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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
1 CAPACITY Resource Financial Adequacy of Financial Total The capacity to develop and Kamis-Gould and
base resources population maintain a full array of services, Hadley
meet the service needs of all
enrollees, and ensure prompt
response, regardless of services
desired, requires significant financial
resources, i.e., average annual
dollars per enrollee, will enable
public entities to compare potential
plans, select endowed plans, and
develop norms for required financial
resources.
2 CAPACITY Resource Financial % of federal dollars PI interviews
base coming into state
increases (Would like
to know how CT
stacks up against
other states in this
regard)
3 CAPACITY Resource Human Adequacy of human Total direct service Total Data on the ratio of available direct Kamis-Gould and
base resources full-time-equivalent population service staff per enrollee reflect the Hadley
staff (FTEs) / # plan's capacity and potential to
enrollees respond to needs and to deliver
required services. Low ratios will
suggest that clients will have to wait
for services or receive services less
frequently than desired. Public
entities could use the data to
compare competing plans and to
develop norms.
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
4 CAPACITY Resource Human Percent of Ratio of providers Administrati Outcomes
base psychiatrists who are with documented ve Roundtable
Board Certified training and
experience
qualifying them as
knowledgeable
about mental
health
development and
the diagnosis and
treatment of mental
health problems in
children and youth
to the number of
children and youth
served
CAPACITY Resource Human Percent of Providers # providers who Administrati IBH
base who are are recredentialed ve
recredentialed annually / total #
annually providers
5 CAPACITY Resource Human Shortage of child PI interviews- Wait
base psychiatrists is lift of evaluation of
addressed med evaluation
6 CAPACITY Resource Human Independently board certified/ Total Independently qualified clinicians, Kamis-Gould and
base qualified clinicians licensed FTEs / population i.e., those certified or licensed to Hadley
total FTEs provide unsupervised services, are
those who have demonstrated
relevant requirements and clinical
skill. A high proportion of clinicians
so certified would be an indication of
highly qualified, direct service
providers.
7 CAPACITY Resource Human Availability of Administrati DS 200+
base appropriate ve
services/specialists
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
8 CAPACITY Resource Human Provider Turnover Administrati Hedis 3.0; AMBHA-
base (HEDIS); Change in ve PERMS 2.0
Provider availability
(AMBHA-PERMS)
9 CAPACITY Management Leadership Degree of consumer # consumers who Enrollment CARF performance
Capacity involvement in the are involved in the data, indicators for
planning, design, service delivery consumer behavioral health
delivery, and system (e.g., survey
evaluation of services planning, design,
design, and/or
evaluation of
services) / total #
consumers
10 CAPACITY Management Innovations Degree of integration # children using HSRI
Capacity of new services newly created Recommendation
services: EMPS,
Care Coordination,
Multisystemic
Therapy,
Wraparound
services
11 CAPACITY Management Innovations % of kids with care PI Interviews- Over
Capacity coordination % of kids who need
care coordination
12 CAPACITY Management Innovations Degree of physician # clinicians HSRI
Capacity training receiving system of Recommendation
care training
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
13 CAPACITY Management Networking/ Networking and # agencies Total The best health and mental health Kamis-Gould and
Capacity systems integration integration with other referring at least population services are provided by an Hadley
systems one client / # integrated system of care; i.e., a
potential referral network of agencies and service
agencies in area systems-including primary care,
behavioral health, and generic
services- that ensures prompt
response to all service needs
through open communication,
referrals, and consultation. A high
proportion of area agencies referring
clients will suggest networking and
interaction, while a low proportion
might signal that agencies are
isolated and less likely to be able to
meet individualized service needs.
14 CAPACITY Management Networking/ Outreach and Consultation & Total The proportion of an agency's staff Kamis-Gould and
Capacity systems integration networking effort education + population devoted to 1- outreach to the public Hadley
information & and to enrollees who might need, but
referral FTEs / do not avail themselves t of,
total FTEs services, and 2- networking with
other agencies and service systems
is a reflection of a desired public
health perspective and a willingness
to invest in the improvement of care.
A low ratio might suggest either
inadequate human resources and
inability to perform networking
functions, or a lack of recognition of
the importance of those functions.
Accumulated data might also
contribute to empirical development
of norms that could be later be built
into contractual requirements.
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
15 CAPACITY Management Networking/ Linkage to primary Percentage of Primary data Outcomes
Capacity systems integration services children/adolescent collection Roundtable
s who have used (self-report Reduced list
behavioral health survey)
services, who have
had at least one
health care visit
with a physician
during the past
year
16 CAPACITY Management Networking/ Co-occurring Number of Outcomes
Capacity systems integration disorders children/adolescent Roundtable
s diagnosed with Reduced List-
both mental health Performance
and substance use measures currently
per 1000 of the being defined,
eligible population and/or
who have a care developmental
plan that reflects measures to be
coordinated/integra defined for possible
ted services for pilot testing in
both disorders in a response to policy
calendar year changes in
(independent of behavioral heath
whether these services.
service systems
are separate
agencies).
17 CAPACITY Management Networking/ Getting medical care PI interviews- 1)
Capacity systems integration in a timely way Coordination of PCP
Coordination for
multiple complex
needs, 2) Know who
PCP is, 3) % have
PCP visit vs. non-
BH, 4) % have a
PCP coordination
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
18 CAPACITY Management Capacity for Capacity for service # non-inpatient Total The provision of appropriate services Kamis-Gould and
Capacity service substitution substitution beds population in the least restrictive setting Hadley
(residential/crisis) / requires a full array of services, as
# enrollees well as the ability to "step down"
clients from inpatient to less
restrictive, yet still intensive,
services. Commonly, the most
inadequate service segment is
residential services, with a lack of
both total number of beds and range
of types. A low ratio of non-inpatient
(i.e., residential and crisis beds)
would be a poor indicator,
suggesting an inability either to
stabilize crises without
hospitalization, or to discharge
hospitalized clients who need
intensive supervision and care but
who would best be served in
residential settings.
19 CAPACITY Management Capacity for Decreased LOS in PI interviews
Capacity service substitution residential treatment
20 CAPACITY Management Capacity for Caregivers are Measured by team Dawn Project
Capacity service substitution committed to plan meeting Outcome measures
attendance
21 CAPACITY Management Capacity for Inpatient PI Interviews
Capacity service substitution administrative days
decline
22 CAPACITY Management Capacity for Fewer kids in ERs PI interviews
Capacity service substitution
23 CAPACITY Management Capacity for Number of referrals to PI interviews
Capacity service substitution ERs from EMPS
declines
24 CAPACITY Management Capacity for LOS in ERs PI Interviews
Capacity service substitution decreases
25 CAPACITY Management Capacity for Number of re- PI interviews-
Capacity service substitution admissions to ERs Track frequent users
26 CAPACITY Management Capacity for ER admissions PI interviews
Capacity service substitution decrease
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
27 CAPACITY Management Capacity for System responds to PI interviews
Capacity service substitution crises more
appropriately (i.e. no
police)
28 CAPACITY Management Capacity for Choices given to PI interviews-
Capacity service substitution families Satisfaction survey
29 CAPACITY Management Capacity for Availablility of the Administrati NAMI
Capacity service substitution most effective ve
medications,
rehabilitative
services, alternatives
to hospitalization and
rehabilitative services
30 CAPACITY Management Dispute Prevalence of % of enrollees who Total Enrollees challenge utilization and Kamis-Gould and
Capacity management disputes appeal decisions population managed care when they disagree Hadley
with decisions about the medical
necessity, choice of, or financial
coverage of services. A high
frequency of disputes, and a level
that is out of line in comparison with
other, similar situation, would
suggest a plan that over-emphasizes
cost containment, probably at the
expense of quality care.
31 CAPACITY Management Dispute Dispute Resolution Average time to Total Delays in handling and resolving Kamis-Gould and
Capacity management resolution of population disputes about choices and financial Hadley
appeals coverage of services could reflect an
attempt to discourage enrollees from
challenging utilization and managed
care decisions. A high average time
to resolve appeals would be a
negative indicator.
32 CAPACITY Management Dispute Number of patient Complaints/ IBH
Capacity management complaints and/or appeals/grie
greivances and vance
timeliness of review records
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
33 CAPACITY Clinical Comprehensiveness % of model array Total Appropriate services and continuity Kamis-Gould and
Capacity Comprehensivenes of array of services of services population of care require a comprehensive Hadley
s of service array and potential for a provided either array of services. It is, therefore,
seamless service directly or through incumbent upon public systems to
system existing (i.e., not develop a model array of services
just promised) against which plans could be
service contracts assessed. The more complete the
range of services a plan offers, that
higher the likelihood that enrollees
will have access to all the services
they need and desire. Conversely, a
low proportion might suggest that
such a plan should not be
considered for public system clients.
34 CAPACITY Clinical More services are PI Interviews- Off
Capacity Comprehensivenes available in hours access to
s of service array afternoons, evenings, clinic services;
and weekends. School-based clinic
care
35 CAPACITY Clinical Access to full array of PI interviews- With
Capacity Comprehensivenes services is insured more specificity
s of service array
36 CAPACITY Clinical Increased availability PI interviews-
Capacity Comprehensivenes of hospital beds Reduced ED stays -
s of service array need to modify
37 CAPACITY Clinical More crisis beds PI interviews- Non-
Capacity Comprehensivenes available immediately hospital, level of
s of service array care needed, EMPS
38 CAPACITY Clinical Increased availability PI interviews
Capacity Comprehensivenes of staffing for small
s of service array group homes
39 CAPACITY Clinical Increase in residential PI interviews
Capacity Comprehensivenes slots, group homes
s of service array
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
40 CAPACITY Clinical Clinical Quality Assurance QA FTEs / total Total Quality assurance activities are Kamis-Gould and
Capacity soundness/QA FTEs population essential to ensure that the right Hadley
services are provided to the right
clients, by the right providers, at the
right time. Because such efforts do
not generate revenues, however, it is
important to monitor the level of
quality assurance efforts. Public
entities might opt to develop
empirical norms about desired levels
and encourage quality assurance by
including this type of indicator in
incentive structures and rewards.
41 CAPACITY Clinical Clinical Congruence with # reviewed cases Total Most area of mental health services Kamis-Gould and
Capacity soundness/QA clinical guidelines within guidelines / population do not have standards against which Hadley
accepted by the field # examined to assess care, but a large and
growing number have clinical
guidelines for practice. Despite the
fact that assessing congruence with
guidelines may involve labor-
intensive record reviews, this type of
evaluation is desirable because
compliance with guidelines is likely to
maximize high quality care and to
minimize liability.
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
42 CAPACITY Clinical Clinical Use of scientifically Percentage of Administrati Outcomes
Capacity soundness/QA up to date and children receiving ve Roundtable
comprehensive active services who
treatment guidelines are treated within
approved practice
guidelines [i.e.,
American
Psychiatric Assoc.,
American Academy
of Child and
Adolescent
Psychiatry,
American Academy
of Pediatrics --
depression,
Pervasive
Developmental
Disorders (PDD),
ADHD, Tic
Disorders and
Stereotypic
Movement
Disorder, Mental
Disorders Due to a
General Medical
Condition,
Schizophrenia and
Other Psychotic
Disorders, Mood
Disorders, Eating
Disorders, etc.]
43 CAPACITY Clinical Clinical Use of scientifically Percentage of Administrati Outcomes
Capacity soundness/QA up to date and clinical staff who ve Roundtable
comprehensive have received
treatment guidelines training and
certification in
evidence-based,
supported-
supported
treatments (CBT,
MST, IPT, etc.)
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
44 CAPACITY Clinical Clinical Medication Percentage of Administrati Outcomes
Capacity soundness/QA management those prescribing ve/ Roundtable
medication within Claims/MIS Reduced list
the service system
who have been
trained to use
established,
empirically based
guidelines
(American
Academy of Child
and Adolescent
Psychiatry,
American
Psychiatric
Association,
American Academy
of Pediatrics, etc.)
for prescribing
medications for
behavioral health
conditions
45 CAPACITY Clinical Clinical Evidence based PI interviews
Capacity soundness/QA practices are
implemented
46 CAPACITY Clinical Clinical Medication Percentage of Administrati Outcomes
Capacity soundness/QA management children/adolescent ve/ Roundtable
s receiving Claims/MIS Reduced list
medications that
also receive
medication-
monitoring
services.
47 CAPACITY Clinical Clinical Percentage and # clients receiving Claims and NASMHPD 16
Capacity soundness/QA penetration of atypical psychotics case State, APA
persons recieving / total # clients records
atypical
antipsychotics; APA
has a very specific
set of diagnosis
related measures
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
48 CAPACITY Clinical Clinical Antidepressant Percentage of Administrati Outcomes
Capacity soundness/QA Medication children treated ve claims Roundtable
Management. within the service data
SUGGESTION: add system who
atypical medications, receive medication
as well as other uses monitoring services
of antidepressants, for antidepressants
prescribed for
serious depression,
school phobias and
other serious
anxiety disorders,
bed wetting, some
bulimic-type eating
disorders, and
attention deficit-
hyperactivity
disorder. Anti
psychotics ("major
tranquilizers"),
such as Haldol,
Stelazine, or
Thorazine
prescribed for the
reduction of
irrational beliefs,
hallucinations,
related panic,
sense of loss of
control.
Lithium/anti-
convulsants such
as carbamazepine
(Tegretol) and
valproic acid
(Depakene) used
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
49 CAPACITY Clinical Clinical Access: Second # persons who The MI mental health code provides MI Dept. of
Capacity soundness/QA opinions received a service a potential recipients of public mental Community Health
as a result of a health services the means to request
second opinion a second opinion if their request for
# persons who any non-emergent CMHSP service is
requested a denied. This indicator measures the
second opinion proportion of persons receiving
following the denial services as a result of a second
of CMHSP service opinion following an initial denial of
or a referral service.
elsewhere during a
professional
assessment.
50 CAPACITY Clinical Clinical Interventions for Percentage of Survey Outcomes
Capacity soundness/QA Family survey Roundtable
Members/Significant respondents who
Others of AOD report using AOD
Clients in Treatment. services and who
also report that
their family
member/significant
other received
preventive
interventions.
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
51 CAPACITY Clinical Clinical Number and Percentage of Administrati Outcomes
Capacity soundness/QA percentage of children (by ve - Claims Roundtable
patients or medication class)
prescriptions for anti- treated within the
psychotic medications service system
for patients not who receive
having an Axis 1 medication
psychotic disorder monitoring services
(SUGGESTION: [Stimulants,
expand medication dexedrine or
classification beyond methylphenidate
anti-psychotics). (e.g., Ritalin) --
prescribed for the
treatment of
ADHD,
Antidepressants
prescribed for
serious depression,
school phobias and
other serious
anxiety disorders,
bed wetting, some
bulimic-type eating
disorders, and
attention deficit-
hyperactivity
disorder. Anti
psychotics ("major
tranquilizers"),
such as Haldol,
Stelazine, or
Thorazine
prescribed for the
reduction of
irrational beliefs,
hallucinations,
52 CAPACITY Clinical Clinical
Capacity soundness/QA
53 CAPACITY Clinical Clinical Caregiver/child/ Percentage of Primary data Outcomes
Capacity soundness/QA adolescent/ families/caregivers collection Roundtable
involvement in who report active (self-report Reduced list
treatment participation in survey)
determining their
child’s treatment
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
54 CAPACITY Clinical Clinical Consumer/family % of consumers on State Report NASMHPD 16
Capacity soundness/QA involvement in policy planning boards State, DS 2000+
development, QA and
Planning
55 CAPACITY Clinical Clinical Adverse drug Clinical NAPHS
Capacity soundness/QA reactions Records
56 CAPACITY Clinical Clinical Medication Errors Clinical NASMHPD 16 State
Capacity soundness/QA Records
57 CAPACITY Clinical Clinical Caregiver/child/ Percentage of Primary data Outcomes
Capacity soundness/QA adolescent/ youth (11 years collection Roundtable
involvement in and older) who (self-report Reduced list
treatment report active survey)
participation in
determining their
own treatment
58 CAPACITY Clinical Clinical Family involvement # ambulatory Annie E. Casey
Capacity soundness/QA treatment Children's
encounters for Benchmarking
children less than Project
or equal to 12
years of age who
also have a family
claim visit within
the same 12 month
period / #
ambulatory
treatment
encounters for
children less than
or equal to 12
years of age
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
59 CAPACITY Clinical Clinical Seclusion and To be defined in Outcomes
Capacity soundness/QA restraint requirements accordance with Roundtable
JCAHO, etc. Reduced List-
Current status: Performance
Restraint/seclusion measures currently
provisions enacted being defined,
in the Children’s and/or
Health Act of 2000, developmental
P.L. 106-310. measures to be
Many of the defined for possible
provisions and pilot testing in
definitions in these response to policy
regulations are changes in
conflicting behavioral heath
(JCAHO, HCFA, services.
etc.) — working to
have the under-21
RCT/hospital rules
modified. Goal is to
advocate for
national standards
that will be
consistent across
treatment settings.
Measures
include the
following:
1. Behavior
requiring
restraint/seclusion
2. Documentation
of less restrictive
alternative failure
3. Type: restraint,
seclusion
4. Qualification of
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
60 CAPACITY Clinical Clinical Continuity of care Percentage of Administrati Outcomes
Capacity soundness/QA children/adolescent ve/ Roundtable
s discharged from Claims/MIS Reduced list
a psychiatric
hospital who have
a behavioral health
service contact
within 7 days and
30 days of the
hospital discharge
61 CAPACITY Clinical Clinical Follow-Up after Percent of children Administrati Outcomes
Capacity soundness/QA hospitalization for and adolescents ve claims Roundtable
substance abuse - who had an data
within 30 days (7 ambulatory or
days for state day/night mental
hospital); Rate of health visit within
persons served who seven days and 30
receive a timely face days of hospital
to face follow-up after discharge
leaving 24 hour care
(ACMHA)
62 CAPACITY Clinical Clinical Least restrictive care (UOS inpatient & Appropriate substitution of residential Kamis-Gould and
Capacity soundness/QA emergency/UOS and ambulatory care for inpatient Hadley
residential & and emergency services can
ambulatory); this produce the same results at lower
year vs. last year levels of restrictiveness. While this
may involve the creation of new
community services to fill gaps in
care, this indicator should be
monitored over time to ensure
desired trends.
63 CAPACITY Clinical Clinical Various quality Clinical Rand, AR Quality
Capacity soundness/QA indicators for different Records Indicators
clinical conditions for
children - ADHD,
Depression
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
64 CAPACITY Clinical Clinical Rate of involuntary Authorizatio SAMHSA EW
Capacity soundness/QA commitment n data system, AMBHA -
PERMS 2.0
65 CAPACITY Clinical Clinical Use of peer review Policies NAPHS
Capacity soundness/QA
66 CAPACITY Technical MIS & turn-around MIS downtime Total Kamis-Gould and
Capacity of reports Population Hadley
67 CAPACITY Technical Monitoring and Provider inclusion in # providers who Total Kamis-Gould and
Capacity evaluation quality monitoring are members of providers Hadley
activities the BHO's quality
monitoring
committee /
total # providers
68 CAPACITY Technical Monitoring and More Capacity at the PI Interviews- Use
Capacity evaluation regional level to of Data
analyze and interpret
data
69 CAPACITY Technical Monitoring and Percent of Clients # clients with post- Self-Report IBH
Capacity evaluation who have post- treatment follow-up or clinical
treatment follow-up to / total # clients records
evaluate outcomes
70 CAPACITY Financial Days in accounts net accounts Total This measure is a common financial Kamis-Gould and
Viability receivable receivable / net population ratio used by accountants and Hadley
service revenue financial officers to assess how well
an entity puts its money to work or
brings money in to minimize the
need to borrow. In industry, this ratio
might be 30, 60, or 90 days. In
indemnity healthcare, it is likely to be
longer because insurance, e.g.,
Medicaid, often takes loner to pay
(i.e., creates a float).
71 CAPACITY Financial Operating margin revenue-expenses Total This measure reflects a profit Kamis-Gould and
Viability ratio / revenue population margin. To ensure that a large Hadley
proportion of capitated dollars are
spent on services rather than, for
example, dividends, a limit on this
ratio must be negotiated up front and
closely monitored.
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
72 CAPACITY Financial Current ratio current assets Total This measure is a common financial Kamis-Gould and
Viability current liabilities population ration used by accountants and Hadley
financial officers to ensure the
financial viability of any organization.
In industry, this measure should not
fall below 1.5:1.0.
73 RESPONSIVENESS Market Access: penetration # children under 18 This indicator addresses the degree MI Dept. of
Penetration Admissions/populat rate served / # to which children under 18, typically Community Health
ion children under 18 an underserved population, are
in the area receiving public mental health
population services. The county population
census is used as the denominator
since all residents are eligible for
public metal health services.
74 RESPONSIVENESS Market Percentage of Administrati HEDIS, AMBHA-
Penetration Admissions/populat children/adults ve claims PERMS 2.0
ion receiving day/night data
mental health
services; percentage
receiving inpatient
and outpatient
services
75 RESPONSIVENESS Market Percentage of Administrati HEDIS, AMBHA-
Penetration Admissions/populat children receiving ve claims PERMS 2.0
ion Inpatient mental data
health services
76 RESPONSIVENESS Market Percentage of Administrati HEDIS, AMBHA-
Penetration Admissions/populat children receiving ve claims PERMS 2.0
ion ambulatory mental data
health services
77 RESPONSIVENESS Market Percentage of Administrati HEDIS
Penetration Admissions/populat children receiving any ve claims
ion chemical dependency data
services
78 RESPONSIVENESS Market Percentage of Administrati HEDIS, AMBHA-
Penetration Admissions/populat children receiving ve claims PERMS 2.0
ion Inpatient chemical data
dependency services
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
79 RESPONSIVENESS Market Percentage of Administrati HEDIS, AMBHA-
Penetration Admissions/populat children receiving ve claims PERMS 2.0
ion ambulatory chemical data
dependency services
80 RESPONSIVENESS Market Percentage of Administrati HEDIS
Penetration Admissions/populat children receiving ve claims
ion day/night chemical data
dependency services
81 RESPONSIVENESS Market Percentage of # with SED in MIS NASMHPD 16 State
Penetration Admissions/populat children and therapeutic foster systems,
ion adolescents with SED care / total # with claims
served by the MH SED
authority in a 24 hour
setting who are in
therapeutic foster
care
82 RESPONSIVENESS Market Active Accessibility to youth # SED clients / # Population 0- Because of the level of disability in Kamis-Gould and
Penetration clients/population with serious estimated SED 18 children with SED, it is incumbent Hadley
emotional children in upon public entities to develop
disturbances (SED) population estimates of the prevalence of SED
in the general population, and to
monitor outreach to ensure that this
indicator is as close as possible to
1.0.
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Data
# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
83 RESPONSIVENESS Market Active Penetration rates of Percent of children Administrati Outcomes
Penetration clients/population therapeutic foster and adolescents ve claims Roundtable
care. SUGGESTION: who receive any of data
Expand categories to the following
all behavioral healthservices: inpatient
services. mental health
services,
residential mental
health services,
therapeutic foster
care, day treatment
or intensive
outpatient mental
health services,
outpatient mental
health services
within a clinic
setting, school-
based mental
health services,
home-based
mental health
services, other
community-based
mental health
services, inpatient
chemical
dependency,
services,
residential
chemical
dependency
services, day
treatment or
intensive chemical
dependency
84 RESPONSIVENESS Market Active Number of cases per Percent of Administrati Outcomes
Penetration clients/population 1,000 members who child/adolescent/fa ve Roundtable
were diagnosed with mily population
AOD abuse or diagnosed with
dependence or who AOD abuse or
received AOD-related dependence who
plan services on an received any AOD
annual basis. services in a year.
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Data
# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
85 RESPONSIVENESS Market Active Use of self-help/ self- Policies or Outcomes
Penetration clients/population management/ family program Roundtable
support description
86 RESPONSIVENESS Market Active Number and Administrati AMBHA-PERMS 2.0
Penetration clients/population percentage of ve- claims
patients remaining in
professional chemical
dependency
rehabilitation
treatment between 60
and 90 days from
admission to
inpatient, alternative
or intensive outpatient
settings
87 RESPONSIVENESS Market Outreach Outreach to increase annual outreach $ total According to data compiled in the Kamis-Gould and
Penetration service accessibility / total budget population epidemiological Catchment Area Hadley
(ECA) projects, only about one-fifth
of persons with behavioral health
diagnoses used any mental health
services. It is important, therefore,
for providers to conduct outreach to
ensure that the level of treated
prevalence is as close as possible to
the prevalence of mental health
disorders.
88 RESPONSIVENESS Market Outreach Utilization of non- Percentage of all Administrati Outcomes
Penetration traditional service child/adolescent/fa ve/ Roundtable
settings mily behavioral Claims/MIS Reduced list
health service and/or other
contacts that occur primary data
in home, school, or collection
other non- (self-report
traditional service survey)
settings
89 RESPONSIVENESS Market Outreach Families and PI interviews-
Penetration providers have Satisfaction survey
knowledge of what's
available regardless
of payer.
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
90 RESPONSIVENESS Market Outreach Penetration rates of Administrati Outcomes
Penetration early intervention ve claims Roundtable
data
91 RESPONSIVENESS Locally unique Geographic Analysis Percent of Administrati Outcomes
ACCESSIBILIT groups of population to population ve Roundtable
Y TO provider distance and (children/adolescen
UNDERSERVE travel times. ts/families) residing
D GROUPS
within 30 miles or
30 minutes of
location of service
providers (this is
the distance/travel
time defined as
reasonable by -------
-)
92 RESPONSIVENESS Accessibility to Locally unique Proximity of service Percentage of Administrati Outcomes
Underserved groups providers population ve/ Roundtable
Groups (children/adolescen Claims/MIS Reduced list
ts/families) who
reside within, or
have access to
services within
specified distances
or travel times.
(For example,
urban/suburban: 30
miles or 30
minutes of location
of service
providers, rural: 60
miles or 60
minutes of location
of service
providers, and/or
frontier: 120 miles
or 120 minutes of
location of service
providers)
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
93 RESPONSIVENESS Accessibility to Locally unique Proximity of service Percentage of Administrati Outcomes
Underserved groups providers population ve/ Roundtable
Groups (children/adolescen Claims/MIS Reduced list
ts/families) living
beyond specified
service distances
(see above) with
access to Internet,
tele-medicine,
other electronic
service/treatment
supports
94 RESPONSIVENESS Accessibility to Locally unique Convenience of # positive Consumer CARF performance
Underserved groups Service locations for consumer survey indicators for
Groups consumers responses to a behavioral health
survey question
regarding location
total # responses
(e.g. The location
of services was
convenient)
95 RESPONSIVENESS Accessibility to Locally unique Convenience of # positive Consumer CARF performance
Underserved groups appointment times for consumer survey indicators for
Groups consumers responses to a behavioral health
survey question
regarding location
/
total # responses
(e.g. Services are
available at times
that were good for
me)
96 RESPONSIVENESS Accessibility to Locally unique Bringing other voices PI interviews-
Underserved groups to the Collaboratives' Level of
Groups tables- schools, Participation or % of
HMOs collaboratives
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
97 RESPONSIVENESS Accessibility to Locally unique Community PI interviews-
Underserved groups involvement and Individual service
Groups support increases plans; Non-
Partnership vs.
Private funding
98 RESPONSIVENESS Accessibility to Locally unique More kids being PI interviews-
Underserved groups served in their district Prior zip
Groups schools code/current zip
code
99 RESPONSIVENESS Accessibility to Locally unique Schools are more PI interviews
Underserved groups involved and there
Groups are DCF and Dept of
Ed liaisons. School
personnel have
regular involvement in
teams around
children's needs in
school.
100 RESPONSIVENESS Congruence Congruence with active caseload / population 0- The prevalence of mental disorders Kamis-Gould and
with Assessed need and expected assessed need 18 varies from one location to another, Hadley
Need demand for service. often due to poverty and other
population characteristics. Public
entities should, therefore, conduct or
sponsor needs assessment
initiatives and ensure that the
number of service recipients is as
close as possible to the estimated
number of people needing services.
101 RESPONSIVENESS Congruence Attention to mental % enrollees Population 0- Primary healthcare providers often Kamis-Gould and
with Assessed health needs of screened for need 18 are ill-equipped to identify and/or Hadley
Need enrollees for mental health treat mental disorders, and managed
services and/or care systems tend to limit access to
referred to a the specialty mental health system in
mental health order to contain costs. Public
specialist. entities must, therefore, monitor the
level of screening for mental
disorders and the number of referral
to the specialty system, and develop
normative data for future monitoring.
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
102 RESPONSIVENESS Congruence Do parents get PI interviews-
with Assessed assessed and are Satisfaction survey
Need their needs being
met.
103 RESPONSIVENESS Percentage of chart review Outcomes
children with following or clinician Roundtable
risk factors: survey
inadequate prenatal
care; low birth weight;
difficult temperment;
poverty;
abuse/neglect; family
history of substance
abuse; history of
medical illness;
exposure to violence;
family discord
104 RESPONSIVENESS Cultural Access: penetration % of the caseload This indicator addresses the degree MI Dept. of
Sensitivity & rate for minorities comprised of to which ethnic minorities, typically Community Health
Accessibility to ethnic minorities / an underserved population, are
Minorities receiving public mental health
% of persons who
are ethnic services.
minorities in the
area population.
105 RESPONSIVENESS Cultural Cultural sensitivity For the most Administrati Outcomes
Sensitivity & (language need prevalent non- ve/ Roundtable
Accessibility to awareness) English language Claims/MIS Reduced list
Minorities spoken in the and/or other
service area, the primary data
proportion of collection
providers speaking (self-report
that language survey)
compared to the
proportion of
individuals residing
in the service area
speaking that
language as their
primary language.
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
106 RESPONSIVENESS Cultural Degree to which # positive Consumer CARF performance
Sensitivity & linguistic consumer survey indicators for
Accessibility to accommodations are responses to behavioral health
Minorities made survey question
regarding staff
language / total #
responses
107 RESPONSIVENESS Cultural Degree to which # positive Consumer CARF performance
Sensitivity & consumers report that consumer survey indicators for
Accessibility to staff are sensitive to responses to behavioral health
Minorities their cultural, ethnic, survey question
or linguistic regarding personal
backgrounds dignity / total #
responses
108 RESPONSIVENESS Selection Responsiveness to # admissions with Total Persons with low levels of Kamis-Gould and
low-functioning low level of admissions 0- functioning due to mental disorders Hadley
persons in need of functioning (LOF) / 18 have high levels of need for services,
services total admissions but they can be difficult to treat and
less appealing to providers.
Therefore, public entities should
monitor plans and systems of care to
ensure that each admits as many
low-functioning people as the rest,
and they should develop normative
data for future monitoring.
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
109 RESPONSIVENESS Response Response Average time from Total Delayed response to needed Based on a Kamis-Gould and
Promptness/Se promptness first urgent/routine population 0- services can discourage service sample of Hadley
lection contact to first 18 utilization and, in emergency records
service situations, can be harmful or
dangerous. To prevent delay,
emergency care should be provided
within one hour, and routine services
should be offered within one week,
from the time of contact or request
for service. Because these types of
data are rarely captured in
automated MIS, monitoring the
promptness of response to service
requests could be accomplished
through a sample survey of
providers' service logs and
recipients' clinical records.
110 RESPONSIVENESS Response Consumer perception Percent of families Self-report, Outcomes
Promptness/Se of access; wait time who report they survey Roundtable
lection for 1st appt were seen for a
first appointment in
a timely manner.
112 RESPONSIVENESS Response Length of time to total # days Administrati CARF performance
Promptness/Se schedule first between initial call ve records indicators for
lection appointment and first behavioral health
appointment /
total # new
admissions (adjust
between types)
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
113 RESPONSIVENESS Response Access: Timeliness # persons who Quick, convenient entry into the MI Dept. of
Promptness/Se received a face-to- mental health system is a critical Community Health
lection face meeting with a aspect of accessibility to services.
professional within Delays can result in inappropriate
14 calendar days care or exacerbation of distress.
of a non-emergent The time it takes to have face-to-
request for service face contact with a mental health
/ professional and start services is a
total # persons who critical component of appropriate
received a face-to- care.
face assessment
with a professional
during the reporting
period.
114 RESPONSIVENESS Response Successful initiation Percentage of Administrati Outcomes
Promptness/Se of services children/adolescent ve/ Roundtable
lection s who received a Claims/MIS Reduced list
diagnosis of a
mental health
disorder or
received a mental
health service visit
and received any
additional mental
health service
within 14 days.
115 RESPONSIVENESS Response Successful initiation Percentage of Administrati Outcomes
Promptness/Se of services children/adolescent ve/ Roundtable
lection s who received a Claims/MIS Reduced list
diagnosis of an
AOD disorder or
received an AOD
service visit who
received any
additional AOD
service within 14
days.
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
116 RESPONSIVENESS Response length of time from total # of days Administrati CARF performance
Promptness/Se first to second between first ve records indicators for
lection appointment appointment and behavioral health
second
appointment /
total # second
appointment
(adjust between
types)
117 RESPONSIVENESS Response Rate of persons Survey ACMHA
Promptness/Se reporting timeliness
lection from first appointment
to second
appointment
118 RESPONSIVENESS Response Percent of patients Survey IBH
Promptness/Se satisfied with access
lection to care
119 RESPONSIVENESS Response Treatment Percentage of Administrati Outcomes
Promptness/Se engagement children/adolescent ve/ Roundtable
lection s diagnosed with Claims/MIS Reduced list
serious emotional
disorders who
received three
mental health
services within 30
days of the
initiation of care.
120 RESPONSIVENESS Response Treatment Percentage of Administrati Washington Circle
Promptness/Se engagement children/adolescent ve Group
lection s diagnosed
withAOD disorders
who received three
plan-provided AOD
services within 30
days of the
initiation of care.
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
121 RESPONSIVENESS Response Percentage of Percent of Claims, Outcomes
Promptness/Se children at risk for children/adolescent Clinical Roundtable
lection psychiatric disorder s/families in the records
who are screened for eligible population
substance abuse that are
disorders. screened/evaluate
d for AOD abuse or
dependence.
122 RESPONSIVENESS Response Sensitivity # refused service/ Total Consumers are and should be active Based on a Kamis-Gould and
Promptness/Se assigned against population 0- participants in decisions about consumer Hadley
lection preference / # 18 treatments and services and, unless opinion
surveyed contraindicated, decisions should be survey
responsive to clients' desires and
preferences. Because there are no
norms about the proportion of
requests that are clinically
inappropriate, contraindicated, or
financially unjustified, public entities
should monitor plans and systems of
care to develop comparative data
and norms.
123 RESPONSIVENESS Response Percentage of Percentage of MIS Outcomes
Promptness/Se children with SED children and youth systems Roundtable
lection who receive services who are living at
in their own homes, in home and receive
school settings or all their treatment,
other community services, and
settings supports in their
own homes,
schools, and other
settings in their
community.
124 RESPONSIVENESS Response Complaints, appeals,
Promptness/Se and grievances
lection decrease and those
that occur are
handled satisfactorily
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
125 RESPONSIVENESS Response Rate of service Authorizatio SAMHSA EW
Promptness/Se denials by service n data system, IBH
lection type
126 RESPONSIVENESS Response % of PCPs know how PI interviews
Promptness/Se to refer within the
lection system
127 RESPONSIVENESS Response Cost Shifting Proportion of Total Due to limited financial resources, Kamis-Gould and
Promptness/Se enrollees in state population 0- providers are often tempted to avoid Hadley
lection hospitals, jails, 18 responding to especially difficult
child welfare, or consumers by intentionally or
juvenile justice unintentionally pushing them toward
service systems. other systems. The proportion of
any plan's enrollees in all systems
where mental health service costs
will be incurred should be minimized.
Public entities should monitor plans
and service systems and compile
empirical data to develop acceptable
levels and norms.
128 RESPONSIVENESS Response Percentage of # children placed in Administrati Outcomes
Promptness/Se children placed in 24 24 hour treatment ve Roundtable
lection hour treatment programs / total #
programs children served
129 RESPONSIVENESS Response Telephone access to calls answered in Administrati SAMHSA EW
Promptness/Se managed care greter than 30 ve- system, IBH
lection organization. seconds / total telephone
calls data
130 RESPONSIVENESS Response Percent of phone Calls placed Administrati IBH
Promptness/Se calls placed on hold onhold / total calls ve-
lection telephone
data
131 RESPONSIVENESS Response Telephone call # calls abandoned Administrati IBH
Promptness/Se abandonment rate / total calls ve-
lection telephone
data
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
132 EFFICIENCY Productivity Clinical case load for # clients / # direct Total The measure of the average number Kamis-Gould and
a select group of staff FTEs population of clients served by direct service full- Hadley
providers time-equivalent staff, or clinical case
load, is a key measure of
productivity. Low ratios might
indicate low productivity. Very high
ratios, on the other hand, might
reflect thinly spread clinical staff and
an inability to provide appropriate
service intensity. Empirical norms
should be developed over time by
meaningful client groups (e.g.,
children, people with SMI, tec.) and
by program elements (e.g., intensive
case management, partial care,
supervised residential services, etc.).
133 EFFICIENCY Productivity Staff productivity for total # units of The average number of units of Kamis-Gould and
a select group of service (UOS) / service provided by clinical staff is Hadley
providers # direct service the most important measure of
FTEs productivity. Data and norms should
be compiled and developed by
program elements or cost centers,
i.e., separately for inpatient,
outpatient, residential services, etc.
134 EFFICIENCY Cost Service cost total $ / total This indicator of average cost per Kamis-Gould and
Containment units of service unit of service is the single most Hadley
important measure of cost
containment and efficiency, as long
as it is produced by program element
(inpatient, outpatient, case
management, emergency,
residential, etc.) or cost center. This
indicator is also useful for detailing
program commitments in
performance contracts. To prevent
undue pressure to reduce costs, this
indicator is best used in conjunction
with outcome measures.
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
135 EFFICIENCY Cost Cost per client total $ / # clients Total The average cost per client is a Kamis-Gould and
Containment served Population 0- useful descriptor of costs of services Hadley
18 across programs or populations and
a prevailing basis for capitation. It is
also often the type of information
requested by politicians and budget
officers. Sound systems might best
be defined enrollee groups (adults,
children, SMI, etc.), and by
multiplying those costs by the size of
the respective groups to arrive at
total expected costs.
136 EFFICIENCY Cost Child and family Measured by Dawn Project
Containment receive cost effective service utilization Outcome measures
services data
137 EFFICIENCY Cost Child and family Measured by Dawn Project
Containment receive cost effective average cost per Outcome measures
services child- separated by
grant and non-
grant populations
138 EFFICIENCY Cost Medicaid direct Direct service Annie E. Casey
Containment service expenditures expenditures for Children's
per Medicaid child Medicaid mental Benchmarking
served health services / Project
# children enrolled
in Medicaid who
received at least
one mental health
service
139 EFFICIENCY Cost Total direct services Direct service Annie E. Casey
Containment expenditures per child expenditures for Children's
served Medicaid and non- Benchmarking
Medicaid mental Project
health services /
# children, both
Medicaid and non-
Medicaid, who
received at least
one mental health
service
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
140 EFFICIENCY Cost Revenues generated 1st + 3rd party $ / This measure of funds generated Kamis-Gould and
Containment total $ from client fees and third party Hadley
insurance is most useful in
assessing the degree to which a
program, system, or plan taps
potentialresources and collects fees,
as compared with reliance on
municipal and other government
support.
141 EFFICIENCY Cost Administrative Administrati Casey
Containment Spending ve Benchmarking; DS
2000+; NASMHPD
16 State
142 EFFICIENCY Service Mix/ Occupancy rate/use average # active Mental health services involve both Kamis-Gould and
Occupancy of capacity clients / capacity fixed and variable costs, and Hadley
occupancy data reflect the level to
which fixed costs are put to the best
use. Thus, full use of capacity will
result in much lower costs per unit of
service than a low occupancy;
maximized.
143 EFFICIENCY Service Mix/ Turnover/use of annual # of Turnover is a measure of efficient Kamis-Gould and
Occupancy capacity admissions / total use of resources, facilities, and Hadley
annual # served capacity; the higher the turnover, the
higher the efficiency. Thus, high
turnover in inpatient beds reflects
efficient use because these beds can
be used to serve more clients per
year. This measure must be
considered very carefully, and norms
should be developed accordingly,
because an extremely high turnover
(e.g., through premature discharges)
could compromise treatment
effectiveness.
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
144 EFFICIENCY Service Mix/ Duration of service average length of The average length of stay is also a Kamis-Gould and
Occupancy stay measure of efficiency. Because Hadley
given fixed capacity, the shorter the
length of stay, the higher the
efficiency and the lower the costs.
Again, premature discharges would
produce low length of stay but would
be likely to reduce effectiveness.
This measure, therefore, should be
examined in conjunction with
effectiveness indicators, and norms
should be developed accordingly.
145 EFFICIENCY Service Mix/ Average number of Administrati IBH
Occupancy sessions/days for ve claims
intensive outpatient. data
Residential and
outpatient care
146 EFFICIENCY Service Mix/ Average length of total # days of Administrati HEDIS; AMBHA-
Occupancy stay in days for chemical ve claims PERMS 2.0
chemical dependency dependency data
hospitalization of hospitalization /
children total # hospitalized
for chemical
dependency
147 EFFICIENCY Service Mix/ Days per thousand in Administrati Casey
Occupancy residential treatment ve Benchmarking
148 EFFICIENCY Service Mix/ Mental health Administrati HEDIS, Casey
Occupancy discharges per 1000 ve claims Benchmarking, IBH,
children data AMBHA-PERMS 2.0
149 EFFICIENCY Service Mix/ Chemical Administrati HEDIS; AMBHA-
Occupancy dependency ve claims PERMS 2.0
discharges per 1000 data
children
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
150 EFFICIENCY Service Mix/ Utilization per Administrati IBH
Occupancy thousand of Intensive ve claims
outpatient, residential data
and Outpatient
services
151 EFFICIENCY Service Proportion of costly inpatient + Inpatient and emergency services Kamis-Gould and
Substitution services emergency costs / are the most expensive types of Hadley
total services costs care, and, as long as clinically
indicated, should be minimized. The
ratio of these expensive services to
the total services costs reflects both
the level of financial management
and the degree to which a plan
employs innovative and less
expensive services, such as crisis
residential care and case
management.
152 EFFICIENCY Service Crisis response Unduplicated # Total To assure a crisis response system Crisis TennCare Partners
Substitution regional users who population 0- that provides alternatives to response Performance
were diverted by 18 unnecessary psychiatric reports, Measures
crisis response hospitalization and provides a Encounter
services during the service that adequately meets the
quarter / needs of those served.
Unduplicated #
regional users
served during the
quarter
153 EFFECTIVENESS Client Service impact on (average LOF at A major objective of mental health Kamis-Gould and
Outcomes/ clients' level of service services is to raise recipients' levels Hadley
Functional functioning (LOF) termination) - of functioning. Thus, the average
Level (average LOF at increase between start and end of
start of service) service is a measure of program
or effectiveness; the higher the
(LOF at service increase, the better, as long as data
termination)-(LOF are compiled by meaningful and
at start of service) comparable groups.
for all clients /
total # clients
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
154 EFFECTIVENESS Client Average client's (average LOF at The difference between average Kamis-Gould and
Outcomes/ functional level 6 follow-up) - functional level at discharge and Hadley
Functional months following (average LOF at follow-up is a measure of the degree
Level service termination service to which program effects have been
termination) sustained. A loss might mean
premature service discontinuation,
and such results should be
minimized.
155 EFFECTIVENESS Client Percentage of Percentage of Survey or Outcomes
Outcomes/ patients with patients in an Clinical Roundtable
Functional improved, maintained active intervention Assessment
Level and reduced levels of setting with Instrument
functioning improved,
maintained and
reduced levels of
functioning based
on a nationally
accepted clinical
assessment survey
instrument.
156 EFFECTIVENESS Client Degree to which The proportion of Consumer CARF performance
Outcomes/ consumers children and surveys, indicators for
Functional experience an adolescents who Case record behavioral health
Level increased level of report to have
functioning increased level of
functioning in the
CAFAS
157 EFFECTIVENESS Client Improved records for # of youth with
Outcomes/ community arrests in first year
Functional supervision for after disenrollment
Level Department of
Corrections youth
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
158 EFFECTIVENESS Client Improved records % of children with Dawn Project
Outcomes/ with the juvenile no further Outcome measures
Functional justice system incidences of
Level delinquency,
runaway or truancy
charges, or
violation of terms
of probation, which
results in
placement failure
for a period of six
and twelve months
from disenrollment.
159 EFFECTIVENESS Client Decrease in arrests Percentages of Survey - Outcomes
Outcomes/ children and youth Self-report, Roundtable
Functional whose encounters Clinician
Level with law report or
enforcement Juvenile
decreased while Justice/Cour
receiving services. t record
match
160 EFFECTIVENESS Client Change in legal Change in the Administrati Outcomes
Outcomes/ encounters/arrests average number of ve/ Roundtable
Functional arrests for children/ Claims/MIS Reduced list
Level adolescents served and/or other
by behavioral primary data
health systems collection
from 30 days (self-report
preadmission to 30 survey)
days post
discharge
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
161 EFFECTIVENESS Client Juvenile justice # children who Annie E. Casey
Outcomes/ system involvement received at least Children's
Functional one mental health Benchmarking
Level service and also Project
had at least one
encounter with the
juvenile justice
system at any time
during the year /
total # children
served
162 EFFECTIVENESS Client Kids remain out of the PI interviews- Aso
Outcomes/ JJ system % of JJ served in
Functional residential LOC
Level
163 EFFECTIVENESS Client Reduction in criminal PI interviews
Outcomes/ activity and substance
Functional abuse
Level
164 EFFECTIVENESS Client Change in school Percentage of Self-report Outcomes
Outcomes/ attendance children and youth or school Roundtable
Functional whose school records
Level performance
improved while
receiving services.
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
165 EFFECTIVENESS Client Change in school Percentage of Administrati Outcomes
Outcomes/ attendance children/adolescent ve/ Roundtable
Functional s whose Claims/MIS Reduced list
Level unexcused and/or other
absences from primary data
school or an collection
approved home (self-report
school program survey)
have decreased
while receiving
services.
(Unexcused
absences do not
include absence
due to illness,
hospitalization,
treatment, etc. —
unexcused
absence is
essentially truancy)
166 EFFECTIVENESS Client Fewer school PI interviews
Outcomes/ suspensions and
Functional expulsions
Level
167 EFFECTIVENESS Client Improved school The Clinical Dawn Project
Outcomes/ functioning Manager Tx Plan Outcome measures
Functional level rating.
Level
168 EFFECTIVENESS Client Educational The proportion of Case CARF performance
Outcomes/ attainment for those children and record, indicators for
Functional who are in school adolescents for school behavioral health
Level whom there is an record,
increase in follow-up
educational with teacher
attainment referrals
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# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
169 EFFECTIVENESS Client Level of satisfaction -The proportion of Case CARF performance
Outcomes/ with school children and record, indicators for
Functional adolescents for follow-up behavioral health
Level whom there is an with children
increase after 3
months on the
CAFAS School
Performance
subscale
-Average rating of
school satisfaction
on the QOLQ
170 EFFECTIVENESS Client For those receiving 16-18 survey, self- Outcomes
Outcomes/ vocational or work report roundtable
Functional readiness services,
Level the change in the
number of days of
paid work from
admission
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Data
# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
171 EFFECTIVENESS Client Completed suicide; Rate: number of Facility Outcomes
Outcomes/ attempted suicide deaths by suicide records Roundtable
Functional per 100,000
Level (consistent with
CDC
Mortality/morbidity
statistics. Age-
adjusted rates are
strongly suggested -
- age-adjusted
refers to weighting
rates by a
population
standard to allow
for comparisons
across time and
among risk
groups). No data
are collected on
suicide attempts.
SUGGESTION:
rate of suicide
attempt reported in
the CDC Youth
Risk Behavior
Surveillance
Survey (YRBSS)
172 EFFECTIVENESS Client
Outcomes/
Functional
Level
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Data
# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
173 EFFECTIVENESS Client Adverse Outcomes: Percentage of Self/Family Outcomes
Outcomes/ client injuries, children/adolescent reporting; Roundtable
Functional elopement, suicide, s who experience Clinical
Level homicide, unexpected adverse outcomes records; law
deaths including injuries, enforcement
elopement from 24 records;
hour programs, Facility
adverse drug reporting
reactions and
unexpected
deaths.
174 EFFECTIVENESS Client Mortality State MIS or NASMHPD 16
Outcomes/ link ot public State; ACMHA
Functional health death
Level records
175 EFFECTIVENESS Client Change in frequency Percent change in Self-report Outcomes
Outcomes/ of use of frequency of use Roundtable
Functional alcohol/other drugs in as a primary or
Level past 30 days from secondary drug of
admission to AOD choice at
treatment setting to admission to a
discharge. treatment setting
as compared to the
frequency of use
as a primary or
secondary drug of
choice at
discharge.
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Data
# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
176 EFFECTIVENESS Client Adverse outcomes The number of Administrati Outcomes
Outcomes/ children/adolescent ve/ Roundtable
Functional s per 1,000 in Claims/MIS Reduced list
Level behavioral heath and/or other
treatment who primary data
experience collection
adverse outcomes (self-report
including injuries, survey)
elopement from 24
hour programs,
adverse drug
reactions,
unexpected
deaths, and suicide
within a calendar
year.
177 EFFECTIVENESS Client Percentage of Percentage of Survey or clinical assessment outcomes
Outcomes/ patients experiencing patients Roundtable
Symptom- symptom relief or experiencing
atology reduction symptom relief or
reduction based on
a nationally
accepted
instrument and
through a
nationally accepted
self-reporting
survey
178 EFFECTIVENESS Client Inpatient readmission Percent of children Administrative claims and Outcomes
Outcomes/ rates within 30 days and adolescents authorization data Roundtable
Symptom- (and 180 days for who are readmitted
atology NASMHPD) and 90 to a psychiatric
and 365 days (for inpatient setting
AMBHA) within 30 days of
discharge (and
subsequent time
periods)
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Data
# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
179 EFFECTIVENESS Client Readmission rates # of persons For some persons with serious MI Dept of
Outcomes/ readmitted to an mental illness, the occasional use of community
Symptom- inpatient psychiatric inpatient care is essential. Health
atology psychiatric unit However, a rapid readmission
within 15 days of following a discharge may suggest
discharge / Total # that persons were prematurely
of persons discharged or that the post-
discharged from discharge follow-up was not timely or
inpatient sufficient. This indicator assesses
psychiatric units whether CMHSPs are meeting the
during the reporting department's standard of no more
period than 15% of persons discharged
from inpatient units being readmitted
within 15 days.
180 EFFECTIVENESS Client Rate of hospital PI interviews
Outcomes/ readmissions is - Institutional
Symptom- reduced LOC
atology
181 EFFECTIVENESS Client completed suicide; Rate: Number of Facility records outcome
Outcomes/ attempted suicide deaths by suicide Roundtable
Symptom- per 100,000
atology (consistent with
CDC
Mortality/Morbidity
statistics. Age
adjusted rates are
strongly suggested.
Age-adjusting
refers to weighting
rates by a
population
standard to allow
for comparisons
across time and
among risk
groups.) No data
are collected on
suicide attempts
reported in the
CDC Youth Risk
Behavior
Surveillance
Survey (YRBSS)
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Data
# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
182 EFFECTIVENESS Client Adverse outcomes: Percentage of Self/family reporting; clinical records; Outcomes
Outcomes/ client injuries, children/adolescent Law enforcement records; Facility Roundtable
Symptom- elopement, suicide, s who experience reporting
atology homicide, unexpected adverse outcomes
deaths including injuries,
elopement from 24-
hour programs,
adverse drug
reactions and
unexpected deaths
183 EFFECTIVENESS Client Change in frequency Percent change in Self-report Outcomes
Outcomes/ of use of the frequency of Roundtable
Symptom- alcohol/other drugs in use as a primary or
atology past 30 days from secondary drug of
admission to AOD choice at
treatment setting to admission to a
discharge treatment setting
as compared to the
frequency of use
as a primary or
secondary drug of
choice at discharge
184 EFFECTIVENESS Client Safety of PI interviews-
Outcomes/ environments Satisfaction survey
Symptom- improve
atology
185 EFFECTIVENESS Client Residential stability % clients in same Residential stability is an important Kamis-Gould and
Outcomes/ residence > 1 year; component of consumers' quality of Hadley
Symptom- this year vs. last life. The change in average
atology year residential stability over time is one
way of monitoring improvements, at
least until empirical norms are
developed.
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Data
# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
186 EFFECTIVENESS Client Community tenure average Community tenure is another aspect Kamis-Gould and
Outcomes/ community tenure of consumers' quality of life and Hadley
Symptom- in months; this year should be monitored and
atology vs. last year maximized. This indicator also can
reveal situations where mental
health plans and systems push
disabled and expensive enrollees to
the state hospital system.
187 EFFECTIVENESS Client Length of time spent Number of days Consumer CARF performance
Outcomes/ in the community spent in the survey/repor indicators for
Symptom- community / total t behavioral health
atology
number of days in
the index period
188 EFFECTIVENESS Client Proportion of children # children who Annie E. Casey
Outcomes/ served who were in received at least Children's
Symptom- out-of-home one mental health Benchmarking
atology placements during service and were in Project
the year foster care or other
out-of-home
placement- under
the purview of the
child welfare
agency- at any
time during the
year / total #
children served
189 EFFECTIVENESS Client Kids are at home PI interviews
Outcomes/
Symptom-
atology
190 EFFECTIVENESS Client Percentage of # children living Chart Outcomes
Outcomes/ children living independently / review; new Roundtable
Symptom- independently total # children data
atology receiving services required
191 EFFECTIVENESS Client Length of # days in a hospital Administrati CARF performance
Outcomes/ hospitalization / total # days in the ve data indicators for
Symptom- index period behavioral health
atology
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Data
# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
192 EFFECTIVENESS Client Change in number of Compare at Administrati NASADAD
Outcomes/ hospital admissions admission to AOD ve- Clinical
Symptom- during past 6 months treatment setting Record
atology and 6 months post-
admission
193 EFFECTIVENESS Client Change in ER visits Compare at Administrati NASADAD
Outcomes/ for psychiatric admission to AOD ve- Clinical
Symptom- purposes in past 6 treatment setting Record
atology months and 6 months post-
admission
194 EFFECTIVENESS Client Change in number of Compare at Administrati NASADAD
Outcomes/ hospital admissions admission to AOD ve- Clinical
Symptom- to a psychiatric treatment setting Record
atology hospital during past 6 and 6 months post-
months admission
195 EFFECTIVENESS Client Quality of life: living # children served Use of this indicator is based on the MI Dept. of
Outcomes/ situation living with their assumption that, in general, the Community Health
Symptom- family / total # quality of life for children will be
atology higher where they live with their own
children receiving
CMHSP services family instead of in an out-of-home
placement.
196 EFFECTIVENESS Client Fewer kids in shelters PI interviews- With
Outcomes/ and lower LOS behavioral health
Symptom- needs
atology
197 EFFECTIVENESS Client Change in quality of Percentage of Primary data Outcomes
Outcomes/ life children/adolescent collection Roundtable
Symptom- s in behavioral (self-report Reduced list
atology health services, survey)
whose quality of
life (i.e., changes
in stress, strain,
etc.) has
decreased,
remained the
same, or
increased.
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Data
# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
198 EFFECTIVENESS Client Maintanenece of # clients who report Survey Washington Circle
Outcomes/ treatment effects specific services Group
Symptom- provided and/or
atology monitored by the
plan to promote
and sustain
positive treatment
outcomes post-
discharge / total #
clients discharged
199 EFFECTIVENESS Client Caregiver strain Measured by Dawn Project
Outcomes/ questionnaire Questionnaire at Outcome measures
Symptom- intake, every 6
atology months until
discharge, and 12
months after
discharge
200 EFFECTIVENESS Client Percent of patients # of patients with Clinical DMA MMC
Outcomes/ with anorexia who are anorexia who are Records Benchmarking
Symptom- able to maintain a able to maintain a Project
atology normal weight within normal weight
6 months of receiving within 6 months of
diagnosis receiving diagnosis
/ total # patients
with anorexia
201 EFFECTIVENESS Client Effectiveness with Survey, Self- Summit 2001; DS
Outcomes/ which presenting Report 2000+
Symptom- problems were
atology addressed;
Improvement in
problem resolution;
quality of life
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Data
# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
202 EFFECTIVENESS Client Patient satisfaction Percentage of Survey Outcomes
Outcomes/ with quality of care patients “satisfied” Roundtable
Consumer with their
Satisfaction professional
treatment services
based on a
nationally accepted
self-report survey
instrument three
months from first
documented
encounter
203 EFFECTIVENESS Client Degree to which # consumers who Consumer CARF performance
Outcomes/ consumers feel good feel good about surveys, indicators for
Consumer about themselves oneself / total # Case record behavioral health
Satisfaction
consumers;
based on scales
from, e.g.,
-Rosenberg Self-
Esteem scale
-SLOF
-Client Satisfaction
(CSQ-8)
-NACBHD -
Respect and
Dignity
204 EFFECTIVENESS Client Families become their PI interviews-
Outcomes/ own advocates Satisfaction survey
Consumer
Satisfaction
205 EFFECTIVENESS Client Parents are true PI interviews-
Outcomes/ partners Satisfaction survey
Consumer
Satisfaction
206 EFFECTIVENESS Client Comfort level of PI interviews-
Outcomes/ families increases in Satisfaction survey
Consumer the collaboratives.
Satisfaction Families feel
comfortable voicing
opinions.
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Data
# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
207 EFFECTIVENESS Client Degree to which # positive Consumer CARF performance
Outcomes/ consumers believe consumer survey indicators for
Consumer they were respected responses to behavioral health
Satisfaction by the staff survey question
regarding
consumer respect
/ total # responses
208 EFFECTIVENESS Client Consumer received Survey Outcomes
Outcomes/ the services Roundtable
Consumer consumer/family
Satisfaction thought were needed
209 EFFECTIVENESS Client Perception of Percentage of Primary data Outcomes
Outcomes/ appropriateness of children/adolescent collection Roundtable
Consumer services s or families who (self-report Reduced list
Satisfaction report they survey)
received the
services that they
needed
210 EFFECTIVENESS Client Satisfaction of PI interviews
Outcomes/ families increases
Consumer
Satisfaction
211 EFFECTIVENESS Client Services meet the Measured by Dawn Project
Outcomes/ real needs of the child biennial, narrative Outcome measures
Consumer and family report of
Satisfaction successes and
barriers based on
Service
Coordinator focus
groups
212 EFFECTIVENESS Client Degree of active # positive Consumer CARF performance
Outcomes/ consumer consumer survey indicators for
Consumer participation in responses to behavioral health
Satisfaction decisions concerning survey question
their treatment regarding
treatment /
total # responses
213 EFFECTIVENESS Client Availability of Administrati DS 2000+
Outcomes/ consumer choice in ve
Consumer plan, treatment,
Satisfaction family involvement
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Data
# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
214 EFFECTIVENESS Client Degree to which # positive Consumer CARF performance
Outcomes/ consumers receive consumer survey indicators for
Consumer information to make responses to behavioral health
Satisfaction informed choices survey question
regarding adequate
information /
total # responses
215 EFFECTIVENESS Client Adequacy of Survey Summit 2001
Outcomes/ information about:
Consumer Assessment results;
Satisfaction treatment incl. risks
and benefits; self-
216 EFFECTIVENESS Client help; patient rights,
Recovery/Hope Survey, Self- Outcomes
Outcomes/ Report Roundtable;
Consumer NASMHPD 16
Satisfaction State; DS 2000+
217 EFFECTIVENESS Client Rate people report Survey ACMHA, Summit
Outcomes/ they feel safe in 2001
Consumer treatment and also in
Satisfaction community
218 EFFECTIVENESS Client Consumer's (family) Survey, Self- Summit 2001
Outcomes/ comfort to refuse Report
Consumer treatment; confort to
Satisfaction complain; experience
of harmful medication
side effects; safety in
their relationship with
provider
219 EFFECTIVENESS Client Kids feel that they are PI interviews-
Outcomes/ heard Satisfaction survey
Consumer
Satisfaction
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Data
# Dimension Domain Subdomain Indicator Measures Target Pop Rationale Source Measure Source
220 EFFECTIVENESS Client Parent/family reports Survey, Self- CAHPS - NCQA,
Outcomes/ on experience with Report APA
Consumer care: How well Drs.
Satisfaction Communicate;
timeliness of care;
getting needed care;
respectfulness and
helpfulness; customer
service; getting
needed drugs and
specialized services;
family centered care;
coordination
of care (APA refers to
Perceptions of care)
221 EFFECTIVENESS Provider Providers' (e.g., % providers Dissatisfied and unhappy providers Provider Kamis-Gould and
Outcomes/ behavioral health satisfied are unlikely to remain in the system survey Hadley
Consumer subcontractors) or to provide good services. Health
Satisfaction satisfaction with both plans should, therefore, conduct
clinical and fiscal periodic surveys of providers to
areas ensure that they are satisfied with
both the clinical and fiscal aspects of
the service system.
222 EFFECTIVENESS Provider Providers appeals Complaints/ IBH
Outcomes/ rate appeals/grie
Consumer vance
Satisfaction records
223 EFFECTIVENESS Provider Rates of Provider Complaints/ IBH
Outcomes/ complaints and appeals/grie
Consumer greivances vance
Satisfaction records
224 EFFECTIVENESS Provider Satisfaction of people PI interviews
Outcomes/ trying to implement
Consumer the system increases
Satisfaction
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