FY17 18 MEDI-CAL SPECIALTY MENTAL HEALTH

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Behavioral Health Concepts, Inc.5901 Christie Avenue, Suite 502Emeryville, CA 17–18MEDI-CAL SPECIALTY MENTAL HEALTHEXTERNAL QUALITY REVIEWALAMEDA MHP FINAL REPORTPrepared for:Review Dates:California Department ofHealth Care Services (DHCS)October 31 - November 2, 2017

-2-TABLE OF CONTENTSALAMEDA MHP SUMMARY OF FINDINGS . 5Introduction . 5Access . 5Timeliness. 6Quality . 6Outcomes . 7INTRODUCTION. 8Validation of Performance Measures . 8Performance Improvement Projects . 9MHP Health Information System Capabilities . 9Validation of State and County Consumer Satisfaction Surveys . 9Review of Recommendations and Assessment of MHP Strengths and Opportunities . 9PRIOR YEAR REVIEW FINDINGS, FY16-17 . 11Status of FY16–17 Review of Recommendations . 11Changes in the MHP Environment and Within the MHP—Impact and Implications . 14PERFORMANCE MEASUREMENT . 16Total Beneficiaries Served . 17Penetration Rates and Approved Claim Dollars per Beneficiary. 17High-Cost Beneficiaries . 21Timely Follow-up After Psychiatric Inpatient Discharge. 22Diagnostic Categories . 23Performance Measures Findings—Impact and Implications . 24PERFORMANCE IMPROVEMENT PROJECT VALIDATION . 26Alameda MHP PIPs Identified for Validation . 26Clinical PIP—Developing Culturally Informed Quality Psychiatric Protocols for Latinos . 28Non-clinical PIP—High Cost Utilizers . 30PIP Findings—Impact and Implications . 31PERFORMANCE AND QUALITY MANAGEMENT KEY COMPONENTS . 32Access to Care . 32Timeliness of Services . 34Quality of Care . 36Key Components Findings—Impact and Implications . 42CONSUMER AND FAMILY MEMBER FOCUS GROUPS . 44Consumer/Family Member Focus Group 1 . 44Consumer/Family Member Focus Group 2 . 45Consumer/Family Member Focus Group Findings—Implications . 47INFORMATION SYSTEMS REVIEW . 48Alameda County MHP CalEQRO ReportFiscal Year 2017–18

-3Key Information Systems Capabilities Assessment (ISCA) Information Provided by the MHP . 48Summary of Technology and Data Analytical Staffing . 49Current Operations . 50Priorities for the Coming Year . 52Major Changes Since Prior Year . 52Other Significant Issues . 53Plans for Information Systems Change . 53Current Electronic Health Record Status. 54Personal Health Record . 54Medi-Cal Claims Processing . 55Information Systems Review Findings—Implications . 56SITE REVIEW PROCESS BARRIERS. 57CONCLUSIONS . 58Strengths and Opportunities . 58Recommendations. 60ATTACHMENTS . 62Attachment A—On-site Review Agenda . 63Attachment B—Review Participants . 64Attachment C—Approved Claims Source Data . 72Attachment D—PIP Validation Tools . 73Alameda County MHP CalEQRO ReportFiscal Year 2017–18

-4-LIST OF TABLES AND FIGURESTable 1: MHP Medi-Cal Enrollees and Beneficiaries Served in CY16, by Race/Ethnicity . 17Table 2: High-Cost Beneficiaries . 21Table 3: PIPs Submitted by MHP . 26Table 4: PIP Validation Review . 27Table 5: PIP Validation Review Summary . 28Table 6: Access to Care Components . 32Table 7: Timeliness of Services Components . 34Table 8: Quality of Care Components. 36Table 9: Distribution of Services, by Type of Provider . 48Table 10: Summary of Technology Staff Changes . 49Table 11: Summary of Data Analytical Staff Changes . 50Table 12: Primary EHR Systems/Applications . 51Table 13: EHR Functionality . 54Table 14: MHP Summary of Short Doyle/Medi-Cal Claims . 55Table 15: Summary of Top Three Reasons for Claim Denial . 56Figure 1A:Figure 1B:Figure 2A:Figure 2B:Figure 3A:Figure 3B:Figure 4A:Figure 4B:Figure 5A:Figure 5B:Overall Average Approved Claims per Beneficiary, CY14-16. 18Overall Penetration Rates, CY14-16 . 18Foster Care Average Approved Claims per Beneficiary . 19Foster Care Penetration Rates, CY14-16 . 19Latino/Hispanic Average Approved Claims per Beneficiary, CY14-16 . 20Latino/Hispanic Penetration Rates, CY14-16 . 207-day Outpatient Follow-up and Rehospitalization Rates . 2230-day Outpatient Follow-up and Rehospitalization Rates. 22Beneficiaries Served, by Diagnostic Categories, CY16 . 23Total Approved Claims by Diagnostic Categories, CY16 . Error! Bookmark not defined.Alameda County MHP CalEQRO ReportFiscal Year 2017–18

-5-ALAMEDA MHP SUMMARY OF FINDINGSBeneficiaries Served in Calendar Year 2016 22,481MHP Threshold Language(s) Cantonese, Mandarin, Spanish, VietnameseMHP Size LargeMHP Region Bay AreaMHP Location OaklandMHP County Seat OaklandIntroductionAlameda is a large Bay Area mental health plan (MHP), serving a county that is intensely urban, andthe seventh most populous in the state. The county has been described as the fourth most diversein the country, and one of the most diverse in the Bay Area. Oakland is the county seat, and thelocus of operation for the MHP. The county is also home to significant higher education resourcessuch as the University of California at Berkeley.During the FY 2017-2018 (FY17-18) review, California External Quality Review Organization(CalEQRO) reviewers found the following overall significant changes, efforts, and opportunitiesrelated to access, timeliness, quality, and outcomes of the Mental Health Plan (MHP) and itscontract provider services. Further details and findings from EQRO-mandated activities areprovided in this report.AccessThe In-Home Outreach Team (IHOT) expansion occurred in the summer of 2016, providingengagement services with peer specialists, clinicians and others to seek to divert those who arereluctant to participate in outpatient services, and failing that, are evaluated for Assisted OutpatientTreatment (AOT). An outpatient conservatorship process has been established to support that legaltrack without requiring the person to be on inpatient status.The St. Rose telemedicine pilot and the Welfare and Institutions Code (WIC) 5150 certification ofstaff for the process of involuntary hospitalization, enables emergency department (ED) consumersto be evaluated by a board-certified psychiatrist and treatment initiated without necessitating atransfer to John George Hospital. The ED may now establish a protocol for the WIC 5150 process.This innovation supports greater decentralization of care, and improves workflow for the crisissystem.Alameda County MHP CalEQRO ReportFiscal Year 2017–18

-6The Alameda County Care Connect (AC3) Whole Person Care project provides integrated care tothose with multiple psychiatric, medical and social needs, and is being supported through the Officeof the Medical Director and the use of Plan, Do, Check, Act (PDCA)/Plan, Do, Study, Act (PDSA)processes to address and resolve barriers to care.The diverse populations that live in Alameda County are met with Culturally and LinguisticallyAppropriate Services (CLAS), which includes trainings, standards, and annual review by theNetwork Office to assure compliance. Numerous CLAS initiatives exist, and include substance usedisorder focus, African-Americans, Native Americans, Latinos, Asian Pacific Islanders (API), lesbian,gay, bisexual, transgender, questioning, intersex, and two spirit (LGBTQI2S), Afghan and other newimmigrants. Efforts to address criminal justice re-entry individuals also exists, with targets ofminimum employment levels established by county government.TimelinessThe MHP still experiences challenges in tracking all aspects of timeliness with sufficient scope tocapture contract providers as well as directly operated programs. For timeliness, the MHP isawaiting the client and services information (CSI) based system under development by the State ofCalifornia Department of Health Care Services (DHCS). Current timeliness data is limited to directMHP services and does not include many children’s points of access, a very small component ofinitial contacts, and other metrics, such as initial psychiatry service.The MHP has discussed and set goals for timeliness metrics in the Quality Improvement Work Plan,but due to lack of data, program enhancements, such as outreach teams, developed withstakeholder input have been the most effective proxy for improving timeliness and access.QualityTurnover in numerous key leadership positions has occurred during this last year, including theresignation of the Behavioral Health Director in December of 2016. That position has been coveredon a temporary basis by a number of interim directors, culminating in the recent hire of yet anotherinterim director through the California Institute of Behavioral Health Services (CIBHS). Therecruitment and hiring of a permanent director is pending following the hire of a Health CareServices Agency Director.Numerous other leadership position retirements and changes have occurred, in addition to areorganization of service divisions. At the Behavioral Health division level, the Child and YoungAdult System of Care was created from the merger of Transitional Age Youth (TAY) with theChildren’s system, and the Adult and Older Adult System of Care (AOASC) resulted from thecombining of those previously separate divisions.While some continuity and institutional knowledge has been retained by the remaining keyleadership staff such as the Medical Director and Quality Management Director, the scope of thesechanges has inevitably impacted departmental vision and planning. A new permanent director isAlameda County MHP CalEQRO ReportFiscal Year 2017–18

-7needed to create, with stakeholders, a vision of the future, and prioritize response to currentchallenges, and fill the remaining leadership positions.The MHP has achieved significant improvements in the area of program compliance. The MHPexperienced a 90% compliance rate from the DHCS triennial outpatient Mental Health Plan (MHP)consolidated specialty mental health services system review conducted in 2017, an impressiveimprovement over the prior 62% in 2014. On the chart review component, the servicedisallowance rate was 16% versus the prior 42%. In October 2017, the inpatient review resulted inpreliminary findings of 81% compliance versus the prior 32%. Achievement of this level ofimprovement indicates a largescale training and monitoring effort was put into place and was veryeffective.OutcomesThe use of the Child and Adolescent Needs and Strengths (CANS) survey and the Adult Needs andStrengths Assessment (ANSA) has been implemented, with more than 11,000 instruments availablefor aggregate analysis. These instruments are also incorporated in standards for assessment andtreatment planning. These instruments reside in Objective Arts software, which is available to bothdirectly operated and contract providers. The MHP has replaced the EMANIO dashboard withYellowfin to improve system access to data on a variety of parameters and provides quick access tosystem information.Improved consumer outcomes are targeted by a number of the engagement approaches alreadymentioned, as well as the disability benefits advocacy program. The intent is to offer individualswithout benefits financial support while navigating the application, and where necessary, appealprocess. The interim cash assistance subsidy is associated with decreased re-incarcerations, crisisevents, and rehospitalizations. Additionally, the program reduces the financial drain on the publicassistance budget of the Social Services Department.Alameda County MHP CalEQRO ReportFiscal Year 2017–18

-8-INTRODUCTIONThe United States Department of Health and Human Services (HHS), Centers for Medicare andMedicaid Services (CMS) requires an annual, independent external evaluation of State MedicaidManaged Care programs by an External Quality Review Organization (EQRO). External QualityReview (EQR) is the analysis and evaluation by an approved EQRO of aggregate information onquality, timeliness, and access to health care services fur

FY17–18 MEDI-CAL SPECIALTY MENTAL HEALTH EXTERNAL QUALITY REVIEW ALAMEDA MHP FINAL REPORT Behavioral Health Concepts, Inc. 5901 Christie Avenue, Suite

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