Information Systems Capabilities Assessment

(ISCA)Version 7.0

California Mental Health Plans

FY 2011

MHP Name: Santa Clara County Mental Health Department

Return an electronic copy of the completed assessment to CAEQRO for review by 11/01/2011

This document was produced by the California EQRO in collaboration with the California Department of Mental Health and California MHP stakeholders.

Information Systems Capabilities Assessment (ISCA)

Contact Information

Insert MHP identification information below. The contact name should be the person completing or coordinating the completion of this assessment.

ISCA contact name and title: Laura Luna, MH Compliance and Privacy Manager

Mailing address: 828 South Bascom Ave, Suite 200, San Jose, CA 94128

Phone number: (408) 793-1874     

Fax number: (408) 885-5792     

E-mail address: Laura.Luna@hhs.sccgov.org     

Identify primary persons who participated in completion of the ISCA (name, title):

Laura Luna, MH Compliance and Privacy Manager     

Leticia Ortiz, IS Manager     

Leticia Rosado, PBS Manager     

Martha Paine, Director, GF Financial Services     

Date assessment completed: 10/30/2010

PURPOSE of the Information Systems Capabilities Assessment (ISCA)

Knowledge of the capabilities of a Mental Health Plan’s (MHP) information systems (IS) is essential to evaluate effectively and efficiently the MHP’s capacity to manage the health care of its beneficiaries. The purpose of this assessment is to specify the desired capabilities of the MHP’s information systems and to pose standard questions to be used to assess the strength of an MHP with respect to these capabilities. This will assist an External Quality Review Organization (EQRO) to assess the extent to which an MHP’s information systems are capable of producing valid encounter data1, performance measures, and other data necessary to support quality 1 “For the purposes of this protocol, an encounter refers to the electronic record of a service provided to an MCO/PIHP [MHP] enrollee by both institutional and practitioner providers (regardless of how the provider was paid) when the service would traditionally be a billable service under fee-for-service (FFS) reimbursement systems. Encounter data provides substantially the same type of information that is found on a claim form (e.g., UB-04 or CMS 1500), but not necessarily in the same format.” – Validating Encounter Data, CMS Protocol, P. 2, May 2002.

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assessment and improvement, as well as managing the care delivered to its beneficiaries.

OVERVIEW of the Assessment Process

Assessment of the MHP’s information systems is a process of four consecutive activities.

Step One involves the collection of standard information about each MHP’s information systems. This is accomplished by having the MHP complete an Information Systems Capabilities Assessment (ISCA) for California Mental Health Plans. CAEQRO developed the ISCA in cooperation with California stakeholders and the California Department of Mental Health. It is provided to the MHP as part of the CAEQRO review notification packet. The California Department of Mental Health defined the time frame in which it expects the MHP to complete and return the tool. The MHP will commonly require input from multiple areas of the organization such as IT/IS, Finance, Operations, and QI in completing the ISCA. The MHP may also attach additional sheets as needed and clearly identify them as applicable to the numbered item on the tool (e.g., 1.4, or 2.2.3).

Step Two involves a review of the completed ISCA by the EQRO reviewers. Materials submitted by the MHP will be reviewed in advance of a site visit.

Step Three involves a series of onsite and telephone interviews, and discussion with key MHP staff members who completed the ISCA, as well as other knowledgeable MHP staff members. These discussions focus on various elements of the ISCA. The purpose of the interviews is to gather additional information to assess the integrity of the MHP’s information systems.

Step Four produces an analysis of the findings from both the ISCA and the follow-up discussions with the MHP staff. A summary report of the interviews, as well as the completed ISCA document, is included in an information systems section of the EQRO report. The report discusses the ability of the MHP to use its information systems and to analyze its data to conduct quality assessment and improvement initiatives. Further, the report considers the ability of the MHP’s information systems to support the management and delivery of mental health care to its beneficiaries.

INSTRUCTIONS for completing the ISCA:

Please complete this survey using Microsoft Word. Insert your response after each question.

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Label the ISCA submission with your county name and applicable fiscal year. For example “Alameda ISCA FY10.doc”.

Be as concise as possible. If information is not available, write “N/A” in your response.

For any ISCA question, you may attach existing documents which provide an answer. For example, if you have current policy and procedure documents that address a particular item, attach and reference these materials.

Do not create documents expressly for the EQRO review.

Do not submit any documents with protected health information (PHI).

This information systems capabilities assessment pertains to the collection and processing of data for Medi-Cal. In many situations, this may be no different from how a Mental Health Plan (MHP) collects and processes commercial insurance or Medicare data. However, if your MHP manages Medi-Cal data differently than commercial or other data, please answer the questions only as they relate to Medi-Cal beneficiaries and Medi-Cal data.

For clarification, certain terms used in this ISCA are defined below:

Practice Management — Supports basic data collection and processing activities for common clinic/program operations such as new consumer registrations, consumer look-ups, admissions and discharges, diagnoses, services provided, billing, CSI reporting, and routine reporting for management needs such as caseload lists, productivity reports, and other day-to-day needs.

Medication Tracking — Includes history of medications prescribed by the MHP and/or externally prescribed medications, including over-the-counter drugs.

Managed Care — Supports the processes involved in authorizing services, receipt and adjudication of claims from network (formerly fee-for-service) providers, remittance advices, and related reporting and provider notifications.

Electronic Health Records — Clinical records stored in electronic form as all or part of a consumer’s file/chart and referenced by providers and others involved in direct treatment or related activities. This may include documentation such as assessments, treatment plans, progress notes, allergy information, lab results, and prescribed medications. It may also include electronic signatures.

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Contract Providers — Typically groups of providers and agencies, many with long-standing contractual relationships with counties, that deliver services on behalf of an MHP and bill for their services through the MHP’s Short-Doyle/Medi-Cal system. These are also known as organizational contract providers. They are required to submit cost reports to the MHP and are subject to audits. They are not staffed with county employees, as county-run programs typically are. Contract providers do not include the former Medi-Cal fee-for-service providers (often referred to as network providers) who receive authorizations to provide services and whose claims are paid or denied by the MHP’s managed care division/unit.

SECTION A. General Information

A.1. List the top priorities for your MHP’s IS department at the present time:

EHR:SCVHHS has elected to move towards an integrated core system, which will include Mental Health Department and Department of Drug and Alcohol Services. SCVHHS has selected a finalist vendor and will soon finish negotiations to reach an agreement for a major project to begin shortly thereafter. Mental Health Department and Department of Drug and Alcohol Services will be implemented in the first phase beginning in January 2012.

Community based organizations providing mental health services as contractors to the Mental Health Department will be migrating to their own EHRs using a small amount of financial assistance from MHSA Technology funds plus their own resources.

Data Warehouse: A data warehouse is in development to house Mental Health Department and Department of Drug and Alcohol Services information. Currently the following concepts are being developed:

Development of the warehouse infrastructure for reports that capture business operations with a focus on billing and payment at the client as well as the program level. This will be a pilot to determine data needed, organization of that data in the warehouse, and reporting outputs.

Analysis of the scope of data and infrastructure needed to produce DADS outcome measures reports.

Analysis of the scope of work involved with producing reports and graphics associated with the Mental Health dashboard project

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Consumer Learning Centers The purpose of the CLC project is to provide additional support for consumers in Mental Health recovery programs and those living in the community by setting up supervised computer labs and basic PC skills training in established Self Help Centers across the County. The project will be implemented in phases beginning with the Downtown Mental Health Self Help Center and Evans Lane residential and outpatient programs

Bed and Housing Exchange Mental Health Department will contract with an ASP to provide an inventory of housing availability for Mental Health clients. An RFP is being prepared to solicit proposals from which a selection will be made in late FY 2012

WEB RedesignMigrating the Mental Health website and increasing content to better support consumers and family members is being explored with the County Information Services Department. This includes issues of design, content and security.

A.2. Describe any significant IS-related achievements or initiatives completed since the last CAEQRO review:

Unicare Hardware Upgrade: Unicare hardware and infrastructure reached end of life and needed to be replaced to meet current support and standards. Project completed October 2011.

A.3. Do you have a written strategic plan for IS? If yes, attach a copy or be prepared to provide it for review at the on-site CAEQRO interview. (Available for Review: Executive Summary and Detail)

Yes No

A.4. How are mental health services delivered?

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Of the total number of services provided, approximately what percentage is provided by:

Type of Provider DistributionCounty-operated/staffed clinics 39%

Contract providers 60%

Network providers 1%

Total 100%

Of the total number of services provided, approximately what percentage is claimed to Medi-Cal.

77%

Of the total number of services provided, approximately what percentage is claimed to Medi-Cal by the following types of providers:

Type of Provider Medi-Cal Non-Medi-Cal TotalCounty-operated/staffed clinics 35% 65% 100%

Contract providers 85% 15% 100%

Network providers 99% 1% 100%

A.5. Provide approximate total annual MHP budget for the following, using your most recent cost report:

Type of Provider Medi-Cal Approved Non-Medi-Cal Total

County-operated/staffed clinics $12,020,815 $22,830.700 $34,851,515

Contract providers $52,544,246 $34,109,145 $86,653,391

Network providers $973,749 $59,963 $1,033,712

Total $65,538,810 $56,999,808 $122,538,61822,538,618

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A.6. Please estimate the number of staff that use your current information system: This data is derived from users who are active on all of the companies and teams

Type of Staff Estimated Number of Hands-on Users

Estimated Number of Total

FTEsMHP Administrative and Clerical 215 71MHP Clinical 423 194

MHP Quality Improvement 9 12

Contract provider Administrative and Clerical 152 Not Available

Contract provider Quality Improvement 0 Not Available

Contract provider Clinical 97 Not Available

Primary Information Systems Used by the MHP

A.7. Describe the primary information systems currently in use:

Vendor/Supplier Product/Module or Function Date implemented (MM/YY)

Unicare Corporation Profiler 2010      Month: October Year: 2003Dell Corporation      Diamond Managed Care System Month: June Year: 1998            Month:       Year:                  Month:       Year:                  Month:       Year:      

A.7.1. What functions do these products perform or support? (Check all that currently are used)

x Practice Management Appointment Scheduling Medication TrackingManaged Care e-Prescribing Data Warehouse/Mart

MHSA Reporting Clinical Functions Document Imaging/Storage

Personal Health Record (PHR)

Other (describe): State CSI Reporting      Billing, Credentialing

A.7.2. Who performs programming changes/upgrades for this software application(s)?

Vendor IS MHP IS (Unicare) County IS

Health Agency IS Contract Staff/Consultant Application Service Provider (ASP)

Other (describe):

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A.7.3. Who is responsible for performing daily operation tasks for this system? (Includes running batch jobs, performing backups, monitoring status, etc.)

Vendor IS MHP IS County ISHealth Agency IS Contract Staff/Consultant ASP

Non-vendor ASP Other (describe):

A.7.4. Where is this system physically housed/sited?

MHP siteHealth Agency IS site

County IS site

ASP Model — hosted by application service provider

ASP Model — hosted by third-party independent hosting service

Other (describe):      

A.7.5. What departments/agencies use this system?

What departments/agencies have direct access to the system? (Check all that apply)

Mental Health Mental Health Contract Providers

Alcohol and Drug Public Health

Hospital Other (describe): Alcohol & Drug Contract Providers

Secondary Information Systems Used by the MHP

A.8. List any other significant information systems used by your MHP in addition to your primary IS:

Vendor/supplier Product/module Purpose/function

Siemens      Invision      FQHC Services, Client Registration/MHSAC

PCSI      Pharmacy System Pharmacy System

                 

                 

                 

                 

                 

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A.9. Selection and implementation of a new Information System

Mark one box that best describes your status today and respond to the associated questions:

A) No plans to replace current systemB) Considering a new system

C) Actively searching for a new system

D) New system selected, not yet in implementation phase

E) Implementation in progress

F) New system in place (use this for systems fully installed in past 5 years)

A.10. Implementation of a new Information System

Santa Clara Valley Health and Hospital System (SCVHHS) recognize the critical importance of its Information Technology (IT) environment in enabling its strategic vision and business goals. Given an opportunity to assess the current strategy and status of IT for Santa Clara Health and Hospital System (SCVHHS), SCVHHS has elected to move towards an integrated core system, which will include Mental Health Department and Department of Drug and Alcohol Services. SCVHHS has selected a finalist vendor and will soon finish negotiations to reach an agreement for a major project to begin shortly thereafter.

If you marked box D, E, or F above, complete the following questions. Otherwise, skip to Section B.

A.10.1. Details of the new system: Even though the new system has not been chosen all of the requirements are still in place:

Vendor: Confidential (in negotiations)Product(s): TBD

Implementation start date: January 2012

Estimated go live date: June 2013

Estimated completion date: December 2013

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A.10.2. For those items listed which you are electronically or manually transferring to the new system, indicate for which consumers these items will be transferred (enter “X” in boxes): To be determined with new system

Item All Consumers

Active Consumers

OnlyMHP consumer ID, name/address, other demographic data

Episode history, including admit/discharge dates

Diagnoses

Services

Medi-Cal/insurance information

Payor Financial Information (UMDAP)

A.10.3. Please identify staff directly responsible for system implementation:

Project Responsibility Name and Title

Overall Project Manager Bruce Copley / Deane Wiley / Leticia Ortiz

Technology Project Manager Sue Clements     

Clinical Project Manager Sheila Yuter     

A.10.4. Specify key modules included in the system:

What functions do these products perform or support?

Practice Management Appointment Scheduling Medication Tracking

Managed Care e-Prescribing Data Warehouse/Mart

MHSA Reporting Clinical Functions Document Imaging/Storage

Personal Health Record (PHR) Other (describe): Billing, CSI Reporting     

A.10.5. What departments/agencies will use the system?

What departments/agencies will have direct access to the system? (Check all that apply)

Mental Health Mental Health Contract Providers Via standard HIPAA Transactions and reports only

Alcohol and Drug Public Health

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Hospital Other (describe): Alcohol & Drug Contract Providers

SECTION B. Data Collection and Processing

Data Timeliness and Accuracy

B.1. Please specify precisely what the expectation is for timely entry of service data (such as same day, within 24 hours after service is delivered, within 3 business days, etc.)?

On the same day services are provided, but no later than 5 business days.

B.1.1. Describe how you track compliance with this policy. Include an example of any available summary data and the period of time this represents.

Unicare AR_USI0038 Service Monitoring Report which shows the duration between service delivery date and service entry/recording date. (Report will be available for review)

B.2. Describe how you ensure that all services actually provided were entered into your information system?

Unicare AR_USI0101 Daily Service Reconciliation Reporting which determines if required actions were completed and the service was recorded. This can be reconciled to the appointment schedule for each day. (Report will be available for review)

B.3. Do you review the following data items for accuracy and completeness at specified frequencies?

Item Yes/NoGender Yes No

Date of birth Yes No

Race/ethnicity Yes No

Primary language Yes No

Dates of services Yes No

Procedure codes Yes No

Diagnoses Yes No

B.3.1. Identify the staff or the unit responsible to monitor for accuracy and completeness.

Clinical and Clerical al at the point of entry, IS Staff, Patient Business Services, QI, and reviewed Mental Health Decision Support Unit using analytical reports.

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B.4. Describe how data errors discovered during back-end validations/processing are reported out and corrected?

There is a suite of Business strategy reports run on the front end and during the service batching process. The goal is to greatly reduce errors before reaching the back-end. All claims are scrubbed by a third party vendor and errors are returned to Providers and Patient Business Services for correction

B.4.1. Who performs any needed corrections?

Through out the continuum of registration service entry, batching, scrubbing and rejections all staff that touch the records are involved. This includes clerical Staff, clinicians IS Staff, third party claims scrubber and Patient Business Services (PBS)     

B.5. Describe any recent audit findings and recommendations. This may include EPSDT audits, Medi-Cal audits, independent county initiated IS or other audits, OIG audits, and others.

B.6.The MHP had no external reviews since December 2010. The MHP Quality Improvement (QI) Program conducted their annual internal Administrative Review and Clinical Records Review (CRR) for their 35 County and Contractor sites. A total of 733 charts were reviewed in FY 2010-2011 CRR. Findings: 8 sites (2 contractors, 6 County) are receiving mandatory mentoring for having more than a 5% disallowance audit finding. In addition, MHP QI program performed an internal clinical records review on thirteen of their Fee-For-Service providers (38 charts).

B.7. On a periodic basis, key system tables that control data validations, enforce business rules, and control rates in your information system must be reviewed and updated. Indicate who maintains these tables (check all that apply):

MHP Staff and IS StaffHealth Agency Staff (“umbrella” health agency)

County IS Staff

Vendor/ASP Staff

Outside consultant

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B.8. Who is responsible for authorizing and implementing the following system activities?

ActivityWho authorizes?

(Staff title or committee/ working group)

Who implements?(Staff title or committee/

working group)

Establishes new providers/ reporting units/cost centers

Bruce Copley, Deputy Director of Mental Health

Leticia Ortiz, IS Manager

Determines allowable services for a provider/RU/CC

Bruce Copley, Deputy Director David Guerrero, QI Manager

Leticia Rosado, Patient Business Services Manager     

Establishes or decides changes to billing rates

Martha Paine, General Fund Finance Director Leticia Ortiz, IS Manager

Determines assignments of payer types to services

David Guerrero, QI Manager       Leticia Ortiz, IS Manager

Determines staff billing rights/restrictions

David Guerrero, QI Manager       Leticia Ortiz, IS Manager

Determines level of access to information system

David Guerrero, QI Manager       Leticia Ortiz, IS Manager

Terminates or expires access to information system

Division Managers reporting to Bruce Copley, Deputy Director

Leticia Ortiz, IS Manager

Staff Credentialing

B.9. Are staff credentials entered into your information system and used to validate appropriate Medi-Cal billing by qualified/authorized staff?

Yes No

Training

B.10. List regular IS training offerings and frequency of trainings, or, provide a list of classes conducted over the past year.

Training is delivered based upon job function: Unicare System navigation for all users, for systems-based clinical operations and procedure and training on all aspect of clerical functioning in the system including registration, service validation, and billing. There is also refresher training as needed. Based upon changes from SD Phase II, a training program for Void and Replace procedures and workflows was delivered to all Unicare users. Also provided was training for the new Denial workflows. The purpose is to insure that data is correctly entered and proper processes are employed to maximize the revenue received for all the services rendered. All training was delivered to both Mental Health and DADS staff. Refresher courses occur monthly. (See Attachment A, Training schedules

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2011, A-1 Clerical Manual and A-2 Clinical Manual , A-3 Void and Replace Training , A-4 Denial Training)

B.11. Do you routinely administer competency tests for IS users, to evaluate training effectiveness?

Yes No

B.12. Do you maintain a formal record or log of IS/computer training activities?

Yes No

B.13. What is your technology staff turnover rate since the last EQRO review?

Total Number of IS Staff

Number of New Hires

Number of Staff Retired, Transferred, Terminated

Current Number of Unfilled Positions

12 4 1 position cut 1

Staff/Contract Provider Communications

B.14. Does your MHP have User Groups or other forums for the staff to discuss information system issues and share knowledge, tips, and concerns?

Type of GroupMeeting Frequency (weekly, monthly,

quarterly, as needed)

Who chairs meetings? (Name and title)

Meeting minutes? (Yes/No)

Clerical User Group Bi monthly Sue Chou Yes

Clinical User Group Bi-monthly Sue Chou Yes

Financial User Group As Needed Leticia Rosado Decisions & Action Items

Contract Providers Bi-monthly Sue Chou YesReports User Group(Reports Lab) Monthly Hung Nguyen      Decisions &

Action Items

IS Vendor Group Monthly Caroline Yip, Sue Chou Decisions & Action Items

Contract Management Bi Monthly Bruce Copley/David Guerrero Yes

B.15. What types of technology do you utilize to communicate policy, procedures, and information among MHP staff (Check all that apply)?

Web server Intranet server

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Shared network folders/files Content management software

E-mail Other (describe): Training and paper documentation

B.15.1. If none of the above, how is information shared among MHP staff?

     

B.16. Is this technology open to contract providers also?

Yes No

B.17. How do contract providers submit client and service data to the MHP? (Check all that apply)

Submittal Method Frequency

Direct entry into MHP IS Daily Weekly Monthly

Electronic transfer to MHP IS Daily Weekly Monthly

Documents/files e-mailed to MHP Daily Weekly Monthly

Paper documents Faxed to MHP Daily Weekly Monthly

Paper documents delivered to MHP Daily Weekly Monthly

Other:       Daily Weekly Monthly

B.18. What is the basis for payment to contract providers? (Check all that apply)

BasisAdvanced 1/12th of annual contract each month

Paid monthly using printout of service units entered in IS

Paid monthly using online report from provider

Paid monthly using estimated units on invoice from provider

Other:      

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B.18.1. If monthly or other, what is the average time lag between end-of-month/date invoice and payment to contract providers?

Lag (in days)≤ 15

16 – 30

31 – 90

> 90

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SECTION C. Medi-Cal Claims Processing

C.1. Who in your organization is authorized to sign the MH1982A attestation statement for meeting the State Medi-Cal claiming regulatory requirements? (Identify all persons who have authority)

Name: Nancy Pena Title: Mental Health DirectorName: Bruce Copley Title: Mental Health Deputy Director

Name: Leticia Rosado Title: Patient Business Services Manager

Name:       Title:      

C.2. Indicate normal cycle for submitting current fiscal year Medi-Cal claim files to DMH.

Monthly More than 1x month Weekly More than 1x weekly

C.3. Do you have an operations manual or other documentation that describes activities to prepare SD/MC claims? (Be prepared to present and discuss this during the on-site CAEQRO review.) (Attachments B & B1: Claims work flow charts)

Yes No

C.4. Do you produce and review test claims before final production of Medi-Cal claims?

Yes No

C.5. What Medi-Cal eligibility sources does your MHP use to determine monthly eligibility? (Check all that apply)

IS Inquiry/retrieval from MEDS POS devicesMEDS terminal (standalone) AEVS

MEDS terminal (integrated with IS) Web-based search (Medi-Cal website) vis a HDX link in Unicare

MMEF FAMEEligibility verification using 270/271 transactions

C.5.1. Do you have procedures in place that monitor or review retroactive eligibility?

Yes No

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C.6. Does your system store the Medi-Cal eligibility information listed below?

ItemSystem stores automatically?

(Y/N)

System stores but manually entered?

(Y/N)

Able to use/query for reports?

(Y/N)CIN N Y YEligibility Verification Confirmation (EVC) N Y Y

County of eligibility N Y Y

Aid code N N YShare of cost information N Y Y

C.7. Do you have an operations manual or other documentation that describes the applications of Medi-Cal EOB (835)? (Be prepared to present and discuss this during the on-site CAEQRO review.) (Attachment D: e-Remit Process)

Yes No

C.8. Do you bill any private insurance?

Yes No

C.9. Do you bill Medicare?

Yes No

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SECTION D. Incoming Claims Processing

Note: “Network providers” (commonly known as fee-for-service providers or managed care network providers) may submit claims to the MHP with the expectation of payment. Network providers do not submit a cost report to the MHP.

D.1. Provide the approximate monthly volume of claims received from network providers:

Average number of claims per month 1,688Average claims in dollars per month $97,730

D.2. Do you have any documentation, such as policies and procedures, for processing incoming claims from network providers? Be prepared to discuss during the on-site CAEQRO interview, if requested.

Item Yes/NoProcessing incoming claims Yes No

Payment to network providers Yes No

Billing Short-Doyle/Medi-Cal Yes NoOther: Void & Replace/Denial Training (See attachments A-3 and A-4) Yes No

D.3. What is the average length of time between claim receipt and payment to network provider, in days?

FFS(Private Office Psychiatrists: 3 weeks IMD: 3 weeks Inpatient Professional Fees: 6 working days

D.4. Does your MHP maintain network provider profiles in your information system?

Yes No

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D.4.1. If Yes, describe what provider information is maintained in the provider profile database.

Provider InformationLanguages spoken Gender-specific care Age-specific careSpecialty health careSpecialty therapyAccessibilityOther:      

D.5. Does your MHP use a manual or an automated system to process, adjudicate and pay incoming claims from network providers?

Manual Automated Combination of Both

D.6. Estimate the percentage of your network providers’ claims that were not approved for payment during the last fiscal year.

6%

SECTION E. Information Systems Security and Controls

E.1. Indicate the frequency of back-ups that are required to protect your primary information systems and data. (Check all that apply)

Back-up Frequency (at least)Daily full back-up Daily incremental back-up

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Weekly full back-up Weekly incremental back-up

Other: Transaction Log back-up every hour

E.1.1. Where is the back-up media stored? (Check all that apply)

Back-up locationMHP site County site

Health department site IS Vendor site

Data Security Vendor Other:      

E.1.2. How often do you require passwords to be changed?

Password Change Frequency (at least)≤ 60 days 61 – 90 days

91 – 180 days 181 – 365 days

> 365 days Never

E.1.3. Do you enforce the use of strong passwords for your core systems?

Yes No

E.2. Do you have policies and procedures that describe the provisions in place for the following? Be prepared to discuss during the on-site CAEQRO interview, if requested.

Item Yes/NoPhysical security of the computer system(s) and hardcopy files Yes No

Security of laptops and other portable storage devices Yes No

Management of user access Yes No

Termination of user access Yes No

Attachment E: Policies and Procedures (P&P) 601E.3. Do you require encryption for laptops or other portable storage devices

that contain PHI? Yes No

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SECTION F. Data Access, Usage and Analysis

F.1. Who is the person(s) most responsible for analyzing data from your information system?

Staff Name/Title Organization/Department/Division

Deane Wiley, Director      Learning Partnership/

Leticia Rosado, PBS Manager Finance Agency, Patient Business Services

Caroline Yip, Manager MHP Information Services

     

           

F.2. Describe two examples of data analyses performed in the last year that were used in quality improvement or business process improvement activities. Be prepared to discuss during the on-site CAEQRO interview, if requested.

Milestones of Recovery data was used to determine that stability is the main achievement of our system. Clients have a tendency to remain at an average level on the scale instead of showing progress toward recovery. To improve these outcomes we have begun trainings in client centered treatment planning to encourage clinicians to focus on improvement strategies designed to help clients continue to progress toward recovery.

F.3. Indicate the reporting tools used by your staff to create reports from the IS.

Microsoft Excel Microsoft AccessCrystal Reports SPSS

SAS Vendor-supplied report writer

Other (describe) SQL, Power Point and Text/Graphic applications

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F.4. Do your systems interface or exchange data with other systems? If Yes, specify the purpose (such as lab, Rx, ER) and standards/methods used for the interface/exchange.

Entity Yes Description of purpose Standards/Methods usedOther internal MHP IS Reporting Requirements      

Other County department A/R and A/P to SAP Manual

DMH Claims and CSI reportingHIPAA transaction for claims, CSI Format for reports

Other State departments

Contract providers Service Data Electronic transfer

Other MHPs            

Other (specify):                  

F.5. Do your consumers have on-line access to their health records, either through a personal health record (PHR) feature provided within your IS or through a third-party PHR such as those available through Network of Care, Google, or Microsoft?

Yes No

F.5.1. If Yes, what product(s) are used?

     

F.6. Does your information system capture co-occurring mental health and substance abuse diagnoses for active consumers?

Yes No

F.6.1. If Yes, what is the percent of active consumers with co-occurring diagnoses?

6 % based upon diagnosis

F.7. What tools or instruments do you use to measure consumer outcomes?

Client-Level Outcome Tools The MHD has adopted a client satisfaction survey based on the State assessment tools. Data from the survey is included in the QI Work plan. Two additional client outcome tools were introduced in FY09, the Milestone of Recovery Scale (MORS) and the Client Informed Outcome Measurement (CIOM). Clinicians use the MORS eight point scale to assess each consumer’s level of risk

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(physical harm to self or others and participation in unsafe behaviors), engagement with the mental health system (degree of connection, not necessarily the amount of service received), and skills (independent living, engaged in work/school/community, managing physical/mental health, finances, substance abuse) and support (family, friends, co-workers, intimacy, sexual expression).

F.7.1. Describe how these outcomes are communicated and used within the organization.

MORS data are reviewed with each consumer in preparing and updating the treatment plan. The CIOM is prepared by the consumer and provides a client-level perspective on how the system is meeting his or her recovery goals. Clinicians throughout the system began using MORS in mid-FY09 and the CIOM is being pilot county and contracted agencies. As data becomes available, it will be analyzed and presented to the Quality Review Council with a view toward including these data in the annual performance review.

Overall system results are also reported directly to clinicians, program managers, and directors for program evaluation.

F.8. Does your information system record consumer missed appointments?

Yes NoUnicare Pro-Filer system has the capability to track missed appointments; however the MHP has not implemented procedures to monitor client service status.

F.8.1. Indicate how you categorize missed appointments by reason, such as cancellation or no-show by consumer versus cancellation by staff.

Missed Appointment Category Yes/NoConsumer no-show Yes No

Consumer called and cancelled Yes No

Staff cancelled/unavailable Yes No

F.8.2. What is your average monthly percentage of missed appointments?

The Unicare system has the capability to track missed appointments. The data will become available for use when the MHP’s Performance Dashboard is implemented. The SCVHHS Enterprise Wide Scheduling System (EWS) will be supply the data for missed appointments in the FQHC clinics

23%

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F.9. Do you have a staff productivity standard?

Yes NoIf No, go to F.10

F.9.1. How do you measure productivity?

Based on the Service Entry into Unicare

F.9.2. What is the expected percentage rate?

66% for regular staff and 33% for

lead

F.9.3. What was the actual rate when last measured?

54.8% for regular staff and 46.4% for

lead

F.9.4. What was the low-high range over the last year?

13.2% to 81.2%

F.10. Do you track and report the time from initial contact to the following events? (Check boxes)

Event Yes/NoAssessment Yes No

First Appointment Yes No

First psychiatric appointment Yes No

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Attachments to Santa Clara ISCA FY 11

Attachment A - Training Schedule 2011Attachment A1 - Clerical ManualAttachment A2 - Clinical Manual Attachment A3 – Mental Health Void and Replace TrainingAttachment A4 – Mental Health Denial Training

Attachment B- Mental Health Flow Chart of Billing and Denial Process

Attachment C – Claim Remedi Pro-Filer Batch Eligibility Interface

Attachment D – Medi-Cal e-Remit Process

Attachment E –Policy and Procedure 601Attachment E –Policy and Procedure 601, Exhibit 1Attachment E –Policy and Procedure 601, Exhibit 2Attachment E –Policy and Procedure 601, Exhibit 3Attachment E –Policy and Procedure 601, Exhibit 4Attachment E –Policy and Procedure 601, Exhibit 5

Attachment F – Business Operations Meetings

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