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8.4.1
Introduction
The Arizona Department of Health Services/Division of Behavioral Health Services
(ADHS/DBHS) is committed to establishing high quality behavioral health
services. One method for achieving this is through adherence to
the standards and guidelines set by the Centers for Medicare and
Medicaid Services (CMS). ADHS/DBHS adheres to CMS standards and guidelines and,
in turn, promotes improvement in the quality of the behavioral health care provided
to behavioral health recipients through the development and implementation of
Performance Improvement Projects (PIPs). Conducting Performance Improvement Projects
consists of utilizing a comprehensive protocol endorsed by CMS, as described in the
AHCCCS Medical Policy Manual (AMPM), Chapter 900.
For Medicaid, the standards and guidelines used in the protocol
for conducting Medicaid External Quality Review Activities ensure
that Medicaid managed care organizations meet the quality assurance
requirements set forth in
42 CFR 438.240.
What are
performance improvement projects (PIPs)?
A PIP is a systematic process designed to:
- Identify, plan and implement
system interventions to improve the quality of care and services provided to behavioral
health recipients;
- Evaluate
and monitor the effectiveness of system interventions and data on an ongoing basis; and
- Result in significant performance
improvement sustained over time through the use of measures and interventions.
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PIPs are designed
to:
- Demonstrate
achievement and sustainment of improvement for significant aspects
of clinical care and non-clinical services; and
- A clinical study topic would be one for which outcome indicators measure a
change in behavioral health status or functional status; and
- A non-clinical or administrative study topic would be one for which indicators measure changes in member satisfaction
or processes of care.
- Correct
significant systemic issues that come to the attention of ADHS/DBHS
in part through:
- Data from DBHS functional
areas (e.g.: network, clinical);
- Statewide contractor
performance data and contract monitoring activities;
- Tracking
and trending of complaints/allegations of abuse
- Provider
credentialing and profiling as well as other oversight activities
such as chart reviews;
- Quality Management/Utilization
Management data analysis and reporting; and
- Member
and/or provider satisfaction surveys and feedback.
What PIPs
are currently included in the Quality Management Utilization Management Annual Plan and Work Plan?
Currently there are two ongoing PIP projects that address clinical topics. Specific information concerning current PIPs can be found in the
ADHS/DBHS Quality Management Utilization Management Plan and Work Plan.
The projects are:
Child and Family Team (CFT) Performance Improvement Project
The Child and Family Team ((CFT) practice is the foundation for assisting children and families in the recovery process and ensures providers are adhering to the Arizona Vision and the 12 Principles. This performance improvement project addresses fidelity to the CFT process (as measured through the Wraparound Fidelity Index) improves outcomes for children. Ongoing monitoring and evaluation of interventions will occur throughout year two of this project.
Recovery Through Employment For Individuals With Serious Mental Illness
ADHS/DBHS believes that recovery for individuals with Serious Mental Illness is dependent on a philosophy that work and economic self-sufficiency are an integral part of service planning an that meaningful work provides opportunities for community integration and reduces the need for expensive mental health interventions. The Division has engaged in and facilitated a variety of activities in order to identify barriers to individuals with Serious Mental Illness gaining and maintaining employment as well as possible solutions to identified barriers. This PIP suggests a statewide focus to identify if increased supported employment and Psychoeducational service utilization leads to an increase in employment rate for persons with a Serious Mental Illness.
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8.4.2
References
The following citations can serve as additional resources for this
content area:
8.4.3
Scope
To Whom Does this Apply?
T/RBHAs and
their subcontracted behavioral health providers.
8.4.4
Did you know…?
The Performance Improvement Project (PIP) protocol includes
activities that public and private sector tools have in common.
The PIP protocol
is based on a guidebook produced by the National Committee for Quality
Assurance (NCQA) under a contract with CMS. The guidebook is entitled
"Health Care Quality Improvement Studies Managed Care Settings:
A guide for State Medicaid Agencies."
8.4.5 Definitions
Interventions
Sound Methodology
Statistical Significance
Study Indicator
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8.4.6
Objectives
To ensure that T/RBHAs and their subcontracted providers
understand and actively participate in the implementation of the PIPs.
The
purpose of a health care quality PIP
is to assess and improve processes, and thereby outcomes, of care.
In order for such projects to achieve real improvements in care,
and for interested parties to have confidence in the reported improvements, PIPs must be designed, conducted and reported in manner that utilizes sound methodology.
8.4.7
Procedures
T/RBHA subcontracted providers play an integral role in
the implementation of the ADHS/DBHS Performance Improvement Projects
(PIPs). Behavioral health providers may be asked to participate
with any or all aspects of the PIP implementation process.
There are ten
(10) steps to be undertaken when conducting PIPs:
- Select the
study topic(s). In general, a clinical or non-clinical issue selected
for study should affect a significant number of behavioral health
recipients and have a potentially significant impact on health,
functional status or satisfaction.
- Define the
study question(s). It is important to clearly state, in writing,
the question(s) the study is designed to answer. Stating the question(s)
helps maintain the focus of the PIP and sets the framework for
data collection, analysis, and interpretation.
- Select the
study indicator(s). A study indicator is a quantitative or qualitative
characteristic reflecting a discrete event (e.g., a behavioral health recipient
has stopped taking medication and has experienced a crisis which resulted in
hospitalization), or a status
(e.g., a behavioral health recipient has/has not experienced a crisis
that resulted in hospitalization) that is to be measured. Each project should have one or
more quality indicators for use in tracking performance and improvement
over time.
- Use a representative
and generalizable study population. Once a topic has been selected,
measurement and improvement efforts must be system-wide. A decision
needs to be made as to whether to review data for the entire population
or use a sample of the population.
- Use sound
sampling techniques (if sampling is used). If a sample is to be
used to select members of the study, proper sampling techniques
are necessary to provide valid and reliable information on the
quality of care provided. When conducting a study designed to
estimate the rates at which certain events occur, the sample size
has a large impact on the level of statistical confidence in the
study estimates.
- Reliably
collect data. Procedures used to collect data for a given PIP
must ensure that the data collected on the PIP indicators are
valid and reliable. Validity is an indication of the accuracy
of the information obtained. Reliability is an indication of the
repeatability or reproducibility of a measurement. Potential sources
of data include administrative data (e.g., enrollment, claims,
encounters), medical records, tracking logs, results of any provider
interviews and results of any recipient interviews and surveys.
Data can be collected from either automated data systems or by
a manual review of records.
- Implement
intervention and improvement strategies. Real, sustained improvements
in care result from a continuous cycle of measuring and analyzing
performance, and developing and implementing system-wide improvements
in care. Actual improvements in care depend on thorough analysis
and implementation of appropriate solutions.
- Analyze
data and interpret study results. Data analysis begins with examining
the performance on the selected clinical or non-clinical indicators.
The analysis of the study data should include an interpretation
of the extent to which the PIP was successful and what follow-up
activities are planned as a result.
- Plan for
“real” improvement. When a change in performance is
found, it is important to know whether the change represents “real”
change or random chance. This can be assessed in several ways,
but is most confidently done by calculating the degree to which
an intervention is statistically significant; and
- Achieve
sustained improvement. Real change results from changes in the
fundamental processes of health care delivery. Such changes should
result in sustained improvements. In contrast, a one-time improvement
can result from unplanned accidental occurrences or random chance.
If real change has occurred, the project should be able to achieve
sustained improvement.
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8.4
Performance Improvement Project
Last Revised: 09/15/2009
Effective Date: 09/15/2009 |
