WRAPAROUND
MILWAUKEE
Phone: (414) 257-7611 9201 Watertown Plank Road, Milwaukee, WI 53226 Fax: (414) 257-7575
QQUUAALLIITTYY AASSSSUURRAANNCCEE &&
QQUUAALLIITTYY IIMMPPRROOVVEEMMEENNTT
__________________________
PPRROOGGRRAAMM DDEESSCCRRIIPPTTIIOONN &&
WWOORRKKPPLLAANN
2015
2
Table of Contents
I. QA/QI Mission Statement and Goals……………….………………….. 3
II. QA/QI Committee Roster……………………………………………….. 4
III. QA Program Description/QA Components……………………………. 5
IV. QI – Measures/Indicators/Activities…….……………………………… 10
V. Acronym Key…………………………………………………………….. 17
Attachments:
#1 2015 QA/QI Director Position Description
#2 2015 QA/QI Components Chart
#3 2015-2016 QA/QI Timeline
#4 2015-2016 Credentialing and Re-credentialing Plan
3
I. QA/QI Mission Statement
To ensure quality care and promote continuous quality improvement of services and
processes in order to meet the needs of the youth, families and young adults being served.
Overall Goals
1. To assess the effectiveness of the wraparound approach in improving the quality of
life for the youth, young adults and their families.
2. To ensure youth, young adults and families have access to care and services that are
individualized, strength-based, culturally intelligent and sensitive, needs-driven and trauma
informed.
3. To join with community and system partners in order to create opportunities for positive
programmatic and systemic change.
4. To establish policies and procedures that promote and ensure best practice and quality service
delivery.
5. To assess and monitor outcomes and implement necessary change.
6. To monitor service provision to ensure quality care.
2015 Goals
1. Review/Revise Care Coordination POC Auditing Tools and auditing process
2. Address areas of deficiency as noted in the 2014 – 2015 MetaStar, Inc. IT and QA Review of
Wraparound Milwaukee
3. Review/Revise Family Provider Satisfaction Survey and administration process to ensure we are
collecting focused information and achieving an adequate return rate
4. Complete the review/revision of all identified policies and procedures
5. Explore the provision of crisis stabilization services to ensure best practice standards are being
achieved and quality care is being provided
Established 12/26/01; Revised 10/27/03, 11/23/2004, 10/24/05, 12/20/07, 12/13/10, 10/8/12, 10/21/2013, 4/1/15
4
II. QA/QI Executive Committee Roster
Members
Member
Agency/Position
Pam Erdman, MS, OTR Wraparound QA/QI Director, Chair
Auriel Ackerman, MA DHHS, Behavioral Health Division -
Community Services Branch, QA Specialist
Wes Albinger, MS Wraparound Provider Network Coordinator
Kenyatta Bryant, MS Wraparound Fiscal Coordinator
Heidi Ciske-Schmidt, MSW Wraparound QA/QI Administrative Coordinator
Cathy Duster State of Wisconsin – DHS, Medicaid Contract Contact
Pam Fleider, RN, MA Alternatives in Psychological Consultation,
Provider Network Representative
Steve Gilbertson Wraparound Clinical Coordinator, Licensed
Psychologist
Melissa Graham, MSW, CSW DHHS, Delinquency & Court Services Division -
Section Manager
Margaret Jefferson Families United of Milwaukee, Inc., Director
Bruce Kamradt, MSW Wraparound Program Director
Stacy Kozel, MSW, LCSW Wraparound REACH/FISS Program Coordinator
Diane Krager, OTR DHHS, Contract Administration - QA Coordinator
Brian McBride Wraparound - O’YEAH Program Coordinator
Mary Jo Meyers, MS Wraparound Deputy Director
De Shell Parker, MS, MSW, CAPSW DHHS, Delinquency & Court Services Division
Administrative Coordinator - Quality Assurance
Makalah Wagner State of Wisconsin - DHS
Wraparound Family Representatives: Parents and caregivers are involved in every meeting.
Regular attendees include: Joyce D., Dorothy N., Marion G., Shirl B., Michael R., Gwendolyn G.
Wraparound Youth Representatives: An open invitation is extended to any youth that would
like to attend.
Guests and/or periodic attendees are also welcome!
5
III. QA Program Description and QA Components
In compliance with 42 CFR 434.34, and 42CFR Part 400, Medicaid Managed
Care Requirements Subpart E:
1. Program Description/Responsible Parties: Wraparound Milwaukee is a Special Managed Care Organization serving youth and young adults
with complex emotional, behavioral, mental health needs, and their families. Wraparound strives
to provide quality services that have a positive impact on the youth/ young adult’s mental health
functioning, school and work performance, sense of community, social responsibility and living
environment, while maintaining the youth/young adult in the least restrictive, community-based
setting possible, containing costs and maintaining expected standards. Wraparound Milwaukee
promotes systemic change, develops policies and procedures to ensure quality care and service
delivery, promotes collaboration amongst the Child & Family Team, school, community,
Juvenile Justice and Bureau of Milwaukee Child Welfare and utilizes a diversified
Administrative and Consultative team that assesses services/service delivery and provides
training in Wraparound philosophy and processes, cultural competency/intelligence, trauma
informed care, motivational interviewing and needs assessment.
A structured Intake process is utilized when enrolling youth/young adults into Wraparound and
when Provider applications are being processed to authorize agencies and individual providers to
provide services in the Wraparound Provider Network. A Care Coordinator/Transition
Coordinator is assigned to each youth/young adult. The Care Coordinator/ Transition
Coordinator organizes and coordinates care for the youth/young adults.
The primary person responsible for the Wraparound Milwaukee program as a whole is the
Director of Wraparound Milwaukee. One component of the Wraparound Program is the QA/QI
Department. This department is responsible for ensuring that quality care and best practice
standards and measures are being implemented and monitored on an ongoing basis. The QA/QI
Director is responsible for all day-to-day QA/QI Departmental operations, supervises 2.0 QA
Staff, chairs the Executive QA/QI Committee and provides technical assistance to the Department
of Health and Human Services (DHHS) Centralized QA Group. (See Attachment # 1 - QA/QI
Director Position Description). The QA/QI Director is supervised by the Director of Wraparound.
The Wraparound Milwaukee Management Team is the governing body that provides oversight to
the Wraparound Milwaukee QA/QI Executive Committee. Wraparound Milwaukee Management,
Providers, Consultants, Advocates, Parents, Youth Representatives and Community
Representatives either serve on and/or support the work of the QA/QI Executive Committee and
the QA/QI Department.
QA/QI data, studies and the QA/QI Annual Report are available to and/or are shared with the
Milwaukee County Director of DHHS and the Milwaukee County Mental Health Board.
6
2. QA/QI Related Committees/Groups: The 2015 QA/QI Components Chart (Attachment # 2) outlines the QA/QI-related
Committees/Groups reporting avenues and feedback loops. Further defined are some of the
components referenced in the chart.
Executive QA/QI Committee is in part, an extension of the Wraparound Milwaukee
Management Team. It includes a variety of Human Service and Mental Health Professionals,
along with parent, caregiver and advocate representation. The Committee meets a minimum of 4
times per year to review data, develop studies, implement activities, review and approve reports,
etc. The activities of the QA/QI Committee are documented in the form of minutes.
Critical Incident Review Panel reviews identified Critical Incident Reports. The Panel assures
that adequate, appropriate follow-up occurs regarding the critical incident and that a plan of
action/change was implemented as recommended. This group meets as needed.
Provider Network Enrollment Committee is a group of administrative representatives
associated with the programs that utilize the Provider Network in addition to Wraparound
affiliated staff. The group assesses service needs, reviews vendor eligibility and
qualifications/credentials, reviews vendor history, recommends other avenues for applicants to
pursue and explores approaches to preserve fidelity of wraparound principles throughout the
Network. The group meets as needed to review applicant requirements and/or to discuss where
there may have been adverse provider activity (i.e. - a complaint) to question as to if the provider
meets the service requirements.
Wraparound Milwaukee Credentialing Committee is a standing subcommittee of the
Provider Network Enrollment Committee and is responsible for administering the Wraparound
Milwaukee Provider Network Credentialing Plan on behalf of Wraparound. The Committee is
responsible for review and approval of clinicians providing mental health/substance abuse
services who meet minimum participation criteria with adverse activity. The Committee meets
on an as-needed basis.
Provider Performance Measures Committee - In 2012, Wraparound Milwaukee launched a
Performance Measures initiative, which formalizes a process for reporting, tracking, and
communicating key measures of Provider performance for Network services. These performance
measures are reported as part of Synthesis resource guide information, and are distributed as reports
to key audiences. Provider Performance Reports are also distributed to Provider agencies for quality
improvement and quality management purposes. Five key domains of performance have been
identified, taking a pragmatic approach which considers reliability and validity, but also leveraging
existing data and systems as much as possible. For most services, one or several existing or newly
developed Performance Measures are reported in each of the following domains: Provider Status
Events, Audit Results, Consumer Satisfaction, Fidelity and Service Outcomes.
Centralized Quality Assurance Committee is a group composed of personnel from the DHHS
Contract Administration, Behavioral Health Division, Wraparound Milwaukee, Delinquency and
Court Services Division (DCSD), Disability Services Division (DSD) and the Community
Access to Recovery (CARS) Division which includes the WIser Choice/SAIL programs. The
committee provides a forum to discuss quality of care issues, report on quality and fiscal
7
audit/review outcomes, discuss programmatic policies and procedures and promote consistency
and uniformity within the County as it relates to quality assurance and quality improvement. The
committee meets monthly.
Wraparound Partnership Council is a group composed of community representatives who
provide services/support for children, non-agency/service individuals and current or former
Wraparound caregivers. One of the group’s goals is to access informal community resources and
supports (i.e.: clergy members, area business leaders) and to provide advisory support to the
Wraparound program.
Family/Provider Advisory Committee - The purpose of the Committee is to provide a forum
for open discussions as it relates to Provider Network happenings such as auditing strategies and
priorities, provider sanctions and performance measures, service array, policy and procedure
development, provider/family concerns and suggestions, etc. The Committee meets every other
month.
Other Groups - Sharing of QA/QI information/special reports also takes place at the
Wraparound Milwaukee Management/Supervisory meeting, bi-monthly Provider Forum
Meetings and at any other committee/group meetings in which QA/QI is of relevance. Task/work
groups are assembled as needed to address specific areas of need.
3. Quality Assurance Related Program Components/Processes
Access to Care/Services - Youth/young adults and their families have access to needed
care/services through the Wraparound Milwaukee Provider Network (WPN) and/or established
community, informal and natural supports, as agreed upon by the Child & Family Team. The
QA/QI Executive Committee may provide feedback regarding access issues and concerns. The
provision of services are held to programmatic policy/guidelines, Fee-for-Service Agreement and
County, State and Federal standards.
Consumer Satisfaction – Consumer satisfaction surveys are an integral part of ensuring that
families and youth/young adults are satisfied with both Care Coordination and Provider Network
services. Surveys that address the consumers’ satisfaction levels with their Care Coordination
services are distributed during the first, sixth and twelfth month of enrollment and then yearly
afterwards. At disenrollment, a Family and Youth Progress Report is completed that addresses
both satisfaction and perceived success with having met their identified needs. In addition,
during the 4th and 9th month of enrollment, a Family Provider Satisfaction Survey is distributed.
This survey addresses the consumers’ satisfaction levels with services they are receiving through
the Wraparound Provider Network. The above surveys are mailed and/or provided directly to the
family by the Care Coordinator. Families United of Milwaukee, Wraparound Milwaukee’s family
advocacy and support agency, assists with the mailing and distribution process.
In addition, Out of Home Care Satisfaction Surveys are administered after a youth is discharged
from a Residential Center for Children (RCC) or Group Home. This survey is conducted over
the phone by Wraparound Milwaukee’s family advocacy agency, Families United of Milwaukee,
Inc.
8
All survey results are entered into Wraparound Milwaukee’s IT System, Synthesis, for data
analysis, interpretation and follow-up, as needed.
Provider Performance/Credentials/Measures - Surveys, audits, outcome studies and site visits
are conducted to assure quality performance by our Providers. Providers sign a 2 year Fee-for-
Service Agreement with Wraparound Milwaukee, referencing performance expectations, QA/QI
expectations, credentialing and service delivery requirements, etc. Credential requirements are
strictly monitored and enforced.).
Grievances/Complaints - Youth /young adults and their families have the right to complain or
grieve any service, procedure and/or process that they feel has not met their expectations. A
formal grievance procedure/policy is in place if the complainant is not satisfied with the
resolution/outcome of their complaint. Complaints are entered into Wraparound Milwaukee’s IT
System, Synthesis, and are investigated in a timely fashion. Providers and any other system
partners are also able to initiate a complaint. The complaint/grievance process is subject to
ongoing review as the needs of the youth, families, providers, system partners and stakeholders
change.
Utilization Management/Review - Utilization Management and Review activities are primarily
performed by Wraparound Milwaukee Management staff and the QA/QI Department.
Wraparound Milwaukee engages in a utilization management review process of its service
delivery system through the use of reports generated through the Wraparound Milwaukee’s IT
System, Synthesis, through prior authorization of Out of Home Care/Day Treatment/Independent
Living and Inpatient Hospitalization, monthly “Confirmation of Services Reports” sent to
families for their review, Mobile Urgent Treatment Team desk reviews of crisis stabilization
services and billings, utilization of the Risk Assessment Tool to determine the provider network
agencies that will be reviewed/audited for the following year, and Care Coordination and
Provider Network audits/reviews that address agency, client and fiscal outcomes. All reports are
analyzed by Wraparound Milwaukee staff for variances from desired practices. The analysis is
conducted on a system-wide level and/or on an individual case-by-case basis.
The following reports/data accessed through Wraparound Milwaukee’s IT System, Synthesis,
focus on:
Authorized Services by month by client, program, and vendor
Expenditures for services provided monthly by client, program and vendor
Placement Status Report
Disenrolled Client Report
Cost Comparison Data
Plan of Care (POC)/RCC Pre-Authorization/Day Treatment Pre-Authorization
Community Resources tracking
Crisis Billing
Submitted/Paid Claims
Client demographics, such as age, sex, race, diagnosis, referral, residence, etc.
Monthly enrollment reports
Care Coordination Service/Productivity Hours and Crisis Hours provided monthly and year-
to-date
Reports reflecting compliance standards that have been established for several outcome,
9
process, and structure indicators related to the provision of Care Coordination
A variety of Vendor Reports and Care Coordination Agency Reports
Service reports reflecting utilization trends, non-permissible mix of services and over/under
utilization.
Special reports may also be produced for specific groups of clients, services, vendors, etc.
Practice and Clinical Review/Oversight by Appropriate Health Professionals and Other
Representatives – Clinical, practice review and oversight is conducted through several methods,
which includes:
All client Plans of Care (POC) must be reviewed at least every 90 days. A licensed
psychologist or psychiatrist must provide consultation at this same time interval. Guidance and
direction is provided to the Care Coordinator at this time. A progress note reflecting the
consultation is entered into Synthesis by the both the Care Coordinator and the consulting
psychologist/psychiatrist.
Community Safety and Resource Development Reviews are conducted weekly by a
Wraparound psychologist regarding youth that are identified as “high risk clients” (in accordance
with the High Risk Youth Review - Policy #023).
Medication management, mental health clinical oversight and consultation is provided for
numerous youth/young adults and their families during monthly medication clinic appointments
with Wraparound affiliated psychiatrists.
Wraparound Administrative clinical staff and consultants are available at all times to
provide consultation to Care Coordinators and Child & Family Teams as needed.
Other QA/QI related issues and documentation are addressed/reviewed by a variety of health
professionals associated with the QA/QI Executive Committee process. These individuals hold
the titles of licensed Psychologist, Social Worker, Occupational Therapist and Registered Nurse,
to name a few. Other system related individuals are also involved in various review processes
related to assuring quality care. These system individuals may include: Parent Representatives,
Family Advocates, Fiscal Representatives, Judicial/Court-related Representatives, State
Representatives, Education Representatives, Milwaukee Bureau of Child Welfare
Representatives, Department of Health and Human Services Representatives and other
community partners.
Evaluation Data Collection on Behavioral and Clinical Outcomes - The Wraparound
Milwaukee evaluation process includes the collection of data pertaining to each individual
youth/young adult before and during treatment in the program. Some data is also collected post-
disenrollment. The evaluation and performance data collected and analyzed includes: functional
performance, community behavior, psychiatric symptomatology, living situation/place of
residence, school participation/performance, juvenile justice involvement, family
satisfaction/quality of care, resiliency, recovery, access to services, recidivism and cost
management outcomes.
Wraparound Milwaukee provides interpretation of the data for dissemination to families, Care
Coordination Agencies, Providers, Government Officials, Juvenile Justice Personnel, and/or
other stakeholders.
10
Wraparound Milwaukee makes programmatic changes through the interpretation of the data
collected, i.e. - Continuous Quality Improvement (CQI).
Data is reviewed for sources and types of variance from the established standards of Wraparound
Milwaukee and other agencies providing similar services. These variances are reviewed by
Wraparound Milwaukee Management and the Executive QA/QI Committee for appropriate
action.
IV. Quality Improvement
Measures/Indicators/Activities
Wraparound Milwaukee implements changes in its program based on QA/QI
outcomes/processes, data reports/queries, and other data source findings. Surveys, quality and
fiscal audits/reviews, interviewing, utilization review, and submission of mandatory data are
some of the means of collecting information. From this information, reports, data and processes
are reviewed and changes are implemented when warranted. The effectiveness of the
implemented action is then monitored and adjusted until an acceptable outcome is achieved.
Reports/studies/audits/reviews reflect the work of the QA/QI Department in collaboration with
other Wraparound-associated Departments, affiliated Agencies, Community/Family
Representatives, Milwaukee County DHHS Centralized Quality Assurance personnel and other
stakeholders.
The objective of the QI Plan and Timeline is to provide a framework to monitor and evaluate the
established indicators, and the quality and appropriateness of youth and family care. Through the
information produced from this monitoring, Wraparound Milwaukee will pursue opportunities to
improve care and resolve identified concerns. The QA/QI’s efforts are client and family driven
and mental health, system and cost-outcome oriented. Efforts rely upon data generated by
Wraparound Milwaukee and its affiliates, as well as that developed by outside sources. The
QA/QI Timeline for 2015 is attached (see Attachment #3). The Timeline identifies QA/QI tasks,
responsibilities and implementation dates.
Referenced in the following table are Fidelity and Process Indicators that are monitored and
analyzed in an effort to ensure quality outcomes and improve processes.
FIDELITY MEASURES Indicator Monitor Frequency/Measurement
1. Functioning – Level of clinical
functioning is monitored through the
administration of the Achenbach
Evaluation Tools, the Child Behavior
Checklist (CBCL) and the Youth Self
Report (YSR)
--------------------------------------- The Child and Adolescent Needs and
Strengths (CANS) assessment tool is
being administered for those youth in
foster care.
Care Coordinator/Transition
Coordinator, Wraparound
Research Consultant, Wraparound
IT System
Wraparound is currently
administering the Achenbach tools
on all Wraparound enrollees at the
time of enrollment, 6 months,
annually and at disenrollment.
---------------------------------------------
The CANS is being administered
upon the youth entering foster care
and then every 6 months thereafter
as long as the youth remains in the
out of home placement.
11
The O’YEAH Program, serving young
adults ages 16.5 – 24 years old,
measures real-life outcomes for people
in recovery from mental health and
substance abuse disorders in several
life domain areas. The Data Appraisal
Tool (DAT), a tool developed by the
O’YEAH Team based off the National
Outcomes Measures (NOMS) tool, is
being utilized.
-------------------------------------------
The O’YEAH program is also
administering the Engagement and
Planning Survey which is a fidelity
measure that assesses the level of
engagement the young adult is having
with the Transition Coordinator in
addition to the level of independence
and planning that is occurring as
evidenced in the Futures Plan.
The DATs is administered at the time
of enrollment, every 180 days
thereafter and at disenrollment.
------------------------------------------
The Engagement and Planning
Survey is administered at 6 months
and at 6 month intervals thereafter.
2. Living Environment - While
enrolled in Wraparound, the
percentage of days that a youth spends
in a restrictive setting will decrease.
Care Coordinator, Wraparound IT
system
This will be measured by comparing
the percentage of days in a restrictive
setting (Inpatient, RCC, Detention,
Group Home and Shelter Facility) to
the percentage of days in a
community-based setting (home,
foster care, living with a relative or
independent living). The time
frames for the collection of this data
will correspond to the Care
Coordination Agency Performance
Report time guidelines (2x’s/year).
3. Community Safety - Criminal
charges and adjudications will
decrease while the youth is enrolled in
Wraparound.
Care Coordination juvenile justice
data entry, Wraparound IT System
This will be measured through
recidivism research in which formal
charges are compiled and evaluated
during enrollment
4. School - Youth school attendance
will improve during their time in
Wraparound.
Care Coordinators, Wraparound
IT System
This will be measured by comparing
the total number of school days
possible to the total number of
school days attended at monthly
intervals during enrollment. This
data is tracked on the POC.
5. Family Satisfaction: Care
Coordinator - Caregivers and
youth/young adults must be satisfied
with Wraparound Milwaukee Care
Coordination services.
Wraparound Milwaukee QA/QI
Department, Families United of
Milwaukee, Inc., Wraparound IT
System
Wraparound Milwaukee, in
collaboration with Families United of
Milwaukee, Inc., will distribute
Family Satisfaction Surveys to every
youth/family enrolled in
Wraparound. These surveys are
mailed at 1 month, 6 months, 1 year,
2 years, etc. of enrollment and at
disenrollment. An average score of
4.0 out of a rating scale of 1-5 is the
established threshold. Survey data is
compiled and reported 2x’s per year
on the Care Coordination Agency
Performance Report.
12
6. Family Satisfaction: Provider –
Caregivers and youth/young adults
must be satisfied with Wraparound
Milwaukee and its Provider Network
services.
Wraparound Milwaukee QA/QI
Department, Families United of
Milwaukee, Inc., Wraparound IT
System
Wraparound Milwaukee in
collaboration with Families United of
Milwaukee, Inc. will distribute
Family Provider Satisfaction Surveys
to every youth/family enrolled in
Wraparound Milwaukee. These
surveys are mailed during the 4th and
9th months of enrollment. An
average score of 4.0 out of a rating
scale of 1-5 is the established
threshold. Survey data is compiled
on an ongoing basis and reported in
the QA/QI Annual Report. Survey
results are forwarded to
Agency/Provider. The
Agencies/Providers are asked to
respond to surveys that reflect
negative comments.
7. Care Coordinator Productivity/
Service Hour Time - time spent per
month, per family providing services
to the youth/family or engaging in
service, related communication,
collaboration with the Child & Family
Team members
Care Coordinator, Wraparound IT
System Fourteen (14) hours (8 hours for
REACH) per month per family. (This
includes 8 hours of crisis billable
time for Wraparound and 5 hours for
REACH). Data is reported 2x’s per
year on the Care Coordination
Agency Performance Report.
8. Face to Face Contacts Care Coordinator, Wraparound IT
System
Wraparound Care Coordinators must
average one face-to-face contact
(with the youth and parent or other
primary caregiver) per week.
REACH Care Coordinators must
average one face-to-face contact
(with the youth and parent or other
primary caregiver) every two weeks.
Data is reported 2x’s per year on the
Care Coordination Agency
Performance Report.
9. Child & Family Team (CFT)
Meeting and Plan of Care Meetings
Care Coordinator and Child &
Family Team, Wraparound IT
System, annual Progress Note
Audit/Review conducted by the
Wraparound QA/QI Department
At least one CFT or POC meeting
per family must be held monthly.
This must be appropriately
documented. This is reported 2x per
year on the Care Coordination
Agency Performance Report.
10. Percentage of Team Meetings
with Informal Support Attendance
Care Coordinator and Child &
Family Team, Wraparound IT
System
At least one Informal Support on the
Child & Family Team must be in
attendance at the Team Meeting 50%
of the time.
11. Number of Disenrollments
Evidencing Progress Family/Youth/Young adult, Care
Coordinator, Wraparound IT
System, Wraparound
Administration
“Progress” will be achieved if the
cumulative outcome percentage
scores in the following areas have
met the established “progress”
threshold of 75 or greater.
Parental and youth perception of
change as evidenced by the
outcome on the Disenrollment
Progress Report.
Needs being met as identified in
13
the Needs Ranking Scoring process
within the final POC.
Living status upon disenrollment
12. Formal/Informal Supports –
Informal supports are described as
community resources serving on the
Child & Family Team in usually a non-
paid role. These individuals may be
family members (other than the youth
and parent), friends, neighbors, faith-
based supports and kinship providers.
Care Coordinator, Wraparound IT
System: based off of data
referenced on the Child & Family
Team member list and those
individuals utilized within the
strategies of the POC Domain/
Need areas.
It is expected that on average, 100%
of all Child & Family Teams should
be utilizing natural/informal
supports. At least 50% of the
supports on those Teams should be
informal. Data is reported 2x’s per
year on the Care Coordination
Agency Performance Report.
13. Family Activities – Every Care
Coordination agency is expected to
conduct an activity that engages
Wraparound youth and their families.
Care Coordination agency,
Wraparound QA/QI Department
1x per month
PROCESS MEASURES Indicator Monitor Frequency/Measurement
1. Plan of Care – POC’s must
reference all required and applicable
life domains, will include a 24 hr.
Crisis Plan, will identify child/family
strengths and needs, will identify
formal, informal, natural, and
community supports and will
acknowledge that the Child & Family
Team was in attendance at the meeting
and participated in the creation and/or
revision of the POC. POC Audits are
conducted by the Wraparound QA/QI
Department
Quality audits/reviews of the POC
will be conducted annually by the
Wraparound QA/QI Department
as specified on the attached QA/QI
Timeline. The Wraparound IT
System and the Care Coordinator
will also monitor compliance. A
licensed psychologist or
psychiatrist will provide
consultation related to the POC
and identified needs at least 1x
every 90 days.
The initial POC must be completed
within 30 days of enrollment. POC’s
must then be updated at least every
90 days. POC quality audit/review
results should evidence at least a
90% overall agency compliance
score. Timeliness of the plans is
reported 2x’s per year on the Care
Coordination Agency Performance
Report. POC Audit results are
reported 1x per year on the Care
Coordination Agency Performance
Report.
2. Wraparound Client Record –
Wraparound client records must be
organized and contain all required
documentation, as per the Client Chart
Format policy and procedure.
Client Chart Reviews will be
conducted by the Wraparound
QA/QI Department as needed. The
Care Coordinator will also
monitor compliance.
Client Record Reviews are
conducted as deemed necessary by
Wraparound Administration and
should evidence at least a 90%
overall agency compliance score.
3. Wraparound Progress Notes –
Wraparound Progress Notes in the
client records must be written in a
manner that abides by the established
standards/policy.
Audits/reviews of the Progress
Notes will be conducted by the
Wraparound QA/QI Department
as specified on the attached QA/QI
Timeline. The Wraparound IT
System and the Care Coordinator
will also monitor compliance.
Timeliness of the Progress Notes is
reported 2x’s per year on the Care
Coordination Agency Performance
Report. A Progress Note Audit is
conducted and reported 1x per year
on the Care Coordination Agency
Performance Report. The progress
note quality audit/review should
evidence at least a 90% overall
agency compliance score.
4. Service Authorization Request
(SARs) – Projected costs and
utilization of services is documented
every 30 days.
Care Coordinator, Wraparound
Fiscal Department, IT system and
QA/QI Department track costs and
utilization
SARs are completed monthly by the
Care Coordinator and must be
entered by the 23rd day of the month
for the subsequent month’s services.
This is done on-line through the
Wraparound IT System. Projected
costs and utilization of services are
captured on the SAR.
14
5. Submission of Evaluation Tools –
Submission of the Child Behavior
Checklist (CBCL) and the Youth Self
Report (YSR)
The family and youth primarily
complete the tool, and the Care
Coordinator provides guidance as
needed. Evaluation tools are
required on every enrollee. Data is
entered by Care Coordination
Agency Support Staff and reports
are generated by the Wraparound
IT system
Evaluation Tools must be completed
by the caregiver/youth and submitted
to Wraparound by the Care
Coordinator at intake, 6 months,
annually and at disenrollment.
Submission compliance is reported
2x’s per year on the Care
Coordination Agency Performance
Report.
6. RCC/Group Home/Foster
Care/Day Treatment Pre-
Authorization and Re-Authorization
Process – All RCC, Group Home,
Foster Care placements and Day
Treatments must be pre-authorized/re-
authorized.
Designated Wraparound
Management and Contract Staff,
Care Coordination Staff and
Wraparound IT system
RCC/Group Homes –
Documentation must be submitted
into Wraparound for pre-
authorization. Renewals or re-
authorizations of a RCC/Group
Home placement must be submitted
14 days prior to the expiration date
of the current authorization.
Foster Care – Documentation must
be submitted into Wraparound for
pre-authorization. Renewals or re-
authorizations of a Foster Home
placement must be submitted 14 days
prior to the expiration date of the
current authorization.
Day Treatment – Documentation
must be submitted into Wraparound
for pre-authorization. Renewals or
re-authorizations of a Day Treatment
placement must be submitted 14 days
prior to the expiration date of the
current authorization.
7. Timely Submission of Legal
Change of Placements & Temporary
Change of Placement Information
Written notice of a change in a
youth’s living situation must be
completed by the Care
Coordinator. Wraparound Court
Liaisons approve and enter the
placement changes into
Wraparound IT system
Legal and Temporary Change of
Placements must be submitted 14
days prior to the move.
This data is reported 2x’s per year on
the Care Coordination Agency
Performance Report.
8. Submission of Facilitator
Reviews – The Facilitator Reviews
provide written Supervisory feedback
to the Care Coordinator on the Care
Coordinator’s fidelity to the Child &
Family Team and POC meeting
process.
Care Coordination agencies
submit the Facilitator Reviews to
Wraparound. The Wraparound
QA/QI Department tracks the
submission. Wraparound
Management and Contract staff
review the Facilitator Reviews and
provide feedback as needed.
Three Facilitator Reviews are
completed per month. Compliance is
reported 2x’s per year on the Care
Coordination Agency Performance
Report.
QA/QI OVERSIGHT ACTIVITIES
Indicator Monitor Frequency/Measurement
1. Performance Improvement
Project (PIP) – A PIP is a mandated
State Medicaid Contract report/study
that must address either a clinical or
Wraparound QA/QI Department,
Wraparound Research Consultant
and the State and/or the State’s
contracted monitoring agency
One PIP will be submitted to the
State by March 1st for the previous
year.
15
administrative topic that the program
wishes to further explore in an effort to
promote quality improvement.
2. Wraparound Provider Network
(WPN) Provider Credentials –
Credential requirements are
established and maintained on
Agencies/Providers servicing the youth
and families enrolled in the program
based on the service being provided.
Agencies/Providers must be licensed
or certified as indicated per the State
statutes and/or Licensing and
Regulatory bodies, where appropriate,
and/or meet Wraparound service–
related requirements. Mental
health/AODA providers are
credentialed utilizing NCQA
compliance standards.
Provider Agencies, Wraparound
Milwaukee. Credential
requirements are reviewed in
conjunction with vendor requests
to add direct service providers.
This information is kept in the
Wraparound IT System. An
application process and specific
outlined requirements must be met
prior to an Agency/Provider being
authorized to enter the Network.
The Provider Network Enrollment
Committee reviews and approves
all Provider applications as
outlined or identified in the
Provider Network Credentialing
and Recredentialing Plan (see
Attachment # 4). Mental health/
AODA applicants that meet
minimum participation with
adverse activity must be approved
through the Wraparound
Milwaukee Credentialing
Committee.
Updates of Agency/Provider
certifications/licenses, etc. occurs on
an ongoing basis.
Three to four credentialing checks
are initially run on clinical/other
providers entering the network:
National Provider Identifier
Registry (NPI)
OIG – Federal Office of Inspector
General (run on all providers)
WI Dept. of Safety and
Professional Services (DSPS)
American Medical Association
(AMA) – MD’s only
3. Provider Performance
Measures Initiative – In 2012,
Wraparound Milwaukee launched a
Performance Measures Initiative,
which formalizes a process for
reporting, tracking, and
communicating key measures of
Provider performance for Network
services. Provider Performance
Reports are distributed to Provider
agencies for quality improvement and
quality management purposes. Five
key domains of performance have been
identified, taking a pragmatic approach
which considers reliability and
validity, but also leveraging existing
data and systems as much as possible.
Provider Agencies, Wraparound
Milwaukee
Audit
Performance being measured:
Agency compliance with service
guidelines and other requirements
Performance Measure: Overall level
of compliance on fiscal and/or
quality reviews
Satisfaction
Performance being measured:
Enrollee and family satisfaction with
services
Performance Measure: Satisfaction
survey results
Complaints
Number of substantiated complaints
and severity level of the complaints
will be noted.
4. Certification and Re-
certification Training/In-services/
Workshops – Care Coordinators
receive approx. 94 hours of initial
training through a curriculum
developed by Wraparound Milwaukee.
Care Coordinators are then certified by
Wraparound Milwaukee to provide
Care Coordination services. Care
Coordinators and Supervisors that
have been in the field one or more
years have to also attend annual re-
Wraparound Administration and
the Provider Network maintain
records of attendees. Attendance
records are then forwarded to
Wraparound QA/QI Department
for data compilation.
Care Coordinators must complete the
Care Coordination Certification
process within six months of hire.
Recertification occurs annually and
is mandatory.
Attendance is taken at all
trainings/in-services/workshops.
Records of all Care Coordinators and
individuals that participate in
trainings/in-services/workshops are
kept on file. Evaluations are
distributed at the end of all
trainings/in-services/workshops
16
certification training, totaling 16 hours.
Re-certification training topics vary
according to the needs of the group at
that time. Care Coordinators,
Wraparound Administrators,
Providers, Caregivers and Community
Representatives also attend regular
meetings, in-services, conferences,
workshops, etc., throughout the year.
summoning feedback from the
participants. Feedback is then
utilized to implement change.
Attendance compliance with
mandatory in-services/trainings is
reported 2x’s per year on the Care
Coordination Agency Performance
Report. Care Coordination in-
services are offered at a minimum of
2 hours per month. Additional
trainings/in-services are offered
throughout the year as scheduled.
5. Provider Network
Audits/Reviews - In collaboration
with the Milwaukee County
Department of Health and Human
Services – Contract
Administration, an annual
audit/review schedule is
determined through the use of the
Risk Assessment Tool.
DHHS Contract Administration,
Wraparound Milwaukee
Administration
Determined by the Centralized QA
Committee in accordance with
auditing protocols that have been
established.
OTHER REVIEW ACTIVITIES Indicator Monitor Frequency/Measurement
1. Number of Substantiated
Complaints Wraparound QA/QI Department,
Wraparound IT System
Outcomes regarding Care
Coordination complaints are reported
2x’s per year on the Care
Coordination Agency Performance
Report. Complaint outcomes
regarding Provider Network agencies
are reported as needed and utilized
when making considerations as to
whom to audit for the year.
2. Number of Care Coordinator
Transfers – The number of times a
youth is transferred to a new Care
Coordinator, either within their own
agency or between Care Coordination
agencies, is monitored.
Wraparound QA/QI Department,
Wraparound IT System
Outcomes are reported 2x’s per year
on the Care Coordination Agency
Performance Report.
3. Costs – The cost of providing
services for youth/young adults and
their families in Wraparound
Milwaukee will be less than the costs
for youth in alternative children’s
mental health and other systems.
Wraparound IT System, system
partner data This will be measured by collecting
and pricing out all Wraparound
services and supports provided to the
youth and the family compared to
alternative children’s mental health
and other systems of care (i.e.-
Corrections, RCC Placements,
Inpatient).
4. Number of Staff Departures –
The number of Care Coordinator staff
that leave an agency will be monitored.
Wraparound QA/QI Department,
Wraparound IT System
This will be reported every 6 months
on the Care Coordination Agency
Performance Report.
17
V. Acronym Key
H:\CATC\QAShare\ERDMAN/2015QA-QIWorkplan
1. AODA Alcohol and Other Drug Abuse
2. AMA American Medical Association
3. CANS Child & Adolescent Needs and Strength Assessment
4. CARS Community Access to Recovery Services Division
5. CBCL Child Behavior Checklist
6. CFR Code of Federal Regulations
7. CFT Child & Family Team
8. CQI Continuous Quality Improvement
9. DAT Data Appraisal Tool
10. DHHS Milwaukee County - Department of Health and Human Services
11. DHS State of WI - Department of Health Services
12. DSD Disability Services Division
13. DSPS WI. Department of Safety and Professional Services
14. IT Information Technology
15. NPI National Provider Identifier Registry
16. NCQA National Committee for Quality Assurance
17. NOMs National Outcomes Measure(s)
18. O’YEAH Older Youth & Emerging Adult Heroes
19. PIP Performance Improvement Project
20. POC Plan of Care
21. QA Quality Assurance
22. QI Quality Improvement
23. REACH Reaching, Engaging and Assisting Children (and Families)
24. RCC Residential Center for Children
25. SARs Service Authorization Request(s)
26. SAIL Supported Assistance for Independent Living
27. SAMHSA Substance Abuse and Mental Health Services Administration
28. WIser
Choice
Wisconsin Supports Everyone’s Recovery Choice
29. WPN Wraparound Provider Network
30. YSR Youth Self-Report
18
WRAPAROUND MILWAUKEE
Phone: (414) 257-7611 9201 Watertown Plank Rd., Milw., WI 53226 Fax: (414) 257-7575
Position: Quality Assurance/Quality Improvement Director
Qualifications: Individual who possesses a Bachelors Degree and/or preferably a Master’s
Degree in a Health Services Related field. This individual should have five plus
years experience in working with emotionally/behaviorally challenged
families/children and mental health systems of care. At minimum, one years
experience in research/ statistics, i.e. – data collection, data analysis, report
writing, etc. Supervisory/management experience of three plus years is
preferable.
Knowledge/ Skills/Abilities: Knowledge of quality standards, terminology, practices, and trends related to the
health and human services and mental/behavioral health arena. Knowledge of
Federal, State and County rules and regulations and funding sources related to
Wraparound and other human services programs. Knowledge of County policies
and procedures related to program/service descriptions, requirements, billing and
payment practices. Ability to prioritize, organize, direct, delegate and coordinate
QA activities. Ability to evaluate/audit client and provider file
documentation/records in an objective manner. Ability to chair meetings and lead
discussions. Ability to prepare, analyze and present documents/reports. Basic
statistical/analytical skills necessary. Ability to make sound programmatic and
departmental decisions/recommendations based off of knowledge acquired through
daily work tasks, report/audit findings and analysis of data. Critical thinking skills
required. Strong communication, interpersonal and organizational skills required.
Ability to work under pressure and within time frames. Ability to work
independently. Ability to work harmoniously and effectively with all levels of
County and State personnel as well as Consumers, Providers, other system
stakeholders, the general public and colleagues. Proficiency in software
applications, electronic mail and internet-based IT systems.
Duties: 1. Coordinates and is responsible for all aspects of the Wraparound QA/QI
program: development, implementation, training, supervision of staff,
monitoring/coaching of co-employees and stakeholders to facilitate change.
2. Establishes strategic plans and policies and procedures for the system of
care to ensure that the quality of the program will meet or exceed internal
and external client and stakeholder standards and expectations.
3. Collects, organizes, analyzes, monitors and distributes
information/data/reports related to the functions of the quality
assurance/improvement program/department (Annual QA/QI Report),
utilization review, identified outcome measures (Care Coordination Agency
Performance Reports), complaints/grievances (Complaint/Grievance
Attachment # 1
19
database maintenance), family/provider satisfaction (Family Survey
database maintenance and Survey analysis and reports), programmatic
auditing and State-Medicaid Contract requirements (general Contract
requirements and Annual Performance Improvement Project).
4. Communicates information on the latest standards, procedures and
requirements related to the mental/behavioral health service delivery
system/Contract requirements.
5. Coordinates with the Wraparound Provider Network and other fee-for
service programs to establish, develop and maintain standards related to
Provider service descriptions, policies, audit indicators/measures, Provider
Site Inspection process, issues related to Provider credentials/criminal
background checks, the Provider Application and Fee-for-Service
Agreement.
6. Chairs the Wraparound Milwaukee QA/QI Executive Committee.
7. Participates in/contributes to the DHHS/Centralized QA monthly meetings.
Collaborates with/consults with Centralized QA staff with regards to all
Provider Network QA related issues/concerns/programmatic
development/establishment of relevant audit indicators. Participates in the
Provider review/auditing process (as available).
8. Partners with Families United of Milwaukee, Inc. (Wraparound
Milwaukee’s family advocacy and support agency) with regards to the
implementation, organization and distribution of the Family Care
Coordination Satisfaction Surveys and the Family Provider Satisfaction
Surveys. Provides supervision for “Family Partner/QA Liaison” employees
during the hours they contribute to the Wraparound QA functions.
9. Provides QA related technical assistance to Providers/Care Coordination
Agencies/other system stakeholders as needed.
10. Provides technical assistance to other national/international sites that have
been awarded “wraparound” type grants, and/or other interested parties.
11. Chairs subcommittees related to QA/QI issues.
12. Attends all relevant/required system meetings/in-services, etc.
13. Attends conferences/workshops related to QA/QI issues and health-field
issues assuring the accumulation of necessary continuing education
requirements to maintain personal licensure.
14. Provides coverage for management personnel/programs as needed.
15. Other duties as assigned.
DHHS Centralized QA Committee
(Review/Audit TeamContract Administration)
•Conducts WPN reviews/ audits•Provides summary reports and recommendations to agencies that were reviewed/audited•Serves as a feedback mechanism for continuous QA and QI as it relates to county-wide standards/ practices•Assists with revisions/ updates of Fee-for-Service Agreement, centralized policies•Identifies short-term QA Subcommittee tasks
Care Coordination Agencies
•Provides Care Coordination (CC) services to Wraparound families•Attends bi-monthly management meetings, monthly CC in-services, bi-monthly provider meetings and other identified mandated trainings•Collaborates with Wraparound in establishing QA/QI and program standards for CC services•Engage in submission of data that is used to measure CC agency performance on a semi-annual basis
Families United of Milwaukee, Inc.
(Family Satisfaction)
•Provides advocacy and support for all Wraparound families and youth•Provides feedback to Wraparound Management regarding family satisfaction with Wraparound services and identifies QA/QI issues for Wraparound to address•Partners with QA/QI Department with regards to the distribution of the Family Satisfaction Surveys and other QA/QI activities
Synthesis -Wraparound's IT System
•Addresses cost of care and service utilization•Addresses outliers and trends in service delivery system•Produces reports to track/ measure outcomes and best practice expectations•Provides mechanism for providers to invoice for services•Wraparound's electronic client Medical Record -maintains all client information (i.e.: demographic info, Plan of
Wraparound Provider Network (WPN)
•Provides a variety of mental health, behavioral and social services to support the Wraparound system of care•Holds in bi-monthly Provider Forum meetings to share information and ideas, provide Network /Wraparound Milwaukee updates•Establishes standards and policies for the various types of services offered•Participates, as requested, in QA/QI activities•Conducts New Provider Orientation and various trainings throughout the year•Collaborates with DHHS and Contract Administration•Implements Fee-for-Service Agreement and other policies and expectations
Mobile Urgent Treatment Team (MUTT)
•Provides community mental health crisis services to Milwaukee County youth and families•Engages in quality reviews of crisis stabilization services and group home services•Gatekeeper to inpatient psychiatric services•Provides mental health assessments/evaluations as requested/needed
Partnership Council•Functions as an advisory group, composed of parents/caregivers and community partners involved in service delivery, which supports systems for youth and their families•Addresses/Provides feedback regarding QA/QI issues and concerns•Meets quarterly
2015Wraparound Milwaukee
Quality Assurance / Quality Improvement
Department
QA/QI Executive Committee
•Utilizes feedback to address and monitor QA/QI concerns and implement change as needed•Reviews and approve QA Annual Report and QA/QI Annual Workplan•Reports to the Management Team, Wraparound Provider Network (WPN) Forum and Partnership Council, as needed, regarding QA/QI concerns and information•Provides feedback and guidance regarding QA/QI related studies, projects, policies, etc. •Meets 4 - 5x’s per year
Wraparound Management Team
•Establishes and implements the Wraparound System of Care, policies and procedures and performance standards and monitors for program integrity/fidelity•Collaborates with families, providers, agencies, the State, community partners, and system of care partners•Provides resource team assistance to families/ providers/CC's as needed•Engages in pre-authorization of inpatient, residential, group home, day treatment services and independent living•Provides oversight to the QA/QI Executive Committee•Meets 2x's month
Critical Incident Review Panel•Reviews identified critical incidents•Approves implementation of corrective action plan that must be completed by the individual/agency in question•Meet on an as needed basis
Family/Provider Advisory Committee
•Provides guidance regarding provider monitoring, compliance and policy expectations•Address service needs•Open discussion regarding family/ provider issues
Provider PerformanceMeasures Committee
•Identifies provider performance measures/indicators•Implements, tracks and reports on outcomes
Provider Network Enrollment Committee
•Reviews and approves new provider applications•Accesses service needs•Reviews vendor eligibility•Reviews vendor qualifications/ credentials•Reviews vendor history•Meets as needed
Wraparound Credentialing Committee•Subcommittee of the Enrollment Committee•Reviews and provides approval of MH/AODA applicants who meet minimum participation criteria with adverse activity•Meets on an as needed basis
Wraparound Evaluation Component
•Collect, analyze and report on outcome data received from Wraparound families, CCs, Courts, school system and Juvenile Justice System
H/CATC/QAshared/Erdman/QAQIFlowchart2015 ATTACHMENT #2
WRAPAROUND MILWAUKEE
2015-2016 Quality Assurance/Quality Improvement Timeline
ATTACHMENT # 3
2016
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan
2014 QA/QI
Annual Report
1st(to the state)
2015 QA/QI Program
Description and Workplan
1st(to the state)
2015-2016 QA/QI
Timeline
1st(to the state)
POC Audits/Reviews
Chart Audits/Reviews
Progress Note
Audits/Reviews
Provider Philosophy /
Other Training
Family/Provider Orientations
Outcome Indicator
Data for 2014
15th(to the state)
Grievance Summary Report
for 2014 & 2015
31st(to the state)
30th(to the state)
31st(to the state)
31st(to the state)
31st(to the state)
Coordination of Benefits
Report for 2014
15th(to the state)
Utilization Data Report for
2014 - 2015
1st ( to the
State for the
first 6 months
of previous
year)
1st ( to the
State for the
second 6
months of
previous year)
Data Attestation Form
2015 Performance
Improvement ProjectDue 3/1/16
2014Activity
Send to State with submission of any data
Ongoing throughout the YearFamily: Every 6 weeks Provider: Every 3 months or as needed
Ongoing throughout the Year
April - May
Conducted as determined necessary
Review for 2016
11/01-12/31
Review for 2016 - 2017
11/01-12/31
09/14 - 10/16
H:\CATC\QA Share\ERDMAN\Timeline2015.xlsx 1
WRAPAROUND MILWAUKEE
2015-2016 Quality Assurance/Quality Improvement Timeline
ATTACHMENT # 3
2016
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan
2014Activity
Utilization Review Processes
Family Care Coordination &
Provider Satisfaction
Surveys and Out-of-Home
Care Surveys
Care Coordination Agency
Performance Reports
24th -
27th
24th -
28th
DHHS/WPN Fiscal and
Quality Audits/Reviews
Monthly Coordination of
Benefits Statement
Bi-annual Policy &
Procedure ReviewApril, 2016 July, 2016
November 1st,
2016 -
Distributed to
providers/CC
January 1st,
2017 - Effective
date of revised
policies
Complaint Follow-up &
Monitoring
Critical Incident Follow-up
& Monitoring
Provider Performance
Measures/Outcomes
Crisis Stabilization Audit
Schedule more
traditional
audit again in
May 2018
Will address various QI measures this year/
Crisis Subcommittee being established
Ongoing throughout the Year
Ongoing throughout the YearMailed, Hand Delivered or Conducted Via Phone
Ongoing throughout the Year
Mailed to each Enrollee on a Monthly Basis
Ongoing throughout the Year
Ongoing throughout the Year
Ongoing throughout the Year
H:\CATC\QA Share\ERDMAN\Timeline2015.xlsx 2
- 2 -
TABLE OF CONTENTS
Introduction ..................................................................................................................................... 2
Authority ......................................................................................................................................... 2
Confidentiality ................................................................................................................................ 3
Scope ............................................................................................................................................... 3
Credentialing And Recredentialing................................................................................................. 4
Initial Credentialing And Recredentialing Requirements ............................................................... 4
Practitioner Responsibilities ........................................................................................................... 5
Right To Appeal .............................................................................................................................. 5
Credentialing Process...................................................................................................................... 5
Initial Credentialing Process: .......................................................................................................... 5
Primary Source Verification (Credentialing) .................................................................................. 6
Recredentialing Process .................................................................................................................. 7
Primary Source Verification (Recredentialing) .............................................................................. 7
Office Site Evaluation and Medical Record Documentation .......................................................... 8
2
INTRODUCTION
As a specialized Managed Care Organization (MCO), Wraparound Milwaukee identifies services
that will be available to participants in the Wraparound Milwaukee Program. The services
available to clients each have a specific definition and credentialing requirements for providers of
each service.
Agencies must complete an application process that includes:
a written application which identifies the services that the agency is applying to provide
through the Wraparound Milwaukee Provider Network
identification of specific services that the agency is requesting authorization for each direct
service provider identified in the application to provide
a desk review to assure agency and direct service provider compliance with service specific
education, training and /or credentialing/licensing requirements
compliance with criteria set forth in the Wraparound Milwaukee Fee-for-Service Agreement
in effect at the time that the application is being processed
a site visit (for agencies located in the Metropolitan Milwaukee area) to confirm that the
physical location meets minimum requirements for service(s) to be provided
a review of direct service provider background checks as required by Milwaukee County for
direct service providers identified in the agency application.
Mental health and Alcohol and other Drug Abuse (AODA) practitioners must also complete a
Universal Application and credentialing process that is consistent with the requirements of the
National Committee for Quality Assurance (NCQA).
AUTHORITY It is the responsibility of Wraparound Milwaukee Administration and the Wraparound Milwaukee Provider Network to ensure the appropriate direct services providers, including psychiatrists, psychologist, socials workers, other mental health practitioners and AODA providers are available through the Wraparound Milwaukee Provider Network to assist in meeting the needs of Wraparound Milwaukee participants. This is accomplished through an effective provider application and credentialing process, including ongoing quality monitoring and quality review activities.
Final decision making for credentialing/recredentialing of providers rests with Wraparound
Milwaukee Administration. The Wraparound Milwaukee Provider Network is responsible for
accepting and processing provider applications and implementation of the credentialing/
recredentialing review process. Provider Network staff process agency applications and review
practitioner Universal Applications for completeness and compliance with service specific
credentialing requirements. Practitioner applications with NO adverse activities are presented to
the Medical Director for review and approval. A summary list of applicants with no adverse
activity that are approved is presented to the Credentialing Committee. The Credentialing
Committee is responsible for reviewing practitioner applications with adverse activity license
sanctions, malpractice claims history, pending malpractice claim(s), and/or quality of care issue(s).
Applicants that do not meet the minimum participation criteria are notified in writing by the
Committee Chair Person and/or Provider Network Coordinator, in the case of a physician, the
notice is co-signed by the Medical Director. The Credentialing Committee may utilize an exception process to credential/recredential certain applicants/practitioners given the needs of the Program’s participants/service recipients. The
3
Credentialing Committee will review all criteria based first on the need for the given practitioner’s services within the Network. If a need exists, criteria associated with approval of the applicant is to be examined on an individual basis taking into account the following:
Malpractice claims history: less than two (2) claims in a five (5) year period, or claims judged to be of nuisance value. Exceptions will be granted and reviewed on an individual basis by the Credentialing Committee.
If there is a history of drug or alcohol abuse, the applicant must be involved in a credible program to correct impairment with concurrent and present monitoring by the medical society or state board. There should be no evidence of recidivism.
Office hours: coverage with less than recommended office hours.
Previous sanction activity: the nature of the sanction and remedy.
Office site visit: a plan to remedy any deficiencies with provisional approval until the remedy is achieved.
Additional exceptions will be granted and reviewed on an individual basis by the Credentialing Committee.
The credentialing/recredentialing process shall not discriminate against any practitioner: on the basis of gender, race, religion, age, disability, sexual orientation, ethnic origin or client
population served. on the basis of license or certification provided the practitioner is acting within the scope of
his/her license or certification under applicable State law or other applicable regulations.
CONFIDENTIALITY Wraparound Milwaukee will be responsible for the development, maintenance, and updating of all confidentiality policies and statements associated with agency and direct service provider applications and the practitioner credentialing process. Policies are reviewed biennially or more often as needed. SCOPE All direct service providers requesting to provide services through the Wraparound Milwaukee Provider Network are subject to review with respect to training, education, and licensing requirement set forth by Wraparound Milwaukee and federal and state licensing and regulatory agencies. Wraparound Milwaukee encourages enrollment of a broad range of providers in order to promote participant choice and diversity within the Wraparound Milwaukee Provider Network. Mental Health and AODA practitioners (practicing individually, in a group or in an outpatient client) who provide the following services will be required to submit a Universal Application and complete the Wraparound Milwaukee credentialing review process.
Physician/Psychiatry Services Psychology Services Psychotherapy Services (individual, family and group) AODA Assessment AODA Counseling Services (individual, family and group) In-Home Therapy (Medicaid Lead) Special Therapy (specifically clinicians who are Certified or Licensed by the State of
Wisconsin such as Occupational Therapy)
4
Practitioners who practice exclusively within the inpatient, residential care or group home settings who provide care for Wraparound Milwaukee participants are not required to undergo credentialing by Wraparound Milwaukee provided the practitioner does not bill for services under an outpatient clinic license.
CREDENTIALING AND RECREDENTIALING
Initial Credentialing and Re-credentialing Requirements Each practitioner must complete a Universal Application for participation as a provider in the Wraparound Milwaukee Provider Network that includes the following minimum requirements:
1. Complete, sign and date Wraparound Milwaukee Universal Application.
2. Complete attestation to:
History associated with clinical license and /or clinical privileges, disciplinary
actions and felony convictions.
Absence of current substance abuse.
Mental and physical competence to perform the essential duties of the profession.
The correctness and completeness of the application.
3. Sign and date releases of information.
4. Current unrestricted license or 3000 hour psychotherapy letter (for employment in a state
certified outpatient mental health facility) from the State of Wisconsin
5. For physicians, valid DEA certificate.
6. Current liability insurance in compliance with the 2011 Wraparound Milwaukee Fee-for-
Service Agreement.
7. Proof of highest level of education, and in the case of physicians, proof of graduation from
an accredited medical school or school of osteopathy or proof of completion of an
accredited residency or fellowship program, or proof of board certification; ECFMG
certification or equivalent, if practitioner is a foreign medical graduate (for 3000 hour
practitioners, there will be a $10.00 fee assessed to the affiliate agency to cover the cost
of education verification).
8. Signed Background Information Disclosure form. Note: if there are any affirmative
answers (except Section B, No. 4 and 5), Wraparound Milwaukee will require the affiliate
agency to submit a current (within the last year) background check in order to complete
the credentialing process.
9. Work history since graduation from professional or medical school.
10. Malpractice and/or professional liability actions for the most recent five years
11. History of Medicaid/Medicare sanctions showing practitioner is currently in good
standing.
12. Disclosure of ownership or financial interest in any clinical laboratory, diagnostic testing
center, hospital ambulatory surgery center, home health, or other business dealing with
the provision of ancillary health services, equipment or supplies.
13. Original copy of application submitted to Wraparound Milwaukee. The above elements may be subject to primary source verification, as applicable, according to
information. Notice of the right to correct erroneous information is contained within the:
Wraparound Milwaukee Primary Source Verification Notice (available on the Wraparound
5
Milwaukee Web Site) and the Wraparound Policy “Provider Network Applicant Right Request
Information and Correct Erroneous Information” and within the Universal Application.
Practitioner Responsibilities Along with the criteria for credentialing, all practitioners must agree to meet the following basic responsibilities in order to be a provider for Wraparound Milwaukee Provider Network:
to abide by the Fee-for-Services Agreement in effective at the time of the provision of services to Wraparound Milwaukee participants/service recipients
to abide by the ethical principles of his/her profession, including but not limited to, refraining from fee splitting or other inducements related to client referral; providing care for participants; refraining from delegating the diagnosis or care of participants/service recipients to a practitioner who is not qualified to undertake this responsibility
Wraparound Milwaukee may perform credentialing functions for other Health Plans or Managed
Care entities and may offer practitioners the option to become service providers for these Plans.
The option to “Opt-In” as a provider for a contracting Health Plan will be based on the contracting
Plan’s agreement with Wraparound Milwaukee. Practitioners electing to become a provider for
the contracting Plan agree to abide by the policies and procedures set forth by contracted Health
Plan. Contracted Plans retain the right to enroll any and all practitioners as service providers within
their plan based on their own credentialing criteria.
Right to Appeal Practitioners who are declined enrollment in the Wraparound Milwaukee Provider Network due to quality of care or liability claims issues have the right to appeal the decision in writing within fourteen (14) days of formal notice of denial. All written appeals should include additional supporting documentation in favor of the applicant’s reconsideration for the Wraparound Milwaukee Provider Network. Appeals will be reviewed by the Credentialing Committee at the next regularly scheduled meeting, but not later than 60 days from the receipt of the additional documentation. The applicant will be sent a written response to his/her appeal within 30 days of appeal decision. Practitioners whose enrollment in the Wraparound Milwaukee Provider Network is suspended, reduced, or terminated, shall have the right to appeal the decision in accordance with Wraparound Milwaukee Policies and Procedures and Fee for Service Agreement. Appeals are reviewed by the Credentialing Appeals Committee which consists of the Program Director, Director of the Mobile Urgent Treatment Team (or his designee) and a Child Psychiatrist from the Milwaukee County Behavioral Health Division. The Committee will review the appeal within 45 days of receipt of the formal written (dated and signed) appeal request by the practitioner. The Appeals Committee hears appeals of decisions to deny, suspend, or restrict participation or to terminate the participation status of practitioners. The Appeals Committee may uphold, reject or modify the decision. The Appeals Committee’s recommendation will be based upon the evidence admitted at the hearing. A final decision related to the appeal rests with the Wraparound Milwaukee Program Director. CREDENTIALING PROCESS
Initial Credentialing Process: All mental health and AODA practitioners applying for initial credentialing with Wraparound Milwaukee are required to complete a Universal Application. The application form must be
6
complete, signed and dated by the applicant. Wraparound Milwaukee verifies the information provided by the practitioner in support of their application for Provider Network enrollment through external primary sources within 60 days prior to the credentialing decision. The practitioner is notified promptly of any problems related to the collection and/or verification of these documents and information. It is the sole responsibility of the practitioner/applicant to produce all necessary information and documentation required to conduct a thorough review of the application. Failure to provide the necessary information within sixty (60) days from the initial application date will result in termination of the process. If the practitioner ever seeks to join the network in the future, he/she must begin the process from inception. An application is not considered complete until all necessary information is obtained and verified by Wraparound Milwaukee Provider Network staff. This includes any supplemental information that may be requested to support the application. The medical staff office of the Milwaukee County Behavioral Division obtains an AMA check/profile and National Data Bank Report for all physician applications on behalf of Wraparound Milwaukee. Applicants who meet the minimum participation criteria and who do not meet the established credentialing criteria (no adverse activity) will be presented in summary format to the Medical Director for review and approval. Applicants who meet the minimum participation criteria with adverse activity (license sanctions, quality of care issues, settled malpractice claims history) and all pending malpractice claim information will be submitted to the Credentialing Committee for review. It is the responsibility of the Credentialing Committee to review each applicant’s qualifications and make approval or denial recommendations to Wraparound Milwaukee Administration. Wraparound Administration then makes the final decision for approval or rejection of the practitioner’s application to become a provider. The practitioner will be sent a written notice of his/her status within 30 days of the rendering of a decision their application to become a provider for Wraparound Milwaukee.
Primary Source Verification
The following information is required for mental health and AODA (alcohol and other drug abuse)
practitioners applying to become a provider with the Milwaukee Wraparound Provider Network.
Wraparound Milwaukee Provider Network staff will obtain this information, review, and verify
documents with the following primary sources:
DOCUMENT VERIFICATION SOURCE
Current Valid License to Practice Wisconsin Department of Regulation
and Licensing Website
3000 Hour Psychotherapy Letter Practitioner must submit with
Application
Medical School, Internship and Residency AMA E-Physician Profile
Board Certification, DEA status, and
Medicaid/Medicare Sanctions (for Physicians)
7
Education for 3000 hour letter practitioners National Student Clearinghouse
or communication with the school
Malpractice Claims National Practitioner Data Bank
Medicaid/Medicare Sanction Information Healthcare Integrity and Protection Data
Bank
National Provider Identification Numbers (NPI) are verified using the National Plan and Provider
Enumeration System web site at https://nppes.cms.hhs.gov/NPPES/NPIRegistrySearch.
Documentation and verification information associated with processing of a properly completed application shall be no more than 60 days old at the time of the credentialing decision. Recredentialing Process
Wraparound Milwaukee formally re-credentials practitioners every three years. Requests for re-credentialing information will be sent to the practitioner with sufficient advance notice to allow the re-credentialing process to be completed by the last day of the month that the re-credentialing renewal is due. Wraparound Milwaukee will forward a recredentialing application form to the practitioner for verification and update of information personal information and work history, completion of attestations regarding the practitioner’s ability to provide services and lack of present illegal drug use, including an original signature and current date.
Primary source verification will be conducted to verify current and new professional licenses, malpractice claims and/or Medicaid/Medicare Sanction Information.
The following information is required for mental health and AODA (alcohol and other drug abuse)
practitioner recredentialing. Wraparound Milwaukee Provider Network staff will obtain the
required information, review, and verify documents with the following primary sources:
Primary Source Verification
DOCUMENT VERIFICATION SOURCE
Current Valid License to Practice Wisconsin Department of Regulation
and Licensing Website
DEA status, Board Certification AMA E-Physician Profile
Medicaid/Medicare Sanctions (for Physicians)
Malpractice Claims National Practitioner Data Bank
Medicaid/Medicare Sanction Information Healthcare Integrity and Protection Data
Bank
All applications, documents and verification information shall be no more than 60 days old at the time of the re-credentialing decision. The practitioner recredentialing process includes a review of the following Participant/service recipient complaints/grievances Client satisfaction surveys Current Professional Liability Insurance Certificate
8
To assist with practitioner re-credentialing, the following may also be reviewed: Medical record audits Office site evaluations Quality improvement studies Utilization management
In the event that credentialing information obtained from other sources varies substantially from
that provided by the practitioner, Wraparound Milwaukee shall notify the practitioner in writing
within two weeks of the discrepancy. The applicant shall have 30 days to correct erroneous
information submitted by other parties and/or to correct his/her own information or the processing
of his/her application will be terminated.
OFFICE SITE EVALUATION AND MEDICAL RECORD DOCUMENTATION The initial credentialing process includes an on-site office evaluation and medical record review for all new agencies that apply to provide service for Wraparound Milwaukee participants and their families. As part of the site review for mental health and AODA practitioners, standards for access to services, including emergency coverage and appointment availability are reviewed in order to assure reasonable access to services for Wraparound Milwaukee participants/service recipients. Medical groups and group practices do not need a separate site visit for each practitioner. The site evaluation includes but is not limited to:
• Practitioner information (i.e. licenses/certifications, background checks, etc.) • Office policies/general information • Physical plant/physical accessibility • Scheduling/appointments availability • Availability of emergency equipment (as applicable) • Medication storage policies and procedures • Medical record keeping format including forms, practices and procedures • Access/on-call coverage policies and procedures
The results of the office site evaluation and medical record keeping review are considered in the initial credentialing decision-making process. Practitioners with evaluation scores that fall below the threshold or 80% or that lack essential elements are subject to corrective action and re-review to monitor compliance as a requirement for enrollment in the Wraparound Milwaukee Provider Network.
Agencies/practitioners whose site evaluation reveals substandard scores will be monitored by the
Wraparound Milwaukee Provider Network Coordinator for corrective action. Agencies/
practitioners will be required to submit evidence of correction in non-compliant areas within a
prescribed time frame not to exceed three (3) months for existing Network agencies/providers and
prior to enrollment in the Network for new agencies/providers.
POLICIES AND PROCEDURES
All Wraparound Milwaukee Provider Network and credentialing policies and procedures are
considered part of the Wraparound Milwaukee Credentialing Plan.
Updated 10/09; 11/10, 11/12, 10/14