Santa Barbara MHP. Conducted on April 4-6, Prepared by:

Transcription

1 FY16-17 Medi-Cal Specialty Mental Health External Quality Review MHP Final Reprt Santa Barbara MHP Cnducted n April 4-6, 2017 Prepared by: Behaviral Health Cncepts, Inc Christie Avenue, Suite 502 Emeryville, CA

2 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year TABLE OF CONTENTS SANTA BARBARA MENTAL HEALTH PLAN SUMMARY FINDINGS... 4 INTRODUCTION... 6 PRIOR YEAR REVIEW FINDINGS, FY STATUS OF FY15-16 REVIEW RECOMMENDATIONS... 8 Assignment f Ratings... 8 Key Recmmendatins frm FY CHANGES IN THE MHP ENVIRONMENT AND WITHIN THE MHP IMPACT AND IMPLICATIONS PERFORMANCE MEASUREMENT TOTAL BENEFICIARIES SERVED PENETRATION RATES AND APPROVED CLAIM DOLLARS PER BENEFICIARY HIGH-COST BENEFICIARIES TIMELY FOLLOW-UP AFTER PSYCHIATRIC INPATIENT DISCHARGE DIAGNOSTIC CATEGORIES PERFORMANCE MEASURES FINDINGS IMPACT AND IMPLICATIONS PERFORMANCE IMPROVEMENT PROJECT VALIDATION SANTA BARBARA MHP PIPS IDENTIFIED FOR VALIDATION CLINICAL PIP IMPROVING TREATMENT: TRAINING, CLIENT ENGAGEMENT AND TEAM-BASED CARE NON-CLINICAL PIP TIMELINESS TO PSYCHIATRY SERVICES PERFORMANCE IMPROVEMENT PROJECT FINDINGS IMPACT AND IMPLICATIONS PERFORMANCE & QUALITY MANAGEMENT KEY COMPONENTS Access t Care Timeliness f Services Quality f Care KEY COMPONENTS FINDINGS IMPACT AND IMPLICATIONS CONSUMER AND FAMILY MEMBER FOCUS GROUP(S) CONSUMER/FAMILY MEMBER FOCUS GROUP CONSUMER/FAMILY MEMBER FOCUS GROUP CONSUMER/FAMILY MEMBER FOCUS GROUP FINDINGS IMPLICATIONS INFORMATION SYSTEMS REVIEW KEY ISCA INFORMATION PROVIDED BY THE MHP CURRENT OPERATIONS PLANS FOR INFORMATION SYSTEMS CHANGE ELECTRONIC HEALTH RECORD STATUS MAJOR CHANGES SINCE LAST YEAR PRIORITIES FOR THE COMING YEAR OTHER SIGNIFICANT ISSUES MEDI-CAL CLAIMS PROCESSING INFORMATION SYSTEMS REVIEW FINDINGS IMPLICATIONS SITE REVIEW PROCESS BARRIERS CONCLUSIONS Page 2

3 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year STRENGTHS AND OPPORTUNITIES Access t Care Timeliness f Services Quality f Care Cnsumer Outcmes RECOMMENDATIONS ATTACHMENTS ATTACHMENT A REVIEW AGENDA ATTACHMENT B REVIEW PARTICIPANTS ATTACHMENT C APPROVED CLAIMS SOURCE DATA ATTACHMENT D PIP VALIDATION TOOL Page 3

4 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year SANTA BARBARA MENTAL HEALTH PLAN SUMMARY FINDINGS Beneficiaries served in CY15 4,868 MHP Threshld Language(s) Spanish MHP Size Medium MHP Regin Suthern MHP Lcatin Santa Barbara MHP Cunty Seat Santa Barbara Intrductin The MHP has cntinued t instill the philsphy f wellness and partnership. Rebranding the MHP tw years ag as the Behaviral Wellness Department reflected this principle. Partnership means wrking cllabratively and chesively with individuals and grups in settings within and beynd the behaviral health system. In additin, the MHP created the Change Agent Cmmittee, cmprised f self-selected vlunteer staff, managers, cnsumers, and leadership cming tgether as Change Agents. This team wrks tgether t identify needed changes and hld thse able t enfrce change as accuntable t the visin t the degree pssible. The MHP perates clinics and services reginally-based, secndary t its gegraphic layut. The three primary regins are identified as the Central (Santa Barbara), the Nrth (Santa Maria), and the West (Lmpc) regins. Access In Octber 2016, the MHP launched its centralized access in which all phne calls, walk-ins and referrals are lgged and tracked fr timely access. Intake appintments and services have expanded in the Carpinteria regin where transprtatin was nted as a barrier. Fllwing the initial cntact, rientatin grups serve as an intrductin t services and a venue fr thse in attendance t receive a timely assessment. Three reginal teams specialize in access and assessment, with special attentin t cultural cnsideratins, such as unique presentatins f crises amng minrities and the imprtance f accessing family and cmmunity supprts. The new reginal teams are based in Lmpc, Santa Maria and Santa Barbara. The teams are guided by recvery and resiliency cncepts and will imprve access t services. Timeliness Timeliness reprts are reviewed fr each clinic and each regin at the mnthly Quality Imprvement Cmmittee meetings. Strategies are discussed and priritized fr system-wide imprvements. A Perfrmance Imprvement Prject was cntinued fr imprved timely access t psychiatry appintments and decreased n-shw rates. Page 4

5 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year Quality The MHP has adpted the as a cmmunity health imprvement strategy based n evidence that three (3) health behavirs elevate risk f fur (4) chrnic cnditins that tgether cause mre than fifty (50) percent f deaths. Studies shw that individuals with mental illness and substance use disrders (SUD) are mre likely t engage in the three behavirs than the rest f the ppulatin, increasing susceptibility t the fur cnditins. These c-ccurring physical and behaviral health cnditins can significantly impact prgnsis, quality f life and lifespan. By acknwledging the cnsequences f these behavirs and emplying strategies that address them, Behaviral Wellness staff can tackle the underlying issue that slw and challenge a client s prgress twards meaningful, lasting recvery. Outcmes The MHP utilizes the Child and Adlescent Needs and Strengths (CANS) and the Milestnes f Recvery Scales (MORS) as indicatrs t measure cnsumer needs and treatment prgress. Varius services and strategies are initiated t address the nging and expansive needs cnsumers may require. Examples include the submissin f the Drug Medi-Cal Expansin Waiver t extend treatment services fr substance use disrders and the establishment f a five-bed residential facility fr hmeless wmen. Page 5

6 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year INTRODUCTION The United States Department f Health and Human Services (DHHS), Centers fr Medicare and Medicaid Services (CMS) requires an annual, independent external evaluatin f State Medicaid Managed Care prgrams by an External Quality Review Organizatin (EQRO). External Quality Review (EQR) is the analysis and evaluatin by an apprved EQRO f aggregate infrmatin n quality, timeliness, and access t health care services furnished by Prepaid Inpatient Health Plans (PIHPs) and their cntractrs t recipients f Managed Care services. The CMS rules (42 CFR 438; Medicaid Prgram, External Quality Review f Medicaid Managed Care Organizatins [MCOs]) specify the requirements fr evaluatin f Medicaid Managed Care prgrams. These rules require an n-site review r a desk review f each Medi-Cal Mental Health Plan (MHP). The State f Califrnia Department f Health Care Services (DHCS) cntracts with 56 cunty Medi- Cal MHPs t prvide Medi-Cal cvered Specialty Mental Health Services (SMHS) t Medi-Cal beneficiaries under the prvisins f Title XIX f the federal Scial Security Act. This reprt presents the FY16-17 findings f an EQR f the Santa Barbara MHP by the Califrnia EQRO (CalEQRO), Behaviral Health Cncepts, Inc. (BHC). The EQR technical reprt analyzes and aggregates data frm the EQR activities as described belw: (1) VALIDATING PERFORMANCE MEASURES 1 This reprt cntains the results f the EQRO s validatin f eight Mandatry Perfrmance Measures (PMs) as defined by DHCS. The eight perfrmance measures include: Ttal Beneficiaries Served by each cunty MHP Ttal Csts per Beneficiary Served by each cunty MHP Penetratin Rates in each cunty MHP Cunt f Therapeutic Behaviral Services (TBS) Beneficiaries Served Cmpared t the fur percent Emily Q. Benchmark (nt included in MHP reprts; this infrmatin is included in the Annual Statewide Reprt submitted t DHCS). Ttal Psychiatric Inpatient Hspital Episdes, Csts, and Average Length f Stay Psychiatric Inpatient Hspital 7-Day and 30-Day Rehspitalizatin Rates Pst-Psychiatric Inpatient Hspital 7-Day and 30-Day SMHS Fllw-Up Service Rates High Cst Beneficiaries ($30,000 r higher) 1 Department f Health and Human Services. Centers fr Medicare and Medicaid Services (2012). Validatin f Perfrmance Measures Reprted by the MCO: A Mandatry Prtcl fr External Quality Review (EQR), Prtcl 2, Versin 2.0, September, Washingtn, DC: Authr. Page 6

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

8 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year PRIOR YEAR REVIEW FINDINGS, FY15-16 In this sectin the status f last year s (FY15-16) recmmendatins are presented, as well as changes within the MHP s envirnment since its last review. STATUS OF FY15-16 REVIEW RECOMMENDATIONS In the FY15-16 site review reprt, the CalEQRO made a number f recmmendatins fr imprvements in the MHP s prgrammatic and/r peratinal areas. During the FY16-17 site visit, CalEQRO and MHP staff discussed the status f thse FY15-16 recmmendatins, which are summarized belw. Assignment f Ratings Fully addressed is assigned when the identified issue has been reslved: reslved the identified issue Partially addressed is assigned when the MHP has either: made clear plans, and is in the early stages f initiating activities t address the recmmendatin addressed sme but nt all aspects f the recmmendatin r related issues Nt addressed is assigned when the MHP perfrmed n meaningful activities t address the recmmendatin r assciated issues. Key Recmmendatins frm FY15-16 Recmmendatin #1: Adequate staffing fr this MHP remains a challenge with implicatins fr access, timeliness and quality f services. Hiring f clinical staff, case management staff and bi-lingual Spanish speaking staff need t be pririty in recruitment as well as retentin. Fully addressed Partially addressed Nt addressed The hiring f staff remains a department pririty. The managers have wrked with the cunty s Human Resurces Department t assist in priritizing the hiring f bi-lingual Spanish-speaking emplyees. Limitatins exist at the cunty level with an impsed freeze n backfilling line staff psitins as they are vacated. T date, the MHP reprts it prvides line staff t meet the needs f the Spanish-speaking cnsumers and it cntinues t recruit t meet the needs fr psychiatry. Reprtedly, nearly 40% f staff are bi-lingual Spanish-speaking. Page 8

9 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year Recmmendatin #2: A lack f cnsistent understanding and adherence t plicies and prcedures acrss the MHP s three regins cntinues t be reprted. Develp and implement a system f plicies and prcedures with checks fr cmpliance t ensure all staff are aware f and cmpliant with plicies and prcedures as well available training pprtunities. Fully addressed Partially addressed Nt addressed New staff are prvided an rientatin and trained in the plicies and prcedures. Online access is available thrugh the database. Frequent updates ccur with annuncements. Supervisrs receive and discuss new plicies at the mnthly supervisr meetings. In the past year, several trainings were ffered and attendance tracked thrugh the Relias Learning mdule. CalEQRO suggests the MHP cnsider a pre-test and pst-test survey t evaluate the level f knwledge integrated frm the trainings which may prvide evidence f change, representing standardized learning r gaps in learning. Recmmendatin #3: Issues arising frm the shrtage f psychiatrists is reprted acrss the system and prgrams. Create a plan t increase telepsychiatry ptins while cntinuing t develp a recruitment and retentin plicy fr effectiveness in filling psychiatry psitins. Fully addressed Partially addressed Nt addressed Current recruitment and retentin effrts have resulted in filling 90% f psychiatrist psitins. This included a new full-time civil service clinic psychiatrist at the Santa Barbara Children s Outpatient Clinic. The MHP expanded the range f prviders t include psychiatric mental health nurse practitiners (NPs) and physician assistants (PAs). The MHP placed a nurse practitiner in a permanent psitin with the Santa Barbara Assertive Cmmunity Treatment (ACT) team. A secnd nurse practitiner psitin awaits recruitment and hiring. Cntracts were negtiated with fur temprary staffing agencies (lcum tenens; MD, NP and PA). Staff are cntracted between three mnths t ne year. Additinally, these cmpanies ffer the ptin f buying ut the emplyee t becme a full-time prvider. This ptin was exercised in the case f the ACT nurse practitiner, and plans using this mechanism in the future are pssible. The Cunty Human Resurces applicatin prcess fr psychiatrist psitins is pen and nging, ffering cash incentives, a vacatin and sick time bank, available at hiring time. Page 9

10 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year Recmmendatin #4: Cntinue t mnitr the twice mnthly utcme measure reprt t assure the Child and Adlescent Needs and Strengths (CANS) and the Milestnes f Recvery Scale (MORS) is used in cmpliance with MHP standards. Fully addressed Partially addressed Nt addressed The MHP develped semi-mnthly autmatically generated CANS and MORS reprts ver the past tw years. This was t further institutinalize the utilizatin f the measures, imprve cmpliance with MHP administratin requirements, and assist prgram staff with mnitring client utcmes. The reprts are designed t help staff and management mnitr cmpletin f the CANS and MORS at specified intervals. These reprts cntinue t be distributed t the Research and Prgram Evaluatin Manager, Chief f Cmpliance, Clinical Operatins Divisin Chief, Reginal Managers and Team Supervisrs (bth MHP and the rganizatinal prviders), wh disperse the reprts t apprpriate staff. In the last year, a significant change t the reprt was t ensure that the CANS due dates and scres fllw the client rather than at prgram admissin and clsure. This methd ensures that the client receives the CANS every six mnths regardless f what prgram the client is enrlled in, prducing ne thread f data fr each client during their admissin t the system. In FY , the MHP began prducing semi-annual and annual departmental reprts fr the Bard f Supervisrs and the cmmunity fr bth the CANS and the MORs. The MHP has als engaged in a Perfrmance Imprvement Prject (PIP), which uses the CANS and the MORS scres as an indicatr f treatment prgress with the implementatin f its Team-Based Treatment. Recmmendatin #5: Cmplete develpment f the Clinical Reprting System t allw users the ability t create custm reprts as well as expand the capacity t refresh canned reprts with current data as needed. Fully addressed Partially addressed Nt addressed In cllabratin with the prject cnsulting vendr the MHP has cmpleted phase ne f the Clinical Reprting System (CRS) prject. The first phase is accessible thrugh the MHP Prvider Prtal and cnsists f tw public facing web based slutins: CRS Dashbard and CRS Details. The secnd phase f the CRS prject was halted in FY and is under review due t cncerns ver the planned security mdel. User authenticatin is required t access the reprts presented in phase tw which cntain persnally identifiable infrmatin. The planned security mdel wuld require management f a user repsitry in additin t the MHP s existing user databases fr Clinician s Gateway and ShareCare. The prcess f maintaining cnsistency acrss the three systems is Page 10

11 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year manual and the ptential exists fr an inadvertent PHI breach under this mdel. A methd t maintain cnsistency with audit cntrl is needed. A brader analysis frm a technlgy perspective revealed the lack f a mdern internal service management tl. ServiceNw has been selected t fill this vid and implementatin is underway. The staff nbarding and ff barding prcesses will be expanded t include tasks fr ensuring apprpriate user access cntrl acrss all MHP infrmatin systems. The MHP anticipates that this new service management slutin will be in active use by the end f FY The CRS prject remains a high pririty and the MHP currently anticipates prceeding with secnd phase when ServiceNw is in prductin. Recmmendatin #6: Maintain cnsistent cntact with The Ech Grup t assure a timely reslutin t the MHP s inability t submit Client Service Infrmatin (CSI) data files t the State. Fully addressed Partially addressed Nt addressed The MHP began the catch-up prcess n the eight mnths f reprting backlg in June The full prcess was riginally anticipated t be cmpleted by early July bringing the MHP current n CSI data submissins. The data exprt fr the reprting mnth f September 2015 was exceptinal in size and required multiple uplads and additinal time t cmplete. Successful prcessing f the September 2015 reprting mnth was achieved in July The data exprt fr the reprting mnth f Octber 2015 generated the first set f data with the Ech Grup s new ICD-10 reprting specificatin in ShareCare. Many errrs were encuntered during validatin by the State. The MHP wrked clsely with The Ech Grup and the State ver the next three mnths t prduce crrect CSI data utput frm ShareCare. The Ech Grup released a sftware patch in August 2016 that reslved the reprting utput, but database issues required an additinal tw mnths f wrk t reslve. Successful prcessing f the Octber 2015 reprting mnth was achieved in Octber During the mnths f Nvember and December 2016 catch-up reprting was successfully cmpleted and submitted t the State fr reprting mnths Nvember 2015 thrugh Nvember Reprts are nw submitted n-time and the MHP is current with required State CSI data submissins. Page 11

12 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year CHANGES IN THE MHP ENVIRONMENT AND WITHIN THE MHP IMPACT AND IMPLICATIONS Changes since the last CalEQRO review, identified as having a significant effect n service prvisin r management f thse services are discussed belw. This sectin emphasizes systemic changes that affect access, timeliness, and quality, including thse changes that prvide cntext t areas discussed later in this reprt. Access t Care Expansin f substance use disrder treatment is underway as the MHP develps its Drug Medi-Cal expansin services. The MHP restructured its Access by establishing a centralized call-in Access Unit which prvides initial screening, referrals and the first scheduled appintment fr an rientatin. Cmmunity based residential facilities were increased by the additin f a new five-bed residence fr hmeless wmen. Mbile and Triage Teams were integrated int Crisis Stabilizatin Unit peratins. Timeliness f Services Revisins fr the centralized access prcess are intended t result in mre timely appintments. Orientatin grups are ffered and the initial assessment is cnducted fr thse in attendance, decreasing wait time. Quality f Care The strategy using the mdel f the methd fr grups is ffered cuntywide is a cmmunity health imprvement strategy based n evidence that three health behavirs elevate risk fr fur chrnic cnditins that tgether cause mre than fifty percent f deaths. The MHP uplads multiple reprts and newsletters n its public website, cntributing t transparency. The Relias Training prtal is fully implemented and has facilitated achieving the gal f 100% cmpliance with mandatry training requirements. Cmpleted publicatin f a Principles and Practice series highlighting Behaviral Wellness system guiding principles is available n the website. Cnsumer Outcmes The MHP cntinues t utilize the CANS and the MORS t indicate cnsumer needs and cnsumer prgress in treatment. The MHP increased mbile crisis teams deplyed cuntywide can deflect the ptential fr higher level services. Page 12

13 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year The MHP expanded cmmunity based residential facilities, adding a new fivebed residence fr hmeless wmen. Page 13

14 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year PERFORMANCE MEASUREMENT CalEQRO is required t validate the fllwing perfrmance measures as defined by DHCS: Ttal Beneficiaries Served by each cunty MHP Ttal Csts per Beneficiary Served by each cunty MHP Penetratin Rates in each cunty MHP Cunt f TBS Beneficiaries Served Cmpared t the fur percent Emily Q. Benchmark (nt included in MHP reprts; this infrmatin is included in the Annual Statewide Reprt submitted t DHCS) Ttal Psychiatric Inpatient Hspital Episdes, Csts, and Average Length f Stay Psychiatric Inpatient Hspital 7-Day and 30-Day Rehspitalizatin Rates Pst-Psychiatric Inpatient Hspital 7-Day and 30-Day SMHS Fllw-Up Service Rates High Cst Beneficiaries ($30,000 r higher) TOTAL BENEFICIARIES SERVED Table 1 prvides detail n beneficiaries served by race/ethnicity. Table 1 Medi-Cal Enrllees and Beneficiaries Served in CY15 by Race/Ethnicity Santa Barbara Race/Ethnicity Average Mnthly Unduplicated Medi-Cal Enrllees* % Enrllees Unduplicated Annual Cunt f Beneficiaries Served % Served White 78, % 3, % Hispanic 17, % % African-American 1, % % Asian/Pacific Islander 6, % % Native American % % Other 7, % % Ttal 112, % 4, % *The ttal is nt a direct sum f the averages abve it. The averages are calculated separately. The actual cunts are suppressed fr cells cntaining n 11. Page 14

15 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year PENETRATION RATES AND APPROVED CLAIM DOLLARS PER BENEFICIARY The penetratin rate is calculated by dividing the number f unduplicated beneficiaries served by the mnthly average enrllee cunt. The average apprved claims per beneficiary served per year is calculated by dividing the ttal annual dllar amunt f Medi-Cal apprved claims by the unduplicated number f Medi-Cal beneficiaries served per year. Regarding calculatin f penetratin rates, the Santa Barbara MHP: Uses the same methd as used by the EQRO. Uses a different methd. Des nt calculate its penetratin rate. Page 15

16 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year Figures 1A and 1B shw 3-year trends f the MHP s verall apprved claims per beneficiary and penetratin rates, cmpared t bth the statewide average and the average fr medium MHPs. Page 16

17 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year Figures 2A and 2B shw 3-year trends f the MHP s fster care (FC) apprved claims per beneficiary and penetratin rates, cmpared t bth the statewide average and the average fr medium MHPs. Page 17

18 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year Figures 3A and 3B shw 3-year trends f the MHP s Hispanic apprved claims per beneficiary and penetratin rates, cmpared t bth the statewide average and the average fr medium MHPs. See Attachment C, Table C1 fr the penetratin rate and apprved claims per beneficiary fr the CY15 Medi-Cal Expansin (ACA) Penetratin Rate and Apprved Claims per Beneficiary. Page 18

19 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year HIGH-COST BENEFICIARIES Table 2 cmpares the statewide data fr high-cst beneficiaries (HCB) fr CY15 with the MHP s data fr CY15, as well as the prir tw years. HCB in this table are identified as thse with apprved claims f mre than $30,000 in a year. MHP Year HCB Cunt Table 2 High-Cst Beneficiaries Ttal Beneficiary Cunt HCB % by Cunt Average Apprved Claims per HCB HCB Ttal Claims HCB % by Apprved Claims Statewide CY15 13, , % $51,635 $715,196, % Santa Barbara CY , % $46,789 $8,000, % CY , % $49,176 $7,573, % CY , % $51,628 $11,874, % See Attachment C, Table C2 fr the distributin f the MHP beneficiaries served by apprved claims per beneficiary (ACB) range fr three cst categries: under $20,000; $20,000 t $30,000; and thse abve $30,000. Page 19

20 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year TIMELY FOLLOW-UP AFTER PSYCHIATRIC INPATIENT DISCHARGE Figures 4A and 4B shw the statewide and MHP 7-day and 30-day utpatient fllw-up and rehspitalizatin rates fr CY14 and CY15. Page 20

21 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year DIAGNOSTIC CATEGORIES Figures 5A and 5B cmpare the breakdwn by diagnstic categry f the statewide and MHP number f beneficiaries served and ttal apprved claims amunt, respectively, fr CY15. MHP self-reprted percent f cnsumers served with cccurring (substance abuse and mental health) diagnses: 14.6% Page 21

22 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year PERFORMANCE MEASURES FINDINGS IMPACT AND IMPLICATIONS Access t Care The MHP s number f eligibles rse frm 106,121 in CY14 t 112,225 in CY15 and beneficiaries increased frm 4,828 t 4,868 during this perid. This crrelates t a penetratin rate drp frm 4.55% in CY14 t 4.34% in CY15. The MHP s Overall CY15 penetratin rate is nw cmparable t the Medium Cunty average (4.31%) and less than the statewide (4.82%) average. The MHP served 1,293 Affrdable Care Act (ACA) beneficiaries f 25,070 eligibles in CY15 fr a penetratin rate f 5.16% fr this sub-grup (see Table C1 in Appendix C). When cmbining the Medi-Cal and ACA data, the MHP s CY15 average mnthly eligibles increased t 137,295 with 6,161 beneficiaries fr a cmbined increase frm CY14 Medi-Cal nly data f 31,174 eligibles and 1,333 additinal beneficiaries. The MHP s Fster Care penetratin rate decreased frm 53.10% in CY14 t 50.00% in CY15, but remains greater than bth the Medium Cunty (48.98%) and statewide (47.19%) averages. The MHP s Hispanic penetratin rate drpped frm 4.51% in CY14 t 4.18% in CY15 but remains greater than bth the Medium Cunty (2.80%) and statewide (3.49%) averages. Timeliness f Services In CY15, the MHP s 7-day and 30-day utpatient fllw-up rates after discharge frm a psychiatric inpatient episde decreased when cmpared t the crrespnding CY14 rates and remain abve statewide averages. Quality f Care The MHP s average verall apprved claims per beneficiary increased frm $5,747 in CY14 t$6,115 in CY15, and is greater than the Medium Cunty ($5,943) and the statewide averages ($5,522). The MHP s Fster Care apprved claims per beneficiary increased frm $7,101 in CY14 t $7,823 in CY15, and remains less than bth the Medium Cunty ($8,324) and statewide averages ($8,127). The MHP had 566 Fster Care beneficiaries in CY15. The MHP s CY15 average Hispanic apprved claims per beneficiary increased frm $5,481 in CY14 $5,979 in CY15 and remains greater than bth the Medium Cunty ($5,287) and statewide ($5,045) averages. The MHP s percentage f high-cst beneficiaries (HCBs) in CY15 (3.51%) increased slightly frm CY14 (3.19%) and is greater than the statewide average (2.86%). Page 22

23 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year The percentage f ttal HCB claim dllars was slightly greater than the statewide average in CY15 (27.67% vs %). The MHP s average apprved claims per HCB declined frm CY14 ($49,176) t CY 15 ($46,789), and is less than the CY15 statewide average ($51,635). The MHP had 171 HCBs in CY15. The MHP had a ntably higher rate f Adjustment and Deferred diagnses and a lwer rate f Depressive, Disruptive and Other diagnses when cmpared t statewide averages. Deferred diagnsis was twice the statewide average (8% vs. 4%). Varying frm the MHP s diagnstic pattern, the percentage f ttal apprved claims fr individuals with psychtic disrders was significantly higher than that f any ther diagnstic categry and prprtinately higher than the statewide average when cmparing diagnstic categry percentage and apprved claims dllars. Other diagnstic apprved claims dllars generally aligned with the MHP s diagnstic pattern. Cnsumer Outcmes The MHP s 7-day re-hspitalizatin rate rse frm 10% in CY14 t 12% in CY15, exceeding the CY15 statewide average (7%). The MHP s CY15 30-day re-hspitalizatin rate rse frm 16% in CY14 t 21% in CY15, exceeding the CY15 statewide average (16%). Page 23

24 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year PERFORMANCE IMPROVEMENT PROJECT VALIDATION A PIP is defined by CMS as a prject designed t assess and imprve prcesses, and utcmes f care that is designed, cnducted and reprted in a methdlgically sund manner. The Validating Perfrmance Imprvement Prjects Prtcl specifies that the EQRO validate tw PIPs at each MHP that have been initiated, are underway, were cmpleted during the reprting year, r sme cmbinatin f these three stages. DHCS elected t examine prjects that were underway during the preceding calendar year SANTA BARBARA MHP PIPS IDENTIFIED FOR VALIDATION Each MHP is required t cnduct tw PIPs during the 12 mnths preceding the review. CalEQRO reviewed and validated tw MHP submitted PIPs as shwn belw. Table 3 PIPs Submitted PIPs fr Validatin # f PIPs PIP Titles Clinical PIP 1 Imprving Treatment: Training, Client Engagement and Team-Based Care Nn-Clinical PIP 1 Timeliness t Psychiatry Services Table 4 lists the findings fr each sectin f the evaluatin f the PIPs, as required by the PIP Prtcls: Validatin f Perfrmance Imprvement Prjects. 4 Table 4 PIP Validatin Review Step PIP Sectin Validatin Item 1 Selected Study Tpics Item Rating* Clinical PIP Nn- Clinical PIP 1.1 Stakehlder input/multi-functinal team M M Analysis f cmprehensive aspects f enrllee needs, care, and services Brad spectrum f key aspects f enrllee care and services 1.4 All enrlled ppulatins M M 2 Study Questin 2.1 Clearly stated M M M M M M Department f Health and Human Services, Centers fr Medicare and Medicaid Service Prtcl 3 Versin 2.0, September EQR Prtcl 3: Validating Perfrmance Imprvement Prjects. Page 24

25 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year Table 4 PIP Validatin Review Step PIP Sectin Validatin Item 3 Study Ppulatin 4 Study Indicatrs Sampling Methds Data Cllectin Prcedures Assess Imprvement Strategies Review Data Analysis and Interpretatin f Study Results Validity f Imprvement Item Rating* Clinical PIP Nn- Clinical PIP 3.1 Clear definitin f study ppulatin M M 3.2 Inclusin f the entire study ppulatin M M Objective, clearly defined, measurable indicatrs Changes in health status, functinal status, enrllee satisfactin, r prcesses f care Sampling technique specified true frequency, cnfidence interval and margin f errr Valid sampling techniques that prtected against bias were emplyed Sample cntained sufficient number f enrllees 6.1 Clear specificatin f data M M 6.2 Clear specificatin f surces f data M M Systematic cllectin f reliable and valid data fr the study ppulatin Plan fr cnsistent and accurate data cllectin Prspective data analysis plan including cntingencies 6.6 Qualified data cllectin persnnel M M Reasnable interventins were undertaken t address causes/barriers Analysis f findings perfrmed accrding t data analysis plan PIP results and findings presented clearly and accurately Threats t cmparability, internal and external validity Interpretatin f results indicating the success f the PIP and fllw-up 9.1 Cnsistent methdlgy thrughut the study NA M 9.2 Dcumented, quantitative imprvement in prcesses r utcmes f care PM M NA NA NA M M M M PM PM PM NA NA M M NA NA NA PM PM PM M PM M PM M M Page 25

26 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year Table 4 PIP Validatin Review Step PIP Sectin Validatin Item 9.3 Imprvement in perfrmance linked t the PIP Item Rating* Clinical PIP Nn- Clinical PIP 9.4 Statistical evidence f true imprvement NA NA 9.5 Sustained imprvement demnstrated thrugh repeated measures. *M = Met; PM = Partially Met; NM = Nt Met; NA = Nt Applicable; UTD = Unable t Determine; NR = Nt Rated (Cncept Only r Nne Submitted) NA NA PM PM Table 5 gives the verall rating fr each PIP, based n the ratings given t the validatin items. Table 5 PIP Validatin Review Summary Summary Ttals fr PIP Validatin Clinical PIP Nn- Clinical PIP Number Met Number Partially Met 4 7 Number Nt Met 0 0 Number Applicable (AP) (Maximum = 28 with Sampling; 25 withut Sampling) Overall PIP Rating ((#Met*2) +(#Partially Met))/(AP*2) 89.5% 85.4% CLINICAL PIP IMPROVING TREATMENT: TRAINING, CLIENT ENGAGEMENT AND TEAM-BASED CARE The MHP presented its study questin fr the Clinical PIP as fllws: Are client utcmes, as measured by the Cnsumer Perceptin Survey (CPS), the Child and Adlescent Needs and Strengths (CANS), and the Milestnes f Recvery Scale (MORS) imprved by implementing: Training fr clinical staff Team-based care mdel and tls; and Page 26

27 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year Imprved MIS treatment related reprts (fr managers and supervisrs)? Date PIP began: Nvember 2015 Status f PIP: Active and nging Cmpleted Inactive, develped in a prir year (Nt Rated) Cncept nly, nt yet active (Nt Rated) Submissin determined nt t be a PIP (Nt Rated) N PIP submitted (Nt Rated) This is a revisin frm the prir year PIP with an increased fcus t measure cnsumer care in the current year. This PIP fcuses n imprving client experience f treatment in terms f: a) ensuring that all clients have high quality current/active treatment plans, b) implementing team-based care, and c) imprving client engagement. As the name suggests, team-based care is nt individual care r care that is rganized between a single client and a single helping prfessinal. While client care is individualized, treatment is nt prvided by a single prfessinal but by a team f prfessinals, all f whm are available t help the client at any given time, regardless f client needs. Each team member may be licensed, certified r have a specific set f skills, but they are als generalists and able t prvide a wide range f supprt and interventins. Team-based care des nt eliminate treatment caselads. All clients have a single pint f cntact, cunselr r therapist, but are managed (and supprted) by an entire team. This differs frm the previus rganizatin and delivery f care wherein a client was assigned t a clinician r case manager and if that persn was unavailable, the client wuld see the fficer f the day. The hypthesis is that this imprved experience f treatment will result in imprved utcmes as measured by imprvements in three client survey measures thrugh the bi-annual Cnsumer Perceptin Survey, an imprved scre fr yuth thrugh the Child and Adlescent Needs and Strengths, and an imprved scre fr adults thrugh the Milestnes f Recvery Scale. The prblem identified thrugh chart review and anecdtal stakehlder feedback was that clients are nt getting the benefit f a timely, high quality treatment plan that engages them. Based n the timeliness metric manner, within 60 days f assessment and annually thereafter, the MHP infers the treatment plan is nt being fully utilized as a clinical tl; bth in that staff are nt wrking tgether as a team and are nt engaging clients in the develpment and nging utilizatin f the treatment plan. Mrever, clinicians are nt initially cmpleting r renewing plans n time (as indicted by MIS Treatment plan reprt), indicative that plans are nt being utilized as intended. Page 27

28 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year The MHP decided t refcus the PIP n the clinical imprvement f treatment planning and prvisin in terms f client engagement and team-based care, while cntinuing the fcus n timeliness twards treatment planning. It was expected that this clinical imprvement in treatment planning and prvisin will have an impact n imprtant client utcmes as measures by the CPS, CANS and MORS. The verarching gal f the PIP is t imprve client utcmes by imprving the prcess and the prvisin f treatment. The interventins planned fr this PIP shuld result in timely, high quality treatment plans that engage clients and their care team, expected t see imprved client utcmes in the CPS, CANS and MORS. Gals fr the PIP included: Cnsumer Perceptin Survey (5% imprvement in three client survey measures related t treatment care and functining) Imprved Child and Adlescent Needs and Strengths (CANS) scres fr yuth (5% imprved scres) Imprved Milestnes f Recvery Scale (MORS) scres fr adults. The MHP will need t clarify the indicatrs fr change based n imprved scres fr the MORS fr adults and will need t be defined with quantifiable gals. Data analysis dne t date indicated sme imprved cnsumer utcmes. During FY15/16, there were 226 clients wh received CANS scres fr three timelines: An initial, at 6-mnths, and at 12- mnths. Results indicated a reductin in the average scres n the fur dmains f Behaviral/Emtinal Needs, Life Functining, Child Risk Behavirs and Schl Behavirs indicated that children have made prgress and reduced the severity f their needs, distress and challenges. The data was reprted in detail in the submissin dcument. Results f MORS data analyses are reprted separately, fr Transitinal Age Yuth (TAY) prgrams, Adult Outpatient and Assertive Cmmunity Treatment (ACT). The Transitinal Age Yuth (TAY) prgrams began using MORS instead f the CANS in spring At six mnths, mre than eighty-five percent (85%) imprved r stayed the same. The adult utpatient clinics began cmpleting the MORS in December 2015/January At six mnths, mre than eighty percent (80%) f clients imprved r stayed the same. The Assertive Cmmunity Treatment (ACT) prgrams implemented MORS in July The ACT prgrams are intended t serve the mst challenged clients in the utpatient system, which can make imprvement in treatment slwer and uncertain. Results at six mnths indicated clse t eighty percent (78.3%) imprved r stayed the same. ACT scres were als examined between 6-mnths and 12-mnths; results were similar: Page 28

29 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year sme (13.9%) imprved, mst (71.2%) remained the same and sme (14.9%) declined ver time. The results f the CPS ver time frm the Fall 2014 t the Spring 2016 indicate imprvements in satisfactin and ability t chse services, ability t cpe and self-efficacy as reprted by cnsumers The MHP distributed a survey t staff (September 2016 and February 2017) t review the verall use f the team-based apprach with results shwing an imprvement in the use f the mdel. The MHP intends t cntinue its data analysis and cmplete this PIP by the end f this fiscal year. The recmmendatins fr the MHP are t quantify the gals fr imprvement n the MORS measures. Relevant details f these issues and recmmendatins are included within the cmments fund in the PIP validatin tl. The technical assistance prvided t the MHP by CalEQRO cnsisted f emphasizing the fcus n client care, measurable and quantifiable gals, and interventins that address cnsumer prgress r benefit and nt the interventins directed twards staff imprvements. Staff benefits frm training, lays the grundwrk fr imprved treatment and ultimately cntributes t imprved client functining. The MHP is encuraged t seek cnsultatin as it utlines clear gals, defines interventins, and establishes the measurable indicatrs fr its PIP. NON-CLINICAL PIP TIMELINESS TO PSYCHIATRY SERVICES The MHP presented its study questin fr the Nn-Clinical PIP as fllws: Will implementing the six (6) interventins f the PIP result in a reductin in client nshw rates and a reductin and wait time between admissin and first psychiatric appintment in the adult and children s systems f care? Interventins include: Appintment reminder calls Team-based appintment management Increasing clinical/peer cntacts prir t psychiatric assessment Implementing f a singular, standardized appintment scheduling system Enhancing recruitment f psychiatrists and physician assistants Incentivizing psychiatrist prductivity. Date PIP began: April 2014 Status f PIP: Page 29

30 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year Active and nging; The MHP intends t cmplete this by the end f FY16/17 and will be cnsidered cmplete. Cmpleted Inactive, develped in a prir year (Nt Rated) Cncept nly, nt yet active (Nt Rated) Submissin determined nt t be a PIP (Nt Rated) N PIP submitted (Nt Rated) This is year tw fr the submissin f this PIP. The gal is t reduce time between admissin and psychiatric assessment, and t decrease the n-shw rates, thus imprving system functining, the prcess f client care and, ultimately, client utcmes. As n standard was in place fr time t the first psychiatry appintment fr new clients, several stakehlder meetings were devted t reviewing the wait time data, discussing hw wait time data are cllected in the Management Infrmatin System/ Infrmatin Technlgy (MIS/IT) system, gaps in that prcess, and client flw thugh the access/intake system. The stakehlders determined that a mre accurate and meaningful measure f access t psychiatry wuld be the time between admissin and the first psychiatric appintment (rather than time between first system cntact and psychiatry appintment). Using this new definitin f timeliness, FY 2013/14 data were examined, which revealed that the adult system wait time was days, and in the children s system wait time was days. It established a twenty-ne-day plicy between first system cntact and psychiatry appintment. The gal is t reduce time t twenty-ne days between admissin and psychiatric assessment, thus imprving system functining, the prcess f client care and, ultimately, client utcmes. An additinal gal is t reduce n-shw rates t 5%. Inferred in this gal is the hpe that earlier appintments will address symptms earlier, engage cnsumers, and lead t imprved functining. The bjective f this nging and evlving PIP is t implement a variety f strategies, in phases, t reduce the time new clients wait befre having their first psychiatric appintment. The MHP is utilizing the NIATx principles and practices f Plan, D, Study, and Act (PDSA) mdel t implement and evaluate the impact f varius interventins ver time, such as: Appintment reminder calls Team-based appintment management Increasing clinical/peer cntacts prir t psychiatric assessment Implementing f a singular, standardized appintment scheduling system Enhancing recruitment f psychiatrists and physician assistants Incentivizing psychiatrist prductivity Page 30

31 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year The results reprted in December 2016, indicated the MHP has successfully reduced adult wait time and achieved the PIP gal t 19.6 days, and reduced child wait time, t 25.5 days. It has nt met its gals fr reduced wait times fr children nr reduced its n-shw rates. The MHP indicated it is training staff in standardized dcumentatin f the n-shws and has captured mre accurate data cllectin via electrnic methds. The MHP intends t cmplete this PIP by the end f the fiscal year with the intent t reduce wait times further and t reduce the n-shw rates. Relevant details f these issues and recmmendatins are included within the cmments fund in the PIP validatin tl. The technical assistance prvided t the MHP by CalEQRO cnsisted f recmmending early cnsultatin regarding defining its new PIP study questin, interventins and gals assciated with cnsumer quality f care. PERFORMANCE IMPROVEMENT PROJECT FINDINGS IMPACT AND IMPLICATIONS Access t Care Reduced wait times fr appintments can lead t engagement and ptentially address symptms earlier. Timeliness f Services Decreased n-shw rates can lead t increased availability f prviders, increased time-slts and imprved timeliness t service with increased accessible appintments. Timely treatment planning prvides grundwrk fr measured cnsumer prgress. Quality f Care Standardized prcesses and metrics infrm the MHP f its cnsumers service needs. Team-based treatment establishes crdinated care fr cnsumer benefit. Cnsumer Outcmes Imprved shw rates can impact cnsumer functining via cnsistent care. Page 31

32 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year PERFORMANCE & QUALITY MANAGEMENT KEY COMPONENTS CalEQRO emphasizes the MHP s use f data t prmte quality and imprve perfrmance. Cmpnents widely recgnized as critical t successful perfrmance management include an rganizatinal culture with fcused leadership and strng stakehlder invlvement, effective use f data t drive quality management, a cmprehensive service delivery system, and wrkfrce develpment strategies that supprt system needs. These are discussed belw. Access t Care As shwn in Table 6, CalEQRO identifies the fllwing cmpnents as representative f a brad service delivery system that prvides access t cnsumers and family members. An examinatin f capacity, penetratin rates, cultural cmpetency, integratin and cllabratin f services with ther prviders frms the fundatin f access t and delivery f quality services. Table 6 Access t Care Cmpnent Cmpliant (FC/PC/NC)* Cmments 1A Service accessibility and availability are reflective f cultural cmpetence principles and practices FC The MHP mved t a Centralized Access System and launched rientatin grups at the utpatient clinics. The MHP mnitrs service data by age, gender, ethnicity and language preference. The Cultural Cmpetence Plan, including a three-year lng-term plan, was updated. The Ethnic Services and Diversity Manager facilitates the mnthly Cultural Cmpetency Actin Team meeting and addresses training and cultural enrichment fr the MHP. Strengthening Families, a pilt prgram funded by the Inter-Agency Plicy Cuncil, will launch in Santa Maria in April Services are targeted t serve mnlingual Spanish-speaking families affected by substance use disrders (SUD). The cntract fr Interpreter services was expanded cunty-wide t prvide fr face-t-face interpretatin in several languages. A prtcl accmpanies this activity. Prmtras d utreach fr Spanish speaking persns with n insurance r under insured and they are n cultural cmpetence team. Cultural trainings include Safe-Guarding Elders, Mental Health First Aid, LGBT fcused and Trauma Infrmed Care and Team-Based Care. LGBTQ utreach prvided training and sensitivity f staff. Designated staff participated in the Pacific Pride Santa Barbara. It is develping a plicy fr transgender issues in the Psychiatric Health Facility (PHF). A survey f staff fr Cultural Cmpetency and Language Prficiency cntinues t be distributed. Currently, 39% Page 32

33 Santa Barbara Cunty MHP CalEQRO Reprt Fiscal Year Table 6 Access t Care Cmpnent Cmpliant (FC/PC/NC)* Cmments f direct care staff are bilingual and 35% direct care speak Spanish. Staff are initially trained t d culturallyrespnsive assessments/treatment. 1B Manages and adapts its capacity t meet beneficiary service needs FC The MHP has fcused n systems change with multiple meetings dedicated t its target ppulatins, such as children, lder adults, c-ccurring disrders, and transitin-age yuth. The MHP designated a multidiscipline Change Agents team acrss its system t discuss and implement its initiatives. The MHP dedicated staff t sme f these endeavrs, fr example, it has hired a Frensic Services Manager, Husing Develpment Crdinatr, and a Crisis Services Manager. The MHP awaits apprval f the Drug Medi-Cal Waiver t implement its Organized Delivery Services fr the Substance Use Disrder ppulatin. Mbile and Triage Teams were integrated int Crisis Stabilizatin Unit peratins. Services t the Katie A. subclass have increased and resulted in prvisins t the subclass yuth members. Cllabrative effrts are in place and yuth are assessed within ten days f referral. Cmbined meetings and trainings have facilitated increased cmmunicatin and crdinatin f services resulting, in imprved care fr ur mst vulnerable yuth. Outreach t the hmeless ppulatin expanded with the pening f New Hpe Cmmunity Center in Santa Barbara. Cmmunity and faith-based agencies have cfunded this service and prvides mnthly assistance t cnsumers. The MHP published a semi-annual reprt f its perfrmance measures. Data included timeliness t service, c-ccurring data, utcme measures results, inpatient utilizatin, and staff service prvisin. The MHP additinally published its findings fr its high utilizers f services, adult crisis services, and crisis residential treatment. All dcuments are psted n-line. Secndary t unfilled psitins, under-staffed prgrams lead t increased caselads, pssibly inadequate t serve clients and by stakehlder reprt increased stress and burnut amng line and supervisry staff. 1C Integratin and/r cllabratin with cmmunity based services t imprve access FC Multiple endeavrs with a wide variety f entities cntinues t spread acrss the MHP. As mentined, prgrams with hmeless, faith-based, Latins, SUD and peer services has enriched this area. Cmmunity based residential facilities established in crdinatin with faith-based grups were increased by Page 33