Q I. Quality Improvement Work Plan FY

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1 Q I Quality Improvement Work Plan FY Health & Human Services Department Mental Health & Substance Use Services Division Suzanne Tavano, PHN, PhD, Behavioral Health Director Dawn Kaiser, LCSW, CPHQ

2 The Marin Mental Health Plan s Quality Management (QM) Department is responsible for providing support to all areas of MHP operations by providing oversight, monitoring and quality improvement functions. The QM Department s activities are guided by the relevant sections of Federal and California State regulations, including the Code of Federal Regulations Title 42, the California Code of Regulations Title 9, Welfare and Institutions Codes, as well as the MHP s performance contract with the State Department of Health Care Services. The QM Department consists of four licensed staff, including two Utilization Review Specialists, a Utilization Management Supervisor and a Division Director, supported by three administrative staff (6.5 FTE total). QM staff conducts a quarterly Quality Improvement Committee (QIC) meeting. The QIC is comprised of a diverse group of stakeholders, including representatives from MHP administration and clinical programs, the mental health board, peers/family members, the patient rights advocate, and community partners. The QIC reviews findings from a range of compliance and quality improvement activities and provides input into these and other areas for improvement. The activities of the Cultural Competency Advisory Board (CCAB), the Compliance and Privacy Officer and the Incident and Grievance Committee are also reported in to the QIC. The findings and recommendations of these bodies with policy-level implications are reported to MHP leadership for further action. The intent of this Quality Improvement (QI) Work Plan is to create systems whereby data relevant to the performance of the MHP is available in an easily interpretable and actionable form. This year s plan focuses on improving the MHP s data collection and analysis capabilities. Improving accessibility to timeliness, outcomes, and other data by all levels of staff is an additional focus. The intent is to provide resources to all levels of staff so that they are able to utilize continuous quality improvement principles in their daily work of supporting the recovery and resiliency of the consumers we serve. The expected implementation of the Drug Medi-Cal Organized Delivery System waiver during this fiscal year provides the opportunity for quality management functions that have been performed separately by Substance Use Services staff and Mental Health staff to integrate under one service. As this occurs, both the membership and focus of the QIC and the goals and objectives of the QI Work Plan will expand to include Substance Use Services. 2

3 Access -- 24/7 Line: Improve quality of 24/7 Access Line and improve documentation of contacts. 1. Increase compliance with test call goal to 75% (n = 36) 2. Increase test call logging to 90%. 3. Ensure test calls are conducted in a proportionate sample of threshold languages. 4. Improve average performance to Access Line metrics (right) to 80%. 5. Revise Access P & P 6. Monitor wait to language service on Access Line. Does the 24/7 Toll-Free Access Line provide: Language(s) Tested: Spanish, Vietnamese, Cantonese Info re: access SMHS including assessment? Info re: services for urgent condition/crisis? Info re: beneficiary problem resolution (grievance) and fair hearing process? Beneficiary name? Date of request? Initial disposition of the request? *B = Business Hours, A = After Hours * # test calls B A B A B A B A B A B A B A #met goal %met goal Partially Not DHCS June 2014 Triennial Review: 25% of test calls logged. (n = 4 calls) FY14-15 QM test calls: 63% of test calls logged. 7% rolled to voice mail. 29% of test calls not logged. (n = 27 calls) FY Test call goal = 48. FY Test calls placed = % of goal. FY14-15 Wait times for language 0-5 minutes. 3

4 Access -- Linguistic Capacity Ensure services are provided in the consumer's preferred language by utilizing bilingual staff and/or qualified interpreters. Ensure all treatmentrelated correspondence is available in consumer s preferred language. 1. Collect language of service provision for each clinical encounter by language provider in the medical record. 2. Institute service language tracking for contracted services. 3. Add service language data element to Utilization Review. 4. Initiate monolingual chart review. 5. Provide support for Client Plans in threshold languages. Directly Operated Services: Service Language Assessment Medication Support Ongoing Care English Spanish Vietnamese Other Total Spanish Interpreter Vietnamese Interp reter Contracted Services: Service Language Assessment Medication Support Ongoing Care English Spanish Vietnamese Other Total Spanish Interpreter Vietnamese Interpreter Partially Not FY14-15 evaluation sample (below) lead to discovery of bug in service language capture that is being addressed by vendor. March 2015 Service Language Assessment Medication Support Ongoing Care English 212 (77%) 1705 (97%) 4017 (88%) Spanish 59 (22%) 33 (2%) 384 (8%) Vietnamese 2 (0.7%) 12 (0.7%) 147 (3%) Other 1 (0.4%) 12 (0.7%) 2 (0.4%) Total Span Interpreter Viet Interpreter No baseline available for contracted services.. 4

5 Access -- Cultural Competency/Healt h Equity Identify and decrease access disparities by age, race/ethnicity and geographic location. 1. Compare location of Medi-Cal beneficiary population to MHP treatment population by age, race/ethnicity and city of residence. Establish baseline data. 2. Evaluate geographic placement of services based on findings. 3. Identify opportunities to enhance geographic placement and types of services to reduce access barriers identified. Partially Not Establish during FY

6 Access System Capacity/ Dashboard 1. Establish baseline utilization of service system capacity. 2. Monitor service initiations and discharges; establish average lengths of service and measures of demand. 3. Build pilot dashboard report, validate data and disseminate for feedback. 4. Put dashboard in monthly production. Partially Not Establish during FY

7 Timeliness to Services Data Collection and Quality 1. Improve data collection mechanism for tracking timeliness from first contact to assessment. 2. Improve capture and analysis of timeliness from treatment referral to treatment initiation. 3. Collect wait times to urgent conditions. 4. Determine strategy to examine wait time by language. Partially Not Current tracking requires linking data across EMR and external logs. 7

8 Timeliness to Services Monitor system performance on key timeliness metrics semi-annually and initiate process improvements as necessary. Monitor wait times: 1. Intake to assessment. 2. Assessment to first psychiatry. 3. Assessment to service initiation. 4. Post-hospital follow up. 5. Response to urgent conditions. 6. Psychiatric rehospitalizations within 30 days. 7. Percentage of missed appointments. Time to: Goal Average Time to: Goal Average Assessment 14 days days Post Hospital 7 days adults days children days Psychiatry 30days days 30 Day Readmit Rate <10% % Urgent 3 days days Missed Appt. <10% % Partially Not Time to: Goal Average Time to: Goal Average Assessment 14 days 11 days Post Hospital 7 days 21 days adults 4 days children Psychiatry 15 days 20 days 30 Day Readmit Rate <10% 7 % Urgent 2 days none Missed Appt. <10% 9% Establish baseline from assessment to service initiation. 8

9 Quality Capacity Dashboard 1. Identify capacity dashboard data elements. 2. Identify data sources and report format. 3 Build pilot report, validate data and disseminate for feedback. 4. Refine as needed and place into monthly production. Partially Not New dashboard FY Quality -- Peer and Family Providers Ensure peer and family member employment in meaningful roles. 1. Initiate Peer/Family Member Provider survey. 2. Analyze and respond to findings. 9

10 Partially Not Establish baseline in FY Outcomes-- Improve data collection and reporting to support decision making. 1. Analyze Milestones of Recovery Scale (MORS) and PHQ9 data to establish baseline for data quality and consumer outcomes. 2. Initiate activities to improve data quality. 3. Implement Child and Adolescent Needs and Strengths (CANS). 4. Initiate Mental Health Outcomes Management System (mhoms) pilot. Partially Not CBCL data examined could not be analyzed on aggregate level due to database corruption. PHQ9 initiated in FY Initial analysis of PHQ-9 and MORS data completed. Began planning for CANS implementation and mhoms pilot. 10

11 Outcomes -- Beneficiary Satisfaction 1. Conduct POQI per DHCS schedule. 2. Improve POQI analysis to increase ability to identify meaningful improvement activities. 3. Analyze POQI responses by language. 4. Identify number of expected vs actual returns and initiate activities to support improved response rate. 5. Increase utilization of POQI by relevant contractors by 75%. 6. Report POQI results to managers/supervisors /line staff and contractors semiannually. 7. Support POQI-related QI efforts. Partially Not 11/2014 = 289 responses 5/2015 = 318 responses 5/2015: 92% respondents endorsed satisfied or very satisfied with services. 11

12 Grievance Process Respond to grievances in a timely manner. Identify and act on improvement opportunities. 1. Ensure grievances are logged and responded to within required timeframes. 2. Track and trend grievances to identify quality improvement opportunities. 3. Conduct Incidence/Grievance Committee semiannually. 4. Report grievance trends to QIC and management. 5. Conduct grievance process refresher training for staff. Category ACCESS Denied Services Change of Provider Quality of Care Confidentialit y Other Q1 Total: Tota l # Grievanc e Appea l Process Expedite d Appeal State Fair Hearin g Expedite d Fair Hearing Referre d Out Disposition Resolve d Still Pendin g Partially Not Initiated QI Grievance SubCommittee Grievances 06/14-04/15 by general reason: Providers/Services 12 Billing 4 12

13 Change of Provider Requests Ensure timely handling of change of provider requests. 1. Track and trend change of provider requests and report to QIC and management annually. 2. Initiate QI activities as warranted. Type of Provider # Requests Approved Denied Other Resolution Resulted in Grievance Medical Staff Non-Medical Staff Partially Not CY14: five change of provider requests CY15 Q1 & Q2 four change of provider requests Treatment Authorization Requests (TARs) Ensure TARs processing within required timeframes. 1. Train additional staff on TAR process. 2. Create process for TAR appeal/denial review. 3. Improve compliance with TAR processing timeframe by 10%. 13

14 Partially Not FY14-15: 82% timely completion rate. Clinical Documentation -- Regulatory Compliance and Quality Improve quality of clinical documentation. 1. Provide six new hire/ and six refresher CG/trainings. 2. Decrease UR disallowance rate for all programs with a previous > 5% disallowance rate by 5%. Partially Not FY14-15 eight programs with > 5% disallowance rate. 14

15 Clinical Documentation -- Utilization Review Review a minimum of 5% of medical records from every MHSUS program and contract provider program annually. 1. Continue to review minimum 5% of medical records. 2. Revise UR report process to provide completed reports to programs within one month of the utilization review. Q1 Q2 Q3 Q4 # UR Average Time to Report Partially Not During FY14-15, Q3 &4, there were 20 reviews Average time from review to report during same period was 92.5 days. Monitor Safety and Effectiveness of Medication Practices 1. QM staff and Medical Director or designee will conduct medication monitoring reviews annually. 2. Report findings inclusive of corrective actions to QI Executive Committee annually. # Reviews Findings POC QI Y N Q2 Y N Q3 Y N Q4 Y N 15

16 Partially Not Six Medication Monitoring reviews were completed during FY Medi-Cal Site Certifications Ensure all Medi-Cal sites are certified/recertified in a timely manner. 1. Train additional staff on site certification process. 2. Achieve and maintain 95% compliance rate. Q1 Q2 Q3 Q4 # Certifications # Recertifications % On Time Partially Not Two staff trained to conduct site certifications 12/14: 83% compliance with 13% pending 16

17 Electronic Medical Record Enhance EMR to promote efficiency and support service delivery. 1. Identify EMR elements to add/enhance including: Brief Clinical Assessment, pre-consumer module, medical staff clinical templates. 2. Document, design and prioritize needed upgrades in EMR vendor project management system. Implement 80% of requested changes during Q 3 & 4 of FY. 3. Add new service areas to EMR (mobile teams/pes/jail MH/ Access.) Partially Not Establish FY15-16 baseline. 17

18 Electronic Medical Record-- End User Support Partially Not 1. Identify and consolidate EMR Helpdesk staff. 2. Finalize Clinical Documentation Manual. 3. Track numbers and types of calls. 4. Identify most common problems. 5. Identify whether EMR customization needed to address issues. 6. Create written FAQ and/or desktop video materials to address three most common difficulties and disseminate. Establish FY15-16 Baseline. 18

Shasta County Health and Human Services Agency Mental Health Plan Quality Management Work Plan. Introduction

Introduction As required by the California State Department of Health Care Services and the Medi Cal Managed Care Plan, the Shasta County Health and Human Services Agency through its Mental Health Plan