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County of Del Norte

Department of Health and Human Services Mental Health Branch

455 K St. Crescent City, CA 95531 707 464-7224

Quality Improvement Work Plan FY 2017/18

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Introduction

As required by the California State Department of Health Care Services and the Medi‐Cal

Managed Care Plan, the following document describes the quality improvement activities, goals and

objectives for Del Norte County-Mental Health Branch for Fiscal Year 2017-18.

Duties for the Quality Improvement Committee included recommending policy changes, reviewing and evaluating the results of QI activities, instituting needed QI actions and ensuring the follow-up of QI processes. The Del Norte County – Mental Health Branch (MHB) Quality Improvement Work Plan evaluates the effectiveness of the QI program and shows how QI activities have contributed to improvement in clinical care and beneficiary services. It also monitors previously identified issues, including tracking of issues over time. Also included are goals and monitoring activities. The QIC researches whether the MHB is conducting activities to meet the following work plan areas. (See Quality Improvement Work Plan Program Description)

The purpose of this Quality Improvement Work Plan is to provide up‐to‐date and useful

information that can be used by stakeholders as a resource and practical tool for informed

decision making and planning. The work plan consists of the following elements:

I. Quality Management Program Description

II. Annual Quality Management Work plan

III. Goals and Objectives by: Staff Training and Retention Utilization Management Accessibility of Services Outcome Measures Problem Resolution

I. Quality Management Program Description

Del Norte County’s Quality Improvement Program (QIP) will be evaluated and updated as necessary on an annual basis. The QIC is accountable to the Mental Health Director. This committee is involved in the development and implementation of QI activities. Additionally, the Mental Health Clinical Services Manager is a licensed clinical position and serves as the Quality Assurance Manager. The Quality Assurance (QA) Coordinator has day-to-day responsibility for the QIP. Del Norte County’s Quality Improvement Committee (QIC) meets monthly. This committee includes representative from Mental Health’s provider staff, (licensed, pre-licensed, and non-licensed). The Mental Health Director, the Assistant Director, the Clinical Services Manager, Fiscal staff, Business Office, Systems Performance, contracted providers, patient’s rights advocate. All are active participants in the planning, design and execution of the QIP. The QA Coordinator drafts the Annual Quality Improvement Work Plan (elements are delineated below). The plan is presented to the QIC for comment and review. Once accepted by all parties, this work plan delineates content for each of the monthly QIC meetings. The QIC work plan follows the fiscal year, starting on July 1st of each year and ending on June 30th of the following year.

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The QIC oversees and is involved in all QI activities, including performance improvement projects. The QIC recommends policy decisions, reviews and evaluates the results of all QIP activities, institutes needed QI actions and ensures follow-up to items that arise out of monthly meetings. The QI Coordinator is often delegated by the QIC to collect and analyze data for presentation at QI meetings. The QI Coordinator records minutes of the monthly QIC meetings and represents them to the Mental Health Director and the QIC for review and comments. These minutes are reviewed by the Quality Assurance Coordinator and they reflect all QIC decisions and actions. The QIC monitors:

24/7 Crisis Line Response

Accessibility to Services

Assessments of Beneficiary and Provider Satisfaction

Beneficiary Satisfaction

Clinical Documentation and Chart Review

Practice Guidelines

Credentialing Processes

Cultural Competency Activities

Notices of Actions

Performance Improvement Projects

Resolution of Grievances, Appeals, and Fair Hearings

Resolution of Provider Appeals

Training

Utilization Management/Review

Contracts with hospitals and organizational providers are developed with input from the QIC. We currently

utilize Remi-Vista, Inc. as an organizational provider and have contracts with various psychiatric hospitals and

long term care facilities.

There is no delegation of any of Del Norte County’ QIP activities.

It is the goal of the QIC to build a structure that ensures the overall quality of services, including

detecting both underutilization of services and overutilization of services. This will be

accomplished by realistic and effective quality improvement activities and data‐driven decision

making; collaboration amongst staff, including beneficiary/family member staff; and utilization of

technology for data analysis. Executive management and program leadership must be present in

order to ensure that analytical findings are used to establish and maintain the overall quality of the

service delivery system and organizational operations.

The QIC meets monthly to monitor the status of the above items and make recommendations for

improvement. Meeting reminders, information, and minutes are sent in advance and reflect all

activities, reports, and decisions made by the QIC. The QIC ensures that client confidentiality is

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protected at all times during meetings, in minutes, and all other communications related to QIC

activities. QIC meeting minutes are kept in the QI folder on the DBH intranet. Copies of the minutes

are kept of all QIC meetings, including the names of members present and absent, and date of

meetings. Committee minutes are filed in the Quality Management Division, and are kept for a period

of not less than three (3) years.

Each participant is responsible for communicating QIC activities, decisions, and policy or

procedural changes to their program areas and reporting back to the QIC on action items,

questions, and/or areas of concern. In an effort to ensure that ongoing communication and

progress is made to improve service quality, the QIC defines goals and objectives on an annual basis

that may be directed toward improvement in any area of operation providing specialty mental

health services.

The QI Work Plan is evaluated and updated annually by the Quality Assurance Coordinator, QIC, and the Clinical staff. The QIC will rely on the input and subject matter expertise of program

and other work groups as needed to ensure an appropriate plan is written. In addition, QIC will

collaborate with other stakeholders, work groups, and committees including but not limited to:

MHP Cultural Competency Committee Compliance Committee Billing Department

MHP & Public Guardian Placement Meetings

MHP Clinical Care Meetings

MHP Electronic Medical Records

MHP Supervisory Team

Organizational Provider Meetings

Utilization Review Committee

II. Annual Quality Management Work Plan ‐

The QI Coordinator completes an annual QI Work Plan. There is an annual evaluation of the overall effectiveness of the QI Program activities and whether they have contributed to meaningful improvement in clinical services and in the quality of services provided by the MHP.

The annual QI Work Plan allows the MHP to regularly review its QI activities. Each of the areas of the QI Work Plan is reported to the QIC. In addition the QIC has oversight in the following areas: Utilization review Utilization review of client charts happens with the majority of clinical notes. All notes are reviewed and signed off by a licensed or waivered mental health practitioner within two weeks of the client being

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seen. All notes are stored electronically in our health record and can be reviewed by licensed clinical staff at any time. In addition we conduct peer reviews quarterly of our documentation and chart compliance.

There is also a dedicated clinical staff to review and record the quality of care, clinical practices, and adequacy of clinical documentation. Some of the areas reviewed include evidence of medical and service necessity, timeliness of required assessments and client plans, cultural competence issues, appropriate authorization for services when required, coordination of services, and evidence of improvement in client’s quality of life. Clinical chart documentation deficiencies, problems, or concerns, as well as suggestions for changes in the type or modality of care are noted and given to clinical staff for review and correction.

Contracted provider charts are also evaluated quarterly to insure that established authorization procedures have been adhered to. Required authorization documents and authorization timelines will be reviewed. QI staff has developed a chart audit tool and document, that will be used that will be used to reviews staff documentation on services delivered.

A medication monitoring program is being developed by MHP. We are currently working to contract with a local pharmacist for utilization review of our medical charts.

Monitoring and Oversight of Goals and Objectives The Del Norte County QIC will be responsible for monitoring and providing oversight of the Quality Improvement Program, Quality Improvement Work Plan, and the Quality Improvement Work Plan goals and objectives. In addition, the QIC will monitor the general service delivery goals of the Mental Health Plan: Service Delivery Goals The Mental Health Plan QIC shall attempt to improve and exceed the number, location, and types of services delivered in fiscal year 2017-2018. The baseline of services delivered will consist of the following services totals for fiscal year 2016-2017 Number of Mental Health Services

Adult Assessments completed in FY 17-18 > 472

Child Assessments completed in FY 17-18 > 341

Mental Health Risk Assessments completed in FY 17-18 > 634

Service Plans completed in FY 17-18 > 681

Brief Screens completed in FY17-18 > 240 Types of Mental Health Services

Assessment

Plan Development

Medication Support

Therapy

Group Therapy

Collateral

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Individual Rehab

Group Rehab

TBS Services

Case Management

Intensive Car Coordination

Crisis

Outreach and Engagement Geographic Distribution of Services All services delivered by the Mental Health Plan shall be delivered at the following locations,

455 K St. Crescent City, CA

1125 Burschell St. Crescent City CA

340 9th St. Crescent City CA

Sutter Coast Hospital, Crescent City, CA

County school sites submitting referrals Due to some clients living far outside of the county seat, if transportation becomes problematic for individual clients, the MHP will provide bus vouchers and rides to service locations Monitoring Goals The Mental Health Plan QIC has developed goals and mechanisms for delivering mental health services and monitoring the success of those goals. Timeliness of Routine Appointments

Initial contact to first appointment

Initial contact to assessment

Initial contact to Treatment plan Timeliness of Services for Urgent Conditions

Urgent conditions – same day

Crisis to follow up appointment - 72 hours Access to after-hours care

Anyone within Del Norte county requiring afterhours care can go to the Sutter Coast Hospital Emergency Room for mental health services

Responsiveness to 24/7 toll-free number

Every call made to the 24/7 number shall be answered, during both business hours and after-hours These goals will be tracked as needed and presented to the QIC at its meeting if issues arise to determine if the standards are being upheld or if adjustments will need to be made. QIC Oversight and Monitoring To ensure the goals set by the MHB are being worked towards the QIC will have agenda items at each of its meetings related to Problem Resolution (grievances, appeals, expedited appeals, fair hearings, provider appeals), Performance Improvement Projects, General timeliness, 24/7 toll free phone number, After-hours access, Beneficiary satisfaction

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Organizational Providers The Del Norte County Specialty Mental Health Plan contracts with organizational providers (certified by Del Norte County Mental Health) that provide services for the plan’s beneficiaries. All providers are required by contract to meet standards established by the Del Norte County Specialty Mental Health Plan. Before being certified, they must agree to participate in the Quality Improvement (QI) Program and to provide access to relevant clinical records to the extent permitted by State and Federal laws. Data that may potentially be monitored includes:

Appeals and tracking of level of resolution

Authorization Processes

Beneficiary Satisfaction

Billing Issues

Change of Provider requests

Clinical Documentation and Chart Review

Complaints/grievances

Service Utilization

Contract Compliance

Credentialing

Incident Reports

NOAs

Performance Outcome Measures

State Fair Hearings

A provider appeal process and a provider problem resolution process are in place as required by the managed care contract with the State Department of Mental Health. These processes provide service providers with an appeal process and problem resolution process that enables providers to formally appeal a decision of the Del Norte County Department of Mental Health Mental Health Plan (MHP) regarding a denied or modified treatment authorization request, a dispute concerning the process or payment of a provider’s claim or resolve issues, complaint or concerns a service provider may have.

III. 2017‐2018 Goals and Objectives

The following goals and objectives are consistent with DHCS Managed Care contract requirements

for quality improvement work plans and EQRO findings:

1. Staff Training and Retention

Based upon recommendation for EQRO, staff training and Retention is prioritized in the QI work

plan to develop system of training newly hired staff in a consistent manner. Also providing

opportunities for staff to get additional training in areas of need for the county as well as

improve the quality of services we provide.

2. Utilization Management

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The MHP is responsible for the monitoring “ At Risk” populations. These populations are

identified as frequent utilizers of emergency services or underserved segments of the community.

The QIC will work to identify, track and establish best clinical practice to reduce utilization or

perform outreach efforts to this population.

3. Accessibility of Services

The MHP is responsible for monitoring accessibility of services. In addition to meeting

statewide standards, the MHP will set goals for timeliness of routine mental health

appointments and urgent care conditions; access to afterhours care; and 24‐hour

responsiveness.

4. Outcome Measures

The MHP is responsible for tracking the effectiveness of the services we deliver. The MHP in

partnership with QIC will research and develop tools to track effectiveness of services and

outcomes for our clients.

5. Problem Resolution

The MHP is responsible for monitoring the tracking and timely resolution of all grievances,

appeals, expedited appeals, and states fair hearings. The MHP will set goals for the timely

resolution and tracking of all filed grievances and appeals.

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Staff Training and Retention

Goal and Objective Planned Steps and Activities to Reach Goal/Objective

Responsible Entity and Lead Individuals

Goal Measurement

Value: MHP training should be consistent for all staff that are hired. MHP should promote educational and training opportunities for staff.

Goal: Standardized training for all new staff. Policy and Procedure for staff training and development.

Objectives:

1. Develop New Hire training manual with relevant policy and procedures for new staff, as well as checklists for competency, in key areas of MHP functions.

2. Have all staff attend at least one training per year, either locally or within the state in areas that promote better clinical outcomes for clients and promote staff development. Baseline: Staff will have proficiency in 95% of job Functions

3. All staff will participate in the MHP annual Cultural Competence training

Baseline: 100% of staff will complete the training.

4. Provide all staff with training in use of the Language Line Translation service

1. Create binder with input from

QI committee, Mental Health Supervisors, and clinical staff, with key Policy and Procedures for all new staff.

2. Create checklist for Proficiency in MHP functioning with a log for new staff to have demonstrated their proficiency by being shadowed by a supervisor.

3. Have the Checklist and Shadow Log part of employees Probation Evaluation.

4. QI staff work to bring trainings to the area. Staff Supervisors promote out of county training with their individual staff trainings logged with QI coordinator.

Quality Improvement Coordinator Clinical Services Manager Mental Health Supervisors Admin Staff Staff Services Analyst

New Staff proficiency improved within the agency by measure of report and better outcomes on Probationary Evaluation.

Better clinical outcomes for clients based on outcome measures due to increased education and training of clinical staff.

Log & Track Cultural competency training

Log & Track Language Line translation service training

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Utilization Management

Goal and Objective Planned Steps and Activities to Reach Goal/Objective

Responsible Entity and Lead Individuals

Goal Measurement

Value: MHP need to ensure high utilizers and underserved populations are receiving access to services.

Goal: Identify, track, and establish best clinical practice to reduce frequent utilizers of emergency services and perform outreach efforts to underserved populations.

Objectives:

1. Develop services and programs to reach and help our vulnerable populations. Have appropriate clinical services at the MHP to address the needs of High utilizers, i.e. psychiatry, case management, housing, AOD counseling etc.

Baseline: Total HCB ≤ 7

2. Decrease the number and

percentage of acute psychiatric discharges that are followed by a psychiatric readmission within a 6 month period.

Baseline: ˂18

1. Internal tracking with Staff Analyst, clinical staff and Admin staff

2. Case Plan appropriate client’s in staff meetings

3. Work with MHSA coordinator to increase outreach and engagement efforts

4. Clinical Performance Improvement Plan based on High Utilizers with Intervention based on identified need i.e streamline referral to AOD, Housing, therapy

Quality Improvement Coordinator Clinical Services Manager Admin/Fiscal Staff Kingsview (EHR) MHSA Coordinator County AOD Department. Staff Services Analyst

Tracking data over time, through reporting, to see if efforts were successful

Reduction in re-hospitalization rates

Have Policy and Procedure developed for Outreach and engagement efforts.

Increase enrollment of Mental Health Services for Homeless population, Jail inmates etc.

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Accessibility of Services

Goal and Objective Planned Steps and Activities to Reach Goal/Objective

Responsible Entity and Lead Individuals

Goal Measurement

Value: Beneficiary outcomes are better with timely access to services.

Goal: Beneficiaries will have timely access to the services they need and services will be available to meet the needs of the community.

Objectives: 1. Improve percentage of non‐urgent

specialty mental health services (SMHS) appointments offered within 15 business days of the initial request by the beneficiary or legal representative for an appointment.

Baseline: 59% 2. Increase percentage of acute (psych

inpatient) discharges that receive a follow up outpatient SMHS (face to face, phone or field) within 7 days of discharge. Baseline: 96.5%

1. Internal tracking of timeliness conducted by Staff Analyst, clinical staff and Admin staff, with Electronic Health Record

2. Create process with non-licensed or waivered staff to conduct brief screens on first follow-up appointments, allowing quicker assessment and Service Plan with licensed and waivered staff.

3. Reserve 1 hour of psychiatry time for intake assessment per week, to ensure crisis follow-ups have availability in psychiatrist’s schedule.

4. Increase capacity of client services by hiring additional therapist and securing additional psychiatry hours both tele-psych and in-person.

Quality Improvement Coordinator Clinical Services Manager Medical Records Staff Medical records Supervisor Admin Staff Psychiatry Department Staff Services Analyst

Reports will show whether or not we are meeting the required standards.

14 days from initial contact for assessment

7 days from assessment to first therapy appointment.

30 days from initial contact to first psychiatry appointment.

Passing 24/7 toll free number test call

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3. Increase percentage of acute (psych inpatient and PHF) and non-acute discharges that receive a follow up outpatient psychiatrist appointment within 30 days of discharge. Baseline: > 75% of patients

discharged will see a doctor within 30 days.

4. Monitor the current number of

mental health services within the county.

5. Monitor accessibility of 24/7 access phone line Baseline: 75% passing rate for test calls

5. Tracks wait times for clients for all manner of specialty mental health services.

6. Set Goals for service capacity based on community needs, wait times for services, and historical data of services delivered.

7. Non Clinical performance

improvement plan to address timeliness of all levels of appointment times.

8. The Staff Services Analyst will conduct an after-hours monthly test call to ensure the 24/7 toll free line is operating correctly.

Track and maintain log of monthly totals of services delivered as part of monthly demographic report

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Outcome Measures

Goal and Objective Planned Steps and Activities to Reach Goal/Objective

Responsible Entity and Lead Individuals

Goal Measurement

Value: MHP services should be effective in treating our consumers.

Goal: Routine mechanisms tracking the effectiveness of services we provide.

Objectives: 1. Have standard policy and procedure

for staff to implement CANS and MORS

Baseline: 10 MORS assessments on a quarterly basis by each staff person

1. Have all children be evaluated by the CANS at intake and again at 6 months and 1 year.

2. Have adults be evaluated by the MORS for specific group treatment, and 10 Adults per caseload done by clinical staff, to start.

Quality Improvement Coordinator Clinical Services Manager Admin Staff Supervisory Staff Staff Services Analyst

Tracking mechanism to ensure all staff are utilizing these tools.

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Problem Resolution

Goal and Objective Planned Steps and Activities to Reach Goal/Objective

Responsible Entity and Lead Individuals

Goal Measurement

Value: The MHP will have a Problem Resolution process that provides tracking of all grievances and appeals and ensures that all grievances and appeals are logged and resolved in a timely manner.

Goal: All grievance and appeals filed will be logged, mailing of 1st notification letter, and resolved in a timely manner until MHP objective is met.

Objectives: 100% of all grievances will be resolved in 60 days. 100% of all appeals will be resolved in 45 days. 90% of expedited appeals will be resolved in 3

days. 100% of all grievance and appeals will be logged

within three days of receipt Baseline: Problem Resolution FY 16-17 Filed that met the timely resolution Grievances: <50% Appeal: <50 % Expedited Appeal: <50% Logged items over three days Grievance: <50%

1. Monitor the problem resolution process tracking and reporting system. Make adjustments as needed to ensure integrity of data.

2. Track, trend and analyze beneficiary grievance, appeal and State Fair Hearing actions. Include type, ethnicity, race, and language as part of this tracking.

3. Track the timeliness of grievance, appeals and expedited appeal resolution for non- compliance tracking.

4. Deliver status updates to the monthly Quality Improvement Committee meetings.

Quality Improvement Coordinator Clinical Services Manager Quality Improvement Committee Members Staff Services Analyst

Filed grievance and appeals will be tracked in the Grievance Log FY 17-18