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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 health
facilities and services consistent with enrolled persons’
needs and professionally recognized standards of health care for
persons receiving services in OBHL licensed Level I facilities.
ADHS/DBHS has established guidelines for the development and reporting
of medical care evaluation studies and ensures that each T/RBHA
has a review process in place to confirm that required Medical Care
Evaluation (MCE) Studies are undertaken, completed, analyzed, and
utilized to improve care. This section outlines the provider’s
role in this process.
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8.5.2
References
The following citations can serve as additional resources for this
content area:
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
adhere to the MCE study requirements.
8.5.5
Objectives
To establish a method to promote the most effective and efficient
use of available health facilities and services consistent with
patient 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:
- Inpatient
hospitals;
- Mental hospitals;
- Residential
treatment centers and sub-acute facilities accredited by the Joint
Commission on Accreditation of Healthcare Organizations (JCAHO),
the Council on Accreditation (COA) or the Commission on Accreditation
of Rehabilitation Facilities (CARF).
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8.5.6-B. Participating provider responsibilities
and requirements
Request for Registration
By May 31st of each year, each subcontracted inpatient hospital,
mental hospital, residential treatment center or sub-acute facility
provider must submit PM
Form 8.5.1, MCE Study Request for Registration, to
the T/RBHA for the upcoming state fiscal year. Behavioral health
providers should consult PM
Attachment 8.5.1, Instructions for the Completion of MCE Study Forms,
when completing PM
Form 8.5.1.
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 Division 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 provider’s MCE Request for Registration
(see PM
Form 8.5.1).
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 determines the methods
to be used in selecting and conducting medical care evaluation studies
in the subcontracted provider facility. The selection of the MCE
study is the responsibility of the facility that provides the service.
PM
Form 8.5.2, Summary of MCE Methodology, must be used
to describe the proposed methodology and must be submitted to the
T/RBHA within the following timeframes:
By June 30th
of each year, each subcontracted inpatient hospital, mental hospital,
residential treatment center or sub-acute facility provider for
whom the Gila River RBHA is the home RBHA must submit PM
Form 8.5.2, Summary of MCE Methodology for the upcoming
state fiscal year.
Behavioral health
providers should consult PM
Attachment 8.5.1, Instructions for the Completion of MCE Study Forms,
when completing PM
Form 8.5.2.
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Each MCE
Study must:
- Identify
and analyze medical or administrative factors related to the subcontracted
provider facility’s patient care;
- Include
analysis of at least the following:
- Admissions;
- Duration
of stay;
- Ancillary
services provided including drugs and biologicals; and
- Professional
services performed;
- If indicated,
contain recommendations for changes beneficial to enrolled persons,
staff, the facility and the community; and
- Use data
obtained from one or more of the following sources: medical records
of other appropriate subcontracted provider facility data; design
profiles and produce other comparative data; and/or cooperative
endeavors with Peer Review Organizations, fiscal agents, other
service providers or other appropriate agencies. Secondary data
sources, such as external organizations that compile statistics,
may be utilized to supplement the above referenced data sources.
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 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 will recommend, as appropriate,
more effective and efficient facility care procedures or designate
certain providers or categories of admissions for review prior
to admission.
- 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.
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.
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8.5-Medical
Care Evaluation Studies
Last Revised: 10/20/2005
Effective: 05/01/2006 |
