DHHS-Mental Health. Quality Improvement Outpatient Work Plan Fiscal Year

Transcription

1 DHHS-Mental Health Quality Improvement Outpatient Work Plan Fiscal Year October, 2017

2 Table of Contents INTRODUCTION AND OVERVIEW... 2 QUALITY IMPROVEMENT WORK PLAN OVERVIEW... 2 QUALITY IMPROVEMENT WORK PLAN AREAS AND GOALS... 2 AREA 1 ACCESS 24/ Area 1 Goal 1. Implement Remote Video Interpreting Service for American Sign Language (ASL) throughout the MHP Area 1 Goal 2. Improve staff performance on addressing all items on the state matrix for 24/7 toll free access line test calls to comply with regulation... 3 AREA 2 CONSUMER INVOLVEMENT... 5 Area 2 Goal 1. Include consumers and / or family members in Continuous Quality Improvement (CQI) Committee activities... 5 AREA 3 EFFECTIVENESS OF CARE... 6 Area 3 Goal 1. Utilize Milestones of Recovery Scale (MORS) outcome measurement scores to inform treatment decision for adults in outpatient settings... 6 AREA 4 CONTINUITY OF CARE... 7 Area 4 Goal 1. Improve coordination of transfers of Medication Support Only clients to Primary Care Providers (PCP)... 7 Area 4 Goal 2. Reduce 30 day readmissions to the Crisis Stabilization Unit (CSU)... 7 AREA 5 QUALITY IMPROVEMENT... 9 Area 5 Goal 1. Establish Report Card for program compliance for clinical documentation Area 5 Goal 2. Develop a structure for comprehensive reporting and evaluating Quality Improvement activities throughout the Mental Health Plan AREA 6 DEPARTMENT TRAINING...11 Area 6 Goal 1. Relias E-Learning Management System Roll-Out to all Mental Health staff...11 AREA 7 UTILIZATION REVIEW...12 Area 7 Goal 1. Finalize Outpatient and Inpatient Clinical Documentation Manuals...12 Quality Improvement Outpatient Work Plan Fiscal Year

3 Introduction and Overview The Humboldt County Department of Health and Human Services (DHHS) is an integrated Health and Human Services Agency under the State s Integrated Services Initiative (AB315 Berg) and includes the former Departments of Mental Health, Public Health, Social Services, Employment Training, Veterans Services and Public Guardian. Over the past decade, Humboldt County DHHS has demonstrated that through its integrated health and human services delivery structures and processes higher quality, more effective, less costly, holistic and outcome-based practices can be planned, funded and implemented. The mission, vision and operating principles of DHHS are listed below. DHHS MISSION To reduce poverty and connect people and communities to opportunities for health and wellness. DHHS VISION People helping people live better lives. DHHS OPERATIONAL PRINCIPLES Our integrated programs for children, families and adults deliver coordinated, efficient services. These services focus on client and community strengths and emphasize prevention, resiliency, recovery and hope. We collaborate with clients in their recovery and tailor our services to fit the values and needs they identify. Our programs are evidence-based and outcome-driven to ensure quality and accountability. We value and nurture our partnerships with community stakeholders. Quality Improvement Work Plan Overview As part of the Humboldt County Mental Health Plan contract with the California Department of Health Care Services (DHCS) and the Managed Care Plan, this document describes the planned quality improvement activities across the department s outpatient system of care for Fiscal Year The purpose of the Quality Improvement (QI) Work Plan is to provide the department and stakeholders with data and data analysis related to client care throughout the outpatient service delivery settings. Quality Improvement Work Plan Areas and Goals Through stakeholder engagement meetings, the QI Unit was able to identify seven areas under which specific goals and objectives were developed. These QI targeted areas support the mission, vision and operating principles of DHHS as well as the strategic goals of DHHS-Mental Health. Within the seven QI Work Plan areas are specific goals and objectives for the department. A baseline was established to assist with measuring change. Additionally, specific actions steps and activities were identified. Quality Improvement Outpatient Work Plan Fiscal Year

4 AREA 1 ACCESS 24/7 Ensuring clients have timely access, 24-hours per day/7 days per week, to mental health services has been identified as a targeted area for the QI Work Plan. The intention is to ensure timely access to Mental Health services by adequately staffing the points of access and improving the data collection and reporting processes in order to better assess types of requests for services. The following specific goals were identified to meet the target area of ensuring clients have timely access to mental health services. Area 1 Goal 1. Implement Remote Video Interpreting Service for American Sign Language (ASL) throughout the MHP. Have functional ASL Video Interpreting in place by June 30, We rely on 1 contracted ASL provider that subcontracts with 2 local interpreters. We are not able to accommodate all requested services. 1. Assess viable ASL services for possible contracting 2. Testing and Implementation of hardware and software configuration 3. Business practice and policy changes 4. Staff training 5. Monitoring and Reporting Information Systems Program Management and QI Coordinator Interpreter Utilization Report Quarterly at OP CQI Committee Area 1 Goal 2. Improve staff performance on addressing all items on the state matrix for 24/7 toll free access line test calls to comply with regulation Increase performance on all 7 Test Call metrics items to 80% or better. Average performance in FY across all 7 Test Call metrics items was 55%. Quality Improvement Outpatient Work Plan Fiscal Year

5 1. Conduct at least two English language test calls and one non-english test call monthly 2. Increase the pool of test callers who can make non-english calls from 3 to 5 and provide instruction and support (involve Org Provider bi-lingual staff) 3. Focus test calls targeting After Hours Crisis Staff (both shifts) in addition to targeting Answering Service 4. Create customized training on how to handle access calls and re-train staff 5. Provide line staff with continued training and feed-back according to test call results Reception, Access, Same Day Services (SDS) PHF / CSU Outpatient clinic, QI Unit Program Management and QI Coordinator Test call reports Quarterly at OP CQI Committee Quality Improvement Outpatient Work Plan Fiscal Year

6 AREA 2 CONSUMER INVOLVEMENT The following specific goal has been identified to meet the target area of ensuring consumer involvement in quality improvement activities. Area 2 Goal 1. Include consumers and / or family members in Continuous Quality Improvement (CQI) Committee activities Identify at least one key contribution from consumer / family member focus into the CQI committee process. One family member attended the OP CQI committee meetings in FY16-17, but was still orienting to the QI objectives. 1. Provide continued support (e.g. emotional support, problem solving to remove barriers, education, stipends) to family members to allow them to take a more active role in committee work 2. Continue to train and orient interested individuals on their role within the CQI committee 3. Conduct at least one consumer / family member focus group to identify areas of program or agency improvement QI Unit QI Coordinator and Program staff Family Liaison CQI meeting agendas and minutes Focus Group report Quarterly at OP CQI Committee Quality Improvement Outpatient Work Plan Fiscal Year

7 AREA 3 EFFECTIVENESS OF CARE Measuring the effectiveness of care at the consumer, program and system levels ensures accountability and provides critical data for programmatic decision-making to improve consumer outcomes. The following specific goal has been identified to meet the target area of measuring effectiveness of care to improve client outcomes and ensure quality care. Area 3 Goal 1. Utilize Milestones of Recovery Scale (MORS) outcome measurement scores to inform treatment decision for adults in outpatient settings Create MORS reports to be utilized by program staff and administration for program accountability and to inform recovery based treatment decisions. MORS widget and report was assigned to subcontractor Xpio in FY to generate for use in Adult System of Care. 1. Obtain timelines for deliverables from Xpio 2. Provide training to all clinical staff on administering the MORS 3. Provide staff training on how to use MORS to inform treatment decisions QI Unit, QI Training Unit Information Systems, Program Management MORS Avatar Reports Quarterly at OP CQI Committee Quality Improvement Outpatient Work Plan Fiscal Year

8 AREA 4 CONTINUITY OF CARE Transitioning to a lower level of care is a milestone in a client s recovery. Coordination with Primary Care Providers in the community is an important aspect of the client s care continuum. The following specific goals have been identified to meet the target area of ensuring clients receive a continuity of care between providers. Area 4 Goal 1. Improve coordination of transfers of Medication Support Only clients to Primary Care Providers (PCP) Monthly monitor and track the status of client transfers to PCPs. A spreadsheet exists for monitoring and tracking, however the uniform process for data entry has been inconsistent. 1. Review and modify (if necessary) PCP transfer P&P Train line staff on coordination of transfer of care with PCPs 3. Utilize tracking mechanism consistently 4. Review spreadsheet monthly 5. Create dashboard for monitoring and reporting Adult Outpatient Medication Support Program Medical Record Staff QI Staff Avatar Data Point Transfer to PCP Tracking Spreadsheet Transfers Tracking Dashboard Quarterly at Outpatient CQI Committee Area 4 Goal 2. Reduce 30 day readmissions to the Crisis Stabilization Unit (CSU) : Reduce 30 day CSU readmits to the target goal of 14% or less. The average 30 day readmission rate to CSU was 17% (all admissions) in FY Identify key program staff to increase contacts with clients discharged from CSU 2. Connect clients with outpatient access and services 3. Create a process to provide timely follow-up contacts (e.g. telephone follow-ups ; connections to peer support; linkage to Med Support) Quality Improvement Outpatient Work Plan Fiscal Year

9 CSU RN Supervisor, Outpatient Sr Program Manager Program staff QI unit QI Indicator dashboard Quarterly at Outpatient CQI Committee Quality Improvement Outpatient Work Plan Fiscal Year

10 AREA 5 QUALITY IMPROVEMENT The following specific goals have been identified to meet the target area of ensuring ongoing quality improvements are effective. Area 5 Goal 1. Establish Report Card for program compliance for clinical documentation. : Create a suite of reports (using existing reports and those under development) and use them to give feedback to each program and department administration. : This has not been established yet. 1. Create a policy and procedure for program report cards 2. Use existing reports to grade programs 3. Create new reports as needed 4. Create new dashboard for analysis and reporting QI Analyst; QI Coordinator Medical Records Analyst 1. Avatar Draft Forms Report 2. Avatar Admission Gap report for possible disallowances and late notes 3. Error Correction Spreadsheets 4. Chart Review Data 5. Late Note Report 6. Reconciliation Duration Quarterly at OP CQI Committee Area 5 Goal 2. Develop a structure for comprehensive reporting and evaluating Quality Improvement activities throughout the Mental Health Plan. : Redesign the QI Work Plan and Work Plan Annual Evaluation and realign it with the QI Dashboard as the core document to establish goals and track changes over time by June 30, QI creates annual Work Plans and Evaluations independently from the QI Dashboard goals and reports. 1. Sample other model work plans and data dashboards to inform a redesign 2. Propose plan options to CQI Committee 3. Identify key areas of focus for the coming year s improvement activities Quality Improvement Outpatient Work Plan Fiscal Year

11 QI Unit Sr. Program Manager Data dashboard and selected workplan and evaluation template Biannually at OP CQI Committee Quality Improvement Outpatient Work Plan Fiscal Year

12 AREA 6 DEPARTMENT TRAINING The implementation of a training program is essential for staff onboarding and retention, and for providing high quality client care. To ensure staff competency and compliance, it is essential to monitor and track training activities. The following specific goals have been identified to meet the target area of ensuring staff training is effective in improving the quality of services. Area 6 Goal 1. Relias E-Learning Management System Roll-Out to all Mental Health staff Relias Learning will be made available to all Mental Health Staff by June 30, Only staff providing Inpatient Services at Sempervirens Psychiatric Health Facility had access to Relias in FY Orientation to supervisors and managers 2. Purchase 100 additional licenses 3. Execute contract addendum 4. Create training plans for programs 5. Assign key staff to manage the system 6. Train all staff QI Unit, Clinical Programs QI Training Clinician and Program Management Relias reports Biannually at OP CQI Committee Quality Improvement Outpatient Work Plan Fiscal Year

13 AREA 7 UTILIZATION REVIEW The following specific goals have been identified to meet the target area of ensuring the establishment of good clinical documentation practices. Area 7 Goal 1. Finalize Outpatient and Inpatient Clinical Documentation Manuals Update the Outpatient Clinical Documentation Manual, and finalize the CSU and Inpatient (Sempervirens) Clinical Documentation Manuals by June 30, Outpatient Clinical Documentation Manual was last revised and published in Review and approve modifications to current Outpatient Clinical Documentation Manual 2. Create workgroups with clinical stakeholders for input in CSU and SV manuals 3. Finalize drafts and send for final review and approval by MH Director 4. Create document highlighting the key changes 5. Release and provide orientation to new manuals to end users QI Unit Program Managers and Supervisors Posting of final manual versions Biannual CQI updates Quality Improvement Outpatient Work Plan Fiscal Year