MONROE COMMUNITY MENTAL HEALTH AUTHORITY REGULAR BOARD MEETING February 28, :30 p.m. Draft Agenda

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1 MONROE COMMUNITY MENTAL HEALTH AUTHORITY REGULAR BOARD MEETING February 28, :30 p.m. Draft Agenda BOARD VALUES: 1.1 Monroe Community Mental Health Authority is the provider of choice for Monroe County by offering the highest quality of treatment with measured results, while maintaining flexibility of treatment at competitive rates. 1.2 Units of service costs are competitive with the private insurance rates. 1.3 Provide treatment with evidence of measurable results that produce positive outcomes. 1.4 Relationships have been developed with community partners that makes us their provider of choice. MISSION STATEMENT: The mission of the Monroe Community Mental Health Authority is to provide quality mental health care in partnership with consumers and our community to enrich lives and promote wellness. Guide I. Call to Order 1 min II. Roll Call 2 min III. Pledge of Allegiance 2 min IV. Motion to Adopt the Agenda as Presented 2 min V. Motion to Approve the Minutes of the January 24, 2018 Regular Meeting 2 min and Waive the Reading Thereof VI. Feedback Summary (handout) 5 min VII. Citizen Comments 3 min/person The Board will listen respectfully to any comments you would like to make, but will not respond directly tonight. You can expect a follow up contact from the Executive Director or her representative within 24 hours if your comment is about a specific problem or complaint. Comments shall be limited to 3 minutes. VIII. Purpose of the Monroe Community Mental Health Authority 2 min (Vision: That people are empowered and supported to reach their maximum potential) Rules of Conduct a. Speak only after being acknowledged by the Chair and only to the Chair. b. Keep deliberation focused on the issue and don t make it personal. c. Divulge all pertinent information on an issue before action is taken. d. Seek to understand before becoming understood. e. Seek to do no harm. Board Concerns a. Executive Director and Organization Evaluation b. Organizational Sustainability and Budget Funding c. Sustain Delivery of High Quality Service a. The Next Board Workshop is scheduled for Saturday, May 19, 2018 from 9am-2pm. IX. Presentations Recognitions, and Celebrations 15 min a. FY CMHPSM Annual Submission Lisa Jennings Page 1 of 49 LJ/dp

2 X. Board Committee Reports 2 min a. Motion to Place on File All Written Committee Reports i. Executive ii. Finance iii. Membership Screening Committee iv. Performance Evaluation v. Program & Planning XI. Items for Board Action 10 min a. Motion to Approve the Consent Agenda Less Item i. Service Contracts as Presented b. Motion to Approve the Proposed Revised FY2018 Budget c. Motion to Approve Dave Stephens, Gloria Rafko, and Jim Neumann to Attend the 2018 NATCON Conference Beginning April 22, 2018 through April 25, 2018 in Washington, D.C. d. Motion to Accept the Performance Evaluation Committee s Recommendation of Lisa Jennings to Receive a Rating of Satisfactory for the Executive Director Performance Evaluation Summary and Receive a Step Increase Effective February 28, 2018 e. Motion to Recommend David O Dell for Re-Appointment to the Pre-Paid Inpatient Health Plan (PIHP) Substance Use Disorder (SUD) Oversight Policy Board for Term October 1, 2017 through September 30, 2020 f. Motion to Endorse the Resolution Concerning the Issue of the State of Michigan s Medicaid Enrollment Misclassification g. Motion to Request the Monroe County Board of Commissioners to Consider Endorsement of the Resolution Concerning the Issue of the State of Michigan s Medicaid Enrollment Misclassification XII. Relationship with the Region, County, and Others 2 min a. Regional Reports i. Regional PIHP Board Meeting Minutes February/January b. MACMHB Committee Reports i. Executive ii. Legislative & Policy XIII. Items from the Executive Director 10 min a. Financial Report b. Executive Director s Report (handout) XIV. New Business 5 min XV. Citizen Comments 3 min/person XVI. Announcements by Board Members 9 min XVII. Adjournment 1 min The next scheduled Regular Meeting is 5:30pm, Wednesday, March 28, 2018 in the Monroe Community Mental Health Authority Aspen Room. 2/22/18, 3:24 p.m. Page 2 of 49 LJ/dp

3 BOARD OF DIRECTORS REGULAR MEETING MINUTES January 24, 2018 Present: Excused: Charles Londo, Chairperson; Sandy Libstorff, Vice Chairperson; Bill Henning, Secretary; David Stephens; Jim Neumann; Gloria Rafko; Rusty Shorter; and Susan Fortney Pam Ray Unexcused: Staff: Guests: Lisa Jennings 4 guests were present I. CALL TO ORDER The Board Chairperson, Charles Londo, called the meeting to order at 5:30 p.m. II. ROLL CALL The Roll Call confirmed a quorum existed. III. PLEDGE OF ALLEGIANCE The Pledge of Allegiance was led by Rusty Shorter. IV. CONSIDERATION TO ADOPT THE DRAFT AGENDA AS PRESENTED Gloria Rafko moved to adopt the draft agenda as presented. Susan Fortney supported. Motion carried unanimously. V. CONSIDERATION TO APPROVE MINUTES Dave Stephens moved to approve the minutes of the December 20, 2017 Regular Meeting and waive the reading thereof. Bill Henning supported. Motion carried unanimously. VI. FEEDBACK SUMMARY Charles Londo reviewed the December Board Feedback Summary. VII. CITIZEN COMMENTS There were no citizen comments. VIII. PURPPOSE OF THE MONROE COMMUNITY MENTAL HEALTH AUTHORITY a. Next scheduled Board Workshop is for Saturday, February 17, 2018 from 9:00am to 12:00pm. Page 3 of 49

4 Monroe Community Mental Health Authority Board Meeting Minutes January 24, 2017 IX. PRESENTATIONS, RECOGNITIONS, AND CELEBRATIONS a. Office of Recipient Rights Annual Summary Report Lisa Jennings introduced Shelley Koyl and Coy Hernandez, Recipient Rights Officers, who presented the annual Recipient Rights Summary Report that was submitted to the State for FY X. BOARD COMMITTEE REPORTS a. Consideration to Place on File Written Committee Reports Rusty Shorter moved to place on file all written committee reports. Dave Stephens supported. Motion carried unanimously. Written Minutes placed on file were: Executive January 9, 2018, Finance & Facilities January 17, 2018, Performance Evaluation January 17, 2018, Program & Planning January 3, 2018, and Recipient Rights Advisory Council December 20, XI. ITEMS FOR BOARD ACTION a. Motion to Approve the Consent Agenda Less Item Rusty Shorter moved to approve the Consent Agenda. Gloria Rafko supported. Roll call: In favor: Henning, Stephens, Neumann, Libstorff, Londo, Rafko, Shorter, and Fortney; opposed: none, motion carried unanimously. Items approved: Service Contracts as presented b. Motion to Approve the Purchase of Four (4) 2017 Chevrolet Malibu LS s Totaling $84, per the Award from the Bid Process Jim Neumann moved to approve the purchase of four (4) Chevrolet Malibu LS s totaling $84, per the award from the bid process. Bill Henning supported. Roll call: In favor: Henning, Stephens, Neumann, Libstorff, Londo, Rafko, Shorter, and Fortney; opposed: none, motion carried unanimously. c. Motion to Approve up to Three (3) Board Members to Attend the MACMHB Winter Conference Beginning Monday, February 5, 2018 through Wednesday, February 7, 2018 in Kalamazoo, Michigan Bill Henning moved to approve up to three (3) Board Member to attend the MACMHB Winter Conference beginning Monday, February 5, 2018 through Wednesday, February 7, 2018 in Kalamazoo, Michigan. Jim Neumann supported. Discussion followed. Bill Henning amended the motion to approve one (1) Board Member to attend the MACMHB Winter Conference beginning Monday, February 5, 2018 through Wednesday, February 7, 2018 in Kalamazoo, Michigan. Jim Neumann supported. Roll call: In favor: Henning, Stephens, Neumann, Libstorff, Londo, Rafko, Shorter, and Fortney; opposed: none, motion carried unanimously. d. Motion to Accept the Recommendations from the Recipient Rights Advisory Council for FY Susan Fortney moved to accept the recommendations from the Recipient Rights Advisory Council for FY Gloria Rafko supported. Motion carried unanimously. Page 4 of 49

5 Monroe Community Mental Health Authority Board Meeting Minutes January 24, 2017 XII. RELATIONSHIP WITH THE REGION, COUNTY, AND OTHERS a. Regional Reports i. Regional PIHP Board Meeting meeting minutes available. ii. MACMHB Committee Reports 1. Jim Neumann commented on the change to the Mental Health Code to allow the level of responsibility for physician assistants to do things. They are talking about taking away the requirement for a Bachelor s Degree in Social Work for Case Managers specifically in social services but could have degrees in other areas. They are trying to get a bill passed as it is difficult to fill positions. There is still some discussion regarding the Direct Care Wage Increase as some Providers do not want to participate. XIII. ITEMS FROM THE EXECUTIVE DIRECTOR a. Financial Report Jeff Koras was available for questions regarding the Financial Report. b. Executive Director s Report Lisa Jennings commented on: the new Electronic Health Record; SUD Services; Section 298; HCBS Transition; CARES Task Force; and DABS Migration. XIV. NEW BUSINESS XV. CITIZEN COMMENTS There were no citizen comments. XVI. ANNOUNCEMENTS BY BOARD MEMBERS Gloria Rafko wished everyone a Happy Valentine s Day. Susan Fortney commented on looking forward to the Board Workshop. Charles Londo commented that discussion on using the board stipend electronically, paper or paperless Board Packets, and standard for attending conferences will take place at the Board Workshop. The Board Membership Screening Committee will interview five candidates in the next few weeks and make a recommendation to the Monroe County Board of Commissioners in March. The Performance Evaluation Committee developed an Executive Director Performance Evaluation Summary and will be sent to the full Board for review. A motion will be added to the February Board Agenda. XVII. ADJOURNMENT Jim Neumann moved to adjourn at 6:50pm. Gloria Rafko supported. Motion carried unanimously. Submitted by, Bill Henning Secretary LJ/dp 1/31/18 Page 5 of 49

6 ESTIMATED FTE EQUIVALENTS CMHSP: Monroe CMHA Contact name/ Jeff TABLE 1 - Total Workforce in Specialized Residential Settings FTEs and Est DCW Cost Actual Filled as of 9/30/17 Approved Vacancies Total Actual and Approved Workforce in Specialized Residential Settings 1 Specialized Residential Settings 2 a. CMHSP Employees 0 3 b. Contract Agency Staff Total TABLE 2 - Total Workforce in Other Settings Total Workforce FTEs Actual Filled as of Approved 9/30/17 Vacancies Total Actual and Approved 5 CMHSP Employees 0 6 Contract Agency Staff Total Expected FY 18 Workforce Changes Provide a brief description (1-2 paragraphs) of expected FY 18 workforce changes Monroe Community Mental Health Authority continues to authorize necessary contracted services for our Consumers. At this point, unless there is a surge in consumer population, we do not expect a sizable shift in services as we estimate services to be essentially the same as FY 17. Also, please provide a brief description of the source of the FTE information (e.g. centrally maintained, surveyed providers, etc.) The source of the FTE count was a combination of what was budgeted at the beginning of the fiscal year and provider surveys. Page 6 of 49

7 Period: October 1, 2016 to September 30, 2017 CMHSP: Monroe CMHA Contact person and e mail: Geralyn Harris/gharris@monroecmha.org Report on the Requests for Services and Disposition of Requests Unknown and All Total CMHSP Point of Entry-Screening DD All Ages Adults with MI Children with SED Others 1 Total # of people who telephoned or walked in Is Info on row 1 an unduplicated count? (yes/no) no no no no no 3 # referred out due to non MH needs (of row 1) Total # who requested services the CMHSP 4 provides (of row1) Of the # in Row 4 - How many people did not 5 meet eligibility through phone or other screen Of the # in Row 4 - How many people were 6 scheduled for assessment other--describe CMHSP ASSESSMENT Of the # in Row 6 - How many did not receive eligibility determination (dropped out, no show, etc.) Of the # in Row 6 - how many were not served because they were MA FFS enrolled and referred to other MA FFS providers (not health plan) Of the # in Row 6 - how many were not served because they were MA HP enrolled and referred out to MA health plan Of the # in Row 6 - how many otherwise did not meet cmhsp non-entitlement eligibility criteria Of the # in row 11 - How many were referred 11a out to other mental health providers Of the # in row 11 - How many were not 11b referred out to other mental health providers a 15b Of the # in Row 6 - How many people met the cmhsp eligibility criteria Of the # in Row 12 - How many met emergency/urgent conditions criteria Of the # in Row 12 - How many met immediate admission criteria Of the # in Row 12 - How many were put on a waiting list Of the # in row 15 - How many received some cmhsp services, but wait listed for other services Of the # in row 15 - How many were wait listed for all cmhsp services Other - explain Page 7 of 49

8 MONROE COMMUNITY MENTAL HEALTH AUTHORITY Narrative: Requests for Services and Disposition of Requests FY 2017 A. DATA COLLECTION Monroe Community Mental Health Authority (MCMHA) Access center collects data through our Electronic Medical Record, E.II. Reports are generated from data fields in the clinical record and information is provided by staff from the consumer or other sources. As well, each Access clinician maintains an Access Request list that details the date of request, name of person, age and gender, severity, provisional diagnosis, Intensity of Services, funding source, population group, and services needed or requested. This back up list is maintained to track individuals that are referred out of the CMH system or who are not requesting a service CMH provides, such as food stamps, housing, Medicaid enrollment, etc. B. ELIGIBILITY DETERMINATION PROCESS MCMHA determines eligibility based on criteria set forth in the Michigan Mental Health Code, the MDHHS PIHP and CMHSP contracts, and the MI Medicaid Provider Manual. Service Eligibility is based on medical necessity criteria and the authorization of a specialty service. The process by which MCMHA determines eligibility for children with severe emotional disturbance (SED) is through the CAFAS. Individuals with Developmentally Disability are determined by the Mental Health Code definition and Adults with mental illness are determined eligible by the following: Diagnosis impact on functional impairment Duration of Illness Severity of Illness And/or whether other community services are available to meet the needs of the individual. A combination of face to face and phone screening is used for the initial screening for services; however denial of services is only completed through a face to face assessment. As well, a second opinion is always offered if there is a denial of service. A biopsychosocial is completed on the same day of request for service unless requested differently by the recipient i.e. Open Access. PECFAS/CAFAS screening tools for children and the DLA-20 for Adults are utilized to assist in assessing functional impairment. These standardized and rater reliable tools are utilized for level of functioning. There are currently no standardized and rater reliable tools utilized to determine diagnosistic criteria. C. TRENDS IN SERVICE REQUESTS FY 2017 continues to trend higher than FY 2015, similar to FY2016. MCMHA theorized, in FY 2016, one of the differences in the overall number increase since FY 2015 was due to better tracking of all calls and walk- ins. This process changed during FY 2015 and was fully implemented in FY Since the trend continued in FY 2017, we feel the calls and walk-in tracking is a fairly solid determinate. Several trends were noted from data collected during FY 2015, FY 2016, and FY2017. MCMHA has seen an increase in the number of individuals that met emergency/urgent conditions criteria, with an IDD/CI or SED diagnosis, the past three years, but significantly in FY MCMHA has been working towards Page 8 of 49

9 enhanced training of clinical services regarding crisis, suicide prevention, and the creation of a team to review cases with critical needs resulting in high rates of emergency room visits. Another continued trend remains the significant increase in individuals seeking testing and assessment for Autism. MCMHA had had an increase in BHT services, unique individual counts, from 5 individuals in 2016 to 56 in MCMHA created a position to absorb the increase in assessments and services, however, has struggled to find qualified candidates as many of those individuals are currently working at For-profit agencies. Future forward, any change to Medicaid expansion or another decrease in General Funds will result in increased strain on the community health system, as CMH will be unable to serve those individuals and the community providers are not equipped with staffing to provide intense, community based services. Page 9 of 49

10 Waiting List Information CMHSP: Monroe CMHA Contact name and phone Geralyn Harris/ As of (Date) 9/30/2017 Time period covered for Added/Removed 10/1/16-9/30/17 Targeted CSM/Supports Coordination MI Adult DD SED Total Specify HCPCS and CPT Codes included in this category Number on waiting list as of date above Added during the time period covered Removed during the time period covered- service provided Removed during time period covered - all other reasons Number left at the end of the time period covered Intensive Interventions/Intensive Community Services Specify HCPCS and CPT Codes included in this category Number on waiting list as of date above Added during the time period covered Removed during the time period covered- service provided Removed during time period covered - all other reasons Number left at the end of the time period covered Clinic Services Specify HCPCS and CPT Codes included in this category Number on waiting list as of date above Added during the time period covered Removed during the time period covered- service provided Removed during time period covered - all other reasons Number left at the end of the time period covered Supports for Residential Living Specify HCPCS and CPT Codes included in this category Number on waiting list as of date above Added during the time period covered Removed during the time period covered- service provided Removed during time period covered - all other reasons Number left at the end of the time period covered Supports for Community Living Specify HCPCS and CPT Codes included in this category Number on waiting list as of date above Added during the time period covered Removed during the time period covered- service provided Removed during time period covered - all other reasons Number left at the end of the time period covered Narrative: How do you assure that service needs are met at an individual level as well as from a program capacity level? Page 10 of 49

11 The data shows the numbers for wait list services for Fiscal year 2017 (October 1, 2016 through September 30th, 2017.) The wait list for FY 2017 had fewer individuals added during the year, but also less individuals removed during the time period. MCMHA is currently only wait listing services for individuals who are not open consumers, coming through the ACCESS department seeking services. Determination of wait listed services is based on the risk for the individuals if they did not receive the service and the availability for services in the community. MCMHA provided brief crisis treatment, mostly in the Access department to stabilize individuals and then provide transitions into community counseling. During this time period, individuals on the wait list received services in the community, but requested to remain on the wait list as they felt the MCMHA services had better treatment packages. MCMHA has a policy for enacting the wait list, the determination criteria and process for placing an individual's services or service requests on the wait list, as well as the frequency of review of the wait listed services. MCMHA assures the service needs are met at an individual level by determining the availability of the service in the community, connecting the individual to those services, and follow-up to assure the individual can participate in those community based services, prior to closing or ending the MCMHA service. The agency also enacts the grievance and appeals process to review any cases where individuals feel MCMHA made an error in its decision. Program capacity is reviewed every three months, with the individuals on the wait list contacted to determine if they wish to remain on the wait list. Program capacity is also determined based on budget review and determination to continue wait listing services for individuals not currently receiving services. Page 11 of 49

12 Attachment E FY 16 Priority Needs and Planned Actions FY Update CMHSP:_Monroe Community Mental Health Authority Based on feedback received from stakeholder groups and data collected from this process, the CMHSP must identify at least 5 priority needs. Of these, the CMHSP must identify the areas where it intends to address and what action is being planned in that area. The table below provides a format for identifying the top issues. Priority Issue: Please give a brief explanation of the issue, in order of priority, with 1 being highest. Reasons for Priority: Identify what makes this a priority issue. For example: the issue was identified by multiple stakeholder groups; or the size of the issue; or consistency with other community efforts, etc. CMHSP Plan: Give a brief overview of what steps the CMHSP intends to take to address the identified issue. Please include basic time frames and milestones. Priority Issue Reasons For Priority CMHSP Plan Progress Report 1. Increase community awareness of MCMHA by expanding outreach efforts and emphasizing referral systems and referral process to ensure those eligible are receiving CMH services. Stake holder feedback indicated confusion about referral process, eligibility criteria, and walk-in Access services. 1. Develop public relations plan to focus on at least 3 new community partners. 2. Provide Mental Health First Aid (MHFA) training to at least 10 new community partners. 1. Developed new relationships with over 3 partners, including Monroe Co Mental Health court, hospital ER, Zero Suicide Program, County Suicide Prevention Committee, Community Public Health Preparedness membership, Community MH Round Table. 2. Six completed to date. 3. Use relevant and appropriate marketing strategies to inform the community of referral process and other resources: 3. Facebook page entering completion stage; post information with community network group, have Page 12 of 49

13 Attachment E Facebook page Postings in community partners Community fairs/events participated in county fair, community event Making Connections, business fairs. 4. Participate in at least 4 community fairs/events per year. 4. Have participated in > 4 per year. 5. Actively partner and participate with at least 2 community projects/ committees that address community needs. (i.e. Suicide Committee) 5. Zero Suicide Program, County Suicide Prevention Committee, VCR Workgroup, Community MH Round Table, HSCN. 6. Enroll in Zero Suicide program. 6. Enrollment completed. 7. MCMHA participation in community collaboration HCSN, SUD Coalition, Making Connections. 7. Participation is ongoing. 2. Expand integrated health efforts specific to comorbidity and SUD needs of community. Statistical significance between crisis contacts/inpatient psychiatric hospitalizations and SUD related issues. 8. Provide educational forums open to the community at least quarterly on various topics 1. Using the Integrated health (IH) block grant, partner with the local SUD/SA Coalition to provide training at least twice per year. 2. Using the IH block grant, incorporate SUD issues in psychoeducational groups for those served though the grant. 8. Presented at four community education forums to date MCMHA developed these partnerships, however resource issues and limitations with how the IH block grant funding could be used resulted in a need to discontinue the IH block grant. MCMHA will be pursuing collaboration with SUD providers on any treatment gaps in the community and how our agency can partner with the community to address those needs. Page 13 of 49

14 Attachment E 3. Pursue SBIRT training from CMHPSM for Access and afterhours staff to respond to SUD needs. 3. Have requested SBIRT training from CMHPSM; date TBD by the PIHP. 4. Meet with SUD providers at least quarterly to explore community needs/ways MCMHA can partner/address SUD needs. 4. SUD provider meetings occurring as planned. 5. Maintain ER collaboration with ProMedica for ER onsite CMH Afterhours staffing to include education and review of SUD needs of crisis population. 5. Continuing to work with ProMedica ER, and continue to have 2 FTE positions that are on site at ProMedica ER in Monroe. 6. Develop documentation and UM review requirements in assessments and recommendations of SUD needs to those entering/involved in CMH system. 6. Created documentation program in new Electronic Health Record that will be implemented 4/1/ Develop approaches to serve the increasing needs of children/ families in the community. Data showing significant increase in children living in poverty and mental health risks this poses for children and families. 7. Provide at least 2 SUD training modules to CMH staff on assessing and addressing SUD needs. 1. Participate in University of Michigan TRAILS program. 2. Partner with at least 2 community schools in the TRAILS program to expand mental health supports in the school community. 7. UM Dept. will attend ASAM training by 10/1/18. Completed one all staff Motivational Interviewing training TRAILS training and Phase I for 2017 has been completed. Phase II implementation to begin 2018 date to be decided by TRAILS program. 3. Develop internal waiver case management team to include those 3. Internal waiver CSM team developed and running. Page 14 of 49

15 Attachment E receiving children receiving ABA/BHT services to better address their needs. 4. Advocate for alternatives to incarceration for people with mental health issues and expand interventions to identify and treat those in the criminal justice system. Jail/court data, increase in arrests of people with a mental health need. County implementation of mental health court system. 4. Provide CMH marketing referral materials to all local schools. 1. Provide jail diversion services and meet jail grant goals. 2. Provide screening and support/ therapy services to adults with mental health needs in Monroe County Jail. 3. Clarify statutory/contractual Jail Diversion relationship between law enforcement agencies and CMHs. 4. Marketing materials completed, distribution ongoing. 1. Providing jail diversion and have been meeting jail grant goals. 2. Increased case management staff for jail diversion. 3. Clarification was completed; have close collaborative partnership with Major at jail. 4. Participate and partner with Monroe County Mental Health Court. 4. Participating in MH Court; have posted for a full time CMH position as MH case manager/liaison. 5. Promoting consumer choice and least restrictive settings. Preparation for HCBS Waiver changes March Stakeholder survey on having more treatment options. 5. Collect baseline performance indicators for diversion and mental health court participants in FY 17; implement any recommended changes in FY Provide community information and staff training on the HCBS waiver and its implications for Monroe consumers. 5. Data and analysis completed for FY Provided training of both staff and contractual providers. Page 15 of 49

16 Attachment E 2. Develop consumer/family education program on consumer choice and least restrictive settings, to include: HCBS changes Provider requirements for choice and integration of service settings Self-determination options available to consumers/ families 3. Provide at least 2 self-determination discussion forums for consumers/ families per year. 4. Identify process improvements in the MCMHA Self-Determination Arrangement orientation and referral program. 5. Provide education and selfassessment tools to contractual providers for compliance with HCBS waiver requirements. 2. Development of IPOS tools to assist with consumer/family education is in process. 3. Offer open sessions at least twice a month. All SDA forum to be scheduled by 10/1/ Found improvement opportunities that make orientation more efficient and compliance more effective. Met with contractual FI February 2018 Developed ways to mainstream referral process and FI will be monitoring training of SDA/CV staff starting March Training and tools completed and provided to contractual providers in 3 meetings in 2017 and one meeting in 2018 to date. Page 16 of 49

17 Commuity Needs Assessment Community Data Sets CMHSP name: Contact person/e mail address: 1 Population (Census)-- As of September -- by county County 1 151, , , , , , County &prodType=table County 3 County 4 County 5 County 6 Total CMHSP Population Change from Prior Year % change from Prior Year #DIV/0! #DIV/0! -0.27% -0.43% -0.33% Cumulative Change since % cumulative change since 2008 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Source: State of Michigan Census Estimates Medicaid Enrollment - Average Enrollment for September: County ,512 21,819 23,403 24,112 23,119 23,166 26,021 27,934 19, County 2 County 3 County 4 County 5 County 6 Total CMHSP Medicaid Enrollment Change from Prior Year % change from Prior Year Cumulative Change since % cumulative change since Source: MDCH to provide data to CMHSP 3 Number of Children in Foster Care data only goes to 2015 Children Ages 0-17 in Out of Home Care-Abuse or Neglect (Number) no data for Children Ages in Out of Home Care-Delinquency (DHS Placement) or 2017 Children Ages 0-5 in Foster Care (Number) Source: **Some information may not be available for every year. Total CMHSP Change from Prior Year % change from Prior Year % -4.55% 51.19% 28.74% -1.53% #DIV/0! Cumulative Change since % cumulative change since % % 20.38% 54.98% 52.61% Number of Licensed Foster Care Beds in Catchment Area Adults - Enter the Total Number of Bed Capacity Kids - Enter the Total Number of Licensed Facilities Youth Center and DHHS noted in state list No bed capacity given on site *This data is also provided by MDCH on the website under "Provided Information" - not on state site 5 Prevalence Proxy Data Change *or most recent projection 5-A Adults with Serious Mental Illness (Kessler Methodology) 1735 not considered accurate (lower than expected) Trend - Kessler Prevalance Data Page 17 of 49

18 Commuity Needs Assessment Community Data Sets CMHSP name: Contact person/e mail address: *Provided by MDCH in B Children at risk for Serious Emotional Disturbance 100% below poverty C Persons with Developmental Disabilities -.005% of census Page 18 of 49

19 Commuity Needs Assessment Community Data Sets CMHSP name: Contact person/e mail address: 6 Community Homelessness- catchment area A Local Continuum of Care Bi-ennial Homeless Count Change from Prior Time Period B # served from CMHSP data- of persons that are homeless 106 Change from Prior Time Period C Community Employment County County 2 County 3 County 4 County 5 County 6 Total CMHSP Change from Prior Year % change from Prior Year % 0.91% 1.20% 1.17% 0.32% Cumulative Change since % cumulative change since % -9.91% -8.83% -7.77% -7.47% Source: State of Michigan Labor Market Information 7 Justice System A Jail diversions (describe data source) local/grant data 66 attempted inaccurate data B Prison discharges-number of people expected to meet SMI Criteria (describe data source) 8 Education System A Number of students aging out or graduating special education 9 Graduation and Dropout Rate County 1 %graduated County 2 %dropped out County 3 County 4 County 5 County 6 CMHSP Total: Source A % graduated B % dropped out Source - Page 19 of 49

20 Commuity Needs Assessment Community Data Sets CMHSP name: Contact person/e mail address: For primary health items, identify point in time being reported Primary Health 83% 85% 87% 85% 81% 77% 10-A % of CMHSP consumers with an identified Primary Care Physican not avail for B CMHSP Medicaid recipients with primary care service/encounter C # with primary care plus emergency room D # with emergency room no primary care DCH to supply data for 10B, 10C, and 10D Number of CMHSP consumers with: 10-E Pneumonia 10-F Diabetes 10-G Asthma 10-H Hypertension 10-I Obesity History of Pneumonia within the past 12 months History of Diabetes but not treated for Diabetes within the past 12 months Treated for Diabetes within the past 12 months History of Asthma but not treated for Asthma within the past 12 months Treated for Asthma within the past 12 months History of Hypertension but not treated for Hypertension within the past 12 months Treated for Hypertension within the past 12 months and blood pressure is stable Have medical diagnosis of Obseity present or BMI > Optional Private Providers and Public SA Providers A Number of Existing Private Providers in Community B Number of providers that utilize a sliding fee scale C Number of providers that are accepting new clients Page 20 of 49

21 BOARD EXECUTIVE COMMITTEE Thursday, February 15, :00pm MAJOR COMMITTEE RESPONSIBILITIES 1. Form agenda for monthly meetings. 2. Monitor long term effectiveness of the Board and Board Committees. COMMITTEE MEMBERS Bill Henning Charles Londo, Chair Sandy Libstorff DRAFT MINUTES I. CALL TO ORDER The meeting was called to order at 4:00pm by Charles Londo. Charles Londo, Sandy Libstorff, Bill Henning, and Lisa Jennings were present. II. REVIEW OF THIS MONTH S BOARD MEETING a. Board Agenda Reviewed b. Committee Reports Reviewed c. Presentation FY CMHPSM Annual Submission III. ITEMS FOR DISCUSSION a. Executive Director Update Recommendation to endorse the Resolution Concerning the Issue of the State of Michigan s Medicaid Enrollment Misclassification was presented. The Resolution will be added to the agenda along with requesting the Monroe County Board of Commissioner s to consider endorsement. b. Board Workshop Agenda Reviewed Agenda. c. Membership Screening Committee Recommendation from the committee for three new Board Members. Candidates will be contacted to confirm terms. Three current Board Members up for re-appointment and have extended their request for an additional term. A letter will be sent on behalf of Charles Londo to the Monroe County Board of Commissioner s for appointment and re-appointment. d. NATCON Conference Discuss how many to attend at the Board Workshop. IV. ACTION ITEMS FOR FUTURE BOARD MEETING AGENDA a. March NATCON Conference confirmations b. April MACMHB Spring Conference and Appoint Nominations Committee c. May Board Officer Elections and PIHP Representative Appointment d. June Board Committee List sign up V. AJOURNMENT The meeting adjourned at 5:57pm. VI. NEXT MEETING The Next Meeting of the Executive Committee is scheduled for Thursday, March 15, 2018 at 4:00pm in the Aspen Room. Respectfully submitted, Charles Londo 2/20/2018 Board Chair Page 21 of 49

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23 MEMBERSHIP SCREENING COMMITTEE Tuesday, February 13, :00pm MAJOR COMMITTEE RESPONSIBILITIES COMMITTEE MEMBERS 1. Develop interview questions for Board candidates. 2. Interview and recommend candidates. DRAFT MINUTES Londo, Charles Henning, Bill Neumann, Jim I. CALL TO ORDER The Membership Screening Committee was called to order by Charles Londo at 3:00pm. Charles Londo, Jim Neumann, Bill Henning, and Lisa Jennings were present. II. III. REVIEW CANDIDATE APPLICATIONS AND RESUMES 1. Total of five applications were submitted for open positions on the Board of Directors. 2. Committee reviewed three applications for today s interviews. INTERVIEWS FOR FEBRUARY 13TH 1. Kandie Collier 2. Ilene Dussia 3. Andrew Hoppert IV. NEXT STEPS 1. Remaining interviews scheduled for Thursday, February 15, Committee to make a recommendation to the Monroe County Board of Commissioners for appointment. V. ADJOURNMENT / NEXT MEETING Meeting adjourned at 6:07pm. The next meeting of the Membership Selection Committee is scheduled for Thursday, February 15, 2018 at 2:00pm in the Sequoia Room. Respectfully submitted, Charles Londo Membership Screening Committee 2/14/18 Page 23 of 49

24 MEMBERSHIP SCREENING COMMITTEE Tuesday, February 15, :00pm MAJOR COMMITTEE RESPONSIBILITIES COMMITTEE MEMBERS 1. Develop interview questions for Board candidates. 2. Interview and recommend candidates. DRAFT MINUTES Londo, Charles Henning, Bill Neumann, Jim I. CALL TO ORDER The Membership Screening Committee was called to order by Charles Londo at 2:00pm. Charles Londo, Jim Neumann, Bill Henning, and Lisa Jennings were present. II. III. REVIEW CANDIDATE APPLICATIONS AND RESUMES 1. Committee reviewed two applications for today s interviews. INTERVIEWS FOR FEBRUARY 15TH 1. John Burkardt 2. Kim VanDevelde IV. NEXT STEPS 1. Committee has completed five interviews and will make a recommendation to the Monroe County Board of Commissioners for appointment. V. ADJOURNMENT / NEXT MEETING Meeting adjourned at 4:00pm. The next meeting of the Membership Selection Committee is scheduled for Tuesday, January 8, 2019 at 5:00pm in the Aspen Room. Respectfully submitted, Charles Londo Membership Screening Committee 2/16/18 Page 24 of 49

25 BOARD PERFORMANCE EVALUATION COMMITTEE Tuesday, January 23, :30pm MAJOR COMMITTEE RESPONSIBILITIES 1. Compile quarterly performance measures for Executive Director. 2. Compile quarterly performance measures for the Board. COMMITTEE MEMBERS Board Chair Bylaws/Policies Chair Finance/Facilities Chair Program & Planning Chair DRAFT MINUTES I. CALL TO ORDER The meeting was called to order by Charles Londo at 3:30pm. Charles Londo, Bill Henning, Susan Fortney, David Stephens were present. Lisa Jennings was excused. II. III. DISCUSS RECOMMENDATION TO THE FULL BOARD a. The Committee reviewed and updated the Executive Director Performance Evaluation Summary which includes a recommendation to the full Board. NEXT STEPS a. The Committee will meet with the Executive Director on Tuesday, January 30 th to review the Executive Directory Performance Evaluation Summary. b. Motion for recommendation to be added to the February Board Agenda. IV. ADJOURNMENT The meeting adjourned at 4:47pm. Next Meeting is scheduled for January 30 th, 2018 beginning at 3:30pm in the Sequoia Room. Respectfully submitted, Charles Londo Performance Evaluation Committee 1/24/18 Page 25 of 49

26 BOARD PERFORMANCE EVALUATION COMMITTEE Tuesday, January 30, :30pm MAJOR COMMITTEE RESPONSIBILITIES 1. Compile quarterly performance measures for Executive Director. 2. Compile quarterly performance measures for the Board. COMMITTEE MEMBERS Board Chair Bylaws/Policies Chair Finance/Facilities Chair Program & Planning Chair DRAFT MINUTES I. CALL TO ORDER The meeting was called to order by Charles Londo at 3:30pm. Charles Londo, Bill Henning, Susan Fortney, David Stephens, and Lisa Jennings was present. II. III. REVIEW EXECUTIVE DIRECTOR PERFORMANCE EVAULATION SUMMARY a. The Committee reviewed and updated the Executive Director Performance Evaluation Summary. b. The Committee then met with the Executive Director and reviewed the Executive Director Performance Evaluation Summary. c. Executive Director to provide feedback of overall summary. NEXT STEPS a. Motion for recommendation to be added to the February Board Agenda. IV. ADJOURNMENT The meeting adjourned at 5:03pm. Next Meeting is scheduled for March 20, 2018 beginning at 5:00pm in the Sequoia Room. Respectfully submitted, Charles Londo Performance Evaluation Committee 1/31/18 Page 26 of 49

27 BOARD PROGRAM & PLANNING COMMITTEE Tuesday, February 20, :00pm MAJOR COMMITTEE RESPONSIBILITIES I. Ensure supports and services needed for consumers to achieve their outcomes are available and accessible. II. Monitor MCMHA programs and services for effectiveness, quality, and consumer satisfaction within the scope of the mission of the organization. COMMITTEE MEMBERS Ray, Pam Londo, Charles (Ex-Officio) Fortney, Susan, Chair Shorter, Rusty Libstorff, Sandy Henning, Bill Rafko, Gloria Neumann, Jim DRAFT MINUTES I. CALL TO ORDER The meeting was called to order at 5:00pm by Susan Fortney. Susan Fortney, Gloria Rafko, Rusty Shorter, Bill Henning, Jim Neumann, Sandy Libstorff, and Lisa Jennings were present. Charles Londo and Pam Ray were excused.. II. INFORMATIONAL ITEMS a. Indicators / Plan of Correction Lisa Jennings presented the 1 st Quarter Strategic Plan Indicators. Lisa commented that the UM/UR Indicator 6 and DLA-20 data will be brought to the March Meeting. 1. Started Service within 14 Days Lisa commented that Geralyn Harris is working with the Access Department and others across the Agency and will have some recommendations that comes out of this group and bring to the March Meeting. 2. Track Wellness Exams Lisa Jennings to meet with the Interim Medical Director to discuss and bring back information in March. 3. Community Workgroup Attendance The 1 st Quarter Indicator is at 76% which is just below the CMH Target of 80%. Staff that attend missed one Great Start Meeting due to a mandatory training, one SUD Meeting due to vacation, and the Network on Homelessness has a new supervisor that was appointed and will attend in 2 nd Quarter. 4. Face to Face Time Lisa Jennings commented that the Performance Improvement Initiative was presented at the Board Workshop. The plan to improve engagement will result in reduction of SAL time and increase to face to face time. Progress will be reported out each month until we meet or exceed the target. b. SUD License Timeline/Workplan Lisa Jennings presented the SUD Timeline at the Board Workshop. A quick review was provided for committee members. Plan is to be up and running by the middle of this calendar year. III. PARKING LOT a. Program & Planning Indicators Plan of Correction Follow Up 1. UM/UR Indicator 5 and 18 April b. SALs & Face to Face Time Engagement Performance Improvement Plan b. What is the role of the PIHP (Do they monitor services? Where do we fit in?) c. SUD License (ongoing) d. Staff Recruitment Plan and Timeline e. DLA-20 Indicator How to Measure? f. Local Consumer Satisfaction Survey (Jul) g. Regional Consumer Satisfaction Survey (Oct) IV. ADJOURNMENT/NEXT MEETING The meeting adjourned at 5:57pm. The next meeting of the Program & Planning Committee will be held on Wednesday, March 2, 2018 beginning at 5pm in the Aspen Room. Respectfully submitted, Susan Fortney Program & Planning Chair dp 2/23/18 Page 27 of 49

28 MCMHA Strategic Plan: Consumer/Customer Perspectives PRIORITY: ACCESSIBLE Goal: Community Members will Readily Access Services Measure: Number of Individuals Served Number of Intakes Completed and Individuals that Received Any Service Info Only Initial Assessment within 14 Days of First Request; Started Service within 14 Days of Initial Assessment; and Discharges from Psychiatric Inpatient seen within 7 days Report: Program & Planning Committee, Quarterly Increase # of Individuals Served Q Q Q Q Q Intakes Completed Individuals Served Initial Assessment within 14 Days of First Request Q Q Q Q Q Q CMH Average Days State Target 14 Days Started Service Within 14 Days of Initial Assessment Q Q Q Q Q Q CMH Average Days State Target 14 Days CMH Target 5 Days Page 28 of 49 Discharges from Psychiatric Inpatient Seen Within 7 Days Q Q Q Q Q Q CMH Average Days CMH Target 5 Days State Target 7 Days 2

29 MCMHA Strategic Plan: Consumer/Customer Perspectives (Continued) PRIORITY: SERVICE Goal: Consumers will Receive Medically Necessary Services for which they are Authorized Measure: UM/UR Peer Review Services are Provided According to IPOS Report: Program & Planning Committee, Quarterly 100% 80% 60% 40% 20% 0% 100% 82% 50% UM/UR Q Q Q Q Q Indicator #5 Indicator #6 CMH Target 95% Indicator #5: All services authorized in IPOS are provided according to the amount, scope, and duration in the plan (Performance Improvement Plan: 2 nd Quarter will spend reviewing detailed information on all peer reviews that are done. Want to know if this is an internal or external issue. Will report out in April 2018 as agreed by Program & Planning). Indicator #6: Any service needs that have been identified outside of the annual assessment/re-assessment process are being addressed Page 29 of 49 3

30 MCMHA Strategic Plan: Consumer/Customer Perspectives (Continued) PRIORITY: OUTCOMES Goal: Consumers Shall Achieve their Desired Outcomes Measure: CAFAS, DLA-20, and Consumer Satisfaction Survey (Annually in 4 th Quarter) Report: Program & Planning Committee, Quarterly/Annually CAFAS (Improvement in Total Score of 20 Points or Greater) 100% 80% 61% 60% 44% 40% 20% 0% Q Q Q Q Q 2018 Q CAFAS State Threshold 100% 80% 60% 40% 20% 0% 60% CAFAS (Blended) Q Q Q Q CAFAS State Target 50% 100% 80% 60% 40% 20% 0% % of Adult Consumers with Positive Change in Score 53.33% 4Q Q Q Q Q 2018 Open Adult Consumers Page 30 of 49 4

31 MCMHA Strategic Plan: Consumer/Customer Perspectives (Continued) PRIORITY: INTEGRATED HEALTH Goal: Consumers Health Needs are Addressed as Part of Treatment Measure: Year 2 Set Consumer Goal and Measure Year 1 Develop a System to Track Wellness Exams (Complete) Measure: Peer Review Indicator Report: Program & Planning Committee, Quarterly 100% 80% 60% 40% 20% 0% Track Wellness Exams (Set Consumer Goal and Measure) Q Q Q Q % 50% 0% Physical Health Needs Addressed 68% 69% Q Q Q Q Q Development Target Indicator #18 CMH Target 95% Indicator #18: The clinical record has evidence that health needs identified in the IPOS have documented clinical follow up. Performance Improvement Plan: 2 nd Quarter, Washtenaw has developed CSM 101 Training and will tweak for Monroe as it focuses on Page 31 of 49 Integrated Health. Report back in April. 5

32 MCMHA Strategic Plan: Consumer/Customer Perspectives (Continued) PRIORITY: COMMUNITY PARTNERSHIPS Goal: Recognized by Community as a Trusted and Competent Behavioral Health Organization (BHO) Measure: Year 2 Stakeholder Survey, Annually in 4 th Quarter Year 1 Develop and Implement a Community Survey Targeting Stakeholders (Complete) Measure: Year 2 Attendance, Quarterly Year 1 Determine Community Workgroups that are Priority for MCMHA Participation (Complete) Report: Program & Planning Committee, Quarterly/Annually 100% 50% 0% Community Workgroup Attendance 100% 76% Q Q Q Q Q Attendance CMH Target 80% Building Health Communities COC Network on Homelessness Human Services Collaborative Network Suicide Prevention Committee Great Start Transition Council Substance Abuse Coalition Page 32 of 49 6

33 MCMHA Strategic Plan: Internal Processes Perspectives PRIORITY: STANDARDIZED AND EFFICIENT INTERNAL PROCESSES Goal: Internal Processes Support Staff Measure: Face to Face Time, SAL Timeliness, and IPOS Timeliness Report: Program & Planning Committee, Quarterly 50% 40% 30% 20% 10% 0% Face to Face Time (By Quarter, Not Rolling Total) 15.85% 16.72% Q Q Q Q Q Agency Overall Average Target SALs (By Quarter Only, Not Rolling Total) Q 2017 Q Q Q Q % 80% 60% 40% 20% 0% IPOS Timeliness 100% 82% Q Q Q Q Q CMH Average Days CMH Target 1 day Page 33 of 49 IPOS CMH Target 100% 7

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40 Attachment #1 February 2018 COMMUNITY MENTAL HEALTH PARTNERSHIP OF SOUTHEAST MICHIGAN REGULAR BOARD MEETING MINUTES January 10, 2018 Members Present: Members Absent: Staff Present: Others Present: Greg Adams, Charles Coleman, Susan Fortney, Roxanne Garber, Sandra Libstorff, Charles Londo, Kent Martinez-Kratz, Sharon Slaton, Ralph Tillotson Judy Ackley, Martha Bloom, Barb Cox, Caroline Richardson Connie Conklin, Jane Terwilliger, Kathryn Szewczuk, Stephannie Weary, Lisa Jennings, Erika Behm, James Colaianne, Marci Scalera Laurie Lutomski, John Lapham I. Call to Order Meeting called to order at 6:00 p.m. by Board Chair R. Tillotson II. III. Roll Call A quorum of members present was confirmed. Consideration to Adopt the Agenda as Presented Motion by S. Slaton, supported by R. Garber, to approve the agenda Motion carried IV. Consideration to Approve the Minutes of the November 8, 2017 Regular Meeting and Waive the Reading Thereof Motion by R. Garber, supported by K. Martinez-Kratz, to approve the minutes of November 8, 2017 Regular Meeting and waive the reading thereof Motion carried V. Audience Participation VI. VII. Old Business a. January Finance Report J. Terwilliger presented the report in S. Stolz s absence. Discussion followed. New Business a. Board Action Requests i. Consideration to approve the Monroe County ISD contract amendment as presented Motion by S. Fortney, supported by K. Martinez-Kratz, to approve the Monroe County ISD contract amendment as presented Motion carried ii. Consideration to approve the Meridian Health Services contract as presented Motion by S. Slaton, supported by C. Coleman, to approve the Meridian Health Services contract as presented Page 40 of 49

41 Attachment #1 February 2018 Motion carried b. Annual CEO Performance Review Board members can either submit their review electronically or with paper copies of the review. VIII. IX. PIHP CEO Report to the Board a. Report from the SUD Oversight Policy Board (OPB) - None b. Veterans Navigator Program E. Behm provided an overview of the Veterans Navigator program. Discussion followed. c. J. Terwilliger provided updates from the state and regional levels. Adjournment Motion by C. Coleman, supported by K. Martinez-Kratz, to adjourn the meeting Motion carried Meeting adjourned at 7:00 p.m. Roxanne Garber, CMHPSM Board Secretary Page 41 of 49

42 Attachment #1 February 2018 COMMUNITY MENTAL HEALTH PARTNERSHIP OF SOUTHEAST MICHIGAN REGULAR BOARD MEETING MINUTES January 10, 2018 Members Present: Members Absent: Staff Present: Others Present: Greg Adams, Charles Coleman, Susan Fortney, Roxanne Garber, Sandra Libstorff, Charles Londo, Kent Martinez-Kratz, Sharon Slaton, Ralph Tillotson Judy Ackley, Martha Bloom, Barb Cox, Caroline Richardson Connie Conklin, Jane Terwilliger, Kathryn Szewczuk, Stephannie Weary, Lisa Jennings, Erika Behm, James Colaianne, Marci Scalera Laurie Lutomski, John Lapham I. Call to Order Meeting called to order at 6:00 p.m. by Board Chair R. Tillotson II. III. Roll Call A quorum of members present was confirmed. Consideration to Adopt the Agenda as Presented Motion by S. Slaton, supported by R. Garber, to approve the agenda Motion carried IV. Consideration to Approve the Minutes of the November 8, 2017 Regular Meeting and Waive the Reading Thereof Motion by R. Garber, supported by K. Martinez-Kratz, to approve the minutes of November 8, 2017 Regular Meeting and waive the reading thereof Motion carried V. Audience Participation VI. VII. Old Business a. January Finance Report J. Terwilliger presented the report in S. Stolz s absence. Discussion followed. New Business a. Board Action Requests i. Consideration to approve the Monroe County ISD contract amendment as presented Motion by S. Fortney, supported by K. Martinez-Kratz, to approve the Monroe County ISD contract amendment as presented Motion carried ii. Consideration to approve the Meridian Health Services contract as presented Motion by S. Slaton, supported by C. Coleman, to approve the Meridian Health Services contract as presented Page 42 of 49

43 Attachment #1 February 2018 Motion carried b. Annual CEO Performance Review Board members can either submit their review electronically or with paper copies of the review. VIII. IX. PIHP CEO Report to the Board a. Report from the SUD Oversight Policy Board (OPB) - None b. Veterans Navigator Program E. Behm provided an overview of the Veterans Navigator program. Discussion followed. c. J. Terwilliger provided updates from the state and regional levels. Adjournment Motion by C. Coleman, supported by K. Martinez-Kratz, to adjourn the meeting Motion carried Meeting adjourned at 7:00 p.m. Roxanne Garber, CMHPSM Board Secretary Page 43 of 49

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