Colusa County. Conducted on August 4, Prepared by:

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1 FY Medi-Cal Specialty Mental Health External Quality Review MHP Final Reprt Clusa Cunty Cnducted n August 4, 2016 Prepared by: Behaviral Health Cncepts, Inc Christie Avenue, Suite 502 Emeryville, CA Page 1

2 TABLE OF CONTENTS COLUSA MENTAL HEALTH PLAN SUMMARY FINDINGS... 4 INTRODUCTION... 6 PRIOR YEAR REVIEW FINDINGS, FY STATUS OF FY15-16 REVIEW RECOMMENDATIONS... 8 Assignment f Ratings... 8 Key Recmmendatins frm FY CHANGES IN THE MHP ENVIRONMENT AND WITHIN THE MHP IMPACT AND IMPLICATIONS PERFORMANCE MEASUREMENT TOTAL BENEFICIARIES SERVED PENETRATION RATES AND APPROVED CLAIM DOLLARS PER BENEFICIARY PERFORMANCE IMPROVEMENT PROJECT VALIDATION COLUSA MHP PIPS IDENTIFIED FOR VALIDATION CLINICAL PIP RECOVERY NON-CLINICAL PIP PARENT INTERVENTION PERFORMANCE IMPROVEMENT PROJECT FINDINGS IMPACT AND IMPLICATIONS PERFORMANCE & QUALITY MANAGEMENT KEY COMPONENTS Access t Care Timeliness f Services Quality f Care KEY COMPONENTS FINDINGS IMPACT AND IMPLICATIONS CONSUMER AND FAMILY MEMBER FOCUS GROUP(S) CONSUMER/FAMILY MEMBER FOCUS GROUP CONSUMER/FAMILY MEMBER FOCUS GROUP FINDINGS IMPLICATIONS INFORMATION SYSTEMS REVIEW KEY ISCA INFORMATION PROVIDED BY THE MHP CURRENT OPERATIONS PLANS FOR INFORMATION SYSTEMS CHANGE ELECTRONIC HEALTH RECORD STATUS MAJOR CHANGES SINCE LAST YEAR PRIORITIES FOR THE COMING YEAR OTHER SIGNIFICANT ISSUES MEDI-CAL CLAIMS PROCESSING INFORMATION SYSTEMS REVIEW FINDINGS IMPLICATIONS SITE REVIEW PROCESS BARRIERS CONCLUSIONS STRENGTHS AND OPPORTUNITIES Access t Care Timeliness f Services Quality f Care Cnsumer Outcmes Page 2

3 RECOMMENDATIONS ATTACHMENTS ATTACHMENT A REVIEW AGENDA... ATTACHMENT B REVIEW PARTICIPANTS... ATTACHMENT C APPROVED CLAIMS SOURCE DATA... ATTACHMENT D PIP VALIDATION TOOL... Page 3

4 COLUSA MENTAL HEALTH PLAN SUMMARY FINDINGS Beneficiaries served in CY MHP Threshld Language(s) Spanish MHP Size Small Rural MHP Regin Superir MHP Lcatin Clusa MHP Cunty Seat Clusa, CA MHP-Reprted Significant Changes The MHP hired a new Quality Imprvement (QI) Crdinatr wh will be respnsible fr data analysis and trending. In the spring f 2016, a cunty administrative fficer was hired, with MHP leadership as a direct reprt. The MHP has experienced difficulties with crisis prtcls since April 2016 with the clsure f the nly hspital in the cunty. The MHP has had great difficulty in wrking with Anthem fr Affrdable Care Act (ACA) referrals. Anthem des nt seem t have any prviders that have penings, and they are nt very respnsive t cnsumers and staff calls. Perfrmance Measurement Findings frm CY15 Claims Data The MHP s percentage f high-cst beneficiaries was similar t statewide and shwed an increase frm CY14. Its percentage f HCB claim dllars was higher than statewide and dubled frm CY14 t CY15. Infrmatin Systems Findings The MHP plans t install and begin implementatin f a Telechart Patient Prtal fllwing system upgrade in September The MHP cntinues t pursue Meaningful Use, Stage I qualificatin thrugh Medicare/Medicaid s EHR incentive prgram with a prjected target date f Octber The MHP is wrking twards electrnic capture f its clinical data and the use f health IT fr cntinuus quality imprvement at the pint f care and the exchange f infrmatin. Page 4

5 MHP has n current plans t expand EHR functinality with the additin f elabs, Level f Care/Level f Service assessments. Strengths and Recmmendatins Findings Investigate the feasibility t prvide mre funding r resurces t supprt crisis staff. Evaluate cntributing factrs fr the increase in hspitalizatin rates frm FY 14/15 t FY15/16. Re-establish and frmalize the Cultural Cmpetence Cmmittee with regularly scheduled meetings. Track timeliness fr psychiatry fr bth children and adults, t determine the impact f the.5 FTE eliminatin f child psychiatry and the implementatin f the plicy requiring cnjint services fr medicatin child clients. Expand EHR functinality thrugh cnsultatin with Kings View and nearby cunties. Quantifiably shw imprvement and expansin thrugh the additin f applicatins, such as elabs, Level f Care/Level f Service, Alerts, etc. Page 5

6 INTRODUCTION The United States Department f Health and Human Services (DHHS), Centers fr Medicare and Medicaid Services (CMS) requires an annual, independent external evaluatin f State Medicaid Managed Care prgrams by an External Quality Review Organizatin (EQRO). External Quality Review (EQR) is the analysis and evaluatin by an apprved EQRO f aggregate infrmatin n quality, timeliness, and access t health care services furnished by Prepaid Inpatient Health Plans (PIHPs) and their cntractrs t recipients f Managed Care services. The CMS (42 CFR 438; Medicaid Prgram, External Quality Review f Medicaid Managed Care Organizatins) rules specify the requirements fr evaluatin f Medicaid Managed Care prgrams. These rules require an nsite review r a desk review f each Medi-Cal Mental Health Plan (MHP). The State f Califrnia Department f Health Care Services (DHCS) cntracts with fifty-six (56) cunty Medi-Cal MHPs t prvide Medi-Cal cvered specialty mental health services t Medi-Cal beneficiaries under the prvisins f Title XIX f the federal Scial Security Act. This reprt presents the fiscal year (FY 16-17) findings f an EQR f the Clusa MHP by the Califrnia External Quality Review Organizatin (CalEQRO), Behaviral Health Cncepts, Inc. (BHC). The EQR technical reprt analyzes and aggregates data frm the EQR activities as described belw: (1) VALIDATING PERFORMANCE MEASURES 1 This reprt cntains the results f the EQRO s validatin f eight (8) Mandatry Perfrmance Measures (PM) as defined by DHCS. The eight perfrmance measures include: Ttal Beneficiaries Served by each cunty MHP Ttal Csts per Beneficiary Served by each cunty MHP Penetratin Rates in each cunty MHP Cunt f TBS Beneficiaries Served Cmpared t the fur percent (4%) Emily Q. Benchmark (nt included in MHP reprts; this infrmatin is included in the Annual Statewide Reprt submitted t DHCS). Ttal Psychiatric Inpatient Hspital Episdes, Csts, and Average Length f Stay Psychiatric Inpatient Hspital 7-Day and 30-Day Rehspitalizatin Rates Pst-Psychiatric Inpatient Hspital 7-Day and 30-Day Specialty Mental Health Services (SMHS) Fllw-Up Service Rates 1 Department f Health and Human Services. Centers fr Medicare and Medicaid Services (2012). Validatin f Perfrmance Measures Reprted by the MCO: A Mandatry Prtcl fr External Quality Review (EQR), Prtcl 2, Versin 2.0, September, Washingtn, DC: Authr. Page 6

7 High Cst Beneficiaries ($30,000 r higher) (2) VALIDATING PERFORMANCE IMPROVEMENT PROJECTS 2 Each MHP is required t cnduct tw Perfrmance Imprvement Prjects (PIPs) during the 12 mnths preceding the review; Clusa MHP submitted tw PIPs fr validatin thrugh the EQRO review. The PIP(s) are discussed in detail later in this reprt. (3) MHP HEALTH INFORMATION SYSTEM CAPABILITIES 3 Utilizing the Infrmatin Systems Capabilities Assessment (ISCA) prtcl, the EQRO reviewed and analyzed the extent t which the MHP meets federal data integrity requirement fr Health Infrmatin Systems (HIS), as identified in 42 CFR This evaluatin included review f the MHP s reprting systems and methdlgies fr calculating Perfrmance Measures (PM). (4) VALIDATION OF STATE AND COUNTY CONSUMER SATISFACTION SURVEYS The EQRO examined available cnsumer satisfactin surveys cnducted by DHCS, the MHP r its subcntractrs. CalEQRO als cnducted ne 90-minute fcus grup with beneficiaries and family members t btain direct qualitative evidence frm beneficiaries. (5) KEY COMPONENTS, SIGNIFICANT CHANGES, ASSESSMENT OF STRENGTHS, OPPORTUNITIES FOR IMPROVEMENT, RECOMMENDATIONS The CalEQRO review draws upn prir year s findings, including sustained strengths, pprtunities fr imprvement, and actins in respnse t recmmendatins. Other findings in this reprt include: Changes, prgress, r milestnes in the MHP s apprach t perfrmance management emphasizing utilizatin f data, specific reprts, and activities designed t manage and imprve quality. Ratings fr Key Cmpnents assciated with the fllwing three dmains: access, timeliness, and quality. Submitted dcumentatin as well as interviews with a variety f key staff, cntracted prviders, advisry grups, beneficiaries, and ther stakehlders serve t infrm the evaluatin f MHP s perfrmance within these dmains. Detailed definitins fr each f the review criteria can be fund n the CalEQRO Website 2 Department f Health and Human Services. Centers fr Medicare and Medicaid Services (2012). Validating Perfrmance Imprvement Prjects: Mandatry Prtcl fr External Quality Review (EQR), Prtcl 3, Versin 2.0, September Washingtn, DC: Authr. 3 Department f Health and Human Services. Centers fr Medicare and Medicaid Services (2012). EQR Prtcl 1: Assessment f Cmpliance with Medicaid Managed Care Regulatins: A Mandatry Prtcl fr External Quality Review (EQR), Prtcl 1, Versin 2.0, September 1, Washingtn, DC: Authr. Page 7

8 PRIOR YEAR REVIEW FINDINGS, FY15-16 In this sectin we discuss the status f last year s (FY15-16) recmmendatins, as well as changes within the MHP s envirnment since its last review. STATUS OF FY15-16 REVIEW RECOMMENDATIONS In the FY15-16 site review reprt, the CalEQRO made a number f recmmendatins fr imprvements in the MHP s prgrammatic and/r peratinal areas. During the FY16-17 site visit, CalEQRO and MHP staff discussed the status f thse FY15-16 recmmendatins, which are summarized belw. Assignment f Ratings Fully addressed reslved the identified issue Partially addressed Thugh nt fully addressed, this rating reflects that the MHP has either: made clear plans and is in the early stages f initiating activities t address the recmmendatin addressed sme but nt all aspects f the recmmendatin r related issues Nt addressed The MHP perfrmed n meaningful activities t address the recmmendatin r assciated issues. Key Recmmendatins frm FY15-16 Recmmendatin #1: As recmmended last year, cllabrate with Cunty Administratin t recruit the unfilled Data Crdinatr psitin in rder t cntinue t mve frward in the develpment f a data driven system f care. Fully addressed Partially addressed Nt addressed This MHP has nt filled its data analyst and/r an equivalent psitin within their cunty system. The MHP has attempted t btain this psitin thrugh the budget prcess withut success. Alternatively, the MHP has recruited a Quality Imprvement Crdinatr wh is a licensed clinician t begin in August The QI crdinatr may perfrm analysis f data such as penetratin rates, billing, access, demgraphics, etc. Recmmendatin #2: Make staffing and space pririties fr the suthern prtin f the cunty. Track all timeliness measures reflected in the Timeliness Self-Assessment frm, fr all regins fr adult and children s services. Allcate staffing and fiscal resurces Page 8

9 that are cmmensurate with the capacity demands, priritizing the ameliratin f wait lists and timeliness issues in Suth Cunty. Fully addressed Partially addressed Nt addressed This Item was nt addressed as this recmmendatin was made in errr and nt crrected befre the reprt was finalized last year. Recmmendatin #3: Reinvigrate the Cultural Cmpetence Cmmittee and reestablish rutine cultural cmpetence activities and rbust utreach effrts that invlve cnsumers/family members n bth a larger scale (cmmunity feedback at meetings, surveys) and als n a smaller scale (i.e., cmmittee level planning and implementatin f utreach). Evaluate the effectiveness f the activities. Establish a diverse leadership f cultural cmpetency and utreach levels t ensure cntinuus effrts. Fully addressed Partially addressed Nt addressed Althugh the MHP des nt frmally have a Cultural Cmpetence Cmmittee, the MHP refrmed its apprach t carrying ut the cultural cmpetency gals. This ccurred due t the departure f the ethnic services manager the prir year. The MHP implemented a significant utreach effrt t the Hispanic cmmunity titled Cultura Es Vida in Octber 2015 with the Hispanic Heritage Prgram. The MHP cllabrated with the English Learner Advisry Cmmittees t prvide twelve presentatins t the preschls and schls addressing the understanding f mental health issues. One hundred cnsumer surveys were cmpleted at the last presentatin. The MHP has negtiated a Memrandum f Understanding (MOU) t increase direct services t the Native American Cmmunity. The MHP has added bilingual Spanish speaking staff: Tw added interns, a clinician, with extra help (transprtatin) in January Additinally, the QI Crdinatr hired in August 2016 speaks Punjabi. Recmmendatin #4: Evaluate the effectiveness f new crisis prtcls thrugh quarterly data cllectin and analysis including cmparisn t baseline data, ver time, with demgraphics infrmatin as well as prvider infrmatin t determine best practices. Cnsider addressing this thrugh a PIP, with cnsultatin and technical assistance prvided by the EQRO. Fully addressed Partially addressed Nt addressed The MHP has been experiencing difficulties with its crisis prtcls since April 2016 with the bankruptcy and clsure f Clusa Reginal Medical Center, the nly hspital in the cunty. Page 9

10 The hspital clsure has cmplicated the lives f cnsumers wh in the past culd receive care lcally after hurs at the hspital 24/7. Since the clsure there is n available emergency rm, the MHP crisis staff is impacted. The MHP is able t access all statistical data thrugh April The MHP nw relies n infrmatin frm Glenn and Sutter-Yuba cunties. Glenn Cunty prvides medical clearance fr thse assessed, while Sutter-Yuba accepts Clusa MHP 5150s with reimbursement by Clusa Cunty. Recmmendatin #5: Create pprtunities fr line staff t encurage their invlvement and ffer crss-training t expand skill sets which can supprt the system. Establish an nging bi-directinal feedback system between leadership, management and staff t evaluate effectiveness and cnsumer/staff satisfactin. Fully addressed Partially addressed Nt addressed In the fall f 2015, the MHP frmed a staff advisry cmmittee (SAC) cmprised f leadership and ther system wide staff. The SAC meets quarterly t identify challenges in prviding effective services and t evaluate cnsumer/staff satisfactin. The staff has advisry cmmittee meetings mnthly. A staff survey frm 2015 indicated that cmmunicatin culd be imprved between leadership and staff particularly arund receiving feedback and cmmunicating changes. The MHP states that they have made sme changes based n the suggestins frm staff, hwever, feedback frm staff indicate that there are still issues remaining. Recmmendatin #6: Identify and incrprate a system wide cnsumer utcme tl fr the children s system f care, such as the child behavir checklist, int the EHR and establish mnthly reprting f cnsumer functining similar t the MHP s implementatin f the MORs fr adults. Use data t develp an evidence based quality driven system. Fully addressed Partially addressed Nt addressed The MHP installed the Child Behavir Check List (CBCL) in December 2015, fllwed by staff training. System implementatin ccurred in January CBCL scring is incrprated int the discharge summary in the EHR and Medical Necessity frm. The MHP shuld be able t perfrm data analyses with the newly hired QI Crdinatr wh cmmences emplyment in August Recmmendatin #7: Cntinue t create and implement ways t increase the peer emplyee presence in prgrams. Increase cnsumer and family member invlvement in service related cmmittees, including plicy making cmmittees. Ensure that there are methds r venues fr Spanish speaking stakehlders t participate. Page 10

11 Fully addressed Partially addressed Nt addressed In January 2016, tw peer psitins were added and were classified as extra help. These are paid part time psitins with n benefits. Three peers have attended certificatin training and the Department has participated in reginal training fr peer certificatin. Certificatin invlved a 13-mnth training n Peer Cre Cmpetency thrugh the Nrthern CA WET Alliance. There is peer participatin in the QI Cmmittee, the BH Advisry Bard, and in Cnsumer Leadership fr Safe Haven Wellness and Recvery Center. The MHP identified bicultural staff within its department fr the Cultura de la Vida utreach prgram and frm there, cllabrated with the district learner advisry cmmittee (DLAC), English learner advisry cmmittee (ELAC), and migrant educatin prgrams. Thrugh these effrts, the MHP is invlving peers and identifying natural leaders t develp a Prmtres prgram. CHANGES IN THE MHP ENVIRONMENT AND WITHIN THE MHP IMPACT AND IMPLICATIONS Changes since the last CalEQRO review, identified as having a significant effect n service prvisin r management f thse services are discussed belw. This sectin emphasizes systemic changes that affect access, timeliness, and quality, including thse changes that prvide cntext t areas discussed later in this reprt. Access t Care The MHP established a Cultura De La Vida prgram which utreaches t the Hispanic cmmunity. Beginning in Octber 2015, the prgram has prvided 12 presentatins in the cmmunity n services, and varius mental health tpics. The lcal hspital went bankrupt and clsed abruptly. There are n emergency rm services. Glenn Cunty prvides medical clearance fr thse assessed. Sutter Yuba will accept 5150s with reimbursement by Clusa Cunty. The wellness center was expanded t be the Safe Haven Wellness and Recvery Center. The new larger site has mre services/prgraming fr cnsumers including staff leads grups, as well as peer lead grups. Timeliness f Services The clsure f the hspital impacts the timeliness f cnsumers btaining medical clearance fr psychiatric hspitalizatin. Quality The MHP has an in-huse psychiatrist full time. The MHP revamped its plicy and prcedure regarding the medicatin f children. They n lnger have Page 11

12 medicatin nly child clients. If receiving medicatin, the child is required t be in services. The MHP plans t install and begin implementatin f a Telechart Patient Prtal fllwing system upgrade in September The MHP nw has a cunty administrative fficer wh started in the spring f Histrically the MHP had nly a bard f supervisrs. Over the last year, the MHP rerganized its preventin prgrams t accmmdate staff changes. The previus preventin crdinatr left, s the MHP rerganized the duties and structure f the AOD preventin prgram. The MHP s Spanish speaking clinical intern became a permanent cunty psitin. In additin, the MHP added case management t AOD and added anther intern wh als speaks Spanish. The MHP hired/prmted several staff members including bringing n QI Crdinatr, wh will start August 22, 2016, adding a clinician fr adult services (currently awaiting clearance), and case manager fr children s services. The MHP expanded its relatinship with the Office f Educatin by assigning ne f the clinicians t prvide services t children n prbatin that are attending the Cmmunity Schl. The MHP has a presence in all schls in Clusa Cunty. Cnsumer Outcmes The MHP hired a new QI Crdinatr wh will be respnsible fr data analysis and trending, including reprts based n data frm the Client Service Infrmatin (CSI), Califrnia Outcmes Measurements System (CalOMS), penetratin rates, billing, walk in appintments, demgraphics, crisis reprts regarding cntacts, utcmes, and hspitalizatin. Page 12

13 PERFORMANCE MEASUREMENT CalEQRO is required t validate the fllwing PMs as defined by DHCS: Ttal Beneficiaries Served by each cunty MHP Ttal Csts per Beneficiary Served by each cunty MHP Penetratin Rates in each cunty MHP Cunt f TBS Beneficiaries Served Cmpared t the fur percent (4%) Emily Q. Benchmark (nt included in MHP reprts; this infrmatin is included in the Annual Statewide Reprt submitted t DHCS) Ttal Psychiatric Inpatient Hspital Episdes, Csts, and Average Length f Stay Psychiatric Inpatient Hspital 7-Day and 30-Day Rehspitalizatin Rates Pst-Psychiatric Inpatient Hspital 7-Day and 30-Day SMHS Fllw-Up Service Rates High Cst Beneficiaries ($30,000 r higher) TOTAL BENEFICIARIES SERVED Table 1 prvides detail n beneficiaries served by race/ethnicity. Table 1 Clusa Cunty MHP Medi-Cal Enrllees and Beneficiaries Served in CY15 by Race/Ethnicity Race/Ethnicity Average Mnthly Unduplicated Medi-Cal Enrllees* Unduplicated Annual Cunt f Beneficiaries Served White 1, Hispanic 5, African-American 36 4 Asian/Pacific Islander Native American Other Ttal 7, *The ttal is nt a direct sum f the averages abve it. The averages are calculated separately. Page 13

14 PENETRATION RATES AND APPROVED CLAIM DOLLARS PER BENEFICIARY The penetratin rate is calculated by dividing the number f unduplicated beneficiaries served by the mnthly average enrllee cunt. The average apprved claims per beneficiary served per year is calculated by dividing the ttal annual dllar amunt f Medi-Cal apprved claims by the unduplicated number f Medi-Cal beneficiaries served per year. Regarding calculatin f penetratin rates, the Clusa Cunty MHP: Uses the same methd as used by the EQRO Uses a different methd Des nt calculate its penetratin rate Page 14

15 Figures 1A and 1B shw 3-year trends f the MHP s verall apprved claims per beneficiary and penetratin rates, cmpared t bth the statewide average and the average fr Small Rural MHPs. $6,000 Figure 1A. Overall Average Apprved Claims per Beneficiary $5,000 $4,000 $3,000 $2,000 $1,000 $0 CY13 CY14 CY15 Clusa Small-Rural State 10.00% 9.00% 8.00% 7.00% 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% Figure 1B. Overall Penetratin Rates CY13 CY14 CY15 Clusa Small-Rural State Page 15

16 Figures 2A and 2B shw 3-year trends f the MHP s fster care (FC) apprved claims per beneficiary and penetratin rates, cmpared t bth the statewide average and the average fr Small Rural MHPs. $16,000 Figure 2A. FC Average Apprved Claims per Beneficiary $14,000 $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $0 CY13 CY14 CY15 Clusa Small-Rural State 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Figure 2B. FC Penetratin Rates CY13 CY14 CY15 Clusa Small-Rural State Page 16

17 Figures 3A and 3B shw 3-year trends f the MHP s Hispanic apprved claims per beneficiary and penetratin rates, cmpared t bth the statewide average and the average fr Small Rural MHPs. $6,000 Figure 3A. Hispanic Average Apprved Claims per Beneficiary $5,000 $4,000 $3,000 $2,000 $1,000 $0 CY13 CY14 CY15 Clusa Small-Rural State 7.00% Figure 3B. Hispanic Penetratin Rates 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% CY13 CY14 CY15 Clusa Small-Rural State Page 17

18 HIGH-COST BENEFICIARIES Table 2 cmpares the statewide data fr high-cst beneficiaries (HCB) fr CY15 with the MHP s data fr CY15, as well as the prir tw years. HCB in this table are identified as thse with apprved claims f mre than $30,000 in a year. MHP Year HCB Cunt Ttal Beneficiary Cunt HCB % by Cunt Average Apprved Claims per HCB HCB Ttal Claims HCB % by Apprved Claims Statewide CY15 13, , % $51,635 $715,196, % Clusa Table 2 High-Cst Beneficiaries CY % $57,859 $810, % CY % $41,594 $332, % CY % $44,346 $354, % Table C1 (Attachment C) shws the penetratin rate and apprved claims per beneficiary fr the CY15 Medi-Cal Expansin (Affrdable Care Act [ACS]) Penetratin Rate and Apprved Claims per Beneficiary. Table C2 (Attachment C) shw the distributin f the MHP CY15 Distributin f Beneficiaries by Apprved Claims per Beneficiary (ACB) Range fr the varius categries; under $20,000; $20,000 t $30,000, and thse abve $30,000. Page 18

19 TIMELY FOLLOW-UP AFTER PSYCHIATRIC INPATIENT DISCHARGE Figures 4A and 4B shw the statewide and MHP 7-day and 30-day utpatient fllw-up and rehspitalizatin rates fr CY14 and CY % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Figure 4A. 7-Day Outpatient Fllw-up and Rehspitalizatin Rates, Clusa MHP and State Oupatient MHP Outpatient State Rehspitalizatin MHP CY14 CY15 Rehspitalizatin State 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Figure 4B. 30-Day Outpatient Fllw-up and Rehspitalizatin Rates, Clusa MHP and State Oupatient MHP Outpatient State Rehspitalizatin MHP CY14 CY15 Rehspitalizatin State Page 19

20 DIAGNOSTIC CATEGORIES Figures 5A and 5B cmpare the breakdwn by diagnstic categry f the statewide and MHP number f beneficiaries served and ttal apprved claims amunt, respectively, fr CY15. MHP self-reprted percent f cnsumers served with cccurring (substance abuse and mental health) diagnses: 20% 35% Figure 5A. Diagnstic Categries, Beneficiaries Served 30% 25% 20% 15% 10% 5% 0% Depressin Psychsis Disruptive Biplar Anxiety Adjustment Other Deferred Clusa CY15 State CY15 35% Figure 5B. Diagnstic Categries, Ttal Apprved 30% 25% 20% 15% 10% 5% 0% Depressin Psychsis Disruptive Biplar Anxiety Adjustment Other Deferred Clusa CY15 State CY15 Page 20

21 PERFORMANCE MEASURES FINDINGS IMPACT AND IMPLICATIONS Access t Care The MHP s verall penetratin rate has declined each year between CY13 and CY15 similar t the trend experienced verall and acrss small rural MHPs. Its penetratin rate has been higher than statewide and small rural MHPs during the same perid. The MHP s fster care penetratin rate is similar t small rural MHPs and lwer than the statewide. The MHP s Hispanic penetratin rate is the same as small rural MHPs and higher than statewide. The MHP s Hispanic penetratin rates have declined between CY13 and CY15 similar t the dwnward trend experienced statewide. Timeliness f Services The MHP s 7-day and 30-day utpatient fllw-up rates after discharge frm psychiatric inpatient episdes were higher than statewide. Quality f Care The MHP s percentage f high-cst beneficiaries was similar t statewide and shwed an increase frm CY14. Its percentage f HCB claim dllars was higher than statewide and dubled frm CY14 t CY15. The MHP s average apprved claims per beneficiary served was lwer than statewide and higher than small rural MHP s. The MHP s average apprved claims per beneficiary served has increased cnsistently fr the three years between CY13 and CY15. The MHP s average apprved claims per beneficiary fr fster care is higher than bth statewide and small rural MHPs. The MHP s average apprved claims per beneficiary fr Hispanics is higher than small rural MHPs but lwer than statewide. Like statewide, a primary diagnsis f Depressive Disrders accunted fr the largest number f beneficiaries served by the MHP. Hwever, the percentage was higher than statewide. The MHP had a higher percentage f beneficiaries with primary diagnsis f anxiety than statewide. The MHP appears t use Deferred Diagnsis slightly lwer than statewide. Cnsumer Outcmes Nne nted. Page 21

22 PERFORMANCE IMPROVEMENT PROJECT VALIDATION A Perfrmance Imprvement Prject (PIP) is defined by CMS as a prject designed t assess and imprve prcesses, and utcmes f care that is designed, cnducted and reprted in a methdlgically sund manner. The Validating Perfrmance Imprvement Prjects Prtcl specifies that the EQRO validate tw PIPs at each MHP that have been initiated, are underway, were cmpleted during the reprting year, r sme cmbinatin f these three stages. DHCS elected t examine prjects that were underway during the preceding calendar year COLUSA MHP PIPS IDENTIFIED FOR VALIDATION Each MHP is required t cnduct tw PIPs during the 12 mnths preceding the review. CalEQRO reviewed and validated tw MHP submitted PIPs as shwn belw. Table 3A PIPs Submitted PIPs fr Validatin # f PIPS PIP Titles Clinical PIP 1 Recvery Nn-Clinical PIP 1 Parent Interventin Table 3B lists the findings fr each sectin f the evaluatin f the PIPs, as required by the PIP Prtcls: Validatin f Perfrmance Imprvement Prjects. 4 Table 3B PIP Validatin Review Step PIP Sectin Validatin Item 1 Selected Study Tpics Item Rating* Clinical PIP Nn- Clinical PIP 1.1 Stakehlder input/multi-functinal team M M Analysis f cmprehensive aspects f enrllee needs, care, and services Brad spectrum f key aspects f enrllee care and services 1.4 All enrlled ppulatins M M 2 Study Questin 2.1 Clearly stated NM M M M M M Department f Health and Human Services, Centers fr Medicare and Medicaid Service Prtcl 3 Versin 2.0, September EQR Prtcl 3: Validating Perfrmance Imprvement Prjects. Page 22

23 Table 3B PIP Validatin Review Step PIP Sectin Validatin Item 3 Study Ppulatin 4 Study Indicatrs Sampling Methds Data Cllectin Prcedures Assess Imprvement Strategies Review Data Analysis and Interpretatin f Study Results Validity f Imprvement Item Rating* Clinical PIP Nn- Clinical PIP 3.1 Clear definitin f study ppulatin M M 3.2 Inclusin f the entire study ppulatin M M Objective, clearly defined, measurable indicatrs Changes in health status, functinal status, enrllee satisfactin, r prcesses f care Sampling technique specified true frequency, cnfidence interval and margin f errr Valid sampling techniques that prtected against bias were emplyed Sample cntained sufficient number f enrllees 6.1 Clear specificatin f data M M 6.2 Clear specificatin f surces f data PM M Systematic cllectin f reliable and valid data fr the study ppulatin Plan fr cnsistent and accurate data cllectin Prspective data analysis plan including cntingencies 6.6 Qualified data cllectin persnnel M M Reasnable interventins were undertaken t address causes/barriers Analysis f findings perfrmed accrding t data analysis plan PIP results and findings presented clearly and accurately Threats t cmparability, internal and external validity Interpretatin f results indicating the success f the PIP and fllw-up M M NM M PM PM M NM UTD 9.1 Cnsistent methdlgy thrughut the study UTD NA 9.2 Dcumented, quantitative imprvement in prcesses r utcmes f care NM M NM NM NA M M NA NA NA PM PM NM M NM NA NA NA NA Page 23

24 Table 3B PIP Validatin Review Step PIP Sectin Validatin Item Imprvement in perfrmance linked t the 9.3 PIP Item Rating* Clinical PIP Nn- Clinical PIP 9.4 Statistical evidence f true imprvement NA NA 9.5 Sustained imprvement demnstrated thrugh repeated measures. *M = Met; PM = Partially Met; NM = Nt Met; NA = Nt Applicable; UTD = Unable t Determine NA NA NA NA Table 3C gives the verall rating fr each PIP, based n the ratings given t the validatin items. Table 3C PIP Validatin Review Summary Summary Ttals fr PIP Validatin Clinical PIP Nn- Clinical PIP Number Met Number Partially Met 3 2 Number Nt Met 6 2 Number Applicable (AP) (Maximum = 28 with Sampling; 25 withut Sampling) Overall PIP Rating ((#Met*2)+(#Partially Met))/(AP*2) 60.42% 82.35% CLINICAL PIP RECOVERY The MHP presented its study questin fr the clinical PIP as fllws: Can the Milestnes f Recvery (MORS) rating scale be used t effectively guide treatment interventins? Date PIP began: January 2015 Status f PIP: Active and nging Cmpleted Page 24

25 Inactive, develped in a prir year Cncept nly, nt yet active Submissin determined nt t be a PIP N PIP submitted The MHP, as a result f its participatin in the Advancing Recvery Cllabrative, cllected MORS scres fr all adult cnsumers beginning in January Higher than expected MORS scres fr 13% f the study ppulatin led t the MHP fcusing n transitining cnsumers t lwer levels f care. The MHP aimed t imprve utcmes fr adults, including graduating frm services f the MHP. The PIP examined which interventins assisted cnsumers in recvery as measured using the Milestnes f Recvery utcme tl (MORs), leading t shrtened and cnsistent time t transitin t lwer level levels f care. The MHP cllected MORS scres mnthly and fund that individuals at MORS 7 were able t transitin ut f services, as well as thse at MORS 6. The MHP then fcused n individuals with a MORS scre f 5. In cntrast t the MORS 6 and 7 individuals, these individuals were nt able t mve quickly up the MORS scale. These individuals stayed at MORS 5 thrughut the measurement cycle. Previusly successful Interventins were dubled (Strength Assessment and Grup Supervisin). Even with these interventins, little mvement was seen fr the MORS 5 individuals. The MHP is nw testing the utcme tls that may be mre sensitive t smaller changes (PHQ 9 and the GAD 7) fr individuals with depressin r anxiety diagnses as they can be administered mre frequently. The study questin design did nt lend itself t be answerable thrugh the PIP prcess. Relevant details f these issues and recmmendatins are included within the cmments fund in the PIP validatin tl. Technical assistance was prvided t the MHP by CalEQRO. Recmmendatins include a discussin n hw the study questin design did nt lend itself t be answerable thrugh the PIP prcess. Recmmend that fr next PIP, set up questin s that it is quantifiable and cntains indicatrs, i.e. Will interventin imprve (symptms/prblem) as measured by utcme tl? As it stands, the PIP s design des nt allw the MHP t track the new utcme tls and des nt identify which interventins imprve which symptms. Clarificatin n whether MORs 6s and 7s entered at the 5 level when they came in fr services initially. This wuld allw fr a meaningful cmparisn regarding hw lng it tk t get t the next level. Fr next steps, the MHP plans t amend its questin, evaluate the impact f strengths assessment n leveling up using the MORs, in cnjunctin with the anxiety and depressin inventry tls. Recmmended that this PIP be cnsidered cmpleted rather than ging int year 3 f this PIP. Instead, develp a new PIP evaluating clinical utcmes pst interventin using the anxiety and depressin assessments. As it stands, this prcess didn t make an imprvement fr clients as they were still discharged fr the same reasn which was nt a result f better implementatin f the MORS. Rather, the PIP prvided mre infrmatin regarding level f care and helped infrm the administrative prcess f discharge/level f care. Page 25

26 NON-CLINICAL PIP PARENT INTERVENTION The MHP presented its study questin fr the nn-clinical PIP as fllws: Will the prvisin parental interventin result in shrter duratin f care, higher levels f parent satisfactin with care, and imprved functining as measured by the Child Behavir Checklist? Date PIP began: August, 2015 Status f PIP: Active and nging Cmpleted Inactive, develped in a prir year Cncept nly, nt yet active Submissin determined nt t be a PIP N PIP submitted This PIP is at the beginning f its secnd year. Year 1 fcused n shrtening duratin f services with the additin f cnjint family services as a standard prtcl. The secnd year f the PIP is aimed at evaluating the impact f cnjint (autmatically assigned) family interventins, specifically Parent-Child Interactin Therapy (PCIT) n client functining. The verarching gal f this PIP will be t imprve child functining in many areas relevant t the child s prgress tward resilience. The MHP analyzed data that cmpared the length f treatment fr children receiving family therapy f any kind r duratin beynd intake as part f their treatment with children wh had nt. The MHP lked at this data fr fiscal year 2014/2015 and fund that 145 children had received family therapy, where 62 children had nt. When cmparing time in treatment fr the tw grups, the MHP fund that children receiving any frm f family invlvement (145 children) averaged mnths in care and thse that received n frm f family invlvement (63 children) averaged mnths. Remeasurement has prven t be a challenge. The MHP had difficulty rlling ut the CBCL due t scring challenges and difficulty in getting the scre entered int the EHR. Additinally, the MHP discvered that they were nt getting discharge CBCL scres because families were chsing t withdraw frm care when the clinician began discussing the end f treatment. Further, n ne has been in care fr a full year since the implementatin f the CBCL. The MHP experienced similar issues with the parent satisfactin survey. A way t amelirate this type f issue wuld be t cllect data n a quarterly basis. Relevant details f these issues and recmmendatins are included within the cmments fund in the PIP validatin tl. Page 26

27 Technical assistance was prvided t the MHP by CalEQRO. Feedback included acknwledgment that the PIP fcus seemed t naturally shift t evaluating the PCIT interventin. The study questin needed clarificatin s that it was measurable an bjective. The interventins listed are nt truly the interventin, but rather assigning all mild t mderate clients t PCIT and all mderate t severe clients t individual as a matter f standard prcedure. It was recmmended that the MHP then cmpare the CBCL scres f frm a baseline at start f treatment after a set perid f time (i.e. 3 mnths). This wuld allw the cunty t see the true effectiveness f the new administrative prcedure. Data shuld be cllected and analyzed quarterly. PERFORMANCE IMPROVEMENT PROJECT FINDINGS IMPACT AND IMPLICATIONS Access t Care If the MHP is successful identifying and implementing interventins that mve clients alng the cntinuum f care, and decrease the level f service prvided, mre space fr new clients wuld be available. Timeliness f Services If the MHP is successful identifying and implementing interventins that mve clients alng the cntinuum f care, and decrease the level f service prvided, timeliness fr appintments fr new clients wuld imprve with the new slts available. If client functining imprves and they are able t transitin ut f service, mre timely appintments are available fr new clients cming in. Quality f Care Interventins which are effective in helping clients t imprve functining cntribute t the quality f services prvided by the MHP and cnvey the message f hpe. Engaging parents in children s treatment imprves quality f care fr children. Cnsumer Outcmes Engaging parents in children s treatment results in better utcmes fr child clients. Using anxiety and depressin symptm inventries wuld allw fr mre nuanced assessment f client utcmes and wuld prve useful fr evaluating client functining, invlvement and perceptins f treatment. Page 27

28 PERFORMANCE & QUALITY MANAGEMENT KEY COMPONENTS CalEQRO emphasizes the MHP s use f data t prmte quality and imprve perfrmance. Cmpnents widely recgnized as critical t successful perfrmance management include an rganizatinal culture with fcused leadership and strng stakehlder invlvement, effective use f data t drive quality management, a cmprehensive service delivery system, and wrkfrce develpment strategies that supprt system needs. These are discussed belw. Access t Care As shwn in Table 4, CalEQRO identifies the fllwing cmpnents as representative f a brad service delivery system that prvides access t cnsumers and family members. An examinatin f capacity, penetratin rates, cultural cmpetency, integratin and cllabratin f services with ther prviders frms the fundatin f access t and delivery f quality services. Table 4 Access t Care Cmpnent Cmpliant (FC/PC/NC)* Cmments 1A Service accessibility and availability are reflective f cultural cmpetence principles and practices FC Cultural, ethnic, racial, and linguistic needs are assessed at intake. Over the last year, the MHP priritized hiring bilingual and bicultural staff as well as identifying current staff fr resurces within. Treatment utcmes are evaluated, hwever, the MHP wuld benefit frm additinal staffing fr analysis. The MHP develped the Cultural Vida prgram and prvided 12 presentatins within the cmmunity beginning Octber Frm there, the MHP cllabrated with the district level English learner advisry cmmittee (DLAC), and English learner advisry cmmittee (ELAC), bth migrant educatin prgrams. The Cultural Vida Prgram is wrking t identify natural leaders t develp a Prmtres Prgram. The Cultural Vida prgram are wrking with the cmmunity and the ffice f educatin with their presentatin hw mental health pertains t yu. The need fr this prgram was identified thrugh a survey where peple said they were aware f mental health but didn t knw hw it pertained t them. With this presentatin, there will be a pre/pst survey The MHP is using MHSA mney t supplement staff salaries s that all staff can are invlved in utreach and engaging the cmmunity. 1B Manages and adapts its capacity t meet beneficiary service needs FC The MHP tracks clients cming in fr appintments and als assesses the need fr bilingual services. The MHP utilizes an ffice assistant wh speaks Spanish and assists psychiatry. The previus preventin crdinatr left. As a result, the MHP rerganized duties Page 28

29 Table 4 Access t Care Cmpnent Cmpliant (FC/PC/NC)* Cmments and structure f the prgram. A Spanish speaking intern became a permanent cunty psitin. The MHP als drew frm the children s department and added anther intern fr this prgram wh als speaks Spanish. 1C Integratin and/r cllabratin with cmmunity based services t imprve access FC The psychiatry department wrks with primary care prviders in the area. There is als a cllabratin fr suicide preventin training fr medical staff. They d nt have cntract prviders in the area. The MHP has integrated AOD services with mental health. They participate in jint trainings. Trainings were ffered t public health but they did nt attend. One Stp manages the transitinal husing fr CalWrks. Hwever, there is n shrt term r lng term husing in the cunty. In April 2016, the lcal hspital went bankrupt and clsed abruptly. There is n access t emergency rm services. Glenn and Sutter-Yuba cunties are assisting with 5150s. Glenn Cunty prvides medical clearance fr thse assessed. And Sutter Yuba will accept 5150s with reimbursement by Clusa Cunty. The MHP cntinues t cllabrate with law enfrcement agencies fr crisis services. Hwever, the MHP s request t Califrnia Highway Patrl (CHP) t limit 5150s t Clusa residents was unsuccessful. CHP still brings ut f twn flks t This impacts crisis staff which is an infrmal mbile crisis unit as there is n fficial funding stream r designated vehicle. Timeliness f Services *FC =Fully Cmpliant; PC = Partially Cmpliant; NC = Nn-Cmpliant As shwn in Table 5, CalEQRO identifies the fllwing cmpnents as necessary t supprt a full service delivery system that prvides timely access t mental health services. The ability t prvide timely services ensures successful engagement with cnsumers and family members and can imprve verall utcmes while mving beneficiaries thrughut the system f care t full recvery. Table 5 Timeliness f Services Cmpnent Cmpliant (FC/PC/NC)* Cmments 2A Tracks and trends access data frm initial cntact t first appintment FC The MHP sets a standard f 10 days, with 100% f its appintments meeting this standard. The range is 0-9 Page 29

30 Table 5 Timeliness f Services Cmpnent Cmpliant (FC/PC/NC)* Cmments days fr bth adults and children with an average f 3 days. 2B Tracks and trends access data frm initial cntact t first psychiatric appintment PC The MHP mnitrs time frm assignment t psychiatry (MD) t first psychiatry appintment. The MHP sets a standard f 45 days, with 100% f its appintments meeting this standard. The range is 2-33 days fr with an average f 16.6 days. Adult and children services are nt tracked separately. In light f the change in plicy (fall 2015) regarding medicatin management by children s psychiatry and the eliminatin f meds nly practice (all children receiving medicatins are required t be in services), it is recmmended that this measure be tracked and trended separately. 2C Tracks and trends access data fr timely appintments fr urgent cnditins FC The MHP reprted a gal f.125 days (3 hurs) wait times fr urgent appintments and that they met this gal 80% f the time, with an average f.125 days. 2D Tracks and trends timely access t fllw up appintments after hspitalizatin FC The MHP reprted 24 hspitalizatins (22 adult, 2 yuth) and that all clients received a fllw up appintment within 7 days f discharge. The MHP sets a gal f 7 days. The average length f time fr a fllw up appintment with clinical staff was 1.7 days, with 100% f the appintments meeting the standard. Last year, the MHP reprted 8 hspitalizatins (7 adults, 1 child) frm January thrugh June 2015 (6 mnths). Hspitalizatin rates increased this last year, even taking int accunt that the data fr 15/16 spanned 12 mnths rather than last year when the MHP reprted n 6 mnths f data. 2E Tracks and trends data n re-hspitalizatins FC The MHP reprts that f the 24 hspitalizatins (22 adult, 2 yuth), n clients were re-hspitalized. The MHP sets a gal f 0 rehspitalizatins within 30 days f discharge. 2F Tracks and trends N Shws NC The MHP reprts that they are just beginning t extract data n this measure and that they have nt yet develped a frmat fr tracking/trending. *FC = Fully Cmpliant; PC = Partially Cmpliant; NC = Nn-Cmpliant Page 30

31 Quality f Care As shwn in Table 6, CalEQRO identifies the fllwing cmpnents f an rganizatin that is dedicated t the verall quality f care. Effective quality imprvement activities and data-driven decisin making require strng cllabratin amng staff (including cnsumer/family member staff), wrking in infrmatin systems, data analysis, clinical care, executive management, and prgram leadership. Technlgy infrastructure, effective business prcesses, and staff skills in extracting and utilizing data fr analysis must be present in rder t demnstrate that analytic findings are used t ensure verall quality f the service delivery system and rganizatinal peratins. Table 6 Quality f Care Cmpnent Cmpliant (FC/PC/NC)* Cmments 3A Quality management and perfrmance imprvement are rganizatinal pririties FC The MHP hired a new Quality Imprvement Crdinatr wh may perfrm analysis f data such as penetratin rates, billing, access, demgraphics, etc. 3B Data are used t infrm management and guide decisins FC Based n intake tracking data n demgraphics, client numbers, language and type f service need, the MHP changed its intake schedule frm 2 clinicians t 3, including a Spanish speaker. The MHP assesses client utcmes using the Milestnes f Recvery scale (MORs) fr all adults nce per mnth via reprting frm the EHR. The MHP will be develping its trending ability with its new QI and EHR crdinatr. They are als wrking t get a depressin inventry tl (PHQ9) and anxiety inventry tl (GAD7) int t the EHR. The MHP is using the Child Behavir Checklist (CBCL) fr children. All children receive the CBCL with results in the EHR. The MHP is beginning t lk at grup data. 3C Evidence f effective cmmunicatin frm MHP administratin PC The MHP hlds a variety f meetings fr cmmunicatin bth within the MHP and in the cmmunity. These include quarterly all-staff, weekly clinical teams, Katie A., multidisciplinary teams each mnth, QIC meets every ther mnth. Leadership/management meets weekly. The MHP has a mnthly newsletter in Spanish and English They als have Facebk pages fr adults/children s services. Client leadership mnthly meets t versee and run the drp-in center. Peers Page 31

32 Table 6 Quality f Care Cmpnent Cmpliant (FC/PC/NC)* Cmments Helping Peers meets twice per mnth t prvide infrmatin n the wellness center. Clinical staff participatin during the review was limited and nt all staff wh wished t participate were permitted. The MHP frmed a representative staff advisry cmmittee that meets regularly t identify challenges in prviding effective services and t evaluate cnsumer/staff satisfactin. Hwever, clinical staff reprted that while the pprtunity t prvide ideas and feedback exists, they felt that they had little input in prgram and system planning. The cnsensus amng line staff was that mrale is very lw, citing a punitive system if prductivity is nt met (either by a little r a lt). The feeling was that there is a big discnnect with what upper management perceives is happening vs. what is really ging n. The MHP did make changes t its all staff meetings and hw the meeting is run. The agenda is psted befre the meeting s that thse wh wish t prvide feedback can. There are nw standing items at each meeting. Mst recently, there was a staff survey regarding hw acknwledgements are made. 3D Evidence f stakehlder input and invlvement in system planning and implementatin PC CFM participants are actively invlved in running the wellness center. Because f the lw attendance the prir year at the MHSA stakehlder planning meeting, this year, the MHP alternatively held meetings within each cmmunity Maxwell, Arbuckle, Williams and Clusa. Spring They were able t update the plan peple participated. During Mental Health Awareness Mnth, May 2016, the MHP held 4 events targeting specific grups mst f which had lw turnut. Hwever, the mst successful event was a Safe Haven Peer Walk In with Veterans centered n a car shw with 33 cars. The MHP utreached and raised $900. There were participants. Page 32

33 Table 6 Quality f Care Cmpnent Cmpliant (FC/PC/NC)* Cmments A staff survey frm 2015 prvided feedback that cmmunicatin was pr regarding feedback and subsequent changes. The MHP states that they have made sme changes due t suggestins frm staff, hwever, feedback frm staff indicate that there are still issues regarding hw feedback is received and whether it is acted upn effectively by leadership. 3E Evidence f strng cllabrative partnerships with ther agencies and cmmunity based services FC As stated abve, the MHP has strng cllabrative relatinships with cmmunity agencies such as law enfrcement (Clusa Cunty Sheriff, Clusa Plice Department., Williams Plice Department, and Califrnia Highway Patrl) as well as prbatin, and health and human services. The MHP als has a rbust yuth prgram thrugh the schl district. The cunty has partnered with Glenn and Sutter-Yuba cunties t cver the gap in mental health services previusly prvided by the lcal hspital, which clsed abruptly in April, F Evidence f a systematic clinical Cntinuum f Care FC The MHP uses the MORS as an utcme tl in adult services. This instrument is scred mnthly n MORS Mnday which is the last Mnday f the mnth. As nted in the PIP write up, this tl is used t measure cnsumer recvery status, and t assist with treatment planning. The PHQ 9 was tested in the adult divisin as a quick measurement tl fr depressin; and the GAD 7 as a quick measurement tl fr generalized anxiety. The MHP recently added the use f the Child Behavir Check List (CBCL) in the Child divisin. This tl is administered at intake, annually and at discharge. T date n discharge CBCL s have been recrded. Regarding, medicatin mnitring, the QI plan referenced that the MHP had nt been cmpliant in having prescribing practices reviewed since the departure f psychiatrist Dr. Samsn. The MHP added this as an actin item t the annual plan. 3G Evidence f individualized, client-driven treatment and recvery PC The MHP s drp-in center mved in June 2016 t a larger space. The MHP wanted t maintain the peer drp in center but within the cntext f wellness and recvery. The center was renamed Safe Haven Page 33

34 Table 6 Quality f Care Cmpnent Cmpliant (FC/PC/NC)* Cmments Wellness & Recvery Center. In additin t drp-in services, the center nw has grups nutritin, mindfulness, and walking. Staff leads grups, as well as peers. Wellness Recvery Actin Planning (WRAP) will be starting as sme staff are trained WRAP leaders. While the MHP utilizes depressin and anxiety inventries with clients in sessin, infrmatin n hw cnsumers are engaged in their wn treatment planning and hw a cnsumer uses level f functin scales/tls, etc. themselves was nt prvided. 3H Evidence f cnsumer and family member emplyment in key rles thrughut the system FC Peer Specialist (a full time benefited psitin) manages greeter psitins at Safe Haven. Greeters receive stipends. The peer specialist recently cmpleted a 13 mnth training n Peer Cre Cmpetency thrugh the Nrthern Califrnia Wrkfrce Educatin and Training (WET) alliance and will be implementing thse cmpetencies at the wellness center. There are 5 part time drivers and safety supprt staff. They are n call, wrk n mre than 20 hurs per week. 3I Cnsumer run and/r cnsumer driven prgrams exist t enhance wellness and recvery FC The MHP s wellness center is the Safe Haven Wellness & Recvery Center. During the site visit, there were at least 3 cnsumers there; a full-time CFM, and 2 parttime CFM s. The center is pen t whmever cmes thrugh the drs. Service and prgram infrmatin were available at the desk. The perating hurs are Mnday thrugh Saturday 8:30-4:30 pm. Clients receive a calendar f activities in their intake packet at assessment. 3J Measures clinical and/r functinal utcmes f cnsumers served FC The MHP assesses client utcmes using Milestnes f Recvery Scale (MORs) fr all adults nce per mnth via reprting frm the EHR. The MHP will develping its trending ability with its new QI and EHR crdinatr. They are als wrking t get a depressin inventry tl (PHQ9) and anxiety inventry tl (GAD7) int the EHR. The MHP is using the Child Behavir Checklist (CBCL) fr children. All children receive the CBCL with results in the EHR. This was Page 34

35 Table 6 Quality f Care Cmpnent Cmpliant (FC/PC/NC)* Cmments implemented August 2015 as part f the medical necessity frm. The MHP is beginning t lk at gruped data. 3K Utilizes infrmatin frm Cnsumer Satisfactin Surveys PC The MHP des prvide the perceptin and utcmes survey but des nt analyze the data prir t State submissin. The State sends raw data back fr review. The MHP des retain the cmments. They added parenting classes as a result f POQI feedback. *FC = Fully Cmpliant; PC = Partially Cmpliant; NC = Nn-Cmpliant KEY COMPONENTS FINDINGS IMPACT AND IMPLICATIONS Access t Care The MHP has added bilingual Spanish speaking staff: Tw added interns, a clinician and a QI Crdinatr in August 2016, with extra help transprtatin psitins added in January In April 2016, the lcal hspital went bankrupt and clsed abruptly. There is n access t emergency rm services. The MHP cllabrates with Glenn Cunty t prvide medical clearance fr thse needing assessment while Sutter Yuba MHP accepts Clusa Cunty 5150s with reimbursement by Clusa Cunty. The MHP is als cllabrating with law enfrcement t assist cnsumers in crisis. The MHP has an infrmal mbile crisis unit as there is n fficial funding stream r designated vehicle. Timeliness f Services The MHP has reprted n change fr length f time frm first request fr service t first clinical assessment frm FY15-16 t FY16-17 average length f time is 3 days surpassing their gal f 10 days. The MHP has reduced their average length f time frm first request f service t first psychiatric appintment frm days fr FY15-16 t 16.6 days fr FY16-17 fr all cnsumers. The MHP des nt track n shws stating they nly recently have had the capability t track electrnically. Page 35

36 Quality f Care Based n intake tracking data n demgraphics, language, and type f service needed, the MHP changed its intake schedule team frm 2 clinicians t 3 including a Spanish speaker. They are als wrking t get a depressin inventry tl (PHQ9) and anxiety inventry tl (GAD7) int the EHR. The MHP recently hired a new QI Crdinatr wh will be respnsible fr data analysis and trending, including reprts based n data frm the Client Service Infrmatin (CSI), Califrnia Outcmes Measurements System (CalOMS), penetratin rates, billing, walk in appintments, demgraphics, crisis reprts regarding cntacts, utcmes, and hspitalizatin. Cnsumer Outcmes The MHP is using the Child Behavir Checklist (CBCL) fr children. All children receive the CBCL with results in the EHR. The MHP is beginning t lk at grup data. The MHP assesses client utcmes using Milestne f Recvery (MORs) fr all adults nce per mnth via reprting frm the EHR. The MHP plans t develp its trending ability with its new QI and EHR crdinatr. The MHP did a Clinical PIP utilizing the MORs t assess hw interventins assist cnsumers in recvery. Page 36

37 CONSUMER AND FAMILY MEMBER FOCUS GROUP(S) CalEQRO cnducted ne (1) 90-minute fcus grup with cnsumers and family members during the site review f the MHP. As part f the pre-site planning prcess, CalEQRO requested ne (1) fcus grup with 8 t 10 participants each, the details f which can be fund in each sectin belw. The Cnsumer/Family Member Fcus Grup is an imprtant cmpnent f the CalEQRO Site Review prcess. Obtaining feedback frm thse wh are receiving services prvides significant infrmatin regarding quality, access, timeliness, and utcmes. The fcus grup questins specific t the MHP reviewed and emphasized the availability f timely access t care, recvery, peer supprt, cultural cmpetence, imprved utcmes, and cnsumer and family member invlvement. CalEQRO prvided gift certificates t thank the cnsumers and family members fr their participatin. CONSUMER/FAMILY MEMBER FOCUS GROUP 1 CalEQRO requested a culturally diverse grup f adult beneficiaries and parents/caregivers f child/yuth beneficiaries including a mix f existing and new clients wh have initiated/utilized services within the past 12 mnths. The fcus grup was held at the MHP ffices in Willws, lcated at 162 E Carsn Street, Clusa, CA The grup was cmprised f 7 wmen and 3 men, 6 f which received services in the last year. Number f participants: 10 Fr the six (6) participants wh entered services within the past year, they described their experience as the fllwing: Regarding timeliness f first cntact t assessment, the respnses varied frm the next day, ne week, r within tw weeks. Regarding timeliness f assignment t and meeting with a therapist, respnses als varied, frm ne week, a cuple f weeks, t a few weeks. General cmments regarding service delivery that were mentined included the fllwing: The cnsensus f the grup was then even if in crisis, it takes tw t three weeks t get help and by that time, the crisis is ver. Impacted by staff turnver r leave, reassignment f therapists takes a lng time. Public transprtatin is unreliable. Recmmendatins fr imprving care included the fllwing: Page 37

38 Timely respnse in rescheduling missed appintments r assignment t therapist after in-take. Fcus grups fr veterans. Prvide intakes mre than nce-a-week. Prvide transprtatin t uter areas. Interpreter used fr fcus grup 1: N Yes Language(s): Spanish CONSUMER/FAMILY MEMBER FOCUS GROUP FINDINGS IMPLICATIONS Access t Care Clients experiences with accessing initial care were psitive. Hwever, there is incnsistencies in the prcess fr being assigned a therapist and fr nging services. Transprtatin frm uter areas cntributes t service access issues. Timeliness f Services Services impacted by staff shrtages make it challenging fr clients t reschedule appintments in a timely manner. Clients reprted that access t crisis services was nt timely. Quality f Care When receiving services, verall, fcus grup members reprted satisfactin with the services, and felt they were getting better. Cnsumer Outcmes N infrmatin prvided. Page 38

39 INFORMATION SYSTEMS REVIEW Knwledge f the capabilities f an MHP s infrmatin system is essential t evaluate the MHP s capacity t manage the health care f its beneficiaries. CalEQRO used the written respnse t standard questins psed in the Califrnia-specific ISCA, additinal dcuments submitted by the MHP, and infrmatin gathered in interviews t cmplete the infrmatin systems evaluatin. KEY ISCA INFORMATION PROVIDED BY THE MHP The fllwing infrmatin is self-reprted by the MHP in the ISCA and/r the site review. Table 8 shws the percentage f services prvided by type f service prvider: Table 8 Distributin f Services by Type f Prvider Type f Prvider Distributin Cunty-perated/staffed clinics 99.5% Cntract prviders 0.5% Netwrk prviders 0% Ttal 100% Percentage f ttal annual MHP budget is dedicated t supprt infrmatin technlgy peratins: (includes hardware, netwrk, sftware license, IT staff) 7.2% Cnsumers have n-line access t their health recrds either thrugh a Persnal Health Recrd (PHR) feature prvided within EHR r a cnsumer prtal r a third-party PHR: Yes In Test/Pilt Phase N MHP currently prvide services t cnsumers using an tele-psychiatry applicatin: Yes In Test/Pilt Phase N If yes, the number f remte sites currently peratinal: 0 Page 39

40 MHP self-reprted technlgy staff changes since the previus CalEQRO review (FTE): Table 9 Summary f Technlgy Staff Changes Number IS Staff Number f New Hires Number f Staff Retired, Transferred, Terminated Current Number f Unfilled Psitins MHP self-reprted data analytical staff changes since the previus CalEQRO review (FTE): Table 10 Summary f Data Analytical Staff Changes Number Data Analytical Staff Number f New Hires Number f Staff Retired, Transferred, Terminated Current Number f Unfilled Psitins The fllwing shuld be nted with regard t the abve infrmatin: The MHP has recruited a QI Crdinatr wh is a licensed clinician t begin in August Their primary jb respnsibilities may encmpass mre intensive analytical tasks. CURRENT OPERATIONS The MHP cntinues t implement the Cerner Behaviral Health System (CCBH) via an Applicatin Service Prvider (ASP) cntract with Kings View Behaviral Health. Table 11 lists the primary systems and applicatins the MHP uses t cnduct business and manage peratins. These systems supprt data cllectin and strage, prvide electrnic health recrd (EHR) functinality, prduce Shrt-Dyle/Medi-Cal (SD/MC) and ther third party claims, track revenue, perfrm managed care activities, and prvide infrmatin fr analyses and reprting. Page 40

41 Table 11 Primary EHR Systems/Applicatins System/Applicatin Functin Vendr/Supplier Cerner Cmmunity Behaviral Health (CCBH) Client Data CCBH - ATP Years Used Operated By Practice Management Cerner 5 Kings View Assessment and Treatment Plan Cerner 5 Kings View CCBH - Scheduling Appintment Scheduler Cerner 5 Kings View CCBH Dctr's Hmepage Clinical and eprescribing Cerner 5 Kings View CCBH-Clinician s Hmepage Clinical infrmatin and functinality Cerner 5 Kings View PLANS FOR INFORMATION SYSTEMS CHANGE The MHP has n plans fr infrmatin systems change. ELECTRONIC HEALTH RECORD STATUS Table 12 summarizes the ratings given t the MHP fr Electrnic Health Recrd (EHR) functinality. Table 12 Current EHR Functinality Functin System/Applicatin Present Partially Present Rating Nt Present Alerts Cerner x Assessments Cerner x Dcument imaging/strage Cerner EHR x Electrnic signature cnsumer Cerner EHR x Labratry results (elab) Level f Care/Level f Service Cerner EHR x Outcmes MORS, CBCL x Prescriptins (erx) Cerner EHR x Prgress ntes Cerner EHR x Treatment plans Cerner EHR x x Nt Rated Summary Ttals fr EHR Functinality 7 3 Page 41

42 Prgress and issues assciated with implementing an electrnic health recrd ver the past year are discussed belw: The MHP has n current plans t implement elab functinality. The MHP has n current plans t implement electrnic Level f Care/Level f Service Assessments. Cnsumer s Chart f Recrd fr cunty-perated prgrams (self-reprted by MHP): Paper Electrnic Cmbinatin MAJOR CHANGES SINCE LAST YEAR The MHP have met Meaningful Use standards fr Phase 1 and will be able t use Citrix/Cerner fllwing system upgrade. The MHP amended bth the Medical Necessity frm and Discharge Assessment frm t allw entry and scring f the Children s Behaviral Checklist (CBCL), which measures utcmes. PRIORITIES FOR THE COMING YEAR The MHP plans t install a SQL upgrade, fllwed by installatin f CCBH - Prmtin 222. The installatin f Prmtin 222 will enable Ultra-Sensitive Exchange (USX) with client prtal which will allw secure client messaging. The MHP has created tw new assessments t accurately measure utcmes fr anxiety GAD-7 (General Anxiety Disrder 7 Item) and majr depressive disrders PHQ-9 (Patient Health Questinnaire 9 Item). These assessments were sent t Kings View fr uplading in July 2016, but at the time f the review were nt upladed. The MHP is prjecting these will be implemented in mid-august The MHP plans t install and begin implementatin f a Telechart Patient Prtal fllwing system upgrade in September The MHP plan t develp and implement Client Prtal dcuments, client training and prgram security. The MHP cntinues t pursue Meaningful Use, Stage I attestatin fr the EHR incentive prgram with a prjected target date f Octber The MHP plans t begin test, training and implementatin f the nn-axial diagnsis review frm. Page 42

43 OTHER SIGNIFICANT ISSUES The MHP states that sme f the clinicians are unable t perfrm the electrnic prvider signature functin when using their laptps ut in the field. MEDI-CAL CLAIMS PROCESSING Nrmal cycle fr submitting current fiscal year Medi-Cal claim files: Mnthly Mre than 1x mnth Weekly Mre than 1x weekly MHP perfrms end-t-end (837/835) claim transactin recnciliatins: Yes N If yes, prduct r applicatin: Kings View Reprts Methd used t submit Medicare Part B claims: Clearinghuse Electrnic Paper Table 13 - Clusa MHP Summary f CY15 Prcessed SDMC Claims Number Submitted Grss Dllars Billed Dllars Denied Percent Denied Number Denied Grss Dllars Adjudicated Claim Adjustments Grss Dllars Apprved 14,529 $2,744,177 $31, % 255 $2,712,760 $66,501 $2,646,259 Nte: Includes services prvided during CY15 with the mst recent DHCS prcessing date f May 19,2016 INFORMATION SYSTEMS REVIEW FINDINGS IMPLICATIONS Access t Care The MHP mandated use f CCBH Scheduler t prduce weekly reprts t determine what percentage f cnsumers are walk-ins withut appintments. Page 43

44 The MHP did nt delineate between adults and children when tracking length f time frm initial cntact t first psychiatric appintment fr FY The MHP did delineate between adults and children fr FY The MHP reprts this was due t lsing their child psychiatrist in June Timeliness f Services The MHP des nt track and trend n shws. Hwever, the MHP nted that they nly recently were able t extract data frm their EHR. The MHP wuld like directin in tracking and trending frm ther cunties as well as dialgue n what ther cunties interventins have been successful t reduce their n shw rate. Quality f Care The MHP plans t install SQL upgrade, fllwed by CCBH Prmtin 222, and then Ultra-Sensitive Exchange with Client Prtal. The MHP has plans t develp and implement Client Prtal dcuments, client training and prgram security fllwing. The MHP has recruited a Quality Imprvement Crdinatr wh is a licensed clinician t begin in August Her primary jb respnsibilities may encmpass mre intensive data analytical tasks. Cnsumer Outcmes The MHP amended bth the Medical Necessity frm and Discharge Assessment frm t allw entry and scring f the Children s Behaviral Checklist (CBCL), which measures utcmes. The MHP did a Clinical PIP n utilizing the MORs t assess hw interventins assist cnsumers in recvery. Page 44

45 SITE REVIEW PROCESS BARRIERS The fllwing cnditins significantly affected CalEQRO s ability t prepare fr and/r cnduct a cmprehensive review: Review planning was challenging as the MHP s Cmpliance Officer/Cnsultant wrks ne day per week, with cmmunicatin being limited t that day. Further, n the date f the review and due t unfreseen circumstances, the Cmpliance Officer/Cnsultant was nt able t attend. Alternatively, a cnference call was held the fllwing week fr further discussin. Page 45

46 CONCLUSIONS During the FY16-17 annual review, CalEQRO fund strengths in the MHP s prgrams, practices, r infrmatin systems that have a significant impact n the verall delivery system and its supprting structure. In thse same areas, CalEQRO als nted pprtunities fr quality imprvement. The findings presented belw relate t the peratin f an effective managed care rganizatin, reflecting the MHP s prcesses fr ensuring access t and timeliness f services and imprving the quality f care. STRENGTHS AND OPPORTUNITIES Access t Care Strengths: With its Cultura Vida prgram, the MHP has a rbust utreach prgram in the Hispanic cmmunity, with ver 12 presentatins n services and mental health issues. The MHP has frged strng cllabrative relatinships with bth Glenn and Sutter-Yuba MHPs t serve Clusa Cunty cnsumers pst hspital clsure. Opprtunities: The MHP has been experiencing difficulties with its crisis prtcl since April 2016 with the clsure f the nly hspital in the cunty. The MHP des nt have a frmalized cultural cmpetence cmmittee, nr has it updated its Cultural Cmpetency Plan since FY11/12. Timeliness f Services Strengths: The MHP is respnsive in prviding intake assessments and respnding t needs fr urgent appintments, cnsistently meeting their timeliness gals. Opprtunities: The MHP tracked their adult and children separately n the Timely Self- Assessment fr FY15-16 fr the length f time frm assignment after assessment t first psychiatric appintment but did nt track separately fr FY Further, they set a gal f 45 days frm assignment after assessment t first psychiatry appintment. The MHP changed its prtcl fr medicatin-nly clients and eliminated medicatin nly clients fr children s services, requiring that children be in ther services t be eligible fr medicatin services. The MHP has the Page 46

47 pprtunity t track timeliness fr psychiatry fr bth children and adults, separately as befre, t determine the impact f the plicy n bth timeliness f service, access and quality f care. The MHP has a need fr full tracking and trending f crisis data fr effective and efficient staff utilizatin in respnse t hspital clsure issues and meeting crisis caselads. The MHP has a need t evaluate the increase in hspitalizatin rates. The MHP has nt yet develped a frmat fr tracking and trending n shws. Cnsulting with nearby cunties n their criteria and methdlgy fr tracking and trending n shws as well as creating and enfrcing a plicy and prcedure culd be beneficial. Quality f Care Strengths: The MHP hired a new QI Crdinatr wh will be respnsible fr data analysis and trending. In spring f 2016, a cunty administrative fficer was hired, with MHP leadership as a direct reprt. Opprtunities: The MHP has recruited a QI Crdinatr wh is a licensed clinician t begin in August Her primary jb respnsibilities may encmpass mre intensive analytical tasks. The MHP has the pprtunity t imprve bi-directinal cmmunicatin and implementatin f staff feedback fr effective reslutin and invlvement f staff at higher levels f prgram planning and service delivery. Cnsumer Outcmes Strengths: The MHP utilizes bth Milestnes f Recvery Scres (MORS) fr adults and has utilized aggregate data fr their Clinical PIP. Opprtunities: CBCL fr children was installed December 2015 and training was dne in January N aggregate reprting and analysis has been dne as yet with CBCL. Page 47

48 RECOMMENDATIONS Investigate the feasibility f additinal funding r resurces t supprt crisis staff, which currently is an infrmal mbile crisis unit with n vehicle. This is relevant and timely with the recent clsure f the lcal hspital and their ER services. Evaluate cntributing factrs fr the increase in hspitalizatin rates frm FY t FY Use data t mnitr and evaluate cnsumers access t crisis services as it relates t the hspital clsure. Use data n the cntributing factrs t identify gaps in service and ptential slutins. Re-establish and frmalize the Cultural Cmpetence Cmmittee with regularly scheduled meetings t address ther aspects f cultural respnsiveness nt limited t Hispanic utreach, cnsidering underserved ppulatins, and gaps in staff training. Actively recruit representatives frm the cmmunity fr stakehlder participatin and their input. Evaluate current timeliness tracking prcedures, and expand reprting (separately) n bth adult and children s measures fr all measures cntained in the timeliness self-assessment, including n shws. Track timeliness fr psychiatry fr bth children and adults, t determine the impact f the.5 eliminatin f child psychiatry and the implementatin f the plicy requiring cnjint services fr medicatin child clients. Expand EHR functinality thrugh cnsultatin with Kings View and nearby cunties. Quantifiably shw imprvement and expansin thrugh the additin f applicatins, such as elabs, Level f Care/Level f Service, Alerts, etc. Page 48

49 ATTACHMENTS Attachment A: Review Agenda Attachment B: Review Participants Attachment C: Apprved Claims Surce Data Attachment D: CalEQRO PIP Validatin Tls Page 49

50 ATTACHMENT A REVIEW AGENDA Page 50

51 Behaviral Health Cncepts, Inc. - Califrnia EQRO 5901 Christie Ave., Suite 502, Emeryville, CA94608 (855) Clusa Cunty MHP CalEQRO Agenda Day 1 Thursday, August 4, 2016 All sessins lcated at Clusa Cunty Behaviral Health 162 E. Carsn St. Clusa, CA unless therwise nted. Time Activity 8:30 a.m. 10:00 am Opening Sessin Intrductin t BHC MHP Team Intrductins Review f Past Year Significant Changes and Key Initiatives Respnses t Last Year s Recmmendatins Use f Data in the Past Year State Survey (#s, use f) Participants: MHP Leadership, Quality Management Staff, Key Stakehlders Lcatin: ROOM 102 BHC Staff: All 1 0 : 0 0 a m 1 0 : 1 5 a m Break 1 0 : 15 a m 12: 00 p m MHP Clinical Staff Grup Interview 6-8 Clinical line staff, representing varius gegraphical regins f the cunty, including crisis staff, with n supervisry level staff included. Lcatin: ROOM 102 BHC Staff: CE, JL Billing/It Key Staff Grup Interview Recmmendatin FY15-16 ISCA Review Cntinuus Training Initiative CHAT Prgram Implementatin Analysis & Use f Data Kings View/Dashbards Prcess t Review Denied Claims and Claims Recnciliatin EHR Deplyment (new functins in past year, pending enhancements) Cnsumer Persnal Health Recrd Lcatin: SUNSHINE ROOM BHC Staff: JT 1 2 : 00 p m 1:00 p m BHC Wrking Lunch Meeting 1:00 p m 2 : 3 0 p m Cnsumer/Family Member Fcus Grup 8-10 culturally diverse adult beneficiaries representing bth high and lw utilizers f service. Access, Timeliness, Outcmes, and Quality Timeliness Self-Assessment Dcument MHP Timeliness Metrics and Prcedures Access Medi-Cal Penetratin Rates Clusa EQRO Review FY16-17 Final Agenda 1