Clinical Care Review Policy

Policy: Clinical Care Review

Policy Number: 309 Policy Section: Quality
Owner: Kevin M. Ramotar, Psy.D. Approved By: Amy Nygaard, MD
Effective Date: 8/31/2022 Date of Last Review: 5/15/2023; 5/25/2024

SUD Specialty Group -- CA; Mental Health Specialty Group, P.A.; Mental Health Specialty Group NJ, PC; and Mental Health Specialty Group KS, P.A. (collectively, the "Group") contracts with Path CCM, Inc. d/b/a Rula Health ("Rula") for management and administrative support services. This policy applies to the Group and Rula. 

Policy Statement

This policy develops a standardized clinical care review (CCR) process to assess and review the need for ongoing care for a patient seen by a Group provider.   The purpose of CCR is to facilitate the provision of quality, efficient behavioral health care services to patients and providers through monitoring, evaluating, measuring and directing processes and behaviors which impact the delivery of services. 

Applicability

This policy applies to team members who provide treatment services to patients. For purposes of this policy, the Group’s and Rula’s team members include individuals who would be considered part of the workforce such as employees, independent contractors, business team members, and other persons whose work performance is under the direct purview of Rula or the Group’s business practices.

Definitions

Clinical care review (CCR): a standardized process of review of a medical record by a trained, qualified, independently licensed social worker, psychologist, marriage and family therapist or professional counselor with the clinical expertise and training to conduct an evaluation of documentation. The reviewer will not be associated with the patient so as to provide an unbiased evaluation of the appropriateness, and clinical indication of the use of health care services. 

Provider: an individual who is qualified by licensure and experience to provide services to patients and who is employed or contracted by the Group to provide those services.

Clinical indication of care/ongoing care: health care services that a Provider, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, treating an illness, or preventing further deterioration in functioning, and that are: (a) in accordance with generally accepted standards of clinical practice; and (b) clinically appropriate, in terms of type, frequency, extent, and duration and considered effective for the patient’s diagnostic needs. 

Generally accepted standards of medical practice:  standards that are based on credible scientific evidence published in peer-reviewed clinical literature generally recognized by the relevant therapeutic community, Provider specialty association recommendations, and the views of Providers practicing in relevant clinical areas and any other relevant factor.

Policy

  1. CCR protections
  1. CCRs are a quality activity, the confidentiality of which is protected by HIPAA.  CCRs are used for ongoing quality improvement efforts related to the appropriateness and/or quality of services rendered to a patient. 
  2. The record of the CCR, including but not limited to: the associated clinical care review form, the data collected, and the resulting reports, findings, and conclusions are confidential and are not part of the patient’s designated record set. 
  3. As part of the quality process, payers may review CCRs upon request.  

B. CCRs are completed during the patient’s course of treatment. 

C. Documentation of review and results

  1. CCR findings will be documented in a standardized format using the Clinical Care Review Form.  
  2. Results of CCRs will be sent to the provider for the purposes of review, quality/practice improvement and clinical efficacy.  The information contained in the CCR is expected to be incorporated into clinical decision making related to the ongoing need for care provided to the patient. 

D. The treating provider for a patient has the final say in the CCR. The provider ultimately determines whether care needs to continue or if the client is ready for graduation from care.

  1. A provider may initiate an additional review by completing a Clinical Review Update Note in the patient’s record and the CCR Request Form. The Clinical Review Update Note is to be used to submit additional information that further supports the clinical indication for ongoing care. At no time may the provider alter the existing medical record. 
  2. A clinical care reviewer who was not involved in the initial decision or the Clinical Review Manager will review the request and respond within 7 calendar days.  
  3. As long as the provider completes the Clinical Review Update note detailing the clinical indication for ongoing care in the client’s medical record and the CCR Request Form, care will continue.   
  4. The provider will be notified that care with the patient may continue. 

E. Tracking of clinical care reviews

  1. The Quality team will maintain a database of all completed reviews for a period of 2 years after the date of the most recent review. 
  2. The Quality team will conduct trend analysis of aggregate data and provider-level analysis for the purposes of quality improvement. 
  3. Aggregate data reporting on determination outcomes and provider-level results of providers treating patients with successive reviews will be regularly reviewed at Quality Assurance Process Improvement committee meetings to determine if additional actions are needed.  

Attachments

  1. None

 

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