers, and health care institutions through Treatment Record Reviews and/or self report surveys. The timeliness of the communication with the PCP and other appropriate practitioners/providers should be soon after the intake assessment is complete, a working diagnosis has been determined, and the initial treatment plan has been developed (usually after the first, but no later than the third visit).

Treatment Record Standards

To maintain consistent and complete documentation among participating providers, we have developed standards for Behavioral Health treatment records. We developed the treatment record standards with input from participating providers based on current Behavioral Health care practice, the requirements of regulatory and accrediting bodies, and Health Plan and Behavioral Health managed care goals. These standards apply to all BH practitioners.

Follow this link to access Treatment Record Standards.

Sample record templates that meet treatment record standards are available on the Behavioral Health Tools & Resources section of our Web site.

Treatment Record Reviews

As part of the recredentialing process, our BH staff review the treatment records of participating BH providers to assess compliance with these standards.

Providers are selected for treatment record reviews (TRR) based on their recredentialing date and claims activity. The Health Plan contacts a provider prior to his/her recredentialing anniversary date to arrange an appointment.

  • Scoring and Follow-up - During a treatment record review, points are assigned to each standard for the purpose of scoring. Illegible records or lack of a DSM-IV-TR diagnosis are cause for automatic failure. After the treatment record review, Behavioral Health notifies the provider in writing of his/her score. If a provider’s score is less than 85 percent, he/she will be asked to submit a corrective action plan within 30 days. Behavioral Health staff will then review the provider’s records again within six to 12 months. A third consecutive TRR with a failing score will result in a recommendation to the Credentialing Committee to revoke credentials approval.

Behavioral Health Practitioner Quality Advisory Committee

The Behavioral Health BH Practitioner Quality Advisory Committee (BHPQAC) provides input to the development and implementation of quality initiatives, measurements, interventions, and guidelines for clinical improvements in the area of Behavioral Health for the purpose of preventive health, and acute and chronic illness. The committee consists of 10-15 Behavioral Health practitioners from the community. Committee representation includes Psychiatrists, Psychologists, Social Workers, Chemical Dependency Practitioners, Registered Nurses, and Health Plan staff.