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Northeast Ohio
Behavioral Health,
Ltd.
Short-Term
Plan
July 1, 2005 -
June 30, 2006
Long-Term Goal A: NEOBH will
continue to provide
high-quality, non-medical mental health services to children,
adolescents, adults and families.
Objective 1: Achieved June 30,
2005: 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.
Objective 2: Partially Achieved
in FY05: 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.
Objective
2 - Recommendation for FY06: Expansion of
Outcome studies to all NEOBH consumers.
Timeline: October 1, 2005
implementation of the
collection of Outcomes for all NEOBH clients.
Tasks:
-
Modify
office procedures to include Outcomes in all client registration
materials
-
Dedication
of specific staff members assigned to scan/process Outcomes data,
insert data in charts for use by Clinical staff, 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: None. Clerical staff members have
already been hired to assume data collection, data entry and filing
duties.
Monitoring: Quarterly review of
progress by CQI
Committee, Executive Director and NEOBH Advisory Board.
Objective 3: Not Achieved in
FY05: During FY 05, NEOBH will create at least one CQI Project
based on
Ohio Consumer Outcomes Data.
Objective 3 – Recommendation for FY06:
Continue
Objective 3, with revised timelines and expectations.
Timeline: Initiation of analysis of
available Outcomes
data by September 1, 2005.
Initiation
of project design by September 1, 2005.
Tasks:
-
Gather
information related to the use of Ohio Consumer Outcomes Data, research
design options, and analysis of data
-
Obtain
consultation from agencies actively using ODMH Outcome studies in CQI
-
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: Partially
Achieved in FY05: 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.
Objective 4 - Recommendation for FY06: Revision
of Objective 4, as follows:
During FY06, NEOBH will actively utilize Outcome data in treatment
planning, as evidenced by CQI review of charts that contain reference
to Outcome data and ISP goals and objectives that reflect client
concerns contained within Outcome data.
Timeline: 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.
Tasks:
-
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: None. Clerical staff has been hired 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: Not Achieved in
FY05: 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.
Objective 5 – Recommendation for FY06: Continuation
of this Objective, with revised timelines.
Timeline: End of FY06 (June 30, 2006)
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: Partially Achieved
in FY05: 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.
Objective 6 – Recommendation for FY06:
Continuation
of this Objective, with additional emphasis on expansion of services
to other niche child/adolescent specialties, such as treatment of
children in post-adoptive placements.
Timeline:
Throughout
FY 06
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.
-
Establishment
of links with Children’s Hospital of Akron/Oak Adoptive Center
and Adoption Units from both Stark County DJFS and Summit County CSB.
Responsibility: Executive/Clinical
Director, with
collaboration from Clinical Staff experienced with Autistic-Spectrum
Disorders, staff affiliated with Kent State University and staff with
expertise in post-adoptive issues.
Financial
Consideration: To be determined RE: training and client
materials
Monitoring: Ongoing development
conducted by
Executive/Clinical Director and interested Clinical Staff, with
updates provided to NEOBH Advisory Board.
Objective 7: Achieved in FY05:
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.
Recommendation for FY06: Additional
specific
Objectives related to the above programs, and additional program
development for parents of children in the care of the SCDJFS.
Objective 8:
During
FY06, NEOBH will participate in the development of Parent
Coordination projects with the Summit County Domestic Relations
Court. NEOBH will provide at least one marketing outreach to the
Stark County Family Court.
Timeline:
Throughout
FY 06
Tasks:
-
Recruitment
and support of clinical staff with an interest in Parent Coordination
practice
-
Collaboration
with the Summit County Domestic Relations Court/Family Court Services
and the Stark County Family Court regarding client needs and referral
expectations/outcomes
-
Participation
in planning meetings conducted by the Summit County DR Court.
Responsibility:
Clinical/Executive
Director
Financial
Consideration: None
Monitoring:
Clinical/Executive
Director
Objective 9: During FY06, NEOBH will
expand programming
for child/adolescent victims and their families via the expansion of
programming at the Children’s Network office and the further
investigation of program possibilities for this site.
Timeline:
Throughout
FY06
Tasks:
Responsibility:
Clinical/Executive
Director
Financial
Consideration: None
Monitoring:
Clinical/Executive
Director
Objective 10: During FY06, NEOBH will
expand
programming for parents referred for Parenting Evaluations by the
Stark County Department of Job and Family Services and Summit County
Children Services
Timeline:
Throughout
FY06
Tasks:
-
Training
and supervision of North Canton and Cuyahoga Falls clinical staff hired
at the conclusion of FY05.
-
Discussion
of evaluation needs via consultation with the SCDJFS and SCCS.
-
Collaboration
with Stark County Goodwill Industries Parenting Skills Training Program
regarding the use of evaluation data.
-
Investigation
of assessment format revisions for parents with developmental handicaps.
-
Collaboration
with the Stark County MR/DD Board regarding services for parents with
intellectual limitations.
Responsibility:
Clinical/Executive
Director
Financial
Consideration: None
Monitoring:
Clinical/Executive
Director
Objective 11: During FY06, NEOBH will
increase
treatment access for Medicaid and Non-Medicaid adults in the North
Canton/Stark County office site, with particular emphasis on the
treatment needs of adult consumer parents of children in the care of
the SCDJFS.
Timeline:
Throughout
FY06
Tasks:
-
Training
and supervision of North Canton office clinical staff hired at the
conclusion of FY05.
-
Purchase
of training/client materials directed toward adult treatment needs.
-
Investigation
of programmatic needs of parents via consultation with the SCDJFS.
-
Collaboration
with the SCDJFS re: reunification goals
-
Collaboration
with Stark County Goodwill Industries Parenting Skills Training Program
re: integration of program goals into treatment planning.
-
Collaboration
with Community-based programs, such as WATOES re: client needs.
-
Provide
all financial reporting regarding Non-Medicaid clients as requested and
as required by the Stark County Community Mental Health Board.
-
Track
utilization of Non-Medicaid units on a monthly basis.
Responsibility:
Clinical/Executive
Director and the Business Manager
Financial
Consideration: Undetermined funds re: Training
materials and clinical staff resources.
Monitoring:
Clinical/Executive
Director
Long-Term Goal B: NEOBH will seek to
maintain the
highest level of client/ consumer satisfaction.
Objective 1: Achieved in
FY05: 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.
Recommendation for FY06: No
new Objectives. NEOBH should continue to use Client Satisfaction Survey
data as part
of CQI.
Objective 2: Achieved in FY05:
NEOBH
will implement at least one procedural or programmatic change based
on Client Satisfaction Survey data.
Recommendation for FY06: Objective
related to the
refinement of business office practices and streamlined procedures
between the Billing and Clinical offices of NEOBH.
Objective 3: During FY06, NEOBH will
develop written
procedures for all Billing functions, per COA standards/expectations.
NEOBH will develop and refine staff roles and areas of
responsibility within staff functions related to clerical, billing
and reception duties.
Timeline:
March
1, 2006
Tasks:
-
Utilize
COA standards to develop Operations Manual for Billing and clerical
procedures.
-
Develop
all COA data necessary for inclusion in Self-Study (i.e. G-6)
-
Provide
clerical staff training and updates to clinical staff re: new
procedures.
-
Redesign
clerical job descriptions to reflect segmentation of duties (i.e. Phone
Intake)
-
Gather
written procedures from staff currently assigned to Outcomes
transmission/follow-up and MACSIS data entry tasks.
Responsibility:
Business
Manager
Financial
Consideration: None
Monitoring: Quarterly review of
progress by CQI
Committee and NEOBH Advisory Board.
Long-Term Goal C: NEOBH will assess
service gaps and
the community assessment of service needs, as well as community
satisfaction, and will respond to this information within the
contents of its Annual/Short-Term Plan.
Objective 1: Achieved in FY05:
During
FY05, NEOBH will develop and distribute a Community Survey.
Recommendations
for FY06: Objective related to the
use of Community Survey data in marketing and referral source
Communication efforts.
Objective 2: In FY06, NEOBH will
actively use Community
Survey data to increase community awareness of NEOBH services and
respond to referral source communication needs.
Timeline: Throughout FY06, with
presentation of plan to
NEOBH Advisory Board by October, 2005.
Tasks:
-
Analysis
of Community Survey data
-
Response
to specific requests for information from identified survey participants
-
Consideration
of ways to increase referral source communication re: client
involvement at NEOBH
-
Development
of a Community Information Packet or extended practice brochure
detailing all services, versus specialty brochures currently in use
Responsibility: Clinical/Executive
Director
Financial
Considerations: Costs
re: brochures, mailing to be determined
Monitoring: Clinical/Executive Director
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: Achieved in FY05:
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.
Recommendation
for FY06: See Long-Term Goal A,
Objective 9 re: further development of Children’s Network office.
Objective 2: Achieved in FY05: During
FY
05, NEOBH will investigate and resolve questions related to chart
storage, record disposal time-frames and the feasibility of
computerized storage methods.
Recommendation
for FY06: None
Objective 3: Achieved in FY05:
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.
Recommendation for FY06: Objective
related to the
procurement of new office space in North Canton.
Objective 4: NEOBH will identify new
and larger office
accommodations and create plans to move to this new site at the
conclusion of its North Canton lease in September of 2006.
Timeline:
End
of FY 06 (June 30, 2006)
Tasks:
-
Identification
of relocation opportunities
-
Creation
of relocation plans
-
Assignment
of financial resources per FY07 budget
Responsibility:
Executive/Clinical
Director
Financial
Consideration: To
be determined as project progresses.
Monitoring:
Executive/Clinical
Director and Quarterly review by NEOBH
Long-Term Goal E: NEOBH will
support, attract and
retain highly motivated and highly qualified personnel within all
areas of its operation.
Objective 1: Achieved in FY05:
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.
Recommendation
for FY06: NEOBH should continue to
participate in CEU providership.
Objective 2: Achieved in FY05:
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.
Recommendation for FY06: Objective
related to NEOBH
response to needs identified in the Staff Training Survey and the
implementation of both Orientation and Ongoing Training programs.
Objective 3: Achieved in FY05:
During FY
05, NEOBH will add the Clinical and Clerical Staff necessary to
enhance its service delivery and promote smooth business operations.
Recommendation for FY06: None
Objective 4: Partially Achieved
in FY05: During FY 05, NEOBH will review and revise Personnel
Policies and
Procedures, including policies related to Clinical Staff
reimbursement, the 401K Plan and Arbitration.
Recommendation for FY06: Continue
Objective 4 as the
COA Project continues and policies are revised/created.
Timeline: Throughout FY 06
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
Objective 5: In FY06, NEOBH will
develop and deliver
additional training modules, and will adjust both Informal and Formal
training efforts to address needs identified in the Staff Training
Survey.
NEOBH will offer at least one additional formal training for staff,
prior to the COA site visit.
Timeline: Throughout FY 06, and prior
to the Site Visit
by COA.
Tasks:
-
Analysis
of Staff Training Needs Survey
-
Continued
development of additional Training Modules for required training
materials and tracking of receipt of staff training
-
Development
of materials to prepare staff for COA Site Visit
-
Investigation
into ways (formal and informal) to provide staff with information
regarding topics of interest outside of required training.
Responsibility:
Executive/Clinical
Director
Financial
Consideration: To be determined, based on time allotted
for formal training
Monitoring: Quarterly reports to the
NEOBH Advisory
Board by the Executive/Clinical Director
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: Partially
Achieved in FY05: 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.
Recommendation for FY06: Retain
Objective 1, re:
the completed revision of the Operating Agreement for NEOBH. Objective
1 is changed to reflect changes required in the
Operating Agreement, only.
Timeline: Revision by January of 2006
Tasks:
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 Operating Agreement
Objective 2: Partially Achieved
in FY05: 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.
Recommendation for FY06: Continuation
of Objective
2, with the maintenance of structures/procedures already created as
part of the COA Project. Objective 2 is changed to reflect
progress needed to accomplish the Goal of COA Accreditation.
Timeline: Self-Study
compilation project: Ongoing through FY 06
COA
Application: August 2005
Tasks:
-
Create required Organization Policies
-
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
-
Compile Self-Study
-
Work with COA toward scheduling of Site Visit
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: Achieved in FY05: 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.
Recommendation for FY06: Continue
Objective 1,
due to the impact of Medical Necessity Reviews and the need for
continued compliance.
Timeline: Throughout FY06: 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: Partially Achieved
in FY05: During FY 05, NEOBH will expand its involvement in
Managed Care by
adding qualified providers to provider panels.
Recommendation for FY06: Continue
with Objective
2. Objective 2 is revised to reflect ongoing work toward
Managed Care involvement.
Timeline: Throughout FY 06
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: Not Achieved in
FY05: 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.
Recommendation for FY06: Continue
with Objective
1. Objective 1 is revised to reflect FY06.
Timeline: Completion of FY 05 audit
data collection by
October 30, 2005
Completion of audit report by December 30, 2005, with presentation
to the Stark County Mental Health Board in early 2006
Submission of NEOBH tax data prior to April 15, 2006
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 05: $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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