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8.5.1
Introduction
Medical Care Evaluation (MCE) Studies are an established method
to promote the most effective and efficient use of available services consistent with
behavioral health recipient needs and professionally recognized standards of care for
persons receiving treatment in an Arizona Department of Health
Services/Division of Behavioral Health/Office of Behavioral Health
Licensing licensed Level I facility. ADHS/DBHS has established guidelines for the development and reporting
of MCE studies and ensures that each Tribal/Regional Behavioral
Health Authority (T/RBHA) has a review process in place to confirm
that required MCE Studies are undertaken, completed, analyzed, and
utilized to improve behavioral health recipient care. This section outlines the provider’s
role in this process.
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8.5.2
References
8.5.3
Scope
To Whom Does this Apply?
- All OBHL
licensed Level I subcontracted providers.
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8.5.4
Did you know...?
- T/RBHAs
must ensure that all OBHL licensed Level I subcontracted providers
(See Participating providers)
adhere to the MCE study requirements.
ADHS/DBHS will ensure the
systematic application of MCE study topics and methodologies across T/RBHAs via
review of statewide utilization data trends. T/RBHA proposed MCE study proposals,
study methodologies and supporting data will be reviewed via the ADHS/DBHS MM/UM
Committee. Final approval of ADHS/DBHS systemic MCE studies will occur at the
ADHS/DBHS MM/UM Committee.
8.5.5
Objectives
To establish a method to promote the most effective and efficient
use of available behavioral health facilities and services consistent with
behavioral health recipient needs and professionally recognized standards of health
care.
8.5.6 Procedures
8.5.6-A. Participating providers
Who participates?
The following provider types must conduct MCE studies:
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8.5.6-B. Participating provider responsibilities
and requirements
Request for Registration
By May 31st of each year, each participating subcontracted Level I provider as described in Section 8.5.6-A must submit PM
Form 8.5.1, MCE Study Request for Registration and Evaluation
Methodology, to
the T/RBHA for the upcoming state fiscal year.
Timeframe
The standard study period for MCE studies starts on July 1st of
each year through June 30th of the succeeding year. Deviations from
this study period and all longitudinal studies must be pre-approved
by the ADHS/DBHS Bureau of Quality Management Operations prior to
initiation. Any request for exemption shall be made in writing and
received by ADHS/DBHS within two (2) weeks from the date the T/RBHA
received the PM
Form 8.5.1, MCE Study Request for Registration and Evaluation
Methodology.
Methodology
For T/RBHA subcontracted providers that provide Title XIX certified
inpatient hospital, mental hospital, residential treatment center
or sub-acute services, the subcontracted provider’s Quality
Management or Utilization Review Committee proposes the methods
to be used in selecting and conducting medical care evaluation studies
in the subcontracted provider facility. The conduction of the MCE
study is the responsibility of the facility that provides the service.
PM
Form 8.5.1, MCE Study Request for Registration and Evaluation Methodology, must be used
to describe the proposed methodology.
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Each MCE
Study must:
- Identify
and analyze medical or administrative factors related to the subcontracted
provider facility’s behavioral health recipient care;
- Include
analysis of at least the following:
- Admissions;
- Length
of stay;
- Ancillary
services provided including drugs and biologicals; and
- Professional
services performed;
- Include recommendations for
improvements beneficial to behavioral health recipients,
staff, the facility and the community; and
- Use data
obtained from one or more of the following sources: dependent on
the scope of the MCE study: medical records
of other appropriate subcontracted provider facility data; profiles and other comparative data; and/or
secondary data
sources, such as external organizations that compile utilization statistics.
Documenting,
Analyzing and Reporting Study Findings
- Each Level
I subcontracted provider facility will document the results of
each study as well as how the results have been used to make changes
to improve the quality of care to behavioral health recipients and promote more effective and
efficient use of facilities and services.
- Each Level
I subcontracted provider facility will analyze its findings for
each study and take action as needed to correct or investigate
any deficiencies or problems in the review process for admissions
or continued stay cases.
- Each Level
I subcontracted provider facility shall recommend, as appropriate,
more effective and efficient facility care procedures based on
study findings.
- Each Level
I subcontracted provider must submit a final MCE study report
to the home T/RBHA by July 31st of each year. This report will
include an in-depth analysis and narrative of how the subcontracted
provider facility plans to use the information to improve care.
To provide the final study report, please see PM Form 8.5.2 Medical
Care Evaluation – Provider and T/RBHA Review of Final Results. If the
final results are not approved by the home T/RBHA, any requests for
provider follow up to final results should be submitted to the home
T/RBHA. Final MCE study reports are to be submitted to the Gila River
RBHA QM/UM Manager utilizing PM
Form 8.5-GR, Medical Care Evaluation (MCE) Final Report. Please contact
Gila River BHS QI Manager at 602-528-7100 for further information regarding the
submission of MCE studies.
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8.5-Medical
Care Evaluation Studies
Last Revised: 06/01/2010
Effective: 07/15/2010 |
