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HomeMy WebLinkAboutHealth services-client access to careHealth Services - Client access to services #10/11-3 January 2012 Health Services – Client access to services Deschutes County, Oregon David Givans, CPA, CIA Deschutes County Internal Auditor PO Box 6005 1300 Wall Street, Suite 200 Bend, OR 97701 (541) 330-4674 David.Givans@deschutes.org Audit committee: Michael Shadrach, Chair - Public member Chris Earnest - Public member Gayle McConnell - Public member Jean Pedelty - Public member Greg Quesnel - Public member Jennifer Welander - Public member Anthony DeBone, County Commissioner Tom Anderson, Community Development Director Scot Langton, County Assessor Health Services - Client access to services #10/11-3 January 2012 TABLE OF CONTENTS: EXECUTIVE SUMMARY 1. INTRODUCTION 1.1. Background on Audit …………..……………………………………......………………...…… 1 1.2. Objectives and Scope ………………….……………………………..………………….......... 1 1.3. Methodology ...…………….……………………......…..................................................... 1-2 2. PRIOR INTERNAL AUDIT RECOMMENDATIONS …………….…………...…. 2-3 3. BACKGROUND ……..………………………………………………….………………..… 3-4 4. FINDINGS AND OBSERVATIONS 4.1. Customer Satisfaction Survey ………………………………………………..…………..… 4-5 4.2. General Measures of Access for Health Services 4.2.1. Days to initial appointment from clinic data ….…………………………………. 5-7 4.3. Behavioral Health Audit Approach ……………………………………………………….. 7-10 4.4. Behavioral Health Audit Observations 4.4.1. Screening times …………………………………………………………………. 10-12 4.4.2. Screening and assessment times ………………………………………...……12-15 4.4.3. Observations on delays to assessment ………………………………………. 15-21 4.5. Issues Common to Public and Behavioral Health …...………………………………... 21-22 4.6. Other ..…………………………………………………………………………………….... 22-24 5. MANAGEMENT RESPONSE 5.1. Health Services …………………..……………………………………………….................. 25 6. APPENDICES 6.1. Additional survey data analyses ……………………………………………………….... 26-27 6.2. Additional Public Health Data Analyses ……………………………………………….... 28-29 6.3. Additional Behavioral Health Data Analyses ………………………………………….... 29-32 6.4. Most recent workplan for outstanding recommendations (from Global follow-up report #10/11) for Health and Behavioral Health ……………. 33-36 Health Services - Client access to services #10/11-3 January 2012 HIGHLIGHTS Why this audit was performed: To identify how new client workflow is working by looking for relative performance measures and areas for potential improvement. What is recommended Recommendations include • Monitoring and reacting when screening resources are insufficient • Calculating and report on benchmarking standards • Evaluating system for processing new clients • Obtaining performance metrics form panel providers • Streamlining process through to panel providers. • Improving timeliness through to assessment • Monitoring and distributing workflow among clinicians HEALTH SERVICES – Client access to services What was found The audit found, through a limited survey of clients, that Public Health and Behavioral Health clients were satisfied with services. The survey also identified that days to appointment were much longer for Behavioral Health. The audit, therefore, was configured to emphasize Behavioral Health services. The path to services in Behavioral health is primarily through a screening and assessment process. Screening times on average are around 7 days. Variations were noted by age group indicating the child age clients had longer waits for screening. For clients that reach assessment, the audit noted that days from call to assessment took on average 18 days. Oregon Health Plan (OHP) clients are supposed to be seen within 14 days from call for service and for some reason their times seems to be a bit longer. Only 54% of clients are being seen within the 14 days. We did note that there were some areas that seem to have contributed to lengthening the overall wait times. These included: • discontinuity of screener staffing for children; • handing off clients for authorization to other providers (such as panel providers); • providing other services prior to assessment; • work distribution among clinicians The audit also identified some areas that could be projects for improving and streamlining workflow. The Behavioral Health department is in the process of implementing an electronic health records system that is likely to address many of the issues observed. Some observations were noted so that they may be clearly addressed in the new system. The department could work more closely with Public Health and vice versa to overcome similar issues. Deschutes County Internal Audit Health Services - Client access to services #10/11-3 January 2012 Page 1 of 36 1. Introduction 1.1 BACKGROUND ON AUDIT Audit Authority/purpose: The Deschutes County Audit Committee authorized the review of Health Services in the fiscal year 10/11 audit workplan. This report covers the area of new client access. The plan was that by looking at this topic for both behavioral and public health some efficiencies might be identified. 1.2 OBJECTIVES and SCOPE Objectives included: 1. Identify the ways new clients are received and the process through to their assessment. a. Look for relevant measures of performance in this area. b. Look for opportunities to streamline and combine activities in this process. 2. Identify how the upcoming electronic medical records system in Behavioral Health (and perhaps eventually Public Health) could influence process for new clients. a. Analyze information for client setups Scope: The audit focus was on current systems and procedures and utilizing data from January 2011 through June 2011. The public and behavioral health clinic record systems do not have a process for consistently classifying clients as new. Appointment notes indicating “new” identified new public health clients. Behavioral health clients were identified by the date they were opened into a new program. These identification methods have their weaknesses. It is not believed they are significant to affect materially the findings within this report. It is important to note that the department has been making improvements to their systems during the course of the audit. The department’s continuous improvement processes have identified areas they are working on, which may already be addressing areas identified within this audit. The department is also working on improvements in response to input from ABHA (the County’s mental health organization). The department has also hired a consultant to help them reduce wait times for new clients. The internal audit is being seen as complimentary to these other efforts. 1.3 METHODOLOGY Audit procedures included:  Discussions with Health Services staff regarding the audit objectives.  Research on similar audits and nature of findings from those reports. Health Services - Client access to services #10/11-3 January 2012 Page 2 of 36  Development of a survey for new clients of public and behavioral health. The survey was provided to new clients at specified locations in Spanish and English versions. The focus of the survey was on satisfaction, and ease of getting an appointment. Staff, for consistency, were to complete certain demographic information – department, location, gender, and age group. The survey was performed early in the planning of the audit and used to identify priorities.  Discussions and observations with various Health Services staff to understand how their systems operate and some of the DHS and contractual rules they are to follow.  Development of an approach to access the needed data.  Analysis of revenue and expenditure data for Health Services.  Review of Health Services budget information and staffing levels.  Review of performance measures for Health Services.  Obtaining detail appointment information for new clients in behavioral and public health clinics.  Development of an approach, for behavioral health data, to review for new clients their access to care from triage through to assessment.  Analyzing clinic appointment data and discussing with staff. We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. (2007 Revision of Government Auditing Standards, issued by the Comptroller General of the United States.) 2. Prior Internal Audit Recommen- dations Health Services has had a number of prior internal audit projects and follow-ups. The following projects had outstanding recommendations. Approximately 80% of the original recommendations have been addressed, 20% are still open. Department or Fund Report # Date Report Issued Follow-up Report(s) Follow-up Date(s) # of Original Recommendations # Recommendations Open % of Original Health 05/06-4 Jul-06 07/08-4 08/09-7 09/10-11 Sep 2007 Dec 2008 June 2010 44 1 2% Mental Health 04/05-6 Mar-05 05/06-11 08/09-5 09/10-11 Jul 2006 Nov 2008 June 2010 52 18 35% 96 19 20%Totals Health Services - Client access to services #10/11-3 January 2012 Page 3 of 36 In addition, there were a number of non-audit letters that included recommendations in response to frauds reported and included: • Public Health - Fraud recommendations 6-2009, 5-2011 • Behavioral Health - Fraud recommendations 10-2009 Follow-ups have been ongoing and the most recent status is outlined in global follow-up report (#10/11-10). The Behavioral Health department has a number of significant items still outstanding. They are anticipating these will be addressed through their implementation of an electronic health records system. The system is expected to be in place in 2012. See Appendix 6.4 for details of the open recommendations. 3. Background Table I: Selected fund financial information Deschutes County Health Services was formed in 2009 through the combination of the County public and behavioral health departments. The departments are some of the larger departments at the County and provide health services to targeted clients. The department receives the greatest share of its revenue from the state of Oregon for providing services to Oregon Health Plan members. It is anticipated with the current economy that service needs will grow. For budgeted fiscal year 2012, health services were planning for 194 FTE (76 in Public / 118 in Behavioral). For the customers, the two departments still look very separate. Despite some of the merged oversight structure, the business and operation sides of public and behavioral health are still very separate. As clinics, they are similar in many ways but the size of the organizations and the separate investments being made in technologies will delay the consolidation of these operations. Probably the most recent change has been the introduction of school based health centers where public health and mental health services are provided to school aged children. More effort is being directed towards providing health and mental health treatment together. Fiscal year - ending June 30, 2009 2010 2011 RESOURCES 259 Public Health 6,370,256$ 6,716,144$ 7,965,258$ 275 Behavioral Health 11,872,091 11,418,741 14,551,766 18,242,347 18,134,885 22,517,024 EXPENDITURES 259 Public Health 6,222,337 6,221,192 7,965,132 275 Behavioral Health 11,977,403 11,357,474 13,994,163 18,199,740 17,578,666 21,959,295 NET OF RESOURCES and EXPENDITURES 42,607$ 556,218$ 557,729$ Source: County financial systems (resources shown without working capital) Health Services - Client access to services #10/11-3 January 2012 Page 4 of 36 Oregon Senate Bill 204 is piloting a regional health council wherein physical and mental health programs are addressed together. The goal is improved health outcomes, improvement in care and reductions to the cost of care. 4. Findings and Observations These findings are intended to assist Health Services and County management evaluate whether improvements are needed. The audit did appear to identify some deficiencies in the system for timely processing clients. These weaknesses could be significant and may warrant significant changes in operations. A deficiency exists when the design or operation of a system does not allow management or employees, in the normal course of performing their assigned functions, to prevent or detect (1) misstatements in performance information, (2) violations of laws and regulations, or (3) impairments of effectiveness or efficiency of operations, on a timely basis. Audit findings result from incidents of non-compliance with stated procedures and/or departures from prudent operation. The findings are, by nature, subjective. The audit disclosed certain policies, procedures and practices that could be improved. The audit was neither designed nor intended to be a detailed study of every relevant system, procedure or transaction. Accordingly, the opportunities for improvement presented in the report may not be all-inclusive of areas where improvement may be needed and do not replace efforts needed to design an effective system of internal control. 4.1 Customer Satisfaction Survey Survey results were limited but did indicate satisfied clients. The health services department, in coordination with the internal audit, performed a customer survey focused on customer overall satisfaction and on ease of getting an appointment. The survey was focused on new clients at the main public health and behavioral health clinic sites. A relatively small number of surveys were collected (61); therefore, the survey results are at best an inference on customer satisfaction. Overall satisfaction was addressed through Chart 1 (below) and indicates a high level of satisfaction from clients for Behavioral and Public Health (with a score of somewhere between a good and an excellent rating). Health Services - Client access to services #10/11-3 January 2012 Page 5 of 36 Chart 1 Overall satisfaction rate by department (Average ranking on 1-5 scale, 5=Excellent) Table II Customer satisfaction survey scores by question 4.5 4.6 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 Behavioral Health Total Public Health Total Satisfaction Scale: 1=Very poor, 2=Poor, 3=Fair, 4=Good, 5=Excellent) The following table summarizes all of the observations (See Appendix Section 6.1 for additional charts): Description Scoring Public Health Behavioral Health Overall satisfaction rate 1-5 ranking (5 = Excellent) 4.6 4.5 Would you recommend to family and friends? % Yes response 100% 98% How easy was it to get appointment? 1-5 ranking (5 = Very easy) 4.4 4.3 Did the time it took to get an appointment meet you expectations % Yes response 100 97 On average, how long did it take to get an appointment? (primarily assessments for BH) Average # of days 2.5 9.0 The observation taken away from the survey was to continue to look for opportunities to understand the difference in the nature and time it takes to get appointments within behavioral health. More focus will be placed on review of behavioral health timing through to appointment. 4.2 General Measures of Access for Health Services For the most part, the audit focused on access as it is delivered in days. Access depending on the acuity of care (urgent, routine, emergency) will dictate the nature and type of response. Public health generally does not distinguish acuity as they do not provide emergency treatment. General review and observation of behavioral health services indicated that crisis care was handled immediately and records provided indicated these normally occurred in a day. Most of the measures are overall and include all acuity types. Health Services - Client access to services #10/11-3 January 2012 Page 6 of 36 PUBLIC HEALTH Chart 2 PUBLIC HEALTH - Clinic data on average days until appointment by age group. 4.2.1 Days to initial appointment from clinic data A combination of the Bend, downtown and Redmond clinic information provides a representation of most of the clinic operations. The following information was isolated for clients identified as new clients. The overall days to an appointment for identified new clients was on average around 4 days. This also includes those who walked in. 3.7 2.9 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 Adult Child Average days until appointment made These measures appear to be relatively consistent over the period and only a bit longer than the data obtained from the client survey of 2.5 days. The above information is based upon 546 new client visits identified and shown as completed. BEHAVIORAL HEALTH Chart 3 BEHAVIORAL HEALTH - Clinic data on average days until screening appointment by age group. The County’s behavioral health organization (ABHA) provides access to care standards for member counties. The overall routine (non-emergency) standard for Oregon Health Plan (OHP) members is to wait no more than two weeks for initial assessment following a request for service. As indicated in Appendix chart A11, OHP members constitute approximately 47% of the services (in minutes). The following data represents clients opened into new programs and the number of days from call for service (triage) until screening. This is typically how clients come into the clinic, but some variation of this was observed (see discussion on clients that receive assessments without screening in Section 4.4.3). 6.2 8.8 0 1 2 3 4 5 6 7 8 9 10 Adult Child Average days from call to screening appointment Health Services - Client access to services #10/11-3 January 2012 Page 7 of 36 Chart 4 BEHAVIORAL HEALTH - Clinic data on average days until assessment appointment by age group (combined with screening). These measures were over the period 1-1-11 through 6-30-11. The average measure from days from call to screening is 7 days and was derived from 2235 client screenings. The longer times to initial screening and trending for children will be discussed further in the report. For behavioral health, the initial “assessment” appointment (discussed further below) represents the initial treatment of the client. Screening is a process for establishing whether the client needs to be seen, where, under what program and setting up an initial assessment appointment. Arguably, the “assessment” appointment is the first substantive service for treatment. 3.0 5.3 15.4 13.1 0 2 4 6 8 10 12 14 16 18 20 Adult Child Average days Average Days to Screening Average of Days to Assessment The data indicates an average of 18 days (derived from 680 client visits). This data is over the period 1-1-11 through 6-30-11 for clients who went through to assessment. This data is indicating much longer times (even for just assessment) than the client survey measure of 9 days. 4.3 Behavioral Health Audit Approach The initial planning and survey did not raise significant concerns about the public health measures. Clients appeared comfortable with the overall service and nature of time it took to get an appointment. For Behavioral health clients, the survey did not raise any significant concerns but the above measure in total through to assessment did seem a bit long. With OHP clients (the primary client for the department), there are certain required measures for access. For non-urgent care, client should receive their initial intake assessment within two calendar weeks. The current system of data for clients does easily portray the overall encounter with the client. The audit strove to Health Services - Client access to services #10/11-3 January 2012 Page 8 of 36 Figure I Simplified client workflow utilized take clients identified as new (by entry to a program) and identify when they first called for service, how long it took to be screened, and how long it took to be assessed. Specific procedure codes were identified – 926 for screenings and 917 for assessments. Department management reiterated that this client workflow should be seen. The simplified client workflow used for the audit looked something like this: Client phone call received Assess if crisis or routine (Triage) Crisis screener takes/or returns call and provides immediate services. Regular screener takes or returns call and sets up appointment with clinician for services. Clinician assesses client and develops initial treatment plan and diagnosis. Clinician provides therapy Days to screening from triage phone call. Days to assessment from screening call. if c r i s i s The department’s data created from client encounters required re-evaluating the data under this kind of workflow. The auditor calculated for each client encounter measures for days to screening, days to assessment, and whether an assessment was received before services were performed was noted. Also noted was whether the client had any history of being an OHP member since this is a target population. The examples below provide some activity for a couple of clients with the associated audit observations noted. Health Services - Client access to services #10/11-3 January 2012 Page 9 of 36 Table III Example client data EXAMPLE CLIENT DATA SCENARIOS Services Service date(s) Member of Oregon Health Plan? Days to Screen Days to assessment Total Minutes Were there services before assessment?Main Program CLIENT 1 EXAMPLE Triage - Phone call 1/11/2011 Yes 0 44 273 No Adult Mental Health Screening call 1/11/2011 (4/5-4/5)(4/5-5/19) Triage - Phone call 4/5/2011 Screening call 4/5/2011 Assessment 5/19/2011 CLIENT 2 EXAMPLE Triage - Phone call 1/11/2011 Yes 9 28 362 Adult Mental Health Screening call 1/20/2011 (1/11-1/20)(1/20-2/17) Group skill training 2/4/2011 Yes Assessment 2/17/2011 Audit observations New Electronic Health Records (EHR) system Behavioral health is in the midst of upgrading to an Electronic Health Records (EHR) system that will better control and faciliate care. The EHR system will handle scheduling, client records of service (paperless), and billing systems. Many of the issues noted in prior internal audits and issues raised in this reporrt will find some support through the advances of the new EHR system. The system focuses on the client and should provide for better coordination of care. The following are some areas that may be relevant as implementation moves forward. • EHR system should o Eliminate a number of the current billing processes. The current process is redundant and assumes that staff must be checked and errors corrected. Some of this occurs without supervisor involvement. The types of errors being made are not routinely monitored. o Not accept obvious errors by staff. o Make it more consistent around the various clinics since some of the other clinics have their own systems and methods for tracking. o Notify clinicians that clients are ready to be seen and when they are supposed to have certain tasks completed. The department has goals to train clinicians on concurrent documentation so more of the work is performed during the client meeting. o Provide opportunity to collect copays from all clients. Copays should be collected from all clients to be equitable. • The current process for clinical records allows for three different versions of the clinical record: the billing record in electronic records system; the copy of the record on the department-shared drive; and the physical Health Services - Client access to services #10/11-3 January 2012 Page 10 of 36 record in the medical file. It is recommended that an interim process be developed to assure these client records always match. 4.4 Behavioral Health Audit Observations The following observations of the data are provided for discussion purposes. There were a number of observations of the data that indicates issues with current system of client workflow. The following discussion are centered around the following: • Screening times, • Screening and assessment times, and • Observations on delays to assessment. 4.4.1 Screening times Chart 5 Screening times by age group and month (Child, Adult >18) Differences in screening system times observed. During an observation at the main clinic, there was a day where the vacation of an adult screener had not been addressed beforehand. This resulted initially in a later appointment for an OHP client. For some programs, namely the OHP population, they want the screening to occur within 2 days. During the internal audit observations, it was noted that screener appointment slots within a reasonable period were not always available (even in Adult) which resulted in clients being scheduled out beyond the expected time frame. 0 2 4 6 8 10 12 14 16 Jan Feb Mar Apr May Jun 2011 Av e r a g e d a y s t o s c r e e n i n g a p p t . Adult Child Health Services - Client access to services #10/11-3 January 2012 Page 11 of 36 Chart 6 Screening times by month for child abuse program clients The limitation on screeners can provide a bottleneck to services. It also was not clear whether there was an active process for monitoring the level of screening resources when times start to increase. It was noticed that screeners were also tasked with performing other services. The department also suffers from different screening processes occurring in different locations and with different programs. From discussions with staff, it appears the screening provides a necessary triaging for services and way of allocating resources. A number of the screening analyses indicate variations in performance. The triage and screening process provide the entry point for client services and therefore can significantly influence a client’s ability to obtain services. The lack of child and family screener resulted in nearly doubled the average screening times for child clients. The Child and Family program hired a part time screener in June to replace a vacant screener position. It was noticed, in particular, the screening times for the child abuse program clients increased when these clients should be heavily prioritized. 4 9 12 19 11 12 0 5 10 15 20 25 Jan Feb Mar Apr May Jun CHILD ABUSE A v e r a g e d a y s This program used to have their calls handed-off to offsite screeners at the program location. In addition to the screener issue, this program suffers from limited space and resources and a waiting list for services. Some recent improvement in the handoff of clients from the main clinic may provide for better results. There is still a potential for some capacity issues. It is recommended for the department to develop a system to understand and monitor screening resource needs in order to make sure it does not become a bottleneck for the clients wanting to be seen. There should be plans for additional resources and flexibility to make sure screeners are available and can perform on a timelier basis. Supervisor/managers should be responsible for making sure there are adequate staff to address the workload. Health Services - Client access to services #10/11-3 January 2012 Page 12 of 36 It is recommended the department endeavor to streamline and make more consistent the screening process for all clients regardless of program or location. {The new EHR system should be a big move in that direction. Implementation is expected in 2012.} 4.4.2 Screening and assessment times Chart 7 Screening and assessment time averages Chart 8 Screening and assessment time averages by month Assessment data indicate delays in getting through to assessment in a timely manner. The current average in days to assessment from the clients call for service is around 18.5 days. 4.1 14.4 0 2 4 6 8 10 12 14 16 18 20 Average days Average Days to Screening Average of Days to Assessment Average days to screening indicate some capacity issues, since for their target clients (Oregon Health Plan) the days to assessment should be 14 days or less. 2.7 4.1 2.9 5.4 6.9 7.6 14.3 17.5 13.7 14.5 13.0 6.0 0 5 10 15 20 25 Jan Feb Mar Apr May Jun 2011 Av e r a g e d a y s Average Days to Screening Average of Days to Assessment Health Services - Client access to services #10/11-3 January 2012 Page 13 of 36 Chart 9 Percentage of new clients (OHP and non-OHP) seen within 14 days. June only has limited information on assessments so the improved June assessment trend is likely not representative. The standard deviation for screening and assessments are 6 days and 18 days, respectively. These numbers are larger than the averages and indicate a significant variability in the numbers being seen. This raises a question about the current system for screening and assessment and indicates one that is inconsistent and may lack the ability to handle increased client volumes. The following chart indicates the percentage of clients seen within the 14-day benchmark as identified by the time it takes to get their assessment. It is taking nearly 52 days to get 95% of the new clients assessed and that is for data where the clients were noted as being assessed. 58% 46% 59% 51% 39% 50%52%57%62%60%53% 83% 0% 20% 40% 60% 80% 100% Jan Feb Mar Apr May JunPe r c e n t a g e o f n e w c l i e n t s s e e n i n 1 4 d a y s . Month OHP Non-OHP The Oregon Health Plan (OHP) population seems to have longer waits (nearly 12%) or 2 days longer for the assessment. It also appears that for most months the OHP group is experiencing longer times and not as close to reaching the benchmark. It is taking nearly 55 days for OHP clients to get 95% of the new clients assessed and that is 25% longer than the 44 days with non-OHP clients. It does not appear the department is meeting the access to care benchmarks and will need to make some significant changes to bring these overall times down. The following could include a relatively small number of urgent and emergency care clients, but audit data was not sufficiently detailed to indicate whether assessments occurred under an emergency or urgent status. Inclusion of those numbers should have lowered the calculated days shown. The audit was not aware of any internal reports on this benchmark being distributed to management on a routine basis. Health Services - Client access to services #10/11-3 January 2012 Page 14 of 36 It is recommended for the department to calculate and report on these benchmarking standards on a routine basis. They should also have these by age group, program and location and be able to use that information to institute targeted improvements. It is recommended for the Department to evaluate their system for processing new clients through to assessment and see if it can be streamlined. Note. Some additional observations follow on some of the areas that may be contributing to the variability and the length of time. Chart 10 Composition of average days through to assessment for Behavioral health and for panel providers utilized. Timing for services to outside providers. The department under agreements with outside providers is able to outsource some of the assessment and treatment of OHP clients. The data for the period identified 469 clients that were outsourced to outside providers and represented about 19% of all of the clients. The process requires additional administration and oversight by the County for the services to the outside provider. It also is a process that helps supplement and address workload. It was not clear that providers provided much information on the services provided let alone any metrics on performance. Some of this information can be obtained but the department is still working on that. A selection of May outsourced clients was used to calculate how long it took for assessment. The outside provider data is not normally requested, monitored or measured. - 5.0 10.0 15.0 20.0 25.0 Internal Panel provider Internal Panel provider Average Days to Screen 4.1 4.2 Days to Authorization 4.3 Average Days to Assessment 14.4 14.6 Average Days to Screen Days to Authorization Average Days to Assessment Health Services - Client access to services #10/11-3 January 2012 Page 15 of 36 The information obtained showed some consistency with the process seen internally for assessments. The current contracts with outside providers do not require any specific performance metrics to be reported. The ABHA standards for authorizations indicate that routine requests should be responded to within five days. This does appear to be occurring. It is recommended for the department to consider with other contractual requirements that outside providers provide information on pertinent performance metrics. Metrics of interest might include days from assumption through to assessment, counts of services by client by month, and reasons why clients are not being provided service. If found necessary, the ongoing requirements for information should be added to the basic contractual elements. The county’s utilization manager is interested in obtaining additional data on panel provider performance directly from the data processor. This should provide better and timelier information on a number of metrics. 4.4.3 Observations on delays to assessment Chart 11 Impact to days to assessment when services were noted prior to assessment. Delays partly caused by services performed before assessments. The audit noted that some 17% of the clients with assessments appeared to have service(s) performed prior to assessment. Services performed before the assessment would likely contribute to some of the delays in average days to assessment. As indicated in the anticipated workflow (Figure I), assessments are supposed to occur prior to providing of services. For many client situations, the treatment performed must follow an assessment and treatment plan. Services performed outside of these may not qualify for billing to certain insurance providers (including OHP). 13 19 - 5 10 15 20 No services noted before assessment Services noted before assessment Average days Average of Days to Assessment Health Services - Client access to services #10/11-3 January 2012 Page 16 of 36 Chart 12 Percentage of clients identified with services performed before assessment by month service started. Chart 11 indicates that services delay assessments on average by six days representing a 46% increase. Services before assessment only had to be noted once, but sometimes there were multiple services. 25% 14%16% 9% 12% 4% 0% 5% 10% 15% 20% 25% 30% Jan Feb Mar Apr May Jun % Services performed before assessment by month service started The trend over the period of review (Chart 12) showed this occurred less as time went on. This might indicate this is improving. However, June numbers are likely low due to fewer assessments being completed on new clients started. Discussions with program managers, of examples of when services were provided before assessment, indicated there could be a number of explanations as well as a need to follow their prescribed workflow. Explanations included: • Assessments performed and not billed, • Assessments performed and billed incorrectly, and • Assessments occurred prior to the dates collected (usually when clients are enrolled in multiple programs). The typical services that were noted as occurring prior to the assessment included services such as • Group therapy (skills, peer services, and training), • Individual therapy, • Case management, and • Consultation. One contributing issue is how the current electronic records system tracks clients by program and not by the overall client. This makes it more difficult to assess the overall client relationship and the assessment needs. It is recommended the Department work on improving the timeliness and sequence of events through to Health Services - Client access to services #10/11-3 January 2012 Page 17 of 36 assessment. The new EHR system is planning to require assessments and treatment plans be setup prior to therapy work. Suggestions include: having reports to supervisors indicate completion and billing of assessments on new clients, as appropriate to the program; monitoring selected metrics such as days to assessment by each clinician could be a useful part of this discussion; and critiquing of new client workflow on a continual basis. Chart 13 Impact to average days to screening if screening noted. Chart 14 Impact to average days to screening if screening noted. (by age group) Some clients appear to get through to assessments without screening process. For nearly a quarter of the clients with assessments, there was no indication of a screening (Procedure code 917). The triage system and whether clients are screened before assessments are not a given for all programs or at all locations. Those that bypass the screening tend to get through to assessment quicker. There is no clear indication of why this is. Nevertheless, the differences appear to be substantial. 4.1 17.9 5.0 0 5 10 15 20 25 Screened Not screened Average Days to Screening Average of Days to Assessment These observations also occur by age group and program. 3.0 5.3 19.9 6.5 15.8 2.0 0 5 10 15 20 25 Screened Not screened Screened Not screened A d u l t Ch i l d Average days Average Days to Screening Average of Days to Assessment Health Services - Client access to services #10/11-3 January 2012 Page 18 of 36 One hypothesis could be that the clients coming in through without normal screenings are coming in through a crisis intervention or other work and are assessed and moved onto therapy. It is also possible the screening code was not used for that service or not billed. It highlights the issue that clinicians are not always following the intended workflow. It was also noticed that clients without triages also seemed to have quicker times to assessment. Screened clients showing longer assessment could be due to the lack of available assessment slots from clinicians. Since these are controllable, a more active process in developing open slots should be used if they extend beyond guidelines desired by the department. In improving this process, the department should work to challenge their processes and look for more rapid handling of clients. It is recommended for the department to look for ways to reduce the days to assessment for all new clients entering the system. Table IV Selected program closure rates New client closure and work distribution may be symptomatic of workload issues. The percent of clients closed vs. opened could indicate a weakness in closing out clients. Not providing room for new clients can hinder capacity to take on new clients. Conversations from managers and staff indicate there is a perception that staff feel overwhelmed. Some selected larger programs had the following rates of closure during the review period: Program % closed Adult mental health 34% Adult - Seniors 79% Child treatment 21% Child abuse 14% In addition to closing out new clients, distribution of new client work by clinician varies. Analyses by clinician of total time spent with these new clients as a percentage of total paid time (adjusted to full time and prorated for part year clinicians for comparison purposes), indicates a wide disparity of time spent on these new clients. Mental health specialist I’s (MHSP I) had on average 118 hours over the six months (11%) with these new clients. Health Services - Client access to services #10/11-3 January 2012 Page 19 of 36 Chart 15 MHSP I services to new clients as percentage of paid time by clinician. Chart 16 MHSP II services to new clients as percentage of paid time by clinician. 11% 0% 10% 20% 30% 40% 50% 0 5 10 15Clinicians Mental Health Specialist I Prorata % of Time Average Mental health specialist II’s (MHSP II) had on average 156 hours over the six months (15%) with the new clients identified. MHSP II’s are more likely to perform the assessments since they hold the higher QMHP license. Nearly 55% of MHSP II’s were identified as QMHP’s. It is even more important these clinicians have higher new client caseloads since they are licensed to perform the assessments. The 36% increase in work for a MHSP II versus the MHSP I is still probably insufficient. 15% 0% 10% 20% 30% 40% 50% 0 10 20 30 40 50 60 Clinicians Mental Health Specialist II Prorata % of Time Average The number of clinicians at the average levels and lower is probably indicative of the continuing client workloads and the impact it has on taking on new client work. It is also clear that clinicians are not sharing new client work equally. A number of the higher percentage clinicians achieve higher productivity mainly through group therapy. Health Services - Client access to services #10/11-3 January 2012 Page 20 of 36 Table V Clinicians by position who had no services to identified new clients Clinic management typically does not count group therapy productivity as equal to individual therapy. The low percentages indicate a relative low overall effort with new clients. The following table (Table V) indicates the number of clinicians that had no data in the review of new clients. This seems to indicate that work is not being distributed and/or may be another symptom of the open client loads. It might also indicate that the department’s processes do not ensure that work is distributed among all staff. Position description Total #Identified % Mental Health Specialist I 25 9 36% Mental Health Specialist II 63 3 5% Fridays appear to be the day with the least amount of new client work. In addition to significantly variability in workload as noted above, additional review of staff schedules indicated that many staff have flexed their schedules or work part time to work less on Fridays. It is recommended for the department to investigate how they distribute and monitor workloads in total and for new clients. Expectations established in treatment plans should be used to extrapolate staffing needs. This should be possible when the new electronic records system is implemented. Some of the areas that are likely to be addressed by new electronic records system. Reception / Clinics: It is not clear that front desk staff duties are consistent between all of the reception staff. Reception staff have different job titles and appear to have some specific duties. Fiscal is not aware of what is required to cover front desk when asked. It is recommended for additional cross training needs to occur between front desk staff (and fiscal). This might also results in more consistent job duties among staff. OHP status checking – Staff must verify whether the clients OHP status is current on the day of services. This must be done for all clients countywide and consumes a lot of time. Since these are taken from electronic databases and electronic appointment calendars, there should be some process to look for matches electronically. It is recommended for the department to consider whether an electronic system could be developed Health Services - Client access to services #10/11-3 January 2012 Page 21 of 36 to verify OHP status of appointmented clients. In addition, the department appears to need a policy to address the OHP clients that lose coverage. Schedule use – A number of clinicians were noted as not having their system turned on which resulted in front desk having to call them every time an appointment comes in. It is still not clear that all clinician’s appointments are entered into the system, which makes it problematic to follow-up on paperwork. It should be emphasized when the new system comes online that staff will be required utilize the new system for appointments and documentation. Fiscal / Front desk: New clients can be setup in Fiscal, by screeners and by a few people at the front desk. This can limit the issues when clients are established. However, it was also noted that some duplicate clients are created and must later be merged. More people being cross-trained in this area could address this potential bottleneck. It is recommended for more staff to have the ability and training to establish clients in the system. Fiscal billing staff track errors on entry that are not reviewed by anybody. The fiscal billing clerk maintains information on errors in billing records received and sent back. Issues noted include; duplicates, not signed, payer issues, client not opened, or other correction needed. Three percent (3%) of the inputs had some error indicated. In addition, certain metrics are gathered by front desk staff that can be calculated by the system. It is recommended that some of these metrics be incorporated in the electronic records system if they are deemed relevant to monitoring operations. 4.5 Issues common to Public and Behavioral Health More communication needed between behavioral and public health. In discussions with behavioral health on their new systems, it is curious that some of the same topics have been worked through in the public health department. Things like front desk workflow, phone call tree, appointment reminders, and staffing issues are not that different for the two departments. Public health went through similar growing pains a couple of years back when the moved to their new clinic system (OCHIN). Behavioral health’s new system will be even more comprehensive. Even with some of the management team now being responsible over both departments, there is a lack of review of what the other is doing or has done to address similar issues. The two departments have opportunities to share and move forward in a collaborative manner. Health Services - Client access to services #10/11-3 January 2012 Page 22 of 36 In the absence of some collaboration, departments may not deploy resources and solutions that make the greatest impact to their customers. It is recommended the two departments consider how they may consolidate and/or coordinate on similar topics and learn from the other’s best practices. Areas to investigate might include, client reception, call handling and phone message tree, and appointment reminders. Fiscal services even with the disparate systems might be improved and made more consistent with similar practices employed or performed together. Front reception areas could be consolidated. Behavioral health and Public health operate separately in the Main Bend Clinic. They each have separate reception areas and behavioral has separate areas for child and adult clients. By separating clients, additional front reception staffing requirements are necessary. A more consolidated reception of clients could be developed. It is recommended the department look for ways to provide a common reception area given the movement to coordinate treatment of physical and mental health issues. 4.6 Other Quality assurance metrics are in development. Behavioral health has started developing and implementing some dashboard metrics for utilization management, calls and access. This kind of information can be very useful in being aware of the drivers of the clinic. It appears the reports are not currently being implemented. The County has been moving towards performance measures for some time now and they can have results with improving efficiency and effectiveness of operations. In the absence of timely reports, it is difficult to understand whether the systems developed for performance of work are having the results intended. It is recommended that the department finalize some measures and get them in the hands of users. An additional suggestion is to make sure they are being used and that staff are trained to interpret the results. Additional metrics may be useful and developed as additional drivers are identified. Health Services - Client access to services #10/11-3 January 2012 Page 23 of 36 Strategies for efficiencies should be advanced. A number of books used to streamline processes and workflow highlight the need for continual and routine improvements. This streamlines processes but not the work. The department has been starting to identify some of these things in its quality assurance initiatives. The following are observations that might be useful in identifying projects for review. Strategies that have been noted include – systematization, removing backlogs, eliminate bottlenecks, eliminating handoffs and removing specialization. Bottleneck/Handoffs – Screenings on average take 22 minutes, whereas assessments take 65 minutes. Screening: One issue noted is the roughly 4 day average time frame for completion of screening. The limited number of screeners creates the need for a message center. Front desk staff have few options other than placing the call in a phone call queue for callback. It is not clear that there are sufficient screeners available and there is an opportunity for more clinicians to be involved. Ultimately having a screener who has time and could move from screening through to assessment would provide the quickest route to therapy. Assessments: The average 14 day to assessment should be able to be made more routinely within a shorter time frame. OHP requires 14 days from call for service to assessment. It is not clear why some of the longer appointments occur. Is it because of available assessment appointments or difficulty with the clients’ available dates/times? What can be done to make sure these happen quicker? The process for tracking exceptions beyond a set time frame should include determining if the client dictated a later appointment. The department should minimize encounters before assessment. These might adversely affecting client times and outcomes. This will help ensure that services will be in coordination with treatment plan and assessment. Systematization – The inconsistent times for screening could use further investigation. The extent of work performed by screeners seems to border on assessment activities and could merit greater systemization. It may also be possible to have screener perform assessment or handoff client directly to a clinician for assessment. Specialization / bottlenecks – One of the screeners indicated that clinicians like to indicate the types of clients they like to work with. Not clear that managers are managing these preferences or workload. In a public clinic, it may not be possible to accommodate preferences of clinicians if they are not in the interest of the clinic. Bottlenecks – It is not clear how much capacity there is. Staffing can be more flexible to be able to target areas that are taking too long to obtain service. Not clear that managers are receiving sufficient information to make decisions. This should be improved as the new electronic records system handles all of the appointments and activity for all clinicians. Health Services - Client access to services #10/11-3 January 2012 Page 24 of 36 Potential future internal audit projects identified: The department’s own quality assurance team is currently performing a number of ongoing projects. Some areas that are not being addressed but that could prove useful to management and identified during the audit include: • Cost benefit of panel provider usage and effectiveness of programs outsourced. Consider documentation review for proof of services performed under panel provider contracts are whether they are supported. • Evaluate accounting system and controls for new electronic records system. Health Services - Client access to services #10/11-3 January 2012 Page 25 of 36 5. MANAGEMENT RESPONSE 5.1 Health Services (Scott Johnson, Director) Health Services - Client access to services #10/11-3 January 2012 Page 26 of 36 6. APPENDICES 6.1 Additional Survey Data Analyses Chart A1 Would you recommend clinic to family and friends by department (percentage responses) Chart A2 How easy was it to get an appointment by department? (Average ranking on scale1-5, 5=very easy) Chart A1 indicates that most would refer the clinics to their friends and family. 97.6% 100.0% 2.4% 0.0% 0%20%40%60%80%100% Behavioral Health Public Health % of Yes/No responses Yes No The next three charts cover scheduling an appointment. About 80% of the responses were from clients who had made appointments (as opposed to walking-in to be seen). Chart A2 indicated clients felt it was easy to get an appointment (with a score of somewhere between a very easy and easy). 4.3 4.4 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 Behavioral Health Public Health Satisfaction Scale:5=Very easy,42=Easy, 3=Neutral,24=Difficult,1=Very difficult Health Services - Client access to services #10/11-3 January 2012 Page 27 of 36 Chart A3 Did the time it took to get an appointment meet your expectation by department? (percentage responses) Chart A4 On average, how long did it take to get an appointment by department? (average # of days) Chart A3 indicates that most thought the time it took to get an appointment for service was acceptable. However, a number of behavioral clients did not. It also was not identified how much time would be acceptable or not. 97% 100% 3% 0% 0%20%40%60%80%100% Behavioral Health Public Health % of Yes/No responses Yes No Chart A4 quantifies that Behavioral Health takes nearly four times as long to arrange for an initial appointment. 9.0 2.5 0.0 2.0 4.0 6.0 8.0 10.0 Behavioral Health Public Health Average # of days to get appointment Whereas, the number of days was consistent among age groups and programs in Public Health, they were not so among the Behavioral health. Programs identified that seemed to have higher values were the Annex programs and the main clinic appointments. Health Services - Client access to services #10/11-3 January 2012 Page 28 of 36 6.2 Additional Public Health Data Analyses Chart A5 % same day appointments by age group Chart A6 % same day appointments by clinic location The following analyses are to further digest some of the appointment information for Public Health. 0%20%40%60%80%100% Adult Child % of appointments made "Same day" vs ">=1 day" Same day >= 1 Day Chart A5 indicates a relatively low number of new clients coming in on same day appointments. Many of the clinics now work on establishing appointments but are remaining flexible for same day or walk-in appointments for those clients that show up and want to be seen. In previous audit work of Public Health, there was a bit of discussion around improving clinic workflow through more appointmented clinics. 0%20%40%60%80%100% DC BEND DC DOWNTOWN DC REDMOND % of appointments made "Same day" vs ">=1 day" Same day >= 1 Day There appears to be less same day visits at the Redmond location. Health Services - Client access to services #10/11-3 January 2012 Page 29 of 36 Chart A7 % same day appointments by procedure description 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% IMMUNIZATIONS OFFICE VISIT EXTENDED OFFICE VISIT LONG OFFICE VISIT SHORT PRENATAL INITIAL WOMEN'S HEALTH LONG WOMEN'S HEALTH SHORT Co m p o s i t i o n % Procedure description Same day >=1 Appointments for certain types of procedures have a greater likelihood of a walk-in or same day appointment. No additional analyses and observation were determined necessary for public health in this particular audit. 6.3 Additional Behavioral Health Data Analyses Chart A8 Composition of behavioral health services (in minutes) by age group. Adult 70% Child 30% Health Services - Client access to services #10/11-3 January 2012 Page 30 of 36 Chart A9 Composition of behavioral health service procedures (by minutes) Chart A10 Triaged client services by procedure (by minutes). INDIVIDUAL THERAPY 19% Other (< 2% ea) 15% GROUP THERAPY 15%CRISIS INTERVENTION SERVICES 7% BEHAVIORAL HEALTH SCREENINGS 7% TRAVEL 7% ASSESSMENT 7% SKILLS TRAINING - GROUP 6% PRE-COMMITMENT 4% CASE MANAGEMENT 4% FAM-THERAPY WITH INDIVIDUAL 4% CONSULTATION 3% SKILLS TRAINING - INDIVIDUAL 2% BEHAVIORAL HEALTH SCREENINGS 67% CRISIS INTERVENTION SERVICES 17% Other 4% PRE - COMMITMENT 4% CONSULTATION 4% INFORMATION & REFERRAL 4% Health Services - Client access to services #10/11-3 January 2012 Page 31 of 36 Chart A11 Composition of services by primary payer.(in minutes) Chart A12 Composition of services by primary payer by age group. Triages (or calls for service) are sourced primarily to screenings but can results in other services as noted above. With screenings, nearly 98% are routine or deferred calls. Only about 2% are urgent/emergency. With crisis intervention services, the emergency/urgent represent 62% of the calls. The department segregates screeners by age group (child/adult). Calls are triaged with crisis calls being acted on quickly. The audit data indicated 22% of the clients did not have a traditional triage and screening. Variances seem to occur by differences in programs and locations and the extent of that the electronic records system is even used. OHP 47% Private Insur&Medicare 22% Selfpay 18% Medicaid 10% Grant 3% PASSR 0% 37% 72% 24% 15% 25% 1% 12% 8% 2% 3% 0%10%20%30%40%50%60%70%80% Adult Child Adult Child Grant 2%3% Medicaid 12%8% Selfpay 25%1% Private Insur&Medicare 24%15% OHP 37%72% Health Services - Client access to services #10/11-3 January 2012 Page 32 of 36 Chart A13 Trend in average screening times per month. Table A1 Analysis of cancellation/no show rates by age group as a percentage of appointments. 0 1 2 3 4 5 6 7 8 9 Jan Feb Mar Apr May Jun Av e r a g e d a y s t o s c r e e n i n g % of total appointments Adult Child Total Appointments kept (by count)87%88%87% Cancellations by Clinicians (by count)2%2%2% No show/cancellations by client (by count)11%10%11% Health Services - Client access to services #10/11-3 January 2012 Page 33 of 36 6.4 Most recent workplan for outstanding recommendations (from Global follow-up report #10/11) for Health and Behavioral Health The original internal audit report(s) should be referenced for the full text of recommendations and associated discussion. Department Audit# Rec# Recommendation Prior or Original Status New Status Updated Comments Estim. Date Health 05/06-4 37 It is recommended the department establish reasonable productivity standards. Underway Underway Working on. 12/31/2011 Mental Health 04/05-6 1.2 It is recommended the Department consider improvements to the Departments computerized business systems to track the handling of received monies before they can be posted to specific clients Underway Underway Electronic records process underway and on schedule to be completed in Fall 2012. 11/1/2012 Mental Health 04/05-6 2 It is recommended for the Department to develop a process to track and obtain service tickets for all clients provided with services. Underway Underway Electronic records process underway and on schedule to be completed in Fall 2012. 11/1/2012 Mental Health 04/05-6 3 It is recommended for Department management to establish performance standards for the turning in of service tickets and monitor for open tickets. Underway Underway Electronic records process underway and on schedule to be completed in Fall 2012. 11/1/2012 Mental Health 04/05-6 4 It is recommended the Department consider requiring support for information used to establish reduced client fees. This might include income tax returns or pay stubs. Planned Planned Will implement proof requirement when revising current procedures due to implementation of Electronic records system in Fall 2012. 11/1/2012 Mental Health 04/05-6 7 It is recommended Department document its accounting policies and procedures. Underway Underway Flowchart process complete. Anticipate additional progress in documentation during Electronic Records implementation. 6/30/2012 Mental Health 04/05-6 8 It is recommended the programmer establish adequate tests for their changes to make sure they are operating as planned. Periodically other Information Technology staff should perform reviews of code and changes to code to make sure that IT Department policies and procedures are being met. Underway Underway Electronic records process underway and on schedule to be completed in Fall 2012. 11/1/2012 Health Services - Client access to services #10/11-3 January 2012 Page 34 of 36 Department Audit# Rec# Recommendation Prior or Original Status New Status Updated Comments Estim. Date Mental Health 04/05-6 9 It is recommended the Mental Health Department periodically review their software needs and consider whether the internal software is the best choice for their operations. Underway Underway Electronic records process underway and on schedule to be completed in Fall 2012. 11/1/2012 Mental Health 04/05-6 9.1 The Department should develop a cost/benefit approach when analyzing potential software solutions. Underway Underway Electronic records process underway and on schedule to be completed in Fall 2012. 11/1/2012 Mental Health 04/05-6 13 It is recommended there be improvements to the Department’s internally developed billing software to include reports and logic checks to test for and identify any overpayment situations. Underway Underway Electronic records process underway and on schedule to be completed in Fall 2012. 11/1/2012 Mental Health 04/05-6 18 It is recommended that appropriate mental health staff maintain their appointments on the computerized business system. Reception staff should have the ability to add, move and delete appointments in the system. Underway Underway Electronic records process underway and on schedule to be completed in Fall 2012. 11/1/2012 Mental Health 04/05-6 19 It is recommended the Department should assess to what extent it can or will pursue collection of charges and develop a collection policy and procedures in line with that assessment. Underway Underway Topic will be discussed as we revise our procedures when implementing our Electronic Records system. 11/1/2012 Mental Health 04/05-6 19.1 Policies and procedures should establish performance standards for effective billing and collection of services. Underway Underway Topic will be discussed as we revise our procedures when implementing our Electronic Records system. 11/1/2012 Health Services - Client access to services #10/11-3 January 2012 Page 35 of 36 Department Audit# Rec# Recommendation Prior or Original Status New Status Updated Comments Estim. Date Mental Health 04/05-6 20 In order to improve collections the Department should consider the following: * Providing front desk staff with information on the amount owing so clients can be asked if they can make a payment * Having front desk staff and clinicians confirm current addresses * Having the billing statements improved so that it shows the age of the unpaid balance. * Considering whether a collection service should be used for some client unpaid balances. The service used by the Solid Waste Department is very efficient and does not cost anything to the department. * Providing more effort on identifying why insurance has not paid to improve collection efforts. * Obtaining pre-authorization from some insurance providers. * Reviewing insurance requirements before additional services are performed * Assigning appropriate clinicians to provide care based on their licensing and credentials to maximize collection when possible. * Establish procedures for handling insufficient fund checks. Underway Underway Electronic records process underway and on schedule to be completed in Fall 2012. 11/1/2012 Mental Health 04/05-6 27 It is recommended staff develop procedures to provide oversight of the Department's activities as maintained in the computerized business system. Underway Underway Topic will be discussed as we revise our procedures when implementing our Electronic Records system. 11/1/2012 Mental Health 04/05-6 29 It is recommended the Department strive to have data in the system to report on internal benchmarks/standards for its operations. The Department might consider adding to the system manual data gathered for certain performance reports. Underway Underway Topic will be discussed as we revise our procedures when implementing our Electronic Records system. 11/1/2012 Health Services - Client access to services #10/11-3 January 2012 Page 36 of 36 Department Audit# Rec# Recommendation Prior or Original Status New Status Updated Comments Estim. Date Mental Health 04/05-6 29.1 Management should receive monthly data of key operating data and benchmark performance to evaluate operations. This “scorecard” approach can be useful in evaluating key data for internal operations on a monthly basis. Underway Underway Topic will be discussed as we revise our procedures when implementing our Electronic Records system. 11/1/2012 Mental Health 04/05-6 30 It is recommended for the Department to develop collection procedures identifying the extent of collection efforts. Underway Underway Topic will be discussed as we revise our procedures when implementing our Electronic Records system. 11/1/2012 Mental Health 05/06- 11 1 It is recommended that management consider tracking all client encounters regardless of funding. Planned Once we get out in front of our OHP business lines, we will extend our efforts to non-OHP lines of business (internal and external). {End of Report}