Behavioral Health Services of Somerset and Bedford Counties, Inc. HealthChoices Program

Transcription

1 Behavioral Health Services of Somerset and Bedford Counties, Inc. HealthChoices Program Annual Report

2 Contents Introduction 3 Enrollment 4 Services 7 Utilization 9 Diagnosis 12 Cost per Member 14 Youth Served 15 Inpatient Admissions 17 Quality Assurance 18 Co-Occurring Disorders Initiative 20 Telepsychiatry 21 WRAP for Kids 22 Behavioral Health Training Program 23 Acronyms 24 Terminology 26 Somerset County Court House BHSSBC Corporate Board of Directors Randy J. Hay, Chairman Philip Gardill, Vice-Chairman Suzanne Edwards, Secretary Amy Kimmel, Treasurer Pam Humbert Larry Mazer Dr. Thomas Otis Dr. Barbara Uncapher Kathy Unger BHSSBC Management Group Pamela Marple, HealthChoices Coordinator Erin Howsare, Somerset SCA Director Dawn Housel, Bedford SCA Director Kathy Unger, Somerset MH/MR Deputy Administrator Philip Gardill, Bedford MH/MR Deputy Administrator Bedford County Court House BHSSBC Corporate Members County Commissioners Pamela Tokar-Ickes John P. Vatavuk James C. Marker Michael J. Herline Steven K. Howsare Gary W. Ebersole BHSSBC Management & Support Staff Pamela Marple, HealthChoices Coordinator Melissa Reilly, HealthChoices Finance Director Tina Heinrich, HealthChoices Clinical/Quality Management Director Tracy Shultz, HealthChoices Project Manager Debra Skrzecz, HealthChoices Administrative Assistant 2 Bedford-Somerset HealthChoices Program

3 HealthChoices HealthChoices is the Commonwealth of Pennsylvania s mandatory Medicaid managed care program administered by the Department of Public Welfare (DPW). This integrated and coordinated health care delivery system was introduced by the Commonwealth to provide medical, psychiatric, and substance abuse services to Medical Assistance (Medicaid) recipients. The three components of the HealthChoices Program are: 1. Physical Health 2. HealthChoices Enrollment Assistance Program 3. Behavioral HealthChoices The Office of Medical Assistance Programs (OMAP) administers the first two components, while the Office of Mental Health and Substance Abuse Services (OMHSAS) oversees the third component, the behavioral health program that provides mental health and substance abuse treatment services. The needs of the high risk populations included in the HealthChoices managed care program requires broad-based coordination to assure appropriate access, service utilization, and continuity of care for persons with serious mental illness and/ or addictive diseases. Because of the cross-cutting coordination needs of Medical Assistance recipients, the unique structure of the behavioral health and human service delivery systems administered by the counties, and their over 30 years experience in administering behavioral health services programs, it was determined that county government would be offered the right-of-first opportunity to enter into a capitated contract with the Commonwealth. The Department of Public Welfare introduced the HealthChoices program on a staggered basis, starting first in southeastern Pennsylvania and expanding the program throughout the state over a period of ten years. As of July 1, 2007, the HealthChoices program was fully implemented throughout the Commonwealth. Bedford and Somerset Counties accepted the right-of-first- opportunity to manage the local program and entered into a full-risk capitation contract with the Commonwealth. The counties formed a 501(c)(3) corporation called Behavioral Health Services of Somerset and Bedford Counties, Inc. (BHSSBC), which has the responsibility of managing the contract with DPW. BHSSBC, in turn, sub-contracts with a behavioral health managed care organization, Community Behavioral Health Network of Pennsylvania (CBHNP). Services provided by CBHNP include care management, provider network development, quality assurance, member services, and claims management. BHSSBC provides oversight and monitoring of all of CBHNP s activities to ensure full compliance with its contract with DPW. Annual Report

4 Enrollment Bedford County HC 7,214 41% Somerset County HC 10,220 59% Enrollment by Quarter Fiscal Year through ,425 17,434 17,236 17,094 17,087 17,031 16,585 16,677 16,424 16,507 16,163 16,024 15,955 15,933 16,021 16,043 Quarter 1 Quarter 2 Quarter 3 Quarter 4 4 Bedford-Somerset HealthChoices Program

5 Medical Assistance Categories of Aid: Governed by federal regulations, Pennsylvania is required to cover a set of mandated services for specific groups of individuals to qualify for federal matching payments. The primary coverage groups in the Medical Assistance Program are: Temporary Assistance to Needy Families (TANF) Assistance to families with dependent children who are deprived of the care or support of one or both parents. Healthy Beginnings Assistance for women during pregnancy and the postpartum period. State Only General Assistance State funded program for individuals and families whose income and resources are below established standards and who do not qualify for the TANF program. This includes the Categorically Needy (CNO) and Medically Needy Only (MNO) groups. Federally Assisted Medical Assistance for General Assistance Recipients Federal and state funded program for individuals and families whose income and resources are below established standards and who do not qualify for the TANF program. Supplemental Security Income without Medicare Assistance for people who are aged, blind, or determined disabled for less than two years. Supplemental Security Income with Medicare Assistance for people who are aged, blind or determined disabled for over two years. Enrollment by Medical Assistance Category of Aid 17,434 individuals were enrolled in the Bedford- Somerset HealthChoices Program at the end of the Fiscal Year. TANF Child 3,606 21% Categorically Needy Only 310 2% Healthy Beginnings 4,401 25% TANF Adult 1,829 11% Federal General Assistance 215 1% SSI with Medicare 3,013 17% SSI Child 1,276 7% SSI Adult 2,528 15% Medically Needy Only 256 1% Annual Report

6 Member Demographics Gender Male 7,679 44% Female 9,755 56% Age 45 to 64 2,964 17% Age 65 and older 1,310 8% Age Group Age 0 to 5 2,732 16% 17,434 individuals were enrolled in the Bedford-Somerset HealthChoices Program at the end of the Fiscal Year. Age 6 to 12 2,991 17% Age 21 to 44 4,351 25% Age 18 to 20 1,088 6% Age 13 to 17 1,998 11% Other % Race North American Indian % Caucasian 16, % Asian % African American % 6 Bedford-Somerset HealthChoices Program

7 Services HealthChoices members are eligible to receive in-plan services offered by their choice of at least two service providers as well as additional services that have been approved for use by the Bedford-Somerset HealthChoices Program. In-Plan Services: Inpatient Psychiatric Hospitalization Inpatient Drug & Alcohol Detoxification, Treatment, Non-Hospital Rehabilitation, and Halfway House Psychiatric Partial Hospitalization Services Outpatient Mental Health and Drug & Alcohol Counseling Laboratory and Diagnostic Services Medication Management and Clozapine Support Psychiatric Evaluation and Psychological Testing Residential Treatment Facilities for Adolescents (RTF) Behavioral Health Rehabilitative Services for Children and Adolescents (BHRS) Methadone Maintenance Blended Case Management Crisis Intervention Family Based Mental Health Services Peer Support Services Mobile Mental Health Treatment CRR Host Home Telepsychiatry Supplemental Services: Drug & Alcohol Level of Care Assessment Drug & Alcohol Intensive Outpatient Drug & Alcohol Targeted Case Management Drug & Alcohol Partial Hospitalization Children s Services enrolled as Program Exceptions Psychiatric Rehabilitation Annual Report

8 Youth-Focused Services Behavioral Health Rehabilitative Services (BHRS), the behavioral health component for Early Periodic, Screening, Diagnosis and Treatment, are services to children through the age of 21 years old designed to develop individual specific plans to care for social and emotional disturbances. Family Based Mental Health Services are 24-hour, 7-days-a-week services designed to assist families in caring for their children or adolescents with emotional disturbance at home. As a licensed program, Family Based Mental Health Services offers mental health treatment, case work services, and family support for up to 32 weeks, and longer if medically necessary. Family Based services are delivered by a team of mental health professionals and mental health workers, primarily in the family home. Residential Treatment Facilities (RTF) are medical assistance approved, mental health treatment facilities for medical assistance eligible children and adolescents (up to age 21) who cannot be maintained in the home. Most Restrictive Continuum of Care for Children and Adolescents Inpatient Hospital high-security, high intensity treament in a psychiatric facility Residential Treatment Facility (RTF) intensive treatment in a residential setting Community Residential Rehabilitation Host Home therapeutic foster-care in a family-like environment Partial Hospitalization Program services provided in a clinic or school setting for 3-6 hours per day to assist a child transitioning from, or prevent, inpatient treatment Family-Based Treatment provides intensive in-home services to prevent out-of-home placement Behavioral Rehabilitation Services for Children and Adults (BHRS) individualized services provided to the child in-home, in the community, or at school Outpatient Services community-based treatment services provided in a clinical setting, that includes therapy and medication management Least Restrictive 8 Bedford-Somerset HealthChoices Program

9 Utilization Members Served and Expenditures Age Group Age % Age % Age % Age % Total Expenditures: $20,015,622 Distinct Members Served: 4,098 Age ,457 35% Age % Age % Age $3,316,289 16% Age $2,149,905 11% Age 65+ $126,143 1% Age 0-5 $1,144,144 6% Age 6-12 $8,204,362 41% Gender Age $719,536 3% Male 1,896 46% Age $4,355,243 22% Female $7,817,274 39% Female 2,202 54% Male $12,198,348 61% Annual Report

10 Utilization by Level of Care Members Served and Expenditures Total Expenditures: $20,015,622 Distinct Members Served: 4,098 RTF % BHRS % Outpatient MH 3, % Community Support Svcs 1, % Inpatient D&A % Inpatient MH % Outpatient MH $2,796, % Outpatient D&A % RTF $879, % Other-Supplemental Svcs % Outpatient D&A $639, % BHRS $7,961, % Other-Supplemental Svcs $1,289, % Inpatient MH $2,348, % Inpatient D&A $737, % 10 Bedford-Somerset HealthChoices Program Community Support Svcs $3,363, %

11 Bedford Served Outpatient MH 1, % RTF 6 0.2% BHRS % Outpatient D&A % Other- Supplemental Svcs % Community Support Svcs % Inpatient D&A % Inpatient MH % Other- Supplemental Svcs $647, % Bedford Paid Outpatient D&A $279, % Outpatient MH $1,021, % RTF $177, % BHRS $2,651, % Somerset Served Outpatient MH 1, % RTF % BHRS % Community Support Svcs % Inpatient MH $586, % Inpatient D&A $414, % Community Support Svcs $1,702, % Outpatient D&A % Total Expenditures: Bedford - $7,480,688 Somerset - $12,534,934 Other- Supplemental Svcs % Distinct Members Served: Bedford - 1,703 Somerset - 2,404 Inpatient D&A % Inpatient MH % Outpatient D&A $359, % Other- Supplemental Svcs $642, % Inpatient MH $1,762, % Somerset Paid Outpatient MH $1,774, % Inpatient D&A $322, % RTF $702, % Community Support Svcs $1,660, % BHRS $5,309, % Annual Report

12 Mental Health Diagnoses Members Served and Expenditures Depression 1, % Other MH % ADHD/Conduct % Bipolar % Adjustment % Austism Spectrum % Total Expenditures: $18,508,432 Distinct Members Served: 3,777 Depression $2,962, % Schizophrenia/ Psychosis % Other MH $97, % Anxiety 1, % Bipolar $1,709, % ADHD/Conduct $6,613, % Austism Spectrum $3,122, % Schizophrenia/ Psychosis $991, % 12 Bedford-Somerset HealthChoices Program Anxiety $1,514, % Adjustment $1,496, %

13 Substance Abuse Diagnoses Members Served and Expenditures Alcohol % Cannabis % Cocaine % Other D&A % Opioid % Total Expenditures: $1,507,190 Distinct Members Served: 575 Cannabis $192, % Cocaine $16, % Other D&A $264, % Alcohol $234, % Opioid $798, % Annual Report

14 Average Cost per Member Level of Care All Levels of Care $4,884 $4,776 $4,991 RTF $39,998 $56,690 $71,691 Outpatient MH $931 $790 $904 Outpatient D&A $1,534 $1,174 $1,573 Supplemental Svcs $1,559 $1,794 $769 Non-Hospital D&A $8,449 $5,899 $4,415 Inpatient MH $5,118 $5,577 $5,570 Community Support Svcs $2,457 $2,407 $2,587 BHRS $10,116 $9,726 $11,418 Age Group Age 65+ $1,660 $1,401 $1, Age $2,600 $2,684 $2,366 Age $2,276 $2,603 $2,222 Age $2,626 $2,767 $3,427 Age $7,516 $8,050 $8,211 Age 6-12 $9,438 $10,781 $11,030 Age 0-5 $6,317 $7,063 $7, Bedford-Somerset HealthChoices Program

15 Youth Members Served and Expenditures Included in the Youth category are all HealthChoices members under age 18 and all members involved in BHRS or RTF services RTF % Outpatient MH 1, % BHRS % Outpatient D&A % Other-Supplemental Svcs % Inpatient MH % Inpatient D&A 8 0.3% Community Support Svcs % Outpatient D&A $25, % Outpatient MH $1,420, % RTF $879, % Total Expenditures: $13,867,685 Distinct Members Served: 1,485 Other-Supplemental Svcs $148, % Inpatient MH $1,277, % Inpatient D&A $96, % BHRS $7,961, % Community Support Svcs $2,057, % Annual Report

16 Diagnosis Average Cost per Member - Youth Drug & Alcohol $3,379 Other Mental Health $513 Depression $4,836 Bipolar $7,398 Autism Spectrum $15,145 Anxiety $1,477 Schizophrenia/Psychosis $9,259 Adjustment ADHD/Conduct $2,640 $7,931 Total Expenditures: $13,867,685 Distinct Members Served: 1,485 Other MH % Anxiety % Schizophrenia/ Psychosis Autism Spectrum % 8.5% Bipolar % Depression % Diagnoses - Youth Total Expenditures: $13,687,685 Distinct Members Served: 1,485 Cannabis, 25, 52% Adjustment % Drug & Alcohol % Alcohol, 9, 18% Opioid, 7, 14% Other D&A, 7, 14% Cocaine, 1, 2% ADHD/Conduct % 16 Bedford-Somerset HealthChoices Program

17 Inpatient Treatment Fiscal Year Mental Health Inpatient Readmission Rate - 11% 377 Fiscal Year Substance Abuse Inpatient Readmission Rate - 5% Admissions Readmissions 7 Admissions Readmissions Voluntary and Involuntary Admissions All Voluntary Involuntary Involuntary admissions may occur when an individual s mental health condition causes behaviors that may result in harm to that individual or other members of the community. Annual Report

18 Quality Assurance Authorization Denials by Fiscal Year A service may be denied in full, a lesser amount of the service may be approved, or a different level of care may be authorized. Only a small percentage of authorization requests are totally denied. The overall trend for service denials decreased signifi cantly as the operating year progressed FY FY FY FY Complaints Filed by Fiscal Year 19 BHSSBC closely monitors complaints fi led by HealthChoices members. Although complaints increased slightly in FY the number of complaints remain low considering that 12 out of 4,098 members fi led a complaint. Each complaint was resolved within 30-days to the satisfaction of the involved member FY FY FY FY Bedford-Somerset HealthChoices Program

19 Level I Grievances Filed by Fiscal Year 230 Members who are dissatisfi ed with treatment decisions may opt to fi le grievances to have the decisions changed. There are two grievance levels and an external review process. Additionally, a member may also choose to fi le a request for a Fair Hearing at any point during the grievance process FY FY FY FY Level II Grievances Filed by Fiscal Year FY FY FY FY Annual Report

20 Co-Occurring Disorders Initiative BHSSBC created the Co-Occurring Disorders (COD) Workgroup in February 2009 to look at cooccurring treatment options, identify barriers to treatment, create solutions to those barriers and develop short-term and long-term changes that will improve the way mental health and substancerelated services are provided. The COD workgroup adopted the Comprehensive, Continuous, Integrated System of Care (CCISC) quality improvement process developed Dr. Kenneth Minkoff and Dr. Christie Cline. Under the CCISC quality improvement model, the COD Initiative has been taking steps to transform the behavioral health service delivery system to be more about the needs of the individuals and families needing services, and the values that reflect welcoming, empowered, helpful partnerships throughout the system. Bedford and Somerset Counties have developed and adopted the following COD vision and mission statements in order to provide more welcoming, accessible, integrated, continuous, and comprehensive services to persons with co-occurring issues and complex conditions: Vision Statement: To build a system without barriers that moves Bedford and Somerset Counties services towards empowering individuals and families experiencing mental health and substance use complexities to live full, satisfying, and productive lives in the community. Mission Statement: To enhance an accessible system of comprehensive quality mental health and substance use services that are welcoming, continuous, and integrated, which promote resiliency and recovery to individuals and families in Bedford and Somerset Counties. On October 24, 2010, the Bedford-Somerset COD Workgroup and Drs. Minkoff and Cline officially launched the Consensus Document. Approximately 125 people including behavioral health care providers, human service agencies, consumers, educators and others attended workshops in both counties to hear Drs. Minkoff and Cline describe how the CCISC model engages every agency, every program in the agency, and every person delivering service around eight principles of evidencebased treatment intervention. Several agencies signed the Consensus Document, making public their commitment to this continuous quality improvement process. The COD Workgroup and the Change Agent committee members meet every month. Several consumers serve on the COD Workgroup and meaningful conversations about systems change are taking place at the monthly meetings. The COD Workgroup follows an action plan built upon the eight CCISCs principles and linked to interventions that can be applied by each clinician, such as welcoming, hope, integrated strength based assessment, stage matched interventions, integrated skill building, and positive contingency management. The CCISC model provides various self-assessment tools that the COD Workgroup and Change Agents continue to utilize to help build co-occurring competencies. The many layers of the CCISC process will lead to integrated partnerships that help people and families (and programs/systems) address multiple issues at the same time. 20 Bedford-Somerset HealthChoices Program

21 In January 2010, BHSSBC, Inc. launched the first telepsychiatry services in Somerset and Bedford Counties through the HealthChoices Program. The goals of telepsychiatry are to improve access to outpatient psychiatric services by reducing wait time, improve choice of outpatient psychiatrists in our rural counties, and offer specialized services (Board Certifi ed Child/ Adolescent Psychiatry). Consumer satisfaction with telepsychiatry is monitored closely and consumer satisfaction rankings are consistently high. 20 Telepsychiatry Telepsychiatry Distinct Members Served January 2010 to June 2011 by County Bedford County MA Somerset County MA Total There are two HealthChoices telepsychiatry Jan-Jun 10 Jul-Dec 10 Jan-Jun 11 providers offering services at four different locations (2 sites per county). The majority of consumers receiving telepsychiatry are children, which relates back to one of the original goals of starting the service: to offer specialized services (Board Certified Child/Adolescent Psychiatrist) The wait time for the initial appointment with a telepsychiatrist remains significantly less (average 3 to 5 weeks) than the wait time for a traditional first appointment with a psychiatrist (1.5 to 2 months) in our counties. The providers utilize different psychiatrists for telepsychiatry services, thus addressing one of the original goals: to improve choice of outpatient psychiatrists in our rural counties. During the fi rst 12 months of telepsychiatry services being available, 130 consumers received services. During the fi rst six-months of the second year of services, that number was surpassed with 155 consumers receiving services. This trend indicates that the need for telepsychiatry will continue to grow. Annual Report

22 WRAP for Kids BHSSBC and the Children s Model Workgroup have joined together to explore WRAP for Kids and will be developing a pilot project to bring WRAP for Kids to Bedford and Somerset counties. Wellness Recovery Action Plans (WRAP) is a self-management and recovery system developed by a group of people who had mental health difficulties and who were struggling to incorporate wellness tools and strategies into their lives. WRAP is designed to: Decrease and prevent intrusive or troubling feelings and behaviors; Increase personal empowerment; Improve quality of life; and Assist people in achieving their own life goals and dreams. Mary Ellen Copeland, WRAP s creator, originally partnered with 2 children to modify the WRAP plans for KIDS. This book guides a child through the process of developing their own Wellness Recovery Action Plan. It will help them discover all the things they can do to feel good, stay well, and even feel better when the going is hard. It starts with listing all those good and fun things that they can use to develop their action plans, like running with the dog, coloring, and talking to a friend. Then, using these tools, the book guides them through the process of listing: What they need to do every day to stay healthy and well Things that might upset them and what they can do if these things do happen Signs that they are not feeling well and things they can do to help themselves feel better Signs that things are going really badly and things that they can do to make the situation better. Once they have completed their WRAP, kids will have a powerful personal guide to daily living. As they get older they may want to revise or update their plans or develop new ones. As children work on these plans, it helps to have supportive parents, teachers, and other adults who provide encouragement and praise as they grow, change, make good decisions, and take positive action on their own behalf. BHSSBC and the Children s Model Workgroup have decided to use a 2 phase approach to the pilot project. The first phase involves a member of the BHSSBC staff conducting presentations to providers, schools and stakeholders regarding WRAP for Kids. The second phase to begin in FY 2012/2013 will include training all interested parties in becoming WRAP facilitators. Then one provider/school will be chosen to conduct the pilot. BHSSBC and the Children s Model Workgroup have attended many trainings regarding WRAP including a 2 day WRAP for Kids training offered by Drexel University, an OMHSAS sponsored lunch and learn on WRAP for KIDS, a Webinar by Mary Ellen Copeland on Kids WRAP, and a Webinar WRAP as an Evidence-Based Practice. 22 Bedford-Somerset HealthChoices Program

23 Behavioral Health Training Program BHSSBC is committed to improving the quality of behavioral health services received by our Members. Providers need to employ competent and highly trained staff to respond to complex behavioral health conditions. In discussions with providers, some of the training barriers include cost, time, travel, and lack of quality trainings. In 2009, BHSSBC convened a Training Committee and completed a network-wide training needs assessment in Over 1,000 people participated in 11 trainings sponsored by BHSSBC during fiscal year All trainings were free of charge and for a minimal processing fee, the participants could receive LPC, LSW/LCSW, or LMFT continuing education credits (CEUs) or Act 48 (educators) credits if desired. Some of the training topics included Trauma and Building Youth Resiliency, Co-Occurring Disorders, Reactive Attachment Disorders, Acquired Brain Injury, Motivational Interviewing and Current Drug Trends. BHSSBC partnered with the Unified Family Services Systems (UFSS) of Bedford County to provide Stress Management and Cultural Competency training. According to feedback from the training evaluations, the providers appreciated the opportunity to attend these high quality no cost trainings without the need to travel out of the area. Being able to attend training in Somerset or Bedford Counties helped providers keep their training costs down and afforded them the opportunity to send multiple staff members to the training events. BHSSBC is excited to meet this need and will continue to plan and provide behavioral health training opportunities in the future. BHSSBC is collaborating with the Western Psychiatric Institute and Clinic (WPIC) of UPMC, Office of Education and Regional Programming, to bring both videoconferences and onsite trainings to our area during FY 2011/2012. Training announcements and registration forms can be found on the BHSSBC website: Annual Report

24 Acronyms AA ADD ADHD ADL AMA ASAM ASD ASP BCM BDAP BH-MCO BHRS BSC BSU C/FST CAC CANS CAO CARF CASSP CBHNP CCM CI CIS CMS COB COD CQI CRR Alcohol Anonymous Attention Deficit Disorder Attention Deficit Hyperactivity Disorder Activities of Daily Living Against Medical Advice American Society of Addiction Medicine Autism Spectrum Disorder After School Program Blended Case Management Bureau of Drug and Alcohol Programs Behavioral Health Managed Care Organization Behavioral Health Rehabilitation Services for Children and Adolescents Behavioral Specialist Consultant Base Service Unit Consumer/Family Satisfaction Team Certified Addictions Counselor Child and Adolescent Needs and Strengths County Assistance Office Commission on Acreditation of Rehabilition Facilities Child and Adolescent Service System Program Community Behavioral HealthCare Network of Pennsylvania Clinical Care Manager Crisis Intervention Client Information Specialist Centers for Medicare and Medicaid Services Coordination of Benefits Co-Occurring Disorder Continuous Quality Improvement Community Residential Rehabilitation CRR-HH CSP CYS D&A DD DOH DPW DSM-IV-TR ECM EPSDT EQRO ER ESY EVS FBMHS FFS FFT FQHC GA HC HEDIS HIPAA HIV/AIDS HMO I/FST IBNR ICD ICM ICSI Community Residential Rehabilitation-Host Home Community Support Program Children and Youth Services Drug and Alcohol Developmental Disability Department of Health Department of Public Welfare Diagnostic and Statistical Manual of Mental Disorders- Fourth Edition-Text Revision Enhanced Care Management Early and Periodic Screening, Diagnosis and Treatment External Quality Review Organization Emergency Room Extended School Year Eligibility Verification System Family Based Mental Health Services Fee-For-Service Functional Family Therapy Federally Qualified Health Center General Assistance HealthChoices Health Plan Employer Data and Information Set Standards Health Insurance Portability and Accountability Act Human Immune Deficiency Virus/Acquired Immune Deficiency Syndrome Health Maintenance Organization Individual/Family Satisfaction Team Incurred But Not Reported Claims International Classification of Diseases Intensive Case Management Integrated Children's Services Initiative 24 Bedford-Somerset HealthChoices Program

25 ICSP IDT IEP IFSP IOP IP ISP ISPT JCAHO JPO LOC LOS LSW MA MAID MATP MCO MH/MR MNC MST MSW MT MTFC NCQA OCYF ODP OMAP OMHSAS OP OVR PCP Individualized Child Services Plan Intensive Day Treatment Individualized Education Plan Individualized Family Service Plan Intensive Outpatient Program Inpatient Individualized Service Plan Individualized Service Plan Team Joint Commission on the Accreditation of HealthCare Organizations Juvenile Probation Office Level of Care Length of Stay Licensed Social Worker Medical Assistance Medical Assistance Identification Number Medical Assistance Transportation Program Managed Care Organization Mental Health/Mental Retardation Medical Necessity Criteria Multisystemic Therapy Master of Social Work Mobile Therapist Multidimensional Treatment Foster Care National Committee for Quality Assurance Office of Children, Youth and Families Office of Developmental Programs Office of Medical Assistance Programs Office of Mental Health and Substance Abuse Services Outpatient Office of Vocational Rehabilitation Primary Care Physician PCPC PH-MCO PHP PMPM POMS PROMISe PTSD QA QI QM RBUC RC RFP RHC RTF SA SAMHSA SAP SCA SED SMH SMI SSA SSDI SSI SSN STAP TANF TCM TIY TPL TSS UM/QM WRAP Pennsylvania Client Placement Criteria Physical Health Managed Care Organization Partial Hospitalization Program Per Member Per Month Performance Outcome Management System Provider Reimbursement & Operations Management Information System in electonic format Post-Traumatic Stress Disorder Quality Assurance Quality Improvement Quality Management Received But Unpaid Claims Resource Coordination Request for Proposal Rural Health Clinic Residential Treatment Facility Substance Abuse Substance Abuse and Mental Health Services Administration Student Assistance Program Single County Authority Socially and Emotionally Disturbed State Mental Hospital Seriously Mentally Ill Social Security Administration Social Security Disability Income Supplemental Security Income Social Security Number Summer Therapeutic Activity Program Temporary Assistance to Needy Families Targeted Case Management The Incredible Years Program Third Party Liability Therapeutic Staff Support Utilization Management/Quality Management Wellness Recovery Action Plan Annual Report

26 Terminology ADMISSION RATE The number of admissions into services per 1000 HealthChoices enrollees. AUTHORIZATION A process that is related to the payment of claims by which a provider receives approval from CBHNP to provide a particular service. Authorizations typically limit the number of units and the time in which the service can be provided. If a service requires authorization for payment, the lack of authorization will result in an unpaid claim. CAPITATION A set amount of money received or paid out; it is based on membership rather than on services delivered and is usually expressed in units of PMPM (per member per month) or PMPD (per member per day). Under the HealthChoices program, capitation rates vary by categories of assistance. CLAIMS A request for reimbursement for a behavioral health service. COMMUNITY RESIDENTIAL REHABILITATION (CRR) CRRs are residential programs designed and operated to assist persons with chronic psychiatric disability to live as independently as possible in the least restrictive setting. COMPLAINT A process by which a consumer or provider can address a problem experienced in the HealthChoices program. CONSUMER HealthChoices enrollees on whose behalf a claim has been adjudicated for behavioral health care services during the reporting period. DENIAL A denial is defined as a determination made by a managed care organization in response to a provider s request for approval to provide in-plan services of a specific duration and scope which (1) disapproves the request completely; (2) approves provision of the requested service(s), but for a lesser scope or duration than requested by the provider; (an approval of a requested service which includes a requirement for a concurrent review by the BHMCO during the authorized period does not constitute a denial); or (3) disapproves provision of the requested service(s), but approves provision of an alternative service( s). DIAGNOSIS A behavioral health disorder based on DSM-IV-TR or ICD-9 diagnostic criteria. DIAGNOSTIC CATEGORIES Subgroups of behavioral health disorders. This report contains the following groupings: Bipolar Disorders a group of mood disorders that characteristically involve mood swings. This group includes: Bipolar I Disorder, Bipolar II Disorder, Bipolar Disorder Not Otherwise Specified, Mood Disorder, and Mood Disorder Not Otherwise Specified. Depressive Disorders a group of mood disorders that includes: Major Depressive Disorder, Dysthymia, and Depressive Disorder Not Otherwise Specified. Schizophrenia and Psychotic Disorders a collection of thought disorders such as Schizophrenia, Schizoaffective Disorder, Schizophreniform Disorder, and Psychotic Disorder Not Otherwise Specified. Anxiety Disorders a group of disorders that includes: Panic Disorder, Social Phobia, Posttraumatic Stress Disorder, Obsessive Compulsive Disorder, Generalized Anxiety Disorder, and Anxiety Disorder Not Otherwise Specified. Adjustment Disorder the development of clinically significant emotional or behavioral symptoms in response to an identifiable psychosocial stressor or stressors. Impulse Control Disorders includes Intermittent Explosive Disorder, Trichotillomania, and Impulse Control Disorder Not Otherwise Specified. 26 Bedford-Somerset HealthChoices Program ADHD and Disorders in Children includes Attention Deficit Hyperactivity Disorder, Conduct Disorder, Oppositional Defiant Disorder, and Disruptive Behavior Disorder Not Otherwise Specified.

27 Other Mental Health Disorders includes Tic Disorders, Learning Disorders, Communication Disorders, and Motor Skills Disorders. Substance Abuse/Dependence Disorders a group of disorders related to taking a drug of abuse. The DSM-IV-TR refers to 11 classes of substances: alcohol, amphetamines, caffeine, cannabis (marijuana or hashish), cocaine, hallucinogens, inhalants, nicotine, opioids (heroin or other narcotics), PCP, and sedatives/ hypnotic/anxiolytics. Mental Retardation includes Mild, Moderate, Severe and Profound Mental Retardation. DSM-IV-TR The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision published by the American Psychiatric Association. This manual provides a diagnostic coding system for mental and substance abuse disorders. ENROLLMENT The number of Medicaid recipients who are active in the Medical Assistance program at any given point in time. FAIR HEARING APPEAL A grievance process through which a HealthChoices member can file a written appeal, to the Department of Public Welfare, regarding a behavioral health care service decision. GRIEVANCE The process by which a consumer addresses a problem with a decision made about his/her behavioral health care service. This may include denial of a service, approving less service than what was requested, or approving a level of care different from that requested. There are two levels of grievances and an external review process. 1st Level Grievance: An issue which is subject to review within 24 hours for urgent care and 30 days for non-urgent care. 2nd Level Grievance: A 2nd Level Grievance may be filed if the member has not received satisfactory resolution to the 1st Level Grievance. The 2nd Level Grievance Committee reviews the issue within 30 days. External Review: An External Review can be requested after the 2nd level Grievance decision. This process is independent from the managed care organization or the primary contractor. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) This is a Federal law that allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. Title II, Subtitle F, of HIPAA gives the Health and Human Services Department of the federal government the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care information. MEMBER Eligible Medical Assistance recipients enrolled in the HealthChoices program during the reporting period. MENTAL HEALTH COMMITMENT An involuntary admission into a psychiatric hospital as per the Pennsylvania Mental Health Procedures Act. Also referred to as a 302 commitment. OUTPATIENT REGISTRATION The process by which HealthChoices members are registered with CBHNP to receive specific outpatient services, eliminating the need for pre-authorization. RESIDENTIAL TREATMENT FACILITY (RTF) A self-contained, secure, 24-hour psychiatric residence for children and adolescents who require intensive clinical, recreational, educational services and supervision. UTILIZATION The amount of behavioral health care services used by Medicaid recipients. Utilization is based on encounter (paid claims) information. Annual Report

28 Behavioral Health Services of Somerset and Bedford Counties, Inc. The Bennett Building 245 West Race Street Somerset, PA BHSSBC