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Annual Performance Analysis

FY13

JULY 1, 2012 ‐ JUNE 30, 2013

FY13 Annual Performance Analysis of 53

Table of Contents 1. MANAGEMENT SUMMARY ........................................................................................................................... 4 2. STRATEGIC GOALS AND STRATEGIC PLANNING ..................................................................................................... 5 Summary of Agency Strategic Initiatives ..................................................................................................... 5 FY13 Strategic Initiatives ........................................................................................................................... 5 Strategic Initiatives for FY 14...................................................................................................................... 7

3. FY 13 PROGRAM INITIATIVES ........................................................................................................................ 7 Management............................................................................................................................................ 7 Administration ......................................................................................................................................... 7 Clinical and Prevention Services ................................................................................................................. 8 Community Support Services ................................................................................................................... 10

4. AGENCY OUTCOMES AND PERFORMANCE IMPROVEMENT MEASURES ...................................................................... 10 Administration ....................................................................................................................................... 10 Outcomes........................................................................................................................................... 10 Objectives for the Coming Year ............................................................................................................ 11

Clinical and Prevention Services ............................................................................................................... 11 Access ................................................................................................................................................ 11 Adult Substance Abuse ........................................................................................................................ 12 Adult Mental Health............................................................................................................................ 13 Charles City/ New Kent........................................................................................................................ 14 Dialectical Behavior Therapy (DBT) ....................................................................................................... 15 Emergency Services............................................................................................................................. 17 Lakeside Center .................................................................................................................................. 18 MH Case Management ........................................................................................................................ 20 MH PACT............................................................................................................................................ 21 MH Residential ................................................................................................................................... 23 MH Support Services ........................................................................................................................... 24 MH Vocational Services ....................................................................................................................... 26 Prevention.......................................................................................................................................... 27 Youth and Family ................................................................................................................................ 29

Community Support Services ................................................................................................................... 32 CSS Case Management ........................................................................................................................ 32 CSS Day Services ................................................................................................................................. 32 CSS Individual Supported Employment ................................................................................................. 35 CSS Residential ................................................................................................................................... 37 Parent‐Infant Program......................................................................................................................... 38

5. POST DISCHARGE INFORMATION FOR CARF SERVICES ............................................................................................ 39 6. SATISFACTION ............................................................................................................................................ 40 Intellectual Disability Services‐ Family Satisfaction Survey.......................................................................... 40 Agency Satisfaction surveys ..................................................................................................................... 41

7. FY 14 MANAGEMENT, ADMINISTRATIVE AND PROGRAM INITIATIVES....................................................................... 41 Management.......................................................................................................................................... 41 Administration ....................................................................................................................................... 41 Clinical and Prevention Services ............................................................................................................... 42 Community Support Services ................................................................................................................... 43


8. QUALITY HEALTH INFORMATION................................................................................................................... 43 Outcomes .............................................................................................................................................. 43 Objectives for the coming year ................................................................................................................ 44

9. RISK MANAGEMENT / INCIDENTS AND COMPLAINTS ........................................................................................... 45 Outcomes .............................................................................................................................................. 45 Objectives for the coming year ................................................................................................................ 46

10. STAFF TRAINING .................................................................................................................................. 46 Outcomes .............................................................................................................................................. 46 FY14 Objectives for the coming year ........................................................................................................ 47

11. CULTURAL AWARENESS AND COMPETENCY .................................................................................................. 47 Outcomes .............................................................................................................................................. 47 FY14 Objectives for the coming year ........................................................................................................ 48

12. DEMOGRAPHICS .................................................................................................................................. 50 13. BUDGET ............................................................................................................................................ 52


1. MANAGEMENT SUMMARY We are proud to report on major initiatives that continue to move the agency and our community forward in several key areas. We have successfully implemented the enhanced case management standards for people covered by Virginia’s settlement with the United States Department of Justice. These have been implemented in order to assure the health and safety of the hundreds of our residents receiving supports and services in our communities. With the added impetus of this settlement and an increased number of Intellectual Disability Waiver slots, we have supported many individuals’ successful move from institutional living to more integrated and satisfying community care. Our staff has been truly excited about witnessing the positive changes in peoples’ lives. Our commitment to improving the experience and outcomes for people with mental illness, intellectual disability or autism when they interact with the criminal justice system culminated in December in the long sought goal of opening a Crisis Receiving Center. The Center, operated by Henrico Area Mental Health and Developmental Services, in partnership with Henrico Doctors Hospital–Parham Campus and the Henrico Division of Police, offers a safe and appropriate location for evaluation and triage to occur. In addition to offering better services for the people brought there and greater support for their families, the center has greatly reduced the time spent by law enforcement officers in these interactions. The result has been better and more efficient care. We continue to seek ways to better integrate mental health and physical health care for those we serve. The large number of individuals that remain uninsured presents a challenge to this goal. The Affordable Care Act will make affordable insurance available to many, but those most in need will remain uninsured awaiting Virginia’s decision about expanding Medicaid coverage for people up to 138% of poverty. The definition of poverty for a family of four is less than $23,550. Major sections of the Affordable Care Act are about to be implemented and Virginia is in the process of initiating several Medicaid reforms. It is our goal to successfully adapt to this changing environment and develop the infrastructure while maintaining state of the art clinical expertise to assure the best services, supports and outcomes for the people we serve and their families. The Board and Staff are grateful to the Boards of Supervisors of Henrico, Charles City and New Kent Counties for their ongoing support.

Evelyn O. Dodge Michael D. O’Connor, L.C.S.W.

Board Chairperson Executive Director


2. STRATEGIC GOALS AND STRATEGIC PLANNING Summary of Agency Strategic Initiatives As the current strategic goals became incorporated into the work of the agency, during FY13 the organization continued their cycle of continuous quality improvement and began outlining their strategic planning process. The leadership group developed a plan and time line to gain input from its internal and external stakeholders using a SWOT analysis, strategic questions and by conducting environmental scans. The input will be used both formally and informally to enhance program planning, improve the agency’s performance, prepare the agency for an increased managed care environment, needed advocacy and to develop new formal strategic goals. Internal SWOTS were completed and detailed information was gained from leadership group and staff from each division: Administrative, Clinical and Prevention Services, and Community Support Services. This information was reported out to Leadership group at the April and May meetings. An expansive list of external stakeholders was developed to gather information about how the agency is viewed by its external stakeholders and gather information about the environment as it relates to the services and business of the agency. Staff was teamed to interview external stakeholders. Input was gathered from stakeholders using a variety of mechanisms and included input from persons served, advocacy groups, and representatives from Henrico, New Kent and Charles City; this included the State Department of Behavioral Health and Developmental Services, Department of Aging and Rehabilitative Services, Henrico Public Schools, Henrico County Board of Supervisors, Criminal Justice System, Henrico Planning Department, Henrico Business League, Henrico Economic Development, and additional external stakeholders. The input was gathered and reported out during several leadership group meetings. A small work group was formed and tasked to flesh out the emerging themes towards developing strategic initiatives that will guide the organization for the next two to three years. In the interim, the agency continued its work on the following strategic goals:

Develop a fully compliant electronic health record by 2013 Assure readiness in all areas for the impact of healthcare reform Meet facility‐related needs of the agency for the next 10 years

FY13 Strategic Initiatives Goal 1. Develop a fully compliant electronic health record (EHR) by 2013 Strategies will include: mobile access for field based staff, electronic consumer signatures, document scanning, and Anasazi upgrades. FY 2013 Accomplishments

Completed Mobility initiative which included purchase and deployment of remaining 80 laptops and signature pads to 11 teams (Total 170 mobile units to 20 teams)

Over 50 remaining paper forms that were determined to be converted to electronic forms were completed

Document scanning was rescheduled to be implemented in FY15


Virtually all agency programs have migrated to a fully compliant electronic health record. The agency has met the initial requirements regarding “meaningful use” of the electronic health record. The last implementation phase, document scanning,will be implemented within the next year. This goal has been substantially achieved.

Goal 2. Assure readiness in all areas for the impact of healthcare reform Strategies will include closely tracking the implementation of healthcare reform in Virginia. Implications are not fully known but the following are anticipated: huge increase in Medicaid enrollees; increased emphasis on primary care integration; increased emphasis on coordination of care; increased use of managed care; increased emphasis on outcomes and comparative effectiveness. We will need to be proactive in influencing implementation in Virginia. FY 2013 Accomplishments

Re‐aligned staff to better support Medical Services and meet meaningful use requirements of the Patient Protection and Affordable Care Act (PPACA).

Seven (7) prescribers were registered for Meaningful Use incentive funds Reporting Meaningful Use 15 Core and 5 Menu measurements through the Anasazi system were tested and implementation began

Prescriber and business processes were established to meet Meaningful Use measurements including obtaining vitals, medical conditions, allergies and medication updates

2 LPN positions were approved by the County; these positions will be supporting prescribers beginning in FY 2014

Strategies will continue in FY2014 and FY 2015 to include new implementations to the Anasazi system, including patient portals and electronic data exchange

Staff and managers were and will continue to be educated on the demands and requirements of healthcare reform. The nursing staff was increased to allow better monitoring of the health status of our clients. The Agency partnered with a Federally Qualified Health Center to plan for integrating primary care with behavioral health. As the implementation of the ACA moves forward we are prepared to adjust and implement as needed.

Goal 3. Meet facility related needs of the agency for the next 10 years Strategies will include: replacing an existing rental facility (East Center) to meet program and growth needs over the next 10 years; more efficiently meeting program needs, address inadequate space in central and Western Henrico County (Woodman, Radford, ID Case Mgt), and accommodate growth over the next 10 years; and studying the cost, need and general feasibility in the current environment of obtaining interim rental space to meet our needs pending Capital Improvement Plan (CIP) approval of the plan outlined above. FY 2013 Accomplishments

Significant progress on this goal was made last year CIP proposals for an East Center Replacement and Woodman Road expansion have been updated and resubmitted; funding has not been identified

The Agency has resolved the acute facility needs as outlined. Due to the current economic climate a longer term solution is not yet available. We will submit a CIP request in September 2013 for the fourth time to address both locations.


Strategic Initiatives for FY 14 In summary, the following strategic initiatives are continuing into early FY14 but will be updated with new initiatives early in FY14:

Develop a fully compliant electronic health record by 2013 Assure readiness in all areas for the impact of healthcare reform Meet facility‐related needs of the agency for the next 10 years

3. FY 13 PROGRAM INITIATIVES MANAGEMENT Health Care Reform

Continued to prepare for health care reform ADMINISTRATION

Implemented Meaningful Use Processes and Reporting throughout the Agency Expanded Dashboard performance measures

Reimbursement

Implemented CPT changes for psychiatric services Implemented additional Medicaid billing opportunities to increase revenue

o Implemented ID Supported Employment Medicaid billing o Implemented ID Intake Medicaid billing o Implemented Truancy Case Management billing o Expanded MH Supported Services billing to 3 locations

Information Services

Implemented Doctor’s Homepage Completed Roll out of Mobility Project Implemented DOJ requirements into the medical record and CCS reporting

Facilities

Completed East Center expansion and move Responded to an Energy Audit of the 10 group homes by replacing windows and HVAC systems, improving insulation and duct systems and adding radiant barriers in the attics as well as other smaller improvements. These should improve air quality and decrease energy usage and expenses.

Financial Management

Implemented new Oracle Financial Release

Business Support Implemented an automated rescheduling request process which will improve efficiency, accuracy and eliminate paper.

Implemented monthly and quarterly reporting of Front Desk Volume at 4 major locations to ensure appropriate staffing


Health Information Management Began formal PIP record reviews in Chart Tracker

CLINICAL AND PREVENTION SERVICES

Access Implemented expanded Access services for court evaluations

Adult Substance Abuse/ Adult Mental Health Services

Added a substance abuse education group in February 2013 Walk in Access was expanded this year in April 2013 from two 2 ½ hour clinics to four (4) days a week/ six (6) hours per day

Adult Recovery Services Reduced or maintained zero rate of hospitalizations after 6 months of treatment for MH Case Management Services for 92% of clients

Doubled the number of Case Management clients receiving Individual Therapy as an adjunct service (from 3.1% of clients to 6.2%)

Completed two full cycles of evidenced based group programs: Family Psychoeducation Group and Illness Management and Recovery Group

Fully transitioned one PACT team to an ICT team Developed more skills‐focused treatment in Psychosocial and Mental Health Support Services

o Psychosocial program adopted a structured curriculum of education groups for clients o Mental Health Support Services developed a resource book for staff to assist in

providing more skill development interventions for clients Emergency Services

Implemented changes in MOT regulations: Developed an MOT system that has resulted in modest increase in the number of MOT orders along with a cross‐jurisdictional agreement with Richmond for MOT

Implemented advanced CIT through increased training and outreach: Implemented CIT grant outreach program that partners MH clinicians and peer counselors with law enforcement officers to provide intensive engagement and outreach services to 56 persons

Implemented a CIT grant to provide advanced training to CIT first responders: This initiative provided 5 separate trainings on a variety or relevant topics designed to enhance the skills of CIT responders

Provided monthly CIT 40 hour training for CIT first responders; trained approximately 300 first responders this year

Implemented Receiving Center: In collaboration with Public Safety and in partnership with Henrico Doctors Hospital Parham and Henrico Division, opened Henrico’s Crisis Receiving Center, which allows for transfer of custody, provides integrated mental health and medical assessments, and stabilization services twelve (12) hours a day

Supported development of regional child Crisis Stabilization Unit (CSU) located in Henrico County; served 43 Henrico youth


Youth & Family Increased the number of child and adolescent case management cases served by 57% over the fiscal year

Served thirty‐eight adolescents in Multi‐Systemic Treatment, an evidence‐based home‐based therapy, through funding through CSA and JABG

Piloted a Truancy Case Management program, in support of County‐wide efforts around truancy; served four new referrals through this effort

Conducted seven hundred one Virginia Independent Clinical Assessments (VICAP) through contract with the Department of Medical Assistance Services

Completed fifty‐eight Substance Abuse Assessments for Henrico County Public Schools in collaboration with their Awareness & Intervention Program for students in violation of school policy around substance use; co‐facilitated educational groups for students in this program on a monthly basis

Completed eighty‐eight Mental Health Assessments and twenty‐seven Substance Abuse Assessments on‐site at Courts Services under contract with VCCCCA

Completed seventy‐two court‐ordered Mental Health/Substance Abuse Assessments in Detention and five Competency Evaluations

Trained four staff in High Fidelity Wraparound Model of Intensive Care Coordination (ICC) , in compliance with new Comprehensive Services Act requirements for vendors of ICC

Presented Voices From A Teen Male Perspective: Who’s Listening? at the Henrico Theatre as part of a collaboration between the Adolescent Team and Prevention, showing a video of a panel of teen males answering questions on their point of view followed by a guided discussion.

Provided a monthly educational and support group to Henrico County Public Schools (HCPS) The Grad Center to address some of the behavioral and mental health needs of the student body at that school; provided two parent workshop days, providing education about parenting skills and techniques

Started a teen mother’s group at The Grad Center in May, serving three mothers, through a collaboration between Outreach and Prevention; this group is an outgrowth of the teen mother’s group at Highland Spring High School, which has been running for several years

Sponsored a Teen Parenting Workshop for young women, with multiple community vendors presenting educational information

Facilitated four self‐esteem groups for middle school girls, two at each location Provided two cycles of the Incredible Years Parenting Program, one at each outpatient location

Provided three children’s treatment groups, as part of the Incredible Years Program Held a series of agency and community events in celebration of Children’s Mental Health Awareness month in May

Prevention

Received aware at the Youth Alcohol and Drug Abuse Prevention Project (YADAPP) Leadership Conference for Youth Ambassadors

Expanded Teen Job Prep Program to forty youth Henrico Arms Connect program participated in a CNN special documentary with Soledad O’Brien on “Colorism”


Received recognition as a Promising Program for Too Smart 2 Start Coalition in partnership with Henrico County Schools, from the Governor's Substance Abuse Prevention Recognition Program, which is a component of the Substance Abuse Awareness is Vital for Virginia Youth (SAVVY) initiative

COMMUNITY SUPPORT SERVICES

Informational meeting with ID Case Management, Employment and Day Services and Henrico County Public Schools department chairs was videotaped for school personnel to access on their web site

Celebrated Developmental Disability month in March through various activities including a program of consumers playing a guitar, singing, dancing, a fashion show, a clown and art work by the participants of Hermitage and Cypress

CRRT Services Four individuals moved from nursing homes to community placement Fourteen individuals moved from state training facilities and residential treatment facilities to homes in the community

Parent Infant Program

Added a Licensed Clinical Social Worker to provide therapy for families through Early Intervention Services

The Virginia Board for People with Disabilities recognized the PIP therapist as a “Compassionate Professional and Emerging Leader” in a article at http://www.vaboard.org/downloads/newsletters/NewsletterSummer2013.pdf

Case Management Services

Moved Individual Supported Employment to Hermitage and changed department name to Employment and Day Services

Day Services

Added new customers including Thankfully Yours, Biscotti Goddess, Herban Life Style, K2 Trophies (enclave), Department of Finance (scanning), Brain Injury (mailing), REM Inc (janitorial)

Registered 13 people to vote in Day Services in coordination with Virginia Office of Protection and Advocacy (VOPA)

Received second place in a nation‐wide government media contest; this was a NATOA award video

Received third annual Organic certification thru San J International Initiated the Employment Readiness Program at Hermitage

4. AGENCY OUTCOMES AND PERFORMANCE IMPROVEMENT MEASURES ADMINISTRATION Outcomes

Efficiency Objective: 95% of charts are filed according to their programs’ chart orders


http://www.vaboard.org/downloads/newsletters/NewsletterSummer2013.pdf

Results: 92%

Analysis/ Action Taken: Objective A was met for one quarter only (2nd quarter), however, three of the four quarters were above 90% and the average for all quarters was 92%.

Performance Improvement: Filing accuracy should improve going forward as the Short‐Term Services Chart Order was revised this past spring and the changes helped to clarify where certain forms should be filed in these charts.

Efficiency Objective: No more than 1% of charts contain misfiles (files for a different client)

Results: 99%

Analysis/ Action Taken: Objective B was met for all quarters except the first one and the average for all quarters was 99%. This result shows that staff are checking name and ID# before filing paper documents in short‐term charts. Performance Improvement: Staff should continue to check that name and case # indicated on paper documents matches the name and case # on the record being filed in and to return paper documents without client ID numbers to clinical staff so they can indicate client # on the document(s). Staff will also check every page of records received from an outside entity to make sure there are no pages for other individuals contained in the records as this was identified as the reason for many misfiles.

Objectives for the Coming Year Effectiveness Objective: There is to be no greater than 10% of Accounts with outstanding balances in the 121+ day bucket


Access

Outcomes

Efficiency Objective: Direct calls to Access will be answered first time 90% of the time.

Results: 85%

Analysis/ Action Taken: Central Access staff were able to answer direct calls an average of 85% of the time, shy of the 90% objective. Throughout the fiscal year Access has struggled to have adequate coverage, with the East Center coverage at times taking precedence. In addition, there has been a significant increase in the number of unscheduled walk‐ins, which further depletes available staff for the phones, as well as Central Access taking on additional access routes that previously have been through other channels. Despite this, Central Access


staff consistently have been able to return calls within hours, and have not had to delay call‐backs to the next business day.

Performance Improvement: Central Access will continue to strive toward an increase in the number of direct calls that can be answered the first time, while providing excellent customer service.

Objectives for the Coming Year

Efficiency Objective: Direct calls to Access will be answered first time 90% of the time

Adult Substance Abuse Outcomes

Effectiveness Objective: 90% of clients admitted to RAP groups will be able to identify one skill learned in group upon weekly survey.

Results: 90%

Analysis/ Action Taken: The acquisition of recovery skills is essential in establishing and maintaining ongoing abstinence from substance abuse. The purpose of this objective was to measure the effectiveness of the RAP (Recovery Addiction Program) curriculum in teaching recovery skills to clients enrolled in the group. The curriculum is based on a Cognitive Behavioral Approach. This year the outcome was based on four quarters of data compared to last year’s results which were based on only two quarters of data. Over the four quarters of FY2013, 90% of clients were able to report skills they had learned in previous group sessions when surveyed. This meets the objective and seems to demonstrate that the curriculum is effective in conveying the skills to the majority of the participating clients. This data supports the use of evidence based treatment. Staff will be encouraged to increase knowledge of and ability to implement such intervention in practical ways that support the growth and healing of the clients served in the Adult Substance Abuse program. Performance Improvement: Now that 18 months of data is available demonstrating the effectiveness of the RAP material and facilitation, ways to measure the use of the skills by clients outside of the group will be explored in the coming year.

Effectiveness Objective: 10% of clients will show change on at least one NOMS data element during each treatment episode from July 1, 2012 to June 30, 2013. #changes/(sample size * #elements)

Results: For the year there was a 21% change in the NOMS data elements reported at admission and discharge.

Analysis/ Action Taken: NOMS data elements are used to determine the change occurring in clients between admission to and discharge from treatment. The data elements examined in this goal are type of housing, rate of use, arrests in the last 30 days, and employment status. It is important for clinicians to accurately record the data upon discharge in order for collection of NOMS to be valid and useful. This goal was developed in 2011 in order to raise awareness among staff of the importance of collecting accurate data. In the third year of


focusing on this data it was determined that 21% of the clients measured have had at least one change in one of the four data elements stated above. This is up from 17% from the first year and from 19% in the second year. It would be helpful to have a national baseline to compare these numbers against however it has been difficult to locate this information

Performance Improvement: This outcome will be continued into FY14 because it seems to keep staff focused on recording accurate data.

Access Objective: On monthly average clients admitted to the Adult Substance abuse program will be seen for a follow up appointment within 10 days of the date they were seen in walk‐in clinic for intake.

Results: Met the objective 4 months out of 12 for client being seen within 10 days of walk in appointment

Recommendations/ Action Taken: Access to the Adult Substance Abuse Program is effective and efficient given the availability of same day access for clients seeking services. Three days during the week in the East and four days during the week in the west end of the county clients are able to be seen for an intake appointment on the day they decide to come to the clinic rather than needing to call and schedule an appointment resulting in zero days of waiting for initiation of services. The data being presented for FY2013 represents the time from intake to the time they are seen for the first follow up appointment which may be a group or individual appointment. It is the first kept appointment, not the first scheduled appointment. The objective is to see clients within 10 days of the intake appointment. Over the last year this objective was met four out of twelve months. While this is only a 33% success rate the high end of the average range was reduced from 15 days in FY12 to 12 days in FY13. Therefore the baseline range was a low of 9 days and a high of 12 days. This information has been reviewed with staff who understand the importance of access and engagement of clients at the time of intake

Performance Improvement: The annual results will be shared with staff in order to continue working on barriers to access for the first follow up appointment.

Objectives for the Coming Year Effectiveness Objective: 90% of clients admitted to RAP groups will identify skills learned in group upon weekly survey Effectiveness Objective: 10% of clients will show change on at least one NOMS data element during each treatment episode from July 1, 2013 to June 30, 2014 Access Objective: Clients admitted to the program will be seen within 10 days for the next available appointment following the walk in intake

Adult Mental Health

Outcomes


Access Objective: A client will have an initial appointment within 10 business days of requesting services.

Results: The days until an intake is scheduled ranged from a low of 12 to a high of 36. There was not a month in which the goal of clients receiving an intake appointment within 10 days was met. Recommendations/ Action Taken During FY13 days until “first offered and accepted appointment” with a MH OP staff member ranged from a low of 12 days to a high of 36 days with one month showing invalid data of ‐64 days. The objective of offering an appointment within 10 days of a client contacting the agency was not met. At this time the agency is serving indigent clients without health care coverage. Those with insurance are being referred out to the community. Despite this the policy, requests far outweigh the resources of two full time clinicians. At the end of this year, due to turn over and continued freezing of some vacant positions it was decided to eliminate the intensive DBT program and move two of these positions back to the MH OP team. In FY14 the team will have two full time positions at both the west and east end locations doubling the current size of the team. The team members will be supervised by a working supervisor at each location who will carry a small number of outpatient clients. Performance Improvement: Once the new team members are oriented the team will look at how to increase capacity through such means as screening vs. completing a full intake and use of groups therapy and education classes. The intention is to meet the goal of providing an appointment in less than 10 days and increase capacity of the program through efficient use of evidence based treatment and both group and individual treatment.

Objectives for the Coming Year Access Objective: Clients will be scheduled for a follow up appointment within ten business days of call to central access.

Charles City/ New Kent

Outcomes

Access Objective: Clients will be seen for Initial appointment within 10 days of contacting Access Results: Clients were seen in average of 8.75 days for their initial appt.

Recommendations/ Action Taken: PF met the goal of seeing clients within the 10 days. Staffing was a significant problem this past year which impacted clients being seen in a timely manner. Performance Improvement: We will continue to monitor the wait time for initial appointments. While the overall goal was met, wait times were significantly impacted by staffing shortages. We believe we can significantly reduce the wait time when we are able to maintain a full contingent of staff.


Efficiency Objective: Staff will engage clients and address their needs appropriately as evidenced by an increase in planned discharges.

Results: 48.5% Recommendations/ Action Taken: New staff will have to be trained on which discharge to select when closing a case to gain consistency. A significant number of completed discharges are from SA. Majority of these clients are court ordered and typically attend a group that has a structured amount of groups for successful completion.

Performance Improvement: More emphasis needs to be placed on MH outpatient clients discharge planning.


Access Objective: Clients will be seen for initial appointment within 10 days of contacting Access Effectiveness Objective: Staff will engage clients and address their needs appropriately as evidenced by an increase in planned discharges

Dialectical Behavior Therapy (DBT)

Outcomes

Effectiveness Objective: Clients will show a reduction in the use of inpatient hospitalizations by the end of their treatment year

Results: 5 hospital admissions during period of enrollment to treatment for 15 clients. 1 hospital admission for the 7 that remained in the 4th quarter or graduated during the year

Recommendations/ Action Taken: There were fifteen (15) outcome clients at baseline. Of these, eight (8) dropped out of treatment during FY13, two completed treatment prior to Q4, and five remained into Q4. For the entire sample (15), there were 10 hospital admissions at baseline, and 5 hospital admissions during FY13. For those who completed treatment and/or remained in Q4 (7), there were 6 hospital admissions at baseline, and 1 hospital admission during FY13. The end result for the year in evaluating hospital admissions was well below baseline for FY13. This information validates that DBT is effective in reducing hospitalizations for clients receiving the treatment. Performance Improvement: These results will be shared with DBT staff. The results do not suggest making any changes in the treatment program at this time.

Effectiveness Objective: Clients will show a reduction in the reported number of suicide attempts by the end of their treatment year.

Results: 0 suicide attempts for 15 clients. 0 suicide attempts for 7 clients remaining in the 4th quarter or graduated during the year


Recommendations/ Action Taken: There were fifteen (15) outcome clients at baseline. Of these, eight (8) dropped out of treatment during FY13, two completed treatment prior to Q4, and five remained into Q4. For the entire sample (15), there were 9 suicide attempts at baseline and no suicide attempts during FY13. For those who completed treatment and/or continued into Q4 (7) there were 4 suicide attempts at baseline and no suicide attempts during FY13. The results were the best possible as no suicide attempts occurred while clients were in treatment. Performance Improvement: These results demonstrate the effectiveness of the DBT intervention and does not suggest any treatment program changes at this time. Results will be shared with team members.

Effectiveness Objective: Clients will show a reduction in the reported number of self‐harm behaviors by the end of their treatment year.

Results: 3 acts of self harm for 15 clients. 1 act of self harm for the 7 that remained in the 4th quarter or graduated during the year

Recommendations/ Action Taken: There were fifteen (15) outcome clients at baseline. (An outcome client is defined here as any client admitted into the DBT Program during the months of July, August, or September of 2012.) Of these, six (6) clients reported one or more episodes of self‐harm in FY 2012, for a total of 33 episodes of self‐harm at baseline. For those who completed treatment and/or remained in Q4 (7), there were 15 episodes of self‐harm at baseline, and 1 episode of self‐harm during FY13 demonstrating marked improvement in this area. Performance Improvement: These results will be shared with the team and do not indicate a need for treatment program changes at this time.

Effectiveness Objective: The intensity of symptoms identified on the Borderline Symptom List 23 (BSL‐23) will show a reduction each quarter. .

Results: For the 7 clients that remained or graduated during the year the mean baseline was 31.57 and the end result was 27.1

Recommendations/ Action Taken There were fifteen (15) outcome clients at baseline. Of these, eight (8) dropped out of treatment during FY13, two completed treatment prior to Q4, and five continued into Q4. For the entire sample (15) the mean baseline BSL score was 36.5. The mean BSL score by end of Q4 was 25.6. For those who completed treatment and/or continued into Q4 (7) the mean baseline BSL score was 31.57. The mean BSL score by end of Q4 was 27.1. This is a significant improvement in symptomotology and indicates the effectiveness of DBT. Performance Improvement: The results do not indicate any need for change at this time. The results will be shared with the team members.


Access Objective: : DBT staff will contact clients within 5 business days of assigning the referral in DBT Team Consultation meeting to schedule the first commitment session.

Results: Objective was met based on the fourth quarter results only (Q1,2, and 3 were invalid) Recommendations/ Action Taken: Unfortunately there was considerable confusion this year regarding the proper way to record information about when referred clients were contacted by staff following the weekly consultation team meeting. As a result the data reviewed is not accurate except for the fourth quarter. During this quarter the time period was zero days from the date the referral was accepted into the program and the client being contacted by staff to set up the first appointment thus the objective was met. Performance Improvement: This information was shared with the DBT team staff. In the future, attention will be paid to how information is communicated when staff are leaving and new staff are coming on board or others are covering for vacant positions in this program.

Emergency Services

Outcomes

Efficiency Objective: ESP clinicians will document consideration of preference/choice on pre‐screenings resulting in hospitalization 90% of the time

Results: 94% of charts reviewed indicate preference was considered

Recommendations/ Action Taken: ESP staff have demonstrated a positive response to the identified need to consider preference as a part of the evaluation process. The documentation confirms that this is a routine aspect of the evaluation process. Performance Improvement: This outcome will not be continued in that it has clearly become a part of the ESP staff practice.

Access Objective: Persons not open to the agency hospitalized through the civil involuntary admissions will attend a non emergency discharge appointment within 7 days of their discharge 75% of the time

Results: 71% (112 OF 157)

Recommendations/ Action Taken: 71% of persons attend their discharge appointment within the 7 day period and 75% attend within a 14 day period. This number represents a slight improvement from previous years (averaging 65 to 67%)


Performance Improvement: In order to attempt to increase the compliance even further, the program is reviewing the entire process of discharge appointments during the month of July and August and will develop a revised written process. This will include a means of gathering written information, including discharge information, a discussion with the client, and up to date insurance information. Training will take place in August and September and a review process will be put in place to support clinician consistency of this process. This outcome is required by the state and will continue for next fiscal year.


Effectiveness Objective: There will be a reduction of persons who are involuntarily hospitalized under an ECO when they are evaluated at the Crisis Receiving Center Access Objective: Persons not open the agency hospitalized through the civil involuntary admissions will attend a non emergency discharge appointment within 7 days of their discharge 75% of the time

Lakeside Center

Outcomes

Effectiveness Objective: There will be a 50% reduction in “dead referrals” (consumer who did not attend at all within 30 days).

Results: 12/50 or 24% Recommendations/ Action Taken: In FY12, we estimated that 35% of referrals were designated as “dead referrals.” In our effort to achieve a 50% reduction in “dead referrals” in FY13, we calculated the need for an 18% “dead referral” rate. In the first quarter of FY13, we did not meet the objective as there were eight referrals, three of which (38%) were “dead referrals”. In the second quarter of FY13, at face value we did not meet the objective. However, there were seventeen referrals, over twice as many as the previous quarter, with four of them being “dead referrals” (24%). If one individual, who was counted twice as a “dead referral” due to being referred on two separate occasions, were to count only once, the percentage of referrals (17) to “dead referrals” (3) would have matched our target of 18%. In the third quarter of FY13, we achieved this objective for the first time! There were fourteen referrals, with only two of them being considered “dead referrals” (14%). In the fourth quarter of FY13, again at face value, we did not meet our objective. Out of eleven total referrals, three of them were considered “dead referrals.” If we were to exclude the individuals who had been previously referred (2), our referral to “dead referral” ratio would be 11:1 or 9%, the best percentage of the year. For the year, our official ratio of referrals (50) to “dead referrals” (12) was 24%, falling short of our target. However, unofficially, and perhaps more representative, our referral (50) to “dead referral” (9) ratio would have met our target (18%) if we had excluded those who had been previously referred from the final calculations. As hypothesized, the most significant variable in the “dead referral” rate was the total number of referrals per quarter. Additional referrals with minimal to no change in the number of “dead referrals,” resulted in improved outcomes. Another factor in improved quarterly ratios was related to tours of the program occurring prior to a referral being made


Performance Improvement: In FY14, our measurable objective will be to not exceed a 20% “dead referral” rate.

Effectiveness Objective: There will be improved coordination of care with other providers over the last twelve months as evidenced by a score of 85% on the record review

Results: 23/26 or 88% Recommendations/ Action Taken: For FY13, we began to measure our success rate with SAI coordination by looking at the last 12 months instead of the past two years. Our calculations were also different in that a two year official chart does not account for the difference between a client chart with one missing note vs. a chart with multiple missing notes. In such a review, if one or more notes are missing, it is counted as not being in compliance. In the one year review, we did account for the number of missing notes. For example, if staff missed one note in a twelve month period, their compliance with this objective would be 92%. Conversely, if they missed five notes out of twelve months, their compliance would be 42%.

For the first quarter of FY13, we had five of seven charts (71%) that scored 85% or better. In the second quarter, we were able to achieve 100% on this measure! All seven charts reviewed contained at least an 85% evidence of monthly coordination rate within a twelve month period. This was quite an accomplishment since we hade not fared well with this outcome in the past. For the third quarter, we again achieved 100% on this measure, making it two consecutive quarters doing so! In the last quarter of FY13, we fell short a bit short of the target, achieving 80% (4 of 5 charts). This quarter had a smaller sample size than in previous quarters, as chart reviews were not conducted in June. If the review would have contained an additional chart, increasing the ratio to six of seven charts with an 85% or better, we would have exceeded our target goal by 1% (86%). Overall for the year, we surpassed our target of 85%, achieving 88%! The results provide tangible evidence that we are much improved in this area, despite lower percentages in an official two year record review, as staff began to routinely include it in the body of their monthly note.

Performance Improvement: Given the results, in FY14 we plan to target a score of 90% on this objective.

Access Objective: Clients will be admitted to LSC within 30 days from receipt of the referral .

Results: 34/34 or 100% Recommendations/ Action Taken: For FY13, we successfully admitted all referrals within 30 days (34 of 34). In the first quarter, referrals were admitted on an average of fourteen days. In quarter two, we had the most referrals (12) of any quarter in the year and they were referred in just under 18 days. In quarter three, they were admitted on average of 14 days, on par with quarter one. In the last quarter of the year, referrals were admitted within 9 days, on average, which was our most expeditious quarter. For the year, we averaged 14 days from receipt of the referral to admission.


Performance Improvement: Our current process continues to remains efficient in serving those being referred to the program. There will be no change in this objective in FY14.

Objectives for the Coming Year Effectiveness Objective: The “dead referral” rate will not exceed 20% (consumer who did not attend at all within 30 days) Efficiency Objective: There will be improved coordination of care with other providers over the last twelve months as evidenced by a score of 90% on the record review Access Objective: 100% of consumers referred to the program will be admitted within 30 days from receipt of the referral

MH Case Management

Outcomes Effectiveness Objective: Newly opened clients will demonstrate a 50% reduction in hospitalization rate from their baseline (measured from 3 months prior to initiation of service to 3 months after initiation of service) as compared with their hospitalization rate from months 4‐9.

Results: 92%

Recommendations/ Action Taken: This is the first year we have measured this objective. The results demonstrate that case management interventions greatly assist with reducing hospitalization rates for people with serious mental illness. These dramatic results may actually be more dramatic in upcoming quarters as it is believed that the hospital rate prior to admission was not accurately captured in opening paperwork and this has been corrected via documentation changes.

Performance Improvement: Continue to monitor in the coming year.

Effectiveness Objective: 70% of clients will be linked to and participate in community integration activities (MHSS, LC, work, school, volunteer, club, Friends for Recovery, Peer Connect, church, etc).

Results: 58.1% Recommendations/ Action Taken: It is well know within the recovery model of treatment that when people with serious mental illnesses participate in their community, recovery is more likely to be achieved. Therefore, the program felt it was important to focus on linking clients to their communities. By the end of the year, 58.1% of clients were actively participating in their community in some manner; this is less that our projected goal of 70%.

Performance Improvement: Supervisors plan to continue to stress the importance of linking clients with their communities as an important part of the recovery process. Staff will also continue to encourage this integration and will work to link them with opportunities to do so.

Access Objective: At least 5% of CM&A clients will receive therapy from CM&A staff


Results: 6.2% Recommendations/ Action Taken: Over the past several years, the number of clients receiving therapy within the case management unit has more than doubled. This is viewed as a great success as it is our strong belief that clients with a serious mentally illness should have the same opportunity for therapy as those without a serious mental illness. By the end of this year, 6.2% of clients in CM&A received therapy by a CM&A clinician, still others were referred to providers in the community. Performance Improvement: Continued efforts by supervisors to educate staff on the effectiveness of providing therapy to the SMI population has added to the success of this outcome. We expect that these numbers will increase in the coming years.

Access Objective: Non‐crisis consumers will be seen within 7 business days of initial attempt to access services

Results: 7 months the objective was met; 5 months the objective was not met Recommendations/ Action Taken: Quick access to service is something that we recognize is valuable and demonstrates good customer service. The program was able to meet the goal of seeing clients requesting services within 7 days, 7 out of 12 months. During the months when the objective was not met, the program was experiencing vacancies.

Performance Improvement: This is a measure we will continue to track in the upcoming year as we are committed to being responsive to client and community needs.

Objectives for the Coming Year Effectiveness Objective: Newly opened clients will demonstrate a 80% reduction in hospitalization rate from their baseline (measured from 3 months prior to initiation of service to 3 months after initiation of service) as compared with their hospitalization rate from months 4‐9. Efficiency Objective: By the end of 4th quarter, 10% of clients in CM&A who see an agency prescriber and who have a BMI 35 and over will have attended an educational session on this topic provided by a agency medical professional Access Objective: Non‐crisis clients will be seen within 7 business days of initial attempt to access services.

MH PACT

Outcomes Effectiveness Objective: There will be a decrease in the number of hospital bed days among PACT and ICT service recipients as compared to the number of crisis stabilization bed days

Results: Collectively, the teams for the years had 510 inpatient bad days and 127 CSU bed days for a ratio of .25


Recommendations/ Action Taken: The year‐end ratio of .25 was slightly better than the baseline of .23. PACT and ICT clients often seem better and more stable upon discharge from the crisis stabilization program as compared to discharge from a hospital, and the teams will continue to try and use crisis stabilization as a preferred intervention when clients need more support than can be provided in the community.

Performance Improvement: Whenever appropriate, clients of the teams will be considered to admission to the crisis stabilization unit rather than inpatient hospitalization, in the hope that increased usage of crisis stabilization services will result in greater stability and increased community tenure among PACT/ICT clients.

Efficiency Objective: Program orientation packets, PACT/ICT assessments, and initial individual service plans will be completed within 30 days on all new referrals to PACT or ICT services

Results: Collectively, the PACT and ICT teams had 24 new referrals for the year. The opening paperwork was completed within 30 days in all but one instance, yielding a completion rate of 95.8%. Recommendations/ Action Taken: Opening paperwork for new referrals to PACT/ICT services was completed within the target 30‐day period 95.8% of the time. This was a new measure for the year, so there exists nothing with which to directly compare the measure from last year. The goal will remain 100% completion within 30 days, as timely completion has implications for client recovery as well as audit purposes, etc. Performance Improvement: The recent inclusion of nearly all of the opening paperwork, including assessments and individual service plans, into electronic format has streamlined the processes and resulted in a much more timely completion of paperwork for new referrals.

Access Objective: Consumers referred for PACT/ICT services will be seen, on average, within 7 days of acceptance into services

Results: Collectively, the PACT and ICT teams saw new referrals within 5.54 days of receipt of referral, on average. Of the 24 new referrals, 18 [75%] were seen within 7 days of referral. Recommendations/ Action Taken: New referrals to PACT/ICT services are seen, on average, 5.54 days after their referral is received by the PACT or ICT team, as compared to an average of 9.6 days last year. In addition, 75% of new referrals are seen within one week of referral, as compared to 64% last year. As quicker engagement seems to correlate with improved symptom management, efforts will continue to see all new referrals for PACT/ICT services within 7 days of referral. Performance Improvement: It is hoped that the new electronic referral in combination with mobile computer technology will further expedite the process of seeing new referrals for services.


Objectives for the Coming Year Effectiveness Objective: There will be a decrease in the number of hospital bed days among PACT and ICT service recipients as compared to the number of crisis stabilization bed days Efficiency Objective: Program orientation packets, PACT/ICT assessments, and initial individual service plans will be completed within 30 days on all new referrals to PACT or ICT services Access Objective: Consumers referred for PACT/ICT services will be seen, on average, within 7 days of acceptance into services

MH Residential

Outcomes

Effectiveness Objective: 80% of residents will show a decrease in the number of prompts needed in completing personal hygiene tasks (measured by showering and wearing clean clothes).

Results: 58% Recommendations/ Action Taken: While we did not meet our objective this year the information was helpful with measuring the individual resident’s abilities. This allowed us to tailor staffs’ attention to meet the resident’s needs with the goal of improving their independent living skills. It also conveyed their resiliency in managing the many changes that they faced during the last quarter. Performance Improvement: This objective will continue with some slight modifications.

Effectiveness Objective: 80% of residents will show an increase in the quality of task of cleaning their bedroom (measured by fixing bed and emptying trash).

Results: 64 % Recommendations/ Action Taken: As with objective A, this objective was not met. However, as with objective A the information was helpful with measuring the individual resident’s abilities. This again allowed us to tailor staffs’ attention to meet the resident’s needs with the goal of improving their independent living skills. It also conveyed their resiliency in managing the many changes that they faced during the last quarter.

Performance Improvement: This objective will continue with some slight modifications.

Efficiency Objective: There will be improved active client involvement in developing and reviewing treatment goals and objectives as evidenced by a score of 80% on the record review.

Results: 93 %

Recommendations/ Action Taken: With the establishment of this objective there has been a significant increase in the client’s participation in the areas of completing their annual assessment, developing their individual service plan and reviewing their quarterly progress.


We are pleased that we exceeded our overall goal for the year with a 93% of cases showing the clients involvement in these areas. Performance Improvement: While monitoring of the client’s involvement in these areas will continue, the objective will not since we far exceeded our goal and, therefore, no improvement is needed in this area.

Access Objective: Vacancies in the program will be offered and accepted within 45 days from the date a resident vacates the home to the move‐in date of a new resident.

Results: 60 days

Recommendations/ Action Taken: During this year we had two vacancies but due to programmatic changes one vacancy was filled. The vacancy was offered and accepted within 24 days, well within 45 days, however, the person moving in lived at an assisted living facility and was required to provide a 30 day notice thus having a later move‐in date. Performance Improvement: The goal of filling vacancies within 45 will continue. Currently no action is required since the selection and acceptance was well within the time frame, and residential services does not have control over the policy of outside programs regarding the amount of time that the client has to give notice to vacate.


Effectiveness Objective: 80% of residents will show an increase in their personal appearance (measured by completing their morning routine: showering, brushing teeth and wearing clean clothes) Effectiveness Objective: 80% of residents will show an increase in the quality of task of cleaning their bedroom (measured by vacuuming their carpet and keeping their floor clear of trash) Efficiency Objective: There will be improved communication between group home staff and client’s SAI as measured by the SAI’s report Access Objective: Vacancies in the program will be offered and accepted within 45 days from the date a resident vacates the home to the move‐in date of a new resident

MH Support Services

Outcomes

Effectiveness Objective: Of consumers currently enrolled in MHSS, 10 will be discharged successfully in the next year. (Successful discharge means consumer achieved their goal(s), and did not require a referral to another provider).

Results: 8/37 Recommendations/ Action Taken: In this past fiscal year, a total of 37 consumers were discharged from MHSS with 8 of these discharges considered successful. This result was two successful discharges short of our goal, and one less than the previous fiscal year. The


remaining 29 consumers were discharged for an assortment of reasons to include: death (1 consumer), moved out of catchment area (4 consumers), client decision/ against advice (5 consumers), change in client need/ transfer (6 consumers), client chose another provider (2 consumers), change in service location (1 consumer), non‐compliance with treatment (4 consumers), extended incarceration (1 consumer), lost contact with client (1 consumer), and ineligible for services (4 consumers).

Performance Improvement: Since this objective was not achieved, this same objective will be used again in the new fiscal year.

Efficiency Objective: MHSS staff will document monthly collateral contacts with case managers 90% of time.

Results: 71% Recommendations/ Action Taken: This objective was not achieved for this fiscal year, and actually our annual performance dropped 5% from the previous fiscal year. This drop in performance is attributable to the hiring of three new staff, the splitting of MHSS into East and West teams, and two team members going out on FMLA; however, 4th quarter results exceeded our annual total from last year showing that MHSS is already rebounding from these changes. Performance Improvement: As a result of MHSS not achieving the desired outcome, this same objective should be measured again for FY 2014 in an effort to achieve compliance 90% of the time.

Access Objective: MHSS will open consumers within 30 days of case manager being notified of opening

Results: 27/42; 64% Recommendations/ Action Taken: Forty‐two consumers were opened this past fiscal year with 27 of these referrals being opened within 30 days. As a result, 64% of consumers were opened within 30 days of referral. The average wait period for the year was 33 days which was a drastic improvement over the previous year which had the average wait period of 87 days. Performance Improvement: As a result of not achieving this goal, this new goal will be continued. Goal for next year should be set at opening 80% of referrals within 30 days of referral date.

Objectives for the Coming Year Effectiveness Objective: Of consumers currently enrolled in MHSS, 10 will be discharged successfully in the next year


Efficiency Objective: MHSS staff will document monthly collateral contacts with case managers 90% of time Efficiency Objective: MHSS will achieve and/or exceed program revenue projections Access Objective: MHSS will open consumers within 30 days of referral from case manager

MH Vocational Services

Outcomes

Effectiveness Objective: Twenty‐four (24) additional assigned program participants will become employed during the evaluation period (7/1/12‐6/30/13)

Results: 19 Recommendations/ Action Taken: Although the team fell short of the goal (24), progress was made with employment for those served. Performance Improvement: The vocational team will continue to create new relationships with employers, especially with retail businesses as there seems to be an upward trend in that market.

Efficiency Objective: ARS Vocational Program staff will meet 45% productivity

Results: 36% Recommendations/ Action Taken: The productivity rate did not reach the 45% objective. Performance Improvement: The productivity rate did not reach the 45%, but we will continue to set the same goal as it is agreed to be a realistic expectation. The team will make adjustments to increase productivity through increased caseloads and increased face to face contact with clients. Also, the supervisor’s productivity rate will not be calculated percentage‐wise, as the responsibilities have changed for that position due to other program involvement.

Efficiency Objective: Increase the number of participants that have received employment services by thirty (30).

Results: 25

Recommendations/ Action Taken: The team will continue to set the goal at a rate that will increase the number of persons served. The vocational team will set in on case management team meeting and reach out to staff to provide information with regard to clients referred to ensure readiness for the vocational program. Performance Improvement: We will work closely with case managers to ensure referrals are ready to start services with reliable transportation plans and realistic expectations around work.


Access Objective: Persons referred will be contacted within five (5) business days of receiving referral

Results: 88% Recommendations/ Action Taken: Five individuals did not respond back but it was uncertain if it was their decision or they were unaware of the messages. Performance Improvement: The plan is to continue to reach for contacting all referrals within five days. Staff will follow‐up with case managers in a timelier manner to contact referrals within the time frame.

Objectives for the Coming Year Effectiveness Objective: Twenty‐four (24) additional assigned program participants will become employed during the evaluation period.

Efficiency Objective: Vocational program staff will meet 45% productivity Access Objective: 95% of persons referred will be contacted within five (5) business days of receiving referral Access Objective: Increase the number of participants that have received employment services by thirty (30)

Prevention

Outcomes

Effectiveness Objective: 95% of CONNECT of 1st – 3rd grade participants shall be reading on or above grade level.

Results: 90%

Recommendations/ Action Taken: At the end of the 2012‐13 school year, 90% of 1st ‐ 3rd graders are reading on or above grade level. Although the 95% objective was not quite achieved, there was significant progress made in reading over the course of the school year. The number of youth reading below grade level was reduced by 50%. At the first report card there weren’t any children reading above grade level. By the end of the school year more than ¼ children (28%) were reading above grade level. The positive reading outcomes in the Connect program can be attributed to the following strategies: Prevention Services requesting additional training for Connect staff and interns by a Title 1 Reading Specialist; interns from area colleges working with participants on creative reading activities; close collaboration and follow‐up with teachers by Connect staff; on‐site tutorials provided by teachers at Connect sites; and Connect staff facilitating greater parental engagement with the schools. Performance Improvement: In recognition of the research that shows that reading skills are crucial to academic success and reducing other risk factors, Prevention Services will continue the prioritization of this important objective.


Effectiveness Objective: Students will show a decrease in favorable attitudes towards Alcohol, Tobacco and other Drugs (ATOD) as demonstrated by the evaluation outcomes of evidence‐based curriculums implemented in the community

Results: 2% decrease Recommendations/ Action Taken: All Connect participants in 3rd‐8th grade receive the Life Skills Training (LST), a nationally recognized substance abuse prevention curriculum. A sample comprised of 3rd, 5th and 7th graders was pre and post tested to determine outcomes. The elementary youth outcomes on post –test show a slight change, with unsure responses regarding ATOD use dropping from 18% to 15%. Favorable responses among this group remained relatively unchanged (i.e., 14% vs. 15%, respectively). In the middle school group there was a significant shift toward uncertainty in attitudes, with12.5% of MS youth responding “unsure” regarding their attitude toward ATOD use. However, 87.5% responded with unfavorable attitudes toward ATOD use. Although more middle school youth responded with uncertainty in their attitudes toward ATOD on the post‐test (12.5%) than pre‐test (0% unsure or favorable responses), the post‐test may be a more valid representation of how these youth are actually thinking about their environment and the information presented in the LST curriculum. Performance Improvement: The Connect program is a community based after‐school and summer program focused on building protective factors for at risk youth. Strengthening life skills, including substance use refusal skills, will remain a paramount objective for Prevention Services.

Efficiency Objective: The Henrico Too Smart to Start Community Coalition shall implement community‐level prevention strategies as measured by the delivery of 4 events annually

Results: 7 events Recommendations/ Action Taken: Prevention Services and Henrico Too Smart 2 Start Coalition (www.toosmart2start.com) implemented seven community‐level activities, surpassing its objective for FY13. The Youth Ambassadors (leadership development component) remains strong with 23 Henrico youth playing an instrumental role in TS2S activities. The Youth Ambassadors attended the 2012 Annual Youth Alcohol & Drug Prevention Project Conference (YADAPP), where they won recognition for their community action plan that culminated in a Healthy Relationship Teen Forum held at JRS Community College held this Spring. Additionally, the youth participated in all of the coalition’s activities with an array of community partners including KMART, Walgreens, Food Lion, and Kroger, area colleges/universities, fraternities and sororities. These community partners supported community health fairs, a prescription drug take back event, and activities that raised community awareness about prevention of under‐age alcohol use and other substance abuse. Additionally, the Henrico TS2S Coalition hosted its first “community conversation” event to inform the community about the work of the coalition, solicit input regarding community needs, and engage new partners in the coalition’s mission of promoting the health and


http://www.toosmart2start.com/

wellness of Henrico County citizens. Participants came from human service organizations, Henrico schools and police, the business community and Henrico citizens. Performance Improvement: The feedback received from the event will help shape the TS2S Coalition’s strategic plan.

Efficiency Objective: The Charles City Community Coalition shall implement community‐ level prevention strategies as measured by the delivery of 2 events annually.

Results: 4 events Recommendations/ Action Taken: The Charles City Prevention Coalition, although in transition, exceeded its objective by partnering with other community efforts in 4 community‐level activities. The Families and Schools Together Program (FAST), an internationally recognized evidence‐based program, coordinated by Henrico Prevention Services employs community partners to deliver the program at Charles City Elementary School. The program continues to thrive and graduating families often move into the parent support group component (FASTWORKS). FASTWORKS actively participates in school and community activities such as PTA/SOL Night, James River Clean‐up, Relay for Life, Community Day, Charles City Holiday Parade, and a Holiday Lights bus tour for families. Each of these events provided an opportunity to disseminate information about the Charles City Prevention Coalition and prevention efforts in the community.

Performance Improvement: The Charles City Coalition is currently in transition and focusing on recruiting a broader active membership. In the interim, all activities will be coordinated through the Charles City School Counseling Director.


Effectiveness Objective: 95% of CONNECT of 1st – 3rd grade participants shall be reading on or above grade level Effectiveness Objective: Students will show a decrease in favorable attitudes towards Alcohol, Tobacco and other Drugs (ATOD) as demonstrated by the evaluation outcomes of evidence‐based curriculums implemented in the community Efficiency Objective: The Henrico Too Smart to Start Community Coalition shall implement community‐level prevention strategies as measured by the delivery of 2 events annually Access Objective: Consumers will be approved for admission into the CONNECT program within 5 business days of request for services

Youth and Family

Outcomes

Effectiveness Objective: MST team will increase the percentage of youth in the program involved with pro‐social peers/activities to 75%

Results: 68.92%


Analysis/ Action Taken: The Multi‐Systemic Therapy (MST) program is an evidence‐based, home‐based therapy proven to be effective with youth who display high risk behaviors and/or are involved with the court system. This model looks at several outcomes as means for tracking success in the program. One of the resiliency factors proven to reduce delinquent behavior is linking youth with pro‐social activities. To show overall improvements across areas of life functioning as a result of participation in services, the MST program tracked involvement in pro‐social activities. The quality improvement outcome was to look at the percentage of youth participating in pro‐social activities with the baseline at 69.23% with the goal at 75%. Factors that influenced the percentage of MST recipients that engage in pro‐social activities was found to be influenced by the resources of the family and community, if the youth was placed in detention/out of the home, flow of referrals and court staff education about the shared goals and staff turnover.

Performance Improvement: Actions taken to improve this outcome measurement include using a community resource list of pro‐social activities in supervision/consultation, implementation of an inventory of client interests and strengths as a guide for identification of possible activities/interests, and continuous reminders about this focus to the therapists in supervision. The MST staff also did education and outreach to the court staff and other agency stakeholders. Engagement and buy‐in from probation staff was an influential factor as placement was one of the barriers to reaching the goal.

Effectiveness Objective: Youth & Family Services Outpatient Clinicians will utilize the MyOutcomes web based program to monitor the alliance. They will address their clients’ needs appropriately and more effectively as evidenced by a minimum of 70% of clients meeting service targets (a score of 26 or better on the Outcomes Rating Scale (ORS) when discharged from services.

Results: 72.9% Youth and Family 69.7% Child 76% Adolescent

Analysis/ Action Taken: The service target is pre‐determined by the Outcomes Ratings Scale (ORS) research and has been normed at a score of 26 or better on the ORS. Myoutcomes is a web‐based program that produces Client‐driven outcomes management based on the ORS and has been shown to be highly feasible for clinicians. The annual outcome is 72.9% of Youth & Family Services outpatient clients are showing that they are meeting their service targets of a 26 on the Outcomes Rating Scale by discharge. Some of the drop in percentage of clients meeting service targets to 72.9% in the fourth quarter could be due to a drop off in services. Also, the Youth and Family team will not be using the MyOutcomes rating scale for next fiscal year, so there may have been some drop in staff utilization of the measure. There were some difficulties in getting accurate measures of younger children’s responses and their participation. There could also be some difficulties with obtaining accurate reports from adolescents involved in treatment just wanting to get the measure out of the way rather than giving it their full attention. Overall, the identified client measures remained consistent over time and across programs. Adolescent Team


scores, which reflected adolescent ratings only, were consistently higher than Child & Family Team scores, which included both child and parent ratings. Performance Improvement: While the decision has been made to terminate our contract with MyOutcomes, some staff have found the Outcomes Rating Scales to be clinically useful, especially in working with older children and adolescents, and may continue to use the paper and pencil rating scales with select clients. All staff have benefited from a long term trial involving the use of client feedback in directing clinical practice. The agency is moving in the direction of participatory documentation of services, and several Youth & Family staff on each team have been piloting this over the past several months. This will become another tool for incorporating client feedback into the clinical process and can be more flexibly adapted to include feedback from the full range of ages served, as well as the parents who are involved in their children’s treatment.

Access Objective: Child and Adolescent non‐crisis consumers will be seen within 10 business days of initial attempt to access services

Results: Waits ranged from 12 to 25 days Analysis/ Action Taken: Youth & Family Services Outpatient Teams did not meet its objective of seeing non‐crisis consumers within 10 business days of initial attempt to access services during any quarter this year. During Fiscal Year 2012, this objective was met 25% of the time. During Fiscal Year 2013, Y&FS staff opened 810 cases, averaging 67.5 cases per month. In Fiscal Year 2012, 849 cases were opened, averaging 71 cases per month. Tracking this objective over time has been helpful in clarifying the impact of multiple contractual and community demands on program capacity and overall access to outpatient services for children and adolescents. While HAMHDS Youth & Family Services staff is able to provide rapid response for court‐ordered evaluations, school‐contracted substance abuse evaluations, and Medicaid‐contracted independent clinical assessments, those commitments diminish our capacity to respond to non‐crisis outpatient consumers. Performance Improvement: Youth & Family Services supervisors and staff are exploring strategies for maximizing access to services, which may include a more integrated access process that allows for more flexibly meeting the needs of clients across programs.


Effectiveness Objective: MST team will increase the percentage of youth in the program who remain in their current placement [in home and community] to program target of 90% Effectiveness Objective: 85% of participants in the Incredible Years Parenting Group will report positive gain in 50% of items on the IY Parenting Scale Efficiency Objective: 35% of the PATH substance abuse treatment group clients will progress at least one step in the stages of change model to help move them through the process of changing their current substance use/abuse Access Objective: Youth & Family Services non‐crisis consumers will be seen within 10 business days of initial attempt to access services



CSS Case Management Outcomes

Effectiveness Objective: Enhance service provision to individuals with a dual diagnosis of ID and MI through one targeted training this FY.

Results: 0

Recommendations/ Action Taken: Trainers were not available this year. Performance Improvement: A small group is continuing to work on scheduling this training however, this will not be an outcome next year

Access Objective: Individuals will be seen within 20 business days of assignment to “Eligibility Complete” unit

Results: 80% Recommendations/ Action Taken: 80% of the charts were processed and individuals were seen within 20 days for their first face to face which did not meet the goal of 100%. There were a number of contributing factors including delays in assignment to Case Manager and family preference regarding meeting time. Performance Improvement: Factors under staff control will be evaluated for possible increased efficiencies in the process of moving the client information from the intake unit to the physical location of the Team assigned to provide services to the client.


Efficiency Objective: All Waiver Slot Discussion Summary forms will be entered into Anasazi by December 31, 2013 Access Objective: Individuals will be seen within 20 days of assignment to “Eligibility Complete” unit

CSS Day Services Outcomes

Effectiveness Objective: Each quarter after the first quarter, the number of activities which meet the criteria for community inclusion will increase by 5%

Results: Met one of 3 quarters after baseline Recommendations/ Action Taken: The outcome was to increase the number of community integrated activities in each quarter following the first quarter baseline. The overall rate of integrated community activities throughout the year did not change substantially, meeting


our outcome only one of the three possible quarters. The program breakdown was as follows (indicates number of quarters with a 5% increase): LEP – increased 1 of 3 quarters; STEP – increased 2 of 3 quarters; Workshop/Enclaves – increased 0 of 3 quarters. Overall, the outcome gave program staff an opportunity to obtain a year‐long baseline for evaluation of the program’s overall involvement in integrated community based activities. Performance Improvement: With the continued focus on integrated community activities as a desired approach for services, the outcome will continue with some modifications to the data collection systems. For the upcoming year, the focus group will be modified to individuals in the LEP and STEP programs as well as the individuals receiving day support services in the VOC/Enclave program. The outcome emphasis will change to ensuring each individual has opportunities versus an overall program outcome.

Effectiveness Objective: 5 individuals who attend the workshop/enclaves will participate in individual supported employment activities by the end of the year.

Results: 3

Recommendations/ Action Taken: Three individuals who expressed interest in integrated community employment were placed in an enclave at K2 Trophy in April 2013. These individuals were hired by the company, paid minimum wage and were fully integrated into their workforce. The group worked alongside others, played basketball with them while on breaks and were considered members of their staff. Due to the seasonal nature of the work, they returned to the workshop in July but will be rejoining the K2 team in the fall. This outcome was to assist five individuals, but we did successfully find community employment for three. Performance Improvement: An outcome similar to this will be continued next year.

Effectiveness Objective: 10 Individuals enrolled in the enclaves will visit a different enclave or community work site.

Results: 8 of 10 for 80% Recommendations/ Action Taken: Our outcome was to encourage 10 of the 27 individuals who were enrolled in the enclave at the start of the year, to explore other options, with the hopes that they might move into even more integrated settings and/or find more independence in their work. Eight individuals agreed to discuss changes and of those, two found new jobs, one is in job development and the other five explored options on their current sites. While we did not see the expected and hoped for results, it became clear that to most of the enclave consumers, they have a job and do not want to leave it. This is a positive sign since most are making minimum wage or more and they are working in an integrated setting. Performance Improvement: We will continue to assist individuals to think about careers and about moving to individual employment opportunities when they arise.


Efficiency Objective: Utilization Peer Review scores on the DATA section will reflect an average of 95% compliance for all waiver charts.

Results:; 95.5% (256/268) Recommendations/ Action Taken: We met this objective for the first time in 3 years. The average across all of the programs was in compliance with 256 of 268 data elements for a 95.5% rate. The breakdown by program for the year is: Enclaves – 90%; Cypress – 96%, HE – 93%, LEP – 98% and STEP – 100%, while individual programs did not meet the objective, each program showed an increase in compliance from the previous year. Staff have worked hard ensuring they were documenting the right things as well as the right way. We have modified forms to ensure we were capturing the important elements. Staff have become more adept on signing appropriately and in ensuring that the methods of collection match the intent of the individual person’s outcome. Performance Improvement: We will continue this outcome for one more year due to the importance in ensuring we are meeting the regulatory body’s requirements.

Access Objective: 100% of Individuals will start their assessments within 30 days from the date the referral is received.

Results: 21% (3 of 14) Recommendations/ Action Taken: The outcome was to schedule an initial assessment within 30 days of the receipt of the referral. We met this objective in 21% of the referrals received (3 of 14). Due to our procedure and belief that an individual should have an opportunity to spend time within the program to determine if this is what s/he is looking for, the initial assessment is 3 to 5 days. We are limited in the number of individuals we can assess at any one time. Most referrals this year were in either the workshop or in the STEP programs. We tend to get referrals in clusters and this expands the amount of time for each one to get in the door. In addition, some families agree to the referral but are not ready to make the arrangements for the actual assessment when first called. This element of choice makes the referral to assessment deadline difficult to meet. Performance Improvement: Next year, we are recommending a change in the outcome to monitor receipt of referral to first contact by the supervisor of the program.

Objectives for the Coming Year Effectiveness Objective: Community Inclusion: 50% of the individuals will participate in at least one activity that meets the community inclusion criteria per quarter Effectiveness Objective: Organizational Employment: 5 individuals who attend the workshop will participate in individual supported employment activities by the end of the year. Efficiency Objective: Utilization Peer Review scores on the DATA section will reflect an average of 95% compliance for all waiver charts Access Objective: Individuals referred will start their assessment within 30 days of the date of referral


CSS Individual Supported Employment

Outcomes

Effectiveness Objective: 95% of individuals looking for employment will complete and submit 4 job applications per month related to their employment goal

Results: 44% Recommendations/ Action Taken: For the year, 44% of the individuals in job development met the objective of completing four applications per month. While we did not meet the 95% objective, the intent was to engage consumers in their own job development activities. There were a variety of obstacles to helping individuals’ complete applications. While many did not meet the criteria, this emphasis on job development helped solidify the objectives of the individual in looking for work they wanted to do. Performance Improvement: For next year, we will adjust this outcome to incorporate the number of contacts with the job coach as a way of monitoring true job development activities.

Efficiency Objective: 100% of SE staff will attend at least one SE Forum training/meeting per year and share information in discussion at SE Specialty meeting

Results:; 71% (5 of 7) Recommendations/ Action Taken: This year 5 of the 7 job coaches were able to attend the SE Forum meetings sponsored by the Department of Aging and Rehabilitative Services to increase their knowledge. However, in the last half of the year, no forums were scheduled. The intent of this outcome was to increase the opportunity for skill building and networking for all job coaches.

Performance Improvement: Next year, our outcome will focus on job coaches participating in a variety of events, rather than just one, to increase the likelihood that they will meet this outcome and benefit from the networking.

Access Objective: Individuals will be seen within 6 business days from the time of acceptance to the employment program

Results: 50% (3 of 6) Recommendations/ Action Taken: 50% of the referrals were seen in six days of acceptance into the program. While this objective was not met, it became clear that the ability for the job coach to meet with the individual was not only dependent upon the schedule of the job coach, but more importantly, the schedule of the individual or family. Performance Improvement: With the move of Supported Employment from the Community Teams to the Employment and Day Services section of the agency, a new process for referrals


has been developed. We will continue the outcome, but the objective will be to see the individual within 10 days rather than 6. The change will take the schedule of the individual into account as well as the change in procedure for the referral.

Objectives for the Coming Year Effectiveness Objective Group Supported Employment: 100% of the new enclaves/crews developed for group employment will incorporate an hourly pay rate of minimum wage or above for the consumers Effectiveness Objective: Individual Employment: 90% of individuals in job development will receive 4 employment contacts per month from their job coach (one of which is face to face) Efficiency Objective: 81% (9 of 11) of the Enclave and Individual Employment Specialists will participate in one networking or community education opportunity with the Business community within the year Access Objective: Individuals will be seen by the employment specialist within 10 days of assignment from the supervisor

CSS Intake

Outcomes Access Objective: Individuals referred to the agency for services will have a face to face intake meeting within 10 business days of the first contact.

Results: 8 of 12 months met objective; 66% Recommendations/ Action Taken: Overall this year the ID intake unit has been able to meet with individuals requesting services within 10 business days of their initial phone call 8 out of 12 months. During the 4 months where the time from the initial call to intake exceeded 10 days the reasons included: families requesting dates further out than 10 days and an increase in the number of intakes related to available slots.

Performance Improvement: We will continue to monitor this area to make sure individuals are seen in a timely manner.

Access Objective: 90% of individuals receiving intake for ID Services will have eligibility resolved within 60 days from initial face‐to‐face visit.

Results: 100%

Recommendations/ Action Taken: The objective of 90% of individual eligibility resolution within 60 days from initial face to face visit was exceeded at an annual result of 100% during FY13. Where psychological evaluations continue to be the major reason for slowing the process down, what has helped are conversations in advance of the intake clearly outlining


what we need to have to determine eligibility. Many families are coming to the appointments with all required information in hand.

Performance Improvement: We will continue to monitor this area and make adjustments as needed.

Objectives for the Coming Year Access Objective: Individuals receiving intake for ID Services will have eligibility resolved within 60 days from initial face‐to‐face visit Access Objective: Individuals currently residing at SVTC will be successfully discharged to the community or transferred to another facility by 6/1/14

CSS Residential Outcomes

Efficiency Objective: 90% (18/20) residents will participate in at least 2 community inclusion activities of choice per month

Results: 90% average for 12 months; 6 of the 12 months objective met Recommendations/ Action Taken: 90% of the residents participated in two community inclusion activities in 6 of the 12 months. Overall this outcome has yielded positive results during the past year but has also taught staff good information about the residents and themselves. Most of our residents like to go out, but possess such a narrow repertoire of places it is difficult at times to get them to agree to branch out and try something new. Also, if we as staff look at the places we go on a monthly basis it usually consists of routine and familiar locations. Staff did a great job of making sure they had ample opportunities to visit these favorite places. The more difficult part was using their creativity to offer additional options based on a resident’s likes and hobbies in an attempt to get them to branch out. Performance Improvement: For the upcoming year, this outcome will remain with a few adjustments. In addition to those routine inclusion activities that the residents enjoy, a component will be added to encourage each resident to try something new each quarter.

Effectiveness Objective: : 90% of residents (whom Henrico staff assist with medical appointments) will visit their primary care physician at least 1 time during the next year

Results: 100% (17 of 17) Recommendations/ Action Taken: Physical health and access to medical care is a significant component to a good quality of life. Through the DOJ settlement access to medical care is an area where they are looking closely. During this year, residential staff tracked doctor appointments to ensure that the residents were seeing at a minimum their primary care doctor at least one time. What we discovered was that our residents have excellent access to medical care and see not only their PCP, but specialists at a frequency that best meets their health care needs. 100% of residents (those whom we assist with medical care) saw their PCP


at least once and appointment types included: sick visits; follow‐up appointments; regular check‐ups; lab work and summer camp physicals. Performance Improvement: The program will continue to monitor access to medical care.

Efficiency Objective: 90% of residents (whom Henrico assists with medical appointments) will have regularly scheduled screenings during the next year to include: mammograms (6 residents due), colonoscopies (4 residents due this year)

Results: 83%‐ mammograms; 25%‐ colonoscopies Recommendations/ Action Taken: Individuals living in Henrico’s residential program are receiving regular screenings for mammograms and colonoscopies per their age and doctor recommendations. These tests have been addressed with family members and physicians and in most cases have occurred routinely. While the objective of 90% was not met this year, 83% of the mammograms were completed and 25% of the colonoscopies were completed. Those procedures not completed were either refused by the resident or scheduled for the next fiscal year.

Performance Improvement: Staff will continue to monitor and schedule residents for age related screenings and provide the needed support to ensure these screenings occur. Staff will work closely with physicians and family members to address any concerns and promote wellness for our residents.

Objectives for the Coming Year Effectiveness Objective: 90% residents will participate in at least 2 community inclusion activities of choice per month Efficiency Objective: 90% of residents (whom Henrico staff assist with medical appointments) will visit their primary care physician at least 1 time during the next year

Parent‐Infant Program

Outcomes

Efficiency Objective: 100 % of children found eligible for Early Intervention services will have an IFSP developed within 45 days of the date of referral

Results: 68% (175 of 258) Recommendations/ Action Taken: 68% of children eligible for Early Intervention services had an IFSP developed within 45 days of the date of referral. Challenges that occurred during the year include having more children requesting services than available intake and assessment slots.

Performance Improvement: We project that we will meet this outcome in the next fiscal year


Efficiency Objective: 100 % of children discharged from Early Intervention Services will have all of their transition steps and services completed on their IFSP.

Results: 100%

Recommendations/ Action Taken: 100 % of children discharged from Early Intervention Services completed their transition steps and services on their IFSP. The program attributes this year’s results to training provided to staff on the required transition steps and services and restructuring of the discharge process. Infant Toddler Connection of Henrico Area has maintained full compliance around the transition. Performance Improvement: The Parent Infant Program will continue to provide the needed training in the area of transition.

Access Objective: The Infant and Toddler of Connection of Henrico, Charles City and New Kent Counties will meet or exceed the December 1 child count determined by the Part C state office

Results: Outcome not met Recommendations/ Action Taken: The Infant and Toddler Connection of Henrico, Charles City and New Kent did not meet its December 1st child count. The target number was 43. Of the possible 50 children referred, 40 were determined eligible by December 1st. The 10 that were not in our system on December 1st was due to the following: no show appointments, families scheduling preference and children being hospitalized (5 were medically fragile). Performance Improvement: Next year an outcome will be added to increase child find activities.


Efficiency Objective: 100 % of children discharged from Early Intervention Services will have all of their transition steps and services completed on their IFSP Access Objective: 100 % of children found eligible for Early Intervention services will have an IFSP developed within 45 days of the date of referral Access Objective: The Infant and Toddler of Connection of Henrico Area will meet or exceed the December 1 child count determined by the Part C state office Access Objective The Infant and Toddler Connection of Henrico Area will conduct 3 child find activities this fiscal year

5. POST DISCHARGE INFORMATION FOR CARF SERVICES Post discharge information is collected for CARF services. The post discharge surveys are mailed approximately 30‐ 60 days after the client is discharge from a CARF service. At least two questions are asked in each survey, including a satisfaction question and a question that refers back to the program goals. Survey questions are reviewed and updated as needed on an annual basis to correspond with the current goals and objectives. In order to complete a timely annual report, the reporting period covers the period of April 1, 2012 through March 31, 2013.


During this fiscal year, ten separate services were tracked. A total of 299 surveys were mailed and 39 were returned. The response rate for programs ranged from 0% to 100% with an average response rate for all of the CARF services of 28%. The response rate is considerably higher than the 6% obtained for FY12. Individual comments are forwarded to the respective program.

6. SATISFACTION INTELLECTUAL DISABILITY SERVICES‐ FAMILY SATISFACTION SURVEY The Virginia Department of Behavioral Health and Developmental Services (DBHDS), Office of Developmental Services administered its twelfth annual statewide survey of family satisfaction with Community Service Boards and other Intellectual Disability (ID) service providers. The family satisfaction survey is designed to measure family perceptions in five areas: family involvement, case management services, choice and access, healthy and safe environment, and service reliability. The 37‐item questionnaire based in part by surveys developed by the National Core Indicators Project (NCI) was handed to family members during the time of the consumer’s annual review. Respondent’s replies included: strongly agree, agree, strongly disagree, disagree or does not apply. Respondents mailed the completed surveys directly to the Office of Intellectual Disability Supports in the provided post‐paid return envelope. Twenty‐six (26) surveys were returned representing a 12.68% return rate. The percentages below include the Strongly Agree and Agree responses. The survey in its entirety can be found at http://www.dbhds.virginia.gov/documents/reports/OMR‐FamilySurvey2012.pdf


http://www.dbhds.virginia.gov/documents/reports/OMR-FamilySurvey2012.pdf

http://www.dbhds.virginia.gov/documents/reports/OMR-FamilySurvey2012.pdf

1. 93% feel that services provided to the person with ID helped to relieve stress on the family 2. 94% feel that the person with ID has access to the special equipment or accommodations that

he/she needs 3. 100% feel that staff help the person with ID get supports needed in the community 4. 100% feel that they get enough information to help the individual participate in planning

services 5. 100% of family members participated in the individual’s yearly plan 6. 93% received information in a reasonable time from their case manager

AGENCY SATISFACTION SURVEYS HMHDS also directly conducted Consumer and Stakeholder satisfaction surveys in some programs, in addition to the surveys administered by the Department of Behavioral Health and Developmental Services (DBHDS). Results below indicate all responders report at least a 70% satisfaction rate with services, with the majority of responses indicating at least a 90% rating. Two programs demonstrated an increase in consumer satisfaction ratings, and three programs demonstrated an increase in stakeholder satisfaction.

Consumer and Stakeholder Satisfaction

0%20%40%60%80%

100%120%

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CSSSupported

Employment

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Prevention

FY13 Consumer Satisfaction FY13 Stakeholder Satisfaction FY 12 Consumer Satisfaction FY 12 Stakeholder Satisfaction

7. FY 14 MANAGEMENT, ADMINISTRATIVE AND PROGRAM INITIATIVES MANAGEMENT

Prepare for Health Care Reform

ADMINISTRATION Determine scope of work to implement collecting and posting copayments at the front desk, through the Scheduler system

Incorporate further enhancements to the 5010 and Electronic Data Exchange, in Anasazi o 270 ‐eligibility verification o 277CA: Electronic file‐ Health Care Claims Status Response o 999: Electronic file‐ Health Care Claims Status Response o 278 Electronic file‐Authorization for services o Expand automation of posting payments to commercial insurance using the 835


Implement Magellan as the Behavioral Health Services Administrator: The Department of Medical Assistance Services awarded the contract for a Behavioral Health Services Administrator (BHSA) to Magellan Health Services. The BHSA contract with Magellan will impact and bring changes to procedures related to: behavioral health service authorizations; provider network enrollment; and claims processing and payment.

Implementation of Virginia’s Commonwealth Coordinated Care program (CCC or dual demonstration): Implementation with three health plans (Anthem/Healthkeepers, Humana and Virginia Premier), contracted by DMAS and CMS to improve coordination of services, enhance quality of care, and reduce service delivery cost for Medicare‐Medicaid Enrollees. Service authorizations; provider network enrollment; and claims processing and payment are affect in this implementation.

Implement Anasazi Assessment Version 3 Phases 1 Implement Anasazi’s new Data Sage Reporting system Purchase and begin preparing for implementation of the Anasazi Exchange (interoperability) Explore integration of a Personal Health Record for consumer access to their own health data Implement Scanning of remaining paper medical records in 3 locations Enhance Chart Tracker to add Archive as a location and designate thousands of records to that location

Implement County KACE system for responding to and tracking IT workorders and Facilities workorder

Implement an automated system for tracking and recording drills and safely inspections Implement Incident and Human Rights on‐line reporting system


Adult Substance Abuse/ Adult Mental Health Services Reconfigure the MH Adult OP team and stand alone DBT team into a single DBT informed MH OP team to meet the greater need with a lower cost service due to shrinking resources

Expand jail diversion resources through the addition of a full time case manager to the jail staff; this will allow for intervention along intercept 2 and increased resources at intercept 5

Adult Recovery Services

Expand the array of residential services available for clients Continue to focus on skill building curriculum to support clients’ ability to live as independently as possible

Emergency Services

Continue to refined and support Henrico’s Crisis Receiving Center Continue outreach and advanced CIT initiatives Continue CIT monthly 40 hour trainings

Youth & Family

Implement High‐Fidelity Wraparound Intensive Care Coordination Services in Henrico, in collaboration with a regional partnership if awarded grant funding through DBHDS


Increase implementation of evidence‐based SA Groups across sites through increased education and partnership with stakeholders

Improve staff skills at assessment and identification of trauma through increased training and implementation of a structured trauma assessment instrument

Implement VICAP‐like assessments for eligible referrals seeking intensive in‐home, day treatment, or mental health support services through CSA funding

Prevention

Work collaboratively with schools and community to promote wellness through prevention of violence (i.e., bullying, relationship violence, etc.) and substance use.

Work with youth, families and schools to enhance early academic success and promote resilience through life skills development


CRRT Services Continue to complete the community placement of individuals residing at SVTC and begin the

process for individuals currently at Central Virginia Training Center

Parent Infant Program Continue to increase collaboration with school systems Educate physicians and the medical community about: Early Intervention Services Eligibility criteria for Early Intervention Part C services Explain the difference between the Early Intervention Model versus the medical rehabilitation

model of therapy Begin group therapy opportunities for children/families in the community

Case Management Services Continue to meet the community need for case management services while implementing

changes required by Department of Justice for the target population Align processes to support new Department of Justice enhanced case management and

reporting requirements Day Services

Increase opportunities for integrated employment at minimum wage or above for those who choose it

Increase opportunities for real engagement in the community for those who attend the facility based programs

Actively engage consumers in their choices and improve understanding of integrated community options.

8. QUALITY HEALTH INFORMATION OUTCOMES Record reviews were completed on approximately 20% of Medicaid charts and 10% of non‐Medicaid charts;


941 Quality reviews and 608 Administrative reviews were done in FY 2013. All ID programs were over 90% compliant. MHSA programs continued to improve with 11 programs at or above 90% compliance and several programs had remarkable improvements percentage wise. Admin was also above 90% in both divisions. OBJECTIVES FOR THE COMING YEAR

Continue improvements of the Utilization Review process Identify and report trends to AMT Continue training to ensure documentation meets all requirements

FY 2013 MH/SA RECORD REVIEW RESULTS SUMMARY

FY 2013 FY 2012 FY

2011 FY 2010 FY2009 Comments

ESP/OUTPATIENT 96% 92% 91% 81% ESP/PRESCREENING 99% 96% 97% 97% 91%

YOUTH & FAMILY EAST 86% 87% 86% 82% 78% no change from last quarter; down slightly from FY12

YOUTH & FAMILY WEST 90% 87% 83% 80% 78% now at 90% compliance; up 3% from FY12

MHOP EAST/WEST 91% 91% 88% 80% 81%

MHOP/SA/YOUTH PF 88% 88% 80% 78% 74% up 1% from last quarter; no change from FY12

SA EAST 92% 88% 83% 66% 75% up 4% from FY12; now above 90% compliance

SA RMP 88% 84% 75% 68% 73% no change from last quarter; up 4% from FY12

DBT OP 94% 97% 95% 91% 92% DBT CM 88% NA 87% 84% 83%

LAKESIDE CENTER 90% 87% 90% 84% 89% now at 90% compliance; up 3% from FY12

LAKESIDE CTR VOC 86% 83% 87% 84% 83% up 1% from last quarter; up 3% from FY12

PACT EAST 91% 84% 84% 62% 84% up 7% from FY12; now above 90% compliance

PACT WEST 86% 76% 76% 73% 72% up 1% from last quarter; up 10% from FY12

CM&A EAST 85% 86% 76% 71% 75% down 1% from last quarter; down slightly from FY12

CM&A WEST 1 87% 88% 82% 77% 81% no change from last quarter; down slightly from FY12

CM&A WEST 2 87% 89% 87% 77% 81% no change from last quarter; down slightly from FY12

CM&A PF 86% 71% 71% 78% 76% no change from last quarter; up 15% from FY12

MH SUPPORTED SVS 90% 89% 87% 82% 82% up 1% from FY12; now above 90% compliance

MH RESIDENTIAL 94% 78% 79% 87% 90% up 16% from FY12


MH ADMINISTRATIVE 93% 89% 87% 84% 80% up 4% from FY12; now above 90% compliance

Percentage represents compliance with standards reviewed Represents area in compliance 90% or better Represents areas where results are below 85%, in BOLD is under 80% Represents areas that improved by more than 5 percentage points Represents areas that improved by 1-4 percentage points Represents areas that dropped FY 2013 CSS RECORD REVIEW RESULTS SUMMARY

FY 2013 FY 2012 FY

2011 FY

2010 FY2009 NORTH 1 WAIVER 98% 97% 96% 95% 88% EAST 1 WAIVER 97% 92% 93% 92% 74% EAST 2 WAIVER 98% 97% 96% 93% 77% WEST 1 WAIVER 98% 98% 96% 93% 90% WEST 2 WAIVER 95% 93% 95% 96% 93% NORTH 1 SPO 91% 100% 97% 93% 97% EAST 1 SPO 96% 95% 98% 91% 91% EAST 2 SPO 99% 98% 95% 95% 94% WEST 1 SPO 99% 98% 96% 98% 92% WEST 2 SPO 98% 97% 98% 97% 94% NORTH 1 SE 100% 100% 99% 90% 99% EAST 1 SE 99% 96% 96% 94% 95% EAST 2 SE 96% 93% 95% 99% 87% WEST 1 SE 95% 99% 97% 100% 96% WEST 2 SE 92% 97% 91% 88% 84% HERMITAGE VOC 94% 93% 94% 90% 84% CYPRESS VOC 98% 97% 95% 94% 89% ENCLAVES 94% 93% 87% 84% 88% LEP 98% 94% 98% 94% 93% STEP 98% 98% 96% 93% 95% RESIDENTIAL 93% 91% 90% 88% 89% ID ADMINISTRATIVE 92% 93% 91% 85% 80% Percentage represents compliance with standards reviewed Represents area in compliance 90% or better Represents areas that improved by more than 5 percentage points Represents areas that improved by 1-4 percentage points (not done in 90%+ range) Represents areas that dropped (not done in 90%+ range)

9. RISK MANAGEMENT / INCIDENTS AND COMPLAINTS OUTCOMES During this past year, all objectives within the agency’s Risk Management Plan were addressed. Highlights include: HAMHDS had a successful DMAS audit reviewing ID case management, day services, supported


employment and residential services; the agency completed implementation of a mobility plan so that staff can perform agency business in community settings; and all group homes (ID and MH) have whole house generators. Critical incidents were regularly reviewed, analyzed and addressed as appropriate. The Risk Management committee completed the 3 year self‐assessment of all agency sites and recommendations were integrated into the accessibility plan of correction.

Critical incidents were regularly reviewed, analyzed and addressed as appropriate. No specific trends were noted requiring significant or organization‐wide interventions. However, it is noted that clientele continue to age and this is reflected in a slight, but steady rise in age‐related incidents. In addition, the agency is serving more complex clients and as a result, a rise in behavioral incidents is noted. The agency continues to provide education and training to support staff in their duties. It is also of note that Meaningful Use practices are being implemented, which will assist staff in monitoring basic client health information.

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FY 2012 FY 2013

OBJECTIVES FOR THE COMING YEAR

Maintain compliance with all regulations and standards related to health and safety Incorporate Meaningful Use procedures

10. STAFF TRAINING OUTCOMES Henrico Area Mental Health & Developmental Services maintains a corporate culture of continuous learning. Staff have the opportunity to registering for training provided directly by the agency through the use of an internal web‐based system known as MyTraining. As County of Henrico employees, Human Resources, Employee Development and Training offers Henrico County Government employees cutting edge, innovative training courses, leadership and customer service certification programs, and career enrichment coaching. All County employees are eligible to attend the wide variety of courses in the Leadership/Professional


Development and Customer Service and Technology categories. Additionally, through the County Risk Management Department, defensive driving courses and refresher courses are offered. With the approval of the department staff attend outside workshops and conferences.

The Agency maintains a group of 24 staff trainers that provides training in a variety of areas such as First Aid & CPR, Prevention of Violence, Therapeutic Options, Prevention of Infectious Diseases, Cultural Competency and training of the agency’s electronic health system, Anasazi. In total 49 classroom style training sessions were offered. During the year, the on‐line training courses were also available in Information Security Awareness, Fraud Awareness, the Code of Ethics, Human Rights, Health Information Management Confidentiality and Privacy, critical incident reporting, Prevention of Violence Refresher, Regulated Medical Waste, Professional Ethics Training and Fire Suppression. On‐line competency based training is provided for all staff annually in the areas of Human Rights and the Reporting of Critical Incidents. A self study course is available for Prevention of Infectious Diseases.

During FY13 two new Therapeutic Options trainers were added. Two additional staff attended a four‐day train – the‐Trainer workshop that lead to their instructor certification. were trained by Therapeutic Options, Inc. offers a four‐day Train‐the‐Trainer workshop leading to instructor certification. The curriculum provides the tools to keep people safe while maintaining their commitment to positive approaches in serving individuals whose behavior sometimes poses danger to themselves or others.

FY14 OBJECTIVES FOR THE COMING YEAR Re‐certification of Therapeutic Options trainers Add an additional American Red Cross Trainer Add additional Cultural Competence/Awareness Instructors Revise on line Critical Incident and Human Rights Training to meet new state requirements and new internal procedures.

11. CULTURAL AWARENESS AND COMPETENCY OUTCOMES Highlights of this year’s activities include the following:

Continued the expectation for all staff to participate in at least one cultural awareness activity per year. This requirement was achieved through staff attending outside training, agency brown bag events, CACC classes and workshops/conferences.

CACC participated in 5 out of 5 (100%) Agency administrative orientations. Committee members provide an overview of the mission of the committee, the annual plan, review CLAS standards and share cultural and linguistic initiatives and activities within the Agency.

One Agency staff member is a certified bi‐lingual interpreter. Held two sensitivity and awareness classes “Understanding Me Helps Me Understand Others”, for new staff. Additionally, provided a class on “Understanding Our Community” which included a more in‐depth discussion of the CLAS standards, the four generations in the workplace, Muslim religion, languages and statistics in Henrico, Charles City, New Kent and Virginia.

Training provided in March 2013 to the Board on the “Browning and Graying” of America


Laminated language identification flashcards for the language guidance folders to Woodman, East and Forge receptionist that includes current County language bank, and Agency interpreter guidelines.

The organization continues to maintain a diverse workforce in leadership, management, direct service and support service positions. These statistics are tracked by the County of Henrico, Human Resources.

The Agency promotes a welcoming environment through the display of diverse art work, consumer art work, and a children’s play area.

Wheel chairs are available at the Woodman and East Center, and automatic doors at Woodman center.

29 events were held, and the Agency also co‐sponsored events with Colaborando Juntos and partnered with the Asian Society of Central Virginia.

Clinical and Prevention Services offered a series of recovery oriented events and workshops for staff and consumers.

Community Support Services Celebrated Developmental Disabilities Month with month long activities.

Special activities were planned for Black /African American History Month. Art work created during the Arte, Musica y Imagination en las Americas event with Colaborando Juntos for Hispanic Awareness month was donated by CJ to Lakeside Center.

Collaborating with community agencies, CACC participated in joint community training efforts with Colaborando Juntos including co‐sponsoring their annual conference in November, “Eschuchame, Listen to Me”, language and intercultural communication and celebration of Hispanic Heritage with a presentation on Arte, Musica y Imagination en las Americas.

Supported the Area Planning and Services Committee for Individuals Aging with Lifelong Disabilities (APSC) with three staff members that participate on this regional multi‐agency coalition.

The Agency has two staff members that are members of the State Department of Behavioral Health and Developmental Disabilities Cultural and Linguistic Awareness Steering Committee, including one member who is the elected Chair of the State committee until January 2014.

The Agency supported the Office of Cultural and Linguistic Awareness and Competence’s National Minority Mental Health Awareness Media Contest.

Partnered with Virginia Commonwealth University using master’s level college students with Instructor review to translate agency forms to Spanish.

Maintained four diversity bulletin boards and purchased several multicultural calendars Partnered with the Virginia Department of Health and the Office of Cultural Awareness and Competence of the Department of Behavioral Health & Developmental Services to launch a pilot program to increase access to services for refugees.

FY14 OBJECTIVES FOR THE COMING YEAR

Provide training on working with interpreters Provide Agency greeting message in Spanish as well as English Support needs and awareness of services to aging population Plan celebration of CACC’s 20 years of work towards cultural competency

DEMOGRAHICS


According to the US Census Bureau, quick facts for 2012, there are about 314,932 people in Henrico County, 60.2% White/Caucasian, 30.1% Black/African American, .04% were Alaskan Native, American Indian, 7.2% Asian, 0.1%, Native Hawaiian and Other Pacific Islander persons, 2.1% Multi‐racial, 5.2% of Hispanic or Latino Origin, Language other than English spoken at home is 13.5%. Median household income is $61,206. In New Kent County there are approximately 19,169 people, 82.2% are White/Caucasian, 13.7% Black/African American, 1.0% Alaskan Native, American Indian, 1.0% Asian, 2.1% Multi‐racial and 2.3% Hispanic or Latino Origin, Language other than English spoken at home is 2.6%. Median household income is $71,198.

In Charles City there are about 7,157 people, 41.7% White/Caucasian, 48% Black/African American, 7.1% American Indian and Alaska Native, .04% Asian, 0.1% Native Hawaiian and Other Pacific Islander persons, 2.7% Multi‐racial, and 1.7% Hispanic or Latino Origin. Median household income is $47,093.

Two year Race & Ethnicity Comparison

Race & Ethnicity FY13* Henrico

FY12 FY13* New Kent

FY12 FY13* Charles City

FY12

White/Caucasian 60.2% 60.7% 82.2% 82% 41.7% 41.9% Black/African American

30.1% 29.9% 13.7% 13.8% 48.0% 47.9%

Alaskan Native, American Indian, Asian/Pacific Islander, Multi‐Racial

9.2% (Asian 7.2%)

9.4% (Asian 6.8%)

2.0% (Asian 1.0%)

4.3% (Asian 1%)

7.5% (Asian.4%)

10.2% (Asian .4%)

For persons served who identify themselves as Hispanic

5.2% 5.1% 2.3% 2.2% 1.7% 1.5%

*Source US Census Bureau, quick facts.census.gov

Language Comparison with County of Henrico and State of Virginia

Order/

Frequency

Seen within Agency Within Henrico County State of Virginia

1. English English English

2. Spanish Spanish Spanish

3. Vietnamese Hindi Korean

4. American Sign Language Chinese Vietnamese

5. Arabic* Vietnamese Chinese

6. Chinese* Arabic Tagalog

7. Korean * (same amount of Arabic, Chinese and Korean


languages seen*)

HAMHDS Henrico Area Mental Health & Developmental Services, HAMHDS, values a diverse workforce that is representative of the person served. Approximately 50% of consumers served were White/Caucasian and 39 % were Black/African‐American. The remaining 11% were: Alaskan Native, American Indian, Asian/Pacific Islander, and Multi‐racial. Of all consumers served 6% percent identified themselves as Hispanic. As of 6/30/13, of the approximately 304 HAMHDS permanent employees 56.91% self identify as White/Caucasian, 40.46% Black/African‐American and 1.65% Alaskan Native, American Indian, Asian/Pacific Islander, and Multi‐Racial, .99% percent identified themselves as Hispanic. Three Year Comparison of Person Served to HAMHDS Employees

Race & Ethnicity FY13 Persons Served

FY12 Persons served

FY11 Persons served

FY13 HAMHDS Employees (304)

FY12 HAMHDS Employees

FY11 HAMHDS Employees

White/Caucasian 50% 49% 52% 56.91% 56% 58% Black/African American

39% 40% 39% 40.46% 41% 39%

Alaskan Native, American Indian, Asian/Pacific Islander, Multi-Racial

11% 11% 9% 1.65% 3% 2%

For persons served who identify themselves as Hispanic

6% 5% 5% .99% 1% 1%

12. DEMOGRAPHICS


Total Consumers Served by Program Area

63%20%

17%

Mental HealthIntellectual DisabilitySubstance Abuse

2736

2831

6731073

605945

0

1000

2000

3000

4000

5000

6000

Number

MentalHealth

IntellectualDisability

SubstanceAbuse

Program Area

Consumers Served by Gender

MaleFemale

Fifty‐one (51) percent of individuals served in the Mental Health program area were male, and 49% served were female. In the Intellectual Disability program area, 61% of individuals served were male, and 39% served were female. In the Substance Abuse program area, 61% of individuals served were male, and 39% served were female.


Distribution of Consumers by Race and Ethnicity

50%

39%

11%

White/ CaucasianBlack/African-AmericanAlaskan Native,American Indian,Asian/ Pacific Islander,Multi-Racial

Fifty‐one percent (50%) of all individuals served were Black/ African‐American, Alaskan, Native American, Indian, Asian/ Pacific Islander, or Multi‐Racial.

1808

3559

238

628

189

825

33

168

1376

10

0%

20%40%

60%

80%

100%

Percentage

MentalHealth

IntellectualDisability

SubstanceAbuse

Program Area

Consumer Ages by Program Area

0-2 3-17 18-64 65+

Seven (7) percent of individuals served were ages 0 – 2; 25% were ages 3 – 17; 65% were ages 18‐ 64; and 3% were ages 65+.

13. BUDGET

REVENUE


21%

6%

42%

30%1%

State Funds

Federal Funds

Local FundsFee Revenues

Other Funds

FY2013 per the Year End Performance Contract Report Revenue by Source State Funds $ 6,998,233 21% Federal Funds $ 1,988,146 6% Local Funds $ 13,995,023 42% Fee Revenues $ 9,999,537 30% Other Funds $ 355,662 1% Total $ 33,336,601

EXPENSES FY2013 per the Year End Performance Contract Report Expenses by Disability Mental Health Services $ 14,969,726 48% Substance Abuse Services $ 2,930,090 9% Developmental Services $ 11,179,002 36% Administrative Services $ 2,127,910 7% Total $ 31,206,728

48%

9%

36%

7%

Mental Health Services

Substance Abuse Services

Developmental Services

Administrative Services


performance analysis fy13 july june - home - county of ... · annual performance analysis fy13 july...

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