MACOMB COUNTY COMMUNITY MENTAL HEALTH QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM ANNUAL EVALUATION, FISCAL YEAR 2009 ANNUAL PLAN, FISCAL

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1 MACOMB COUNTY COMMUNITY MENTAL HEALTH QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM ANNUAL EVALUATION, FISCAL YEAR ANNUAL PLAN, FISCAL YEAR 2010 AUGUST, 2010

2 MACOMB COUNTY COMMUNITY MENTAL HEALTH QUALITY IMPROVEMENT PROGRAM EVALUATION: FISCAL YEAR I. INTRODUCTION The Macomb County Community Mental Health (MCCMH) maintains a comprehensive Quality Assessment and Performance Improvement Program (QAPIP) under the direction of the Board. In accordance with the QAPIP, MCCMH reviews the functioning of the Quality Improvement Program annually and assesses overall compliance with the Key Performance Indicators and Objectives established during that fiscal year for both Behavioral Health and Substance Abuse. MCCMH presents recommended Key Performance Indicators to the Board, which adopts these indicators in the areas of effectiveness, efficiency, access and customer satisfaction. MCCMH then monitors these indicators quarterly through Quality Council or Executive Staff to ensure that quality care is provided to persons with mental illness or developmental disabilities who receive care from the MCCMH provider network. Indicators may be derived from the Michigan Department of Community Health, national standards and/or results of activities conducted by the Organization during the prior period. In addition, MCCMH monitors the following areas through the Executive Staff and Quality Council Committees, the Behavior Treatment Plan Review Committee (BTPRC), the Clinical Risk Management Committee (CRMC) and the directlyoperated program Quality Assurance Committee: Sentinel Events Consumer Satisfaction Utilization Management Clinical Risk Management Concerns, including Recipient Rights (Behavioral Health and Substance Abuse) Grievances and Appeals Care Coordination Behavioral Treatment Plans/Challenging Behaviors Performance Improvement Projects II. AREAS ADDRESSED DURING FY A. PIHP Activities MCCMH continues to address the Performance Indicators where standards are not being met, or where compliance is variable. The Key Performance Indicators for Access (provision of a face-to-face assessment with a professional within 14 days of first request and receiving any needed service within 14 days of a face-to-face QAPIP ANNUAL EVALUATION, FISCAL YEAR 1

3 assessment) continue to be closely monitored for compliance with the Michigan Department of Community Health s standard for 95% within 14 days. During FY 2008, MCCMH began reviewing individual providers performance on the initial assessment access indicator and requiring corrective action plans where the standard of 95% had not been met. Subsequent quarterly data were monitored to ensure that the actions taken were sufficient to improve the provider s performance. As a result of the attention paid to this Indicator, MCCMH has been able to meet or exceed the standard in each quarter for all populations and fund sources since FY 2008 (see Attachment A, Performance Indicator Report, FY ). MCCMH has also experienced difficulty providing ongoing services following intake, particularly to children. MCCMH was able to achieve the standard for all populations and fund sources in the first two quarters of FY, and the first three quarters for the Medicaid population. For all funding sources, MCCMH exceeded the state average despite missing the standard; it is likely that the increasing pressure on General Fund resources may have contributed to the delay in receiving services. For the Medicaid population, the fourth quarter was below the state average as well as below the standard. One provider was largely responsible for the PIHP s failure to achieve the standard, and corrective action plans will be required from that provider. MCCMH now requires all Behavior Treatment Plans to be submitted through its MCO BTPRC to ensure plan quality and consistency across direct and contract provider programs. In other areas, the MCCMH Clinical Risk Management Committee (CRMC) continues to address the issues of consumer deaths and sentinel events through monitoring program s mortality reviews and root cause analyses. The Committee continues to take an active role in monitoring the activities undertaken by the provider network and proposing solutions to be implemented system-wide. As a result of the activities undertaken during FY 2008, the CRMC recommended that the system begin a clinical Performance Improvement Project to address how to better treat consumers with co-occurring disorders and/or at risk for self-harm. This project was begun in FY, and has included developing protocols for managing consumers at risk along with reviewing ways in which the electronic medical record (EMR) can provide automatic alerts for staff. Performance Improvement Projects MCCMH began two Performance Improvement Projects (PIP) in FY, in accordance with the Federal requirements for Pre-paid Inpatient Health Plans. The first project, chosen by the Michigan Department of Community Health for the PIHPs (targeting Medicaid consumers), addresses the PIHP s penetration rate for children. The second, chosen by MCCMH for all populations, addresses the identification of QAPIP ANNUAL EVALUATION, FISCAL YEAR 2

4 consumers at high risk for suicide and overdose (accidental or intentional). These Projects have continued into the current Fiscal Year. The Medicaid population Performance Improvement Project mandated by MDCH follows the contract requirement that PIHPs increase the penetration rate for Medicaid children served, with slight variations to enable the project to be reported within the EQR guidelines. MCCMH was able to exceed the target through actions taken as a result of the project; ongoing monitoring will determine if these actions are sufficient to maintain the increased penetration rate. MCCMH will continue to work with the HSCB s Children s Standing Committee and its sub-committees and work groups to improve county-wide services to children. The second PIP involved the identification of consumers at risk for premature death. In addition to reviewing the process for supervision and implementing risk protocols at the outpatient and case management sites, a cross-division team within MCCMH worked with the electronic medical record (EMR) to develop an algorithm which would trigger a more extensive assessment of suicide risk by the clinicians providing services for the consumer. This process is still under development; it is expected that it will be further tested during FY 2010 for implementation during FY Customer Satisfaction During FY, MCCMH participated in the Consumer Satisfaction process designed by the Quality Improvement Council of the Michigan Department of Community Health. All consumers in Assertive Community Treatment and children s Home Based programs were offered the Federally-developed MHSIP questionnaire assessing individual or family satisfaction with services during a two-week period in the summer of. The results were submitted to the MDCH, which provided state-wide compiled totals for these programs. It is expected that this process will be repeated in FY In addition to the satisfaction survey process required by MDCH, MCCMH completed its own concurrent satisfaction surveys with a sample of consumers who received services during the Spring,. Each program selected two consecutive weeks during March to survey consumers who received services during that time. Clinic-based providers handed the surveys to consumers as they came in for their appointments; community-based providers brought the surveys with them when they visited the consumers in the community. Consumers were able to mail the survey back to the Policy Management Division, or place the completed survey in a sealed envelope and return it to the staff member, who would forward it to PMD. The results of the survey were quite positive, with all sites receiving at least 95% positive ratings. Attachment B contains the survey results summary. QAPIP ANNUAL EVALUATION, FISCAL YEAR 3

5 B. Direct-Operated Service Unit Activities The Quality Assurance Committee met regularly during Fiscal Year. Activities focused on continuing to review risk areas for consumers (begun during FY 2006), and reviewing sentinel events and consumer mortality. The group discussed ways to improve system processes, including meeting KPIs and improving clinical record documentation and service delivery. III. QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROCESS A. PIHP Activities During the Fiscal Year, Quarterly Reports of KPI s were presented to the Executive Staff and discussed by the Deputy Director with the Supervisors. The Executive Staff reviewed areas where standards were not achieved during the quarter, and made recommendations for further review by other organizational bodies. These activities are summarized in this document. In addition, the KPI reports were reviewed twice during the year by the MCCMH Board, in response to concerns about the levels of compliance with the KPI standards. MCOSA also continues to monitor indicators for the network of substance use disorders providers; the annual report for this system, along with the goals for FY 2010 are included as Attachment C. B. Direct Operated Service Unit (DOSU) Activities During FY, the Quality Assurance Committee met nine times, reviewing quality concerns within the network, along with discussion and review of Root Cause Analyses and Mortality Reviews. In addition, the QA Committee continued addressing risk assessment processes, in particular reviewing consumers with cooccurring mental illness and substance use disorders. IV. CONCLUSIONS/RECOMMENDATIONS Key Performance Indicators for MCCMH are included as Attachment A. As can be seen from the exhibits, MCCMH has improved its performance on all of the KPIs during FY. MCCMH continues to have difficulty meeting the ongoing service KPI for children (achieving 94% and 93% in the third and fourth quarters for the CMHSP, and 91% for the fourth quarter PIHP). MCCMH continues to review the KPIs quarterly, and require corrective action plans from providers who have failed to meet the standard. QAPIP ANNUAL EVALUATION, FISCAL YEAR 4

6 Of increasing concern to MCCMH is the number of hospital discharges who return within 30 days. MDCH has established a recidivism standard of 15%; MCCMH has exceeded that standard for two quarters in the Medicaid population (both children and adults); two quarters for the adult CMHSP population and one quarter for the CMHSP child population. As a result of these recidivism numbers, MCCMH is continuing intensive utilization review activities for high utilizers of hospital services. MCCMH began a Medicaid Performance Improvement Project to address the provision of services to children (penetration rate). This project involved working closely with the HSCB s Children and Youth Standing Committee and its workgroups, and addressing referral patterns from community partners. As a result of these activities, the penetration rate for children covered by Medicaid has increased. This PIP will continue into FY The second PIP, chosen by MCCMH, is also still underway, and involves the development of protocols and processes to address risk factors for premature death in the adult MI population. Following the initial stages of the project, MCCMH began exploring mechanisms to use the Electronic Medical Record to help in the identification of this population. This project is continuing into FY 2010, with implementation of revised procedures planned for FY The Quality Improvement Program continues to evolve to better meet the needs of the system and the stakeholders we serve. The Quality Assurance Program maintained by the direct-operated services has been a strong component in the quality system, as incidents, deaths, and sentinel events are reviewed and processed, with recommendations made for improving care for the entire system, rather than being limited to specific program sites. Systemic concerns are continuing to be addressed through the established Executive Staff Committee. It is recommended that the Executive Staff Committee continue its oversight function during FY 2010, with the Quality Council convened for those instances where peerreview activities are to occur. Input from consumers has been achieved through the Citizens Advisory Council (as well as through review of customer satisfaction surveys, Ombudsman information, case manager/access Center feedback, etc.). This group continues to provide valuable feedback to the quality improvement process. It is recommended that MCCMH continue to work with this group as additional satisfaction measures are identified for implementation across the system. QAPIP ANNUAL EVALUATION, FISCAL YEAR 5

7 ATTACHMENT A MCCMH Annual Report ATTACHMENTS PAGE 1 Macomb County Community Mental Health CMHSP (All Consumers) PERFORMANCE INDICATORS Fiscal Year Objective October-December, 2008 January - March, April - June, July - Sept. MCCMH STATE MCCMH STATE MCCMH STATE MCCMH STATE INDICATOR 5: CMHSP Unduplicated Count of Consumers Served UNDUPLICATED COUNT: Served in the Quarter 1. MI Children 927 1,090 1, MI Adults 5,232 5,539 5,548 5, Children with Developmental Disabilities Adults with Developmental Disabilities 2,136 1, ,002 Total Served: 8,989 9,253 9,286 8,648 INDICATOR 1: CMHSP Inpatient Screening Timeliness ACCESS: Timeliness/Inpatient Screening (Standard = 95%) 1. Percent of Emergency Referrals of All Children completed in less than 3 hours N = % N = 2097 N = % N = 1,853 N = % N = 2, % N = % N = 1, Percent of Emergency Referrals of All Adults completed in less than 3 hours 98.5% N = 1, % N = 11,559 N = % N = 9, % N = % N = 11, % N = % N = 11,721 Note: N = Total Number for each category on which a percentage is calculated. For example, the N in the access penetration indicator represents the total number served in each population group during the time period. Final June 1, 2010 Page 1 of 17

8 ATTACHMENTS PAGE 2 Macomb County Community Mental Health CMHSP (All Consumers) PERFORMANCE INDICATORS Fiscal Year Objective October-December, 2008 January - March, April - June, July - Sept. MCCMH STATE MCCMH STATE MCCMH STATE MCCMH STATE INDICATOR 2: CMHSP Initial Call to Assessment ACCESS: Timeliness Initial Call to Assessment - All Consumers (Standard = 95%) 1. Percent of Children with SED receiving an initial assessment within 14 calendar days of first request N= % N = 3,515 N = % N = 3,835 N = % N = 3, % N = % N = 2, Percent of Adults with MI receiving an initial assessment within 14 calendar days of first request N = % N = 7,270 N = % N = 7, % N = % N = 7, % N = % N = 7, Percent of Children with DD receiving an initial assessment within 14 calendar days of first request N = % N = 307 N = % N = 339 N = % N = 367 N = % N = Percent of Adults with DD receiving an initial assessment within 14 calendar days of first request 97.8% N = % N = 436 N = % N = 437 N = % N = 515 N = % N = 439 Total 99.8% N = % N = 11,528 N = % N = 12, % N = % N = 12, % N = % N = 11,069 Note: N = Total Number for each category on which a percentage is calculated. For example, the N in the access penetration indicator represents the total number served in each population group during the time period. Final June 1, 2010 Page 2 of 17

9 ATTACHMENTS PAGE 3 Macomb County Community Mental Health CMHSP (All Consumers) PERFORMANCE INDICATORS Fiscal Year Objective October-December, 2008 January - March, April - June, July - Sept. MCCMH STATE MCCMH STATE MCCMH STATE MCCMH STATE INDICATOR 3: CMHSP Assessment to Start of Service ACCESS: Timeliness Assessment to Start of Service All Consumers (Standard = 95%) 1. Percent of Children with SED who started an ongoing service within 14 days of an assessment with a professional 97.4% N = % N = 2, % N = % N = 3, % N = % N = 2, % N = % N = 2, Percent of Adults with MI who started an ongoing service within 14 days of an assessment with a professional 98.% N = % N = 5, % N = % N = 5, % N = % N = 4, % N = % N = 4, Percent of Children with DD who started an ongoing service within 14 days of an assessment with a professional N = % N = 253 N = % N = 291 N = % N = 354 N = % N = Percent of Adults with DD Who started an ongoing service within 14 days of an assessment with a professional 97.0% N = % N = 379 N = % N = 358 N = % N = % N = % N = 391 Total 98.0% N = % N = 8, % N = % N = 8, % N = % N = 8, % N = % N = 7,715 Note: N = Total Number for each category on which a percentage is calculated. For example, the N in the access penetration indicator represents the total number served in each population group during the time period. Final June 1, 2010 Page 3 of 17

10 ATTACHMENTS PAGE 4 Macomb County Community Mental Health CMHSP (All Consumers) PERFORMANCE INDICATORS Fiscal Year Objective October-December, 2008 January - March, April - June, July - Sept. MCCMH STATE MCCMH STATE MCCMH STATE MCCMH STATE INDICATOR 4a: CMHSP Psychiatric Inpatient Discharge to 7 day follow up CONTINUITY OF CARE: Inpatient Discharge Follow Up 1. Percent of Children discharged from a psychiatric inpatient unit seen within 7 days N = % N = 526 N = % N = 593 N = % N = 655 N = % N = Percent of Adults discharged from a psychiatric inpatient unit seen within 7 days 97.0% N = % N = 2, % N = % N = 3, % N = % N = 3, % N = % N = 3,371 INDICATOR 6: CMHSP face to face Assessment - Denial/Appeal ACCESS - Denial/Appeal 1. Percent of Individuals Receiving an Initial Face-to-Face Non-Emergent Professional Assessment Denied CMHSP Service or Referred Elsewhere N = Number of Individuals Assessed 0.0% N = % N = 12,947.09% N = % N = % N = % N = 13, % N = % N = 12, Number of Consumers Assessed but Denied CMHSP Service or Referred Elsewhere 6 1, , , , Total Number of Consumers Requesting a Second Opinion Total Number of Consumers Receiving Service Following a Second Opinion Note: N = Total Number for each category on which a percentage is calculated. For example, the N in the access penetration indicator represents the total number served in each population group during the time period. Final June 1, 2010 Page 4 of 17

11 ATTACHMENTS PAGE 5 Macomb County Community Mental Health CMHSP (All Consumers) PERFORMANCE INDICATORS Fiscal Year Objective October-December, 2008 January - March, April - June, July - Sept. MCCMH STATE MCCMH STATE MCCMH STATE MCCMH STATE INDICATOR 12: CMHSP Inpatient Recidivism OUTCOME: Inpatient Recidivism (Standard = Less than 15%) 1. Percent of Children re-admitted to inpatient psychiatric care within 30 days of discharge. N = Number discharged in period 10.1% N = % N = % N = % N = % N = % N = % N = % N = Percent of Adults re-admitted to inpatient psychiatric care within 30 days of discharge. N = Number discharged in period 13.5% N = % N = 5, % N = % N = 5, % N = % N = 5, % N = % N = 5,452 Note: N = Total Number for each category on which a percentage is calculated. For example, the N in the access penetration indicator represents the total number served in each population group during the time period. Final June 1, 2010 Page 5 of 17

12 ATTACHMENTS PAGE 6 Macomb County Community Mental Health CMHSP (All Consumers) PERFORMANCE INDICATORS Fiscal Year Objective October-December, 2008 January - March, April - June, July - Sept. MCCMH STATE MCCMH STATE MCCMH STATE MCCMH STATE INDICATOR 13: CMHSP Recipient Rights Complaints (Annual Reporting) OUTCOME: Recipient Rights Complaints- All Beneficiaries(Medicaid and Non-Medicaid) 1. Abuse I: Number of Complaints 6 Number of Complaints Substantiated 1 2. Abuse I I: Number of Complaints 45 Number of Complaints Substantiated Neglect I: Number of Complaints 4 Number of Complaints Substantiated 2 4. Neglect I I: Number of Complaints 12 Number of Complaints Substantiated 7 Note: N = Total Number for each category on which a percentage is calculated. For example, the N in the access penetration indicator represents the total number served in each population group during the time period. Final June 1, 2010 Page 6 of 17

13 ATTACHMENTS PAGE 7 Macomb County Community Mental Health CMHSP (All Consumers) PERFORMANCE INDICATORS Fiscal Year Objective October-December, 2008 January - March, April - June, July - Sept. MCCMH STATE MCCMH STATE MCCMH STATE MCCMH STATE INDICATOR 14a: CMHSP SENTINEL EVENTS: SED Waiver Consumers Death of Recipient Injuries requiring emergency visit/hospital admission Physical illness requiring hospital admission Arrest of recipient Conviction of recipient Serious challenging behaviors Medication errors INDICATOR 14b: CMHSP SENTINEL EVENTS: Children s Waiver Consumers Death of Recipient Injuries requiring emergency visit/hospital admission Physical illness requiring hospital admission Arrest of recipient Conviction of recipient Serious challenging behaviors Medication errors Note: N = Total Number for each category on which a percentage is calculated. For example, the N in the access penetration indicator represents the total number served in each population group during the time period. Final June 1, 2010 Page 7 of 17

14 ATTACHMENTS PAGE 8 Macomb County Community Mental Health CMHSP (All Consumers) PERFORMANCE INDICATORS Fiscal Year Objective October-December, 2008 January - March, April - June, July - Sept. MCCMH STATE MCCMH STATE MCCMH STATE MCCMH STATE INDICATOR 15a: CMHSP NUMBER OF DEATHS: Consumers with Developmental Disabilities (Annual Reporting) NUMBER OF DEATHS: Consumers with Developmental Disabilities years and under 1 Suicide 0 2. Ages 19 to 35 years 9 Suicide 0 3. Ages 36 to 60 years 24 Suicide 0 4. Sixty-One years of age or Older 10 Suicide 0 Note: N = Total Number for each category on which a percentage is calculated. For example, the N in the access penetration indicator represents the total number served in each population group during the time period. Final June 1, 2010 Page 8 of 17

15 ATTACHMENTS PAGE 9 Macomb County Community Mental Health CMHSP (All Consumers) PERFORMANCE INDICATORS Fiscal Year Objective October-December, 2008 January - March, April - June, July - Sept. MCCMH STATE MCCMH STATE MCCMH STATE MCCMH STATE INDICATOR 15c: CMHSP NUMBER OF DEATHS: Consumers with Mental Illness (Annual Reporting) NUMBER OF DEATHS: Consumers with Mental Illness years and under 1 Suicide 0 2. Ages 19 to 35 years 10 Suicide 2 3. Ages 36 to 60 years 50 Suicide 8 4. Sixty-One years of age or Older 11 Suicide 0 Note: N = Total Number for each category on which a percentage is calculated. For example, the N in the access penetration indicator represents the total number served in each population group during the time period. Final June 1, 2010 Page 9 of 17

16 ATTACHMENTS PAGE 10 Macomb County Community Mental Health PIHP (Medicaid) PERFORMANCE INDICATORS Fiscal Year Objective October - December, 2008 January - March, April - June, July - Sept. MCCMH STATE MCCMH STATE MCCMH STATE MCCMH STATE PIHP Unduplicated Count of Consumers Served 1. MI Children MI Adults 3,133 3, , Children with Developmental Disabilities Adults with Developmental Disabilities 1,996 1,880 1,913 1,948 Total Served: 6,558 6,713 6,807 6,418 INDICATOR 1: PIHP Inpatient Pre-Admission Screening Timeliness ACCESS: Timeliness/Inpatient Screening Medicaid-Eligible Consumers (Standard = 95%) 1. Percent of emergency referrals of Children completed in less than 3 hours N = % N = 1,456 N = % N = 1,516 N = % N = 1, % N = % N = 1, Percent of emergency referrals of Adults completed in less than 3 hours 98.7% N = % N = 5,598 N = % N = 5, % N = % N = 5,877 N = % N = 5,557 Note: N = Total Number for each category on which a percentage is calculated. For example, the N in the access penetration indicator represents the total number served in each population group during the time period. Final June 1, 2010 Page 10 of 17

17 ATTACHMENTS PAGE 11 Objective INDICATOR 2: PIHP Initial Call to Assessment Macomb County Community Mental Health PIHP (Medicaid) PERFORMANCE INDICATORS Fiscal Year October - December, 2008 January - March, April - June, July - Sept. MCCMH STATE MCCMH STATE MCCMH STATE MCCMH STATE ACCESS: Timeliness Initial Call to Assessment Medicaid-Eligible Consumers (Standard = 95%) 1. Percent of Children with SED receiving an initial assessment within 14 calendar days of first request N = % N = 2,603 N = % N = 2,872 N = % N = 2, % N = % N = 2, Percent of Adults with MI receiving an initial assessment within 14 calendar days of first request N = % N = 2,638 N = % N = 2, % N = % N = 2,785 N = % N = 2, Percent of Children with DD receiving an initial assessment within 14 calendar days of first request N = % N = 218 N = % N = 256 N = % N = 286 N = % N = Percent of Adults with DD receiving an initial assessment within 14 calendar days of first request 96.0% N = % N = 298 N = % N = 323 N = % N = 393 N = % N = Percent of Persons with Substance Use Disorders receiving an initial assessment within 14 calendar days of first request 99.4% N = % N = 2, % N = % N = 2, % N = % N = 2, % N = % N = 2,885 Total 99.6% N = % N = 8, % N = % N = 8, % N = % N = 8, % N = % N = 8,493 Note: N = Total Number for each category on which a percentage is calculated. For example, the N in the access penetration indicator represents the total number served in each population group during the time period. Final June 1, 2010 Page 11 of 17

18 ATTACHMENTS PAGE 12 Objective Macomb County Community Mental Health PIHP (Medicaid) PERFORMANCE INDICATORS Fiscal Year October - December, 2008 January - March, April - June, July - Sept. MCCMH STATE MCCMH STATE MCCMH STATE MCCMH STATE INDICATOR 3: PIHP Assessment to Start of Service ACCESS: Timeliness Assessment to Start of Service Medicaid-Eligible Consumers (Standard = 95%) 1. Percent of Children with SED who started an ongoing service within 14 days of an assessment with a professional 2. Percent of Adults with MI who started an ongoing service within 14 days of an assessment with a professional 3. Percent of Children with DD who started an ongoing service within 14 days of an assessment with a professional 4. Percent of Adults with DD Who started an ongoing service within 14 days of an assessment with a professional 5. Percent of Persons with Substance Use Disorders who started an ongoing service within 14 days of an assessment with a professional 98.3% N = % N = 121 N = % N = 24 N = % N = 2, % N = 1, % N = % N = % N = 2, % N = % N = 83 N = 19 N = 30 N = % N = 2, % N = 2, % N = % N = % N = 2,036 N = % N = 71 N = 31 N = 25 N = % N = 2, % N = 1, % N = % N = % N = 2, % N = 54 N = 52 N = % N = 31 N = % N = 1, % N = 1, % N = % N = % N = 2,305 Total 99.3% N = % N = % N = % N = 6, % N = % N = 7, % N = % N = 6,545 Note: N = Total Number for each category on which a percentage is calculated. For example, the N in the access penetration indicator represents the total number served in each population group during the time period. Final June 1, 2010 Page 12 of 17

19 ATTACHMENTS PAGE 13 Macomb County Community Mental Health PIHP (Medicaid) PERFORMANCE INDICATORS Fiscal Year Objective October - December, 2008 January - March, April - June, July - Sept. MCCMH STATE MCCMH STATE MCCMH STATE MCCMH STATE INDICATOR 4a: PIHP Psychiatric Inpatient Discharge to 7 day follow up CONTINUITY OF CARE: Inpatient Discharge Follow Up Medicaid-Eligible Consumers (Standard = 95%) 1. Percent of Children discharged from a psychiatric inpatient unit seen within 7 days 2. Percent of Adults discharged from a psychiatric inpatient unit seen within 7 days 3. Percent of Persons with Substance Use Disorders discharged from a substance abuse detox unit seen within 7 days N = % N = % N = % N = % N = 1, % N = % N = % N = % N = % N = % N = 1, % N = 452 N = % N = % N = % N = % N = 1, % N = 523 N = % N = 116 N = % N = % N = 1, % N = 567 Note: N = Total Number for each category on which a percentage is calculated. For example, the N in the access penetration indicator represents the total number served in each population group during the time period. Final June 1, 2010 Page 13 of 17

20 ATTACHMENTS PAGE 14 Macomb County Community Mental Health PIHP (Medicaid) PERFORMANCE INDICATORS Fiscal Year Objective October - December, 2008 January - March, April - June, July - Sept. MCCMH STATE MCCMH STATE MCCMH STATE MCCMH STATE INDICATOR 5: PIHP Unduplicated and Medicaid service penetration 1. Percentage of area Medicaid recipients having received PIHP- Managed services 7.1% N = 6, % N = 100, % N = 6, % N = 100, % N = 6, % N = 101, % N = 6, % N = 96,653 Number of Area Medicaid Recipients 92,220 1,516, ,131 1,645, ,791 1,655,935 99,315 1,592,105 INDICATOR 12: PIHP Inpatient Recidivism OUTCOME: Inpatient Recidivism Medicaid-Eligible Consumers (Standard = Less than 15%) 1. Percent of Children re-admitted to inpatient psychiatric care within 30 days of discharge. N = Number discharged in period 11.0% N = % N = % N = % N = % N = % N = % N = % N = Percent of Adults re-admitted to inpatient psychiatric care within 30 days of discharge. N = Number discharged in period 14.7% N = % N = 2, % N = % N = 2, % N = % N = 2, % N = % N = 2,678 Note: N = Total Number for each category on which a percentage is calculated. For example, the N in the access penetration indicator represents the total number served in each population group during the time period. Final June 1, 2010 Page 14 of 17

21 ATTACHMENTS PAGE 15 Macomb County Community Mental Health PIHP (Medicaid) PERFORMANCE INDICATORS Fiscal Year Objective October - December, 2008 January - March, April - June, July - Sept. MCCMH STATE MCCMH STATE MCCMH STATE MCCMH STATE INDICATOR 13: PIHP Recipient Rights Complaints (annual reporting) OUTCOME: Recipient Rights Complaints - Medicaid 1. Abuse I: Number of Complaints 4 Number of Complaints Substantiated 1 2. Abuse I I: Number of Complaints 40 Number of Complaints Substantiated Neglect I: Number of Complaints 2 Number of Complaints Substantiated 2 4. Neglect I I: Number of Complaints 11 Number of Complaints Substantiated 6 INDICATOR 14a PIHP SENTINEL EVENTS: MI Adults Death of Recipient Injuries requiring emergency 1 visit/hospital admission 0 0 Physical illness requiring hospital 3 admission 0 6 Arrest of recipient Conviction of recipient Serious challenging behaviors Medication errors Note: N = Total Number for each category on which a percentage is calculated. For example, the N in the access penetration indicator represents the total number served in each population group during the time period. Final June 1, 2010 Page 15 of 17

22 ATTACHMENTS PAGE 16 Objective Macomb County Community Mental Health PIHP (Medicaid) PERFORMANCE INDICATORS Fiscal Year October - December, 2008 January - March, April - June, July - Sept. MCCMH STATE MCCMH STATE MCCMH STATE MCCMH STATE INDICATOR 14b: PIHP SENTINEL EVENTS: MI Children Death of Recipient Injuries requiring emergency 0 visit/hospital admission 0 0 Physical illness requiring hospital 0 admission 0 0 Arrest of recipient Conviction of recipient Serious challenging behaviors Medication errors INDICATOR 14b: PIHP SENTINEL EVENTS: Persons with Developmental Disabilities, not Hab Waiver Death of Recipient Injuries requiring emergency 0 visit/hospital admission 0 0 Physical illness requiring hospital 0 admission 0 3 Arrest of recipient Conviction of recipient Serious challenging behaviors Medication errors INDICATOR 14b: PIHP SENTINEL EVENTS: Persons on Habilitation Supports Waiver Note: N = Total Number for each category on which a percentage is calculated. For example, the N in the access penetration indicator represents the total number served in each population group during the time period. Final June 1, 2010 Page 16 of 17

23 ATTACHMENTS PAGE 17 Objective Macomb County Community Mental Health PIHP (Medicaid) PERFORMANCE INDICATORS Fiscal Year October - December, 2008 January - March, April - June, July - Sept. MCCMH STATE MCCMH STATE MCCMH STATE MCCMH STATE Death of Recipient Injuries requiring emergency 0 visit/hospital admission 0 0 Physical illness requiring hospital 0 admission 0 4 Arrest of recipient Conviction of recipient Serious challenging behaviors Medication errors INDICATOR 14b: PIHP SENTINEL EVENTS: Persons Receiving Substance Abuse Death of Recipient Injuries requiring emergency 0 visit/hospital admission 0 0 Physical illness requiring hospital 0 admission 0 0 Arrest of recipient Conviction of recipient Serious challenging behaviors Medication errors Note: N = Total Number for each category on which a percentage is calculated. For example, the N in the access penetration indicator represents the total number served in each population group during the time period. Final June 1, 2010 Page 17 of 17

24 ATTACHMENTS PAGE 18 MACOMB COUNTY COMMUNITY MENTAL HEALTH UNDUPLICATED COUNT POPULATIONS SERVED FY TO FY FISCAL YEAR MI - C MI - A DD TOTALS ,415 3,647 1,015 6, ,427 4,500 1,163 7, ,114 5,952 1,017 8, ,292 5,717 1,863 8, ,084 5,182 1,922 8, ,464 1,747 6, ,669 1,837 7, ,974 2,103 7, ,127 5,848 2,050 9, ,164 6,305 2,290 9, ,286 5,681 2,127 9, ,390 6,145 2,207 9, ,374 6,648 2,415 10, ,361 7,266 2,830 11, ,625 7,719 3,002 12, ,668 7,843 3,113 12,624

25 APR-JUN JUL-SEP 120, ,000 80,000 60,000 40,000 20,000 0 Medicaid Recipients by Quarter APR-JUN 2007 JUL-SEP 2007 OCT-DEC 2007 JAN-MAR 2008 APR-JUN 2008 JUL-SEP 2008 OCT-DEC 2008 JAN-MAR Quarter 8% 7% 6% 5% 4% 3% 2% 1% 0% JAN-MAR 2007 OCT-DEC 2006 OCT-DEC 2004 JUL-SEP 2006 Total Medicaid Eligibles Percent Medicaid Served MEDICAID RECIPIENTS % Medicaid Served ATTACHMENTS PAGE 19

26 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 ATTACHMENTS PAGE 20 Total Population Served Fiscal Year Children with SED Adults with MI Persons with DD Total Served Number Served

27 ATTACHMENTS PAGE 21 UNDUPLICATED COUNT OF CASES SERVED BY QUARTER 10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 OCT-DEC 2004 JUL-SEP 2006 OCT-DEC 2006 JAN-MAR 2007 APR-JUN 2007 JUL-SEP 2007 OCT-DEC 2007 JAN-MAR 2008 APR-JUN 2008 JUL-SEP 2008 OCT-DEC 2008 JAN-MAR APR-JUN JUL-SEP QUARTER CHILDREN W SED ADULTS W MI CHILDREN W DD ADULTS W DD TOTAL SERVED CASES SERVED TREND NUMBER SERVED

28 APR JUN JUL SEP 90% 80% 70% 60% 50% Timeliness: Initial Call to Assessment Totals FY 2005 FY Standard = 95% OCT DEC 2005 JAN MAR 2006 APR JUN 2006 JUL SEP 2006 OCT DEC 2006 JAN MAR 2007 APR JUN 2007 JUL SEP 2007 OCT DEC 2007 JAN MAR 2008 APR JUN 2008 JUL SEP 2008 OCT DEC 2008 JAN MAR Quarter MCCMH TOTALS STATE TOTALS STANDARD ATTACHMENTS PAGE 22 JUL SEP 2005 APR JUN 2005 JAN MAR 2005 OCT DEC 2004 % Seen within 14 Days

29 90% 80% 70% 60% 50% ATTACHMENTS PAGE 23 Timeliness: Initial Call to Assessment by Population FY FY Standard = 95% JUL-SEP 2006 OCT-DEC 2006 JAN-MAR 2007 APR-JUN 2007 JUL-SEP 2007 OCT-DEC 2007 JAN-MAR 2008 APR-JUN 2008 JUL-SEP 2008 OCT-DEC 2008 JAN-MAR APR-JUN JUL-SEP Quarter Standard Children with SED Adults with MI Children with DD Adults with DD OCT-DEC 2004 % Completed in 14 Days

30 90% 80% 70% 60% 50% ATTACHMENTS PAGE 24 TIMELINESS: ASSESSMENT TO ONGOING SERVICE TOTALS FY FY Standard = 95% JAN-MAR 2005 APR-JUN 2005 JUL-SEP 2005 OCT-DEC 2005 JAN-MAR 2006 APR-JUN 2006 JUL-SEP 2006 OCT-DEC 2006 JAN-MAR 2007 APR-JUN 2007 JUL-SEP 2007 OCT-DEC 2007 JAN-MAR 2008 APR-JUN 2008 JUL-SEP 2008 OCT-DEC 2008 JAN-MAR APR-JUN JUL-SEP QUARTER MCCMH TOTALS STATE TOTALS STANDARD OCT-DEC 2004 % STARTING SVCS WITHIN 14 DAYS OF ASSESSMENT

31 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% ATTACHMENTS PAGE 25 ACCESS TIMELINESS: ASSESSMENT TO ONGOING SERVICE: All Populations FY 2005 FY Standard = 95% JUL SEP 2005 OCT DEC 2005 JAN MAR 2006 APR JUN 2006 JUL SEP 2006 OCT DEC 2006 JAN MAR 2007 APR JUN 2007 JUL SEP 2007 OCT DEC 2007 JAN MAR 2008 APR JUN 2008 JUL SEP 2008 OCT DEC 2008 JAN MAR APR JUN JUL SEP QUARTER STANDARD Children with SED Adults with MI Children with DD Adults with DD JAN MAR 2005 APR JUN 2005 OCT DEC 2004 % Starting Ongoing Service within 14 Days of Assessment

32 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% ATTACHMENTS PAGE 26 Percent of Hospital Discharges Seen within 7 Days of Discharge NOTE: Beginning in FY 2006, Standard = 95% JAN-MAR 2005 APR-JUN 2005 JUL-SEP 2005 OCT-DEC 2005 JAN-MAR 2006 APR-JUN 2006 JUL-SEP 2006 OCT-DEC 2006 JAN-MAR 2007 APR-JUN 2007 JUL-SEP 2007 OCT-DEC 2007 JAN-MAR 2008 APR-JUN 2008 JUL-SEP 2008 OCT-DEC 2008 JAN-MAR APR-JUN JUL-SEP Quarters STANDARD Children with SED Adults with MI State Children with SED State Adults with MI OCT-DEC 2004 Percent Followed-Up within 7 Days

33 ATTACHMENTS PAGE 27 Consumers Placed in CARO JAN-MAR 2005 APR-JUN 2005 JUL-SEP 2005 OCT-DEC 2005 JAN-MAR 2006 APR-JUN 2006 JUL-SEP 2006 OCT-DEC 2006 JAN-MAR 2007 APR-JUN 2007 JUL-SEP 2007 OCT-DEC 2007 JAN-MAR 2008 APR-JUN 2008 JUL-SEP 2008 OCT-DEC 2008 JAN-MAR APR-JUN JUL-SEP Quarter OCT-DEC 2004 Total Bed-Days Average Cases TOTAL BED-DAYS PER QUARTER AVERAGE CLIENTS PER MONTH Linear (AVERAGE CLIENTS PER MONTH)

34 25% 20% 15% 10% 5% 0% ATTACHMENTS PAGE 28 INPATIENT RECIDIVISM: READMISSION WITHIN 30 DAYS OF DISCHARGE STANDARD: NO MORE THAN 15% WITHIN 30 DAYS JAN-MAR 2005 APR-JUN 2005 JUL-SEP 2005 OCT-DEC 2005 JAN-MAR 2006 APR-JUN 2006 JUL-SEP 2006 OCT-DEC 2006 JAN-MAR 2007 APR-JUN 2007 JUL-SEP 2007 OCT-DEC 2007 JAN-MAR 2008 APR-JUN 2008 JUL-SEP 2008 OCT-DEC 2008 JAN-MAR APR-JUN JUL-SEP QUARTER Children with SED Adults with MI State Children with SED State Adults with MI OCT-DEC 2004 PERCENT READMITTED WITHIN 30 DAYS OF DISCHARGE

35 ATTACHMENTS PAGE 29 ATTACHMENT B Macomb County Community Mental Health Concurrent Satisfaction Survey: Fiscal Year Introduction In March,, Macomb County Community Mental Health (MCCMH) conducted a survey of recipients currently receiving services within our system. The process involved a convenience sample of consumers who came to MCCMH clinics or were seen in the community by their case managers for a two week time period. Consumers or parents/guardians were asked to complete the survey. They were informed that participation was voluntary and confidential. Consumers could add comments and request contact from the Ombudsman. The surveys were color-coded by program; however, there were no means to identify the consumer from the survey. The survey weeks were chose randomly with the intent being that the participants would represent a sample of the population of MCCMH consumers. This process also ensured that the sample not be associated with a particular occurrence or treatment event. There were a total of 4,361 cases open as the survey began. MCCMH received 806 questionnaires, for an overall sample of 18%. Results As evidenced by the percentage summary scores by program, all programs scored very well with a majority of the satisfied percentages ranging from 97%-. There were five outliers with a satisfaction score of 92%-93%. The corresponding questionnaire items were related to consumers choice of team members and treatment goals, as well as staff helping the consumer receive other needed services. The second grid represents the mean score for each questionnaire item. The scores are broken down by program as well as an overall (across all programs) mean score for each item. The scores are based on a Likert scale where 5 represents the highest level of satisfaction/agreement with the questionnaire item. The results are very positive. Majority of the scores are well above 4.5. The lowest score is Supervisors were provided the results for their programs for their review and for the implementation of program improvements. The MCCMH Ombudsman contacted all consumers who had requested it. Upon contact, most consumers reiterated their satisfaction with services. In cases where an issue/concern was identified by the consumer, the Ombudsman played a part in the resolution. CONCURRENT SATISFACTION PAGE 1 OF 2

36 ATTACHMENTS PAGE 30 Consumers were also able to identify areas that they found to be most helpful, least helpful, and what they would like to see changed/added at MCCMH. Positive comments made reference to specific staff members who the consumer felt was someone that they could tell anything to or was the best case manager. General or more global statements regarding MCCMH were also included by consumers, for example, It s there when you need it. There was a theme of consumers reporting that case managers/assigned staff listen to them in order to make sure the staff understand what the consumer needs. Overall, the consumers felt that MCCMH staff were genuinely concerned for their well-being and that this was reflected in the services provided. Staff were friendly and knowledgeable in the areas of consumer illness. Several consumers reported that staff saved my life. This appears to be the most profound statement that a consumer could write regarding the influence of MCCMH staff. Consumers expressed the desire to have more groups for consumers and family members, including children. Some ideas mentioned for these groups included assertive behavior and anger management. Another consumer suggested an interactive parent/teen group. Several consumers commented on the desire to obtain and/or maintain a job and felt that more resources could be identified in that area. The desire for less paperwork/assessments was noted by several consumers; although the desire to have more communication between MCCMH and primary care physicians was noted. Long waiting times for psychiatrist appointments was noted. Consumers would also like to see more free medications available. Overall, as is evidenced by the high level of satisfaction reported, as well as the volume of positive comments, consumers find services provided by MCCMH to be beneficial in their lives. MCCMH services are provided to many consumers with various diagnoses and disabilities. For MCCMH, improving the delivery of available services, as well as expanding services, is a dynamic process in which the input from consumers is vital. CONCURRENT SATISFACTION PAGE 2 OF 2

37 ATTACHMENTS PAGE 31 FY Consumer Satisfaction Survey Concurrent Questionnaire Items Total ACT CCM CrossRoads FRN FSE FSW IMH SRS VDPS % S % D %S %D % S % D % S % D % S % D % S % D % S % D % S % D % S % D % S % D Staff treat me with respect. 99.4%.6% 100.0%.0% 98.6% 1.4% 100.0%.0% 100.0%.0% 100.0%.0% 98.4% 1.6% 100.0%.0% 98.1% 1.9% 100.0%.0% Staff answer my calls promptly. 99.0% 1.0% 99.0% 1.0% 98.6% 1.4% 100.0%.0% 98.6% 1.4% 100.0%.0% 98.4% 1.6% 100.0%.0% 98.1% 1.9% 99.3%.7% Staff treat me courteously on the phone. 99.4%.6% 100.0%.0% 95.7% 4.3% 100.0%.0% 100.0%.0% 100.0%.0% 98.3% 1.7% 100.0%.0% 99.4%.6% 100.0%.0% Staff explain what to expect from services. 99.4%.6% 99.0% 1.0% 100.0%.0% 100.0%.0% 100.0%.0% 99.3%.7% 96.7% 3.3% 100.0%.0% 99.4%.6% 100.0%.0% I was able to choose the treatment goals. 98.6% 1.4% 99.0% 1.0% 100.0%.0% 96.2% 3.8% 100.0%.0% 99.2%.8% 93.2% 6.8% 100.0%.0% 98.1% 1.9% 100.0%.0% Staff are available when I need to talk. 98.5% 1.5% 99.0% 1.0% 98.6% 1.4% 96.2% 3.8% 100.0%.0% 99.3%.7% 96.6% 3.4% 100.0%.0% 97.4% 2.6% 99.3%.7% I am comfortable asking questions about my services. 98.4% 1.6% 97.0% 3.0% 100.0%.0% 94.2% 5.8% 100.0%.0% 99.3%.7% 95.1% 4.9% 100.0%.0% 98.1% 1.9% 100.0%.0% Staff help me receive other services I need. 97.9% 2.1% 98.0% 2.0% 100.0%.0% 92.3% 7.7% 100.0%.0% 98.5% 1.5% 93.4% 6.6% 100.0%.0% 97.4% 2.6% 99.3%.7% I am able to invite people I want to service planning meetings. 98.0% 2.0% 96.9% 3.1% 97.2% 2.8% 94.0% 6.0% 100.0%.0% 98.5% 1.5% 98.3% 1.7% 100.0%.0% 96.8% 3.2% 100.0%.0% I am able to choose team members. 96.5% 3.5% 94.9% 5.1% 92.9% 7.1% 96.2% 3.8% 97.1% 2.9% 97.7% 2.3% 95.1% 4.9% 100.0%.0% 95.5% 4.5% 99.2%.8% MCCMH helps me make community connections. 97.2% 2.8% 98.0% 2.0% 98.5% 1.5% 95.9% 4.1% 100.0%.0% 97.7% 2.3% 93.2% 6.8% 100.0%.0% 94.8% 5.2% 98.5% 1.5% My life is better because of CMH Services. 97.9% 2.1% 99.0% 1.0% 98.6% 1.4% 94.2% 5.8% 98.6% 1.4% 98.5% 1.5% 95.1% 4.9% 100.0%.0% 96.2% 3.8% 100.0%.0% The services I'm receiving are helping. 98.2% 1.8% 99.0% 1.0% 97.1% 2.9% 96.2% 3.8% 98.6% 1.4% 97.8% 2.2% 96.7% 3.3% 100.0%.0% 98.1% 1.9% 100.0%.0% I would tell a friend to call MCCMH for a problem like mine. 97.9% 2.1% 97.0% 3.0% 95.7% 4.3% 100.0%.0% 100.0%.0% 99.3%.7% 95.1% 4.9% 100.0%.0% 95.5% 4.5% 100.0%.0% I will continue to seek help from MCCMH. 98.8% 1.3% 99.0% 1.0% 95.7% 4.3% 100.0%.0% 100.0%.0% 100.0%.0% 96.7% 3.3% 100.0%.0% 97.4% 2.6% 100.0%.0% TOTAL Questionnaires Returned S = Satisfied D = Dissatisfied ACT=Assertive Community Treatment CCM = Community Case Management FRN = First Resources North FSE = First Resources Southeast FSW = First Resources Southwest IMH = Infant Mental Health SRS = Specialized Residential Services VDPS = Vocational and Day Program Services

38 MCCMH Concurrent Satisfaction Survey FY ATTACHMENTS PAGE 32 Questionnaire Items Total ACT CCM XR FRN FSE FSW IMH SRS VDPS N Mean N Mean N Mean N Mean N Mean N Mean N Mean N Mean N Mean N Mean Staff treat me with respect Staff answer my calls promptly Staff treat me courteously on the phone Staff explain what to expect from services I was able to choose the treatment goals Staff are available when I need to talk I am comfortable asking questions about my services. Staff help me receive other services I need. I am able to invite people I want to service planning meetings I am able to choose team members MCCMH helps me make community connections. My life is better because of CMH Services The services I'm receiving are helping I would tell a friend to call MCCMH for a problem like mine. I will continue to seek help from MCCMH. Valid N (listwise) Mean Scores by Program and Item

39 ATTACHMENTS PAGE 33 MACOMB COUNTY OFFICE OF SUBSTANCE ABUSE FY PERFORMANCE INDICATORS OBJECTIVE Oct - Dec 2008 Jan-March April- June July - Sept Penetration Rates Person Age 18 & Older (Population=118,808) 1873 (1.58%) 1679 (1.41%) 1831 (1.54%) 1953 (1.64%) Persons Under 18 Years (Population=47,446) 92 (0.19%) 81 (0.17%) 57 (0.12%) 34 (0.07%) Women of Child-bearing Age (Population=192,443) 705 (0.37%) 629 (0.33%) 638 (0.33%) 664 (0.35%) Persons Injecting Drugs (Population=4,100) 544 (13.27%) 509 (12.41%) 583 (14.22%) 679 (16.56%) Native Americans (Population=2,478) 9 (0.36%) 7 (0.28%) 12 (0.48%) 15 (0.61%) Asian/Pacific Islander (Population=17,021) 4 (0.02%) 1 (0.01%) 2 (0.01%) 5 (0.03%) African American/Black (Population=21,326) 97 (0.45%) 92 (0.43%) 114 (0.53%) 108 (0.51%) Hispanic (Population=12,435) 24 (0.19%) 21 (0.17%) 18 (0.14%) 15 (0.12%) Age18 & Over Satisfied 403/416 (97%) 547/568 (96%) 544/555 (98%) 586/605 (97%) Under Age18 Satisfied 27/30 (90%) 15/16 (94%) 25/26 (96%) 10/10 ()