Post on 05-Oct-2020
Health & Human Services Department
Behavioral Health and Recovery Services Division
Suzanne Tavano, PHN, PhD, Behavioral Health Director
Dawn Kaiser, LCSW, CPHQ, Quality Manager
Q I Quality Improvement Work Plan
FY 2017-2018
Marin County MHP Quality Improvement Work Plan FY17-18
2
Quality Management Program Description
The Marin Mental Health Plan’s (MHP) Quality Management (QM) program is responsible for monitoring the MHP’s effectiveness and for providing
support to all areas of MHP operations by conducting performance monitoring activities which include, but are not be limited to: utilization
management, utilization review, provider appeals, credentialing and monitoring, resolution of beneficiary grievances, and analysis of beneficiary
and system outcomes. The QM program’s activities are guided by the relevant sections of Federal and California State regulations, including the
Code of Federal Regulations Title 42, the California Code of Regulations Title 9, Welfare and Institutions Codes, as well as the MHP’s performance
contract with the State Department of Health Care Services (DHCS).
The QM program consists of five licensed staff, including the Quality Improvement Coordinator, three mental health Utilization Review Specialists (2.5
FTE) and one substance use services Utilization Review Specialist (1FTE). The QM program also includes two data analyst staff (2FTE), two
administrative staff (2FTE) and a .25 FTE consulting contractor. The QM program is overseen by a Division Director who is additionally responsible for
Access and Information Technology, for a total QM workforce of 9.75 FTEs. QM staff carries out their job responsibilities as defined by their individual
professional disciplines and scope of practice. The Information Technology team (3 FTE) provides essential support to the QM program.
The Utilization Management (UM) program is a component of the QM program. The UM program assures that beneficiaries have appropriate access
to specialty mental health services. Program activities include: the evaluation of medical necessity determinations, the appropriateness and
efficiency of services, as well as the access to capacity and geographical distribution of services provided to Marin County Medi-Cal beneficiaries.
The different programs and committees within the QM Department provide structure for the quality improvement and oversight responsibilities of the
organization.
The Admin Compliance Committee is formed by the QM Department, Fiscal, Children Services, and Substance Use Services representatives. The
HHS/BHRS Compliance Officer, Office Services Supervisors, Billing Manager, IT staff and administrative lead staff members also comprise the
committee. During these meeting, stakeholders identify and discuss issues across the BHRS system that relate to the Electronic Health Record (EHR)
system, the practice management system, policies and procedures, documentation processing, and other administrative tasks that are essential to
providing quality services to consumers and family members.
Quality Improvement Program:
The Quality Improvement program monitors the overall service delivery system with the aim of improving processes of care provision and increasing
consumer and family member satisfaction and outcomes.
Marin County MHP Quality Improvement Work Plan FY17-18
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The Quality Improvement Committee (QIC) is a combined MH and SU services committee, and is comprised of a diverse group of stakeholders,
including representatives from MHP administration and clinical programs, the mental health board, peers/family members, the patient rights
advocate, and contractors/community partners. QM staff is responsible for facilitating a quarterly QIC meeting to review findings from a range of
compliance and quality improvement activities, including specified DMC-ODS data elements, and to obtain input into these and other areas for
improvement.
The Incidence and Grievance Sub-Committee of the QIC is attended by the Medical Director, QI Coordinator, Utilization Management Coordinator,
QM Division Director, Adult Services Division Director, Youth and Family Division Directors, Program Manager Crisis Continuum of Care, Program
Manager Adult Services and on ad hoc basis Program Supervisors. It is a standing group that meets quarterly to evaluate and analyze trends of
grievances, appeals, fair hearings, and unusual occurrences to identify issues or trends that require implementation of system changes. The sub-
committee is responsible for identifying employees that require additional supervision or work plans to correct poor performance. It also makes
improvement recommendations to the system such as additional trainings policies, workflows and operational changes. The subcommittee is led by
the Utilization Review Supervisor. Findings from this meeting are presented to the QIC stakeholders as required.
The MHP has an active Cultural Competency Advisory Board (CCAB) which is comprised of BHRS management, BHRS line staff, contract agency
providers, consumer advocates, consumers, community leaders from ethnic communities and an administrative aide to one of the county’s
Supervisors. There are three existing working committees within the Board: Training, Policy, and Access. The 21-member board is tasked to analyze
data, review existing improvement plans, examine practice approaches and make recommendations related to policy, service delivery, staffing
and training needs, and system improvements. QM staff provides data for the CCAB, and there is shared participation in both the QIC and CCAB on
the management, staff and consumer level.
Quality Improvement Work Plan:
The intent of the Quality Improvement (QI) Work Plan is to create systems whereby data relevant to the performance of the MHP is available in an
easily interpretable and actionable form. This year’s plan continues the work of previous plans work of improving the capture, analysis and use of
data to support contractual compliance, performance management and decision making. Performance improvement activities focus on
improving accessibility, timeliness and outcomes of services and serve to enhance the MHP’s daily work of supporting the recovery and resiliency of
the consumers and family members in our community.
The QI Work Plan is evaluated and updated at least annually. The elements of this QI Work Plan are informed by the quality improvement
requirements of the MHP performance contract as well as feedback received from the CalEQRO review and DHCS Triennial audit findings and
recommendations.
Marin County MHP Quality Improvement Work Plan FY17-18
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Quality Improvement Work Plan Goals Note: Goals marked with an asterisk (*) indicate quarterly review of data. Goals without asterisks can be reviewed bi-annually.
All baseline data is for FY16/17 unless otherwise stated.
Goal(s) Objectives Baseline
I. *Access -- 24/7 Line:
Improve quality of 24/7
Access Line and ensure
that beneficiaries are
provided with information
on how to access
specialty mental health
services.
1. Test call goal = four calls/month
2. Increase call logging of test calls to 100%.
3. Ensure test calls are conducted in a proportionate
sample to threshold languages (Spanish = 46% total).
4. Review adherence to test call requirements on a
monthly basis and provide feedback and training to
Access team and Optum semi-annually.
FY16/17
MEASURE GOAL FY16/17
OUTCOME
Total test calls placed 48 44
Test call logging % 75% 73%
Test calls in threshold
language (Spanish) 46% 36%
Evaluation Performance Metrics
Annual Goal Items Met:
Met: Item # __________
Partially Met: Item # _____
Not Met: Item # ______
Continued: Item # _____
MEASURE GOAL FY17/18
OUTCOME
Total test calls placed 48
Test call logging % 100%
Test calls in threshold
language (Spanish) 46%
Evaluation Details:
Marin County MHP Quality Improvement Work Plan FY17-18
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Goal(s) Objectives Baseline
II. *Access -- Linguistic
Capacity:
Ensure services are
provided in the
consumer's preferred
language by utilizing
bilingual staff and/or
qualified interpreters.
1. Evaluate whether preferred
language is captured at initial
registration. Establish baseline.
2. Evaluate accuracy of the
recording of language service
provision in clinical
documentation.
- 92% of clients served during FY16/17 had their preferred language
documented in our EMR.
Breakdown of preferred languages captured:
Evaluation Performance Metrics
Annual Goal Items Met:
Met: Item # _________
Partially Met: Item # _____
Not Met: Item # _____
Continued: Item # ______
Evaluation Details:
Preferred
Language % Clients
English 89.4%
Spanish 7.8%
Vietnamese 1.3%
Other 1.5%
Marin County MHP Quality Improvement Work Plan FY17-18
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Goal(s) Objectives Baseline
III. *Access -- Timeliness to
Services:
Monitor system
performance on key
timeliness metrics
semi-annually and
initiate process
improvements as
necessary.
Monitor wait times:
1. Screening to first offered assessment
appointment
2. Screening to completed assessment.
3. Completed assessment to psychiatry
appt.
4. Service request for urgent
appointment to actual encounter.
5. Post-psychiatric hospital follow-up.
6. Psychiatric inpatient readmission rates
within 30 days.
7. No Show appointment rates –
psychiatrists and clinicians.
FY16/17
Actual Goal
Avg time from screening to first
appt. 3.4 days 14 days
Avg time from screening to
completed assessment 9.6 days 14 days
Avg time from assessment to
psychiatry 15.5 days 15 days
Avg time to post hospital follow up 14 days 7 days
Avg Mobile Team response to
urgent 107 min 180 min
30 day re-hospitalization rate 12% 10%
Missed appt. rate: all appointments 11% <10%
Evaluation Performance Metrics
Annual Goal Items Met:
Met: Item # ________
Partially Met: Item # ______
Not Met: Item # _______
Continued: Item # ______
FY17/18
Evaluation Details:
Children Adults Children Adults
Avg time from screening to first
offered assessment appt.14 days 14 days
Avg time from screening to first
clinical completed assessment10 days 10 days
Avg time from assessment to
psychiatic appt.15 days 15 days
Avg time from service request for
urgent appt to actual encounter
(Mobile Team response)
180 minutes 180 minutes
Avg time to post-psychiatric
hospital follow up appt.7 days 7 days
Psychiatric inpatient readmission
rates within 30 days8% 15%
No show appt. rate - Psychiatrists 10% 10%
No show appt. rate - Clinicians
(non-psychiatrists)10% 10%
ACTUAL GOALS
Marin County MHP Quality Improvement Work Plan FY17-18
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Goal(s) Objectives Baseline
IV. Network
Adequacy – Monitor
the service capacity
and service
distribution of the
MHP.
1. Evaluate geographic placement
of services based on beneficiary
city of residence.
2. Publish network adequacy
standards in website and have
these available at no cost to
enrollees with disabilities in
alternate formats. Note: - Age data is expressed as a percentage of the population. Child = 0-17 & Adult = 18+.
- Medi-Cal beneficiaries’ data obtained from MMEF files.
Evaluation Baselines
Annual Goal Items Met:
Met: Item # ________
Partially Met: Item #
_____
Not Met: Item # _____
Continued: Item # ______
Evaluation Details:
Marin County MHP Quality Improvement Work Plan FY17-18
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Goal(s) Objectives Baseline
V. Network
Adequacy – Provider
Network
Management:
Maintain and
monitor a network of
providers that is
sufficient to provide
adequate access to
services.
1. Analyze geographic location of
providers and their accessibility to
beneficiaries to meet network
adequacy standards.
2. Update providers’ directory on a
monthly basis and incorporate new
Medi-Cal managed care requirements.
3. Determine number of network
providers who are not accepting new
Medi-Cal patients in a monthly basis.
4. Determine panel capacity for all BHRS
providers.
Note: Maps showing network adequacy standards can be found on appendix A.
Evaluation Performance Metrics
Annual Goal Items Met:
Met: Item # ________
Partially Met: Item # _____
Not Met: Item # _____
Continued: Item # ______
Evaluation Details:
SAN
RAFAELNOVATO BON AIR
MARIN CITY/
SAUSALITO
WEST
MARIN
46% 23% 11% 8% 3%
Buckelew Counseling Services 3 MILES 9 MILES 6 MILES 11 MILES 24 MILES
Lincoln Ave
Community Ins for Psyc
Child Therapy Ins of Marin
Marin Treatment Ctr
Alex Markels
Rose Rutman
250 Bon Air
Adult Med Clinic
Crisis Stabilization Unit
Mobile Crisis Teams
Marin General Hosp
Center of Restorative Practice 6 MILES 9 MILES 8 MILES 14 MILES 23 MILES
Huckleberry Youth Programs 1 MILE 11 MILES 3 MILES 11 MILES 21 MILES
10N San Pedro
HOPE
Jewish F&C Services 1 MILE 11 MILES 3 MILES 9 MILES 26 MILES
3230 Kerner
Children Med Clinic
Children MH Services
3270 Kerner
Adult Med Clinic
Adult Case Management
STAR
Odyssey
Individual Provider
Mathew Carter
Individual Provider
Anca Severin
Individual Provider
Mario Sandoval
Individual Provider
Michael Mesmer
West Marin Center 21 MILES 19 MILES 27 MILES 33 MILES 3 MILES
Notes: Accesssible to Adults
Accessible to Child & Youth
3 MILES 9 MILES 20 MILES
11 MILES 25 MILES
8 MILES
9 MILES 20 MILES
0.6 MILES 34 MILES
28 MILES
3 MILES
5 MILES 3 MILES 26 MILES
6 MILES
5 MILES
3 MILES 8 MILES 28 MILES
3 MILES
0.3 MILES 11 MILES
0.2 MILES 11 MILES
8 MILES 19 MILES
9 MILES 20 MILES
9 MILES3 MILES
2 MILES 12 MILES
2 MILES 12 MILES
2 MILES 15 MILES 2 MILES 8 MILES 21 MILES
26 MILES
FY16/17 NETWORK ADEQUACY DATA
FY15/16 % Medi-Cal Beneficiaries
Served by City (n=2,389):
1 MILE 10 MILES 5 MILES 10 MILES
BHRS Marin County Network Adequacy Standards: 30 miles/60 minutes (Medium Size County)
Marin County MHP Quality Improvement Work Plan FY17-18
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Goal(s) Objectives Baseline
VI. Quality &
Appropriateness of
Care -- Cultural and
Linguistic
Competency
1. Update and review Cultural
Competence Plan annually.
2. Track and ensure that all BHRS
staff completes a minimum of
four hours of cultural
competence training annually.
- During FY16/17 291 BHRS staff completed Cultural Competence Training.
Evaluation Performance Metrics
Annual Goal Items Met:
Met: Item # ________
Partially Met: Item # _____
Not Met: Item # _____
Continued: Item # ______
Evaluation Details:
Marin County MHP Quality Improvement Work Plan FY17-18
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Goal(s) Objectives Baseline
VII. *Outcomes--
Improve data collection
and reporting to support
decision making
1. Continue utilization and analysis of
MORS (Milestones of Recovery Scale).
2. Continue working with vendor to
resolve any CANS (Child and Adolescent
Needs and Strengths) data and software
issues that arise after implementation
and conduct data analysis.
3. Continue PHQ-9 (Patient Health
Questionnaire) utilization and enhance
analysis of data.
FY16/17
Note: MORS and CANS baseline data can be found on appendix B.
Evaluation Performance Metrics
Annual Goal Items Met:
Met: Item # ____
Partially Met: Item # _____
Not Met: Item # ____
Continued: Item # ______
Evaluation Details:
Marin County MHP Quality Improvement Work Plan FY17-18
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Goal(s) Objectives Baseline
VIII. Outcomes--
Beneficiary Satisfaction:
Assess beneficiary/family
satisfaction
1. Conduct POQI per DHCS schedule.
2. Increase number of POQI responses in
Spanish.
3. Identify response return rate benchmark.
4. Report POQI results to
managers/supervisors/line staff and
contractors semiannually.
5. Continue analysis of Access Team
customer satisfaction survey and provide
results to team and clients.
NOTE: See appendix C for Access Team satisfaction survey baseline
data.
Evaluation Performance Metrics
Annual Goal Items Met:
Met: Item # ____
Partially Met: Item # _____
Not Met: Item # ____
Continued: Item # ______
Evaluation Details:
Marin County MHP Quality Improvement Work Plan FY17-18
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Goal(s) Objectives Baseline
IX. *Utilization Management -
- Grievance Process:
Respond to grievances in
a timely manner. Identify
and act on improvement
opportunities.
1. Ensure grievances are logged and
responded to within required timeframes.
2. Track and trend grievances to identify
quality improvement opportunities.
3. Conduct Grievance Committee meeting
semi-annually.
4. Report grievance trends to QIC and
management.
5. Conduct grievance process refresher
trainings for staff at least annually.
6. Ensure NOAs are issued when required. Add
a NOA trigger date to current grievance log
by Oct. 31, 2017.
FY16/17
Evaluation Performance Metrics
Annual Goal Items Met:
Met: Item # __________
Partially Met: Item # _____
Not Met: Item # ________
Continued: Item # ______
Evaluation Details:
Category
Total
Grievances
#
Resolved Pending
Access 0 0 0
Denied Services 0 0 0
Change of Provider 8 6 2
Quality of Care 8 6 2
Confidentiality 1 1 0
Other 12 7 5
Total: 29 20 9
Marin County MHP Quality Improvement Work Plan FY17-18
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Goal(s) Objectives Baseline
X. *Utilization Management
-- Change of Provider
Requests:
Ensure timely
handling of change
of provider requests.
1. Track and trend change of
provider requests and report to
QIC and management
annually.
2. Initiate QI activities as
warranted.
FY16/17
Type of
Provider
#
Requests Approved Withdrawn Denied
Medical
Staff 53 49 3 1
Non-
Medical
Staff
4 4 0 0
Evaluation Performance Metrics
Annual Goal Items Met:
Met: Item # _______
Partially Met: Item # _____
Not Met: Item # _____
Continued: Item # ______
Type of
Provider
#
Requests Approved Withdrawn Denied
Pending
Medical
Staff
Non-
Medical
Staff
Evaluation Details:
Marin County MHP Quality Improvement Work Plan FY17-18
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Goal(s) Objectives Baseline
XI. Utilization Management --
Treatment Authorization
Requests (TARs):
Ensure TARs processing
within required
timeframes.
1. Improve/maintain compliance with
TAR processing timeframe to 100%.
FY16/17 TAR Timely Completion Rate by month:
Evaluation Performance Metrics
Annual Goal Items Met:
Met: Item # _____
Partially Met: Item # _____
Not Met: Item # ______
Continued: Item # ______
Evaluation Details:
Marin County MHP Quality Improvement Work Plan FY17-18
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Goal(s) Objectives Baseline
XII. *Utilization Management -
-Service Authorization
Requests (SARs):
Ensure SARs are
processed within
required timeframes.
1. Establish timeframe baseline. 2. Ensure SARs are adjudicated within
the required timeframes (14
calendar days). 3. Modify SARs tracking system to
capture all required elements by
Oct. 31, 2017. 4. Conduct training for Access staff to
reinforce time requirements.
No baseline data available.
Evaluation Performance Metrics
Annual Goal Items Met:
Met: Item # _____
Partially Met: Item # _____
Not Met: Item # ______
Continued: Item # ______
Evaluation Details:
Marin County MHP Quality Improvement Work Plan FY17-18
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Goal(s) Objectives Baseline
XIII. *Utilization Management
--- Monitor Safety and
Effectiveness of Medication
Practices: Improve patient
safety.
1. QM staff and Medical Director or designee will conduct
two medication monitoring reviews quarterly.
2. QM staff will support corrective action activities.
3. Report review findings/corrective actions to MHP Senior
Management annually.
4. Ensure medication consent form is available for signature
in the EHR by Oct. 2017.
FY16/17
#
Reviews Findings
Q1 3 Reported to Medical Director
Q2 1 Reported to Medical Director
Q3 0 N/A
Q4 0 N/A
Evaluation Performance Metrics
Annual Goal Items Met:
Met: Item # _______
Partially Met: Item # _____
Not Met: Item # _______
Continued: Item # ______
Evaluation Details:
Marin County MHP Quality Improvement Work Plan FY17-18
17
Goal(s) Objectives Baseline
XIV. *Utilization
Management --
Certifications: Ensure all
Medi-Cal sites are
certified/re-certified in a
timely manner. Ensure
certification of all individual
clinicians’ sites.
1. Maintain 100% compliance on that all Medi-Cal sites
are certified in a timely manner.
2. Monitor compliance with contractual fee-for-service
requirement certification standards for all individual
clinicians’ practices by the end of fiscal year.
FY16/17
# Certifications % On Time
Q1 39 100%
Q2 40 100%
Q3 39 100%
Q4 38 100%
Evaluation Performance Metrics
Annual Goal Items Met:
Met: Item # _______
Partially Met: Item # _____
Not Met: Item # _____
Continued: Item # ______
Evaluation Details:
Marin County MHP Quality Improvement Work Plan FY17-18
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Goal(s) Objectives Baseline
XV. *Clinical
Documentation --
Regulatory Compliance
and Quality:
Improve quality of clinical
documentation.
1. Establish baseline to ensure that all new staff
receives clinical documentation trainings within the
first six months after hire.
2. Offer clinical documentation trainings on ongoing
basis.
3. Decrease UR disallowance rate for all programs with
a previous > 5% disallowance rate to less than 5%. 4. Update Clinical Documentation Manual as needed.
FY16/17
DISALLOWANCE RATE
> 5% < or equal to
5%
# of programs
9 15
Total programs reviewed during FY16/17 = 24.
Note: Clinical Documentation Manual was last updated on
4/4/2017.
Evaluation Performance Metrics
Annual Goal Items Met:
Met: Item # ________
Partially Met: Item # _____
Not Met: Item # _____
Continued: Item # ______
Evaluation Details:
Marin County MHP Quality Improvement Work Plan FY17-18
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Goal(s) Objectives Baseline
XVI. *Clinical
Documentation -- Utilization
Review:
Review a minimum of 5% of
medical records from every
BHRS program and contract
provider program annually.
1. Continue to review minimum 5% of medical
records.
2. Revise UR report process to provide completed
reports to programs within one month of the
utilization review.
FY16/17
# UR Average Time to Report (days)
Q1 10 270
Q2 7 82
Q3 7 38
Q4 1 71
Note: Due to triennial review during Q4 there was only one UR
completed.
Evaluation Performance Metrics
Annual Goal Items Met:
Met: Item # ________
Partially Met: Item # ______
Not Met: Item # _______
Continued: Item # ______
Evaluation Details:
Marin County MHP Quality Improvement Work Plan FY17-18
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Goal(s) Objectives Baseline
XVII. *Beneficiary Support &
Protections -- Beneficiary
Informing Materials
1. Update beneficiary informing materials as
per new Medi-Cal Managed Care rules.
No baseline data available.
Evaluation Performance Metrics
Annual Goal Items Met:
Met: Item # _______
Partially Met: Item # ____
Not Met: Item # _____
Continued: Item # ______
Evaluation Details:
Marin County MHP Quality Improvement Work Plan FY17-18
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Goal(s) Objectives Baseline
XVIII. Health Information
Systems – EMR: Enhance HIS
technology to promote
efficiency and support
service delivery.
1. Establish EMR workgroup and continue
search for new EMR.
- QM Director and IT Supervisor met with County IST experts and
there is active engagement in the procurement analysis of
software.
Evaluation Performance Metrics
Annual Goal Items Met:
Met: Item # _______
Partially Met: Item # _____
Not Met: Item # ___
Continued: Item # ______
Evaluation Details:
Marin County MHP Quality Improvement Work Plan FY17-18
22
APPENDIX A
SAN
RAFAELNOVATO BON AIR
MARIN CITY/
SAUSALITO
WEST
MARIN
46% 23% 11% 8% 3%
Buckelew Counseling Services 3 MILES 9 MILES 6 MILES 11 MILES 24 MILES
Lincoln Ave
Community Ins for Psyc
Child Therapy Ins of Marin
Marin Treatment Ctr
Alex Markels
Rose Rutman
250 Bon Air
Adult Med Clinic
Crisis Stabilization Unit
Mobile Crisis Teams
Marin General Hosp
Center of Restorative Practice 6 MILES 9 MILES 8 MILES 14 MILES 23 MILES
Huckleberry Youth Programs 1 MILE 11 MILES 3 MILES 11 MILES 21 MILES
10N San Pedro
HOPE
Jewish F&C Services 1 MILE 11 MILES 3 MILES 9 MILES 26 MILES
3230 Kerner
Children Med Clinic
Children MH Services
3270 Kerner
Adult Med Clinic
Adult Case Management
STAR
Odyssey
Individual Provider
Mathew Carter
Individual Provider
Anca Severin
Individual Provider
Mario Sandoval
Individual Provider
Michael Mesmer
West Marin Center 21 MILES 19 MILES 27 MILES 33 MILES 3 MILES
Notes: Accesssible to Adults
Accessible to Child & Youth
3 MILES 9 MILES 20 MILES
11 MILES 25 MILES
8 MILES
9 MILES 20 MILES
0.6 MILES 34 MILES
28 MILES
3 MILES
5 MILES 3 MILES 26 MILES
6 MILES
5 MILES
3 MILES 8 MILES 28 MILES
3 MILES
0.3 MILES 11 MILES
0.2 MILES 11 MILES
8 MILES 19 MILES
9 MILES 20 MILES
9 MILES3 MILES
2 MILES 12 MILES
2 MILES 12 MILES
2 MILES 15 MILES 2 MILES 8 MILES 21 MILES
26 MILES
FY16/17 NETWORK ADEQUACY DATA
FY15/16 % Medi-Cal Beneficiaries
Served by City (n=2,389):
1 MILE 10 MILES 5 MILES 10 MILES
BHRS Marin County Network Adequacy Standards: 30 miles/60 minutes (Medium Size County)
Marin County MHP Quality Improvement Work Plan FY17-18
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Marin County MHP Quality Improvement Work Plan FY17-18
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Marin County MHP Quality Improvement Work Plan FY17-18
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APPENDIX B
MORS Data Analysis
Marin County MHP Quality Improvement Work Plan FY17-18
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CANS Data Analysis
27
APPENDIX C
Client Satisfaction Survey Results (Jan 2017 – June 2017)