Attachment 3
ADAMHSCC Quality Performance Indicators (QPIs)
CalendarYear 2014
January 1, 2014 through December 31, 2014
(Updated 12/15/13)
The ADAMHSB Quality Performance Indicators are designed to align the Cuyahoga County behavioral health system with state and national strategic indicators. These include the SAMHSA National Outcomes Measures (NOMs), OMHAS Strategic Plan Priorities, and ADAMHSCC Community Plan Priorities.
Providers who receive non-Medicaid funding will agree to work towards improving their results as outlined on the combined AOD/ Mental Health Quality Performance Indicators Report. Agencies should specifically demonstrate how they programmatically address improving on their quality performance indicators in their CY14 Agency Service Plan.
For purposes of evaluating the quality performance indicators, improvement will be determined by taking the individual agency data established for CY12 and CY13, and then comparing it to the agencies individual results achieved during CY14, and calculating the amount of improvement.
In general, each indicator is measured by either being above the system mean, meeting an established threshold, showing clinically significant change, or showing statistically significant improvement above the prior year.
If an area is identified by the Board as being in significant need of improvement based on an agency’s individual data, the Board will request a follow up improvement plan from the agency.
Providers of MH and AoD treatment services shall submit updated outcomes data as submitted in the Provider’s response to the 2014 Request for Information (RFI) and approved by the ADAMHS BOARD.
On or before November 1, 2014, Provider shall submit outcomes data which captures the program activities completed during January 1, 2014 through September 30, 2014.
Providers of AoD Prevention Services shall submit their outcome plans for each ADAMHS Board funded prevention program into the Initial Prevention Workbook and submit with the RFI for Board Approval. Prevention providers shall electronically complete and submit, on a quarterly basis, the ADAMHS BOARD Prevention Workbook.
Additionally, Providers of MH and AoD Treatment and Prevention services who receive Non-Medicaid funding will collaborate and cooperate with the ADAMHS Board in CY2014, to transition to the Shared Health and Recovery Enterprise System (SHARES). This will include:
1.Collecting the revised and shortened Consumer version of the Ohio Outcomes for adults (age 18 and older) for those receiving mental health services, at time of intake and discharge, or else every 12 months.
2.Collecting the slightly revised Ohio Scales Parent Version for youth receiving mental health services at the time of intake or discharge, or, alternately, 3 months and then every 12 months (Note: the Youth version and Worker version will also be available through SHARES, but will not be required).
3.Collecting the Brief Addiction Monitor (BAM) for adult clients (age 18 and older) receiving AOD treatment services at intake and discharge.
4.Prevention agencies will continue to submit the Prevention Quarterly Workbook in SHARES.
5.Providers must obtain prior permission in writing from the Board to use other outcomes to satisfy these SHARES outcomes requirements.
AOD prevention providers will continue to submit the Quarterly Prevention Workbook.
GUIDING VALUES:
- Eliminate duplication.
- Utilize existing data as much as possible.
- Avoid excessive new data reporting requirements.
- Data must be timely, practical, and relevant.
- Providers and Board to be accountable and responsible.
- Use indicators as quality improvement and technical assistance tools, not as tools for punishment.
- Quality process must include provider input.
- Summary of results and conclusions must be shared with providers.
Domain / Indicator / Formula / Desired Target
ACCESS TO QUALITY CARE / A1. Post-State Hospital Discharge Pharmacologic Management Appointment
(MACSIS claims data) / Percentage of consumers who receive an agency pharmacologic management appointment within 14, 30, 60, or 90 days following discharge from NCBHS / Above the system mean, or statistically significant improvement in percentage seen in 14 days or fewer above the prior year.
A2. Post-State Hospital Discharge CPST Appointment
(MACSIS claims data) / Percentage of consumers who receive a CPST appointment within 14, 30, 60, or 90 days following discharge from NCBHS / Above the system mean, or statistically significant improvement in percentage seen in 14 days or fewer above the prior year.
A3. Repeat State Hospitalizations
(PCS Hospital Report) / Number of consumers who undergo two or more state psychiatric hospitalizations in a 12-month period / Decreased number of consumers with repeated hospitalizations.
A4. Average Wait Time for MH and/or AOD Diagnostic Assessment for Children and Adults
(per Scale Central Intake) / Average number of days’ wait for Diagnostic Assessment / Above the system mean, or statistically significant improvement in average wait timeabove the prior year.
A5. Average Wait Time from Initial for MH and/or AOD Assessment to Treatment for Children and Adults
(MACSIS claims data) / Average number of days’ wait from Diagnostic Assessment to initial treatment service appointment (per MACSIS – based on last billing for D.A. and first billing for services) / Above the system mean, or statistically significant improvement in average wait time above the prior year.
A6. Community-Based Care
(MACSIS claims data) / Ratio of Adult CPST delivered in the community / 70% or statistically significant improvement in percentage Adult CPST delivered in the community.
A7. Use of Evidenced Based Practices, Best Practices, and Emerging Best Practices
(Agency RFI proposals, Agency Service Plans and Board Program Reviews) / # of clients/consumers receiving treatment based on established practices / Increased # of practices, or increased proportion of consumers/clients served by the specific practice
Domain / Indicator / Formula / Desired Target
CLINICAL OUTCOMES / O1. Decreased symptom distress / Adult consumers who experience decreased symptom distress
as measured by Ohio Adult Consumer Outcomes, Consumer Outcomes Tool (COM-T) or other tool of agency’s choice approved by Board / Statistically significant or clinically significant improvement in decreased symptom distress.
O2. Increased quality of life / Adult consumers who experience
increased quality of life as measured by Ohio Adult Consumer Outcomes, Consumer Outcomes Tool (COM-T) or other tool of agency’s choice approved by Board / Statistically significant or clinically significant improvement in increased quality of life.
O3. Ohio Outcomes Scales for Youth
(For those agencies continuing with Ohio Scales for Youth or other tool of agency’s choice approved by Board) / Overall results for youth consumers who experience:
- increased hopefulness
- decreased problem severity
- increased overall functioning
- improvement in attendance and grades
- decreased placement in restrictive settings such as Juvenile Detention and jail (per OH Scales ROLES score)
O4. Employed Consumers
(Program data) / # of consumers employed / Increased #
O5. Homeless Consumers
(Program data) / # of homeless consumers / Decreased #
Domain / Indicator / Formula / Desired Target
RISK MANAGEMENT / R1. AOD & MH Reportable Incidents (MUIs) / Overall results for:
- Timeliness of initial report, and timeliness of follow-up (as required by ADAMHS Reportable Incident Policy)
Domain / Indicator / Formula / Desired Target
FISCAL / F1. Medicaid Benefits
(ODJFS data and provider data)) /
- Percentage of consumers with lapsedMedicaid
F2. Central Pharmacy
(Central Pharmacy Reports) / Agencies that are above or below their annual allocation / On schedule with annual allocation
Domain / Indicator / Formula / Desired Target
AOD PREVENTION / Standards documentation compliance
(Agency record review by Board) / Percentage of adherence to documentation requirements / 80% or statistically significant improvement in percentage above the prior year.
Acceptable outcome plans
(Agency records reviewed by Board) / Percentage of agency outcome plans that are acceptable / 100% or statistically significant improvement in percentage above the prior year.
Acceptable outcomes
(Agency records reviewed by Board) / Percentage of participants that meet performance targets / 60% or statistically significant improvement in percentage above the prior year.
Use of Best Practices/ Standardized Curriculum
(Agency RFI proposals and Agency Service Plans) / Number of EBPs in use/ number of standardized curricula utilized / At least 1 or more
Domain / Indicator / Formula / Desired Target
Treatment Initiation
(BH Data) / 2 treatment service visits within 14 days of completion of assessment / 90% or statistically significant improvement in percentage above the prior year.
Treatment Engagement
(BH Data) / Percentage of clients successfully engaged in treatment / 80% or statistically significant improvement in percentage above the prior year.
Treatment Retention
(BH Data) / Percentage of clients that complete treatment without ASA, rejecting services / 70% or statistically significant improvement in percentage above the prior year.
Linkage to treatment from detox
(MACSIS Claims Data) / Percentage of successful linkages within 14 days / 50% or statistically significant improvement in percentage above the prior year.
Consumer Satisfaction
(Agency reports) / Percentage of clients satisfied / 70% or statistically significant improvement in percentage above the prior year.
Treatment appropriateness
(Board Review of Agency Records) / Percentage of services provided that are appropriate / 80% or statistically significant improvement in percentage above the prior year.
Individualized services
(Board Review of Agency Records) / Percentage of treatment services provided that are individualized / 80% or statistically significant improvement in percentage above the prior year.
Programmatic documentation compliance
(Board Review of Agency Records) / Percentage of adherence to documentation requirements / 80% or statistically significant improvement in percentage above the prior year
*Evidenced-Based Practices, Best Practices, and Emerging Best Practices include:
- Integrated Dual Disorder Treatment (IDDT)
- Supported Employment (SE) or Individual Placement and Support (IPS) Dartmouth Model
- Motivational Interviewing (MI)
- Illness Management & Recovery (IMR)
- Multi-Systemic Therapy for Youth (MST)
- Assertive Community Treatment (ACT)
- Family-Psycho education
- Dialectical Behavior Therapy (DBT)
- Cognitive Behavioral Therapy (CBT)
- Tobacco Recovery (TR)
- Wellness, Management & Recovery (WMR)
- Trauma Informed Cognitive Behavioral Therapy for Adults with SMD
- (others as indicated by agencies and accepted by Board)
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