1. Overview of Findings from CAEQRO Statewide Annual Report of FY Presented to: California Department of Health Care Services
June 18, 2012

2. Presenters Michael Reiter, PharmD Sandra Sinz, LCSW, CPHQ
Executive Director
Sandra Sinz, LCSW, CPHQ
Operations Director
Saumitra SenGupta, Ph.D.
Director of Information Systems

3. The Annual Report is in 3 Volumes
Volume I – Narrative
Volume II – Attachments
Volume III – MHP Summaries

4. CMS Priorities for EQRO
Quality
Access
Timeliness
Outcomes
Use of the Key Component Protocol allows CAEQRO to standardize review of the diverse MHPs for core and essential quality management practices

5. CMS Priorities for EQRO
Quality
Commitment to quality
Use of data in quality management
Inclusion of key stakeholders in various processes and program
Information technology issues, including claims integrity
Access
Evidence of cultural competence principles
Managing the workforce and system capacity to meet the needs of the MHP’s diverse communities

6. CMS Priorities for EQRO
Timeliness
Setting goals for timely service access
Monitoring toward meeting those goals
Initiating improvement activities when goals are not being met
Outcomes
Monitoring and improvement of consumer outcomes
Performance Improvement Projects
Consumer Satisfaction

7. Economic and Regulatory Challenges for MHPs
Medi-Cal Specialty Mental Health
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
MHSA
AB3632
Transition of State DMH Medi-Cal Responsibilities to DHCS
Health Care Reform and Integration Initiative
Short-Doyle/Medi-Cal Phase II and HIPAA compliance

8. CAEQRO Values
Movement towards equalization of mental health penetration rate differences that exist between racial/ethnic groups, genders, age and other groups.
Increased consumer/family involvement in the decision making process of the MHP.
Increased employment and training opportunities with planned exit strategies into independent employment.
Wellness centers which are truly consumer led, with consumer advisory groups and consumers in key leadership roles.

9. Quality and Performance Improvement
CAEQRO 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
Measurement
Final
Report
CAEQRO Activities
August 2008

10. Site Review Team Composition
Lead Reviewer
Information Systems Reviewer
Consumer/Family Member Consultant
Sometimes an additional Reviewer for efficiency

11. Review Participants Fiscal Year Staff, Contractors, & Others
Consumers and Family Members
Total
04-05
1,047
N/A
1,047 +
05-06
1,612
1,612 +
06-07
2,003
663
2,666
07-08
2,144
713
2,857
08-09
2,507
767
3,274
09-10
2,263
612
2,875
10-11
2,373
585
2,958

12. Consumer and Family Focus Groups
CFM Focus Groups
Group Specification
Number of Groups
Representation
New consumer in last 12 months 21
22%
Youth Services - caregivers 15
16%
Latino 14
15%
Other specific groups: other languages, outlying areas, age-specific, co-located services
Acute Services 8 8%
Wellness Center 6 6%
TAY
Foster care
General, diverse group 5 5%

13. MHP Response to Prior Year Recommendations: Overall Findings
Review Recommendations to the MHPs
MHPs tend to respond with some degree of action to the
recommendations made in their EQRO report
MHP Response to Prior Year Recommendations: Overall Findings
Total MHPs 56
Total Recommendations
273
Percent of MHPs responding partially or fully to all priority recommendations from the prior year
64% (36 MHPs)
Percent of recommendations rated as “not addressed”
13% (35 recs)
Give examples? Speak to the role APS CAEQRO plays in MHP leadership. Explain how outcomes – many other actions need to take place before APS can make outcome recommendations.

14. Types of Recommendations
Type and Percentage of Recommendations Addressed by MHPs
Recommendation n
Most common county size
Fully Addressed
Partially Addressed
Total
Collaboration—Primary Care 7
Medium
57%
43%
100%
Communication 13
All sizes
54%
46%
IS Use/Training 8
Large
75%
25%
Wellness & Recovery—Consumer Employment
Small
63%
37%
IS Implementation—Use of Clinical Component 16
50%
44%
94%
IS Use/Claiming 14
93%
Wellness & Recovery—Consumer Leadership in MHP 15
73%
20%
IS Implementation—Report Development 12
42%
92%
Outcomes
67%
Collaboration 11
55%
36%
91%
Quality—Appropriate LOC 10
40%
90%

15. Types of Recommendations, cont.
Type and Percentage of Recommendations Addressed by MHPs
Recommendation n
Most common county size
Fully Addressed
Partially Addressed
Total
Quality—QI function 12
Small-rural
33%
50%
83%
IS Implementation 17
Medium
41%
82%
Timeliness 18
Small-Rural
37%
44%
81%
Access 10
60%
20%
80%
Wellness & Recovery-Systemic 5
Large
40%
Access—Underserved 35
24%
64%
Outcomes—analyze claims data 11
Large, Small-rural
46%
18%
Workforce
Small, Small-rural
36%
54%
Quality—Use of Data/ Create a Dashboard 27
22%

16. Quality
98 percent of MHPs now show evidence of using data to inform decisions
However, there are many barriers to optimal use of data
We made specific recommendations regarding improving the use of data in 27 MHPs
Fully addressed 18%
Partially addressed 22%
QUALITY
PRESENT
PARTIALLY
NOT MET
Data are used to inform management and guide decisions
63%
35% 2%

17. Quality – Use of data
Many MHPs are unable to generate data that is useful for management and decision making and instead rely on anecdote
Factors that contribute
Delayed and problematic information system implementations
Failure of MHPs to invest in analytic person power

18. Information Systems
While half of the MHPs have yet to completely implement any clinical module, there has been noticeable advancement over the past year
Anasazi, Echo ShareCare, and Netsmart Avatar continue to dominate the marketplace
The incremental rollout of system changes … created situations in which all MHPs needed to make numerous changes to their claim processing to be HIPAA-compliant

19. Short/Doyle Phase II Claims
7 counties successfully navigated new systems with CY10 claims equal to or exceeding CY09
24 MHPs have 15% or less claims in CY10 when compared to CY09
25 MHPs have had significant problems and therefore low revenue generation (ranging from 30 – 90% less claims)
New IS implementation within the last year
Loss of S/D claims subject matter experts
QUALITY
PRESENT
PARTIALLY
NOT MET
Integrity of Medi-Cal claim process, including determination of beneficiary eligibility and timely claims submission
43%
52% 5%

20. New Implementation Status
Figure New Information System Status
FY06-07
FY07-08
FY08-09
FY09-10
FY10-11 # %
No plans for new information system 5 9% 4 7% 7
12% 14
25% 17
30%
Considering new information system 6
11% 2 4%
Actively searching for new information system 11
20% 12
21% 9
16%
New information systems selected, not implemented
13% 3 5%
Implementation in progress 22
39% 25
45% 10
18%
New system in place
TOTAL 56
100%
# = Number of MHPs

21. Electronic Health Record Functionality
Figure Electronic Health Record Functionality, FY10-11

22. Quality & Access – Communication and Collaboration
Small-rural MHPs were particularly noted for their communication.
Large and small MHPs were noted for their need to improve communication among staff and stakeholders.
QUALITY
PRESENT
PARTIALLY PRESENT
NOT MET
Communication from MHP administration
45%
53% 2%
Stakeholder input and involvement in system planning and implementation
41%
57%
Collaboration with primary care, in particular, were strengths in large and medium MHPs, and less so for small-rural MHPs.
Small MHPs were more frequently cited for their strengths in general collaborative efforts.
Large MHPs were more likely to be noted for their need to improve collaborative efforts.
ACCESS
PRESENT
PARTIALLY
NOT MET
Integration and/or collaboration with community-based services
95% 4% 1%

23. Access
Eligibles versus beneficiaries served

24. Access – High Cost Beneficiaries
More resources are going to a small number of beneficiaries
Total Claims for High-Cost Beneficiaries Served

25. Access – Cultural Competence
Improving access for underserved groups
The most frequently made recommendation
One of the less frequently addressed recommendations, with 36% of MHPs not responding
ACCESS
PRESENT
PARTIALLY
NOT
MET
Service accessibility and availability reflect cultural competence principles and practices
36%
59% 5%

26. Access – Measuring Penetration Rates
A significant number of MHPs do not use penetration rates to measure access by sub-groups, particularly underserved populations
ACCESS
PRESENT
PARTIALLY
NOT MET
Penetration rates are used to monitor and improve access for Medi-Cal beneficiaries
43%
32%
25%

27. MHP Size Groups and Penetration Rates
From Volume II, Attachment 13
MHP Size Groups and Penetration Rates
MHP Size
Small-Rural
Small
Medium
Large *
Penetration Rate
(13.17%– 9.00%)
Siskiyou
Lassen
Plumas
Mariposa
Trinity
Modoc
Inyo
Nevada
Humboldt
Tuolumne
Tehama
El Dorado
Shasta
Marin
Butte
San Francisco
Alameda
Del Norte
Calaveras
Alpine
Mendocino
San Benito
Napa
Yolo
Kings
Imperial
San Luis Obispo
San Mateo
Placer/Sierra
Santa Cruz
Santa Barbara
Contra Costa
San Diego
Sacramento
(8.99% %)
Colusa
Amador
Glenn
Mono
Sutter/Yuba
Lake
(5.99% %)
Madera
Stanislaus
San Joaquin
Monterey
Solano
Sonoma
Tulare
Merced
Los Angeles
San Bernardino
Santa Clara
Ventura
Kern
Riverside
Orange
Fresno
* Los Angeles included in Large

28. MHP Size Groups and Average Benefit
From Volume II, Attachment 13
MHP Size Groups and Average Benefit
MHP Size
Small-Rural
Small
Medium
Large *
Average Benefit
($11,551 - $6,000)
Siskiyou
Colusa
Nevada
Mendocino
Humboldt
Santa Cruz
Sonoma
Monterey
Santa Barbara
Santa Clara
San Francisco
Contra Costa
Alameda
($5,999 - $4,841)
Trinity
Glenn
Napa
San Luis Obispo
Marin
Tulare
Los Angeles
Ventura
($4,840 - $1,151)
Plumas
Lassen
Alpine
Mono
Modoc
Calaveras
Inyo
Del Norte
Mariposa
Amador
Yolo
Lake
Sutter/Yuba
Tuolumne
Madera
Tehama
El Dorado
Shasta
Imperial
San Benito
Kings
San Mateo
Solano
Butte
Placer/Sierra
Stanislaus
Merced
San Joaquin
Sacramento
Kern
San Diego
Riverside
Fresno
San Bernardino
Orange
* Los Angeles included in Large

29. Access – Disparities
Disparities in access and services to Latinos have diminished every year since FY05-06

30. Foster Care Penetration

31. Services to Older Adults

32. Timeliness
We ask counties for data on timeliness of first appointment, first psychiatric appointment, access to urgent care, post-hospitalization services, and No Shows
Critical gaps in data exist for measuring timeliness of access
TIMELINESS
PRESENT
PARTIALLY
NOT
MET
Tracks and trends access data from initial contact to first appointment
50%
36%
14%
TIMELINESS
PRESENT
PARTIALLY
NOT
MET
Tracks and trends access data from initial contact to first psychiatric appointment
25%
46%
29%

33. Timeliness
Many MHPs do not have mechanisms in place to assure prompt outpatient care after an inpatient episode
TIMELINESS
PRESENT
PARTIALLY
NOT
MET
Has a mechanism to assure timely access (within seven days) to follow up appointments after hospitalization
32%
29%
39%
17% of inpatient admissions result in another
admission within 30 days of discharge
The majority of MHPs have outpatient follow-up within 7 days
50% or less of the time

34. Performance Measure Service within 7 days of hospital discharge

35. Performance Measure Service within 7 days of hospital discharge
Added this chart in because we changed the text on slide 33 from “57% of MHPs have outpatient follow-up within 7 days 50% or less of the time” to
“The majority of MHPs have outpatient follow-up within 7 days 50% or less of the time.”
Should we keep it and the 30-day outpatient chart or cut the 30-day chart?

36. Performance Measure Service within 30 days of Hospital Discharge
ENC added this figure just in case you guys want the whole set. But please cut if don’t need it.

37. Performance Measure Service within 30 days of Hospital Discharge

38. Timeliness
Few MHPs are closely monitoring no-shows which represent unutilized service capacity
TIMELINESS
PRESENT
PARTIALLY
NOT
MET
Tracks and trends no-shows and implements quality improvement activities to improve overall timeliness to services
20%
41%
39%

39. Outcomes – Consumer-run Programs
87% of MHPs now show evidence of consumer-run or consumer-driven programs
86% of MHPs show evidence that consumers and family members are employed in key roles throughout the system
Present was represented mostly by Large MHPs
OUTCOMES
PRESENT
PARTIALLY
NOT MET
Consumer run and or consumer-driven programs
75%
12%
13%
QUALITY
PRESENT
PARTIALLY
NOT MET
Consumers and family members are employed in key roles throughout the system
45%
41%
14%

40. Outcomes – Consumers Served
Some MHPs demonstrate no outcomes monitoring
OUTCOMES
PRESENT
PARTIALLY
NOT MET
Measures functional outcomes of consumers served
39%
41%
20%

41. Outcomes – 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)
Challenges
Minimal resources allocated to outcome measurement in general
Rapid cycle measurements have been lacking
CiMH has been of assistance

42. Outcomes – Performance Improvement Projects
77% of MHPs now show evidence of two active Performance Improvement Projects (over half of MHPs have both PIPs active)
OUTCOMES
PRESENT
PARTIALLY
NOT MET
Active and ongoing clinical PIP
64%
20%
16%
Active and ongoing non-clinical PIP
57%
23%
Many MHPs find it difficult to collect complete and accurate data to support their PIPs
MHPs have been more successful in designing their PIPs than actually implementing them and harvesting results

43. Overall PIP Count Over Five Years
Performance Improvement Projects
Number of MHPs with PIPs has increased slightly over time
Overall PIP Count Over Five Years
Count of MHPs with:
FY06-07
FY07-08
FY08-09
FY09-10
FY10-11
Two PIPs 38 46 44
One PIP 12 11 15 9
No PIP 6 7 3 1
Total MHPs 56

44. Statewide Client Count
EPSDT PIP
Statewide Client Count
FY07-08
FY08-09
FY09-10
FY10-11
EPSDT Total
187,436
203,882
209,984
204,802
EPSDT
High Cost
21,750
25,715
25,355
24,868
High Cost %
11.60%
12.61%
12.07%
12.14%

45. Innovative, Exemplary, and Promising Practices
Use of data – Alameda, Humboldt, Sonoma, Trinity
Cultural Competence – San Mateo, San Luis Obispo, Ventura
Health care integration – Los Angeles, Marin, Santa Clara
Wellness and Recovery – Contra Costa, San Bernardino, Trinity

46. Overall Conclusions
Gaps in data contribute to difficulties in effective quality management
Information Systems implementations and Short-Doyle Phase II implementation have led to claiming challenges
PIPs are in place but with difficulties in full implementation associated with data access issues, lack of analytic staff, and system wide resources for applying interventions

47. Conclusions, cont.
Latino access disparities remain in terms of penetration rates but there is more equity when comparing claims dollars
Timeliness to services is problematic in many counties
There are more and more consumer-run or consumer-driven services throughout the state
Most counties are making efforts to enact improvements in line with our recommendations

48. The End Questions and discussion
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