network administration - council on accreditationcoanet.org/standard/net/purpose.pdfnetwork...

Network Administration

Purpose

Network services are delivered to adefined population through an integratednetwork of providers with the goal ofensuring optimal access, quality of care,and consumer satisfaction.

DEFINITION

COA's Network Administration standards apply to network managemententities (NME) and address core administrative practices that contribute tothe effective management and coordination of an integrated network ofservice providers.

There are many types of networks and any number of ways that a networkcan be organized. It could be said that every service-provider network isunique. This is due to many factors that can include: the needs anddemographics of the population being served; the availability--bothgeographically and numerically--of qualified providers and providerorganizations; whether the network was formed in response to a legislativeor regulatory mandate or was formed voluntarily; its mission and mandates;whether it was formed to realize administrative efficiencies, create a systemof care, or compete for managed care contracts; and others.

In all cases, high-functioning service networks provide individuals andfamilies with services that are appropriate to their needs and are provided ina timely manner by qualified providers.

Interpretation: Networks generally are in business to ensure and managethe quality of services provided to covered persons and families.

Note: Core administrative practices related to the administration andmanagement of networks are not limited to the Network Administrationstandards, but are also reflected in each of the Administration andManagement and Service Delivery Administration standards sections forPrivate organizations.

Note: Please see Policies and Procedures Manual - Network for additionalassistance with this standard.

Note: Please see NET Reference List for a list of resources that informedthe development of these standards.

Table of Evidence

Self-Study Evidence

- Provide an overview of the different programs being accredited underthis section. The overview should describe: a. the program's service philosophy and approach to delivering

services;b. eligibility criteria;c. any unique or special services provided to specific populations;

andd. major funding streams.

Council on Accreditation - Copyright 2018


Purpose


- How are the network's services funded?- Describe how your organization manages communication with

providers throughout the network.- Describe the scope of the network's utilization management activities

(e.g., Does utilization management include authorization that isexternal to the provider? Is it limited to establishing criteria, reportingutilization data, and retrospective reviews?).

- How does the network/lead agency monitor the quality of its servicesnetwork-wide?

- Provide any additional information that would be useful to the PeerTeam.

- Updated list of contractors with contact information, services providedto the network, accredited or not, and if so by whom.

- Network Organization chart- Completed Network Standards Matrix

On-Site Evidence

No On-Site Evidence

On-Site Activities

No On-Site Activities



Purpose


NET 1: Network Characteristics

The network operates through a centralized entity or structure that providesfor the integration and coordination of services of participating entities orcommunity partners.

Table of Evidence

Self-Study Evidence

- Mission Statement- Articles of Incorporation/Bylaws- List of Governing Body and Advisory Body members and affiliations- A narrative describing organizational structure, the scope of services,

network partners/owners

On-Site Evidence

No On-Site Evidence

On-Site Activities

- Interview:a. Managing entity CEOb. Network advisory/Governing bodyc. Directors of organizations that contract with the managing entityd. Persons served/community stakeholders

NET 1.01

The network is legally authorized to operate as a:

a. separately incorporated entity that coordinates and manages care onbehalf of a group of cooperating organizations; or

b. designated lead agency or management entity; orc. group of public and/or private providers organized to integrate and

coordinate services.

NET 1.02

The network:

a. defines in writing the scope of services offered;b. establishes a written agreement regarding services to be provided by



Purpose


specific network members, community partners, or practitioners in thenetwork; and

c. structures services so it can readily adapt to changes in the serviceenvironment and the needs of persons served to achieve desiredoutcomes.



Purpose


NET 2: Network Organization

The network organizes individual network members, community partners,and other network participants into an integrated delivery system.

Table of Evidence

Self-Study Evidence

- Narrative overview of how the network management entity ensuresclear communication throughout the network

- Narrative overview of service delivery system- List of network provider organizations and individual providers

including the network services they provide- Grievance/complaint procedures for network service providers

On-Site Evidence

No On-Site Evidence

On-Site Activities

- Interview:a. Managing entity CEOb. Network Advisory/Governing Bodyc. Directors of organizations that contract with the managing entity d. Independent practitionerse. Persons served/community stakeholders

NET 2.01

The network is structured such that:

a. the unique contributions and different goals that each network participantmay bring to the common endeavor can be recognized; and

b. the network's business goals can be reconciled with the members'ethical and mission-driven interests.

NET 2.02

Integrating network functions include:

a. a process that ensures ease of entry into a system of highly accessibleservices;



Purpose


b. agreed upon quality improvement expectations for the network as asystem;

c. uniform utilization and management protocols; andd. a system for managing information that integrates network operations

and network participants' information, including key costs, performancedata, outcome indicators, and member or consumer satisfaction data.

Related: ASE 2.03, RPM 5

NET 2.03

Clear communication throughout the network to network providers, personsserved, and payors, as applicable, is facilitated through a system that:

a. provides all parties with the information necessary to operate effectively;b. facilitates clear understanding of mutual expectations for all parties; andc. describes a mechanism for the resolution of conflicts, including conflicts

of interest, among member networks and/or community partners.

Related: RPM 5

NET 2.04

The network maintains a formal mechanism through which providerorganizations and independent practitioners can express and resolvecomplaints and grievances, including:

a. denial or termination of the clinical privileges, including of individualservice providers within owner and provider organizations;

b. decisions not to contract with providers;c. decisions to abrogate contracts with providers;d. the network's referral practices; ande. claims payments.



Purpose


NET 3: Planning

A network-wide planning process supports the network's commitment toachieving positive outcomes for the persons and families it serves.

Related: NET 9.02

Interpretation: Networks annually conduct a network-wide assessment ofthe number, geographic distribution, qualifications, and skills of directservice providers needed to serve the populations for which they areresponsible, and add capacity or shift resources, as necessary, to meetthose needs.

Table of Evidence

Self-Study Evidence

- Long-term and annual plans- Planning procedures- Network-level workforce analysis and documentation of actions taken

On-Site Evidence

No On-Site Evidence

On-Site Activities

- Interview: a. Managing entity CEOb. Network Advisory/Governing Bodyc. Directors or organizations that contract with the managing entityd. HR Director for the managing entity and representative network

provider organizations

NET 3.01

In developing and maintaining the network, the network's leaders consider,and annually review as part of their annual planning:

a. the full range of services within the network's scope and the network'scapacity to meet its responsibilities and goals;

b. geographic access to network services, including travel times tolocations and proximity to public transportation;

c. the demographic makeup of network service providers compared to thedemographic makeup of service recipients;

d. access to specialty service providers, including culturally relevant service



Purpose


providers; ande. flexible hours of operation that meet the needs and preferences of

service recipients.

Interpretation: Specialty service providers can include providerorganizations or independent contractors able to meet the linguistic,cultural, ethnic, or other needs of specific groups within the network'sdefined service population.

NET 3.02

Every three years, the network management entity conducts anetwork-wide, long-term, strategic planning process that:

a. reviews the network's mission, values, and mandates;b. assesses its strengths and weaknesses;c. establishes goals and objectives that flow from its mission and mandated

responsibilities;d. identifies appropriate strategies for meeting identified goals, including

consideration of the network's continued sustainability and possible needto redirect, eliminate, or expand service to respond to changingcommunity demographics and needs;

e. allocates resources to support capacity development for the deliverysystem, as needed;

f. addresses changes in the funding environment;g. addresses changes in the regulatory environment; andh. includes the input of service recipients and their families.

Interpretation: Depending on the network's development, this may be theinitial network development plan or the most recent strategic plan.

Note: Please enter demographic information on the organization'sgoverning body and community advisory group on the CommunityDemographic Profile - Private, Network Private.

NET 3.03

Once every long-term planning cycle, the network creates a demographicprofile of the persons and families it serves and compares it to thedemographics of its defined service population.

NET 3.04



Purpose


The network annually develops a short-term plan that:

a. evaluates and identifies the type and number of service providersrequired to accomplish the network's mission, goals, and objectives; and

b. supports the achievement of the network's long-term goals andobjectives.



Purpose


NET 4: Network Services

The network delivers the most appropriate array of services for meeting theneeds of its service recipients.

Table of Evidence

Self-Study Evidence

- Service coordination procedures- Admissions procedures/criteria- Eligibility of criteria- Level of care procedures

On-Site Evidence

No On-Site Evidence

On-Site Activities

- Interview:a. Network Commissioner/Executive Managementb. Provider Clinical Management/Supervisors and Independent

practitionersc. Community Stakeholdersd. Persons served

NET 4.01

Network service recipients:

a. are provided with a choice of service providers, to the extent possiblewithin available resources and service requirements; and

b. can move readily between programs or levels of care as service needschange or progress is made.

Interpretation: The network should give consumers a choice of providerorganizations. When resource limitations make this impossible (for example,the funding body will fund only one provider of a particular service in aregion) then the network needs to assure that the sole organization offeringa particular service provides consumers choices of service times andpractitioners.

NET 4.02



Purpose


Network services are coordinated, such that:

a. current eligibility information is maintained for the entire coveredpopulation to minimize administrative barriers to prompt service delivery;and

b. case records follow persons served to facilitate maximum benefit andcontinuity of care.

NET 4.03

Least restrictive and most appropriate service that meet consumer needsand preferences is achieved through flexible, responsive admissions andutilization management criteria for persons with multiple or chronic needs,such as:

a. substance use disorders;b. serious and persistent mental illness or serious emotional disturbance;c. substantial developmental and physical disability; andd. severe, chronic family and individual problems with multiple, or

interacting causes.

NET 4.04

The network develops a mechanism and strategy for implementation ofbest, promising, and evidence-based service practices.

Interpretation: Many observers are appropriately distressed by the time lagbetween research finding and application of research findings in health andhuman services. Networks can be vehicles for the delivery of services thatare grounded in research, yet in most cases, the introduction ofresearch-based services cannot be done in a single year contract cycle.This is for several reasons:

There is no universally accepted definition of what constitutesevidence-based practices for all services. Evidence-based practices havenot been developed and identified for all services that may be offered withina network. Some evidence-based practices require the development offunding mechanisms, structures for access to physicians and otherspecialists, staff development and training, and other activities that maytake time and resources that may not be readily available.

Consequently, effective networks recognize that they cannot require that allservices be grounded in the findings of research studies conducted with



Purpose


experimental designs, published in peer reviewed journals, and promotedby expert panels. Instead, networks develop realistic targets for importingresearch findings into its service offerings. Their annual and strategic plansidentify goals and objectives for importing and using research-basedpractices that are supported by such activities as training, service andcapacity development, and the introduction of service requirements thatmeet recognized fidelity scales.



Purpose


NET 5: Access to Network Services

The network's service delivery system is characterized by triage of needand timely access to services.

Table of Evidence

Self-Study Evidence

- Access procedures and guidelines- Triage and critical care criteria

On-Site Evidence

No On-Site Evidence

On-Site Activities

- Interview:a. Clinical Management/Supervisorsb. Provider Clinical Management/Supervisors and Independent

practitionersc. Community stakeholdersd. Persons served

- Review:a. Client recordsb. Utilization management data/reports

NET 5.01

Information about how to access network services is available to the publicand is included in information provided to clients at intake.

NET 5.02

The network, as appropriate to the service requested:

a. accepts referrals through established access points or anotherfunctionally equivalent approach to providing accessible care;

b. establishes access guidelines that result in prompt telephone responseand low telephone abandonment rates; and

c. responds to non-urgent requests for services with an offer of anappointment within a week of the initial call.



Purpose


NET 5.03

Networks that pre-authorize services or provide emergency services:

a. maintain cost-free telephone accessibility at all hours;b. provide intake, assessment, and admission or referral 24 hours-a-day,

seven days a week; andc. have mobile capability and can send practitioners or teams into the

home, school, emergency room, or police department for purposes ofimmediate evaluation and crisis intervention, when necessary.

NA The network management entity does not pre-authorize services orprovide emergency services.

NET 5.04

Access to emergency and crisis intervention services is available 24hours-a-day, seven days a week, and:

a. emergency care is available immediately, within six hours or less of aninitial call; and

b. urgent care is available within 24 to 72 hours of the initial call.

NET 5.05

Triage and critical care decision-making are carried out by, or under thedirect supervision of, experienced and/or licensed personnel.



Purpose


NET 6: Screening and Intake

The network promptly and responsively screens applicants to identify anddirect them to appropriate services.

Table of Evidence

Self-Study Evidence

- Screening procedures

On-Site Evidence

No On-Site Evidence

On-Site Activities

- Interview:a. Clinical Management/Supervisorsb. Provider Clinical Management/Supervisors and Independent

practitionersc. Community stakeholdersd. Persons served

- Review:a. Client recordsb. Utilization management data/reports

NET 6.01

Applicants are screened at intake and informed:

a. whether they are eligible to receive network services; andb. what services will be available and when.

NET 6.02

Individuals who cannot be served, or cannot be served promptly, arereferred or connected to appropriate resources.

NET 6.03

Prompt, responsive screening guidelines:



Purpose


a. ensure equitable treatment;b. give priority to urgent needs and emergency situations;c. support timely initiation of services; andd. provide for placement on a waiting list, if desired.



Purpose


NET 7: Utilization Management

The network conducts utilization management to ensure that its services areappropriate, represent the best value for the purchaser and consumer ofservice, and meet the needs and preferences of service recipients.

Related: RPM 5

Table of Evidence

Self-Study Evidence

- A description of the scope of utilization management activities (Forexample, does utilization management include authorization that isexternal to the provider? Is it limited to establishing criteria, reportingutilization data, and retrospective reviews?)

- Utilization management procedures, including:a. Criteria for placement decisions;b. Processes of approving the criteria and making the criteria

available to those applying the criteria;c. Authorizing services; andd. Appeals, and notifications of appeals when requests are denied

On-Site Evidence

- Utilization management reports- Records of authorization decisions, including the application of the

criteria to the decision- Records of utilization management reviews at provider locations- Evidence of the source of UM criteria

On-Site Activities

- Interview:a. Care managersb. Clinical directors at provider organizationsc. Independent practitionersd. Direct service providers

- Review:a. Personnel files of UM personnel

NET 7.01

The utilization management process is continuous and includes the use of



Purpose


common criteria across the network for admission, service provided, lengthof service, level of care, and discharge decisions.

NET 7.02

Utilization management criteria are available upon request to networkservice providers, and the network identifies the source or sources of thecriteria.

Interpretation: Networks manage utilization in several ways; however, in allcases, networks need criteria that help guide service delivery decisions.

Utilization management criteria should be applied to help inform clinicaljudgments - not to substitute for clinical judgments - and to protect theinterests of both service recipients and purchasers. This does not mean thatall decisions must conform to criteria to be considered appropriate. Forexample, the preferences of individual clients are also an important factor inthe decision-making process, and in the case of clients whose services arevoluntary, the preference of a client for lower intensity care than thatindicated by the criteria may result in an appropriate placement decisionthat is at variance with the criteria. The criteria may protect recipients frombeing placed in services that are more restricted than needed and beingdenied access to services that meet the recipient's need for more intensiveor lengthy services. Also, the criteria may protect the purchaser from payingfor services that are more expensive than needed.

Sources for utilization criteria commonly include expert panels or bodies,and documented evidence. In many cases the purchaser will providecriteria. If the network develops its own criteria, it should rely on personswith the credentials and experience to provide the direct services to developthe criteria. The network may use nationally recognized criteria, such as theaddictions-treatment placement criteria developed by the American Societyof Addiction Medicine (ASAM), it may develop its own criteria according tonationally recognized practice guidelines, or it may use criteria identified bythe purchaser. In any case, the network needs a formal process ofapproving the criteria it uses and making the criteria available to thoseapplying the criteria, including direct service providers.

NET 7.03

Utilization management personnel are qualified as follows:

a. personnel conducting utilization reviews have appropriate by experienceand training;



Purpose


b. supervisors of service authorization personnel have appropriateexperience and possess relevant credentials;

c. medical necessity decisions are made by licensed and qualifiedclinicians; and

d. appeals are reviewed by persons who are licensed or credentialed toprovide the service under review.

NET 7.04

Networks that provide centralized service authorization include a designatedcare manager or centralized care management unit to ensure that serviceplanning is continuous, comprehensive, and integrated.

NA The network does not provide authorization for services.

NET 7.05

Utilization management includes, as appropriate to the services beingprovided, a regular review of data related to:

a. appropriateness of admissions and authorization decisions, ifauthorizations are part of network services;

b. intake and referral processes;c. service planning and service delivery milestones; andd. intake and discharge data including length of service per event, number

of encounters per event, and number of re-admissions, as applicable tothe service being provided.

Interpretation: Networks manage utilization in several ways; however, in allcases, networks need criteria that help guide service delivery decisions.

NET 7.06

The network management entity conducts:

a. a quarterly review of its authorization and placement decisions for allnetwork services that includes a ten percent sample of open and closedcases, including a representative sample of high-risk cases; and

b. at least annually, a review of ten percent of contractor case records.



Purpose


NET 7.07

Managing entities that conduct preauthorization and reauthorization forservices:

a. respond to requests for authorization, initial screening, or reauthorizationaccording to standards for timeliness that are in proportion to theurgency of the request;

b. provide a 24-hour response line when responsible for authorization ofcrisis, emergency, or urgent care; and

c. record the reason for placement decisions and relate this decision tocriteria.

Interpretation: When network managing entities provide these initial orcontinuing authorizations, these more intensive utilization managementactivities are usually provided as a core network service. See theinterpretation for NET 4.02 for a discussion of criteria.

NA The network does not provide pre- or continuing authorization forservices.

NET 7.08

If authorization for services is denied the network management entity:

a. informs the person or service provider requesting the authorization of thereason for the denial;

b. relates the reason for the denial to the criteria used for makingauthorization decisions; and

c. informs the person or service provider of the right to appeal the denial ofauthorization and the timeframes for the appeal.

Related: CR 1.01

Interpretation: As used in NET 7.08, the term "appeal" refers to a requestfor a review and reconsideration of the denial. It does not imply anysuggestion of wrongdoing or failure to follow criteria or procedures. This isin contrast to a grievance, which means that the person filing the grievancebelieves that their rights have been violated or that procedures have notbeen followed. Appeals can be made by the service recipient or his/herservice provider.

NET 7.09

Timeframes for appeals of denials of service authorizations:



Purpose


a. ensure that appeals are reviewed and the results communicated in timefor the service recipient to enter or continue services without interruption;and

b. vary according to the urgency of the issue.

Related: CR 1.01



Purpose


NET 8: Outcomes Measurement

A network-wide outcomes measurement system evaluates individualprogress and service delivery program effectiveness at the program level.

Interpretation: The entities purchasing services from the network can beexpected to mandate certain performance measures. In many cases, thesemandated measures will be the core of the performance managementsystem. However, in addition to mandated measures, networks need toround out their performance measures with measures that addressimportant dimensions of service not already included in the mandatedmeasures and those that measure the network's performance onnetwork-specific functions. The network may wish to review nationalsources for possible measures, some of which may already be mandated bythe network's purchasers.

Some examples of frequently used measures can include the following:

Access to care, such as the average lengths of time between initial call andinitial screening assessment and the average lengths of time between initialscreening assessment and admission to treatment.

Coordination of care, such as the percentage of persons discharged froman inpatient or residential level of treatment who attend a session at theirnext level of care within a defined period of time (seven days or fourteendays for example) from leaving the residential or inpatient unit.

Client feedback and satisfaction, which could include a wide variety of itemsin addition to satisfaction with services. For example, the administration ofthese surveys give opportunities to gather valuable client information, suchas the percentage of clients who indicate a drive time of greater than 30minutes, the percentage of clients who say that they have access to publictransportation to reach the facility if needed.

In addition to client satisfaction, the network may wish to measure thesatisfaction of stakeholders, such as high volume referral agents, includingjudges, court workers, employee assistance agents, and others withrepeated experience with network access and services.

Table of Evidence

Self-Study Evidence

No Self-Study Evidence

On-Site Evidence

- See evidence provided for PQI 3 and PQI 4



Purpose


On-Site Activities

- Interview:a. Network PQI Coordinatorb. Relevant staff from provider organizationc. Independent practitioners



Purpose


NET 9: Members and Community Partners

Network participation ensures full access to needed services and supportswithin a system of care.

Table of Evidence

Self-Study Evidence

No Self-Study Evidence

On-Site Evidence

- See evidence provided for PQI 3 and PQI 4

On-Site Activities

- Interview:a. Managing entity CEOb. Network Advisory/Governing Bodyc. Directors of organizations that contract with the managing entityd. Independent practitionerse. Persons served/community stakeholders

NET 9.01

The network recruits or contracts with members and community partnersbased on anticipated and identified needs of the service population,including needs related to geographic location, and cultural and linguisticdiversity.

NET 9.02

The network demonstrates a commitment to providing clients with access toprovider organizations that best meet their needs and preferences, includingproviders who are responsive to the diverse cultural needs of clients andare able to connect clients with natural supports.

Related: NET 3

Interpretation: The network demonstrates this commitment by includingproviders who might not otherwise be able to participate in the networkbecause of constraints of size, budgetary capacity, organizationaldevelopment, or similar limitations, when such inclusion is necessary to



Purpose


allow clients access to providers that meet their needs and preferences.



Purpose


NET 10: Network Application Process

Organizations that deliver services to the network's service population arequalified to provide network services.

Table of Evidence

Self-Study Evidence

- Network application procedures- Network application(s)

On-Site Evidence

- Records of on-site visits and reviews of the specific applications,including the reasons for approving or not approving applications

On-Site Activities

- Interview:a. Program director b. CEO/Commissioner/Executive Managementc. Providersd. Contract Management

NET 10.01

The process of becoming a network participant includes:

a. a written application;b. verification of licensure or authorization to provide services; andc. an on-site review of compliance with the network's protocols and

requirements.

NET 10.02

The network application process emphasizes the continuity of care for thenetwork's service population.

Interpretation: Continuity of care for the network's service population is animportant consideration for network development and requirements toparticipate as a network provider. Consequently, the network applicationprocess includes continuity of care requirements and the impact that an



Purpose


applying provider organization may have on continuity of care for thenetwork's service population.

NET 10.03

The network's application process is consistent with applicable legalrequirements, and includes procedures for:

a. making decisions to accept or reject applicants;b. denying admission to the network;c. appealing application decisions; andd. terminating the relationship.


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