Procedures - Quality Improvement Program

	LOS ANGELES COUNTY DEPARTMENT OF MENTAL HEALTH
	POLICY 1100.01 Quality Assurance and Performance Improvement Program
	PROCEDURES

A. Quality Assessment and Performance Improvement (QAPI)

1. The Los Angeles County Department of Mental Health (DMH) shall implement an ongoing comprehensive QAPI Program for the covered services it furnishes to Medi-Cal members, including quality management. (42 C.F.R. § 438.330(a)(1).) The QAPI Program:
  1. Shall be administered by a licensed mental health professional who has adequate knowledge of Quality Improvement (QI) and data, ensuring a robust data-driven approach.
  2. Shall address Specialty Mental Health Services (SMHS) and describe strategies to ensure access to coordinated and culturally responsive care for members.
2. The QAPI Program shall improve established outcomes through structural and operational processes and activities that are consistent with current standards of practice.
3. DMH shall have a written description of the QAPI Program that clearly defines the QAPI Program’s structure and elements, assigns responsibility to appropriate individuals, and adopts or establishes quantitative measures to assess performance and to identify and prioritize area(s) for improvement. DMH shall evaluate the impact and effectiveness of its QAPI Program annually and update the Program as necessary. (42 C.F.R. § 438.330(e)(2); 9 C.C.R. § 1810.440(a)(6).)
4. The QAPI Program shall include collection and submission of performance measurement data required by the Department of Health Care Services (DHCS), which may include performance measures specified by Centers for Medicare and Medicaid Services (CMS). (42 C.F.R. § 438.330(a)(2).)
  1. DMH shall measure and annually report to DHCS its performance, using the standard measures identified by DHCS. (42 C.F.R. § 438.330(b)(2), (c)(2).)
  2. The monitoring of accessibility of services outlined in the Quality Improvement (QI) Work Plan will at a minimum include:
    1. Timeliness of first initial contact to face-to-face appointment or synchronous video or audio-only interaction, consistent with BHIN 23-018 or any subsequent guidance from DHCS.
    2. Frequency of follow-up appointments.
    3. Access to after-hours care.
    4. Responsiveness of the member access line.
    5. Strategies to reduce avoidable hospitalizations.
    6. Coordination of physical, mental health, and substance use disorder (SUD) services at the provider level.
    7. Assessment of the members’ experiences.
    8. Telephone access line and services in the prevalent non-English languages.
  3. With respect to the data elements required for External Quality Review (EQR), as described below, DMH’s QAPI Committee (as defined below) shall review performance measurement data at a minimum on a quarterly basis.
5. DMH shall conduct performance monitoring activities throughout its operations. These activities shall include, but not be limited to, member and system outcomes, utilization management, utilization review, provider appeals, credentialing and monitoring, and resolution of member grievances.
6. DMH shall have mechanisms to detect both underutilization of services and overutilization of services. (42 C.F.R. § 438.330(b)(3).)
7. DMH shall implement mechanisms to assess member/family satisfaction. Member/family satisfaction shall be assessed by:
  1. Surveying member/family satisfaction with services at least annually;
  2. Evaluating member grievances, appeals and State Hearings at least annually; and
  3. Evaluating requests to change persons providing services at least annually.
8. DMH shall inform providers of the results of member/family satisfaction activities described above.
9. DMH shall implement mechanisms to monitor the safety and effectiveness of medication practices. The monitoring mechanism shall be under the supervision of a person licensed to prescribe or dispense prescription drugs. Monitoring shall occur at least annually.
10. DMH shall implement mechanisms to address meaningful clinical issues affecting members system-wide.
11. DMH shall implement mechanisms to monitor appropriate and timely intervention of occurrences that raise quality of care concerns. DMH shall take appropriate follow-up action when such an occurrence is identified. The results of the intervention shall be evaluated by DMH at least annually.
12. The QAPI Program shall include Performance Improvement Projects (PIPs) as specified below.
13. DMH shall ensure continuity and coordination of care with other managed care plans and medical providers. DMH shall coordinate with other human services agencies used by its members. DMH shall assess the effectiveness of any Memorandum of Understanding (MOU) with a managed care plan.
Quality Improvement (QI) Work Plan
1. DMH shall have a Quality Improvement (QI) Work Plan covering the current Contract cycle with DHCS with documented annual evaluations and documented revisions as needed. The QI Work Plan shall include:
  1. Evidence of monitoring activities including:
    1. Maintaining, and reviewing member grievances, appeals, expedited appeals, State Hearings, expedited State Hearings, provider appeals, and clinical records reviews as required by 9 C.C.R. section 1810.440(a)(5) and 42 C.F.R. section 438.416(a) and under the DHCS Contract; and
    2. Performance measurement data monitoring the accessibility of services, as specified above.
  2. Evidence that QI activities, including PIPs, have contributed to meaningful improvement in clinical care and member services.
  3. A description of completed and in-process QI activities, including PIPs. The description shall include:
    1. Monitoring efforts for previously identified issues, including tracking issues over time;
    2. Objectives, scope, and planned QI activities for each year; and,
    3. Targeted areas of improvement or change in service delivery or program design.
  4. A description of mechanisms DMH has implemented to assess the accessibility of services within its service delivery areas.
  5. Evidence of compliance with the requirements for cultural competence and language and format.
2. DMH will submit its QI Work Plan to DHCS upon request, including in connection with any reporting under the Behavioral Health Services Act.
QAPI Committee and Program
1. DMH’s QAPI program shall monitor DMH’s service delivery system with the aim of improving the processes of providing care and better meeting the needs of its members.
2. DMH shall establish and convene a QAPI Committee to review the quality of covered services provided to members. The QAPI Committee shall recommend policy decisions; review and evaluate the results of QI activities, including PIPs; institute needed QI actions; ensure follow-up of QI processes; and document QAPI Committee meeting minutes regarding decisions and actions taken.
3. The QAPI Program shall be accountable to DMH’s Director.
4. Operation of the QAPI program shall include substantial involvement by a mental health Licensed Practitioner of the Healing Arts (LPHA), as applicable for the services covered under the Contract with DHCS. (9 C.C.R. § 1810.440(a)(4).)
  1. DMH’s QI program will include substantial involvement by a mental health LPHA and involvement by a SUD LPHA.
5. DMH’s practitioners and providers, members who have accessed specialty mental health through DMH, family members, legal representatives, or other persons similarly involved with members as described in 9 C.C.R. § 1810.440(a)(2)(A-C) shall be actively involved in the planning, design and execution of the QI Program.
6. QI activities shall include:
  1. Collecting and analyzing data to measure against the goals or prioritized areas of improvement that have been identified;
  2. Identifying opportunities for improvement and deciding which opportunities to pursue;
  3. Identifying relevant committees internal or external to DMH to ensure appropriate exchange of information with the QAPI Committee;
  4. Obtaining input from providers, members and their family members in identifying barriers to delivery of clinical care and administrative services;
  5. Designing and implementing interventions for improving performance;
  6. Measuring effectiveness of the interventions; and
  7. Incorporating successful interventions into operations as appropriate.
PIPs
1. DMH shall conduct a minimum of two PIPs per year, including any PIPs required by DHCS or CMS (42 C.F.R. § 438.330(a)). DHCS may require additional PIPs. One PIP shall focus on a clinical area and one on a non-clinical area. (42 C.F.R. § 438.330(b)(1) and (d)(1).) Each PIP shall:
  1. Be designed to achieve significant improvement, sustained over time, in health outcomes and member satisfaction; (42 C.F.R. § 438.330(d).)
  2. Include measurement of performance using objective quality indicators; (42 C.F.R. § 438.330(d)(2)(i).)
  3. Include implementation of interventions to achieve improvement in the access to and quality of care; (42 C.F.R. § 438.330(d)(2)(ii).)
  4. Include an evaluation of the effectiveness of the interventions based on the performance measures collected as part of the PIP; (42 C.F.R. § 438.330(d)(2)(iii).) and,
  5. Include planning and initiation of activities for increasing or sustaining improvement. (42 C.F.R. § 438.330(d)(2)(iv).)
2. DMH shall report the status and results of each PIP to the Department as requested, but not less than once per year. (42 C.F.R. § 438.330(d)(3).)
3. Each PIP shall be completed in a reasonable time period so as to generally allow information on the success of PIPs in the aggregate to produce new information on quality of care annually. (42 C.F.R. § 438.330(d)(3).)
Practice Guidelines
1. DMH shall adopt practice guidelines. (42 C.F.R. § 438.236(b) and 9 C.C.R. § 1810.326)
2. Such guidelines shall meet the following requirements (42 C.F.R. § 438.236(b):
  1. They are based on valid and reliable clinical evidence or a consensus of health care professionals in the applicable field;
  2. They consider the needs of the members;
  3. They are adopted in consultation with network providers; and
  4. They are reviewed and updated periodically as appropriate.
3. DMH shall disseminate the guidelines to all affected providers and, upon request, to members and potential members. (42 C.F.R. § 438.236(c).)
4. DMH shall take steps to assure that decisions for utilization management, member education, coverage of services, and any other areas to which the guidelines apply shall be consistent with the guidelines. (42 C.F.R. § 438.236(d).)