trr & cpg summary 2015 overview 161118-final · 2015 magellan of virginia trr & cpg summary...

Welcome!To our Summary Presentation of the

2015 Treatment Record Review and Clinical Practice Guideline Review.

Magellan of Virginia

Quality Improvement Department

2016 December

Treatment Record Review (TRR)

Clinical Practice Guideline (CPG)


Quality Improvement Department

2016 December

What is a Treatment Record Review?

What is a Clinical Practice Guideline Review?

•Treatment Record Review (TRR) is part of our Quality Improvement (QI)

program. It is one of the methods we use to evaluate care being provided to

members and to identify opportunities for improvement that will assist

providers with addressing the overall quality of care that members receive.

•For quality improvement purposes, Magellan reviews a sample of treatment

records from randomly selected providers. We conduct routine TRRs to monitor

network provider treatment record documentation and record keeping

practices against Magellan standards. During the TRR, we also measure

network provider performance against important clinical process elements of

Clinical Practice Guidelines (CPGs).


Treatment Record Review & Clinical Practice Guideline Review – 2015 summary – December 2016

Why we conduct TRRs

•We want our members to receive quality care. The information gathered

during this process allows us to validate compliance with our standards and, if

necessary, work to resolve issues that may impede the quality or success of

member treatment.

•All Magellan Network Providers participate in the TRR process. Magellan of

Virginia reviews all outpatient levels of care under the TRR process. The

Network Provider agreement states: For quality improvement purposes,

Magellan generally reviews a random sample of treatment records from

providers who received referrals from Magellan.



Where to locate information about the TRR process

�TRR Presentation – January 2016

�CPG Presentations – February 2016

http://www.magellanofvirginia.com � 2016 Training

�TRR Flyer (Magellan Documentation Standards* guide) – July 2016

http://www.magellanofvirginia.com �For Providers � Quality Improvement Resources and Tools

�TRR Worksheet

https://magellanprovider.com � News & Publications � Handbooks Link - “Handbook Appendices”

Under Appendix A, locate the Treatment Record Documentation Worksheet

�CPG information and Worksheets

https://magellanprovider.com

Link under “Providing Care” drop-down; Link in the Get Information section

*Magellan documentation standards for behavioral health treatment records do not replace the documentation

requirements as outlined in state and federal law, including, but not limited to, the Virginia Administrative Code,

Department of Medical Assistance Services (DMAS) Emergency Regulations or the DMAS Provider Manuals.



2015 Magellan of Virginia TRR & CPG Summary Overview

The Summer edition of Provider Focus featured the Virginia Care Management

Center (VA CMC) TRR and CPG review outcomes for calendar year 2015.

You can review the full article in the quarterly Provider Focus newsletter. The

newsletter is available on Magellan’s provider website:

http://magellanprovider.com

or directly at http://magellanproviderfocus.com



TRR Scoring

The TRR scoring is broken into three percentage ranges.

The Goal we have for our providers is 80%.

Scoring –

• 80-100% – compliant.

• 70-79% – opportunities for improvement.

• 0-69% – opportunities for improvement.

Aggregate scores below 70% may be reviewed under our Quality of Care review process, which could include a request for additional records.

We may also review the scores and the records with our Medical Director for feedback and direction.

Magellan of Virginia has not yet implemented a Corrective Action Plan (CAP) process for TRR. Providers will be notified via Email Blast if a TRR CAP process is initiated.




TRR: Overall Score - 2015 78%

Section Score

�General 88%

�Consumer Rights and Confidentiality 59%

�Initial Evaluation 77%

�Individualized Treatment Plan 65%

�Ongoing Treatment 65%

�Addendum for Special Populations 88%

�Coordination of Care 40%

�Medication Management 100%

�Addendum - Adverse Incidents N/A




TRR

General: (88%)

�Record is legible – 98%

�Consumer name or ID number noted on each page of record – 80%

�Entries are dated and signed by appropriately credentialed provider – 93%

�Record contains relevant demographic information, including address, employer/school, phone, emergency contact – 81%

Consumer Rights and Confidentiality: (59%)

�Signed Informed Consent for Treatment or refusal documented – 65%

�Patient Bill of Rights signed or refusal documented – 77%

�Psychiatric Advance Directives questioned/discussed – 30%

�Informed consent for medications signed or refusal documented – 49% (applied to 35 records)

�Releases for communication with PCP and other providers, parties, are signed or refusal is documented –59%

Initial Evaluation: (77%)

�Reason member is seeking services (presenting problem) and mental health status exam – 82%

�DSM diagnosis (documented) – 85%

�History & symptomology consistent with DSM criteria – 70%

�Psychiatric History – 80%




TRR

Initial Evaluation (continued): (77%)

�Co-occurring (co-morbid) substance induced disorder assessed – 70%

�Current and past suicide/danger risk assessed – 71% (Goal is 100%)

�Assess of consumer strengths, skills, abilities, motivation etc – 77%

�Level of familial/supports assessed and involved as indicated – 85%

�Consumer identified areas for improvement/outcomes documented – 72%

�Medical history – 85%

�Exploration of allergies and adverse reactions – 69%

�All current medications with dosages – 84%

�Discussion of d/c (discharge) planning/linkage to next level – 67%

Individualized Treatment Plan: (65%)

�Individualized strengths based treatment plan is current – 74%

�Measurable goals/objectives documented – 60%

�Goals/objectives have timeframes for achievement – 61%

�Goals/objectives align with consumer identified areas for improvement/outcomes – 73%

�Use of preventive/ancillary services including community & peer supports considered – 58%



TRR

Ongoing Treatment: (65%)

�Documentation substantiates treatment at the current intensity of support (level of care) – 77%

�Progress towards measurable consumer identified goals & outcomes evidenced. If not, barriers are being

addressed – 64%

�Clinical assessments & interventions evaluated at each visit – 75%

�Substance use assessment is current/ongoing – 49%

�Comprehensive suicide/risk assessment is current/ongoing – 42%

�Member compliance or non-compliance with medications is documented; if non-compliant,

interventions considered – 73%

�Family/support systems contacted/involved as appropriate/feasible – 68%

�Ancillary/preventive services considered, used and coordinated as indicated – 62%

�Crisis plan documented – 26%

�D/C (discharge) planning/linkage to alternative tx (level of care) leading to D/C occurring – 53%

* This question applied to 128 of the 252 records. Sixty-eight (68) records with actual

discharges occurring did not include a full d/c note indicating recommended after care or

continued care.





TRR

Addendum for Special Populations

�Guardianship information noted – 96%

�Developmental history for children and adolescents – 79%

Coordination of Care: (40%)

�Evidence of provider request of consumer for authorization for PCP communication – 54%

�Evidence consumer refused authorization for PCP communication – 18%

�PCP communication after initial assessment/evaluation – 36%

�Evidence of PCP communication at other significant points in treatment, e.g.- Medication initiated, discontinued, or significantly altered- Significant changes in diagnosis or clinical status- At termination of treatment – 24%

�Treatment Record reflects continuity and coordination of care between primary behavioral health clinician and (note all that apply under comments): psychiatrist, treatment – 51%

Medication Management: (100%) (Scored for prescribers)

�Medication flow sheet completed or progress note includes documentation of current psychotropic medication, dosages, date(s) of dosage changes – 100%

�Documentation of member education regarding reason for the medication, benefits, risks, and side effects – 100%

�Documentation of member verbalization of understanding of medication education – 100%



The Treatment Record Review Tool Section J

TRR

Adverse Incident

�If record indicates that an adverse incident occurred during treatment period, did Magellan receive an

Incident Reporting form based on the established protocol (within 24 hours of the incident)?

Inclusion of this TRR question began with the 3rd Quarter 2016 selection.

The Magellan National Provider Handbook (Section 4, Adverse Outcome Reporting) defines an Adverse

Outcome as any of the following incidents involving a Magellan member currently in treatment or a

member who was discharged from treatment within 180 days prior to the occurrence of:

• Death;

• Suicide or serious suicide attempt;

• An incident of violence initiated by the member; and

• Other incidents resulting in serious harm to the member or others that includes, but is not limited to

serious complications from a psychotropic medication regimen that required medical intervention.



Implementation of Adverse Outcomes Reporting

Effective September 1, 2016, Magellan participating providers are required to notify us of any member Adverse Outcome that comes to their attention.

Expectations about reporting Adverse Outcomes are outlined within the Magellan National Provider Handbook, Section 4, Adverse Outcome Reporting. Please also refer to Section 2 of your Program Participation Agreement for more information about compliance with Magellan’s policies and procedures.

This reporting requirement affects all Magellan covered services and all levels of care.*

A recorded presentation and a document presentation are available in the For Providers section of MagellanofVirginia.com, under 2016 Provider Training.

*Residential Treatment Centers – Level C providers will continue to follow the Adverse Outcomes/Serious Incident Reporting process already in place (please refer to the July 28, 2014 Provider Communication).

The Magellan National Provider Handbook can be located with the following link:

http://www.magellanofvirginia.com/for-providers-va/provider-handbook.aspx




Current Magellan of Virginia areas of focus:

Ongoing Care section of TRR worksheet

Question: Comprehensive suicide/risk assessment is current/ongoing

2015 Score – 42%

Ongoing Care section of TRR worksheet

Question: Crisis Plan Documented

2015 Score – 26%

Coordination of Care section of TRR worksheet

Question: Primary Care Provider (PCP) Communication after initial assessment

2015 Score – 36%



CPG Scoring

The Clinical Practice Guideline (CPG) scoring is based on the number of questions in the CPG worksheet

not meeting the documentation expectation. Each CPG is specific to a diagnosis.

Magellan of Virginia is currently focusing on the CPGs for Attention Deficit/Hyperactivity Disorder (ADHD),

Major Depressive Disorder (MDD), Schizophrenia and Substance Use Disorder (SUD).

The Suicide Risk Assessment and Management CPG is reviewed with each record review regardless of the

diagnosis.

The providers participating in the TRR/CPG review process receive a CPG score report with a numeric

value reflecting the average score of all "Not Met" questions from the records reviewed.

The CPG adherence goal is a score from 0 to 3. Scores of 3.1 to 6 and 6.1 and above indicate opportunities

for improvement.



Quantitative

(Average score from all records reviewed)

0 - 3 average total

score

3.1 – 6 average total

score

> 6 average total

score

Compliant Improvement

opportunity

Improvement

opportunity




The following grids represent the CPG scores for 2015

CPG ADHD: Overall Score - 2015 6.8

82 Records Reviewed

Section Score

Diagnostic Assessment 5

Therapeutic Interventions 1.7

CPG MDD: Overall Score - 2015 3.2

88 Records Reviewed

Section Score

Diagnostic Assessment 1.7


CPG Schizophrenia: Overall Score - 2015 4.7

82 Records Reviewed

Section Score

Diagnostic Assessment 2.4


CPG Suicide Risk Assessment and

Management: Overall Score - 2015

2.5

252 Records Reviewed

Section Score

Suicide Risk Assessment and Management 2.5

The CPG goal is a score of 0 to 3.

Scores of 3.1 to 6 and 6.1 and above indicate opportunities for improvement.


Diagnostic Assessment

�Screened for presence and duration of symptoms meeting DSM-5 criteria for ADHD and persisting for at

least six months – 61%

�Screened for presence of several inattentive or hyperactive-impulsive symptoms present prior to age 12

years – 62%

�Screened for presence of several inattentive or hyperactive-impulsive symptoms present in two or more

settings (home, work, school) – 73%

�Confirmed symptoms across settings received from multiple informants, e.g., parents, guardians,

teachers, clinicians involved in care of individual (including results of symptom-focused rating scales from

self, parents, teachers, clinicians) – 77%

�Noted clear evidence that symptoms of older adolescents and adults (age 17 and older) reflect

inattention causing problems with executive functions – 75%

�Considered whether fewer than full criteria have been met for the past 6 months when full criteria were

previously met (partial remission) – 39%

�Considered whether few or many symptoms are in excess of those required to make diagnosis of ADHD

(based on DSM-5) specifying level of severity (mild, moderate or severe) with the use of screening tools –

24%

ADHD CPG





�Assessed whether symptoms are not better explained by another mental disorder (e.g., substance use

disorder, personality disorder, mood disorder, anxiety disorder, dissociative disorder) – 54%

�Assessed whether symptoms are not solely a manifestation of oppositional behavior, defiance, hostility,

or failure to understand tasks or instructions – 56%

�Coordinated care with medical provider and medical evaluation during diagnostic process ruled out

medical causes of symptoms of ADHD and assessed cardiovascular functioning (if treatment with

stimulants considered) – 26%

�Assessed for suicidal thoughts or behaviors with potential for injury to self or others , especially if

atomoxetine treatment is considered – 65%

�If suicidal thoughts or behaviors were present, appropriate actions were taken to intervene – 15% * This

applied to 26 records.

�If provider is not a physician, reviewed findings from consultation with psychiatrist or primary care

physician – 44%

ADHD CPG (Continued)



Therapeutic Interventions

�If referral for a medical/psychiatric evaluation, provider included the results of the evaluation in the treatment planning – 46%

�Conducted education about ADHD and its treatment including behavioral intervention, pharmacological intervention, family therapy delivered to parents, guardian, and if applicable, to the patient – 31%

�Discussed diagnostic findings, treatment options and goals and treatment plan with parents, guardians, and if applicable, with patient – 73%

�Evidence that provider actively involved parent, guardian, teacher(s), and patient in treatment planning – 88%

�Co-morbid medical and psychiatric conditions discussed with parents, guardians, and if applicable patient –31%

�Provider assessed if psychotherapy is indicated – 43%

�Provider prescribed a stimulant (methylphenidates and amphetamines), atomoxetine, extended release guanfacine or extended release clonidine, bupropion or tricyclic antidepressants or other agents deemed appropriate or explained why medication was not prescribed – 100%

�If provider is a physician, treatment plan explains the rationale of the selection of pharmacological intervention including risks, benefits, and side effects – 89%

�Education delivered to parents, guardian, and if applicable, patient, about pharmacological treatment, including risks, benefits, side effects of medicine – 100%

�Parents and guardians were educated about follow up within 30 days of initial prescription and two more times within 270 days – N/A






�Evidence of ongoing/continued assessment of patient response to medication, side effects, adverse effects,

and any laboratory monitoring that is necessary – 100%

�Rationale for any changes in medication, if any changes or augmentation – 100%

�If any evidence of a comorbid substance use disorder, provider developed plan to support sobriety – 100%

(applied to 1 record)

�If antidepressants prescribed, provider delivered education about a possible increased risk of suicidal

behavior, including early warning signs - 100%

�If patient is preschool-aged (4-5 years), provider prescribed parent-and/or teacher-administered behavior

therapy as first line of treatment or explained why this was not prescribed – N/A

�If patient is elementary-aged (6-11 years), provider prescribed FDA-approved medication and/or parent-

and/or teacher administered behavior therapy or explained why this was not prescribed – 100%

�If patient is adolescent (12-18 years), provider prescribed FDA-approved medication for ADHD with assent of

the adolescent or explained why this was not prescribed – 100%

�If patient is adolescent, provider gave special consideration to provide medication coverage for symptom

control while driving – N/A

�If behavior therapy is prescribed, ongoing assessment of treatment progress using clinical observation,

interviews, and/or rating scales from parent, guardian, teacher, and if applicable, self – 82%

�If behavior therapy is prescribed, training provided to parents in specific techniques to improve their abilities

to modify and shape child s behavior while improving the childs ability to regulate own behavior – 89%






MDD CPGDiagnostic Assessment

�History and symptom presence and duration that meet DSM criteria for major depressive disorder – 81%

�A co-morbid substance induced disorder – 66%

�Other psychiatric disorders that could account for the symptoms or complicate treatment – 84%

�Psychosocial stressors – 91%

�Medical conditions that may cause depression and/or complicate treatment – 90%

�Psychotic features – 67%

�Severity level of MDD (e.g. Mild, Moderate or Severe) – 70%

�Dangerousness to others – 71%

�Past History (of depressive episodes and treatment) – 86%

�If provider is a non-MD, there is documentation of a referral for a medical/psychiatric evaluation if any of the following are present: psychotic features, complicating medical/psychiatric conditions, severity level of moderate or above – 57%


�The provider assess if psychotherapy was indicated – 50%

�If psychotherapy was indicated, the provider specified the therapy type and specific measurable goals –42%

�The provider delivered education about MDD and its treatment to the patient, and if appropriate, to the family – 66%

�If MDD was of moderate severity or above, the treatment plan uses a combination of psychotherapy and antidepressant medication, or clear documentation why not – 54%




�Positive & Negative Symptoms (symptom presence and duration that meet DSM criteria) – 68%

�A co-morbid substance-induced disorder – 63%

�Other psychiatric disorders that could account for the symptoms or complicate treatment – 75%

�Psychosocial Stressors – 86%

�Medical Conditions that may cause depression and/or complicate treatment – 83%

�Medications (past and current medications and response) – 81%

�Compliance (potential barriers to treatment compliance, e.g. History of noncompliance, unsupportive

home environment) – 77%

�Dangerousness to others (history of and current potential) – 70%

�Reason for recurrence (if not first episode) – 20%

�Psychiatric Referral: If provider is a non-M.D., and there is no evidence of a recent psychiatric evaluation,

there is documentation of a referral for a psychiatric evaluation) – 77%




Schizophrenia CPG


�Appropriate psychosocial interventions (consistent with the phase of illness, e.g., diminishing arousal in

the acute phase, increasing social skills and community functioning in the stable phase) – 74%

�Measurable targets for each intervention – 54%

�The provider delivered education about Schizophrenia, its treatment, signs of relapse, and community

resources, to the patient and family/caregivers – 49%

�If the provider is a non-MD, and a psychiatric referral had been made, the provider documented the

results of that evaluation and any relevant adjustments to the treatment plan – 50%

�If evidence was found of a co morbid substance use disorder, the provider developed a plan to support

sobriety – 36%

�If evidence of a co morbid mental health disorder was found , the provider developed a plan to address

the co morbid disorder – 35%




Schizophrenia CPG


�The provider selected a first- or second-generation antipsychotic, implemented it as soon as feasible, or

documented why not – 75%

�If initiating treatment with a second-generation antipsychotic, the provider documented baseline

physical and lab results, including height, weight, lipid profile and fasting blood glucose, and documented

periodic monitoring of these parameters – 0% (applied to 1 record of 82)

�If there have been several medication trials that were unsuccessful, or the patient presented with severe

suicide risk, the provider considered clozapine or ECT – 0% (applied to 1 record of 82)

�If clozapine is prescribed, evidence of weekly laboratory monitoring for first 6 months and then every

other week thereafter – 0% (applied to 1 record of 82)

�If the provider finds there is evidence of potential patient non-compliance with treatment, provider plans

interventions to address non-compliance (e.g. Depot meds, outpatient commitment, medication groups,

family support, self-help groups) – 44%




Schizophrenia CPG

�Current Suicidal Ideation and Plans – 70%

�History of Suicidal Ideation and Attempts – 68%

�Presence of High Risk Factors, such as significant behavior change in teens, advanced age/debilitating

illness/male senior citizens, insomnia, substance use/abuse, anxiety, recent inpatient discharge, history of

violence or bullying (victim or perpetrator) – 77%

�Plan for frequent evaluation for suicidal thinking or behavior in patients prescribed Anti-Depressant

and/or Anticonvulsant Medications (assessed when reviewing for MDD CPG) – 39%

�Assessment of Lethal Intent. Documentation shows interventions to address this with patient and

response to measures – 24% (applied to 72 records)

�Assessment for access to any weapons or Lethal Means, if suicidal – 13% (applied to 63 records)

�Developed plan to Diminish Access to Weapons/Lethal Means, if suicidal – 8% (applied to 61 records)

�Developed Plan for maintaining sobriety and discussed the role of substance use in increasing suicide risk

– 26%

�Attempted to Involve Family and Other Support System Members in suicide management plans, or

documented why not appropriate – 11%

�Documented Actual Family/Support System Involvement in suicide management plan – 10%

�Hallucination intervention (Intervention to alleviate command hallucinations, if present) (assessed when

reviewing for Schizophrenia CPG) – 45%




Suicide Risk Assessment & Management CPG

Crisis Planning/Safety Planning for MemberWhat is a crisis?

• When a member experiences acute symptoms or distress that if unmanaged, is expected to lead to an unstable or dangerous situation that may compromise the member’s, or others’, safety.

Why have a crisis/safety plan?

• Comprehensive crisis plans provide the member and their family/supports with tools to de-escalate a crisis, emergency contacts, phone numbers for mental health contacts, crisis line numbers, etc.

When and how should a crisis plan be developed?

• During the initial assessment/first session, as soon as high-risk behaviors are identified.

• Engage the member (parents/guardians, etc) in a discussion about past crises. Discuss what happened, what was helpful/not helpful.

• These plans should be a helpful tool for the member and should be written in the member’s own words; the plan should be unique to the member.

• The sooner a plan is developed, the sooner members can begin practicing.

** We recommend conducting and documenting a risk assessment at each visit and implementing the use of comprehensive crisis plans throughout treatment.



Crisis Planning/Safety Planning for the Member

What should be included in a safety/crisis plan?

Formats can vary, however plans should include, at minimum:

•Possible anticipated crises (suicidal, self-harm, running away, psychiatric hospitalization, physical

aggression toward others, etc.)

•Description of triggers / warning signs that a crisis is approaching

•How the member/family can create a safe environment (remove weapons/guns, keep medications

locked, etc.)

•Coping skills/interventions the member identifies that can help de-escalate or calm them

•Names and phone numbers/addresses of people they identify as helpful who they can talk with or

visit

•Emergency numbers (agency’s on-call/after-hours phone number, local CSB crisis, 911, closest

emergency room, etc.)

•Names and signatures of those who participated in the creation of the crisis plan





Additional Information:

Adverse Outcome Reporting

http://www.magellanofvirginia.com/media/1465762/07-22-

16_adverse_outcome_reporting_process_training_deck.pdf

Behavioral /Medical Care Coordination

http://www.magellanofvirginia.com/for-providers-va/behavioralmedical-care-coordination-

toolkit.aspx

Quality Improvement Resources and Tools

http://www.magellanofvirginia.com/for-providers-va/quality-improvement-resources-and-

tools.aspx

Legal disclaimers

Confidentiality Statement for Educational

Presentations

By receipt of this presentation, each recipient agrees that the information contained herein will be kept

confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others

at any time without the prior written consent of Magellan Health, Inc.

The information contained in this presentation is intended for educational purposes only and is not intended to

define a standard of care or exclusive course of treatment, nor be a substitute for treatment.

The information contained in this presentation is intended for educational purposes only and should not be

considered legal advice. Recipients are encouraged to obtain legal guidance from their own legal advisors.



Confidentiality Statement for Providers

The information presented in this presentation is confidential and expected to be used solely in support of the

delivery of services to Magellan members. By receipt of this presentation, each recipient agrees that the

information contained herein will be kept confidential and that the information will not be photocopied,

reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan

Health, Inc.

The information contained in this presentation is intended for educational purposes only and should not be

considered legal advice. Recipients are encouraged to obtain legal guidance from their own legal advisors.



Thank You

trr & cpg summary 2015 overview 161118-final · 2015 magellan of virginia trr & cpg summary...

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