Quality Improvement Program Member

Availability

UMBH standards for the number of psychiatrists, psychologists, masters-level therapists, and facilities per 1000 members were exceeded in 2007. Also, the driving distances between members and each type of practitioner and facility were found to be appropriate in 2007. All members are within 30 minutes drive to a UMBH network provider, on average a member is within 5 minutes to a umbh provider and 10 minutes to a hospital.  UMBH regularly assesses the ability of the Practitioner Network to meet the linguistic, cultural and special needs and preferences of the membership. We add new practitioners on a regular basis to continue to meet our standards and these needs of the membership.

Accessibility

UMBH standards for accessibility to outpatient appointments are:

• Routine care within 10 business days for Commercial health plan members and within 7 business days for Medicare and Medicaid members.
• Urgent care within 48 hours for Commercial health plan members and within 24 hours for Medicare and Medicaid members.
• Non-life threatening emergency care within 6 hours.
• Medication evaluations by psychiatrists within 10 business days for Commercial members and within 7 business days for Medicare/Medicaid members.
• Psychiatric consults within 6 hours for stat consults and within 24 hours for routine consults.
• Psychological testing within 30 days for Commercial/Medicare/Medicaid members.

In 2007, for Commercial health plan members:

• 71 percent of members were seen for routine appointment within 10 business days of referral.
• 57 percent of members were seen for urgent appointment within 48 hours.
• 64 percent of members were seen for medication evaluations within 10 business days.

In 2007, for Medicare and Medicaid members:

• 60 percent of members were seen for routine appointment within 7 business days of referral.
• 50 percent of members were seen for an urgent appointment within 24 hours.
• 57 percent of Medicare members were seen for medication evaluations within 7 business days.
• 52 percent of Medicaid members were seen for medication evaluations within 7 business days. 

In 2007, for all Commercial/Medicare/Medicaid members:

• 92 percent were seen within 6 hours for stat psychiatric consults.
• 99 percent were seen within 24 hours for routine psychiatric consults.

Members with urgent care needs and non life-threatening emergency care needs are tracked. The members who did not keep their appointments within the specified time frames frequently arranged times that were more convenient to them and were not at risk. Personal scheduling issues of the member (vacation, work schedules, etc.) were found most often to be the reason why members did not keep their appointments within time standards.

Telephone Accessibility

UMBH's standard for the average time to answer the telephone is within 30 seconds. The standard for telephone call abandonment rate (the number of calls where the caller hangs up before reaching a live operator), is less that 5 percent. In 2007, both of these standards were met when UMBH's abandonment rate was determined to be 2 percent, well below the national average. We also have staff and practitioners available to assist members in languages other than English, including Spanish, Creole, and French.

UMBH also has a TTY line available for the hearing impaired. The telephone number to access this service is 877-520-6254.
 

Continuity and Coordination of Care

UMBH has many activities that focus on improving the coordination of care between behavioral health and medical care and also among all behavioral practitioners treating the same member.  This is important for member safety.  We encourage members to sign consent to release information to facilitate communications with primary care physicians (PCPs) and behavioral health practitioners.

The rate of communication between practitioners is tracked using practitioner surveys every quarter. Information regarding treatment coordination is also included in treatment record review.

In 2007, the rate of practitioner coordination with members' PCPs between psychiatrists to PCP was 90 percent, psychologist to PCP was 70 percent, psychotherapists to PCP was 67 percent and CMHC to PCP was 89 percent.

UMBH has noted that one of the major barriers to improved coordination is refusal of the enrollees to sign the required release of authorize coordination with the PCPs.  UMBH will continue to educate practitioners, CMHCs and enrollees about the importance of coordination of care through communication on the UMBH website and in the enrollee and practitioner newsletters.

UMBH began compiling an annual Practitioner Profile Report (Provider Report Card) in an effort to inform providers on their average episodes, average length of stay, and coordination rates compared to   the network averages as an effort to increase coordination rates to standard level.   The Provider Report Card is mailed annually to all practitioners. 

Member Satisfaction   

Member satisfaction is very important to UMBH. A member satisfaction survey is conducted annually. More detailed information on the member satisfaction survey results can be accessed here . Overall, 92 percent of respondents to the satisfaction survey said that they were satisfied with UMBH and the management of their mental health/substance abuse benefits and treatment. Areas identified for improvement were fully informing members of their rights as a patient, informing patients about medication side effects, and giving members as much information as they wanted about managing their mental health/substance abuse condition.

UMBH considers complaints carefully. Complaints from members are reviewed individually as soon as they are received, and a thorough investigation of the issues surrounding the complaint is conducted. Although the time standard for resolving complaints is 30 days from receipt, UMBH strives to resolve all complaints within 72 hours. The member is notified of the resolution of the complaint and of the right to appeal the decision, if appropriate. Appeals of the proposed resolution of complaints are also carefully considered. In 2007:

• 100 percent of complaints were resolved within 72 hours.
• Of the complaints logged, 95 percent were for change of providers, with Clinical reasons most often cited.

Please click here for more detailed information on complaints.

Clinical Quality Improvement Activities

UMBH has identified specific clinical quality improvement activities that affect a significant portion or high risk segments of the membership. Interventions have been implemented over time to successfully improve performance in these areas.

The rate of members who complete an initial outpatient appointment within 30 days of discharge from inpatient care for a behavioral health condition is monitored on a quarterly basis. There were 85 percent of commercial members, 91 percent of Medicaid members and 89 percent of Medicare members who had a follow-up appointment within 30 days of inpatient discharge in 2007.

The rate of members who completed an initial outpatient appointment within 7 days of discharge from inpatient care for behavioral health condition is monitored on quarterly basis. There were 63 percent of Commercial members, 68 percent of Medicaid members, and 70 percent of Medicare members who had a follow-up appointment within 7 days of inpatient discharge in 2007. Efforts to maintain and continue improvement will continue in 2008. 

Preventive Behavioral Health Programs

UMBH has established four preventive health programs that are designed for members with specific diagnoses. These programs are for Attention Deficit Hyperactivity Disorder (ADHD), Major Depressive Disorders (MDD), Intensive Targeted Case Management, and Post-Partum Depression. Please see the Preventive Health Information Section for more information. Members who have used the programs tell us that the programs are very helpful.

In 2007, as in the previous years, ADHD ranked as the top diagnosis (96 percent) for children and adolescents (age 0 to 17).

In 2007, Schizopherenia ranked as the top adult outpatient diagnosis at 45 percent. 

In 2007,  among the commercial population depression diagnosis was at 28 percent of all adult diagnosis.

The Targeted Case Management Program, designed to increase time spent in the community for members with a history of severe mental illness and multiple hospitalizations, has had positive results.  The members in the program have remained in the community for longer periods of time and have had fewer hospital admissions with shorter duration. With the excellent results of this program in 2002 and 2003, UMBH expanded this to all members with multiple hospitalizations and monitors this program on an ongoing basis.

The Post-Partum Depression Program was implemented in collaboration with AvMed Health Plan. All AvMed Health Plan enrollees in prenatal programs receive educational materials about Post-Partum Depression. Approximately 4300 members have been enrolled in the program. The program was well received and was expanded to Jackson Health Plan and the University of Miami Health Plan in 2004.

Achievements of the UMBH Quality Improvement Program - 2007

In 2007, UMBH:

• UMBH maintained and increased UMBH's network of practitioners to preserve and improve access and availability standards by addition of 137 practitioners in 2007, as well recredentialling 248 providers.

• Member Services Department maintained excellent accessibility for enrollees by telephone with an abandonment rate of  2 percent.

• UMBH has over 75 percent of its Member Services and Care Management who speak both English and  Spanish; UMBH also has AT&T’s Translation Service available to meet other language preferences as requested.

• UMBH's access to practitioners for routine commercial outpatient visits within 10 days is 71 percent in 2007.

• UMBH's access to practitioners for routine Medicare outpatient visits within 7 days  is 60 percent in 2007.

• UMBH's access to practitioners for routine Medicaid outpatient visits within 7 days is 56 percent in 2007.

• UMBH's access to practitioners for urgent commercial outpatient visits within 48 hours is 57 percent in 2007.

• UMBH's access to practitioners for urgent Medicare outpatient visits within 48 hours is 50 percent in 2007.

• UMBH's access to practitioners for urgent Medicaid outpatient visits within 48 hours is 43 percent in 2007.

• UMBH has maintained the access to psychiatrists for stat consults at 92 percent and routine consults at 99 percent.

• UMBH has maintained the PCP coordination rate between 67  percent and 90 percent with all practitioner levels.

• UMBH's overall practitioner satisfaction is 76 percent in 2007.

• The Commercial 7-day post discharge follow-up compliance rate increased from 50 percent in 2006 to 63 percent in 2007.

• The Medicaid 7-day post discharge follow-up compliance rate increased from 62 percent in 2006 to 68 percent in 2007.

• The Medicare 7-day post discharge follow-up compliance rate increased from 51 percent in 2006 to 70 percent in 2007.

• The Commercial 30-day post discharge follow -up compliance rate increased from 82 percent in 2006 to 85 percent in 2007.

• The Medicare 30-day post discharge follow -up compliance rate increased from 87 percent in 2006 to 89 percent in 2007.

• The Medicaid 30-day post discharge follow-up compliance rate increased from 89 percent in 2006 to 91 percent in 2007.

• UMBH continued to upgraded its automatic document manager and fax server system. This system is used for automated access to outpatient treatment review materials to streamline and improve the utilization management process for outpatient treatment.

• UMBH continued to provide enrollees and practitioners with newsletters and other diagnostic specific educational information including practice guidelines (ADHD and MDD), and preventative behavioral health information (ADHD, MDD, PPD, & TCM).

Opportunities for Improvement in QI Programs in 2008

• To continue to improve coordination with PCP
  
• To continue to expand the functionality of the web site to provider claim submission and lookup, eligibility lookup, member case management, and treatment form submission.
  
• To select new software system to manage referrals, eligibility, claims and disease management
  
• To increase the rate of return on the member satisfaction survey.

If you would like more information about, or paper copies of materials, please contact the UMBH QI Department at 1-800-294-8642, or send an e-mail to umbhadmin@med.miami.edu. We welcome your comments and ideas about how we can improve our care and services.