Muskegon_July_Sept07 by goodbaby

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									                                                    MICHIGAN MISSION BASED PERFORMANCE INDICATOR SYSTEM




                       CMH BOARD NAME                   Muskegon CMHSP
                      TIME PERIOD FROM:                    July 1, 2007
                         TIME PERIOD TO:                September 30, 2007
                               DUE DATE:                    12/31/2007
                         COMPLETED BY:                     Deb Fiedler

UNDUPLICATED COUNT
                                1                                2                                 3                           4

                                                                                  Unduplicated Number of
                                                 Unduplicated Number of                                         % of Medicaid Recipients
                                                                                 Medicaid Eligible Persons
                         POPULATION             Persons Served in the Time                                       served by the CMHSP
                                                                                 Served by CMHSP During
                                                         Period                                                 during the Report Period
                                                                                        the Period


                           MI Children                     359
                                                                                             285                         79.39%
                            MI Adults                      1613
                                                                                             863                         53.50%
                          Adultswith
                         Developmental                     588
                          Disabilities                                                       227                         38.61%
                          Children with
                         Developmental                     164
                           Disabilities                                                      126                         76.83%
                       Total Unduplicated
                                                           2724
                              count                                                         1831                         67.22%




TABLE 01: INDICATOR #: ACCESS - TIMELINESS/INPATIENT SCREENING

                          POPULATION
                                              Number of Emergency Referrals        Number of Emergency          Percent (%) of Emergency
                                              for Medicaid Inpatient Screening    Referrals completed within    Referrals Completed within
                                                   During the Time Period           Three Hours or Less             the Time Standard


                                               B2                                 C2
                      # Children                               13                                 13                     100%
                                               D2                                 E2
                      # Persons                               173                              173                       100%




TABLE02: INDICATOR #2: TIMELINESS__Request To Assessment Within 14 Calendar Days of First Request

 1: Population     2: Number Persons           3: Number of New Persons          4: Net of Persons Receiving     5: Number of Persons      6. % of Persons
                  Receiving an Initial Non-       From Col #2 Who are            an Initial Assessment (Col 2 - From Col 4 Who Started a   Receiving Initial
                  Emergent Professional               Exceptions                              Col 3)             F/F Services With in 14  Assessment within
                 Assessment following first                                                                       Calendar days of a F/F 14 Calendar days of
                          request                                                                                  Assessment with a         1st Request
                                                                                                                      professional.

                 H2                            I2                                                                K2
     MI-C                      63                               5                            58                               58             100.00%
                 L2                           M2                                                                 O2
     MI-A                      222                              1                           221                               220             99.55%
    DD-C         P2            21              Q2               0                            21                  S2           21             100.00%
    DD-A         T2             8              U2               0                             8                  W2            8             100.00%

AGENCY TOTAL     X2            314             Y2               6                                               AA2           307             99.68%
                                                                                            308




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                                                       MICHIGAN MISSION BASED PERFORMANCE INDICATOR SYSTEM




TABLE03: INDICATOR #3: TIMELINESS__ Assessment To Start of Ongoing Services Within 14 Calendar Days.

 1: Population    2: Number Persons Who          3: Of New Persons From Col      4: Net Number of Persons   5: Number of Persons             6. % of Persons
                 Started F/F Services During        #2 Who are Exceptions        Who Started Services (Col From Col 4 Who Started a            Who Started
                      the Report Period                                                  2 - Col 3)         F/F Services With in 14         Services Within 14
                                                                                                             Calendar days of a F/F         calendar days of a
                                                                                                              Assessment with a              F/F Assessment
                                                                                                                 professional.
                 AG2                             AH2                                                            AJ2
     MI-C                        52                              7                           45                               44                 97.78%
                 AK2                             AL2                                                            AN2
     MI-A                        187                            18                          169                              167                 98.82%
                 AO2                             AP2                                                            AR2
    DD-C                         19                              0                           19                               19                100.00%
    DD-A         AS2              5              AT2             0                            5                 AV2            5                100.00%

                 AW2                             AX2                                                            AZ2
AGENCY TOTAL                     263                            25                          238                              235                 98.74%




TABLE 4a: Indicator 4a: Follow-up to an Inpatient Discharge Within 7 Days

 1: Population     2: Number of Discharges       3: Number of Discharges From         4: Net Number of          5: Number of Discharges       6. % of Persons
                  from a Psychiatric Inpatient     Col #2 That are Exceptions     Discharges (Col 2 - Col 3)    From Col 4 Followed up by     Receiving Initial
                             Unit                                                                                 CMHSP within 7 Days        Assessment within
                                                                                                                                            14 Calendar days of
                                                                                                                                                1st Request

                 BF2                             BG2                                                            BI2
   Children                       3                              3                            0                                0                 #DIV/0!

                 BJ2                             BK2                                                            BM2
    Adults                       62                             21                           41                               41                100.00%




TABLE5: INDICATOR #6: ACCESS - DENIAL/APPEAL

                 Number Persons Receiving
                                                   Total Number of Persons        Total Number of Persons           Total # of Persons
                 an Initial Face-to-Face Non-
                                                 Assessed but Denied CMHSP         Requesting a Second              Receiving Service
                   Emergent Professional
                                                 Service or Referred Elsewhere            Opinion              Following a Second Opinion
                          Assessment

                 BU2                             BV2                             BW2                            BX2
                                 314                            25                                0                            0
                               Percentage of
                            persons referred
                                  elsewhere                       8.0%




Table 06:     INDICATOR #12: OUTCOME: Inpatient Recidivism

 1: Population      2. # Discharges From     3: Number of Discharges From             4: Net Number of          5: Number of Discharges     6. % of Discharges
                  Psychiatric Inpatient Care   Col #2 That are Exceptions         Discharges (Col 2 - Col 3)    From Col 4 Readmitted to       Readmitted to
                 by During Reporting Period                                                                      Inpatient Care within 30      Inpatient Care
                                                                                                                    Days of Discharge        Within 30 Days of
                                                                                                                                                 Discharge




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                             MICHIGAN MISSION BASED PERFORMANCE INDICATOR SYSTEM




           B Y2        BZ2                                                          CB2
Children          3                  0                           3                        0   0.00%
           CC2         CD2                                                          CF2
Adults            62                 0                           62                       6   9.68%




                                         9897cdf4-13ad-4662-b2b7-4affcd9a2f35.xls                     Page 3
                                                      Community Mental Health Services of Muskegon County
                 Michigan Misson Based Performance Indicator System (MMBPIS): Reports and Graphs Per Indicator Per Quarter for FY 2007
                                                           Report Date: December 11, 2007



Indicator The percent of children & adults receiving a pre-admission screening for psychiatric inpatient care for whom the disposition
   #1     was completed within three hours.
          Standard     95%
                                                                                                                           100%
                   Oct-Dec06                   Jan-Mar 07               Apr-June 07                 July-Sept 07            95%
              # in       #       % in     # in       #    % in      # in      #    % in        # in        #    % in        90%
            Compl-    Com-     compl-   Compl- Com- compl-        Compl- Com- compl-         Compl- Com- compl-             85%
             iance    pleted    iance    iance    pleted iance     iance   pleted iance       iance     pleted iance        80%
Children         29      29     100%        25     25    100%          30     30    100%          13      13    100%        75%

Adults          133     133     100%       121    121    100%         127    125     98%         173     173    100%        70%
                                                                                                                            65%
Analysis:   Both Children and Adult Popultions met DCH standards this quarter they were at 100% for this quarter.           60%
            Increase noted in the number of Adult Gatekeeping Screenings completed this quarter --increase of 46.           55%
            The number of Children screened down by 17.                                                                     50%
                                                                                                                                       Oct-Dec06        Jan-Mar07        Apr-June07     July-Sep07
Action      None needed - continue to monitor
                                                                                                                                                          Children          Adults
Taken:




Indicator The percent of new persons receiving a f/f assessment with a profressional within 14 calendar days of a non-emergency
   #2     request for service
          Standard     95% in 14 days
                   Oct-Dec06                Jan-Mar 07                 Apr-June 07                July-Sept 07
                                                                                                                         100%
              # in       #       % in     # in    #    % in         # in     #    % in         # in      #     % in
            Compl-    Com-     compl-   Compl- Com- compl-        Compl-   Com- compl-       Compl-   Com- compl-        95%
             iance    pleted    iance    iance pleted iance        iance  pleted iance        iance   pleted  iance
                                                                                                                         90%
MI Child         65      67       97%       69      73 94.5%           72     72 100%             58       58  100%
MI Adult        199     200      100%      212    213 100%            211 211 100%               220     221 99.5%       85%
DD Child         14      14      100%        8       8 100%            10     10 100%             21       21  100%      80%
DD Adult         10      10      100%       19      19 100%            16     16 100%              8        8  100%
Agency          288     291       99%      308    313   98%           309 309 100%               307     308 99.7%       75%

                                                                                                                         70%
Analysis:   All Population groups met the DCH Standards this quarter. Muskegon CMHSP was at 100% for all
            populations with the exception of MI Adult in which one case was found out of compliance on this indicator   65%
            this quarter. Improvement noted in the MI Child population group --Been at 100% for the last two quarters
                                                                                                                         60%

                                                                                                                         55%

                                                                                                                         50%
Action      Case found "Out of Compliance" are to be reviewed by supervisor. Supervisors are closely monitoring                   Oct-Dec06            Jan-Mar07        Apr-June07      July-Sep07

Taken:      timeliness indicators per direction of CMH Director.
                                                                                                                            MI Child        MI Adult         DD Child        DD Adult       Agency




Indicator The percent of new persons starting any needed ongoing service within 14 days of a non-emergent assessment with a
   #3     professional
          Standard     95% in 14 days
                   Oct-Dec06                 Jan-Mar 07                Apr-June 07                July-Sept 07
                                 % in                   % in                      % in                        % in       100%
              # in       #                # in     #                # in     #                 # in      #
            Compl-    Com-     compl-   Compl-  Com- compl-       Compl-   Com- compl-       Compl-   Com- compl-
                                                                                                                          95%
             iance    pleted    iance    iance  pleted iance       iance  pleted iance        iance   pleted iance
MI Child         49      50      98%        53     55  96%             51     52     98%          44      45     98%      90%

MI Adult        149     152      98%       145    147  99%            158    160     99%         167     169     99%      85%
DD Child         13      13     100%         6      6 100%              9      9    100%          19      19    100%
DD Adult          9       9     100%        10     11 90.9%             9      9    100%           5       5    100%      80%
Agency          224     220      98%       214    219  98%            227    230     99%         235     238     99%
                                                                                                                          75%
Analysis:   All Population groups met the DCH Standards this quarter. The reason why cases were found out of
                                                                                                                          70%
            compliance: MI Chid : Contracted Case (21 days)-- no documented reason given. The two MI Adult
            cases were both due to staff cancellations. There were 29 cases that no showed or cancelled this quarter.     65%
            (20 MI Adults and 9 MI Children) --these were excluded from the data
                                                                                                                          60%

                                                                                                                          55%

            All cases found "Out of Compliance" were reviewed by supervisors. Supervisors are closely monitoring          50%
Action      timeliness indicators per direction of CMH Director.                                                                  Oct-Dec06            Jan-Mar07        Apr-June07      July-Sep07
Taken:
                                                                                                                            MI Child        MI Adult         DD Child        DD Adult       Agency




                                                                                     Page 4 of 6
                 Michigan Misson Based Performance Indicator System (MMBPIS): Reports and Graphs Per Indicator Per Quarter for FY 2007
                                                           Report Date: December 11, 2007




Indicator The percentage of discharges from a psychiatric inpatient unit who are seen for follow-up care within seven days
   #4

            Standard                95%
                                                                                                                                              100%
                                                                                                                                               95%
                    Oct-Dec06                      Jan-Mar 07                      Apr-June 07                     July-Sept 07
                                                                                                                                               90%
              # in         #        % in       # in         #    % in          # in         #    % in           # in        #        % in      85%
            Compl-      Com-      compl-     Compl-      Com- compl-         Compl-      Com- compl-          Compl-     Com-      compl-      80%
             iance      pleted     iance      iance      pleted iance         iance      pleted iance          iance     pleted     iance      75%
                                                                                                                                               70%
Children           6         6     100%             7         7    100%             5         5    100%             0         0 #DIV/0!        65%
Adults            24        24     100%            37        37    100%            35        36     97%            41        41   100%         60%
                                                                                                                                               55%
Analysis:   Both the Children and Adult categories met the DCH Standards this quarter. MI Child had three Inpatient                            50%
            Discharges this quarter but all were followed up by Community Agencys and not included in this data.                               45%
                                                                                                                                               40%
                                                                                                                                               35%
                                                                                                                                               30%
                                                                                                                                                      Oct-Dec06    Jan-Mar07         Apr-June07    July-Sep07

Action      None needed - Continue to monitor
                                                                                                                                                                    Children              Adults
Taken:




Indicator The percentage of face to face assessment with professionals that result in decisions to deny CMHSP services.
   #6

                    Oct-Dec05                      Jan-Mar 06                      Apr-June 06                     July-Sept 06               20%
                                                                                                                                              18%
                                                                                                                                              16%
                #         #                      #         #                     #         #                              #
                                                                                                                                              14%
            assessed    Denied    % Denied   assessed    Denied % Denied     assessed    Denied % Denied     # assessed Denied     % Denied
                                                                                                                                              12%
                                                                                                                                              10%
                                                                                                                                               8%
# Persons       224         18        8%         317         27       9%         313         36      12%          314        25         8%
                                                                                                                                               6%
Analysis:   Number of individuals seen and referred elsewhere decreased 4% this quarter                                                        4%
                                                                                                                                               2%
                                                                                                                                               0%
                                                                                                                                                      Oct-Dec06   Jan-Mar07         Apr-June07     July-Sep07

Action      None needed --continue to monitor
                                                                                                                                                                              # Persons
Taken:




Indicator The percent of Section 705 second opinions that result in services.
   #7

                    Oct-Dec06                      Jan-Mar 07                      Apr-June 07                     July-Sept 07               6%

                                                                                                                                              5%
            # ask 2nd   # start    % start   # ask 2nd   # start   % start   # ask 2nd   # start   % start   # ask 2nd   # start    % start
                                                                                                                                              4%
             opinion    service    service    opinion    service   service    opinion    service   service    opinion    service    service
                                                                                                                                              3%

# Persons          0          0       0%            0          0      0%            0         0        0%            0         0        0%    2%

Analysis:   There were no requests for second opinions following a non-emergent assessment for services in which                              1%
            the person was referred elsewhere for services this quarter                                                                       0%
                                                                                                                                                     Oct-Dec06    Jan-Mar07         Apr-June07     July-Sep07

Action      None needed --continue to monitor
                                                                                                                                                                                # Persons
Taken:




Indicator The percent of adults with mental illness and the percent of adults with developmental disabilities served by CMHSP who are
   #10    in competitve employment.

                                                                                                                                              50%
                    Oct-Dec06                      Jan-Mar 07                      Apr-June 07                     July-Sept 07               45%
                                    %                               %                                                                         40%
                      #            Who         #          #        Who                 #    % Who                      #    % Who             35%
            # Served Works         Work      Served      Works     Work      # Served Works Work             # Served Works Work              30%
                                                                                                                                              25%
MI Adults      1576        224       14%        1985       290       15%        2373       331       14%        2758       395         14%
                                                                                                                                              20%
DD Adults       581         83       14%         648        89       14%         705        94       13%         725        95         13%    15%
                                                                                                                                              10%
Analysis:   The data for this indicator is taken from the QI Data which is an accumulative file starting from Oct 06.
                                                                                                                                               5%
                                                                                                     Page 5 of 6
                 Michigan Misson Based Performance Indicator System (MMBPIS): Reports and Graphs Per Indicator Per Quarter for FY 2007
                                                                           Report Date: file starting from 2007
            The data for this indicator is taken from the QI Data which is an accumulative December 11, Oct 06.
                                                                                                                          5%
                                                                                                                          0%
                                                                                                                                 Oct-Dec06   Jan-Mar07    Apr-June07    July-Sep07

Action      Continue to monitor and advocate for ensuring employment data is being updated in the information
                                                                                                                                             MI Adults     DD Adults
Taken:      system




Indicator The percent of adults with mental illness and the percent of adults with developmental disabilities served by CMHSP who earn
   #11    minimum wage or more from employment activities

                                                                                                                          100%
                   Oct-Dec06                  Jan-Mar 07                 Apr-June 07                 July-Sept 07          95%
                                                                                                                           90%
              #       # Min    % Min      #     # Min % Min           #     # Min % Min                  # Min    % Min    85%
            working   Wage     Wage     working Wage Wage           working Wage Wage          # working Wage     Wage     80%
                                                                                                                           75%
MI Adults       225     164     73%         290     212    73%          235    331     71%          396     277     70%    70%
DD Adults        95      60     63%         105      70    67%           74    111     67%          112      73     65%    65%
                                                                                                                           60%
Analysis:   The data for this indicator is taken from the QI Data which is an accumulative file starting from Oct 06.      55%
                                                                                                                           50%
                                                                                                                                 Oct-Dec06   Jan-Mar07    Apr-June07    July-Sep07

Action      Continue to monitor and advocate for ensuring employment data is being updated in the information                                 MI Adults     DD Adults
Taken:      system




Indicator The percent of children and adults readmitted to an inpatient pyschiatric unit within 30 days of discharge
   #12
          Standard    15% or Less
                                                                                                                          20%
                   Oct-Dec06                  Jan-Mar 07                 Apr-June 07                 July-Sept 07         18%
                                                                                                                          16%
             # Dis-   # Re-    %Re-      # Dis- # Re- %Re-           # Dis- # Re- %Re-           # Dis- # Re-     %Re-    14%
            charges   Admit    Admit    charges Admit Admit         charges Admit Admit         charges Admit     Admit   12%
                                                                                                                          10%
Children         12        1     8%           9       1    11%            6       0      0%           3       0      0%
                                                                                                                           8%
Adults           48        0     0%          46       1     2%           47       4      9%          62       6     10%    6%
                                                                                                                           4%
Analysis:   Both the Children and Adult Categories Met the DCH Standard this quarter. Increase of two individuals
                                                                                                                           2%
            who went back into a inpatient pyschiatric unit within 30 days of discharge as compared to last quarter.       0%
                                                                                                                                 Oct-Dec06   Jan-Mar07    Apr-June07    July-Sep07

Action      None needed --continue to monitor
                                                                                                                                               Children      Adults
Taken:




                                                                                       Page 6 of 6

								
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