INTEGRATION TREND DRIVES TODAY’S ACCREDITATION OUTLOOK

Quality improvement must include collaborative efforts among providers

A ccrediting organizaL1 tions are paying JL JL close attention to the evolution of integrated care, raising the bar on what they expect from providers. Meanwhile, states have their own licensure rules, and managed-care Medicaid payers have accreditation expectations for programs to qualify for reimbursement. In fact, the state-contracted, commercial payer requirements of Medicaid providers have increasingly driven behavioral healthcare organizations toward accreditation.

The main purpose of accreditation is to create systems to improve care for the patient. But payers are becoming increasingly interested in providers that are able to improve comprehensive care and thus reduce utilization, so health homes and integration are increasingly being used to measure quality.

The four main accrediting organizations in the field are on task to keep up with healthcare system demands and vet the providers that seek their seal of approval.

CARF

Formerly the Commission on the Accreditation of Rehabilitation Facilities

Michael W. Johnson, managing director of CARF International's behavioral health accreditation, recalls the time when a CEO asked him to define the benefit of accreditation. Johnson responded: "Having a set of standards that are external to you and not influenced by local politics but represent a true measure of quality improvement strengthens your organization."

For example, one of the historic problems in the behavioral health market is a written document for succession planning. Johnson believes there are a significant number of CEOs planning to retire-some fairly soon-yet only 35 percent have groomed anyone in the organization to step into their shoes.

CARF International, based in Tucson, Ariz., is a not-for-profit entity that aligns its standards with the philosophy adopted by most behavioral health organizations, including recovery-oriented, person-centered care. The organization's history is rooted in the long-term recovery-based facilities that predominated in the substance use disorder (SUD) field, in which rehabilitation rather than medical treatment remains the focus.

And the addiction field is ahead of the mental health field when it comes to accreditation, according to Johnson.

"When I go to addictionsfocused conferences, the organizations that are in the for-profit market or cater to the insurance industry recognize that they're in business," he says. "In the mental health world, it seems that unless someone is making them do it, it takes them longer to make the decision to become accredited."

For-profit programs often have to convince payers of their value overall, and accreditation is one way to do that, he says. But it's not just payers that want to see value.

Integration trends in the healthcare system as a whole call for behavioral health to align with medical providers. Most often a hospitalbased system in a particular market has the competitive advantage, and behavioral providers would be smart to create integrated models with the local leading system, according Johnson. However, the hospital system likely will want to align its efforts with behavioral health organizations that are accredited, he says.

Johnson says with any accreditation, organizations should maintain a focus on quality improvement. CARF allows for accreditation of individual services.

"You might operate 15 different programs, but might want to get only 10 accredited," Johnson says.

Accreditation is effective for three years, but there is also a one-year accreditation offered by CARF for providers who have "serious gaps that need to be addressed," he says.

The Joint Commission

Tracy Griffin Collander, executive director for behavioral healthcare accreditation of the Oakbrook Terrace, Illinois-based Joint Commission came to the not-for-profit a year ago after six years with a Joint Commission accredited addiction treatment organization. Collander views accreditation as a partnership between the treatment provider and the accrediting organization.

In selecting accreditation, the treatment organization should take its own mission and values into account, she says.

Payers want to see national level accreditation in order to reimburse at higher rates, particularly when the provider has achieved health-home status. For example, in Maryland, The Joint Commission accredits and certifies behavioral health care organizations that function as health homes, which is required for reimbursement. The opioid treatment programs (OTPs) receive additional per patient reimbursement for managing care in a more comprehensive way.

Substance use disorder (SUD) treatment and eating disorder treatment are the top disciplines examined by insurance companies, Col- lander says, however, a low percentage of SUD treatment providers have such accreditation. For example, when Collander worked for Gateway prior to coming to The Joint Commission, care coordinators from a local Blue Cross Blue Shield plan would ask for proof of Joint Commission accreditation.

Because The Joint Commission accredits the entire organization, not just the program, she says accreditation leads to a "whole leadership structure" to rely on. Organizations are able to focus on continuous quality improvement by collecting data on risk points for addiction treatment services.

In particular, organizations can monitor patients throughout treatment using The Joint Commission's tracer tool. Tracer methodology is an evaluation method in which surveyors select a patient, resident or client and use that individual's record along with interviews with the care team and the patient as a roadmap to move through an organization to assess and evaluate the organization's compliance with Joint Commission standards.

When there was a spike in patients leaving against medical advice during Collanders days at Gateway, leadership would look back at the experiences of the departing patients to find out where the organization went off track, she says. In addition, the data helped Gateway hone in on best practice treatment and techniques among the patients who continued on in recovery.

"The data you track and the leadership structure that The Joint Commission requires follows all the way up to the CEO," says Collander.

Far from a one-time test, accreditation creates a framework that drives the day-today practices of an organization. About 80 percent of organizations accredited by The Joint Commission are multi-service providers including services such as community mental health, child welfare, developmental disabilities, eating disorders and addiction treatment, as well as providers that serve the homeless and the offender population. The Joint Commission accredits 2,080 behavioral health organizations; about half are not-for-profit, a quarter are for-profit, and the remaining one-quarter are governmental agencies.

Because The Joint Commission accredits the majority of hospitals in the country, inpatient programs typically choose it for accreditation. Likewise, about 800 residential treatment providers are accredited by The Joint Commissions Behavioral Healthcare Accreditation program.

About half of the Federally Qualified Health Centers (FQHCs) across the country are accredited by The Joint Commission's Behavioral Healthcare Accreditation program. The Joint Commission just started offering a new certification in January for behavioral health homes in addition to behavioral health care accreditation.

"There has been a great deal of interest in Joint Commission Behavioral Health Home Certification from a vast variety of service types," says Collander. "This tells me that integration is happening."

Community mental health centers, FQHCs, OTPs, and multi-service organizations have been particularly interested in health home status. For the certification, the annual fee is $350, and the survey fee is $800.

"If you want to show you are meeting the triple aim, then why wouldn't you seek Joint Commission Behavioral Health Home Certification?" says Collander.

Council on Accreditation

The Council on Accreditation (COA) is a childand family-service and behavioral healthcare accrediting organization. It offers its standards for free, so prospective applicants can study them before making an investment.

According to Stephanie Pacinella, director of standards development for the New York City-based organization, the focus is solely on community-based organizations. Like the Joint Commission, COA accredits the entire organization rather than one capability at a time.

"In order to have strong service delivery, you need to have a strong organization in place," says Pacinella. "Ethical practice, governance, quality improvement, risk prevention and management-you need all of those. If you aren't looking at your finances, budget planning and long-term strategic planning, you don't necessarily have what you need to support and sustain services."

COA accredits 150 types of programs, with standards for different populations: children, adults, case management, crisis intervention, day treatment, residential treatment, short-term diagnostic centers, group living, and sober homes. Its measures also include a standard for integrated care/health homes.

Recently, COA began issuing standards for primary care, used when an organization is providing an integrated model. Health homes that are eligible for federal reimbursement under the Affordable Care Act do not have to include the full array of behavioral health care, but must include comprehensive care management and health promotion, Pacinella says. COA standards reflect those federal models.

The peer reviewers are all volunteers, who review documents before and during site visits, interview staff and patients, and ask any questions that pertain to the level of implementation, which is also used to determine costs of accreditation.

Accreditation Commission for Health Care

The not-for-profit Accreditation Commission for Health Care (ACHC), based in Cary, N.C., is the newest of the accrediting organizations in behavioral healthcare. It was originally formed in 1986 at the behest of private duty nurses who found that existing standards from other accreditation organizations didn't apply to their day-to-day work. According to Britt Welch, behavioral health clinical manager, ACHC subsequently developed standards for other providers that met the needs of the non-hospital community, such as home health, hospice and specialty pharmacy.

Within its behavioral health component, organizations can be affiliated with a hospital, a FQHC, or any other provider-the ACHC standards stand separately. ACHC accredits the services selected by the provider, not the entire program, says Welch.

ACHC has standards for various services, not limited to clinical measures, such as supportive employment. These services are commonly used in behavioral healthcare, especially as integration moves forward. Helping patients find housing, for example, can help their overall health.

ACHC does not have standards for OTPs. However, ACHC standards do refer to medication management and systems in place when providers prescribe medication therapies. Also, ACHC is in beta testing of its behavioral health home accreditation.

"I'm really excited about this, because it ties into integrated care," says Welch. "It makes so much sense. Integration helps treat the whole person and create good outcomes with cost effectiveness."

ACHC accreditation is good for three years. Once accreditation is in place, the provider gets tools to use online "to make sure they are staying on task," says Welch. "I view this as a quality improvement process."

On the way to ACHC accreditation, providers can have different designations: accreditation-pending or accreditation-dependent. If accreditation is denied, there are opportunities for the provider to submit a plan of correction that could be approved, says Welch.

ACHC has a partnership with DNV Healthcare, which accredits hospitals (similar to the Joint Commission). Through this partnership, ACHC can offer a full range of accreditation, says Welch.

carf INTERANTIONAL

COST: $995 FOR THE APPLICATION; $1,550 PER SURVEYOR DAY

TYPICAL SURVEY: 2 SURVEYORS, 2 DAYS

ACCREDITATION: 3 YEARS

PROGRAMS ACCREDITED: 24,061

SITES WITH PROGRAMS: 9,152

COST: INITIAL DEPOSIT OF $1,700

FEES: DETERMINED BY THE VOLUME OF SERVICES AND THE LEVEL OF INTENSITY OF THE TREATMENT

ORGANIZATIONS ACCREDITED: 2.080

SITES WITH PROGRAMS: 7.400

INITIAL COSTS: DOWNLOAD THE STANDARDS FOR $199

FEES: $1,500 DEPOSIT, WHICH IS APPLIED TOWARD THE TOTAL ACCREDITATION FEE

SURVEY: TIME AND COST DEPEND ON THE NUMBER OF LOCATIONS /SERVICES

ACCREDITATION: 3 YEARS

COSTS: $750 APPLICATION FEE

FEES: SLIDING SCALE BASED ON REVENUE; FEES START AT A MINIMUM OF $6,720 FOR AN ORGANIZATION WITH REVENUE OF $500.000 OR LESS

SURVEY: FLAT FEE OF $2,000 PER REVIEWER FOR 2-DAY ONSITE REVIEW. PLUS $425 PER DAY PER REVIEWER FOR EACH ADDITIONAL DAY.

MAINTENANCE FEE: $400 PER YEAR

ACCREDITATION: 4 YEARS; OTP IS 3 THREE YEARS

More Online

CARF International:

http://www.carf.org/home/

Joint Commission:

http://www.jointcommission.org/

Council on Accreditation:

http://coanet.org/

Accreditation Commission for Health Care:

http://www.achc.org/

Alison Knopf is a freelance writer based In Carmel, N.Y.