Site Self Assessment Evaluation Tool for the Maine Health Access Foundation Integration Initiative

April 2010

MeHAF - Site Self Assessment

Scheirer, M.A., Leonard, B.A., Ronan, L., Boober, B.H. 2008, revised 2010. Site Self Assessment Tool for the Maine Health Access Foundation Integrated Care Initiative. Augusta, Maine: Maine Health Access Foundation.

(Adapted from the PCRS developed by the Robert Wood Johnson Foundation Diabetes Initaitive, www.diabetesinitiative.org, also adapted from the ACIC survey developed by the MacColl Institute for Heatlhcare Innovation, Group Health Cooperative.)

For further information on the MeHAF Site Self Assessment, please see the full document here.

Instructions for Completing the Site Self Assessment (SSA) Survey

This form was adapted from similar formats used to assess primary care for chronic diseases. We would like you to focus on your site’s current extent of integration for patient and family-centered primary care, behavioral and mental health care. The purpose of this assessment is to show you and the MeHAF staff your current status along several dimensions of integrated care. Future repeat administrations of the SSA form will help to show changes your site is making over time. Grantees working with more than one site should ask each site to complete the SSA.

Please respond in terms of your site’s current status on each dimension, as of (date of administration). It is very desirable to obtain input from your team to complete this form, for example, by asking each team member to score it, then discussing the scores in a team meeting, and reaching consensus. If that is not feasible, then the site manager may complete it individually. Please rate your patient care team(s) on the extent to which they currently do each activity for the patients/clients in the MeHAF project. By “patient care team” we mean the staff members that work together to manage integrated care for patients. This often, but not always, involves health care providers, behavioral health specialists and possibly case managers or health educators and front office staff.

Using the 1-10 scale in each row, select one numeric rating for each of the 18 characteristics. If you are unsure or do not know, please give your best guess. NOTE: There are no right or wrong answers. If some of this wording does not seem appropriate for your project, please suggest alternative wording that would be more applicable, on the form itself or in a separate email.

Thank you!

Question Title

* 1. Name of your site:

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* 2. Name of the person completing this SSA form:

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* 3. Your Job Role:

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* 4. Did you discuss these ratings with other members of your team?

Yes

No

Integrated Services and Patient and Family-Centeredness

Choose one number for each question by moving the slider bar to the desired number, or entering it in the box to the right of the bar.

Question Title

* 5. Co-location of treatment for primary care and mental/behavioral health care

Levels:
1: ...does not exist; consumers go to separate sites for services

2-4: . . . is minimal; but some conversations occur among types of providers;
established referral partners exist

5-7: . . . is partially provided; multiple services are available at same site; some coordination of appointments and services

8-10: . . . exists, with one reception area; appointments jointly scheduled; one visit can address multiple needs

1

10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 6. Emotional/behavioral health needs (e.g., stress, depression, anxiety, substance abuse)

(Alternate: If you are a behavioral or mental health site, respond in terms of medical care needs)

Levels:
1: . . . are not assessed (in this site)

2-4: . . .are occasionally assessed; screening/assessment protocols are not
standardized or are nonexistent

5-7: . . .screening/assessment is integrated into care on a pilot basis; assessment results are documented prior to treatment

8-10: . . . screening/assessment tools are integrated into practice pathways to routinely assess MH/BH/PC needs of all patients; standardized screening/ assessment protocols are used and documented.

1

10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 7. Treatment plan(s) for primary care and behavioral/mental health care

Levels:
1: . . . do not exist

2-4: . . .exist, but are separate and uncoordinated among providers; occasional sharing of information occurs

5-7: . . .Providers have separate plans, but work in consultation; needs for specialty care are served separately

8-10: . . . are integrated and accessible to all providers and care manager; patients with high behavioral health needs have specialty services that are coordinated with primary care

1

10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 8. Patient care that is based on (or informed by) best practice evidence for BH/MH and primary care

Levels:
1: . . . does not exist in a systematic way

2-4: . . .depends on each provider’s own use of the evidence; some shared evidence-based approaches occur in individual cases

5-7: . . .evidence-based guidelines available, but not systematically integrated into care delivery; use of evidence-based treatment depends on preferences of individual providers

8-10: . . . follow evidence-based guidelines for treatment and practices; is supported through provider education and reminders; is applied appropriately and consistently

1

10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 9. Patient/family involvement in care plan

Levels:
1: . . . does not occur

2-4: . . .is passive; clinician or educator directs care with occasional patient/family input

5-7: . . .is sometimes included in decisions about integrated care; decisions about treatment are done collaboratively with some patients/families and their provider(s)

8-10: . . . is an integral part of the system of care; collaboration occurs among patient/family and team members and takes into account family, work or community barriers and resources

1

10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 10. Communication with patients about integrated care

Levels:
1: . . . does not occur

2-4: . . . occurs sporadically, or only by use of printed material; no tailoring to patient’s needs, culture, language, or learning style

5-7: . . . occurs as a part of patient visits; team members communicate with patients about integrated care; encourage patients to become active participants in care and decision making; tailoring to patient/family cultures and learning styles is frequent

8-10: . . .is a systematic part of site’s integration plans; is an integral part of interactions with all patients; team members trained in how to communicate with patients about integrated care

1

10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 11. Follow-up of assessments, tests, treatment, referrals and other services

Levels:
1: . . . is done at the initiative of the patient/family members

2-4: . . . is done sporadically or only at the initiative of individual providers; no system for monitoring extent of follow-up

5-7: . . . is monitored by the practice team as a normal part of care delivery; interpretation of assessments and lab tests usually done in response to patient inquiries; minimal outreach to patients who miss appointments

8-10: . . . is done by a systematic process that includes monitoring patient utilization; includes interpretation of assessments/lab tests for all patients; is customized to patients’ needs, using varied methods; is proactive in outreach to patients who miss appointments

1

10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 12. Social support (for patients to implement recommended treatment)

Levels:
1: . . . is not addressed

2-4: . . . is discussed in general terms, not based on an assessment of patient’s individual needs or resources

5-7: . . . is encouraged through collaborative exploration of resources available (e.g., significant others, education groups, support groups) to meet individual needs

8-10: . . . is part of standard practice, to assess needs, link patients with services and follow up on social support plans using household, community or other resources

1

10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 13. Linking to Community Resources

Levels:
1: . . . does not occur

2-4: . . . is limited to a list or pamphlet of contact information for relevant resources

5-7: . . . occurs through a referral system; staff member discusses patient needs, barriers and appropriate resources before making referral

8-10:. . . is based on an in-place system for coordinated referrals, referral follow-up and communication among sites, community resource organizations, and patients

1

10

Clear

i We adjusted the number you entered based on the slider’s scale.

Practice/Organization

Question Title

* 14. Organizational leadership for integrated care

Levels:
1:. . . does not exist or shows little interest

2-4:. . . is supportive in a general way, but views this initiative as a “special project” rather than a change in usual care

5-7: . . . is provided by senior administrators, as one of a number of ongoing quality improvement initiatives; few internal resources supplied (such as staff time for team meetings)

8-10:. . . strongly supports care integration as a part of the site’s expected change in delivery strategy; provides support and/or resources for team time, staff education, information systems, etc.; integration project leaders viewed as organizational role models

1

10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 15. Patient care team for implementing integrated care

Levels:
1:. . . does not exist

2-4:. . . exists but has little cohesiveness among team members; not central to care delivery

5-7: . . . is well defined, each member has defined roles/responsibilities; good communication and cohesiveness among members; members are cross-trained, have complementary skills

8-10:. . . is a concept embraced, supported and rewarded by the senior leadership; “teamness” is part of the system culture; case conferences and team meetings are regularly scheduled

1

10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 16. Providers’ engagement with integrated care (“buy-in”)

Levels:
1:. . . is minimal

2-4:. . . engaged some of the time, but some providers not enthusiastic about integrated care

5-7: . . . is moderately consistent, but with some concerns; some providers not fully implementing intended integration components

8-10:. . . all or nearly all providers are enthusiastically implementing all components of your site’s integrated care

1

10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 17. Continuity of care between primary care and behavioral/mental health

Levels:
1:. . . does not exist

2-4:. . . is not always assured; patients with multiple needs are responsible for their own coordination and follow- up

5-7: . . . is achieved for some patients through the use of a care manager or other strategy for coordinating needed care; perhaps for a pilot group of patients only

8-10:. . . systems are in place to support continuity of care, to assure all patients are screened, assessed for treatment as needed, treatment scheduled, and follow-up maintained

1

10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 18. Coordination of referrals and specialists

Levels:
1:. . . does not exist

2-4:. . . is sporadic, lacking systematic follow-up, review or incorporation into the patient’s plan of care; little specialist contact with primary care team

5-7: . . . occurs through teamwork & care management to recommend referrals appropriately; report on referrals sent to primary site; coordination with specialists in adjusting patients’ care plans; specialists contribute to planning for integrated care

8-10:. . . is accomplished by having systems in place to refer, track incomplete referrals and follow-up with patient and/or specialist to integrate referral into care plan; includes specialists’ involvement in primary care team training and quality improvement

1

10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 19. Data systems/patient records

Levels:
1:. . . are based on paper records only; separate records used by each provider

2-4:. . . are shared among providers on an ad hoc basis; multiple records exist for each patient; no aggregate data used to identify trends or gaps

5-7: . . . use a data system (paper or EMR) shared among the patient care team, who all have access to the shared medical record, treatment plan and lab/test results; team uses aggregated data to identify trends and launches QI projects to achieve measurable goals

8-10:. . . has a full EMR accessible to all providers; team uses a registry or EMR to routinely track key indicators of patient outcomes and integration outcomes; indicators reported regularly to management; team uses data to support a continuous QI process

1

10

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 20. Patient/family input to integration management

Levels:
1:. . . does not occur

2-4:. . . occurs on an ad hoc basis; not promoted systematically; patients must take initiative to make suggestions

5-7: . . . is solicited through advisory groups, membership on the team, focus groups, surveys, suggestion boxes, etc. for both current services and delivery improvements under consider- ation; patients/families are made aware of mechanism for input and encouraged to participate

8-10:.. . . is considered an essential part of management’s decision-making process; systems are in place to ensure consumer input regarding practice policies and service delivery; evidence shows that management acts on the information

1

10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 21. Physician, team and staff education and training for integrated care

Levels:
1:. . . does not occur

2-4:. . . occurs on an ad hoc basis; not promoted systematically; patients must take initiative to make suggestions

5-7: . . . is solicited through advisory groups, membership on the team, focus groups, surveys, suggestion boxes, etc. for both current services and delivery improvements under consideration; patients/families are made aware of mechanism for input and encouraged to participate

8-10:.. . . is considered an essential part of management’s decision-making process; systems are in place to ensure consumer input regarding practice policies and service delivery; evidence shows that management acts on the information

1

10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 22. Funding sources/resources

Levels:
1:. . . are only from MeHAF grant; no shared resource streams

2-4:. . . separate PC/MH/BH funding streams, but all contribute to costs of integrated care; few resources from participating organizations/agencies

5-7: . . . separate funding streams, but some sharing of on-site expenses, e.g., for some staffing or infrastructure; available billing codes used for new services; agencies contribute some resources to support change to integration, such as in-kind staff or expenses of provider training

8-10:. . . fully integrated funding, with resources shared across providers; maximization of billing for all types of treatment; resources and staffing used flexibly

1

10

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 23. In the text box below (using your completed assessment above), please identify an area of focus for the following twelve (12) month period to improve Behavioral and Physical Health Integration: