Clinical Services Team: Quality Improvement & Clinical Integrity Unit

The Quality Improvement & Clinical Integrity Unit (QICIU) includes the Quality Team and the Clinical Utilization Review Team. The Quality Team collaborates with AHS partners to develop a culture of continuous quality improvement, maintains the Vermont Medicaid Quality Plan and Work Plan, coordinates quality initiatives including formal performance improvement projects, coordinates the production of standard performance measures, and is the DVHA lead unit for the Results Based Accountability (RBA) methodology & produces the DVHA RBA Scorecards.

The Clinical Utilization Review Team (UR) is responsible for the utilization management of mental health and substance use disorder services. The team works toward the integration and coordination of services provided to Vermont Medicaid members with substance use disorders and mental health needs. The team performs utilization management activities including concurrent review and authorization of mental health and substance use disorder services. The UR Team also administers the Team Care program, which locks a member to a single prescriber and a single pharmacy. In addition, the Autism Specialist authorizes applied behavior analysis (ABA) services for children.  

Please note that in the Summer of 2020, the Quality & Clinical Integrity Unit, the Clinical Operations Unit, and the Pharmacy Unit came together as the Clinical Services Team.  The Units are displayed separately in this scorecard due to their different lines of work.

The QICIU serves Vermonters enrolled in Medicaid who require behavioral health inpatient, residential, and ABA services.

The Quality Team supports the Department in creating a culture of quality improvement; supporting units to strive for and demonstrate improvement.

The Clinical Utilization Review Team ensures that our members get the services needed for the appropriate length of time.

For the Quality Team, the SFY22 priorities are:

• Continuation of formal PIP.
• Develop team approach to a risk and quality management program.
• Continue to support the Department in creating and maintaining a culture of continuous quality improvement (e.g. LTC data tracking, scorecards, COVID dashboard, Team Care and ABA program improvements).

For the Clinical Utilization Review Team, the SFY22 priorities are:

• Team Care Program: continue to refine the review process and focus on increased provider/partner outreach.
• Increase access to specialized treatment: Work to identifying providers/facilities and assisting in enrollment with VT Medicaid. Current areas of focus include eating disorder treatment and inpatient psychiatric treatment for members with developmental disabilities.
• Continue to monitor quality of care for inpatient psychiatric stays for VT Medicaid members. Continue weekly meetings with DMH/DCF regarding disposition issues. Regular communication with utilization review staff at facilities that are providing treatment to our members. Continue to use InterQual and continue to participate in yearly training and IRR. Expand knowledge where we can i.e., trainings.