CHAPTER 5: STRUCTURE AND MANAGEMENT
http://www.dhhs.state.nc.us/mhplan/stateplanpart5.pdf

Role and Functions of Local Management Entity (LME)

Administrative functions are:

• General administration and program support
• Business management and accounting
• Screening assessment, authorization
• Utilization management
• Information management and reporting
• Resource development
• Monitoring and evaluation-continuous quality improvement program
• Provider relations and support
• Consumer affairs and services
• Community core services: community coordination, information and referral, emergency services

The state plan calls for the development of a local business plan to implement strategies for a smooth and thoughtful transition process. Business plans much include the following:

• A mission and values statement conforming to the State Plan
• Focus on consumer/family and citizen involvement in all components
• Emphasis on practice platforms and models of best practice consistent with the State Plan
• A three-year strategic plan that includes performance goals, objectives, strategies, specific outcomes and timelines for completion
• A plan for development of a qualified provider network
• A methodology for providing and overseeing core functions and management of the system of services/support to target populations
• Financial accountability mechanisms in compliance with the reform statute and the State Plan
• Evidence of technological capacity to meet state standards for data collection, reporting and other management information system requirements
• A detailed quality management plan that ensures compliance with the statewide system components
• User-friendly and consistent access processes and procedures in accordance with state uniform portal specifications.

A technical document attached to the state plan focuses specifically on the requirements of the local business plan and its submission. NAMI North Carolina will review the local business plan in a separate document.

The state plan recognizes that there will be individuals currently receiving services in the public system who will not meet eligibility criteria for a target population. It requires that these individuals be assisted to move to other alternatives within the system over a clinically appropriate but reasonable length of time. These alternatives include community human service agencies.

Individuals who seek services, but are determined through an assessment process not to meet eligibility criteria, will be referred to other resources. LMEs are expected to identify community resources including medical services, nutrition services, transportation, employee assistance programs, and self-advocacy groups.

The local business plan must include an assessment of current providers and other service resources and a transition plan, with specific strategies, for developing a qualified provider network that delivers the full range of services needed in the amounts required.

Making sure that consumers have choices of services/supports and service providers is one of the driving forces behind the reform effort. Providing consumers choice means that there is an array of qualified providers to choose from, otherwise known as a provider network. Secretary Hooker-Odom has stated that any providers who wish to receive public funds must join the local provider network. This provides an incentive for providers to join and places an obligation on LMEs to admit qualified providers.

In order to manage resources effectively, some services will have to be contracted to specific providers instead of allowing anyone who want to offer the service to do so. Services or programs such as rehabilitation programs, supported employment, emergency/crisis system, ACT teams are most likely to be contracted arrangements with the LME. The LME must ensure that models of acceptable practice are defined; that scope and economies of scale are considered; and that costs per service category have been determined. A "request for proposal" process should be used to award contracts to the best applicants. The selection process must include participation and recommendations of people with disabilities and their families. All such contracts must be re-bid at least every three years.

Ideally, LMEs should provide no direct services in order to devote its attention to management and coordinating the array of services and supports. The state plan recognizes, however, that potential providers may not always be available, especially during the transition period. Decisions about whether an LME can provide direct services will be determined on a case-by-case basis. Factors to be weighed will be:

• Efforts by the LME to attract and retain and adequate private provider network
• Possible divestiture of current area program clinicians to a private, non-profit arrangement
• Level of community support for the LME to continue providing some services pending development of an adequate network

Some area programs have initiated efforts to spin out (AP direct service staff to existing provider organizations) and/or spin off (AP direct service staff to newly developed provider organizations) as a way to develop a comprehensive and competitive provider network. These practices are acceptable if they adhere to the following conditions:

• They shall neither inhibit nor relieve the AP (Prospective LME) of their responsibility to aggressively and continuously recruit and retain a competitive and comprehensive provider network
• This effort shall be only a part of the overall strategy to build the provider network
• The AP (prospective LME) shall have no tie to these organizations that is unlike the ordinary relationship it would have with any other provider organization. For example, the AP (emerging LME) director may not be on the organization’s board of directors
• These organizations shall be legally freestanding organizations
• The transfer process shall not place these organizations at an unfair advantage over any other provider organization
• Components of the transfer and transition shall not create an immediate or future unfair advantage over other provider organizations
• The organizations shall be expected to compete in an equal and fair manner with all other comparable entities that are in the network at the point of transfer and into the future
• As expected of all provider organizations, these organizations shall be required to shift practice expectations to meet state expectations. If service practice expectations as well as quality, effectiveness and efficiency expectations are not met, these organizations shall be treated equally and have the same consequences as any other provider organization.

This section reviews the Division’s efforts to review and revise documentation requirements and make requirements as flexible and simple as possible. The Division will promote the use of technology to expedite documentation and reporting procedures. As the system evolves into an outcome-based system, quality assurance activities will decrease their reliance on paper reviews.

A state level monitoring workgroup has completed a draft model of system monitoring. The Division of Facility Services (DFS) is the state agent for licensed services. As such, DFS will be responsible for conducting inspections for compliance with licensure requirements. Results of these inspections will be published and used as quality indicators for performance. The LME will monitor qualified providers within the network. Local monitoring will focus on the quality of clinical and program delivery and will not be considered a licensure inspection. The state monitoring workgroup is developing standardized monitoring protocols and criteria.

Each LME will establish a consumer and family advisory committee. The CFAC will convene at the beginning of local planning efforts and will have an active role with delineated responsibilities throughout the planning process. They will advise staff regarding local planning effort and will review and submit a separate report(s) on local business plans to the Division. Each local advisory committee will be staffed by an employee of the LME whose responsibilities will include:

• Obtaining consumer and family input from the community
• Carrying forward recommendations of the advisory committee for implementation
• Serving as liaison to the state advisory committee and other local agencies, organizations and associations
• Recruitment of initial members of the local advisory committee in collaboration with local consumer and family advocacy organizations.

The Division will also convene a CFAC composed of representatives of the local committees. Composition of both state and local CFACs will reflect:

• 100 percent consumers and family members
• Equal representation of all disability groups
• Membership representative of the race and ethnicity of the community
• Representation for each disability group including a man, a woman, and a youth member.

Roles and responsibilities of the state and local advisory committees will be established according to specifications in the state strategic and local business plans. They must:

• Advise and comment on all state and local plans
• Make recommendations on areas of service eligibility and service array, including identifying gaps in services
• Assist in the identification of under-served populations
• Provide advice and consultation regarding development of additional services and new models of service
• Participate in monitoring service development and delivery
• Review and comment on the state and local service budgets
• Observe and report on the implementation of state and local business plans
• Participate in all quality improvement activities, including tracking and reporting on outcome measures and performance indicators
• Ensuring consumer and family participation in all quality improvement projects at both the provider and LME levels.

The state plan calls for supports to be provided to ensure consumer/family participation. These supports could include:

• Stipends
• Transportation or compensation for travel expenses
• Childcare or eldercare
• Flexible scheduling of meeting times
• Information, education, and materials

An implementation workgroup of consumers is reviewing current activities and recommending plans for the future. An interim report was prepared this spring. A second progress report that contains recommendations is currently being reviewed by the Division director. Final plans must be approved by the Department secretary and presented to the Legislative Oversight Committee.

This section looks a collection and analysis of data, including the new integrated payment and reporting system (IPRS). This reporting system will be phased in beginning July 1, 2002. Changes to the system will have to occur to incorporate some the changes and clarifications regarding target populations.

There is a discussion on the use of outcomes as a way to manage system-wide quality. A workgroup is developing a set of individual and system outcomes and a way to monitor the system’s performance. There also is a commitment in the state plan to support best practice services and supports but it doesn’t identify how these best practices will be supported and promoted by the state. Periodic report cards on system performance will be published on a regular basis beginning in 2004.

A competency-based system for qualified service providers is in development. Its purpose is to raise the level of quality and consistency statewide for delivery of services and to achieve measurable outcomes. The current design includes seven core skill areas required to meet minimal standards:

• Technical knowledge
• Cultural awareness
• Analytical skills
• Decision-making
• Interpersonal skills
• Communication skills
• Clinical skills

Prior to moving to such a system statewide the Division will assess the benefits of such a system as well as any measurable impact on quality.

The state plan recognizes the current economic downturn and the financial crisis the state is experiencing. The current finance strategy revolves around just one practice—billing. A service is provided and a fee is received. Best practice strategies evolving around the country suggest that in the future the system will be financed through additional sources and strategies. In fiscal year 02-03 the Department will provide the following documents to provide direction and clarity around funding:

• Coordinated realignment of funding within the Department
• Re-organization of the Division to support local management of resources and away from an institutional focus
• LME cost model project will produce information regarding best practice protocols for LME functions, core functions, and cost estimates for practices.
• Market cost mode to look at rate setting methods to better align resources and move to a more market-oriented approach
• Funding fairness to make sure that allocation of state funds are fair and equitable
• State Medicaid Plan revisions to make optimum use of community based Medicaid funded services
• Regulatory, rule and/or practice modifications: reduce unnecessary regulations, rules, monitoring and administrative costs
• Integrated Payment and Reporting System (IPRS) to provide LMEs with a data and claims payment infrastructure that aligns with the state
• Medicaid eligibility to optimize federal dollars through targeted changes in eligibility
• Coordination of benefits so local programs can capture and track 3^rd party billings
• Community placement to successfully transition institutionalized individuals to their home communities with an associated movement of institutional dollars to the community.
• Target/Priority population to have a defined service array and the ability to track data to demonstrate shifts in services received consistent with reform goals
• Innovations in practice
• Expedited LME development