Information Systems Capabilities Assessment (ISCA) Version 7.0 California Mental Health Plans FY 2011 MHP Name: Santa Clara County Mental Health Department Return an electronic copy of the completed assessment to CAEQRO for review by 11/01/2011 This document was produced by the California EQRO in collaboration with the California Department of Mental Health and California MHP stakeholders. Information Systems Capabilities Assessment (ISCA) Contact Information Insert MHP identification information below. The contact name should be the person completing or coordinating the completion of this assessment. ISCA contact name and title: Laura Luna, MH Compliance and Privacy Manager Mailing address: 828 South Bascom Ave, Suite 200, San Jose, CA 94128 Phone number: (408) 793-1874 Fax number: (408) 885-5792 E-mail address: [email protected] Laura Luna, MH Compliance and Privacy Manager Identify primary persons who participated in completion of the ISCA (name, title): Date assessment completed: Leticia Ortiz, IS Manager Leticia Rosado, PBS Manager Martha Paine, Director, GF Financial Services 10/30/2010 PURPOSE of the Information Systems Capabilities Assessment (ISCA) Knowledge of the capabilities of a Mental Health Plan’s (MHP) information systems (IS) is essential to evaluate effectively and efficiently the MHP’s capacity to manage the health care of its beneficiaries. The purpose of this assessment is to specify the desired capabilities of the MHP’s information systems and to pose standard questions to be used to assess the strength of an MHP with respect to these capabilities. This will assist an External Quality Review Organization (EQRO) to assess the extent to which an MHP’s information systems are capable of producing valid encounter data1, performance measures, and other data necessary to support quality assessment and improvement, as well as managing the care delivered to its beneficiaries. 1 “For the purposes of this protocol, an encounter refers to the electronic record of a service provided to an MCO/PIHP [MHP] enrollee by both institutional and practitioner providers (regardless of how the provider was paid) when the service would traditionally be a billable service under fee-for-service (FFS) reimbursement systems. Encounter data provides substantially the same type of information that is found on a claim form (e.g., UB-04 or CMS 1500), but not necessarily in the same format.” – Validating Encounter Data, CMS Protocol, P. 2, May 2002. PAGE 3 OF 28 OVERVIEW of the Assessment Process Assessment of the MHP’s information systems is a process of four consecutive activities. Step One involves the collection of standard information about each MHP’s information systems. This is accomplished by having the MHP complete an Information Systems Capabilities Assessment (ISCA) for California Mental Health Plans. CAEQRO developed the ISCA in cooperation with California stakeholders and the California Department of Mental Health. It is provided to the MHP as part of the CAEQRO review notification packet. The California Department of Mental Health defined the time frame in which it expects the MHP to complete and return the tool. The MHP will commonly require input from multiple areas of the organization such as IT/IS, Finance, Operations, and QI in completing the ISCA. The MHP may also attach additional sheets as needed and clearly identify them as applicable to the numbered item on the tool (e.g., 1.4, or 2.2.3). Step Two involves a review of the completed ISCA by the EQRO reviewers. Materials submitted by the MHP will be reviewed in advance of a site visit. Step Three involves a series of onsite and telephone interviews, and discussion with key MHP staff members who completed the ISCA, as well as other knowledgeable MHP staff members. These discussions focus on various elements of the ISCA. The purpose of the interviews is to gather additional information to assess the integrity of the MHP’s information systems. Step Four produces an analysis of the findings from both the ISCA and the follow-up discussions with the MHP staff. A summary report of the interviews, as well as the completed ISCA document, is included in an information systems section of the EQRO report. The report discusses the ability of the MHP to use its information systems and to analyze its data to conduct quality assessment and improvement initiatives. Further, the report considers the ability of the MHP’s information systems to support the management and delivery of mental health care to its beneficiaries. INSTRUCTIONS for completing the ISCA: Please complete this survey using Microsoft Word. Insert your response after each question. Label the ISCA submission with your county name and applicable fiscal year. For example “Alameda ISCA FY10.doc”. Be as concise as possible. If information is not available, write “N/A” in your response. PAGE 4 OF 28 For any ISCA question, you may attach existing documents which provide an answer. For example, if you have current policy and procedure documents that address a particular item, attach and reference these materials. Do not create documents expressly for the EQRO review. Do not submit any documents with protected health information (PHI). This information systems capabilities assessment pertains to the collection and processing of data for Medi-Cal. In many situations, this may be no different from how a Mental Health Plan (MHP) collects and processes commercial insurance or Medicare data. However, if your MHP manages Medi-Cal data differently than commercial or other data, please answer the questions only as they relate to Medi-Cal beneficiaries and Medi-Cal data. For clarification, certain terms used in this ISCA are defined below: Practice Management — Supports basic data collection and processing activities for common clinic/program operations such as new consumer registrations, consumer look-ups, admissions and discharges, diagnoses, services provided, billing, CSI reporting, and routine reporting for management needs such as caseload lists, productivity reports, and other day-to-day needs. Medication Tracking — Includes history of medications prescribed by the MHP and/or externally prescribed medications, including over-the-counter drugs. Managed Care — Supports the processes involved in authorizing services, receipt and adjudication of claims from network (formerly fee-for-service) providers, remittance advices, and related reporting and provider notifications. Electronic Health Records — Clinical records stored in electronic form as all or part of a consumer’s file/chart and referenced by providers and others involved in direct treatment or related activities. This may include documentation such as assessments, treatment plans, progress notes, allergy information, lab results, and prescribed medications. It may also include electronic signatures. Contract Providers — Typically groups of providers and agencies, many with longstanding contractual relationships with counties, that deliver services on behalf of an MHP and bill for their services through the MHP’s Short-Doyle/Medi-Cal system. These are also known as organizational contract providers. They are required to submit cost reports to the MHP and are subject to audits. They are not staffed with county employees, as county-run programs typically are. Contract providers do not include the former Medi-Cal fee-for-service providers (often referred to as network providers) who receive authorizations to provide services and whose claims are paid or denied by the MHP’s managed care division/unit. PAGE 5 OF 28 SECTION A. General Information A.1. List the top priorities for your MHP’s IS department at the present time: EHR: SCVHHS has elected to move towards an integrated core system, which will include Mental Health Department and Department of Drug and Alcohol Services. SCVHHS has selected a finalist vendor and will soon finish negotiations to reach an agreement for a major project to begin shortly thereafter. Mental Health Department and Department of Drug and Alcohol Services will be implemented in the first phase beginning in January 2012. Community based organizations providing mental health services as contractors to the Mental Health Department will be migrating to their own EHRs using a small amount of financial assistance from MHSA Technology funds plus their own resources. Data Warehouse: A data warehouse is in development to house Mental Health Department and Department of Drug and Alcohol Services information. Currently the following concepts are being developed: Development of the warehouse infrastructure for reports that capture business operations with a focus on billing and payment at the client as well as the program level. This will be a pilot to determine data needed, organization of that data in the warehouse, and reporting outputs. Analysis of the scope of data and infrastructure needed to produce DADS outcome measures reports. Analysis of the scope of work involved with producing reports and graphics associated with the Mental Health dashboard project Consumer Learning Centers The purpose of the CLC project is to provide additional support for consumers in Mental Health recovery programs and those living in the community by setting up supervised computer labs and basic PC skills training in established Self Help Centers across the County. The project will be implemented in phases beginning with the Downtown Mental Health Self Help Center and Evans Lane residential and outpatient programs Bed and Housing Exchange Mental Health Department will contract with an ASP to provide an inventory of housing availability for Mental Health clients. An RFP is being prepared to solicit proposals from which a selection will be made in late FY 2012 WEB Redesign Migrating the Mental Health website and increasing content to better support consumers and family members is being explored with the County Information Services Department. This includes issues of design, content and security. PAGE 6 OF 28 A.2. Describe any significant IS-related achievements or initiatives completed since the last CAEQRO review: Unicare Hardware Upgrade: Unicare hardware and infrastructure reached end of life and needed to be replaced to meet current support and standards. Project completed October 2011. A.3. Do you have a written strategic plan for IS? If yes, attach a copy or be prepared to provide it for review at the on-site CAEQRO interview. (Available for Review: Executive Summary and Detail) Yes No A.4. How are mental health services delivered? Of the total number of services provided, approximately what percentage is provided by: Type of Provider Distribution County-operated/staffed clinics 39% Contract providers 60% Network providers 1% Total 100% Of the total number of services provided, approximately what percentage is claimed to Medi-Cal. 77% Of the total number of services provided, approximately what percentage is claimed to Medi-Cal by the following types of providers: Type of Provider Medi-Cal Non-Medi-Cal Total County-operated/staffed clinics 35% 65% 100% Contract providers 85% 15% 100% Network providers 99% 1% 100% PAGE 7 OF 28 A.5. Provide approximate total annual MHP budget for the following, using your most recent cost report: Medi-Cal Type of Provider Non-Medi-Cal Total Approved County-operated/staffed clinics $12,020,815 $22,830.700 $34,851,515 Contract providers $52,544,246 $34,109,145 $86,653,391 Network providers $973,749 $59,963 $1,033,712 $65,538,810 $56,999,808 $122,538,618 22,538,618 Total A.6. Please estimate the number of staff that use your current information system: This data is derived from users who are active on all of the companies and teams Estimated Number of Hands-on Users 215 Estimated Number of Total FTEs 423 194 9 12 152 Not Available Contract provider Quality Improvement 0 Not Available Contract provider Clinical 97 Not Available Type of Staff MHP Administrative and Clerical MHP Clinical MHP Quality Improvement Contract provider Administrative and Clerical 71 PAGE 8 OF 28 Primary Information Systems Used by the MHP A.7. Describe the primary information systems currently in use: Vendor/Supplier Unicare Corporation Dell Corporation Product/Module or Function Date implemented (MM/YY) Profiler 2010 Diamond Managed Care System Month: October Year: 2003 Month: June Year: 1998 Month: Year: Month: Year: Month: Year: A.7.1. What functions do these products perform or support? (Check all that currently are used) x Practice Management Appointment Scheduling Medication Tracking Managed Care e-Prescribing MHSA Reporting Clinical Functions Data Warehouse/Mart Document Imaging/Storage Personal Health Record (PHR) Other (describe): State CSI Reporting Billing, Credentialing A.7.2. Who performs programming changes/upgrades for this software application(s)? Vendor IS MHP IS (Unicare) Health Agency IS Contract Staff/Consultant County IS Application Service Provider (ASP) Other (describe): A.7.3. Who is responsible for performing daily operation tasks for this system? (Includes running batch jobs, performing backups, monitoring status, etc.) Vendor IS MHP IS County IS Health Agency IS Contract Staff/Consultant ASP Non-vendor ASP Other (describe): PAGE 9 OF 28 A.7.4. Where is this system physically housed/sited? MHP site Health Agency IS site County IS site ASP Model — hosted by application service provider ASP Model — hosted by third-party independent hosting service Other (describe): A.7.5. What departments/agencies use this system? What departments/agencies have direct access to the system? (Check all that apply) Mental Health Mental Health Contract Providers Alcohol and Drug Public Health Other (describe): Alcohol & Drug Contract Providers Hospital Secondary Information Systems Used by the MHP A.8. List any other significant information systems used by your MHP in addition to your primary IS: Vendor/supplier Product/module Purpose/function Siemens Invision FQHC Services, Client Registration/MHSAC PCSI Pharmacy System Pharmacy System PAGE 10 OF 28 A.9. Selection and implementation of a new Information System Mark one box that best describes your status today and respond to the associated questions: A) No plans to replace current system B) Considering a new system C) Actively searching for a new system D) New system selected, not yet in implementation phase E) Implementation in progress F) New system in place (use this for systems fully installed in past 5 years) A.10. Implementation of a new Information System Santa Clara Valley Health and Hospital System (SCVHHS) recognize the critical importance of its Information Technology (IT) environment in enabling its strategic vision and business goals. Given an opportunity to assess the current strategy and status of IT for Santa Clara Health and Hospital System (SCVHHS), SCVHHS has elected to move towards an integrated core system, which will include Mental Health Department and Department of Drug and Alcohol Services. SCVHHS has selected a finalist vendor and will soon finish negotiations to reach an agreement for a major project to begin shortly thereafter. If you marked box D, E, or F above, complete the following questions. Otherwise, skip to Section B. A.10.1. Details of the new system: Even though the new system has not been chosen all of the requirements are still in place: Vendor: Confidential (in negotiations) Product(s): TBD Implementation start date: January 2012 Estimated go live date: June 2013 Estimated completion date: December 2013 PAGE 11 OF 28 A.10.2. For those items listed which you are electronically or manually transferring to the new system, indicate for which consumers these items will be transferred (enter “X” in boxes): To be determined with new system All Consumers Item Active Consumers Only MHP consumer ID, name/address, other demographic data Episode history, including admit/discharge dates Diagnoses Services Medi-Cal/insurance information Payor Financial Information (UMDAP) A.10.3. Please identify staff directly responsible for system implementation: Project Responsibility Name and Title Overall Project Manager Bruce Copley / Deane Wiley / Leticia Ortiz Technology Project Manager Sue Clements Clinical Project Manager Sheila Yuter A.10.4. Specify key modules included in the system: What functions do these products perform or support? Practice Management Appointment Scheduling Medication Tracking Managed Care e-Prescribing MHSA Reporting Clinical Functions Data Warehouse/Mart Document Imaging/Storage Personal Health Record (PHR) Other (describe): Billing, CSI Reporting A.10.5. What departments/agencies will use the system? What departments/agencies will have direct access to the system? (Check all that apply) Mental Health Alcohol and Drug Hospital Mental Health Contract Providers Via standard HIPAA Transactions and reports only Public Health Other (describe): Alcohol & Drug Contract Providers PAGE 12 OF 28 SECTION B. Data Collection and Processing Data Timeliness and Accuracy B.1. Please specify precisely what the expectation is for timely entry of service data (such as same day, within 24 hours after service is delivered, within 3 business days, etc.)? On the same day services are provided, but no later than 5 business days. B.1.1. Describe how you track compliance with this policy. Include an example of any available summary data and the period of time this represents. Unicare AR_USI0038 Service Monitoring Report which shows the duration between service delivery date and service entry/recording date. (Report will be available for review) B.2. Describe how you ensure that all services actually provided were entered into your information system? Unicare AR_USI0101 Daily Service Reconciliation Reporting which determines if required actions were completed and the service was recorded. This can be reconciled to the appointment schedule for each day. (Report will be available for review) B.3. Do you review the following data items for accuracy and completeness at specified frequencies? Item Yes/No Gender Yes No Date of birth Yes No Race/ethnicity Yes No Primary language Yes No Dates of services Yes No Procedure codes Yes No Diagnoses Yes No B.3.1. Identify the staff or the unit responsible to monitor for accuracy and completeness. Clinical and Clerical al at the point of entry, IS Staff, Patient Business Services, QI, and reviewed Mental Health Decision Support Unit using analytical reports. PAGE 13 OF 28 B.4. Describe how data errors discovered during back-end validations/processing are reported out and corrected? There is a suite of Business strategy reports run on the front end and during the service batching process. The goal is to greatly reduce errors before reaching the back-end. All claims are scrubbed by a third party vendor and errors are returned to Providers and Patient Business Services for correction B.4.1. Who performs any needed corrections? Through out the continuum of registration service entry, batching, scrubbing and rejections all staff that touch the records are involved. This includes clerical Staff, clinicians IS Staff, third party claims scrubber and Patient Business Services (PBS) B.5. Describe any recent audit findings and recommendations. This may include EPSDT audits, Medi-Cal audits, independent county initiated IS or other audits, OIG audits, and others. B.6. The MHP had no external reviews since December 2010. The MHP Quality Improvement (QI) Program conducted their annual internal Administrative Review and Clinical Records Review (CRR) for their 35 County and Contractor sites. A total of 733 charts were reviewed in FY 2010-2011 CRR. Findings: 8 sites (2 contractors, 6 County) are receiving mandatory mentoring for having more than a 5% disallowance audit finding. In addition, MHP QI program performed an internal clinical records review on thirteen of their Fee-For-Service providers (38 charts). B.7. On a periodic basis, key system tables that control data validations, enforce business rules, and control rates in your information system must be reviewed and updated. Indicate who maintains these tables (check all that apply): MHP Staff and IS Staff Health Agency Staff (“umbrella” health agency) County IS Staff Vendor/ASP Staff Outside consultant PAGE 14 OF 28 B.8. Who is responsible for authorizing and implementing the following system activities? Activity Establishes new providers/ reporting units/cost centers Determines allowable services for a provider/RU/CC Establishes or decides changes to billing rates Determines assignments of payer types to services Determines staff billing rights/restrictions Determines level of access to information system Terminates or expires access to information system Who authorizes? (Staff title or committee/ working group) Bruce Copley, Deputy Director of Mental Health Bruce Copley, Deputy Director David Guerrero, QI Manager Martha Paine, General Fund Finance Director David Guerrero, QI Manager David Guerrero, QI Manager David Guerrero, QI Manager Division Managers reporting to Bruce Copley, Deputy Director Who implements? (Staff title or committee/ working group) Leticia Ortiz, IS Manager Leticia Rosado, Patient Business Services Manager Leticia Ortiz, IS Manager Leticia Ortiz, IS Manager Leticia Ortiz, IS Manager Leticia Ortiz, IS Manager Leticia Ortiz, IS Manager Staff Credentialing B.9. Are staff credentials entered into your information system and used to validate appropriate Medi-Cal billing by qualified/authorized staff? Yes No Training B.10. List regular IS training offerings and frequency of trainings, or, provide a list of classes conducted over the past year. Training is delivered based upon job function: Unicare System navigation for all users, for systems-based clinical operations and procedure and training on all aspect of clerical functioning in the system including registration, service validation, and billing. There is also refresher training as needed. Based upon changes from SD Phase II, a training program for Void and Replace procedures and workflows was delivered to all Unicare users. Also provided was training for the new Denial workflows. The purpose is to insure that data is correctly entered and proper processes are employed to maximize the revenue received for all the services rendered. All training was delivered to both Mental Health and DADS staff. Refresher courses occur monthly. (See Attachment A, Training schedules PAGE 15 OF 28 2011, A-1 Clerical Manual and A-2 Clinical Manual , A-3 Void and Replace Training , A-4 Denial Training) B.11. Do you routinely administer competency tests for IS users, to evaluate training effectiveness? Yes No B.12. Do you maintain a formal record or log of IS/computer training activities? Yes No B.13. What is your technology staff turnover rate since the last EQRO review? Total Number of IS Staff Number of New Hires Number of Staff Retired, Transferred, Terminated Current Number of Unfilled Positions 12 4 1 position cut 1 Staff/Contract Provider Communications B.14. Does your MHP have User Groups or other forums for the staff to discuss information system issues and share knowledge, tips, and concerns? Type of Group Meeting Frequency (weekly, monthly, quarterly, as needed) Who chairs meetings? (Name and title) Meeting minutes? (Yes/No) Clerical User Group Bi monthly Sue Chou Yes Clinical User Group Bi-monthly Sue Chou Yes Financial User Group As Needed Leticia Rosado Contract Providers Bi-monthly Sue Chou Reports User Group (Reports Lab) Monthly Hung Nguyen IS Vendor Group Monthly Caroline Yip, Sue Chou Contract Management Bi Monthly Bruce Copley/David Guerrero Decisions & Action Items Yes Decisions & Action Items Decisions & Action Items Yes B.15. What types of technology do you utilize to communicate policy, procedures, and information among MHP staff (Check all that apply)? Web server Intranet server PAGE 16 OF 28 Shared network folders/files Content management software Other (describe): Training and paper documentation E-mail B.15.1. If none of the above, how is information shared among MHP staff? B.16. Is this technology open to contract providers also? Yes No B.17. How do contract providers submit client and service data to the MHP? (Check all that apply) Submittal Method Frequency Direct entry into MHP IS Daily Weekly Monthly Electronic transfer to MHP IS Daily Weekly Monthly Documents/files e-mailed to MHP Daily Weekly Monthly Paper documents Faxed to MHP Daily Weekly Monthly Paper documents delivered to MHP Daily Weekly Monthly Other: Daily Weekly Monthly B.18. What is the basis for payment to contract providers? (Check all that apply) Basis Advanced 1/12th of annual contract each month Paid monthly using printout of service units entered in IS Paid monthly using online report from provider Paid monthly using estimated units on invoice from provider Other: PAGE 17 OF 28 B.18.1. If monthly or other, what is the average time lag between end-ofmonth/date invoice and payment to contract providers? Lag (in days) ≤ 15 16 – 30 31 – 90 > 90 PAGE 18 OF 28 SECTION C. C.1. Medi-Cal Claims Processing Who in your organization is authorized to sign the MH1982A attestation statement for meeting the State Medi-Cal claiming regulatory requirements? (Identify all persons who have authority) Name: Nancy Pena Title: Mental Health Director Name: Bruce Copley Title: Mental Health Deputy Director Name: Leticia Rosado Title: Patient Business Services Manager Name: Title: C.2. Indicate normal cycle for submitting current fiscal year Medi-Cal claim files to DMH. Monthly C.3. More than 1x month No Do you produce and review test claims before final production of Medi-Cal claims? Yes C.5. More than 1x weekly Do you have an operations manual or other documentation that describes activities to prepare SD/MC claims? (Be prepared to present and discuss this during the on-site CAEQRO review.) (Attachments B & B1: Claims work flow charts) Yes C.4. Weekly No What Medi-Cal eligibility sources does your MHP use to determine monthly eligibility? (Check all that apply) IS Inquiry/retrieval from MEDS POS devices MEDS terminal (standalone) AEVS Web-based search (Medi-Cal website) vis a HDX link in Unicare FAME MEDS terminal (integrated with IS) MMEF Eligibility verification using 270/271 transactions C.5.1. Do you have procedures in place that monitor or review retroactive eligibility? Yes No PAGE 19 OF 28 C.6. Does your system store the Medi-Cal eligibility information listed below? System stores automatically? (Y/N) System stores but manually entered? (Y/N) Able to use/query for reports? (Y/N) CIN N Y Y Eligibility Verification Confirmation (EVC) N Y Y County of eligibility N Y Y Aid code N N Y Share of cost information N Y Y Item C.7. C.8. C.9. Do you have an operations manual or other documentation that describes the applications of Medi-Cal EOB (835)? (Be prepared to present and discuss this during the on-site CAEQRO review.) (Attachment D: e-Remit Process) Yes No Yes No Yes No Do you bill any private insurance? Do you bill Medicare? PAGE 20 OF 28 SECTION D. Incoming Claims Processing Note: “Network providers” (commonly known as fee-for-service providers or managed care network providers) may submit claims to the MHP with the expectation of payment. Network providers do not submit a cost report to the MHP. D.1. Provide the approximate monthly volume of claims received from network providers: Average number of claims per month 1,688 Average claims in dollars per month $97,730 D.2. Do you have any documentation, such as policies and procedures, for processing incoming claims from network providers? Be prepared to discuss during the on-site CAEQRO interview, if requested. Item Yes/No Processing incoming claims Yes No Payment to network providers Yes No Billing Short-Doyle/Medi-Cal Other: Void & Replace/Denial Training (See attachments A-3 and A-4) Yes No Yes No D.3. What is the average length of time between claim receipt and payment to network provider, in days? FFS(Private Office Psychiatrists: 3 weeks IMD: 3 weeks Inpatient Professional Fees: 6 working days D.4. Does your MHP maintain network provider profiles in your information system? Yes No PAGE 21 OF 28 D.4.1. If Yes, describe what provider information is maintained in the provider profile database. Provider Information Languages spoken Gender-specific care Age-specific care Specialty health care Specialty therapy Accessibility Other: D.5. Does your MHP use a manual or an automated system to process, adjudicate and pay incoming claims from network providers? Manual Automated Combination of Both D.6. Estimate the percentage of your network providers’ claims that were not approved for payment during the last fiscal year. 6% PAGE 22 OF 28 SECTION E. E.1. Information Systems Security and Controls Indicate the frequency of back-ups that are required to protect your primary information systems and data. (Check all that apply) Back-up Frequency (at least) Daily full back-up Daily incremental back-up Weekly full back-up Weekly incremental back-up Other: Transaction Log back-up every hour E.1.1. Where is the back-up media stored? (Check all that apply) Back-up location MHP site County site Health department site IS Vendor site Data Security Vendor Other: E.1.2. How often do you require passwords to be changed? Password Change Frequency (at least) ≤ 60 days 61 – 90 days 91 – 180 days 181 – 365 days > 365 days Never E.1.3. Do you enforce the use of strong passwords for your core systems? Yes E.2. No Do you have policies and procedures that describe the provisions in place for the following? Be prepared to discuss during the on-site CAEQRO interview, if requested. Item Physical security of the computer system(s) and hardcopy files Security of laptops and other portable storage devices Management of user access Termination of user access Yes/No Yes No Yes No Yes No Yes No Attachment E: Policies and Procedures (P&P) 601 PAGE 23 OF 28 E.3. Do you require encryption for laptops or other portable storage devices that contain PHI? Yes No SECTION F. F.1. Data Access, Usage and Analysis Who is the person(s) most responsible for analyzing data from your information system? Staff Name/Title Organization/Department/Division Deane Wiley, Director Learning Partnership/ Leticia Rosado, PBS Manager Finance Agency, Patient Business Services Caroline Yip, Manager MHP Information Services F.2. Describe two examples of data analyses performed in the last year that were used in quality improvement or business process improvement activities. Be prepared to discuss during the on-site CAEQRO interview, if requested. Milestones of Recovery data was used to determine that stability is the main achievement of our system. Clients have a tendency to remain at an average level on the scale instead of showing progress toward recovery. To improve these outcomes we have begun trainings in client centered treatment planning to encourage clinicians to focus on improvement strategies designed to help clients continue to progress toward recovery. F.3. Indicate the reporting tools used by your staff to create reports from the IS. Microsoft Excel Microsoft Access Crystal Reports SPSS SAS Vendor-supplied report writer Other (describe) SQL, Power Point and Text/Graphic applications PAGE 24 OF 28 F.4. Do your systems interface or exchange data with other systems? If Yes, specify the purpose (such as lab, Rx, ER) and standards/methods used for the interface/exchange. Entity Yes Description of purpose Standards/Methods used Other internal MHP IS Reporting Requirements Other County department A/R and A/P to SAP Manual DMH Claims and CSI reporting HIPAA transaction for claims, CSI Format for reports Service Data Electronic transfer Other State departments Contract providers Other MHPs Other (specify): F.5. Do your consumers have on-line access to their health records, either through a personal health record (PHR) feature provided within your IS or through a third-party PHR such as those available through Network of Care, Google, or Microsoft? Yes F.5.1. F.6. No If Yes, what product(s) are used? Does your information system capture co-occurring mental health and substance abuse diagnoses for active consumers? Yes F.6.1. No If Yes, what is the percent of active consumers with co-occurring diagnoses? 6 % based upon diagnosis F.7. What tools or instruments do you use to measure consumer outcomes? Client-Level Outcome Tools The MHD has adopted a client satisfaction survey based on the State assessment tools. Data from the survey is included in the QI Work plan. Two additional client outcome tools were introduced in FY09, the Milestone of Recovery Scale (MORS) and the Client Informed Outcome Measurement (CIOM). Clinicians use the MORS eight point scale to assess each consumer’s level of risk (physical harm to self or others and participation in unsafe behaviors), engagement with the mental health PAGE 25 OF 28 system (degree of connection, not necessarily the amount of service received), and skills (independent living, engaged in work/school/community, managing physical/mental health, finances, substance abuse) and support (family, friends, coworkers, intimacy, sexual expression). F.7.1. Describe how these outcomes are communicated and used within the organization. MORS data are reviewed with each consumer in preparing and updating the treatment plan. The CIOM is prepared by the consumer and provides a client-level perspective on how the system is meeting his or her recovery goals. Clinicians throughout the system began using MORS in mid-FY09 and the CIOM is being pilot county and contracted agencies. As data becomes available, it will be analyzed and presented to the Quality Review Council with a view toward including these data in the annual performance review. Overall system results are also reported directly to clinicians, program managers, and directors for program evaluation. F.8. Does your information system record consumer missed appointments? Yes No Unicare Pro-Filer system has the capability to track missed appointments; however the MHP has not implemented procedures to monitor client service status. F.8.1. Indicate how you categorize missed appointments by reason, such as cancellation or no-show by consumer versus cancellation by staff. Missed Appointment Category Yes/No Consumer no-show Yes No Consumer called and cancelled Yes No Staff cancelled/unavailable Yes No F.8.2. What is your average monthly percentage of missed appointments? The Unicare system has the capability to track missed appointments. The data will become available for use when the MHP’s Performance Dashboard is implemented. The SCVHHS Enterprise Wide Scheduling System (EWS) will be supply the data for missed appointments in the FQHC clinics 23% F.9. Do you have a staff productivity standard? Yes No PAGE 26 OF 28 If No, go to F.10 F.9.1. How do you measure productivity? Based on the Service Entry into Unicare F.9.2. What is the expected percentage rate? 66% for regular staff and 33% for lead F.9.3. What was the actual rate when last measured? 54.8% for regular staff and 46.4% for lead F.9.4. What was the low-high range over the last year? 13.2% to 81.2% F.10. Do you track and report the time from initial contact to the following events? (Check boxes) Event Yes/No Assessment Yes No First Appointment Yes No First psychiatric appointment Yes No PAGE 27 OF 28 Attachments to Santa Clara ISCA FY 11 Attachment A - Training Schedule 2011 Attachment A1 - Clerical Manual Attachment A2 - Clinical Manual Attachment A3 – Mental Health Void and Replace Training Attachment A4 – Mental Health Denial Training Attachment B- Mental Health Flow Chart of Billing and Denial Process Attachment C – Claim Remedi Pro-Filer Batch Eligibility Interface Attachment D – Medi-Cal e-Remit Process Attachment E –Policy and Procedure 601 Attachment E –Policy and Procedure 601, Exhibit 1 Attachment E –Policy and Procedure 601, Exhibit 2 Attachment E –Policy and Procedure 601, Exhibit 3 Attachment E –Policy and Procedure 601, Exhibit 4 Attachment E –Policy and Procedure 601, Exhibit 5 Attachment F – Business Operations Meetings PAGE 28 OF 28
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