Healthcare Measure Development Meeting

August 24, 2018

Agenda

• Introduction

• Overview of Human Services Performance Management System

• Overview of Measure Development Process

• Overview of Healthcare Applications

• Overview of Balanced Sets of Measures

• Measure Development Exercises2

Agenda

Overview of Human Services Performance Management System

3

History

• 2009 Service Delivery Act• Established Steering Committee• Recommendations made in 2012 report

• 2013 Legislation• Adopted recommendations• Provided resources• Established Performance Council

• 2014 Planning• Built structure• Hired staff• Provided baseline reports• Established thresholds

• 2015 Implementation4

Children’s services

Adult services

Income supports

Mission and Values

Mission: to improve outcomes for people through creativity, flexibility, accountability,

collaboration, and performance management

Values: accountability, collaboration, continuous improvement, equity, flexibility,

inclusiveness, reliance on data, sustainability, and transparency

No single entity can achieve client outcomes alone.

We need to work together to improve lives for the people we serve.

5

Performance

Assureperformance

thresholds are metImprovement

Provide technical assistance

Measurement

Developperformance framework

Develop Performance Improvement Plans

Performance Management System Overview

The Human Services Performance Management System creates an opportunity for the Minnesota Department of Human

Services, counties, and community partners to work more closely together to improve the lives of people served.

Goals:• Establish shared outcomes and measures • Allow counties more flexibility in the “how”

• Emphasis on continuous improvement • Ensure achievement of positive outcomes

• Create accountability and provides transparency

Outcomes and Measures

Adults and children are safe and secure

Of all children who were victims of a substantiated maltreatment report during a

12-month reporting period, the percent who were not victims of another

substantiated maltreatment report within 12 months of their initial report.

Percent of vulnerable adult maltreatment

allegations where there is not a repeat of the

same type within six months

Children have stability in their living situation

Of all children who enter foster care in a 12-month period, the percent who are

discharged to permanency within 12 months of entering foster care. (Includes

discharges from foster care to reunification with the child’s parents or primary

caregivers, living with a relative, guardianship, or adoption.)

Percent of current child support that is paid

Children have the opportunity to develop to their fullest potential

Of all days that children spent in family foster care settings during a 12-month

reporting period, the percentage of days spent with a relative.

Percent of open child support cases for which

paternity is established

People are economically secure

Percent of MFIP/DWP adults

working 30 or more hours per

week or off cash assistance

three years after baseline (Self-

Support Index)

Percent of expedited SNAP

applications where support was

issued within one business day

of application

Percent of public assistance

applicants who received

benefits within mandated

timeframes

Percent of open child support

cases with a child support order

established

Vulnerable adults experience quality of life

People have access to health care and receive effective services

Agenda

Overview of Measure Development Process

8

Measure Development Approach

• Bring together stakeholders from DHS, Counties, and the community to develop shared measures.

• Performance management is more than developing measures. A successful system integrates the use of data into all facets of the organization.

• We meet our partners where they are on their performance management journey to develop a system that meets their organizations unique needs.

• We leverage our partners expertise throughout the process of developing a performance management system.

9

Team Team Members Team Responsibilities

Steering Committee

• Representatives from DHS

• Representatives from Counties

• Agency & County Performance

• Provide background information and understanding of DHS Healthcare services

• Provide feedback on key deliverables

• Guide measure development work

Data Team • Representatives from Policy, Program,

and Data areas

• Conduct research and provide information aboutHealthcare

• Collect information needed to review Healthcare

Measure

Development Team

• Representatives from DHS

• Representatives from Counties

• Provider representatives

• Partners and advocates

• Provide subject matter expertise, experience, and strategic thinking to develop

Performance Measures forADAD

Agency & County

Performance Project

Team

• Carol Becker, project manager

• Olufemi Fajolu, county data

• Gary Mortensen, HSPM

• Manage the measurement development, gaps analysis, and data infrastructure

phases of the project

• Facilitate the outcome measures development conversations

• Collect and manage project information from County and DHS teams

• Synthesize key findings to develop measurement inventory, data inventory and

program inventory.

Team Roles and Responsibilities

Project Overview (page 1 of 2)

• Steering committee of DHS and county staff identifies participants and reviews meeting agenda.

• Host meeting of DHS, county and community folks to discussion current measures, the Balanced Framework and potential new measures.

• Outcome: List of potential new measures.

• Give list of potential new measures to data team to determine what is feasible.

• Get participants from meeting back together to discuss which potential new measures:

• are feasible.• have data quality issues and what could be done about that.• could be built into future system development.• will not be possible anytime soon.

11

Project Overview (page 2 of 2)

• For measures that are currently possible, move them into the existing measurement processes.

• Develop draft measures for each county. Give them a year to adjust their processes before moving the measure into the PIP process.

• For measures that have data quality issues, carry out discussions among DHS, counties and providers to identify what is needed to improve data quality.

• For measures that could be included in future system development, ensure that these needs are included in planning documents.

• For measures that are not possible, hold further discussions on how to address these needs.

• Repeat process as necessary.

12

Agenda

Overview of Healthcare Applications

13

Health Care Application Processing

Performance Measures Development

August 24, 201814

Federal and State Requirements

• Plain language, accessible, LEP services

• Apply without delay

• No face-to-face interview required

• Questions only needed to determine eligibility

• Agency must provide assistance to applicants

• Document information needed to determine eligibility

• Must take action and notify applicant

• 15-45-60 day processing timelines

15

16

Past Applications

17

Applications and Supplements

• DHS-3531-ENG Application for Medical Assistance for Long-Term-Care Services (MA-LTC)

• DHS-3876-ENG MHCP Application for Certain Populations

• DHS-6696-ENG MNsure Application for Health Coverage and Help Paying Costs

• DHS-6696A-ENG Supplement to MNsure Application (DHS-6696) for Health Coverage and Help Paying Costs

• DHS-6696B-ENG Supplement to the Minnesota Health Care Programs Application (DHS-3876)

Procedures

THEN

• MMIS User Manual

• POLI/TEMP

• Combined Manual (CM)

NOW

• ONEsource

• POLI/TEMP

18

Changing Landscape

19

•Affordable Care Act/MNsure

•Integrated Services Business Model (ISBM)

•Systems Modernization

•Age Wave

Thank You!

Kim Carolan

Christina Cox

20

Agenda

Overview of Balanced Sets of Measures

21

Background

Statutory Requirement - 402A.10 Definitions

Subd. 1a.Balanced set of program measures.

A "balanced set of program measures" is a set of measures that, together, adequately quantify achievement toward a particular program's outcome. As directed by section 402A.16, the Human Services Performance Council must recommend to the commissioner when a particular program has a balanced set of program measures.

Subd. 4d.Performance management system for human services.

A "performance management system for human services" means a process by which performance data for essential human services is collected from counties or service delivery authorities and used to inform a variety of stakeholders and to improve performance over time.

22

Background

Research

• Partnered with the Management Analysis and Development team at MN Management and Budget to guide us in the development of planning Balanced Sets of Measures

• Researched scorecards and performance measures used by other organizations

• Interviewed organizations with strong performance management systems

• Presented to MACSSA Forum for feedback

23

Balanced Sets of Measures – Guiding Principles

• A list of ten guiding principles was created to ensure measures are developed with people and communities at the core, the stakeholders involved, and using the principles of Results-Based Accountability.

• The measures developed will represent the core components that create a strong program so that we can identify and promote what is working, identify systemic issues and work with counties to improve performance.

24

Category How it will be used

Client Engagement

How satisfied/ respected are the people receiving services?

EquityDo diverse groups have different experiences or outcomes? (i.e. racial disparities measures)

FinancialWhat are the costs of providing these activities? (i.e. program ROI)

Operations How efficiently do we do our work? (e.g. staff training, staffing levels, data collection, etc.)

Program Quality

How well do we do our work? (e.g. application processing times, quality of services, impact on individuals)

Balanced Sets of Measures

Measure categories used to assess balanced set of program measures

25

Category Sample Measures

Client Engagement

• Were you treated with dignity and respect?• Were staff members courteous and helpful?• Staff had the knowledge to handle my request?

Equity• County staff reflects population served• Rates of out-of-home placement by race• Family Assessment versus Investigation by race

Financial• Cost effectiveness of services• Return on Investment• Timeliness of payments / submitting requests for reimbursement

Operations • Percentage of staff trained in a timely manner• Staff to case load ratio• Data integrity

Program Quality

• Percent of applications processed within one business day• Number of hours between initial contact and crisis assessment• Percent of people with paying jobs

Balanced Sets of Measures – Sample Measures

26

Criteria Description of Criteria

DataPower

Timely, reliable, currently exists, easily accessible, high validity, low

human error

CommunicationPower

Easily understood, compelling to stakeholders

ProxyPower

Says something of central importance, matches direction of other

measures in the mix

Balanced Sets of Measures

Measure criteria used to select and create a balanced set of measures

27

Comprehensive Performance Measurement Framework

28

Questions?

Agenda

Results Based Accountablity

30

Key RBA concepts

• Two levels of accountability: population and program

• Three questions for program accountability

• How much did we do?

• How well did we do it?

• Is anyone better off?

Optional Tagline Goes Here | mn.gov/dhs 31

Results accountabilityis made up of two parts

Performance accountability:

about the well-being of

client populations

For Programs – Agencies – Service Systems

Population accountability:

about the well-being of

whole populations

For Communities – Cities – Counties – States – Nations

DEFINITIONS

Rate of low-birthweight babies, Percent ready at K entry,

crime rate, air quality index, unemployment rate

1. How much did we do?

2. How well did we do it?

3. Is anyone better off?

RESULT or OUTCOME

INDICATOR or BENCHMARK

PERFORMANCE MEASURE

A condition of well-being for children, adults,

families or communities

A measure that helps quantify the achievement

of a result

A measure of how well a program, agency or

service system is working

Three types: = Customer

Results

Po

pu

lati

on

Per

form

ance

Children born healthy, children ready for school, safe

communities, clean environment, prosperous economy

From Ends to Means

ENDS

MEANS

Po

pu

lati

on

Perf

orm

an

ce

RESULT or OUTCOME

INDICATOR or BENCHMARK

PERFORMANCE

MEASURECustomer result = Ends

Service delivery = Means

From Talk to Action

Key concept 1:

Population accountability

For whole populationsin a geographic area

DEFINITIONS

Rate of low-birthweight babies, Percent ready at K entry,

crime rate, air quality index, unemployment rate

1. How much did we do?

2. How well did we do it?

3. Is anyone better off?

RESULT or OUTCOME

INDICATOR or BENCHMARK

PERFORMANCE MEASURE

A condition of well-being for children, adults,

families or communities

A measure that helps quantify the achievement

of a result

A measure of how well a program, agency or

service system is working

Three types: = Customer

Results

Po

pu

lati

on

Per

form

ance

Children born healthy, children ready for school, safe

communities, clean environment, prosperous economy

Which population are we talking about?

• A safe city

• Inclusive and diverse communities

• Citizens value and protect the natural

environment

• A well-governed county

• A prosperous community

Sample Community Results

Results and Indicators

Key concept 2:

Performance Accountability

For programs, agencies and service systems

Results accountabilityis made up of two parts

Performance accountability:

about the well-being of

client populations

For Programs – Agencies – Service Systems

Population accountability:

about the well-being of

whole populations

For Communities – Cities – Counties – States – Nations

How

Muchdid we do?

( # )

How

Welldid we do it?

( % )

Quantity Quality

Performance Measures

EffortHow hard did we try?

EffectIs anyone better off?

Performance measures

How much

did we do?

Program performance measures

How well

did we do

it?

Is anyone

better off?

Quantity Quality

Eff

ect

E

ffo

rt

# %

How much did we

do?

Education

How well did we do

it?

Is anyone better off?

Quantity Quality

Eff

ect

E

ffo

rt Number of

students

Student-

teacher

ratio

Number of

high school

graduates

Percent of

high school

graduates

RBA Categories Account for All Performance Measures(in the history of the universe)

Quantity Quality

Efficiency, Admin overhead, Unit cost

Staffing ratios, Staff turnover

Staff morale, Access, Waiting time,

Waiting lists, Worker safety

Customer Satisfaction(quality service delivery

& customer benefit)

Cost / Benefit ratio

Return on investment

Client results or client outcomes

Effectiveness

Value added

Productivity

Benefit value

Product

Output

Impact

Process

Input

Eff

ect

Eff

ort

Cost

TQM

Effectiveness

Efficiency

How much did we

do?

Not All Performance Measures Are Created Equal

How well did we do

it?

Is anyone better off?

LeastImportant

Quantity Quality

Eff

ect

E

ffo

rt

MostImportant

Least

Most

Also

Very Important

How much did we

do?

The Matter of Control

How well did we do

it?

Is anyone better off?

Quantity Quality

Eff

ect

E

ffo

rt

LeastControl

PARTNERSHIPS

MostControl

How much did we do?

Types of measures found in each quadrant

How well did we do it?

Is anyone better off?

# Clients/customers

served

# Activities (by type

of activity)

% Common measures

client staff ratio, workload ratio, staff

turnover rate, staff morale, % staff fully

trained, % clients seen in their own

language, worker safety, unit cost

% Skills / Knowledge(e.g. parenting skills)

#

% Attitude / Opinion(e.g. toward drugs)

#

% Behavior(e.g. school attendance)

#

% Circumstance (e.g. working, in stable housing)

#

% Activity-specific measures

% timely, % clients completing activity,

% correct and complete, % meeting

standard

Point in time

vs. point-to-point

improvement

The matter of use

1. The first purpose of performance

measurement is to

IMPROVE PERFORMANCE.

2. Avoid the “performance measurement equals

punishment trap.”

• Create a healthy organizational

environment.

• Start small.

• Build bottom-up and top-down

simultaneously.

Different Descriptions of Progress

1. Data

a) Population indicators: movement for the better away from the baseline

b) Program performance measures: customer progress and better service

How much did we do?How well did we do it?Is anyone better off?

2. Accomplishments: Positive activities, not included above

3. Stories behind the statistics that show how individuals are better off

Agenda

Measure Development Exercises

52

Ground Rules

• All voices hold equal weight

• Respect others, respect yourself

• This is only one step in the process

• Do not assume we are all on the same page

53

Table Introductions

• Share your name

• What “hat” you’re wearing today (your role or roles)

• Ice Breaker

54

Table Introductions

• Share your name

• What “hat” you’re wearing today (your role or roles)

• Ice Breaker

55

Healthcare Application Processing Measures Development Meeting Outcomes: Measures and Data Requests

The potential measures listed below were generated by a workgroup held on Aug. 24, 2018. Participants included representatives from counties and DHS. All potential measures are listed in bold below.

Potential Measures

Average Processing Time

Measure:

• Average processing time per application type

Discussion included the need for the following data by county and application type, in both METS and MAXIS:

• Number of applications received• Number of applications completed• Number of applications still in process• Average number of days prior to moving to a pending status

Meeting participants requested ongoing reporting of this data to assist in county improvement efforts, specifically the number of applications processed within the reporting period, the number and percent of applications processed within the specified time frame for that form (30/60 days depending)

Accuracy

Measures:

• Error rate, the number and percent of applications processed accurately during the reporting period.• Percent of applications approved/Percent of applications denied during this period (Denial rate)• Percent of applications processed without any extra intervention

Discussion included the need for the following data by county and application type, in both METS and MAXIS:

• Number of applications received• Number of applications completed• Number of applications still in process

• Number of applications entered into both systems • Count of applications denied by reason • Number of applications that required reentry

Population Utilization

Measure:

• Percent of population that could be receiving MA but are not (would need to develop threshold for this measure)

Discussion included the need for the following data by county/SDA:

• Number of people receiving health insurance of any type (from MDH) • Number of people eligible for MA • Number of people receiving MA/active on healthcare • Denial rate

Healthcare Utilization

Measures:

• Percent of people actively on MA that used their healthcare benefits o Break down utilization by major categories like preventative care, ER, mental health, dental,

transportation etc.

Meeting participants did not discuss specific data points for this measure.

Equity

Measures:

• Application approval and denial rates by different populations • Number of people using services from different populations • Percent of applications for non-English speakers determined timely and accurately • Number of people receiving coverage by race

Discussion included the need for the following data by county:

• Number of applications by racial and ethnic groups • Number of citizens versus non-citizens by application • Number of applications requested in other languages, by language • Number of incomplete LEP applications

Staffing

Measures:

• Ratio of staff to people using services • Staff turnover rates • Percent of staff fully trained • Number of bilingual staff

Meeting participants did not discuss specific data points for this measure.

Interaction

Measures:

• Percent of phone calls returned in a timely manner • Length of time consumer waits to see worker • Wait times for phone calls • Number of applications received on-line

Meeting participants did not discuss specific data points for this measure.

Incarceration

Measure:

• Percent of people released from incarceration who are screened for MA

Meeting participants did not discuss specific data points for this measure.

Stability

• Percent of people remaining on the program for a full year rather than going on and off

Reapplication

Measure:

• Percent of people reapplying for insurance after having it and then losing it within a specified timeframe

Meeting participants did not discuss specific data points for this measure.

Response time to customer complaints at the County level

• Response time to participant complaints

Requested Data

During the meeting, participants shared a number of data points they felt could help in their improvement efforts. These items may not directly relate to reported measures, but reporting on or making this data available may be useful to counties.

State Computer System Efficiency

• Number of official work-arounds in MAXIS • Number of official work-arounds in METS • Number of phone calls from county staff to the state for help • Wait times for phone calls at HCEO

Number of cases with an adverse action taken

• Number of cases where there is an adverse action being taken (denial of coverage, cancellation of coverage, reduction in coverage)

• Percent of individuals contacted within ten days

Overpayment/Third Party Liability

• Percent of cases with overpayment • Percent of applications reviewed for private or other health insurance

Number of customer complaints at the County level

• Number of Complaints

Number of customer complaints at the state level

• Number of complaints to the state call line • Response time to participant complaints • Response time to calls by county

Multiple Barriers

• Number of people using other programs in addition to MA, broken down by program

Front-line worker survey

• Number of front-line workers who have gotten each kind of training • Survey of front-line workers on how knowledgeable they are policies • Survey of front-line workers on job satisfaction • Survey of front-line workers on largest barriers to high quality work

Duplicate PMI

• Duplicate PMI Report

Customer Survey

• Did people understand the services they are eligible for? • Did people receive the services they needed? • Were people happy with the services they got? • Were people happy with how they were treated? • Are people using services knowledgeable about the available programs?

Appeals

• How many appeals filed? • How many appeals lost? • How many appeals from system errors? • How many appeals from client errors? • How many appeals from agency errors?

Outreach

• Report on outreach carried out by the agency