1/19/02 Draft - for Discussion Only
Community Mental Health Affiliation of Mid-Michigan
Application for Participation
1.1.1. document the involvement of primary consumers, family members, and advocates in the development and approval of the response to the AFP and:
1.1.1.1. provide a plan for ongoing involvement of primary consumers, family members, and advocates in the implementation of the resulting contract
Approach of Affiliation: The Affiliation employs a number of methods to insure the involvement of primary consumers, family members, advocates, contractual providers, and other community stakeholders in the development and approval of the Affiliation’s AFP and in the on-going implementation of the work carried out under the contract with DCH. This plan consists of the following components, each implemented in ways locally tailored to the needs and traditions of each Affiliate community:
a. Consumer and family member representatives on the Affiliation’s Core Group – the group, made up of representatives from each of the Affiliates, which meets regularly to develop the Affiliation and the AFP and to plan the day-to-day operations of the Affiliation. This group, by its very nature, will continue to meet, after the AFP submission, to oversee the on-going work of the Affiliation in fulfilling the contract with DCH.
b. Stakeholder AFP Review Groups, in each of the four Affiliate communities will meet, on a regular basis, to review, discuss, and modify, the Affiliation’s AFP, its development and implementation. These groups will have a number of members who are also the consumer and family member representatives on the Affiliation’s Core Group.
c. All four Affiliates have Boards of Directors, of which 1/3 are primary consumers or their family members. These 16 people, 8 of whom are primary consumers, are a powerful force on these Boards, which make the final decisions relative to the formation of the Affiliation, its direction relative to the development and implementation of the AFP.
d. The review of the AFP, its development and implementation, by longstanding advisory councils in each affiliate community. These councils are made up of consumers, family members, advocates, and other community stakeholders
d. The mailing of the draft AFP, to a broad range of stakeholders, and the solicitation of their comments by mail or e-mail.
f. The placement of the initial draft of the AFP and all subsequent drafts on the Affiliation’s web site with an e-mail address dedicated to receiving stakeholder responses to each draft.
Evidence: Stakeholder involvement grid, list of consumers and other stakeholders involved in this effort, dates of AFP Review Group meetings, copies of written and listserve discussions and comments.
Approach by Affiliate:
| Gratiot: Gratiot Co. CMHSP has had two primary consumers participating g in the series
of telephone conferences with HCFA relative to the AFP development; has had consumer
involvement at Core Group meetings; and on a continuous basis has had information sharing
and feedback/input fro the Client Advisory Panel, Board, and Community groups relative to
the AFP process. Ionia: |
| Four Primary consumers have attended one meeting and two others have volunteered to participate in reviewing and advising on the AFP. Two other consumers, one of whom is a Board Member, have attended several Core group meetings. Per Diems are being paid. | List of names, meeting dates and
minutes. Comments will be documented and discussed. |
| Through QI Director an initiative to
recruit consumers to serve on numerous committees is underway.
Advocacy community is sparse in Ionia Co. An ARC was attempted by CMH but did not maintain a core group. |
Letters to consumers, bulletins to staff, public postings in building, "will also develop recruitment as part of ongoing marketing plan". |
Newaygo: Newaygo Mental Health will draw input and provide summary reports to consumers and family members, and advocates through existing committees, and groups, such as The Respite Advisory Committee, The Empowerment Group, the Board of Directors (of which there are at least 6 primary or secondary consumers), as well as the newly developed Consumer Advisory Group. This latter group will be comprised of consumers and family members representing severely mentally ill persons, persons living in independent and dependent living arrangements. Consumers will be asked to participate in review of the draft AFP response.
The above mentioned groups of consumers, family members, and advocates will given updates to the AFP process. There will be opportunities for consumers to give input, as well as receive progress reports on agency performance such as satisfaction data, MBPIS indicators, etc. Additionally, per QISMC guidelines, consumer input will be sought regarding projects to be improved in the delivery of services, and other areas where improvement is needed.
CEI: CEI used a number of methods to ensure that primary consumers, family members, advocates, and other community stakeholders, were involved in the development and approval of the AFP and the on-going implementation of the PHP and affiliation’s contract. These methods include:
1. A set of community stakeholder meetings to discuss the AFP and the Affiliation
2. Development of an Stakeholder AFP Review process:
a. a series of regular face-to-face discussion sessions, by a Stakeholder AFP Review Group, focusing specifically on the AFP, its development and implementation, This Stakeholder Review Group discussed the AFP, several times prior to and during the AFP development. This group will continue to meet, after the submission of the AFP, to provide guidance to CEI and the affiliation in its fulfillment of the contract.
b. the regular review of the AFP, its development and implementation by CEI’s longstanding four Advisory Councils. These Councils are made up of consumers, family members, advocates, and other community stakeholders
c. a mailing group which receives AFP-related documents via the mail and responds via written comments
d. an internet-based listserve group which receives AFP-related documents via the listserve and responds via the listserve.
These consumer and stakeholder involvement initiatives are but one component of CEI’s broader stakeholder involvement system.
Evidence: Stakeholder involvement grid, list of consumers and other stakeholders involved in this effort, dates of AFP Review Group meetings, copies of written and listserve discussions and comments.
1.1.2. be legally established and operating as a Community Mental Health Services Program (CMHSP), in one of the forms described in statute (Act 258 of the Public Acts of 1974 as amended)
Approach of Affiliation: Each member of the Affiliation is duly established and operated as a CMHSP consistent with P.A. 258.
Evidence: Compliance with Mental Health Code
Approach by Affiliate:
a. Gratiot: Gratiot Co. CMHSP became a Community Mental Health Authority on September 23, 1997, consistent with the provisions of Section 330.1205 of Michigan’s Mental Health Code.
b. Ionia:
| Ionia was the first CMHSP Authority in Michigan. Established in 1996 | Documentation on Authority Status per Mental Health Code requirements 204 & 205 |
d.CEI: CEI is an organization CMHSP as
described in Act 258. Evidence includes: Tri-county agreement, DCH certification. 1.1.3 comply with the Mental Health Code, Section 222(1) requirements on Board
membership composition and a broad and diverse representation of the community Approach of Affiliation: Each member of the Affiliation meets the requirements of
Section 222(1) of the Mental Health Code, with their Boards of Directors consisting of
primary consumers, family members, and community members who represent the broad cross
section of the persons who make up the communities served by these CMHs. Evidence: Chart outlining affiliation/identity of each Board member. Affidavits,
signed by each Board member, indicating which constituency group each represents. 1.1.4. be certified per the Mental Health Code requirements Approach of Affiliation: All members of the Affiliation are certified, as per Section
330.1232a of the Mental Health Code. Evidence : DCH certification letter and records of certification on file at DCH.
c. Newaygo: Newaygo County CMH operates as a community mental health authority as
noted in Act 258, Section 330.1205.
| Citation #: 1.1.5 |
Must have a certified rights system |
Affiliation Agreement/Status and Evidence:
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CMH - CEI -Specific Status and Evidence:
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Gratiot CMH specific status and evidence
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Ionia CMH specific status and evidence
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Newaygo CMH specific status and evidence
Newaygo CMH was found to be in substantial compliance. |
Approach of affiliation: All of the members of the Affiliation have certified rights systems.
Approach by Affiliate:
Status for CMH-CEI:
A.
CMH-CEI has a certified recipient rights systemB.
Evidence includes DCH-ORR review of December 10-13, 2001. CMH-CEI was found to be in substantial compliance.
Status for Gratiot CMH
A. Gratiot CMH has a certified recipient rights system.
B Evidence includes DCH-ORR review dated October 24-26, 2000. Gratiot CMH was found to be in substantial compliance.
Status for Ionia CMH
| A. Ionia CMH has a certified recipient rights system. B. Evidence includes DCH-ORR review dated April 27-29, 2001. Ionia CMH was found to be in substantial compliance. Status for Newaygo CMH A. Newaygo CMH has a certified recipient rights program. B. Evidence includes DCH-ORR review dated September 26-28, 2000. Newaygo CMH was found to be in substantial compliance
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| 1.1.6 meet the minimum covered lives criterion: |
| 1.1.6.1: Standalone applicants must have a minimum of 20,000 covered lives 1.1.6.2: Consolidated applicants must have a minimum of 20,000 covered lives within their combined geographic service area |
Approach of Affiliation: The Affiliation has over 50,000 covered Medicaid lives in the counties served by its members.
Evidence : Most recent average monthly Medicaid eligible count (MSA/DCH) and DCH confirmation of review of survey of interest (DCH response as of 12/7/01)
1.1.6 Affiliate members must meet applicable contiguity standards in Public Act No. 60 or Public Acts 2001 unless otherwise stipulated by other acts of law.
Approach of Affiliation: The counties served by Affiliation’s members are within 45 miles of another Affiliate’s county, as per the definition of contiguity contained in PA 60 of 2001.
Evidence: DCH confirmation of review of survey of interest (DCH response 12/7/012)
1.1.7. Define the vision and values of the participating organizations that:
1.1.7.1. describe how the affiliation arrangement will actualize this vision and build upon the existing strengths of member organizations
Approach of Affiliation: The Affiliation’s vision and values are central to its formation and day-to-day operation. The Affiliation’s formation, in fact, was driven by the similarity of values, among the Affiliation members. The Affiliation exists to ensure and promote:
Consumer choice and empowerment
Sound service and support provision
Best value in the services and supports that it provides, to consumers, as well as administrative and PHP services. Best value is defined as the highest quality services and supports at competitive costs.
Local community-driven, local control and responsiveness
Outcome and data based decision making
Fiscal soundness
Proven capacity to manage risk
Sound care management capabilities
Regulatory compliance
The public good, public equity, social justice
The Affiliation carries out this vision and adheres to these values through a number of means:
The use of the Affiliation Agreement and the Medicaid subcontract to guide the work of the Affiliation and the relationship between each spoke and the hub and among the spokes. The Affiliation agreement reflects the Affiliation model developed by the Affiliation members. It makes the vision real through the promotion of the existing strengths of the Affiliates and through the identification and strengthening of weaknesses. In summary, the strengths of the affiliates which are bolstered through the agreement and the affiliation are:
Promoted by the use of federation-style affiliation: strong local presence, strong local participation and decision making, strong consumer and community stakeholder involvement, ability to rapidly respond to local community need and variations, alignment of interests of provider and care manager via its integration in each Affiliate
Promoted through the strategic use of centralization, standardization, and autonomy in the carrying out of PHP and provider functions: The Affiliation, through the operation of cross-Affiliate work groups, draws on the best of what each Affiliate has to offer and the development of one of three approaches: centralization of function and responsibility; application of affiliation-wide best practices and standards to functions carried out locally, by each Affiliate ; or autonomous functions, carried out locally, by each Affiliate. The decision, as to which approach to pursue is made on the basis of effectiveness, cost (via economies of scale or economies of autonomous parties/small scale) , capacity for synergy, nimbleness of action, value of uniform approach, existence of unique local characteristics.
The Core Group, made up of representatives of all of the Affiliate members, to guide the Affiliation.
These representatives consist of staff, consumers, advocates, and other stakeholders. This group is advisory to the PHP’s/hub’s Board of Directors, but, is charged with the day-to-day operations of the Affiliation.
Evidence : Guiding principles, Affiliation Agreement and Medicaid subcontract (attachment to Agreement), Core Group minutes, mission of each Affiliate
1.1.7.2. indicate how functional integration - to achieve economies of scale in administrative activities - will be accomplished.
Functional integration, among the Affiliates, is carried out via the use of function-specific work groups. These work groups:
Identify areas of potential integration, efficiency, or upgrading Analyze the current practices of each affiliate
Determine the goal of integration. The goals can be any one or a combination of: reduced total cost/efficiency, increased effectiveness or sophistication to meet industry or contractual standards, improved ability of hub/PHP to ensure compliance with contractual requirements, improved or retained local responsiveness and/or uniqueness.
Determine the best course of action to achieve integration
Functional integration has occurred in a number of administrative areas:
Recipient rights: The Recipient Rights services for three of the Affiliates (Gratiot, Ionia, and CEI) have been integrated, at considerable savings and increased effectiveness from the previous methods of providing these services
Consumer, service, and encounter data: An integrated consumer and service data aggregation, integrity-assurance, and reporting system has been developed that will serve the needs of all four affiliates – at a savings over what such services would cost if provided or purchased, on the market, by each Affiliate
Information services: An integrated IS system is being developed for all four Affiliates. The system will initially, 2002 and 2003, integrate the IS systems of three of the affiliates (Gratiot, Ionia, CEI) and will bring Newaygo into the system in 2003 and 2004. This integrated system achieves substantial efficiencies and substantial increases in quality and sophistication in the IS systems of each Affiliate
Contract/Network management: Development of a uniform provider application for use by all four affiliates. Development of increased standardization in contract/network management by all four affiliates
Quality Improvement: Integration of QI systems across all four affiliates, via: quarterly integration DCH mandated performance indicators, for all four affiliates, into a single set of graphs; formation of a QI Core Group, made up of representatives of all four affiliates, to review performance indicators; formation of cross-affiliate work groups around QI categories.
Financial Management: Development of a uniform administrative costing method for application across all four affiliates; joint review of proposed DCH contract.
Corporate Compliance/HIPAA: Development of a common corporate compliance/HIPAA approach, across all four affiliates.
Evidence: Purchase of service agreements between Affiliates, Core Group minutes, work plans of each work group, analysis of pre-affiliation and post-affiliation functions relative to integration goals cited above.
1.1.9. Member boards must maintain local representation, stakeholder participation, accessibility, participation, accountability, collaboration, and fulfillment of public policy and public interest responsibilities
Approach of the Affiliation: These qualities are maintained and promoted through a number of methods:
A. The structure of the CMHAMM, in itself, works to ensure local representation and participation, accessibility, accountability, and collaboration in that it is an affiliation of locally-responsive CMHs tied together by functional integration and a number of legal documents (Affiliation Agreement, Medicaid subcontract, purchase of service agreements between Affiliates). This structure, in contrast to a merger of the CMHs or a more centralized regional model, ensures that centralization and standardization, across the Affiliation, are balanced with the autonomy of each Affiliate. This autonomy is crucial for each Affiliate, within its own community, in carrying out its locally-responsive mission. The presence of the Affiliation is virtually transparent to consumers, families, advocates, elected officials, community organizations, and other community stakeholders in the local community of each CMH affiliate, in that the local CMH will still be locally-based and locally-driven. The Affiliation provides for integration, cost effectiveness (through the sharing or resources, economies of scale, and expertise), and increased effectiveness and sophistication, without losing local representation and stakeholder participation.
B. The Core Group consists of consumers and stakeholders from each local community.
C. Each CMH continually communicates, and seeks guidance, about the work of itself and the Affiliation via a number of locally-based venues: its local Board of Directors (consisting of 1/3 consumers), local consumer advisory councils, and the on-going, day-to-day dialogue with local consumers, collaborative partners, and stakeholders.
Gratiot: Gratiot’s venues for local representation and stakeholder participation include: the Gratiot CMH Board of Directors, its Client Advisory Panel, the Gratiot County multi-purpose collaborative body, a wide range of community education activities.
Newaygo: The Newaygo Mental Health Board is comprised of at least 6 primary or secondary consumers. The Program Committee is held on the same day as Board meetings, resulting in extremely good attendance over the 3 ½ to 4 hour monthly meeting. This presents an opportunity to present to the Board information on current developments regarding DCH, education on new federal compliance legislation, QISMC guidelines and project nominations, QAPI, etc. Consumer involvement, and consumer participation is addressed and integrated in frequent discussions. The Program Committee features one or more programs, and frequently discussion generates suggestions, improvements, and recommendations regarding access to services, penetration of services, reaching to minorities, collaboration with schools, courts, etc.
Additionally, Board members are encouraged to participate in the State Board’s Association sponsored conference and trainings three times each year. Routinely, at least half of the board members attend, and Board members are challenged to tell about what they have learned at the sessions they have attended.
Ionia:
| All 12 Board Members are Ionia County Residents. Board has committee structure to assure maximum participation. Increasing Consumer participation. Partner in a very strong local MPCB initiative. | Rosters and minutes from Board Mtgs., and Consumer Advisory meetings. |
CEI: CEI’s board is representative of the community served by CEI and meets the requirements of the Mental Health Code. CEI ensures local representation and participation via involvement in dozens of community collaboratives and dialogues in the tri-county area, including: multi-purpose collaborative bodies, homeless resolution networks, hospital advisory boards, neighborhood center boards, disaster response collaboratives, juvenile justice committees, and supported employment bodies.
Evidence includes: List of members of each of the local governance and guidance-providing bodies, meeting minutes, reports of accrediting bodies, list of community collaboratives of which each CMH is an active member.
1.1.10. Affiliations formed under the Intergovernmental Contracts Between Municipal Corporations Act or Intergovernmental Transfer of Functions and Responsibilities Act that submit a consolidated application must identify or designate a single CMHSP within the affiliation to act as the applicant
CEI will act as the applicant for the Affiliation, under the ICA or ITFRA.
1.1.11. Describe how it will execute administrative obligations of a specialty PHP
While CEI is the specialty PHP in the Affiliation, contracting, on behalf of the Affiliation’s members, directly with the Michigan Department of Community Health (DCH) for the provision and management of Medicaid specialty services, each member of the Affiliation will carry out the administrative functions of the PHP, via contract with and under the supervision of CEI, the PHP. These functions are described in both the Affiliation Agreement and the Medicaid Subcontract (an attachment to the Affiliation Agreement) as is the method by which CEI will monitor the fulfillment of these functions.
1.1.12. Describe other roles (e.g. service provider) that it intends to fulfill in the managed care program and how any apparent conflict of interest would be resolved
All of the members of the Affiliation will fulfill both care manager and service provider roles in the fulfillment of the contract with DCH. The care management model being used by this Affiliation is akin to a provider sponsored plans/organizations, in that the four CMH affiliates will:
·
Be responsible for managing a population-based rate (the population being the Medicaid eligibles within the community served by each Affiliate)·
Employ a range of risk management methods in managing the benefit to the Medicaid recipients in their community·
Make decisions as to whether to directly provide or purchase services, for the Medicaid eligibles within its community, based upon consumer choice, quality, and cost considerations.·
Be able to capture and reinvest savings created by sound clinical, fiscal and risk management approachesThis model is a hybrid of the best of provider-sponsored plans, staff model HMOs/PHPs, and network model HMOs/PHPs and applies a growing body of research, by the Robert Wood Johnson Foundation and others, regarding the use of tight-knit provider systems to ensure the highest total quality care at the lowest total cost for persons suffering from chronic health conditions, such as serious mental illness and developmental disabilities.
This model avoids the principal (payer/caremanager) – agent (provider) conflict found in traditional fee-for-service (FFS) or case rate managed care arrangements. This conflict is avoided in aligning the incentives of the provider with those of the care manager. Far fewer resources and dollars are lost in this integrated approach than in the traditional FFS or case-rate system in which administrative and transaction costs skyrocket as a result of: fragmented, missing, duplicative, or conflicting care risk shifting between providers; authorization dispute and adjudication costs; and claim dispute and resolution efforts.
While this model does avoid the traditional conflict between the principal (payer/care manager) and the agent (provider), it has the same potential conflict between the interests of these two parties and the interests of the consumer. This conflict is addressed, in the Affiliation’s model through the use of the following mechanisms:
1. Concurrent and retrospective utilization review and quality assurance in the initial access stage: The on-going review of initial triage and access contacts with each Affiliate’s Access Center to ensure against the denial of access to assessment appointments.
2. Broad provider panel: The assurance that a provider panel of sufficient size is maintained to ensure adequate choice, by consumers, of their providers.
3. Safeguards against bias during the person-centered planning process:
A. The on-going review of the person-centered planning process, via document review and direct observation, to ensure against "steering" of the consumer toward select providers in the Affiliation’s provider network.
B. The availability of outside facilitators (those who are not on the staff of the Affiliate CMH) to facilitate the person-centered planning process works to ensure against bias in the planning and provider selection steps of the process
4. Concurrent utilization review of care provision: The continual review of the type of care provided to a consumer and its convergence with the consumer’s person-centered plan and the community’s standard of care.
5. Strong and user-friendly grievance and appeal processes: The widespread dissemination of information, to consumers and their families, relative to the grievance and appeal rights of consumers; and the process used to access those rights.
1. Sections 1.1.13 thru 1.1.16 CMHSPs planning to subcontract or outsource any P.H.P. administrative responsibilities (e.g., authorizations, claims payment) must have a description of:
This section is not applicable to the CMHAMM members. All CMHSPs in the affiliation will continue to perform their own administrative functions.
CMHSPs planning to be a provider of direct services must have:
1.1.17. an organizational configuration or structural arrangement that:
1.1.17.1. preserves the integrity of beneficiary interests and public policy objectives in the event these conflict with provider interests of the agency
The integrity of beneficiary interests and public policy objectives (consumer choice, etc.) is ensured through a number of methods, including:
1. Concurrent and retrospective utilization review and quality assurance in the initial access stage: The on-going review of initial triage and access contacts with each Affiliate’s Access Center to ensure against the denial of access to assessment appointments.
2. Broad provider panel: The assurance that a provider panel of sufficient size is maintained to ensure adequate choice, by consumers, of their providers.
3. Safeguards against bias during the person-centered planning process: The on-going review of the person-centered planning process, via document review and direct observation, to ensure against "steering" of the consumer toward select providers in the Affiliation’s provider network. The availability of outside facilitators (those who are not on the staff of the Affiliate CMH) to facilitate the person-centered planning process works to ensure against bias in the planning and provider selection steps of the process.
4. Concurrent utilization review of care provision: The continual review of the type of care provided to a consumer and its convergence with the consumer’s person-centered plan and the community’s standard of care.
5. Strong and user-friendly grievance and appeal processes: The widespread dissemination of information, to consumers and their families, relative to the grievance and appeal rights of consumers; and the process used to access those rights.
| Newaygo CMH-Specific Status and Evidence: NCMHSP complies with the DCH contract. Evidence: Policies
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| 1.1.17.2. requires separate reporting responsibilities and lines of authority for PHP
functions and provider activities
The lines of authority for the PHP functions, of each Affiliate, are segregated from those of the provider activities of each Affiliate in the following ways: |
Line of authority for PHP functions flow through |
Line of authority for provider functions flow through |
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| Gratiot | ||
| Ionia | ||
| Newaygo | Evidence: Policies
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| CEI | The PHP functions (utilization management, access center, inpatient pre-admission screening unit, customer services, grievance/appeal system, recipient rights, quality improvement, ISF management) report through the Deputy Executive Director or Access Supervisor or Customer Quality Improvement/ Recipient Rights Director , whom report to the executive director. | Each of four program directors; coordinated by the Program and Clinical Services Committee (PCS), which is chaired by the Medical Director and made up of two clinical leaders from each Program (one of whom is the program’s director, and the Nursing Administrator. This group reports to the executive director. |
1.1.17.3. requires special independent oversight structures (consumer, family, advocate organizations representation).
The Affiliation has a number of independent oversight structures, to further assure that payer/caremanager, provider, and consumer interests are integrated into an organized system of care that promotes consumer choice, independence, and inclusion; fiscal, clinical, and community system stability; and strong clinical practice. These structures include:
a. All four Affiliates have Boards of Directors, of which 1/3 are primary consumers or their family members. These 16 people, 8 of whom are primary consumers, are a powerful force on these Boards, which make the final decisions relative to the formation of the Affiliation, its direction relative to the development and implementation of the AFP.
b. All four Affiliates have strong consumer and advocate participation on their Recipient Rights Committees and Appeals Committees.
c. Consumer and family member representatives on the Affiliation’s Core Group – the group, made up of representatives from each of the Affiliates, which meets regularly to plan the day-to-day operations of the Affiliation. This group, by its very nature, will continue to meet, after the AFP submission, to oversee the on-going work of the Affiliation in fulfilling the contract with DCH.
d. All four Affiliates have a number of longstanding advisory councils in each affiliate community. These councils are made up of consumers, family members, advocates, and other community stakeholders. (Gratiot CMH is supporting the re-establishment of an Arc Chapter in Gratiot County)
Newaygo CMH-Specific Status and Evidence:
Evidence: Policies
09.02.00.00 Admission Referral Policy
09.02.00.01 Utilization Management Procedures – Outpatient Authorizations, Reauthorization and Level of Care Changes
Services to the Courts 09.09.01.00
Services to Nursing Home 09.09.02.00
Continuity of Services – Emergency Services –24 hour 09.12.03.00
Sheriff’s Dept/Jail Services09.12.04.01
Accessibility of Services 09.13.00.00
Hospital & Crisis Residential Admission, Discharge & After-Care Procedure 09.13.01.00
Home-Based Services 09.13.02.00A
Infant Mental Health Home-Based Program 09.13.03.00
Synergy 09.13.05.00
Children’s Case Management 09.13.06.00
Contracted Specialized Residential Services for Adults 09.14.01.01
Substance Abuse Services 09.14.01.03
Supported Employment Entry/Exit Procedures 09.14.10.00
Physician Utilization Protocol 09.16.01.05
Eye Movement Desensitization and Reprocessing 09.25.00.01
Inpatient Services- Hospitalization 09.26.00.00
Alternative to Hospitalization 09.26.02.00
Family Support and Respite Programs 09.26.05.00
Momentum Program 09.46.00.00
Supported Independent Living 09.48.00.00
Jail Diversion and Conditional Release 09.49.00.00
Grievance and Dispute Resolution Process09.36.00.01
1.2.1. Opportunities for stakeholder and community input and their involvement in policy formulation and implementation must be available through:
1.2.1.1. existing advisory boards
A number of advisory boards exist throughout the Affiliation. Examples of such boards/councils are provided below:
Gratiot: A Gratiot County CMH Client Advisory Panel currently meets on a monthly basis. Responsibilities of the panel include consumer satisfaction survey review, review of performance indicator data, consumer orientation to services, consumer recognition, suggestions for program development, affiliation updates, and other issues related to agency service delivery and policy development. Secondary and primary consumers serve as members of the Recipient Rights Advisory Committee and Human Rights Committee. Consumers have the opportunity to provide input into policy development related to service delivery.
Evidence of Compliance: Meeting minutes are available for the Client Advisory Panel, the Recipient Rights Advisory Committee and the Human Rights Committee.
Ionia:
| Ionia has a Customer Relations Committee and has a new consumer committee to provide input on the AFP. | CRC Roster and minutes, AFP Roster, minutes and input |
Newaygo: Existing advisory committee - Respite Advisory Committee
CEI: CEI has four advisory councils, made up of consumers, family members, and advocacy organizations. These advisory councils are associated with the four major populations served by CMH and its four major service\support programs: Community Support Service Advisory Council (services to adults with mental illness), Community Services to the Developmentally Disabled Advisory Council (services to persons with developmental disabilities), Children’s Services Advisory Council (services to children and adolescents with emotional disturbances), Substance Abuse Advisory Council (services to persons with substance abuse disorders).
Evidence: Roster and minutes of Advisory Councils.
1.2.1.2. scheduled community meetings
Gratiot: Gratiot County CMH has not held a community meeting to date for fiscal year 2001/2002. A community meeting is planned to educate and inform stakeholders and the community about the AFP bid process and ongoing affiliation activities and benefits. This meeting will be scheduled as agreed upon by the CMHAMM core group.
Ionia: Not yet done.
d. Newaygo: Newaygo CMHSP participates on many community committees and community benefit activities at which input is elicited from participants including stakeholders and community members.
e. CEI holds several community meetings on a regular basis to obtain community input on the work of CMH. These include an annual stakeholder briefing (usually held in the summer of each year) on the upcoming year’s budget and other large-scale developments; an annual report to the community, in which the past year’s events and accomplishments are reviewed with community stakeholders (in February of each year).
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Gratiot: The local newspaper is contacted when an event is determined to be of benefit and/or interest to stakeholders and community members. In addition, the agency submits a "Mental Health Corner" article bi-monthly. These articles have been authored by consumers, staff, advocacy organizations and community members.
Gratiot County CMH utilizes the public access television to advertise and announce upcoming events and other information. The public access station has also aired, on occasion, our agency video.
Evidence of Compliance: Copies of news articles, agency video, agency scrapbook.
Ionia:
Just beginning to use local press and radio. Limited opportunity. Other organization newsletters regularly utilized. Catalogue of newspaper articles and newsletters. Newaygo:
NCMHSP submits articles to the local press at least on a monthly basis. To date all articles are printed as written.
CEI: CEI works closely with the print and electronic media in the greater Lansing area. This has resulted in well-informed coverage of a wide range of CMH-related issues and events.
1.2.1.4. self-disclosure by consumer members of CMHSP board and other advisory committees
Gratiot
Ionia:
One consumer on CMHSP Board has publicly disclosed. We have 5 Board Members who claim to be or have been a primary consumer. Survey of CMHSP Board Members. Newaygo
The members of the NCMHSP Board of Directors have openly discussed their respective roles as primary and secondary users of mental health services on numerous occasions.
CEI: Signed affidavits, collected as part of CMH’s certification process, indicate, by self-disclosure the consumer status of board members.
1.2.1.5. other opportunities
a. Gratiot: Consumers have the opportunity to provide input and are involved in policy formulation and implementation through participation on the MDCH Consumer and Advocate Group, Client Advisory Panel, Affiliation Core Group meetings, local ARC, Board of Directors meetings, quality improvement projects, and the Recipient Rights Advisory Committee.
Consumers participated in a joint informational meeting of the affiliation board and core group to discuss affiliation activities and progress.
Internal and external service providers, and consumers have a role in the quality improvement process (e.g., focus groups to determine QISMC project). Results of quality improvement activities are shared with appropriate staff, contract providers, and other stakeholders as warranted.
Any individual is welcome to address the Gratiot County CMH Board of Directors at their regular monthly meeting during the public comment portion of the agenda.
Evidence of Compliance: Community Needs Survey, Client Advisory Panel, AFP review, meeting minutes. Minutes from Affiliation, Board of Directors focus group meetings and TQM activities
b.Ionia
c.Newaygo:
Other opportunities to secure feedback have come in the development of a local group, Empowerment Inc. This group consists of persons with mental illnesses and developmental disabilities living independently or in AFC. They have met with management to give feedback, asked to participate in the AFP process and have offered to assist in the future.
The Board of Directors appointed board members to begin the process of developing a consumer advocacy sub committee to the board. Several of those board members have disclosed in open session of the board their use of services as primary or secondary users. The group will begin recruiting consumer representatives (equal to or more than the number of board members) to work with and on this committee as it develops its mission, vision and scope. This committee will be ethnically and ability/disability diverse representing the community they will serve.
Annually NCMHSP has published an annual report and numerous news articles regarding consumers of services including names, services, and pictures.
CEI: CEI publishes an annual report, outlining the past year’s accomplishments and challenges. CMH actively participates in a number of community education efforts, including the installation and staffing of educational booths at health and community fairs and events, providing speakers at community events.
1.2.2. Interested parties should represent the scope and diversity of the community
The participants in all of the stakeholder and community input venues and methods, described above, represent the scope and diversity of the communities served by the Affiliation, by gender, income, racial and ethnic group, age, disability, family status, sexual orientation, and geography.
Status for Gratiot County CMH: Gratiot County has limited cultural diversity. Consumers from all service populations, family members, stakeholders, and community members are encouraged to participate in, and are involved in all levels of decision making within the agency. Evidence of Compliance: Community education program documentation, listing of consumer involvement activities.
The Board of Directors appointed board members to begin the process of developing a consumer advocacy sub committee to the board. Several of those board members have disclosed in open session of the board their use of services as primary or secondary users. The group will begin recruiting consumer representatives (equal to or more than the number of board members) to work with and on this committee as it develops its mission, vision and scope. This committee will be ethnically and ability/disability diverse representing the community they will serve.
Annually NCMHSP has published an annual report and numerous news articles regarding consumers of services including names, services, and pictures.
Evidence
Board Meeting minutes, Annual report, newspaper articles. Samples to be provided to CEI CMHSP with full documentation available from NCMSHP.
Evidence: Breakdown, by these characteristics, of the participants in these venues.
1.2.3. The names of key local individual advocates and advocacy groups must be available
Status of Gratiot County CMH: A listing of advocates and advocacy groups are available
1.2.3.1. and any arrangements for ongoing dialogue, meetings, consultation with these individuals and entities
Status for each Affiliation member:
Gratiot: Letters of agreement with local schools, local law enforcement agencies and the judicial system, human service agencies and QHPs.
As part of our continued commitment to the community staff representatives actively participate in a variety of human service organizations and initiatives.
A designated agency representative meets regularly with local law enforcement agencies to educate and inform these entities about mental health issues and to discuss coordination of services for shared consumers.
Several agency employees participate monthly on the Gratiot County Multi-Collaborative Council. The Gratiot County CMH Prevention Coordinator is responsible for the organization of this committee.
Evidence of Compliance: A list of community partnerships and commitments our staff are involved in is available.
B. Ionia: Alzheimer’s Association has a presence.
C. Newaygo: Key individuals and advocates in Newaygo County to whom the mental health authority has active dialogue and meetings are:
Maria Kiss, president, Newaygo County Autism Society
Arc/Newaygo County
Homeless advisory forum
Agency consumer advisory group
School transition advisory group
Drug-free schools committee
Newaygo Health Care Council
Senior Council of Newaygo
These organization have agency liaisons who report on board recommendations/concerns/comments regarding agency services, which are then incorporated into the overall agency QI system.
ARC of Newaygo County remains the sole advocacy organization in Newaygo County.
The NCMHSP Board of Directors appointed a consumer advocacy committee in the December 2001 meeting. Three board members have been assigned with one staff person to begin the process of consumer and family recruitment in January 2002. The full committee’s first task will be the development of mission, vision and scope.
This committee is expected to make reports and suggestions to the board and the agency ( QI, management team, service units, etc.).
CEI: CEI has on-going relationships with the following advocates and advocacy groups:
Alliance for the Mentally Ill (AMI)-Lansing: Member of CMH’s CSS Advisory Council
Tri-County Community Advocates (local Arc affiliate): Member of CMH’s CSDD Advisory Council and Stakeholders AFP Review Group
Justice in Mental Health Organization (JIMHO): Member of CMH’s CSS Advisory Council, Stakeholders AFP Review Group; contract provider of a wide range of consumer operated services.
Association for Children’s Mental Health: Member of CMH’s Children’s Services Advisory Council and Stakeholders AFP Review Group.
Project VOX : Member of CMH’s Substance Abuse Advisory Council
United Cerebral Palsy, Michigan Protection and Advocacy, Michigan Association of Emotionally Impaired Children: Invitees to annual stakeholder briefing and annual report to the community, recipients of monthly CMH Executive Directors Report and Board packet,
| Citation #: 1.2.4.1 |
Assess how the CMHSP, and each affiliate member have: Integrated person-centered planning into all organizational practices and Supported its implementation. |
|
Affiliation Agreement Status: |
| To ensure that the Affiliation has the ability to respond, rapidly, to
local needs and circumstances and to promote local control and local stakeholder
involvement, each of the Affiliation members designs, guides, (via policies and
procedures) and implements this function independently, within the confines of contractual
requirements, state and federal statutes and regulations. CEI, as the hub/PHP, is
responsible for ensuring compliance, on the part of each Affiliation members, with these
requirements, statutes, and regulations.
|
| Ionia CMH Status: |
|||
| Ionia has multiple clinical policies and procedures that are reflective
of principles of PCP Ionia has a full time Person Centered Planning Coordinator who monitors PCP compliance based on DCH and JCAHO standards. The Person Centered Planning Conference is well attended by both staff and consumers Support Coordination caseloads have been reduced Paraprofessionals have been added to the Support Coordination Team to increase their ability to meet the needs of the consumers Agency values incorporate PCP principles: Community Inclusion, Best Practice, Family and Children, Quality, Accountability, and Partnerships
Evidence of Compliance: documentation, individual case records, agency values, policies, procedures, organizational structure, training records, PCP reviews
|
|||
| Gratiot CMH Status: |
|||
The agency’s Person-Centered Planning Policy drives
service delivery. Person-centered planning training is mandatory for all staff at the time
of orientation. Annually the agency provides additional training in PCP to enhance skill
development of the staff. Information from PCP training attended outside of the agency is
shared by clinical and administrative staff. The required elements of person-centered
planning are monitored through a chart review process and reported on through the TQM
system. Informational brochures are distributed to consumers at the time of intake.
Training is slated for consumers in what person-centered planning means to them.
Evidence of Compliance: PCP documents, chart monitoring, training records, Strategic Plan goal, policy document, brochures, data through the TQM system, MDCH site review
|
|||
| Newaygo CMH Status: Newaygo CMH-Specific Status and Evidence: Newaygo has adopted into policy the DCH PCP Guidelines. PCP is integrated into the highest levels of management and board decision making. All staff are trained during orientation and annually on the practice and implementation of PCP including key management staff.
|
| CEI CMH Status: |
| CEI has modeled its PCP policies after the DCH policy guideline and fully
implemented this policy. All staff are trained in the basics of PCP at time of hire. Other trainings are offered to staff throughout the year. PCP brown-bag lunches are held quarterly. The PCP training committee plans and evaluates the needs of the organization for education and skill training. The process is monitored through a UM process by PCP committees. Supervisors review plans and discuss plans are part of employee performance reviews. Agency principles include person-centered statements. Evidence of compliance: PCP policies and documents, chart monitoring, training curriculum and records, Strategic Plan, data through the UM system, MDCH site review and JCAHO review.
|
| Citation #: 1.2.4.2 |
Assess how the CMHSP, and each affiliate member have: Integrated person-centered planning into all organizational practices and Supported its implementation. |
| Affiliation Agreement Status: |
| To ensure that the Affiliation has the ability to respond, rapidly, to
local needs and circumstances and to promote local control and local stakeholder
involvement, each of the Affiliation members designs, guides, (via policies and
procedures) and implements this function independently, within the confines of contractual
requirements, state and federal statutes and regulations. CEI, as the hub/PHP, is
responsible for ensuring compliance, on the part of each Affiliation members, with these
requirements, statutes, and regulations.
|
| Ionia CMH Status: |
| Ionia has multiple clinical policies and procedures that are reflective of principles of PCP Ionia has a full time Person Centered Planning Coordinator who monitors PCP compliance based on DCH and JCAHO standards. The Person Centered Planning Conference is well attended by both staff and consumers Support Coordination caseloads have been reduced Paraprofessionals have been added to the Support Coordination Team to increase their ability to meet the needs of the consumers Agency values incorporate PCP principles: Community Inclusion, Best Practice, Family and Children, Quality, Accountability, and Partnerships
Evidence of Compliance: documentation, individual case records, agency values, policies, procedures, organizational structure, training records, PCP reviews
|
| Gratiot CMH Status: |
The agency’s Person-Centered Planning Policy drives
service delivery. Person-centered planning training is mandatory for all staff at the time
of orientation. Annually the agency provides additional training in PCP to enhance skill
development of the staff. Information from PCP training attended outside of the agency is
shared by clinical and administrative staff. The required elements of person-centered
planning are monitored through a chart review process and reported on through the TQM
system. Informational brochures are distributed to consumers at the time of intake.
Training is slated for consumers in what person-centered planning means to them.
Evidence of Compliance: PCP documents, chart monitoring, training records, Strategic Plan goal, policy document, brochures, data through the TQM system, MDCH site review
|
| Newaygo CMH Status: All person-centered planning documents are reviewed by the team leaders of the clinical units for completion and compliance with PCP standards. At least annually the Team Leaders conduct a review of PCP implementation through file review of PCP documents. All clinical staff are trained during orientation and annually on the practice and implementation of PCP including key management staff. All clinical staff are encouraged to attend PCP training offered within the state. Evidence
Staff orientation checklist 09.31.11.00 |
| CEI CMH Status: |
| CEI has modeled its PCP policies after the DCH policy guideline and fully
implemented this policy. All staff are trained in the basics of PCP at time of hire. Other trainings are offered to staff throughout the year. PCP brown-bag lunches are held quarterly. The PCP training committee plans and evaluates the needs of the organization for education and skill training. The process is monitored through a UM process by PCP committees. Supervisors review plans and discuss plans are part of employee performance reviews. Agency principles include person-centered statements. Evidence of compliance: PCP policies and documents, chart monitoring, training curriculum and records, Strategic Plan, data through the UM system, MDCH site review and JCAHO review. |
1.2.5 There must be a policy basis that insures consistency across the applicant’s area in the provision of supports coordination and case management options for consumers.
Approach of Affiliation:
Gratiot:
Ionia - staff are willing to meet with other affiliate partners to develop a policy that is reflective of consistency in the provision of supports coordination and case management options for consumers across the affiliation.
The concept of "provider of choice options" are reflective in various Ionia policies, including but not limited to the policy related to person-centered planning.
The Board of Directors program committee reviewed and recommended the adoption of the draft "provider of choice" policy to the full Board of Directors on December 10, 2001.
Newaygo: All intakes and annual assessments, service authorizations, PCP documents, and discharges are reviewed by the Team Leader of each clinical unit to assure consistency in the provision of support services. All documents are reviewed using JCAHO standards, DCH contract
Evidence
1. Person-Centered Planning Guidelines 09.06.00.00
2. Person-Centered Planning Meeting Summary 09.06.01.00
3. Staff Training Records
4. Accessibility of Services 09.13.00.01 including Adult Services Guidelines and Persons with Developmental Disabilities Guidelines.
5. DCH contract
Utilization Management Criteria – Level of Care Determination Guidelines
CEI - insures consistency in the provision of supports coordination and case management options for consumers with mental illness and developmental disabilities through the use of the following:
1) use of program descriptions and assessment of consumer’s needs at CEI Access Point,
2) use of program decriptions and assessment of consumer’s needs and desires at initial assessment and person centered planning process, as these needs or desires change, and at least annually thereafter,
3) education of consumers and their advocates regarding available supports and case management options during Person Centered Planning.
4) review of supports coordination and case management needs for consumers with mental illness through the Service Review Committee and for consumers with developmental disabilities through the Person Centered Planning Committee
Evidence includes:
1) CEI -Access Level of Care Assessment Instrument, CSS Level of Care Assessment Instrument, CSS Program Descriptions, CSDD Program Descriptions, CSDD PCP Committee and CSS Service Review Committee descriptions
2) Ionia - Draft policy, "Provider of Choice" Program committee meeting minutes from December 10, 2001.
| Citation #: 1.2.6.1 |
Prepare an analysis of changes in service delivery system patterns over the past three years (October 1998-September 2001) across populations (MI, DD, SA, co-occurring, ages, cultural backgrounds): Increased use of flexible options |
| Affiliation Agreement Status: |
| To ensure that the Affiliation has the ability to respond, rapidly, to local needs and circumstances and to promote local control and local stakeholder involvement, each of the Affiliation members designs, guides, (via policies and procedures) and implements this function independently, within the confines of contractual requirements, state and federal statutes and regulations. CEI, as the hub/PHP, is responsible for ensuring compliance, on the part of each Affiliation members, with these requirements, statutes, and regulations. |
| Ionia CMH Status: |
| Ionia CMH prides itself in being able to be responsive and flexible with our consumers. Supports and services are determined through a person-centered planning process, which often lends itself to the use of increased creative options. Since September 1998, Ionia CMH has terminated all contracts with traditional day treatment providers, offering instead a more personalized support-oriented, community-based option for those in need of additional supports in the community. Ionia CMH has assisted several people with developmental disabilities in moving from an institutional based setting (Mount Pleasant Center) into the community. These individuals now live in homes they rent with one or two other individuals, with staffing support. Currently, Ionia CMH supports twenty individuals with developmental disabilities living in their own home, with varying levels of supports. Ionia CMH employs paraprofessionals to provide additional support to individuals diagnosed with a severe and persistent mental illness, as well as those individuals with developmental disabilities, who have a case manager or support coordinator, to promote greater community involvement and achievements. This flexibility has also allowed us to be more responsive to consumers in a timely manner. In an attempt to promote people staying in their community verses being psychiatrically hospitalized, Ionia CMH has utilized a significant number of safe alternatives, such as staffing support, motels, car repair, etc. Ionia CMH was awarded funding to support an Elderly Outreach worker to promote greater penetration in this population. This position is designed to not only promote services, but to provide flexible mental health related services to the elderly in the community. This funding was applied for and granted during the timeframe noted; however implementation began after October 1, 2001. Evidence: Board Meeting minutes, Community Support Services Team statistics; Individual case records; Listening Ear Contract(s); Pre-admission screening documentation; Elderly Outreach contract |
| Gratiot CMH Status: |
| A significant increase in the number of individuals with Developmental
Disabilities residing in semi-independent and independent settings has occurred during the
cited period. Individuals that previously received day activity services in a segregated
day program now access their community through the support of community living staff.
Environmental modifications have been made to several homes of children residing with
their families. Housing assistance dollars are available for consumers meeting eligibility
for this benefit. The agency has provided consumer and community education as well as
family skills development training. Departmental reorganization in DD Services has
resulted in expansion and growth in family support and respite care services. Evidence of Compliance: List of Consumer and Community Education activities, MDCH Performance Indicators, Consumer Records, and Financial Records. |
| Newaygo CMH Status: Beginning prior to 1993 Newaygo CMHSP has been expanding the service array to provide consumer with more flexible treatment options. Those services changes include substance abuse services for co-occurring disorders, wraparound and home-based for children and families, 4E Michigan Families program. To meet the growing identified needs within Newaygo County, children’s services have been increased and diversified to access funding streams from community organizations. Collaborative agreements exist with Newaygo County Courts for home-based and substance abuse services for juveniles. Newaygo CMHSP has diverted clinical staff to the development of new and flexible services to meet the changing needs of the populations served including the development of community integration and independent living options and supports. This County continues to grow according to census reports. The demand for services is increasing in the area of children, Borderline Personality Disorders and decreasing in geriatric services. The agency has designated staff to become certified in Dialectical Behavioral Therapy to meet the treatment needs of those persons with Borderline Personality Disorder. Finally, to reach the large geriatric population a grant was applied for and received from DCH for a geriatric outreach staff person to work 50% of the time out of the Commission on Aging. |
| CEI CMH Status: |
| CEI has continued to provide a range of living options for its consumers
including a homeless outreach program, supported independence, group homes, home
purchasing and residential treatment program in substance abuse. Children’s services provide a range of options for families including home based services, wrap-around and early intervention and consultation services. Day programs continue to reduce the use of segregated facilities and increase community options using the club house model and community drop-in centers. DD programs make use of over 120 sites for community inclusion activities. All of these are supported by the use of person-centered planning, consumer focus groups and consumer satisfaction surveys. Evidence of Compliance: Review of program descriptions, consumer surveys and focus group reports. Community inclusion site lists. DCH reviews. |
| Citation #: 1.2.6.2 |
Prepare an analysis of changes in service delivery system patterns over the last three years (October 1998-September 2001) across populations (MI, DD, SA, Co-occurring, ages, cultural backgrounds): more consumer-operated services |
| Affiliation Agreement Status: |
| To ensure that the Affiliation has the ability to respond, rapidly, to local needs and circumstances and to promote local control and local stakeholder involvement, each of the Affiliation members designs, guides, (via policies and procedures) and implements this function independently, within the confines of contractual requirements, state and federal statutes and regulations. CEI, as the hub/PHP, is responsible for ensuring compliance, on the part of each Affiliation members, with these requirements, statutes, and regulations. |
| Ionia CMH Status: |
| Prior to October 1998, Ionia CMH did not have any formalized
consumer-operated services. In the Fall of 2000, Ionia CMH began the process of
establishing a consumer run drop-in center. The River’s Edge Drop-In Center
officially opened in February of 2001. The River’s Edge Drop-in Center embraces all
populations. The Board of Directors of the River’s Edge continues to receive ongoing training from various sources (Ionia CMH, JIMHO, etc.) and continues to grow and develop. The River’s Edge is incorporated, but still seeking their non-profit status. The Board of the River’s Edge vacillates between feeling they are ready, trained and organized enough to be given the responsibilities of a contractual relationship with CMH and needing continued CMH support. Ionia CMH has committed .5 FTEs of CMH staffing support to assist the River’s Edge further growth and development. Ionia CMH committed a portion of their reinvestment monies for FY 00/01 to the support of the River’s Edge Drop-in Center. Evidence: Organizational Chart; Building lease contract; Independent provider contracts; Board Meeting minutes, Contract with MDCH, Reinvestment Funding approval for FY 00/01. |
| Gratiot CMH Status: |
| One consumer with developmental disabilities owns and operates a beverage
service micro-enterprise. Several other consumers with developmental disabilities are in
the preliminary stages of developing their micro-enterprises. A Jobs Club for DD consumers
has been organized to assist consumers in the development of a micro-enterprise. Evidence of Compliance: Service descriptions, Jobs Club minutes |
| Newaygo CMH Status: |
| NCHMSP is in the process of closing a lease for property, which will be funded for the Empowerment, Inc.. Empowerment, Inc is a consumer run support group for consumers with severe and persistent mental illness as well as those persons with developmental disabilities. The group has asked for financial support from the agency to fund a drop-in center in Fremont, Mi. The drop-in center will be consumer run and will be opening some time after January 1, 2002. |
| CEI CMH Status: |
| The Justice in Mental Health Organization (JIMHO) operates a number of
support and training services in the 3 counties. JIMHO has also expanded into other areas
of the state. Several parent groups have developed housing options for their children;
including Rainbow homes, House of Ruth and Chosen Vision. The directors of these groups
are parents and interested others. Evidence of Compliance: DCH and JCAHO site visits to JIMHO. Board minutes supporting these organizations. |
| Citation #: 1.2.6.3 |
Prepare an analysis of changes in service delivery system patterns over the last three years (October 1998-September 2001) across populations (MI, DD, SA, co-occurring, ages, cultural backgrounds): greater choice |
| Affiliation Agreement Status: |
| To ensure that the Affiliation has the ability to respond, rapidly, to local needs and circumstances and to promote local control and local stakeholder involvement, each of the Affiliation members designs, guides, (via policies and procedures) and implements this function independently, within the confines of contractual requirements, state and federal statutes and regulations. CEI, as the hub/PHP, is responsible for ensuring compliance, on the part of each Affiliation members, with these requirements, statutes, and regulations. |
| Ionia CMH Status: |
| From the point of initial contact with Ionia CMH, consumers are asked
about their preferences related to when an appointment is scheduled; place of contact,
clinician, etc. and the principles of self-direction are promoted though out the tenure of
services received. Since September of 1998, the variety of supports and services provided by Ionia County CMH has increased, including the River’s Edge Drop-in Center, Supported Employment, Community Supports Staffing assistance, and Assertive Community Treatment. All of these supports and services, in addition to the greater flexibility provided in Medicaid Chapter III have broadened options for consumers to choose what would best meet their needs during the person centered planning process. Evidence: Organizational chart; RFS and PCP documentation; individual case files; Clinical policies, including but not limited to Person centered planning and draft Provider of Choice. |
| Gratiot CMH Status: |
| The agency provides a comprehensive array of services to allow consumers
greater choice in the services they receive. Through the PCP process service delivery is
tailored to meet the individual’s desires and needs. Evidence of Compliance: Individual PCPs, Service Eligibility Protocols, Informational Flyers, Agency Brochure, and Member Handbook. |
| Newaygo CMH Status: |
| Through the provision of a wider array and diversity of
services NCMHSP has been able to provide consumers with greater choice of provider and
service type. Within the outpatient services, clinicians are paid per contact as opposed
to being full time staff. This change in payment has allowed for this agency to provider a
greater number of outpatient clinicians and therefore greater choice. Options for greater
choice are further offered in the community living supports services. Consumer may chose
from two providers under contract with this agency. Those providers are willing and able
to train qualified persons identified by the consumers to be providers of direct care and
supports. Further, NCMHSP has developed substance abuse services (group and individual)
for those person with co-occurring disorders. Evidence Substance Abuse 09.14.01.02 |
| CEI CMH Status: |
| At Access consumers are given chose about times for initial appointments.
In Childrens’ services families are given choice of service providers for respite
care and in-home care. Consumers can also chose to change supports coordinators or case
managers. Ranges of living and work opportunities allow people to have a choice about
where they live and work. Choice is the basis of the PCP process. Evidence of Compliance: Consumer satisfaction surveys, Board Minutes, DCH indicators – timeliness, agency brochures, PCP plans. |
| Citation #: 1.2.6.4 |
Prepare an analysis of changes in service delivery system patterns over the last three years (October 1998-September 2001) across populations (MI, DD, SA, co-occurring, ages, cultural backgrounds): Self-determination |
| Affiliation Agreement Status: |
| To ensure that the Affiliation has the
ability to respond, rapidly, to local needs and circumstances and to promote local control
and local stakeholder involvement, each of the Affiliation members designs, guides, (via
policies and procedures) and implements this function independently, within the confines
of contractual requirements, state and federal statutes and regulations. CEI, as the
hub/PHP, is responsible for ensuring compliance, on the part of each Affiliation members,
with these requirements, statutes, and regulations. CEI and Ionia have both completed the self-determination training process offered by MDCH. |
| Ionia CMH Status: |
| Ionia currently has two individuals who are fully involved in the
self-determination process. There are several others that are in various stages of the
process. It is expected that a minimum of 10 individuals will be fully involved in the
process by 9-30-01. It is difficult to discern the changes to the service system as a result of self-determination, in isolation. The advances and progress of person centered planning and the movement to less traditional service models are entwined in changes made related to self-determination. It has certainly promoted a greater awareness of individual budgets by staff and those consumers and their support system involved in self-determination. Those involved in Self-determination currently have elected to move away from more traditional providers of services. It appears to have promoted a greater collaboration of efforts between programmatic and fiscal staff. Evidence of Compliance: Policy; Self-determination team meeting minutes; organizational chart; newsletters; training calendars; training registrations; individual case files; etc. |
| Gratiot CMH Status: |
| Staff has received training in self-determination with additional
training slated in the upcoming months. Evidence of Compliance: Training records |
| Newaygo CMH Status: |
| Newaygo CMHSP developed a self-determination strategic
plan and concept paper which have been shared with the community. All agency staff have
received several training sessions provided internally related to the agency position/plan
and self-determination from a more macro view. Plans to continue training and development
of strategic plan. Evidence of Compliance: Strategic plan and concept paper. |
| CEI CMH Status: |
| CEI staff participated in the self-determination replication training
offered by MDCH and the Michigan Association of CMH Boards. The team has continued to plan
for self-determination implementation. Training and orientation has been done for staff,
administrators and Board members. Staff serving MI adults are now participating in the
local team and in state level discussions on how to implement self-determination for the
people they serve. A plan has been developed for implementation. Two consumers are
actively in self-determination planning. CEI has also taken a position that
self-determination policy guidelines and person-centered guidelines should be merged into
a single policy position. It is too early to show the impact on the system, but it is
anticipated that more consumer choice and control will be the end result of the full
implementation of self-determination. Evidence of Compliance: Training presentation, Board minutes, self-determination team minutes. |
| Citation #: 1.2.6.5 |
Prepare an analysis of changes in service delivery system patterns over the last three years (October 1998-September 2001) across populations (MI, DD, SA, co-occurring, ages, and cultural backgrounds): Increase in independent living situations |
| Affiliation Agreement Status: |
| To ensure that the Affiliation has the ability to respond, rapidly, to local needs and circumstances and to promote local control and local stakeholder involvement, each of the Affiliation members designs, guides, (via policies and procedures) and implements this function independently, within the confines of contractual requirements, state and federal statutes and regulations. CEI, as the hub/PHP, is responsible for ensuring compliance, on the part of each Affiliation members, with these requirements, statutes, and regulations. |
| Ionia CMH Status: |
| Ionia CMH currently supports 20 individuals with Developmental
Disabilities living in their own homes, with various levels of supports. These numbers
have remained relatively steady since October 1998. Most of the people diagnosed with a
severe and persistent mental illness are supported by casemanagement staff to live in
their own home. Ionia CMH has a clinical policy on housing that supports each consumer living where and with whom they chose. Ionia CMH was the primary sponsor of a community-wide housing resource fair in August 2001. Ionia CMH has had a "housing committee" to look at issues related to housing, in response to interest from the 2000 PCP conference. This committee is currently reorganizing and reprioritizing issues related to housing. Evidence: Statistics related to # of individuals living in their own home; policy; housing committee meeting minutes; newspaper articles, etc. |
| Gratiot CMH Status: |
| As cited above in 1.2.6.1 a significant increase in individuals residing
independently has occurred over the past three years. Individual community living support
services are provided to maintain consumers in the least restrictive living situation
possible. Evidence of Compliance: MDCH Performance Indicators, Individual PCPs, Housing Minutes, Provider Contracts |
| Newaygo CMH Status: |
| NCMSHP has diverted a clinical staff person to the
development of housing options in Newaygo County. This person is working collaboratively
with local housing and social service organizations to locate and secure affordable
housing options within the county. Further, this clinician works directly with supports coordinators and consumers to identify and develop necessary skills and supports to make independent living a safe and successful option. Evidence Substance Abuse 09.14.01.02 Consumer Safety 09.15.02.01C Momentum 09.46.00.00 a community integration and linkage program Integrated Health Care 09.47.00.00 providing services directly through the primary physicians office Supported Independent Living 09.48.00.00 Supported Independent Living Discretionary Fund 09.48.01.00. |
| CEI CMH Status: |
| There are 135 people with developmental disabilities and people with
mental illness living independently. Through the efforts of teams like the Homeless
Outreach Program, Supported Independence Team and Assertive Community Treatment people are
supported in living arrangements of their choice. CEI makes use of subsidies and low
interest loan programs to assist people to find affordable housing. One staff person has
been designated as a housing broker to assist consumers in locating suitable housing. Evidence of Compliance: Individual plans, minutes from staff meetings of teams, indicator reports, residential placement minutes. |
| Citation #: 1.2.6.6 |
Prepare an analysis of changes in service delivery system patterns over the last three years (October 1998-September 2001) across populations (MI, DD, SA, co-occurring, ages, cultural backgrounds): increase in employment opportunities |
| Affiliation Agreement Status: |
| For autonomous operations): To ensure that the Affiliation has the ability to respond, rapidly, to local needs and circumstances and to promote local control and local stakeholder involvement, each of the Affiliation members designs, guides, (via policies and procedures) and implements this function independently, within the confines of contractual requirements, state and federal statutes and regulations. CEI, as the hub/PHP, is responsible for ensuring compliance, on the part of each Affiliation members, with these requirements, statutes, and regulations. |
| Ionia CMH Status: |
| EmployAbilities was implemented in the Fall of 1998. EmployAbilities
refers to the supported employment activities at Ionia CMH. EmployAbilities is open to all
consumers that are in need of assistance finding employment, particularly those people who
also have casemanagement or support coordination services, that are not able to utilize
other community resources to obtain employment. Since EmployAbilities inception, 145 people have been open to this service, with 73 of these individuals having successfully obtained at least one job. Ionia CMH does not support the use of deviated wages, thus all employment found through EmployAbilities is at minimum wage or higher. Evidence: EmployAbilities data and information, EmployAbilities brochure. |
| Gratiot CMH Status: |
| Gratiot CMH contracts with a vocational service provider for job
development and job placement services. The agency has a tri-party W agreement funded by
MRS, CMH and the RESD. This agreement allows for job development, job placement, job
coaching, and job readiness training. Also, in the past 6 months the agency has developed
a job placement service to increase the number of individuals that are competitively
employed at minimum wage or higher. This service is available to adults with mental
illness and/or developmental disability, and RESD students and has resulted in 21
individual job placements. The agency is also a member of the RESD School-to-Work
Transition Council. Evidence of Compliance: Employment Services Contract, Tri-Party W-Agreement between MDCD-RS, GI-RESD and CMH, MDCH Performance Indicators, Job Placement Data |
| Newaygo CMH Status: |
| NCMSHP continues to work collaboratively with Michigan
Rehabilitation and other county based employment organizations to develop and improve
employment options for consumers within this county. Evidence Supported Employment 09.14.10.00 including coordination with MRS, ISD and other community work organizations |
| CEI CMH Status: |
| In 1998 there were XXX people with mental illness in supported employment
compared to XXX in 2001. During the same period there were XXX and XXX people with
developmental disabilities in supported employment. It is mot practical to compare the
change from 1998 to present because consumers do not stay involved in supported employment
– they move on to simply being employed. CEI is committed to job placement. We have a
Supported Employment Team made up of staff from MRS, CMH and Peckham Industries. In
addition, we work with local schools to assure placements as students transition from
schools. Evidence of Compliance: Indicator reports, employment data, MRS cash match agreements, Supported employment team minutes. |
| Citation #: 1.2.7.
1.2.7.1. 1.2.7.2. |
Analyze the numbers and demographics of persons from the CMHSP (and the affiliate members) currently in state institutions: Compare institutional usage over the last three years Develop plans for providing community-based alternatives for the populations no longer needing |
| Affiliation Agreement/Status and Evidence: To ensure that the Affiliation has the ability to respond, rapidly, to local needs and circumstances and to promote local control and local stakeholder involvement, each of the Affiliation members designs, guides, (via policies and procedures) and implements this function independently, within the confines of contractual requirements, state and federal statutes and regulations. CEI, as the hub/PHP, is responsible for ensuring compliance, on the part of each Affiliation members, with these requirements, statutes, and regulations. |
| CMH-Specific Status and Evidence: Ionia CMH 1.2.7. We have 2 males and 1 female at Mt. Pleasant Center. We have 3 males under Forensic Order, 2 in the Forensic Center and 1 in Kalamazoo Regional Hospital. 1.2.7.1. See attached grid. 1.2.7.2. Reestablished ACT in July 2001; opened a consumer-run drop-in center in February 2001. In 1999 formed the Community Support Team staff by para-professionals to offer an alternative to a structured traditional model day treatment. Ionia began the institutional reduction process prior to 1998. Mt. Pleasant Center PCP records; State psychiatric hospital records; agency service use and demographic reports. Gratiot CMH 1.2.7. One Caucasian male consumer with developmental disabilities has resided at the Mt. Pleasant Center during the time period cited. At this time his prognosis for community placement remains guarded. (1.2.7.1.) Over the past three years two Caucasian female consumers with mental illness have been admitted to a state psychiatric hospital. 1.2.7.2. Newaygo CMH 1.2.7. Has no persons placed in any state institutions. 1.2.7.1 Over the past three years there have been sporadic short-term placements only when community alternatives have been exhausted and consumer safety can be assured in no other way. 1.2.7.2 Newaygo County has no persons placed in any state institutions. Over the past three years there have been sporadic short term placements only when community alternatives have been exhausted and consumer safety can be assured no other way. In those short term cases community resources are developed and supports in place to allow for return to the community. CEI CMH 1.2.7. There is currently one adolescent female (age 15) placed in the Hawthorne Psychiatric Center as of December 1,2001. Over the past three years there have been a total of 5 placements into the state institution ranging in age from 10-17. Four of the admissions were male; one was female. Four of the admissions were from Ingham County, and one was from Eaton County. As of December 1, 2001, there are 14 people with developmental disabilities in Mt. Pleasant Center. Thirteen are male. Ages range between 23 and 67. All are Caucasian. Eight are from Ingham County, 4 from Eaton County, and 2 from Clinton County. There are currently (December 11, 2001) five mentally ill adults in state facilities. They are all male, all from Ingham County and 4 are African American and 1 is Caucasian. They range in age from 28-58. 1.2.7.1 Hawthorne Psychiatric Center is the state institution that is utilized by this Board. The placement of children into Hawthorne over the last three years has been very infrequent. The Center specializes in longer term care of children who present with severe emotional/behavioral instability that is both persistent and of high risk to themselves and/or others. Our admissions have also been characterized by children who have severe cognitive limitations. Over the past three years there have been 5 placements into the Hawthorne Center. There were two admissions in FY99, two admissions in FY 2000, and one admission in FY 2001. The discharges of these children have been primarily to residential settings that offer 24 hour staffing, structured milieu, and specializing in children with intellectual limitations and behavioral disorders. The utilization of the state institution has been consistently low for a number of years as a result of an array of available supportive community alternatives. The admission of people with developmental disabilities to the Mt. Pleasant Center occurred 19 times in FY1999, 20 times in FY2000 and 14 times in FY 2001. The three types of admissions for mentally ill adults to state facilities include Probated admissions, Not Guilty for Reason of Insanity (NGRI) admissions, and Incompetent to Stand Trial (IST) admissions. CEI has no authority over IST admissions and shares authority with the Center for Forensic Psychiatry and state hospitals over NGRI admissions. (See attached grid for admissions for the past three years using the aforementioned categories.) 1.2.7.2 The community has in place alternatives to institutional care that have allowed for the treatment of children and their families to take place on a regular basis in the community. The strong home based programming through C.H. that includes an array of respite options including mentors, foster care, crisis residential care and prescribed social recreational opportunities supported by well developed psychiatric interventions allows for most children and their families to be supported in their own community. The efforts of our agency also is supported by community collaborative efforts to share resources via the Single Door (multi agency community team committed to solutions for exceptionally high needs children), use of non-traditional creative alternatives via Wraparound and a strong community mental health belief in family centered processes has created an environment where the need for long term institutional care placements are infrequent and the exception. Community Mental Health continues to work with the Mt. Pleasant Center to identify and develop plans to prepare consumers with developmental disabilities for placement. Specialized housing has been developed in some cases and for others placements in specialized housing in other areas of the state is being considered. CEI is in the process of building tow specialized care group homes for adults with mental illness. These homes are designed to serve individuals requiring intensive services, including currently hospitalized in state faculties. Staffing levels will be consistent with the needs of these residents. Staff will also receive specialized training. Both homes will offer an enriched environment with special activities and individualized treatment. The target date for opening thee homes is April 30, 2002. |
CMHB- CEI STATE FACILITY ADMISSIONS FOR ADULTS WITH MENTAL ILLNESS |
|||
| TYPE OF ADMISSION | TOTAL ADMISSIONS |
TOTAL DAYS |
AVERAGE DAYS PER PERSON |
FY 2001 |
|||
| Kalamazoo: Probated NGRI IST Totals |
30 3 9 42 |
2,731 513 1,104 4,348 |
91 171 123 104 |
| Mt. Pleasant: IST |
1 |
365 |
|
| Caro: Probated |
1 |
8 |
|
FY 2000 |
|||
| Kalamazoo: Probated NGRI IST Totals |
32 5 10 47 |
2,400 718 587 3,705 |
75 144 59 79 |
| Mt. Pleasant: IST |
1 |
95 |
|
| Northville: NGRI |
1 |
223 |
|
FY 1999 |
|||
| Kalamazoo: Probated NGRI IST Totals: |
24 3 5 32 |
2,411 636 923 3,970 |
100 212 185 124 |
| Northville: NGRI |
1 |
365 |
|
1.2.8 The PHP and affiliate members must demonstrate affirmative efforts to increase agency and subcontractor employment of consumers.
Agreement of the Affiliation: Each member of the affiliation promotes employment of consumers.
Gratiot:
Ionia: Currently, Ionia employs a minimum of six consumers and anticipates hiring an additional FTE during the new few months for two half-time peer advocate positions. Ionia employs approximately 89 FTEs. Thus, a minimum of 6.7% of people employed at Ionia CMH are consumers.
Ionia CMH has promoted the employment of consumers via "word of mouth", posting of open positions in common areas of the agency for consumers to review, and development of positions specifically requiring a consumers expertise (i.e., peer advocate positions).
Newaygo:
CEI - has developed a policy on consumer employment (Joel Weiss) calling for the employment of consumers in positions ranging from temporary training positions to regular employee status in all areas and at all levels of the Board’s and subcontractors operations.
CEI consumers are currently employed in a wide variety of areas in both training and regular employment positions. Consumers work in clinical/administrative services as receptionists, mail carriers, doing filing, doing computer work, answering phones, doing copy projects, etc.. Consumers work in building maintenance and janitorial services. Finally, two consumers were recently hired (November 2001) as Client Care Specialists to provide direct service to other consumers.
Evidence includes:
1) CEI –Policy on Employment of Consumers (developed by Joel Weiss), Charter House TEP records, CSDD employment records, Employee Job Descriptions for Client Care Specialists on CSS Team I and II.
2) Ionia – RFP and Contractors
1.2.8.1 Identify any agency organizational units specifically dedicated to consumer interests and staffed by consumers and/or family members.
Agreement of Affiliation:
Gratiot:
Ionia - Ionia does currently employ the staff for the River’s Edge Drop-In Center. The River’s Edge is designed to be consumer-run and operated. While it still operates under the auspices of Ionia CMH, this is one unit in the organization that is dedicated and staffed by consumers.
Newaygo - NCHMSP is in the process of closing a lease for property, which will be funded for the Empowerment, Inc.. Empowerment, Inc. is a consumer run support group for consumers with severe and persistent mental illness as well as those persons with developmental disabilities. The group has asked for financial support from the agency to fund a drop-in center in Fremont, MI. The drop-in center will be consumer run and will be opening some time after January 1, 2002.
CEI - has a contractual relationship with the Justice In Mental Health Organization (JIMHO). Under the terms of this contract JIMHO employs fifteen consumers who are engaged in providing services ranging from Drop-In Center services, Temporary Emergency Housing Services (6 beds), Transitional Housing Services (4 beds), Project Stay Services, a consumer run business and consumer computer training. JIMHO is the largest consumer run drop-in with associated services in the state of Michigan.
CEI and JIMHO are currently developing a contract to expand JIMHO services to include employment of consumers as paid facilitators for Person Centered Planning. CEI and JIMHO are also cooperating on a Housing and Urban Development (HUD) grant that will employ consumers who will assist persons with mental illness and their landlords. Finally, CEI and JIMHO are cooperating on the opening of a consumer-run Drop-In Center in Clinton County.
B. Evidence includes:
1) CEI - JIMHO Quarterly Reports, JIMHO Staffing Tables, JIMHO PCP Contract, JIMHO HUD Grant Application, JIMHO Proposal for Clinton County Drop-In.
2) Ionia - Job description, organizational structure, employee contract, etc..
3) Newaygo -
1.2.9 Compile the PHP’s Policies that ensure access by person’s with
1.2.9.1 LEP
1.2.9.2 diverse ethnic or cultural backgrounds
1.2.9.3 communication impairments
1.2.9.4 mobility constraints
Status of CEI:
Gratiot County CMH Evidence: Policies providing evidence to these requirements include: Dignity and Respect, Cultural Diversity, Person-Centered Planning, Right to Access, Treatment by Spiritual Means, Freedom of Movement, and Services Suited to Condition. Additionally, the following resources also address these requirements: Member Handbook, Agency brochures (English and Spanish), Member Handbook on Audio tape, Listing of Bi-lingual Staff and Interpretation Resources, COA accreditation survey report, MDCH On-site Review, Service Descriptions and Eligibility Protocols.
Status of Ionia:
1.2.91. LEP ICCMH requires through its policies, based on the MDCH Consumerism Best Practise Guideline,
accommodations for individuals seeking access to services having limited-English proficiency.
Accomodations to include the availability of service deliver information and forms in an understandable
format and interpretation of services.
Evidence: ICCMH policy # 11-005-003
1.2.9.2 diverse ethnic or cultural backgrounds: ICCMH requires through its policies, based on the MDCH Consumerism Best Practice
Guideline,accomodations for indivduals seeking access to services having diverse ethnic or cultural
backgrounds. Accommodations to incldue the availability of service delivery information and forms in an
understandable format and interpretation of services.
Evidence: ICCMH Policy #11-005-003 abd #111-002-003
1.2.9.3 communication impairments: ICCMH reequires through its policies, accommodations for individuals seeking access to services having
communication impairments. Accomdodations include the availability of sign language interpreters,
service delivery information on cassette tape, and TDD phone equipment.
Evidence: ICCMH Policy #111-005-003 and #111-002-003
1.2.9.4 mobility constraints: ICCMH provides reserved parking, wheelchair accessible ramps, automatic doors and baaarrier free
restroom facilities for indiviudals with mobility constraints. ICCMH also has transportation arrangements
with area transit authorities to transport individuals to service sites and provides its own transporation
services for individuals receiving services to CMH aas well as to other appointments and activities in the
community.
Evidence: no specific policies; compliance with American’s with Disabilities Act
Status of Newago:
| Citation #: 1.2.10 |
The PHP and its affiliate members must assure
standardized access to and response from:
|
| 1.2.10.1 | Office of Recipient Rights |
| Affiliation Agreement/Status and Evidence: A. Access: Community Mental Health of Clinton-Eaton-Ingham Counties has contracted to provide rights protection to the recipients of Gratiot and Ionia Counties. Newaygo Community Mental Health operates an autonomous rights protection system for their recipients. Each member of the affiliation assures access to rights protection for its members. Recipients may contact an affiliate rights office by phone (toll-free or local numbers), in person or in writing. Response: Staff from the rights office responds to every contact within 24 hours. If there are allegations of abuse or neglect, the investigation is initiated within 24 hours of receiving the report. A written response to tell the person who filed the complaint what will happen with his/her complaint is sent to every complainant within 5 business days. B. Evidence for each affiliate includes:
|
1.07.02
| Citation #: 1.2.10.2 |
Local appeal and grievance mechanisms |
| Affiliation Agreement/Status and Evidence: Affiliation Agreement/Status and Evidence: A. The affiliates provide an array of local appeal and grievance mechanisms. Affiliates have agreed to a standardized appeal and grievance process including local appeals. A standard policy and procedure as well as standard appeal and grievance notice to inform consumers of all their appeal rights has been developed. Notice of appeal rights are given to each consumer, his or her guardian, or parent of a minor child at the time of: · Request for service,· When agreement is reached on an individual plan of service· When services are reduced, suspended or deniedThe local appeal and grievance processes include 3 informal processes:
There are 4 formal local grievance and appeal processes:
B. Evidence includes:
|
| Citation #: 1.2.10.3 |
Administrative Hearings |
Affiliation Agreement/Status and Evidence:
|
B. Evidence will include the performance indicators, quarterly reports, and minutes of the local Member Services committee meeting, the local QI Steering Committee minutes and the Affiliation Quality Management Council Meeting minutes
| Citation #: 1.2.10.4 |
Use of information from the complaints to improve the service. |
Affiliation Agreement/Status and Evidence:
In addition to data on recipient rights complaints, the affiliates will use standardized methods to father data on all other complaint processes. The complaint data will be analyzed each quarter by the local Member Services Committee, a committee of the Quality Improvement Steering Committee. Based on the analysis of the data, the Member Services Committee will make recommendations to improve the appeal and grievance process or the service delivery system of the CMH. Local appeal and grievance data along with any recommendations will be shared with Affiliation Quality Management council. this will allow affiliate member to identify possible process improvement opportuniti4es as well as to compare the data with the other affiliate and identify best practices. B. Evidence will include the performance indicators, quarterly reports, and minutes of the local Member services Committee meeting, the local QI Steering Committee minutes and Affiliation Quality Council Meeting minutes. |
| Citation #: 1.2.11 |
|
| 1.2.11.1 |
|
| Affiliation Agreement/Status and Evidence: A. The Affiliation has established standardized policies and procedures to address the reporting, review and follow-up for each occurrence of a sentinel event. Every sentinel event will have a root cause analysis to examine the current process(es) involved in the event, if the current process design was followed when the event occurred and if so, what improvements will be made to prevent reoccurrences of the event. The Medical Director is included in the formulation of recommendations for changes in order to prevent reoccurrences. Sentinel Events are reported to Michigan Department of Community Health and accrediting bodies as required. The affiliates have established standardized performance indicators for Sentinel Events. B. Evidence includes policies and procedures, Sentinel event reports, Sentinel event quarterly performance indicator data with analysis of the data and recommendations for prevention of future occurrences |
| CMH-CEI Specific Status and Evidence: A. Sentinel events are reported on a sentinel event reporting form to the Department of Quality, Customer Service and Recipient Rights and may also be identified on peer review quality assurance forms. Sentinel events are analyzed through root cause analysis which is co-chaired by the Medical Director and the Director of Quality, Customer Service and Recipient Rights. Aggregate data and recommendations developed from the root cause analysis are reported to the QI Steering Committee. B. Evidence includes policy and procedure, Sentinel Event Reporting Form, root cause analyses, Sentinel Event quarterly performance indicator data and minutes of the QI Steering Committee. |
| Gratiot CMH Specific Status and Evidence: A. Sentinel Events are reported through the Office of Recipient Rights. The Medical Director is involved in the root cause analysis. Aggregate data and recommendations developed from the root cause analysis are reported to the QI Steering Committee. B. Evidence includes policies and procedures, Sentinel event reports, Sentinel event quarterly performance indicator data with analysis of the data and recommendations for prevention of future occurrences. |
Ionia CMH Specific Status and Evidence:
|
| Newaygo CMH Specific Status and Evidence: A. Newaygo has a policy and procedure on Sentinel Events. Sentinel Events are reported through the Office of Recipient Rights. The Medical Director is involved in the root cause analysis. Aggregate data and recommendations developed from the root cause analysis are reported to the QI Steering Committee. B. Evidence includes the policy and procedure. |
| Citation #: 1.2.11.2 |
health and safety critical incidents |
Affiliation Agreement/Status and Evidence:
|
The data for the common indicators will be collected, reviewed and analyzed quarterly through each affiliate’s QI process with recommendations for improvement. Affiliate reports and recommendations will be reviewed by the Quality Management Council, the affiliation QI oversight body.
| CMH-CEI Specific Status and Evidence: A. CMH-CEI has policies and procedures for reporting of health and safety critical incidents through a peer review, quality assurance indicator process. Incidents are reported on a quality assurance/indicator reporting form. The record of an incident is recorded on the form and is reviewed by designated responsible staff for comment and recommendations. The completed form is channeled to the Department of Quality customer Service and Recipient Rights where it is logged into a data base. The aggregate data by type of incident is reported quarterly to the QI sub-committee on Health, Safety, Medication and Infection Control. The Committee analyses the data and makes recommendations for prevention or process improvement to the QI Steering Committee. The QI Steering Committee reviews the recommended actions and supports implementation. B Evidence includes the QI plan, quality assurance indicators reports and logs. Quarterly reports of data and analysis as well as recommendations can be viewed on the Intranet, an internal resource . |
Gratiot CMH Specific Status and Evidence:
|
| Ionia CMH Specific Status and Evidence: A. Ionia has a policy and procedure which addresses Health and Safety Critical Incidents. Health and Safety Critical Incidents are recorded and tracked through Customer Service as well as through Quality Improvement. The QI-Health and Safety Committee reviews all reports and determines if protocols need to be established or any further action needs to be taken to reduce future incidents. B. Evidence includes policy and procedure, Chapter III, Section 003, Subject 002, and health and safety critical incident logs. |
| Newaygo CMH Specific Status and Evidence: A. Newaygo has policy and procedure which address Health and Safety Critical Incidents. All health and safety critical incident reports are reviewed at all levels of the management team. Improvement plans are developed and monitored for success. B. Evidence includes: policy and procedure and health and safety critical incident logs. |
1.2.12 Review the applicant’s provisions for:
1.2.12.1 crisis stabilization and response services
Status of CEI: Crisis stabilization and response is provided by CEI’s 24 hour Emergency Services program and three Crisis Response Teams (CRT), located in each of CEI’s three counties.
Evidence: ES and CRT program Contact Logs, ES and CRT Crisis Intervention data reports. Crisis Response Team Level of Care Criteria, 7.1.3.1.
Status of Gratiot County CMH: The agency maintains a 24-hour, 7 days a week Crisis Response Team. Response time is evaluated quarterly and typically occurs within ten minutes. In addition, Nursing Services is on call after-hours and weekends to meet the needs of individuals with developmental disabilities. The agency also has several staff trained in Critical Incident Stress Debriefing and recently hosted a two-day Critical Incident Stress Debriefing in-service available to the community.
Evidence: Emergency Services Contact Forms, Progress Notes, Nursing Notes, Emergency Services & RN Services On-Call Schedule, Training Records.
Status of Ionia: A 24-hur crisis line is available to consumers and the community at large in compliance with the Michigan Mental Health Code. Crisis stabilization and response is directly provided by Ionia CMH staff.
Evidence: ICCMH Policy and Procedure: Chapter III, Section 002, Subject 002
Satus of Newago:
1.2.12.2 Pre-admission Screening Unit(s)
Status of CEI: Pre-Admission screening is available 24/7 via CEI’s Emergency Services (ES). ES staff work closely with hospital emergency rooms, law enforcement agencies and courts. ES staff conduct crisis intervention, pre-admission screening for adults and children, and assistance with the involuntary commitment process.
Evidence: Michigan Mental Health Code, primarily sections 4 and 7, ES Procedure Manual including procedure for voluntary and involuntary pre-admission screening, Adequate Notice and 2nd Opinion, Restraints. On-Call psychology and psychiatry schedules, ES Phone/Face Contact Logs and reports, ES data reports, Pre-admission Screening Report Within 3 Hours.
Status of Gratiot County CMH: The agency collaborates with local hospitals to provide 24-hour pre-admission screening. Most consumers are seen first in the Emergency Room. The Emergency Services staff typically respond to these crisis calls within 30 minutes or less. Our Emergency Services unit is trained to conduct pre-admission screenings.
Evidence: Staff Training Records, Completed Pre-Admission Screen Forms.
Status of Ionia: Ionia is in compliance with the M Mental Health Code. ICCMH pre-admission screening unit consists of the Access staff during work hours and the on-call therapists after-hours. All hospitalizations must be reviewed/authorized by Access staff. Ionia follows the level of care guidelines-utilization management criteria, in patient psychiatric and partial hospitalization services as identified in the current DCH contract.
Evidence: ICCMH policy and Procedure, Chapter III, Section 002, Subject 002
Status of Newago:
1.2.12.3 Children’s diagnostic and treatment program
Status of CEI: Pre-Admission screening for Children is available 24/7 via CEI’s Emergency Services Program as listed in 1.2.12.2.
Evidence: Michigan Mental Health Code, primarily sections 4A and 7, After-hours Hospitalization of Children, Adequate Notice and 2nd Opinion, Restraints,. ES Phone/Face Contact Logs and reports. ES data report, Pre-admission Screening Report Within 3 Hours.
Status of Gratiot County CMH: The agency operates a certified Children’s Diagnostic and Treatment
Program. Two Board Certified Child Psychiatrists provide psychiatric services.
Evidence: MDCH Certification, MDCH On-site Review, CAFAS scores, consumer charts, Service
Provider Contracts.
Status of Ionia: Ionia CMH is certified by DCH as a Children’s Diagnostic and Treatment Service Center as Defined in the Michigan Mental Health Code.
Evidence: Certification from DCH; ICCMH policy Chapter III, Section 004, Subject 001
Satus of Newago:
1.2.13. Assess cultural and ethnic characteristics of the service area, and
| 1.2.13.1. efforts to ensure culturally appropriate and competent services Affiliation: The Affiliation’s Cultural Competence Plan provides an analysis of the strengths and weakness of the Affiliation, relative to a number of standards on cultural and linguistic competence. This plan is modeled after the with the Cultural Competence Standards in Managed Care Mental Health Services; Center for Mental Health Services; Substance Abuse and Mental Health Service Administration, U.S. Department of Health and Human Services, 2000. should this apply to the full Affiliation ? Gratiot: Ionia: 1. Ionia County has no minority populations which equal two percent of the
Evidence: 1. 2000 Census Report
ICCMH Policy and Procedure: Chapter II, Section 005, Subject 003 ICCMH Policy and Procedure: Chapter IV, Section 003, Subject 006
Newaygo: Newaygo county has a population of less than 2% non-white. The population is predominately white middle class (a bedroom community to Grand Rapids) and poor.
|
2000 Census (Tri-County Region) |
CEI Consumer Demographics (Most Recent Year: FY 2001) |
|||
Count |
Percentage |
Count |
Percentage |
|
| African-American | 36,335 | 8.1% | 1,665 | 16.1% |
| American Indian | 2,087 | 0.5% | 61 | 0.6% |
| Arab American | * | 13 | 0.1% | |
| Asian | 11,810 | 2.7% | 81 | 0.8% |
| Hispanic | ** | 4.7% | 440 | 4.3% |
| Multi-Racial | 10,928 | 2.4% | 125 | 1.2% |
| Unknown/Refused | 8,473 | 1.9% | 491 | 4.7% |
| White | 378,095 | 84.4% | 7,461 | 72.2% |
| Total (of race categories only) | 447,728 | 100% | ||
| Total (When Hispanic,as a category is added to the total) | 104.7% | 10,337 | 100% | |
*Not a category in 2000 census.
** Persons of Hispanic origin made up 4.7% of the population. Hispanic origin was recorded, by each census respondent, in addition to race category
. Evidence includes:
| 1.2.14. Identify jail diversion policies and activities for the period from 10-01-98 through 09-30-01 |