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150 Cross Street Akron, Ohio 44311
www.cssbh.org
2016 Annual
Report
Quality Improvement and Compliance
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Quality Improvement and Compliance 2016 Summary
Community Support Services, Inc. serves as the premiere non-profit behavioral healthcare provider for Summit County and the surrounding communities. The agency offers a comprehensive array of holistic services to promote wellness for persons with severe and persistent mental illnesses.
The Quality Improvement and Compliance (QIC) Annual Report is presented to stakeholders of Community Support Services, Inc. in an effort to demonstrate excellence in service provision as a result of continuous performance monitoring and quality improvement.
The QIC Annual report has been designed to provide a snapshot of services and programs offered in 2016, while providing a summary of Quality Improvement initiatives and reported measures for the year. The QIC Annual Report highlights our efforts and demonstrates the agency’s progress in meeting QIC expectations and best practices during the year.
During the year, the agency embarked on an initiative to provide services coupled with the Trauma Informed Care Model to increase effectiveness of all program services. Moving forward to 2017, continued implementation of Trauma Informed Care practices and a Zero Suicide initiative, will lead to improved client satisfaction and client outcomes agency wide.
Additionally, Quality Improvement (QI) has made efforts to collaborate with Information Technology Services to streamline QI indicators and program service reviews to continue improving efficiency in the monitoring process while incorporating data collection for Healthcare Effectiveness Data and Information Set (HEDIS), Physician Quality Reporting System (PQRS), and Medicare Access and CHIP Reauthorization Act (MACRA). Further adoption of these measures in 2017 will lead to better continuity of care among Primary and Behavioral Health Care services.
TA B L E OF C ONTENTS :
I. PROGRAMS & SERVICES
CPST & Specialized Services
Forensic & Employment
Rehabilitative Services
Residential Services
Client Advocacy
II. QUALITY IMPROVEMENT &
COMPLIANCE (QIC) COMMITTEE
2016 REPORTED INDICATORS
QIC SUB-COMMITTEES
III. WHO WE SERVE
AGENCY CASELOAD
SERVICE PROVISION & AGENCY STAFF
MENTAL HEALTH DIAGNOSIS
CLIENT DEMOGRAPHICS
IV. 2016 QUALITY
IMPROVEMENT & COMPLIANCE SUMMARY
V. IN THE COMMUNITY
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Programs and Services
Page 1
Figure 2. Distribution of Specialty CPST
Team’s caseload. (December 31, 2016)
Figure 1. Distribution of the agency CPST
caseload according to Program CPST
service. (December 31, 2016)
Forensic
4%
Regional
66.7%
Specialty
25.3%
Homeless
4%
CPST Services By Program
COMMUNITY PSYCHIATRIC SUPPORTIVE TREATMENT (CPST) AND SPECIALIZED
SERVICES
Community Psychiatric Supportive Treatment (CPST) (Group and Individual Treatment) provides clients
with Individualized Service Plans including interventions
that address daily living skills, resource acquisition,
medication management, etc. Community
Rehabilitation Specialists (CRS) advocate and support
the client in their recovery by coordinating care to
achieve the most effective outcomes. Regional
treatment team caseloads are based on client’s
geographic location (see Figure 1).
Assertive Community Treatment (ACT) services are provided by the Assertive Community Treatment Team to clients with more intensive needs requiring frequent community contact to maintain stability and by the Intensive Treatment Team (ITT) to clients that are
younger adults (see Figure 2).
Substance Abuse and Mental Illness Program of ACT
(SAMI-PACT) provides wrap-around services for persons
with significant mental health and substance use
concerns; the agency implements the principles of the Integrated Dual Diagnosis Treatment (IDDT)
model. This evidence based practice employs motivational interviewing techniques and a stage of
change model to provide community-based services to
address the unique needs of persons with severe
mental illnesses and significant substance use disorders
(see Figure 2).
Geriatric and Long Term Care team strives to ensure the
highest quality of life for the older adult. The
specialized team includes Community Rehabilitation
Specialists, Geriatric Psychiatrists, Advanced Practical
Nurse and a Long-Term Care Services Administrator.
Comprehensive treatment and mental health
evaluations are provided for persons living in the
community and/or residing in extended care facilities.
The team utilizes a treatment approach based on the
strengths and needs of the individual while encouraging
family involvement in their loved one’s treatment (see Figure 2).
ITT 13%
SAMI 15%
ACT 15%
GER 36%
ENG 12%
Specialized Team's Case Load
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Programs and Services
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Engagement Service Specialists provide outreach CPST using various resources to locate and engage
clients who have not consistently participated in treatment. Once re-engaged, clients learn to minimize
treatment barriers in order to transition to traditional CPST and psychiatry services.
HOME Choice, is a program provided by the Geriatric team. A Transition Coordinator assists eligible
older adults and persons with disabilities in the transition
from a facility-based placement to a home in the community.
Supports include locating housing, coordinating benefits, and
obtaining referrals for additional supports and services to
ensure a successful transition into the community.
SSI Project provides service to individuals through trained staff members who have extensive knowledge
of the benefit application process. The goals of the program are to expedite the SSI (Supplemental
Security Income) and SSDI (Social Security Disability Insurance) application process, reduce barriers and
increase the number of disabled adults receiving SSI/SSDI benefits for the first time.
Liaison workers provide Community Psychiatric Supportive Treatment for persons receiving behavioral
health services at Portage Path Behavioral Health.
Representative Payee services assist individuals who are financially negatively impacted by symptoms of
their mental illness to manage their funds. Clients who are at risk of losing housing, utilities and other
basic needs can elect to have Community Support Services designated as their representative payee for
Social Security benefits in order to maintain independent living.
Intake workers conduct Clinical Evaluation Assessment interviews with persons referred for public
mental health treatment. Intake workers determine a person’s eligibility to receive services at either
Community Support Services, Inc. or at Portage Path Behavioral Health.
Assessment specialists provide the initial contact with the agency after referral from Adult Mental
Health Admissions. Through an in-depth assessment, specialists determine the unique strengths, needs,
abilities and preferences of each consumer in an effort to link them to appropriate agency programs and
services, and other community based resources.
FORENSIC AND EMPLOYMENT SERVICES
Forensic Assertive Community Treatment (FACT) is an ACT team designed to service individuals who have
severe and persistent mental illnesses with psychosis, extensive criminal history, and a current
misdemeanor charge, Persons eligible for FACT services are court ordered to participate in the program.
Persons with sexual offenses and/or persons designated as a registered sex offender are not eligible for
the program. Persons referred to FACT must be assessed by the FACT team to determine eligibility prior
to the court ordering the person to FACT.
Forensic and Mental Health Court (MHC) teams specialize in serving clients involved with the criminal
justice system (see Figure 3). Forensic Services are provided to clients deemed “Incompetent to Stand
Trial” and continues throughout the inpatient competency restoration process and to clients who are
found “Not Guilty by Reason of Insanity”, supporting clients during Conditional Release. The MHC team
Home Choice Services 2016
Number of Individuals Served: 37
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Programs and Services
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RHO 13%
Fact 28%
MHC 22%
Conditional
Release 33%
All Other
Forensic
3.8%
Forensic Caseload
Figure 3. Distribution of the Forensic CPST Team’s
caseload. (December 31, 2016)
provides service to individuals facing qualifying misdemeanor charges in Akron, Stow and Barberton
Courts.
Returning Home Ohio (RHO) is a permanent
supportive housing program that targets
offenders released from the Ohio Department
of Rehabilitation and Correction (ODRC) state
institutions who are identified as homeless or at
risk of homelessness upon release and fall into
one of 2 categories: 1) Severe and persistent
mental illness (SPMI) with or without a co-
occurring disorder; 2) HIV with or without a
SPMI. RHO is a collaborative program with
ODRC and Corporation for Supportive Housing
(CSH) created to prevent homelessness and
reduce recidivism in this population. RHO offers
a cost effective combination of safe, affordable
housing with a range of supportive services that
helps participants live stable, independent and healthy lives. Linkages and partnerships with local
resources and community organizations provide additional options for services and continued rental
subsidy which are essential to the program.
Referrals can be accepted for an offender up to 120 days post release. Priority is given to offenders
identified as being most likely to require supportive services in order to maintain housing and stability.
Referrals are also accepted from community providers such as homeless shelters, Projects for Assistance
in Transition from Homelessness (PATH) teams and halfway houses.
Crisis Intervention (CIT) provides immediate intervention for individuals who may be experiencing acute
mental health symptoms. CIT staff works with Sherriff’s Deputies and Police Officers from local
communities to intervene and promote mental health treatment.
Vocational and Employment services help to identify career interests as well as barriers to employment. The program(s) focuses on helping individuals secure and retain employment. Referrals are accepted from Community Support Services, Child Guidance & Family Solutions, Community Health Center, and Portage Path Behavioral Health.
Supported Employment (SE), an evidence-based practice, emphasizes consumer preferences, rapid job search and placement, integration with mental health services, benefits advocacy, and time-unlimited supports to help persons with mental illness find competitive jobs in the community. Consistently, research has demonstrated Supported Employment programs are effective in helping individuals with severe and persistent mental illnesses secure and retain employment.
Supported Employment offers guidance through all phases of the process of obtaining employment; discussion of work-readiness, benefits planning, assessment of interests, job search support, resume writing, application assistance, interviewing, and job coaching follow-along support at the job site.
Supported Employment 2016
Number of New Job Starts: 84
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Programs and Services
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GroupHomes
SafeHavens
Vet SafeHaven
MadalinePark I
MadelinePark II
N.CoastApts
2016 Census based on MaxCapacity
81% 97% 76% 97% 97% 99%
0%
20%
40%
60%
80%
100%
Residential Services and Housing Facilties
Figure 4. Residential Services; Residential/Group Home Treatment,
Supportive and Independent living facility’s census (December 31, 2016).
REHABILITATIVE SERVICES
The Medication Clinic serves clients who are prescribed injectable psychiatric medications. Clinicians are
specially trained to address pharmacological issues and guide clients through Ohio’s Central Pharmacy
and other patient assistance programs to ensure continued availability of medications.
Pharmacological Management is comprised of community and clinic nursing, psychology, inpatient and
outpatient psychiatry, and medication prescribing and monitoring.
The Margaret Clark Morgan Integrated Care Clinic offers clients physical healthcare and preventive
screenings. A clinic, laboratory and Klein’s Pharmacy comprise the Primary Care Clinic. The staff
includes a physician, nurse practitioners, registered nurses, podiatrist, medical assistants and dietician.
The Primary Care Clinic has served as a training site for nursing and other healthcare related students
and has formed many collaborative efforts with the Summit County Health Department to provide
comprehensive health services to our consumers.
Health and Wellness Services are provided under a Substance Abuse Mental Health Services
Administration (SAMHSA) grant and focuses on the integration of primary and behavioral health while
emphasizing wellness. Available on-site is yoga, smoking cessation, health and wellness education, and a
dietician. Additionally, Recovery Specialists work with clients at the YMCA three days a week and end
the week with a Walk with a Doc©.
RESIDENTIAL SERVICES
Residential Services
includes Group Home,
Supportive and
independent living
facilities (see Figure 4
for 2016 Census).
Residential Services
also assists individuals
with placement into
proprietary group
homes and offers
Housing Assistance and
Loan Assistance
Programs (HAP & LAP).
Homeless Outreach
identifies and engages homeless individuals who may benefit from mental health treatment. The
Homeless Outreach Team works with clients in referral status until they are determined eligible for
active agency services and ready to transition to traditional CPST teams or are linked to other treatment
options (see Figure 5).
Supportive Services for Veteran Families (SSVF) is a grant funded program by the U.S. Department of
Veteran Affairs. Outreach efforts, case management services and assistance in obtaining benefits are
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Programs and Services
Page 5
Figure 5. Client’s agency status for
Homeless Outreach’s caseload. (December
31, 2016)
provided by the Homeless Outreach team to Veteran families that without assistance would likely be
homeless.
In 2015, The Veteran’s Safe Haven was opened, a
Housing First program aimed to provide housing and
stabilize veterans who are Chronically Homeless with
Severe and Persistent Mental Illness. The ultimate goal
of this program is to link program participants to
permanent housing and services. All program
participants must be Veterans who were honorably
discharged and have a severe and persistent mental
illness.
Cooperative Agreement to Benefit Homeless Individuals (CABHI)-is a new program service offered by the Homeless Outreach team in 2014. The Substance Abuse and Mental Health Services Administration (SAMHSA) funds the program with a goal of enhancing and/or increasing critical services for chronically homeless individuals with substance use disorders, serious mental illness and those with co-occurring substance use and mental illnesses. Services are provided to help individuals access permanent housing, benefits, comprehensive treatment and recovery oriented supports.
Intensive Treatment Services offer an array of recovery-based therapies including group sessions that provide psycho-education and promote the development of social skills, functional abilities, coping mechanisms and other tools that enhance independence.
Art Therapy uses the art media, the creative process, and the resulting artwork to explore feelings, reconcile emotional conflicts, foster self-awareness, manage behavior and addictions, develop social
skills, improve reality orientation, reduce anxiety, and increase self-esteem. Art therapy may be offered in group and individual formats.
The overall aim of art therapists is to enable a client to effect change and growth on a personal level through the use of art materials in a safe and facilitating environment through individual and/or group sessions.
Individual and Group Counseling sessions, led by licensed clinicians, provide more in-depth and focused attention on unique issues. Counseling often is provided over a shorter term to address temporary concerns and crises.
Art Therapy Services 2016
Number of Individuals Served: 35
Referral
77%
Active
23%
Homeless Outreach Case Status
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Programs and Services
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Table 2. Grievances/Complaints by
Subject/Department (2016-2014)
Resolutions 2014 2013 2012 2011 2010
Explanation Given 103 107 112 110 Referral Made 2 1 0 2 Treatment Revised 16 29 24 20 Staff Correction/Discipline 1 3 2 3 Policy Recommendation 0 1 1 0 Withdrawn/No Response 19 10 8 9
Total 141 151 147 144 Table 2. Grievances/Complaints by Resolution
2014-2010
Table 1. Grievances/Complaints by
Source 2016-2014
Table 3. Resolutions (2016-2014)
Resolutions 2014 2013 2012 2011 2010
Explanation Given 103 107 112 110 Referral Made 2 1 0 2 Treatment Revised 16 29 24 20 Staff Correction/Discipline 1 3 2 3 Policy Recommendation 0 1 1 0 Withdrawn/No Response 19 10 8 9
Total 141 151 147 144 Table 2. Grievances/Complaints by
Resolution 2014-2010
CLIENT RIGHTS AND ADVOCACY
One hundred twenty-eight (144) complaints were filed in 2016 (see Table 1). There has been a significant
increase in the number of grievances filed by Client and Family since last year as well as an increase
grievances related to Payee ship and financial matters.
As complaints regarding payee ship and financial
issues increased during 2016 it was noted that
changes in payee/finance processes and
department staffing were suspected reasons for
the increase. The payee staffing has stabilized and
a reduction in these types of complaints are expected for 2017. Also noted, it is often a challenge to
differentiate between payee and Community Rehabilitation Specialist complaints. This is due to the
perception of the source.
SUBJECT / DEPARTMENT
2016 2015 2014
Another Client 4 1 1 CPST 49 55 30
Payee/Finance 55 28 41 Pharm Mgmt. 11 8 11
Front Desk/Support 3 0 2 Residential 6 3 9 Vocational 0 0 1
Whole Agency 3 2 1 Outside 1 0 9
Homeless Outreach 3 1 7 Counseling 0 2 1
Billing 0 4 0 Other 9 9 15
Total 144 113 128
ORIGINATION SOURCE
2016 2015 2014
Client 126 103 122 Family 13 5 0
Ohio Legal Rights 0 0 0 Other Agency 3 1 1
ADM Board 0 0 0 Primary Care Clinic 0 NR NR
CSS Staff 2 4 5 Total 144 113 128
RESOLUTIONS
2016 2015 2014
Explanation Given 117 90 101 Referral Made 1 0 0 Treatment Revised 10 17 19 Staff Correction/Discipline 3 1 1 Policy Recommendation 0 0 1 Withdrawn/No Response 14 5 6
Total 145 113 128
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Quality Improvement and Compliance - 2016
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Figure 6. Quality Improvement Plan Indicators
2016-2014
Figure 5. 2014 PI Plan Indicators
Table 4. PI Plan Indicator by key area category as: Reported, Deferred or Under Development in
2016 (some indicators measure more than one key area and/or were reported more than once)
Table 4. PI Plan Indicator by key area category as: Reported, Deferred or Under Development in
2014
*Some Indicators deferred during 2016 are under consideration for removal/revision in 2017
The QUALITY IMPROVEMENT & COMPLIANCE program has been established by the Board of Directors.
The policies of the Board authorize the Chief
Executive Officer to establish a QUALITY
IMPROVEMENT & COMPLIANCE Program and an
Agency wide QUALITY IMPROVEMENT &
COMPLIANCE Committee.
The purpose of the Quality Improvement and
Compliance Program is to continually monitor and
evaluate the quality and appropriateness of clinical,
administrative and support services provided by
Community Support Services, Inc. These efforts
ensure that effective, efficient and high quality care
is delivered to individuals served by the agency.
2016 REPORTED INDICATORS
To determine and evaluate important aspects of clinical care one-hundred and thirty-nine (139)
outcome indicators were reviewed by the QUALITY IMPROVEMENT & COMPLIANCE Committee in 2016
(see Figure 6).
Analysis of these indicators affords the QUALITY IMPROVEMENT & COMPLIANCE committee the
opportunity to assess risk, identify potential problems and identify areas requiring or showing
improvement. To stay on target, the QUALITY IMPROVEMENT & COMPLIANCE Committee constantly
monitors and assesses performance against a series of indicators and goals. Indicators are based on
service delivery performance and are categorized in four key areas: Effectiveness, Efficiency,
Accessibility and Satisfaction (see Table 4).
Indicator Category
Total Number Reported to
QUALITY IMPROVEMENT & COMPLIANCE
*Number of Indicators Deferred
Number of Indicators Under Development
Efficiency 28 6 3
Effectiveness 79 3 4
Accessibility 26 0 2 Satisfaction 7 2 0 Peer Review 4 0 1
Target/Compliance 4 0 0
Total 139 11 10
0306090
120150180
PIC Reviewed Deferred UnderDevelopment
Quality Improvement Plan Indicators
2016 Indicators
2015 Indicators
2014 Indicators
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Quality Improvement and Compliance - 2016
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Effective 31%
Efficient 4.8%
Accessibility
14.3%
Satisfaction
4.8%
2016 Improvement by CARF Standard
Figure 7. Reported Quality Improvement by Quarter
2016
Figure 6. 2014 Reported Quality Improvement by
Quarter
Figure 8. Reported Quality Improvement by
CARF Standard 2016
Figure 7. 2014 Reported Quality
Improvement by CARF Standard
3 2 2
28
14
10
16
9
2 4 3 4 2 1
0
5
10
15
20
25
30
100% 90-99% 80-89% Below 80%
Reported Indicators by Threshold Range
Efficiency
Effectiveness
Accessibility
Satisfaction
Compliance
Figure 9. Quarterly Reported Indicators by Compliance Threshold Range 2016
Figure 8. 2014 Quarterly Reported Indicators by Compliance Threshold Range
Overall, there was more than a 60% improvement (see Figure 7) among indicators that were reported
below the targeted threshold in 2015. Again, in 2016, indicators measuring effectiveness were reported
to have the greatest improvement in 2016 (see Figure 8).
Eighty-One percent (81%) of all reported indicators were reported to be at or above the Eighty percent
(80%) compliance threshold range (see Figure 9). Indicators not at or above the desired threshold are
subject to further review by the QUALITY IMPROVEMENT & COMPLIANCE committee and a plan of
action is developed to improve outcomes and performance.
2015 Improvement by CARF Standard
2014 Improvement by CARF Standard
67%
68%
48% 33%
61%
0%10%20%30%40%50%60%70%80%
2016 Indicator Improvement
Improvement
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Quality Improvement and Compliance - 2016
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Table 5. Quarterly compliance and Utilization Reviews conducted
in 2016
During the year, Utilization/Compliance Reviews were completed as scheduled. A couple of additional
utilization and target reviews were also conducted for baseline reporting (see Table 5.). These baseline
reports help in the development of meaningful indicators for Quality Improvement monitoring in 2016.
In comparison to the number of cases reviewed in the previous year, there was an eleven-percent (30%)
increase in the number reviewed
during 2016.
REVIEW PROCESS NUMBER CASE FILES REVIEWED
Quarterly Compliance 660 Target & Utilization 515
Psychiatric Inpatient 454 Program Outcomes 290
Nursing Services 100 Peer Review 88
Finance 72
Total *2,179
*Some of the cases reviewed may have been reviewed under more than one
process; the total number does not represent a unique case count.
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Quality Improvement and Compliance - 2016
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4 7 9
26
14 13
1
20's 30's 40's 50's 60's 70's 80+
Deaths by Age -2016
Deaths by Age
Figure 10. Client Deaths based on age at time of
death; 2016
QUALITY IMPROVEMENT & COMPLIANCE SUB-COMMITTEES
CLIENT CARE MONITORING
There were seven challenging cases presented to the Client Care Monitoring Committee (CCMC) during
2016. Seventy four deaths were reported this year. (73 in 2015) There has been one death investigation
reviewed to date, with two in process, and one only recently requested.
Case presentations decreased by nearly 75% since 2014. There were a variety of client issues reported,
including outpatient commitment, behavioral, and review of diagnoses in order to clarify primary issues.
The Clinical Alert for Problematic Behaviors was put in place twice this year for two clients based on
CCMC recommendations.
Deaths increased from 55 in 2014 to 73 in 2015 to 74
this year. The majority of the deaths were individuals in
their 50’s. Medical issues were generally the cause of
death based on the Major Unusual Incident Report.
There were six heroin overdoses or suspected
overdoses, and two suicides this past year. Very few
Medical Examiner Reports are completed and/or
received as the death is usually clearly due to
natural/physical health causes.
Level of care was discussed early in the year after
review of a Death Investigation raised concerns. There
is a critical need to have levels of care in place for all
clients so that clients receive the appropriate level of
services based on their clinical needs and risks. All staff had refresher training on how to determine the
levels. As we move forward with managed care, we need to pay even greater attention to levels of
care.
COMPLIANCE AND RISK MANAGEMENT
The Compliance and Risk Management (C&RM) Committee continues to review indicators related to
clinical documentation and utilization for compliance to established clinical best practices and agency’s
policies and procedures (see Figure 21). Chart reviews, with indicators related to treatment planning,
service provision and client progress were reviewed to determine if the staff members were adhering to
aforementioned practices. Chart reviews were conducted on all treatment teams which revealed that
progress was made and that there is room for more improvement. A specialized chart review was
conducted to examine the effectiveness of Group CPST Services which are provided in the following
programmatic areas: Partial Hospitalization, ITS, FACT, SAMI PACT, and ITT. All programs demonstrated
areas of strength and need for improvement. All programs need to continue to review the admission /
discharge criteria, work on curriculum / activities to keep clients engaged, and develop indicators to
monitor progress.
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Quality Improvement and Compliance - 2016
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4
33
3
2
1
0 10 20 30 40 50
Efficiency
Effectiveness
Accessibility
Satisfaction
Utilization…
Number of Indicators reported to ROC in 2016
Number ofIndicators
Figure 12. Indicators reported to Research & Outcomes
Committee during 2016 according to CARF standard
Figure 11. Indicators reported to Research & Outcomes
Committee according to CARF standard
Figure 21. Number of indicators reported to C&RM by
quarter during 2016 according to CARF Standard
0
10
20
30
40
50
Number of Indicators Reported to C&RM in 2016
2016Indicators
A termination summary review was
completed and the review indicated a 100%
of the summaries were completed and in the
record. However, teams should make sure all
outreach efforts are made & referrals are
made to the Engagement Team to utilize all
efforts to engage clients before cases are
terminated.
HIPPA Risk Assessment is being conducted to
ensure compliance with HIPPA regulations.
RESEARCH AND OUTCOMES
The Research and Outcomes committee (ROC) met four (4) times in 2016 and reviewed results on Forty-Three (43) indicators primarily related to effectiveness standards (see Figure 12). During the year, one research proposal was reviewed and approved from the County of Summit Alcohol, Drug Addiction and Mental Health Services Board in concert with Kent State university titled: “WHAT
IMPACT DO REIMBURSEMENT MODELS, POLICIES, & INTERVENTIONS, INCLUDING PPLAT’S HAVE ON SOCIETAL OUTCOMES (E. G. ARREST, INCARCERATION, AND HOSPITALIZATION) AND COSTS?” This is targeted for completion in 2017. This committee continues to review the variables regarding individuals hospitalized for psychiatric
reasons to both reduce the initial hospitalization, as well those that are subsequently re-hospitalized.
Although our number of individuals hospitalized is minimal, we continue to look for ways to improve
even further.
This committee is in process of revamping our currently measured indicators to be consistent with the
Medicare Access and CHIP Reauthorization Act (MACRA) variables now required for agencies to measure
beginning 2017.
We have begun reviewing the Fidelity measures of all our Evidence Based Best Practices as evaluated
through the Coordinating Center of Excellence currently consisting of our Assertive Community
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Quality Improvement and Compliance - 2016
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Treatment Teams and Supported Employment. Additionally, several of our services provided to and
reviewed by the Veteran’s Administration are analyzed.
Additionally, this committee reviews measures regarding the success of our Primary Care Clinic in
helping individuals in managing key vital signs such as blood pressure, A1C levels and weight. To assist in
this effort, services geared towards a healthier lifestyle such as smoking cessation, “Walk with a Doc”,
Dietician services, Optical services, Dental services, HIV and Podiatry are reviewed.
This is an active committee where much work is conducted between meetings geared toward continual
analysis and improvement of our services all targeted to improve outcomes for those we serve.
RECOVERY ADVISORY COUNCIL
In 2016, there were six Recovery Advisory Council (RAC) meetings. Attendees presented news articles
on mental health-related interests as well as shared their artistry with the group. RAC developed LIFE
CHAT, a publication born from the quarterly RAC newsletter to include contributions from the Health &
Wellness Department and the Art Therapy program. In an effort to reach more consumers, the
distribution of LIFE CHAT was increased with the mailing of the newsletter to all active consumers’
homes. The intent of the mass mailings has been to increase the exposure of CSS services and those of
other resources in the Akron area, all of which can help in the consumers’ recovery and draw interest to
other readers who would otherwise not be informed.
Numerous surveys were presented for review during RAC meetings, including: Agency Satisfaction;
Family/Significant Other Satisfaction; Accessibility of Service; Work Tech Employer Satisfaction; Internal
Referral Source; and External Referral Source. Also, RAC completed the consumer sections of the tool,
Creating Cultures of Traumatic Informed Care Program Fidelity Scale, to begin giving more attention to
trauma informed care at CSS.
RECOGNITION & RETENTION
The committee met nine times in 2016. 417 Catch the Spirit awards were given. A survey for eliciting
feedback on committee pursuits for 2016 was
completed. Softball returned. A summer picnic was
planned and organized. A Rubber Ducks outing and four
additional events were hosted.
INCLUSION & DIVERSITY
During 2016, an Ambassador program was implemented. Each committee member is considered an
ambassador for the agency and a representative of the core values: Honesty, Respect, and Trust.
Committee members are dedicated to meeting with new staff within the first sixty days of employment
to welcome the staff to the agency and to review the inclusive behaviors of the committee. The
Inclusion Moments initiative was created. The goal is for a staff member to recognize a fellow co-worker
when the employee models the identified inclusive behaviors. The program was initially rolled out and
Staff earned 417 Catch the Spirit Awards during 2016
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Quality Improvement and Compliance - 2016
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Figure 13. Number of Hours Staff Dedicated to
Training. (2013-2016)
Figure 13. Number of Hours Staff Dedicated to
Training. 2014-2010
0
1000
2000
3000
4000
Web BasedExternal
Training Hours Completed in 2016
2016
2015
2014
2013
introduced during the All Staff meeting is the last quarter. Cultural Diversity day was in September and
determined to be successful. The Inclusion Committee has officially changed its name to the Inclusion &
Diversity Committee to acknowledge the work the committee is doing to address the ongoing changing
demographics of our staff and the individual served.
STAFF TRAINING & EDUCATION
Staff Training & Education provided seven
internal trainings in 2016. There were a
total of 5.5 continuing education hours
available to all staff members of
Community Support Services, Inc. to help
staff learn more about human trafficking in
the Summit County community and to
increase our awareness of the importance
of Self-Care. Three of the internal sessions
were geared towards the Assertive
Community Treatment teams to reinforce
the ACT fidelity model. The sessions were
facilitated by the Coordinating Center of Excellence at Case Western Reserve University.
The agency continues to provide training and ongoing supervision in HYCBt-p for persons with
psychosis. The Intensive Treatment Team participated in a partnership with the Traumatic Stress Center
at Summa Health for screening and identification of individuals that have experienced trauma any time
through the lifespan.
Clinical and non-clinical staff completed 1,286 hours external training hours.
3,362.25 hours of web-based learning were completed in 2016 as part of the agency’s annually required
trainings and CEU-based trainings for licensed staff.
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Quality Improvement and Compliance - 2016
Page 14
HEALTH & SAFETY
There were one-
hundred and forty-
seven (147) Safety
Inspections generating
four hundred and
eighty-six (486) Safety
Work Orders. All
deficiencies were
corrected. The Safety
Director reviewed Two-
Hundred and Seventy-
Five (275) Major
Unusual Incident (MUI)
reports during 2016
(see Table 6).
75% of Death Related
MUI Reports
documented a known
cause of death, a 15%
increase from 2015.
The majority of death
cases were reportedly
in their 50’s.
In non-death related
MUI’s there was an
increase in reported
medication errors.
These incidents were
noted to have occurred
at the pharmacy level.
The increase in Verbal
& Physical Aggression
category is likely due to
the classification
process of MUI’s.
Efforts to consistently
categorize these types
of occurrences will be
made in 2017. The
continued decrease in Code Green incidents is noted to be largely due to the presence of The Akron
Police Department in the Med Clinic and Cross Street; client lobby area. Continuous efforts are made
2016 2015 2014
WORK ORDERS & INSPECTIONS
Work Orders 176 Not Reported Not Reported
Safety Work Orders 486 Not Reported Not Reported
Completed Inspections 147 Not Reported Not Reported
Completed Drills 211 Not Reported Not Reported
MAJOR UNUSUAL INCIDENT (MUI) REPORTS
Death Related:
Unknown Cause 18 26 27
Illness/Natural Cause 46 39 30
Suicide 2 5 0
Suspected/Confirmed Heroin OD 6 2 0
Homicide 1 1 0
Non-Death Related:
Other 58 52 37
Verbal Aggression 16 32 22
Illness 28 27 26
Fall 25 23 29
Physical Aggression 18 20 24
Property Damage/Loss 16 14 20
Injury 10 8 10
AWOL 7 5 3
Non-Participation in Drill 9 5 7
Suicide Threat 6 5 6
Medication Error 16 4 12
Auto Accident (Staff) 10 4 16
Verbal &Physical Aggression 30 2 0
Alleged Criminal Activity 4 1 5
Infection Control 0 1 4
Seizure 5 1 6
Suicide Attempt 1 1 6
Alleged Abuse/Neglect 2 1 4
Weapon 2 1 4
Alarm 2 0 5
Code Red (Fire) 2 1 1
Code Blue (Medical) 1 3 10
Code Green (Behavior) 1 1 6
Code Black (Tornado) 0 0 0
Total of all MUI Reports 269 280 273
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Quality Improvement and Compliance - 2016
Page 15
agency-wide to reinforce the prompt completion of incident reports for all required situations as well as
for other concerns that may warrant further review.
In 2016, health and safety related indicators were continued to be reported quarterly. This monitoring has
assisted Quality Improvement in recognizing the issues facing staff and clients and has improved overall
awareness of safety matters across the agency.
CREDENTIALING
FQHC related credentialing and privileging was completed for approximately 80 providers. Processes
and policies were updated for FQHC related compliance.
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Quality Improvement and Compliance - 2016
Page 16
COMMITTEE MEMBERS
Allyson Haley
Barbara Krannich
Becki Thompson
Bruce Winer
Christian Ritter
Cindy Johnson Crystal Dunivant
Danya Bailey
Denise Cunningham
Denise Ronk
Dorothea Hilson Doug Wagner
Dr. M. Elahi
Duane Perry
Ed Casey
Eileen Schwartz
Fran Thomas Frank Sepetauc
James Karpawich
Jan Jones
Janet Catalano
Janet Swartzel
Jerry Shadley
Joanna Hewett Jon Garey
Julie Morehead
Kay Bowman Keith Stahl
Kim Hartman
Kim Meals Kristi DeArmitt
Lee Snyder
Linda Omobien
Lora Walker
Michele Nepsa
Michell Montgomery
Mike Greenfelder Nancy Mackey
Narkeetah Brazil
Natasha Westfall
Patricia Henderson
Patricia Rohlender Penny Moore
Shaunta Scruggs
Stephanie Sanders
Stephen Maddox
Steve Rastetter
Susan Ritz
Tasha Young Terry Dalton
Tim Edgar
Tom Baker
Tracy Prohaska
The Quality Improvement Program would like to
thank each person who served on a standing
committee during 2016.
Your participation is GREATLY appreciated!
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Who We Serve
Page 17
Figure 14. Agency Caseload (2016-2013).
Figure 10. Agency caseload 2014-2010
0
1,000
2,000
3,000
4,000
2016 2015 2014 2013
2016 Agency Caseload
Number of Clients
Figure 15. Agency Staff according to Program Role 2016
.2015
21.6%
17.9% 19.6%
9.8%
2.7%
7.8%
4.4% 3.4% 2.4%
7.1%
3.4%
Agency Staff Roles
AGENCY CASELOAD
Community Support Services, Inc.
provided service to 5,857 unique
individuals during 2016.
As of December 31, 2016, there were
3,456 clients on the agency’s caseload
(see Figure 14).
The agency’s caseload continues on
the up rise and is largely due to the
continued addition of new and
expanded agency program services
and our successful efforts to provide
comprehensive health care services,
and quality coordination of care.
SERVICE PROVISION & AGENCY STAFF
During 2016, the agency employed approximately 296 employees. 75% are Direct Service providers
while the remaining, work in administrative and support staff roles (see Figure 15).
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Who We Serve
Page 18
Figure 16. Agency Services (based on hours) provided in 2016-2015
Figure 15. Agency Services (based on hours) provided in 2014
Figure 17. Number of Patient Encounters in 2016
Figure 15. Agency Services (based on hours) provided in
2014
TotalUnique New
PCCPatients
Total newPatients-Podiatry
PrimaryCare andPodiatry
Office Visits
2016 241 38 3496
0
500
1000
1500
2000
2500
3000
3500
4000
Ax
is T
itle
Primary Care and Podiatry
Service provision (based on the total number of documented hours) in 2016 demonstrates that the bulk
of agency services provided are group and individual CPST services, Employment/Vocational, and Social
Recreation (see Figure 16).Many of the comprehensive services the agency provides are supplemental
to traditional and specialty CPST services and are based on crisis events and individual client needs.
The Primary Care Clinic has provided wrap-around healthcare services to 241 new patients, while, 38
new patients received Podiatry services in 2016. Combined, there were 3,496 documented office visits
(see Figure 17), for 1,135 unique patients.
0%
25%
50%
75%
100% Agency Service Provision
2016
2015
*does not include Primary Care Services
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Who We Serve
Page 19
Table 7. Client's Primary Mental Health Diagnosis based on ICD10 Code, 2016
Table 7. Client's Primary Mental Health Diagnosis. 2014
Figure 18. Primary Diagnosis by Schizophrenia Related Disorder;
2016
Figure 11. Axis I primary diagnosis by Schizophrenic Related
Disorder 2014
Paranoid 47.4%
Schizoaffective 41.7%
Unspecified 10.5%
Type of Schizophrenia Related Disorder
DIAGNOSIS
MENTAL HEALTH
According to a National Survey on Drug Use and Health (NSDUH) survey conducted in 2014 by the Substance Abuse and Mental Health Services Administration (SAMHSA), an estimated 43.6 million (18.1%) Americans ages 18 and older experience some form of mental illness. Serious mental illness among people ages 18 and older is defined at the federal level as; “at any time during the past year, a diagnosable mental, behavior, or emotional disorder that causes serious functional impairment that substantially interferes with or limits one or more major life activities”. SAHMSA also reports that “in 2014, there were an estimated 9.8 million adults (4.1%) ages 18 and up with a serious mental illness in the past year”.
According to SAHMSA 1% of the US
population suffers from Schizophrenia. The National Institute of Mental Health indicates that diagnostic records for active cases show that individuals with a diagnosed Schizophrenia related brain disorder account for 38.2% of Mental Health Diagnosis (see Table 7).
These individuals are most often diagnosed with Schizophrenia, Paranoid Type or Schizoaffective Disorder (see Figure 18).
Mental Health Related Diagnosis Number of DX Percentage of DX
Schizophrenia 1329 44.3%
Mood Disorders 551 17.3%
Anxiety Related 629 19.7%
Behavioral & Personality Disorders 490 15.4%
Total 2,999
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Who We Serve
Page 20
Male, 56%
Female44%
Client's Gender
323 413
517
815
538
143
0
200
400
600
800
1000
18-29 30--39 40-49 50-59 60-69 70+
Number of Clients in Age Range
3%
62%
8%
4%
20%
3%
Widowed
Single
Married
Separated
Divorced
No Data
Client's Marital Status
29.0%
47.0%
1.0%
1.0%
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Who We Serve
Page 21
INCOME AND BENEFITS
Monthly Household Income
2016
Below $500.00 4.7% $500.00 - $999.00 70.0%
$1000.00 – 1499.00 17.6% $1500.00 - $1999.00 4.6%
$2000.00 + 3.1%
Client’s Individual Income Source
2016
Wage/Salary 4.0%
SSI 42.2% SSD 49.7%
Retirement 1.7% Welfare/TANF 0.7%
*Other Source Reported 1.6%
Table 10. Client’s Income Source 2016 Table 9. Client’s Monthly Household
Income 2016
*Other sources include: family member, savings, child
support, alimony, disability insurance/ workers comp and
unemployment compensation.
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Who We Serve
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GEOGRAPHIC LOCATION
Clients reside throughout Summit County, but are most concentrated in Akron and surrounding
communities (see figure 23.).
Cuyahoga Falls
8%
Akron 52%
West Akron 17%
Barberton &
Surrounding
Areas 11%
Stow/Tallmadge
4%
Northern Summit County 5%
Southern Summit County 2%
Figure 23. Map of Summit County, Client’s area of residence
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In The Community
Page 23
In 2016, Community Support Services served as an internship/residency site
for seventeen students from social work, counseling, psychology, medical
assistants, and other related programs. These students completed 4801
intern hours. The dollar value of the work completed by students
was $110,759.07. Equally important, these students learned about
Community Support Services and severe mental illness. As they begin their
careers, they will be better positioned to assist others who may be
struggling as well as connect individuals to appropriate services.
Agency staff and clients benefited greatly from the efforts of one dedicated volunteer who performed 302 hours of service. The work of the volunteers had a monetary value of $6,967.14 These individuals provided support services to assist the agency in meeting its goals. Community Support Services, in addition to its volunteers, is grateful for the ongoing dedication of the Board of Directors who collectively donated 513 hours to the agency in 2016.
Community Support Services, Inc. continued to host Lunch with Leaders in 2016 with 27 attendees.
These sessions introduce community leaders to the agency while challenging the stigma associated with
mental illness. The agency also invited adult care providers and apartment managers to an appreciation
luncheon to provide an opportunity to share information about agency services while recognizing them
for being a valuable part of the team. Additionally, the Supported Employment program shared the
power of employment for our clients at a luncheon for potential employers.
The organization maintained its presence in the community in 2016 with fifteen community
presentations reaching 320 people. Additionally, staff and board members represented the agency at
twenty community events such as the Annual NAMIWalk, the WAKR Senior Luncheon series, and the
ADM Recovery Challenge. The agency proudly displayed consumer artwork during the Art of Recovery
event held at Greystone Hall.
Community Support Services continued efforts to increase its presence on social media with more than
300 new followers on Facebook. Additionally, the agency actively engaged with Twitter. The agency
also updated its website in an effort to me more user friendly and provider website visitors with an
opportunity to connect directly with the agency for guidance. In 2016, the agency had more than
28,000 visitors to its website.