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WRAPAROUND

MILWAUKEE

Phone: (414) 257-7611 9201 Watertown Plank Road, Milwaukee, WI 53226 Fax: (414) 257-7575

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2015

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Table of Contents

I. QA/QI Mission Statement and Goals……………….………………….. 3

II. QA/QI Committee Roster……………………………………………….. 4

III. QA Program Description/QA Components……………………………. 5

IV. QI – Measures/Indicators/Activities…….……………………………… 10

V. Acronym Key…………………………………………………………….. 17

Attachments:

#1 2015 QA/QI Director Position Description

#2 2015 QA/QI Components Chart

#3 2015-2016 QA/QI Timeline

#4 2015-2016 Credentialing and Re-credentialing Plan

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I. QA/QI Mission Statement

To ensure quality care and promote continuous quality improvement of services and

processes in order to meet the needs of the youth, families and young adults being served.

Overall Goals

1. To assess the effectiveness of the wraparound approach in improving the quality of

life for the youth, young adults and their families.

2. To ensure youth, young adults and families have access to care and services that are

individualized, strength-based, culturally intelligent and sensitive, needs-driven and trauma

informed.

3. To join with community and system partners in order to create opportunities for positive

programmatic and systemic change.

4. To establish policies and procedures that promote and ensure best practice and quality service

delivery.

5. To assess and monitor outcomes and implement necessary change.

6. To monitor service provision to ensure quality care.

2015 Goals

1. Review/Revise Care Coordination POC Auditing Tools and auditing process

2. Address areas of deficiency as noted in the 2014 – 2015 MetaStar, Inc. IT and QA Review of

Wraparound Milwaukee

3. Review/Revise Family Provider Satisfaction Survey and administration process to ensure we are

collecting focused information and achieving an adequate return rate

4. Complete the review/revision of all identified policies and procedures

5. Explore the provision of crisis stabilization services to ensure best practice standards are being

achieved and quality care is being provided

Established 12/26/01; Revised 10/27/03, 11/23/2004, 10/24/05, 12/20/07, 12/13/10, 10/8/12, 10/21/2013, 4/1/15

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II. QA/QI Executive Committee Roster

Members

Member

Agency/Position

Pam Erdman, MS, OTR Wraparound QA/QI Director, Chair

Auriel Ackerman, MA DHHS, Behavioral Health Division -

Community Services Branch, QA Specialist

Wes Albinger, MS Wraparound Provider Network Coordinator

Kenyatta Bryant, MS Wraparound Fiscal Coordinator

Heidi Ciske-Schmidt, MSW Wraparound QA/QI Administrative Coordinator

Cathy Duster State of Wisconsin – DHS, Medicaid Contract Contact

Pam Fleider, RN, MA Alternatives in Psychological Consultation,

Provider Network Representative

Steve Gilbertson Wraparound Clinical Coordinator, Licensed

Psychologist

Melissa Graham, MSW, CSW DHHS, Delinquency & Court Services Division -

Section Manager

Margaret Jefferson Families United of Milwaukee, Inc., Director

Bruce Kamradt, MSW Wraparound Program Director

Stacy Kozel, MSW, LCSW Wraparound REACH/FISS Program Coordinator

Diane Krager, OTR DHHS, Contract Administration - QA Coordinator

Brian McBride Wraparound - O’YEAH Program Coordinator

Mary Jo Meyers, MS Wraparound Deputy Director

De Shell Parker, MS, MSW, CAPSW DHHS, Delinquency & Court Services Division

Administrative Coordinator - Quality Assurance

Makalah Wagner State of Wisconsin - DHS

Wraparound Family Representatives: Parents and caregivers are involved in every meeting.

Regular attendees include: Joyce D., Dorothy N., Marion G., Shirl B., Michael R., Gwendolyn G.

Wraparound Youth Representatives: An open invitation is extended to any youth that would

like to attend.

Guests and/or periodic attendees are also welcome!

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III. QA Program Description and QA Components

In compliance with 42 CFR 434.34, and 42CFR Part 400, Medicaid Managed

Care Requirements Subpart E:

1. Program Description/Responsible Parties: Wraparound Milwaukee is a Special Managed Care Organization serving youth and young adults

with complex emotional, behavioral, mental health needs, and their families. Wraparound strives

to provide quality services that have a positive impact on the youth/ young adult’s mental health

functioning, school and work performance, sense of community, social responsibility and living

environment, while maintaining the youth/young adult in the least restrictive, community-based

setting possible, containing costs and maintaining expected standards. Wraparound Milwaukee

promotes systemic change, develops policies and procedures to ensure quality care and service

delivery, promotes collaboration amongst the Child & Family Team, school, community,

Juvenile Justice and Bureau of Milwaukee Child Welfare and utilizes a diversified

Administrative and Consultative team that assesses services/service delivery and provides

training in Wraparound philosophy and processes, cultural competency/intelligence, trauma

informed care, motivational interviewing and needs assessment.

A structured Intake process is utilized when enrolling youth/young adults into Wraparound and

when Provider applications are being processed to authorize agencies and individual providers to

provide services in the Wraparound Provider Network. A Care Coordinator/Transition

Coordinator is assigned to each youth/young adult. The Care Coordinator/ Transition

Coordinator organizes and coordinates care for the youth/young adults.

The primary person responsible for the Wraparound Milwaukee program as a whole is the

Director of Wraparound Milwaukee. One component of the Wraparound Program is the QA/QI

Department. This department is responsible for ensuring that quality care and best practice

standards and measures are being implemented and monitored on an ongoing basis. The QA/QI

Director is responsible for all day-to-day QA/QI Departmental operations, supervises 2.0 QA

Staff, chairs the Executive QA/QI Committee and provides technical assistance to the Department

of Health and Human Services (DHHS) Centralized QA Group. (See Attachment # 1 - QA/QI

Director Position Description). The QA/QI Director is supervised by the Director of Wraparound.

The Wraparound Milwaukee Management Team is the governing body that provides oversight to

the Wraparound Milwaukee QA/QI Executive Committee. Wraparound Milwaukee Management,

Providers, Consultants, Advocates, Parents, Youth Representatives and Community

Representatives either serve on and/or support the work of the QA/QI Executive Committee and

the QA/QI Department.

QA/QI data, studies and the QA/QI Annual Report are available to and/or are shared with the

Milwaukee County Director of DHHS and the Milwaukee County Mental Health Board.

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2. QA/QI Related Committees/Groups: The 2015 QA/QI Components Chart (Attachment # 2) outlines the QA/QI-related

Committees/Groups reporting avenues and feedback loops. Further defined are some of the

components referenced in the chart.

Executive QA/QI Committee is in part, an extension of the Wraparound Milwaukee

Management Team. It includes a variety of Human Service and Mental Health Professionals,

along with parent, caregiver and advocate representation. The Committee meets a minimum of 4

times per year to review data, develop studies, implement activities, review and approve reports,

etc. The activities of the QA/QI Committee are documented in the form of minutes.

Critical Incident Review Panel reviews identified Critical Incident Reports. The Panel assures

that adequate, appropriate follow-up occurs regarding the critical incident and that a plan of

action/change was implemented as recommended. This group meets as needed.

Provider Network Enrollment Committee is a group of administrative representatives

associated with the programs that utilize the Provider Network in addition to Wraparound

affiliated staff. The group assesses service needs, reviews vendor eligibility and

qualifications/credentials, reviews vendor history, recommends other avenues for applicants to

pursue and explores approaches to preserve fidelity of wraparound principles throughout the

Network. The group meets as needed to review applicant requirements and/or to discuss where

there may have been adverse provider activity (i.e. - a complaint) to question as to if the provider

meets the service requirements.

Wraparound Milwaukee Credentialing Committee is a standing subcommittee of the

Provider Network Enrollment Committee and is responsible for administering the Wraparound

Milwaukee Provider Network Credentialing Plan on behalf of Wraparound. The Committee is

responsible for review and approval of clinicians providing mental health/substance abuse

services who meet minimum participation criteria with adverse activity. The Committee meets

on an as-needed basis.

Provider Performance Measures Committee - In 2012, Wraparound Milwaukee launched a

Performance Measures initiative, which formalizes a process for reporting, tracking, and

communicating key measures of Provider performance for Network services. These performance

measures are reported as part of Synthesis resource guide information, and are distributed as reports

to key audiences. Provider Performance Reports are also distributed to Provider agencies for quality

improvement and quality management purposes. Five key domains of performance have been

identified, taking a pragmatic approach which considers reliability and validity, but also leveraging

existing data and systems as much as possible. For most services, one or several existing or newly

developed Performance Measures are reported in each of the following domains: Provider Status

Events, Audit Results, Consumer Satisfaction, Fidelity and Service Outcomes.

Centralized Quality Assurance Committee is a group composed of personnel from the DHHS

Contract Administration, Behavioral Health Division, Wraparound Milwaukee, Delinquency and

Court Services Division (DCSD), Disability Services Division (DSD) and the Community

Access to Recovery (CARS) Division which includes the WIser Choice/SAIL programs. The

committee provides a forum to discuss quality of care issues, report on quality and fiscal

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audit/review outcomes, discuss programmatic policies and procedures and promote consistency

and uniformity within the County as it relates to quality assurance and quality improvement. The

committee meets monthly.

Wraparound Partnership Council is a group composed of community representatives who

provide services/support for children, non-agency/service individuals and current or former

Wraparound caregivers. One of the group’s goals is to access informal community resources and

supports (i.e.: clergy members, area business leaders) and to provide advisory support to the

Wraparound program.

Family/Provider Advisory Committee - The purpose of the Committee is to provide a forum

for open discussions as it relates to Provider Network happenings such as auditing strategies and

priorities, provider sanctions and performance measures, service array, policy and procedure

development, provider/family concerns and suggestions, etc. The Committee meets every other

month.

Other Groups - Sharing of QA/QI information/special reports also takes place at the

Wraparound Milwaukee Management/Supervisory meeting, bi-monthly Provider Forum

Meetings and at any other committee/group meetings in which QA/QI is of relevance. Task/work

groups are assembled as needed to address specific areas of need.

3. Quality Assurance Related Program Components/Processes

Access to Care/Services - Youth/young adults and their families have access to needed

care/services through the Wraparound Milwaukee Provider Network (WPN) and/or established

community, informal and natural supports, as agreed upon by the Child & Family Team. The

QA/QI Executive Committee may provide feedback regarding access issues and concerns. The

provision of services are held to programmatic policy/guidelines, Fee-for-Service Agreement and

County, State and Federal standards.

Consumer Satisfaction – Consumer satisfaction surveys are an integral part of ensuring that

families and youth/young adults are satisfied with both Care Coordination and Provider Network

services. Surveys that address the consumers’ satisfaction levels with their Care Coordination

services are distributed during the first, sixth and twelfth month of enrollment and then yearly

afterwards. At disenrollment, a Family and Youth Progress Report is completed that addresses

both satisfaction and perceived success with having met their identified needs. In addition,

during the 4th and 9th month of enrollment, a Family Provider Satisfaction Survey is distributed.

This survey addresses the consumers’ satisfaction levels with services they are receiving through

the Wraparound Provider Network. The above surveys are mailed and/or provided directly to the

family by the Care Coordinator. Families United of Milwaukee, Wraparound Milwaukee’s family

advocacy and support agency, assists with the mailing and distribution process.

In addition, Out of Home Care Satisfaction Surveys are administered after a youth is discharged

from a Residential Center for Children (RCC) or Group Home. This survey is conducted over

the phone by Wraparound Milwaukee’s family advocacy agency, Families United of Milwaukee,

Inc.

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All survey results are entered into Wraparound Milwaukee’s IT System, Synthesis, for data

analysis, interpretation and follow-up, as needed.

Provider Performance/Credentials/Measures - Surveys, audits, outcome studies and site visits

are conducted to assure quality performance by our Providers. Providers sign a 2 year Fee-for-

Service Agreement with Wraparound Milwaukee, referencing performance expectations, QA/QI

expectations, credentialing and service delivery requirements, etc. Credential requirements are

strictly monitored and enforced.).

Grievances/Complaints - Youth /young adults and their families have the right to complain or

grieve any service, procedure and/or process that they feel has not met their expectations. A

formal grievance procedure/policy is in place if the complainant is not satisfied with the

resolution/outcome of their complaint. Complaints are entered into Wraparound Milwaukee’s IT

System, Synthesis, and are investigated in a timely fashion. Providers and any other system

partners are also able to initiate a complaint. The complaint/grievance process is subject to

ongoing review as the needs of the youth, families, providers, system partners and stakeholders

change.

Utilization Management/Review - Utilization Management and Review activities are primarily

performed by Wraparound Milwaukee Management staff and the QA/QI Department.

Wraparound Milwaukee engages in a utilization management review process of its service

delivery system through the use of reports generated through the Wraparound Milwaukee’s IT

System, Synthesis, through prior authorization of Out of Home Care/Day Treatment/Independent

Living and Inpatient Hospitalization, monthly “Confirmation of Services Reports” sent to

families for their review, Mobile Urgent Treatment Team desk reviews of crisis stabilization

services and billings, utilization of the Risk Assessment Tool to determine the provider network

agencies that will be reviewed/audited for the following year, and Care Coordination and

Provider Network audits/reviews that address agency, client and fiscal outcomes. All reports are

analyzed by Wraparound Milwaukee staff for variances from desired practices. The analysis is

conducted on a system-wide level and/or on an individual case-by-case basis.

The following reports/data accessed through Wraparound Milwaukee’s IT System, Synthesis,

focus on:

Authorized Services by month by client, program, and vendor

Expenditures for services provided monthly by client, program and vendor

Placement Status Report

Disenrolled Client Report

Cost Comparison Data

Plan of Care (POC)/RCC Pre-Authorization/Day Treatment Pre-Authorization

Community Resources tracking

Crisis Billing

Submitted/Paid Claims

Client demographics, such as age, sex, race, diagnosis, referral, residence, etc.

Monthly enrollment reports

Care Coordination Service/Productivity Hours and Crisis Hours provided monthly and year-

to-date

Reports reflecting compliance standards that have been established for several outcome,

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process, and structure indicators related to the provision of Care Coordination

A variety of Vendor Reports and Care Coordination Agency Reports

Service reports reflecting utilization trends, non-permissible mix of services and over/under

utilization.

Special reports may also be produced for specific groups of clients, services, vendors, etc.

Practice and Clinical Review/Oversight by Appropriate Health Professionals and Other

Representatives – Clinical, practice review and oversight is conducted through several methods,

which includes:

All client Plans of Care (POC) must be reviewed at least every 90 days. A licensed

psychologist or psychiatrist must provide consultation at this same time interval. Guidance and

direction is provided to the Care Coordinator at this time. A progress note reflecting the

consultation is entered into Synthesis by the both the Care Coordinator and the consulting

psychologist/psychiatrist.

Community Safety and Resource Development Reviews are conducted weekly by a

Wraparound psychologist regarding youth that are identified as “high risk clients” (in accordance

with the High Risk Youth Review - Policy #023).

Medication management, mental health clinical oversight and consultation is provided for

numerous youth/young adults and their families during monthly medication clinic appointments

with Wraparound affiliated psychiatrists.

Wraparound Administrative clinical staff and consultants are available at all times to

provide consultation to Care Coordinators and Child & Family Teams as needed.

Other QA/QI related issues and documentation are addressed/reviewed by a variety of health

professionals associated with the QA/QI Executive Committee process. These individuals hold

the titles of licensed Psychologist, Social Worker, Occupational Therapist and Registered Nurse,

to name a few. Other system related individuals are also involved in various review processes

related to assuring quality care. These system individuals may include: Parent Representatives,

Family Advocates, Fiscal Representatives, Judicial/Court-related Representatives, State

Representatives, Education Representatives, Milwaukee Bureau of Child Welfare

Representatives, Department of Health and Human Services Representatives and other

community partners.

Evaluation Data Collection on Behavioral and Clinical Outcomes - The Wraparound

Milwaukee evaluation process includes the collection of data pertaining to each individual

youth/young adult before and during treatment in the program. Some data is also collected post-

disenrollment. The evaluation and performance data collected and analyzed includes: functional

performance, community behavior, psychiatric symptomatology, living situation/place of

residence, school participation/performance, juvenile justice involvement, family

satisfaction/quality of care, resiliency, recovery, access to services, recidivism and cost

management outcomes.

Wraparound Milwaukee provides interpretation of the data for dissemination to families, Care

Coordination Agencies, Providers, Government Officials, Juvenile Justice Personnel, and/or

other stakeholders.

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Wraparound Milwaukee makes programmatic changes through the interpretation of the data

collected, i.e. - Continuous Quality Improvement (CQI).

Data is reviewed for sources and types of variance from the established standards of Wraparound

Milwaukee and other agencies providing similar services. These variances are reviewed by

Wraparound Milwaukee Management and the Executive QA/QI Committee for appropriate

action.

IV. Quality Improvement

Measures/Indicators/Activities

Wraparound Milwaukee implements changes in its program based on QA/QI

outcomes/processes, data reports/queries, and other data source findings. Surveys, quality and

fiscal audits/reviews, interviewing, utilization review, and submission of mandatory data are

some of the means of collecting information. From this information, reports, data and processes

are reviewed and changes are implemented when warranted. The effectiveness of the

implemented action is then monitored and adjusted until an acceptable outcome is achieved.

Reports/studies/audits/reviews reflect the work of the QA/QI Department in collaboration with

other Wraparound-associated Departments, affiliated Agencies, Community/Family

Representatives, Milwaukee County DHHS Centralized Quality Assurance personnel and other

stakeholders.

The objective of the QI Plan and Timeline is to provide a framework to monitor and evaluate the

established indicators, and the quality and appropriateness of youth and family care. Through the

information produced from this monitoring, Wraparound Milwaukee will pursue opportunities to

improve care and resolve identified concerns. The QA/QI’s efforts are client and family driven

and mental health, system and cost-outcome oriented. Efforts rely upon data generated by

Wraparound Milwaukee and its affiliates, as well as that developed by outside sources. The

QA/QI Timeline for 2015 is attached (see Attachment #3). The Timeline identifies QA/QI tasks,

responsibilities and implementation dates.

Referenced in the following table are Fidelity and Process Indicators that are monitored and

analyzed in an effort to ensure quality outcomes and improve processes.

FIDELITY MEASURES Indicator Monitor Frequency/Measurement

1. Functioning – Level of clinical

functioning is monitored through the

administration of the Achenbach

Evaluation Tools, the Child Behavior

Checklist (CBCL) and the Youth Self

Report (YSR)

--------------------------------------- The Child and Adolescent Needs and

Strengths (CANS) assessment tool is

being administered for those youth in

foster care.

Care Coordinator/Transition

Coordinator, Wraparound

Research Consultant, Wraparound

IT System

Wraparound is currently

administering the Achenbach tools

on all Wraparound enrollees at the

time of enrollment, 6 months,

annually and at disenrollment.

---------------------------------------------

The CANS is being administered

upon the youth entering foster care

and then every 6 months thereafter

as long as the youth remains in the

out of home placement.

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The O’YEAH Program, serving young

adults ages 16.5 – 24 years old,

measures real-life outcomes for people

in recovery from mental health and

substance abuse disorders in several

life domain areas. The Data Appraisal

Tool (DAT), a tool developed by the

O’YEAH Team based off the National

Outcomes Measures (NOMS) tool, is

being utilized.

-------------------------------------------

The O’YEAH program is also

administering the Engagement and

Planning Survey which is a fidelity

measure that assesses the level of

engagement the young adult is having

with the Transition Coordinator in

addition to the level of independence

and planning that is occurring as

evidenced in the Futures Plan.

The DATs is administered at the time

of enrollment, every 180 days

thereafter and at disenrollment.

------------------------------------------

The Engagement and Planning

Survey is administered at 6 months

and at 6 month intervals thereafter.

2. Living Environment - While

enrolled in Wraparound, the

percentage of days that a youth spends

in a restrictive setting will decrease.

Care Coordinator, Wraparound IT

system

This will be measured by comparing

the percentage of days in a restrictive

setting (Inpatient, RCC, Detention,

Group Home and Shelter Facility) to

the percentage of days in a

community-based setting (home,

foster care, living with a relative or

independent living). The time

frames for the collection of this data

will correspond to the Care

Coordination Agency Performance

Report time guidelines (2x’s/year).

3. Community Safety - Criminal

charges and adjudications will

decrease while the youth is enrolled in

Wraparound.

Care Coordination juvenile justice

data entry, Wraparound IT System

This will be measured through

recidivism research in which formal

charges are compiled and evaluated

during enrollment

4. School - Youth school attendance

will improve during their time in

Wraparound.

Care Coordinators, Wraparound

IT System

This will be measured by comparing

the total number of school days

possible to the total number of

school days attended at monthly

intervals during enrollment. This

data is tracked on the POC.

5. Family Satisfaction: Care

Coordinator - Caregivers and

youth/young adults must be satisfied

with Wraparound Milwaukee Care

Coordination services.

Wraparound Milwaukee QA/QI

Department, Families United of

Milwaukee, Inc., Wraparound IT

System

Wraparound Milwaukee, in

collaboration with Families United of

Milwaukee, Inc., will distribute

Family Satisfaction Surveys to every

youth/family enrolled in

Wraparound. These surveys are

mailed at 1 month, 6 months, 1 year,

2 years, etc. of enrollment and at

disenrollment. An average score of

4.0 out of a rating scale of 1-5 is the

established threshold. Survey data is

compiled and reported 2x’s per year

on the Care Coordination Agency

Performance Report.

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6. Family Satisfaction: Provider –

Caregivers and youth/young adults

must be satisfied with Wraparound

Milwaukee and its Provider Network

services.

Wraparound Milwaukee QA/QI

Department, Families United of

Milwaukee, Inc., Wraparound IT

System

Wraparound Milwaukee in

collaboration with Families United of

Milwaukee, Inc. will distribute

Family Provider Satisfaction Surveys

to every youth/family enrolled in

Wraparound Milwaukee. These

surveys are mailed during the 4th and

9th months of enrollment. An

average score of 4.0 out of a rating

scale of 1-5 is the established

threshold. Survey data is compiled

on an ongoing basis and reported in

the QA/QI Annual Report. Survey

results are forwarded to

Agency/Provider. The

Agencies/Providers are asked to

respond to surveys that reflect

negative comments.

7. Care Coordinator Productivity/

Service Hour Time - time spent per

month, per family providing services

to the youth/family or engaging in

service, related communication,

collaboration with the Child & Family

Team members


System Fourteen (14) hours (8 hours for

REACH) per month per family. (This

includes 8 hours of crisis billable

time for Wraparound and 5 hours for

REACH). Data is reported 2x’s per

year on the Care Coordination

Agency Performance Report.

8. Face to Face Contacts Care Coordinator, Wraparound IT

System

Wraparound Care Coordinators must

average one face-to-face contact

(with the youth and parent or other

primary caregiver) per week.

REACH Care Coordinators must

average one face-to-face contact

(with the youth and parent or other

primary caregiver) every two weeks.

Data is reported 2x’s per year on the

Care Coordination Agency

Performance Report.

9. Child & Family Team (CFT)

Meeting and Plan of Care Meetings

Care Coordinator and Child &

Family Team, Wraparound IT

System, annual Progress Note

Audit/Review conducted by the

Wraparound QA/QI Department

At least one CFT or POC meeting

per family must be held monthly.

This must be appropriately

documented. This is reported 2x per



10. Percentage of Team Meetings

with Informal Support Attendance

Care Coordinator and Child &

Family Team, Wraparound IT

System

At least one Informal Support on the

Child & Family Team must be in

attendance at the Team Meeting 50%

of the time.

11. Number of Disenrollments

Evidencing Progress Family/Youth/Young adult, Care

Coordinator, Wraparound IT

System, Wraparound

Administration

“Progress” will be achieved if the

cumulative outcome percentage

scores in the following areas have

met the established “progress”

threshold of 75 or greater.

Parental and youth perception of

change as evidenced by the

outcome on the Disenrollment

Progress Report.

Needs being met as identified in

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the Needs Ranking Scoring process

within the final POC.

Living status upon disenrollment

12. Formal/Informal Supports –

Informal supports are described as

community resources serving on the

Child & Family Team in usually a non-

paid role. These individuals may be

family members (other than the youth

and parent), friends, neighbors, faith-

based supports and kinship providers.


System: based off of data

referenced on the Child & Family

Team member list and those

individuals utilized within the

strategies of the POC Domain/

Need areas.

It is expected that on average, 100%

of all Child & Family Teams should

be utilizing natural/informal

supports. At least 50% of the

supports on those Teams should be

informal. Data is reported 2x’s per



13. Family Activities – Every Care

Coordination agency is expected to

conduct an activity that engages

Wraparound youth and their families.

Care Coordination agency,


1x per month

PROCESS MEASURES Indicator Monitor Frequency/Measurement

1. Plan of Care – POC’s must

reference all required and applicable

life domains, will include a 24 hr.

Crisis Plan, will identify child/family

strengths and needs, will identify

formal, informal, natural, and

community supports and will

acknowledge that the Child & Family

Team was in attendance at the meeting

and participated in the creation and/or

revision of the POC. POC Audits are

conducted by the Wraparound QA/QI

Department

Quality audits/reviews of the POC

will be conducted annually by the


as specified on the attached QA/QI

Timeline. The Wraparound IT

System and the Care Coordinator

will also monitor compliance. A

licensed psychologist or

psychiatrist will provide

consultation related to the POC

and identified needs at least 1x

every 90 days.

The initial POC must be completed

within 30 days of enrollment. POC’s

must then be updated at least every

90 days. POC quality audit/review

results should evidence at least a

90% overall agency compliance

score. Timeliness of the plans is

reported 2x’s per year on the Care


Report. POC Audit results are

reported 1x per year on the Care


Report.

2. Wraparound Client Record –

Wraparound client records must be

organized and contain all required

documentation, as per the Client Chart

Format policy and procedure.

Client Chart Reviews will be

conducted by the Wraparound

QA/QI Department as needed. The

Care Coordinator will also

monitor compliance.

Client Record Reviews are

conducted as deemed necessary by

Wraparound Administration and

should evidence at least a 90%

overall agency compliance score.

3. Wraparound Progress Notes –

Wraparound Progress Notes in the

client records must be written in a

manner that abides by the established

standards/policy.

Audits/reviews of the Progress

Notes will be conducted by the


as specified on the attached QA/QI

Timeline. The Wraparound IT

System and the Care Coordinator

will also monitor compliance.

Timeliness of the Progress Notes is



Report. A Progress Note Audit is

conducted and reported 1x per year


Performance Report. The progress

note quality audit/review should

evidence at least a 90% overall

agency compliance score.

4. Service Authorization Request

(SARs) – Projected costs and

utilization of services is documented

every 30 days.

Care Coordinator, Wraparound

Fiscal Department, IT system and

QA/QI Department track costs and

utilization

SARs are completed monthly by the

Care Coordinator and must be

entered by the 23rd day of the month

for the subsequent month’s services.

This is done on-line through the

Wraparound IT System. Projected

costs and utilization of services are

captured on the SAR.

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5. Submission of Evaluation Tools –

Submission of the Child Behavior

Checklist (CBCL) and the Youth Self

Report (YSR)

The family and youth primarily

complete the tool, and the Care

Coordinator provides guidance as

needed. Evaluation tools are

required on every enrollee. Data is

entered by Care Coordination

Agency Support Staff and reports

are generated by the Wraparound

IT system

Evaluation Tools must be completed

by the caregiver/youth and submitted

to Wraparound by the Care

Coordinator at intake, 6 months,

annually and at disenrollment.

Submission compliance is reported

2x’s per year on the Care


Report.

6. RCC/Group Home/Foster

Care/Day Treatment Pre-

Authorization and Re-Authorization

Process – All RCC, Group Home,

Foster Care placements and Day

Treatments must be pre-authorized/re-

authorized.

Designated Wraparound

Management and Contract Staff,

Care Coordination Staff and

Wraparound IT system

RCC/Group Homes –

Documentation must be submitted

into Wraparound for pre-

authorization. Renewals or re-

authorizations of a RCC/Group

Home placement must be submitted

14 days prior to the expiration date

of the current authorization.

Foster Care – Documentation must

be submitted into Wraparound for

pre-authorization. Renewals or re-

authorizations of a Foster Home

placement must be submitted 14 days

prior to the expiration date of the

current authorization.

Day Treatment – Documentation

must be submitted into Wraparound

for pre-authorization. Renewals or

re-authorizations of a Day Treatment

placement must be submitted 14 days

prior to the expiration date of the

current authorization.

7. Timely Submission of Legal

Change of Placements & Temporary

Change of Placement Information

Written notice of a change in a

youth’s living situation must be

completed by the Care

Coordinator. Wraparound Court

Liaisons approve and enter the

placement changes into

Wraparound IT system

Legal and Temporary Change of

Placements must be submitted 14

days prior to the move.

This data is reported 2x’s per year on

the Care Coordination Agency

Performance Report.

8. Submission of Facilitator

Reviews – The Facilitator Reviews

provide written Supervisory feedback

to the Care Coordinator on the Care

Coordinator’s fidelity to the Child &

Family Team and POC meeting

process.

Care Coordination agencies

submit the Facilitator Reviews to

Wraparound. The Wraparound

QA/QI Department tracks the

submission. Wraparound

Management and Contract staff

review the Facilitator Reviews and

provide feedback as needed.

Three Facilitator Reviews are

completed per month. Compliance is



Report.

QA/QI OVERSIGHT ACTIVITIES

Indicator Monitor Frequency/Measurement

1. Performance Improvement

Project (PIP) – A PIP is a mandated

State Medicaid Contract report/study

that must address either a clinical or

Wraparound QA/QI Department,

Wraparound Research Consultant

and the State and/or the State’s

contracted monitoring agency

One PIP will be submitted to the

State by March 1st for the previous

year.

15

administrative topic that the program

wishes to further explore in an effort to

promote quality improvement.

2. Wraparound Provider Network

(WPN) Provider Credentials –

Credential requirements are

established and maintained on

Agencies/Providers servicing the youth

and families enrolled in the program

based on the service being provided.

Agencies/Providers must be licensed

or certified as indicated per the State

statutes and/or Licensing and

Regulatory bodies, where appropriate,

and/or meet Wraparound service–

related requirements. Mental

health/AODA providers are

credentialed utilizing NCQA

compliance standards.

Provider Agencies, Wraparound

Milwaukee. Credential

requirements are reviewed in

conjunction with vendor requests

to add direct service providers.

This information is kept in the

Wraparound IT System. An

application process and specific

outlined requirements must be met

prior to an Agency/Provider being

authorized to enter the Network.

The Provider Network Enrollment

Committee reviews and approves

all Provider applications as

outlined or identified in the

Provider Network Credentialing

and Recredentialing Plan (see

Attachment # 4). Mental health/

AODA applicants that meet

minimum participation with

adverse activity must be approved

through the Wraparound

Milwaukee Credentialing

Committee.

Updates of Agency/Provider

certifications/licenses, etc. occurs on

an ongoing basis.

Three to four credentialing checks

are initially run on clinical/other

providers entering the network:

National Provider Identifier

Registry (NPI)

OIG – Federal Office of Inspector

General (run on all providers)

WI Dept. of Safety and

Professional Services (DSPS)

American Medical Association

(AMA) – MD’s only

3. Provider Performance

Measures Initiative – In 2012,

Wraparound Milwaukee launched a

Performance Measures Initiative,

which formalizes a process for

reporting, tracking, and

communicating key measures of

Provider performance for Network

services. Provider Performance

Reports are distributed to Provider

agencies for quality improvement and

quality management purposes. Five

key domains of performance have been

identified, taking a pragmatic approach

which considers reliability and

validity, but also leveraging existing

data and systems as much as possible.

Provider Agencies, Wraparound

Milwaukee

Audit

Performance being measured:

Agency compliance with service

guidelines and other requirements

Performance Measure: Overall level

of compliance on fiscal and/or

quality reviews

Satisfaction

Performance being measured:

Enrollee and family satisfaction with

services

Performance Measure: Satisfaction

survey results

Complaints

Number of substantiated complaints

and severity level of the complaints

will be noted.

4. Certification and Re-

certification Training/In-services/

Workshops – Care Coordinators

receive approx. 94 hours of initial

training through a curriculum

developed by Wraparound Milwaukee.

Care Coordinators are then certified by

Wraparound Milwaukee to provide

Care Coordination services. Care

Coordinators and Supervisors that

have been in the field one or more

years have to also attend annual re-

Wraparound Administration and

the Provider Network maintain

records of attendees. Attendance

records are then forwarded to


for data compilation.

Care Coordinators must complete the

Care Coordination Certification

process within six months of hire.

Recertification occurs annually and

is mandatory.

Attendance is taken at all

trainings/in-services/workshops.

Records of all Care Coordinators and

individuals that participate in

trainings/in-services/workshops are

kept on file. Evaluations are

distributed at the end of all

trainings/in-services/workshops

16

certification training, totaling 16 hours.

Re-certification training topics vary

according to the needs of the group at

that time. Care Coordinators,

Wraparound Administrators,

Providers, Caregivers and Community

Representatives also attend regular

meetings, in-services, conferences,

workshops, etc., throughout the year.

summoning feedback from the

participants. Feedback is then

utilized to implement change.

Attendance compliance with

mandatory in-services/trainings is



Report. Care Coordination in-

services are offered at a minimum of

2 hours per month. Additional

trainings/in-services are offered

throughout the year as scheduled.

5. Provider Network

Audits/Reviews - In collaboration

with the Milwaukee County

Department of Health and Human

Services – Contract

Administration, an annual

audit/review schedule is

determined through the use of the

Risk Assessment Tool.

DHHS Contract Administration,

Wraparound Milwaukee

Administration

Determined by the Centralized QA

Committee in accordance with

auditing protocols that have been

established.

OTHER REVIEW ACTIVITIES Indicator Monitor Frequency/Measurement

1. Number of Substantiated

Complaints Wraparound QA/QI Department,

Wraparound IT System

Outcomes regarding Care

Coordination complaints are reported

2x’s per year on the Care


Report. Complaint outcomes

regarding Provider Network agencies

are reported as needed and utilized

when making considerations as to

whom to audit for the year.

2. Number of Care Coordinator

Transfers – The number of times a

youth is transferred to a new Care

Coordinator, either within their own

agency or between Care Coordination

agencies, is monitored.



Outcomes are reported 2x’s per year


Performance Report.

3. Costs – The cost of providing

services for youth/young adults and

their families in Wraparound

Milwaukee will be less than the costs

for youth in alternative children’s

mental health and other systems.

Wraparound IT System, system

partner data This will be measured by collecting

and pricing out all Wraparound

services and supports provided to the

youth and the family compared to

alternative children’s mental health

and other systems of care (i.e.-

Corrections, RCC Placements,

Inpatient).

4. Number of Staff Departures –

The number of Care Coordinator staff

that leave an agency will be monitored.



This will be reported every 6 months


Performance Report.

17

V. Acronym Key

H:\CATC\QAShare\ERDMAN/2015QA-QIWorkplan

1. AODA Alcohol and Other Drug Abuse

2. AMA American Medical Association

3. CANS Child & Adolescent Needs and Strength Assessment

4. CARS Community Access to Recovery Services Division

5. CBCL Child Behavior Checklist

6. CFR Code of Federal Regulations

7. CFT Child & Family Team

8. CQI Continuous Quality Improvement

9. DAT Data Appraisal Tool

10. DHHS Milwaukee County - Department of Health and Human Services

11. DHS State of WI - Department of Health Services

12. DSD Disability Services Division

13. DSPS WI. Department of Safety and Professional Services

14. IT Information Technology

15. NPI National Provider Identifier Registry

16. NCQA National Committee for Quality Assurance

17. NOMs National Outcomes Measure(s)

18. O’YEAH Older Youth & Emerging Adult Heroes

19. PIP Performance Improvement Project

20. POC Plan of Care

21. QA Quality Assurance

22. QI Quality Improvement

23. REACH Reaching, Engaging and Assisting Children (and Families)

24. RCC Residential Center for Children

25. SARs Service Authorization Request(s)

26. SAIL Supported Assistance for Independent Living

27. SAMHSA Substance Abuse and Mental Health Services Administration

28. WIser

Choice

Wisconsin Supports Everyone’s Recovery Choice

29. WPN Wraparound Provider Network

30. YSR Youth Self-Report

18

WRAPAROUND MILWAUKEE

Phone: (414) 257-7611 9201 Watertown Plank Rd., Milw., WI 53226 Fax: (414) 257-7575

Position: Quality Assurance/Quality Improvement Director

Qualifications: Individual who possesses a Bachelors Degree and/or preferably a Master’s

Degree in a Health Services Related field. This individual should have five plus

years experience in working with emotionally/behaviorally challenged

families/children and mental health systems of care. At minimum, one years

experience in research/ statistics, i.e. – data collection, data analysis, report

writing, etc. Supervisory/management experience of three plus years is

preferable.

Knowledge/ Skills/Abilities: Knowledge of quality standards, terminology, practices, and trends related to the

health and human services and mental/behavioral health arena. Knowledge of

Federal, State and County rules and regulations and funding sources related to

Wraparound and other human services programs. Knowledge of County policies

and procedures related to program/service descriptions, requirements, billing and

payment practices. Ability to prioritize, organize, direct, delegate and coordinate

QA activities. Ability to evaluate/audit client and provider file

documentation/records in an objective manner. Ability to chair meetings and lead

discussions. Ability to prepare, analyze and present documents/reports. Basic

statistical/analytical skills necessary. Ability to make sound programmatic and

departmental decisions/recommendations based off of knowledge acquired through

daily work tasks, report/audit findings and analysis of data. Critical thinking skills

required. Strong communication, interpersonal and organizational skills required.

Ability to work under pressure and within time frames. Ability to work

independently. Ability to work harmoniously and effectively with all levels of

County and State personnel as well as Consumers, Providers, other system

stakeholders, the general public and colleagues. Proficiency in software

applications, electronic mail and internet-based IT systems.

Duties: 1. Coordinates and is responsible for all aspects of the Wraparound QA/QI

program: development, implementation, training, supervision of staff,

monitoring/coaching of co-employees and stakeholders to facilitate change.

2. Establishes strategic plans and policies and procedures for the system of

care to ensure that the quality of the program will meet or exceed internal

and external client and stakeholder standards and expectations.

3. Collects, organizes, analyzes, monitors and distributes

information/data/reports related to the functions of the quality

assurance/improvement program/department (Annual QA/QI Report),

utilization review, identified outcome measures (Care Coordination Agency

Performance Reports), complaints/grievances (Complaint/Grievance

Attachment # 1

19

database maintenance), family/provider satisfaction (Family Survey

database maintenance and Survey analysis and reports), programmatic

auditing and State-Medicaid Contract requirements (general Contract

requirements and Annual Performance Improvement Project).

4. Communicates information on the latest standards, procedures and

requirements related to the mental/behavioral health service delivery

system/Contract requirements.

5. Coordinates with the Wraparound Provider Network and other fee-for

service programs to establish, develop and maintain standards related to

Provider service descriptions, policies, audit indicators/measures, Provider

Site Inspection process, issues related to Provider credentials/criminal

background checks, the Provider Application and Fee-for-Service

Agreement.

6. Chairs the Wraparound Milwaukee QA/QI Executive Committee.

7. Participates in/contributes to the DHHS/Centralized QA monthly meetings.

Collaborates with/consults with Centralized QA staff with regards to all

Provider Network QA related issues/concerns/programmatic

development/establishment of relevant audit indicators. Participates in the

Provider review/auditing process (as available).

8. Partners with Families United of Milwaukee, Inc. (Wraparound

Milwaukee’s family advocacy and support agency) with regards to the

implementation, organization and distribution of the Family Care

Coordination Satisfaction Surveys and the Family Provider Satisfaction

Surveys. Provides supervision for “Family Partner/QA Liaison” employees

during the hours they contribute to the Wraparound QA functions.

9. Provides QA related technical assistance to Providers/Care Coordination

Agencies/other system stakeholders as needed.

10. Provides technical assistance to other national/international sites that have

been awarded “wraparound” type grants, and/or other interested parties.

11. Chairs subcommittees related to QA/QI issues.

12. Attends all relevant/required system meetings/in-services, etc.

13. Attends conferences/workshops related to QA/QI issues and health-field

issues assuring the accumulation of necessary continuing education

requirements to maintain personal licensure.

14. Provides coverage for management personnel/programs as needed.

15. Other duties as assigned.

DHHS Centralized QA Committee

(Review/Audit TeamContract Administration)

•Conducts WPN reviews/ audits•Provides summary reports and recommendations to agencies that were reviewed/audited•Serves as a feedback mechanism for continuous QA and QI as it relates to county-wide standards/ practices•Assists with revisions/ updates of Fee-for-Service Agreement, centralized policies•Identifies short-term QA Subcommittee tasks

Care Coordination Agencies

•Provides Care Coordination (CC) services to Wraparound families•Attends bi-monthly management meetings, monthly CC in-services, bi-monthly provider meetings and other identified mandated trainings•Collaborates with Wraparound in establishing QA/QI and program standards for CC services•Engage in submission of data that is used to measure CC agency performance on a semi-annual basis

Families United of Milwaukee, Inc.

(Family Satisfaction)

•Provides advocacy and support for all Wraparound families and youth•Provides feedback to Wraparound Management regarding family satisfaction with Wraparound services and identifies QA/QI issues for Wraparound to address•Partners with QA/QI Department with regards to the distribution of the Family Satisfaction Surveys and other QA/QI activities

Synthesis -Wraparound's IT System

•Addresses cost of care and service utilization•Addresses outliers and trends in service delivery system•Produces reports to track/ measure outcomes and best practice expectations•Provides mechanism for providers to invoice for services•Wraparound's electronic client Medical Record -maintains all client information (i.e.: demographic info, Plan of

Wraparound Provider Network (WPN)

•Provides a variety of mental health, behavioral and social services to support the Wraparound system of care•Holds in bi-monthly Provider Forum meetings to share information and ideas, provide Network /Wraparound Milwaukee updates•Establishes standards and policies for the various types of services offered•Participates, as requested, in QA/QI activities•Conducts New Provider Orientation and various trainings throughout the year•Collaborates with DHHS and Contract Administration•Implements Fee-for-Service Agreement and other policies and expectations

Mobile Urgent Treatment Team (MUTT)

•Provides community mental health crisis services to Milwaukee County youth and families•Engages in quality reviews of crisis stabilization services and group home services•Gatekeeper to inpatient psychiatric services•Provides mental health assessments/evaluations as requested/needed

Partnership Council•Functions as an advisory group, composed of parents/caregivers and community partners involved in service delivery, which supports systems for youth and their families•Addresses/Provides feedback regarding QA/QI issues and concerns•Meets quarterly

2015Wraparound Milwaukee

Quality Assurance / Quality Improvement

Department

QA/QI Executive Committee

•Utilizes feedback to address and monitor QA/QI concerns and implement change as needed•Reviews and approve QA Annual Report and QA/QI Annual Workplan•Reports to the Management Team, Wraparound Provider Network (WPN) Forum and Partnership Council, as needed, regarding QA/QI concerns and information•Provides feedback and guidance regarding QA/QI related studies, projects, policies, etc. •Meets 4 - 5x’s per year

Wraparound Management Team

•Establishes and implements the Wraparound System of Care, policies and procedures and performance standards and monitors for program integrity/fidelity•Collaborates with families, providers, agencies, the State, community partners, and system of care partners•Provides resource team assistance to families/ providers/CC's as needed•Engages in pre-authorization of inpatient, residential, group home, day treatment services and independent living•Provides oversight to the QA/QI Executive Committee•Meets 2x's month

Critical Incident Review Panel•Reviews identified critical incidents•Approves implementation of corrective action plan that must be completed by the individual/agency in question•Meet on an as needed basis

Family/Provider Advisory Committee

•Provides guidance regarding provider monitoring, compliance and policy expectations•Address service needs•Open discussion regarding family/ provider issues

Provider PerformanceMeasures Committee

•Identifies provider performance measures/indicators•Implements, tracks and reports on outcomes

Provider Network Enrollment Committee

•Reviews and approves new provider applications•Accesses service needs•Reviews vendor eligibility•Reviews vendor qualifications/ credentials•Reviews vendor history•Meets as needed

Wraparound Credentialing Committee•Subcommittee of the Enrollment Committee•Reviews and provides approval of MH/AODA applicants who meet minimum participation criteria with adverse activity•Meets on an as needed basis

Wraparound Evaluation Component

•Collect, analyze and report on outcome data received from Wraparound families, CCs, Courts, school system and Juvenile Justice System

H/CATC/QAshared/Erdman/QAQIFlowchart2015 ATTACHMENT #2


2015-2016 Quality Assurance/Quality Improvement Timeline

ATTACHMENT # 3

2016

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan

2014 QA/QI

Annual Report

1st(to the state)

2015 QA/QI Program

Description and Workplan

1st(to the state)

2015-2016 QA/QI

Timeline

1st(to the state)

POC Audits/Reviews

Chart Audits/Reviews

Progress Note

Audits/Reviews

Provider Philosophy /

Other Training

Family/Provider Orientations

Outcome Indicator

Data for 2014

15th(to the state)

Grievance Summary Report

for 2014 & 2015

31st(to the state)

30th(to the state)

31st(to the state)

31st(to the state)

31st(to the state)

Coordination of Benefits

Report for 2014

15th(to the state)

Utilization Data Report for

2014 - 2015

1st ( to the

State for the

first 6 months

of previous

year)

1st ( to the

State for the

second 6

months of

previous year)

Data Attestation Form

2015 Performance

Improvement ProjectDue 3/1/16

2014Activity

Send to State with submission of any data

Ongoing throughout the YearFamily: Every 6 weeks Provider: Every 3 months or as needed

Ongoing throughout the Year

April - May

Conducted as determined necessary

Review for 2016

11/01-12/31

Review for 2016 - 2017

11/01-12/31

09/14 - 10/16

H:\CATC\QA Share\ERDMAN\Timeline2015.xlsx 1


2015-2016 Quality Assurance/Quality Improvement Timeline

ATTACHMENT # 3

2016

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan

2014Activity

Utilization Review Processes

Family Care Coordination &

Provider Satisfaction

Surveys and Out-of-Home

Care Surveys

Care Coordination Agency

Performance Reports

24th -

27th

24th -

28th

DHHS/WPN Fiscal and

Quality Audits/Reviews

Monthly Coordination of

Benefits Statement

Bi-annual Policy &

Procedure ReviewApril, 2016 July, 2016

November 1st,

2016 -

Distributed to

providers/CC

January 1st,

2017 - Effective

date of revised

policies

Complaint Follow-up &

Monitoring

Critical Incident Follow-up

& Monitoring

Provider Performance

Measures/Outcomes

Crisis Stabilization Audit

Schedule more

traditional

audit again in

May 2018

Will address various QI measures this year/

Crisis Subcommittee being established


Ongoing throughout the YearMailed, Hand Delivered or Conducted Via Phone


Mailed to each Enrollee on a Monthly Basis




H:\CATC\QA Share\ERDMAN\Timeline2015.xlsx 2


CREDENTIALING

AND

RECREDENTIALING

2015-2016

Attachment #4

- 2 -

TABLE OF CONTENTS

Introduction ..................................................................................................................................... 2

Authority ......................................................................................................................................... 2

Confidentiality ................................................................................................................................ 3

Scope ............................................................................................................................................... 3

Credentialing And Recredentialing................................................................................................. 4

Initial Credentialing And Recredentialing Requirements ............................................................... 4

Practitioner Responsibilities ........................................................................................................... 5

Right To Appeal .............................................................................................................................. 5

Credentialing Process...................................................................................................................... 5

Initial Credentialing Process: .......................................................................................................... 5

Primary Source Verification (Credentialing) .................................................................................. 6

Recredentialing Process .................................................................................................................. 7

Primary Source Verification (Recredentialing) .............................................................................. 7

Office Site Evaluation and Medical Record Documentation .......................................................... 8

2

INTRODUCTION

As a specialized Managed Care Organization (MCO), Wraparound Milwaukee identifies services

that will be available to participants in the Wraparound Milwaukee Program. The services

available to clients each have a specific definition and credentialing requirements for providers of

each service.

Agencies must complete an application process that includes:

a written application which identifies the services that the agency is applying to provide

through the Wraparound Milwaukee Provider Network

identification of specific services that the agency is requesting authorization for each direct

service provider identified in the application to provide

a desk review to assure agency and direct service provider compliance with service specific

education, training and /or credentialing/licensing requirements

compliance with criteria set forth in the Wraparound Milwaukee Fee-for-Service Agreement

in effect at the time that the application is being processed

a site visit (for agencies located in the Metropolitan Milwaukee area) to confirm that the

physical location meets minimum requirements for service(s) to be provided

a review of direct service provider background checks as required by Milwaukee County for

direct service providers identified in the agency application.

Mental health and Alcohol and other Drug Abuse (AODA) practitioners must also complete a

Universal Application and credentialing process that is consistent with the requirements of the

National Committee for Quality Assurance (NCQA).

AUTHORITY It is the responsibility of Wraparound Milwaukee Administration and the Wraparound Milwaukee Provider Network to ensure the appropriate direct services providers, including psychiatrists, psychologist, socials workers, other mental health practitioners and AODA providers are available through the Wraparound Milwaukee Provider Network to assist in meeting the needs of Wraparound Milwaukee participants. This is accomplished through an effective provider application and credentialing process, including ongoing quality monitoring and quality review activities.

Final decision making for credentialing/recredentialing of providers rests with Wraparound

Milwaukee Administration. The Wraparound Milwaukee Provider Network is responsible for

accepting and processing provider applications and implementation of the credentialing/

recredentialing review process. Provider Network staff process agency applications and review

practitioner Universal Applications for completeness and compliance with service specific

credentialing requirements. Practitioner applications with NO adverse activities are presented to

the Medical Director for review and approval. A summary list of applicants with no adverse

activity that are approved is presented to the Credentialing Committee. The Credentialing

Committee is responsible for reviewing practitioner applications with adverse activity license

sanctions, malpractice claims history, pending malpractice claim(s), and/or quality of care issue(s).

Applicants that do not meet the minimum participation criteria are notified in writing by the

Committee Chair Person and/or Provider Network Coordinator, in the case of a physician, the

notice is co-signed by the Medical Director. The Credentialing Committee may utilize an exception process to credential/recredential certain applicants/practitioners given the needs of the Program’s participants/service recipients. The

3

Credentialing Committee will review all criteria based first on the need for the given practitioner’s services within the Network. If a need exists, criteria associated with approval of the applicant is to be examined on an individual basis taking into account the following:

Malpractice claims history: less than two (2) claims in a five (5) year period, or claims judged to be of nuisance value. Exceptions will be granted and reviewed on an individual basis by the Credentialing Committee.

If there is a history of drug or alcohol abuse, the applicant must be involved in a credible program to correct impairment with concurrent and present monitoring by the medical society or state board. There should be no evidence of recidivism.

Office hours: coverage with less than recommended office hours.

Previous sanction activity: the nature of the sanction and remedy.

Office site visit: a plan to remedy any deficiencies with provisional approval until the remedy is achieved.

Additional exceptions will be granted and reviewed on an individual basis by the Credentialing Committee.

The credentialing/recredentialing process shall not discriminate against any practitioner: on the basis of gender, race, religion, age, disability, sexual orientation, ethnic origin or client

population served. on the basis of license or certification provided the practitioner is acting within the scope of

his/her license or certification under applicable State law or other applicable regulations.

CONFIDENTIALITY Wraparound Milwaukee will be responsible for the development, maintenance, and updating of all confidentiality policies and statements associated with agency and direct service provider applications and the practitioner credentialing process. Policies are reviewed biennially or more often as needed. SCOPE All direct service providers requesting to provide services through the Wraparound Milwaukee Provider Network are subject to review with respect to training, education, and licensing requirement set forth by Wraparound Milwaukee and federal and state licensing and regulatory agencies. Wraparound Milwaukee encourages enrollment of a broad range of providers in order to promote participant choice and diversity within the Wraparound Milwaukee Provider Network. Mental Health and AODA practitioners (practicing individually, in a group or in an outpatient client) who provide the following services will be required to submit a Universal Application and complete the Wraparound Milwaukee credentialing review process.

Physician/Psychiatry Services Psychology Services Psychotherapy Services (individual, family and group) AODA Assessment AODA Counseling Services (individual, family and group) In-Home Therapy (Medicaid Lead) Special Therapy (specifically clinicians who are Certified or Licensed by the State of

Wisconsin such as Occupational Therapy)

4

Practitioners who practice exclusively within the inpatient, residential care or group home settings who provide care for Wraparound Milwaukee participants are not required to undergo credentialing by Wraparound Milwaukee provided the practitioner does not bill for services under an outpatient clinic license.

CREDENTIALING AND RECREDENTIALING

Initial Credentialing and Re-credentialing Requirements Each practitioner must complete a Universal Application for participation as a provider in the Wraparound Milwaukee Provider Network that includes the following minimum requirements:

1. Complete, sign and date Wraparound Milwaukee Universal Application.

2. Complete attestation to:

History associated with clinical license and /or clinical privileges, disciplinary

actions and felony convictions.

Absence of current substance abuse.

Mental and physical competence to perform the essential duties of the profession.

The correctness and completeness of the application.

3. Sign and date releases of information.

4. Current unrestricted license or 3000 hour psychotherapy letter (for employment in a state

certified outpatient mental health facility) from the State of Wisconsin

5. For physicians, valid DEA certificate.

6. Current liability insurance in compliance with the 2011 Wraparound Milwaukee Fee-for-

Service Agreement.

7. Proof of highest level of education, and in the case of physicians, proof of graduation from

an accredited medical school or school of osteopathy or proof of completion of an

accredited residency or fellowship program, or proof of board certification; ECFMG

certification or equivalent, if practitioner is a foreign medical graduate (for 3000 hour

practitioners, there will be a $10.00 fee assessed to the affiliate agency to cover the cost

of education verification).

8. Signed Background Information Disclosure form. Note: if there are any affirmative

answers (except Section B, No. 4 and 5), Wraparound Milwaukee will require the affiliate

agency to submit a current (within the last year) background check in order to complete

the credentialing process.

9. Work history since graduation from professional or medical school.

10. Malpractice and/or professional liability actions for the most recent five years

11. History of Medicaid/Medicare sanctions showing practitioner is currently in good

standing.

12. Disclosure of ownership or financial interest in any clinical laboratory, diagnostic testing

center, hospital ambulatory surgery center, home health, or other business dealing with

the provision of ancillary health services, equipment or supplies.

13. Original copy of application submitted to Wraparound Milwaukee. The above elements may be subject to primary source verification, as applicable, according to

information. Notice of the right to correct erroneous information is contained within the:

Wraparound Milwaukee Primary Source Verification Notice (available on the Wraparound

5

Milwaukee Web Site) and the Wraparound Policy “Provider Network Applicant Right Request

Information and Correct Erroneous Information” and within the Universal Application.

Practitioner Responsibilities Along with the criteria for credentialing, all practitioners must agree to meet the following basic responsibilities in order to be a provider for Wraparound Milwaukee Provider Network:

to abide by the Fee-for-Services Agreement in effective at the time of the provision of services to Wraparound Milwaukee participants/service recipients

to abide by the ethical principles of his/her profession, including but not limited to, refraining from fee splitting or other inducements related to client referral; providing care for participants; refraining from delegating the diagnosis or care of participants/service recipients to a practitioner who is not qualified to undertake this responsibility

Wraparound Milwaukee may perform credentialing functions for other Health Plans or Managed

Care entities and may offer practitioners the option to become service providers for these Plans.

The option to “Opt-In” as a provider for a contracting Health Plan will be based on the contracting

Plan’s agreement with Wraparound Milwaukee. Practitioners electing to become a provider for

the contracting Plan agree to abide by the policies and procedures set forth by contracted Health

Plan. Contracted Plans retain the right to enroll any and all practitioners as service providers within

their plan based on their own credentialing criteria.

Right to Appeal Practitioners who are declined enrollment in the Wraparound Milwaukee Provider Network due to quality of care or liability claims issues have the right to appeal the decision in writing within fourteen (14) days of formal notice of denial. All written appeals should include additional supporting documentation in favor of the applicant’s reconsideration for the Wraparound Milwaukee Provider Network. Appeals will be reviewed by the Credentialing Committee at the next regularly scheduled meeting, but not later than 60 days from the receipt of the additional documentation. The applicant will be sent a written response to his/her appeal within 30 days of appeal decision. Practitioners whose enrollment in the Wraparound Milwaukee Provider Network is suspended, reduced, or terminated, shall have the right to appeal the decision in accordance with Wraparound Milwaukee Policies and Procedures and Fee for Service Agreement. Appeals are reviewed by the Credentialing Appeals Committee which consists of the Program Director, Director of the Mobile Urgent Treatment Team (or his designee) and a Child Psychiatrist from the Milwaukee County Behavioral Health Division. The Committee will review the appeal within 45 days of receipt of the formal written (dated and signed) appeal request by the practitioner. The Appeals Committee hears appeals of decisions to deny, suspend, or restrict participation or to terminate the participation status of practitioners. The Appeals Committee may uphold, reject or modify the decision. The Appeals Committee’s recommendation will be based upon the evidence admitted at the hearing. A final decision related to the appeal rests with the Wraparound Milwaukee Program Director. CREDENTIALING PROCESS

Initial Credentialing Process: All mental health and AODA practitioners applying for initial credentialing with Wraparound Milwaukee are required to complete a Universal Application. The application form must be

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complete, signed and dated by the applicant. Wraparound Milwaukee verifies the information provided by the practitioner in support of their application for Provider Network enrollment through external primary sources within 60 days prior to the credentialing decision. The practitioner is notified promptly of any problems related to the collection and/or verification of these documents and information. It is the sole responsibility of the practitioner/applicant to produce all necessary information and documentation required to conduct a thorough review of the application. Failure to provide the necessary information within sixty (60) days from the initial application date will result in termination of the process. If the practitioner ever seeks to join the network in the future, he/she must begin the process from inception. An application is not considered complete until all necessary information is obtained and verified by Wraparound Milwaukee Provider Network staff. This includes any supplemental information that may be requested to support the application. The medical staff office of the Milwaukee County Behavioral Division obtains an AMA check/profile and National Data Bank Report for all physician applications on behalf of Wraparound Milwaukee. Applicants who meet the minimum participation criteria and who do not meet the established credentialing criteria (no adverse activity) will be presented in summary format to the Medical Director for review and approval. Applicants who meet the minimum participation criteria with adverse activity (license sanctions, quality of care issues, settled malpractice claims history) and all pending malpractice claim information will be submitted to the Credentialing Committee for review. It is the responsibility of the Credentialing Committee to review each applicant’s qualifications and make approval or denial recommendations to Wraparound Milwaukee Administration. Wraparound Administration then makes the final decision for approval or rejection of the practitioner’s application to become a provider. The practitioner will be sent a written notice of his/her status within 30 days of the rendering of a decision their application to become a provider for Wraparound Milwaukee.

Primary Source Verification

The following information is required for mental health and AODA (alcohol and other drug abuse)

practitioners applying to become a provider with the Milwaukee Wraparound Provider Network.

Wraparound Milwaukee Provider Network staff will obtain this information, review, and verify

documents with the following primary sources:

DOCUMENT VERIFICATION SOURCE

Current Valid License to Practice Wisconsin Department of Regulation

and Licensing Website

3000 Hour Psychotherapy Letter Practitioner must submit with

Application

Medical School, Internship and Residency AMA E-Physician Profile

Board Certification, DEA status, and

Medicaid/Medicare Sanctions (for Physicians)

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Education for 3000 hour letter practitioners National Student Clearinghouse

or communication with the school

Malpractice Claims National Practitioner Data Bank

Medicaid/Medicare Sanction Information Healthcare Integrity and Protection Data

Bank

National Provider Identification Numbers (NPI) are verified using the National Plan and Provider

Enumeration System web site at https://nppes.cms.hhs.gov/NPPES/NPIRegistrySearch.

Documentation and verification information associated with processing of a properly completed application shall be no more than 60 days old at the time of the credentialing decision. Recredentialing Process

Wraparound Milwaukee formally re-credentials practitioners every three years. Requests for re-credentialing information will be sent to the practitioner with sufficient advance notice to allow the re-credentialing process to be completed by the last day of the month that the re-credentialing renewal is due. Wraparound Milwaukee will forward a recredentialing application form to the practitioner for verification and update of information personal information and work history, completion of attestations regarding the practitioner’s ability to provide services and lack of present illegal drug use, including an original signature and current date.

Primary source verification will be conducted to verify current and new professional licenses, malpractice claims and/or Medicaid/Medicare Sanction Information.

The following information is required for mental health and AODA (alcohol and other drug abuse)

practitioner recredentialing. Wraparound Milwaukee Provider Network staff will obtain the

required information, review, and verify documents with the following primary sources:

Primary Source Verification

DOCUMENT VERIFICATION SOURCE

Current Valid License to Practice Wisconsin Department of Regulation

and Licensing Website

DEA status, Board Certification AMA E-Physician Profile

Medicaid/Medicare Sanctions (for Physicians)

Malpractice Claims National Practitioner Data Bank

Medicaid/Medicare Sanction Information Healthcare Integrity and Protection Data

Bank

All applications, documents and verification information shall be no more than 60 days old at the time of the re-credentialing decision. The practitioner recredentialing process includes a review of the following Participant/service recipient complaints/grievances Client satisfaction surveys Current Professional Liability Insurance Certificate

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To assist with practitioner re-credentialing, the following may also be reviewed: Medical record audits Office site evaluations Quality improvement studies Utilization management

In the event that credentialing information obtained from other sources varies substantially from

that provided by the practitioner, Wraparound Milwaukee shall notify the practitioner in writing

within two weeks of the discrepancy. The applicant shall have 30 days to correct erroneous

information submitted by other parties and/or to correct his/her own information or the processing

of his/her application will be terminated.

OFFICE SITE EVALUATION AND MEDICAL RECORD DOCUMENTATION The initial credentialing process includes an on-site office evaluation and medical record review for all new agencies that apply to provide service for Wraparound Milwaukee participants and their families. As part of the site review for mental health and AODA practitioners, standards for access to services, including emergency coverage and appointment availability are reviewed in order to assure reasonable access to services for Wraparound Milwaukee participants/service recipients. Medical groups and group practices do not need a separate site visit for each practitioner. The site evaluation includes but is not limited to:

• Practitioner information (i.e. licenses/certifications, background checks, etc.) • Office policies/general information • Physical plant/physical accessibility • Scheduling/appointments availability • Availability of emergency equipment (as applicable) • Medication storage policies and procedures • Medical record keeping format including forms, practices and procedures • Access/on-call coverage policies and procedures

The results of the office site evaluation and medical record keeping review are considered in the initial credentialing decision-making process. Practitioners with evaluation scores that fall below the threshold or 80% or that lack essential elements are subject to corrective action and re-review to monitor compliance as a requirement for enrollment in the Wraparound Milwaukee Provider Network.

Agencies/practitioners whose site evaluation reveals substandard scores will be monitored by the

Wraparound Milwaukee Provider Network Coordinator for corrective action. Agencies/

practitioners will be required to submit evidence of correction in non-compliant areas within a

prescribed time frame not to exceed three (3) months for existing Network agencies/providers and

prior to enrollment in the Network for new agencies/providers.

POLICIES AND PROCEDURES

All Wraparound Milwaukee Provider Network and credentialing policies and procedures are

considered part of the Wraparound Milwaukee Credentialing Plan.

Updated 10/09; 11/10, 11/12, 10/14

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