HHCD Annual Performance Analysis

Transcription

1 Introduction HHCD Annual Performance Analysis Healing Hearts for Community Development is committed to continually improving our organization and service delivery systems. Through an organized system of data collection and information management, HHCD seeks to increase the outcomes of our services, and initiate new methods and/or services that can further support our mission and core values. Information about HHCD s business function and service delivery outcomes are shared with the organization s stakeholders, who are essential partners in the process of supporting continual improvements within the organization. Overview of Performance Improvement System HHCD has an ongoing performance improvement system within its operational structure. That system supports the development of data and information used for business and service delivery decision-making within the ongoing operations of the organization. An overview of HHCD s information management and performance improvement system is as follows: A. Business Function Improvement: HHCD has an information management structure that allows for information/data to be utilized by the Board of Directors and the Executive Team to make decisions that improve the operations of the organization. Information is utilized in making decisions that support the health of the organization. Areas of information key to decisionmaking are as follows: finances, accessibility, resource allocation, corporate compliance, cultural diversity and competency, risk management, human resources, technology, health and safety, field trends, and service delivery. B. Service Delivery Improvement: All HHCD programs maintain an organized data collection system for program improvement. Data is collected at various points in service to measure the effectiveness of services, the efficiency of the provision of services, access to services, and satisfaction with services. HHCD s service delivery performance is managed through the program staff continuing quality improvement meetings to develop quality indicators, collection of the data, utilization of the data/information to make service delivery and program improvements, and reports to the HHCD Executive Team for analysis, consultation, and needed resource allocation.

2 Performance Analysis for The following is an analysis of information management and performance improvement activities for the fiscal year of : A. Business Functions: 1. Financial/Resource Allocation Summary: During the fiscal year, Healing Hearts for Community Development (HHCD) experienced a significant change in the way our addictive disorders services were funded. Prior to this year, HHCD held a cost reimbursement contract with Jefferson Parish Human Services Authority (JPHSA) which paid the salaries of the entire Addiction Team. Over the past two (2) years, the State of Louisiana has engaged a State Management Organization (Magellan) to facilitate the authorization and payment of all Medicaid-funded behavioral health services throughout Louisiana. JPHSA funded our addictive disorder services with their portion of the federal block grant funds which flowed through the Louisiana Office of Behavioral Health. With the start of the fiscal year, the JPHSA contract changed to a fee for service method instead of cost reimbursement. This resulted in a significant learning curve for our Addiction Team. Although HHCD did not receive the total amount of the contract, the Team now has a complete understanding of the new billing processes and HHCD has been awarded the same contract for the fiscal year. HHCD also received a similar fee for service contract from Metropolitan Human Services District (MHSD) to provide addictive disorder services at our St. Bernard Celebration Hope Center site. Again, the Team experienced the same type of learning curve to establish the processes for billing with a fee for service contract. HHCD has received another contract to work with MHSD for the fiscal year. During the fiscal year, HHCD has partnered with the Council on Alcohol and Drug Abuse to implement a Offender Reentry Grant. This has resulted in a contract to pay for the salary and benefits for a full-time substance abuse counselor. This is the first of a three-year grant. Under the HHCD Prevention Program, the contract with MHSD was significantly increased. However, during this school year, unusual difficulties were experienced in working with Orleans and St. Bernard Parishes school systems. As a result, the contract has been reduced. During the fiscal year, the mental health services were primarily funded from a sliding fee scale paid by the clients. HHCD also receives funding from a contract with the Jefferson Parish Office of Community Development to serve clients with HUD approved low to moderate incomes. HHCD also contracts with the Jefferson Parish Department of Juvenile Services to treat clients within the Juvenile Justice System. These services are paid according to a fee for service payment scale. HHCD is also paid 2

3 to provide mental health counselors at five (5) of the Jefferson Parish School-based Health Centers. These services are billed according to the hours worked. HHCD also provides a counselor for Crescent City Christian School based on the hours worked. In addition, HHCD has a contract with the Louisiana Children s Trust Fund to implement the Triple P Positive Parenting Program and Darkness to Light Sexual Abuse Prevention Program on a cost reimbursement basis. In August, 2013, HHCD received a significant settlement from the 2010 BP Oil Spill in Louisiana. These funds allowed HHCD to overcome the deficits experienced from the significant changes in addiction services billing and the difficulties experienced by the Prevention Program. Financial/Resource Allocation Planning and Improvement for Because of the deficits experienced by the Addiction services and Prevention programs, the Mental Health services were not fully funded for HHCD yearly budgets were traditionally developed under one agency umbrella. Starting with the HHCD budget preparation, each department (Addictions, Mental Health, and Prevention) will assist in developing a programmatic budget indicating the various funding sources and expenses. Each month the income and expenses of each department will be analyzed and discussed at the Executive Team meeting prior to the HHCD Board of Directors meeting to make any changes to the budget or service delivery. 1. Accessibility Summary: For the first time in its history, HHCD Executive Team focused on the topic of accessibility, mostly because the integration of the CARF accreditation standards expanded activities in this area beyond what the organization traditionally viewed as accessibility issues. Our first accessibility plan was developed that looked at various topics: architectural, attitudinal, environmental, employment, communication and transportation. During this process of evaluation of current accessibility, an assessment of staff and persons served was completed to help better understand the main challenges that we face in the area of accessibility. We also evaluated as an agency as a whole and then program accessibility. To see the full accessibility plan for , please read the HHCD Accessibility Plan Fiscal Year

4 Accessibility Planning and Improvement for : Full accessibility at the new addictions site at the New Orleans Mission will need to be completed. All external safety inspections and DHH licensure requirements will need to be completed so that residents can receive treatment at the NO Mission. Our facilities lack warmth that slows down or impedes the healing process. We need to add meaningful art work in the center, as well as make water and coffee more accessible to those waiting for services. We need to take better care of our staff to avoid burnout and turnover. We plan on developing a new staff pay scale that will encourage staff to stay beyond the entry years. We also need to plan a quarterly self-care/ team building activity. We lack in our ability to communicate about current services provided, which then limits the numbers of people who can benefit from the excellent clinical programs. We will work within our programs to try to address creative ways that we can communicate about services within the challenges of lack of funding. Many of our homeless addiction clients have no transportation. We would like to purchase our first HHCD van to help provide transportation to those who are in residential care and those who have no transportation. 4

5 2. Corporate Compliance Summary: Before pursuing CARF, HHCD had an internal reporting system in place for ethical violations. In this last year, a full corporate compliance program has been developed and implemented. Policies and procedures have been written and implemented. The entire team has received information from the HHCD Board and Executive Team, so that everyone knows how this process works. Corporate Compliance Planning and Improvement for : Needed Improvements: Since this process is new, further training needs to be done to make sure that all team members fully understand processes and procedures. Further trainings will be done on an agency and program level. As the system is used, further discussion and evaluation will be done. Accreditation Now ongoing trainings will be completed by employees that include training on corporate compliance. 3. Cultural Competency and Diversity Summary: Cultural competency and diversity were evaluated during to determine areas of concern and improvements needed. Before this evaluation process, our agency certainly had some training and awareness of the importance of cultural competency and diversity. By purposely focusing on this area, the whole team has become much more aware of and sensitive to cultural competency issues. A complete cultural survey was done with both team members and persons served. Based upon those surveys, a cultural plan was developed. Clinical staff receives ongoing cultural diversity training and all employees participated in cultural competency training through Accreditation Now. For a complete look at the cultural competency plan, read the HHCD Cultural Competence and Diversity Plan Cultural Competency and Diversity Planning and Improvement for Needed Improvement The prevention materials being used in the schools are not culturally relevant for the community served. 5

6 The Prevention Coordinator will research and choose new prevention curriculum that will better meet the cultural needs of children in the Greater New Orleans area. Once she chooses new materials, then she will pursue training and will then implement the new program into her prevention program. All facilitators will be trained in the new curriculum. This new curriculum will be used in the school year. Our team lacks cultural training in working with the homeless population, since our Addiction Team especially has a greater number of homeless clients. An addiction staff in-service will be held to train staff concerning specific cultural characteristics of homeless persons with alcohol and drug addictions. We lack Hispanic counselors to work with those clients who can only speak Spanish. We will develop Spanish paperwork for Spanish speaking mental health clients. We will also pursue interns who are bi-lingual who can work with this population. 4. Risk Management Summary: In , the Executive Director developed the first HHCD Risk Management Plan. In the process of focusing on this issue, the Executive Director completed the Risk Management Assessment Form before writing the plan for the upcoming year. Although we have always done risk management at HHCD, this process proved very helpful in helping the Executive Team determine what the greatest risks factors are for HHCD and to develop/ implement a plan for addressing those risks. For a complete understanding of the risk management plan, read the HHCD Risk Management Plan for The greatest risk management issues for HHCD in were our IT system and lack of program funding. The IT system is outdated. Since the organization has grown so much, the IT system cannot function with so many users. Slow internet services and a vulnerable server created great stress for the clinical staff. If the system crashed, this would have been a huge financial blow to the organization. HHCD also became vulnerable financially due to the new changes in the state through Magellan and cost reimbursement for addiction clients versus direct funding of the program, as well as cuts in the Prevention contracts. 6

7 Risk Management Planning and Improvement for We need a total overhaul of our IT system due to age of equipment, number of users and internet bandwidth. The Clinical Director and IT Coordinator will work with a corporate volunteer to assess current IT system and then to address the various issues in order of priority. Funding will also be pursued to add more cameras to the facility to help with supervision and safety issues. The lack of program funding has to be addressed. Program budgets will be developed and monitored through a new budget development process. The HHCD Board of Directors and the HHCD Executive Team will pursue more funding sources to help with the program needs, as well as to help expand current services. A corporate fund development program will be developed and implemented to help with funding issues. 5. Human Resources Summary: HHCD Employees participated in the first employee survey in 2013 through Accreditation Now. The results were shared both with the employees and the HHCD Board. The results were used in the strategic planning process. Employees were very positive about the HHCD working environment. 100% answered that co-workers are pleasant and helpful. 96% of the employees believed that their supervisors were competent, that morale is good, and that workers are treated equally, fairly, consistently, and with respect. 96% of the HHCD employees are satisfied with working at HHCD. The two main areas that scored the lowest were focused on salary and internal communication of policies and procedures. For example, only 40% believed that their pay is appropriate for skill level and education. 54% believed that they received the proper HR information when hired. One employee perfectly summarized working at HHCD by saying this: Even though we have our problems, this is by far the best place that I have ever worked. 7

8 Human Resource Planning and Improvement for : Although HHCD pays an appropriate entry level salary for therapists/ staff, there has been very few pay increases throughout its history. To avoid staff turnover and to honor current staff expertise, HHCD needs to do a better job with raises and incentives. HHCD will transition the budget process in 2014 to program budgeting versus agency budgeting. By budgeting this way, programs can both be more accountable fiscally as well as work towards pay increases and incentives. Due to being born in the crisis of Katrina which led to unusually fast growth plus need to focus more on crisis services, the organization struggled with policy formation. Due to the pursuit of CARF accreditation, HHCD has been and will continue purposely focusing on policy development and implementation. As policies are developed, they will be given to HHCD team members for review and discussion. On critical policies, training will be conducted in program staff/ team meetings. HHCD is using the Accreditation Now testing program, so all employees can do ongoing training in various areas. All HHCD employees will be given an employee handbook for the first time. We plan to eventually record some of the training for employee orientation to streamline the orientation process. 6. Technology Summary: Technology has been our greatest risk during Due to size increase as an agency and an aging technical infrastructure, we have serious technical challenges. Funding has been a barrier for revamping the agency s IT system. We are running on the same internet capacity when we were 1/3 rd of the current size. We have computers that are mostly more than 5 years old and are no longer supported by Microsoft Office. Our server was designed to work with a smaller staff as well. Other major challenge is that we are not paperless as an agency yet. Due to our threats of hurricanes and flooding, it would greatly benefit our agency to have electronic medical records. The number of funders and contracts have also greatly increased, which makes the administrative tasks of reporting very challenging. Transitioning to an electronic medical records system would decrease staff 8

9 administrate time, as well as help us do a better job of evaluating services. On the positive side, in spite of these technical challenges, we have had no major technical crisis. Our tech support team says that our functioning on our current system is miraculous. Staff do, however, complain of being kicked off the internet and slow internet response. For the first time, the HHCD IT Coordinator did a full IT assessment that is included in the HHCD Policy and Procedure manual. Due to our lack of funding, we actually have a volunteer corporate executive who is working closely with us to pursue outside funding to address the technical issues that we face. In the HHCD Policy and Procedure Manual, you will find a working draft of the process to resolve the internet connection, server, hardware, software, electronic medical records, and camera issues, as well as the overall plan for technical improvement. Technology Planning and Improvement : We have limited internet wireless capability. We need a greater connection bandwidth to meet the needs of our size organization. We will work with our corporate executive volunteer to develop a business plan to determine technical needs plus prioritize the order that we will address. Internet bandwidth is the first issue that we will change. See the business plan for more details. We have old technical equipment and a server that is too small and too old. We will pursue corporate funding to help with technical overhaul. The process is listed in the business plan. We need to transition to electronic medical records. After we improve our technical infrastructure, we will pursue funding for electronic medical records. 9

10 7. Health and Safety Summary: Preparing for CARF in has certainly improved our overall health and safety systems. Our entire team actually participated in a special Disaster Mitigation program led by a team from University of New Orleans. The CHC Clinical Director, who serves as the Safety Officer, became a trainer with the UNO Center for Hazards Assessment, Response and Technology. During that training, we worked on a specialized disaster plan for our center, which included focusing on the process for chemical spills since we are located near a railroad track. We developed a safe room to use for chemical spills and severe weather incidents. The HHCD team has also had various trainings in our health and safety policies through Accreditation Now and team meetings. The CHC Addictions Coordinator became a CPR trainer. A local corporation has agreed to lend us their CPR equipment, so we will start training staff in CPR in fall Health and Safety Planning and Improvement for Needed Improvements: Full time staff needs CPR training Addictions Coordinator will prepare to teach the class to full time employees. We need to determine whether or not we are going through Red Cross. The challenge for her is that she is supposed to train 100 people a year to keep her certification. Needed Improvements: Our evacuation plan is not current, due to room number changes. Our front desk team will create a new evacuation map based upon the current room numbers in the center. This plan will be placed at strategic points in the center. 8. Field Trends Summary: HHCD has a history of closely monitoring clinical field trends in order to provide the best possible evidence-based services for all three of the current programs: prevention, addiction and mental health. A main focus for prevention in was cultural relevancy. Based upon internal and external assessment, the prevention program determined that the materials being used in the schools were not culturally relevant for the population served. Research was done to determine the best curriculum that would 10

11 both be clinically excellent and culturally relevant. A main focus for the addiction program in was a greater emphasis on trauma-informed services and Motivational Enhancement Therapy. The entire addiction staff received training in both of these areas, and the team now implements MET in therapy. Although CHC has been providing both addiction and trauma services, the addiction program is working on trauma informed improvements. A main focus for the mental health program during was on Emotionally Focused Therapy. Two staff members were extensively trained in this model for couples and families, and they provided ongoing training for the mental health team. Future plans include further training for all mental health staff in EFT, as well as becoming an EFT training site. EFT has the best long term results for marital therapy. In , HHCD Board of Directors restructured its governance model. The board added members that would better reflect both the community served and the staff. The HHCD Board used Accreditation Now to help develop and implement the appropriate governance policies and procedures. Before this process, the HHCD Board had mostly focused on budget oversight. They are now more aligned with current trends in governance models and assist with a more streamlined decision-making approach to governance. The HHCD Board of Directors are now better trained and more invested in the overall functioning of HHCD. Field Trends Planning and Improvement for 2012: All three programs need to implement the new clinical programs focused on during Prevention facilitators will be trained in the new culturally relevant life skills program. Addiction staff will receive on-going supervision for MET. They will restructure current Intensive Outpatient program to align with trauma informed standards. Two of the mental health staff will complete the qualification process for Emotionally Focused Therapy and begin supervising others who are learning EFT. Needed Improvements: HHCD Board s knowledge of governance policies and procedures need to improve so that they can provide better oversight to HHCD. The HHCD Board will read and review all of the HHCD Policy and Procedure Manual. They will use the strategic plan to expand focus beyond budget to the overall health and well being of the agency. 11

12 9. Service Delivery Systems/ Improvements Summary: HHCD has three different programs that will be evaluated for effectiveness, efficiency and access. Prevention, Addiction and Mental Health Teams have all established ongoing quality improvement systems. During , each team worked to increase the effectiveness of quality improvement by establishing strong policies and procedures, as well as adding new ways that consumers could provide input concerning services. We still have gaps in our programs, mostly due to not transitioning to electronic medical record systems. Without this system, evaluation is much more difficult. Each program strives for consumer excellence, because all staff members greatest desire is for consumer well being. 1. Effectiveness of Services Program Description: Prevention The Prevention Department of HHCD implements evidence-based programs in public, private, and charter schools in the Greater New Orleans Region. HHCD utilized the LifeSkills Training program in both Orleans and Jefferson Parish, as well as the 21 st Century after school program. This program is 8-16 weeks in length, depending upon grade level and is taught by facilitators who are certified in the curriculum. The fiscal year saw many challenges and successes. HHCD was able to serve over 1000 students in area schools with substance abuse prevention programming. This year also saw the addition of service to the Recovery School District, with LifeSkills Training and Substance Abuse Support Groups and afterschool programming through the 21 st Century program in Jefferson Parish Public Schools. A new part-time staff member was added to support the Prevention Coordinator with data entry tasks. Prevention Planning and Improvement for This year also found the prevention department noting areas in need of improvement. One such area was the prevention curriculum being used. While the LifeSkills curriculum is evidence-based and has been in use for many years, it was found that it was not culturally relevant for some of the schools being served in the Greater New Orleans Region. With this being the case, the Prevention Coordinator researched available evidence-based programs and found two new programs of interest, Too Good for Drugs, and Protecting You, Protecting Me. These programs are both culturally relevant and excellent substance abuse prevention materials that will allow HHCD to reach a broader range of students beginning in kindergarten through high school. The Prevention Coordinator was trained in each of these programs of the summer, and will teach Too Good for Drugs during the fall semester so that she can become a Trainer of Trainer for the program, allowing the other facilitators to become trained as well for further implementation later in the year. 12

13 HHCD also realized during the evaluation of this year s programming that there was a need to move the prevention facilitators from contractual employees to staff. This will be done during August HHCD has also conducted in classroom evaluations of facilitators, but has not completed formal evaluation of its facilitators. Moving forward, HHCD has instilled a policy of biannual in-classroom evaluations and yearly overall evaluations of its facilitators to ensure success and growth of staff. Program Description: Addictions The HHCD Addictions Treatment program enjoys a respected reputation in the community. Our clients frequently express their appreciation for the care and respect they receive in our program and enthusiastically recommend HHCD to their family and friends in need of addition services. The HHCD Addiction program continues to expand our relationships with other agencies in the community and provide substance abuse and trauma treatment for their clients. During the last fiscal year, HHCD contracted with several new agencies to provide substance abuse services. Although this has allowed us to increase the number of clients we are serving it has also presented us with some new and unique problems. Every new contract bears new reporting deadlines and requirements. HHCD has not upgraded its IT capabilities to accommodate the increased demands. We are always striving to increase our capacity in order to serve more clients in the community, however we are finding it increasingly more difficult to provide the necessary services these clients demand without increasing staff. Every counselor on the Addictions staff is wearing at least two hats due to the statewide transition to Managed Care for behavioral health services. All service recipients must apply for Medicaid and our staff is required to assist them in doing so if needed. Prior authorization for treatment is required for 100% of our IOP client population. Many of these clients are also in need of recovery support services such as transportation, housing and employment. At this time we are unable to assist them in these areas except for providing referrals. The population we serve is notorious for missing appointments or arriving late. Our staff members who are performing Intakes and Assessments are frequently stood up for appointments. During these times those staff members are performing other responsibilities. If everyone showed up for their appointments much of this other work would not get done. The addiction has a small but highly dedicated staff that care so much for the clients. We have several areas where we have fallen short of our desired goals in terms of meeting the timeframes established in our Addictions Policies & Procedures Manual. We are diligently working to correct those failings. The Addictions staff remains determined to provide our clients with the individualized treatment they need and deserve to achieve their goals. We do this by empowering our clients to make decisions about their care with the expected outcome of an increased quality of life. 13

14 Prior to fiscal year , HHCD Addictions program only compiled outcome data for clients served under our primary contractor (Contract #1). We are currently in the process of compiling the same data for clients served during that time frame under our other contractors. When completed, these figures will be combined in order to provide a benchmark for future comparison. We are also adding other categories of data that we intend to track this year and in the future and plan to use the stats as a benchmark for those new categories. We have been selected by the Tulane University School of Social Work for a grant study which we are in the process of getting underway. They will be performing a program evaluation of HHCD s Addictions Treatment Program that includes measuring outcome variables, analyzing client satisfaction surveys, and performing a qualitative analysis of our intake interviews and bio-psychosocial assessments in order to more fully understand the needs of the population we serve. The following statistics are based on the data from Contract #1unless otherwise specified. Total Number of Clients in on 6/30/13 (All Contracts) = 88 Total Number of Admits (All Contracts) = 81 Total Number of Clients served (All Contracts) = 152 (17 clients transferred from one contract to another during the year) Number of Approved Discharges = 46 Number of Unapproved Discharges = 44 Clients on Waiting List = 0 Average Length of Stay (Contract #1) = 25 Clients with Positive UDS (excluding baseline at Admit, Contract #1) = JP 3 Clients employed during treatment = 70 Clients employed at discharge = 53 Clients attending outside self help = 54 Total Number of Screenings (Contract #1) = 157 Total Number of Assessments (Contract #1) = 43 Billable Hours of Case Management (Contract #1) = 22 Hours of Individual Sessions (Contract #1) = 55 Total Number of Hours Leading Group (all contracts) = Hours of Family Sessions (Group & Individual) (all contracts) = 27 Number of Clients attending Family Sessions (all contracts) = 25 Program Strengths: Highly individualized treatment planning Respect for clients cultural, spiritual & religious beliefs High client satisfaction with services received Clients apply for readmission following relapse because they believe our program works High percentage of clients completing IOP with over 30 days clean and sober Positive reputation in the community and with the Department of Corrections Majority of clients surveyed stated they would choose HHCD even if they had other options including clients mandated to attend All clients surveyed state they would recommend our program to others High word-of-mouth referrals for admission 14

15 During the fiscal year CHC instituted the following new policies and procedures: Completed client handbook Increased Fee for Services scale. Began monthly Family Education group for addiction clients and their support teams Began individual family sessions for addiction clients and their support teams. Continued to improve and expand procedures for Addictions and Mental Health to report to each other and work together to better serve these clients. Began the process of acquiring CARF certification We continued to expand our client base at our St. Bernard site. We began working with CADA to provide outpatient services to OPP inmates eligible for early release. We began implementing some CARF-required procedures, e.g., the interpretive summary following assessment and intake. Established a system for scheduling individual family sessions when clients are admitted and a reservation system for family group each month. CHC trained certain staff members to become trainers for CARF and DHH required certifications so that those trainings can be done on site. We expanded our partnership with the New Orleans Mission to provide outpatient services to clients in their residential discipleship program. We changed the lab processing our Urine Drug Screens in order to be able to follow levels of illicit substances and ensure clients had decreased usage. The new lab also allows us to download results as soon as the analysis has been completed. Addiction Program Planning for Improvement for : In , the addiction team will work on ways to increase the capacity to serve more clients by restructuring the team and services, as well adding electronic medical records. We will increase access and become more pro-active in client recovery support services, such as housing, transportation and employment. We will work with CABHI to help provide more houses to our homeless clients. We will develop a system that enables us to analyze data collected for the evaluation of treatment outcomes on a quarterly basis, so that we can respond to the data in a more effective manner. We will identify options available to further streamline intake and orientation procedures to save time and money in order to meet the demands of expansion without increasing staff and other expenditures. We will identify the priority for hiring new employees and pursue funding for those positions through corporate funding or other grants. We will transition to electronic medical records to help with the multiple contracts and the measurement of success. 15

16 Program Description: Mental Health The CHC Mental Health program works with over 500 clients a year, plus another 300 group members. The program works with a wide array of ages and clinical issues. At the heart of the program is intensive trauma recovery. We have become the trauma recovery center of our community working with the most abused and hurt children, teens, and adults in our community. We passionately focus on both learning and teaching at the center. Our staff constantly pursues expertise in evidence-based treatment models that work with the population that we serve. We are a training site for master level and state interns, training over 120 in the last 8 years was a foundational year for our mental health program, because we worked diligently on our internal policies and procedures. Since we were born out of the trauma of Katrina, we were unable to establish strong policies and procedures since we began. Preparing for CARF forced us to work on this much needed area of improvement. The mental health staff worked a year on writing policies and procedures. In , the whole CHC Mental Health team is working on reviewing and implementing the policy and procedures. As a part of the process, the mental health staff began weekly staffing meetings, which has greatly improved the team work and overall efficiency of the program. Doing on-going chart audits and CQI meetings has helped the program better understand and correct gaps and problems within the program. Using a different consumer satisfaction survey has also helped the team improve services. Although we have greatly improved our internal systems in , we still have great room for improvement. Here are the stats from from the clients served, not including the clients who attend groups: 67% of clients were females 33% of clients were males 20% of clients were under 17 36% of clients were between 18 and 34 44% of clients were between 35 and 64 1% of clients were over 65 85% of clients were Caucasian 8% of clients were African American 4% of clients were Hispanic 74% of clients lived in Jefferson Parish 10% of clients lived in Orleans 4% of clients lived in St. Bernard 2% of clients lived in St. Tammany 8% of clients lived in other parishes beyond the ones above plus Plaquemines and Tangapahoa which were the other 2% 44% of clients were from couple with children household 10% of clients were from couple with no children 16

17 19% of clients were from female household 2% of clients were from male household 21% of clients were from single household 11% of clients were unemployed 4% of clients were disabled 68% of clients lived in households making less than $50,000 49% lived in households making less than $35,000 36% lived in households making less than $25,000 Trauma stats: 63% of all clients were trauma survivors 33% of kids/ teens were sexual trauma 40% of kids/teens were other trauma Over 70% of kids/teens were trauma survivors 50% of women clients were sexual abuse survivors 20% of men clients were sexual abuse survivors 41% of adult clients were sexual abuse survivors 21% of adult clients were other trauma survivors 60% of adult clients were trauma survivors Program Strengths: We became a member of SART (Sexual Assault Response Team) in Orleans Parish We trained 5 more mental health counselors in Triple P Positive Parenting We trained 4 more Darkness to Light (Sexual Abuse Prevention) facilitators Two mental health counselors completed all of the training for Emotional Focus Therapy and started supervision to become qualified EFT therapist. Clinical Director and 4 counselors went to New York 4 times to help with Hurricane Sandy recovery We worked as a team to develop the CHC Mental Health Policy and Procedure Manual More than 75% of our mental health team went to the American Association of Christian Counselor World Conference in Nashville, TN We started weekly mental health staff meetings on Monday We were chosen by Tulane University to become a research partner We wrote a grant that was accepted to provide mental health services at a new medical clinic in the 9 th ward 17

18 Mental Health Planning and Improvement for In , a great deal of emphasis will be focused on helping our entire mental health team understand and implement the policies and procedures. An on-going CQI process is in place to focus on specific programs within the mental health program to make the necessary improvements. Persons served will be encouraged to provide ongoing feedback to help with service improvement through satisfaction surveys and consumer council involvement. Focus will also continue on improving clinical and supervisory skills. In late 2014, the team will open a new site at a medical clinic in the 9 th Ward, one of the most devastated communities in Hurricane Katrina. This area struggles with both poverty and violence, so adding behavioral health services to the medical clinic will be best practice for this community. The mental health team is also doing their first research project with Tulane University to determine clinical effectiveness of its intensive trauma recovery program. Due to our technical infrastructure challenges, we struggle with measuring success. Our plan is to transition to electronic medical records in 2015 if we can acquire the needed funding. 2. Efficiency of Services HHCD has historically provided outpatient services from early morning until late evenings Monday through Thursday and day appointments on Friday. Most clients are happy with our hours of service, but they do struggle with transportation to our center since we serve a large population of over 10 parishes. We have provided limited transportation for addiction clients, but struggle to do that with no van of our own. We have used the church s van in the past, but that has become a greater challenge due to less availability. Although we have a site in Jefferson and St. Bernard parishes, we desperately need a site in Orleans Parish, and especially at the New Orleans Mission. We have started the licensure process for the Mission. We provided addiction services for them in the past, but with new leadership we have been asked to provide a comprehensive behavioral health program for their homeless population. We need other sites in Orleans parish to help with accessibility and grant writing. Planning and Improvement for : Efficiency With the help of our corporate executive volunteer and other avenues, we will pursue funding for our own van. We will be able to bill for transportation services, which will sustain the cost for transportation, but we need the initial money for the van. We will finish the licensure process for the New Orleans Mission and begin services by the end of This will eliminate the need for transportation services for residents at 18

19 the NO Mission. We will start providing behavioral health services at the Baptist Community Health Service clinic in the 9 th Ward by January 3. Access to Services We made major changes in access to services for both the addiction and mental health programs during In our addiction program, we actually added a part time administrative staff person to help our Intake Coordinator with intakes due to the added time needed for Magellan. By adding this person, we have been able to continue meeting the DHH requirements regarding 72 hour admission. In our mental health program, we changed the process for intakes. In the past, the front desk staff would complete a phone intake assessment. That form was given to the Intake Coordinator so that she could call to schedule the intake appointment. Often that process was longer due to the challenge of talking on the phone with the person seeking services. We changed the process so that when someone calls in, they are immediately assigned an intake appointment. Another issue for the mental health program was that people had to wait for weeks just for the intake appointment. The Intake Coordinator trained counseling interns to do intakes, so that the intake process was much quicker. To address no show intake appointments in mental health, the front desk staff started giving reminder calls the day before the appointment. Planning and Improvement for Access to Services The addiction program will continue to monitor access to services. One major change that is needed, but is based upon funding, is to add a utilization nurse to the staff to help with the initial intake procedure. Additional staff is needed to help with the entire intake process in order to keep up with the growth. This last year, we have added two new partners, so we are seeing more addiction clients. The mental health program will continue to monitor access to services as well. The Intake Coordinator is developing a specific training curriculum to help train interns and other staff so that we can expand the number of intake appointments available. Our goal is to have clients scheduled for an intake within one week of the initial screening. 4. Feedback From Persons Served and Other Stakeholders Feedback from persons served has been addressed through many methods of eliciting information. Persons served have been provided with surveys and have participated in focus groups. Community Stakeholders have also participated in surveys and focus groups. Employees have participated in the employee satisfaction survey, in which the results have been communicated and discussed. Multiple improvements have been made through these methods and are reflected throughout this report/performance analysis. 19

20 Planning and Improvement for : Feedback Continued surveys and focus groups will be conducted and the results will be analyzed and used by the program staffs and HHCD Executive Team for program improvement. The mental health program staff is working on a system to get more client participation with satisfaction surveys. We would like to get the percentage of clients participating up to over 50% by the end of the fiscal year. Eliminating access to computers as a barrier and providing an incentive are both ways that the mental health program staff plans on increasing consumer involvement in this important area. The HHCD Executive Team will determine a better process to encourage consumer councils. Although we had one successful council in 2014, we did not have anyone show up for the last one of that fiscal year. 20