Quality Improvement Work Plan Q I - MARIN HHS...Marin County MHP Quality Improvement Work Plan...

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

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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.


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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.


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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:


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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:



Met: Item # _________


Not Met: Item # _____

Continued: Item # ______

Evaluation Details:

Preferred

Language % Clients

English 89.4%

Spanish 7.8%

Vietnamese 1.3%

Other 1.5%


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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%



Met: Item # ________

Partially Met: Item # ______

Not Met: Item # _______


FY17/18

Evaluation Details:

Children Adults Children Adults


offered assessment appt.14 days 14 days


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


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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


Met: Item # ________

Partially Met: Item #

_____



Evaluation Details:


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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.



Met: 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


6 MILES

5 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)


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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.



Met: Item # ________




Evaluation Details:


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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.



Met: Item # ____


Not Met: Item # ____


Evaluation Details:


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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.



Met: Item # ____


Not Met: Item # ____


Evaluation Details:


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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



Met: Item # __________


Not Met: 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


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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



Met: Item # _______




Type of

Provider

#

Requests Approved Withdrawn Denied

Pending

Medical

Staff

Non-

Medical

Staff

Evaluation Details:


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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:



Met: Item # _____




Evaluation Details:


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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.



Met: Item # _____




Evaluation Details:


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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



Met: Item # _______




Evaluation Details:


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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%



Met: Item # _______




Evaluation Details:


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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.



Met: Item # ________




Evaluation Details:


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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.



Met: Item # ________

Partially Met: Item # ______



Evaluation Details:


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XVII. *Beneficiary Support &

Protections -- Beneficiary

Informing Materials

1. Update beneficiary informing materials as

per new Medi-Cal Managed Care rules.

No baseline data available.



Met: Item # _______

Partially Met: Item # ____



Evaluation Details:


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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.



Met: Item # _______


Not Met: Item # ___


Evaluation Details:


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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


11 MILES 25 MILES

8 MILES

9 MILES 20 MILES

0.6 MILES 34 MILES

28 MILES

3 MILES


6 MILES

5 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)


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APPENDIX B

MORS Data Analysis


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CANS Data Analysis

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APPENDIX C

Client Satisfaction Survey Results (Jan 2017 – June 2017)

Quality Improvement Work Plan Q I - MARIN HHS...Marin County MHP Quality Improvement Work Plan...

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