access redesign state grant final report 5-24-11 · final report may 24, 2011 version access...

Prepared and Presented By:

M.T.M. Services P. O. Box 1027

Holly Springs, NC 27540 Phone: 919-387-9892

Together…we can make a difference!

Final Report May 24, 2011 Version

Access Redesign Quality Improvement Initiative # 2

Access Redesign Quality Improvement Initiative

Submitted By: M.T.M. Services

Executive Summary The National Council selected MTM Services to manage and implement this project. The Consultants from MTM Services worked with change teams from 45 organizations selected from Pennsylvania, Minnesota and Washington State from June of 2010 through February of 2011 to accomplish the identified goals below: • 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 teams’ work as seen in the project summary report (Figure One) below. This report is a representative sample of 13 organizations that were able to complete the full change process in the time allocated, while others are finishing now and report similar/better results as they move forward:

Figure One

• Total Annual Time Savings: The teams’ efforts produced significant improvements based upon

the changes that are being or have already been implemented in their access models. The changes created a 40% reduction in staff time, up 6% when compared to the last Access Redesign Grant (AR1) and a 25% reduction in the client time required to complete the average Access process, up 7% compared to AR1.

• Total Annual Monetary Savings: This savings comparison report submitted by 13 grant Organizations shows a total annual savings for these organizations is $2,664,611.04 or $222,050.92 per agency, up from the $199,989.43 per agency that took part in AR1.

Total Staff Time (Hrs)

Total Client Time without Wait-time (Hrs) Cost for Process Total Wait-time

(Days)

Old Process Averages: 4.83 2.76 ($355.13) 52.37

New Process Averages: 2.91 2.08 ($221.61) 24.78

Savings: 1.93 0.68 $133.52 27.59

Change %: 40% 25% 38% 53%

1,663.00

5%

$222,050.92

$2,664,611.04

$222,050.92 Average Savings Per Center:

Access Comparison Worksheet

Avg. Number of Intakes Per Month

Intake Volume Change %:

Monthly Savings:

Annual Savings:www.mtmservices.org© Copyright 2008



Extrapolating that average annual savings across all 50 organizations would generate a total annual savings of $11,102,546.00.

• Total Wait-time (Days): The teams’ efforts also produced a significant 53% reduction in the total amount of wait-time incurred by the average client going through their access models, up 13% when compared to the AR1 numbers. As can be seen in Figure Two below, during these grant projects we have been able to establish a direct link between the client’s wait time and his/her level of engagement in the treatment by reviewing over 22,000 service events that took place during the time frame of the grants:

Figure Two

The correlation shows us that even if seen the same day, a client has roughly a 10% chance of not keeping their appointment; however for a client that has to wait even one day, the chance that they will not show up for their appointment jumps to almost 25%. When looking over the long term trend line, clients are 1% less likely to show up for their assessment appointment for every day that the client has to wait for their assessment appointment. (Example: A client waiting 60 days is 70% less likely to show up for that assessment appointment.)

Ability to Replicate Results – The change teams’ efforts and results relied mainly upon the following change concepts that MTM’s consultants have utilized across the country. Based upon MTM’s experience in quickly and successfully implementing these change concepts with organizations across the country (MTM has worked with over 500 organizations in 40 states), we are confident that we can replicate our results:



• Collaborative Documentation: Eradicating post session documentation time while increasing

client buy-in for their care by involving them in the creation of their clinical documentation.

o Streamlining Documentation: Helping organizations reduce their documentation requirements by focusing on the removal of repetitively captured data elements, data elements that are not required by funding or accreditation organizations, and/or changing the answer formats utilized to capture their data elements to reduce overall documentation time.

• Walk-In Models: A zero no show model, that is helping organizations across the country offer

more expedient access to care and increased engagement. This technique has been extremely successful and the second most popular change strategy utilized by teams, second only to Collaborative Documentation.

• No Show Management: Utilizing policy changes, policy enforcement, and/or reminder programs

to help clients increase their show rates and engagement levels.

• Utilization Review and Utilization Management: Helping organizations across the country establish the proper episode of care for each client that is tied to a functional scale to assure a consistent application of services to each client.

All of the change techniques above helped the teams work to maximize the productivity of their direct care staff, but to see the exact changes that were utilized most often please refer to Figure Three below:

Figure Three

These increases in productivity have allowed the direct service staff to maximize their time with clients by reducing the amount of time they spend performing non-billable activities. Therefore everyone is satisfied with the changes, as the numbers from the grant efforts show in Figure Four:

#

Total # of Organizations at Start 45 %

Total # of Organizations at the Finish 34 76%

Status of Change Strategy Initially Selected % Piloted % Implemented %

Collaborative Documentation 33 97% 31 91% 11 32%

Walk-In Models 30 88% 21 62% 3.5 10%

No Show Models 16 47% 8.5 25% 4 12%

Utilization Review and Utilization Management 13 38% 5 15% 2 6%



Figure Four

Summary or Achievements:

• Total Annual Savings: The efforts of the teams from both of the Access Redesign Grants produced an average annual savings of $242,813.93 per agency annually based upon the changes that are being or have already been implemented in their access models. The changes created a 35% reduction in staff time and a 19% reduction in the client time required to complete the average Access process. The total annual savings for these organizations is $11,655,068.79.

• Total Wait-time (Days): The team’s efforts also produced a significant 47% reduction in the total amount of wait-time incurred by the average client going through their access models.

Overview of Each State’s Change Efforts The effort to assess all of the organizations’ current access to care processes required the production of 207 individual process flow charts. These flow charts chronicled all of the process steps necessary to take a client from their first call through their Assessment and Treatment Planning Appointments and then their arrival at their first service appointment. By entering the details and calculating the reality of their access systems, teams were able to understand the size of the challenge at hand and therefore make the changes needed to improve their systems. Here is a breakdown of the average starting points and the average changes achieved per state:



(Days)



Savings: 1.67 0.63 $122.39 23.72

Change %: 35% 19% 37% 47%

7,935.65

15%

$971,255.73

$11,655,068.79

$242,813.93

The sample size of this change information is taken from 48 organizations in 14 states.

Average Savings Per Center:

Access Comparison Worksheet

Avg. Number of Intakes Per Month

Intake Volume Change %:

Monthly Savings:

Annual Savings:www.mtmservices.org© Copyright 2008



Wait Times in Days for All Organizations (Yellow is the Average)

Figure Five

As you can see in Figure Five, wait times for clients ranged greatly from a low of 2 up 299.8 days. This range has been pretty consistent in all of our redesign initiatives and again reminds us that a starting point is only that; the key is where we end up once we have completed our work.



Average Wait Times in Days by Service Type and State

Figure Six

As you can see in Figure Six, the average wait times for clients broken down by service type in each state ranged greatly. You can see that outside of Children’s and Adult Targeted CM, Pennsylvania had the lowest starting points, Washington State was next and then Minnesota. Staff Hours (Blue) vs. Client Hours (Red) Per Intake for All Organizations (Yellow is the Average)

Figure Seven



Figure Seven highlights the challenge faced by most organizations at the start of the grant, which is a problem faced by a lot of organizations around the country as well. That challenge is staff spending a significant amount of time outside of their face-to-face time with their clients completing non-billable tasks like paperwork, travel, meetings, etc., and that kind of challenge is compounded by other system issues like No Shows that leave staff in an office without a client to bill for their time. Avg. Staff Hours (Blue) vs. Client Hours (Red) Per Intake by Service Type by State

Figure Eight

Figure Eight shows us that the challenge seen in regard to the staff time ratio versus client time is pretty similar for most of the organizations across all three states. This challenge is addressed primarily with the introduction of Collaborative Documentation; however that typically requires Documentation Streamlining as well.



Average Intake Cost (Red) vs. Revenue (Green) in Dollars for All Organizations

Figure Nine

Finally, Figure Nine shows the reality of the average cost versus revenue for the organizations’ access processes. As you can see, most of the starting comparison points showed that each service type was either losing money or was not able to access/offer reimbursement numbers at all. This was a big focus point during our work and the teams were able to make a lot of impact on the financial realities. Change Techniques and Outcomes: The charts below outline the utilization of each change technique by state and the final outcomes achieved. As you will see, Collaborative Documentation was the most popular and effective change. Pennsylvania: Change Techniques Usage:

Pennsylvania #





Walk-In Models 15 83% 8 44% 2 11%

No Show Models 11 61% 4 22% 1 6%




Outcomes:

Minnesota: Change Techniques Usage:

Outcomes:



(Days)



Savings: 1.53 0.71 $118.96 41.20

Change %: 38% 29% 39% 67%

Access Comparison Worksheet - PA

Minnesota #





Walk-In Models 4 100% 2.5 63% 0.5 13%

No Show Models 2 50% 1.5 38% 0%

Utilization Review and Utilization Management 2 50% 0% 0%



(Days)



Savings: 1.18 0.30 $50.77 14.40

Change %: 28% 12% 18% 28%

Access Comparison Worksheet - MN



Washington State: Change Techniques Usage:

Outcomes:

Historical Overview of Initiative Statement of Need and Historical Outcomes to Support the Initiative: The desire and commitment to improve access to mental health care is present within community behavioral healthcare organizations (CBHOs) nationally. CBHOs are dedicated to relieving the symptoms of serious mental illnesses and to helping individuals living with these conditions achieve improved functionality in their daily living activities. The episodic de-compensation characteristics of these illnesses require that mental health services be available on a timely basis when they are needed in order to reduce negative symptoms such as re-hospitalization and suicide. In addition to the tragic human costs, unreasonable delays in the access to treatment appointments is usually the result of excessive and redundant documentation access to care models that are based on process flows that are ripe with delays, time/cost ineffectiveness that was born out of the grant funding era. Additionally, there is a growing awareness that there is a wide gulf at the community provider level between commitment to improvement and actual improvement. Ongoing inadequate access to services is an example of that gulf. There is a high level of commitment to improving access to services but little actual improvement in accessibility over time.

Washington State #





Walk-In Models 11 92% 10.5 88% 1 8%

No Show Models 3 25% 3 25% 3 25%




(Days)



Savings: 2.69 0.88 $194.83 24.61

Change %: 46% 28% 45% 54%

Access Comparison Worksheet - WA



Beginning in September 2007, The National Council developed and managed a Learning Collaborative for four community behavioral healthcare providers local in Oregon, Florida, New Mexico and Maine to focus on rapid cycle change initiatives that will improve access to care timelines and cost effectiveness. Appendix “A” provides a more complete summary of the original Access and Retention Quality Improvement Learning Collaborative Initiative including identification of specific outcomes achieved. The initial outcomes from this collaborative have been very helpful to understand the core challenges that CBHOs face to improve access to care. As are result of the positive enhancements to access to care timeliness and cost effectiveness realized in the Access and Retention initiative, the National Council has pursued additional funding to support a more focused Access Redesign Quality Improvement Initiative that is further defined below: Access Redesign Project Objectives: The objectives of the initiative are to identify community behavioral healthcare organizations (CBHOs) in three states that will agree to design and implement strategies that will effectively respond to: • The need for a statewide system of CBHOs to improve the timeliness of their individual and

collective consumers’ access to care into their system

• The need to develop cost effective access to care models, compare them to current revenue levels available to reimburse the efficient models and advocate for higher reimbursement rates based upon demonstrated efficiencies that have been designed into the revised models

• The need for qualitative sound access to care processes that improve the timeline for consumers accessing services

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: • 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 Access Redesign Project Scope of Work: The 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 a state department/division of behavioral health and up to twenty-five CBHOs within each selected state that meet the selection criteria identified in item four below (total of up to fifty CBHOs will be funded by the grant funds available).

3. Sponsor a one day learning conference within each state to provide 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 initiative b. Identify specific measurement processes/costing tools that will be used to identify current

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

effective standardized access to care process flow d. 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 Internet based meetings for participating CBHOs with MTM Services consultation team members to:

a. Identify/design current process flows being used within each CBHO including costing for

the flows identified b. 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 Internet based closing learning conference for each state and all CBHOs participating in the initiative to summarize the findings and recommendations for the participating state trade association(s) and/or state department/divisions and the respective CBHOs.

Selection Process and Commitment Criteria: To accomplish the above objectives and scope of work, the National Council and MTM Services will select two State Behavioral Health Trade Associations and/or State Departments/Divisions of Behavioral Health and up to twenty-five 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 in the member CBHOs

2. Commitment by the Executive Director of the State Behavioral Health Trade Association and/or State Department/Division of Behavioral Health and 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 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 one-day learning session 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” 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 ratio of one dollar for every nine dollars provided by the grant funds. Therefore, the total local state match contribution requirement will be $10,000 per state ($20,000 collective match for both states) based on the total of $180,000 in grant funds available for this portion of the initiative. 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.

• 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

access redesign state grant final report 5-24-11 · final report may 24, 2011 version access...

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