LBHA Functions Draft for NTBHA Board Presentation February 10, 2016

Clinical Operations: Consumer Services Key FunctionExisting OperationsDevelopment Member services call center: information and referrals Value Options (VO) and NTBHA NTBHA needs to enhance existing processes to meet increased consumer services function, investigate rights complaints, and violations as required by regulations. Registering complaints / grievances / Ombudsman NTBHA formally registers complaints & grievances; maintains ombudsman program oversight, and tracks complaints. NTBHA will confirm compliance with requirements. 2

Clinical Operations: OSAR Key FunctionExisting OperationsDevelopment Outreach, screening, assessment and referral to SUD services Value Options (VO)NTBHA needs to develop this function for the six county region. 3

Clinical Operations: Crisis Management Key FunctionExisting OperationsDevelopment Single Portal Authority Function Delegated to VO through an MOU NTBHA will facilitate procurement process and provide direct contract management and oversight of the subcontractor and all SPA activities. Inpatient and Emergency Room System Oversees VO’s P&Ps for care coordination and tracks coordination NTBHA will determine a locally managed system of inpatient services and create a system for authorization and management. Crisis AlternativesVO currently contracts with providers NTBHA will develop crisis alternatives to hospitalization such as crisis respite, crisis residential, and 23-hour observation. Indigent and Medicaid Services VO contracts with provider with oversight from NTBHA NTBHA will continue to provide oversight and will contract for crisis services, including hotline and MCOT. 4

Clinical Operations: Care Management Key FunctionExisting OperationsDevelopment Mental Health Service planning and linkages Oversees VO’s P&Ps and standards for service planning NTBHA needs to develop. Chemical Dependency Service planning and linkages Oversees VO’s P&Ps and standards for service planning NTBHA needs to develop. Care coordination among provider services Oversees VO’s P&Ps for care coordination and tracks coordination NTBHA needs to develop. 5

Clinical Operations: Utilization Management Key FunctionExisting OperationsDevelopment Centralized Medical Director oversight VO provides medical direction, including oversight of CM, UM, QM, and pharmaceutical care Position would likely be half-time. Could be contracted. Medical necessity determinations Oversight of medical necessity criteria and determinations with input from a Clinical Advisory Committee with NTBHA participation NTBHA will need to develop P&Ps and functions for UM oversight. Care authorization, management of appeals Performed by VO; NTBHA manages appeals through case review and use of independent physician advisors Will be an internal function at NTBHA. Need to develop P&Ps and functions for appeals. Annual Utilization Management Plan VO develops Annual UM PlanNew NTBHA Care Managers will provide input into annual UM Plan. 6

Clinical Operations: Provider Network Management Key FunctionExisting OperationsDevelopment Network Development – Annual Network Development Plan Currently performed by VO; processes identify region- wide network needs (service gaps) and writes plan Establish a Planning and Network Advisory Committee. Develop staff responsible for network development processes. Network Management – recruitment, site visits/credentialing, contracting and claims payment VO currently maintains P&Ps to meet state requirements and manages contracting, credentialing (agency with oversight), and claims payment NTBHA will need staff responsible for network management; currently initiating provider open enrollment. Provider Relations, including orientation, training and complaints VO function currentlyNTBHA will need to perform provider relations functions locally. Provider Quality – in collaboration with Quality Management VO maintains P&Ps for provider quality in collaboration with QM NTBHA will need to conduct provider on-site reviews and give provider quality feedback. 7

Clinical Operations: Quality Management Key FunctionExisting OperationsDevelopment QI Committee(s); Annual Quality Management (QM) Plan VO develops annual QM Plan with input from the QM committee NTBHA needs to develop. Quality reporting – state, federal, and health plan requirements; quality of care concerns, outcomes NTBHA and VO collect and produce quality reporting and address quality of care concerns; focus on improving outcomes Will be NTBHA’s responsibility to produce quality reporting. NTBHA needs to develop. Internal review of clinical operations Currently performed by VO with oversight activities by NTBHA Will be a NTBHA responsibility in the future. NTBHA needs to develop. External review of provider quality in collaboration with Network Management Currently performed by VO with oversight activities by NTBHA Will be a NTBHA responsibility in the future. NTBHA needs to develop. 8

Administrative Operations: General Administrative Functions Key FunctionExisting OperationsDevelopment Financial managementNTBHA-contracted CPAFinancial management solution will be needed (with staff). Human Resources – currently has an HR vendor NTBHA-contracted vendor Compliance oversightVONTBHA Legal AffairsConsultant services Public Affairs/Communications NTBHA function Establishing Consumer Eligibility, e.g. Medicaid No formal processes in place today Organized processes for consumer benefits required. 9

Administrative Operations: Systems Support Key MH and CD FunctionExisting OperationsDevelopment Information technology to support clinical and administrative operations VO NTBHA has limited internal IT staff and contracting services NTBHA will hire and train additional staff to support operations. Software consulting services may be engaged to implement new systems as required. Claims managementVONTBHA will need to develop a provider payment solution. ReportingVO (provider and service reporting) NTBHA (financial and quarterly) NTBHA’s reporting requirements and solutions will be more complex. Disaster PlanningNTBHA contracts this service today NTBHA’s expanded infrastructure will need a more robust disaster recovery solution. 10