Common use of Quality Mechanism Clause in Contracts

Quality Mechanism. The Contractor shall also have internal mechanisms to review for quality assurance and quality and performance improvements. 9.4.1. Reviews must at least address the following: 9.4.1.1. Timely access that meets the Access Standards of this Agreement. 9.4.1.2. Consistent coordination efforts with primary medical care. 9.4.1.3. Consistent referrals for Healthy Child screens for EPSDT. 9.4.1.4. Efforts to pursue and report third party revenue. 9.4.1.5. Quality Improvement activities, including participation in relevant Performance Improvement Projects previously implemented by the Contractor and Great Rivers. 9.4.1.6. The implementation of Great Rivers wide and/or provider specific Practice Guidelines. 9.4.1.7. The implementation of the GAIN-SS and the co-occurring assessment for quadrant placement of individuals at time of the initial assessment. 9.4.1.8. Efforts to support the delivery of behavioral health services that are driven by and incorporate the needs identified by the Individual and those they identify as family. 9.4.1.9. The degree to which behavioral health services delivered are age, culturally and linguistically competent. 9.4.1.10. Provision of behavioral health services in the least restrictive environment. 9.4.1.11. Services that are being provided promote recovery and resiliency. 9.4.1.12. Local efforts to provide services that are integrated and coordinated with other formal/informal service delivery systems. 9.4.1.13. Services requested in comparison to services identified as medically necessary. 9.4.1.14. Youth receiving medication without accompanying behavioral or therapeutic intervention 9.4.1.15. Which goals identified in the Individual Service Plan have been met, have been discontinued, or have continued need. 9.4.1.16. Use of Evidence-Based and other identified practice guidelines 9.4.1.17. Use of discharge planning guidelines 9.4.1.18. Community standards governing activities such as coordination of care among treating professionals 9.4.1.19. Coordination with Tribal and Recognized American Indian Organizations (RAIO) and other Client serving agencies 9.4.2. The Contractor shall use Great Rivers Level of Care guidelines to identify appropriate utilization of services for Great Rivers’ clients. Contractor shall make every effort to meet service levels guidelines and document rationale for services requested or provided outside guideline recommendations. 9.4.3. The Contractor shall insure face-to-face contact with clients to re- assess mental health symptoms, diagnosis and needs within 45 days of request for re-authorization of services unless otherwise specified. 9.4.4. The Contractor shall ensure crisis plans are current and available to clinical team and crisis services.

Quality Mechanism. The Contractor shall also have internal mechanisms to review for quality assurance and quality and performance improvements. 9.4.1. Reviews must at least address the following: 9.4.1.1. Timely access that meets the Access Standards of this Agreement. 9.4.1.2. Consistent coordination efforts with primary medical care. 9.4.1.3. Consistent referrals for Healthy Child screens for EPSDT. 9.4.1.4. Efforts to pursue and report third party revenue. 9.4.1.5. Quality Improvement activities, including participation in relevant Performance Improvement Projects previously implemented by the Contractor and Great Rivers. 9.4.1.6. The implementation of Great Rivers wide and/or provider specific Practice Guidelines. 9.4.1.7. The implementation of the GAIN-SS and the co-occurring assessment for quadrant placement of individuals at time of the initial assessment. 9.4.1.8. Efforts to support the delivery of behavioral health services that are driven by and incorporate the needs identified by the Individual Enrollee and those they identify as family. 9.4.1.9. The degree to which behavioral health services delivered are age, culturally and linguistically competent. 9.4.1.10. Provision of behavioral health services in the least restrictive environment. 9.4.1.11. Services that are being provided promote recovery and resiliency. 9.4.1.12. Local efforts to provide services that are integrated and coordinated with other formal/informal service delivery systems. 9.4.1.13. Services requested in comparison to services identified as medically necessary. 9.4.1.14. Youth receiving medication without accompanying behavioral or therapeutic intervention 9.4.1.15. Which goals identified in the Individual Service Plan have been met, have been discontinued, or have continued need. 9.4.1.16. Use of Evidence-Based and other identified practice guidelines 9.4.1.17. Use of discharge planning guidelines 9.4.1.18. Community standards governing activities such as coordination of care among treating professionals 9.4.1.19. Coordination with Tribal and Recognized American Indian Organizations (RAIO) and other Client serving agencies 9.4.2. The Contractor shall use Great Rivers Level of Care guidelines to identify appropriate utilization of services for Great Rivers’ clients. Contractor shall make every effort to meet service levels guidelines and document rationale for services requested or provided outside guideline recommendations. 9.4.3. The Contractor shall insure face-to-face contact with clients to re- assess mental health symptoms, diagnosis and needs within 45 days of request for re-authorization of services unless otherwise specified. 9.4.4. The Contractor shall ensure crisis plans are current and available to clinical team and crisis services.