Quality Assurance Improvement Encompass Health Home

Quality assurance improvement encompass health home

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Care Management
Policy & Procedure Manual
Care Management Policy #24 – Quality Management: Assurance and Improvement (QA/QI)
Effective Date: 2/1/16
Revised Date: 9/1/16, 10/1/16, 1/2/17, 3/31/17, 6/1/17, 7/17/17, 11/1/17, 1/30/18, 2/9/18
With a passion for health and compassion for all people, Encompass Health Home is committed to connecting
Participants/Families to their chosen supports and services, in a way that is respectful to their preferences,
culturally sensitive to their needs and directed in a way to promote the most positive outcomes for mind, body
and spirit

To achieve this, Encompass Health Home will maintain an effective Quality Management program by collecting
and reviewing available data and developing strategies designed to improve and maintain the quality of
Participant services and outcomes, as well as the performance of contracted Care Management Agencies

A. The Quality Management program will be implemented and overseen by the Director of Quality
Management; with the support of the Policy and Compliance Coordinator, and the involvement and
participation of the Health Home Administrative Team

B. Care Management Staff/Supervisors will be trained on quality initiatives and processes upon hire

C. The Health Home will collect and review data from multiple sources, to evaluate outcomes, quality,
processes, care coordination effectiveness and CMA performance

1. The Health Home will analyze necessary data to measure the effectiveness of Care
Coordination on Participant’s chronic disease management and overall improvement of quality
of life

D. Information gained will be shared continuously with CMAs, during Provider Meetings, as well as one-
on-one consultation with individual CMAs as needed

1. Provider meetings will be utilized additionally to share and develop best practices for the Health
Home, and for providing CMAs with needed support and development

2. CMAs will provide representation at each scheduled meeting, or request call-in information to
participate via teleconferencing

E. CMAs will be trained on Health Home requirements during the orientation process, and instructed on
the use of audit tools, required reporting and plan of correction processes

F. The Health Home will provide training and instruction as needed to define new initiatives; roll out new
policies and procedures; and address deficiencies found as part of the Quality Management oversight

G. QA/QI issues will be discussed as needed during regular Provider meetings

H. The Health Home will review and monitor clinical outcomes and CMA performance based on the
following processes:
1. State level reports will be reviewed and assessed by the Health Home and CMAs for needed
improvements as follows:
i. State Plan Quality Measures Report and Center for Medicare and Medicaid Services
(CMS) Measures
a. The Health Home will review data when received to determine Health Home and
CMA performance regarding:
1) Utilization associated with avoidable (preventable) inpatient stays;
2) Utilization associated with avoidable (preventable) emergency room
3) Outcomes for persons with mental illness (SMI), serious emotional
disturbance (SED), Complex Trauma and/or substance use disorders;
Care Management
Policy & Procedure Manual
Care Management Policy #24 – Quality Management: Assurance and Improvement (QA/QI)
4) Clinical outcomes for appropriate disease-related care for chronic
conditions, including HIV/AIDS;
5) Appropriate delivery of preventative care

b. The Health Home will share results with CMAs to develop specific improvements
on performance and delivery of services

ii. Medicaid Analytics Performance Portal (MAPP)
a. MAPP dashboards will be accessed by the Health Home and CMAs monthly to
track agency performance regarding enrollments; HARP services; ER utilization;
inpatient utilization, and utilization of Primary care, to gain insight into improving
Care Management services related to the population served

b. The Health Home will track trends and performance issues and will provide
feedback and guidance to CMAs accordingly, either through provider meetings or
directly with the CMA when needed

iii. Health Home Quarterly Capacity Report
a. The Health Home will monitor CANS-NY completions, type and acuities through
monthly billing reports

1) The Health Home will review appropriateness of reassessments and
acuity changes by reviewing supporting documentation found in the
Netsmart record, and will notify the CMA of any concerns or issues

2) The Health home will review CANS-NY assessments and reports in the
UAS as needed, but no less than quarterly for accuracy

b. The CMA will submit the Caseload Spreadsheet to the Heath Home on a monthly
basis, identifying Care Manager caseloads and acuities

c. The Health Home will contact the CMA if caseloads fall outside of the established

d. The Health Home will compile and forward data containing CMAs caseload
information to DOH on a Quarterly basis through the Capacity Report

e. The Health Home will compare monthly reports to the Quarterly Capacity Report
for accuracy and for tracking caseload sizes within other Health Homes, and will
follow up with CMAs that require additional information or review

f. The Health Home will respond to any DOH requests for additional information
regarding monitoring of caseload and acuity

g. Additional monitoring of caseloads and acuities will occur during auditing of

iv. The HH will develop reports from Netsmart regarding all required Care Management
activities and submit to DOH through the HCS portal, utilizing the Care Management
Assessment Reporting Tool (CMART-3) on a quarterly basis, the first Monday of the
second month following the close of the reporting period

a. This includes data regarding:
1) Number of assessments performed (excluding CANS-NY);
2) The volume and type of interventions (Outreach/Core Services and
3) Number of Plans of Care developed

b. The Health Home will review and fix any errors and resend data if necessary

c. The Health Home will analyze turnaround CMART-3 data from DOH in regards to
the percentage of Participants who received at least 1 intervention, and those
who did not, to evaluate and develop additional strategies for improvement

Care Management
Policy & Procedure Manual
Care Management Policy #24 – Quality Management: Assurance and Improvement (QA/QI)
v. The Health Home will share results of DOH audits/visits or technical assistance as they

2. Managed Care level reports will be reviewed by the Health Home and CMAs and assessed as
i. The Health Home will review reports received from Managed Care Organizations
identifying specific gaps in care for Participants. These reports will be inclusive of
performance measures under the Quality Assurance Reporting Requirements (QARR)
and will be evaluated and shared with the appropriate CMAs, who will report back to the
Health Home, measures taken and/or the plan to fill identified care gaps, within 2
business days

ii. MCOs who are accredited through National Committee for Quality Assurance (NCQA)
will provide the Health Home with performance and compliance results based on NCQA
standards through audits, evaluations of Healthcare Effectiveness Data and Information
Set (HEDIS) and other measures

iii. MCOs will monitor performance of the Health Home and CMAs through auditing, and the
use of oversight tools and outcome measures

iv. The Health Home will follow-up with CMAs as needed to address and reduce care gap
trends as well as provide guidance and recommendations as necessary

3. Additional Health Home level monitoring will occur as follows:
i. Health Home outreach and engagement, Care Management (case record) and billing
audits will be conducted with CMAs minimally on a bi-annual basis. This includes a
comparison audit once a year with records that have been previously reviewed by the
CMA during their quarterly audits. These comparison audits will assist in ensuring
quality assurance is being maintained throughout the CMA internal auditing process

The audit results will be immediately shared to provide feedback and support, and the
Health Home will assist the CMA in developing a corrective action/performance
improvement plan for any areas scoring 65% or below within 30 days of the audit if

a. Performance Improvement Plans will include:
1) Specific expectations and timeframes for improvement;
2) Recommendations for additional training or Health Home support;
3) Time frames for required response and follow-up;
4) Possible sanctions or additional corrective action that may be imposed if
improvements do not occur

b. Follow up to the corrective action plan will be provided as documented, including
time frames for improvement, based on the seriousness of the deficiency. (See
attached audit tools)
c. Additional audits will be conducted/scheduled as needed based on findings, to
monitor needed improvements

ii. The Health Home will track CMA complaints and incidents to monitor CMA performance
as well as incident trends. The Health Home will provide assistance regarding resolution
of complaints and incidents per the Complaints/Incident Policy

a. Corrective action/performance improvement plans will be initiated as needed to
address performance expectations and Health Home standards not met, as
discovered during the Incident review/investigative process

Care Management
Policy & Procedure Manual
Care Management Policy #24 – Quality Management: Assurance and Improvement (QA/QI)
iii. A Participant/Family satisfaction survey of Health Home Services will be conducted twice
a year. The Health Home will forward surveys and return envelopes to the CMAs for
distribution to those Participants/Families seen during the survey week. Surveys will be
returned directly to the Health Home for evaluation. Surveys will be used to identify
levels of satisfaction with Care Management services as well as the perceived value of
the service that is offered. Results from the surveys will be analyzed by the Health
Home, and shared with CMAs as part of the Quality Improvement cycle

iv. The Health Home will perform a site visit with CMAs within 3-9 months of initial
Participant assignments to evaluate adherence to standards, and provide additional
guidance and instruction

a. Site visits may also be conducted in conjunction with documented corrective
action plans

b. Initial site visits will address at a minimum:
1) Review of appropriate written policies and procedures for Care
2) Care Manager clearances, qualifications and appropriate caseloads for
service tier;
3) Completion of training requirements;
4) Appropriate documentation of services and use of Netsmart;
5) A review of Incidents and internal quality processes and initiatives;
6) Review of chart audits and needed corrective action

c. Additional site visits will be scheduled as needed to provide required follow-up
and/or technical assistance for necessary improvements

4. Care Management Agencies will be responsible for developing internal monitoring/auditing
protocols for case records; caseloads; outreach and engagement processes; effective
preventive care and disease management; complaints/incidents and billing functions. The CMA
will utilize the Health Home audit tools to conduct quarterly audits, and will report outcomes to
the Health Home. CMAs will distribute QA information from their audits, the Health Home and
other oversight agencies to Care Managers as needed, in order to improve individual Care
Manager performance

i. CMAs will have a plan to review and audit Participant records. These audits will include
records from all Care Managers, as well as Participants that are enrolled, in outreach or

a. CMAs will conduct quarterly audits on a minimum of 2 records per Care

b. CMAs will forward quarterly audit tool and summary of results to the Health
Home as follows:
1) January-March due April 15th;
2) April –June due July 15th;
3) July-September due October 15th;
4) October-December due January 15th

c. The Health Home will review CMA audits, provide feedback, and offer assistance
with developing individualized corrective action plans that may be required for
areas that do not meet minimal standards

1) Health Home will follow up with the CMA within 3 months after corrections
have been made, to assure understanding of needed corrections, and to
offer feedback for sustaining performance

Care Management
Policy & Procedure Manual
Care Management Policy #24 – Quality Management: Assurance and Improvement (QA/QI)
d. Additional corrective action measures regarding CMA performance will be
formally developed as needed

1) CMA performance may impact additional Participant assignments until
identified improvements occur and are sustained

ii. CMAs will develop processes to evaluate Participant utilization of services, care
coordination effectiveness and continued need for services

a. Reviews for adult Participants will be completed no less than every 6 months,
and may be completed and documented in conjunction with the interdisciplinary
team meeting

b. Reviews for children will be completed no less than quarterly, and can occur as
part of the family wraparound

c. CMAs will regularly utilize clinical information and available data from RHIOS,
PSYCKES (BH-QARR), MCOs and MAPP dashboards to monitor care
coordination effectiveness, and develop improvements to service delivery

iii. CMAs will investigate and resolve complaints and incidents to ensure Participant
satisfaction; prevent re-occurrence; promote the ongoing delivery of quality services and
protection of Participant rights; and maintain the health and welfare of Health Home
Participants as indicated fully in the Complaint and Incident Monitoring/Investigation

iv. CMAs will support the Health Home Satisfaction Survey process twice a year, by
encouraging each Participant/Family to complete the survey when received, to provide
valuable input and recommendations for improved services to the Health Home

a. It is recommended that the CMA conduct an internal Participant satisfaction
survey at a minimum frequency of once a year, in addition to the surveys
conducted by the Health Home, at an interval that does not interfere with the
Health Home Survey. These surveys can elicit other specific CMA feedback and
suggestions for improvement of service delivery

b. The CMA will report on survey results, revealing trends and action steps to
improve care. These reports will be sent to the Health Home Policy and
Compliance Coordinator

v. CMAs will provide regular supervision for employees at all levels. Supervision will
include identifying strengths and how to best utilize them as well as identifying areas in
need of improvement

a. Supervision outcomes will be documented and reevaluated at least annually,
during yearly Performance Evaluation

b. Remediation or training will be provided to address any areas in need of
improvement as appropriate

c. Suggestions for regular Supervision content include:
1) Monitoring progress of Care Managers towards learning the skills
required for Care Management;
2) Reflecting on training and development activities contributing to effective
care coordination, and identifying any continued outstanding needs;
3) Providing feedback on performance and the delivery of quality services;
4) Providing support, direction, consultation and guidance on individual
cases, including guidance on providing culturally competent services;
5) Providing oversight of appropriate care coordination activities, including
transitional care and needed follow-up that meets Health Home
Care Management
Policy & Procedure Manual
Care Management Policy #24 – Quality Management: Assurance and Improvement (QA/QI)
6) Reviewing documentation for accuracy, timeliness, completion and
understanding of Care Management role;
7) Ensuring Care Managers are assigned caseloads that maintain Health
Home standards of size and acuity;
8) Ensuring policies/procedures and standards are understood and met

I. Health Home QA/QI Committee
1. The Health Home will meet with CMA representatives, on at least a quarterly basis, to focus on
issues related to quality and CMA performance. These meetings will provide education,
guidance and information specific to the identified needs of CMAs to assist them with targeting
identified areas for improvement

i. The meetings will provide additional feedback to the Health Home to develop additional
quality measures as needed, and will provide CMAs an opportunity to share best
practices with other CMAs within the Health Home

2. The Health Home will develop and chair a QA/QI Committee that meets quarterly, to provide
oversight and evaluation of the Health Homes Quality Management program

i. The QA/QI Committee will consist of representatives from CMAs; Providers; Clinicians;
and Health Home Management

a. Additional representation will be solicited as needed in response to identified
QA/QI needs

ii. Meetings will be facilitated by the Committee Chairperson, and will be assisted by the
Director of Quality Management

iii. The Committee will review Health Home reports to oversee and provide guidance on
meeting performance goals and quality initiatives, including:
a. Monitoring corrective action and performance improvement plans/efforts for
b. Reviewing Incidents for trends and appropriate follow-up;
c. Prioritizing quality initiatives based on available data and analytics;
d. Identifying barriers and needed resources/training to support improvements;
e. Making recommendations for changes in service provision, operations and/or
policies and procedures that support quality performance goals;
f. Reviewing initiatives on a yearly basis, and making necessary revisions and

iv. The Committee will provide documentation to present to the Encompass Board on a
quarterly basis, identifying progress towards quality goals and outcomes

J. Corporate Compliance
1. CMAs will have an active Corporate Compliance program inclusive of the following:
i. Written standards of conduct, policies and procedures that demonstrate the CMA’s
commitment to compliance implementation;
ii. Designated Compliance Officer to monitor and enforce standards;
iii. Regular training and education on corporate compliance and those standards specific to
the CMA, Health Home and billing;
iv. Periodic internal monitoring and compliance audits;
v. Monitoring of both internal and external audits to detect potential for compliance-related


Quality assurance is being maintained throughout the CMA internal auditing process. The audit results will be immediately shared to provide feedback and support, and …

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Frequently Asked Questions

What is an internal quality assurance and improvement program?

Internal quality assurance and improvement programs are developed and used by provider organizations of their own accord as a way to improve the systems and processes that help them realize the goal of providing excellent care that continues to improve over time (JCAHO, 1994).

How do you implement quality assurance and improvement strategies in home care?

How actually to implement quality assurance and improvement strategies can be a complicated proposition, particularly given the remarkable diversity of the population receiving home and community-based care. Substantive evaluation never relies on only one type of measure or approach.

What is an effective quality assurance program?

Put another way, an effective quality assurance program is not an end in itself; rather, it is a means of maintaining and improving care (O'Leary, 1988). NCBI Skip to main content

What is the purpose of the health home quality improvement program?

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