“The mission of the Mental Health Division is to promote recovery and safety.”

Mental Health Division Quality Strategy Plan

Table of Contents (quick links to page content):

I. Introduction and Purpose

II. Goal

III. Mission Statements

IV. Objectives

V. Access Criteria

VI. Quality Management

VII. Management Information Systems

VIII. Structure and Operations

IX. Information Requirements

X. Additional Care Management Requirements

XI. State Responsibilities for Oversight

I. Introduction and Purpose

The Quality Strategy is meant to be a coordinated, systematic approach to the planning, implementation and management of our quality assessment and improvement strategy. This strategy is expected to continuously and consistently monitor the appropriateness and quality of the consumer care delivery system in Prepaid Inpatient Health Plans (PIHPs) providing mental health care to eligible consumers in Washington State.

II. Goal

Our goal is to assess, monitor and measure for improvement the mental health services provided to members served by PIHPs contracting with the Mental Health Division (MHD). This goal requires the development of a process through which the MHD and the PIHPs (also known as Regional Support Networks or RSNs) work in a collaborative manner to establish objectives and timetables for improvement of health care service and delivery if and when needed. The quality strategy also seeks to improve Medicaid Managed Care's ability to meet the priorities of the MHD, Medicaid program, and Medicaid managed care programs in Washington State.

III. Mission Statements

The mission of the Washington State mental health system is to ensure that people of all ages experiencing mental illness can better manage their illness, achieve their personal goals, and live, work, and participate in their communities. The mission of the Mental Health Division is to administer a public mental health system that promotes recovery and safety.

IV. Objectives

At a minimum, the PIHPs will be in compliance with and seek to continuously improve outcomes compliant with Federal and State statutes and requirements. This includes, but is not limited to, State contract and program requirements such as those listed below:
1. Availability of services
2. Continuity and coordination of care
3. Access standards
4. Enrollee information
5. Enrollee rights and protections
6. Confidentiality and accuracy of enrollee information
7. Provider selection
8. Sub-contractual relationships and delegation
9. Practice guidelines applicable to mental health
10. Health Information Systems
11. Mechanisms to detect both under- and over-utilization
12. Quality improvement
13. Utilization management
14. Member services
15. Provider services
16. Record keeping
17. Data reporting.
The PIHP's quality management process must include ongoing quality improvement efforts that are implemented and maintained through internal processes that meet the following content requirements:
1. RSN/PIHP contract provisions that require the PIHPs to assess the quality and appropriateness of care and services furnished to all Medicaid enrollees and to individuals with mental illness. All Medicaid persons requesting mental health services shall be screened, assessed and authorized based on Access to Care standards and minimum eligibility requirements. This includes those with special health care needs populations as defined by CMS. Those are:
  1. SSI beneficiaries of all ages;
  2. adults 65 years of age and older;
  3. five groups of children: foster children, children in adoption support, blind children, disabled children, and children on Title V; and
  4. Children with multiple needs who meet EPSDT requirements shall receive services that comply with the EPSDT plan found in the MHD contract.
2. The PIHP shall conduct monitoring and review its ongoing quality management process to ensure continued assessment and improvements to the quality of mental health services in their service area.
3. The PIHP is expected to implement service delivery protocols for the coordination and integration of services for consumers with multiple needs. These protocols are to be implemented in the beginning of the new contract period. In addition, a quality improvement initiative directed toward services for and service delivery to children and youth is a focus for this biennium. The development and implementation of plans for protocols must include a method to evaluate progress in cross-system coordination and integration of services. The impacted populations include, but are not limited to:
  1. Native American/Indian children
  2. Children served by DSHS Juvenile Rehabilitation Administration, and Children's Administration
  3. Adults and older adults served by DSHS Aging and Adult Services Administration.
4. MHD requires compliance with state and federal non-discrimination policies and expects PIHPs to participate whenever possible in the coordination of mental health services with other systems of care. MHD is part of a Disease Management project with Medical Assistance Administration (MAA) and is monitoring the collaborative efforts regarding the management of these high risk, co-morbid conditions as documented in the client's mental health record.
The Department identifies certain demographic characteristics of Medicaid clients for PIHPs at the time of enrollment. When enrolling in Medicaid, beneficiaries are asked to indicate their race, ethnicity and preferred language. When provided, the information is passed into the MMIS system and on to MHD. When clients seek services at a PIHP provider, the PIHP provider checks the information the client provides with the MMIS data. On a monthly basis, the MHD requires (through its Data Dictionary) PIHPs to submit race, ethnicity, and the client's preferred language for consumers in or accessing services. MHD summarizes this information and makes it available to each PIHP to use in assessing translation and interpretation requirements. Using this information in combination with census data and other DSHS databases, PIHPs determine prevalent languages in their service region to fulfill document translation requirements. The PIHP notifies clients what services are available in their preferred language and how to access them. MHD also expects the PIHP to demonstrate that these notification mechanisms are effective.
An External Quality Review (EQR) of the PIHP will be conducted annually related to quality outcomes, timeliness of and access to the services covered under each contract. The MHD Quality Assurance and Improvement Team (QA&I) conducts the annual PIHP monitoring process as outlined in the required CMS protocol to insure that the PIHP is in compliance with Medicaid managed care regulatory provisions. The team will conduct interviews and client record reviews (30 per PIHP) to gather information to assess the PIHP's ability to provide oversight of client care. The information concerning federal requirements will be sent forward to the EQRO (or EQRO-like entity) for further evaluation. The EQRO will then provide CMS with the appropriate reports.
Two addition requirements for external quality review will be met as follows:
1. Validation of two quality improvement projects required by the State to comply with 438.240(b)(1) that were underway during the preceding 12 months. Some quality improvement may be required by the state to be continued, based on specific outcomes for a specified time period in each PIHP. For the two federally required quality improvement projects, the state's QA&I team will join with the MHD's Performance Indicator Workgroup to oversee the conduct of these projects and to help the PIHPs prepare for project validation by the EQRO. MHD has decided to institute two statewide quality improvement projects: increasing client participation in treatment planning (a clinical indicator) and improving data quality (a non-clinical indicator). MHD will use the CMS protocol for conducting QI projects to develop the projects for each PIHP. The data from these projects will go forward to the EQRO for validation, with the required report going forward to CMS.
2. Validation of performance measures reported (as required by the State) or performance measures calculated by the State during the preceding 12 months to comply with requirements in 438.240(b)(2). The MHD Performance Indicator (PI) work group will use the required external quality review protocol to evaluate the accuracy of these performance measures, and determine the extent the PIHP followed specifications for calculating the measures. The PI workgroup has already produced two annual PI reports (2001 and 2002), and will decide if all or some of the measures are used in this process. The process the PI workgroup follows and their findings will be reviewed and validated by the EQRO.

The information gathered via the three federally mandated EQRO protocols is forwarded on to the MHD EQRO for further evaluation. For the first year of this biennium, the MHD has asked to use the Washington Institute for Mental Illness Research and Training (WIMIRT) in Spokane, as their EQRO-like entity. If approved,the information gathered from the mandated protocols would be forwarded to WIMIRT for analysis and validation. In addition to providing an EQRO report to CMS, WIMIRT will compile the information in more detail than typically expected from an EQRO to provide a training exercise in consistency and inter-rater reliability for MHD staff. Included in this waiver modification, the MHD is seeking approval to use this training and technical assistance process for both years of the biennium. In the event WIMIRT is not approved, MHD has developed a contingency plan which includes submitting a budget request to DSHS for BBA implementation funding. The contingency plan involves an RFP for EQRO services. Two EQROs with mental health experience responded to the joint MAA/MHD EQRO RFI.The plan includes ongoing communication with these two respondents regarding time frames for implementing EQRO services should their services be required.

The State Auditor will continue to monitor fraud and abuse once MHD and the PIHPs receive the requested CMS training on this subject. Monitoring will be adjusted based on the outcome of the training.

Remedial Action. PIHPs must agree that MHD may initiate remedial action if MHD determines any of the following situations exist:
1. A problem exists in the PIHP service delivery area that negatively impacts consumers;
2. The PIHP has failed to perform any of the mental health services required in the contract;
3. The PIHP has failed to develop, produce, and/or deliver to the MHD any of the statements, reports, data accountings, claims, and/or documentation described in the contract;
4. The PIHP has failed to perform any administrative function required in the contract. 'Administrative function' is defined as any obligation other than the actual provision of mental health services;
5. The PIHP has failed to implement corrective action required by the State and within the MHD prescribed time frames.
6. MHD may impose one or more of the following remedial actions in response to findings of situations as outlined above:
  1. The MHD may require the PIHP to plan and execute corrective action. Corrective action plans include:
    1. a brief description of the finding;
    2. specific steps taken to correct the situation and a timetable for performance of specified corrective action steps;
    3. a description of the monitoring to be performed to ensure that the steps are taken;
    4. A description of the monitoring to be performed that will reflect the resolution of the situation.
  2. Corrective actions plans developed by the PIHP must be submitted to the MHD within 30 calendar days of notification. The MHD may extend or reduce the time allowed for corrective action depending upon the nature of the situation as determined by the MHD. Corrective action plans shall be subject to approval by the MHD, which may accept the plan as submitted, accept the plan with modifications, or reject the plan as follows:
    1. require modification of any policies or procedures by the PIHP relating to the fulfillment of its obligations pursuant to the contract;
    2. Withhold one percent of the next month's capitation payment and each monthly capitation payment thereafter until the corrective action has achieved resolution. The MHD, at its sole discretion, may return all or a portion of any or all payments withheld once satisfactory resolution has been achieved;
    3. compound withholdings identified above by an additional one half or one percent for each successive month during which the remedial situation has not been resolved;
    4. Deny any incentive payment to which the PIHP might otherwise have been entitled under the contract of any other arrangement by which the MHD provides incentives.
Contract termination may occur in the following situations:
1. Termination due to change in funding in the event that funding from State, federal or other source is withdrawn, reduced, or limited in any way.
2. Termination due to change in 1915(b) Mental Health Services Waiver. DSHS may terminate this agreement, subject to re-negotiation (if applicable) under new terms and conditions.
3. Termination for convenience. Except as otherwise provided in the contract, either party may terminate the agreement upon 90 days written notice.
4. Termination for default. The contracting officer may terminate the agreement for default, in whole or in part, by written notice to the PIHP, if DSHS has a reasonable basis to believe that the PIHP has:
  1. Failed to meet or maintain any requirement for contracting with DSHS;
  2. failed to perform under any provision of the agreement;
  3. violated any law, regulation, rule, or ordinance applicable to the services provided under the agreement; and/or
  4. Otherwise breached any provision of condition of the agreement.
All mental health services covered in the State Plan are the responsibility of the PIHP and must be available and accessible to their enrollees.
1. Benefit package
  1. Covered lives. The PIHP shall provide crisis mental health services and medically necessary mental health services to the following:
    1. Enrollees of all ages included in the1915(b) Waiver. All Medicaid persons requesting mental health services shall be screened, assessed and authorized based on the Access to Care Standards and minimum eligibility requirements
    2. Enrollees who reside in the PIHP service area pursuant to Contract Exhibit E;
    3. Enrolled children with "D" coupons or its legal substitute, or other evidence of placement by DSHS, who currently reside in the PIHP service area without regard to the child's original residence;
    4. Persons who reside in the PIHP service area who are experiencing a crisis may receive mental health services regardless of financial eligibility;
    5. Persons who meet the non-Medicaid "state priority populations" as defined in RCW 71.05, 71.24, 71.34 or any successors, with special attention to children, older adults and minorities shall be served based on available state, federal block grant or other available resources;
    6. Persons eligible for state only programs (MI, GAU) shall receive voluntary inpatient hospitalization when the PIHP has determined that such services are medically necessary. Community support services for these persons shall be provided based upon eligibility per this agreement and within available state or other local resources;
    7. Persons who are mentally ill shall have access to all components of the Involuntary Treatment Act applicable to PIHPs as identified under this agreement, state law, and the 1915(b) Waiver, regardless of financial eligibility.
2. General Services. The PIHP shall ensure:
  1. The provision or the purchase of medically necessary mental health services for all enrollees in accordance with the PIHPs obligations under the contract;
    1. The PIHP shall ensure that each of the services provided are sufficient in amount and intensity to reasonably be expected to achieve the purpose for which the services are furnished. These services are listed in the State Plan and in the waiver as Attachment A.IV.c.2.a.i.;
    2. The PIHP shall ensure services are not arbitrarily denied or reduced (e.g., amount,duration or scope of a required service) solely based on the diagnosis, type of mental illness, or the enrollee's mental health condition.
    3. Enrollees can access medically necessary mental health services upon request that do not exceed the access standards below. A request for mental health services is defined as a point in time when mental health services are sought or applied for through a telephone call, referral, walk-in, or written request for mental health services. The determination of eligibility for authorization to service shall be based on the Access to Care standards. Authorization shall not take more than fourteen calendar days, unless the enrollee or the CMHA requests an extension. An extension of up to 14 additional calendar days is possible upon request by the enrollee or the CMHA if: a) the Contractor provides written justification to the MHD regarding the need for additional information; and b) the Contractor indicates how the extension is in the enrollee's best interest. Urgent and emergent medically necessary mental health services (e.g. crisis mental health services, stabilization mental health services) maybe accessed without full completion of intake evaluations and/or other screening and assessment processes. The Contractor shall ensure:
      1. an intake assessment is initiated within 10 working days of the request for mental health services;
      2. routine mental health services are offered to occur within 14 calendar days of a determination of eligibility. An extension is possible upon request by the enrollee. A total of 28 calendar days from request for services to first routine appointment will be the normal time period expected;
      3. the PIHP provides written justification to the MHD regarding the need for additional information; and
      4. The PIHP indicates how the extension is in the enrollees' best interest.
    4. emergent mental health services occur within 2 hours of the request for mental health services from any source;
    5. Urgent care occurs within 24 hours of the request for mental health service from any source.
  2. Each enrollee is able to choose a participating MHCP in accordance with WAC or any successors. If the enrollee does not want to make a choice, the PIHP or its designee must assign a MHCP no later than 14 working days following the request for mental health services. The enrollee may change MHCP in the first 90 days of enrollment and once during a twelve-month period for any reason. Any additional change of a MHCP during a twelve-month period may be made at the enrollee's request with justification documented by the PIHP.
  3. Enrolled children who meet the requirements of EPSDT guidelines shall receive mental health services that comply with Contract Exhibit J.
  4. Children are referred to physical health care when the MHCP determines a referral is needed based on the periodicity schedule.
  5. Based on available resources, consumers receive community support, residential and employment services described in RCW 71.24.025.
  6. Consumers, including children and their families, have voice in developing individualized service plans, advance directives, and crisis plans.
  7. Consumer strengths, family involvement, formal/informal and natural supports are incorporated into the individualized service plan.
  8. Implementation of mechanisms that promote rapid and successful reintegration of consumers back into the community from long-term placements from psychiatric hospitals and children's long term inpatient facilities which ensures the following:
    1. Designation of a MHCP as primarily responsible for coordinating the mental health care services provided to the consumer;
    2. CMHAs have the information necessary for effective continuity of care and quality improvement;
    3. Continued implementation of the Expanding Community Services (ECS) Project according to contract exhibit M or N, whichever is applicable.
    4. The PIHP shall be able to demonstrate that its community reintegration mechanisms are effective.
  9. Use treatment interventions that are research-based and shown to be effective in achieving positive outcomes (e.g., wraparound, multi-systemic therapy, and intensive case management) when providing mental health services to children and youth. DSHS will plan with the PIHPs, parents, MCHAs and others (e.g., Universities, Child Welfare, families)involved in the delivery of services to children and youth to identify and establish:
    1. statewide reform in the clinical practices offered to these youths;
    2. a collaborative means to shift the practice for this population;
    3. establish best practices and develop practice guidelines and clinician protocols. (Final report to the Secretary of DSHS from the Select Committee on Adolescents in Need of Long Term Placement, recommendation #9 for Children with Complex Mental Health Needs);
    4. Participate in the review of newly issued national practice guidelines with MHD, CMHAs, and other interested parties to determine their utility in the mental health system statewide. Once selected, guidelines will be disseminated to CMHAs and to enrollees upon request.
    5. The PIHP must adopt and implement practice guidelines that meet the following requirements:
    6. Are based on valid and reliable clinical evidence or a consensus of mental health professionals;
    7. Consider the needs of the enrollees;
    8. Are adopted in consultation with contracting mental health professionals when applicable;
    9. Are reviewed and updated biennially as appropriate;
    10. Ensure dissemination to all affected providers and, upon request, to enrollees; and
    11. Ensure decisions for utilization management, enrollee education, coverage of services, and other areas to which the guidelines apply are consistent with the guidelines and consistently applied throughout the service area.
3. Psychiatric Inpatient Services: Community Hospitals. The PIHPs shall ensure:
  1. Contact with the community hospital staff occurs within three working days of a consumer's admission to a community hospital unit. The PIHP's liaison or designated CMHA shall participate with the community hospital inpatient treatment team in both treatment and discharge planning.
  2. A CMHA is designated for consumers and their families seeking community support services prior to discharge from an inpatient setting.
  3. Response to calls requesting certification of the need for psychiatric inpatient care for consumers in community hospital units occurs within two hours. AA decision concerning certification of the need for psychiatric inpatient care shall be made within twelve hours of the initial call.
  4. A physician reviews determinations of clinical appropriateness for consumers if the PIHP denies a request for authorization of a psychiatric inpatient admission.
  5. Response to appeals within fourteen calendar days if the PIHP's decision to deny payment of any portion of a psychiatric inpatient stay for consumers is appealed by the inpatient facility. The inpatient facility may appeal the PIHP's decision(s) to the MHD after all reasonable effort is made to resolve the dispute between the PIHP and the inpatient facility.
  6. Adherence to the requirements set forth in the psychiatric inpatient exhibits combined in contract Exhibit E.
  7. Ensure the continued provision of community psychiatric inpatient services should a community hospital become insolvent.
  8. MAA holds the contract for External Quality Review for these hospitals.

V. Access Criteria.

The PIHPs will provide standards for access to care so that covered services are available 24 hours a day, 7 days a week within reasonable response time frames, and in a manner that ensures continuity of care and adequate capacity. MHD believes it is important for consumers to be seen quickly at each stage of treatment, and for care continuity to be coordinated when the consumer transitions between care or service settings. MHD has recently developed Access to Care standards which clearly defines who is seen for care;the access standards for timeliness have been incorporated into the contract. PIHPs monitor access and care continuity timeliness at six critical points:
1. At initial entry into the system, intake is initiated within 10 days of request for mental health services (to minimize the number of days from initial contact to outpatient service appointment);
2. To minimize the number of days from intake appointment to onset of initial treatment services, routine mental health services are offered to occur within 14 calendar days of a determination of eligibility (an extension of 14 additional calendar days is possible if there are extenuating circumstances and the extension is made in the interest of patient care). We expect that a total of 28 days will be the norm for routine services;
3. At periodic points during treatment --at a minimum, the treatment plan must be updated every 180 days;
4. As the client transitions from outpatient to inpatient care--provider contact occurs with facility team to coordinate care and discharge planning;
5. As the client transitions from inpatient to outpatient care--to minimize the number of days from hospital discharge to first face-to-face outpatient appointment;
6. At entry into the crisis system (time from initial call to CDMHP triage)--emergent mental health services occur within 2 hours of the request for mental health services from any source. Urgent care is to occur within 24 hours of the request for mental health services from any source;
7. For services that occur in the provider's office, wait time should not exceed 1 hour beyond the scheduled appointment time.
Additional Access Criteria: The minimum Access to Care standards and minimum eligibility criteria will be in place to begin in August 2003. The PIHP level of care guidelines submitted to and approved by MHD are to be in place within 90 days of contract execution. The PIHP's guidelines shall be submitted to MHD for approval within 30 days of any change to content. The PIHP shall maintain its 2001-2003 Level of Care Guidelines until such time as the 2003-2005 Guidelines are approved.
Resource and Utilization Management. The PIHP shall:
1. The PIHP must be able to demonstrate that its resource management mechanisms are effective. This includes ensuring mechanisms are in place to adjust to situations in which there is:
  1. unanticipated need for MHCP with certain types of expertise;
  2. unanticipated limitation of the availability of such MHCP including identifying the number of MHCP whom are not accepting new enrollees.
2. Ensure the capacity to adjust the number, mix and geographic distribution of MHCP and other qualified personnel to meet access and travel standards as the population of enrollees needing mental health services shifts within the service area. Any change that results in reduced capacity must be approved in advance by the MHD.
3. Maintain written policy and procedures that ensures consistent application of review criteria for authorization decisions and the consistent application of the Access to Care Standards and consultation with requesting provider when appropriate in determining what constitutes medically necessary mental health services within the Contractor's service area.
4. Ensure the consistent application of the Access to Care standards in determining what constitutes medically necessary mental health services within the PIHP service area.
5. Ensure enrollees are notified of authorization decisions through written or oral means.
6. Ensure that any decision to deny a service authorization request or to authorize a service in an amount, duration or scope that is less that requested or described in the individuals service plan is made by a mental health professional with the appropriate clinical expertise to make such a decision.
7. Notify the requesting CMHA, and give the enrollee written notice, of any PIHP decision that:
  1. denies a service authorization request; or
  2. authorizes a service in an amount, duration or scope that is less than requested.
8. Ensure that mental health professionals have effective communication with enrollees with sensory impairments.
9. Ensure mental health professionals and MHCP, acting within the lawful scope of mental health practice, are not prohibited or restricted from advising or advocating on behalf of an enrollee with respect to:
  1. the enrollee's mental health status,or mental health treatment options, including any alternative treatment, in a culturally competent manner;
  2. any information the enrollee needs in order to decide among all relevant mental health treatment options;
  3. the risks, benefits, and consequences of mental health treatment (including the option of no mental health treatment;
  4. the enrollee's right to participate in decisions regarding his or her mental health care, including the right to refuse treatment, and to express preferences about future treatment decisions;
  5. the enrollees right to be treated with respect and with due consideration for his or her dignity and privacy;
  6. the enrollee's right to be free from any sort of restraint or seclusion used as a mean of coercion, discipline, convenience or retaliation;
  7. the enrollee's right to request and receive a copy of his or her medical records,and to request that they be amended or corrected, as specified in 45 CFR part 164;
  8. The enrollee's right to be free to exercise his or her rights, and to do so does not adversely affect the way the PIHP, CMHA of MHCP treats the enrollee.
10. For the purpose of utilization control, the PIHP may place appropriate limits on a mental health service based on criteria such as medical necessity provided the mental health services furnished can reasonably be expected to achieve their purpose. The PIHP may specify what constitutes medical necessity in a manner that is:
  1. no more restrictive than the State Medicaid program; and
  2. to the extent that the PIHP is responsible for covering mental health services related to the screening, diagnosis and treatment of mental illness;
  3. congruent with the consumer's ability to attain, maintain or regain functional capacity.
11. Ensure that utilization management activities are not structured so as to provide incentives for any individual or entity to deny, limit, or discontinue medically necessary mental health services to any consumer.
12. Provide upon request a second opinion from a qualified mental health professional within the network. If an additional qualified mental health professional is not currently available within the network, the PIHP shall provide or pay for a mental health professional outside the network, at no cost to the consumer. The second opinion is offered to occur within 30 days of the request for a second opinion.

VI. Quality Management.

The State will conduct a statewide review to assess the quality and appropriateness of care and services furnished under the State's PIHP contracts for all Medicaid enrollees using the mandatory EQRO protocols.
The PIHP conducts monitoring and reviews its ongoing quality management program to ensure continued assessment and improvements to the quality of mental health services in their service area, and to determine the effectiveness of the overall regional system of care (42 CFR 438.240).
In addition, the PIHP shall:
1. Assess the clinical appropriateness of fit between what services were needed and what services were provided;
2. Assess the degree to which mental health services and planning incorporate consumer/family voice;
3. Assess the degree to which mental health services are age, culturally, and linguistically competent;
4. Assess the degree to which mental health services are provided in the least restrictive environment;
5. Assess the degree to which needs for housing, employment and education options were met;
6. Assess the degree to which there are appropriate linkages and integration with other formal/informal systems and settings;
7. Assess the effectiveness of mechanisms to detect both under-utilization and over-utilization of mental health services;
8. Assess performance and efficiency of CMHA and ascertain that their performance is within current standards for mental health;
9. Ensure relevant grievance and fair hearing results are incorporated into system improvement;
10. Ensure the interpretation of quality improvement feedback is conveyed to CMHAs, the advisory board and other interested parties;
11. Measure allied system satisfaction.
Participate with the MHD in the implementation of the Quality Strategy.
Participate with the MHD in the development and implementation of a standard set of performance indicators to measure access, quality and appropriateness. Participation shall include:
1. providing necessary data;
2. participating in the analysis of results and the development of system improvements based on that analysis on a statewide basis;
3. incorporating results into PIHP-specific quality improvement activities.
Participate with the MHD in completing the two Mental Health Statistics Improvement Project (MHSIP) surveys, one for adults and one for youth/families. Participation shall include, at a minimum:
1. providing consumer contact information to the MHD;
2. participating in the analysis of results and the development of system improvements based on that analysis on a statewide basis; and
3. incorporating results into PIHP-specific quality improvement activities.
Participate with the MHD and other PIHPs in the development and implementation of two statewide Quality Assessment and Improvement projects. These projects shall include one clinical (consumer participation in treatment) and one non-clinical (data quality).
Participate with the MHD in its annual review activities (e.g., PIHP certification,Medicaid managed care reviews, provider licensure and certification). At a minimum, participation shall include:
1. submission of deliverables and other materials necessary for the team's visit prior to their arrival on site;
2. completion of site visit protocols;
3. assistance in scheduling interviews and agency visits.

VII. Management Information System. The PIHP shall:

Provide MHD all data described in the data dictionary for the MHD Consumer Information System (MHD-CIS) (Data Dictionary), or any successor. Data shall be submitted within 60 days of the close of each calendar month. Upon receipt of the data, the MHD will generate an error report. Upon receipt of the error report, the PIHP will remedy all data errors within 30 calendar days of the receipt of the error report.
Demonstrate a primary and backup system for electronic submission of data requested by the MHD. This shall include the use of the Inter-Governmental Network (IGN), ISSD-approved secured Virtual Private Network (VPN), or the SHIVA toll-free telephone system. Alternate media are not acceptable.
Participate in MHD decisions to add or delete data elements that shall included projected cost analysis.
Implement changes made to the MHD data dictionary within 120 days from the date of published changes.
Provide daily written certification which attests, based on best knowledge, information, and belief, of the PIHP Administrator:
1. to the accuracy, completeness, and truthfulness of data;
2. that the PIHP is in compliance with this agreement;
3. to the accuracy, completeness, and truthfulness of documents specified by the MHD.
Ensure that the requested information is received in a manner that will allow for a timely response to inquiries from CMS, the legislature, MHD, and other parties about system operations. Such data shall be provided in a time frame developed with the MHD at the time of the request and takes into consideration the needs of the inquiring party.
Monitor to ensure the data received from CMHAs is accurate and complete by verifying the accuracy and timeliness of reported data; screening the data for completeness, logic and consistency; and have available proof to document to the MHD that the monitoring is occurring.

VIII. Structure and Operations. Each PIHP must:

Purchase age, linguistic and culturally competent community mental health services for consumers who experience mental illness or who are severely emotionally disturbed.Such services will also be purchased for those they define as family (e.g., parents, foster parents, assigned/appointed guardians, siblings, caregivers and significant others) pursuant to:
1. RCW38.52, 70.02,71.05,71.24, and 71.34, or any successors;
2. WAC 388-865 or any successors;
3. Federal Public Law 102-321 (Federal Block Grant), or any successors;
4. CFR 42CFR 438.10; 206; 207 or any successors.
Operate a PIHP to provide medically necessary mental health services to enrollees pursuant to:
1. Federal 1915(b) Mental Health Waiver or any successors;
2. Other provisions of Title XIX of the Social Security Act or any successors;
3. Other applicable state and federal statutes and regulations, or any successors;
4. Administrative policies, or any successors.
Along with its subcontractors, comply with all applicable federal statutes and regulations, whether or not a specific citation is identified in various sections of this agreement, and all amendments thereto that are in effect when the agreement is signed, or that comes into effect during the term of the agreement.
This includes, but is not limited to, Title XIX of the Social Security Act and Title 42 of the Code of Federal Regulations. Any provisions of this agreement which conflict with state and federal statutes, or regulations, or CMS policy guidance is hereby amended to conform to the provisions of state and federal law and regulations.
DSHS remains the single state authority for Medicaid.
The Department of Social and Health Services (DSHS), Office of the State Auditor, The Department of Health and Human Services, Centers for Medicare and Medicaid Services, the Comptroller General, or any of their duly authorized representatives, have the authority to conduct announced and unannounced:
1. surveys;
2. audits;
3. reviews of compliance with licensing and certification requirements and compliance with this agreement;
4. audits regarding the quality, appropriateness, and timeliness of mental health services of the PIHP and subcontractors;
5. audits and inspections of financial records of the PIHP and its subcontractors.
Along with its subcontractors, recognize the unique social/legal status of Indian nations; the tribes under the Supremacy clause; the Indian Commerce Clause of the United State Constitution; federal treaties; executive orders; Indian Citizens Act of 1924 statutes; state and federal court decisions; and maintain compliance with DSHS American Indian Policy 7.01, or any successor, pursuant to the Centennial Accord between the Washington State Government and the Washington Tribes.
Operate a mental health managed care system with necessary authority, accountability, and administrative capability for its entire geographic area.
Adjust to funding constraints that may further limit capacity to provide mental health services to state priority populations by planning for the need for crisis intervention and mental health services for those most in need.
Furnish the necessary personnel, materials, and /or mental health services and otherwise do all things necessary for, or incidental to, the performance of the work set forth here and as attached. Unless otherwise specified, the PIHP shall be responsible for performing or ensuring fiscal and program responsibilities. No subcontract will terminate the legal responsibility of the PIHP to perform the terms of this agreement.
Provide for the availability of crisis mental health services and medically necessary mental health services on a 24-hour, 7 days per week basis. The PIHP shall purchase crisis mental health services where the PIHP has no formal crisis service arrangements.
Provide all components of the Involuntary Treatment Act applicable to PIHPs, as identified in this agreement, state law, and 1915(b) waiver.
Ensure a sufficient number, mix, and geographic distribution of community mental health agencies (CMHA) and/or qualified personnel, including mental health care providers (MHCPs) to meet:
1. an age appropriate range of mental health services;
2. access to medically necessary mental health services to meet the needs of the anticipated number of enrollees; and
3. Access and travel standards.
Oversees and is accountable for any functions and responsibilities that it delegates to any contractor.
Ensure that when enrollees must travel to service sites, they are accessible per the following standards:
1. in rural areas, service sites are within a 30 minute drive time;
2. in large rural geographic areas, sites are available within a 90 minute commute time;
3. in Urban areas, service sites are accessible by public transportation, with the total trip including transfers not to exceed 90 minutes each way;
4. travel standards do not apply:
  1. when a consumer chooses to use service sites that require travel beyond the travel standard;
  2. to psychiatric inpatient services;
  3. Under exceptional circumstances(e.g., inclement weather,hazardous road conditions due to accidents or road construction,public transit shortages,delayed ferry service).
Purchase medically necessary mental health services pursuant to this agreement outside of the PIHP service area in a timely manner if the CMHA and/or qualified personnel is unable to provide the services covered under this agreement.The PIHP shall continue to pay for medically necessary mental health services outside the service area until the PIHP is able to provide there within its service area.
Include consumer and family voice in planning,implementation,and evaluation of the public mental health system.

IX. Information Requirements

Maintain and comply with an Advance Directive policy that respects consumer's advance directives for psychiatric care. If the state law changes, the MHD will send notice to the PIHP who shall then ensure the provision of notice to consumers within 90 days of the change.
Ensure Healthy Options enrollees are informed of their choice to receive mental health services either through the PIHP on the Healthy Options enrollee's managed care plan and in a manner that in no way limits or directs their choice.
Ensure enrollee information complies with 42 CFR438.100 (a) 2, 438.6(l)(3), or any successors. In addition, the PIHP shall:
1. have mechanisms in place to notify enrollees:
  1. that oral interpretation in any language and written interpretation in prevalent languages as called out by DSHS (i.e., Cambodian, Cantonese,Mandarin, Korean, Laotian, Russian, Spanish, and Vietnamese) is available;
  2. how to access these services. The PIHP shall be able to demonstrate that its notification mechanisms are effective.
  3. cooperate with MHD as it develops and provides all enrollment notices, informational materials, and instructional materials relating to enrollees in a manner and format that may be easily understood. This includes the provision of written information in each prevalent non-English language in its service area.
  4. help enrollees understand the requirements and benefits of the managed care plan. This includes information on grievance and fair hearings. It is expected this education will be provided by the enrollee’s case manager.
2. make available and provide in a chart-like format enrollee rights and protections;
  1. oral interpretation services free of change to the enrollee for any language;
  2. information about benefits and authorization requirements, to include the provision of such information in alternative formats and in an appropriate manner that considers special needs. Further, enrollees must be informed of the availability of these formats and how to access them;
  3. sufficient detail regarding the amount, and intensity of benefits available to ensure enrollees understand the benefits to which they are entitled.
  4. Procedures for obtaining benefits, to include authorization requirements.
  5. Information about obtaining care from out of network providers.
  6. Information on how to access and use after-hours and crisis coverage.
  7. Information on what constitutes an emergent condition and emergent services and how to access them.
  8. identification of MHCPs who are not accepting new enrollees upon request;
  9. Information of advance directives for psychiatric care.
3. Additional annual information upon request from enrollees, including:
  1. the fact that enrollee benefits will continue during an appeal or requestor fair hearing if enrollee procedures are followed;
  2. information on the structure and operation of the PIHP;
  3. CMHA licensure, certification and accreditation status;
  4. Information that includes, but is not limited to, education, licensure, and Board certification/re-certification of mental health professionals and MHCPs.
4. Collaborate with MHD to develop the required enrollee information;
5. Ensure its Grievance process complies with BBA requirement sand WAC 388-865-0255or any successors.

X. Additional Care Management Requirements. The PIHP must:

Incorporate the Access to Care standards within the PIHP's Level of Care Guidelines as they pertain to minimum eligibility criteria for enrollee access to outpatient mental health services. Guidelines must include length of stay (LOS) and discharge criteria.
Implement mechanisms to ensure the consistent application and utilization of its Level of Care. The PIHP shall be able to demonstrate that its mechanisms are effective.
Participate wherever possible in the coordination of mental health services with other systems of care. These include,but are not limited to, physical health care, Alcohol and Substance Abuse, Developmental Disabilities, Child Welfare,Juvenile Justice, Aging and Disabilities Services Administration, Tribes, Vocational Rehabilitation, jails, corrections, informal/natural supports, and education. The PIHP will also:
1. Implement service delivery protocols developed under the 01-03agreement for the coordination and integration of services for children and adults/older adults.
2. In accordance with the privacy requirements in 45 CFR parts 160 and 164 subparts A and E,protect the enrollee's privacy in the process of coordinating care.
Ensure it does not:
1. operate any physician incentive plan as described in42 CFR 422.208;
2. does not contract with any subcontractor operating such a plan. If the PIHP desires to implement any form of physician incentive plan, the PIHP shall provide60days written notice to the MHD and shall comply with all requirements of 42 CFR438.6(h).
Ensure enrollees are not held liable for any of the following:
1. Community psychiatric hospitals in the case of insolvency.The PIHPs are specifically exempt from the requirements of 42 CFR 438 regarding solvency.
2. Covered mental health services provided to the enrollee for which:
  1. the State does not pay the PIHP; or
  2. the PIHP does not pay the MHCP or CMHA that furnishes the service under a contract, referral or other arrangement, to the extent those payments are in excess of the amount the enrollee would owe if the PIHP provided the services directly
Have administrative and management procedures in place that are designed to guard against fraud and abuse including:
1. a mandatory compliance plan;
2. written policies, procedures, and standards of conduct that articulate the PIHP's commitment to comply with all applicable federal and state standards;
3. designation of a compliance officer and a compliance committee that is accountable to senior management;
4. effective training and education for the compliance officer, staff of the RSN, and MHD selected staff of the CMHAs. The MHD shall request this training be provided by CMS to ensure compliance with their guidelines and expectations including the use of the List of Excluded Individuals(LEIE)and CMS Publication69 or their equivalent. MHD will notify the PIHP when this training is planned;
5. effective lines of communication between the compliance officer,the PIHP, and the PIHP's network of CMHAs;
6. enforcement of standards through well-publicized disciplinary guidelines;
7. provision of internal monitoring and auditing;
8. provision for prompt response to detected offenses and for development of corrective action initiatives.
Notify the MHD of any incident where the potential for negative media coverage exists(e.g., unexpected death of a consumer served by the PIHP, loss of crisis lines, loss of service or residential sites, natural disasters or acts of terrorism);
1. Notification shall be made to the Mental Health Services chief or his/her designee during the business day in which the PIHP becomes aware of the event. If the event occurs after business hours, notice shall be given as soon as possible during the next business day.
2. Notification shall include:
  1. a description of the event;
  2. any actions taken in response to the event;
  3. the purpose or end for which any action was taken;
  4. any implications to the service delivery system.
3. Within 2 weeks of the original report, provide information regarding efforts designed to prevent or lessen the possibility of future similar incidents.
Respond in a timely manner to requests to provide information necessary to respond to inquiries from DSHS, CMS, MHD or other entities;
Ensure plans or reports required by this agreement, including Exhibit F(Deliverables), are provided to MHD in compliance with the timelines and/or formats indicated.
Implement mechanisms to ensure the selection and retention of a network that is licensed or certified by the state. The PIHP shall be able to demonstrate that its mechanisms are effective.
Insure there is no discrimination with respect to:
1. the participation, reimbursement or indemnification of any CMHA that is acting within the scope of its license, or certification under applicable state law, solely on the basis of that license or certification;
2. particular CMHAs who serve high-risk mental health consumers of specialize in mental health conditions that require costly treatment.
Provide written notice to individuals or groups of CMHAs of the reason for the PIHP's decision if they are not selected for the PIHP's CMHA network. All contracts with CMHAs shall comply with 42 CFR 438.214.
Notify the MHD 30 days in advance of public notice before the PIHP terminates any of its CMHA subcontracts. If the PIHP terminates a CMHA contract in less than 30 days, the PIHP shall notify the MHD as soon as there is a determination to terminate the subcontract and in advance of public notice.
PIHP and Subcontractors
1. The PIHP and all levels of subcontractors shall comply with all applicable state and federal statutes,rules and recommendations,or any successors. In addition,the PIHP will:
  1. Ensure distribution of enrollee notification of applicable changes in state law (e.g.,Advance Directives)upon receipt of notice from the MHD;
  2. Ensure a process is in place to demonstrate that all third-party resources are identified and pursued in accordance with Medicaid being the payer of last resort;
  3. Oversee, be accountable for, and monitor all functions and responsibilities delegated to a subcontractor on an ongoing basis including formal reviews;
  4. Evaluate subcontractors' ability to perform delegated activities prior to any delegation of responsibility or authority to the subcontractor;
  5. Ensure enrollee access and mental health services are equal to or greater than access and services would be under Medicaid fee for service.
2. Ensure that all subcontracts are in writing and that subcontracts specify all duties, reports, and responsibilities delegated under this agreement. Those written subcontracts shall:
  1. Require that the subcontractor neither employs any person nor contracts with any person or CMHA excluded from participation in federal health care programs under either section 1128 or section 1128A of the Social Security Act, or debarred or suspended per this agreement's general terms and conditions;
  2. Require subcontractors to hold all necessary licenses, certifications, and/or permits as required by law for the performance of services to be performed under this agreement. This includes any additional requirements established by the State.;
  3. Require compliance with state and federal non-discrimination policies,Health Insurance Portability and Accountability Act (HIPAA), and DSHS Administrative policies (e.g., 7.01, 7.20, 7.21 or any successors) to the extent they are applicable to the subcontract;
  4. Include clear means to revoke delegation, impose corrective action, or take other remedial actions if the subcontractor fails to comply with the terms of the subcontract;
  5. Require that the contractor correct any areas of deficiencies in the subcontractor's performance that are identified by the PIHP;
  6. Require best efforts to provide written or oral notification within 15workingdays of termination of a MHCP to enrollees who had been assigned to the affected MHCP.

XI. State Responsibilities for Oversight of the Quality Strategy

Quality Strategy reviews
1. MHD's information system supports the initial and ongoing operation and review of the State's quality strategy by:
  1. The collection of data and calculation of Performance Measures used in the Quality Strategy and the Contract.
  2. The collection and reporting of data used in the non-clinical QAPI.
  3. Provide a sample of mental health service enrollees to use for the MHSIP consumer surveys,and to provide service data for survey respondents.
  4. Summarizes demographic information on Medicaid enrolled clients and report this information to each PIHP to use in assessing translation and interpretation requirements. Using this information in combination with census data and other DSHS databases, PIHPs will determine prevalent languages in their service region to fulfill document translation requirements.
2. MHD will use its own quality management infrastructure to evaluate the effectiveness of the Quality Strategy.
  1. The Performance Data Group (PDG)
    1. Membership from the Performance Indicator (PI) Workgroup and the Quality Steering Committee (QSC). The PDG membership includes stakeholders (e.g., consumers, family members, representatives from consumer advocacy groups), staff from PIHPs and CMHAs, and MHD staff (to include the quality coordinators from MHD HQ and all three facilities).
    2. The primary role of this group is to review system-wide performance data as well as data collected from the CMS EQRO protocols: MHD's QA&I team's monitoring reviews as well as data collected in support of the performance measure and quality improvement protocols. This review is done at the same time the data is sent on to the EQRO for evaluation and validation.
    3. A secondary role of this group is to review QI project information from the IDG and use it to inform ongoing data review work. PDG develops new performance indicators as a result of this review.
    4. The group presently meets quarterly, and makes recommendations to the MHD Quality Council (the MHD Management Team).
  2. The Implementation and Design Group (IDG) was formed to:
    1. Membership includes QSC members, PDG members, and members from standing MHD stakeholder groups (e.g., WAC rewrite, Advisory Council, Consumer Roundtable).
    2. Design and implement QI efforts (to include timelines and outcome measures)in response to system-wide priorities set by the Quality Council after reviewing PDG recommendations;
    3. Sends QI project information to the PDG and communicates the QI project information to constituency groups.
    4. The group meets monthly.
  3. The MHD Quality Council:
    1. Reviews recommendations from the PDG and prioritizes them.
    2. Send priorities to IDG for QI project development.
    3. Reviews EQRO and CMS reports.
    4. Reviews the Quality Strategy every six months after reviewing PDG recommendations and EQRO/CMS reports.
Communication of Quality Management work (to include the Quality Strategy) to the mental health community-at-large.
1. Presentations of initial quality strategy drafts were made to the membership of regularly meeting groups such as RSNs, Washington County Executives, Mental Health Planning and Advisory Council, Washington County Mental Health Agency Council, Performance Indicator Group, Quality Steering Committee, and SAFE-Washington. Feedback from these groups was incorporated into the reviewed draft, and new drafts were released to internal and external stakeholders.
2. The overall strategy will be released in its entirety for public comment before its final adoption, and will undergo reviews every six months by MHD and the Quality Management infrastructure. To broadly solicit feedback, the strategy will be posted on the MHD Internet. As information and performance data is obtained, it will also be posted.
3. The MHD quality strategy is viewed as a 'living' document, responsive to the needs of customers and stakeholders and sensitive to system change. Further changes to the quality strategy will be made as the monitoring and evaluation process evolves.

image displaying quality process

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For more ways to get in touch with the Department of Mental Health Services, go to the DSHS Contact Information Web page. Mental Health Related Questions Contact: