Behavioral Health
Guidelines, Standards, and Related Files for eNET-ME
Provider Enrollment & Service Review
Procedure Manual - Introduction
Chapter 1 Introduction
The mission of the Department of Health and Human Services (DHHS) states; “Our purpose is to provide integrated health and human services that effectively meet the needs of Maine peoples and communities”. To that end, DHHS is making substantial changes in its adult mental health delivery system, guided by these principals and the Consent Decree work plan developed to demonstrate compliance with the Settlement Agreement in Bates v. DHHS. Per that work plan, DHHS has identified “three key components” for a successful system: “clear responsibility for service delivery and decisions, good information on which to base decisions, and clear standards for system performance in concert with good mechanisms to assure quality assurance and quality improvement”. This manual will provide an overview of recent changes and describe in detail the processes for providers.
In July 2004, DHHS contracted with Beacon Health Strategies, LLC, a behavioral health management company, to assist in the development of informational, data, and quality assessment systems. This led to the establishment of an Enrollment and Service Review Unit in each regional office. Staff in each unit consists of at least one Clinical Advisor from Beacon Health Strategies, LLC, one Consent Decree Coordinator, UR nurses and the Regional Mental Health Team Leader who provides overall direction. The Clinical Program Manager for Beacon Health Strategies, LLC provides oversight and interface between the Clinical Advisors and the staff as noted above from each region, and collaborates with designated staff from DHHS Central Office.
Thus the initial step of the DHHS work plan was to begin to identify Maine’s behavioral health consumer population. An enrollment system was created for all consumers currently receiving and seeking Community Support (CSS) and Residential (PNMI) services, beginning July 19, 2004. The enrollment system is designed to provide essential data on consumer demographics, service delivery, wait-lists for services, and statewide gaps in services. This data can then serve as a basis for making quality improvement decisions. Further information regarding the enrollment system’s purpose and process is found in Chapter 2.
In February 2005, DHHS began the process of performing initial service reviews for consumers receiving CSS and PNMI Services. The sample of consumers selected for initial service reviews is derived from the enrollment data. The goals of the initial service reviews are, per the work plan, to measure “system performance” and to establish a process for “meaningful internal and external review” of services. The scope of the initial service reviews addresses clinical appropriateness of services, flexibility in addressing consumer needs, consumer progress towards recovery goals, and agency quality improvements. Further information about the initial service review process may be found in Chapter 3.
The follow-up reviews were initiated on October 1, 2005 and all 231 reviews were completed by October 31, 2005. The process is outlined in Chapter 4. The goals of the follow-up review were to identify to what degree quality improvement opportunities are being utilized and to track consumer outcomes.
The Service Review Version 2 services reviews were initiated in January 2006 and will be completed by May 31, 2005. These reviews are similar in scope and purpose as the initial reviews, but will focus on those consumers utilizing the most intensive levels of care: ACT, ICI and PNMI. More information on this process is found in Chapter 5.
The attached appendices contain information on commonly used definitions and acronyms in the Adult Mental Health System, The Enrollment Form, Service Review Version 2 Tool and Instructions, Enrollment Reports and Service Review Reports as well as contact information for the three regional offices.
Information can be located at the DHHS Office of Adult Mental Health Services website - http://www.maine.gov/dhhs/bh/enet-me/index.html.
It is appropriate to note that given this collaboration between Beacon Health Strategies and DHHS, no extra release of information is needed in order to provide clinical data to the Enrollment and Service Review Unit. The contract covers confidentiality in that Beacon is an agent of The Office of Adult Mental Health Services, almost as if they were an office within the department authorized to act and receive information in our stead. So where agencies might be used to dealing with The Office of Adult Mental Health Services and disclosing confidential information freely to The Department, they should continue to deal in the same way with Beacon for contract activities--they are our agent and so Beacon is in effect The Office of Adult Mental Health Services. As long as our contract with Beacon requires patient/consumer protection of privacy in the same manner that The Office of Adult Mental Health Services protects privacy, there is no need for an additional release of confidentiality naming Beacon as a proper receiver of information it is enough if the consumer names The Office of Adult Mental Health Services.
