1. Performance Indicators
Michigan Mission based Performance Indicator System (MMBPIS)
Sandy Gettel, Quality Manager

2. Why do we collect the Performance Indicators
To ensure individuals have timely access to services. (Indicator #2)
Rationale for Use
Quick, convenient entry into the public mental health system is a critical aspect of accessibility of services. Delays in clinical and psychological assessment may lead to exacerbation of symptoms and distress and poorer role functioning. The amount of time between a request for service and clinical assessment with a professional is one measure of access to care.
To ensure individual's receive timely treatment and supports. (Indictor #3)
The amount of time between professional assessment and the delivery of needed treatments and supports addresses a different aspect of access to care than Indicator #2. Delay in the delivery of needed services and supports may lead to exacerbation of symptoms and distress and poorer role functioning.

3. Why do we collect the Performance Indicators
To ensure coordination and continuity of care during the individuals most vulnerable times.(Indicator 4b)
Rationale for Use
When responsibility for the care of an individual shifts from one organization to another, it is important that services remain relatively uninterrupted and continuous. Otherwise, the quality of care and consumer outcomes may suffer. This is an indicator required by the federal Substance Abuse and Mental Health Services Administration.

4. PIHP Data

5. Lets Talk Numbers

6. Lets Talk Numbers

7. Lets Talk Numbers

8. Exceptions-Indicator 2

9. Exceptions-Indicator 3

10. Exceptions – Indicator 4b

11. Indicator 2: What do we collect?
Indicator 2: Request for Service: The percentage of new persons during the quarter receiving a face-to-face Assessment or Welcoming Session with a professional within 14 calendar days of the date services were first requested
# of New Persons Receiving an Initial Non-Emergent Professional Assessment Following a First Request
# of New Persons who are Exceptions
# of Persons Receiving an Initial Assessment within 14 calendar days of First Request
Where is this documented?
SUD Treatment Episode Admission Form Request Date-Date the request for Services was made
Date of First Appointment-Date of the Consumers Assessment or welcome appointment.
Calculations
Number of Days is calculated between “Date of First Request/Contact” and “Admission Date”
Exceptions;
Consumers who request an appointment outside of 14 days of the “Date of First Request/Contact” or refused an appointment offered within 14 days (indicated in the Treatment Episode in the “First / Welcoming Appointment” section)
Consumers who cancel or no-show for the first appointment (indicated in the Treatment Episode in the “First / Welcoming Appointment” section)
Notes: If consumer reschedules the first appointment, count the “Reschedule Request Date” as "Date of First Request" (indicated in the Treatment Episode in the “First / Welcoming Appointment” section)

12. Indicator 3: What do we collect?
Indicator 3: First Ongoing Service: Percentage of new persons during the quarter starting on-going service with a face- to-face appointment within 14 days of a face-to-face first appointment (assessment or welcoming session) with a professional
Where is this documented?
SUD Treatment Episode Admission Form: First Ongoing Service
How is the First on-going service determined?
SUD Claim is in “paid” or “approved for payment” status
Claim is attached to an authorization related to the SUD admission
Allow assessment code (H0001) to be counted as a first on-going service, as long as it’s not on the date of admission (to accommodate Recovery Oriented Systems of Care model)
First on-going service must be on (if not H0001) or after the date of admission
Calculations
Number of Days is calculated between the Admission Date indicated on the SUD Admission form and date of the “First On-Going Service” related to that admission
Exceptions
 Consumers who request an appointment outside of 14 days of the “Admission Date” or refused an appointment offered within 14 days of the “Admission Date” (indicated in the Treatment Episode in the “Next Appointment” section or in the SUD Admission form)
 Consumers who cancel, reschedule or no-show for an appointment scheduled within 14 days of “Admission Date” (indicated in the Treatment Episode in the “Next Appointment” section or in the SUD Admission form)

13. Frequently Asked Questions Indicator 3:
Consumer is scheduled for an appointment with a clinician within 14 days for their first ongoing service but the clinician cancels.  Clinician is unable to reach consumer to reschedule, leaves messages, including an offer date of a new appt that is still within the 14 days.  Consumer does not call back/cannot be reached despite multiple attempts.  Is this in-compliance or out-of-compliance?
Answer:  This is out-of-compliance.  Since the clinician cancelled then the obligation falls upon the agency to reschedule within the 14 days. The “Offered via voic " of a new appointment should not be counted as a viable appointment to meet the Indicator criteria or to later consider the appointment an exception.   If the appointment is confirmed but is cancelled or a no show then it would be considered an exception.  
10/26/17 QIC discussion additions: There was discussion around whether a letter sent with an appointment date to a consumer meets the definition of “offering” an appointment. After discussion, it was agreed that a letter does constitute an offered date for an appointment. It was also agreed that if an agency sends a letter as confirmation of an appointment and the client does not show, then it is also acceptable to count it as an exception.

14. Indicator 3: FAQ continued
We get a referral from a jail for a person that will be paroled soon to our area.  The jail has a re-entry project where they connect with us for services. The Jail is located out of county for us, but some of the inmates are paroled to our counties. Once we get a referral, a member our Assessment and Referral Team, goes out and completes an assessment to see if they qualify and what services they should receive when they are released. This starts the clock to then start services within 14-days, but they are often not paroled until after that, so services cannot start.  Is there some exception to use so that we are not out-of-compliance?
ANSWER: Since the consumer is unable to receive services prior to the release this would be counted as a “request outside of the 14 days” therefore, this would be an exception.
What date is used when a Jail calls to schedule an appointment after release, however the release is not for another two weeks?
ANSWER: Requested a follow up appointment outside of the 14-day period.

15. Indicator 4b: What do we collect?
Indicator 4b: Follow up within 7 days. The percent of discharges from a substance abuse detox unit who are seen for follow-up care within 7 days.
Where is this documented?
SUD Discharge Form
First follow-up service must be:
SUD Claim with “paid” or “approved for payment” status
Service Date could be after the end of the quarter (look up to 60 days forward)
Service code is not H0010 or H0012 (Detox codes) – to avoid finding the detox service that occurred on the discharge date
Calculations
Number of Days is calculated between “Detox Discharge Date” specified in the SUD Discharge form for Detox episode and service date of the first follow-up service with a substance abuse professional. If no follow-up service is found, the event is recorded as “Not within 7 days”.
Exceptions
Consumers who request an appointment outside of 7 days of Discharge Date or refused an appointment offered within 7 days of Discharge Date (indicated in the SUD Discharge Form in the “Detox Discharge” section)
Consumers who choose not to use MSHN “in-network” follow up services. 3/12/2019 Chose to not use CA/CMHSP/PIHP Services
Consumers who cancel, reschedule or no-show for an appointment scheduled within 7 days of Discharge Date
One of the “reasons for delay” is indicated on the “SUD Discharge” form in “Reason for Delay when Follow-up Treatment Admission is scheduled more than 7 Days past Detox Discharge Date” drop-down.

16. Indicator 4b: What do we collect?
The Reasons for Delay are as follows:
1.            Refused a follow up appointment within the 7-day period (requires an appointment)
2.            Requested a follow up appointment outside of the 7-day period(requires an appointment)
3.            A consumer who chose to not use a MSHN in Network SUD Provider
Consumers who choose not to use CA/CMHSP/PIHP services (effective 3/12/2019)
4.            Client chose to leave treatment (dropped out)
5.            Rescheduled the appointment within the 7-day period
6.            No showed for an appointment within the 7-day period
Date of Appointment and Provider is not required if one of the following Reasons for Delay is selected (required otherwise):
Consumers who choose not to use CA/CMHSP/PIHP services
Client chose to leave treatment (dropped out)
Note: Must come back into Discharge to update the Status of the Appointment 

17. Indicator 4b: FAQ
A consumer has been discharged from services as a result of not following facility rules. Is this an exception? Or Out of compliance? What should the “Reason for Delay” be?
ANSWER: The reason for delay is “A client chose to leave services.” This would be considered an exception.
A resident leaves against staff advise? What should the “Reason for Delay” be?
ANSWER The reason for Delay is “Client chose to leave treatment (dropped out)” . this is considered an exception.
A resident refused to schedule a follow up appointment and indicates they will call to schedule an appointment when they are home. What should the “Reason for Delay” be?
ANSWER: The reason for delay is “Refused a follow up appointment within 7 days” However only if it is supported by documentation of an appointment offered within the 7 days. If an appointment has not been offered, it would be out of compliance. It is staff’s responsibility to offer an appointment.
 ANSWER: the reason for Delay should be “Consumer who choose not to use CA/CMHSP/PIHP services (3/12/2019)” If they refuse services.

18. Indicator 4b FAQ continued
 An appointment is not scheduled with a provider. Staff document that the consumer will attend AA. Is this an exception? What should the “Reason for Delay” be?
ANSWER: The reason for delay would be “A consumer who chose to not use a MSHN in Network SUD Provider/Consumer chose not to use CA/CMHSP/PIHP”. This would be an exception. 
 A consumer is being discharged and referred for residential treatment. They are put on a waiting list. How should this be documented?
ANSWER: An attempt should be made to locate a residential program that does not have a waiting list to ensure continuity of treatment. Those with Medicaid or HMP must not be put on a wait list. Alternate treatment options should be made available.
If the consumer does not want a different residential program and request the wait list. This would be documented by the reason for delay “Consumer chose not to use CA/CMHSP/PIHP”
 If you offer an appointment with a different provider and they chose to not accept the appointment, you must document the appointment offered and indicate “Refused a follow up appointment within the 7-day period “

19. Thank You!
Questions????