Michigan’s mission-based performance indicator system version 0

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MICHIGAN’S MISSION-BASED PERFORMANCE INDICATOR SYSTEM

VERSION 6.0

Please refer to the following Attachments for data reporting “codebooks”:

Attachment I = CMHSP Quarterly Performance Indicator Codebook

Attachment II = PIHP Quarterly Performance Indicator Codebook

Attachment III = CMHSP Annual Recipient Rights Codebook

Attachment IV = PIHP Annual Recipient Rights Codebook

Attachment V = CMHSP Annual Death Report Codebook


February 2007

*Codebook Revisions 10/3/2006*

*Due Date Revisions 7/13/2007*
Michigan Department of Community Health

Mental Health & Substance Abuse Administration

MICHIGAN MISSION-BASED PERFORMANCE INDICATOR SYSTEM, VERSION 6.0

October 1, 2005 Effective Date

The Michigan Mission-Based Performance Indicator System was first implemented in fiscal year 1997. Over the next eight years, the original list of indicators grew in number to 51. During the fiscal year 2004, the Michigan Department of Community Health (MDCH) and Quality Improvement Council measured the indicators against a set of criteria that asked:

“Is the indicator…


  • Quantifiable

  • Valid

  • Reliable

  • Sensitive to change

  • Calibrated to standard

  • Benefit/cost ratio positive

  • Consistent with the system’s values and mission

  • Mandated by federal or state funders?”

The list of 51 shrunk to 12. Next considered were indicators developed by federal agencies and national associations. Finally, attempts were made to construct new indicators that might address concerns raised by the Mental Health Commission. When the proposed indicators were measured against the set of criteria, most failed to meet the test. The result is that 15 indicators were selected, approved by the QIC and MDCH, and the Contract and Financial Issues Committee of the Michigan Association of Community Mental Health Boards.
The indicators measure the performance of the CMHSPs for all persons with mental health and developmental disabilities served; the PIHPs for the Medicaid beneficiaries, including those Medicaid beneficiaries served through the auspices of the Substance Abuse Coordinating Agencies (CAs); or in some cases measure the performance of both. Since the indicators are a measure of performance, deviations from standards (where applicable) and negative statistical outliers may be addressed through contract action. Information from these 15 indicators will be published on the MDCH web site within 90 days of the close of the reporting period, following one opportunity for CMHSPs and PIHPs to make corrections.

Where possible, MDCH will use data from encounters, Quality Improvement (QI) or demographic information or Medicaid Utilization and Net Cost Reports, and CMHSP Sub-element Cost Reports to calculate the indicators. However, most of the indicators will still require separate reporting by the CMHSPs and PIHPs. This year, for the first time, PIHPs are expected to report, where noted, on Medicaid beneficiaries who receive substance abuse services through sub-contracts with CAs or substance abuse providers. Those entities will not report performance indicators for their Medicaid beneficiaries separately to the state. CMHSPs and PIHPs must use the instructions herein to collect and calculate indicators and use quality control strategies to assure accurate reporting. The External Quality Review (EQR) process will annually validate the Medicaid indicators.

Additional measures, called “dashboard indicators” and “site review indicators” will be calculated from the above data sources and used within MDCH to track patterns or trends. MDCH may use the measures to follow-up with CMHSPs and PIHPs. However, those measures will not be published on the web site.

MICHIGAN MISSION-BASED PERFORMANCE INDICATOR SYSTEM, VERSION 6.0
Note: Indicators that can be constructed from encounter or quality improvement data or cost reports are marked with an *.
ACCESS DOMAIN

Definition of Access: the ease with which care can be initiated and maintained

Indicators:


  1. The percent of children and adults receiving a pre-admission screening for psychiatric inpatient care for whom the disposition was completed within three hours.

    1. Standard = 95% in three hours

    2. Quarterly report

    3. PIHP for all Medicaid beneficiaries

    4. CMHSP for all consumers




  1. The percent of new persons receiving a face-to-face assessment with a professional within 14 calendar days of a non-emergency request for service.

    1. Standard = 95% in 14 days

    2. Quarterly report

    3. PIHP for all Medicaid beneficiaries

    4. CMHSP for all consumers

    5. Scope: MI adults, MI children, DD adults, DD children, and Medicaid SA

  1. The percent of new persons starting any needed on-going service within 14 days of a non-emergent assessment with a professional.


    1. Standard = 95% in 14 days

    2. Quarterly report

    3. PIHP for all Medicaid beneficiaries

    4. CMHSP for all consumers

    5. Scope: MI adults, MI children, DD adults, DD children, and Medicaid SA

4.a. The percent of discharges from a psychiatric inpatient unit who are seen for follow-up

care within seven days.


  1. Standard = 95%

  2. Quarterly report

  3. PIHP for all Medicaid beneficiaries

  4. CMHSP for all consumers

Scope: All children and all adults (MI, DD) - Do not include dual eligibles (Medicare/Medicaid) in these counts.
4.b. The percent of discharges from a substance abuse detox unit who are seen for follow-up

care within seven days.



  1. Standard = 95%

  2. Quarterly report

PIHP for all Medicaid beneficiaries - Do not include dual eligibles (Medicare/Medicaid) in these counts.


  1. *The percent of Medicaid recipients having received PIHP managed services.

    1. Quarterly report (MDCH calculates from encounter data)

    2. PIHP for all Medicaid beneficiaries

    3. Scope: MI adults, MI children, DD adults, DD children, and SA




  1. The percent of face-to-face assessment with professionals that result in decisions to deny CMHSP services.

    1. Quarterly report

    2. CMHSP

    3. Scope: all MI/DD consumers


  1. The percent of Section 705 second opinions that result in services.

    1. Quarterly report

    2. CMHSP

    3. Scope: all MI/DD consumers





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