Clinical Services Team: Quality Improvement & Clinical Integrity Unit

What We Do

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.

Who We Serve

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

How We Impact

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.

Action Plan

The top priorities/initiatives for the QICIU in SFY20 are:

  • Continue to strengthen and increase our provider network.
  • Modify utilization management activities to align with payment reform initiatives.
  • Help address social determinants of health including housing and recovery services post discharge.
  • Continue the work of the Substance Use Disorder Treatment PIP (telehealth and alcohol treatment interventions). Key metric = HEDIS IET Initiation Rate (in the GC Core Measure Set)
  • Plan to maximize the use of available resources, including the potential use of the Vermont Clinical Registry and contracted ACO-attributed hybrid measure rates, to comply with Quality Measure reporting requirements. Key metric = % of CMS Adult/Child/Behavioral Health Quality Core Measures reported by DVHA.
  • Collaborate with other units and Departments to reduce duplication of efforts and promote a culture of continuous quality improvement.
Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy