Health Home Quality Management Program

Health Home Supporting Documentation for POC and PMPM Acuity Final

• Guidance is also available in Portable Document Format (PDF)

Policy Title: Health Home Quality Management Program

Policy number: HH003 Effective date: June 1, 2017

Last revised:

Approved by:                                                             Date:

Purpose: To promote a culture of learning and continuous quality improvement, monitoring, and oversight within the Health Home network.

The New York State Department of Health (the Department) is responsible for assuring that Health Home members receive appropriate and effective care management services to: prevent avoidable inpatient stays and emergency room visits; improve disease–related care and outcomes for individuals with Serious Mental Illness (SMI), HIV/AIDS, or chronic conditions including Substance Use Disorders (SUD); improve preventive care; and, lower Medicaid costs. For Health Homes serving children (HHSC), the provision of care management services expands to include individuals with Serious Emotional Disturbance (SED) and/or Complex Trauma.

Health Homes must provide timely, comprehensive, high quality health home services using the ´person–centered´ approach to care. To meet these requirements, Health Homes must maintain an environment that fosters continuous quality improvement strategies. This is achieved through implementation of a Quality Management Program (QMP), a system to monitor and objectively evaluate Health Home quality, efficiency, and effectiveness.

To track their performance, Health Homes must collect, analyze, and report on data in a way that measures the effectiveness of care coordination and chronic disease management on individual–level clinical outcomes (e.g., medical conditions, impact on health–related or general quality of life, resource utilization, etc.), member satisfaction (e.g. timely appointments, easy access to information, good communication with care managers, etc.), and quality of care outcomes at the population level (e.g., readmissions, etc.).

Sources of data Health Homes may use include: Center for Medicare and Medicaid Services´ (CMS) Health Home Core Measure Set; State Plan Amendment Quality Measures; CMART data reports provided through the Office of Quality and Patient Safety (OQPS); Medicaid Analytics Performance Portal (MAPP) (dashboards and tracking system); claims and encounters from Salient; data from Managed Care Plans; and, internal Health Home electronic health records (EHR) or care management software system. Other means to evaluate the effectiveness and quality of service provision include: chart reviews, member experience surveys, and complaint/incident reports, etc.

The purpose of this policy is to provide guidance on the practice of quality management and an overview of the components, requirements, best practices, and activities associated with a Health Home Quality Management Program (QMP).

Scope

QMP supports the development of a quality culture in which all staff assume responsibility for quality and engage in quality management at all levels. This includes: clinical and administrative areas of Health Home operations and other entities involved in Health Home activities; care management agencies and staff; NYS Department of Health; State Partners; and other stakeholders (e.g., members and family).

Defining a Quality Management Program (QMP)

QMP is a system that documents processes, procedures, and responsibilities for achieving quality practices and objectives. It is a proactive approach rather than reactive, identifying and resolving issues before they occur. An effective QMP not only evaluates the ability of the Health Home and care management agencies to provide quality services to members, but also the impact of the services on health outcomes for members.

There are two aspects of an effective QMP: Quality Assurance and Performance Improvement (QAPI).

Quality Assurance/Performance Improvement (QAPI)

QAPI is the coordinated application of two mutually–reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, comprehensive, and data–driven approach to maintaining and improving quality and processes within the Health Home program while involving all care management agencies in practical and creative problem solving.

QA is a process undertaken by an organization that assures care is maintained at acceptable levels in relation to specifications of standards for service quality and outcomes. QA is a continuous process that assesses organizational performance, both prospectively and retrospectively, including where and why performance is at risk or has failed to meet standards.

PI (also called Quality Improvement–QI) is the continuous study and improvement of processes with the intent to better services or outcomes, and prevent or decrease the likelihood of problems, by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems or barriers to improvement. PI in the Health Home program aims to improve processes involved in care management service delivery and member quality of life.

Procedures

Health Homes must develop and maintain a Quality Management Program in alignment with Health Home Standards and Requirements that objectively, systematically, and continuously assess, assure, monitor, evaluate, and improve the quality of processes, activities, and services provided to Health Home members.

Health Homes must have policies and procedures that outline the components of an effective Quality Management Program. These components include the following:

1. Define the organization´s mission and how a QMP will be integrated.
2. Identify the individual who will have overall responsibility for the daily operation of the QMP.
3. Assure involvement of leadership and/or management in QMP processes. Effective support from senior management/leadership is critical to the success of a QMP.
   
   For Health Homes that are part of a larger system such as a hospital or PPS, with an existing Quality Management system that includes involvement in quality activities by senior leadership and management (e.g., CEO, Board of Directors, Medical Director, Quality Committees, and so forth), the Health Homes must assure that activities and outcomes of the Health Home Quality Management Program are included in the organization´s reporting structure.
   
   For Health Homes that are not part of a larger system, a QMP system must be in place that includes organizational leadership (e.g., Board of Directors, etc.) to support a culture of quality and secure resources necessary to conduct quality improvement efforts. Reporting on QMP activities to leadership/management must occur no less than quarterly. QMP Committee minutes will include all reporting to leadership.
4. Identify individuals to serve on a QMP Committee.
   
   The QMP Committee must be multi–disciplinary, adequately representing of all key departments, with clearly defined roles and responsibilities. The Quality Management Committee monitors the ongoing effectiveness of the Quality Management Program.
   
   Members of the QMP Committee should include:
   • QMP Committee Chair: facilitates committee meetings, reports on activities and findings of the Committee to leadership and/or management;
   • QMP Coordinator: designs, directs and oversees implementation of QMP projects to include review of data and performance measures, manage work plans, oversee performance improvement activities, and monitor progress.
   NOTE: The QMP Chair and Coordinator are responsible to provide the oversight needed to run an efficient QMP.
   • Various other entities: Health Homes must consider representation on the QMP Committee by other entities that serve the Health Home population. This may include: medical, clinical, technical, financial, operations, Care Management Agencies, stakeholders such as PPS, housing providers, criminal justice, etc.
   • Health Homes must obtain feedback from members and family members and apply their input into QMP processes.
   • Other subcommittees: Subcommittees/teams may be established in response to various QI activities.
5. Define Responsibilities and Activities of the QMP Committee:
   
   The Committee is responsible for defining, overseeing and monitoring the objectives and goals of the QMP. This includes:
   • prioritizing performance improvement efforts utilizing strategic goals, aggregating and analyzing performance and benchmark data, and trend analysis;
   • identifying barriers and needed resources to support PI implementation;
   • monitoring performance improvement efforts for effectiveness;
   • making recommendations for changes in service provision or operations; and,
   • preparing written reports to leadership that include findings, actions, and outcomes of the Quality Management Program.
6. Establish a process and frequency for approving, revising and evaluating QMP activities. Consideration should be given to the availability of resources that may be needed to support improvement activities.
7. Hold QMP Committee meetings, at least quarterly, or more frequently as defined by the Health Home´s network or governance.
8. Describe a process for the Health Home to notify the QMP Committee of any critical issues identified (e.g., a significant trend or pattern in member incidents governed by the Complaint/Incident policy) to identify root cause(s), implement and monitor corrective action plans, and implement quality performance improvement strategies to prevent recurrence.
9. Document QMP Committee activities that promote continuous quality improvement and support the objectives and goals of the QMP. Such activities include, but are not limited to: audit findings and outcomes; Performance Improvement Plans (PIP) with outcomes of success or corrective action; and, outcomes of policy change requests. Health Homes may choose to report on quality goals through quality report cards, dashboards, monitoring reviews, or any other quality reporting tool(s) determined by the Health Home.
10. Include a clear quality statement with specific expectations integrated into each appropriate Health Home policy to assure continuous quality improvement within that domain.
11. Maintain the components of confidentiality in compliance with State and Federal laws to protect information obtained and utilized in QMP activities.
12. Review the QMP annually to evaluate progress towards objectives and goals, identify any needed improvements/revisions in QMP processes, and determine topics for the coming year. Summaries of the evaluation are provided to the appropriate leadership for review.
13. Identify how negative outcomes will be addressed through the use of a Performance Improvement Plan (PIP), a written document that clearly and objectively identifies:
    • areas where performance expectations and standards have not been met, including examples to clarify the patterns or severity of performance issues, and the impact of the unmet performance;
    • root cause analysis;
    • expectations for improvement using measurable goals;
    • timeline for improvement to be reached;
    • assignment of tasks to appropriate staff;
    • the need for staff training or support;
    • expectations for reviewing progress including any barriers; and,
    • sanctions that may be imposed if improvements are not made.
14. Maintain QMP records that include but are not limited to: minutes of all QMP Committee activities, administrative reporting, quality assurance strategies, performance improvement activities, corrective actions taken and outcomes, and annual QMP review.
15. Health Homes must inform and engage staff in quality–related activities. This is vitally important to the success of the QMP. Health Homes will provide training regarding the QMP to new staff, and ongoing as needed to support successful quality outcomes through staff inclusion. In addition, Health Homes will ensure that Health Home care management agencies receive QMP training to support a culture of quality, for example: inclusion in core curriculum provided by Health Homes for their care management agency network; and, review key principles at the onset of each quality improvement initiative.

References:

1. CMS.gov. "QAPI Description and Background." Center for Medicare & Medicaid Services. page last updated 09/20/2016. https://www.cms.gov/Medicare/Provider–Enrollment–and–Certification/QAPI/qapidefinition.html
2. New York State Department of Health. "NYS Implementation of Health Homes Guidance Documents." Retrieved from: http://devweb.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/med_spa.htm Medicaid State Plan Amendments
3. "Health Homes Provider Manual – Billing Policy and Guidance." Version 2014–1, January 9, 2014. Retrieved from: https://www.emedny.org/ProviderManuals/HealthHomes/PDFS/Health_Homes_Provider_Manual.pdf
4. New York State Department of Health. "Health Homes Serving Children." HHSC Eligibility, Appropriateness, Prioritization and 6 Core Services (PDF). Retrieved from: https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/hh_children/