board meeting - comtrea › files › board › june 2018 board...turner, patty vanek) sue. ongoing....

21 Municipal DriveArnold, M O 63010

LOCATION+1 636 933 2700

PHONE NUMBERwww.comtrea.org

WEBSITE

Board MeetingJune 18, 2018

FACEBOOKhttps://www.facebook.com/COMTREA/

OUR MISSIONTo lead in providing quality,

comprehensive healthcare that is

affordable and accessible, and to

support the dedicated professionals

who make caring for the individuals

we serve their number one priority.

AGENDA7:30 AM – Meeting Open

Approval of Agenda and Minutes

CLOSED SESSION

Financials

CEO Report

Action Items

Discussion Items

Adjournment

MOTION:

“I, ______, move that the Board approve the June 18, 2018 Meeting Agenda.”

APPROVAL OF AGENDA

MOTION:

“I, ______, move that the Board approve the May 14, 2018 Meeting Minutes.”

APPROVAL OFMEETING MINUTES

CLOSED SESSION

BOARD MEMBERS ONLY

• REAL ESTATE• PERSONNEL

“As a member of the Finance Committee, I _________, move that the Board approve the financials for the month of March, 2018.”

ACCOUNT RECIEVABLES$3,947,041.39

FINANCIAL REPORT

CASH ON HAND$1,580,257.81

MOTION:

FINANCIAL FOCUS UPDATE ADVOCACY UPDATE DIVISIONAL UPDATES HRSA FY 2019 STRATEGIC PLANNING

PROCESS VOLUNTEERS

CEO REPORT

GROWTH REPORTS

CASH FLOW ACTION PLAN

CEO REPORT

FINANCIAL FOCUSUPDATE

GROWTH REPORT – PRIMARY CARENet Revenue Per Visit PC 166.00

Weekly GOALS # DAYS MTD

4

Net Patient Rev/Visit 99.00 92 Schedule 76 Actual WEEK ONE [5/01 - 5/05]THRU 5/04

MONTH END FORECAST - PRIMARY CARE REVENUE & BUDGET

PRIMARY CARE VISITS >

Schedule

10-Hr Day Actual

10-Hr Day VISITS % GOAL

AVE/DAY

REVENUE ACT MTD

PROJ VISITS GOAL % GOAL

PROJ REV BUD REV

VAR REV % VAR

Dr. Turner 0.50 46.0 11.5 38.0 9.5 19 50% 4.8 3,154 19 100 16,559

Dr. Helton 1.00 92.0 23.0 76.0 19.0 46 61% 11.5 7,636 46 242 319 76% 40,089Ashley Whitley (ADD BH) 0.90 82.8 20.7 68.4 17.1 61 89% 15.3 10,126 61

320287 111% 53,162

Ashleigh McGrath 1.00 92.0 23.0 76.0 19.0 61 80% 15.3 10,126 61 320 319 100% 53,162

Amanda Sherwood 0.75 69.0 17.3 57.0 14.3 51 89% 12.8 8,466 51 268 239 112% 44,447

Dr. Hampton 0.50 46.0 11.5 38.0 9.5 32 84% 8.0 5,312 32 168 160 105% 27,8880.0 0.0 0.0 0.0 #DIV/0! 0.0 0 0 0 0 #DIV/0! 0

TOTALS 4.15 427.8 107.0 353.4 88.4 270 76% 67.5 44,820 270 1,418 1,325 107%235,30

5 178,44956,85

6 31.86%

83%Patient

Revenue$140,333

GROWTH REPORT – ORAL HEALTH / DENTIST

Net Rev Per Dental Visit 225.00 Weekly GOALS

Net Patient Rev/Visit 113.00 75 Schedule 62 Schedule WEEK ONE [5/01 - 5/05] THRU 5/04MONTH END FORECAST

ORAL HEALTH-DENTISTS FTE

Schedule 10 Hr Day Actual

10 Hr Day VISITS % GOAL AVE/DAY

REVENUE ACT MTD

PROJ VISITS GOAL % GOAL PROJ REV

Dr Suter 0.30 22.5 5.6 18.6 4.7 19 102% 3.8 4,275 19 100 78 128% 22,444

Dr. Garland 0.75 56.3 14.1 46.5 11.6 16 34% 3.2 3,600 16 84 195 43% 18,900

Dr. Empkey 0.50 37.5 9.4 31.0 7.8 26 84% 5.2 5,850 26 137 130 105% 30,713

Dr. Garrity 0.80 60.0 15.0 49.6 12.4 25 50% 5.0 5,625 25 131 208 63% 29,531

Dr Blattel 0.80 60.0 15.0 49.6 12.4 23 46% 4.6 5,175 23 121 208 58% 27,169

Dr. Landsford 1.00 75.0 18.8 62.0 15.5 25 40% 5.0 5,625 25 131 260 50% 29,531

Dr. Mazuranic 0.30 22.5 5.6 18.6 4.7 5 27% 1.0 1,125 5 26 78 34% 5,906

Dr. Desamero 0.50 37.5 9.4 31.0 7.8 14 45% 2.8 3,150 14 74 130 56% 16,538

Dr. Puisis 1.00 75.0 18.8 62.0 15.5 50 81% 10.0 11,250 50 263 260 101% 59,063

Dr. Greaves 0.30 22.5 5.6 18.6 4.7 10 54% 2.0 2,250 10 53 78 67% 11,813

0.0 0.0 0.0 0.0 #DIV/0! 0.0 0 0 0 0 #DIV/0! 0

TOTALS 6.25 468.8 117.2 387.5 96.9 213 55% 42.6 47,925 213 1,118 1,628 69% 251,606

83%Patient Revenue$126,362

GROWTH REPORT – ORAL HEALTH / HYGENISTSWeekly GOALS

# Pts 42 Schedule 33 Schedule WEEK ONE [5/01 - 5/05] THRU 5/04 MONTH END FORECASTOH - HYGIENISTS FTE Schedule 10 Hr Day Actual 10 Hr Day VISITS % GOAL AVE/DAY REVENUE ACT MTD PROJ VISITS GOAL % GOAL PROJ REVSandy Holified 0.10 4.20 1.1 3.3 0.8 0 0% 0.0 0 0 0 14 0% 0Suzanne Seawel 0.80 33.60 8.4 26.4 6.6 15 57% 3.0 3,375 15 79 111 71% 17,719Anna Kloeppel 0.20 8.40 2.1 6.6 1.7 3 45% 0.6 675 3 16 28 57% 3,544Amanda Govreau 0.80 33.60 8.4 26.4 6.6 5 19% 1.0 1,125 5 26 111 24% 5,906Renee Blanken 0.75 31.50 7.9 24.8 6.2 0 0% 0.0 0 0 0 104 0% 0Ashley Wegener 0.25 10.50 2.6 8.3 2.1 3 36% 0.6 675 3 16 35 45% 3,544Angelica Miller 1.00 42.00 10.5 33.0 8.3 9 27% 1.8 2,025 9 47 139 34% 10,631Tiffany Grant 0.50 21.00 5.3 16.5 4.1 25 152% 5.0 5,625 25 131 69 189% 29,531Kate Poleos 0.75 31.50 7.9 24.8 6.2 0 0% 0.0 0 0 0 104 0% 0

0.00 0.0 0.0 0.0 #DIV/0! 0.0 0 0 0 0 #DIV/0! 00.00 0.0 0.0 0.0 #DIV/0! 0.0 0 0 0 0 #DIV/0! 0

TOTALS 5.15 216.3 54.1 170.0 42.5 60 35% 12.0 13,500 60 315 714 44% 70,875

79%Patient

Revenue $35,595

MONTH END FORECAST - DENTAL REVENUE & BUDGETPROJ VISITS GOAL REV/VISIT PROJ REV BUD REV VAR REV % VAR

1,118 1,628 69% 251,606315 714 44% 70,875

1,433 2,341 61% 322,481 454,880 -132,399 -29.11%Patient

Revenue 161,957

CASH FLOW ACTION PLAN# ACTION STEP OWNER Apr-181 Develop a "Growth Report" with publication

each Tuesday that records the units of service (visits) each for Primary Care and Oral Health. The run rate for each week will be used to forecast the revenue at the month-to-date run rate. This report will be reviewed with weekly alignment steps.

Sue The Growth Report has been designed and implemented with publication each Tues. to Leadership Council, Practice Managers for Primary Care & Oral Health, and Finance Committee.

(a) Develop the Growth Report format Sue Developed 4/06 with revisions over the next two weeks with its current format.

(b) Produce the number units of service for the prior week that is due to Sue by noon each Monday.

Darlene; Nicole

Compliance with meeting this expectation by the Practice Managers, Darlene Herrell for PC and Nicole Bollinger for OH.

(c) Obtain the revenue production for the prior week and send to Sue by noon each Monday.

Amy Report revised to use net revenue per visit to forecast the revenue MTD and month end. CEO & CFO worked together to derive the conservative rate based on an annual trend.

(d) Populate the Growth report and distribute by 3 PM each Tuesday to Leadership Council, Primary Care and Dental Leadership.

Sue Distributed per plan.

(e) Review of the Growth report by C-Team with assessment of ongoing progress, or lack of, and alignment steps.

Sue, Amy, Lisa, Margo

C-Team meets weekly on Mondays to review of Growth Report, Cash Flow report and other measures as part of financial management.

# ACTION STEP OWNER Apr-182 Primary Care Action Plan with 4 key action

steps that is reported on with weekly updates and in-depth review at MORs, which are scheduled the 4th Monday of each month.

Darlene Prior Action plan revised to focus on 4 key initiatives with inclusion of Office Managers in the implementation and oversight. Scheduled call each Friday to review progress and daily email/calls as needed.

(a) Inclusion of the Primary Action Plan with this Improvement Plan.

Sue Completed.

(b) Weekly review with Darlene Herrell (Primary Care Operations Manager) on Fridays at 7:30 AM.

Sue Ongoing.

(c) Monthly review and alignment discussions with Primary Care Leadership (Darlene Herrell, Dr. Turner, Patty Vanek)

Sue Ongoing. Dr. Turner has added one additional hours (20 per week) for seeing patients. Ongoing discussions on collocation of primary care providers at the BH clinics. Plan to have NP, Ashley Whitley at Arnold eff. 7/1. We have moved Dr. Hampton to The Valley after Jill was terminated and patient visits are increasing.

(d) Reduction in staff - one NP effective 4/06/18 HR Completed.

(e) Add one day additional treatment to Dr. Turner's schedule

Sue Completed.

(f) Continue with enhanced marketing plan. Kim; Liz Two meetings this month with Nathanael (Marketing) and Primary Care. Outcomes are updated brochures and input for the social media postings.

CASH FLOW ACTION PLAN, cont.# ACTION STEP OWNER Apr-183 Oral Health Action Plan with monthly

projection that outlines the dates for each of the five dentists joining the agency and the corresponding increase in visits and revenues.

Dr. Garland; Nicole

Bollinger

The six dentist positions have been filled with all dentists onboarding between 5/21 and 8/13. Forecast developed by Dr.. Garland and Dr. Suter with review by the C-Team.

(a) Expectation for positive contribution margin and weekly monitoring through the Growth Report and weekly call with Nicole.

Sue Dental Leadership working towards fulfillment of this expectation, which is tied to dentists onboard and at capacity. Scheduling for each dentist will begin prior to each start date.

(b) Flex the additional expenses incurred with the Dunklin SBHC with use of existing equipment when possible.

Amy This is a component of the work plan.

(c) No further expansion; get our current sites performing at expectation when fully staffed.

Sue; All Communicated to Dental Leadership and C-Team holding to accountability.

(d) HR to revise/expand operational workflows to ensure all providers are credentialed and privileged the day each one starts.

Donna Workflow revisions completed and start date in the offer letter contingent on provider’s submission of credentialing and privileging paperwork by specified date. If not received, start date will be changed to allow full opportunity for provider to be credentialed at the start date.

(e) Schedule patients in advance so provider starts with a schedule of patients.

Amanda Integrated as part of the new process.

# ACTION STEP OWNER Apr-184 Strategic Planning and 2019 FY Budget Sue; Amy

(a) Deep dive analysis into requested positions and verification of need; review current roles and determine needs of the business and re-alignment.


In process.

(b) Determine which positions could be eliminated or reduced in the FY2019 Budget based on the changing needs of the business.


In process.

(c) Review the ratio of Medical Assistants to Providers and determine best practice ratio with implementation and consistency across divisions.

Patty, Margo, Dr.

Garland

Review completed for Primary Care with average of 1.5 per provider, which is minimum for optimal practice and rooming two patients at each appointment time.

(d) Assess treatment time percentages for Clinical Leadership and any changes given the needs of the business.


To be discussed.

(e) Identify opportunities for a more "lean" Administrative support.


In process.

ADVOCACY

LEGISLATIVE EVENT JUNE 19

CEO REPORT

PRIMARY CARE ORAL HEALTH

DIVISIONAL UPDATESBEHAVIORAL HEALTH

PSYCHIATRY

CEO REPORT

MONTHLY ANNUAL REVIEW− NEEDS

ASSESSMENT− CONTINUITY OF

CARE

Site Visit Protocol Section and Demonstrating Compliance Elements

HRSA Primary Reviewer

COMTREA -Delegated

To

Month Review

Compliance Demonstrated?

NEEDS ASSESSMENT GOVERNANCE/ADMIN

Sue Curfman

May YES NO NA

a. Service Area Identification and Annual Review1

b. Update of Needs Assessment 1TOTAL 2 0 0

% 100%CONTINUITY OF CARE AND HOSPITAL ADMITTING CLINICAL Sue

CurfmanMay YES NO NA

a. Documentation of Hospital Admitting Privileges or Arrangements 1

b. Procedures for Hospitalized Patients 1c. Post-Hospitalization Tracking and Follow-up 1

TOTAL 3 0 0

% 100%

BOARD MEMBERS USING FQHC SERVICES

2018

53% Of Board Members are using FQHC Services

47% Board Members NOT utilizing FQHC Services

HRSA REQUIRES

51%

53% 47%

APRIL

IN COMPLIANCE

FY 2019 STRATEGIC PLANNINGFISCAL YEAR 2019 STRATEGIC PLANNING SCHEDULE

STATUS DATE TASK

3/28/18 Distribution of Stakeholder questionnaires, both internal and external, along with the Annual Report. Request for feedback by 4/20/18.

Lisa Wigger

4/06/18 C-Team review of 3-year strategic plan (Fiscal Years 2018 – 2020) with review of draft 2019 goals and action steps.

Sue, Amy, Margo, Lisa R.

5/07/18 Strategic planning retreat with Leadership Council. Sue & L.C.

5/16/18 All Employee Open Forum 2019 Strategic Planning Sue

5/1718 – 6/06/18 Finalize draft FY 2019 Strategic Plan with integration of feedback and priority needs from multiple inputs.

Sue & Lisa W

6/07/18 Review of draft FY 2018 Strategic plan with Executive Subcommittee of the Board Sue

6/19/18 Presentation of the FY 2018 Strategic Plan and Budget Board & LC

EXTERNAL STAKEHOLDER SURVEY - PERFORMANCE

PERFORMANCE MEASURES (EXTERNAL STAKEHOLDERS) -Scores calculated w/o "Not Applicable" Rating Measures 2018 - All

Responses %

Stro

ngly

Agre

e or

Ag

ree 2017 - All

Responses %

Stro

ngly

Agre

e or

Ag

ree % Change in

SA/A in 2018 over PY

2016 - All Responses %

St

rong

ly Ag

ree

or

Agre

e % Change in SA/A in 2017

over PYTOTAL REPORTING 89 89 38

The mission and successes of COMTREA are effectively communicated

Strongly Agree 27 34% 79% 19 24% 82% -4% 7 18% 63% 19%Agree 36 45% 46 58% 17 45%

Disagree 12 15% 10 13% 12 32%Strongly Disagree 5 6% 4 5% 2 5%

Not Applicable 10 3 0

Satisfied or highly satisfied with being a COMTREA community partner.




Education and training of COMTREA services for your organization and/or community

Strongly Agree 17 24% 75% 15 19% 69% 5% 3 9% 59% 10%Agree 36 51% 39 50% 16 50%



Access to services in a timely manner




Ensuring that the physical health needs of clients in our care are met

Strongly Agree 16 30% 81% 10 16% 84% -3% 4 14% 89% -5%Agree 27 51% 44 69% 21 75%



Ensuring that mental health needs/substance use treatment needs of clients in our care are met




Ensuring that the oral health needs of clients in our care are met

Strongly Agree 21 36% 83% 15 25% 87% -4% 7 28% 96% -9%Agree 28 47% 38 62% 17 68%



EXTERNAL STAKEHOLDER SURVEY – PERFORMANCE, CONTINUEDPERFORMANCE MEASURES (EXTERNAL STAKEHOLDERS) - Scores calculated w/o "Not Applicable" Rating Measures 2018 - All

Responses %

Stro

ngly

Agre

e or

Agre

e 2017 - All Responses %

St

rong

ly Ag

ree o

r Ag

ree % Change in


2016 - All Responses %

St

rong

ly Ag

ree o

r Ag

ree % Change in


TOTAL REPORTING 89 89 38

Providing a range of support services needed by clients and their families

Strongly Agree 25 34% 86% 16 21% 87% 0% 8 24% 71% 16%Agree 38 52% 49 65% 16 47%



Responding to you/your organization’s concerns




Providing staff who are well-trained and knowledgeable




Coordinating services with other agencies or community organizations




Clients, family members and/or community partners are treated with respect




Access to information on the COMTREA website




EXTERNAL STAKEHOLDER SURVEY - AWARENESS

AWARENESS OF SERVICES -EXTERNAL STAKEHOLDERS

2018 Total

Responses - 90

2017 Total

Responses - 102

% Change

in YES in 2018 over prior year

2016 Total

Responses -35

% Change

in YES in 2017 over prior year

YES NO YES NO YES NOPrimary medical care for children/youth/adults

79 11 75 2714%

27 8-4%88% 12% 74% 26% 77% 23%

Dental care for children/youth/adults 84 6 73 2922%

30 5-14%93% 7% 72% 28% 86% 14%

Integrated care delivery for medical, dental and behavioral health.

80 10N/A N/A89% 11%

Co-occurring/Integrated Tx service for SA & mental disorder

82 8 78 2415%

31 4-12%91% 9% 76% 24% 89% 11%

Residential treatment for adult alcohol/substance abuse

77 25N/A

19 1621%75% 25% 54% 46%

Out-patient counseling 84 6 91 114%

34 1-8%93% 7% 89% 11% 97% 3%

Residential tx for adolescent alcohol or other substance abuse

85 17N/A

31 4-5%83% 17% 89% 11%

CSTAR substance Abuse 84 6 88 147%

34 2-8%93% 7% 86% 14% 94% 6%

“A Safe Place” shelter for domestic violence

82 8 88 145%

28 88%91% 9% 86% 14% 78% 22%

Keaton ALF for persons with serious and persistent mental illness

57 33 60 414%

9 2734%63% 37% 59% 41% 25% 75%

Supportive Parents court-ordered program

58 32 65 360%

17 1917%64% 36% 64% 36% 47% 53%

AWARENESS OF SERVICES -EXTERNAL STAKEHOLDERS

2018 Total Responses - 90

2017 Total Responses - 102

% Change in YES in 2018 over prior year

2016 Total

Responses - 35

% Change in YES in 2017 over prior year

YES NO YES NO YES NO

Community Psychiatric Rehabilitation 68 22 81 20-5%

30 6-3%76% 24% 80% 20% 83% 17%

OP, both office and community based, case management

81 9 79 2212%

35 3-14%90% 10% 78% 22% 92% 8%

Psychosocial Rehabilitation Program (PSR) 64 26 52 4920%

15 2110%71% 29% 51% 49% 42% 58%

DWI Court (SROP – serious repeat offender program)

59 31 75 26-9%

22 1413%66% 34% 74% 26% 61% 39%

Family Drug Court 65 25 85 16-12%

32 4-5%72% 28% 84% 16% 89% 11%

Motivational Probation, formerly known as Juvenile Drug Court

55 35 78 23-16%

34 2-17%61% 39% 77% 23% 94% 6%

Veterans Court 43 47 70 31-22%

21 1511%48% 52% 69% 31% 58% 42%

Adult Drug Court 69 21 71 285%

28 8-6%77% 23% 72% 28% 78% 22%

Children’s Advocacy Center 73 17 81 18-1%

32 4-7%81% 19% 82% 18% 89% 11%

Crime Victim Services: adding Court & Community Victim Advocacy

65 25 59 4113%

24 12-8%72% 28% 59% 41% 67% 33%

Hospital and ED intervention/ diversion services

58 32 43 5721%

10 2615%64% 36% 43% 57% 28% 72%

Disease Management and Care Coordination 54 36 33 6727%

8 2811%60% 40% 33% 67% 22% 78%

Tails with Tails program/canine program 80 10N/A N/A89% 11%

School Liaisons to assist in Jefferson County Schools

80 10N/A N/A89% 11%

VOLUNTEER REPORTLocation JULY AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUN TOTAL HOURS

Bridle Ridge 68 102 24 28 12 8 0 0 0 0 242

A Safe Place 5 38 6 8 8 6 10 72 8 8 169

CAC 21 164 29 16 19 9 14 76 18 29 395

Employees 19 21 39 31 38 30 38 55 67 43 381

Board Members 78 74 76 131 84 71 72 45 94 87 812

Adult and C&Y Div. 0 0 0 0 0 0 0 0 0 0 0

Tails with Tales 22 26 37 51 121 84 82 63 84 81 651

Community Events 71 216 154 49 12 10 6 15 26 87 646

Job Shadowing 0 0 76 182 191 59 68 118 60 89 843

TOTAL Hours: 284 641 441 496 485 277 290 444 357 424 0 0 4139

ACTION ITEMS

REQUIRES A VOTE

MOTION:

“I, ______, move that the Board approve the April 2018 Leadership Reports to the Board.”

APPROVALLeadership Council Reports

Emailed to Board

MOTION:

“I, ______, move that the Board approve the CEO Evaluation signed 04/30/18 as presented.

APPROVALCEO Evaluation

Discussed in the Closed Session, Approval must be done in Open Session

MOTION:

“I, ______, move that the Board approve the FY 2019 Board Calendar as presented.

APPROVALFY 2019 Board Meeting Calendar

Additional Copy provided

MOTION:

“I, ______, move that the Board approve the continuation of Schowalter & Jabouri, P.C. for the purpose of audit services.

APPROVALAudit Services

TOTAL COSTS: $39,500

MOTION:

“I, ______, move that the Board approve the awarding of Schowalter & Jabouri, P.C. the contract for Cost Report Services.”

APPROVALCost Report Services

TOTAL COSTS: $1,500

MOTION:

“I, ______, move that the Board approve to discontinue the staff insurance reimbursement benefit as of June 30, 2018.

APPROVALStaff Insurance Reimbursement

Benefit Elimination

MOTION:

“I, ______, move that the Board approve the revisions of HR Policy 7.2.6 Exempt Employees as presented.”

APPROVALRevision –HR Policy

“7.2.6 Exempt Employees”

MOTION:

“I, ______, move that the Board approve the revisions of HR Policy 7.2.7 Non-Exempt Employees as presented.”


“7.2.7 Non-Exempt Employees”

MOTION:

“I, ______, move that the Board approve the revisions of HR Policy 10.2 Attendance as presented.”

APPROVALRevision –HR Policy“10.2 Attendance”

MOTION:

“I, ______, move that the Board approve the revisions of HR Policy 10.2.1 Charging Leave as presented.”


“10.2.1 Charging Leave”

MOTION:

“I, ______, move that the Board approve the revisions of HR Policy 12.2.2 to 12.2.1 Non Exempt Employees.”


“12.2.2 to 12.2.1 Non Exempt Employees”

MOTION:

“I, ______, move that the Board approve the revisions of HR Policy 14.4.2 Reporting as presented.”

APPROVALRevision –HR Policy“14.4.2 Reporting”

Employee Abuse, Harassment or Grievance Policy

MOTION:

“I, ______, move that the Board approve the deletion of HR Policies 12.4, 12.4.1, 12.4.2, 12.4.3, 12.4.4 and the original 12.2.1 as presented.”

APPROVALDeletion –HR Policy

“12.4, 12.4.1, 12.4.2, 12.4.3, 12.4.4 and the original 12.2.1”

MOTION:

“I, ______, move that the Board approve the revision of MED 35 Med Refill Policy for the G11 Medical Manual as presented.”

APPROVALRevision G11 Medical Manual“MED 35 Med Refill Policy”

CREDENTIALING & PRIVILEGINGNew Staff / Interns Requiring Privileging

(during the month of April 2018)

Name Title Division

Hope Clark Resident Assistant BH

Taylor Kennedy Dentist OH

Brian Darling Pediatric Dentist OH

Emily Kennedy Dentist OH

Christine Reynolds Advanced Practice Nurse BH

Name Title DivisionAmanda Sherwood Nurse Practitioner PCMelissa Hollrah Intensive In-Home Specialist BHMonica Beauchamp Community Support Specialist BHRachael Bersdale VP - Adult Behavioral Health BHRachel Pourchot AVP - Adult Behavioral Health BH

Judy Jennewein School Liaison BHMelanie Hampton Pediatrician PCJeffrey Best Community Case Manager/Therapist BH

Current Staff Re-Privileged (during the month of April 2018)

MOTION:“I, ______, move that the Board accept the

April 2018 Credentialing & Privileging Report as presented.”

QIQA REPORT• Continue to work on improvement to the peer review process. Some health insurance partners are

requiring quarterly peer review updates. Katy is monitoring and addressing as issues / concerns / questions come up. Need to have consistency prior to go live with electronic peer reviews.

• Discussed how/what to share on the TVs located in the Physician Offices. Jump drives will be provided to all locations with pre-loaded loops to share information on chronic disease, patient survey results, etc.

• Opioid Dispensing Monitoring: Dr. Turner has implemented a process to review prescribing practices and address outliers / issues with the prescribing physician. Dr. Turner also will be discussing this in the Primary Care Provider meeting.

• Darlene, Katy, and Patty did a fantastic job of completing the QIAQ website! The new site has a link to launch the tracking tools for PDSA’s and Quality Measures.

• Review of quality measures shows positive trend for all tracked items

• IT IS IMPERATIVE THAT WE HAVE INCREASED BOARD USAGE OF COMTREA’S SERVICES! We have to maintain at least 51% of board members within a rolling 2 years to be using / or have used Comtrea’s services.

QIQA REPORT - MPCA QUALITY MEASURES

“I, ___, move that the Board approve the April 2018 QIQA Coordinating Council Report.”MOTION:

Name Target Result Mar 2018 Result Apr 2018Result Trailing Year Mar 2018

Result Trailing Year Apr 2018

Hypertension Controlling High Blood Pressure (NQF 0018) 55.0% 82% 78% 77.0% 78%Child Weight Screening / BMI (NQF 0024) 50.0% 96.8% 97.8% 97.0% 96.7%Child Weight Screening / Nutritional Counseling (NQF 0024) 15.0% 62.9% 67.4% 62.3% 63.1%Child Weight Screening / Physical Activity (NQF 0024) 8.0% 46.0% 57.6% 34.8% 36.5%Tobacco Use: Screening and Cessation (NQF 0028) 80.0% 97.1% 96.2% 96.4% 96.2%Cervical Cancer Screening (NQF 0032) 60.0% 42.4% 43.0% 36.8% 37.1%Colorectal Cancer Screening (NQF 0034) 40.0% 53% 43.1% 42.3% 42.3%Use of Appropriate Medications for Asthma (NQF 0036) 75.0% 100.0% 75.0% 84.6% 79.3%Diabetes A1c > 9 or Untested (NQF 0059) 25.0% 22.4% 31.1% 36.0% 37.3%

Screening for Clinical Depression and Follow-Up Plan 12-17 yrs (NQF 0418) 2.3% 67.2% 77.8% 52.4% 52.2%

Screening for Clinical Depression and Follow-Up Plan 18+ yrs (NQF 0418) 2.4% 85.9% 82.7% 76.4% 75.7%BMI Screening and Follow-Up 18+ Years – 2 BMI Ranges (NQF 0421 –CMS69v4) 75.0% 85.7% 84.0% 83.6% 83.2%

TEAL color indicates quality measure target achieved

DISCUSSION ITEMS

INFORMATIONAL

MONTHLY REPORT TO THE BOARD

Building and Grounds Capital Campaign Marketing & Events

BOARD MEMBER

RECRUITMENT

OLD BUSINESS

FOR DISCUSSION

NEXT SCHEDULED BOARD MEETING

THURSDAY, JUNE 14TH 7:30AM -10:00AM

Full Board Strategic Planning & Budget Overview

MONDAY, JUNE 18TH 7:30AM

Regular Board Meeting

ADJOURNMENT

“With no further business to discuss, I, ______, move that the Board adjourn.”

MOTION:

21 Municipal DriveArnold, M O 63010

LOCATION+1 636 933 2700

PHONE NUMBERwww.comtrea.org

WEBSITE FACEBOOKhttps://www.facebook.com/COMTREA/

board meeting - comtrea › files › board › june 2018 board...turner, patty vanek) sue. ongoing....

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