Rev: 01/09, 03/09 SATILLA COMMUNITY SERVICES OUTCOME MANAGEMENT PLAN FOR FY 2009 PURPOSE: The Outcome Management Plan is created within the framework of the Performance Improvement Program, Policy 9.01. It is intended to increase the effectiveness, efficiency and service quality of Satilla Community Services’ programs for the benefit of the people served. The Plan outlines how information is collected and used to improve planning, operations and service delivery. OBJECTIVES: 1. Evaluate the effectiveness (outcomes) of programs and services in relation to their stated purpose and impact on the lives of the people that are served. 2. Evaluate and demonstrate efficiency in the provision of services. 3. Provide management and the Satilla Community Services with objective data to assess program performance in relation to established criteria and measures of acceptability. 4. Identify changes in the needs, preferences, and expectations of the consumer population, and provide direction for program development. 5. Promote consumer satisfaction. PROCEDURES: Annual Strategic Planning. The Annual Strategic Plan is created within the framework of the Performance Improvement Program, Policy 9.01. The Annual Strategic Plan is shaped by pooling information from a variety of sources, including input from persons served, to provide a comprehensive and integrated basis for strategic planning which takes place in the Leadership Team, the Satilla Community Services Board, and the Regional Board. This process shapes the Outcomes Management Plan in accord with National, Statewide and Regional priorities and requirements. Performance Improvement Department and Committee. The Performance Improvement Department and Committee are created within the framework of the Performance Improvement Program, Policy 9.01 and Management Structure, Policy 2.01. Information is collected and collated by the Performance Improvement Department under the oversight of the Performance Improvement Committee (meets monthly). The remit of this committee includes: a) To identify appropriate objectives for specific programs, and for the agency as a whole, which are set into the Outcomes Management Plan. b) To identify appropriate specific measures for these objectives, and systems for collecting the required information. c) To recommend the Outcomes Management Plan to the Leadership Team. d) To collect and review performance information on a quarterly basis. e) To conduct and analyze needs assessments. f) Identify and monitor available resources (in part through Utilization Management Subcommittee.) Rev: 01/09, 03/09 Annual Management Summary. The Annual Management Summary (Annual Organizational Report) is created within the framework of the Performance Improvement Program, Policy 9.01. Performance Improvement Department submits an Annual Management Summary after the end of each Fiscal Year to the Performance Improvement Committee, the Leadership Team, and the Satilla Board. The Annual Management Summary will be based on a Balanced Score Card approach, combining data on program effectiveness, efficiency, and cost with information on consumer satisfaction. The Satilla Balanced Score Card was launched in FY 2004 and monitors quarterly the performance of programs in meeting agreed targets. The Annual Management Summary will include: a) Reports on the extent to which the objectives set out in the annual strategic plan were achieved. b) Presents the results of the performance measures identified for each program. c) Demonstrates the use of performance measures to improve the quality of services and the efficiency and effectiveness of the agency. d) Forms the basis for a review and updating of the Annual Strategic Plan. e) Is distributed to program managers, leadership team, Board members, and to other entities or individuals at the discretion of the Executive Director and/or the Board. Executive Summary. Executive summaries will be made available on request to constituents and consumers. INFORMATION GATHERED AND OBJECTIVES FOR FY2009: Effectiveness Measures 1. Days of Active Client Enrollment (DACE) from Georgia Regional Hospital-Savannah. 2. Improvement: Improvement in presenting problems in treatment should be demonstrated by a mean program score of at least 85% in consumer’s response to Q #3 of the MHCA Customer Survey conducted by polling at least 15% of consumer’s served annually. In addition, matched pairs of CAFAS and LOCUS will be measured biannually. a. Beginning FY09, the SIS assessment will be monitored as an effectiveness measure for Community Support Services. 3. Community Integration Activities: (not reported on Balanced Scorecard) a. Compliance with the requirement that at least 60% of contacts with consumers be in the community for Rehabilitation Option Services. b. A minimum of 6 hours per month of interventions promoting community integration for all DD consumers receiving Day Services. Efficiency Measures 1. Consumer Service Time/Productivity: a) 100 consumer service hours per month for full-time direct care Behavioral Health providers; part-time pro rata. Contract clinicians should meet contract requirements. b) Day service providers should achieve 100% of their maximum possible consumer-staff ratio as outlined in the Medicaid Program Standards. 2. Cost per Consumer (not reported on the Balanced Scorecard): The intent of the Cost per Consumer data is to have comparable data between like programs to determine efficiency of expenditure allocations. Rev: 01/09, 03/09 3. Annual Financial Audit: The agency is required to comply with an annual financial audit. Accessibility to Services 1. Service Response Time: The Service Response Time is utilized to ensure that consumers are seen in clinic within five days of their initial phone contact. The target is that 90% of all consumers will be seen face-to-face by a clinician within five days of the initial phone contact with the Scheduling Unit, or GCAL, for a routine appointment. 2. Physician Wait Time: Physician Wait Time it utilized to ensure that consumers are seen by a physician within an acceptable amount of time from the scheduled appointment. 3. Access Data via Satisfaction Surveys: The Intake Service Quality Survey, CARF’s midtreatment uSPEQ Consumer Satisfaction survey, and the Discharge Satisfaction Survey assess for satisfaction, as well as barriers, to accessing services. Service Quality Measures 1. uSPEQ Customer Survey: Consumer satisfaction should be demonstrated by a mean score of at least 85% conducted by polling at least 15% of consumer’s served annually, utilizing CARF’s uSPEQ Customer Survey Form. 2. Post Discharge Survey: Post discharge measures and consumer satisfaction in treatment should be demonstrated by a mean program score of at least 85% by seeking a telephone interview with at least 10% of consumer’s who are no longer receiving services with Satilla. 4. Employee Turnover and Satisfaction: Report staff turnover for all program sites and collect employee satisfaction questionnaires from at least 85% of all employees attending annual update training. All departing employees (excluding terminations) are invited to complete an exit questionnaire. 5. Internal Audits: The UM Coordinator, in conjunction with the program managers, conducts a quarterly audit for each program with the sample target size of minimum 2.5% (10% annually) of the consumers served, which consists of documentation, service delivery, and billing. 6. External Audits: The agency is required to comply with all external audit processes including, but not limited to, APS, ORS, Medicaid, and Medicare. Outcomes per Provider Contract 1. Recovery/Improved Level of Functioning: Of the adults served by Satilla for whom the LOCUS indicates the need for at least a LEVEL-3 “High Intensity Community Based Service” level of care upon intake, at least fifty percent (50%) shall show improvement in functioning, as indicated by a reduction of at least one LOCUS level of care recorded in the Multipurpose Information Consumer Profile (MICP). 2. Employment: At least 20 percent (20%) of adults served during the reporting period who are unemployed and available for work will become employed as reported on the MICP. 3. Increased Stability in Housing: At least twenty percent (20%) of adults served during the reporting period who report they are homeless, living in a homeless shelter, or who are at risk of homelessness will report a stable living environment as reported on the MICP. 4. Engaging the Homeless: At least seventy-five percent (75%) of eligible consumers who are reported to be “homeless” or “at risk of homelessness’ at intake will initiate services within seven days of the initial contact (date of registration or assessment) and will show evidence of treatment engagement within 30 days of initial contact as evidenced by the MICP and encounter data reports. Rev: 01/09, 03/09 5. Decreased Criminal Justice Involvement: At least eight-five percent (85%) of adults served in the reporting period will have no arrests in the past 30 days at reauthorization or discharge. 6. Reduced Utilization of Psychiatric Inpatient Beds: Less than ten percent (10%) of adults discharged from a state hospital who are assigned to the provider for services and supports will be readmitted to a state hospital within the 30 days following discharge. 7. Hospital Utilization: Satilla will work with the Regional Provider Network to achieve the Department’s goal of a 10% reduction in state hospital admissions and readmissions. 8. Consumer Perception of Care: Consumers reporting perception of positive change on the Annual Consumer Survey will increase by one percentage point (1%). Outcomes per Crisis Stabilization Program Contract 1. Episodes of Seclusion/Restraint: The target goal is to have zero episodes of seclusion and restraint. When such an incident occurs, a form critical incident is completed, with a full administrative review. 2. Transfers to a Higher Level of Care: If a consumer is unable to stabilize in the Crisis Stabilization Program with 5-7 days then they will be referred to a higher level of care for stabilization. Target goal is no more than three per quarter. 3. Length of Stay: Average length of stay for a consumer in the Crisis Stabilization Program is 5-7 days. This excludes consumers placed on Transitional Status. 4. Re-Admits: The target goal is to have zero re-admits to the Crisis Stabilization Program within a 30-day period. 5. Use of PRN Medications and Effectiveness: The therapeutic need for PRN medication is discussed during staffing with the physician on a daily basis and documented in the consumer’s records accordingly. 6. Days to Physician Assessment: The consumer will be seen by the physician within 24hours from admission. 7. Follow-up after Discharge: CSP staff will follow-up with consumers within five days after discharge. Episodes of Seclusion/Restraint and Use of PRN medications with Effectiveness will be reviewed daily during treatment team meetings with, but not limited to, the Program Director, Staff Physician and Nurse Manager. All measures will be reviewed on a weekly basis with the Program Director, Staff Physician and Nurse Manager and on a monthly basis with the Program Manager, Staff Physician, Nurse Manager, Performance Improvement Coordinator, and Clinical Director to review for trends and to implement any corrective actions, as indicated. All CSP outcomes data will be captured on the CSP Outcomes Data form and the agency Balanced Scorecard.
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