Conference Call Report

January 6, 2000

MHSIP 16 State Indicator Pilot Project

Minutes Reported by: Dr. Craig Colton, Utah and Dr. Bernadette Phelan, Arizona

Ron Manderscheid convened the meeting and called roll for the 16 State data and planner State grantees

The following updates from subcommittee were made:

Penetration Utilization Rates-John Pandiani, Vermont

John reported that he has received l999 hospital inpatient data from half of the States. He urged that states submit information for completion of data collection-he plans to more forward with collection and analyses of groupings requested. He hopes to then collect outpatient data with categories used in the inpatient data collection.

Level of Functioning and Symptoms-Mary Smith, Illinois

Mary Smith stated that more members are needed for the workgroup. A committee will convene in the future to review instruments and make recommendations...five or six instruments will be addressed and survey developers will be a part of this committee. Ron will follow-up with Mary to plan the meeting.

Consumer Survey- Judy Hall, Colorado

Judy reported that she has received survey data from 9 states which she has analyzed in terms of findings. She will be sending charts and analyses to each State, as well as request that States review the data again for differences or changes. Judy encouraged the rest of the States to submit their survey data for completion of the data collection and analyses.

John Whitbeck, WA, requested information on the status and validity of the MHSIP 40 and the 21 item consumer survey.

Ron indicated that several things are happening on consumer survey at this time;

1- one is the study that Steve Davis has commissioned to HSRI to look at instruments ... there will be a meeting to discuss the results of that and look at next step for NCQA and the survey on 1/19. Out of that will come some efforts to develop an integrated instrument that can be recommended to NCQA. This project is moving ahead very rapidly.

2- Steve Davis indicated that a document now on the MHSIP website was drafted by Vijay. The aim is to try to provide a background as to what has been happening with regard to the survey and its direction. Feedback is requested in regard to the document. Mary Smith and Cindy Hopkins of the MHSIP Policy Group and Co-Chairs of a Policy Group committee have been working on developing guidelines for the future of MHSIP surveys in general; they will tie recommendations to Vijay=s document.

3- Ted Lutterman stated that within NASMHPD he has sent out list of ORYX indicators for JCAHO accreditation ... They are using the 21 item version which is strictly for adults. Any participating hospital can use the 21 item version as far as the joint commission is concerned although hospitals can still use larger survey. NASMHPD has not determined that the 21 vs 40 or 24 or 44 item is the best version.

There will be a conference call with the MHSIP Policy group today to talk about the task force group that will officially set up a process where MHSIP would endorse updating what is the official version of the consumer survey.

Danny Dirkson, Utah stated that they have been interested in results that have come out of the 40 item or any of the surveys that have been done so that they can begin to compile data and look at comparisons, reliability, validity, etc. They haven=t known what is out there.

Judy Hall and Randy Koch, Va offered to provide information on results and analyses of their respective surveys to Danny.

Community contact within 7 days of discharge-Steve Davis, OK

Steve reported that New York, South Carolina, and Oklahoma are providing data, and that no one else has reported yet. Colorado will be sending data at the end of month, and Washington, DC will be sending data soon.

Readmission to Hospital at 30 days-Al Volo (Readmission)

Al Volo reported that he and Bruce Way have been working on this project. Bruce reported that 5 states have sent data on the 30 day/180 day readmission- DC, SC, VT, OK, VA. Bernadette Phelan (AZ) will be providing data today. Al will send the readmission rates to the group for every state to get a sense of how they compare.

Cost per client-Nancy Callahan

Nancy reported that she has sent out graphs that illustrate the differences in service use dollars between 93/94 and 97/98 with comparisons and trends across time in California. The data is split into four program area categories for analysis (inpatient which is psychiatric hospitals not state hospitals, crisis services, outpatient services and day treatment. CA had medicaid data only. Some states have access to total dollars which would be preferable, and it would be interesting to compare both. If people are in support of trying to do this across the 16 states we can work on trying to get those defined. Nancy took total number of clients that were served and the total dollars and divided it to get a total dollar per client. The cost went down over time, while the number clients remained about the same. The total number of bed days decreased from l993-97.

Ron stated that WA has 1993 data in Mental Health USA >98 which may be compared with Nancy=s work. The Branch also has Medicaid data for 3 states- WA, MI, and NJ for >93 and >94 medicare data and some >94 private plans. There is an effort now for collecting >94 medicaid data for the same 3 states adding PA and then working on >95 medicare data and >95 private sector data and another contract in place through the next 2 cycles. The effort is to build a preimposed managed care file based on 100% sampling to see how these factors change. John will work Nancy in regard to Washington State efforts. Ron asked Nancy to come forth with a proposal to group of what she thinks the group ought to do and the group then needs to discuss it, and decide on the proposal.

Nancy will work on a proposal as suggested.

Ron asked if it is possible to join state revenues and expenditures and link that to the penetration data that John Pandiani is working on with further translation into cost per client? Penetration data is supposed to be unduplicated, if really true should be able to compute.

Nancy stated that some states can get unduplicated count of clients and others cannot.

Administrative cost.-Eva Jakuba

Eva indicated that the group is combining discussion of administrative cost with Nancy=s cost per client effort. The committee will be looking at data and starting reviews of some states.

Atypical medications-Amy Elliott, RI

Amy Elliott has received 10 to 15 responses on her survey to states to date.

Assertive Community Treatment and Supported Employment-John McGrew

John McGrew has sent out a proposed checklist for ACT and supported employment to States, and is requesting that States review and send comments to him.

John Whitbeck was appreciative of information, especially in the support of employment because Washington has 3 ways of looking at employment, 1-we have our utilization data of people that have paid and unpaid employment, 2- information on all the identified persons in the utilization data base against employment security by social security number to see if consumers have been employed now and or in the prior year, and 3-a relationship with state department of rehabilitation. What Washington does not have is a way of thinking about supported employment, and as a subset of that and what does that mean? I think that employment is a very significant issue in particular related to recovery.

Ron indicated that one of the GPRA measures is employment. An important question is whether these clients are employed. That needs to be operationalized. What clients are being addressed and what kind of employment is being referred to are important questions. Competitive employment, supported employment, non-salary employment, all these areas are important and will become more important in the future.

John McGrew commented that both (ACT) and supported housing are different kinds of indicators. ACT is a best practice indicator as opposed to outcome indicator.

Ted stated that John makes a good point-in the 5 state study, the participants looked at both things C they look at supported employment as an evident state, sort of best practice, and they looked at what % of clients are employed, as more of an outcome measure. He was not sure about what is happening in the employment measure- NASMHPD supports that supported employment is an example of a service that has been demonstrated to be effective for people with SMI.

A question was posed in terms of the indicators being addressed in Washington State.

John stated that they are trying to triangulate and look for all of the people who would show up in a database ... They are trying to look at the efficacy of our long term partnership with the dept of rehabilitation and some of the things they are doing which could include a small subset that would look like supported employment; they are having difficulties with our utilization data indicator which has been problematic because of how people report (whether it is self report and how often is it renewed). We theoretically look at it monthly, but we have deep suspicions about it. And so what we are doing is struggling for triangulation and identifying a sub proxy for outcome or independent data collection. John stated he would be glad to write up and show some illustrations of what Washington does at a future meetings.

Ron asked if John Whitbeck would send around an e-mail to discuss this further at the next meeting, and John agreed.

ORYX indicators-Ted Lutterman

Ted stated that NASMHPD NRI is we still tabulating responses from states. As of January 1 every hospital had to pick 2 more measures so every facility now has to be reporting at least 4 measures. Two will be going to JCAHO. It looks like most states were collecting readmission rates, seclusion and restraint, and use of new generation antipsychotic drugs. It looks as though seclusion and restraint are being added by many of the states that were doing readmission. Additional states are starting to focus on the injury issue of new generation meds. We will have shortly a list of how many of the facilities are reporting those measures to us.

Ron stated that one of the issues that was up last time is the issue of this project getting access to the ORYX data. He asked is there had been any progress on that.

Ted indicated that there had not yet been a response as yet. They are just now starting to run a series of analyses and have been meeting with Steve and a group of people looking at risk adjusting the data . A report will be sent back to all the states. They have not resolved the issue yet in terms of whether they can give out data from states and permission issues. NASMHPD can only give the collection to the states. States should be getting data from us within the next few weeks. The states have the right to do whatever they want in terms of data distribution. It is a question of NASMHPD giving it directly to the 16 State project. NASMHPD is going to have to get state approval. The board had a tight agenda and did not discuss this at the Commissioners meeting.

Steve asked if we could survey the 16 states and see how many of the people involved in the project have access to the data that is going to NASMHPD? For OK that data comes out of the state 16 state section. They could just as easily take it and report it into a table for the 16 state project. If other states can do that it will be done more directly rather than having to go to NASMHPD and then back to the state.

Denny Geertsen, Utah stated that they are receiving the data directly from their state hospital so that they can get it cleaned up for the ORX project and then send the office a copy of the clean data. Steve=s suggestion would work in Utah.

Judy Hall posed that if extensive risk adjustments were being effected at NASMHPD would there be different numbers in the states?

Ted indicated that risk adjustment reporting would be reported back to the states shortly. Reports will going to each of the commissioners as well as the state hospitals.

Ron asked if can we follow up on Steve=s suggestion and whether Steve and Ted could send that information over the e-mail as to who is doing what?

Ted indicated that what Steve is talking about is the raw data before we compute the risk adjustment.

Ron stated that we need to know how many have access to it.

John Whitbeck stated that WA has access to it but he is looking for ORYX and NASMHPD and CMHS nodding their heads. He stated that we can have the data because it is ours. But then the luxury of having the data after it has gone through a refinement so that we understand the algorithm and what is going on seems to be the point.

Ron stated what Ted is saying is once they have analyzed it and given back to you then you are free to do whatever you want with it. We have it both in the raw form that Steve is talking about and the refined form that Ted is talking about. Do these 2 things actually come together in the state is the issue. Can Steve and Ted do this mini survey of the states over the e-mail to report on who is doing what?

Judy asked Ted if there is a separate inpatient version of the MHSIP consumer survey now?

Ted said that yes, one was submitted to the joint commission. There were items that had been modified slightly: AI was able to see my psychiatrist within 24 hours@ was not deemed appropriate for inpatient setting. AI was able to get an appointment promptly or services location was convenient@ were not appropriate. Those were changed. There were 3 states that sent us a modified version of the consumer survey for an inpatient setting with the same items changed. That was what the ORYX task force that met back in Nov. made their choices from. A copy was sent out last November or December.

Planner committee report-Marie Danforth

Marie reported that the planners met in November. The committee concentrated on stakeholder involvement. They felt that one of the things they could contribute was documenting how stakeholders are involved in this project...how training, education materials, and activities have gone on and particularly in involving and educating consumers and family members. Erwin Kerzner and Nancy Chang from Illinois prepared an analysis of stakeholder involvement which was described in the July report when we met in DC. They developed a grid of different stakeholders that could be involved. They decided (because those reports were not consistent) that they are going to develop a form and ask all the states to fill out when they are getting ready to take a look on yearly basis. They will be collecting information with a real goal being to be able to share this information with the other planners at the national meeting in May or June. We also took a look at the performance indicators included in the state plan and had some discussion about the core measures that we have been talking about in the applications of the state mental health plans. We will be having another call in Feb. and will let everybody know the date and time.

In terms of government performance and reform act. (it is supposed to have a performance goals with viable measures to demonstrate effectiveness) They have been working on it for a couple years now, but this December submitted the project. Marie has been giving materials to SAMHSA policy office to be included in the budget. The president=s budget that will come out in February. There are two things to be looked at under block grant program. 1- SAMHSA core measures. These are the 6 measures that are included in the block grant application and the states have been voluntarily asked to report on these measures. 2- Another area they are looking at is the 16 state project. As far as the 6 SAMHSA core measures: 1-increasing the percent of adults w/SMI who are (1)-...employed, (2-)...living independently, (3)-decreasing...have had contact with criminal justice system, (4)-increasing the percent of children w/sed who attend school regularly, (5)-....who reside in a stable environment, (6)- decreasing children w/sed who have had contact with the juvenile justice system. As Ron indicated they are not operational because we don=t have regulations in the block grant program. That is why they are voluntary. OMB won=t let us define them. Thus, no standardized definition.

Ron suggested that maybe to Operationalized would be to look at who is reporting something and convene those people by phone to discuss that measure.

Marie responded that is what they did because the state implementation report came in Dec 1. This was the first time the states voluntarily reported on any of these 6 measures. Twenty-three states reported at least 1. Three states reported 6. Five states reported on 4. Four states reported on 3. Nine states reported on 2. Two states reported 1. They have developed a target. For the persons who are employed they have a 17.3% baseline. The one that was least reported was stable environment for children. The 13 states report on employment for adults, 16 states on living independently for adults, and 11 states for juvenile justice and criminal justice. Then they moved on to the measure on performance indicators for the 16 states. John will see his hospital penetration rates as well as Judy Hall=s report on the consumer surveys. All were pleased at higher levels at SAMHSA. Olinda was very helpful in putting together this GPRA report. Once it goes out we can share it with you.

Ron wanted to make sure that everybody receives a table that Judy Hall produced - >it is an interesting table and shows what one can do with some of the consumer survey data when put it together=.

Mental Health US article-Olinda González

Olinda reported that the group of writers (for selected performance indicators) met in late December. The areas cover in the article will include penetration rates, the consumer survey questions, ACT and supportive employment, contact 7 days after hospitalization, 30 day discharge, indicator atypical medication, level of functioning, and costs. All of the 4 domains are covered in terms of the indicators. The focus will be on how the findings or data from these indicators can be used in policy decision making. Group members will be working how findings from individual indicators can be used to impact policy decision making. There also will be highlighting of penetration rates and the consumer survey as there will be data to display.

Ron ended the presentations with a call for three areas that needed to be addressed in year 2: First, indicators that we have scheduled for completion in year 2- A1, A2, Q1, Q3, Q4, Q11, O1, S3. If we are working on all of these are we going to be able to have data for all of these by summer of this year. We may want to review and then come back to discuss next time or get some feedback from people between now and our next call. One of the issues is Awhat are we going to be able to produce and when@. We will be coming up at the end of year 2 at the end of the summer. Also, we need to know where are we in the cycle with the GPRA process that Marie was talking about and all these things.

Ron recommended to pose the question to find out from everybody and feed it back to the relevant work group. Is that reasonable?

Question 2: how many indicators that were scheduled for testing in year 2 will be tested year 2? One of the issues there, none of the indicators we said we were going to test have any sub groups on. Q2, 10, O2, O3, O9, O12, O13. Do we need to begin to have some discussion of those as we were beginning to do with employment today? To ask the questions, how are we going to move ahead on these.

Judy Hall stated that she could can speak for the family involvement and treatment. The child and family surveys that we may be able to speak to some of the issues about family involvement and treatment.

Indiana ,Washington State, Vermont, and Virginia representatives (J. McGrew, J. Whitbeck, Lucille Schacht, and Randy Koch) indicated interested in participating in a criminal justice sub-committee.

Ron addressed the school improvement issue, and Randy Koch indicated that he would look into a survey Molly Brunk is working on.

Nancy C. offered to work on the living situation indicator.

Ron posed Question 3- we have talked about all except: O11-Reduced Substance Abuse, S1-Consumer/Family Member involvement in policy, quality assurance, and planning. He asked Ted to look at MHSIP indicator for consumer family involvement and provide a report.

Ron asked about reduced substance abuse, and Eva Jacuba agreed to see if someone on the CT team would review this for leading a group. Randy K. and Bernadette Phelan stated that they would be interested in participating as members.

Ron requested from Ted L. the reporting of any indicators that may have been collected by the states on ORYX by the following meeting.

April 27-28, 2000, was the date selected for the states to meet in Washington, DC.. Before developing an agenda, Ron suggested needing to pick several of the key areas in which we are working including data and what we are actually going to have. Between now and the next call we ought to be thinking about what would those areas be. An agenda item will be State Indicator topics for the national conference on mental health, and the conference on state planning. Next time we will come back and talk about these items, and build the agenda on our next conference call. The next call was scheduled for Monday, February 7, 1-3pm est. The agenda for next call will include working on the agenda for the face to face meeting and follow up on major issues.