Gila River Health Care Corporation
Gila River Health Care Corporation
PROVIDER MANUAL
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Arizona Department of Health Services

Division of Behavioral Health Services
PROVIDER MANUAL
Gila River Regional Behavioral Health Authority Edition

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). Performance Improvement Projects consist of utilizing a comprehensive protocol endorsed by CMS, as described in the AHCCCS Medical Policy Manual (AMPM), Chapter 900 and 42 CFR 438.240. The protocol standards and guidelines help to ensure that Medicaid managed care organizations meet these quality assurance requirements when conducting Medicaid External Quality Review Activities.

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 ADHS/DBHS functional areas (e.g.: network, medical director's office);
    • Statewide contractor performance data and contract monitoring activities;
    • Tracking and trending of complaints, grievance and appeal data and quality of care concerns;
    • 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?
Specific information concerning current PIPs can be found in the ADHS/DBHS Quality Management Plan.

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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 T/RBHA contracted behavioral health providers.

8.4.4 Did you know…?
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 outcomes. 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 contracted providers play an integral role in the implementation of the ADHS/DBHS Performance Improvement Projects (PIPs). Behavioral health providers shall participate with any or all aspects of the PIP implementation process.

There are ten (10) steps to be undertaken when conducting PIPs:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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
  10. 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: 10/25/2011
Effective Date: 12/01/2011

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