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WRBHO BEST Meeting & Quarter Three Performance Report Presentation Finger Lakes Region December 11, 2012. WRBHO BEST Meeting Agenda. I. Introductions and Key Findings II. Q3 Regional Overview Regional Overview of all domains

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WRBHO BEST Meeting &

Quarter Three Performance Report Presentation

Finger Lakes Region

December 11, 2012


WRBHO BEST Meeting Agenda

I. Introductions and Key Findings

II. Q3 Regional Overview

  • Regional Overview of all domains
  • Sub-regional info focused on the Linkages with After Care Services domain.
  • Role of the BHO in supporting Health Homes

III. Q3 Sub-Regional Review (compared to the region)

  • Review of key metrics tied to the “Effective Linkages” domain for the sub-region
  • Discuss the information to determine what it means to those in attendance (Are there opportunities for improvement?)

IV. Effective practices presentations

  • St. Joseph’s Hospital: Effective scheduling of outpatient appointments
  • Intro to Consumer Centered Family Consultation and opportunity for technical assistance

IV. Identify areas of focus for improving sub-region BH system of care

VI. Next steps

  • Would a Learning Collaborative be helpful?

John Lee, WRBHO Program Director, Beacon

Christine Mangione, WRBHO Manager of Clinical Operations, Beacon

Elisabeth Hager, MD, Physician Advisor, Beacon


Q3 Performance Report Organization:

  • Domains
  • Metrics within each domain (Data Sources: BHO data collection and OMH BHO Portal)
the 5 performance metric domains
The 5 Performance Metric Domains

Performance Domain 1: Coordination with the BHO

Performance Domain 2: Person-Centered Care Coordination during the Inpatient Stay

Performance Domain 3: Linkages to After Care Services

Performance Domain 4: Continuity of Care

Performance Domain 5: Engagement in Care

highlights of wrbho findings
Highlights of WRBHO Findings

Observed changes that support transformation:

  • Improved provider performance within the WRBHO’s 19 county region
    • 6 out of 8 metrics within the Performance Domain: Linkage to After Care Services, reflect improvement: Q2 to Q3.
    • A number of OMH BHO Portal metrics reflect performance in WNY that exceeds the Statewide rates: outpatient visits, readmission rates.
  • County MH Directors convening meetings to engage providers about the changes that need to take place to prepare for BH Managed Care.
  • Facility COO expressing appreciation that the State is monitoring data to assess the ability of providers to work as a system of care.
  • MH inpatient providers expressing interest in learning how to be more effective in linking patients with PH providers.
  • Facility discharge planners requesting help from the WRBHO in securing housing for a patient, recognizing impact on avoidance of readmissions.
  • Providers devoting a full day to listen to feedback from those with a inpatient psychiatric experience (The WRBHO forums)
performance domain 1 coordination with the rbho
Performance Domain 1 – Coordination with the RBHO

Domain includes measures helpful in ensuring complete and timely data report and review practices


  • The number of Notices of Admission submitted by providers is consistent with established targets
  • Notices of Admission are received within 24 hours of admission
  • Initial Reviews are completed within 72 hours of admission
performance domain 2 person centered care coordination during the stay
Performance Domain 2 – Person-Centered Care Coordination During the Stay

Domain includes metrics that describes the extent to which effective, person-centered care coordination practices during the inpatient stay are evident.

  • Particular interest in efforts to ensure that the individual’s needs have been identified so that an effective discharge plan can be developed.
  • Additional metrics will be added under this domain over time.


  • Treatment history is shared with the inpatient provider during the Initial Review
performance domain 3 linkages to after care services
Performance Domain 3 – Linkages to After-Care Services

Domain includes metrics that measures the extent to which steps were taken during the inpatient stay to establish linkages to needed outpatient services.


  • The current or prior mental health outpatient provider was contacted during stay
  • An appointment for mental health outpatient treatment was scheduled as part of the discharge plan
  • The case summary was sent to the outpatient mental health or substance use disorder (SUD) outpatient Provider
  • A physical health appointment scheduled post-discharge if a physical health care need was identified during the stay
  • A SPOA application was submitted for case management, housing and other services
  • For youth with multi-system needs, the discharge plan includes referrals /linkages for the provision of basic needs
  • For youth with multi-system needs, the discharge plan documents post discharge educational needs
  • There is improvement in housing status for individuals who are homeless at admission
performance domain 3 linkages to after care services1
Performance Domain 3 – Linkages to After-Care Services

Provider Profile Summaries

  • Provide a “drill down” on the metrics presented at the regional level to look more closely at provider-level performance
    • Available for the Linkages to After Care Services domain metrics
    • Identification of higher performance providers
    • Strategies being deployed to achieve higher levels of performance.
  • Higher performing providers
    • Fall in the top 25% for the performance metric
    • 8 or more discharges during the quarter
    • Data collection process for Q3 was viewed as an accurate reflection of the providers’ work by the WRBHO Utilization Review Clinician.
  • Efforts have focused on identifying barriers to performance.

Performance Domain 3 – Linkages to After-Care Services

  • Best Practices:
  • Gathers collateral information from outpatient provider and is linked closely with other outpatient agencies.
  • Attempts to keep MH clients within their system of care, which appears to help with continuity of care.
  • Is protocol that the Discharge Planner notifies outpatient provider of individuals admitted (once identified) and shares appropriate collateral information.
  • Has a “no wrong door” philosophy and offers co-existing treatment with mental and physical health providers in close proximity of each other. Encourages effective communication.

Performance Domain 3 – Linkages to After-Care Services

  • Barriers:
  • Gaps in communication between UR clinicians and discharge planners.
  • The practice is not built in to standard facility procedures.
  • The treatment team does not reach out to current or active providers to collaborate and work together towards the recovery of patients.

Performance Domain 3 – Linkages to After-Care Services

  • WRBHO Actions:
  • Clarified meaning of the indicator during one-on-one provider meetings through issuing a new review template and holding provider calls.
  • WRBHO System of Care Transition Coordinator’s role redefined to include contacting outpatient providers when an active client has been admitted and encouraging follow-up. This outreach continues to encourage contact between inpatient and outpatient providers.
  • Focused on the importance of the transition to outpatient treatment during the February and June BEST Meetings.
  • Effective linkage to after care services was the theme during the September 27 BEST Meeting.

Performance Domain 3 – Linkages to After-Care Services

  • Best Practices:
  • Strong ties to the system’s array of outpatient services facilitate effective communication and efficient scheduling.
  • Follow a person-centered, thorough and comprehensive discharge planning process.
  • Connecting with outpatient treatment is a standard practice for those individuals not transferring to another facility for inpatient rehabilitation (SUD).
  • Standard operating practice to ensure linkage with a community- based provider prior to discharge.
  • Intake coordinator assigned to client and follows him or her from inpatient to discharge.
  • Outreach is performed if the aftercare appointment is missed.

Performance Domain 3 – Linkages to After-Care Services

  • Barriers:
  • In instances where the individuals do not have an outpatient provider at the time of admission, this process is more difficult to accomplish during the inpatient stay.
  • Lack of outpatient capacity is a barrier in some areas.

Performance Domain 3 – Linkages to After-Care Services

  • WRBHO Actions:
  • During September 27 BEST Meeting, providers shown to be successful in scheduling outpatient appointments spoke about their practices.
  • December BEST meeting will focus on sharing practices in place at providers having success with individuals leaving inpatient care with a outpatient mental health appointment scheduled.
  • WRBHO staff will follow-up directly with providers with lower performance in this area to further define barriers and identify solutions.

Performance Domain 3 – Linkages to After-Care Services

  • Best Practices:
  • Standardized practice has been implemented to submit the discharge summary so the outpatient provider is aware of the discharge diagnosis, GAF, and medications/instructions.
  • It is a standard operating practice that when a patient signs a release, case summaries are sent to the outpatient provider. If patient initially declines, staff will discuss with the patient the need to send the summary for good continuity of care.
  • Provider has effective linkages to outpatient programs in their organization’s system of care.

Performance Domain 3 – Linkages to After-Care Services

  • WRBHO Actions:
  • Confusion existed as to what constituted a “case summary.” WRBHO clarified definition: Discharge instructions which include dates of admission, discharge diagnosis, and medication list.
  • Definition shared with providers and the WRBHO UR Clinicians are using this definition in their reviews.
  • We anticipate that we will continue to see improvement on this important dimension.

Performance Domain 3 – Linkages to After-Care Services

  • Best Practices:
  • Facility goal is to ensure that all patients are well connected to all areas of health care - both mental and physical.
  • Provider has a protocol requiring the case manager to link the patient with a Primary Care provider if the patient is admitted without one. The provider has developed relationships with two PCP practices to help expedite creating this very important link.
  • Provider strives to connect clients to previous primary care providers, if none have been established, they refer clients to the county system. The County provides a list of accepting physicians.

Performance Domain 3 – Linkages to After-Care Services

  • Barriers:
  • The responsibility is placed on the individual to follow up with their primary care physician after discharge.
  • Some facilities have procedures that focus on SUD and mental health outpatient appointments only (not physical health).
  • Many individuals admitted do not have a primary care provider and inpatient staff says that it is too hard to link the individuals with a PCP during the inpatient stay.

Performance Domain 3 – Linkages to After-Care Services

  • WRBHO Actions:
  • Developed a template for inpatient providers that details the rationale and offers a definition of this (and other) metric(s). Template reviewed with inpatient providers via webinar.
  • WRBHO Utilization Review Clinicians engaged in a thorough review of all questions contained in the review cycle to be better prepared to extract more accurate information from the providers during these reviews.
  • WRBHO will continue to work to identify effective practices for integrating physical health engagement into the behavioral health admissions through surveying providers for effective practices and sharing strategies via BEST Meetings and other provider forums.

Performance Domain 3 – Linkages to After-Care Services

Provider Profile Summary

  • Best Practices:
  • Overall, SPOA referrals are made for 12% of adults discharged from inpatient care and 19% of youth. However, the range varies considerably, with several providers reporting much higher referral rates. Based on interactions with providers, we have identified a few practices that appear to be proving successful:
    • SPOA “consultant” from the county is placed on each unit to help identify and assist discharge planners with application process.
    • Provider uses a team approach in working with the patient. That is, the discharge planner, the social worker/therapist and the MD/NPP all meet together with the patient to assist in determining needs for a successful transition.

Performance Domain 3 – Linkages to After-Care Services

Provider Profile Summary

  • Barriers:
  • Lack of SPOA services (care management) to support the needs of those with SU diagnosis. 
  • SPOA review processes occur on a monthly basis only in some counties. 
  • Inpatient facilities will start process if needed but rely on outpatient services to finish the referral.
  • WRBHO Actions:
  • The WRBHO has begun to work with county directors to assess the interest in developing greater consistency in SPOA processes.
  • WRBHO UR Clinicians have been oriented to county specific SPOA processes so that they are in a better position to support the providers’ needs in each county.
  • WRBHO UR Clinicians have been encouraged to support specific SPOA requests by helping with the application or even attending SPOA meetings to represent the needs of the individual and the provider.

Performance Domain 3 – Linkages to After-Care Services

Provider Profile Summary

  • Best Practices:
  • Discharge planning is comprehensive and involved all outside agencies.
  • Weekly team meetings are held for the interdisciplinary team and UR team.
  • On-site team member meetings.
  • Provider gathers collateral information from outpatient providers and is very knowledgeable about resources that are available in the community.

Performance Domain 3 – Linkages to After-Care Services

Provider Profile Summary

Best Practices:

Supporting the multi-system needs of children requires very comprehensive planning, involving a number of outside agencies in regular interdisciplinary team meetings. Higher performing providers have made school programming mandatory for children and youth.


Performance Domain 3 – Linkages to After-Care Services

  • WRBHO Actions:
  • WRBHO staff will review these measures with providers following the release of the Q3 data to ensure that data collection and reporting accurately reflect current practice.
  • A Clinical Grand Rounds scheduled for 2013 will focus on children’s services and will be presented by the WRBHO Child Psychiatrist, Mario Testani.   Dr. Testani will spend a portion of his presentation discussing the importance of addressing educational needs.

Performance Domain 3 – Linkages to After-Care Services

  • WRBHO Actions:
  • As access to stable housing is critical to achieving recovery this measure has been an area of focus in our review and discussion of both system and provider performance.
  • WRBHO UR clinicians have been asked to encourage providers to work diligently to address this need for cases we review.
  • WRBHO staff has also worked with county SPOAs to support an expedited review for inpatients, especially those in need of housing.
  • Providers have been encouraged to begin the housing planning process for individuals admitted as homeless as soon as they are admitted.
performance domain 4 continuity of care
Performance Domain 4 – Continuity of Care

Domain includes metrics that look at the extent to which individuals are connected to outpatient mental health services following discharge from inpatient – as well the timeliness of that connection.

  • Utilize data collected by WRBHO and data available through BHO Portal.


  • The percentage of scheduled Mental Health clinic outpatient appointments attended (WRBHO collected)
  • The percentage of Mental Health Discharges followed by an outpatient visit for Mental Health treatment within 7 days (BHO Portal)
  • The percentage of SUD Detox discharges with lower level SUD services with 14 days (BHO Portal)
  • The percentage of SUD rehabilitation discharges with lower level SUD services within 14 days (BHO Portal)

Performance Domain 4 – Continuity of Care

  • WRBHO Actions:
  • WRBHO clinicians gather these data through follow-up w/identified the outpatient mental health providers.
    • WRBHO follow-up takes place for up to 60-days post discharge (or until there can be confirmation of either attendance or a “no show.”)
  • Complements data available from the BHO Portal by providing a more timely way for staff to monitor the rate at which individuals are attending their outpatient mental health appointments.
  • WRBHO focus will be on identifying barriers to after care attendance and strategies providers are finding effective in increasing attendance.
performance domain 5 engagement in care
Performance Domain 5 – Engagement in Care


  • % of Mental Health discharges followed by 2 or more MH outpatient visits within 30 days (BHO Portal)
  • % of SUD Detox or Rehabilitation services followed by 2 or more SUD services within 14 days of discharge (BHO Portal)

Role of the WRBHO in Supporting Health Homes

  • Notify inpatient providers when an admitted individual being reviewed by the WRBHO is enrolled in a Health Home or eligible for Health Home outreach
  • Ensure the provider has contact information for the Health Home care coordinator.
  • Contact Health Home care coordinators to review and assist with post-discharge follow-up as needed.
  • Share past treatment history as found in PSYCKES and FlexCare
  • Alert Health Home when Health Home member is admitted.
  • Support community referrals to Health Homes

Complex Needs Population

Special Study

  • Detox Clients who Leave Against Medical Advice:
  • NYS has identified an area of interest and concern related to improving care coordination for individuals admitted to SUD detox who leave against medical advice (AMA).
  • These individuals do not complete treatment and often leave before discharge plans are in place, including coordinating the next level of care.
    • In addition to receiving incomplete care, these individuals are at risk for rapid readmission to detox.
  • Understanding the needs of these individuals as well as the barriers to their treatment may help us provide better, patient-centered care, and improve overall outcomes.
  • WRBHO is in a unique position to lead a process to better understand the characteristics of these individuals, system characteristics that may contribute to these discharges, to identify best practices that improve engagement / retention for this group.

Complex Needs Population

  • Detox Clients who Leave Against Medical Advice (cont’d):
  • Project will engage consumers and providers.
  • Learning Community will be established with the ultimate plan to pilot best practices in at least two sites.
  • Special emphasis is made to integrate knowledge and sensitivity of cultural issues that may impact an individual’s experience of detox services and the decision to leave AMA.

Complex Needs Population

  • Detox Clients who Leave Against Medical Advice (cont’d):
  • Claims data from Q 1-3, 2012 were evaluated. An evaluation of detox AMA discharges for the 19 county region shows the following:
    • 16% of all detox discharges were AMA
    • 84% male; 16% female
    • 50% white; 32 % black; 18% Hispanic
    • Opioids were the drug of choice (DOC) for white individuals leaving AMA (39%)
    • Alcohol was the DOC for black individuals leaving AMA (71%)
  • Next steps include:
    • Developing background materials,
    • Establishing the Learning Community
    • Identifying pilot sites to develop and test models to improve care coordination of individuals leaving detox AMA.





Sub-Regional Analysis Summary

  • Initial sub-regional reports show performance within each sub-region by county of residence.
  • While the number of cases within some counties is small, Q3 data do show some variation in performance within the sub-region when compared to the region as a whole.
  • These reports will be followed with a report by county of fiscal responsibility that provides a view of provider-specific performance, which we believe will be helpful in better understanding patterns of care and identifying opportunities to strengthen effective linkages to after care services.



  • Scheduling of outpatient MH & SUD appointments: Stacy Miller, Nursing Staff Coordinator at St. Joseph’s Hospital
  • Consumer Centered Family Consultation - Family Institute for Education, Practice and Research, U of R Medical Center

Scheduling of outpatient MH & SUD appointments

Stacy Miller, Nursing Staff Coordinator at St. Joseph’s Hospital


The Family Institute for Education, Practice and Research (at URMC) and Consumer Centered Family Consultation

  • Family Institute has been funded by the NYS Office of Mental Health for over 10 years; has worked with over 200 agencies in a variety of settings
  • Provides training and implementation support for agencies that are adopting evidence based family-involving approaches for people with severe mental illness
  • Offers training and consultation related to evidence based practices as well as organizational changes related to the successful implementation of those practices
  • One core offering is Consumer Centered Family Consultation (can also be called person centered family consultation)
  • See 2012 article for additional detail and background

Consumer Centered Family Consultation

  • Consumer Centered Family Consultation (CCFC) is a brief, education-based engagement and consultation service that is typically completed in one to three sessions
  • It promotes collaboration among adult consumers of mental health services, members of their family or social network, and service providers to support each consumer’s recovery
  • The focus of CCFC is the person/consumer with a behavioral health issue (the focus is not the family or family therapy)
  • There are specific shared decision-making tools embedded in the process of engaging people and their natural supports
  • CCFC provides an opportunity to help prevent avoidable hospitalizations and to help facilitate linkage with outpatient services by involving people’s natural supports in meaningful ways

Sub-Regional Areas of Focus

  • Top 4 reasons for admission for Individuals with Complex Needs
    • Lack of engagement with outpatient provider
    • Non-adherence to medication
    • Drug & alcohol use
    • Increased symptomology w/o Precipitant Noted
  • Improve access to housing at discharge
  • Address any gaps in the SPOA process and help county prepare for Health Homes
  • Support the introduction of Consumer Centered Family Consultation across the sub-region
  • Add more…


  • Schedule Consumer Centered Family Consultation Webinar in January
  • Distribute provider-specific reports
  • Distribute county of origin reports to County Directors
  • Survey to identify areas of focus for each region / begin to plan for Learning Collaborative
  • Support Regional Health Homes
  • Grand Rounds Webinars