180 SCAN: SYSTEM PERFORMANCE DMC-ODS 6 MONTHS POST IMPLEMENTATION - - PowerPoint PPT Presentation

180 SCAN:

SYSTEM PERFORMANCE – DMC-ODS 6 MONTHS POST IMPLEMENTATION

PRESENTED BY RESEARCH & OUTCOME MEASUREMENT (ROM), QUALITY IMPROVEMENT & DATA SUPPORT & ADMINISTRATION SUBSTANCE USE TREATMENT SERVICES FEBRUARY 28 2018

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Agenda

Welcome  Overview DMC-ODS Changes– Presenter: Kakoli Banerjee  Authorization, Placement & QI measures – Presenters: Olena Chesnakova, Katherine Christian  Contract performance measures – Presenters: Patricia Rubio-Corona, Sujung Kim  Waiver services trends: Presenter: Kakoli Banerjee  Client outcomes: Presenter: Kimberly D'zatko  Service efficiency: Presenter: Leilani Villanueva  Wrap up: Kakoli Banerjee

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The 180 SCAN

A 180 scan is analogous to a wide angled view or perspective of a landscape in which the entire field is visible.

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Goals of the 180 SCAN

The goals of the 180 Scan are to:  Review the state of the System of Care six-months post implementation

• f the DMC-ODS, also known as the Medi-Cal Waiver

 The 180 Scan examines the following elements of the SUTS System of Care:  clinical processes,  client outcomes,  system performance,  system efficiency

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180 SCAN Series Purpose

 To foster a culture of data driven system improvement in the SUTS system of care  To provide managers, decision makers, clinicians and others with a high level view of how the system is functioning  To develop a common understanding of the strengths & weaknesses of the system

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Brief Overview of DMC-ODS Pilot: The 3 Main Components of the Medi-Cal Waiver

Clinical: ASAM-based clinical framework of treatment delivery Operational philosophy: Use of managed care principles (based on 438) to operate the business side of the delivery system Quality improvement: Monitoring service quality according to Managed Care Plan’s Quality Improvement Plan

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Clinical Framework of Tx Delivery Pre-& Post-Waiver

Domain ASAM Levels Authorization for svcs

Medical Necessity

Pre-Waiver

OP 1.0, 2.1 Residential 3.1 WM 3.2

None

Medical necessity limited to few SUTS services

Post-Waiver

OP 2.5 Residential 3.3, 3.5 Recovery Svcs Additional MAT

Authorization-Residential Tx

Application to all SUTS services

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Managed Care Changes Pre-& Post-Waiver

Domain County Operations Framework Certification Medi-Cal billable services Pre-Waiver Managed care for some functions

DHCS certification not mandatory

Limited billable modalities & Svcs Post-Waiver

Operations based on 42 CFR 438 principles (Federal managed care principles)

DHCS certification for billing

Expanded array of billable modalities & svcs

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Quality Improvement Requirements Pre- & Post-Waiver

Domain Service provider credentials Evidence –based treatment Quality Improvement Pre-Waiver

Functions of credentialed & licensed staff not clearly defined

Recommended No external review Post-Waiver

Distinctions between LPHA and credentialed staff, particularly for billable services

Required- at least two per tx modality

External Quality Review Organization (EQRO)

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180 SCAN OF SUTS SYSTEM OF CARE: Key Components

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ALOC & Access measures System performance measures Waiver Services Client

• utcomes

Efficiency measures

Crosswalk Between 180 Scan & External Requirements

180 SCAN EXTERNAL REQUIREMENTS Clinical measures (ALOC) EQRO – Quality (Transitions in ASAM care, Authorization for residential tx, indicated versus actual LOC) System Performance measures SUTS contract performance metrics EQRO – Access metrics, admissions by AID code DHCS – Timeliness metrics IGA – Section 24 – Timeliness metrics, care coordination, Waiver services IGA Section Quality Management & Services utilization Client outcomes IGA – Section 24 –Assessment of beneficiaries experience Efficiency measures EQRO- Access/Cost effectiveness

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Scope of the 180 Scan

The 180 Scan reviews data for approximately 6 months of the DMC

• ODS

 July 1 – December 31, 2017  Covers about 3,400 admissions across all tx modalities in AOSC & YSOC

The analysis focuses mainly on DMC providers, but data from the whole system of care is presented where relevant The 180 Scan is designed as a point in time system assessment The first year DMC-ODS evaluation results will be presented in December 2018

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Admissions by Modality in the Adult System of Care (n=3,068 admissions)

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Admissions by Modality - Youth System (n= 350 admissions)

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ALOC & Access Measures

Clinical state of the system

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 Gateway timeliness: Screen to referral date, Referral date to admission  ALOCs: How is ALOC used? Admission ALOCs Discharge ALOCs Approvals of Residential Admissions Other ASAM levels needed that are not yet offered Extension of Residential LOS requests  Clinical measures: Risk Ratings for six dimensions Change in Risk Rating from Admission to Discharge Discharge Status and Risk Rating Actions Steps – assigned and completed at Discharge

Access to System of Care

Access to Residential Services:

This section will cover:  Timeliness between First Screening Date to Referral Date (Gateway);  Timeliness between Referral Date to Admission Date (Gateway) (Requirement: 10 business days).

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Timeliness: Gateway Screen Date to Referral Date & Referral Date to Residential Admission (n=685) Jul – Dec 2017

50 100 150 200 250

2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 33 35 37 39 41 43 46 70 75 93

NUMBER OF ADMISSIONS BUSINESS DAYS Time between First Screening Date and Referral Date (n=425)

20 40 60 80 100 120 140 160 180 2 4 6 8 10 12 14 16 18 20 22 24 26 29 31 34 37 41 44 47 67 111

NUMBER OF ADMISSIONS BUSINESS DAYS Time between Referral Date and Admission Date (n=439)

Average = 7 Business Days

n=339; 77% Average 8 Business Days

n=100; 23%

Weekends and County Holidays are excluded. If Referral Date is missing, the Screening Day is used as the Referral Day. Data intervals

• f less than 0 days are excluded. DMC-ODS requirement is placement within 10 Business days.

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Timeliness of Gateway Calls: Residential Admissions (n=685) Jul - Dec 2017

27% 50% 15% 9% 0% 20% 40% 60% 80% 100%

Total Admissions (n=685)

No Gateway Calls Last 6 Months 11 Days and more 10 Business Days Gateway Call Last 6 Months 77% 23% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Percent of Admissions with Direct Gateway Calls (n=439)

10 Business Days 11 Days and more

77% of Residential Admissions occur within 10 business days of the Gateway Referral. The average is 7 business days.

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ALOC is the ticket into the SUTS System of Care

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Requirements:  A QI determination and approval is required for each residential admission.  An ALOC is required for each Residential and OP admission and discharge. Data Analysis:  At waiver start (7-1-17), ALOCs were saved in PDF format. Starting mid-August, ALOCs were entered into Profiler. The ALOC PDF and Profiler data were merged for analysis.  ASAM determines the appropriate placement of clients into intervention or treatment services.  Clinical data is collected at both admission and discharge  Client admissions to residential tx are from July 1, 2017 – Dec. 31, 2017 unless otherwise noted.  Residential discharges are linked to admissions that occurred in the first 6 months of the waiver.  DMC and non-DMC clients are included in the ALOC and Access section. Timeframe:

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Request from Residential directly Increased LOC request from OP & OTP/NTP When Admitted to WM , received Residential approval

ALOC Organization

 B1 – Initial authorization for residential LOC  B2 – Authorization of extension for residential LOC  B3 – Assessments – Not authorization requests  Only one section: B1, B2 or B3 is required to be completed per ALOC .

Residential Authorizations can occur on 3 ‘types’ of ALOCs

Residential authorizations can occur on 3 ‘types’ of ALOCs

Initial Authorization for Residential LOC (B1)

Percent of Total ALOCs (n=861)

(Jul – Dec 2017)

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22% 11% 67% Increased LOC request from OP Other Request from Residential 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% % of Total ALOCs

“Other” includes: Not open; needs other LOC than indicated by GW screen; Pre-auth request from DWC/Juvenile Hall etc..; Request from call center

Residential Admission ALOCs & QI Determination

(n = 685)

(Jul – Dec 2017)

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Approved by QI 79% Missing QI determination 11% Missing ALOC 9% Rejected <1% Denied <1%

Missing ALOC includes: Admit/Discharge within 2 days; Residential transfer; Missing.

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81% 16% <3%

Same Business Day 1 Business Day 2 or more Business Days

*The requirement is that authorization for residential tx will be provided within 24 hours. Weekends and County Holidays are excluded.

More than 97%

• f all requests were completed

at the same day or within 1 business day. Less than 3% of requests were completed after 1 business day.

Time between Receipt of ALOC Assessment & QI Authorization (n=587) Jul- Dec 2017

Residential ALOC Assessment – Non-authorization Requests (B3) Percent of Total ALOCs (n=92)

(Jul – Dec 2017)

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51% 25% 1% 1% 4% 4% 13% 20 40 60 80 100 Other Discharge ALOC - no follow up services DMC extension of OP treatment services Interval Assessment Routine LOC change - Not authorization request Transfer to different provider same LOC Intake - NotAuthRequest % of Total ALOCs

Number of Residential ALOCs that have a value in B3 (n=92), 24 of which also have B1 value. An ALOC must be classified as B1 or B2 or B3. There should not be values in both B1 and B3.

Indicated LOC vs Actual LOC in ALOCs

Percent of Total ALOCs (n= 1,102)

Residential & Withdrawal Management

(Jul – Dec 2017)

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8% 7% 3% 14% 3% 65% 20 40 60 80 100 Other to Other 3.2 WM to 3.2 WM 1 WM to 1 WM 3.5 RES to 3.1 RES 3.3 RES to 3.1 RES 3.1 RES to 3.1 RES % of Total ALOCs Other = blank, none, OP, OP/NTP, 2 WM, 2.1 IOP,

Authorization of Extensions for Residential Stays (B2)

Number of ALOCs (n=13)

(Jul – Dec 2017)

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Authorization of Extension for Residential (B2)

# of ALOCs QI Determination

Approved Denied Missing YSOC - 30 day extensiona 4 3 1 ASOC - 30 day extensionb 7 5 1 1 ASOC - over 120 day, extensionc 2 2

aYSOC - Clients are initially approved for 30 days in residential; can be extended for another 30 days if medical necessity is met. bASOC - Clients are initially approved for 90 days in residential; can be extended for another 30 days if medical necessity is met. cASOC – Perinatal clients can be extended over 120 days if medical necessity is met.

3.6% 94% 3% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% %of Total ALOCs Not Recognized Adults Youth ALOC assessments that are not associated with an admission: Missing or ‘N/A’ for current Provider; Missing or incorrect admission date; No admissions found in Unicare

• n January 16th.

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Total Residential ALOC Assessments Percent of total ALOCs -Jul – Dec 2017(n=890)

Residential Discharges (n=607) Discharge ALOC Assessments (n=138) Jul -Dec 2017

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685 607

138 100 200 300 400 500 600 700 800

Number of Assessments Admissions Discharges Discharge ALOC 23% 77% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% % Residential Discharge ALOC Assessments (n=138) Discharge ALOC No Discharge ALOCs

Only 23 % (n=138) Discharge ALOC Assessments are completed in Unicare on January 16th

Average Change in Severity of Risk Rating (Summary) Jul - Dec 2017 (n=607)

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No Discharge ALOCS (n=469) 77.27% 22.73%

75% 14% 11%

Decrease AVG( 5.02) Increase AVG( 3.5) No Change

Discharge ALOC Assessments (n=138)

75% of clients exhibited a decrease in Severity of Risk Ratings with an average decrease of 5.02. 14% of clients exhibited an increase in Severity of Risk Ratings with an average increase of 3.5. 11 % of clients exhibited no change in Severity of Risk Ratings.

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CALOMS Discharge Status & Change in Risk Rating Severity Jul – Dec 2017 (n=138)

CalOMS Discharge Status Decrease Increase No Change Completed treatment 60% 6% 6% Left before completion 5% 3% 2% Administrative Discharge 9% 2% 2% No Caloms Discharge 1% 2% 0%

60% of all discharges (n=138) were coded as ‘Completed Treatment’ and were associated with decreased severity in risk ratings.

Risk Rating Severity by Dimension at Residential Admission Jul – Dec 2017 (n=685)

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Risk Rating

*Shades of green indicate the percentage of clients by level of risk, with light green indicating low percentage. **Risk rating is indicated from dark blue to pink, with blue indicating Very Low (0) and pink- Critical(4).

1.Acute Intoxication and/or Withdrawal Potential;

• 2. Biomedical

Conditions and Complications

• 3. Emotional,

Behavioral, or Cognitive Conditions and Complications; 4 .Readiness to Change;

• 5. Relapse, Continued

Use, or Continued Problem Potential; 6.Recovery Environment.

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Changes in Risk Rating Severity by Dimension between Admission & Discharge-Jul - Dec 2017(n=138)

• 1. AIWP
• 2. BIOCC
• 3. EBCCC
• 4. RTC
• 5. RCCPP
• 6. RE

4 1 1 1 3 3 5 3 6 2 16 13 2 15 13 21 8 34 30 1 19 26 32 30 40 37 79 79 69 75 37 36

• 1

16 11 4 17 7 15

• 2

3 6 6 3 2 3

• 3

1 1 1

• 4

1 Average of Risk Rating Severity Change by Dimensions (Increase and Decrease only)

Risk Rating Severity Level Change

• 1. AIWP
• 2. BIOCC
• 3. EBCCC
• 4. RTC
• 5. RCCPP
• 6. RE

0.78 0.64 1.10 0.41 1.45 1.22

• 4
• 3
• 2
• 1

1 2 3 4

Change in Risk Ratings between Admission & Discharge by Dimension Jul - Dec 2017(n=138)

1.Acute Intoxication and/or Withdrawal Potential;

• 2. Biomedical

Conditions and Complications

• 3. Emotional,

Behavioral, or Cognitive Conditions and Complications; 4 .Readiness to Change;

• 5. Relapse, Continued

Use, or Continued Problem Potential; 6.Recovery Environment.

• 1. AIWP
• 2. BIOCC
• 3. EBCCC
• 4. RTC
• 5. RCCPP
• 6. RE

No Change 57% 57% 50% 54% 27% 26% Increase 14% 12% 7% 16% 7% 14% Decrease 29% 30% 43% 30% 66% 60% 29% 30% 43% 30% 66% 60% 14% 12% 7% 16% 7% 14% 57% 57% 50% 54% 27% 26%

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3% 4% 12% 45% 36% 0% less than 50% between 50% and 99% 100% Missing

Action Steps Assigned vs Completed at Discharge by Number of ALOC Discharges- Jul – Dec 2017 (n=138)

36% of discharge ALOCs did not contain information on assigned/ completed steps. 3% of discharge ALOCs contained no information on assigned or completed steps. 45% of discharge ALOCs showed that 100% of assigned steps had been completed.

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Take Home Message

 The interval between the receipt of an ALOC assessment (by QI) &

authorization for residential treatment was 24 hours for 97% of requests.

 Only 138 (23%) discharge/transfer ALOCs were completed for 607 discharges  The large number of missing ALOCs made it difficult to provide a reliable

picture of clinical outcomes

 Admission and discharge/transfer ALOC assessments should be done for each

completed admission

Contract Performance Measures

Patricia Rubio-Corona & Sujung Kim

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DMC-ODS Adult Residential

 Please note that we do not report DMC-ODS Youth Residential because it has fewer than 10 admissions from July 2017 to December 2017.

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 Contract performance measures are included in the contract (Exhibit 3-A) to monitor services and outcomes.  All data used in this report are extracted from Profiler (Unicare)  Please note that the report assumes that all agencies are entering their data regularly and accurately. ( Admission data were pulled from UNICARE on Jan 16th 2018)  Reporting period runs from Jul 1st to Dec 31st 2017 (FY18 first quarter and second quarter)

Introduction

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 Monthly admissions to treatment

 Monthly open clients (active clients)  Monthly discharges from treatment  Percent of administrative discharges and treatment completions

Measures

• Client flow measures (common to all modalities)
• Residential specific measures

 Dropout rate within 9 days of admission  Transfer rate within 15 days of discharge

 Vacancy rate

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DMC-ODS Adult Monthly Admissions Jul - Dec 2017 (n=591)

100 120 85 102 96 88

20 40 60 80 100 120 140

Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017

Number of Admissions

 Chart compares the total number of admissions for each month during the first half of FY18. Monthly admissions provide a snapshot of how many new clients enter the SUTS DMC-ODS Adult system and the variations in admissions by month. Six month Average: 99 Admissions

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195 203 173 193 182 170 50 100 150 200 250 300 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Number of Unique clients

 Total monthly capacity is 134 beds.  Open Clients: A client is considered open if she/he was admitted during that month or a previous month, and had not been discharged. In the chart, n (n=611) represents the number of unique clients who were open from July to December 2017, not the sum of unique clients for each month.

Six month average: 186 Clients

DMC- ODS Adult Monthly (Unduplicated) Open clients Jul - Dec 2017 (n=611)

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 The chart compares the total number of discharges for each month during the first half of FY18. Monthly discharges provide a snapshot of how many clients exit the SUTS DMC-ODS Adult system and the variations in discharges by month.

114 112 84 110 95 92 20 40 60 80 100 120 140 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Number of discharges

Six month average : 102 Discharges

DMC-ODS Adult Monthly discharges Jul -Dec 2017 (n=607)

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Note: Of 607 clients discharged from July to December 2017, 590 clients had CalOMS discharge status and 17 clients (3%) didn’t have CalOMS discharge status.

4% 4% 2% 2% 4% 1%

31% 38% 32% 30% 32% 29% 50% 50% 52% 59% 44% 50% 16% 8% 13% 9% 20% 20% 0% 20% 40% 60% 80% 100%

Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017

Percent of discharge status

Left before treatment completion (Not administrative discharge) Completed Treatment/Recovery Plan Adminstrative discharge No CalOMS discharge status

** Summary Treatment completion: Average 51% Administrative discharge: Average 32%

DMC-ODS CalOMS Discharge Status for Adult Residential Clients Jul -Dec 2017 (n=607)

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 Drop-out rate Percent of clients who leave within nine days of admission  Transfer rate Percent of residential clients transferred to OP, IOP, or other step-down treatment modalities within 15 days after residential discharge (Timeliness of transfer)  Vacancy rate Vacancy rate based on daily contracted capacity

Residential Treatment-specific Measures

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DMC-ODS Adult Residential – Drop-out rate Jul -Dec 2017 (n=591)

26% 21% 16% 21% 30% 18% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Dropout percent

Six month average : 22%

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Transfers within this time framework represent timely transfers from residential to other modalities. Note: OP, IOP or other services include Outpatient, Intensive Outpatient, OTP/NTP, and Additional MAT. 44% 40% 43% 50% 44% 33% 0% 20% 40% 60% 80% 100% Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Transfer percent

Six month average : 43%

• Transfer rate : Percent of adult residential clients transferred to OP, IOP or other step-down modalities

within 15 days after residential discharge out of total residential discharges

DMC-ODS Adult Residential Clients Transferred to OP, IOP or Other Services within 15 days - Jul -Dec 2017 (n=607)

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DMC-ODS Residential Vacancy Rate Jul - Dec 2017

 The vacancy rate is commonly used measure of utilization of bed capacity during a given period of time.  The total DMC-ODS daily contracted beds was 134 beds.

31% 32% 25% 29% 35% 36% 0% 20% 40% 60% 80% 100% Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Vacancy Percent

Six month average: 31%

• Vacancy rate : The percent of vacant bed capacity based on contracted capacity

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Withdrawal Management 3.2

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 The chart compares the total number of admissions for each month during the first half of FY18. Monthly admissions provide a snapshot of how many new clients enter the Withdrawal Management treatment and the variations in admissions by month.

87 86 63 66 69 63 20 40 60 80 100 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Number of Admissions

Six month average : 73 Admissions

Monthly admissions Jul -Dec 2017 (n=434)

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 Open Clients: A client is considered open if she/he was admitted during that month or a previous month, and had not been

• discharged. In the graph, n (n=389) represents the number of unique clients who were open from July to December 2017, not

the sum of unique clients for each month.

99 97 77 83 79 72 20 40 60 80 100 120 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Number of Unique Clients

Six month average: 85 Clients

Monthly (Unduplicated) Open Clients Jul -Dec 2017 (n=389)

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 The chart compares the total number of discharges for each month during the first half of FY18. Monthly discharges provide a snapshot of how many clients exit the Withdrawal Management treatment and the variations in discharges by month.

89 83 62 70 71 61 20 40 60 80 100 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Number of Discharges

Six month average : 73 Discharges

Monthly Discharges Jul -Dec 2017 (n=436)

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 This measure is used to assess the extent to which withdrawal management patients admitted to continuum of care within 15 days after receiving withdrawal management service.  Note: Other level of care includes all modalities such as Outpatient, Intensive Outpatient, Residential, OTP/NTP, and additional MAT except for Withdrawal management.

37% 60% 65% 66% 62% 57% 0% 20% 40% 60% 80% 100% Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Continuum of Care Percent

Six month average: 58%

Withdrawal Management Transferred to Other Levels

• f Care within 15 Days - Jul -Dec 2017 (n=436)

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Performance measurements are only as good as the data uploaded to Profiler by treatment agencies.

Take home message

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Waiver Services

Kakoli Banerjee

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Waiver services

This section focuses on ASOC & YSOC DMC-ODS providers  The figures shown do not include NTP/OTP, county clinics, and contract agencies that are not currently certified to provide DMC services  All data are from UniCare, extracted on January 17 2018. December data was refreshed on February 16 2018 This section covers:  Length of stay  Categories of OP services  Medi-Cal payors for services  Cancellations and no shows

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OP, IOP, Residential & Recovery Services Adult System – Jul-Dec 2017 (n=30,386)

579 1,456 1,467 3,803 3,620 3,078 6 35 43 68 87 76 1,089 2,680 3,017 2,878 2,579 2,730 42 159 56 323 286 370 1,000 2,000 3,000 4,000 July Aug Sep Oct Nov Dec Units of service OP Rec Svcs Bed days IOP

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OP, IOP, Rec Svcs, Residential Tx by Medi-Cal Payor- Adult System – Jul-Dec 2017 (n=30,646 services)

63% 56% 57% 53% 52% 48% 62% 49% 68% 62% 56% 39% 67% 57% 23% 25% 35% 28%

68% 77% 75% 84% 84% 84%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

July Aug Sep Oct Nov Dec % of services

OP IOP REC SVCS RES

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Length of stay residential Tx-Adult System – Jul-Dec 2017 (n=641 discharges)

87 89 101 176 26 26 26 27 26 25 21 25 20 40 60 80 100 120 140 160 180 200 Mariposa P House Horizon SoC Number of days Max Mean Median

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Take home message

 The DMC-ODS pilot provides an opportunity to expand our service array.  SUTS capacity to track these services depends on timely and accurate data entry.  My take home message:

Enter data early and often!

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Client Outcomes

Kimberly D’zatko

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Client Outcomes

 Treatment episodes over time (Data sources: CalOMS, Profiler)  Change in substance use from admission to discharge (Data source: CalOMS  Other outcomes:

• Connection to school or employment (CalOMS)
• Income change (Client Feedback Survey),
• Housing status change (Client Feedback Survey),
• Legal issues change (Client Feedback Survey)

Outcomes pertain to clients who were discharged during the period Jul– Dec. 2017

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79% 14% 4% 2% 1% < 1% < 1% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 2 3 4 5 6 7 Percent of Clients Number of Distinct Treatment Episodes*

Vast Majority of Clients Discharged during the Period (n=2,568) were in SCC Treatment System for the First Time

History of the clients who were discharged Jul– Dec 2017 (n=2,568)

*Treatment episode defined for these analyses as an admission occurring 50 or more days from previous discharge.

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Substance use at discharge Jul-Dec 2017 (n = 2,787*)

52% 1% 8% 5% 1%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

No substance use Used once Used between 2 and 20 days Used between 21 and 29 days Used every day

Percent of Discharged Clients

Number of Days Used During 30 Days Leading up to Discharge

Substance use leading up to discharge

*No reported substance use data for 1,379 (33%)discharged clients

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Just Over Half of Discharged Clients (n = 2,787*) Reported Complete Abstinence in 30 Days Prior to Discharge

Substance Use in 30 Days Prior to Discharge by Modality- Jul-Dec 2017 (n=2,568 unduplicated clients; n=2,871 discharges)

43% 1% 4% 1% 1% 50% 71% 2% 5% 1% <1% 20% 7% 12%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

NO SUBSTANCE USE USED ONCE USED BETWEEN 2 AND 20 DAYS USED BETWEEN 21 AND 29 DAYS USED EVERY DAY NO DATA

Percent of Discharged Clients

OP/IOP (n=2,027) Res (n=385) WM (n=459)

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Housing status after having been in treatment – Sep-Dec 2017 (n=680)

 After having been in treatment, 80% of those clients (n=216) reported having STABLE HOUSING  At the time they entered treatment, 40% (269)of OP clients who completed the survey (n=680) reported HOUSING INSTABILITY (couch-surfing, homeless)

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Income status after having been in treatment – Sep-Dec 2017 (n=324)

 24% of clients with CalOMS data reported being connected to school or work at discharge  After having been in treatment, 55% of those clients (n=178) reported that their INCOME HAD IMPROVED  At the time they entered treatment, 48% (324) of OP clients who completed the survey (n=680) reported INSUFFICIENT INCOME

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Unresolved legal issues after being in treatment-Sep-Dec (n=430)

 After having been in treatment, 58% of those clients (n=249) reported having RESOLVED OR BEING IN THE PROCESS OF RESOLVING THEIR LEGAL ISSUES  At the time they entered treatment, 63% (430) of OP clients who completed the survey (n=680) reported

UNRESOLVED LEGAL ISSUES

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Activities of Daily Living after having received treatment – Sep – Dec (n=145)

 After having been in treatment, 22% of those clients (n=32) reported NO LONGER HAVING DIFFICULTY MANAGING THEIR DAILY LIVING ACTIVITIES  At the time they entered treatment,  21% (145) of OP clients who completed the survey (n=680) reported  DIFFICULTY WITH ACTIVITIES OF DAILY LIVING

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Efficiency Measures

Leilani Villanueva

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Efficiency measures

 Staff Productivity: This measures the efficiency of staff time; the standard for the System of Care is 65% spent in direct services  Capacity Efficiency: This measures a clinic's capacity in terms of clients served. For instance, an OP clinic is expected to provide 448 hours to client in July (65% of its actual total available staff hours).  Service Efficiency: This measures the expected quantity of service per client per period. For instance, an OP provider is contracted to provide 30 hours of service per client for a 90 day LOS.  Cost Efficiency This measures the clinic's cost efficiency (cost divided by the number of staff available hours).

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County clinic efficiency measures-Adult & Youth System Jul– Nov 2017

97%

81% 69% 50% 60% 63% 90% 10% 73%

100%

100% 100% 100% 100% 100% 100% 18% 100% 36% 26% 32% 30% 29% 28% 38% 55% 32%

100% 80% 50% <1% <1% <1% 90% <1% 60% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Central Valley Central TAP Perinatal YSOC South County Alexian Health Re-Entry Center Re-Entry Center BH Total County System

Percentages

Staff Productivity Capacity Efficiency Service Efficiency Fiscal Efficiency

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Contract agency efficiency measures-Adult & Youth System- July – Nov 2017

53% 68% 26% 49% 41% 42% 40% 6% 48% 100% 100% 72% 100% 100% 100% 100% 15% 100% 32% 22% 37% 16% 17% 24% 15% 42% 24%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Caminar GFC Advent HR360 A HR360 Y IHC Pathway AACI Total Contracts Percentages Staff Productivity Capacity Efficiency Service Efficiency Fiscal Efficiency

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Contract Agency Efficiency Measure – Adult Intensive Outpatient Jul– Nov 2017

70% 70% 100% 100% 67% 67% 0% 20% 40% 60% 80% 100% Caminar Total Contracts

Percentages

Staff Productivity Capacity Efficiency Service Efficiency Fiscal Efficiency

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Contract Agency Efficiency measures – Adult & Youth Residential Jul-Nov 2017

44% 48% 36% 39% 49% 10% 40% 80% 100% 90% 100% 80% 0% 100%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

CADS 10 Horiz 30 Path 56 (PH) Path 48 (ML) Parisi 41 Advent 8 Total Contracts Percentages Capacity Efficiency Fiscal Efficiency

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WRAP UP

Kakoli Banerjee

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WRAP – UP- I

Access & ALOCs

77 % of residential clients are placed in treatment within 10 days of the referral 76 % of OP clients are placed in treatment within 10 days of referral ALOCs are being used regularly for residential authorizations BUT, ALOCS are not being used consistently for placement in other modalities or for continuum of care referrals Why is this important? In an ASAM-driven system, placements must be linked to the 6-dimensional assessment.

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WRAP – UP- II

Capacity utilization & Services

Adult OP operational capacity was about 75% for the July to December 2017 period. In other words, ¼

• f the slots were not used.

Only 45% of adults clients received 4 services in 30 days. By comparison, 65% of youth clients received 4 services in 30 days. Adult residential vacancy rate was 31% for the July to December 2017 period.

In other words, about 1/3 bed days were underutilized.

Residential drop rate (clients leaving within 9 days of admission) out was 22% for the July to December 2017 period. The Demand & Capacity Hotgroup will address these issues.

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WRAP UP - III

Waiver Services

Over 80% of residential bed days recorded in Unicare indicated Medi-Cal as payor in the past quarter (Oct-Dec 2017) Adult OP services lagged behind and only about 50% of services had a Medi-Cal payor attached at the point of service

This means that once the non-submissions, late submissions, denials, etc. are accounted for, actual Medi-Cal reimbursements for OP services could fall below 50%

This is clearly a matter of concern to SUTS and has been addressed by SUTS administration in face-to-face meetings with providers.

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WRAP UP - IV

Waiver services  Another data point to bear in mind is the ratio of individual to group sessions in outpatient treatment.

 In the first quarter, individual sessions outnumbered group sessions although the ratio became less skewed by December

 However, some providers had unusually high number of individual services relative to group services, which had the effect of reducing overall system capacity.  When one or two providers reduce their capacity, it cascades through the whole system and creates problems elsewhere in the system  The goal is to manage the System of Care so that all providers operate more or less at the same utilization level

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WRAP UP - V

Client outcomes  An important question for the system is whether clients improve with the treatment they receive in this system of care.

 The data on client outcomes is limited; clients improve with treatment. Definitive results cannot be provided as long as discharge data and client feedback surveys cover only a percent of all discharges.

 Data collection at discharge needs to be improved to answer questions about client

• utcomes.

 Administrative discharges rates should be reduced and the percentage of clients who complete the Client Feedback Survey increased.

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WRAP UP - VI

 SUTS administration has begun to monitor efficiency measures and these will be refined in the months to come

A question for the system is: How can service efficiency (which is the expected quantity of services per client) can be low while staff productivity is high? Data needed to calculate fiscal efficiency, which is the cost of each staff hour, needs to become available in real time.

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FINIS! THANK YOU!

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Contact information

Katherine Christian – QIDS – katherine.christian@hhs.sccgov.org Olena Chesnakova – QIDS – olena.chesnakova@hhs.sccgov.org Patricia-Rubio Corona – ROM –patricia.rubio-corona@hhs.sccgov.org Kimberly D’zatko –ROM – kimberly.w.dzatko@hhs.sccgov.org Sujung Kim – ROM – Sujung.kim@hhs.sccgov.org Leilani Villanueva -Administration – Leilani.Villanueva@hhs.sccgov.org Kakoli Banerjee –ROM – kakoli.banerjee@hhs.sccgov.org

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