FY17–18 MEDI-CAL SPECIALTY MENTAL HEALTH EXTERNAL … and Summaries/Fiscal Ye… · The MHP...

FY17–18MEDI-CALSPECIALTYMENTALHEALTHEXTERNALQUALITYREVIEW

MONOMHPFINALREPORT

BehavioralHealthConcepts,Inc.5901ChristieAvenue,Suite502Emeryville,CA94608

[email protected]

Preparedfor:

CaliforniaDepartmentofHealthCareServices(DHCS)

ReviewDates:

April26,2018

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MonoCountyMHPCalEQROReport FiscalYear2017–18

TABLEOFCONTENTSMONOMHPSUMMARYOFFINDINGS.............................................................................................5Introduction.................................................................................................................................................................................5Access..............................................................................................................................................................................................5Timeliness.....................................................................................................................................................................................6Quality............................................................................................................................................................................................6Outcomes.......................................................................................................................................................................................6

INTRODUCTION.....................................................................................................................................7ValidationofPerformanceMeasures................................................................................................................................7PerformanceImprovementProjects.................................................................................................................................8MHPHealthInformationSystemCapabilities...............................................................................................................8ValidationofStateandCountyConsumerSatisfactionSurveys...........................................................................8ReviewofRecommendationsandAssessmentofMHPStrengthsandOpportunities................................8

PRIORYEARREVIEWFINDINGS,FY16-17.................................................................................10StatusofFY16–17ReviewofRecommendations......................................................................................................10ChangesintheMHPEnvironmentandWithintheMHP—ImpactandImplications.................................13

PERFORMANCEMEASUREMENT...................................................................................................14TotalBeneficiariesServed...................................................................................................................................................15PenetrationRatesandApprovedClaimDollarsperBeneficiary........................................................................15High-CostBeneficiaries.........................................................................................................................................................19TimelyFollow-upAfterPsychiatricInpatientDischarge.......................................................................................20DiagnosticCategories............................................................................................................................................................21PerformanceMeasuresFindings—ImpactandImplications...............................................................................22

PERFORMANCEIMPROVEMENTPROJECTVALIDATION......................................................23MonoMHPPIPsIdentifiedforValidation.....................................................................................................................23ClinicalPIP—StrengthsModelInterventionforEmployment-RelatedGoals...............................................25Non-clinicalPIP—Strengths-BasedLearningCollaborative:StrengthsModelGroupSupervisionforEmployment-RelatedGoals.................................................................................................................................................26PIPFindings—ImpactandImplications........................................................................................................................27

PERFORMANCEANDQUALITYMANAGEMENTKEYCOMPONENTS..................................28AccesstoCare............................................................................................................................................................................28TimelinessofServices...........................................................................................................................................................29QualityofCare...........................................................................................................................................................................30KeyComponentsFindings—ImpactandImplications............................................................................................34

CONSUMERANDFAMILYMEMBERFOCUSGROUPS...............................................................36Consumer/FamilyMemberFocusGroup1..................................................................................................................36Consumer/FamilyMemberFocusGroup2..................................................................................................................36Consumer/FamilyMemberFocusGroupFindings—Implications....................................................................38

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INFORMATIONSYSTEMSREVIEW................................................................................................39KeyInformationSystemsCapabilitiesAssessment(ISCA)InformationProvidedbytheMHP............39SummaryofTechnologyandDataAnalyticalStaffing.............................................................................................40CurrentOperations.................................................................................................................................................................41PrioritiesfortheComingYear...........................................................................................................................................42MajorChangesSincePriorYear........................................................................................................................................42OtherSignificantIssues........................................................................................................................................................42PlansforInformationSystemsChange..........................................................................................................................42CurrentElectronicHealthRecordStatus......................................................................................................................43PersonalHealthRecord........................................................................................................................................................44Medi-CalClaimsProcessing................................................................................................................................................44InformationSystemsReviewFindings—Implications............................................................................................45

SITEREVIEWPROCESSBARRIERS...............................................................................................47

CONCLUSIONS......................................................................................................................................48StrengthsandOpportunities..............................................................................................................................................48Recommendations...................................................................................................................................................................50

ATTACHMENTS...................................................................................................................................52AttachmentA—On-siteReviewAgenda........................................................................................................................53AttachmentB—ReviewParticipants..............................................................................................................................54AttachmentC—ApprovedClaimsSourceData...........................................................................................................56AttachmentD—PIPValidationTools..............................................................................................................................57

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LISTOFTABLESANDFIGURESTable1:MHPMedi-CalEnrolleesandBeneficiariesServedinCY16,byRace/EthnicityTable2:High-CostBeneficiariesTable3:PIPsSubmittedbyMHPTable4:PIPValidationReviewTable5:PIPValidationReviewSummaryTable6:AccesstoCareComponentsTable7:TimelinessofServicesComponentsTable8:QualityofCareComponentsTable9:DistributionofServices,byTypeofProviderTable10:SummaryofTechnologyStaffChangesTable11:SummaryofDataAnalyticalStaffChangesTable12:PrimaryEHRSystems/ApplicationsTable13:EHRFunctionalityTable14:MHPSummaryofShortDoyle/Medi-CalClaimsTable15:SummaryofTopThreeReasonsforClaimDenialFigure1A:OverallAverageApprovedClaimsperBeneficiary,CY14-16Figure1B:OverallPenetrationRates,CY14-16Figure2A:FosterCareAverageApprovedClaimsperBeneficiaryFigure2B:FosterCarePenetrationRates,CY14-16Figure3A:Latino/HispanicAverageApprovedClaimsperBeneficiary,CY14-16Figure3B:Latino/HispanicPenetrationRates,CY14-16Figure4A:7-dayOutpatientFollow-upandRehospitalizationRatesFigure4B:30-dayOutpatientFollow-upandRehospitalizationRatesFigure5A:BeneficiariesServed,byDiagnosticCategories,CY16Figure5B:TotalApprovedClaimsbyDiagnosticCategories,CY16

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MONOMHPSUMMARYOFFINDINGSBeneficiariesServedinCalendarYear2016¾206

MHPThresholdLanguage(s)¾Spanish

MHPSize¾Small-Rural

MHPRegion¾Central

MHPLocation¾MammothLakes,CA

MHPCountySeat¾Bridgeport,CA

Introduction

LocatedintheEasternSierraregion,MonoCountyisthefifthleastpopulouscountyintheStateofCalifornia,withMammothLakesthesoleincorporatedcity.ThecountyseatislocatedinBridgeport.Themaineconomicsourceistherecreationindustry,dominatedbyMammothMountainsnow-relatedactivityinthewinter.TheMHP’smainofficesarelocatedinMammothLakes,whichhasapopulationof8,073,andcanincreaseto45,000duringthepeaksnowseason.ThereisasignificantHispanic/Latinopopulation(2013USCensus:27.9%)includingundocumentedindividuals.OutsideofMammothLakes,theremainderofMonoCountytendstobeinvolvedwithagricultureandsummerrecreation,withmountainlakesandHighSierracountryasattractions.LeeVining,intheMonoBasin,servesastheeasterngatewaytoYosemiteNationalPark.

Duringthefiscalyear2017-2018(FY17-18)review,CaliforniaExternalQualityReviewOrganization(CalEQRO)reviewersfoundthefollowingoverallsignificantchanges,efforts,andopportunitiesrelatedtoaccess,timeliness,quality,andoutcomesoftheMentalHealthPlan(MHP)anditscontractproviderservices.FurtherdetailsandfindingsfromEQRO-mandatedactivitiesareprovidedinthisreport.

Access

TheMHP’sservicelocationsincludeMammothLakes,whereboththeclinicandmainwellnesscenterarelocated.AMedi-CalcertifiedsiteislocatedinWalker,85milestothenorth,andhometothesecondwellnesscenter.Apart-timefieldofficeissituatedinBenton,California,46milesnortheast.Theremotenessofthisareacreateschallengesinrecruitmentandhiringoflicensedmentalhealthprofessionalstaff.ThenearestmajoreconomichubandshoppinglocationsareintheCarsonCity/Reno,Nevadaareas,adistanceof130-170milesandisperiodicallyinaccessibleduringthewinter.TheMHPhasfacedchallengeswithmeetingpsychiatry/prescriberneeds,andis

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currentlycompletelyreliantupontelepsychiatry,whichservestheMHP’sMammothLakesandWalkerlocations.Therecruitmentofbilinguallicensedclinicalstaffisverychallenging.

Timeliness

TheMHP’strackingoftimelinessislimitedtotheinitialclinicalaccesstocare.Thelocalstandardis10daystotheintakeassessment,withanactualaverageforallpopulationsofapproximately5.5days.Thistrackingisaccomplishedwithspreadsheets.Noothertimelinesstrackingcurrentlyoccurs.

Quality

TheMHPcontinuestodemonstratechallengesinthedevelopmentofacomprehensivequalityimprovement(QI)WorkPlanandthetrackingofqualityindicatorsoutsideofthosetypicallyassociatedwithacompliancereview.

Thediagnosticpresentationofconsumersservedsignificantlydiffersfromthestatewideprofile,withmuchlowerprevalenceofseriousmentalillnessandhigherprevalenceofadjustmentandanxietydisorders.

Exceptforasmallcoreofyear-roundconsumers,asignificantcomponentoftheMHP’sconsumersfollowthetrendsofresortutilizationandmovestootherareasduringoff-peaktimes.

Outcomes

TheMHPutilizestheGeneralizedAnxietyDisorder-7item(GAD-7)questionnaireandPatientHealthQuestionnaire-9(PHQ-9)fordepressionforalladultsatintake.TheMHP’sadultoutcomeinstrumentsarelimitedtospecificdiagnosticconditionsandutilizesnoinstrumentsthatapplybroadlytoalladults.TheChildAdolescentNeedsStrengths(CANS)outcometoolisusedtoinformthetreatmentofchildrenandyouth.

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INTRODUCTIONTheUnitedStatesDepartmentofHealthandHumanServices(HHS),CentersforMedicareandMedicaidServices(CMS)requiresanannual,independentexternalevaluationofStateMedicaidManagedCareprogramsbyanExternalQualityReviewOrganization(EQRO).ExternalQualityReview(EQR)istheanalysisandevaluationbyanapprovedEQROofaggregateinformationonquality,timeliness,andaccesstohealthcareservicesfurnishedbyPrepaidInpatientHealthPlans(PIHPs)andtheircontractorstorecipientsofStateMedicaidmanagedcareservices.TheCMS(42CFR§438;MedicaidProgram,ExternalQualityReviewofMedicaidManagedCareOrganizations)rulesspecifytherequirementsforevaluationofMedicaidmanagedcareprograms.Theserulesrequireanon-siterevieworadeskreviewofeachMedi-CalMentalHealthPlan.

TheStateofCaliforniaDepartmentofHealthCareServices(DHCS)contractswith56countyMedi-CalMHPstoprovideMedi-Calcoveredspecialtymentalhealthservices(SMHS)toMedi-CalbeneficiariesundertheprovisionsofTitleXIXofthefederalSocialSecurityAct.

ThisreportpresentstheFY17-18findingsofanEQRoftheMonoMHPbytheCaliforniaExternalQualityReviewOrganization,BehavioralHealthConcepts,Inc.(BHC).

TheEQRtechnicalreportanalyzesandaggregatesdatafromtheEQRactivitiesasdescribedbelow:

ValidationofPerformanceMeasures1

BothastatewideannualreportandthisMHP-specificreportpresenttheresultsofCalEQRO’svalidationofeightmandatoryperformancemeasures(PMs)asdefinedbyDHCS.TheeightPMsinclude:

• TotalbeneficiariesservedbyeachcountyMHP;

• TotalcostsperbeneficiaryservedbyeachcountyMHP;

• PenetrationratesineachcountyMHP;

• CountofTherapeuticBehavioralServices(TBS)beneficiariesservedcomparedtothe4%EmilyQ.Benchmark2;

• Totalpsychiatricinpatienthospitalepisodes,costs,andaveragelengthofstay(LOS);

1 Department of Health and Human Services. Centers for Medicare and Medicaid Services (2012). Validation of Performance Measures Reported by the MCO: A Mandatory Protocol for External Quality Review (EQR), Protocol 2, Version 2.0, September, 2012. Washington, DC: Author.

2 The Emily Q. lawsuit settlement in 2008 mandated that the MHPs provide TBS to foster care children meeting certain at-risk criteria. These counts are included in the annual statewide report submitted to DHCS, but not in the individual county-level MHP reports.

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• Psychiatricinpatienthospital7-dayand30-dayrehospitalizationrates;

• Post-psychiatricinpatienthospital7-dayand30-daySpecialtyMentalHealthServices(SMHS)follow-upservicerates;and

• High-CostBeneficiaries(HCBs),incurringapprovedclaimsof$30,000orhigherduringacalendaryear.

PerformanceImprovementProjects3

EachMHPisrequiredtoconducttwoPerformanceImprovementProjects(PIPs)—oneclinicalandonenon-clinical—duringthe12monthsprecedingthereview.ThePIPsarediscussedindetaillaterinthisreport.

MHPHealthInformationSystemCapabilities4

UsingtheInformationSystemsCapabilitiesAssessment(ISCA)protocol,CalEQROreviewedandanalyzedtheextenttowhichtheMHPmeetsfederaldataintegrityrequirementforHealthInformationSystems(HIS),asidentifiedin42CFR§438.242.ThisevaluationincludedareviewoftheMHP’sreportingsystemsandmethodologiesforcalculatingPMs.

ValidationofStateandCountyConsumerSatisfactionSurveys

CalEQROexaminedavailableconsumersatisfactionsurveysconductedbyDHCS,theMHP,oritssubcontractors.

CalEQROalsoconducted90-minutefocusgroupswithbeneficiariesandfamilymemberstoobtaindirectqualitativeevidencefrombeneficiaries.

ReviewofRecommendationsandAssessmentofMHPStrengthsandOpportunities

TheCalEQROreviewdrawsuponprioryears’findings,includingsustainedstrengths,opportunitiesforimprovement,andactionsinresponsetorecommendations.Otherfindingsinthisreportinclude:

3 Department of Health and Human Services. Centers for Medicare and Medicaid Services (2012). Validating Performance Improvement Projects: Mandatory Protocol for External Quality Review (EQR), Protocol 3, Version 2.0, September 2012. Washington, DC: Author.

4 Department of Health and Human Services. Centers for Medicare and Medicaid Services (2012). EQR Protocol 1: Assessment of Compliance with Medicaid Managed Care Regulations: A Mandatory Protocol for External Quality Review (EQR), Protocol 1, Version 2.0, September 1, 2012. Washington, DC: Author.

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• Changes,progress,ormilestonesintheMHP’sapproachtoperformancemanagement—emphasizingutilizationofdata,specificreports,andactivitiesdesignedtomanageandimprovequality.

• Ratingsforkeycomponentsassociatedwiththefollowingthreedomains:access,timeliness,andquality.Submitteddocumentationaswellasinterviewswithavarietyofkeystaff,contractedproviders,advisorygroups,beneficiaries,andotherstakeholdersinformtheevaluationoftheMHP’sperformancewithinthesedomains.DetaileddefinitionsforeachofthereviewcriteriacanbefoundontheCalEQROwebsite,www.caleqro.com.

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PRIORYEARREVIEWFINDINGS,FY16-17Inthissection,thestatusoflastyear’s(FY16-17)recommendationsarepresented,aswellaschangeswithintheMHP’senvironmentsinceitslastreview.

StatusofFY16–17ReviewofRecommendations

IntheFY16-17sitereviewreport,theCalEQROmadeanumberofrecommendationsforimprovementsintheMHP’sprogrammaticand/oroperationalareas.DuringtheFY17-18sitevisit,CalEQROandMHPstaffdiscussedthestatusofthoseFY16-17recommendations,whicharesummarizedbelow.

AssignmentofRatings

Metisassignedwhentheidentifiedissuehasbeenresolved.

PartiallyMetisassignedwhentheMHPhaseither:

• Madeclearplansandisintheearlystagesofinitiatingactivitiestoaddresstherecommendation;or

• Addressedsomebutnotallaspectsoftherecommendationorrelatedissues.

NotMetisassignedwhentheMHPperformednomeaningfulactivitiestoaddresstherecommendationorassociatedissues.

KeyRecommendationsfromFY16-17

Recommendation#1:Evaluatefortheexpansionoftelemedicine,bothatclinicsandatthelocalemergencydepartment.

Status:Met

• TheMHPisabletoutilizetheirtelepsychiatryatboththemainclinicinMammothLakesandtheWalkerClinic,whichisopenfourdayseachweek,withtelepsychiatryeveryWednesdayfrom1:00pmto5:00pm.

• TheMHPworkscloselywiththelocalEmergencyDepartment(ED)whichcontractsfortelepsychiatryservices.ThiscollaborationincludesconsultationandcoordinationofcareneedsbetweentheMHP,theemergencydepartmentanditstelepsychiatryservice.

• TheMHPcontinuestoevolveitsimplementationoftelepsychiatry.Itisplanningaformalreevaluationofserviceneedsatthebeginningofthenextfiscalyear,incorporatinglessonslearnedfromthecurrentimplementation.OneissueisthetelemedicineprovideruseofanotherEHRsystem,resultinginindirectentryintotheMHP’ssystem.

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Recommendation#2:ObtaintechnicalassistancefromlargerMHP’sontherequirementsandstructureofaQIWorkPlan,includingthedocumentationofQICmeetingsandregulartrackingofPIPprogressandtimelinessmeasures.

Status:PartiallyMet

• TheQICmeetingminutesreflectedeffortstoobtaintechnicalassistancefromNorQIC,aregionalNorthernCaliforniaqualityimprovementworkgroup,andothersources.Theseeffortswereevidentinsomeimprovementsmadetotheinternalqualityprocesses.

• TheMHPstilldoesnothaveaQIWorkPlanstandardnortrackingforinitialpsychiatricappointment,urgentappointments,post-hospitalfollow-up,orno-shows.TheWorkPlantendstobecomplianceorientedorgeneralinitiativefocused.Whiletheseareimportantfoci,standardsofaccesstocareareimportanttoestablishandmonitor.InitialclinicalaccessistheonlyareainwhichtheMHPhasatimelinessstandardaccompaniedbyongoingtracking.

• TheMHPsubmittedtwoPIPsforthisreviewperiod.

Recommendation#3:Trainstaffintheuseoftheelectronictreatmentplan.

Status:Met

• TheMHPprovidesregulartrainingstostafftofacilitatethisneed.

Recommendation#4:ReviewworkflowbusinessrulesandprocessestoensuretheproperdifferentiationbetweenMedi-CalbillableandMHSAnon-billableservicesofalldirectservices,andthattheseareproperlyrecordedinthesystem.

Status:PartiallyMet

• WhiletheMHPconductedtrainingsattheinceptionofthenewEHR,broadstakeholderfeedbackindicatedastrongneedtorevisitthisareatoensurethatstaffwereindeedcapturinganddocumentingservicestothebenefitoftheconsumers.TherearealsoconcernsthattheintendedEHRfunctionalityisnotoperatingasrobustlyasintended.

• Denialsduringthebillingcyclecontinuetobehigherthanthestatewideaveragebuttheexecutiveteamappearscommittedandknowledgeableenoughtogetthisundercontrol.

Recommendation#5:Developprocesstomonitorandreconcile835/837claimtransactions,andfollow-uponthosethatareapparentlymissing,obtainingoutsideconsultationifthisisnotwithintheMHP’sskillset.

Status:Met

• TheMHPiscurrentlyutilizingpracticemanagementintegratedprocessestoperformthisfunctionality.

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• TheMHPhasrecognizedtheneedforenhancedfunctionalityinthisareaandiscurrentlyexploringitsoptionswithsuitableoutsidevendors.Theyanticipateimprovedusabilityandenhancereportingcapabilityfromtheirclaimsdataflow.

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ChangesintheMHPEnvironmentandWithintheMHP—ImpactandImplications

DiscussedbelowareanychangessincethelastCalEQROreviewthatwereidentifiedashavingasignificanteffectonserviceprovisionormanagementofthoseservices.Thissectionemphasizessystemicchangesthataffectaccess,timeliness,andquality,includinganychangesthatprovidecontexttoareasdiscussedlaterinthisreport.

AccesstoCare

• TheMHPhasaugmentedaccesscapacityduringthepastyearthroughthehireofapsychiatricspecialistandwellnesscenterassociate.

• IncreasedoutreachandengagementwasprovidedtounderservedpopulationsinallthreeNorthCountyschools.

TimelinessofServices

• Noissuesidentified.

QualityofCare

• TheMHPisparticipatingintheEasternSierraStrengthsModelLearningCollaborativewithInyoandAlpineCounties,seekingtoimprovethedesiredlifeoutcomesofconsumersintheareasofhousing,education,andemployment.

• TheMHPhasadoptedtheTechnologySuitetouseinnovationforimprovementofaccess.

• TheMHPisreviewingtelemedicinerelatedneedsinpreparationforarequestforproposal(RFP)processinearlysummerof2018,whereitwillseektomeetconsumerneedsthroughgreaterspecificityofdeliverables.

ConsumerOutcomes

• TheMHPplanstoholdthreeWellnessForumsintheJuneLakeareatoaddressmentalhealthandsubstanceusetreatmentissues,includingstigmareduction.

• TheMHPhasfocusedonthedevelopmentofhousingresourcesforitsconsumersthroughMHSAfundingandlocalhousingauthoritycollaboration,plustheuseofexistingMHPresidentialproperties.

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PERFORMANCEMEASUREMENTAsnotedabove,CalEQROisrequiredtovalidatethefollowingPMsasdefinedbyDHCS:

• TotalbeneficiariesservedbyeachcountyMHP;

• TotalcostsperbeneficiaryservedbyeachcountyMHP;

• PenetrationratesineachcountyMHP;

• CountofTBSBeneficiariesServedComparedtothe4%EmilyQ.Benchmark(notincludedinMHPreports;thisinformationisincludedintheAnnualStatewideReportsubmittedtoDHCS);

• Totalpsychiatricinpatienthospitalepisodes,costs,andaverageLOS;

• Psychiatricinpatienthospital7-dayand30-dayrehospitalizationrates;

• Post-psychiatricinpatienthospital7-dayand30-daySMHSfollow-upservicerates;and

• HCBsincurring$30,000orhigherinapprovedclaimsduringacalendaryear.

HIPAASuppressionDisclosure:

Valuesaresuppressedtoprotectconfidentialityoftheindividualssummarizedinthedatasetswherebeneficiarycountislessthanorequaltoeleven(*).Additionally,suppressionmayberequiredtopreventcalculationofinitiallysuppresseddata,correspondingpenetrationratepercentages(n/a);andcellscontainingzero,missingdataordollaramounts(-).

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TotalBeneficiariesServed

Table1providesdetailonbeneficiariesservedbyrace/ethnicity.

StartingwithCY16performancemeasures,CalEQROhasincorporatedtheACAExpansiondatainthetotalMedi-Calenrolleesandbeneficiariesserved.SeeAttachmentC,TableC1forthepenetrationrateandapprovedclaimsperbeneficiaryforjusttheCY16ACAPenetrationRateandApprovedClaimsperBeneficiary.

PenetrationRatesandApprovedClaimDollarsperBeneficiary

Thepenetrationrateiscalculatedbydividingthenumberofunduplicatedbeneficiariesservedbythemonthlyaverageenrolleecount.TheaverageapprovedclaimsperbeneficiaryservedperyeariscalculatedbydividingthetotalannualdollaramountofMedi-CalapprovedclaimsbytheunduplicatednumberofMedi-Calbeneficiariesservedperyear.

Regardingcalculationofpenetrationrates,theMonoMHPdoesnotcalculateitspenetrationrate.

Race/EthnicityAverage Monthly

Unduplicated Medi-Cal Enrollees

% Enrollees

Unduplicated Annual Count of

Beneficiaries Served

% Served

White 1,385 36.2% 94 45.6%Latino/Hispanic 1,898 49.6% 85 41.3%African-American 16 0.4% * n/aAsian/Pacific Islander 43 1.1% * n/aNative American 120 3.1% * n/aOther 365 9.5% 17 8.3%

Total 3,826 100% 206 100%

Table 1: Mono MHP Medi-Cal Enrollees and Beneficiaries Served in CY16, by Race/Ethnicity

The total for Average Monthly Unduplicated Medi-Cal Enrollees is not a direct sum of the averages above it. The averages are calculated independently.

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Figures1Aand1Bshow3-year(CY14-16)trendsoftheMHP’soverallapprovedclaimsperbeneficiaryandpenetrationrates,comparedtoboththestatewideaverageandtheaverageforsmall-ruralMHPs.

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

CY14 CY15 CY16

Figure 1A. Overall Average Approved Claims per Beneficiary

Mono Small-Rural State

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

CY14 CY15 CY16

Figure 1B. Overall Penetration Rates


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Figures2Aand2Bshow3-year(CY14-16)trendsoftheMHP’sfostercare(FC)approvedclaimsperbeneficiaryandpenetrationrates,comparedtoboththestatewideaverageandtheaverageforsmall-ruralMHPs.

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

$9,000

$10,000

CY14 CY15 CY16

Figure 2A. FC Average Approved Claims per Beneficiary


0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

CY14 CY15 CY16

Figure 2B. FC Penetration Rates


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Figures3Aand3Bshow3-year(CY14-16)trendsoftheMHP’sLatino/Hispanicapprovedclaimsperbeneficiaryandpenetrationrates,comparedtoboththestatewideaverageandtheaverageforsmall-ruralMHPs.

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

CY14 CY15 CY16


Figure 3A. Latino/Hispanic Average Approved Claims per Beneficiary

0.00%0.50%1.00%1.50%2.00%2.50%3.00%3.50%4.00%4.50%5.00%

CY14 CY15 CY16

Figure 3B. Latino/Hispanic Penetration Rates


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High-CostBeneficiaries

Table2comparesthestatewidedataforHigh-CostBeneficiariesforCY16withtheMHP’sdataforCY16,aswellasthepriortwoyears.HCBsinthistableareidentifiedasthosewithapprovedclaimsofmorethan$30,000inayear.

SeeAttachmentC,TableC2forthedistributionoftheMHPbeneficiariesservedbyapprovedclaimsperbeneficiary(ACB)rangeforthreecostcategories:under$20,000;$20,000to$30,000;andthoseabove$30,000.

MHP Year HCB Count

Total Beneficiary

Count

HCB % by

Count

Average Approved

Claimsper HCB

HCB Total Claims

HCB % by Approved

Claims

Statewide CY16 19,019 609,608 3.12% $53,215 $1,012,099,960 28.90%CY16 * 206 n/a - - n/aCY15 * 214 n/a - - n/aCY14 * 123 n/a - - n/a

Table 2: Mono MHP High-Cost Beneficiaries

Mono

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TimelyFollow-upAfterPsychiatricInpatientDischarge

Figures4Aand4BshowthestatewideandMHP7-dayand30-dayoutpatientfollow-upandrehospitalizationratesforCY15andCY16.

0%

10%

20%

30%

40%

50%

60%

70%

Outpatient MHP Outpatient State RehospitalizationMHP

RehospitalizationState

Figure 4A. 7-Day Outpatient Follow-up and Rehospitalization Rates, Mono and State

CY15 CY16

0%

10%

20%

30%

40%

50%

60%

70%

Outpatient MHP Outpatient State RehospitalizationMHP

RehospitalizationState

Figure 4B. 30-Day Outpatient Follow-up and Rehospitalization Rates, Mono and State

CY15 CY16

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DiagnosticCategories

Figures5Aand5BcomparethebreakdownbydiagnosticcategoryofthestatewideandMHPnumberofbeneficiariesservedandtotalapprovedclaimsamount,respectively,forCY16.

MHPself-reportedpercentofconsumersservedwithco-occurring(substanceabuseandmentalhealth)diagnoses:41%.

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Depression Psychosis Disruptive Bipolar Anxiety Adjustment Other Deferred

Figure 5A. Diagnostic Categories, Beneficiaries Served

Mono CY16 State CY16

0%

5%

10%

15%

20%

25%

30%

35%

Depression Psychosis Disruptive Bipolar Anxiety Adjustment Other Deferred

Figure 5B. Diagnostic Categories, Total Approved

Mono CY16 State CY16

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PerformanceMeasuresFindings—ImpactandImplications

AccesstoCare

• WhiletheMHP’snumberofeligiblesincreasedslightlyCY15toCY16,beneficiariesservedremainedstable.Thiscorrelatestoayearoveryearslightdropinoverallpenetrationrate.However,evenwiththisslightdecrease,theMHP’sCY16overallpenetrationrateisgreaterthanthestatewideaverage.

• TheMHP’sfostercarepenetrationratedeclinedfromCY15toCY16.Itisbelowboththesmall-ruralandstatewideaverages.

• TheMHP’sHispanicpenetrationratehasincreasedslightlyfromCY15.Itiscomparabletothesmall-ruralaverageandslightlyexceedsthestatewideaverage.


• DuringCY16,theMHP’sconsumersdidnotutilizeinpatientservices,therebylackingdatafortracking7-dayand30-dayoutpatientfollow-upratesafterdischargefromapsychiatricinpatientepisode.

QualityofCare

• TheMHP’saverageoverallapprovedclaimsperbeneficiaryhasbeguntoestablishadownwardtrendfromCY14toCY16.Itislessthanhalfofthesmall-ruralaverageandaboutonequarterthestatewideaverageinCY16.

• TheMHP’saveragefostercareapprovedclaimsperbeneficiaryincreasedfromCY15toCY16.Itremainssubstantiallylowerthanboththesmall-ruralandstateaveragesandismuchlowerthanthestatewideaverageinCY16.

• FollowingtheoverallMHPtrend,theaverageHispanicapprovedclaimsperbeneficiarydeclinedsubstantiallyfromCY14toCY16.Itremainsapproximatelyone-thirdofthesmall-ruralaverageandafifthofthestatewideaverageinCY16.

• AprimarydiagnosisofadjustmentdisordersaccountedforthelargestpercentageofbeneficiariesservedbytheMHPbyalargemargin.TheMHPhadanotablylowerrateofbothdepressionandpsychosisdisorderswhencomparedtostatewideaverages.

• TheMHPidentifiesco-occurringdisorderstoasignificantdegree.

ConsumerOutcomes

• TheMHPhadno7-dayor30-dayrehospitalizationsinCY16.

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PERFORMANCEIMPROVEMENTPROJECTVALIDATIONAPerformanceImprovementProject(PIP)isdefinedbyCMSas“aprojectdesignedtoassessandimproveprocessesandoutcomesofcarethatisdesigned,conducted,andreportedinamethodologicallysoundmanner.”TheValidatingPerformanceImprovementProjectsProtocolspecifiesthattheEQROvalidatetwoPIPsateachMHPthathavebeeninitiated,areunderway,werecompletedduringthereportingyear,orsomecombinationofthesethreestages.DHCSelectedtoexamineprojectsthatwereunderwayduringtheprecedingcalendaryear.

MonoMHPPIPsIdentifiedforValidation

EachMHPisrequiredtoconducttwoPIPsduringthe12monthsprecedingthereview.CalEQROreviewedandvalidatedoneMHP-submittedPIPs,asshownbelow.

Table3liststhefindingsforeachsectionoftheevaluationofthePIPs,asrequiredbythePIPProtocols:ValidationofPerformanceImprovementProjects.5

Table3:PIPsSubmittedbyMonoMHP

PIPsforValidation

#ofPIPs PIPTitles

ClinicalPIP 1 StrengthsModelInterventionforEmployment-RelatedGoals

Non-clinicalPIP 1Strengths-BasedLearningCollaborative:StrengthsModel

GroupSupervisionforEmployment-RelatedGoals

Table4,onthefollowingpage,providestheoverallratingforeachPIP,basedontheratingsgiventothevalidationitems:Met(M),PartiallyMet(PM),NotMet(NM),NotApplicable(NA),UnabletoDetermine(UTD),orNotRated(NR).

5 2012 Department of Health and Human Services, Centers for Medicare and Medicaid Service Protocol 3 Version 2.0, September 2012. EQR Protocol 3: Validating Performance Improvement Projects.

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Table4:PIPValidationReview

ItemRating

Step PIPSection ValidationItem ClinicalNon-clinical

1SelectedStudy

Topics1.1 Stakeholderinput/multi-functionalteam M NR

1.2Analysisofcomprehensiveaspectsofenrolleeneeds,care,andservices

PM NR

1.3 Broadspectrumofkeyaspectsofenrolleecareandservices PM NR

1.4 Allenrolledpopulations UDT NR

2 StudyQuestion 2.1 Clearlystated PM NR

3 Study 3.1 Cleardefinitionofstudypopulation PM NR

Population 3.2 Inclusionoftheentirestudypopulation UDT NR

4Study

Indicators4.1 Objective,clearlydefined,measurableindicators PM NR

4.2Changesinhealthstatus,functionalstatus,enrolleesatisfaction,orprocessesofcare

M NR

5SamplingMethods

5.1Samplingtechniquespecifiedtruefrequency,confidenceintervalandmarginoferror

NA NR

5.2Validsamplingtechniquesthatprotectedagainstbiaswereemployed

NA NR

5.3 Samplecontainedsufficientnumberofenrollees NA NR

6 DataCollection 6.1 Clearspecificationofdata PM NR

Procedures 6.2 Clearspecificationofsourcesofdata UDT NR

6.3Systematiccollectionofreliableandvaliddataforthestudypopulation

NM NR

6.4 Planforconsistentandaccuratedatacollection UDT NR

6.5 Prospectivedataanalysisplanincludingcontingencies M NR

6.6 Qualifieddatacollectionpersonnel M NR

7Assess

ImprovementStrategies

7.1Reasonableinterventionswereundertakentoaddresscauses/barriers

PM NR

8ReviewDataAnalysisand

8.1 Analysisoffindingsperformedaccordingtodataanalysisplan NA NR

InterpretationofStudyResults

8.2 PIPresultsandfindingspresentedclearlyandaccurately NA NR

8.3 Threatstocomparability,internalandexternalvalidity NA NR

8.4InterpretationofresultsindicatingthesuccessofthePIPandfollow-up

NA NR

9Validityof

Improvement9.1 Consistentmethodologythroughoutthestudy NA NR

9.2Documented,quantitativeimprovementinprocessesoroutcomesofcare

NA NR

9.3 ImprovementinperformancelinkedtothePIP NA NR

9.4 Statisticalevidenceoftrueimprovement NA NR

9.5Sustainedimprovementdemonstratedthroughrepeatedmeasures

NA NR

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Table5providesasummaryofthePIPvalidationreview.

Table5:PIPValidationReviewSummary

SummaryTotalsforPIPValidation ClinicalPIPNon-clinical

PIP

NumberMet 4 NR

NumberPartiallyMet 7 NR

NumberNotMet 1 NR

NumberApplicable(AP)

(Maximum=28withSampling;25withoutSampling)16 NR

OverallPIPRating((#Met*2)+(#PartiallyMet))/(AP*2) 46.85% 0%

ClinicalPIP—StrengthsModelInterventionforEmployment-RelatedGoals

TheMHPpresenteditsstudyquestionfortheclinicalPIPasfollows:

“WillusingtheStrengthsModelhelpclientsmakeprogresstowardtheiremployment-relatedgoals,asmeasuredbytheachievementoftheiremployment-relatedgoalsasrecordedintheStrengthsAssessmentoverthetwo-yearstudyperiod?”

DatePIPbegan:January,2018

StatusofPIP:Activeandongoing

TheMHPdevelopedthisPIPfromcommunitysurveydatainwhichmembersofthecommunity,includingsomecurrentandpastconsumers,identifiedlifedomaingoalsinwhichsupportwasdesired.TheMHPutilizedtheStrengthsModel(SM)assessmentwith14highneedconsumers,anddiscoveredthat11hademploymentoreconomicgoalsforlifeimprovement.

Thissetof14individualsweredesignatedashigh-needbyhavingjusticeinvolvement,severementalhealthsymptoms,substanceusehistoryandpersistentneedforclinicalattention.Nootherdataanalysiswasprovidedorreportedofthekeycharacteristics,suchasservicelevels.NobaselineemploymentdatawasofferedbytheMHPforitsoveralladultpopulationforcomparison.

TheMHPdescribedthevariousaspectsoftheSMapproach,includingtheSMAssessment,PersonalRecoveryPlan,andgroupsupervisionofclinicalstaff.Nospecificinterventionwasdescribedthatrelatedtothespecificactionsofstaffwithconsumers,whichwouldseemtobeakeyelementofthismodel.

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Thestudyquestiondidnotprovidetheanticipatedquantifiableimprovementgoal,asrequiredforaPIP.Thestudyindicatorincludesachievementofemployment-relatedgoals.However,thedatatablebreaksoutseparatenumeratorsforthosewhoachieveemploymentgoalsanddeclinetosetanothergoalfromthosewhoachievethelistedgoalandthensetanewgoal.Sinceachievementofemploymentseemstobethegoalofthisactivity,themeetingofthisgoalwouldseemsufficient.

RelevantdetailsoftheseissuesandrecommendationsareincludedwithinthecommentsfoundinthePIPvalidationtool.

ThetechnicalassistanceprovidedtotheMHPbyCalEQROconsistedofdiscussionofneededelementstoaddtothePIPandresubmissionoftheupdate.EQRsharedhowthelackofbaselinedata,lackofspecificityofwhatdefinesinclusioninthestudygroupbywayofbeing“stuck”or“highneed”isproblematic.OverthecourseofthisnextreviewperiodtheMHPneedstoadddataelementssuchastheserviceutilizationlevelofthese“high-need”individuals.Theinclusionofconsumersseemstolackspecific,definedquantifiableparametersthatwouldsupportreplication.

TheresubmittedPIPwasimproved,andwasreviewed,butcontinuedwithsignificantflawslistedabove.

Non-clinicalPIP—Strengths-BasedLearningCollaborative:StrengthsModelGroupSupervisionforEmployment-RelatedGoals

TheMHPpresenteditsstudyquestionforthenon-clinicalPIPasfollows:

“WillusingSMGS(StrengthsModelGroupSupervision)helpclientsmakeprogresstowardtheiremployment-relatedgoals,asmeasuredbytheachievementofand/orchangeinemployment-relatedgoalsoverthetwo-yearstudyperiodasreportedontheStrengthsAssessment?”

DatePIPbegan:January,2018

StatusofPIP:SubmissiondeterminednottobeaPIP(notrated)

TheMHPhasidentifiedfulfillmentoflifegoalsofconsumersasnotwellsupportedbytheusualclinicalfocusofstaff,whichtendstoalignwithsymptomsandimpairmentsofillness.Theexistenceoflifedomainareasthatareunfulfilled,suchashousing,educationandemployment,hasbroughttheMHPtofocusonanapproachgearedtosupportothersuccesses.TheStrengthsModelisassociatedwithaspecificassessmentapproach,thedevelopmentofapersonalrecoveryplanandsupportedbyaspecificfocusingroupsupervision.Likelythisisassociatedwithchangesinapproachbyclinicalstaff,buttheseinterventionsarenotdescribedwithinthisPIP.

ThisPIPisverysimilartotheclinicalPIPbutwithaslightlydifferentfocus.TheoverlapissufficienttoconcludethatbothcannotbeacceptedasactivePIPsforthisMHP.

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RelevantdetailsoftheseissuesandrecommendationsareincludedwithinthecommentsfoundinthePIPvalidationtool.

ThetechnicalassistanceprovidedtotheMHPbyCalEQROconsistedofdiscussionoftheduplicativeaspectsofthisPIP,andidentificationofpotentialalternatePIPtopics.Onetopicthatwasdiscussedwasthatoftelepsychiatryappointmentno-shows,whichtheMHPhasbeentracking.

PIPFindings—ImpactandImplications

AccesstoCare

• ThePIPsubmissionsdidnotaddressissuesofinitialaccesstocare.


• ThePIPsubmissionsdidnotaddressissuesoftimelinessofservices.

QualityofCare

• TheclinicalPIPinvolvestheuseoftheStrengthsModeltofocuscasemanagersandcliniciansonthediscoveryandsupportofimprovementsinlifedomainareassuchashousing,education,andemployment.

ConsumerOutcomes

• TheclinicalPIPisintendedtoresultinachievementofpositivelifedomainoutcomesforconsumers,currentlytargetingemployment,butalsoincludinghousingandeducation.

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PERFORMANCEANDQUALITYMANAGEMENTKEYCOMPONENTSCalEQROemphasizestheMHP’suseofdatatopromotequalityandimproveperformance.Componentswidelyrecognizedascriticaltosuccessfulperformancemanagementincludeanorganizationalculturewithfocusedleadershipandstrongstakeholderinvolvement,effectiveuseofdatatodrivequalitymanagement,acomprehensiveservicedeliverysystem,andworkforcedevelopmentstrategiesthatsupportsystemneeds.Thesearediscussedbelow,alongwiththeirqualityratingofMet(M),PartiallyMet(PM),orNotMet(NM).

AccesstoCare

Table6liststhecomponentsthatCalEQROconsidersrepresentativeofabroadservicedeliverysystemthatprovidesaccesstoconsumersandfamilymembers.Anexaminationofcapacity,penetrationrates,culturalcompetency,integration,andcollaborationofserviceswithotherprovidersformsthefoundationofaccesstoanddeliveryofqualityservices.

Table6:AccesstoCareComponents

Component QualityRating

1AServiceaccessibilityandavailabilityarereflectiveofculturalcompetenceprinciplesandpractices

M

TheMHPutilizesaculturalcompetenceplan(CCP)updatedfortheFY17-18/FY18-19period.TheMHPdemonstratedeffortstounderstandtheneedsofthecommunitieswithinthelargercounty.TheMHPplanstooutreachtotheJuneLakeareatoreduce/improvestigmaaboutsubstanceabuseandmentalhealthtreatment.TheMHP’seffortstoengagecommunitymembersthroughouttheregionisquiteevidentinthemeetings,flyersandotheractivitiespresentedforthisreview.

EveryothermonththeMHPrunsaForoLatino,designedtoengageHispanic/Latinocommunitymembers,andconductedinSpanish.Thiseventisconductedinavarietyofenvironments,includingSocialServices,PublicHealth,MammothLakesHousing,andothers.CirculodeMujeresisconductedweekly,whichisanopengroupforSpanish-speakingwomentodevelopfriendshipsandprovidemutualsupport.TherearesimilargroupsforLatino/Hispanicmen.AfulltimebilingualcasemanagerworksattheSierraWellnesscenter,aspartoftheeffortstoengagemoreHispanic/LatinoandSpanishspeakers.Atthesmallersites,similareffortsareprovidedtoengagethepotentiallyunderservedHispanic/Latinopopulation.

CY16datashowsthatthreefostercareyouthaccessedservicesunderPathwaystoWellbeing/KatieA.provisions.Aspreviouslyidentified,fostercarepenetrationratesremainbelowthesmall-ruralandstatewideaverages.

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1B Managesandadaptsitscapacitytomeetconsumerserviceneeds M

TheinstallationoftelemedicineinthesmallWalkerClinic,nearlytwohoursawayfromthemainMammothLakesoffices,providesevidenceofeffortstoimproveaccesstoremoteareas.TheadoptionoftheStrengthsModelreflectstheMHP’sre-evaluationofcurrentpracticesandshiftsfocustoassistingconsumerswithattainmentoffunctionallifegoals.TheMHPlacksanyonsitemedicalcapacity,includingnursingorothermedicalstaff.Thiscreatesapotentialbarriertotheuseoflong-actinginjectables,ofwhichnonearecurrentlyprescribed.TheMHPwouldneedtorelyuponpublichealthoraprimarycareproviderwerelong-actinginjectablesdeemednecessary.ThiscanalsoserveasabarrierifVivitrolwasdeemedappropriateforMedicationAssistedTreatmentforSUDorduallydiagnosedconsumers.

1CIntegrationand/orcollaborationwithcommunity-basedservicestoimproveaccess M

TheMHPoperateswithsubstanceabuseservicesintegratedintheBehavioralHealthdepartment.Thereisaclearandactiveconnectionwiththeschoolsystemandincreasedeffortstooutreachtoat-riskyouth.TheMHPisworkingcloselywithlocalhousingdevelopmentresourcesandisfocusedondevelopingresourcesformentalhealthconsumers.ThereisacloserelationshipbetweenthelocalemergencydepartmentandtheMHPtoserveindividualsincrisis.Thathospitalalsohasacquireditsowndistinctpsychiatrytelemedicineconsultativecapacity.Achallengeinthatareaisthatthetelemedicineresourceislimitedtotheemergencydepartmentandnotavailabletopatientsonotherunitswithinthehospital.Telepsychiatryserviceswerereportedlyunavailableforanolderadultduetothecredentialingofthetelepsychiatristnotincludingthispopulation.TheMHPisintheprocessoffullyreassessingitspsychiatryneedsandwillbeincorporatingtheseneedsintherequestforproposal(RFP)requirementsdueinthesummerof2018.TheMHPisconsideringarequirementthattelepsychiatryusethelocalEHRforserviceentry.


AsshowninTable7,CalEQROidentifiesthefollowingcomponentsasnecessarytosupportafullservicedeliverysystemthatprovidestimelyaccesstomentalhealthservices.Thisensuressuccessfulengagementwithconsumersandfamilymembersandcanimproveoveralloutcomes,whilemovingbeneficiariesthroughoutthesystemofcaretofullrecovery.

Table7:TimelinessofServicesComponents

Component QualityRating

2A Tracksandtrendsaccessdatafrominitialcontacttofirstappointment M

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TheMHPreportsinitialaccessfromdataofallfirstappointmentsscheduled,includingthosewhichtheconsumerfailedtomake.Essentially,thetimetofirstofferedappointmentisreported.TrackingoccurswithinadedicatedExcelspreadsheet.

TheMHPreportsa10-daystandardforinitialaccess,andanadultmeanof5.42days,andchildrenandyouth5.29days,withanattainmentofstandardrangesfrom86.3percentforchildren,to91.7percentforadults.

Intrackingtimetofirstkeptappointmentforconsumersnewtoservices,theMHPreportsthatapproximatelyfivepercentdeclinedthefirstofferedappointmentforalaterdate.About16percentnevercamein,andabout16percentmissedorrescheduledthefirstappointment.

Focusgroupparticipantsofthoseinitiatingserviceswithinthelastyearwerenotwellrepresented.Fromthelimitedsample,therewerenocomplaintsofdelaysforinitialaccess.

2BTracksandtrendsaccessdatafrominitialcontacttofirstpsychiatricappointment

NM

TheMHPhasnotestablishedaninitialpsychiatryaccessstandardandisnottrackingthisdata.

2CTracksandtrendsaccessdatafortimelyappointmentsforurgentconditions

NM

TheMHPdoesnottrackorreporturgentservicerequests,noristhereanidentifiedstandard.

2DTracksandtrendstimelyaccesstofollow-upappointmentsafterhospitalization NM

TheMHPdidnotreportastandardfortimelinessofpost-hospitaldischarge,andforthecurrentreviewedtimeperiod,theMHPexperiencednohospitalizationevents.ThereisalsonostandardortrackingmentionedintheQIWorkPlan.

2E Tracksandtrendsdataonrehospitalizations M

Therewerenohospitalizationeventsforthereviewedtimeperiod.TheQIWorkPlandoesnotspecifyanyrehospitalizationtrackingorstandard.

2F Tracksandtrendsno-shows NM

TheMHPdidnotreportno-showeventsforthisreview.TheQIWorkPlandoesnotidentifystandardsforno-shows.

QualityofCare

InTable8,CalEQROidentifiesthecomponentsofanorganizationthatisdedicatedtotheoverallqualityofcare.Effectivequalityimprovementactivitiesanddata-drivendecisionmakingrequirestrongcollaborationamongstaff(includingconsumer/familymemberstaff),workingininformationsystems,dataanalysis,clinicalcare,executivemanagement,andprogramleadership.Technologyinfrastructure,effectivebusinessprocesses,andstaffskillsinextractingandutilizing

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dataforanalysismustbepresentinordertodemonstratethatanalyticfindingsareusedtoensureoverallqualityoftheservicedeliverysystemandorganizationaloperations.

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Table8:QualityofCareComponents

ComponentQualityRating

3AQualitymanagementandperformanceimprovementareorganizationalpriorities NM

TheMHPhassoughtoutsidehelpinthedevelopmentofitsQIWorkPlan.TheAnnualWorkPlanandtheevaluationofthepriorplanshowincreaseddetailbutlittleinthewayofchangeswithidentifiedmetrics.Forexample,thereisanextensiveanalysisofcomplianceareasincludingthetrackingofgrievances,trainings,chartreviews,theaccesslineandinitialaccess.However,therearenoadditionalqualityindicatorssuchastimelinessofinitialpsychiatryaccess,post-hospitaldischargefollow-upstandards,urgentappointmentstandardsandtracking,orno-shows.

TheMHPhasunderstandablyplacedemphasisonimprovingandmaintainingaccessatthemoreremotelocations(Walker,Coleville,Bridgeport,Benton),whichisquiteappropriate.Fortheseareastherearestandardsintermsofdaysofserviceavailability.Wellnesscenterprogramaccessistrackedforthetwocurrentsites.

ItstillappearsthattheMHPwouldbenefitfromconsultationsupporttohelpitdevelopabroaderQIWorkPlanthatcontainsadditionalqualitystandards.

Thereviewprocessuncoveredmixedperceptionsaboutbilling,documentationrequirements,andhowdeterminationsaremadeastowhetherservicesareclaimedtoMedi-Cal.Forsuchasmallorganization,thesemattersshouldbeeasilydetermined.Itislikelythattherearemissedopportunitiestodirectlyclaimforservicesduetothelackofclarity,designatedsubjectmatterexperts,andlackofconsistencyinmessage.Thedecisionsaboutclaimingappeartobewidelydiffusedwithintheorganizationandamongtoomanyindividualswhomaybeprovidingdifferentandnotwell-coordinatedmessaging.

ItisnotuncommonthatsmallandremoteMHPsexperiencethistypeofissueduetoapprehensionsaboutclaimingmistakes.Thesecircumstancescreateagoodcaseforformalexternalconsultationandtrainingbysubjectmatterexpertsthatcouldhelpwithspecifics,i.e.writtenpolicy,andprocess.

ThereappeartobenumerousunresolvedEHRissuesthatcreatechallengesandbarriersforstafftobeincompliancewithstandards.Thisresultsinindividualpractitionersmaintainingexternaltrackingdatabasessoastohaveeasyaccesstoimportantconsumerinformation.ThisisunlikelytoberesolveduntiltheEHRisupdated.

3B Dataareusedtoinformmanagementandguidedecisions PM

Thedataelementsmonitoredtendtowardsprocessmeasures,suchasresponsetogrievances,andoftenlackanestablishedperformanceoroutcomestandard.Initialaccesstimelinessappearstocompriseanannualreviewandevaluation.Otherqualitymeasuressuchasconsumerperceptionalsohaveaprocessgoalbutlackanexpectationforactualresultsoroutcomes.The

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improvementsintheQIWorkPlanstilllacktheinclusionofimportantmetricssuchaspost-hospitaldischargefollow-up,rehospitalizationrates,initialpsychiatryaccesstimeliness,andurgentcarestandardsandtracking.

3CEvidenceofeffectivecommunicationfromMHPadministration,andstakeholderinputandinvolvementonsystemplanningandimplementation

M

TheMHPpresentedinformationregardingitscomingeffortstoobtaininputfromtheMammothLakesareaandaccomplishedworkonthesurroundingsmaller,distantcommunitiesthatcompriseMonoCountywithbothinformationaboutservicesandalsoseekinginput.CommunityinvolvementalsooccurswithrepresentationofthelocalBoardofSupervisors,Sheriff’sDepartment,SocialServicesandotherentitiesontheMentalHealthAdvisoryBoard.

NoneofthefocusgroupparticipationsfeltthatinformationaboutserviceswaswidelyavailableintheMammothLakesarea,andthatmuchmorecouldbedonetoensurethisinformationwaspresentinpublicplacesand,forexample,onthelocaltransitsystembusesandatpublicmeetingplaces.

3D Evidenceofasystematicclinicalcontinuumofcare PM

TheMHPlocallylacksmanyofthehigh-endresourcessuchaspsychiatricinpatientcareandcrisisstabilization.Creativesolutionsandpracticesexistforresponsetocrisisevents,andconsultationwiththelocalemergencydepartment.

Theservicesthatexistlargelyrelatetotraditionaloutpatienttherapy,casemanagement,andpsychiatryservicesdeliveredbywayoftelemedicinebyKingsViewproviders.Theactivitiesofthewellnesscentersupplementthetraditionalservices.TheMHP’sadoptionoftheStrengthsModeliscurrentlytargetingthehigh-need,seriouslymentallyillwithanapproachtoassisttheirattainmentoflifedomaingoalssuchasemployment,withanticipatedinclusionofimprovedhousing,andeducationovertime.

TheMHP’sabilitytodeliverlong-actinginjectablemedicationsishamperedbythelackofon-sitepsychiatryornursingpresence.Thiscouldbeanissueforthosewithaddictionortheseverelymentallyillwithmedicationadherenceissues.AworkaroundinvolvingpartneringwithpublichealthorprimarycarewouldberequiredforNaltrexoneorlong-actingantipsychotics,andlikelyreducesconsiderationofthesedrugsduetochallengesindelivery.

Apsychiatryaccessissuewasmentionedduringthisreviewwhichrelatedtotelepsychiatrybeingunwillingtoprescribeforindividualsover60years,duetolackofolderadultcertification.Ifthisremainsanissue,alternativesforobtainingpsychiatricservicesfortheolderadultpopulationshouldbeconsidered.TheMHPisconsideringalltypesofunmetneedsintheirre-

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evaluationofthetelepsychiatrycontractrequirements.ThetelepsychiatryproviderusesanotherEHRsystemwhichdiffersfromtheMHPsandmayproducedelaysinprogressnotesbeingavailableforreviewbylocalpractitioners.TheseissueswillbeaddressedwithintheupcomingtelepsychiatryRFP.

3EEvidenceofconsumerandfamilymemberemploymentinkeyrolesthroughoutthesystem NM

TheMHP’sCCPincludesexplorationoflivedexperienceamongtheMHPstaff.Approximatelyone-thirdidentifiedasacurrentconsumerandanotherone-thirdidentifiedasapriorconsumer.Awellnesscenterassociatewasrecentlyhired.Thereisnoevidenceofformalconsumer/familymemberpositionsexisting,norspecificrecruitmentsofindividualswithlivedexperience.

3FConsumerrunand/orconsumerdrivenprogramsexisttoenhancewellnessandrecovery PM

TheMHPoperatestwowellnesscenters,oneinWalkerandtheotherinMammothLakes.Bothoperateonapart-timebasisthatdoesnotmirrorthehoursoftheMHP’soperations.ThescheduleoftheSierraWellnessCenter(MammothLakes)listssomeeventsinSpanish.

3G Measuresclinicaland/orfunctionaloutcomesofconsumersserved PM

TheMHPutilizestheGAD-7andPHQ-9routinelywithintheEHR.TheCANSisintegratedintheEHRworkflow,andisutilizedforchildrenandyouth.Aggregationofdataisnotcurrentlyoccurring.

3H UtilizesinformationfromConsumerSatisfactionSurveys PM

TheMHPreviewedthemethodologyandcompletionresultsofitssatisfactionsurvey.TheMHPestablishedagoalof50percentcompletion.InSpring2017,theMHPreceived37andinFall2017,41responses.AnadditionalMHSAsurveywasalsoadministered.TheMHPdescribedthemethodologyindetail,butnoresultsorfindingswerepresented,norhowtheywerecirculated.

KeyComponentsFindings—ImpactandImplications

AccesstoCare

• TheMHPprovidesgroupsandforumstosupporttheLatino/HispanicconsumersandtheSpanish-speakingpopulation.

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• TelemedicineisprovidingfunctionalaccesstopsychiatricservicesattheMammothLakesandWalkerlocations.


• TheMHPtracksthetimeofinitialaccessandreportsapositiveresult(approximately5.2days)forinitialaccesstocare.

• TheMHPhasnoothertimelinessstandards,northeabilitytotrackandreportinitialpsychiatry,aftercarefollowinginpatientdischarge,andurgentcaretimeliness.

QualityofCare

• WhiletheMHPhasobtainedinformationfromotherMHPsandNorQIC,theQIWorkPlanretainsaverylimitedqualityfocus.

• TheEHRapparentlypresentssignificantbarrierstoclinicalstaff.Reportsofupdatesdueandremindersareneeded.Accuracyoftheinformationthatispresentedisoftenquestionedbystaff.

• TheMHPlacksin-housecapacityforuseoflong-actinginjectablemedications,suchastheanti-psychoticsandNaltrexoneformedicationassistedtreatment(MAT).

ConsumerOutcomes

• TheMHPlacksaformalsystemfortheemploymentofindividualswithlivedexperience,reflectedintheabsenceofpositionsspecificallyidentifiedwiththispopulationandacareerladder.TheMHPemphasizesthenumberofunlicensedstaffwhoarehiredintocompetitivepositionsthatpossesslivedexperiencewithmentalhealthandaddictionissues.

• TheMHPtracksandreportsthenumberofconsumerperceptionsurveyscompleted,andthenarrativecommentsarecompiled.TheMHPdoesnotestablishagoalforthemeasurements,norisitclearhowthisfeedbackisutilizedforcorrectiveactionstakentoimproveactualresults.ItisapparentthattheMHPhasmadeeffortstoimproveparticipationbuthasnotfullyutilizedsurveyresults.

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CONSUMERANDFAMILYMEMBERFOCUSGROUPSCalEQROconductedone90-minutefocusgroupwithconsumersandfamilymembersduringthesitereviewoftheMHP.Aspartofthepre-siteplanningprocess,CalEQROrequestedtwofocusgroupswith8to10participantseach,thedetailsofwhichcanbefoundineachsectionbelow.

Theconsumer/familymemberfocusgroupisanimportantcomponentoftheCalEQROsitereviewprocess.Obtainingfeedbackfromthosewhoarereceivingservicesprovidessignificantinformationregardingquality,access,timeliness,andoutcomes.ThefocusgroupquestionsarespecifictotheMHPbeingreviewedandemphasizetheavailabilityoftimelyaccesstocare,recovery,peersupport,culturalcompetence,improvedoutcomes,andconsumerandfamilymemberinvolvement.CalEQROprovidesgiftcertificatestothanktheconsumersandfamilymembersfortheirparticipation.

Consumer/FamilyMemberFocusGroup1

Aparent/caregiverofchildrenandyouthwasrequested,totheextentpossible,themajorityofwhominitiallyaccessedcarewithintheprior6-15months.Onlytwoparticipantsattended,resultinginthecancellationofthisfocusgroup.

Consumer/FamilyMemberFocusGroup2

Thesecondfocusgroupwasrequestedas:AnAdultconsumerfocusgroup,consistingof8-10culturallydiverseadultbeneficiariesrepresentingbothhighandlowutilizersofservice.ThisfocusgroupwasconductedattheMHP’sofficesinMammothLakes,California.

Numberofparticipants:4

Thesingleparticipantwhoenteredserviceswithinthepastyeardescribedtheirexperiencesasthefollowing:

• Initialaccessoccurredwithintwotothreedays.

• Initialaccesswasdescribedas“amazing,great,comfortable.”

• Theconsumerlearnedaboutservicesthroughthelandlord,anddoesnotrecallseeinganyinformationaboutmentalhealtharoundtown.

• Therewerenobarrierstoaccessingcare.

Generalcommentsregardingservicedeliverythatwerementionedincludedthefollowing:

• Themajorityofparticipantsidentifiedreceivingregularpsychotherapyservices.Thefrequencyisconsideredbymosttobesufficientforprogresstooccur.

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• Themajorityreceiveservicesweekly.

• Telepsychiatryisreportedlyunavailabletotheolderadultparticipantbecausetheprovidingpsychiatristisnotcertifiedforthispopulation.

• Severalreportedhavingparticipatedinamedicationeducationclass.

• Themajorityhavereceivedcasemanagementservices.Asmallnumberreceiveregularassistance,butmostdonot.Somewouldlikemoreofthistypeofassistance.

• Halfreceiveweeklygroupservices.

• ThemajorityhavereceivedadditionalurgentcareservicesfromtheMHP.Theneedhasbeenmetalmostimmediately.

• Crisisneedsaremetimmediately.TheparticipantsrecalledthatifacutecarewasneededtheyhadbeentransportedtoPlacervilleifona72-hourhold.

• Allparticipantsexperienceinvolvementwiththeirtreatmentplanning.

• WellnessandRecoveryActionPlans(WRAP)iswithintheawarenessofthemajorityofparticipants,somethinkingtheytalkaboutitallofthetime.

• Coordinationbetweenpsychiatryandprimarycareoccurredinthepast,butnotrecently.

• ParticipantsbelieveprogressischeckedagainsttheWRAPorpersonalrecoveryplans.

• Oneparticipantnotedthatwhatisdoneisamazing.“Youask,yougetit.”

Recommendationsforimprovingcareincludedthefollowing:

• Improvedpromotionofmentalhealthserviceswithinthecommunityisneeded.Increasedadvertisinginthepapersisneeded.Communicationoftheofficelocationneedstobeimproved.

• Thereremainsagreatdealofprejudiceandstigmaaboutmentalhealthinthecommunityatlarge.

• Rehabilitationfacilitiesareneededinthearea.

• Improveservicestonumerouslocalveterans,forwhomfewdedicatedservicesexistlocally.

Interpreterusedforfocusgroup2:No

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Consumer/FamilyMemberFocusGroupFindings—Implications

AccesstoCare

• Accesstocareisquicklyachievedforfocusgroupmembers,andtheservicesareuniversallyexperiencedpositively.

• Informationaboutservicesisnotwidelyavailableinthelargercommunity.

• ReportedreluctanceoftelepsychiatrytotreatolderadultsmeritsexplorationbytheMHPtodetermineifadditionalpsychiatryresourcesmayberequired.TimelinessofServices

• Initialaccessisreportedlyveryquick.

• Therewerenoparticipantswithinitialtelepsychiatryoroffice-basedpsychiatrywithinthelastyear.

QualityofCare

• Participantsreportedgoodaccesstoroutinetherapyandbest-practicessuchasWRAPservices,groups,andtimelyresponsetoneeds.

• Withthestartoftelepsychiatry,consumersperceivethatthecommunicationprocessbetweenprimarycareandthepsychiatristhasnotcontinued.

• Informationisprovidedaboutmedicationinastructured,class-likeformat.

ConsumerOutcomes

• Nospecificoutcomesorrelatedissueswereidentified.

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INFORMATIONSYSTEMSREVIEWUnderstandinganMHP’sinformationsystem’scapabilitiesisessentialtoevaluatingitscapacitytomanagethehealthcareofitsbeneficiaries.CalEQROusedthewrittenresponsetostandardquestionsposedintheCalifornia-specificISCA,additionaldocumentssubmittedbytheMHP,andinformationgatheredininterviewstocompletetheinformationsystemsevaluation.

KeyInformationSystemsCapabilitiesAssessment(ISCA)InformationProvidedbytheMHP

Thefollowinginformationisself-reportedbytheMHPthroughtheISCAand/orthesitereview.

Table9showsthepercentageofservicesprovidedbytypeofserviceprovider.

Table9:DistributionofServices,byTypeofProvider

TypeofProvider Distribution

County-operated/staffedclinics 100%

Contractproviders 0%

Networkproviders 0%

Total 100%

PercentageoftotalannualMHPbudgetdedicatedtosupportinginformationtechnologyoperations(includeshardware,network,softwarelicense,ITstaff):4%

Thebudgetdeterminationprocessforinformationsystemoperationsis:

�UnderMHPcontrol�AllocatedtoormanagedbyanotherCountydepartment�CombinationofMHPcontrolandanotherCountydepartmentorAgency

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MHPcurrentlyprovidesservicestoconsumersusingatelepsychiatryapplication:

� Yes � No � InpilotphaseNumberofremotesitescurrentlyoperational:2

Identifyprimaryreason(s)forusingtelepsychiatryasaserviceextender(checkallthatapply):

�Hiringhealthcareprofessionalstafflocallyisdifficult�Forlinguisticcapacityorexpansion�Toserveoutlyingareaswithinthecounty�Toserveconsumerstemporarilyresidingoutsidethecounty�Reducetraveltimeforhealthcareprofessionalstaff�Reducetraveltimeforconsumers

TelepsychiatryservicesareavailablewithEnglishandSpanishspeakingpractitioners(notincludingtheuseofinterpretersorlanguageline).Approximately39telepsychiatrysessionswereconductedinSpanish.

SummaryofTechnologyandDataAnalyticalStaffing

MHPself-reportedtechnologystaffchanges(Full-timeEquivalent[FTE])sincethepreviousCalEQROreviewareshowninTable10.

Table10:TechnologyStaff

ISFTEs(IncludeEmployeesandContractors)

#ofNewFTEs

#Employees/ContractorsRetired,

Transferred,Terminated

Current#UnfilledPositions

0 0 0 0

- 41 -


MHPself-reporteddataanalyticalstaffchanges(inFTEs)thatoccurredsincethepreviousCalEQROreviewareshowninTable11.

Table11:DataAnalyticalStaff

ISFTEs(IncludeEmployeesandContractors)

#ofNewFTEs

#Employees/ContractorsRetired,

Transferred,Terminated

Current#UnfilledPositions

1 0 0 0

Thefollowingshouldbenotedwithregardtotheaboveinformation:

• ReporteddataforTable10doesnotreflectcountyorvendorcontractedFTEs.

CurrentOperations

• TheMHPcontinuestouseandmatureitsEHR,Sharecare/Clinician’sDesktopfromtheEchoGroup,toprovidefiscalandclinicalfunctionalityforthesystemofcare.Unfortunately,atthistimetheMHPdoesnotappeartobeusingsystemcapabilitiesformedicalstaff.

Table12liststheprimarysystemsandapplicationstheMHPusestoconductbusinessandmanageoperations.Thesesystemssupportdatacollectionandstorage,provideelectronichealthrecord(EHR)functionality,produceShort-Doyle/Medi-Cal(SD/MC)andotherthirdpartyclaims,trackrevenue,performmanagedcareactivities,andprovideinformationforanalysesandreporting.

Table12:PrimaryEHRSystems/Applications

System/Application Function Vendor/SupplierYearsUsed OperatedBy

SharecarePractice

ManagementEcho 8 Echo

Clinician’sDesktopElectronic

HealthRecord Echo 2 Echo

- 42 -


PrioritiesfortheComingYear

• AllAssessmentswillbeintheElectronicHealthRecord

• UpgradingtoEchoVantageProgram

MajorChangesSincePriorYear

• AllclinicalstaffisnowusingtheEHRforTreatmentPlans

• MonoCountyisnowtrackingPHQ-9andGAD-7scoresintheEHR

OtherSignificantIssues

• BroadstakeholderfeedbacknotedagenerallackofconsistencyintheusabilityofthenewEHR.Systemperformance,whichtheMHPdoesnotmonitorforuptimeorresponsiveness,appearedtobecausingsignificantproductivityandreliabilityissuesforlinestaff.Whilemanagementappearedtobeaddressingissuesonacasebycasebasistherehasn’tappearedtohavebeensignificantenergyexpendedtoholdthevendoraccountableforperformanceandreliability.Hopefully,anupgradewhichtheMHPisstronglycontemplatingwillgoalongwaytoresolvetheseissues.

• TheMHPdemonstratedafunctionalsharedtrackingdatabaseforitsfostercarecollaborationswithChildWelfare.Thisdatabaseisindailyusetoimproveclinicalcoordinationamongcountyagenciesprovidingservicetothispopulation.

PlansforInformationSystemsChange

• TheMHPhasanewsysteminplaceandcontinuestorefineitsimplementation.

• WhiletheMHPhasanewsysteminplaceitisalsoexploringthepossibilityofupgradingsystemfunctionalitytoitsvendor’snewproduct,EchoVantagewhichisafullyrewrittenandretooledsystem.Implementationofthisnewproductmayprovideneededrelieftostaffwhocurrentlyappeartobeexperiencinglessthanseamlessfunctionality.

- 43 -


CurrentElectronicHealthRecordStatus

Table13summarizestheratingsgiventotheMHPforEHRfunctionality.

Table13:EHRFunctionality

Rating

Function System/Application PresentPartiallyPresent

NotPresent

NotRated

Alerts x Assessments x CareCoordination xDocumentimaging/storage x Electronicsignature—consumer

x

Laboratoryresults(eLab) x LevelofCare/LevelofService

x

Outcomes x Prescriptions(eRx) x Progressnotes x ReferralManagement xTreatmentplans x SummaryTotalsforEHRFunctionality: 5 0 5 2

Progressandissuesassociatedwithimplementinganelectronichealthrecordoverthepastyeararediscussedbelow:

• TheMHPhasnotyetimplementedeLabsoreRxtoolsinitsEHR.ThetelepsychiatryprovidersdonotenterservicesintotheMHP’sEHR,butmayconsiderthiswhenthetelepsychiatryresourceneedsarere-evaluatedthissummer.

• TheMHPisinvolvedwiththeexpansionoftheuseofformaloutcomestoolswithintheEHRworkflow.ItcurrentlyhasthePHQ-9andGAD-7intheworkflowandhasaddedtheCANSaswelltomeetstaterequirements.TheMHPhasnotasyetchosenanadultoutcometool/scalewhichcouldassistothereffortslikeitsStrengthsAssessmentproject.TheMHPdoesnot,asyet,appeartohaveengagedinsecondaryanalysisofitsoutcomesdatatofurthercarequalityinitiatives.

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Consumer’sChartofRecordforcounty-operatedprograms(self-reportedbyMHP):

� Paper � Electronic � Combination

PersonalHealthRecord

DoconsumershaveonlineaccesstotheirhealthrecordseitherthroughaPersonalHealthRecord(PHR)featureprovidedwithintheEHR,consumerportal,orthird-partyPHR?

� Yes � No

Ifno,providetheexpectedimplementationtimeline.

☐Within6months�Withinthenextyear☐Withinthenexttwoyears�Longerthan2years

Medi-CalClaimsProcessing

MHPperformsend-to-end(837/835)claimtransactionreconciliations:

Ifyes,productorapplication:

EchoSharecare

MethodusedtosubmitMedicarePartBclaims:

☐ Paper � Electronic ☐ Clearinghouse

Table14summarizestheMHP’sSDMCclaims.

Number Submitted

Gross Dollars Billed

Number Denied

Dollars Denied

Percent Denied

Gross Dollars Adjudicated

Claim Adjustments

Gross Dollars Approved

1,983 $328,615 133 $24,343 7.41% $304,272 $35,121 $269,151

Table 14: Mono MHP Summary of CY16 Short Doyle/Medi-Cal Claims

Includes services provided during CY16 with the most recent DHCS process ing date of May 19, 2017.The statewide average denia l rate for CY2016 was 4.48 percent.Change to the FFP reimbursement percentage for ACA a id codes delayed a l l cla im payments between the months of January-May 2017.

� Yes � No

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Table15summarizesthemostfrequentlycitedreasonsforclaimdenial.

• Deniedclaimtransactionswithreason“Othercoveragemustbebilledpriortosubmissionofthisclaim”and“Invalidprocedurecodemodifiercombination”aregenerallyre-billablewithintheStateclaimsresubmissionguidelines.

• WhiletheMHP’sdenialratesarecurrentlywellabovethestateaverage,billingstaffareawareoftheissuesandarediligentlyworkingtosolvethese.Ofmoreconcernwasconsistentfeedbackfromstakeholdersthatexistingprotocolswerenotbeingfollowedbystaffwhichledtopotentiallysignificantunderbillingsandpotentiallyinconsistentdocumentation.TheQIteammaybeobligatedtoundertakearoundofrefreshertrainingsforstafftoresolvetheseissues.

InformationSystemsReviewFindings—Implications

AccesstoCare

• TheMHPisleveragingitstelepsychiatryresourcestoimproveaccesstoservicesinitsremoteclinicsitesliketheWalkercenterinNorthCounty.


• Nofindings.

QualityofCare

• TheMHPhasdeployedtreatmentplan(TxP)functionalitytoallstaffviaitsEHRenhancements.

• TheMHPisinneedofreengagingstaffwithbillinganddocumentationprotocolstoensurethehighestqualityofcareforconsumers.

• TheMHPdemonstratedafunctionaltrackingdatabaseforitsfostercarecollaborations.

ConsumerOutcomes

Denial Reason Description Number Denied

Dollars Denied

Percent of Total Denied

Beneficiary not eligible or aid code invalid or restricted service indicator must be "Y" 91 $14,549 60%Other coverage must be billed prior to submission of this claim 31 $5,971 25%Invalid procedure code and modfier combination 1 $2,073 9%Total Denied Claims 133 $24,343 100%

Table 15: Mono MHP Summary of CY16 Top Three Reasons for Claim Denial

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• TheMHPhasbegunbroaddeploymentofavarietyofoutcomestoolswithintheEHRworkflowbuthasyettobeginsecondaryanalysisofoutcomesdata(e.g.;longitudinaltrendingofPHQ-9andGAD-7scores)informqualitycareinitiatives.

• TheMHPhasnotyetchosenauniversaladultoutcomesscaleforsystemwideEHRimplementation.

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SITEREVIEWPROCESSBARRIERSThefollowingconditionssignificantlyaffectedCalEQRO’sabilitytoprepareforand/orconductacomprehensivereview:

• Nobarrierswereencounteredduringthisreview.

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CONCLUSIONSDuringtheFY17-18annualreview,CalEQROfoundstrengthsintheMHP’sprograms,practices,orinformationsystemsthathaveasignificantimpactontheoveralldeliverysystemanditssupportingstructure.Inthosesameareas,CalEQROalsonotedopportunitiesforqualityimprovement.Thefindingspresentedbelowrelatetotheoperationofaneffectivemanagedcareorganization,reflectingtheMHP’sprocessesforensuringaccesstoandtimelinessofservicesandimprovingthequalityofcare.

StrengthsandOpportunities

AccesstoCare

Strengths:

• TheMHPisutilizingitstelepsychiatryresourcestoimproveaccesstoservicesinitsremotesitessuchastheWalkerclinicinNorthCountyinadditiontotheMammothClinic.

• TheMHPincreasedoutreachintotheNorthCountyschoolswiththeintentofprovidingearlyidentificationandtreatmentofmentalhealthissues.

Opportunities:

• TheMHP’sfostercarepenetrationrateislowerthanthesmall-ruralaverageandthestatewideaverages.


Strengths:

• TheMHPisabletouseamanualprocessfortrackingtimelinessofinitialaccesstocare,whichreflectsaveryshortwaittimeforbothchildrenandadults,averagingslightlymorethanfivedays.Thisisconsistentwithconsumerfocusgroupfeedback.

Opportunities:

• TheMHPisunabletotrackandreportotherimportanteventssuchasinitialpsychiatryaccess,postinpatientdischargefollow-up,andno-shows.

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QualityofCare

Strengths:

• TheMHPisutilizingtheStrengthsModeltoimprovetheoutcomesofconsumersintheareasofhousing,educationandemploymentthroughtheuseofthestrengthsassessmentandpersonalrecoveryplan.

• TheMHPidentifiesco-occurringconditionsatahighlevelof41%,demonstratinganinclusiveapproachtothediagnosticprocess.

• TheMHPhasdeployedtreatmentplan(TxP)functionalitytoallstaffviaitsEHRenhancements.

• TheMHPisactivelyanticipatinganupgradetothelatestiterationofitsvendor’sEHR(EchoVantage).

• TheMHPdemonstratedafunctionaltrackingdatabaseforitsfostercarecollaborations.

• TheMHPhasdocumenteditseffortstoimprovethetrackingandresolutionofgrievances,chartmonitoringforcomplianceissues,andeffortstoimproveparticipationinthetwiceayearconsumerperceptionsurveys.

Opportunities:

• TheStrengthsModelPIPinvolvesspecificclinician/consumerstrategieswhicharenotevidentinthecurrentdocumentandareimportanttoincludeforpracticereplicability.

• BroadfeedbackindicateschallengeswiththeusabilityoftheEHR,impactingproductivityandreliability.MHPeffortstoresolvetheseissuesoccursonacasebycasebasis,butthecontinuedproblemsresultinusersdevelopingoff-linesolutionsforthereportingandtrackingthatshouldroutinelyaccompanyEHRdeployment,includingcaseloadlistsandremindersforkeyupdateevents.

• TheMHPisinneedofreengagingstaffwithbillinganddocumentationprotocolstoensurethehighestqualityofcareforconsumers,whichmaybeanelementinthedownwardtrendinaverageapprovedclaimsoverthelastthreeyears.

• TheMHPidentifieslowerratesofdepressionandpsychoticdisorders,andhigherratesofadjustmentdisorders,whichmeritsevaluation.

• TheoverallaverageofapprovedclaimsperbeneficiaryhavetrendeddownwardfromCY14throughCY16,andaresignificantlylowerthanpeersmall-ruralandthestatewideaverage.Thismeritsexplorationastothereasonforthisdecline,anddeterminationifthisalignswiththeapparentmixedmessagesaboutclaiming.

- 50 -


• TheMHPcurrentlylacksareliableproductivityreportingprocess,whichisessentialformanagingservicedelivery.

• TheMHP’sQIWorkPlancontinuestoheavilyfocusoncomplianceissues,withoutincreasingtheinclusionofotherqualitymetrics.Theseneedtoincludeinitialpsychiatryaccess,post-hospitaldischargefollow-up,no-shows,consumerperceptionsurveyanalysiswithactiontakentorespondtothenarrativefeedback,andperhapstrackingandreportingMedi-Calclaimingmonthtomonth.

• ConsumersbelievethatinformationaboutservicesisinadequatelypublicizedintheMammothLakesarea,particularlyincommonpublicareasandonpublictransport.

ConsumerOutcomes

Strengths:

• TheMHPhasbegunbroaddeploymentofavarietyofoutcomestoolswithintheEHRworkflowbuthasyettobeginsecondaryanalysisofoutcomesdata(e.g.;longitudinaltrendingofPHQ-9andGAD-7scores)informqualitycareinitiatives.

• TheadoptionoftheStrengthsModelprovidesastructurethatassiststheMHPwithprovidingservicesthatextendbeyondthenarrowsymptomandimpairmentclinicalfocusandoffersconsumerssupportintheachievementoflifegoals.

Opportunities:

• TheMHPhasnotyetchosenanadultoutcomesscaleforsystemwideEHRimplementation.

• TheMHP’sclinicalPIPiscurrentlynarrowlyfocuseduponemploymentandmayunnecessarilyexcludethoseforwhomhousingoreducationgoalsexist.

Recommendations

• ContinueimprovementoftheQualityImprovement(QI)processandWorkPlan,includingthedevelopmentofadditionalqualitymeasures,suchastimelinessofinitialpsychiatryservice,urgentcareresponse,andno-shows,coupledwithquarterlytracking(continuedfromFY16-17).Considerseekingconsultationwithoutsidesubjectmatterexperts.

• Identifyandimplementauniversaladultconsumeroutcomesinstrumenttotrackconsumerprogress.

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• Broadlyreassesstelepsychiatryneeds,ensuringadequatecoverageforallserviceareasandage-relatedpopulations,andincludethecriteriaintherequestforproposal(RFP)laterthissummertobestbenefitconsumerservicedemands,includingtheprovider’suseofthelocalEHR.

• IdentifyasinglestaffmemberdesignatedtoadjudicateallMedi-Calclaimingquestionsandwhoalsodevelopsandprovidestrainingforstaff.

• DevelopatrackingsystemtomonitorMedi-Calclaimingthatreferencestheprioryearfortrendidentificationrelatedtothedownwardtrendofthepriorthreeyears.

• ExplorewithChildWelfareServices(CWS)thelowfostercarepenetrationrate,andidentifyifthereexistareasinwhichqualityimprovementactionsareindicated.

• Engageinthedevelopmentofmechanismstoprovidebroadercirculationofinformationaboutmentalhealthservices,specificallytargetingcommunitygatheringplacesandpublictransportationthroughoutthearea.

- 52 -


ATTACHMENTS

AttachmentA:CalEQROOn-siteReviewAgenda

AttachmentB:On-siteReviewParticipants

AttachmentC:ApprovedClaimsSourceData

AttachmentD:CalEQROPerformanceImprovementPlan(PIP)ValidationTools

- 53 -


AttachmentA—On-siteReviewAgenda

ThefollowingsessionswereheldduringtheMHPon-sitereview,eitherindividuallyorincombinationwithothersessions.

TableA1—EQROReviewSessions-MonoMHP

OpeningSession–Changesinthepastyear;currentinitiatives;andstatusofpreviousyear’srecommendations

UseofDatatoSupportProgramOperations

DisparitiesandPerformanceMeasures/TimelinessPerformanceMeasures

QualityImprovementandOutcomes

PerformanceImprovementProjects

ClinicalLineStaffGroupInterview

ConsumerFamilyMemberFocusGroup(s)

ValidationofFindingsforPathwaystoMentalHealthServices(KatieA./CCR)

ISCA/Billing/Fiscal

EHRDeployment

TeleMentalHealth

- 54 -


AttachmentB—ReviewParticipants

CalEQROReviewers

RobWalton,QualityReviewer,ConsultantDuaneHenderson,InformationSystemsReviewer,ConsultantJanyceLeathers,Consumer-FamilyMember,Consultant

AdditionalCalEQROstaffmemberswereinvolvedinthereviewprocess,assessments,andrecommendations.Theyprovidedsignificantcontributionstotheoverallreviewbyparticipatinginboththepre-siteandthepost-sitemeetingsandinpreparingtherecommendationswithinthisreport.

SitesofMHPReview

MHPSites

MonoCountyBehavioralHealth452OldMammothRoad,$304MammothLakes,CA93546

- 55 -


TableB1-ParticipantsRepresentingtheMHP

LastName FirstName Position Agency

Bonneau RichardAlcoholandDrugCounselor

MCBH

Cruz LauraFiscal&TechnicalSpecialist

MCBH

Edwall Heather PsychiatricSpecialistI MCBH

Galloway RachelS. CaseManagerI MCBH

Gastelum Perla OfficeTechnician MCOE

Gonzalez MariaL.PsychiatricSpecialistII

MCBH

Greenberg AmandaMentalHealthServicesActCoordinator

MCBH

Jimenez Bertha CaseManagerIII MCBH

Jones Julie QA/QICoordinator MCBH

Linaweaver Annie ClinicalSupervisor MCBH

Martin ShirleyFiscal&AdministrativeServicesOfficer

MCBH

Montanez SalvadorBehavioralHealthServicesCoordinator

MCBH

Raust Michelle ProgramManager MCDSS

Roberts Robin Director MCBH

Stewart DebraAddictionsSpecialistIII

MCBH

Villalpando Andres CaseManagerI MCVH

- 56 -


AttachmentC—ApprovedClaimsSourceData

ApprovedClaimsSummariesareprovidedseparatelytotheMHPinaHIPAA-compliantmanner.Valuesaresuppressedtoprotectconfidentialityoftheindividualssummarizedinthedatasetswherebeneficiarycountislessthanorequaltoeleven(*).Additionally,suppressionmayberequiredtopreventcalculationofinitiallysuppresseddata,correspondingpenetrationratepercentages(n/a);andcellscontainingzero,missingdataordollaramounts(-).

TableC1showsthepenetrationrateandapprovedclaimsperbeneficiaryforjusttheCY16ACAPenetrationRateandApprovedClaimsperBeneficiary.StartingwithCY16performancemeasures,CalEQROhasincorporatedtheACAExpansiondatainthetotalMedi-Calenrolleesandbeneficiariesserved.

TableC2showsthedistributionoftheMHPbeneficiariesservedbyapprovedclaimsperbeneficiaryrangeforthreecostcategories:under$20,000;$20,000to$30,000,andthoseabove$30,000.

EntityAverage

Monthly ACA Enrollees

Number of Beneficiaries

Served

Penetration Rate

Total Approved Claims

Approved Claims per Beneficiary

Statewide 3,674,069 141,926 3.86% $611,752,899 $4,310Small-Rural 30,196 2,135 7.07% $5,865,681 $2,747Mono 1,302 73 5.61% $98,901 $1,355

Table C1: Mono MHP CY16 Medi-Cal Expansion (ACA) Penetration Rate and Approved Claims per Beneficiary

Range of ACB

MHP Count of Beneficiaries

Served

MHP Percentage of Beneficiaries

Statewide Percentage of Beneficiaries

MHP Total Approved

Claims

MHP Approved Claims per Beneficiary

Statewide Approved Claims per Beneficiary

MHP Percentage

of Total Approved

Claims

Statewide Percentage

of Total Approved

Claims

< $20K 206 100.00% 94.05% $300,229 $1,457 $3,612 100.00% 59.13%

>$20K - $30K * n/a 2.83% - - $24,282 n/a 11.98%

>$30K * n/a 3.12% - - $53,215 n/a 28.90%

Table C2: Mono MHP CY16 Distribution of Beneficiaries by ACB Range

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AttachmentD—PIPValidationTools

PERFORMANCEIMPROVEMENTPROJECT(PIP)VALIDATIONWORKSHEETFY17-18 CLINICALPIP

GENERALINFORMATION

MHP: Mono

PIP Title: Strengths Model Intervention for Employment-Related Goals

Start Date (MM/DD/YY): January 2018

Completion Date (MM/DD/YY): NA

Projected Study Period (#of Months): 24 months

Completed: Yes � No �

Date(s) of On-Site Review (MM/DD/YY): 4/26/18

Name of Reviewer: Rob Walton

Status of PIP (Only Active and ongoing, and completed PIPs are rated):

Rated

� Active and ongoing (baseline established and interventions started)

� Completed since the prior External Quality Review (EQR)

Not rated. Comments provided in the PIP Validation Tool for technical assistance purposes only.

☐ Concept only, not yet active (interventions not started)

☐ Inactive, developed in a prior year

☐ Submission determined not to be a PIP

☐ No Clinical PIP was submitted

Brief Description of PIP (including goal and what PIP is attempting to accomplish):

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Based on community survey information and the subsequent group supervision findings, the MHP is aware of consumers’ desire to receive assistance with housing, education, and employment. The MHP is aware that its traditional approach was to focus upon clinical symptoms and impairments, and insufficiently addressed the larger life domain goals.

The MHP applied the Strengths Assessment with 14 high-need consumers and discovered 11 of these individuals had either an employment or economic goal. The MHP states that these individuals are identified as the highest need through justice involvement, persistent severe mental health symptoms, substance use history, and persistent need for intensive clinical contact.

The Strengths Assessment is supported by the Personal Recovery Plan (PRP), which emphasizes strengths over pathology. With the case manager/consumer relationship primary, interventions are based on self-determination, with the intent of utilizing strengths established in the past.

ACTIVITY 1: ASSESS THE STUDY METHODOLOGY

STEP 1: Review the Selected Study Topic(s)

Component/Standard Score Comments

1.1 Was the PIP topic selected using stakeholder input? Did the MHP develop a multi-functional team compiled of stakeholders invested in this issue?

� Met

☐ Partially Met

☐ Not Met

☐ Unable to Determine

The MHP demonstrates the involvement of the community and MHP staff in the process through a community survey. The survey obtained information from 137 individuals, of whom 42 percent were consumers or family members and had participated in previous mental health programming. Adequate housing, financial insecurity and social isolation were the key areas identified.

In addition, review of group supervision minutes identified areas of employment, housing security, and isolation were key topics discovered for consumers.

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1.2 Was the topic selected through data collection and analysis of comprehensive aspects of enrollee needs, care, and services?

� Met

� Partially Met

☐ Not Met


The MHP cites literature that indicates unemployment among seriously mentally ill adults ranges from 70 to 90 percent. An equally high percentage of these individuals desire employment. There was no data presented that indicates with level of care instrument or other acuity indicator that these are the most severely ill individuals, although one can argue that the co-morbidities identified likely reflect high acuity.

The MHP presents no data on what constitutes the highest need consumers, how many there are, what service levels are considered high. Data runs for recent service levels for these participants vs. the MHP average service levels has not occurred.

Select the category for each PIP: Clinical: ☐ Prevention of an acute or chronic condition ☐ High volume services

� Care for an acute or chronic condition ☐ High risk conditions

Non-clinical: ☐ Process of accessing or delivering care

1.3 Did the Plan’s PIP, over time, address a broad spectrum of key aspects of enrollee care and services?

Project must be clearly focused on identifying and correcting deficiencies in care or services, rather than on utilization or cost alone.

☐ Met

� Partially Met

☐ Not Met


The MHP’s focus is on using self-determination interventions, although it is not clear exactly what that means. Ensuring clients are heard and understood is mentioned. Supporting the consumer in life goal attainment is logical. But it would be helpful to give examples of how this intervention approach would be applied by the clinician or case manager.

1.4 Did the Plan’s PIPs, over time, include all enrolled populations (i.e., did not exclude certain enrollees such as those with special health care needs)?

Demographics: ☐ Age Range ☐ Race/Ethnicity ☐ Gender ☐ Language ☐ Other

☐ Met

☐ Partially Met

☐ Not Met

� Unable to Determine

The determination of who qualifies to be included seems significantly reliant upon qualitative analysis without effort to qualify or support with a known instrument such as MORS, LOCUS or even GAF. The intent is to serve the most severely ill consumers and those with the greatest needs. But this appears to be a qualitative determination.

Totals 1 Met 2 Partially Met 0 Not Met 1 UTD

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STEP 2: Review the Study Question(s)

2.1 Was the study question(s) stated clearly in writing?

Does the question have a measurable impact for the defined study population?

Include study question as stated in narrative: Will using the Strengths Model help clients make progress toward their employment-related goals, as measured by the achievement of their employment-related goals as recorded in the Strengths Assessment over the two-year study period?

☐ Met

� Partially Met

☐ Not Met


The degree of anticipated success was not stated.


STEP 3: Review the Identified Study Population

3.1 Did the Plan clearly define all Medi-Cal enrollees to whom the study question and indicators are relevant?

Demographics: ☐ Age Range ☐ Race/Ethnicity ☐ Gender ☐ Language � Other

☐ Met

� Partially Met

☐ Not Met


Justice involvement, debilitating mental illness symptoms, substance use, ongoing desire for intensive clinical services. These are all qualitative measures, for which the MHP has not established a ranking or entire listing of the eligible caseload.

3.2 If the study included the entire population, did its data collection approach capture all enrollees to whom the study question applied?

Methods of identifying participants:

☐ Utilization data ☐ Referral ☐ Self-identification

� Other: MHP sorting and evaluating all consumers

☐ Met

☐ Partially Met

☐ Not Met


While the Strengths Model (SM) targets housing, employment, education, the MHP is currently focused on those with an employment goal, which was 11 of the 14 SM assessed.

It seems if high service levels are part of the equation, the MHP would be in a position to create a list of the number of high-level served consumers who are not yet ready to be brought into the process but are qualified by service level. The MHP describes this approach as a paced ramp-up.


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STEP 4: Review Selected Study Indicators

4.1 Did the study use objective, clearly defined, measurable indicators?

List indicators: Percent of clients achieving their employment-related goals

☐ Met

� Partially Met

☐ Not Met


The performance indicator is a bit unclear. There is one denominator: number of consumers in the study. But there are two numerators: 1) the number of individual who achieved employment goal and did not create a new goal; 2) those who achieve an employment goal and did create a new employment goal. There is no baseline information.

4.2 Did the indicators measure changes in: health status, functional status, or enrollee satisfaction, or processes of care with strong associations with improved outcomes? All outcomes should be consumer focused.

☐ Health Status � Functional Status

☐ Member Satisfaction ☐ Provider Satisfaction

Are long-term outcomes clearly stated? � Yes ☐ No

Are long-term outcomes implied? � Yes ☐ No

� Met

☐ Partially Met

☐ Not Met


Attainment of employment goal.


STEP 5: Review Sampling Methods

5.1 Did the sampling technique consider and specify the: a) True (or estimated) frequency of occurrence of the event?

b) Confidence interval to be used?

c) Margin of error that will be acceptable?

☐ Met

☐ Partially Met

☐ Not Met

� Not Applicable


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5.2 Were valid sampling techniques that protected against bias employed?

Specify the type of sampling or census used: <Text>

☐ Met

☐ Partially Met

☐ Not Met

� Not Applicable


5.3 Did the sample contain a sufficient number of enrollees?

______N of enrollees in sampling frame

______N of sample

______N of participants (i.e. – return rate)

☐ Met

☐ Partially Met

☐ Not Met

� Not Applicable


Totals 0 Met 0 Partially Met 0 Not Met 3 NA 0 UTD

STEP 6: Review Data Collection Procedures

6.1 Did the study design clearly specify the data to be collected?

� Met

� Partially Met

☐ Not Met


Employment data/achieving vocational goals. It is not clear what the source of that information is and how it will be consistently collected.

6.2 Did the study design clearly specify the sources of data? Sources of data:

� Member ☐ Claims ☐ Provider

� Other: Presumably from the consumer reporting employment

☐ Met

☐ Partially Met

☐ Not Met


Not stated what the source of this data is.

6.3 Did the study design specify a systematic method of collecting valid and reliable data that represents the entire population to which the study’s indicators apply?

☐ Met

☐ Partially Met

� Not Met


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6.4 Did the instruments used for data collection provide for consistent, accurate data collection over the time periods studied?

Instruments used:

☐ Survey ☐ Medical record abstraction tool

☐ Outcomes tool ☐ Level of Care tools

� Other: MHSA Coordinator

☐ Met

☐ Partially Met

☐ Not Met


It is aligning reporting with the MHSA coordinator, and it is not clear how this individual will access the information.

6.5 Did the study design prospectively specify a data analysis plan?

Did the plan include contingencies for untoward results?

� Met

☐ Partially Met

☐ Not Met


Threshold of 25 percent improvement is set, and if not accomplished a proposed plan exists to revisit the process and determine what aspects require change or improvement.

6.6 Were qualified staff and personnel used to collect the data? Project leader: Amanda Fenn Greenberg, MPH

� Met

☐ Partially Met

☐ Not Met



STEP 7: Assess Improvement Strategies

7.1 Were reasonable interventions undertaken to address causes/barriers identified through data analysis and QI processes undertaken?

Describe Interventions: Strengths Model (including Strengths Assessment and PRP)

☐ Met

� Partially Met

☐ Not Met


While the assessment and personal recovery plan are important there are implications for the case manager/consumer interactions that somehow different than usually occur. Those elements should also be identified as interventions.


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STEP 8: Review Data Analysis and Interpretation of Study Results

8.1 Was an analysis of the findings performed according to the data analysis plan?

This element is “Not Met” if there is no indication of a data analysis plan

(see Step 6.5)

☐ Met

☐ Partially Met

☐ Not Met

� Not Applicable


8.2 Were the PIP results and findings presented accurately and clearly?

Are tables and figures labeled? ☐ Yes ☐ No

Are they labeled clearly and accurately? ☐ Yes ☐ No

☐ Met

☐ Partially Met

☐ Not Met

� Not Applicable


8.3 Did the analysis identify: initial and repeat measurements, statistical significance, factors that influence comparability of initial and repeat measurements, and factors that threaten internal and external validity?

Indicate the time periods of measurements: ___________________

Indicate the statistical analysis used: _________________________

Indicate the statistical significance level or confidence level if available/known: _______% ______Unable to determine

☐ Met

☐ Partially Met

☐ Not Met

� Not Applicable


8.4 Did the analysis of the study data include an interpretation of the extent to which this PIP was successful and recommend any follow-up activities?

Limitations described: <Text>

Conclusions regarding the success of the interpretation: <Text>

Recommendations for follow-up: <Text>

☐ Met

☐ Partially Met

☐ Not Met

� Not Applicable


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STEP 9: Assess Whether Improvement is “Real” Improvement

9.1 Was the same methodology as the baseline measurement used when measurement was repeated?

Ask: At what interval(s) was the data measurement repeated? Were the same sources of data used?

Did they use the same method of data collection? Were the same participants examined? Did they utilize the same measurement tools?

☐ Met

☐ Partially Met

☐ Not Met

� Not Applicable


9.2 Was there any documented, quantitative improvement in processes or outcomes of care?

Was there: ☐ Improvement ☐ Deterioration Statistical significance: ☐ Yes ☐ No Clinical significance: ☐ Yes ☐ No

☐ Met

☐ Partially Met

☐ Not Met

� Not Applicable


9.3 Does the reported improvement in performance have internal validity; i.e., does the improvement in performance appear to be the result of the planned quality improvement intervention?

Degree to which the intervention was the reason for change: ☐ No relevance ☐ Small ☐ Fair ☐ High

☐ Met

☐ Partially Met

☐ Not Met

� Not Applicable


9.4 Is there any statistical evidence that any observed performance improvement is true improvement?

☐ Weak ☐ Moderate ☐ Strong

☐ Met

☐ Partially Met

☐ Not Met

� Not Applicable


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9.5 Was sustained improvement demonstrated through repeated measurements over comparable time periods?

☐ Met

☐ Partially Met

☐ Not Met

� Not Applicable



ACTIVITY 2: VERIFYING STUDY FINDINGS (OPTIONAL)


Were the initial study findings verified (recalculated by CalEQRO) upon repeat measurement?

☐ Yes

� No

ACTIVITY 3: OVERALL VALIDITY AND RELIABILITY OF STUDY RESULTS: SUMMARY OF AGGREGATE VALIDATION FINDINGS

Conclusions: This PIP is newly implemented, and thus does not have results to report. There are, however, issues with the formulation – the identification of the study population is very unclear and non-specific, other than the justice and substance involvement. It is not clear what threshold of service level merits inclusion, nor of the total eligibles that are planned to receive services. What hours of service per month is the PIP high needs group vs. the MHP’s overall averages.

The second area is in the interventions. The SBM contains an assessment, a recovery plan, and it seems group supervision. These component elements seem to also be associated with some change in behavior as to how a clinician or case manager interacts with the consumer regarding achieving goals, in this case being employment. That case manager/consumer interaction is not described beyond being “strength-based.” It seems that there should be more specificity to that interaction so that it is replicable.

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Recommendations: The PIP has been improved from its original submission format. It needs to include greater specificity to the high user population so that this template can be reapplied as needed. More data-focused elements to supplement the qualitative. The other aspect to be improved is specificity of the case manager/consumer intervention. As written, it would be difficult to replicate.

Check one: ☐ High confidence in reported Plan PIP results ☐ Low confidence in reported Plan PIP results

☐ Confidence in reported Plan PIP results ☐ Reported Plan PIP results not credible

� Confidence in PIP results cannot be determined at this time

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PERFORMANCEIMPROVEMENTPROJECT(PIP)VALIDATIONWORKSHEETFY17-18 NON-CLINICALPIP

GENERALINFORMATION

MHP: Mono

PIP Title: Strengths-Based Learning Collaborative: Strengths Model Group Supervision for Employment-Related Goals

Start Date (MM/DD/YY): January 2018

Completion Date (MM/DD/YY): N/A

Projected Study Period (#of Months): 24 Months

Completed: Yes ☐ No �

Date(s) of On-Site Review (MM/DD/YY): 4/26/18

Name of Reviewer: Rob Walton

Status of PIP (Only Active and ongoing, and completed PIPs are rated):

Rated

☐ Active and ongoing (baseline established and interventions started)

☐ Completed since the prior External Quality Review (EQR)

Not rated. Comments provided in the PIP Validation Tool for technical assistance purposes only.

☐ Concept only, not yet active (interventions not started)

☐ Inactive, developed in a prior year

� Submission determined not to be a PIP

☐ No Non-clinical PIP was submitted

Brief Description of PIP (including goal and what PIP is attempting to accomplish): This non-clinical PIP followed the basic establishment approach of the clinical PIP also reviewed. It focused on the findings of community members and consumers/former consumers surveyed wherein challenges with housing, and unemployment were identified.

Within the MHP’s consumers, individuals characterized as “high need,” and “feeling stuck,” were selected to receive the Strength Assessment. The assessment is intended to identify consumer strengths and key goals in life domain areas, which may include housing, education, or employment. For this PIP,

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the MHP determined that employment was the domain area of focus. The process of creation of change in how the MHP team/staff interacted with the consumer was through Strengths Model Group Supervision.

Details of the EQR feedback are found below. However, top level observations include: The MHP has stressed a number of criteria for inclusion “high need,” and “feeling stuck,” and provided no quantifiable data regarding what constitutes high need, what are the typical levels of the non-high-need. The described intervention for this aspect is identified as SMGS. There is some description of what constitutes this approach. There is not, however, any description of what changes in the case manager/clinician and consumer interaction. The approaches and standards of practice related to group supervision narrowly, and do not address the proximate consumer-staff interaction.

This non-clinical PIP submission is a refocus of the clinical PIP. Submission of the same topic – Strengths Model – does not qualify as a separate PIP because the study question and intervention strategy are essentially the same and belong within the original clinical PIP.

ACTIVITY 1: ASSESS THE STUDY METHODOLOGY

STEP 1: Review the Selected Study Topic(s)


1.1 Was the PIP topic selected using stakeholder input? Did the MHP develop a multi-functional team compiled of stakeholders invested in this issue?

� Met

☐ Partially Met

☐ Not Met


As in the clinical PIP, the topic is drawn from the survey of consumers and community members that indicated that unaddressed issues with major life domains were occurring.

1.2 Was the topic selected through data collection and analysis of comprehensive aspects of enrollee needs, care, and services?

☐ Met

� Partially Met

☐ Not Met


The MHP did not present data on high-need consumers and the level of services they received. No analysis of the employment status of high level served consumers was provided. The focus was determined from the results of a small, hand-picked, population who had reported employment as a significant factor.

Select the category for each PIP: Clinical: ☐ Prevention of an acute or chronic condition ☐ High volume services

☐ Care for an acute or chronic condition ☐ High risk conditions

Non-clinical: � Process of accessing or delivering care

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1.3 Did the Plan’s PIP, over time, address a broad spectrum of key aspects of enrollee care and services?

Project must be clearly focused on identifying and correcting deficiencies in care or services, rather than on utilization or cost alone.

☐ Met

� Partially Met

☐ Not Met


The MHP seems open to addressing other life domain areas including housing and education when they SM Assessment indicates this need.

This PIP is focused on employment only.

1.4 Did the Plan’s PIPs, over time, include all enrolled populations (i.e., did not exclude certain enrollees such as those with special health care needs)?


☐ Met

☐ Partially Met

� Not Met


It is not possible to identify how the MHP determined “highest need” consumers. Is this related to service levels? If so, what is the service level threshold for high-need consumers? Is there an instrument for clinicians and case managers to use to determine a consumer is “stuck”? This is a very subjective, non-replicable definition.


STEP 2: Review the Study Question(s)

2.1 Was the study question(s) stated clearly in writing? Does the question have a measurable impact for the defined study population?

Include study question as stated in narrative: Will using SMGS help clients make progress toward their employment-related goals, as measured by the achievement of and/or change in employment-related goals over the two-year study period as reported on the Strengths Assessment?

☐ Met

☐ Partially Met

� Not Met


The SM is already identified in the clinical PIP in the SQ. The difference is that the non-clinical identifies group supervision as the vehicle of change.

This essentially is repeating the same conceptual intervention.

Extent of anticipated change is not identified as is required.


STEP 3: Review the Identified Study Population

3.1 Did the Plan clearly define all Medi-Cal enrollees to whom the study question and indicators are relevant?


☐ Met

☐ Partially Met

� Not Met


High need, stuck, and selecting employment as a life goal domain area of focus.

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3.2 If the study included the entire population, did its data collection approach capture all enrollees to whom the study question applied?

Methods of identifying participants:

☐ Utilization data ☐ Referral ☐ Self-identification

� Other: See comment column

☐ Met

☐ Partially Met

� Not Met


The individuals are hand-picked by the MHP without the use of any data, other than subjective determinations by staff coupled with consumer selection of employment as a goal.


STEP 4: Review Selected Study Indicators

4.1 Did the study use objective, clearly defined, measurable indicators?

List indicators: Percent of clients achieving their employment-related goals

☐ Met

� Partially Met

☐ Not Met


The MHP might consider development of some standardized categories for success, which would support quantifiable analysis.

In addition, for the numerator the MHP created a split, between those who achieve employment goal and no further goal is set and those who achieve employment goal and set a new goal. It is not clear how this would be reported out.

4.2 Did the indicators measure changes in: health status, functional status, or enrollee satisfaction, or processes of care with strong associations with improved outcomes? All outcomes should be consumer focused.

☐ Health Status � Functional Status

☐ Member Satisfaction ☐ Provider Satisfaction

Are long-term outcomes clearly stated? � Yes ☐ No

Are long-term outcomes implied? � Yes ☐ No

☐ Met

� Partially Met

☐ Not Met


Employment goal achievement would be a functional life domain change. This would appropriately be determined as a functional status change.

This categorization process would likely benefit from establishment of categories related to employment.


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STEP 5: Review Sampling Methods

5.1 Did the sampling technique consider and specify the:

a) True (or estimated) frequency of occurrence of the event?

b) Confidence interval to be used?

c) Margin of error that will be acceptable?

☐ Met

☐ Partially Met

☐ Not Met

� Not Applicable


There is no formal sampling methodology established, but the MHP is selecting individuals based on no quantifiable data elements, such as service level.

5.2 Were valid sampling techniques that protected against bias employed?

Specify the type of sampling or census used: <Text>

☐ Met

☐ Partially Met

☐ Not Met

� Not Applicable


5.3 Did the sample contain a sufficient number of enrollees?

______N of enrollees in sampling frame

______N of sample

______N of participants (i.e. – return rate)

☐ Met

☐ Partially Met

☐ Not Met

� Not Applicable


Totals 0 Met 0 Partially Met 3 Not Applicable 0 UTD

STEP 6: Review Data Collection Procedures

6.1 Did the study design clearly specify the data to be collected?

� Met

☐ Partially Met

☐ Not Met


Achievement of employment goal and no further goal.

Achievement of employment goal with new goal established.

6.2 Did the study design clearly specify the sources of data? Sources of data:

� Member ☐ Claims ☐ Provider

☐ Other: <Text if checked>

☐ Met

☐ Partially Met

� Not Met


The PIP did not specify the source of data, but attributes collection to the MHSA coordinator.

Presumably the data source is the consumer.

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6.3 Did the study design specify a systematic method of collecting valid and reliable data that represents the entire population to which the study’s indicators apply?

� Met

☐ Partially Met

☐ Not Met


6.4 Did the instruments used for data collection provide for consistent, accurate data collection over the time periods studied?

Instruments used:

☐ Survey ☐ Medical record abstraction tool

☐ Outcomes tool ☐ Level of Care tools

☐ Other: <Text if checked>

☐ Met

☐ Partially Met

� Not Met


6.5 Did the study design prospectively specify a data analysis plan?

Did the plan include contingencies for untoward results?

� Met

☐ Partially Met

☐ Not Met


6.6 Were qualified staff and personnel used to collect the data? Project leader: Amanda Greenberg

� Met

☐ Partially Met

☐ Not Met



STEP 7: Assess Improvement Strategies

7.1 Were reasonable interventions undertaken to address causes/barriers identified through data analysis and QI processes undertaken?

Describe Interventions: Strengths Model (including Strengths Assessment and PRP)

☐ Met

☐ Partially Met

☐ Not Met


No data analysis was provided in the data analysis leading up to the PIP development other than in gathering data about life domain concerns of local residents and consumers. No analysis of the characteristics of the involved consumers was included, such as: duration of treatment, level of services.

- 74 -



STEP 8: Review Data Analysis and Interpretation of Study Results

8.1 Was an analysis of the findings performed according to the data analysis plan?

This element is “Not Met” if there is no indication of a data analysis plan

(see Step 6.5)

☐ Met

☐ Partially Met

☐ Not Met

� Not Applicable


8.2 Were the PIP results and findings presented accurately and clearly?

Are tables and figures labeled? ☐ Yes ☐ No

Are they labeled clearly and accurately? ☐ Yes ☐ No

☐ Met

☐ Partially Met

☐ Not Met

� Not Applicable


8.3 Did the analysis identify: initial and repeat measurements, statistical significance, factors that influence comparability of initial and repeat measurements, and factors that threaten internal and external validity?

Indicate the time periods of measurements: ___________________

Indicate the statistical analysis used: _________________________

Indicate the statistical significance level or confidence level if available/known: _______% ______Unable to determine

☐ Met

☐ Partially Met

☐ Not Met

� Not Applicable


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8.4 Did the analysis of the study data include an interpretation of the extent to which this PIP was successful and recommend any follow-up activities?

Limitations described: <Text>

Conclusions regarding the success of the interpretation: <Text>

Recommendations for follow-up: <Text>

☐ Met

☐ Partially Met

� Not Met

� Not Applicable



STEP 9: Assess Whether Improvement is “Real” Improvement

9.1 Was the same methodology as the baseline measurement used when measurement was repeated?

Ask: At what interval(s) was the data measurement repeated? Were the same sources of data used?

Did they use the same method of data collection? Were the same participants examined? Did they utilize the same measurement tools?

☐ Met

☐ Partially Met

� Not Met

� Not Applicable


9.2 Was there any documented, quantitative improvement in processes or outcomes of care?

Was there: ☐ Improvement ☐ Deterioration Statistical significance: ☐ Yes ☐ No Clinical significance: ☐ Yes ☐ No

☐ Met

☐ Partially Met

� Not Met

� Not Applicable


9.3 Does the reported improvement in performance have internal validity; i.e., does the improvement in performance appear to be the result of the planned quality improvement intervention?

Degree to which the intervention was the reason for change: ☐ No relevance ☐ Small ☐ Fair ☐ High

☐ Met

☐ Partially Met

� Not Met

� Not Applicable


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9.4 Is there any statistical evidence that any observed performance improvement is true improvement?

☐ Weak ☐ Moderate ☐ Strong

☐ Met

☐ Partially Met

� Not Met

� Not Applicable


9.5 Was sustained improvement demonstrated through repeated measurements over comparable time periods?

☐ Met

☐ Partially Met

� Not Met

� Not Applicable



ACTIVITY 2: VERIFYING STUDY FINDINGS (OPTIONAL)


Were the initial study findings verified (recalculated by CalEQRO) upon repeat measurement?

☐ Yes

� No

ACTIVITY 3: OVERALL VALIDITY AND RELIABILITY OF STUDY RESULTS: SUMMARY OF AGGREGATE VALIDATION FINDINGS

Conclusions: This non-clinical PIP effort essentially duplicates the focus of the clinical PIP (SBM) with a narrow focus on group supervision as the intervention. This does not create a distinct PIP.

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Recommendations: Develop distinct PIP topics going forward. Utilize data about the served population to narrow the focus, and without reliance on soft, subjective categorizations by staff.

Check one: ☐ High confidence in reported Plan PIP results ☐ Low confidence in reported Plan PIP results

☐ Confidence in reported Plan PIP results ☐ Reported Plan PIP results not credible

� Confidence in PIP results cannot be determined at this time

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