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Northeast
Ohio
Behavioral Health, Ltd.
Short-Term
Plan
July
1, 2004 - June 30,
2005
Long-Term
Goal A: NEOBH will continue to provide high-quality,
non-medical mental health services to children, adolescents, adults
and families.
Objective
1: During FY 05, NEOBH will create and execute at least two
CQI Projects that address issues related to the implementation of
Best Practices and/or the improvement of care to the general client
population and/or to “niche” specialty client populations.
Timeline: Initiation of first CQI
Project by September
1, 2004, second CQI Project by February 1, 2005.
Tasks:
-
Create CQI
Projects
-
Set up and
completion of data collection
-
Analysis of data
-
Produce report to
Consumers, Stakeholders, NEOBH Advisory Board and NEOBH Staff re:
results
Responsibility: NEOBH Executive
Director, in
cooperation with QA Officer and with input from the CQI Committee
Financial
Consideration: None
Monitoring: Monthly/quarterly reports
from QA Officer
to the Executive/Clinical Director regarding QA review data and the
progress of additional data collection for CQI projects related to
Chart Reviews.
Quarterly
review of
progress by CQI Committee and NEOBH Advisory Board
Expansion/continuation
of projects via recommendation of CQI Committee and
Executive/Clinical Director
Objective
2: During FY 05, NEOBH will collect Ohio
Consumer Outcomes Data on Medicaid-eligible and private-pay NEOBH
clients, and will successfully monitor and track Outcomes
administration.
Timeline: Immediate (July 1, 2004)
implementation of
the collection of Outcomes for all Medicaid-eligible clients
Collection of Outcomes data for all NEOBH clients by March 1, 2005
Tasks:
-
Set up of office
procedures to include Outcomes in client registration materials
-
Set up of Outcomes
data collection procedures by clerical staff
-
Completion of
Worker Scales/Tracking Sheets by Clinical Staff
-
Dedication of
specific staff members assigned to scan/process Outcomes data, run
Outcomes Reports and provide these to the Executive/Clinical Director
on a consistent schedule
Responsibility: Business
Manager/Supervisor for
clerical staff, in cooperation with the Executive/Clinical Director,
Clerical Staff responsible for Outcomes, and Clinical Staff members
Financial
Consideration: Hiring of one clerical
staff member, 4-6
hours per week, with sole responsibility for processing Outcomes data
Monitoring: Quarterly review of
progress by CQI
Committee and NEOBH Advisory Board
Objective 3:
During FY
05, NEOBH will create at least one CQI Project based on Ohio
Consumer Outcomes Data.
Timeline: Initiation of first Project
on or before
March 1, 2005
Tasks:
-
Gather information
related to the use of Ohio Consumer Outcomes Data, research design
options, and analysis of data
-
Create CQI
Project(s) based on Ohio Consumer Outcomes data
-
Conduct analysis
of data reports
-
Report to
Consumers, Stakeholders, NEOBH Advisory Board and NEOBH Staff re:
results
Responsibility: Executive/Clinical
Director, with
assistance and input from CQI Committee, QA/Case Review
Financial
Consideration:
None
Monitoring: Quarterly review of
progress by CQI
Committee and NEOBH Advisory Board
Expansion/continuation
of projects via recommendation of CQI Committee, NEOBH Advisory Board
and Executive/Clinical Director
Objective 4: During FY 05,
NEOBH will consider
ways to utilize Ohio Consumer Outcomes Data in individual treatment
planning and discussions with clients regarding their progress. NEOBH
will determine criteria for the documentation of the
utilization of this data by Clinical Staff
Timeline: The actual date for the
implementation of the
Ohio Department of Mental Health (ODMH) Outcomes Rule regarding this
issue is September 5, 2005. By this date, NEOBH must be able to
offer evidence that the agency is using Outcomes data in both
Performance Improvement and treatment planning activities. Therefore,
for the purpose of Objective 4, throughout FY05, NEOBH
will gather information regarding how to best comply with this rule,
and will pilot ways to document Outcomes use in treatment planning.
The use of Outcomes in treatment planning activities will be
presented to Clinical Staff as part of the Annual Training Event in
January of 2005.
Tasks:
-
Arrange for
consultation regarding the interpretation of existing Outcomes data
-
Set up processes
for the immediate review of data by Clinical Staff and the inclusion of
Outcomes Data in the clinical chart after it has been processed by
Clerical Staff
-
Create training
module for current Clinical Staff, and include this data in Orientation
materials presented to new Clinical Staff Members
Responsibility: Executive/Clinical
Director with
assistance from consultation Business Manager/Supervisor of Clerical
Staff
Executive Director provides reports to ODMH via methods requested by
ODMH
Financial
Consideration: Hiring of one part-time
(10-12 hours per
week) clerical staff to assist with filing and other office duties
Monitoring:
Quarterly
review by CQI and NEOBH Advisory Board
Reports
to ODMH at
intervals specified by ODMH
Objective 5: During FY 05, NEOBH will
launch a website
containing information regarding services available, areas of staff
expertise, recommended sources of client information regarding mental
health issues, and other data that will educate the public.
Timeline: End of FY05 (June 30, 2005)
Tasks:
-
Gather information
regarding staff specialty areas, biographical information, and
recommendations for client educational materials (accomplished April,
2004)
-
Compile data in
Word files
-
Create outline for
links and web design
-
Gather information
regarding costs for website design, set up and maintenance
Responsibility: Executive/Clinical
Director, with the
assistance of NEOBH Clinical Staff
Financial
Consideration: To be determined by
research
Monitoring: Quarterly review by CQI
Committee and NEOBH
Advisory Board
Objective 6: During FY 05, NEOBH will
collaborate with
existing staff providers as well as specialty providers at Akron
Children’s Hospital to expand services to children and
adolescents
with Autistic-Spectrum Disorders within the Cuyahoga Falls/Summit
County office. NEOBH will examine the feasibility of expanding such
services to the Canton/Stark County office at such time when space is
available.
Timeline:
Throughout FY
05
Tasks:
-
Establish links
with physician referral sources
-
Investigate
opportunities to increase the current level of collaboration with Kent
State University, with consideration of NEOBH as a training site/pilot
program site for interns
-
Provide resources
for the training and supervision of intern staff, and include training
opportunities for existing staff interested in this specialized
population
Responsibility: Executive/Clinical
Director, with
collaboration from Clinical Staff experienced with Autistic-Spectrum
Disorders, as well as staff directly affiliated with Kent State
University
Financial
Consideration: To be determined RE:
training and client
materials
Monitoring: Ongoing discussions between
Executive/Clinical Director and interested Clinical Staff, with
presentation to NEOBH Advisory Board when program possibilities are
sufficiently outlined
Objective 7: During FY 05, NEOBH will
expand the
availability of Parent Coordination Services, Sexual Abuse Assessment
and Parent Evaluation via the recruitment and training of additional
staff within these areas of specialization.
Timeline:
Throughout FY
05
Tasks:
-
Specific
recruitment of clinical staff with an interest in these areas of
practice
-
Collaboration with
the Summit County Domestic Relations Court/Family Court Services and
the Stark County Department of Job and Family Services regarding client
needs and referral expectations/outcomes
Responsibility:
Clinical/Executive
Director
Financial
Consideration:
None
Monitoring:
Clinical/Executive
Director
Long-Term Goal B: NEOBH will seek to
maintain the
highest level of client/consumer satisfaction.
Objective 1: During FY 05,
NEOBH will redesign
its Client Satisfaction Survey and will implement a new survey based
on elements of Client Satisfaction that it determines to be most
important toward promoting client progress.
Timeline:
End of
FY 05 (June 30, 2005)
Tasks:
-
Gather information
regarding standardized Client Satisfaction Survey formats, as well as
those in use at other mental health agencies
-
Redesign Survey
and distribute draft for Clinical Staff, CQI Committee and Advisory
Board review
-
Implement new
Survey, and evaluate results
Responsibility: Executive/Clinical
Director
Financial
Consideration:
None
Monitoring: Quarterly review of
progress by CQI
Committee and NEOBH Advisory Board
Review
of Survey
drafts by CQI Committee, Clinical Staff and NEOBH Advisory Board
Objective 2: NEOBH will implement at
least one
procedural or programmatic change based on Client Satisfaction Survey
data.
Timeline:
End of FY 05
(June 30, 2005)
Tasks:
-
Analyze of Client
Satisfaction Survey data, and recognize pertinent trends
-
Distribute and
analyze NEOBH Staff Survey, with questions pertaining to elements of
client satisfaction related to treatment progress (accomplished July
2004)
-
Create
programmatic or procedural changes in response to the data
Responsibility:
Executive/Clinical
Director
Financial
Consideration:
To be
determined, if programmatic changes require
Monitoring: Quarterly review by CQI
Committee (internal
procedure review), and NEOBH Advisory Board
Long-Term
Goal D: NEOBH will create a practice environment conducive
to the needs of our clients and to the professional practice of our
clinical and office staff members. NEOBH will pursue the purchase of
office space at the conclusion of current rental agreements.
Objective 1: During FY 05, NEOBH will
fully staff two
additional clinical offices, located within the Stark County Child
Advocacy Center. These offices will be completely dedicated to the
assessment and treatment of child and adolescent victims of sexual
abuse.
Timeline:
Projected
date: January 2005
Tasks:
-
Collaboration and
planning with community agencies involved in the establishment of the
Stark County Child Advocacy Center (i.e. the Stark County Prosecutors
Office, the Stark County Department of Job and Family Services, et al)
-
Collection of data
(safety inspections, Certificates of Occupancy, etc.) required by ODMH
to certify site
-
Review of lease
-
Purchase of
materials, furniture, etc.
-
Participation in
program planning
Responsibility: Executive/Clinical
Director, Business
Manager and legal consultant for NEOBH, with the participation of
selected Clinical Staff
Financial
Considerations: 418.00/month rental
cost is preliminary
figure, inclusive of utilities and office maintenance.
Phone
charges are
to be determined, with a conjointly-owned phone system planned.
Furnishings/computer/fax
estimated at 1800.00 - 2000.00
Rental
space of
three parking spaces at 50.00 per month is proposed.
Hiring
of part-time
clerical staff – cost to be determined
Monitoring: Executive/Clinical
Director, with quarterly
reports to the NEOBH Advisory Board
Objective 2: During FY 05, NEOBH will
investigate and
resolve questions related to chart storage, record disposal
time-frames and the feasibility of computerized storage methods
Timeline:
Throughout FY
05
Tasks:
-
Purchase
additional storage units for financial and clinical files
-
Investigate legal
requirements regarding clinical records storage and liquidation
-
Clarify legal
requirements/ODMH mandates regarding financial record storage and
liquidation
-
Investigate
feasibility/cost of scanning/computerized record storage methods
Responsibility: Executive/Clinical
Director, with
input/consultation from NEOBH Advisory Board, NEOBH legal counsel,
independent financial auditor engaged by NEOBH for Medicaid audits
Financial
Consideration:
To be
determined, based on method decided upon
Monitoring: Executive/Clinical
Director, NEOBH Advisory
Board, NEOBH Business Manager, NEOBH Clerical Staff
Objective 3: At the conclusion of FY
05, (June 30,
2005) NEOBH will conduct an analysis of its North Canton office space
needs, and will engage consultation regarding the purchase of new
space at the conclusion (September 2006) of the current North Canton
Office lease. NEOBH will additionally conduct an analysis of
clinical utilization and billing office needs in the Cuyahoga Falls
Office.
Timeline:
June 30, 2005,
and continuing into FY 06
Tasks:
-
Conduct analysis
of office utilization and staffing patterns in each office location
-
Conduct analysis
of market needs and referral patterns in both offices
-
Conduct analysis
of Clerical Staff needs and Business Management/Billing needs for both
offices
-
Engage
consultation regarding real estate and financing
Responsibility: Executive/Clinical
Director, with data
provided by Business Manager
Financial
Consideration: To be determined, based
on decisions
reached at conclusion of analysis
Monitoring: Executive/Clinical
Director, with input
from NEOBH Advisory Board
Long-Term
Goal E: NEOBH will support, attract and
retain highly motivated and highly qualified personnel within
all
areas of its operation.
Objective
1:
During
FY 05, NEOBH
will continue to participate as a provider of Continuing Education
Units (CEU’s) for the Ohio Counselor and Social Worker Board and
the State Board of Psychology.
Timeline:
Throughout FY
05
Tasks:
-
Complete
applications for CEU providership for Counselor/Social Worker Board and
Ohio Psychological Association, Office of Continuing Education
-
Completion and
retention of records necessary to secure CEU’s and retain
providership
Responsibility:
Executive/Clinical
Director
Financial
Consideration:
None for
Counselor/Social Worker Board
450.00 for State
Board of
Psychology, two-year providership
Monitoring:
Executive/Clinical
Director
Objective 2:
During
FY 05, NEOBH
will plan and execute at least one formal Clinical Staff training
event, with the January Staff Training Event maintained as the
primary source of staff training. NEOBH will meet requirements
regarding additional staff trainings as required by the Council on
Accreditation (COA) concerning the orientation needs of new staff,
safety requirements and training requirements related to COA Generic
and Service standards. NEOBH Clerical Staff will receive training
based on changes in office hardware and software technology and data
reporting requirements of funding sources.
Timeline: Throughout FY 05, including
the January 2005
Training Event for Clinical Staff
Tasks:
-
Create agenda and
materials for January Staff Training Event
-
Create orientation
materials for new staff RE: clinical charting, completion of Outcomes
and Billing Sheets, et al.
-
Create additional
orientation materials for new Clinical Staff per COA requirements
-
Create
COA-compliant training schedule for new Clinical Staff that
incorporates topics introduced by Executive/Clinical Director, Business
Manager and Quality Assurance Officer
-
Create a
COA-compliant training schedule for Clerical Staff
-
Conduct analysis
of best way to meet COA safety requirements regarding CPR Training in
Cuyahoga Falls and North Canton Offices
Responsibility: Executive/Clinical
Director, in
cooperation with Business Manager and Quality Assurance Officer
Financial
Consideration:
CPR
Training class, cost to be determined
Reimbursement of QA Officer for time spent developing materials @
30.00/hour
Monitoring: Executive/Clinical
Director, with Quarterly
Updates to CQI Committee (training and supervision review) and NEOBH
Advisory Board
Objective 3: During FY 05, NEOBH will
add the Clinical
and Clerical Staff necessary to enhance its service delivery and
promote smooth business operations
Timeline: Throughout FY 05, and as
office space
expansion permits
Tasks:
Responsibility:
Executive/Clinical
Director and Business Manager
Financial
Consideration: Clerical Staff at
appropriate hourly
rate based on training/qualifications and job duties
Clinical Staff at usual and customary NEOBH rates for Medicaid and
insurance client reimbursement
Monitoring: Quarterly reports to the
NEOBH Advisory
Board regarding new staff, open positions, personnel utilization
Objective 4: During FY 05, NEOBH will
review and revise
Personnel Policies and Procedures, including policies related to
Clinical Staff reimbursement, the 401K Plan and Arbitration.
Timeline: Throughout FY 05
Tasks:
-
Obtain legal
consultation regarding clarification of 401K Plan terms, Arbitration
Policy and Clinical Staff reimbursement
-
Revise Personnel
Policies and Procedures to comply with COA requirements
-
Disseminate and
explain revised policies to Staff of NEOBH as changes are made
Responsibility: Executive/Clinical
Director, with
consultation from NEOBH Advisory Board, NEOBH legal counsel, and 401K
Plan Administrator
Business Manager: Follow up regarding signed policies for Personnel
File, completion of all required elements of Personnel File, and
updated Personnel Files
Financial
Considerations: Costs associated with
legal
consultation for revision of present policies to be determined, with
legal consultation engaged when appropriate
Monitoring: Executive/Clinical
Director, with Annual
Risk Management review by NEOBH Advisory Board and CQI Committee
Long-Term Goal F: NEOBH will
achieve and maintain
certification by the
Council
on
Accreditation for Children and Family Services (COA). It will obtain
accreditation prior to September of 2006, and will continue to
implement the organizational changes created by the certification
readiness process, in preparation for re-accreditation.
Objective 1: During FY 05,
NEOBH will revise its
Articles of Incorporation to represent the withdrawal of Gary
Robinson, Ph.D., as a Partner/Member of NEOBH. The revised Articles
of Incorporation will include all elements required by the Council on
Accreditation.
Timeline: Revision by January of 2005
Tasks:
-
Create
a complete list of COA-required elements for revised Articles of
Incorporation, including references related to the responsibility of
the owner of NEOBH, the mission of the organization and the structure,
function and roles of the NEOBH Advisory Board
-
Review
and revise drafts of Articles of Incorporation reflecting changes
Responsibility: Executive/Clinical
Director, with
assistance from the legal counsel for NEOBH, and legal consultation
available from the NEOBH Advisory Board
Financial
Consideration: Fees associated with
legal consultation
Monitoring: Executive/Clinical Director
Quarterly
review of corporate changes by the NEOBH Advisory Board, and Board
approval of revised Articles of Incorporation
Objective
2:
During
FY 05, NEOBH will complete the application to begin the formal
process of Council on Accreditation (COA) Accreditation. NEOBH will
create organization structures, policies, and procedures toward the
completion of the COA Self-Study document.
Timeline:
Self-Study
compilation project: Ongoing through FY 05
COA
Application: Prior to March 2005
Quarterly
meetings of NEOBH Advisory Board: Beginning in October of 2004
Quarterly
meetings of CQI Committee: Beginning in October of 2004
Education
of Clinical, Clerical and Business Management Staff: Ongoing since
June of 2004
Tasks:
-
Create
required Organization Policies
-
Research
and invite candidates for NEOBH Advisory Board
-
Create
Board meeting structure and Board Orientation materials
-
Create
necessary Clinical Policies and Procedures
-
Revise
existing Clinical Policies and Procedures in compliance with COA
standards
-
Revise
existing Personnel Policies and create additional Personnel Policies in
compliance with COA standards
-
Gather
data from resources familiar with COA standards
-
Educate
Clinical, Clerical and Business Management Staff regarding changes in
policies, procedures, performance expectations, organizational
structure and long-term/short-term goals of the agency
-
Train
staff in areas related to COA standards, including orientation of new
staff, safety issues, and updated areas of clinical and clerical skill
Responsibility:
Executive/Clinical
Director
Financial
Consideration: Application fee for COA,
based on Agency
Budget figures, to be determined at the time of application. Costs
are also associated with site-visit travel and accommodations of COA
Reviewers. Estimated total cost to achieve COA: $10,000 - $12,000.
Monitoring: Executive/Clinical
Director, with Quarterly
updates provided to the NEOBH Advisory Board, and monthly (or more
frequent) updates provided to Clinical and Clerical Staff, as
policies are updated/created.
Long-Term Goal G: NEOBH will expand
its involvement
in Managed Care, while maintaining its contracts with local
Mental Health Boards.
Objective 1: During FY 05, NEOBH will
participate in
Medical Necessity audits of its Clinical Charts, conducted by the
Summit County ADMH Board and the Stark County Mental Health Board.
NEOBH
will complete any necessary Plans of Correction and will implement
procedural or policy changes to avoid future errors, if indicated.
NEOBH will participate in audits required by Managed
Care
organizations such as Medical Mutual, SummaCare, Value Options and
Qual Choice, at the request of these organizations.
Timeline: Medical Necessity audits
occur at the request
of the Summit County ADMH Board and the Stark County Mental Health
Board at irregular/unpredictable intervals, but are required
annually, per contract. Clinical chart audit requests from Managed
Care organizations also appear to operate on irregular schedules.
Tasks:
-
Utilize
monthly QA/Chart Review as a method to accomplish internal auditing of
Medical Necessity requirements, clinical chart completion and billing
record accuracy, in preparation for Managed Care and Medical Necessity
Compliance Audits
-
Identify
and correct any documentation problems demonstrated within individual
charts reviewed during QA/Chart Review procedures, and identify
problems encountered by staff based on QA/Chart Review data
-
Revise
QA/Chart Review Audit Tool to reflect any changes in Medical Necessity
Compliance Audit elements published by the Ohio Department of Mental
Health (ODMH)
-
Provide
Mental Health Board Staff and ODMH with clinical and financial data as
required by contract
Responsibility: Executive/Clinical
Director, in
cooperation with the QA Officer and the Business Manager for NEOBH
Financial
Consideration: Reimbursement of QA
Officer for time
devoted to QA/Case Review Audit Tool revision
Monitoring: Executive/Clinical
Director, with
applicable reports to the NEOBH Advisory Board and the CQI Committee
(external audit review)
Objective 2: During FY 05, NEOBH will
expand its
involvement in Managed Care by adding qualified providers to provider
panels.
Timeline: Conclusion of FY 05
Compilation of Provider Relations contact persons
from 10 most
frequently utilized Managed Care companies: November 15, 2004
Compilation of data re: present providers/eligible
providers: Accomplished June 2004
Compilation of staff specialty areas: Updated June
2004
Contact with identified Provider Relations contacts:
December 30,
2004
Tasks:
-
Compile
data re: Provider Relations contacts
-
Update
Personnel Files with appropriate licensure, liability insurance and
generic application data
-
Create
data packets for Managed Care Provider Relations Staff re: niche
specialties of eligible providers, organizational structure of NEOBH
-
Complete
application packets as available
Responsibility: Executive/Clinical
Director, with
assistance from the Business Manager of NEOBH
Financial
Consideration: None
Monitoring: Executive/Clinical Director
and Business
Manager
Long-Term
Goal H: NEOBH will maintain financial solvency and meet
all expectations regarding accurate and timely
financial reporting.
Objective 1: During FY 05, NEOBH will
implement all
recommendations resulting from the FY 04 financial audit conducted by
the independent auditor, per contract requirements. It will seek
additional consultation from our auditor and Advisory Board members
regarding ways to safeguard the financial health of the organization.
Timeline: Completion of FY 04 audit
data collection by
October 30, 2004
Completion of audit report by December 30, 2004, with presentation
to the Stark County Mental Health Board in early 2005
Submission of NEOBH tax data prior to April 15, 2005
Tasks:
-
Compile financial
data for independent auditor
-
Review audit
report recommendations
-
Revise procedures
to incorporate recommendations
-
Provide financial
reports to Mental Health Board staff per monthly, quarterly and annual
schedules established per contract
-
Provide quarterly
financial reports to the Executive/Clinical Director and the NEOBH
Advisory Board
-
Provide additional
financial reports to the Ohio Department of Mental Health (ODMH) as
required
Responsibility: NEOBH Business Manager
in consultation
with the Executive/Clinical Director
Financial
Consideration: Estimated cost for
independent audit of
FY 04: $5,000
Monitoring: Business Manager and
Executive/Clinical
Director, Mental Health Board staff in Summit and Stark counties,
independent auditor, NEOBH Advisory Board
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