June 16, 2011 Michael Reiter, PharmD Walter Shwe Executive DirectorConsultant Saumitra SenGupta, PhDSandra Sinz, LCSW, CPHQ Information Systems Director Operations Director Overview of APS California External Quality Review Organization with a Special Focus on Rehospitalization California Mental Health Planning Council Quality Improvement Committee

© 2011 APS Healthcare, Inc. 2  Data: Hui Zhang, PhD  Production: Esperanza Calderon

© 2011 APS Healthcare, Inc. 3 Our Approach EQRO Reviews Quality and Performance Improvement Wellness, Recovery, and Resilience Key Informant Interviews Technical Assistance and Training Cultural Competence Consumer and Family Member Focus Groups Performance Improvement Projects Data Analysis Information Systems Capabilities Assessment Performance Measurement Final Report CAEQRO Activities August 2008

© 2011 APS Healthcare, Inc. 4 Site Review Process Highlights  Consistent core phases –Pre-site planning –Site visit –Post-site analysis  Customized to MHP –Seven years’ data –Input from many individuals –Year-to-year follow up  Annual update and revision of review materials We Heard From…  1,047 people (FY05)  1,612 people (FY06)  2,666 people (FY07) –663 Consumers and family members  2,857 people (FY08) –713 Consumers and family members  3,274 people (FY09) –767 Consumers and family members  2,875 people (FY10) –612 Consumers and family members

© 2011 APS Healthcare, Inc. 5 Key Components 1.Quality 2.Access 3.Timeliness 4.Outcomes Mandated by Centers for Medicare and Medicaid Services (CMS)

© 2011 APS Healthcare, Inc. 6 Key Components  A current strategic plan/initiatives drives the service delivery system  Quality management and performance improvement are organizational priorities  Data is used to inform management and guide decisions  Investment in information technology infrastructure is a priority  Integrity of Medi-Cal claim process, including determination of beneficiary eligibility and timely claims submission  Effective communication from MHP administration  Stakeholder input and involvement in system planning and implementation  Consumers and family members are employed in key roles throughout the system 1. Quality Components

© 2011 APS Healthcare, Inc. 7 Key Components  Service accessibility and availability are reflective of cultural competence principles and practices  Manages and adapts its capacity to meet service needs  Penetration Rates are used to monitor and improve access  Integration and/or collaboration with community based services 2. Access Components

© 2011 APS Healthcare, Inc. 8 Key Components  Tracks and trends access data from initial contact to first appointment.  Tracks and trends access data from initial contact to first psychiatric appointment.  Tracks and trends access data for timely appointments for urgent conditions.  Has a mechanism to assure timely access (within 7 days) to follow up appointments after hospitalization.  Tracks and trends No Shows and implements quality improvement activities to improve overall timeliness to services. 3. Timeliness Components

© 2011 APS Healthcare, Inc. 9 Key Components  Consumer run and or consumer driven programs  Measures clinical and/or functional outcomes of consumers served  Has one active and ongoing (clinical) PIP  Clinical PIP shows post-intervention results  Has one active and ongoing (non-clinical) PIP  Non-Clinical PIP shows post-intervention results  Utilizes information from DMH/POQI Satisfaction Surveys  Utilizes information from Consumer Satisfaction Surveys 4. Outcomes Components

© 2011 APS Healthcare, Inc. 10 Consumer/Family Member Process  How do the EQRO reviews compare to other reviews you’ve participated in?  What parts of the review do you typically participate in? –Pre- and post-site, on-site –Key components –Focus groups  Please share some experiences in conducting CFM focus groups (both the positives and the challenges).

© 2011 APS Healthcare, Inc. 11 Promising Practices County Webinar Presentations  Monterey –Using data for quality management and client centered care: Monterey experience post-EMR implementation –Presented on November 15, 2010  Trinity –Process Mapping and Workflow Analysis: What, Why, How –Presented on December 16, 2010  Marin –Providing Behavioral Health & Primary Care Services under One Roof: The Marin County Mental Health Experience –Presented on February 10, 2011

© 2011 APS Healthcare, Inc. 12 Access Key Findings — Eligibles v. Beneficiaries Served Medi-Cal Eligibles & Beneficiaries Served Calendar Year Calendar Year StatewideCANOLA Total Medi-Cal Eligibles Total Beneficiaries Served Total Medi-Cal Eligibles Total Beneficiaries Served CY056,810,962430,8774,353,453302,116 CY066,783,625426,1584,380,931297,839 CY076,837,351430,4064,470,483300,005 CY086,983,132445,6514,630,972310,086 CY097,381,253441,6824,954,687302,406

© 2011 APS Healthcare, Inc. 13 Quality: Performance Improvement Projects  What is a Performance Improvement Project (PIP)? –In general terms, a PIP is “a systematic process for improving the quality of care and service designed, conducted and reported in a methodologically sound manner.” –To elaborate, the Protocol defines a PIP as “a set of related activities designed to achieve measurable improvement in processes and outcomes of care. Improvements are achieved through interventions that target health care providers, practitioners, plans, and/or beneficiaries.” (Human Services Research Institute, 2004)  PIPs are generally more functional if the MHP receives support than creating it in isolation. –Examples: SCERP I, SCERP II, CalMEND  Challenges –Rapid cycle measurements have been problematic; CalMEND can be of assistance

© 2011 APS Healthcare, Inc. 14 Quality: Performance Improvement Projects Figure 5-5. PIP Descriptive Category by MHP Size Descriptive Category Fiscal Year MHP Size TotalPercent Small- RuralSmallMediumLarge Use of acute or inpatient Services % % % % Improved diagnosis or treatment processes % % % %  Other PIP categories include: –Business process improvement –Co-occurring disorders –Physical health care –Psychiatrist/medication appointment –Retention –Wellness, recovery and resilience –Other

© 2011 APS Healthcare, Inc. 15 Outcomes High Cost Beneficiaries Statewide Medi-Cal Eligibles & Beneficiaries Served Approved Claims Summary CY05-09 CY05CY06CY07CY08CY09 Total Medi-Cal Eligibles6,810,9626,783,6256,837,3516,983,1327,381,253 Total Beneficiaries Served430,877427,232430,406445,651441,682 Total Approved Claims (in Billions)$1.68$1.85$1.93$2.09$2.11 % of Approved Claims by Top 4% of Beneficiaries Served 36%37% 38%37%

© 2011 APS Healthcare, Inc. 16 Timeliness We ask counties for data on timeliness of first appointment, first psychiatric appointment, access to urgent care, post-hospitalization services, and No Shows

© 2011 APS Healthcare, Inc. 17 Information Systems

© 2011 APS Healthcare, Inc. 18 Information Systems Figure 3-3. New Information System Status FY05-06FY06-07FY07-08FY08-09FY09-10 #%#%#%#%#% No plans for new information system 916%59%47%712%1425% Considering new information system 814%47%611%59%47% Actively searching for new information system 1120%1730%1425%1120%1221% New information systems selected, not implemented 1934%713%35%47%35% Implementation in progress 916%1730%2239%2545%1730% New system in place 00%611%713%47%611% TOTAL 56100%56100%56100%56100%56100% # = Number of MHPs

© 2011 APS Healthcare, Inc. 19 CAEQRO Website – Homepage 

© 2011 APS Healthcare, Inc. 20 CAEQRO Website – Register

© 2011 APS Healthcare, Inc. 21 CAEQRO Website – Login Page

© 2011 APS Healthcare, Inc. 22 CAEQRO Website – Finding Data  Reports and Presentations Tab

© 2011 APS Healthcare, Inc. 23 CAEQRO Website – Finding Data  Data Analysis Tab

7 and 30 Day Follow-up Services after Psychiatric Inpatient Episodes in Medi-Cal – CY09 Questions/Comments –

© 2011 APS Healthcare, Inc. 25 Overview  Inpatient Rate Measure –How CAEQRO does it –Common Managed Care way of doing it  Follow-up to Inpatient Psychiatric Discharge –7 day follow-up –30 day follow-up –By region and size

© 2011 APS Healthcare, Inc. 26 Inpatient Rate  CAEQRO calculates as an annual percentage [Annual unduplicated count of individuals receiving Psychiatric Inpatient] *100 / [Number of Average Monthly Medi-Cal Eligibles] The Denominator: Average Monthly Eligible = [Total # of Eligibles] / 12

© 2011 APS Healthcare, Inc. 27 Alternative Calculations  Per Thousand Member Months Total Member Months = ∑ [No. of months each individual has remained Medi-cal eligible during a year] For example, if 2 individuals were eligible for 6 months and 4 individuals for 8 months, the total member months would be 44.  Without going into the algebra, the annualized per thousand member months translate to CAEQRO’s rate calculation times 10. In essence, one can calculate the usual managed care indicator from the CAEQRO measure.

© 2011 APS Healthcare, Inc. 28 Statewide Mean = 9.9 monthsMedian = 9.5 months

© 2011 APS Healthcare, Inc. 29 HEDIS Measures Mental illness MeasureCare, screening, or test needed Follow-up after hospitalization for mental illness Age 6 and over Patients discharged from an inpatient mental health admission and receive:  One follow-up encounter with a mental health provider within 7 days after discharge.  One follow-up encounter with a mental health provider within 30 days after discharge. National Committee for Quality Assurance (NCQA) – 2011 HEDIS ® Measures Inpatient Utilization-General Hospital/Acute Care The Inpatient Utilization-General Hospital/Acute Care measures utilization of acute inpatient services in the; Total Services, Medicine, Surgery, and Maternity categories. Discharges are reported per 1,000 member months, days per 1,000 member months and average length of stay (ALOS) for the Medi-Cal population.

© 2011 APS Healthcare, Inc. 30 Data Description  CY09 Approved SD/MC Claims  Psych Inpatient Services through Nov 09  30-day follow-up through Dec 09  Focused on system-level performance  Two MHPs did not have any psych inpatient episode in CY09

© 2011 APS Healthcare, Inc. 31 Context (CY09 Figures)  CA Total Population = 38,476,724  Medi-Cal Eligible* = 7,381,253  Served by MHPs = 441,682  Total Approved Claims = $2.1bn  Psych Inpatient Episodes = 51,059  Psych Inpatient Approved Claims =~$250 m  First psych Inpatient in CY09 = 28,258 *Monthly Average

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© 2011 APS Healthcare, Inc. 59 Discussion Points  What is this data telling us?  What questions is it raising?  What further analyses would be appropriate to answer these questions?  How would you utilize this information?

© 2011 APS Healthcare, Inc. 60 Limitations  No demographic analysis yet  No individual level analysis  No survival analysis yet  No non-Medi-Cal data  No inpatient ALOS yet  Methodology and analysis in progress

© 2011 APS Healthcare, Inc. 61 Further Analysis Needed  By demographics  Trending across 3-5 years  Inpatient days  ALOS and recidivism correlation  Demographics and recidivism correlation  Other?

62 Questions? Comments? Suggestions?