Access Redesign Quality Improvement InitiativeCommunity Behavioral Health Organization

2010 Participation Application

Please complete the information requested on page 5 of this Participation Application and return it by Friday, May 7th, 5:00 pm eastern, to RebeccaF@thenationalcouncil.org.

Project OverviewMultiple years of state budget cuts, along with increased demand for services due to the recession, are putting a strain on the public behavioral health safety net in this country. Since 2009, states have been forced to make $1.6 billion in cuts to mental health funding and cuts to addiction services reflect a similar pattern. In this financial climate, community behavioral health organizations (CBHOs) are making every effort to provide high quality services to children and adults with mental health and substance use problems and seek clear strategies to streamline client access and other organizational processes.   At the same time, the implementation of the Mental Health Parity and Addiction Equity Act and coverage expansions that will occur as a result of healthcare reform will increase the number of persons seeking treatment from community-behavioral healthcare organizations. In response to these dynamics, the National Council has developed and managed multiple year-long projects aimed at reducing wait times and costs associated with treatment initiation. By utilizing real-time client data, participating CBHOs are empowered to critically analyze their access processes to create efficiencies and better serve clients.

It is the National Council’s pleasure to announce the availability of funding to support a focused Access Redesign Quality Improvement Initiative to be conducted with up to 40 organizations in two states.

Access Redesign Project ObjectivesThe objectives of the initiative are to identify up to 40 community behavioral healthcare organizations in two states that will agree to design and implement strategies that will:

Assess current intake and assessment process and engage in a re-design effort to reduce client wait times

Develop cost effective intake and assessment processes that are compliant with federal, state and regulatory requirements and that are financially viable.

Better engage clients and thus reduce no-show and cancel rates. 

The National Council has selected MTM Services to manage and implement this project. The Consultants from MTM Services will work with the selected organizations to accomplish the identified goals by:

         Assessing each organizations access to care process and offering suggestions for improvement

         Providing successful models used by other CBHOs to make access to care more timely

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Identifying a standardized access to care process flow which includes costing awareness and recommendations for implementation.

         Identifying ability to replicate in other states the positive access to care models implemented

Access Redesign Project Scope of WorkThe scope of work for the Access Redesign Quality Improvement Initiative is:

1. Develop application process for statewide community provider trade associations and/or CBHO member organizations to complete to confirm their interest in participating in this initiative.

2. Based on grant participation request applications received, identify two different state behavioral health trade association and/or up to twenty CBHOs within each selected state that meet the selection criteria identified in item four below (total of up to fourty CBHOs will be funded by the grant funds available).

3. Sponsor a 3 hour Internet learning conference with each state to provide a specific orientation and access to care solution tool development for management team representatives from each participating CBHO. The curriculum focus for the learning conference will be:

a. Provide an overview of the initiativeb. Identify specific measurement processes/costing tools that will be used to identify

current access to care challenges within each CBHOc. Identify the process that will be used for each CBHO to design a more timely and cost

effective standardized access to care process flowd. Identify case study access to care solution models developed and implemented by

other CBHOs to prevent each CBHO from having to “start over”

4. Provide additional Internet based meetings for participating CBHOs with MTM Services consultation team members to:

a. Identify/design current process flows (based on current access and intake processes) being used within each CBHO including costing for the flows identified

b. Address the system issues that keep staff from being able to focus on the organization’s clients. The main strategies identified during the other initiatives that will be utilized to achieve these changes include:

i. Concurrent Documentation : Eradicating post session documentation time while increasing client buy-in for their care by involving them more and creating documentation that is much more compliant to assist with auditing concerns.

ii. Walk-In Models : Offering more expedient access to care which helps increase engagement by reducing wait times and works to eradicate/greatly reduces no shows.

iii. No Show Management : Work through policy changes and counseling clients to increase show rates/client engagement.

iv. Maximizing Staff Productivity / Employee Engagement : Helping direct service staff maximize their time with clients by reducing the amount of time they spend performing non-billable activities.  

c. Develop a standardized process flow for each center that will minimize the staff and client time required and a costing summary to support newly developed process flow.

5. Provide an onsite closing learning conference within each state and all CBHOs participating in the initiative to summarize the findings and recommendations for the participating state trade association(s) and/or the respective CBHOs.

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Selection Process and Commitment CriteriaTo accomplish the above objectives and scope of work, the National Council and MTM Services will select two state behavioral health trade associations and/or up to twenty CBHOs within each state through a competitive application process based on the following minimum participation criteria:

1. Recognition of timely access to care challenges in the state and within the member CBHOs

2. Commitment by the Executive Director of the state behavioral health trade association and/or the Chief Executive Officer/management team of each member CBHO to participate in the initiative through support of the following:

a. Agree to implement a local Access Redesign Improvement Team consisting of a four to six person team that will provide adequate time, energy and enthusiasm to participate in this CQI process.

b. Agree to work with the consultation team and the National Council to define the access to care challenges and generate process flow solutions using case studies or uniquely developed solutions.

c. Agree to participate in a half-day learning session during the first week of June 2010 to provide orientation about the project and develop the final components of the project.

d. Agree to participate in a formal “Intake Process Flow Analysis” and “Access to Care Cost Finding Process” in June 2010 to identify bottlenecks, time parameters, process cost, etc.

e. Agree to design a standardized access to care process flow and modify intake processes to accommodate more timely and efficient access to care.

3. Arrange and contribute local state level matching funds for the access redesign initiative on a local contribution of five hundred dollars for each of the 20 organizations that will take part in this initiative. Therefore, the total local state match contribution requirement will be $10,000 per state ($20,000 collective match for both states). Additionally, each state can increase the number of participating CBHOs from a total of up to twenty-five per state upon payment of $2,500 per additional CBHO that desires to participate which will be paid in addition to the state match indicated above.

4. Consent to and support publishing the findings of the initiative.

5. CBHOs must have the capacity to participate in Internet based meetings including an adequate high speed Internet connection, conference phone equipment and an LCD Projector.

Benefits to Participating Organizations

Participating organizations will receive the benefit of intense consultation by expert national consultants to assist in the achievement of project objectives. All consultant fees and expenses will be covered. (See Appendix A on Page 6 for examples of the outcomes from the previous work completed)

Participating organizations will have access to specialized tools and strategies that they can use beyond the duration of the project.

Participating organizations will receive consultation support to enhance access to care timelines/cost effectiveness and costing of access to care processes.

Statewide access to care timeliness should improve

Please complete the information requested below on page 5 and return it by May 7th, 2010, 5:00 pm eastern, to RebeccaF@thenationalcouncil.org. By signing and submitting the application that follows, the organization is indicating that it has read and agrees to the project commitments outlined above.

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Participation Application Organization Name:      

Organization Type Statewide Trade Association Group of CBHOs

Mailing Address:      

City, State and Zip: City:       State:       Zip Code:      

Contact Person/Title: Contact Person:       Title:      

Phone/Fax/Email:Phone Number:

     

Fax Number:

     

Email:

     Access Redesign Initiative CBHO Participant List

Please attach a list of the CBHOs, the primary contact person, his/her phone number and email address that have been identified to participate in this initiative

Signed By:

     

Title:

Executive Director

Date:

     

Overview of Access To Care Needs SummaryWhat was the average CBHO’s no show / cancellation percentage rate in the previous fiscal year for:

Intake/ Assessment Appointments?

On Going Appointments?

Percentage

     

     

What is the average wait time across the state (in days) from an adult client’s first call for services to Intake/ Assessment?

Days

     

What is the average wait time across the state (in days) from a child/adolescent client’s first call for services to Intake/ Assessment?

Days

     

Additional Information/CommentsPlease tell us why the CBHOs in your state would like to participate in this improvement project and/or provide any other supportive comments:      

Please answer the following questions:

1) Has your state/organization undergone clinical process improvement in the past? Please describe your experiences with this, including organizational and/or health outcomes.      

2) What do you currently see as organizational factors that are influencing your no-show rate and/or wait time for appointments?      

3) What policy or advocacy action do you anticipate being able to take as a result of participation in this project?      

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Verification of Commitment: The attached list of CBHOs commit that they will individually and collectively support the Organizational Commitments as outlined in numbers 1 – 5 above.

Appendix “A”

2007 – 2009 Access and Retention / Access Redesign

Quality Improvement Initiatives

Prepared and Presented By:

M.T.M. Services

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Access and Retention / Access RedesignQuality Improvement Initiative Outcomes

Overview of Initiative

Since September of 2007, The National Council has developed and managed multiple Learning Collaborative opportunities across the country. The first 12 month Access and Retention collaborative included four community behavioral healthcare providers located in Oregon, Florida, New Mexico and Maine. The second 12 month Access and Retention collaborative included ten community behavioral healthcare providers located in Oregon, Florida, New Mexico, Pennsylvania, Arkansas, Illinois, Georgia, New Jersey, and Colorado. The third 6 month Access Redesign collaborative included fifty community behavioral healthcare providers located in Ohio, Florida, and Wyoming. All of these collaborative projects focused on rapid cycle change initiatives that worked to improve access to care timelines, enhance client engagement and increase the cost effectiveness of the services delivered. The outcomes from these collaborative projects offers a clear understanding of the core challenges that CBHOs face to improve access to care, but more importantly how to overcome them.

Access Redesign Quality Improvement Initiative Results – Executive SummaryThe National Council selected MTM Services to manage and implement this project. TheConsultants from MTM Services worked with change teams from 48 organizations selected from 3different states from June of 2009 through February of 2010 to accomplish the identified goalsbelow:

Assess current models of access to care process flows used by the up to fifty participating CBHOs within each state and identify the types of barriers to time effective access

Increasing awareness of processes/practices that may improve access to services

Organizational assessment and identification of current access to care process flow barriers to serve as targets for change. This will include analyses of “intake flow processes”, and costing development for the current process flows within each CBHO.

Identification of a standardized access to care process flow including costing awareness.

Identify ability to replicate in other states the positive access to care models implemented

This report will highlight the specific techniques used to generate the results of the organizational change team’s work as seen in the project summary report (Figure One) below:

Total Number of Processes

Total Staff Time (Hrs)

Total Client Time without Wait-time

(Hrs)Cost for Process

Total Wait-time (Days)

Old Process Averages: 5.70 5.06 3.65 (331.63) 49.25

New Process Averages: 5.04 3.34 2.99 (210.20) 29.31

Savings: 0.66 1.73 0.65 $121.43 19.94

Change %: 12% 34% 18% 37% 40%

3,843

$466,642.00

$5,599,704.00

Avg. Number of Intakes Per Month

Monthly Savings:

Annual Savings:

www.mtmservices.org© Copyright 2008

Figure One

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Total Annual Savings : The team’s efforts produced an average annual savings of $199,989.43 per agency annually based upon the changes that are being or have already been implemented in their access models. The changes created a 34% reduction in staff time and an 18% reduction in the client time required to complete the average Access process. This savings is based upon the comparison reports submitted by 28 grant Organizations from Florida (7), Ohio (12), & Wyoming (9); the total annual savings for these organizations is $5,599,703.99. Extrapolating that average annual savings across all 48 organizations would generate a total annual savings of $9,599,492.64.

Total Wait-time (Days) : The team’s efforts also produced a significant 40% reduction in the total amount of wait-time incurred by the average client going through their access models. During this project, we were able to establish a direct link between a client’s wait time and their level of engagement in the treatment by reviewing over 17,000 service events that took place during the timeframe of the grant. The correlation showed us that for each day that the average client waited for their assessment appointment, they were 1% less likely to show up for that assessment appointment. (Example: A client waiting 60 days is 60% less likely to show up for that assessment appointment.)

Access and Retention Initiative ResultsThe four CBHOs who took part in the first Access and Retention identified during a two day learning conference important collaborative team objectives that were determined to be core quality improvement initiatives that are needed to improve access to care. Additionally, the learning collaborative developed specific access to care outcome measures, measurement obstacles and impact strategies (Figure Two below) to provide a support framework to attain improved access to care within their community programs.

Figure Two:

Access and Retention Project Outcome Measures, Measurement Obstacles, Impact Strategies

Access and Retention Dimension

Potential Measures(baseline and change)

Challenges Potential Strategies

ACCESS Wait Lists Days to Service Entry

Points (e.g. first call to intake; intake to assessment; assessment to therapy and psychiatry)

Definitions

Ability to Measure

Intake Process Improvement

Adequate Scheduling Rate

Priority Based Intake Criteria

To support uniform access to care outcome measurement, the learning collaborative agreed on the need to create performance standard definitions, which provides an ability to develop measurement tools to support improvements. Figure Three provides the agreed upon six Access Measures that each collaborative member began to measure effective December 1, 2007.

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Figure Three

The MTM Services project management faculty developed a uniform access to care measurement capacity through the use of a newly designed First Call to First Appointment measurement report as identified in Figure Four. The purpose of this report is to provide each collaborative member the ability to track all new clients beginning December 1, 2007 from his/her first call for services to the first available Intake appointment. The measurement tool also provides the ability to measure the first offered appointment date and the actual appointment date along with measurement of client no shows and client cancellations.

Secondly, the measurement tool tracks the access for clients that kept his/her Intake appointment to the first treatment appointment that would typically be used to develop a treatment plan. Again, the measurement tool provides the ability to record the first available appointment date and the actual appointment date along with measurement of whether the client kept, canceled or no showed for the first treatment appointment.

Thirdly, the measurement tool tracks the access for clients that kept his/her first treatment appointment to the first appointment with a psychiatrist or advanced nurse specialist along with the disposition of the scheduled appointment.

The measurement outcomes from collaborative members has been very revealing regarding the level of no show/cancelation activity in correlation to the wait time in days between each of the face to face service opportunities.

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Figure Four

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Access delays can be shortened through identification of excessive and redundant data collection during the intake process and through identifying access to care process flows that are focused on serving the system which create timely access barriers rather than serving the clients.

Two measurement techniques are being used with community behavioral healthcare providers to objectively identify access to care challenges as follows:

Data Mapping: Typically, CBHOs have determined individual center access to care documentation needs through decades of adding new documentation data element requirements on top of the historically collected data elements. This cumulative process has created significant information collection challenges.

Case Study of Exhaustive Data Collection Model: M.T.M. Services provides project management and consultation services for the Access and Retention Grant. In their work with CBHOs they provide data mapping of the number of data elements each center collects from the first call for services through the completion of the diagnostic assessment/intake. A recent data mapping effort for a community provider produced the following outcomes:

1. Total number of data elements collected in the process = 1,8542. Total number of redundant data elements collected in the process = 5643. Total number of data elements really required for access to treatment planning

processes = 9574. Total staff time required to administer the original flow process = Four hours ten

minutes5. Total staff time required to administer the revised flow process = One hours

twenty minutes

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This level of staff time efficiency per admission in the Intake process can significantly reduce the wait time for clients into treatment. As indicated above, experience indicates that the shorter the wait time from first call for help to the face-to-face diagnostic assessment/intake the lower the no show/cancellation rates. Figure Five provides a sample of how data mapping is accomplished with CBHOs.

Figure Five:Assessment Data Point Collection/Mapping

Process Flows: The second phase of the solution plan to decreasing the bottlenecks for

clients to enter services is supported by the development of process flow charts of the current access/intake procedures. This level of consultation has produced an awareness that the process flows vary within individual programs/units/clinic locations within one community provider and vary dramatically from provider agency to provider agency.

The purpose of the process flow effort is to bring an objective reality to a subjective process. An important part of the process flow development is to focus on identification of specific barriers to timely access such as:

1. Access to care dependence on one staff member which results in significant delays when that specific staff person is not on duty

2. Specific requirements to call the client back because the process is not empowered to make a decision about access to care when the client initially calls the center for help. Trying to reconnect with clients can be difficult based on lack of phone accessibility or transitioning living situations and locations.

3. Redundant work flow processes

Figure Six provides an example of the level of time delay into services that were identified. The next step is for local staff to develop a more time, effort and cost effective access to care flow process and use a Rapid Cycle Change model to implement the new process flow.

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Figure Six

With the development of identified solutions to access to care timeliness challenges came the need to ensure that solutions were not just discussion points, but were rather action items that could be operationalized at the CBHO staff level to ensure implementation in a timely manner. Figure Seven provides a sample of the actual Rapid Cycle Change Implementation Plan developed by Learning Collaborative member Carlsbad Mental Health Center. The initial focus of the plan was to enhance access to care and address the need to manage the schedule rates differently. As a result of the

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solution develop efforts that the Rapid Cycle planning efforts provided; Carlsbad Mental Health Center designed a same day access to care model that supported the client entering care the same day he/she called the center for help with a masters level clinician intake service being provided.

Figure Seven

The access to care standards developed by the Carlsbad Team included the following benchmarks:1. Same day intake/diagnostic assessment provided by a masters level clinician on the day the

client calls/walks into the center seeking services2. A face to face therapy session with a masters level clinician within ten days from the initial

call/walk in seeking services3. A face-to-face medical service with a psychiatrist or an advance practice nurse within ten

days from the initial call/walk in seeking services.

The positive Access to Care outcomes achieved by Carlsbad Mental Health Center are identified in Figure Eight which indicate that the 10 day to standard from first call/walk in seeking service to a masters level therapy session and a medical service was achieved in November 2008.

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Figure Eight:

The Access and Retention Grant initiative provided an excellent opportunity to develop and implement objective measurement tools that have demonstrated the significant challenges CBHOs are experiences when they focus on the need to enhance access to care timelines. The grant also provided an awareness of solution options that can be used by CBHOs to provide favorable outcomes.

Proposal to Enhance the Access to Care InitiativeThe Access and Retention Grant Learning Collaborative in 2007 - 2008 provided an excellent opportunity to objectively assess the barriers to timely access to care and develop solutions to the identified challenges. The focus in the grant initiative shifted from trying to address access to care challenges from a retrospective solution model to a more concurrent process/data measurement and prospective solution development and implementation approach.

Additionally, the level of information gathering, solution development and implementation achieved has provided a further awareness that the solution processes that have been developed for CBHOs participating in the Access and Retention Grant can be replicated within the service delivery systems of a larger number of CBHOs.

Therefore, the funder has agreed to support a two state Access Redesign Quality Improvement Initiative that further uses and develops the access to care enhancement efforts.

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Access Redesign Quality Improvement Initiative Support TeamThe National Council staff leadership for the initiative will be provided by Linda Rosenberg, MSW, President and CEO and Chuck Ingoglia, MSW, Vice President, Public Policy.

Further, the National Council has engaged the MTM Services consultation team as the primary consultants for the initiative. The MTM consultation team members available for this initiative will be:

David Lloyd, Founder and President of MTM Services and Senior Consultant for the

National Council Scott Lloyd, Vice-President of MTM Services and Consultant for the National Council Bill Schmelter, Ph.D., Lead Clinical Consultant for MTM Services and Consultant for the

National Council Randy Love, Chief Information Officer for SPQM™ Data Reporting Services Michael Flora, M.B.A., M.A.Ed., L.P.C.C., L.S.W., Lead Operations Consultant for MTM

Services and CEO of the Ben Gordon Center in DeKalb, IL Willa Presmanes, M.Ed., M. A., Medical Necessity/Utilization Management Expert and Co-

Author of the DLA-20 (Daily Living Activities) functionality scale

Conclusions

The level of access to care service delivery process change efforts identified in this proposal are critically important to positively impact timely access to care for clients. CBHOs nationwide have attempted to solve access to care challenge for a number of years without achieving a level of improvement that is needed. This proposal asks for support to provide a statewide quality improvement initiative using a more concurrent and prospective solution focus which we believe will have better outcomes than have been experienced in the past. Thank you for your consideration of this proposal.

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