The following is a summary of the actions Fayette County took in year one to address findings in the Early Warning Report.
Outpatient Mental Health:
Fayette County met the criteria for low utilization of Outpatient Mental Health services (defined as less than 50% of the mean rate for the total eligible population) in the First Quarter of 1999, but not in the remaining three quarters of 1999.
When the HealthChoices program began in Fayette County, there were only 2 primary providers of OP services located within the county of Fayette. Although members were free to cross over county lines and access other providers of Outpatient Services in the VBH Network, it became apparent to the county that to meet access standards additional providers were needed within the county. During 1999, two new in county providers were added to the network providing Outpatient Psychiatric Services to members in Fayette County.
In addition, Fayette County conducted studies to determine the reasons that members failed to receive Outpatient Services within 7 days of a request. The most frequent reasons members fail to receive Outpatient Services within 7 days, according to the reviews, were that the members decided not to keep the appointment, requested an appointment at a later time, or reported that they no longer felt the need for services after a crisis was resolved.
Outpatient Drug & Alcohol:
Fayette County noted the low rate of utilization for Drug and Alcohol Services by their members. In response the county took the following actions: The Quality of Care/Utilization Management Committee of VBH and Fayette County plan to analyze the low utilization of D&A services by Fayette members and recommend "best practices" to improve utilization.
Care Managers in Fayette County have routinely inquired about the D&A assessment/treatment needs of their "High Utilizer" population and referred for services when appropriate. In addition, the Quality/Risk Management Coordinator has monitored telephone contacts, as well as records to identify the D&A needs of members and refer members for services when indicated. These activities will continue.
Fayette County has initiated a number of activities to improve the identification and assessment of substance abusers among inpatients. The Fayette Single County Authority inquires daily on inpatient units whether any members need a D&A assessment. There are fewer requests for such services than would be indicated by estimates of incidence of D&A problems in the target population. In addition, the Fayette County Drug and Alcohol Commission sends staff to local inpatient mental health facilities to assess inpatient members for D&A problems using PCPC and ASAM criteria. The County and VBH are analyzing re-admissions to determine if inpatient psychiatric facilities failed to adequately screen and detect current or historical substance use and abuse by members. In addition, all patients that are recommended for transfer to a State Mental Hospital are assessed by a Certified Addiction Nurse Practitioner ADAPT team nurse who assesses D&A service needs.
The county also notes that the rates of denials, complaints and grievances for D&A services is very low.
Detoxification:
The low rate of authorization for Outpatient Detoxification Services in Fayette County may be explained by the absence of a service provider within the county. VBH is in the process of contracting and credentialing an in county Detox service provider. Detox authorizations are expected to increase when local services become available.
Drug and Alcohol Rehabilitation:
Authorization and claims data indicate that utilization of D&A rehabilitation facilities is low for Fayette members. The low utilization of D&A services may be due to a number of factors including: changes in eligibility status associated with welfare reform; fears of legal/financial consequences and stigmatization for those who seek treatment; the influence of family culture in an Appalachian mining community where alcohol use/abuse is quite prevalent and accepted; and the lack of D&A rehab facilities in the local community.
Significant progress was made during 1999 as the VBH Provider Network was expanded to include Clearbrook, Olympic Center Preston, ASI, and Progressive Services. The County/VBH-PA are currently in the process of contracting with Another Way, a new halfway house facility for women that is located in Fayette County. Contract negotiations are also ongoing to secure services of Chestnut Ridge Hospital in Morgantown, WV, and Fairmont General Hospital in Fairmont, WV, which would improve access for members residing in the Southwest quadrant of Fayette County. In addition, planning activities are in progress toward developing a "23-hour bed" that will divert inappropriate and unnecessary hospitalizations, as well as provide assessment and treatment of both MH and D&A needs.
Intensive Case Management:
Fayette met the criteria for low utilization of Intensive Case Management (ICM) and Resource Coordination (RC) services in three-quarters of 1999. Fayette County has hired 1.0 FTE Adult ICM and 1.0 FTE Children's ICM. In addition, Fayette County has monitored the availability of ICM and RC services. ICM and RC services are available within 7 days of referrals. There have been no waiting lists for ICM/RC services nor have there been any complaints or grievances regarding denials of care. The need for ICM and RC services for children are reviewed during BHRS Interagency Treatment Meetings, CASSP Interagency Service Planning forums and the CHIPP Interagency Service Planning meetings.
Fayette County and VBH are conducting a study to determine if inpatient readmission rates are lower for members who are receiving Intensive Case Management or Resource Coordination services at the time of readmission. In addition, the County is reviewing utilization of ICM/RC services by the "High Utilizer" population.
The rate of authorization for ICM and RC services in Fayette County is lower than some other counties in the SW HealthChoices program. The County has enhanced community resources and support systems through a number of program initiatives that include the Specialized Personal Care Home Program, the Long Term Structured Residential facility, enhanced Social Rehabilitation Programs, Drop In Centers with expanded hours, Representative Payee Program, and Intensive Vocational Rehabilitation Programs. In addition, Fayette ranks second only to Westmoreland County in utilization of BHRS services for children in the Southwest HC zone. These programs may provide members with services that substitute for and result in a lower utilization of ICM/RC services.
Grievances:
The overall rates of grievances were low given the volume of services that were provided. However, Fayette County notes that the percent of denials that were grieved for the counties managed by VBH increased from 10% in the Second Quarter, to 26% in the Third Quarter and 41% in the Fourth Quarter of 1999.
The increase in the percentage of denials that are grieved in Fayette County may be associated with a better-informed membership with regards to their rights to file complaints and grievances. Awareness of grievance procedures has been increased through distribution of Member Handbooks, mini consumer and provider forums, presentations to advocacy groups and various stakeholders, along with the PE&O Coordinator and Ombudsman outreach activities.