BHD/OP Alan Orenstein x0927, Carol Sacks x4872, Alexis Speight x4855, Shelli Wargo x5006 Program Purpose Program Information Help individuals with serious mental illness achieve and maintain symptom improvement and community integration through stable housing, employment, and reduced episodes of hospitalization. Services are licensed by the Virginia Department of Behavioral Health and Developmental Services, and include: o Case management: assessment, treatment planning, linkage to services, monitoring progress, advocacy, and solution-focused counseling. o Therapy: the provision of individual and group therapy services that address adjustment to disability, crisis intervention, psychosocial and environmental challenges, and personal growth. Most staff provide both therapy and case management services. Staff work in 3 teams with particular specialties such as young adults, specific language needs, and co-occurring mental health and substance abuse disorders. The most common client diagnoses are mood disorders, co-occurring substance abuse, schizophrenia or other psychoses, and anxiety disorders. Partners: o The teams work with DHS psychiatric services to arrange psychiatric evaluation, medication management, and related nursing services. o Case managers link individuals to supportive services within and outside of DHS. These services may include employment assistance, psychosocial day programs, medical care, residential services, Mental Health Skill Building Services, and permanent supported housing. o Job Avenue provides employment services for clients served by the. Housing is provided in collaboration with Housing Bureau s Permanent Supportive Housing program. PM1: How much did we do? Staff Total 33.5 FTEs: o 3 FTE Supervisors o 30.5 FTE Case Managers/Therapists Customers and Service Total clients served (unduplicated, adult and young adult) FY 2016 FY 2017 FY 2018 1,333 1,389 1,467 End-of-year census 1,057 1,082 1,169 New clients 376 375 379 Annual number of case management / therapy clients served 995 / 689 1,049 / 594 1,084 / 718 Annual direct service hours in office / in community 25,420 / 9,472 26,688 / 8,512 26,778 / 8,587 FY 2018 Page 1
PM2: How well did we do it? 2.1 Consumer satisfaction with services 2.2 Medicaid reimbursements 2.3 Staff active caseloads / case mix 2.4 Clinical documentation compliance PM3: Is anyone better off? 3.1 Inpatient hospitalization episodes/clients served 3.2 Daily Living Activities (DLA) assessment FY 2018 Page 2
Measure 2.1 Consumer satisfaction with services 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 98% 97% 98% Satisfaction With Services 93% Target: 85% 95% 97% 95% 95% FY 2016 FY 2017 FY 2018 FY 2019 (proj.) Percent Satisfied with Services Percent Getting Services Wanted During FY 2016, 2017 and 2018, positive responses for satisfied with services and for getting services I want exceeded the target of 85%. Satisfaction is measured using the annual (two-week duration) division-wide client satisfaction survey. In FY 2018, the response rate was 80% (111 completed/138 distributed). There were 218 responses to these items; 106 indicated satisfaction with services and 108 reported they were getting the services they wanted. These questions psychometrically reflect general satisfaction with services and indicate that clients are generally satisfied with services. Open-ended comments were generally positive and supported the high level of reported general satisfaction. Multiple clients commented positively about their therapist, getting the help they needed, and feeling supported. Stay the course. It is anticipated that approximately 95% of respondents will report general satisfaction with services, and 95% will report receiving the type of services they want. FY 2018 Page 3
Measure 2.2 Medicaid reimbursements Medicaid Revenue and Percent of Target $1,200,000 $1,000,000 $800,000 $823,192 176% $960,698 205% $992,387 212% $1,000,000 $600,000 $400,000 Target $467,583 $200,000 $0 FY 2016 FY 2017 FY 2018 FY 2019 (proj.) During FY 2016, 2017 and 2018, the exceeded their Medicaid revenue targets. is collected from monthly Financial Management Bureau reports of Medicaid revenue. The Community Support Team staff maximizes Medicaid revenue by ensuring all services are promptly documented. The increase in FY 2018 may be related to an increased number of clients served and continued efforts to capture all billable services in the electronic health record. Managers closely monitor service capture using a weekly report of productivity, and review results with staff in supervision and performance appraisals. Stay the course. Medicaid expansion goes into effect in FY 2019. Conduct outreach to clients who are potentially eligible. Monitor impact and adjust procedures and targets as needed. In FY 2019, Medicaid Revenue will continue to exceed the target and will be at least $1,000,000. FY 2018 Page 4
Clients per FTE Staff Measure 2.3 Staff active caseloads 45 40 35 30 25 20 15 10 5 0 Average Case Management Caseload (Adult) 39 37 38 39 40 37 FY 2016 968 clients FY 2017 971 clients Target 32:1 FY 2018 1087 clients 40 42 FY 2019 (proj.) 1100 clients Total (all positions filled) Actual From FY 2016 to FY 2018, the year-end average caseload assuming all positions filled was constant at 37:1. The actual average caseloads (with vacancies) increased from 37:1 to 40:1, which exceeded the target of 32 clients per 1 FTE staff. Calculation is based on end-of-year active adult client census that does not include young adults. The adult census (excluding young adults) increased 12% from FY 2016 (968) to FY 3018 (1087). The total census (including young adults) for all teams increased 8% from FY 2017 (1082) to FY 2018 (1169). This continues a pattern of continued increases in the outpatient teams, with the census increasing 11% over 3 years and 29% over five years. Same Day Access was initiated during the second quarter of FY 2018. Since then, the number of admissions to the teams increased 28% compared to the previous year. An analysis of the client mix by level of community functioning indicated that the assumption of a 32:1 standard is justified. Licensing and policy requires that clients not served in 90 days be discharged. Continue to screen and admit only appropriate (predominantly seriously mentally ill) clients and promptly discharge inactive clients. Fill vacant positions promptly as permitted. It is anticipated that the client census will continue to increase in FY 2019 and, therefore, the average caseload (actual and with all positions filled) will increase to approximately 42 and 40:1, respectively. FY 2018 Page 5
Measure 2.4 Clinical documentation compliance 100% Percent Audited Records Compliant with Standard 90% 80% 70% 84% 85% Target: 90% 71% 82% 60% 50% 40% 30% 20% 10% 0% Supervisors 281/334 Supervisors 261/307 Consensus Score 197/277 Consensus Score FY 2016 FY 2017 FY 2018 FY 2019 (proj.) Beginning in FY 2018, the data is based on monthly reviews of the same records performed by both CST supervisors and the Compliance Review Team (CRT) using a common set of clinical record item standards. A consensus rating is achieved at monthly Team-CRT meetings. The ratings in FY 2016 and FY 2017 are supervisor ratings only. Chart reviews are summarized as excellent ( 90% of reviewed elements meeting standards), fair (89-75%) or poor (<75%). The percentage of charts rated excellent is shown above. The percent of records meeting the standard of compliance based on consensus ratings was 71% which is not at the target 90% level. Program compliance (the overall compliance rate of each of the 3 Teams) varies from 59% to 86%. The most common areas of non-compliance were: timeliness of case manager assessment, completion of the treatment plan before the quarterly assessment, and the general timeliness of other documents. Continue supervisor documentation monitoring, counseling and training and collaborate with CRT in regular rating reconciliation meeting. Continue the inclusion of record compliance in supervisor appraisals. In FY 2019, it is anticipated that 82% of charts will receive a consensus rating of excellent. FY 2018 Page 6
Measure 3.1 Inpatient hospitalizations /clients served Inpatient Episodes per Unduplicated Client Served 0.25 0.20 0.15 0.14 0.14 0.10 0.05 Target: <0.10 0.06 0.06 0.09 0.09 0.07 0.07 0.11 0.11 0.11 0.10 0.10 0.09 0.09 0.08 0.00 FY 2016 1333 total served 117 hospitalized FY 2017 1389 total served 130 hospitalized FY 2018 1467 total served 155 hospitalized FY 2019 (proj.) 1600 total served 160 hospitalized Team A Team B Team C Total In FY 2018 there were 155 hospitalizations among the 1467 unduplicated clients served, a rate of 0.10 hospitalizations per person served. All admissions and readmissions, including multiple admissions of the same person, are reported here. Hospitalization data is collected manually by each supervisor based on case manager reports at weekly team meetings. Overall, the hospitalization rate is at the targeted level. The hospitalization rate for Team C clients continues to be higher than the other teams. Team C predominantly serves clients with a dual mental health and substance abuse disability, who are at greater risk of hospitalization. Prior to FY 2018, there were slight differences in the data collection methodology across teams. Beginning in FY 2018, data has been collected in a standardized format for all teams. Stay the course. In FY 2018, it is anticipated that the number of hospitalizations per person served will total 0.10, as targeted. FY 2018 Page 7
Measure 3.2 Daily Living Activities (DLA) Assessment Changes in DLA Score 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 20%, 116 15% 28%, 164 6%, 33 5%, 29 34%, 199 15% 5% 10% 45% 9%, 51 10% FY 2018 N=592 High Functioning (5.1-7.0), Improved High Functioning, Stable High Functioning, Declined Goal: 55% green FY 2019 (proj.) Impaired Functioning(1.0-5.0), Improved Impaired Functioning, Stable Impaired Functioning, Declined The DLA-20 is administered at admission by intake staff and quarterly by the case manager. The assessment evaluates 20 dimensions of client functioning including coping skills, family relationships, safety, personal hygiene, leisure, housing stability and maintenance, money management, etc. Clients are rated on a scale of 1 to 7 (from extremely severe impairments to no impairment or problem in functioning). The chart reports the change in score from admission to the latest assessment after at least a year of service. The data were collected for all clients who were opened after January 25, 2017, when the DLA was initially implemented and who have been in services a year or more. In FY 2018, 48% of clients achieved or remained high functioning, or had impaired functioning and showed improvement (5% high functioning stable, 9% high functioning improved, 34% impaired functioning improved). The greatest improvement was among clients who were admitted with impaired functioning and improved (34%). The average DLA score for these clients increased from 4.1 to 4.3. Of those 164 high functioning clients that declined, 42.1% remained within the high functioning range (>5.0). This is the first year that the DLA 20 is used as a measure of outcome. Therefore, the treatment length of the sample of clients varied from 1 year to 1.6 years. Previous data indicate it takes several years to see a notable change in functioning, on average. Stay the course FY 2018 Page 8
An analysis of the high functioning clients (admission DLA was 5.1 and higher) whose DLA decreased revealed that 42% remained in the high functioning range (5.1 or higher). During this period, the average DLA was 4.7 at both admission and at the one year plus measure. In FY 2019, it is anticipated that there will be an increase in positive outcomes (improved or high functioning stable) to about 55%. FY 2018 Page 9