DCS Comprehensive Health Plan

Proactive Care Coordination

Statement/Purpose

This policy establishes the Department of Child Safety Comprehensive Health Plan (DCS CHP)’s identification of members, through the Quality of Care/Management review process, who may require proactive care coordination, and includes the system for documenting, tracking, trending, and evaluating complaints and allegations received from members and providers regarding services or the AHCCCS Program. This policy functions independently or with policy HS-CC-02 Care Management and HS-CC-03 Identifying Members with Special Health Care Needs.

Maintaining a dedicated process, DCS CHP proactively provides for the appropriate care coordination for members who have multiple complaints regarding services or the AHCCCS Program. This includes, but is not limited to, members who do not meet criteria for case management as well as members who contact governmental entities, including AHCCCS, for assistance.

Definitions

Care Management: A group of activities performed to identify and manage clinical interventions or alternative treatments for identified members to reduce risk, cost, and help achieve better health care outcomes. Distinct from Case Management, Care Management does not include the day-to-day duties of service delivery.

Case Management: A collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes.

Quality of Care (QOC): An expectation that, and the degree to which the health care services provided to individuals and patient populations improve desired health outcomes and are consistent with current professionally recognized standards of care and service provision.

Quality of Care (QOC) Concern: An allegation that any aspect of care, or treatment, utilization of behavioral health services or utilization of physical health care services that caused or could have caused an acute medical or psychiatric condition or an exacerbation of a chronic medical or psychiatric condition and may ultimately cause the risk of harm to an AHCCCS member.

Quality Management (QM): The evaluation and assessment of member care and services to ensure adherence to standards of care and appropriateness of services; can be assessed at a member, provider, or population level.

Incident, Accident and Deaths (IAD): A report entered into the AHCCCS Quality Management (QM) Portal by a provider to document an occurrence that caused harm or may have caused harm to a member and or to report the death of a member.

Internal Referrals (IRF): A report entered into the AHCCCS QM Portal by an employee of a health plan to document an occurrence that caused harm or may have caused harm to a member and or to report the death of a member.

Policy

DCS CHP and its subcontracted MCO are responsible for incorporating a system to identify, document, track, trend, and evaluate grievances, complaints, and allegations per AMPM 960, received from members and providers. The purpose is to proactively and regularly review Quality of Care review process data, which includes IADs, IRFs, QOCs and member grievance and appeal data to:

• Identify members who have filed multiple complaints, grievances, or appeals regarding services, or against the health plan, or

• Identify members who contact governmental entities for assistance, including contacting AHCCCS.

• Identify members who persistently filed complaints over a period of time about multiple, distinct issues.

• Assign a care coordinator to assist the member in navigating the healthcare system, if one is not already assigned, or inform the care coordinator of any additional needs noted to attempt to improve the members’ care experience.

The subcontracted MCO is required to track and trend data which is then submitted to, reviewed by, and considered for action by their QM committee and Medical Director or designee, quarterly or as needed; and reported to DCS CHP.

DCS CHP documents, tracks, trends and evaluates reports per AMPM 960 to identify member data which may require proactive care coordination.

Procedure

Identification of trends related to members who have filed multiple complaints, grievances, or appeals regarding services, or against the contractor, or members who contact governmental entities for assistance, including contacting AHCCCS, for the purposes of assigning an appropriate advocate as needed to assist the member in navigating the health care system and resolve the members concerns.

• DCS CHP QM proactively and regularly obtains and reviews member grievance and appeal data; and

• DCS CHP QM, in conjunction with Grievance & Appeals and representation from all other areas within DCS (as needed), evaluates data monthly to determine whether the reasons for complaint requires:

  • Provider specific concerns may be addressed and tracked through internal and external coordination between DCS CHP and its subcontracted MCO.

  • Members specific interventions: proactive care coordination referrals.

QM monitors members identified in monthly reports as potentially requiring a higher level of coordination. These cases are reviewed during the QM Committee meetings as needed. At the direction of the QM Committee or Medical Director, member concerns may be referred to the Health Services team or Mercy Care CMO if other resolution methods have been unsuccessful.

Operating Protocols

Systems

• DCS CHP’s Grievance and Appeals (G&A) department tracking

• AHCCCS QM portal including QOC (Incident Report Search) and SAR (SAR Cases Search) tracking

Measurements

• Track members filing multiple complaints or identified as needing higher level of coordination to meet their needs;

• Trend the individual member’s complaint volume;

• Distinguish between member complaints stemming from episodic issues and member complaints which indicate a need for higher level of care coordination; and

• Document identified Proactive Care Coordination members within Proactive Care Coordination Tool and discuss outstanding concerns and present summary quarterly in DCS CHP QM Committee Meeting.

Reporting

• Meeting minutes in QM

• Outcomes reporting through QM Committee