Accreditation Planning and Preparation April 14, 2015 Mildred Brooke Health Management Consultants mbrooke@hmconsult.com

Agenda Overview of Project Accreditation Requirement Accreditation Process Planning for Accreditation Preparing for Accreditation Regional Technical Assistance Sessions Questions – submit through “Chat”. We will respond to questions at the end of the presentation.

Training & Technical Assistance Webinar – Training session on planning for your accreditation process. Workgroups - Regional Technical Assistance sessions to begin accreditation preparation. Send email by 4/17/15 to mbrooke@hmconsult.com with name, agency, address, phone, & email address.

Accreditation in Maryland Some MH and SUD programs in Maryland are already accredited. “Deemed Status”: COMAR 10.21.16.10 and 10.47.04.05 (provider can request accreditation be accepted as part of program certification or approval process). Behavioral Health Integrated Regulations Workgroup began exploring accreditation over 2 years ago. http://dhmh.maryland.gov/bhd/SitePages/Behavioral%20Health%20Integration%20Stakeholder%20Workgroup.aspx

Accreditation Requirement Draft Regulations (1/7/15) COMAR 10.63.01 Community Behavioral Health Programs Program – Application and Licensure Processes and Program Descriptions (includes requirements other than those pertaining to accreditation)

Three Categories NO License & Accreditation

No License & No Accreditation COMAR 10.63.01.04A (draft) Health professional, in solo or group practice, who is licensed under the Health Occupations Article & who is providing services IAW the requirements of the professional board Programs/organizations that hold meetings/provide support services but do not provide treatment EAP of a business Outpatient behavioral health & rehabilitation services in regulated space of hospital Therapeutic Group Home

License & No Accreditation COMAR 10.63.01.05C (draft) Substance-related disorder assessment & referral program operated by a State or local government entity DUI education programs Early intervention Level 0.5 programs

License & Accreditation COMAR 10.63.01.06C (draft) Integrated behavioral health programs Intensive outpatient treatment Level 2.1 Mobile Treatment Services Outpatient treatment Level 1 Outpatient Mental Health Center Partial hospitalization Psychiatric Day Treatment Program Psychiatric Rehabilitation Program (Adult & Minor)

License & Accreditation COMAR 10.63.01.06C (draft) continued Residential – low intensity Level 3.1 Residential – medium intensity Level 3.3 Residential – high intensity Level 3.5 Residential – intensive Level 3.7 Respite Care Services Supported Employment Program

License & Accreditation COMAR 10.63.01.07B (draft) Group Homes for Adults with Mental Illness Residential Crisis Services Residential Rehabilitation Program

License & Accreditation COMAR 10.63.01.06E (draft) Integrated behavioral health program Intensive outpatient Level 2.1 Outpatient Level 1 Partial hospitalization Level 2.5 Residential 3.1, 3.3, 3.5, 3.7 IF license specifically authorizes may provide: Withdrawal management service Opioid treatment service

Important Dates BHA Regulations – Proposed Implementation Timeline All dates proposed: 7/1/2015 Regulations effective 10/1/2016 Accreditation-based programs must be accredited 12/31/2016 ADAA & MHA regs repealed 1/1/2017 All programs (requiring licensure) must be licensed under new BHA regs 7/1/2015 No applications accepted for NEW approval/certification under ADAA/MHA regs

Important Timeline Accrediting organizations predict agencies need 12-18 months to achieve accreditation. Accreditation requirement effective in 18 months (10/1/2016)-planned date. Accrediting organization also needs time to prepare/respond to applicants. Most accrediting organizations require any new policies or procedures to be in place for 6 months prior to survey & accreditation follows 1-3 months after survey.

Accreditation planning and preparation starts NOW. Impact of Timeline Any changes needed to meet accreditation standards implemented by 12/1/2015 (approximate date). Accreditation planning and preparation starts NOW.

Accrediting Process (general) Agency contacts accrediting organization & buys standards. Agency prepares to meet accreditation standards. Agency applies for accreditation & submits some documents & fee. Agency contracts for survey & pays fee. Agency has on-site survey. Agency receives accreditation decision. Agency submits quality improvement plan (if needed). Agency has ongoing contact with accrediting organization.

Agency Process to Accreditation Phase I: PLANNING Good planning supports successful preparation. Phase II: PREPARATION Multi-step process to become “accreditation-ready”.

Accreditation Planning Steps Determine which programs need to be accredited. Research approved accrediting organizations. Discuss accreditation process with Board. Discuss accreditation process with Staff. Establish accreditation team. Develop accreditation budget. Develop accreditation plan.

1. Programs to be Accredited Review current programs to determine which, if any, need to be accredited. Consider any new programs under development that will need accreditation. (Accrediting organizations issue short-term “provisional” accreditations before program implemented & follow-up after implementation)

2. Accrediting Organizations Explore approved accrediting organizations. Review accreditations offered. Review standards. Review requirements, schedule, & fees. Assess compatibility with agency. Confirm which accreditations needed for agency’s programs.

3. Board Involvement Present accreditation plan. Discuss accrediting organization’s process. Set expectations: Board, management, staff Identify needed resources. Seek participation & buy-in. Provide updates on progress.

4. Staff Involvement Present accreditation plan. Discuss accrediting organization’s process. Set expectations: Process will result in some operational and/or administrative changes. Offer training as needed. Solicit Input and feedback. Seek participation and buy-in. Provide frequent communication & updates.

5. Accreditation Team Need participation from multiple competencies. May have difference leads for various sections of standards. Develop accountability to stay on plan & meet deadlines. Need frequent communication – some overlap in standards. Structured approach more likely to lead to success.

6. Accreditation Budget With accrediting organization develop estimated cost of accreditation (majority of cost depends on number of surveyors needed therefore, affected by number of programs & number of locations). Determine when payments will be due to accrediting organization. Estimate any other costs to achieve accreditation (resources, training, materials, etc.). Identify financial resources. Plan on annual costs with survey every 3 years.

7. Accreditation Plan Includes: Steps in process Timelines Milestones Responsible parties Monitor: Progress Decision-making process

Accrediting Organizations Receive “approval” from DHMH to be recognized as accrediting organization for behavioral health treatment programs in Maryland. Develop working relationships with BHA and OHCQ.

Behavioral Health Providers Apply for and maintain program licenses from OHCQ. Achieve accreditation from approved accrediting organization by required deadline. Maintain accreditation(s).

Planning & Preparing for Accreditation Requires resources. Needs commitment. Agency-specific project. Team approach within agency. Structured approach.

Accreditation Review Accrediting organization seeks to confirm agency’s compliance with accreditation standards by reviewing agency’s evidence of compliance. Evidence is often written policies & procedures but includes other documents as well as interviews and observations.

Accreditation Preparation Conduct gap analysis. Develop any needed “new evidence”. Revise any existing “evidence” requiring update/change. Develop training plan for staff to prepare for any new/revised policies, procedures, etc. Implement any new policies, procedures, etc. (6 months prior to survey). Prepare for survey.

1. Gap Analysis Identify “repositories” of existing evidence: For each section of accreditation standards (financial, HR, etc.) identify source document(s) with relevant policies, procedures, plans, etc. Compare existing evidence to standard & its requirements: For each accreditation standard, note source document for “possible evidence”. For each accreditation standard requirement, note if “evidence” is satisfactory or if “evidence” needs to be revised or developed.

2. & 3. New/Revised Evidence Organize any new/revised “needed evidence” by section of accreditation standards (financial, HR, etc.). Prepare needed evidence (new and revised) & incorporate into existing “repository” (Financial Management P&P, Personnel P&P, etc.) Add new/revised evidence to training list. Determine if any new/revised evidence affects other operational or administrative activities.

4. Training Plan Check for any required training by accrediting organization. Prepare annual training plan. Document all training conducted & received. Include Board. Clinical staff. Administrative & Management staff. Share resources.

5. Implementation Plan Any new/revised evidence implemented 6 months prior to accrediting organization’s on-site survey. Document effective dates for any new/revised evidence. Review impact on other clinical & administrative functions. Monitor.

6. Preparation for Survey Notify Board. Notify Staff. Inform individuals you serve. Consider “mock survey”.

Success - Acknowledge Accreditation Inform stakeholders. Publicize accreditation status. Review continuing commitments to accrediting organization. CELEBRATE!

Benefits of Accreditation Consistent with current medical practice. Sets minimum standards. Reduces redundancy. Increases simplifications & flexibility. Promotes evidence-based practices.

Regional TA Sessions Begin in May and run through the summer Half-day sessions to conduct gap analysis Participants can share strategies & resources If interested send email to mbrooke@hmconsult.com by 4/17/2015 with name, agency, address, phone number, & email address.

Questions Submit questions through “Chat”. Presentation will be available on website.