Quality Improvement and Compliance 2016 Annual Report...Intake workers conduct Clinical Evaluation Assessment interviews with persons referred for public mental health treatment. Intake

150 Cross Street Akron, Ohio 44311

www.cssbh.org

2016 Annual

Report

Quality Improvement and Compliance

Quality Improvement and Compliance 2016 Summary

Community Support Services, Inc. serves as the premiere non-profit behavioral healthcare provider for Summit County and the surrounding communities. The agency offers a comprehensive array of holistic services to promote wellness for persons with severe and persistent mental illnesses.

The Quality Improvement and Compliance (QIC) Annual Report is presented to stakeholders of Community Support Services, Inc. in an effort to demonstrate excellence in service provision as a result of continuous performance monitoring and quality improvement.

The QIC Annual report has been designed to provide a snapshot of services and programs offered in 2016, while providing a summary of Quality Improvement initiatives and reported measures for the year. The QIC Annual Report highlights our efforts and demonstrates the agency’s progress in meeting QIC expectations and best practices during the year.

During the year, the agency embarked on an initiative to provide services coupled with the Trauma Informed Care Model to increase effectiveness of all program services. Moving forward to 2017, continued implementation of Trauma Informed Care practices and a Zero Suicide initiative, will lead to improved client satisfaction and client outcomes agency wide.

Additionally, Quality Improvement (QI) has made efforts to collaborate with Information Technology Services to streamline QI indicators and program service reviews to continue improving efficiency in the monitoring process while incorporating data collection for Healthcare Effectiveness Data and Information Set (HEDIS), Physician Quality Reporting System (PQRS), and Medicare Access and CHIP Reauthorization Act (MACRA). Further adoption of these measures in 2017 will lead to better continuity of care among Primary and Behavioral Health Care services.

TA B L E OF C ONTENTS :

I. PROGRAMS & SERVICES

CPST & Specialized Services

Forensic & Employment

Rehabilitative Services

Residential Services

Client Advocacy

II. QUALITY IMPROVEMENT &

COMPLIANCE (QIC) COMMITTEE

2016 REPORTED INDICATORS

QIC SUB-COMMITTEES

III. WHO WE SERVE

AGENCY CASELOAD

SERVICE PROVISION & AGENCY STAFF

MENTAL HEALTH DIAGNOSIS

CLIENT DEMOGRAPHICS

IV. 2016 QUALITY

IMPROVEMENT & COMPLIANCE SUMMARY

V. IN THE COMMUNITY

Programs and Services

Page 1

Figure 2. Distribution of Specialty CPST

Team’s caseload. (December 31, 2016)

Figure 1. Distribution of the agency CPST

caseload according to Program CPST

service. (December 31, 2016)

Forensic

4%

Regional

66.7%

Specialty

25.3%

Homeless

4%

CPST Services By Program

COMMUNITY PSYCHIATRIC SUPPORTIVE TREATMENT (CPST) AND SPECIALIZED

SERVICES

Community Psychiatric Supportive Treatment (CPST) (Group and Individual Treatment) provides clients

with Individualized Service Plans including interventions

that address daily living skills, resource acquisition,

medication management, etc. Community

Rehabilitation Specialists (CRS) advocate and support

the client in their recovery by coordinating care to

achieve the most effective outcomes. Regional

treatment team caseloads are based on client’s

geographic location (see Figure 1).

Assertive Community Treatment (ACT) services are provided by the Assertive Community Treatment Team to clients with more intensive needs requiring frequent community contact to maintain stability and by the Intensive Treatment Team (ITT) to clients that are

younger adults (see Figure 2).

Substance Abuse and Mental Illness Program of ACT

(SAMI-PACT) provides wrap-around services for persons

with significant mental health and substance use

concerns; the agency implements the principles of the Integrated Dual Diagnosis Treatment (IDDT)

model. This evidence based practice employs motivational interviewing techniques and a stage of

change model to provide community-based services to

address the unique needs of persons with severe

mental illnesses and significant substance use disorders

(see Figure 2).

Geriatric and Long Term Care team strives to ensure the

highest quality of life for the older adult. The

specialized team includes Community Rehabilitation

Specialists, Geriatric Psychiatrists, Advanced Practical

Nurse and a Long-Term Care Services Administrator.

Comprehensive treatment and mental health

evaluations are provided for persons living in the

community and/or residing in extended care facilities.

The team utilizes a treatment approach based on the

strengths and needs of the individual while encouraging

family involvement in their loved one’s treatment (see Figure 2).

ITT 13%

SAMI 15%

ACT 15%

GER 36%

ENG 12%

Specialized Team's Case Load


Page 2

Engagement Service Specialists provide outreach CPST using various resources to locate and engage

clients who have not consistently participated in treatment. Once re-engaged, clients learn to minimize

treatment barriers in order to transition to traditional CPST and psychiatry services.

HOME Choice, is a program provided by the Geriatric team. A Transition Coordinator assists eligible

older adults and persons with disabilities in the transition

from a facility-based placement to a home in the community.

Supports include locating housing, coordinating benefits, and

obtaining referrals for additional supports and services to

ensure a successful transition into the community.

SSI Project provides service to individuals through trained staff members who have extensive knowledge

of the benefit application process. The goals of the program are to expedite the SSI (Supplemental

Security Income) and SSDI (Social Security Disability Insurance) application process, reduce barriers and

increase the number of disabled adults receiving SSI/SSDI benefits for the first time.

Liaison workers provide Community Psychiatric Supportive Treatment for persons receiving behavioral

health services at Portage Path Behavioral Health.

Representative Payee services assist individuals who are financially negatively impacted by symptoms of

their mental illness to manage their funds. Clients who are at risk of losing housing, utilities and other

basic needs can elect to have Community Support Services designated as their representative payee for

Social Security benefits in order to maintain independent living.

Intake workers conduct Clinical Evaluation Assessment interviews with persons referred for public

mental health treatment. Intake workers determine a person’s eligibility to receive services at either

Community Support Services, Inc. or at Portage Path Behavioral Health.

Assessment specialists provide the initial contact with the agency after referral from Adult Mental

Health Admissions. Through an in-depth assessment, specialists determine the unique strengths, needs,

abilities and preferences of each consumer in an effort to link them to appropriate agency programs and

services, and other community based resources.

FORENSIC AND EMPLOYMENT SERVICES

Forensic Assertive Community Treatment (FACT) is an ACT team designed to service individuals who have

severe and persistent mental illnesses with psychosis, extensive criminal history, and a current

misdemeanor charge, Persons eligible for FACT services are court ordered to participate in the program.

Persons with sexual offenses and/or persons designated as a registered sex offender are not eligible for

the program. Persons referred to FACT must be assessed by the FACT team to determine eligibility prior

to the court ordering the person to FACT.

Forensic and Mental Health Court (MHC) teams specialize in serving clients involved with the criminal

justice system (see Figure 3). Forensic Services are provided to clients deemed “Incompetent to Stand

Trial” and continues throughout the inpatient competency restoration process and to clients who are

found “Not Guilty by Reason of Insanity”, supporting clients during Conditional Release. The MHC team

Home Choice Services 2016

Number of Individuals Served: 37


Page 3

RHO 13%

Fact 28%

MHC 22%

Conditional

Release 33%

All Other

Forensic

3.8%

Forensic Caseload

Figure 3. Distribution of the Forensic CPST Team’s

caseload. (December 31, 2016)

provides service to individuals facing qualifying misdemeanor charges in Akron, Stow and Barberton

Courts.

Returning Home Ohio (RHO) is a permanent

supportive housing program that targets

offenders released from the Ohio Department

of Rehabilitation and Correction (ODRC) state

institutions who are identified as homeless or at

risk of homelessness upon release and fall into

one of 2 categories: 1) Severe and persistent

mental illness (SPMI) with or without a co-

occurring disorder; 2) HIV with or without a

SPMI. RHO is a collaborative program with

ODRC and Corporation for Supportive Housing

(CSH) created to prevent homelessness and

reduce recidivism in this population. RHO offers

a cost effective combination of safe, affordable

housing with a range of supportive services that

helps participants live stable, independent and healthy lives. Linkages and partnerships with local

resources and community organizations provide additional options for services and continued rental

subsidy which are essential to the program.

Referrals can be accepted for an offender up to 120 days post release. Priority is given to offenders

identified as being most likely to require supportive services in order to maintain housing and stability.

Referrals are also accepted from community providers such as homeless shelters, Projects for Assistance

in Transition from Homelessness (PATH) teams and halfway houses.

Crisis Intervention (CIT) provides immediate intervention for individuals who may be experiencing acute

mental health symptoms. CIT staff works with Sherriff’s Deputies and Police Officers from local

communities to intervene and promote mental health treatment.

Vocational and Employment services help to identify career interests as well as barriers to employment. The program(s) focuses on helping individuals secure and retain employment. Referrals are accepted from Community Support Services, Child Guidance & Family Solutions, Community Health Center, and Portage Path Behavioral Health.

Supported Employment (SE), an evidence-based practice, emphasizes consumer preferences, rapid job search and placement, integration with mental health services, benefits advocacy, and time-unlimited supports to help persons with mental illness find competitive jobs in the community. Consistently, research has demonstrated Supported Employment programs are effective in helping individuals with severe and persistent mental illnesses secure and retain employment.

Supported Employment offers guidance through all phases of the process of obtaining employment; discussion of work-readiness, benefits planning, assessment of interests, job search support, resume writing, application assistance, interviewing, and job coaching follow-along support at the job site.

Supported Employment 2016

Number of New Job Starts: 84


Page 4

GroupHomes

SafeHavens

Vet SafeHaven

MadalinePark I

MadelinePark II

N.CoastApts

2016 Census based on MaxCapacity

81% 97% 76% 97% 97% 99%

0%

20%

40%

60%

80%

100%

Residential Services and Housing Facilties

Figure 4. Residential Services; Residential/Group Home Treatment,

Supportive and Independent living facility’s census (December 31, 2016).

REHABILITATIVE SERVICES

The Medication Clinic serves clients who are prescribed injectable psychiatric medications. Clinicians are

specially trained to address pharmacological issues and guide clients through Ohio’s Central Pharmacy

and other patient assistance programs to ensure continued availability of medications.

Pharmacological Management is comprised of community and clinic nursing, psychology, inpatient and

outpatient psychiatry, and medication prescribing and monitoring.

The Margaret Clark Morgan Integrated Care Clinic offers clients physical healthcare and preventive

screenings. A clinic, laboratory and Klein’s Pharmacy comprise the Primary Care Clinic. The staff

includes a physician, nurse practitioners, registered nurses, podiatrist, medical assistants and dietician.

The Primary Care Clinic has served as a training site for nursing and other healthcare related students

and has formed many collaborative efforts with the Summit County Health Department to provide

comprehensive health services to our consumers.

Health and Wellness Services are provided under a Substance Abuse Mental Health Services

Administration (SAMHSA) grant and focuses on the integration of primary and behavioral health while

emphasizing wellness. Available on-site is yoga, smoking cessation, health and wellness education, and a

dietician. Additionally, Recovery Specialists work with clients at the YMCA three days a week and end

the week with a Walk with a Doc©.

RESIDENTIAL SERVICES


includes Group Home,

Supportive and

independent living

facilities (see Figure 4

for 2016 Census).


also assists individuals

with placement into

proprietary group

homes and offers

Housing Assistance and

Loan Assistance

Programs (HAP & LAP).

Homeless Outreach

identifies and engages homeless individuals who may benefit from mental health treatment. The

Homeless Outreach Team works with clients in referral status until they are determined eligible for

active agency services and ready to transition to traditional CPST teams or are linked to other treatment

options (see Figure 5).

Supportive Services for Veteran Families (SSVF) is a grant funded program by the U.S. Department of

Veteran Affairs. Outreach efforts, case management services and assistance in obtaining benefits are


Page 5

Figure 5. Client’s agency status for

Homeless Outreach’s caseload. (December

31, 2016)

provided by the Homeless Outreach team to Veteran families that without assistance would likely be

homeless.

In 2015, The Veteran’s Safe Haven was opened, a

Housing First program aimed to provide housing and

stabilize veterans who are Chronically Homeless with

Severe and Persistent Mental Illness. The ultimate goal

of this program is to link program participants to

permanent housing and services. All program

participants must be Veterans who were honorably

discharged and have a severe and persistent mental

illness.

Cooperative Agreement to Benefit Homeless Individuals (CABHI)-is a new program service offered by the Homeless Outreach team in 2014. The Substance Abuse and Mental Health Services Administration (SAMHSA) funds the program with a goal of enhancing and/or increasing critical services for chronically homeless individuals with substance use disorders, serious mental illness and those with co-occurring substance use and mental illnesses. Services are provided to help individuals access permanent housing, benefits, comprehensive treatment and recovery oriented supports.

Intensive Treatment Services offer an array of recovery-based therapies including group sessions that provide psycho-education and promote the development of social skills, functional abilities, coping mechanisms and other tools that enhance independence.

Art Therapy uses the art media, the creative process, and the resulting artwork to explore feelings, reconcile emotional conflicts, foster self-awareness, manage behavior and addictions, develop social

skills, improve reality orientation, reduce anxiety, and increase self-esteem. Art therapy may be offered in group and individual formats.

The overall aim of art therapists is to enable a client to effect change and growth on a personal level through the use of art materials in a safe and facilitating environment through individual and/or group sessions.

Individual and Group Counseling sessions, led by licensed clinicians, provide more in-depth and focused attention on unique issues. Counseling often is provided over a shorter term to address temporary concerns and crises.

Art Therapy Services 2016

Number of Individuals Served: 35

Referral

77%

Active

23%

Homeless Outreach Case Status


Page 6

Table 2. Grievances/Complaints by

Subject/Department (2016-2014)

Resolutions 2014 2013 2012 2011 2010

Explanation Given 103 107 112 110 Referral Made 2 1 0 2 Treatment Revised 16 29 24 20 Staff Correction/Discipline 1 3 2 3 Policy Recommendation 0 1 1 0 Withdrawn/No Response 19 10 8 9

Total 141 151 147 144 Table 2. Grievances/Complaints by Resolution

2014-2010

Table 1. Grievances/Complaints by

Source 2016-2014

Table 3. Resolutions (2016-2014)

Resolutions 2014 2013 2012 2011 2010

Explanation Given 103 107 112 110 Referral Made 2 1 0 2 Treatment Revised 16 29 24 20 Staff Correction/Discipline 1 3 2 3 Policy Recommendation 0 1 1 0 Withdrawn/No Response 19 10 8 9

Total 141 151 147 144 Table 2. Grievances/Complaints by

Resolution 2014-2010

CLIENT RIGHTS AND ADVOCACY

One hundred twenty-eight (144) complaints were filed in 2016 (see Table 1). There has been a significant

increase in the number of grievances filed by Client and Family since last year as well as an increase

grievances related to Payee ship and financial matters.

As complaints regarding payee ship and financial

issues increased during 2016 it was noted that

changes in payee/finance processes and

department staffing were suspected reasons for

the increase. The payee staffing has stabilized and

a reduction in these types of complaints are expected for 2017. Also noted, it is often a challenge to

differentiate between payee and Community Rehabilitation Specialist complaints. This is due to the

perception of the source.

SUBJECT / DEPARTMENT

2016 2015 2014

Another Client 4 1 1 CPST 49 55 30

Payee/Finance 55 28 41 Pharm Mgmt. 11 8 11

Front Desk/Support 3 0 2 Residential 6 3 9 Vocational 0 0 1

Whole Agency 3 2 1 Outside 1 0 9

Homeless Outreach 3 1 7 Counseling 0 2 1

Billing 0 4 0 Other 9 9 15

Total 144 113 128

ORIGINATION SOURCE

2016 2015 2014

Client 126 103 122 Family 13 5 0

Ohio Legal Rights 0 0 0 Other Agency 3 1 1

ADM Board 0 0 0 Primary Care Clinic 0 NR NR

CSS Staff 2 4 5 Total 144 113 128

RESOLUTIONS

2016 2015 2014

Explanation Given 117 90 101 Referral Made 1 0 0 Treatment Revised 10 17 19 Staff Correction/Discipline 3 1 1 Policy Recommendation 0 0 1 Withdrawn/No Response 14 5 6

Total 145 113 128

Quality Improvement and Compliance - 2016

Page 7

Figure 6. Quality Improvement Plan Indicators

2016-2014

Figure 5. 2014 PI Plan Indicators

Table 4. PI Plan Indicator by key area category as: Reported, Deferred or Under Development in

2016 (some indicators measure more than one key area and/or were reported more than once)

Table 4. PI Plan Indicator by key area category as: Reported, Deferred or Under Development in

2014

*Some Indicators deferred during 2016 are under consideration for removal/revision in 2017

The QUALITY IMPROVEMENT & COMPLIANCE program has been established by the Board of Directors.

The policies of the Board authorize the Chief

Executive Officer to establish a QUALITY

IMPROVEMENT & COMPLIANCE Program and an

Agency wide QUALITY IMPROVEMENT &

COMPLIANCE Committee.

The purpose of the Quality Improvement and

Compliance Program is to continually monitor and

evaluate the quality and appropriateness of clinical,

administrative and support services provided by

Community Support Services, Inc. These efforts

ensure that effective, efficient and high quality care

is delivered to individuals served by the agency.

2016 REPORTED INDICATORS

To determine and evaluate important aspects of clinical care one-hundred and thirty-nine (139)

outcome indicators were reviewed by the QUALITY IMPROVEMENT & COMPLIANCE Committee in 2016

(see Figure 6).

Analysis of these indicators affords the QUALITY IMPROVEMENT & COMPLIANCE committee the

opportunity to assess risk, identify potential problems and identify areas requiring or showing

improvement. To stay on target, the QUALITY IMPROVEMENT & COMPLIANCE Committee constantly

monitors and assesses performance against a series of indicators and goals. Indicators are based on

service delivery performance and are categorized in four key areas: Effectiveness, Efficiency,

Accessibility and Satisfaction (see Table 4).

Indicator Category

Total Number Reported to

QUALITY IMPROVEMENT & COMPLIANCE

*Number of Indicators Deferred

Number of Indicators Under Development

Efficiency 28 6 3

Effectiveness 79 3 4

Accessibility 26 0 2 Satisfaction 7 2 0 Peer Review 4 0 1

Target/Compliance 4 0 0

Total 139 11 10

0306090

120150180

PIC Reviewed Deferred UnderDevelopment

Quality Improvement Plan Indicators

2016 Indicators

2015 Indicators

2014 Indicators


Page 8

Effective 31%

Efficient 4.8%

Accessibility

14.3%

Satisfaction

4.8%

2016 Improvement by CARF Standard

Figure 7. Reported Quality Improvement by Quarter

2016

Figure 6. 2014 Reported Quality Improvement by

Quarter

Figure 8. Reported Quality Improvement by

CARF Standard 2016

Figure 7. 2014 Reported Quality

Improvement by CARF Standard

3 2 2

28

14

10

16

9

2 4 3 4 2 1

0

5

10

15

20

25

30

100% 90-99% 80-89% Below 80%

Reported Indicators by Threshold Range

Efficiency

Effectiveness

Accessibility

Satisfaction

Compliance

Figure 9. Quarterly Reported Indicators by Compliance Threshold Range 2016

Figure 8. 2014 Quarterly Reported Indicators by Compliance Threshold Range

Overall, there was more than a 60% improvement (see Figure 7) among indicators that were reported

below the targeted threshold in 2015. Again, in 2016, indicators measuring effectiveness were reported

to have the greatest improvement in 2016 (see Figure 8).

Eighty-One percent (81%) of all reported indicators were reported to be at or above the Eighty percent

(80%) compliance threshold range (see Figure 9). Indicators not at or above the desired threshold are

subject to further review by the QUALITY IMPROVEMENT & COMPLIANCE committee and a plan of

action is developed to improve outcomes and performance.



67%

68%

48% 33%

61%

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

2016 Indicator Improvement

Improvement


Page 9

Table 5. Quarterly compliance and Utilization Reviews conducted

in 2016

During the year, Utilization/Compliance Reviews were completed as scheduled. A couple of additional

utilization and target reviews were also conducted for baseline reporting (see Table 5.). These baseline

reports help in the development of meaningful indicators for Quality Improvement monitoring in 2016.

In comparison to the number of cases reviewed in the previous year, there was an eleven-percent (30%)

increase in the number reviewed

during 2016.

REVIEW PROCESS NUMBER CASE FILES REVIEWED

Quarterly Compliance 660 Target & Utilization 515

Psychiatric Inpatient 454 Program Outcomes 290

Nursing Services 100 Peer Review 88

Finance 72

Total *2,179

*Some of the cases reviewed may have been reviewed under more than one

process; the total number does not represent a unique case count.


Page 10

4 7 9

26

14 13

1

20's 30's 40's 50's 60's 70's 80+

Deaths by Age -2016

Deaths by Age

Figure 10. Client Deaths based on age at time of

death; 2016

QUALITY IMPROVEMENT & COMPLIANCE SUB-COMMITTEES

CLIENT CARE MONITORING

There were seven challenging cases presented to the Client Care Monitoring Committee (CCMC) during

2016. Seventy four deaths were reported this year. (73 in 2015) There has been one death investigation

reviewed to date, with two in process, and one only recently requested.

Case presentations decreased by nearly 75% since 2014. There were a variety of client issues reported,

including outpatient commitment, behavioral, and review of diagnoses in order to clarify primary issues.

The Clinical Alert for Problematic Behaviors was put in place twice this year for two clients based on

CCMC recommendations.

Deaths increased from 55 in 2014 to 73 in 2015 to 74

this year. The majority of the deaths were individuals in

their 50’s. Medical issues were generally the cause of

death based on the Major Unusual Incident Report.

There were six heroin overdoses or suspected

overdoses, and two suicides this past year. Very few

Medical Examiner Reports are completed and/or

received as the death is usually clearly due to

natural/physical health causes.

Level of care was discussed early in the year after

review of a Death Investigation raised concerns. There

is a critical need to have levels of care in place for all

clients so that clients receive the appropriate level of

services based on their clinical needs and risks. All staff had refresher training on how to determine the

levels. As we move forward with managed care, we need to pay even greater attention to levels of

care.

COMPLIANCE AND RISK MANAGEMENT

The Compliance and Risk Management (C&RM) Committee continues to review indicators related to

clinical documentation and utilization for compliance to established clinical best practices and agency’s

policies and procedures (see Figure 21). Chart reviews, with indicators related to treatment planning,

service provision and client progress were reviewed to determine if the staff members were adhering to

aforementioned practices. Chart reviews were conducted on all treatment teams which revealed that

progress was made and that there is room for more improvement. A specialized chart review was

conducted to examine the effectiveness of Group CPST Services which are provided in the following

programmatic areas: Partial Hospitalization, ITS, FACT, SAMI PACT, and ITT. All programs demonstrated

areas of strength and need for improvement. All programs need to continue to review the admission /

discharge criteria, work on curriculum / activities to keep clients engaged, and develop indicators to

monitor progress.


Page 11

4

33

3

2

1

0 10 20 30 40 50

Efficiency

Effectiveness

Accessibility

Satisfaction

Utilization…

Number of Indicators reported to ROC in 2016

Number ofIndicators

Figure 12. Indicators reported to Research & Outcomes

Committee during 2016 according to CARF standard

Figure 11. Indicators reported to Research & Outcomes

Committee according to CARF standard

Figure 21. Number of indicators reported to C&RM by

quarter during 2016 according to CARF Standard

0

10

20

30

40

50

Number of Indicators Reported to C&RM in 2016

2016Indicators

A termination summary review was

completed and the review indicated a 100%

of the summaries were completed and in the

record. However, teams should make sure all

outreach efforts are made & referrals are

made to the Engagement Team to utilize all

efforts to engage clients before cases are

terminated.

HIPPA Risk Assessment is being conducted to

ensure compliance with HIPPA regulations.

RESEARCH AND OUTCOMES

The Research and Outcomes committee (ROC) met four (4) times in 2016 and reviewed results on Forty-Three (43) indicators primarily related to effectiveness standards (see Figure 12). During the year, one research proposal was reviewed and approved from the County of Summit Alcohol, Drug Addiction and Mental Health Services Board in concert with Kent State university titled: “WHAT

IMPACT DO REIMBURSEMENT MODELS, POLICIES, & INTERVENTIONS, INCLUDING PPLAT’S HAVE ON SOCIETAL OUTCOMES (E. G. ARREST, INCARCERATION, AND HOSPITALIZATION) AND COSTS?” This is targeted for completion in 2017. This committee continues to review the variables regarding individuals hospitalized for psychiatric

reasons to both reduce the initial hospitalization, as well those that are subsequently re-hospitalized.

Although our number of individuals hospitalized is minimal, we continue to look for ways to improve

even further.

This committee is in process of revamping our currently measured indicators to be consistent with the

Medicare Access and CHIP Reauthorization Act (MACRA) variables now required for agencies to measure

beginning 2017.

We have begun reviewing the Fidelity measures of all our Evidence Based Best Practices as evaluated

through the Coordinating Center of Excellence currently consisting of our Assertive Community


Page 12

Treatment Teams and Supported Employment. Additionally, several of our services provided to and

reviewed by the Veteran’s Administration are analyzed.

Additionally, this committee reviews measures regarding the success of our Primary Care Clinic in

helping individuals in managing key vital signs such as blood pressure, A1C levels and weight. To assist in

this effort, services geared towards a healthier lifestyle such as smoking cessation, “Walk with a Doc”,

Dietician services, Optical services, Dental services, HIV and Podiatry are reviewed.

This is an active committee where much work is conducted between meetings geared toward continual

analysis and improvement of our services all targeted to improve outcomes for those we serve.

RECOVERY ADVISORY COUNCIL

In 2016, there were six Recovery Advisory Council (RAC) meetings. Attendees presented news articles

on mental health-related interests as well as shared their artistry with the group. RAC developed LIFE

CHAT, a publication born from the quarterly RAC newsletter to include contributions from the Health &

Wellness Department and the Art Therapy program. In an effort to reach more consumers, the

distribution of LIFE CHAT was increased with the mailing of the newsletter to all active consumers’

homes. The intent of the mass mailings has been to increase the exposure of CSS services and those of

other resources in the Akron area, all of which can help in the consumers’ recovery and draw interest to

other readers who would otherwise not be informed.

Numerous surveys were presented for review during RAC meetings, including: Agency Satisfaction;

Family/Significant Other Satisfaction; Accessibility of Service; Work Tech Employer Satisfaction; Internal

Referral Source; and External Referral Source. Also, RAC completed the consumer sections of the tool,

Creating Cultures of Traumatic Informed Care Program Fidelity Scale, to begin giving more attention to

trauma informed care at CSS.

RECOGNITION & RETENTION

The committee met nine times in 2016. 417 Catch the Spirit awards were given. A survey for eliciting

feedback on committee pursuits for 2016 was

completed. Softball returned. A summer picnic was

planned and organized. A Rubber Ducks outing and four

additional events were hosted.

INCLUSION & DIVERSITY

During 2016, an Ambassador program was implemented. Each committee member is considered an

ambassador for the agency and a representative of the core values: Honesty, Respect, and Trust.

Committee members are dedicated to meeting with new staff within the first sixty days of employment

to welcome the staff to the agency and to review the inclusive behaviors of the committee. The

Inclusion Moments initiative was created. The goal is for a staff member to recognize a fellow co-worker

when the employee models the identified inclusive behaviors. The program was initially rolled out and

Staff earned 417 Catch the Spirit Awards during 2016


Page 13

Figure 13. Number of Hours Staff Dedicated to

Training. (2013-2016)

Figure 13. Number of Hours Staff Dedicated to

Training. 2014-2010

0

1000

2000

3000

4000

Web BasedExternal

Training Hours Completed in 2016

2016

2015

2014

2013

introduced during the All Staff meeting is the last quarter. Cultural Diversity day was in September and

determined to be successful. The Inclusion Committee has officially changed its name to the Inclusion &

Diversity Committee to acknowledge the work the committee is doing to address the ongoing changing

demographics of our staff and the individual served.

STAFF TRAINING & EDUCATION

Staff Training & Education provided seven

internal trainings in 2016. There were a

total of 5.5 continuing education hours

available to all staff members of

Community Support Services, Inc. to help

staff learn more about human trafficking in

the Summit County community and to

increase our awareness of the importance

of Self-Care. Three of the internal sessions

were geared towards the Assertive

Community Treatment teams to reinforce

the ACT fidelity model. The sessions were

facilitated by the Coordinating Center of Excellence at Case Western Reserve University.

The agency continues to provide training and ongoing supervision in HYCBt-p for persons with

psychosis. The Intensive Treatment Team participated in a partnership with the Traumatic Stress Center

at Summa Health for screening and identification of individuals that have experienced trauma any time

through the lifespan.

Clinical and non-clinical staff completed 1,286 hours external training hours.

3,362.25 hours of web-based learning were completed in 2016 as part of the agency’s annually required

trainings and CEU-based trainings for licensed staff.


Page 14

HEALTH & SAFETY

There were one-

hundred and forty-

seven (147) Safety

Inspections generating

four hundred and

eighty-six (486) Safety

Work Orders. All

deficiencies were

corrected. The Safety

Director reviewed Two-

Hundred and Seventy-

Five (275) Major

Unusual Incident (MUI)

reports during 2016

(see Table 6).

75% of Death Related

MUI Reports

documented a known

cause of death, a 15%

increase from 2015.

The majority of death

cases were reportedly

in their 50’s.

In non-death related

MUI’s there was an

increase in reported

medication errors.

These incidents were

noted to have occurred

at the pharmacy level.

The increase in Verbal

& Physical Aggression

category is likely due to

the classification

process of MUI’s.

Efforts to consistently

categorize these types

of occurrences will be

made in 2017. The

continued decrease in Code Green incidents is noted to be largely due to the presence of The Akron

Police Department in the Med Clinic and Cross Street; client lobby area. Continuous efforts are made

2016 2015 2014

WORK ORDERS & INSPECTIONS

Work Orders 176 Not Reported Not Reported

Safety Work Orders 486 Not Reported Not Reported

Completed Inspections 147 Not Reported Not Reported

Completed Drills 211 Not Reported Not Reported

MAJOR UNUSUAL INCIDENT (MUI) REPORTS

Death Related:

Unknown Cause 18 26 27

Illness/Natural Cause 46 39 30

Suicide 2 5 0

Suspected/Confirmed Heroin OD 6 2 0

Homicide 1 1 0

Non-Death Related:

Other 58 52 37

Verbal Aggression 16 32 22

Illness 28 27 26

Fall 25 23 29

Physical Aggression 18 20 24

Property Damage/Loss 16 14 20

Injury 10 8 10

AWOL 7 5 3

Non-Participation in Drill 9 5 7

Suicide Threat 6 5 6

Medication Error 16 4 12

Auto Accident (Staff) 10 4 16

Verbal &Physical Aggression 30 2 0

Alleged Criminal Activity 4 1 5

Infection Control 0 1 4

Seizure 5 1 6

Suicide Attempt 1 1 6

Alleged Abuse/Neglect 2 1 4

Weapon 2 1 4

Alarm 2 0 5

Code Red (Fire) 2 1 1

Code Blue (Medical) 1 3 10

Code Green (Behavior) 1 1 6

Code Black (Tornado) 0 0 0

Total of all MUI Reports 269 280 273


Page 15

agency-wide to reinforce the prompt completion of incident reports for all required situations as well as

for other concerns that may warrant further review.

In 2016, health and safety related indicators were continued to be reported quarterly. This monitoring has

assisted Quality Improvement in recognizing the issues facing staff and clients and has improved overall

awareness of safety matters across the agency.

CREDENTIALING

FQHC related credentialing and privileging was completed for approximately 80 providers. Processes

and policies were updated for FQHC related compliance.


Page 16

COMMITTEE MEMBERS

Allyson Haley

Barbara Krannich

Becki Thompson

Bruce Winer

Christian Ritter

Cindy Johnson Crystal Dunivant

Danya Bailey

Denise Cunningham

Denise Ronk

Dorothea Hilson Doug Wagner

Dr. M. Elahi

Duane Perry

Ed Casey

Eileen Schwartz

Fran Thomas Frank Sepetauc

James Karpawich

Jan Jones

Janet Catalano

Janet Swartzel

Jerry Shadley

Joanna Hewett Jon Garey

Julie Morehead

Kay Bowman Keith Stahl

Kim Hartman

Kim Meals Kristi DeArmitt

Lee Snyder

Linda Omobien

Lora Walker

Michele Nepsa

Michell Montgomery

Mike Greenfelder Nancy Mackey

Narkeetah Brazil

Natasha Westfall

Patricia Henderson

Patricia Rohlender Penny Moore

Shaunta Scruggs

Stephanie Sanders

Stephen Maddox

Steve Rastetter

Susan Ritz

Tasha Young Terry Dalton

Tim Edgar

Tom Baker

Tracy Prohaska

The Quality Improvement Program would like to

thank each person who served on a standing

committee during 2016.

Your participation is GREATLY appreciated!

Who We Serve

Page 17

Figure 14. Agency Caseload (2016-2013).

Figure 10. Agency caseload 2014-2010

0

1,000

2,000

3,000

4,000

2016 2015 2014 2013

2016 Agency Caseload

Number of Clients

Figure 15. Agency Staff according to Program Role 2016

.2015

21.6%

17.9% 19.6%

9.8%

2.7%

7.8%

4.4% 3.4% 2.4%

7.1%

3.4%

Agency Staff Roles

AGENCY CASELOAD

Community Support Services, Inc.

provided service to 5,857 unique

individuals during 2016.

As of December 31, 2016, there were

3,456 clients on the agency’s caseload

(see Figure 14).

The agency’s caseload continues on

the up rise and is largely due to the

continued addition of new and

expanded agency program services

and our successful efforts to provide

comprehensive health care services,

and quality coordination of care.

SERVICE PROVISION & AGENCY STAFF

During 2016, the agency employed approximately 296 employees. 75% are Direct Service providers

while the remaining, work in administrative and support staff roles (see Figure 15).

Who We Serve

Page 18

Figure 16. Agency Services (based on hours) provided in 2016-2015

Figure 15. Agency Services (based on hours) provided in 2014

Figure 17. Number of Patient Encounters in 2016

Figure 15. Agency Services (based on hours) provided in

2014

TotalUnique New

PCCPatients

Total newPatients-Podiatry

PrimaryCare andPodiatry

Office Visits

2016 241 38 3496

0

500

1000

1500

2000

2500

3000

3500

4000

Ax

is T

itle

Primary Care and Podiatry

Service provision (based on the total number of documented hours) in 2016 demonstrates that the bulk

of agency services provided are group and individual CPST services, Employment/Vocational, and Social

Recreation (see Figure 16).Many of the comprehensive services the agency provides are supplemental

to traditional and specialty CPST services and are based on crisis events and individual client needs.

The Primary Care Clinic has provided wrap-around healthcare services to 241 new patients, while, 38

new patients received Podiatry services in 2016. Combined, there were 3,496 documented office visits

(see Figure 17), for 1,135 unique patients.

0%

25%

50%

75%

100% Agency Service Provision

2016

2015

*does not include Primary Care Services

Who We Serve

Page 19

Table 7. Client's Primary Mental Health Diagnosis based on ICD10 Code, 2016

Table 7. Client's Primary Mental Health Diagnosis. 2014

Figure 18. Primary Diagnosis by Schizophrenia Related Disorder;

2016

Figure 11. Axis I primary diagnosis by Schizophrenic Related

Disorder 2014

Paranoid 47.4%

Schizoaffective 41.7%

Unspecified 10.5%

Type of Schizophrenia Related Disorder

DIAGNOSIS

MENTAL HEALTH

According to a National Survey on Drug Use and Health (NSDUH) survey conducted in 2014 by the Substance Abuse and Mental Health Services Administration (SAMHSA), an estimated 43.6 million (18.1%) Americans ages 18 and older experience some form of mental illness. Serious mental illness among people ages 18 and older is defined at the federal level as; “at any time during the past year, a diagnosable mental, behavior, or emotional disorder that causes serious functional impairment that substantially interferes with or limits one or more major life activities”. SAHMSA also reports that “in 2014, there were an estimated 9.8 million adults (4.1%) ages 18 and up with a serious mental illness in the past year”.

According to SAHMSA 1% of the US

population suffers from Schizophrenia. The National Institute of Mental Health indicates that diagnostic records for active cases show that individuals with a diagnosed Schizophrenia related brain disorder account for 38.2% of Mental Health Diagnosis (see Table 7).

These individuals are most often diagnosed with Schizophrenia, Paranoid Type or Schizoaffective Disorder (see Figure 18).

Mental Health Related Diagnosis Number of DX Percentage of DX

Schizophrenia 1329 44.3%

Mood Disorders 551 17.3%

Anxiety Related 629 19.7%

Behavioral & Personality Disorders 490 15.4%

Total 2,999

Who We Serve

Page 20

Male, 56%

Female44%

Client's Gender

323 413

517

815

538

143

0

200

400

600

800

1000

18-29 30--39 40-49 50-59 60-69 70+

Number of Clients in Age Range

3%

62%

8%

4%

20%

3%

Widowed

Single

Married

Separated

Divorced

No Data

Client's Marital Status

29.0%

47.0%

1.0%

1.0%

Who We Serve

Page 21

INCOME AND BENEFITS

Monthly Household Income

2016

Below $500.00 4.7% $500.00 - $999.00 70.0%

$1000.00 – 1499.00 17.6% $1500.00 - $1999.00 4.6%

$2000.00 + 3.1%

Client’s Individual Income Source

2016

Wage/Salary 4.0%

SSI 42.2% SSD 49.7%

Retirement 1.7% Welfare/TANF 0.7%

*Other Source Reported 1.6%

Table 10. Client’s Income Source 2016 Table 9. Client’s Monthly Household

Income 2016

*Other sources include: family member, savings, child

support, alimony, disability insurance/ workers comp and

unemployment compensation.

Who We Serve

Page 22

GEOGRAPHIC LOCATION

Clients reside throughout Summit County, but are most concentrated in Akron and surrounding

communities (see figure 23.).

Cuyahoga Falls

8%

Akron 52%

West Akron 17%

Barberton &

Surrounding

Areas 11%

Stow/Tallmadge

4%

Northern Summit County 5%

Southern Summit County 2%

Figure 23. Map of Summit County, Client’s area of residence

In The Community

Page 23

In 2016, Community Support Services served as an internship/residency site

for seventeen students from social work, counseling, psychology, medical

assistants, and other related programs. These students completed 4801

intern hours. The dollar value of the work completed by students

was $110,759.07. Equally important, these students learned about

Community Support Services and severe mental illness. As they begin their

careers, they will be better positioned to assist others who may be

struggling as well as connect individuals to appropriate services.

Agency staff and clients benefited greatly from the efforts of one dedicated volunteer who performed 302 hours of service. The work of the volunteers had a monetary value of $6,967.14 These individuals provided support services to assist the agency in meeting its goals. Community Support Services, in addition to its volunteers, is grateful for the ongoing dedication of the Board of Directors who collectively donated 513 hours to the agency in 2016.

Community Support Services, Inc. continued to host Lunch with Leaders in 2016 with 27 attendees.

These sessions introduce community leaders to the agency while challenging the stigma associated with

mental illness. The agency also invited adult care providers and apartment managers to an appreciation

luncheon to provide an opportunity to share information about agency services while recognizing them

for being a valuable part of the team. Additionally, the Supported Employment program shared the

power of employment for our clients at a luncheon for potential employers.

The organization maintained its presence in the community in 2016 with fifteen community

presentations reaching 320 people. Additionally, staff and board members represented the agency at

twenty community events such as the Annual NAMIWalk, the WAKR Senior Luncheon series, and the

ADM Recovery Challenge. The agency proudly displayed consumer artwork during the Art of Recovery

event held at Greystone Hall.

Community Support Services continued efforts to increase its presence on social media with more than

300 new followers on Facebook. Additionally, the agency actively engaged with Twitter. The agency

also updated its website in an effort to me more user friendly and provider website visitors with an

opportunity to connect directly with the agency for guidance. In 2016, the agency had more than

28,000 visitors to its website.

Documents

Quality Improvement and Compliance 2016 Annual Report...Intake workers conduct Clinical Evaluation Assessment interviews with persons referred for public mental health treatment. Intake