Performance Indicators Example of Human Resources Manager by fpt11744

VIEWS: 22 PAGES: 54

More Info
									                                                                                                                                                      Data
#    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.




         a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                     1 of 54                                                                      6/30/2011
                                                                                                                                                       Data
#    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




         a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                      2 of 54                                                                            6/30/2011
                                                                                                                              Data
#    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




         a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                         3 of 54                                              6/30/2011
                                                                                                                                                          Data
# 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.




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                              4 of 54                                                                   6/30/2011
                                                                                                                            Data
# 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




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                           5 of 54                                               6/30/2011
                                                                                                                                                             Data
# 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




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                              6 of 54                                                                       6/30/2011
                                                                                                                                                              Data
# 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




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                                7 of 54                                                                           6/30/2011
                                                                                                                                                         Data
# 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




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                             8 of 54                                                                    6/30/2011
                                                                                                                                                    Data
# 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.




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                       9 of 54                                                                    6/30/2011
                                                                                                                        Data
# 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.)



      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                       10 of 54                                           6/30/2011
                                                                                                                       Data
# 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




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                     11 of 54                                               6/30/2011
                                                                                                                       Data
# 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




     a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                      12 of 54                                           6/30/2011
                                                                                                                                                     Data
# 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.




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                      13 of 54                                                                     6/30/2011
                                                                                                                          Data
# 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




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                         14 of 54                                            6/30/2011
                                                                                                                    Data
# 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




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                    15 of 54                                           6/30/2011
                                                                                                                       Data
# 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




     a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                     16 of 54                                          6/30/2011
                                                                                                                                                         Data
# 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




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                          17 of 54                                                                            6/30/2011
                                                                                                                                                           Data
# 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.



      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                        18 of 54                                                                                 6/30/2011
                                                                                                                                                            Data
# 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




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                             19 of 54                                                                       6/30/2011
                                                                                                                                                            Data
# 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.




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                             20 of 54                                                                        6/30/2011
                                                                                                                           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.




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                         21 of 54                                            6/30/2011
                                                                                                                                                           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.



      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                            22 of 54                                                                            6/30/2011
                                                                                                                               Data
# 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)




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                          23 of 54                                               6/30/2011
                                                                                                                            Data
# 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




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                          24 of 54                                              6/30/2011
                                                                                                                                                              Data
# 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.




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                             25 of 54                                                                       6/30/2011
                                                                                                                                                         Data
 # 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.




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                        26 of 54                                                                          6/30/2011
                                                                                                                                                             Data
 # 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.




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                           27 of 54                                                                         6/30/2011
                                                                                                                                                       Data
 # 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)




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                    28 of 54                                                                               6/30/2011
                                                                                                                                                   Data
 # 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.




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                      29 of 54                                                                       6/30/2011
                                                                                                                          Data
 # 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.




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                      30 of 54                                                6/30/2011
                                                                                                                                                           Data
 # 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




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                       31 of 54                                                                              6/30/2011
                                                                                                                                                       Data
 # 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




      a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                      32 of 54                                                                              6/30/2011
                                                                                                                                                     Data
 # 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.




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                      33 of 54                                                                    6/30/2011
                                                                                                                                                        Data
 # 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



       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                      34 of 54                                                                        6/30/2011
                                                                                                                                            Data
 # 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.




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                 35 of 54                                                                       6/30/2011
                                                                                                                                                    Data
 # 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




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                     36 of 54                                                                         6/30/2011
                                                                                                                                                       Data
 # 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




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                     37 of 54                                                                           6/30/2011
                                                                                                                                                  Data
 # 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




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                     38 of 54                                                                   6/30/2011
                                                                                                                     Data
 # 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




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                   39 of 54                                           6/30/2011
                                                                                                                       Data
 # 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.




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                      40 of 54                                            6/30/2011
                                                                                                                       Data
 # 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




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                   41 of 54                                                6/30/2011
                                                                                                                       Data
 # 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




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                    42 of 54                                               6/30/2011
                                                                                                                     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




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                 43 of 54                                           6/30/2011
                                                                                                                        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.




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                     44 of 54                                             6/30/2011
                                                                                                                                           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)




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                     45 of 54                                                                 6/30/2011
                                                                                                                                                    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)



       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                 46 of 54                                                                                 6/30/2011
                                                                                                                                                     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.




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                      47 of 54                                                                         6/30/2011
                                                                                                                                                 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




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                      48 of 54                                                                  6/30/2011
                                                                                                                                                    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.




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                       49 of 54                                                                       6/30/2011
                                                                                                                        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




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                     50 of 54                                            6/30/2011
                                                                                                                        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.



       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                    51 of 54                                            6/30/2011
                                                                                                                       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


       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                     52 of 54                                            6/30/2011
                                                                                                                        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




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                      53 of 54                                            6/30/2011
                                                                                                                                             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




       a3ea571d-53f9-4934-8fb3-563c3992782d.xls                                   54 of 54                                                                     6/30/2011

								
To top