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Sixteen State Pilot Study State Mental Health Agency Performance Measures

Draft Operational Measure Definitions

February 27, 2001

Prepared by the National Association of State Mental
Health Program Directors Research Institute, Inc.

Draft: please send corrections or additions to Ted Lutterman (NRI)– 703-739-9333 ext 21 (p), 703-548-9517 (f), or ted.lutterman@nasmhpd.org (e-mail).

February 2, 2001

Draft Operational Definitions for the Performance Indicators tested by the Sixteen-State Indicator Pilot Study

These are the data definition and table shells that the Sixteen States are currently using for the Sixteen-State Pilot Study on State Mental Health Agency Performance Measures. These definitions and table shells were developed cooperatively by the States, the National Association of State Mental Health Program Directors Research Institute (NRI) and CMHS over the past two and a half years.

Please contact either Ted Lutterman at the NRI (phone:703-739-9333 ext 21 or e-mail: ted.lutterman@namshpd.org) or Olinda Gonzalez at CMHS (phone 301-443-2849 or e-mail at ogonzale@samhsa.gov)

NASMHPD Framework of Mental Health Performance Indicators

Domain: Access

Initial Set:
A1 Penetration/Utilization rates (by age, sex, race, setting)
A2 Consumer perception of access

Developmental Set:
A3d Average time to first service
A4d Denial of care
A5d Homeless & rural access

Domain: Quality/Appropriateness

Initial Set:
Q1 Consumer participation in treatment planning (Adults)
Q2 Consumers linked to primary health services
Q3 Contact within 7 days following hospital discharge
Q4 Consumer perception of Quality/Appropriateness

Adults w/ SMI receiving effective services:
Q5 adults receiving assertive community treatment "ACT"
Q6 adults in supported employment
Q7 adults in supported housing
Q8 adults receiving new generation "atypical" medications

Children receiving "Best Practice"
Q9 For example, children receiving in-home services)

Q10 Family Involvement in treatment for Children/Adolescents
Q11 Readmissions within 30 days
Q12 Seclusion
Q13 Restraint
Q14 Medication errors

Developmental Set
Q15d Follow-up after emergency services
Q16d Family involvement in treatment (Adults)
Q17d Screening for TB, HIV, etc

Domain: Outcome

Initial Set:
O1 Consumer perception of Outcomes
O2 School Improvement (Children)
O3 Employment (adults)
O4 Functioning
O5 Symptom relief

Adverse outcomes:
O6 Consumer injuries
O7 Elopement
O8 Out of home placements

O9 Health status: mortality
O10 Recovery/Hope/Personhood (surrogate measures)
O11 Reduced substance abuse impairment
O12 Living situation
O13 Criminal Justice

Developmental Set
O14d Recovery/Personhood/Hope
O15d Abnormal Involuntary Movements (AIMS)

Domain: Structure/Plan Management

Initial Set
S1 Consumer/Family member involvement in policy development, quality assurance & planning
S2 Proportion of expenditures on administration
S3 Per member per month/average resources spent for MH

Developmental Set
S4d Stakeholder satisfaction
S5d Cultural competence

Domain: Early Intervention/Prevention

Initial Set
None

Developmental Set
P1d Substance abuse screening
P2d Use of self-help/self-management
P3d Identification of high risk populations
P4d Psycho-educational programs

INDICATOR: A1. PENETRATION/UTILIZATION RATES

RATIONALE FOR USE: This indicator addresses the fundamental issue of whether persons with mental illnesses are receiving mental health services and whether the system is responsive to various consumer populations. In managed care settings, penetration rates have been reported for Medicaid managed care ranging from 1% to 7%. Benchmarks clearly need to be established for various subpopulations. In non-managed care settings, similar benchmarks are needed, but comparisons across states may be confounded by the different types of populations for which a state mental health authority is responsible. However, comparisons across subpopulations areas would be informative.

APPROACH TO MEASURE: The basic construct of this measure is to reflect the proportion of persons in the population or sub-population that is receiving services. For an enrolled population, the denominator is easily defined. The denominator for a more general population is more problematic. In this situation, the general population is recommended.

Penetration rates can be computed for various demographic breakouts, for various service categories and for different diagnostic groups. The workgroup has developed a general table from which different penetration rates can be computed. For the diagnostic and service categories, the denominators recommended are the state population.

MEASURE(S): For break-outs by age (0-12, 13-17, 18-30, 31-45, 46-64, 65-74, 75+), ethnicity (white, African-American, Asian or Pacific Islander, Native American, Hispanic), gender, diagnosis (see attached table), adults with a serious mental illness or children with a serious emotional disturbance, and setting (inpatient and community services). See attached Tables 1 and 2 for recommended categories.

Numerator: Unduplicated number of persons (in category) served during the year: Information is reported for State Fiscal Year 2000 for patients in:

1. the total unduplicated number of people served by state hospitals in each state, and
2. Community MH programs--Some work remains to define what is reported on the community system. At a minimum, states should report on all state operated and/or state funded community MH programs

Denominator: State population in each of the standard Sixteen State reporting categories (age, sex, race/ethnicity). For diagnosis, the denominator is currently the total state population.

CURRENT IMPLEMENTATIONS STATUS: Most of the 16 State Study states have reported data on utilization rates for state psychiatric hospitals and are currently reporting data for community mental health programs.

If States are not able to report precisely in these categories, please report in the categories for which you have data. The raw data are available for individuals or states that wish to conduct more detailed analyses.

SOURCES OF DATA: Administrative data, enrollment data.

POPULATIONS:
Children with a Serious Emotional Disturbance
Adults w/ a Serious Mental Illness
All Children
All Adults
Geriatric

SETTINGS:
Psychiatric Inpatient Settings
Community-based Settings

Workgroup Chair: John Pandiani (Vermont)

TABLE 1: Utilization by Component FY:_______

INDICATOR: A2 CONSUMER PERCEPTION OF GOOD ACCESS

RATIONALE FOR USE: Timely and convenient access to services are major values of the public mental health system and are major factors in ensuring that persons receive needed services.

APPROACH TO MEASURE: The important aspect is to obtain the consumer perspective through a confidential, self-report mechanism. A consumer survey is recommended. While penetration rates are a good systemic indicator of access, particular problems and barriers are difficult to identify. The approach inherent in this indicator is: " Ask the consumer." It is a customer-oriented indicator.

MEASURE(S): The important aspect is to obtain the consumer perspective on aspects of the accessibility of services received through a confidential, self-report mechanism. A consumer survey is recommended.

The expectation is that an annual, cross-sectional survey of consumers be conducted that includes an assessment of consumers' perception of their access to services. Given the widespread use of the MHSIP Consumer Survey by public mental health systems and consideration being given to its adoption by the private sector, it is recommended that this instrument be used.

1. The location of services was convenient.
2. Staff were willing to see me as often as I felt it was necessary.
3. Staff returned my calls within 24 hours.
4. Services were available at times that were good for me.

1. Recode ratings of "not applicable" as missing values.
2. Exclude respondents with more than 1/3rd of the items missing.
3. Calculate the mean of the items for each respondent.
4. Calculate the percent of scores less than 2.5. (percent agree and strongly agree).
   
   Numerator: Total number of respondents with an average scale score 2.5.
   
   Denominator: Total number of respondents.

CURRENT IMPLEMENTATION STATUS: Many of the states participating in the 16 State Study are implementing a version of the MHSIP Consumer Survey.

SOURCES OF DATA: Consumer Survey: recommended measure: MHSIP Consumer Survey -- short or long versions.

POPULATIONS:
Children with a Serious Emotional Disturbance
Adults w/ a Serious Mental Illness
All Children
All Adults
Geriatric

SETTINGS:
Psychiatric Inpatient Settings
Community-based Settings

Workgroup Chair: Judy Hall (Washington)

QUALITY/APPROPRIATENESS

INDICATOR: Q1 PERCENTAGE OF CONSUMERS THAT ACTIVELY PARTICIPATE IN DECISION MAKING REGARDING TREATMENT. (From MHSIP Consumer Survey)

RATIONALE FOR USE: Participation by consumers (and family members for children) in decisions regarding treatment fosters a collaborative, trusting relationship and supports the consumer's (or family member's) ability to make decisions and act responsibly. Both for health and mental health services, research indicates that such involvement is correlated with positive outcomes.

APPROACH TO MEASURE: The important aspect is to obtain information from the consumer regarding both active involvement in treatment decision-making and definition of treatment goals. This should be a consumer self-report measure and assess whether the desires of the consumer are considered in treatment planning.

MEASURE(S): The workgroup recommends that this indicator be calculated using information collected directly from consumers and their families. From the MHSIP Report Card Consumer Survey, responses to the following items will be combined to create this measure:

• I, not staff, decided my treatment goals
  
• I felt comfortable asking questions about my treatment and medication

1. Recode ratings of "not applicable" as missing values.
2. Exclude respondents with more than 1/3rd of the items missing.
3. Calculate the mean of the items for each respondent.
4. Calculate the percent of scores less than 2.5. (percent agree and strongly agree).

Numerator: Total number of "agree" or "strongly agree" responses (i.e.,# items marked agree or strongly agree across all respondents).

Denominator: Total number of possible responses (i.e., # respondents x 2 items) minus the number of missing values.

CURRENT IMPLEMENTATION STATUS: Many of the states participating in the 16 State Study are implementing a version of the MHSIP Consumer Survey.

SOURCES OF DATA: Consumer Survey: recommended measure: MHSIP Consumer Survey -- short or long versions.

POPULATIONS:

SETTINGS:

ISSUES: The items in the MHSIP report card are indirect measures of involvement or participation in treatment planning.

Some consumers (especially in state psychiatric hospitals) may choose to not participate in treatment planning.

INDICATOR: Q2. PERCENTAGE OF CONSUMERS LINKED TO PHYSICAL HEALTH SERVICES. (Was consumers linked to "Primary health care")

RATIONALE FOR USE: People with mental illness have relatively poor access to general healthcare. This often compounds their mental health problems and makes recovery difficult. Also, persons with serious mental illness are under served in medical care systems and have higher mortality rates due to medical causes.

APPROACH TO MEASURE: The important aspect of this measure is whether the person with mental illness has had a face-to-face contact with a doctor or nurse primary care physician and not just whether the consumer has access to such a doctor or nurse physician . Ideally, the measure should address whether the consumer has had an annual physical exam but this was considered too problematic from a technical perspective.

The measure could be obtained from administrative management information systems or from a consumer self-report. The 16 State Study Workgroup on this indicator is recommending several potential survey questions. Any states preparing a survey - please use the recommended (2) questions.

Measure: The proportion of persons with emotional disturbances/mental illnesses surveyed during a year, who had a face-to-face contact with a doctor or nurse.

Numerator: The number of persons surveyed with emotional disturbances/mental illnesses who had at least one face-to-face contact with a doctor or nurse in the last year.

Denominator: Number of persons with emotional disturbances/mental illnesses surveyed who received a mental health service in the last year.

Note: Reporting states are currently asking one or more of the following questions –

• "In the last year, did you see a doctor or a nurse for a health check-up or because you were sick?"
  Yes / No / Do not remember
• "Other than going to a hospital emergency room, did you see a medical doctor in the past year?"
  Yes / No / Do not remember
• "Have you had a complete physical exam, including annual screening tests in the past 12 months"?
  Yes / No / Do not remember

Future recommended survey questions if we want to focus on non-emergency room contact per the preference stated in the President's Task Force Report (The Report also focuses on ‘primary care physician' – however no states are currently using this language, so the preference is to simplify with doctor/nurse):

• "In the last year, did you (your child) see a doctor or nurse in a hospital emergency room?"
  Yes / No / Do not remember
• "In the last year, other than going to a hospital emergency room, did you (your child) see a doctor or nurse for a health check-up, physical exam or because you were sick?"
  Yes / No / Do not remember

Recommended Plan: Include the two above questions on the MHSIP Consumer Survey and the Child/Family Survey (with slight wording modification for the family survey).
Note…in addition, a few states are looking at Medicaid claims data to address this indicator.

CURRENT IMPLEMENTATION STATUS: ??

SOURCES OF DATA: Consumer response to questions added to MHSIP Survey or Analysis of Medicaid claims data for Medicaid eligible consumers.

POPULATIONS:

SETTINGS:

Workgroup Chair: Deb Kupfer, Colorado Mental Health Services

INDICATORS: Q3 CONSUMERS ARE CONTACTED BY COMMUNITY PROVIDERS WITHIN 7 DAYS OF STATE HOSPITAL DISCHARGE

RATIONALE FOR USE: Continuity of care is critical to avoid recurrence of symptoms and to move the process of recovery forward.

APPROACH TO MEASURE: The important aspect of this measure is to monitor continuity of care in the period following a hospital discharge. Some systems may not be able to obtain follow-up information from all community providers. If this is the case, the measure should focus on follow-up among a pre-defined subset of providers.

MEASURE: Contacts should be a face-to-face contact occurring in a consumer's family's home, school, place of employment, or clinic between a consumer and a psychiatrist, other mental health professional, or case manager; no forensic/drug/alcohol or domestic violence contacts should be included.

Discharge is an event, (that is to say, count all discharges; do not count a patient with multiple discharges as one discharge). Outpatient Service is a contact to the CMHC's only. Inpatient Hospitalization is for a state psychiatric hospital in which only planned discharges are included; no leave releases, AWOLs or transfers should be included. If someone is "discharged from pass," then the date of the "discharge" should then be the first date of the pass."

The data for the 0-7 days time period is the minimum dataset to report; data for additional time periods may be reported and will be compiled for comparison. for the "29-_____ " time period, please indicate the extent of your state's collection by filling in the blank (i.e., 29-60 days or 29-730 days).

Numerator: Total number of persons discharged from any acute care or long-term care state psychiatric hospital who receive at least one face-to-face contact within seven days with a community mental health center.

Denominator: Total number of persons discharged from any acute care or long-term care state psychiatric hospital.

Definitions:

Discharge: Released from the hospital (or other facility) without contingency; excludes those who are released on leave, who leave without consent, or who are transferred.

Outpatient service: Any outpatient contact occurring in a consumer's/family's home, school, place of employment, or clinic between a consumer and a psychiatrist, other mental health professional, or case manager.

Inpatient Psychiatric Services:
Psychiatric services provided on an inpatient basis within any acute care or long-term care state psychiatric hospital.

Comments: The indicator references services provided to an individual who has been discharged from a long-term or short-term care state psychiatric hospital. Information on discharges from psychiatric units of general hospitals or non-state or county-operated psychiatric hospitals may not be available in all states and are therefore not included in this data collection.

CURRENT IMPLEMENTATION STATUS:

POPULATIONS:

SETTINGS:

SOURCE OF DATA: Management information systems or aggregate reports

Workgroup Leader: Tracy Leaper, Oklahoma

INDICATORS: Q4 CONSUMER PERCEPTION OF THE QUALITY/APPROPRIATENESS OF SERVICES

RATIONALE FOR USE: Research suggests that a positive therapeutic relationship results in positive outcomes. The sensitivity to and respect for the consumer, the collaborative connection between the consumer and the therapist, and the consumer's perception of the competence of staff and the quality of care are factors which will determine the consumer's willingness to remain in treatment.

APPROACH TO MEASURE: The important aspect is to obtain the consumer perspective on the quality and appropriateness of the services received through a confidential, self-report mechanism. A consumer survey is recommended. The approach inherent in this indicator is: "Ask the consumer." It is a customer-oriented indicator.

MEASURE: The important aspect is to obtain the consumer perspective on the impact of the services received through a confidential, self-report mechanism. A consumer survey is recommended. Given the widespread use of the MHSIP Consumer Survey by public mental health systems and consideration being given to its adoption by the private sector, it is recommended that this instrument be used. If the MHSIP Consumer Survey is used, perception of the quality of services will be measured by responses to the following items:

1. My caregivers believed that I could grow, change and recover.
2. I felt free to complain.
3. I was told what side effects to watch for.
4. My wishes about who is and is not to be given information about my treatment were respected.
5. My caregivers were sensitive to my cultural/ethnic background.
6. My caregivers helped me obtain the information needed so I could take charge of managing my illness.

Scoring:

1. Recode ratings of "not applicable" as missing values.
2. Exclude respondents with more than 1/3rd of the items missing.
3. Calculate the mean of the items for each respondent.
4. Calculate the percent of scores less than 2.5. (percent agree and strongly agree).

Numerator: Total number of respondents with an average scale score < 2.5.

Denominator: Total number of respondents.

CURRENT IMPLEMENTATION STATUS: Many of the states participating in the 16 State Study are implementing the a version of the MHSIP Consumer Survey.

SOURCES OF DATA: Consumer Survey: recommended measure: MHSIP Consumer Survey -- short or long versions.

POPULATIONS:
Children with a Serious Emotional Disturbance
Adults w/ a Serious Mental Illness
All Children
All Adults
Geriatric

SETTINGS:
Psychiatric Inpatient Settings
Community-based Settings

INDICATOR: Q5: PERCENTAGE OF ADULTS WITH A SERIOUS MENTAL ILLNESS RECEIVING ASSERTIVE COMMUNITY TREATMENT SERVICES

RATIONALE FOR USE: This an example of an innovative program model designed to meet the needs of persons who are seriously mentally ill. States are expected generally to plan for the development of such innovative programs as alternatives to inpatient services when warranted. The workgroup recognizes that not all states offer assertive community treatment programs, and that not all persons with serious mental illness necessarily need such services, however research has demonstrated the effectiveness of these services for many consumers.

APPROACH TO MEASURE: This measure - with the other exemplary services - is intended to reflect quality and appropriateness by monitoring the extent of the implementation of these services. Monitoring this measure in conjunction with inpatient penetration rates or for persons with a history of inpatient services could also prove useful. The 16 State Study workgroup has developed a brief survey that is being used to assess the extent to which a program meets criteria to be included as an "Assertive Community Treatment" (ACT) program.

MEASURE(S): Although many states have services they describe as "assertive community treatment", these services may be conceptualized and operationalized differently. A recommended survey to help operationalize ACT is included below.

Numerator: The number of consumers with severe mental illness receiving assertive community treatment.
Denominator: Total number of persons served in the community 18 and older, with a serious mental illness (Unduplicated).

POPULATIONS:
Children with a Serious Emotional Disturbance
Adults w/ a Serious Mental Illness
All Children
All Adults
Geriatric

SETTINGS:
Psychiatric Inpatient Settings
Community-based Settings

ISSUES: Highlighting these services in the performance measurement system will not only help establish benchmarks but will also promote these services.

Workgroup Chair: John McGrew (Indiana)

ASSERTIVE COMMUNITY TREATMENT PROGRAM INFORMATION State______________ Contact person______________________ Phone____________________ Name of program_______________________________________ Date information collected _____/_____/_______ Program setting (e.g., rural, urban, mixed)________________ Date ACT program started __________________ Percent of ACT caseload with SMI ___________ ACT team caseload size:____________________
Number items fully met	Assertive Community Treatment Checklist Componet Created by John McGrew, adopted from Critical Components of Assertive Community Treatment Interview and Dartmount Assertive Community Treatment Survey
___/4=______ score	ACT programs use a team approach for treatment as defined by: [  ] team size of at least three FTE staff/members (at least half of the staff are full-time, i.e., NOT part time) Enter team size using all full time equivalent staff _______ Enter defination used for full-time worker (e.g., 40 hours/week) _______ hours/week [  ] shared caseloads for treatment planning (all staff involved in treatment planning for all clients) [  ] shared caseloads for treatment provision (all staff can & do see all clients-also see brief definations) [  ] daily team meetings attended by all members.
___/3=______ score	The ACT team makeup is: [  ] multidiciplinary (e.g., some combination of mental health counselors, case workers, social workers, vocational counselors, substance abuse counselors) and must include: [  ] a full-time registered nurse or equivalent (at least 70% of time dedicated to ACT) as a member of team [  ] a psychiatrist available to the team at least 12 hours per week for every 50 clients on the caseload.
___/3=______ score	The team assumes ultimate clinical responsibility for the client [  ] as a philosophy (i.e., the "buck stops here", a single point of entry to services), [  ] organizationally (e.g., team designated as primary therapist of record) [  ] as primary provider of treatment (i.e., treatment is NOT brokered to other services).
___/3=______ score	Intesive treatment as defined by: [  ] individualized treatment (treatment not based on a menu of standardized treatments/programs, treatment plans/goals/contacts are designed/executed to fit the unique needs of each individual) [  ] easily available when needed (clients can quickly and easily make contact with team members, either brokered thru crisis team or directly, anytime 24 hours a day, 7 days a week} [  ] appropriately intensive (average of at least 2 contacts per week per client).
___/3=______ score	ACT team members continue to maintain close involvement with client's treatment when hospitalization is required: [  ] coordinate closely with hospital personnel concerning all hospital admissions (at least 65% of admissions) [  ] coordinate closely with hospital personnel concerning all hospital discharge decisions/plans (at least 65% of discharges) [  ] continue to stay in contact with clients when they are in the hospital (at least 65% of clients).
___/5=______ score	The ACT team maintains a primary treatment focus on supporting clients to live successfully in the community including assistance with: [  ] obtaining basic needs/entitlements (e.g., SSI/SSDI, welfare, HUD waivers, housing, food, medicaid, etc.) [  ] medication/symptom management (e.g., monitor systems, help insure medication compliance) [  ] living skills (instructions or help in ADLs, IADLs) [  ] increasing overall quality of life (e.g., client satisfaction in broad array of life domains--financial, housing, relationships, family, vocations, recreational, health, etc.) [  ] increasing community tenure (e.g., focus on maintaining client in community NOT hospital).
___/2=______ score	Participative treatment model: [  ] clients are fully involved in treatment planning (client assumes at least 50% of responsibility for treatment decisions) [  ] the team consults/works with family/significant others when appropriate (average 1 contact every 2 weeks)
___/2=______ score	The ACT treatment team is assertive in: [  ] engaging clients in treatment and [  ] retaining clients (e.g., 15 mos of refusals before stopping attempts to engage/retain).
Score 1 if fully met, 0 otherwise
	ACT team has a designed team leader/coordinator who provides direct services to clients on ACT team and whose responsibilities are limited to ACT team.
	The majority of treatment contacts occur in the home or community (minimum of 60%), NOT in the office.
	The ACT team has a small client:staff ratio. Client:staff ratio no greater than 15:1.
	The ACT team successfully engages and retains clients (at least 80% retained over a 12-month period)
	Clients never discharged from the ACT team, although when appropriate, clients may "graduate" to less intensive services graduation typically limited to less than 10% clients per year, no credit if > 20% per year.
	Admission to the ACT team is reserved for clients with severe and persistant mental illness meeting specific admission criteria, especially targeting clients who require more intensive services (e.g., homeless, co-occuring substance abuse, history of frequent hospital use).

Identify putative ACT sites and the clinical director of the identified ACT team.

• Mail or otherwise deliver copies of the checklist to the clinical director. The clinical director should then attempt to fill out the checklist to the best of his/her capability working from records and consulting with other team members as needed.
• Arrange a time to call the clinical director to go over his/her responses to the checklist items. During the phone call go over each item and ask the director his/her understanding of the item. After insuring that the clinical director correctly understood the item, then ask for his/her rating of the item. Also ask the director to identify his/her data source for making the item rating (best guess, team records). Inform the clinical director of any discrepancies in the use of the checklist. If you identify a discrepancy in the use of the checklist that may have affected an item rating, try to come to an agreement with the clinical director in the understanding of or in the rating of the item. However, your judgment, and not that of the clinical director, should take precedence in the final rating.
• All items and subparts of items are to be rated as either present or absent. If a program cannot fully meet the criteria contained within an item it should be given a score of 0 on that item or subpart.

ACT Brief Definitions
Full time equivalent - one FTE unit refers to 40 hours per week or more of full-time responsibilities dedicated to the ACT team. However, the definition of full-time may vary by state, such that 35 hours may be considered full-time in some locales. An FTE may be satisfied by one person working full-time or two or more part time employees whose hours sum to at least 40 hours (may replace 40 hours with the local standard for full-time work).

Shared caseloads - indicates that all team members are involved in the direct provision of services (one item) or treatment planning (second item) for all clients. For shared caseloads for service provision, a rule of thumb here is that at least 90% of caseload has contact with more than one staff member during a two week period.

Multidisciplinary - by definition to be multidisciplinary the team cannot be made up exclusively of one type of practitioner (e.g., all general caseworkers) or one degree credential (e.g, all nurses, all social workers, all MS in psychology ).

Ultimate clinical responsibility -

1. as a philosophy means that ACT team sees itself as the entity that must take responsibility for the client's care, both proactively and if necessary reactively;
2. organizationally means that ACT team is the designated entity with primary responsibility for the client's treatment within the organization;
3. as primary provider means that in addition to case management and psychiatric services team provides most needed services, as a rule of thumb at least 3 of following services - counseling/psychotherapy, housing support, substance abuse, employment, rehabilitation services

1. hospital admissions, at least 65% of admissions initiated by team,
2. hospital discharges, at least 65% of discharges done in cooperation with team

1. Clients fully involved , at least 50% of responsibility for treatment decisions rest with client
2. Team consults with family, team averages one contact every two weeks with client's support system

INDICATOR: Q6:PERCENTAGE OF ADULTS WITH A SERIOUS MENTAL ILLNESS RECEIVING SUPPORTED EMPLOYMENT

RATIONALE FOR USE: Evidence-based services that promote long-term recovery should be important component of any system that serves people with serious mental illness. The workgroup recognizes that not all states offer Supported Employment programs, and that not all persons with serious mental illness necessarily need such services, however research has demonstrated the effectiveness of these services for many consumers.

APPROACH TO MEASURE: This measure - with the other exemplary services - is intended to reflect quality and appropriateness by monitoring the extent of the implementation of these services.
The 16 State Study workgroup has developed a brief survey that is being used to assess the extent to which a program meets criteria to be included as a "Supported Employment" (SE) program.

MEASURE(S): Although many states have services they describe as "supported employment", these services may be conceptualized and operationalized differently. A recommended survey to help operationalize SE is included below.

MEASURE:

Numerator: The number of consumers with severe mental illness receiving supported employment services.

Denominator: Total number of persons served in the community 18 and older, with any serious mental illness (Unduplicated).

It is recommended that some standardized method be used for identifying consumers to be counted in the numerator. The 16 State Study Workgroup on ACT and SE is currently testing an instrument to measure the fidelity of a program to ACT standards. The survey is attached below.

CURRENT IMPLEMENTATION STATUS:

SOURCE OF DATA: Management Information Systems, Medicaid data

POPULATIONS:

SETTINGS:

ISSUES:

Workgroup Chair: John McGrew (Indiana)

SUPPORTED EMPLOYMENT PROGRAM INFORMATION State______________ Contact person__________________ Phone________________ Name of program_______________________ Date information collected ___/___/___ Program setting (e.g., rural, urban, mixed)_________ Date SE program started _____________ Percent of SE caseload with SMI _________ SE team active caseload size (i.e.,receiving services):________ Total number of persons with SMI in SE catchment area ________
Number fully met	Supported Employment Checklist Component Created by John McGrew, adapted from Quality of Supported Employment Implementation Scale
___/4=______ score	SE programs use a team approach for treatment as defined by: [  ] team size of at least three FTE members (e.g., employment specialists, job coach) Enter team size using number of full time equivalent staff ____ Number who are Full time ____ Enter definition used for full-time worker (e.g.,40 hours /week) ____ hours/week [  ] team forms a distinct vocational unit, with shared office space (see brief definitions) [  ] team shares caseloads for treatment planning (all members participate in treatment planning for all clients), provides backup/support to other team members for treatment provision [  ] regular team meetings (ES's meet as group with supervisor at least weekly)
___/4=______ score	SE services are integrated with clinical treatment services [  ] Ideally, single agency provides both treatment and vocational services at same location, minimum requirement is that there is a single agency but different locations for treatment and vocational services [  ] All ES's (ideally, but one team member at a minimum), regularly attend clinical treatment team meetings at least once/week [  ] ES have frequent contact with treatment team (one contact/week-minimum) [  ] Vocational and treatment team records are integrated (kept in same file)
___/2=______ score	Employment specialists (ES) provide continuous, intensive, vocational services [  ] ES is responsible for carrying out all vocational services from intake through follow-along (vocational services are not brokered to other agencies or persons outside SE team) [  ] ES responsibilities are limited to vocational services (i.e., at a minimum less than 30% of ES time spent on non-vocational services, excluding work necessary to support vocational services, for example, paperwork).
___/2=______ score	Clients have minimal to no pre-screening requirements prior to admission to SE: [  ] Consumers are not excluded based on vocational readiness or level of functioning [  ] Consumers do not require case management approval prior to admission
___/4=______ score	SE engages clients in vocational services rapidly [  ] Rapid approval by payer of vocational services (e.g., VR), within 4 (max) weeks of referral, or no approval required (i.e., access to program not blocked by delays in approval for payment) [  ] Consumers meet with ES within 2 (max) weeks of expressing initial interest in SE [  ] Any vocational assessment needed as part of employment process completed within 2 (max) weeks for >90% of clients [  ] No pre-vocational assessment required
___/2=______ score	Rapid job placement [  ] Majority of clients (minimum > 60%) receive NO prevocational work-readiness training (e.g., no Transitional employment, job trials, classroom activities, sheltered work) [  ] First job application within 2 (maximum) months of program entry
___/4=______ score	Job placements are: [  ] community-based (i.e., not sheltered workshops, not onsite at SE or other treatment agency offices), [ ] competitive (i.e., jobs are not exclusively reserved for SE clients, but open to public), [  ] in normalized settings (at least 50% of coworkers are not persons with disabilities), and [  ] utilize multiple employers (< 40% [max] of jobs are with limited # of employers)
___/2=______ score	Individualized job search including: [  ] Focus on consumer needs and preferences, not market requirements (<30% jobs are drawn from a pool of jobs created for generic job development) [  ] Consideration of long-term career goals, opportunities for advancement and possible future jobs
___/3=______ score	Long-term (at least one year) follow-along/support after job placement which is: [  ] continuous and individualized (e.g., considers preferences for involvement of coworkers in support) [  ] includes consumer supports (e.g., crisis intervention, job coaching, job counseling) and [  ] employer supports (e.g., education, guidance)
Score 1 if fully met, 0 otherwise
	Multiple jobs are permitted. Clients have no set clinical or prevocational preconditions, or waiting times before beginning next job search (true for at least 65% of clients at a minimum)
	The SE team has a small client:staff ratio. Client:staff ratio <31:1 (as a maximum)
	SE contacts occur in the home, at the job site, or in the community (> 40% of contacts minimum).
	The SE team is assertive in engaging and retaining clients in treatment, especially utilizing face-to-face community visits, rather than phone or mail contacts
	The SE team consults/works with family and significant others when appropriate (at least monthly contact for >20% of clients)

1. Identify putative SE sites and the clinical director of the identified SE team.
2. Mail or otherwise deliver copies of the checklist to the clinical director. The clinical director should then attempt to fill out the checklist to the best of his/her capability working from records and consulting with other team members as needed.
3. Arrange a time to call the clinical director to go over his/her responses to the checklist items. During the phone call go over each item and ask the director his/her understanding of the item. After insuring that the clinical director correctly understood the item, then ask for his/her rating of the item. Also ask the director to identify his/her data source for making the item rating (best guess, team records). Inform the clinical director of any discrepancies in the use of the checklist. If you identify a discrepancy in the use of the checklist that may have affected an item rating, try to come to an agreement with the clinical director in the understanding of or in the rating of the item. However, your judgment, and not that of the clinical director, should take precedence in the final rating.
4. All items and subparts of items are to be rated as either present or absent. If a program cannot fully meet the criteria contained within an item it should be given a score of 0 on that item or subpart.

INDICATOR: Q7: PERCENTAGE OF ADULTS WITH A SERIOUS MENTAL ILLNESS RECEIVING SUPPORTED HOUSING

RATIONALE FOR USE: Evidence-based services that promote long-term recovery should be important component of any system that serves people with serious mental illness. The workgroup recognizes that not all states offer Supported Housing programs, and that not all persons with serious mental illness necessarily need such services, however research has demonstrated the effectiveness of these services for many consumers.

APPROACH TO MEASURE: This measure - with the other exemplary services - is intended to reflect quality and appropriateness by monitoring the extent of the implementation of these services.
The 16 State Study workgroup is developing a definition of Supported Housing that can be used to assess the extent to which a program meets criteria to be included as a "Supported Housing" (SH) program.

MEASURE(S): Although many states have services they describe as "supported housing", these services may be conceptualized and operationalized differently. Recommended Definition: Supported Housing helps people with special needs to successfully select, obtain, and maintain safe, decent, affordable housing that is linked to individualized and flexible services provided within the community.

MEASURE:

Numerator: The number of consumers with severe mental illness receiving supported housing services.

Denominator: Total number of persons served in the community 18 and older, with any serious mental illness (Unduplicated).

Recommended Coding Categories:

1. Yes, person receives services from a Supported Housing Program
2. No, person does not receive services from a Supported Housing Program
3. Not Applicable, Supported Housing Programs not available.
4. Unknown

Proposed Frequency of Reporting Living Situation:

1. At time of Admission
2. Periodically: Annually; Semi-Annually
3. At time of Discharge

CURRENT IMPLEMENTATION STATUS:

SOURCE OF DATA: Management Information Systems, Medicaid data

POPULATIONS:

SETTINGS:

Workgroup Chair: Nancy Callahan

INDICATOR Q8-ATYPICAL MEDICATION USE

RATIONALE FOR USE: Consumers should be receiving treatments that are consistent with the definition of "best practices." New generation (atypical) antipsychotic are considered to be preferable to older agents in the treatment of psychosis. Therefore, use of these agents may be an indication of the degree to which clients are receiving treatments that conform to best practices.

MEASURES TO BE COLLECTED:

1. Percentage of Persons with a 295 Diagnosis that Receive Atypical Antipsychotic Medications
   
   

   This measure was broken into two stages to allow for maximum comparability across states (Stage I), while allowing states with greater diagnostic reporting capabilities to use all diagnostic criteria (Stage II). It also recognizes that there may be a considerable difference in clients who have a primary versus a tertiary diagnosis of schizophrenia. At this point in time, the focus for this measure should be Stage I.

   For states that can provide multiple diagnoses, it is very important to use only primary diagnoses when reporting counts for Stage I. States that can only extract data for primary diagnosis should not report counts for Stage II.

   Stage I:

   Numerator: The number of persons with a primary 295 diagnosis receiving a scheduled or standing order of one or more atypical antipsychotic medications (see list of atypical antipsychotic medications on page 2) at any time during their treatment in the fiscal year.

   Denominator: Count of all persons with a primary 295 diagnosis receiving treatment during the same fiscal year.

   Stage II:

   Numerator: The number of persons with any (primary, secondary, or tertiary) 295 diagnosis receiving a scheduled or standing order of one or more atypical antipsychotic medications (see list of atypical antipsychotic medications on page 2) at any time during their treatment in the fiscal year.

   Denominator: Count of all persons with any (primary, secondary, or tertiary) 295 diagnosis receiving treatment during the same fiscal year.

2. Percentage of Persons Prescribed Antipsychotic Medications that receive Atypical Antipsychotics
   
   

   This measure is consistent with the NRI Behavioral Healthcare Performance Measurement System measure: "New Generation Antipsychotic Use."

   Numerator: The number of persons receiving a scheduled or standing order of one or more atypical antipsychotic medications (see list of atypical antipsychotics on page 2) at any time during their treatment in the fiscal year.

   Denominator: Count of all persons receiving one or more antipsychotic medications (see list of antipsychotics on page 2), and receiving services during the same fiscal year.

3. Penetration Rate (Per 100, 000) of Persons Prescribed Atypical Antipsychotic Medications

   Measure 3 will be calculated by the workgroup for this Indicator. See *Note on page 3.

   Numerator: The number of persons in a given demographic category receiving a scheduled or standing order of one or more atypical antipsychotic medications (see list of atypical antipsychotics on page 2) at any time during their treatment in the fiscal year.

   Denominator: The number of persons in a given demographic category in the general state population.

Reporting Guidelines:

1. Collection Period:

   The timeframe for collection is fiscal year.

2. ANTIPSYCHOTIC Medications** (only the following medications should be considered antipsychotic medications):

   Traditional:
   Chlorpromazine, Mesoridazine, Trifluoperazine, Fluphenazine, Molindone, Thioridazine, HALOPERIDOL, PERPHENAZINE, THIOTHIXENE, LOXAPINE, PIMOZIDE

   Atypical:
   Clozapine, Quetiapine, Olanzapine, Risperidone, Other Approved Agents

3. Dosing:**

   Clients who received new generation or traditional antipsychotics only "as needed," "p.r.n.," "now," or "stat" medications should not be recorded. Only clients who receive these medications as a result of "standing" or "scheduled" orders (e.g., BID, TID, QD) should be counted.

4. Prescribed vs. Filled (Received) Medications:

   In order to more accurately capture the percentage of clients taking atypical medications (and to more closely correspond to NRI's ORYX measure), the numerator and denominator (where applicable) of each measure state medications received. However, data from states that only can report information on prescribed medications is acceptable, but should be labeled accordingly.

5. Unduplication:

   Counts should be unduplicated within and between all hospital settings. Counts should also be unduplicated within and across all community providers. However, counts should be duplicated across hospital and community settings for patients/clients served in both settings.

   For clients who are admitted/discharged multiple times throughout the reporting period, and whose diagnosis (es) change(s) across admissions, the diagnosis (es) from the client's most recent discharge or current as of the end of the fiscal year should be reported. For example, for the FY 99 reporting period (July 98 _ June 99), if a client was discharged in October '98 and April '99, the diagnosis(es) as of April '99 would be reported. If a client was discharged in October '98, readmitted in April '99, and was still hospitalized at the end of the fiscal year, the diagnosis(es) as of the end of the fiscal year would be reported.

   **Note: The Antipsychotic Medication and Dosing criteria have been adopted from the NRI Behavioral Healthcare Performance Measurement System.

BREAKOUTS FOR REPORTING:

1. Settings:

   The NASMHPD framework suggests that this indicator be collected separately for hospital and community settings.

   Hospital: (counts reported separately for the following types)

   1. A psychiatric institution that is operated by the state mental health authority.
   2. A state_operated general hospital with inpatient psychiatric services.
   3. Non_state operated hospital that provides inpatient psychiatric services that are purchased by the state mental health authority. This does not include services reimbursed by Medicaid.

   Community: Any community provider that is operated or funded (in full or in part) by the state mental health authority.

2. Demographics:(Demographic/Diagnostic categories listed the NASMHPD Framework, with additional modifications)
   
   

   Gender
   Age
   Race/Ethnicity
   Diagnosis

Calculating the Counts:

Example 1:
Patient/client with a primary 295 diagnosis prescribed Haloperidol BID, Thioridazine QD, Clozapine QOD, and Risperdone TID over the course of a fiscal year. For calculating the counts for each measure:

Measure 1/Stage I:
1 (2 Atypical Rx & Primary 295 Dx)
1 (Primary 295 Dx)

Measure 1/Stage II:
1 (2 Atypical Rx & 295 Dx)
1 (295 Dx)

Measure 2:
1 (2 Atypical Rx)
1 (4 Antipsychotic Rx)

Example 2:
Patient/client with a primary 296 diagnosis is prescribed Thioridazine BID, and Fluphenazine TID, and Loxapine QD over the course of a fiscal year. For calculating the counts for each measure:

Measure 1/Stage I:
Not counted (NO Primary 295 Dx)

Measure 1/Stage II:
Not counted (NO 295 Dx)

Measure 2:
0 (No Atypical Rx)
1 (3 Antipsychotic Rx)

Example 3:
Patient/client with a secondary 295 diagnosis not prescribed any antipsychotic medications over the course of a fiscal year. For calculating the counts for each measure:

Measure 1/Stage I:
Not counted (NO Primary 295 Dx)

Measure 1/Stage II:
0 (No Atypical Rx)
1 (295 Dx)

Measure 2:
Not counted (No Antipsychotic Rx)

Example 4:
Patient/client with a primary 295 diagnosis prescribed Risperdone p.r.n. and Perphenazine BID over the course of a fiscal year. For calculating the counts for each measure:

Measure 1/Stage I
0 (No Atypical Rx [p.r.n.])
1 (Primary 295 Dx)

Measure 1/Stage II:
0 (No Atypical Rx [p.r.n.])
1 (295 Dx)

Measure 2:
0 (No Atypical Rx [p.r.n.])
1 (1 Antipsychotic Rx)

*Note: Upon collection of the data template from each state, the workgroup will calculate Measure 3 by dividing the counts provided for the numerator of Measure 2 (persons receiving atypical antipsychotic) by the appropriate state population for that category (e.g., penetration rate of atypical medication use for White persons = [Number of whites in the numerator of measure 2 /Number of White persons in the state census] * 100,000).

IMPLEMENTATION STATUS:

Workgroup: Jocelyn Letourneau (RI), Nancy Covell
(CT), Eva Jakuba (CT), Ellen Sparks (SC), John Pandiani(VT).

RATIONALE FOR USE: Services for children and adolescents are best provided in the home or in home-like settings. To the extent possible, placing children and adolescents in 24-hour settings such as hospitals should be avoided.

MEASURE Definition: Percent of children and adolescents with SED served by the mental health authority who are living in a family-like setting while receiving services.

Numerator: The total number of unduplicated children and adolescents with a SED that lived in a family-like setting at any time during the reporting period.

Denominator: The total number of children and adolescents with SED served by the mental health authority during the reporting period.

Related Definitions:

Family-Like Setting: Living at home with parents or in a relative's home, living in foster home, living in regular boarding school/college, living in home or apartment (option with roommate) independently, living in a community Residential Respite home. In other words, living in a setting that is not a jail, detention, residential treatment setting, or homeless.

Children With Serious Emotional Disturbance: "are persons from birth up to age 18, who currently or at any time during the past year, have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within DSM-III-R, that resulted in functional impairment which substantially interferes with or limits the child's role or functioning in family, school, or community activities." (pursuant to Section 1912(c) of the Public Health Service Act, as amended by Public Law 102-321).

SOURCE OF DATA: MIS, Family and /or Self-report

CURRENT IMPLEMENTATION STATUS: Virginia has completed a survey of the 16 State study states regarding their ability to report this indicator. Seven (7) States report they can report this indicator if it is defined as "currently living in a family-like setting".

POPULATIONS:

SETTINGS:

ISSUES: Many States report that they can only report the current living situation of children and adolescents, not where they lived the "entire" reporting period or "most" of the reporting period.

WORKGROUP LEADER: Molly Brunk, Virginia

RATIONALE FOR USE: Therapeutic Foster Care is considered the least restrictive form of out-of-home placement for children with severe emotional disorders. The Surgeon General's Report on Mental Health highlighted therapeutic foster care as an efficacious service. (see p.176) "Care is provided in private homes with specially trained foster parents. The combination of family-based care with specialized treatment interventions creates a 'therapeutic environment in the context of a nurturant family home.

RECOMMENDED MEASURE:
Percentage of children in 24 hours settings who are in therapeutic foster care settings

Numerator: Total number of children and adolescents with SED in therapeutic foster care at any time during the reporting period.

Denominator: Total number of children and adolescents with SED in any 24-hour supervised residential setting during the reporting period.

CURRENT IMPLEMENTATION STATUS: Virginia has completed a survey of the 16 State study states regarding their ability to report this indicator. Five (5) States report they can report this indicator.

SOURCE OF DATA: MIS

POPULATIONS:

SETTINGS:

ISSUES: Defining what residential settings are counted as therapeutic foster care programs is the key issue. The Surgeon General's report offers the following guidance: "Children are placed with foster parents who are trained to work with children with special needs. Usually, each foster home takes one child at a time, and caseloads of supervisors in agencies overseeing the program remain small. In addition, therapeutic foster parents are given a higher stipend than to traditional foster parents, and they receive extensive pre-service training and in-service supervision and support. Frequent contact between case managers or care coordinators and the treatment family is expected, and additional resources and traditional mental health services may be provided as needed." (p.176)

WORKGROUP LEADER: Molly Brunk, Virginia

RATIONALE FOR USE: The Children's Workgroup felt that the provision of services to children and adolescents in natural settings (i.e., "out-of-the-office") is an important measure of a responsive community mental health system.

RECOMMENDED MEASURE:
Percentage of children and adolescents who receive services in their own homes, in school settings, or other community settings.

Numerator: Total number of contacts by the mental health agency to children and adolescents with SED that occurred in natural settings during the reporting period.

Denominator: Total number of contacts by the mental health agency to children and adolescents with SED during the reporting period.

CURRENT IMPLEMENTATION STATUS: Virginia has completed a survey of the 16 State study states regarding their ability to report this indicator. Three (3) States report they can report this indicator.

SOURCE OF DATA: MIS

POPULATIONS:

SETTINGS:

ISSUES: It is unknown if State MIS systems can identify "in-home" and "in-school" services.

WORKGROUP LEADER: Molly Brunk, Virginia

RATIONALE FOR USE: Parents perceptions of their involvement in the treatment process will affect their willingness to allow their child to remain in treatment. Research indicates that involvement in decisions regarding treatment is correlated with positive outcomes.

APPROACH TO MEASURE: This measure applies to family participation in treatment planning and treatment delivery for children. The important aspect is to obtain information from the family regarding both active involvement in treatment decision-making and definition of treatment goals. This should be a family self-report measure and should reflect that the desires of the family are considered in treatment planning. Alternatively, this indicator could be measured by an MIS system that has objective measures of family participation in treatment provision.

MEASURE: The important aspect is to obtain parents' perspectives on their involvement in their children's treatment through a confidential, self-report mechanism. A parent survey is recommended.

The expectation is that an annual, cross-sectional survey of parents of child mental health consumers be conducted that includes an assessment of parents' perceptions of their participation in their children's treatment.

The 16 State Study workgroup is currently piloting the Youth Services Survey (YSS) and the Youth Services Survey for Families YSS-F. The YSS-F includes items that can be used to assess information parent's perceptions of their involvement in treatment planning for their children. The current pilot will identify specific items that will be used to generate a score for the numerator for this indicator.

Numerator: Total number of respondents with an average scale score > 2.5.

Denominator: Total number of respondents.

BURDEN:

SOURCE OF DATA:

CURRENT IMPLEMENTATION STATUS: Currently being piloted in ___ states.

POPULATIONS:

SETTINGS:

ISSUES:

WORKGROUP LEADER: Molly Brunk, Virginia

RATIONALE FOR USE: Given the increasing limited use of psychiatric inpatient care, hospitalization most likely indicates an acute episode of illness. An important goal of mental health treatment is to minimize such episodes. This indicator reflects the performance of the system (inpatient and outpatient) rather than the performance of only the hospital.

APPROACH TO MEASURE: The important aspect of this measure is the rehospitalization of the consumer. Ideally, the system should monitor any rehospitalization, not just rehospitalization to the particular hospital from which the consumer was discharged

MEASURE(S): The total number of admissions to state psychiatric hospital inpatient care that occurred within 30 and 180 days of a discharge from a psychiatric inpatient care during the past year divided by the total number of discharges during the year.

Numerator: The number of episodes of readmission to any state psychiatric hospital within 30 days and within 180 days of being discharged during the year. Readmission is defined as returned to any state psychiatric hospital without contingency; this would exclude those who were not discharged, including on leave, visits, leaves without consent, and elopements.

Denominator: The total number of discharges from a psychiatric hospital (not unduplicated by episode). Discharged is defined as released from the hospital without contingency; this would exclude those who are released on leave, including visits, leaves without consent and transfers.

For 30 day and 180 day readmission you will need the data for 13 month and 18 month periods respectively (one month and six month beyond the FY or CY respectively; whichever you use).

CURRENT IMPLEMENTATION STATUS:

SOURCE OF DATA: Existing MIS.

POPULATIONS:

SETTINGS:

ISSUES: When reporting by diagnostic categories: when there are different diagnoses between the first admission and the readmission, use the discharge diagnosis from the first admission.

Ideally, this indicator would be expanded to include all readmissions to any hospital, not just state psychiatric hospitals. With the increased use of local general hospital psychiatric units, it will be come important over time to expand this indicator beyond the current focus on state psychiatric hospitals.

WORKGROUP LEADER: Sudha Mehta, New York

RATIONALE FOR USE: Mental health service providers that are consumer-focused value an individual's autonomy and independence. Therefore, these providers seek to maximize the use of service modalities that are minimally, if at all, restrictive. While restrictive treatments are sometimes necessary, utilization of such treatments must be minimized and closely monitored. Overutilization of highly restrictive treatments may represent the unavailability of more appropriate, less restrictive therapies or the presence of treatment providers who lack respect for client autonomy and dignity.

APPROACH TO MEASURE: While the amount of hours in seclusion is one indicator, data suggest that a small number of consumers experiencing seclusion account for a disproportionate share of the total time. The second measure obtains the actual number of persons experiencing seclusion.

MEASURE 1: Hours of seclusion as a percent of client hours

Numerator: The total number of hours that all clients spent in seclusion.

Denominator: Sum of the daily census (excluding clients on leave status) for each day (client days) multiplied by 24 hours

Measure 2 Definition: Percent of clients secluded at least once during a reporting period

Numerator: The total number of clients (unduplicated) who were secluded at least once during a reporting period

Denominator: The total number of unduplicated clients who were inpatients at the facility during a reporting period

Related Definitions:
Seclusion - the involuntary confinement of a client alone in a room where the client is physically prevented from leaving (from JCAHO standards). Physically preventing egress may be accomplished via a variety of means including but not limited to manually or electronically locked doors, doors constructed so that when closed and unlocked they may not be opened from the inside (e.g. "one-way doors"), and the presence of staff proximal to the room preventing exit. A seclusion event should not be reported if an individual is prevented from leaving a room secondary to being restrained.

Begin and End Times - an "episode" of restraint or seclusion is an event that begins when an individual goes into seclusion or restraint ("Event Begin Time") and ends when the individual is released ("Event End Time"). It is possible for one event to be associated with multiple orders. For example, if an order for restraint is renewed and the client never exits the restraints between the original order and the renewal, only one event has occurred. Also, cases may exist in which a client has multiple seclusion or restraint events associated with a single order. For example, this would occur if an individual is removed from seclusion within the time limits of the initial seclusion order and staff are allowed to reapply seclusion without obtaining a new order. If a client is removed from seclusion or restraint only briefly for the purpose of toileting or to evaluate the need for continuation of the intervention and is then quickly returned to seclusion or restraint, the initial event should be considered to have continued. In such a case, only one event has occurred.

SOURCE/S OF INFORMATION: MIS, Hospital Incident Monitoring System

CURRENT IMPLEMENTATION STATUS:

POPULATIONS:

SETTINGS:

ISSUES:

RATIONALE FOR USE: Mental health service providers that are consumer-focused value an individual's autonomy and independence. Therefore, these providers seek to maximize the use of service modalities that are minimally, if at all, restrictive. While restrictive treatments are sometimes necessary, utilization of such treatments must be minimized and closely monitored. Over-utilization of highly restrictive treatments may represent the unavailability of more appropriate, less restrictive therapies or the presence of treatment providers who lack respect for client autonomy and dignity.

APPROACH TO MEASURE: While the amount of hours in restraint is one indicator, data suggest that a small number of consumers experiencing restraint account for a disproportionate share of the total time. The second measure obtains the actual number of persons experiencing restraint.

MEASURE 1 DEFINITION: Hours of restraint as a percent of client hours

Numerator: The total number of hours that all clients spent in restraint during a reporting period

Denominator: Sum of the daily census (excluding clients on leave status) for each day in a reporting period (client days) multiplied by 24 hours

MEASURE 2 DEFINITION: Percent of clients restrained at least once during the reporting period

Numerator: The total number of clients (unduplicated) who were restrained at least once during a reporting period

Denominator: The total number of unduplicated clients who were inpatients at the facility during the reporting period

Related Definitions:

Restraint: any involuntary method of physically restricting a client's freedom of movement, physical activity, or normal access to his or her body (from JCAHO standards). Restraints used for security purposes during transport of a client out of the building or off the premises to receive therapeutic services or to participate in activities directly related to the client's illness (such as court proceedings or appointments necessary to acquire human services) are not to be reported. Also, restraint devices employed for medical purposes (Geri-chair, posey, etc..) or as personal protective devices (helmets, bed rails, etc..) should not be reported.

Begin and End Times - an "episode" of restraint or seclusion is an event that begins when an individual goes into seclusion or restraint ("Event Begin Time") and ends when the individual is released ("Event End Time"). It is possible for one event to be associated with multiple orders. For example, if an order for restraint is renewed and the client never exits the restraints between the original order and the renewal, only one event has occurred. Also, cases may exist in which a client has multiple seclusion or restraint events associated with a single order. For example, this would occur if an individual is removed from seclusion within the time limits of the initial seclusion order and staff are allowed to reapply seclusion without obtaining a new order. If a client is removed from seclusion or restraint only briefly for the purpose of toileting or to evaluate the need for continuation of the intervention and is then quickly returned to seclusion or restraint, the initial event should be considered to have continued. In such a case, only one event has occurred.

SOURCE/S OF INFORMATION: MIS, Hospital Incident Monitoring System

CURRENT IMPLEMENTATION STATUS:

POPULATIONS:

SETTINGS:

ISSUES:

RATIONALE FOR USE: A critical component of the treatment of mentally ill clients, particularly those clients with severe and persistent illness is pharmacotherapy. If appropriately prescribed, distributed, administered and monitored, pharmacotherapy can produce significant improvement in symptoms. However, if inappropriately prescribed, distributed, administered or monitored, medications can be associated with significant harm or death to the client. Given the relatively high incidence of medication use among psychiatric clients and the high potential for adverse outcomes of medication-related errors, tracking of such errors and subsequent identification of causal factors is an essential component of the performance improvement process in organizations providing psychiatric health care.

MEASURE: Ratio of the number of medication errors reported to the duplicated count of clients served during the reporting period

Numerator: Total number of medication errors occurring during an inpatient stay.

Denominator:The sum of the total number of clients on the inpatient census at the end of the reporting period, the total number of discharges during the reporting period and the total number of deaths occurring during the reporting period (duplicated count)

Related Definitions:

Medication Error - A medication error occurs when a client receives an incorrect drug, drug dose, dosage form, quantity, route, concentration, or rate of administration. To be defined as an error, some form of variance in the desired treatment or outcome must have resulted. Therefore, both the failure to administer a drug ("missed dose") or the administration of a drug on a schedule other than intended constitute medication errors.

Medication Error Types - The three key types of medication errors are:

Error of Prescribing: An error of prescribing occurs when there is an incorrect selection of drug, drug dose, dosage form, quantity, route, concentration, rate of administration, or instructions for use of a drug product ordered or authorized by physician or other legitimate prescriber. Additionally, the error must have resulted in some form of variance in the desired treatment or outcome of care. Errors may occur due to improper evaluation of indications, contraindications, known allergies, existing drug therapy and other factors. Illegible prescriptions or medication orders that lead to client level errors are also defined as errors of prescribing.

Error of Dispensing: An error of dispensing occurs when the incorrect drug, drug dose or concentration, dosage form, or quantity is formulated and delivered for use to the point of intended use. Additionally, the error must have resulted in some form of variance in the desired treatment or outcome of care.

Error of Administration: An error of prescribing occurs when there is an incorrect selection and administration of drug, drug dose, dosage form, quantity, route, concentration, rate of administration, or instructions for use of a drug product ordered or authorized by physician or other legitimate prescriber. Additionally, the error must have resulted in some form of variance in the desired treatment or outcome of care.

Medication Error Severity: While medication errors are not uncommon, most result in few if any significant, enduring consequences. However, the frequency with which errors are reported varies widely across health care organizations with some reporting all errors despite frequency and others only reporting those considered serious. The measurement system considers it important to encourage reporting of all incidents so that quality improvement efforts may be initiated to identify the factors contributing to even "minor" errors. Heightened awareness of and vigilance in preventing such minor errors will contribute to the prevention of more serious errors. This concept is consistent with the foundational principles of quality management. The following severity ratings are proposed for use in reporting data to NRI. These following definitions represent a distillation of several states' current practices.

SOURCE/S OF INFORMATION:

CURRENT IMPLEMENTATION STATUS:

SOURCE OF DATA:

POPULATIONS:

SETTINGS:

ISSUES:

RATIONALE FOR USE: This indicator is the most direct measure of the consumer's perception of the effectiveness of services.

APPROACH TO MEASURE: The important aspect is to obtain the consumer perspective on the impact of the services received through a confidential, self-report mechanism. A consumer survey is recommended. The approach inherent in this indicator is: "Ask the consumer." It is a customer-oriented ind

MEASURE(S): The important aspect is to obtain the consumer perspective on the impact of the services received through a confidential, self-report mechanism. A consumer survey is recommended.

The expectation is that an annual, cross-sectional survey of consumers be conducted that includes an assessment of consumers' perception of the outcome of services. Given the widespread use of the MHSIP Consumer Survey by public mental health systems and consideration being given to its adoption by the private sector, it is recommended that this instrument be used. If the MHSIP Consumer Survey is used, perception of the outcomes of services will be measured by responses to the following items:

1. I deal more effectively with daily problems.
2. I am better able to control my life.
3. I am better able to deal with crisis.
4. I am getting along better with my family.
5. I do better in social situations.
6. I do better in school and/or work.
7. My symptoms are not bothering me as much.

Scoring:

1. Recode ratings of "not applicable" as missing values.
2. Exclude respondents with more than 1/3rd of the items missing.
3. Calculate the mean of the items for each respondent.
4. Calculate the percent of scores less than 2.5. (percent agree and strongly agree).

Numerator: Total number of respondents with an average scale score > 2.5.

Denominator: Total number of respondents.

CURRENT IMPLEMENTATION STATUS: Many of the states participating in the 16 State Study are implementing the a version of the MHSIP Consumer Survey

POPULATIONS:

SETTINGS:

SOURCES OF DATA: MHSIP Consumer Survey -- short or long versions.

ISSUES:

RATIONALE FOR USE: From a societal perspective, this is a major indicator of improvement in functioning produced by treatment. The technical workgroup recognized that school attendance or school performance are not determined solely by the mental health services received and that mental health service providers can not be held responsible for school performance. However, this is a critical objective for such services and mental health services should have some impact. This was considered an important outcome to track.

APPROACH TO MEASURE: Various measures of school performance can be used: school attendance, school performance, behavior problems. As an outcome measure, a longitudinal approach monitoring change for an individual is recommended but cross-sectional approaches can be used. Measures of school attendance - while not necessarily ideal - were considered less burdensome.

The Children's Workgroup of the 16 State Study has surveyed participating states regarding several potential measures related to the impact of mental health services on school.

• Percentage of consumers enrolled in school whose absence rate is equal to or less than 10% for the last 30 calendar days. Measured at 6 months and 12 months post admission.

  Numerator: Number of consumers enrolled in school, 6 - 17 years old, for whom the number of days absent divided by the number of available school days =< .10.

  Denominator: Total number of consumers 6 - 17 years old enrolled in school.

• Average change in the percentage of available school days attended from admission to 6 (12) months post admission. (negative change indicates decline in school performance and a positive change indicates improvement)
• Absence rate is defined as number of days absent in last 30 days divided by number of available school days.

  Numerator: Sum across all consumers 6 - 17 years old enrolled in school (Absence rate at admission minus Absence rate at 6(12) months)

  Denominator: Total number of consumers 6 - 17 years old enrolled in school

• Percentage of youth who show improvement in absence rate. Absence rate is defined as number of days absent in last 30 days divided by number of available school days.

  Numerator: Number of youth 6 - 17 years old enrolled in school where [Absence rate at admission - absence rate at 6(12) months] is greater than zero.

  Denominator:Total number of consumers 6 - 17 years old enrolled in school

CURRENT IMPLEMENTATION STATUS: The Children's Workgroup has found that although states reported these indicators to be of very high utility, that very few states can currently report necessary data for these indicators.

SOURCES OF DATA:

1. Consumer/family member report obtained through clinician/staff interview
2. Official school records

POPULATIONS:

SETTINGS:

ISSUES:

1. Standard for attendance rate should be based on national average for entire student population.
2. Must have a method for handling situations in which no or a small number of school days are available.
3. This is a distal outcome which is determined by several factors outside the control of the mental health system.

RATIONALE FOR USE: For payers, this is the payoff. The ultimate "so what?" Productive activity is an important component of role functioning for adults. Clearly, this is a distal outcome which is determined by several factors, some of which are outside the control of the mental health system. Monitoring this indicator for populations with mental illness, however, is critical.

As in the case of school performance for children and adolescents, mental health service providers can not be held responsible for employment. However, this is a critical objective and mental health services should have some impact. This was considered a critical outcome to track.

APPROACH TO MEASURE: The important aspect of this measure is to monitor change in employment status over time. As an outcome measure, a longitudinal approach monitoring change for an individual is recommended but cross-sectional approaches can also be used.

The 16 State Study workgroup is currently surveying study participants to assess their ability to report employment data in several potential formats. A copy of the survey is attached.

MEASURE(S):     1(a). For persons age 18-64 receiving services more than six months.

Numerator:
(Days of paid work in last month) at 6 months - (Days paid work in last month) at admission

Denominator:
(All admissions during year who were in system 6 months or more)

CURRENT IMPLEMENTATION STATUS:

SOURCE OF DATA:      MIS    Consumer/report

POPULATIONS:

SETTINGS:

ISSUES: See attached survey currently being completed regarding state ability to track employment status:

Note: Please send hard copies of documents and forms that you use to collect employment data to: Denny Geertsen, Ph.D., 120 N. 200 West #415, Salt Lake City, UT 84103, or email dgeertse@hs.state.ut.us or fax (801) 538_9879

1. What are the response categories that you use for employment status at the time of admission? (Sending a copy of your admission form will answer this question)

2. How is your admission data collected?
   _____ Client self_report
   _____ Person interview
   _____ Phone interview
   _____ Other (Specify)

3. What time frames do you use for collecting employment data? (Check all that apply)
   _____ Admission
   _____ Discontinuation
   _____ Every six months
   _____ Annually
   _____ Other period (be specific)

4. How is employment data collected at times subsequent to admission?
   _____ Client self_report
   _____ Support staff interview
   _____ Support staff phone interview
   _____ By clinical staff
   _____ Other (Specify)

5. If you are not currently collecting employment status data beyond admission, what time frames do you intend to collect these data?
   _____ Discontinuation
   _____ Every six months
   _____ Annually
   _____ Other period (be specific) _____________________

6. What is your target date for collecting data beyond admission?
   _______________________________________________

7. For what populations do you collect the data? (Check all that apply)
   _____ All adult admissions
   _____ SMI
   _____ Other

8. Do you currently have the capacity to link MH consumer data with data from your state employment agency database?
   _____ Yes (Please indicate if this capacity is other than SSN)
   _____ No

9. Do you have an agreement in place with the state employment agency to link such data?
   _____ Yes     _____ No
   (If no) Do you intend to pursue an agreement that might allow linkage to occur?
   _____ Yes     _____ No Explain:

10. What is your target date for having the linkage completed?

11. Have you given any thought to how you will use linked data in your state, or how the 16_state project might use this information?

12. What limitations exist for linking MH data with Employment Security data? (Some of these were mentioned in our conference call on 10-17-00)

13. Do you see the Banks_Pandiani model (probabilistic matching) as answering questions about linkage? What benefits or limitations do you see with that approach?

RATIONALE FOR USE: Mental health services are expected to improve a person's ability to respond to problems, crises, and everyday situations they encounter. The important aspect is to monitor change in functioning for an individual across time. Depending on the particular situation of the consumer, success could be denoted by either improvement in functioning or in maintenance of functioning level. Different standardized instruments exist for the measurement of functioning.

APPROACH TO MEASURE: The important aspect is to monitor change in functioning for an individual across time. Depending on the particular situation of the consumer, success could be denoted by either improvement in functioning or in maintenance of functioning level. Different standardized instruments exist for the measurement of functioning.

RECOMMENDED MEASURE:

1. Percentage of consumers with improved functioning

Numerator: Number of persons with functioning change greater than RCI (at t2)

Denominator: Number of persons in t1cohort
[The t1 cohort could be persons admitted or persons at last evaluation. For new admissions, t2 - t1 = 3 months; for persons receiving ongoing care t2 - t1 = 6 months. All persons should have measures at admission and discharge.]

2. Percentage of consumers with maintained functioning

Numerator: Number of persons with functioning change less than RCI (at t2)

Denominator: Number of persons in t1cohort
[The t1 cohort could be persons admitted or persons at last evaluation. For new admissions, t2 - t1 = 3 months; for persons receiving ongoing care t2 - t1 = 6 months. All persons should have measures at admission and discharge.]

INSTRUMENTS RECOMMENDED: The workgroup has reviewed a number of instruments currently being used by the States. The workgroup has requested states submit de-identified client level information for these instruments that will be analyzed by the workgroup to explore issues in calculating these measures and in comparing results across different instruments.

Adults-BSI, FARS, BASIS-32, SF36/12, Multnomah, CCAR, GAF, GSOF, SLOF, RAFLS, QOL, NYS-PMHP/CAF, FA-SSA, WHO/DAS

Children-CAFAS, CASA, CGAS, CHIP, CHQ, CIS, Vanderbilt, CCAR, GAF, CAAP (Information related to psychometric properties, burden, cost, etc. for these instruments are provided in Appendix B.)

CURRENT IMPLEMENTATION STATUS:

POPULATIONS:

SETTINGS:

ISSUES: An important consideration is that various measures are currently being implemented by the states. To compare across these measures, it may be important to develop calibration studies to compare these measures. For elderly persons, maintaining functioning may be the goal, not improving.

On the next page, guidelines for the submission of data from the 16 State study states are described.

The Reliable Change Index, (RCI) described in the literature by Jacobson and Traux, is a statistical method to calculate how much change has occurred at post test in cases where using a cutoff point is not statistically reliable. The formula for the RCI is:

Where X1 represents the pretest score, X2 represents the same consumer's post test score, and Sdiff is the standard error of the difference between the two test scores. Sdiff can be computed directly from the standard error of measurement (SE); Sdiff = the square root of 2(SE) . An RCI of 1.96 or greater is significant (p < .05) and would be unlikely to occur without actual change. In other words, using the RCI adjusts for the S.D. in the pretreatment group and the test-retest reliability of the measure. But, using the RCI alone does not allow one to differentiate change based upon the value of the pre-test score. That is, it does not differentiate the significance of a similar point change in persons starting out at different levels on a scale (a one point change from 5 to 6 versus 34 to 35). Using the log of the pre and post-test scores and the log of Sdiff allows for this differentiation. This is useful in determining the amount of change that is needed to reach significance for people starting out at high as opposed to low scores and for ascertaining cutoffs where change is not possible, based upon the raw score change needed to achieve a significant RCI (ceiling effect).

Workgroup: Mary Smith, Illinois - Chair

Goals: Obtain Item Level Data Sets from States for the following instruments:

Program Type:     Goal: Community Setting
If all that is available is Hospital Data for a given instrument then send Hospital Data - Noted as Hospital Data.

Sample: Unduplicated individuals who during a two-year window (for example: FY9798-FY9899 or FY9899-FY9900) had at least two evaluations: An Admission Evaluation, and at least one additional evaluation (Review or Discharge)

If more than one episode, unduplicate by choosing the first episode.
If more than two evaluations within an episode: send all evaluations (e.g. admission, 6-month review, 12-month review, 18-month review, discharge).

Sample Size:

Goal: 5000 to 10000 unduplicated individuals per instrument
If less than 5000 unduplicated individuals:
Send what is available.
If more than 10000 unduplicated individuals: Randomly select a 10000-person sample.

Mult. Instruments: We are very interested in obtaining any samples that you may have of consumers with simultaneous (same evaluation points, e.g. admission, 6-month review, discharge) evaluations on more than one instrument. (for example: CAFAS, CBCL and CGAS). If you have any samples with multiple instruments (at least 500 unduplicated individuals), please note and include.

Reliability: For each instrument, if available, send inter-rater or test-retest reliability estimates.
Indicate if estimate is from the Literature or obtained in the field (Local to State)

Data Type:

Data sent as: SPSS 7-10 .SAV File (System File for pc version of SPSS)
SPSS .POR File (Portable file from pc or mainframe SPSS)
Microsoft Access-97
Delimited ASCII (include Data List of Variable Names)
Fixed Record ASCII
(Include Data list statement of Variable names, Column positions, and data type)

Data sent to:	Jack Wackwitz
	3824 W. Princeton Circle
	Denver, CO 80236
	e-mail: jack.wackwitz@state.co.us
	Phone: 303-866-7425
	FAX: 303-866-7428

Data sent via:	Zipped attachment to e-mail
	Iomega 100mb Zip Disk
	Floppy disk

Records:	One Record per Assessment (Admission, Review, Discharge)
	Two or More Records per consumer (first record = admission)

Data Records:

State	Character (a2) State Abbreviation (e.g. CO)
Instrument	Character (a5) GAF, MCAS, BPRS, BASIS, CCAR, AZLOF, CGAS, CAFAS, CBCL
Sample Type	Character (a1) C=Community, H=Hospital
Date of Eval	Numeric (f8) yyyymmdd
Type of Eval	Character (a3) ADM, REV, DIS
Case Status	Character (a1) O=Open D=Discharged/Closed
Discharge/Closed Date	Numeric (f8) yyyymmdd (Blank if Case is Open)
Record Number	Numeric (f1) 1,2,3, …, n (1=adm, 2=2nd eval, 3=3rd eval, etc.
Consumer Id #	Character (a9) Unique Identification of Consumer across records and instruments
Consumer Birth-date	Numeric (f8) yyyymmdd
Age at Eval	Numeric (f3) (if Birth-date is Unavailable)
Gender	Character (a1) M, F
Ethnicity	Numeric (f1) 1=White 2=Black 3=AmerIndian 4=Asian 5=Hispanic
Residence	Numeric (f1) 1=Corrections/Jail 2=Inpatient 3=Residential 4=Group Quarters 5=Foster Home 6=Homeless 7=Home (Other Independent )
Primary Diagnosis	Character (a5) DSMIV
Diagnosis-Category	Numeric (f2) 1=AttentionD 2=Conduct 3=MR/Autis 4=OtherChild 5=Schiz 6=Delus/Other Psychosis 7=MajorDepression and Mood Disorders 8=OBS 9=SubAbuse 10=Anxiety 11=PersDis 12=OthMH 13=None
Category	Numeric (f1) 1=SMI-Adult 2=Other-Adult 3=SED-Child/Adol 4=Other Child/Adol
Inpatient Services	Character (a1) Y=Any Service during 2 years N=None
24 Hour Services	Character (a1) Y=Any Service during 2 years N=None
Day/Partial Services	Character (a1) Y=Any Service during 2 years N=None
Outpatient Services	Character (a1) Y=Any Service during 2 years N=None
Item Data:	Specific to each Instrument. Provide Record Layout for Instrument

Functioning and Symptoms Instruments: Mary Smith (IL) leader, with Randy Koch (VA), Jack Wackwitz (CO), Ted Lutterman (NRI), and Vijay Ganju (TX)

RATIONALE FOR USE: A major function of mental health treatment is to provide relief from the symptoms associated with mental illness including suicidality, psychotic symptoms and depressive symptoms.

APPROACH TO MEASURE: The important aspect is to monitor change in functioning for an individual across time. Depending on the particular situation of the consumer, success could be denoted by either reduction in symptoms or in maintenance of symptoms level. Different standardized instruments exist for the measurement of functioning. See discussion of "Indicator O4- Client Functioning" for a further discussion of measuring change.

RECOMMENDED MEASURE:

1. Percentage of consumers with reduction in symptoms

Numerator: Number of persons with symptoms change greater than RCI (at t2)

Denominator: Number of persons in t1cohort
[The t1 cohort could be persons admitted or persons at last evaluation. For new admissions, t2 - t1 = 3 months; for persons receiving ongoing care t2 - t1 = 6 months. All persons should have measures at admission and discharge.]

CURRENT IMPLEMENTATION STATUS:

SOURCE OF DATA:   Clinician Report;    Self Report

POPULATIONS:

SETTINGS:

ISSUES: The Client Assessment Instrument Workgroup is currently requesting 16 State Study states submit data in a standardized format to test the construction of these measures. See rules for submission of data in Indicator O4, Client Functioning above.

INDICATOR: O6 ADVERSE OUTCOMES: CONSUMER INJURIES

Rationale: If inpatient mental health services are to be maximally effective, clients must feel that they are in a safe environment that is free of unusual physical risks. The rate of physical injury reflects not only the safety of the physical structures of the facility but may also reflect the effectiveness or appropriateness of care. Ineffective care may result in abnormally high instances of harm to clients by self (self-injurious behavior) or others (acts of physical violence). Inappropriate care may be reflected in high rates of injury caused by neglect (e.g. falls) or injuries inflicted by abusive staff.

Measure: Number of client injuries per client day

Numerator: Total number of reported incidents that resulted in injury to clients on the inpatient census (including clients on leave status) during the reporting period

Nenominator: Sum of the daily census (including clients on leave status) for each day in the reporting period (client days)

Related Definitions:
Injury - An injury occurs when a client suffers physical harm or damage which requires medical treatment more intensive than minor first aid. Injury events should not be reported for clients whose injuries require:

No Treatment: The injury received does not require first aid, medical intervention, or hospitalization; the injury received by a client (e.g., a bruised leg) may be examined by a licensed nurse or other nursing staff working within the facility but no treatment is applied to the injury

Minor First Aid: The injury received is of minor severity and requires the administration of some level of treatment; further, at this level of severity, the treatment received is provided within the facility and does not require medical intervention or hospitalization; the injury received by the client (e.g., a minor cut on an arm) may be examined by a licensed nurse or other nursing staff working within the facility, who may provide the aid necessary to properly treat the injury (e.g., clean and disinfect the cut and place a band-aide on the cut), but treatment by a medical doctor, physician's assistant, or nurse practitioner is not necessary, required, or applied for.

The following are valid categories for describing the severity of reportable injuries:

Medical Intervention Required: The injury received is severe enough to require the treatment of the client by a licensed medical doctor, osteopath, podiatrist, dentist, physician's assistant, or nurse practitioner, but the treatment required is not serious enough to warrant or require hospitalization; further, the treatment received may be provided within the facility or provided outside the facility where it may range from treatment at a doctor's private office through treatment at the emergency room of a general acute care

hospital.

Hospitalization Required: The injury received is so severe that it requires medical intervention and treatment as well as care of the injured client at a general acute care medical ward within the facility or at a general acute care hospital outside the facility; regardless of the length of stay, this severity level requires that the injured client be formally admitted as an inpatient to the hospital and assigned to a bed on a unit outside of the emergency room.

Death Occurred: The injury received was so severe that it resulted in - or complications from the injury lead to - the termination of the life of the injured client.

If the cause of the injury is known, the cause may be accidental, self-inflicted or the result of an assault.

SOURCE OF DATA:   MIS

POPULATIONS:

Children with a Serious Emotional Disturbance
Adults w/ a Serious Mental Illness
All Children
All Adults
Geriatric

SETTINGS:

Psychiatric Inpatient Settings
Community-based Settings

ISSUES:

INDICATOR: O7 ADVERSE OUTCOMES: ELOPEMENT

RATIONALE FOR USE: Psychiatric hospitals, particularly institutions serving severely and persistently ill clients, have a unique responsibility for insuring both client and public safety. Often, the effects of brain disorders that produce mental illness render an individual's thinking unclear and, at times, irrational. Actions based on such distorted thinking can result in harm to self or others. Harm secondary to distorted thinking can be minor (the development of a minor illness due to insufficient clothing during cold weather) or serious (traffic accident injuring several people). When such consequences are likely, it is desirable for clients to be closely cared for in a safe environment. High rates of elopement from inpatient psychiatric facilities may represent insufficient efforts to insure client and public safety. Alternatively, such high rates may indicate a less than desirable treatment environment from which clients are likely to leave. In either case, opportunities for improvement exist.

MEASURE: Proportion of time during the reporting period that clients were absent without authorization

Numerator: The total number of elopements which occurred during the reporting period

Denominator: Sum of the daily census (including clients on leave status) for each day in the reporting period (client days). Included Populations: All inpatients (inpatients on the last day of the reporting period, inpatients discharged during the reporting period and inpatients who died during the reporting period)

Related Definitions:

Elopement - Absent from the facility without authorization regardless of leave status; multiple elopement events for the same client during the same reporting period should be included as separate events in the numerator

CURRENT IMPLEMENTATION STATUS:

SOURCE OF DATA:   MIS

POPULATIONS:

Children with a Serious Emotional Disturbance
Adults w/ a Serious Mental Illness
All Children
All Adults
Geriatric

SETTINGS:

Psychiatric Inpatient Settings
Community-based Settings

ISSUES:

INDICATOR: O8 ADVERSE OUTCOMES: PLACEMENTS IN 24 HOUR SUPERVISED TREATMENT PROGRAMS FOR CHILDREN AND ADOLESCENTS

ISSUES: The children's workgroup recommended this indicator be changed to assess the children living in home like environments. Thus this indicator has been replaced by indicator Q9a "Percent Living in a Family-like Setting for Children and Adolescents with a Serious Emotional Disturbance"

INDICATOR: O9 MORTALITY: HEALTH STATUS OF THE SERVED POPULATION AS MEASURED BY THE STANDARDIZED MORTALITY RATE AND AVERAGE AGE OF DEATH.

RATIONALE FOR USE: Mortality rates are commonly used as global measures of health status for populations (Grob, 1983; Zopf, 1992). There are increasingly being used as indicators of performance of public health efforts; for 9example, mortality rates are used a number of times in Healthy People 2000 as performance measures. In addition, there is a long and extensive literature indicating that persons with mental illness die at higher rates and at younger ages from nearly all causes, both natural and medico legal (i.e., homicide, suicide, or accidents/injuries) (e.g., Dembling, 1995; Segal & Kotler, 1991; Winokur & Black, 1987; Babigian & Ordoroff, 1969). This literature provides compelling evidence to track mortality as a measure of health status for persons receiving mental health services.

APPROACH TO MEASURE: While few states monitor this information, this was considered an important indicator for monitoring the health status of persons with mental illnesses even though the incidence of such occurrences might be low. Various alternative measures for monitoring this indicator are proposed below.

MEASURE 1: The crude mortality rate (CMR) for the population of persons who received at least one service in the past year.

Numerator: The number of deaths occurring in the last year among persons who had received at least one service in the last year.

Denominator: The total number of persons who had received at least one service in the last year.

Measure 3. The average number of years of life lost (YLL) for service recipients who died during the past year. The YLL is defined as the difference between the age at death and the current life expectancy for an individual.

Numerator: The sum of the difference between the age of death and current life expectancy for a person of that age for each person who received at least one service in a certain year and who died during that year.

Denominator: The number of persons who received at least one service in that year who died and whose age of death was available.

BURDEN: The burden of calculating these measures depends on how the data are collected. One option is the electronic linking of enrollment or client registry records with death records state Departments of Public Health or vital statistics agencies. This linking requires some technical capacity, considerable data processing resources, and probably requires a data sharing agreement with another agency. Alternatively, if a system tracks deaths of service recipients in an ongoing way, these records would obviate the need for an electronic match. Even if such a system is in place, overall population death records or at least summary statistics would need to be obtained for Measure 2.

CURRENT IMPLEMENTATIONS STATUS:

SOURCE(S) OF DATA: Management Information Systems, encounter data, vital statistics/public health authority death records, other mortality tracking system.

POPULATIONS:

Children with a Serious Emotional Disturbance
Adults w/ a Serious Mental Illness
All Children
All Adults
Geriatric

SETTINGS:

Psychiatric Inpatient Settings
Community-based Settings

ISSUES: Several points should be made, particularly with respect to use and interpretation of this indicator. First, as with other measures, appropriate risk adjustment methods need to be employed before certain comparisons can be made; this is particularly important for the first measure, since the SMR adjusts for age, sex and the overall mortality rate of a geographic area by definition. Second, mortality is the result of complex processes that may be influenced by events from the immediate and the more distant past. As such, mortality may be influenced by events occurring before the period for which performance is to be measured. Unless these events are irreversible, however, we can expect successful service interventions aimed at improving the health status of a population to be reflected in these measures. Third, this indicator is most useful when the served population is large, for example in a statewide system. If the system serves only a relatively small number of persons, random variation over time may be misinterpreted as reflecting system performance.

Workgroup Chair: Craig Colton, Utah

INDICATOR: O10: RECOVERY/PERSONHOOD/HOPE

RATIONALE FOR USE: This is the most critical emergent concept and goal in the treatment of mental illness and is related to a sense of the loss of self that is associated with mental illness. It is multidimensional in nature and subsumes hope, dignity, self-respect, self-mastery, self esteem, self worth and a sense of empowerment.

APPROACH TO MEASURE: The recovery workgroup recognized that measures related to recovery are under development. Several members of the 16 State study are working with consumers in their states to convene a series of focus groups to develop a common measure of recovery. The 16 State study focus group effort will be completed by April, 2001. These focus groups will explore key domains associated with mental health recover: resources, choices, independence, connections with others, hope, and services and staff. Based on input from these focus groups, a draft instrument will be developed for pilot testing by states.

MEASURE(S): Being developed

Numerator:

Denominator:

CURRENT IMPLEMENTATION STATUS:

SOURCE OF DATA: Consumer Survey

POPULATIONS:

Children with a Serious Emotional Disturbance
Adults w/ a Serious Mental Illness
All Children
All Adults
Geriatric

SETTINGS:

Psychiatric Inpatient Settings
Community-based Settings

ISSUES:

WORKGROUP CHAIR: Vijay Ganju, NRI

INDICATOR: O11: PERCENTAGE OF CONSUMERS WHO EXPERIENCE REDUCED IMPAIRMENT FROM SUBSTANCE ABUSE.

RATIONALE FOR USE: Large proportions of persons with mental illness are also substance abusers. To achieve some of the outcomes that are the objectives of the system, the substance abuse component must also be addressed.

MEASURE(S):

Numerator:

Denominator:

CURRENT IMPLEMENTATION STATUS:

SOURCE OF DATA:   Clinician Report;   Self Report

POPULATIONS:

Children with a Serious Emotional Disturbance
Adults w/ a Serious Mental Illness
All Children
All Adults
Geriatric

SETTINGS:

Psychiatric Inpatient Settings
Community-based Settings

ISSUES: The Substance Abuse Impairment Workgroup is conducting a survey of 16 State Study states to ascertain what form this indicator can be reported. The survey is attached below.

WORKGROUP CHAIR: Jack Wackwitz, Colorado

Return Completed Questionnaire to:	Jack Wackwitz, Ph.D.
	Colorado Mental Health Services
	3824 W. Princeton Circle
	Denver, CO 80236
	e-mail: jack.wackwitz@state.co.us
	Phone: 303-866-7425
	FAX: 303-866-7428

Please attach copies of any instruments you use to assess comorbid substance abuse.

State  ________________________
Department  _____________________________________
e-Mail  ________________________________________
Phone  _______________________________________

A1.	At a data system level how are Substance Abuse and Mental Health Integrated? ___ One data system with common consumer id ___ Separate data systems but with common consumer id ___ Separate data systems but without common consumer id ___ Other Please Comment
A2.	At an individual consumer level can you match substance abuse and mental health records? ___ No ___ Yes If Yes: Do you match substance abuse and mental health records? ___ No ___ Yes, but do not do so regularly ___ Yes, and do so regularly
A3.	Do you have special programs for persons with comorbid mental health and substance abuse problems? ___ No ___ Yes  If Yes: How many consumers are served?_____ Are program codes maintained in your database that allow you to select samples from these program(s)? ___ No ___ Yes
B1.	Do you use a screening instrument(s) to assess Comorbid Substance Abuse? ___ No ___ Yes, but only on some consumers ___ Yes, on all consumers

If YES, BUT ONLY ON SOME CONSUMERS: Please describe the conditions that must exist in order for an assessment to take place. Also indicate what groups of consumers are assessed.

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

Please list and describe the screening instruments:

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

________________________
___________________________________

Does the assessment result in a scale indicating the degree of Substance Abuse?
___ No
___ Yes

Is the assessment conducted on more than one occasion?
___ No
___ Yes
If Yes: Please indicate how often and on what occasions the assessment is conducted.
___________________________________________________________

___________________________________________________________

___________________________________________________________

Please describe the procedures you use to assess change.
___________________________________________________________

___________________________________________________________

C1.	How many Diagnoses do you have in your State's Mental Health database: ___ One (Primary) ___ Two    If Two or Three or More: ___ Three or More Is one of the Diagnoses reserved for Comorbid Substance Abuse? ___ No ___ Yes
C2.	If there are any other ways that you assess comorbid substance abuse in your state, please describe. ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
D1.	What do you see as the major challenges to our task of assessing changes in substance abuse? ___________________________________________________________ ___________________________________________________________ ___________________________________________________________

INDICATOR: O12 LIVING SITUATION OF MENTAL HEALTH CONSUMERS

RATIONALE FOR USE: Independent living is an important goal for persons with serious mental illness. Though housing status is affected by a variety of factors, systems that address and support independent community living are expected to show a higher proportion of individuals living in independent settings. The proportion of persons living in each Living Situation is a measure of system performance.

APPROACH TO MEASURE: Examining a person's change in Living Situation across time (e.g., annually) provides a Performance Indicator of the client's level of functioning and ability to perform activities of daily living. A change in a client's residential arrangement during mental health treatment/services may reflect the level of recovery and/or increased need for services.

Living situation is comprised of two major components.

First, what is the Place of Residence (i.e., structure or 'four walls') in which the person is living? Examples of Place of Residence may include a Private Residence (e.g., house or apartment), group home, skilled nursing facility, jail, or homeless.

Second, what level of support is needed to maintain in that 'structure'. For example, one person may live with a family member and require daily support to remain stable in the home. Another person may live with a family member and require no support. Level of support only applies to a private residence because all other living situations provide 'support' as a component of the program.

Recommended Living Situation Categories: Individual's Primary Living Situation

Private Residence without support      (e.g., individual's own house, apartment, trailer, hotel, dorm, barrack)

Private Residence receiving support   (e.g., house, apartment, trailer, hotel, dorm, barrack)

24-Hour Residential Care    (e.g., Group Home, Board and Care, Foster Home, Crisis Residential, Rehabilitation Center, Children's Residential Care/Treatment Facility)

Institutional Setting    (e.g., Skilled Nursing/Intermediate Care Facility, Institute of Mental Disease (IMD), Inpatient Psychiatric Hospital, Psychiatric Health Facility (PHF), Veterans Affairs Hospital, State Hospital)

Jail/ Correctional Facility    (e.g., Jail, Correctional Facility, Prison, Youth Authority Home, Juvenile Hall)

Homeless/ Shelter    (e.g., no identifiable residence, on the street, in a shelter)

Other

Unknown/Not Reported
Note: Persons receiving evidence-based Supported Housing Programs will also be recorded under a separate data element, "Adults in Supported Housing".

Use of the Indicator:

A single, point in time, measure of Living Situation provides system level information on clients' place of residence. This may be reported at Admission, at the time of the report, and/or at discharge. This point in time measurement describes the mental health system's client population by type of residence. It is a system level performance indicator.

To use as a client outcome measure, Living Situation is collected across time, using two or more data points. By examining a client's Living Situation at two or more points in time, you obtain a measure of change. For example, if a client were living in a 24-hour residential care facility at admission and in a private residence with support at one year, this client would show an improved outcome on Living Situation.

Collecting this outcome measure on an annual basis provides a macro view of the client's progress across time. Many clients move several times during a year. A program or region may choose to collect this measure more frequently, and/or with additional categories to provide additional levels of detail. However, at a state level, this more global view of change in Living Situation may be adequate.

Proposed Frequency of Reporting Living Situation:

1. At time of Admission
2. Periodically: Annually; Semi-Annually
3. At time of Discharge

Definitions:

Private Residence:

Individual lives in a house, apartment, trailer, hotel, dorm, barrack, Single Room Occupancy (SRO).

Without Support:

Individual lives in a Private Residence and does not require routine or planned support to maintain his/her independence in the living situation.

Receiving Support:

Individual lives in a private residence and receives support to maintain independence in his/her private residence. This may include individualized services to promote recovery, manage crises and symptoms. Support services are delivered in the person's home environment. Support services may be delivered by another individual living in the home or provided by a person/organization periodically visiting the home.

24-Hour Residential Care:

Individual resides in a residential care facility with care provided on a 24 hour, 7 day a week basis. This level of care may include a Group Home, Therapeutic Group Home, Board and Care, Foster Home, Therapeutic Foster Care Facility, Crisis Residential, Residential Treatment, or Rehabilitation Center, or Residential Care/Treatment Facility

Institutional Setting:

Individual resides in an institutional care facility with care provided on a 24 hour, 7 day a week basis. This level of care may include a Skilled Nursing/Intermediate Care Facility, Institute of Mental Disease (IMD), Inpatient Psychiatric Hospital, Psychiatric Health Facility (PHF), Veterans Affairs Hospital, or State Hospital.

Jail/ Correctional Facility:

Individual resides in a Jail and/or Correctional facility with care provided on a 24 hour, 7 day a week basis. This level of care may include a Jail, Correctional Facility, Prison, Youth Authority Facility, Juvenile Hall, Boot Camp, or Boys Ranch.

Homeless:

A person has no permanent place of residence where a lease or mortgage agreement between the individual and the owner exists (TANF: CA SB 1357).

A person is considered homeless if he/she lacks a fixed, regular, and adequate nighttime residence and/or his/her primary nighttime residency is:

1. a supervised publicly or privately operated shelter designed to provide temporary living accommodations,
2. an institution that provides a temporary residence for individuals intended to be institutionalized, or
3. a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings (e.g., on the street). (McKinney Act, 1994)

Other

Unknown:

Information on an individual's residence is not available.

MEASURE(S):

Numerator:

Denominator:

CURRENT IMPLEMENTATION STATUS:

SOURCES OF DATA:	(1) Consumer self report
	(2) MIS

POPULATIONS:

Children with a Serious Emotional Disturbance
Adults w/ a Serious Mental Illness
All Children
All Adults
Geriatric

SETTINGS:

Psychiatric Inpatient Settings
Community-based Settings

ISSUES:.
WORKGROUP CHAIR: Nancy Callahan

INDICATOR: O13 PERCENTAGE OF CONSUMERS ARRESTED.

RATIONALE FOR USE: Often as a result of inadequate or inappropriate community placements, an increasing number of people with mental illness are involved inappropriately with the criminal justice system. This is a surrogate measure for adequacy of funding and development of community placements. This measure looks at the potential for mental health systems to cost-shift to public safety agencies if mental health services are not available or effective and is not meant to indicate or imply that individuals with a mental health concern pose any specific dangerousness to the general public.

MEASURE(S):

Percentage of consumers with no arrests within the last 30 days at 6 and 12 months post admission.

Numerator: Number of consumers with no arrests within the last 30 days at 6 (12) months post admission.

Denominator: Total number of consumers in service at 6 (12) months post admission.



Average decrease in the number of arrests from admission to six months post admission.

Numerator: (Number of arrests in last 30 days) admission - (Number of arrests in last 30 days) 6 months

Denominator: Total number of persons with arrests at admission who are reassessed at 6 months post admission.

CURRENT IMPLEMENTATION STATUS:

POPULATIONS:

Children with a Serious Emotional Disturbance
Adults w/ a Serious Mental Illness
All Children
All Adults
Geriatric

SETTINGS:

Psychiatric Inpatient Settings
Community-based Settings

SOURCES OF DATA:
(1) Consumer report obtained through clinician/staff interview
(2) Official records

ISSUES: The length of time over which the number of arrests is measured is related to the reliability of the data source. If official records were used across the board, it would be reasonable to extend the period of time. For instance, if there are six months between assessments, arrests for the whole six months could be measured. In some instances, however, it may not be possible to collect official record data on all consumers being assessed and self-report may be the only source. In this situation, research has demonstrated that self-report is reliable only up to a period of 30 days.

WORKGROUP CHAIR: Lucille Schacht, NRI

INDICATOR: O13(B) AVERAGE NUMBER OF DAYS OF INCARCERATION PER CONSUMER IN PAST 30 DAYS.

RATIONALE FOR USE: Often as a result of inadequate or inappropriate community placements, an increasing number of people with mental illness are involved inappropriately with the criminal justice system. This is a surrogate measure for adequacy of funding and development of community placements. This measure looks at the potential for mental health systems to cost-shift to public safety agencies if mental health services are not available or effective and is not meant to indicate or imply that individuals with a mental health concern pose any specific dangerousness to the general public.

MEASURE:

Percentage of consumers with no days of incarceration within the last 30 days at 6 and 12 months post admission.

Numerator: Number of consumers with no days of incarceration within the last 30 days at 6 (12) months post admission.

Denominator: Total number of consumers in service at 6 (12) months post admission.



Average decrease in the number of days incarcerated from admission to six months post admission.

Numerator: (Number of days incarcerated in last 30 days) admission - (Number of days incarcerated in last 30 days) 6 months

Denominator: Total number of persons who had been incarcerated with 30 days of admission who are reassessed at 6 months post admission.

BURDEN: Although the item may not be reported accurately by all consumers, matching mental health and criminal justice system records may be too onerous.

CURRENT IMPLEMENTATION STATUS:

POPULATIONS: Adults with SMI who were incarcerated one or more days within the last 30 prior to admission.

SOURCES OF DATA:
(1) Consumer report obtained through clinician/staff interview
(2) Official records

ISSUES: The length of time over which the number of incarcerations is measured is related to the reliability of the data source. If official records, such as jail records, were used across the board, it would be reasonable to extend the period of time. For instance, if there are six months between assessments, incarcerations for the whole six months could be measured. In some instances, however, it may not be possible to collect official record data on all consumers being assessed and self-report may be the only source. In this situation, research has demonstrated that self-report is reliable only up to a period of 30 days.

WORKGROUP CHAIR: Lucille Schacht, NRI

O13: Percent of Children and Adolescents with SED Involved in the Juvenile Justice System

Percentage of children and adolescents with SED who are involved with the juvenile justice system. Measured at admission and 6 months and 12 months post admission.

Numerator: Total number of children and adolescents with SED who had at least one arrest during the reporting period.

Denominator: Total number of children and adolescents with SED being served at admission, 6 (12) months post intake.

Percentage of youth who show improvement in arrests during the reporting period.

Numerator: Total number of children and adolescents with SED being served where [# arrests at admission - # arrests at 6(12) months] is greater than zero.

Denominator: Total number of children and adolescents with SED who report being arrested during the reporting period prior to admission and are reassessed.

S1 Consumer/Family member involvement in policy development, quality assurance & planning

Consumer Participation in Planning: Donna Stimpson (CT), w/ Deb Kupfer (CO, Irwin Kerzner (IL), Kitty Hepfer (SC), Pat Dunston (DC), Judy Gosney (WA), Melinda Murtaugh (VT), and Marie Danforth (CMHS)

Planning a reduced survey of state planners.

Focus on 2 indicators:
1)    % of consumers on planning boards
2)    % of family members on planning boards

Comments-may need to also separate out parents of child consumers

Time frame-Teleconference in Sept-after state plans are due. Survey of states will be ready by October/November.

INDICATOR: S3 AVERAGE RESOURCES EXPENDED ON MENTAL HEALTH SERVICES.

RATIONALE FOR USE:

MEASURE(S): The total amounts of direct service expenditures on mental health services in one year divided by (1) the total number of enrolled (or general population) and (2) the total number of persons who received at least one mental health service. Expenditures are depicted by (1) type of service and by (2) the numbers of units of service and (3) cost per unit of service provided.

1(a). Numerator:
          Total amount of annual direct services expenditures for sub-population

          Denominator:
          Total number of full-time enrollees in sub-population

1(b). Numerator:
          Total amount of direct services expenditures for sub-population

          Denominator:
          Total number of persons in sub-population with at least one visit

CURRENT IMPLEMENTATION STATUS:

POPULATIONS:

Children with a Serious Emotional Disturbance
Adults w/ a Serious Mental Illness
All Children
All Adults
Geriatric

SETTINGS:

Psychiatric Inpatient Settings
Community-based Settings

SOURCE OF DATA: Administrative records

WORKGROUP CHAIR: Nancy Callahan: (other workgroup members are: Eva Jakuba & Linda Frisman (CT), Steve Reeves (MO), Deb Kupfer (CO), Denny Geertsen (UT), Judy Gosney (WA), Sudha Mehta (NY).

Please find attached three tables for collecting information on the number of unduplicated clients, units, and dollars for Your State. Some states may only be able to provide some of the requested data. However, Please complete as much of each table as possible.

If possible, provide the additional level of detail for Age (Child: 0-17 Years and Adult/Older Adult: 18 + Years) and Service Category (Inpatient Services, Outpatient Services, Day Treatment/Residential Services), and Medicaid and Non-Medicaid dollars.

Many states will NOT be able to complete this level of detail. Please provide as much information as you have available!

TABLE 1: Total State Unduplicated Clients Receiving Publicly Funded Mental Health Services

1. Statewide total of unduplicated clients seen in Fiscal Year 1998/99 (TOP LEFT BOX ON TABLE).

Important: This number should include all mental health clients who received one or more publicly funded mental health services, across all ages (>0 through elderly) and all service categories for FY 1998/99. This includes all clients receiving variants of publicly funded psychiatric inpatient services, and all "community" or outpatient clients. For example, include clients receiving mental health services from community inpatient psychiatric hospitals, State Hospitals, crisis, residential facilities, ACT, outpatient, etc.

These clients have a primary mental health diagnosis or are receiving treatment from a mental health service provider. Dual diagnosis clients with a primary mental health diagnosis are included. Forensic clients receiving mental health services in the community are included. Jail diversion clients receiving mental health services are also included.

Do Not Include:

Substance Abuse Only Clients
Developmentally Delayed Only Clients
Forensic Clients in the State Hospital

Identify Unique Characteristics for your state:

Please list any Qualifiers (Exclusions or Inclusions) for your state. For Example:

If children, or some part of the mental health population, is not covered, or counted in your database.
If your service population includes only Medicaid eligible or does not have Medicaid data available for a sector of the information

List any additions-if DD clients, or alcohol or substance abuse clients cannot be extracted from mental health clients.

If you do not have an unduplicated state-wide client count, note that it is duplicated, or an estimate of an unduplicated count (if possible).

Please Foot Note if Clients who are paid from other sources (for example, private insurance) are included in this total.

Please note if the client count is of those 'enrolled' rather than those served.

ADDITIONAL BREAK DOWN OF CLIENT POPULATION

AGE: Unduplicated Clients by Age:
Child = 0-17 years
Adult = 18 Years and Older

MEDICAID/ NON-MEDICAID:
Unduplicated Medicaid Clients by Age and Total

Unduplicated Non-Medicaid Clients by Age and Total

SERVICE CATEGORY (Inpatient Services, Outpatient Services, Day Treatment / Residential Services

Unduplicated Clients within Service Category:

PLEASE NOTE: The sum of the unduplicated client counts across all service categories SHOULD NOT equal the total state unduplicated count. Clients may be seen in a number of different service categories (e.g., Inpatient, Outpatient).

Count the number of clients receiving services for EACH Service Category described below:

Inpatient Services (Units are Days)

State Hospital
Children's Long Term Residential; Children's Treatment Facility
Community Psychiatric Inpatient Settings
Institutes of Mental Disease (IMD)
Psychiatric Health Facility

Crisis Services (Units are Contacts/Minutes or Hours)
NOTE: Some States may not be able to separate Crisis from Outpatient Services. In this instance, include Crisis in the Outpatient Data.

Crisis Services (Including Crisis Contacts, Crisis Stabilization, Mobile Crisis)

Outpatient Services (Units are Contacts/Minutes or Hours)

Outpatient Services (including Medications, Individual, Group, Family)
Case Management Services
ACT
Rehabilitation Services; Vocational Services

Day Treatment / Residential Services (Units are Full or Partial Days)
NOTE: Some States may be able to separate Day Treatment from Residential Services. In this instance, Please report the data separately so we can examine the differences in these two types of services.

Full or Partial Day Treatment Services
Partial Hospitalization
Vocational / Rehabilitation Day Services
Psycho-Social Rehabilitation Day Services

Crisis Residential Services
Crisis Respite Beds
Other Residential Services

TABLE 2: Total State Units of Service for Publicly Funded Mental Health Services

Using the data "Rules" described above, please list the Total Units of Service for Each Service Category. NOTE: It is not logical to provide Total Units of Service across ALL SERVICES because "Day Units" and "Contact Units" can not be combined.

Total Units of Inpatient Services (Units are Days) and By Age

State Hospital
Children's Long Term Residential; Children's Treatment Facility
Community Psychiatric Inpatient Settings
Institutes of Mental Disease (IMD)
Psychiatric Health Facility

Total Units of State Hospital Services and By Age

Total Other Inpatient Services and By Age

Crisis Services (Units are Contacts/Minutes or Hours)
NOTE: Some States may not be able to separate Crisis from Outpatient Services. In this instance, include Crisis in the Outpatient Data.

Crisis Services (Including Crisis Contacts, Crisis Stabilization, Mobile Crisis)

Total Units of Outpatient Services (Units are Contacts/Minutes or Hours) and By Age

Outpatient Services (including Medications, Individual, Group, Family)
Case Management Services
ACT
Rehabilitation Services; Vocational Services

Total Units of Day Treatment / Residential Services (Units are Full or Partial Days)

NOTE: Some States may be able to separate Day Treatment from Residential Services. In this instance, Please report the data separately so we can examine the differences in these two types of services.

Full or Partial Day Treatment Services
Partial Hospitalization
Vocational / Rehabilitation Day Services
Psycho-Social Rehabilitation Day Services
Crisis Residential Services
Crisis Respite Beds
Other Residential Services

TABLE 3: Total State Dollars for Publicly Funded Mental Health Services

Important: This number may be calculated from the dollars the state is paying for mental health services across several categories including Medicaid and Block Grant dollars. Alternatively, It may be obtained from Financial statements /Cost Reports submitted by the regional centers/ mental health entities across the state to the Mental Health State Authority. This may include all monies available in your system for FY 1998/99 for State dollars and federal match disproportionate share monies used to supplement inpatient mental health services, etc.

Do Not Include:

Substance Abuse Only Dollars
Developmentally Delayed Only Dollars
Dollars for Forensic Clients in the State Hospital

Other fiscal sources for Inpatient Services (private insurance).
Other fiscal sources for Outpatient Services

Unique Characteristics:

• As above, list any exclusions (by state law or custom) that would limit this money number (e.g. your system deals only with Medicaid eligible persons-there is no state money that is unmatched).
• Please include a Foot Note on Indirect Costs and Admin Costs - Does you state include these dollars in the reported figures or excludes them.

Using the data "Rules" described above, please list the Total Dollars for Each Service Category.

Total Dollars for Inpatient Services (Units are Days) and By Age

State Hospital
Children's Long Term Residential; Children's Treatment Facility
Community Psychiatric Inpatient Settings
Institutes of Mental Disease (IMD)
Psychiatric Health Facility

Total Dollars for State Hospital Services and By Age

Total Dollars for Other Inpatient Services and By Age

Total Dollars for Crisis Services (Units are Contacts/Minutes or Hours)
NOTE: Some States may not be able to separate Crisis from Outpatient Services. In this instance, include Crisis in the Outpatient Data.

Crisis Services (Including Crisis Contacts, Crisis Stabilization, Mobile Crisis)

Total Dollars for Outpatient Services (Units are Contacts/Minutes or Hours) and By Age

Outpatient Services (including Medications, Individual, Group, Family)
Case Management Services
ACT
Rehabilitation Services; Vocational Services

Total Dollars for Day Treatment / Total Dollars for Residential Services (Units are Full or Partial Days)

NOTE: Some States may be able to separate Day Treatment from Residential Services. In this instance, Please report the data separately so we can examine the differences in these two types of services.

Full or Partial Day Treatment Services
Partial Hospitalization
Vocational / Rehabilitation Day Services
Psycho-Social Rehabilitation Day Services
Crisis Residential Services
Crisis Respite Beds
Other Residential Services

Computation and Display:
This data will be combined in tables, along with published census data for state population data estimated for FY 1998/99 to calculate dollars per client and dollars per unit of service for each state and across service categories. The finished tables displaying these data will be distributed and then discussed during conference calls and at our July meeting.

Thank you for your help. Please provide as much information on your state as possible. If you have questions, please e-mail Nancy Callahan at nancycal@dcn.davis.ca.us or call 530-758-8815