2019 Community quality improvement plan

Georgia Department of Behavioral Health & Developmental Disabilities
FY 2019 Community Quality Improvement Plan
November 8, 2018

Table of Contents
DBHDD Vision, Mission, and Commitment to Quality.................................................................... 2 Vision and Mission ...................................................................................................................... 2
Quality Improvement (QI) Plan....................................................................................................... 2 Characteristics of the QI Plan ...................................................................................................... 2
Quality Improvement Organization and Leadership ...................................................................... 2 Organization ................................................................................................................................ 2 Office of Quality Improvement ................................................................................................... 2 Vision Statement ..................................................................................................................... 2 Scope of Service....................................................................................................................... 3 Leadership ................................................................................................................................... 3
Quality Improvement Process ........................................................................................................ 5 Key Characteristics of the QI Process.......................................................................................... 5 Alignment with DBHDD Priorities ............................................................................................... 5 Sources of Quality Improvement Projects .................................................................................. 6
Quality Improvement Initiatives ..................................................................................................... 9 Overview ..................................................................................................................................... 9 Completed Initiatives ................................................................................................................ 10 Strategic Priorities ................................................................................................................. 10 Communications Priorities .................................................................................................... 10 Enterprise Priorities ............................................................................................................... 12 Ongoing and Planned Initiatives ............................................................................................... 13 Strategic Priorities ................................................................................................................. 13 Communications Priorities .................................................................................................... 15 Enterprise Priorities ............................................................................................................... 18
Conclusion..................................................................................................................................... 21

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DBHDD Vision, Mission, and Commitment to Quality
Vision and Mission The Quality Improvement Plan supports the Georgia Department of Behavioral Health and Developmental Disabilities' (DBHDD) Vision and Mission
Vision:
"Easy access to high-quality care that leads to a life of recovery and independence for the people we serve."
Mission:
"Leading an accountable and effective continuum of care to support Georgians with behavioral health challenges, and intellectual and developmental disabilities in a dynamic health care environment."
Quality Improvement (QI) Plan
Characteristics of the QI Plan The QI Plan serves as an overarching, high-level organizational framework for DBHDD's community clinical and operational quality improvement activities. The QI Plan describes a systematic approach to identify and pursue opportunities to improve services and resolve identified problems.
The QI Plan is a living document reflective of a dynamic process that is responsive to opportunities for improvement, priorities, and resources. The plan is reviewed annually at the September meeting of the Executive Quality Council.
Quality Improvement Organization and Leadership
Organization The Quality Improvement process is deployed and distributed throughout the organization, with the Office of Quality Improvement (OQI) serving as a hub for many QI projects, initiatives, the QI plan, and overall QI process. The OQI is organized as a separate office under the leadership of the director of DBHDD's Division of Performance Management and Quality Improvement (PMQI). Key partners in the development and implementation of QI objectives include the Office of Performance Analysis, the Office of Provider Relations, the Office of Internal Audit & Risk Management, the Office of Incident Management and Investigations, and the Office of Results Integration.
Office of Quality Improvement Vision Statement The Office of Quality Improvement embraces the following quote by W. Edwards Deming:

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"We are here to make another world."
The Office of Quality Improvement considers its primary purpose to be a valuable partner with the programmatic and other support divisions and offices in effecting changes to our agency and provider partners that ultimately benefit the people we serve.
Scope of Service The Office of Quality Improvement (OQI) provides quality and process improvement support and service primarily to the Divisions of Behavioral Health and Developmental Disabilities. The programmatic divisions retain ultimate responsibility for and control over the quality improvement work occurring in their respective divisions. The goal of the OQI is to partner with and assist these divisions in improving the lives of the people we serve. The work of the OQI is structured to be:
Aligned with the goals and priorities of DBHDD; Focused on making improvements that benefit the people we serve; Collaborative; Guided by established quality improvement techniques and principles; and Informed by best practices and peer-reviewed information
The broad strokes of this collaborative work include: Strengthening and broadening of the provider network, resulting in greater effectiveness and access; Detecting and eliminating non-value-added effort, resulting in higher efficiency; and Leveraging information technology and systems to improve efficiency and facilitate reporting, which supports better informed decision making.
Leadership Quality Improvement Leadership is provided by several internal councils, DBHDD partners, and the people we serve. Quality initiatives are governed through quality councils that meet quarterly.
Executive Quality Council The Executive Quality Council is comprised of senior leadership from the Commissioner's office and the Divisions of Developmental Disabilities, Hospital Services, Performance Management and Quality Improvement, and Accountability and Compliance. The Executive Quality Council meets quarterly in March, June, September, and December and is the highest-level quality committee at DBHDD. The Executive Quality Council sets priorities and direction for areas to be addressed, receives periodic updates on existing projects, and provides input from external stakeholders as needed.

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Behavioral Health Quality Council (BHQC) The BHQC meets quarterly in January, April, July, and October and includes representation from the Divisions of Behavioral Health, Performance Management and Quality Improvement, and Accountability and Compliance. It is chaired by the director of the Division of Behavioral Health. This council reports on ongoing and planned QI initiatives and evaluates potential new projects.
Intellectual/Developmental Disabilities Quality Council (I/DDQC) The I/DDQC meets quarterly in January, April, July, and October and includes representation from the Divisions of Developmental Disabilities, Performance Management and Quality Improvement, and Accountability and Compliance. It is jointly chaired by the assistant director of the Division of Developmental Disabilities and the director of the Office of Quality Improvement. This council reports on ongoing and planned QI initiatives and evaluates potential new projects.
Division Director, PMQI The division director is a member of the executive leadership team and enjoys high visibility throughout the organization. The division director provides advanced strategic, operational, and administrative oversight to the OQI with the goal of maximizing the coordination between offices within PMQI and partnership with other offices and divisions. See figure 1 for a visual depiction of the PMQI structure.

Figure 1 PMQI Structure
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Director, OQI The director occupies a senior management position with high visibility throughout the organization. The director provides functional and administrative leadership to the OQI team in addition to providing organizational leadership to the overall quality process.
Quality Improvement Process
Key Characteristics of the QI Process Key characteristics of the DBHDD Community QI process include:
Alignment with DBHDD strategic, communication, and enterprise priorities; Use of a systematic process with identified leadership, accountability, and dedicated
resources; Use of data and measurable outcomes to determine progress toward relevant,
evidence-based benchmarks; Formalized QI Plan which is reviewed annually with the Executive Quality Council and
revised if needed; and Routine project status reporting at the programmatic and Executive Quality Councils
Alignment with DBHDD Priorities It is vitally important to DBHDD's mission that quality improvement projects are aligned with agency priorities. In January 2017, DBHDD Commissioner Judy Fitzgerald shared a graphic outlining DBHDD's priorities with the leadership team. This graphic was developed by DBHDD senior leadership and is shown below as figure 2. It serves as a foundational guiding document when potential projects are being considered and evaluated. The graphic is bookended top and bottom with DBHDD's vision and mission statements; the cornerstones of the agency. Agency priorities are categorized into three broad target areas strategic, communications, and enterprise. Strategic priorities are those identified by the Commissioner and senior leadership for more active management. Communications priorities involve areas that necessitate communications planning and stakeholder engagement strategies, while enterprise priorities involve target areas that impact the entire continuum of care.

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Figure 2 DBHDD Priorities
Sources of Quality Improvement Projects Ideas for quality improvement projects may be initiated from many sources and are then evaluated, selected, and prioritized by the relevant programmatic division(s) with assistance from the OQI as needed. Those deemed most vital are selected to become QI initiatives, subject to time and resource constraints. See figure 3 for a non-exhaustive listing of potential project sources.

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Figure 3 Sources of QI Projects
Once the performance of a selected process has been measured, assessed, and analyzed, the information gathered is used to identify possible quality improvement initiatives. The decision on whether to undertake the initiative is based on DBHDD priorities and resource availability and is generally made by the programmatic division either directly via the division director, or through divisional quality councils. Please see figure 4 below for a visual depiction of this process.

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Figure 4 Decision to Accept a Project
National, State, and Local Trends In 2015, DBHDD created a new office dedicated to the analysis of performance data, the Office of Performance Analysis (OPA). Strategically aligned with the OQI within the Division of Performance Management and Quality Improvement, this office uses DBHDD and external data to drive performance improvement initiatives and demonstrate outcomes of these initiatives. This is achieved through a variety of activities:

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Identification, development, testing, and analysis of performance metrics
Scientific literature review/research necessary to identify research hypotheses, study design, data collection, and analytic models
Outcomes analysis to determine impact of a program, modification, or intervention
Provision of analytic reports and results using understandable language while retaining scientific foundation
Consultation on developing impactful, data-driven studies
Georgia Collaborative ASO (ASO) The Georgia Collaborative Administrative Services Organization (ASO) is an external partner of DBHDD. It is comprised of three partner companies: the Georgia Crisis and Access Line (GCAL), Beacon Health Options (Beacon), and Qlarant, formerly the Delmarva Foundation. Among the many services the ASO provides on behalf of DBHDD are quality improvement services. This important function provides on-site review of providers and subsequent quality improvement activities at both the system and provider level. Under the direction of the OQI, the Quality Improvement arm of the ASO is charged with:
Assessing and reviewing services rendered to individuals across the state; Providing a preliminary and final scored report to both provider agencies and DBHDD of
summarized findings; Providing technical assistance and training to the providers, based on the review and
overall findings; and Analyzing, tracking, and trending the data collected in these reviews to make
recommendations to providers, stakeholders and to DHBDD regarding areas that are doing well or those that could benefit from some type of performance improvement initiative.
Quality Improvement Initiatives
Overview In general, Quality Improvement initiatives should align with at least one of the priorities noted in figure 2 on page 6, and many QI projects address more than one goal or target area. Quality improvement processes may also take several forms. The OQI noted areas where we are partnering to create changes or provide a direct intervention to spur improvement; we describe these as partnered initiatives. In other cases, we may be using our finding to improve processes in incremental steps. Finally, we may be pursuing additional research or knowledge related to a subject matter to advance sophistication. A non-exhaustive list of completed, current, and planned initiatives follows, attached to the priority target with which they are most closely associated. Those initiatives denoted with an asterisk (*) are being actively supported by the OQI.

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Completed Initiatives

Strategic Priorities Safety Net Stability Fiscal stability is a key component of safety net stability and is a central goal of the Provider Productivity Project*. This project identified low provider employee productivity as a potential contributing factor to poor fiscal performance. The project educated providers on the root causes of various productivity issues and provided a free, user friendly tool to help providers measure and manage employee productivity. A secondary, and equally important goal of this project was to improve access to core services. The tool has been moved to production and is available, along with support from the OQI, to all providers.
Enhancing Collaboration with the Georgia Department of Community Health The Georgia Department of Community Health (DCH) and DBHDD collaborated on several quality improvement initiatives. The Expanded Therapy (ST/OT/PT) Services Project allowed DBHDD and DCH to work together to meet the sometimes-complex therapy needs people with intellectual and developmental disabilities. This project focused on ensuring that waiver amounts are sufficient to meet the identified need and that rates and codes were aligned between the two agencies.
Communications Priorities Strengths Deployment Inventory (SDI): Healthy Relationships Promote Healthy Teamwork Most of the Strengths Deployment Inventory (SDI) initiatives revolve around keeping the awareness of SDI at the forefront and enabling employees to fully realize the value and benefit of the program. Thus far, more than 2,500 employees have participated in the initial SDI workshop. As the interest in this program has continued to grow, additional SDI facilitators have been trained and deployed to keep up with demand. Many recurring meetings now actively use SDI and open with an SDI exercise.
The Personal SDI Identifier Initiative recognized that employees need some way to quickly identify others' MVS style when table tents and other more formal options are impractical. Several options were considered, and use of an identifying badge sticker and MVS as part of employee email signatures have been operationalized.
The Hospital Engagement Initiative was created in response to the unique culture, workday, and staffing challenges hospital employees face when trying to embrace a new initiative such as SDI. These educational sessions have now become part of the hospital culture and are routinely conducted at all facilities.
The SDI Lunch and Learn Project allows employees an opportunity to take a deeper dive into SDI principles. This project addresses an identified need for ongoing, informal educational opportunities for employees to understand better how to deploy SDI in their workgroups,

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teams, and offices. This initiative is now agency wide, with monthly meetings routinely conducted at each DBHDD campus.
Management Academy The Management Academy Initiative supports attracting, retaining, and mentoring current and emerging leaders within DBHDD. It includes certification by the University of Georgia's Carl Vinson Institute of Government and is designed to equip these current and future leaders with the skills and tools to position DBHDD as an "Employer of Choice" while supporting our vision and mission. Cohort Nine is in progress, with approximately 225 participants having graduated or currently in attendance. Cohort Nine also marks the first session in which five community service board (CSB) staff have participated in the academy, further enhancing our lines of communication and collaboration between DBHDD and our partners/community safety net. DBHDD anticipates five cohort slots being dedicated to CSB staff in calendar year 2019's cohorts 10 and 11 of the academy to further strengthen these important relationships.
Engage and Retain Workforce With so many projects underway, having an effective Change Management process that is aligned with the department's restructuring, and supportive of key program outcomes and project deliverables is vital to success. This embrace of change management has supported other workforce projects, such as:
Migration to a new operating model and associated realignment, creating expanded leadership opportunities
Comprehensive efforts to Increase and Enhance Internal and External Communication, using the department's vision, mission, and core values as anchors. Some recent initiatives included a refresh of DBHDD's logo and Be DBHDD campaign emphasizing DBHDD's values and commitment to them in everything we do. Also included is a comprehensive integration of branding into workplace and stakeholders via collaboration and support between leadership, the Office of Public Affairs, and our Brand Ambassador network.
Since its inception in April 2017, DBHDD's Spotlight on Excellence Award has recognized 18 award winners (15 individuals and three teams) for outstanding contributions toward achievement of our vision and mission, and for exemplifying our core values. Up to three awards are now presented quarterly, with the vast majority of DBHDD staff being eligible to receive recognition, and all being able to nominate those to be recognized.
Compensation Enhancement has been addressed through reinstated merit increases for eligible staff. The state's Job Classification and Career Path program has been restructured to increase market competitiveness and provide enhanced opportunities for career pathing. Additionally, DBHDD has worked with the Georgia Department of Administrative Services, the Governor's Office of Planning and Budget, and the General Assembly to address specific recruitment and retention issues in key identified problem areas (ex. non-clinical direct care staff, nursing, other clinical staffing, and others)

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New Staff Orientation (NSO) has been redesigned and implemented to provide a more meaningful, engaging, and enhanced onboarding process and learning experience for new staff (employees, agency staff, contractors, etc.) NSO was further enhanced/augmented through implementation of a New Staff Orientation On-boarding Portal in May 2018.
Many initiatives have occurred in Staff Development, covering topics such as general management/supervisory skills, refreshed annual and compliance offerings, project management, digital skills, discipline-specific training, and a variety of other soft-skills training. As a part of this initiative, almost 3,000 courses have been added to DBHDD University's Learning Management System so far.
Enterprise Priorities Manage Redesign of Support Coordination The redesign of support coordination was a multifaceted target and included several quality initiatives. Of note is the Individualized Service Plan (ISP) Revision and Quality Assurance Directives Project*. The intent of this project, implemented on December 1, 2017, was to create an improved ISP template in our current case management system ahead of the launch of our new ASO IDD Case Management System template, such that support coordinators could get acclimated to a more streamlined approach to service planning and engage in stratified change management relating to the redesign of the ISP. The revised ISP template eliminated redundancy and provided additional guidance on writing plans in a standardized manner, while maintaining a commitment to developing meaningful, person-centered plans. The project also provided for statewide consistency in the evaluation of ISPs, with an eye toward increasing quality and accountability of support coordinators and service providers. The ISP template that will be housed in the new ASO IDD Case Management System is further condensed from this interim template, has information that populates directly from assessments and screenings, and is easily editable as changes occur.
DBHDD seeks to review data regularly supplied by support coordination agencies and performance data collected on support coordination agencies through the Support Coordination Performance Report. The purpose of this report is to present data analyzed and to assess the performance of support coordinators, their agencies, and Medicaid Waiver support coordination service provision. This analysis and assessment is offered from a statewide viewpoint of support coordination as a whole, as well as a review of each support coordination agency in comparison to the others. As a result, this report offers insight for statewide management of performance and quality of support coordination service provision and also acts as a guide for individual support coordination agencies to target specific areas of focus for their internal performance and quality improvement plans.

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To enhance our capacity for outcome-based data collection, support coordination leads have worked with the Office of Performance Analysis on revising the Individual Quality Outcome Measures Review - the tool used by support coordinators to evaluate outcomes and identify action steps to improve outcomes. This project has been implemented effective January 1, 2018. After the initial deployment of the IQOMR in July 2016, to move from a compliance monitoring assessment tool to an outcome-based holistic evaluation tool, the Division of Developmental Disabilities recognized a need for improvement of the tool and initiated an effort to improve the ability to capture of discrete variables elicited from the IQOMR. Although this project significantly increased the quantity of questions requiring response on the tool, it offered greater clarity of understanding for the use of the tool by support coordination, as well as improvement in data analysis opportunities for support coordination leads and Office of Performance Analysis at DBHDD.
Additionally, Support Coordination Review Tools*, used by the Georgia Collaborative/ASO in evaluating provider performance, have undergone review and revision to align with changes in policy, procedure, and best practices.
Implement Intellectual and Developmental Disability Provider Recruitment and Development Plan To Expand the Network of Clinical Services Providers, DBHDD revised the enrollment policy and procedures to support this category of provider (individual practitioner). Typical enrollment procedures are reflective of an "agency" enrolling. An expedited pathway for clinicians to be able to enroll and apply for services was created, resulting in an increase in the number of clinicians.
IT Enablement The Certification Review Instrument used by the Office of Provider Certification and Service Integrity (OPCSI) to assess provider performance and certification was, until recently, completed via spreadsheets and paper. As the Vision App became operational, OPCSI staff were able to complete reviews electronically, produce reports electronically with a weighted score, and track deficiencies and the corrections of those deficiencies. This system was designed to facilitate reporting, easily updates as policies change, and has increased the productivity of the OPCSI staff.

Ongoing and Planned Initiatives
Strategic Priorities Hospital to Community Partnership (Behavioral Health) DBHDD's crisis service system is a key component to the service array provided. Crisis services are offered through community partners, such as community service boards' crisis stabilization

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units, the Georgia Crisis and Access Line, as well as DBHDD's state hospital system. DBHDD's director of behavioral health and medical director have teamed up to develop and implement a variety of initiatives that cross the community and state hospital system to create a more unified experience and better outcomes. Examples of this multi-pronged approach include policy alignment*, enhancement of the discharge process to ensure coordination with aftercare providers*, and addressing a wide variety of challenges related to individuals transitioning to and from the community and hospital*.
Policy alignment* is ongoing, and needed changes have been identified and are being vetted with stakeholders. The discharge process* has been analyzed, improvements proposed, and recommendations are currently being vetted with stakeholders.
Managing a Network of Providers Ongoing Improvements to Standard and Key Performance Indicators (KPIs)* provides a platform, supported by data and analysis, for moving the network toward greater accountability and higher performance for Tier 1, 2, and 2+ providers. This ongoing behavioral health quality improvement initiative features several feedback loops to providers, including engagement with providers in designing and embracing the standards and KPIs as they evolve, with an eye toward ensuring accountability in monitoring and quantifying access to care.
Work is currently occurring on the Community Stakeholder Project*, involving both providers and community stakeholders such as jails, prisons, schools, and hospitals. The goal of this work is for providers to be able to demonstrate effective coordination with community stakeholders. Thus far, the survey tool and associated metrics have been developed, policy has been put in place, and providers educated. Work is under way to develop a method for survey deployment and data collection.
Development of Key Performance Indicators (KPIs)* is also a focus for the Division of Developmental Disabilities. Preliminary KPIs have been identified and vetted, and appropriate data sources are being developed for each KPI.
A key element to managing a network of providers is effective and timely communication. With that in mind, the Office of Provider Relations Newsletter was created to serve as a semimonthly electronic outreach to providers. The newsletter contains information about upcoming training, changes to policies, how to get assistance from DBHDD, and other topics of interest to providers. Sustained marketing efforts are paying off, and the newsletter is currently being distributed to over 2,000 providers with an average open rate of around 50 percent.
One of the ways in which providers can now get assistance from DBHDD is via the Provider Issues Management System (PIMS). This electronic, outward-facing portal gives providers a `one stop shop' to get assistance from DBHDD. Providers log in and submit their question or

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concern, and the issue is picked up and worked by the Office of Provider Relations team. The Office of Provider Relations staff identifies and contacts the appropriate resource for the provider and remains engaged until the issue is resolved. Next steps include the quarterly aggregation and analysis of PIMS information. The plan is to use this aggregate information, along with related observations and recommendations, as a source for potential systemic improvements.
The Improving Health Outcomes Initiative involves working with key providers and support coordinators to understand and overcome barriers to sustainable improvements in the delivery of supports and services to individuals in our intellectual and developmental disability service system.
Enhancing DCH Collaboration DBHDD and DCH are collaborating on several QI initiatives which are used to inform each other's work, increase alignment on common initiatives, and avoid duplications of effort.
DBHDD is engaged with DCH in its development of a Moratorium Review Board to improve cross-agency coordination to ensure effective and timely actions are taken to ensure the health and welfare of waiver participants
DBHDD attends and contributes to the DCH Quality Review Committee Meetings*. The committee is responsible for assisting Medicaid in prioritizing, facilitating, and monitoring performance activities within the Home and Community Based Services/Waivers Programs to improve and strengthen the health, welfare, and the quality of care for members.
In collaboration with DCH, DBHDD conducts routine analysis and review of the CMS Waiver Assurances*. Where opportunity for improvement is identified, DBHDD and DCH collaborate to improve processes, data collection, and outcomes.
Communications Priorities Enterprise Crisis Plan There are multiple components to a comprehensive enterprise-wide crisis plan, and several quality improvement initiatives address these components. The High Utilizer Management (HUM) Program Development Project* is serving this goal by identifying and investigating root causes of high use of crisis services and developing strategies to mitigate and address this concern. To date, a workflow has been created, job descriptions written and needed policy changes identified. This system will also collect information describing what barriers individuals are having trouble connecting to community services. This information will be used to make adjustments to the system to remove barriers and improve earlier access to community

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services. By reducing overuse of crisis resources, the capacity to serve those for whom the crisis system is intended is preserved and enhanced.
Other initiatives supporting the efficient and appropriate use of crisis services include the Standardization of Admission and Exclusion Criteria across the DBHDD system. All community service boards and state hospitals will use the same criteria to determine appropriate access and qualification for referral to the correct level of care. Hand in hand with this initiative has been the identification of Crisis Workflow Training needs. This training helps equip provider CSU/BHCC staff on the effective use of peers in crisis, diversion techniques, unit flow, engagement strategies, and developing successful partnerships with first responders.
Key Performance Indicators (KPIs) for Crisis Service Unit (CSU) Providers* have been developed and are being collected. This year is a pilot year for providers as they become used to collecting the data and meeting the new standards.
Bed Board Revision is resulting in better and more timely data collection. Underway now is the creation of standardized reporting and introduction of the reports to providers and DBHDD staff. This information will drive future KPIs and dashboards where program managers will see in real time how well the system is functioning.
Additionally, concerns were identified in Intellectual and Developmental Disability Crisis Support Home Discharge Planning*. The goal of this work is to add clarity to roles and responsibilities and reduce timeframes for transitions back into the community from crisis support homes.
Response to Opioid Use Georgia's Opioid State Targeted Response is a SAMHSA-funded program that addresses the opioid crisis and spans the two-year period of May 1, 2017-April 30, 2019. This project is developing a targeted response to the opioid crisis in Georgia through prevention, treatment, and recovery initiatives. Project activities will strengthen infrastructure, focus on addressing gaps in evidence-based practices and services, and create a continuum of prevention and recovery-oriented treatment. Some of the ongoing initiatives in this area include MedicationAssisted Treatment (MAT) Partnerships with the Department of Corrections and Department of Community Supervision. This initiative provides support for medication-assisted treatment (MAT) for individuals while incarcerated and focuses on continuity of care as they transition back into the community.
Another aspect of this work is the Partnership with Community Providers, which is resulting in bed capacity expansion, detox capacity expansion, and expansion of community-delivered MAT treatment and support.
Advancing Service Delivery Models The Enhanced Supports and Services Project* seeks to identify and remediate gaps and inefficiencies, create accountability, and enhance communication regarding requests for

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enhanced supports and services for individuals with intellectual and developmental disabilities. Thus far, workflows for current and future state have been created, potential policy changes identified, and job aids have been created. Next steps include developing a training and rollout plan.
Spanish-Language Translation Updates* cover the Georgia Collaborative/ASO Referral Connect element of the website as well as the intellectual and developmental disability case management portal application. The goal of this project is to use native Spanish speakers to evaluate and revise existing Spanish-language translations emphasizing context, word usage, and reading level. This update is designed to support ease of comprehension by a wide range of Spanish speakers regardless of country of origin or education level.
As part of the focus on addictive disease delivery models, DBHDD supports a recovery-oriented system of care, which moves our system toward a prevention-focused, strength-based continuum of care that provides sustained support to affected individuals. To assess the current state of our provider network's recovery orientation, DBHDD partnered with the Yale University School of Medicine to deploy its Recovery Self-Assessment Survey* (RSA-R) to all appropriate providers in the DBHDD network. The results from this survey will be used to identify areas of strength and concern and to design interventions that move the network forward.
Best Practices in Providing Behavior Supports in the Community is a developmental disability initiative undertaken to disseminate best practice standards and facilitate skill development to those providers who render services to individuals with behavioral challenges. The initial response from providers has been very favorable, and additional topics and trainings are scheduled for Fall 2018. DBHDD is currently working with educators from Georgia State University to develop a certification process in applied behavior analysis designed to enhance the skills of existing behavior providers, attract, and increase the capacity of qualified providers of behavior supports working with people with intellectual and developmental disabilities.
The Standardization of Health Risk Screening Tool (HRST) Nursing Assessments and Health Care Plans is another initiative whose goal is to provide customizable templates and other supporting resources to providers to assist them in creating robust, individualized assessments and plans. The HRST Nursing Assessment is a comprehensive assessment that prompts registered nurse assessment and generation of data resulting in holistic support planning. The assessment trends changes of condition, associated treatment and interventions, and triggers the generation of Health Care Plans and other indicated follow-up. Health care plans are translation tools and incorporate interventions that are medically necessary to reduce risk and respond to symptoms. By using these web-based templates, providers are more likely to consider and document all information necessary for sound decision making regarding clinical recommendations and clinical supports needed.

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Planning List Administrator (PLA) Redesign work has focused on improving processes and customer service in order to operate with greater efficiency and consistency and to communicate more effectively with consumers and families. This has resulted in greater numbers of individuals being served. Work now is focused on the partnership with the Georgia Tech Research Institute in the validation and training for the needs assessment tool, which contains the four needs assessments used to prioritize the planning list. The objective is to be able to determine "most in need" status in real time.
The Emory Intellectual and Developmental Disability Curriculum is a 12-week course, developed in conjunction with Emory University, and executed through Emory's (interactive) Canvas platform. The pilot class began in July 2018. The content is taught online by Emory instructors with expertise in ICU, geriatric and wound care nursing. The content was developed with a focus on skilled intellectual and developmental disability nursing. The participants include field office, provider, and Office of Health & Wellness nurses.
Partnership with Sister Agencies to Address Autism In partnership with the Departments of Community Health, Public Health, and Human Services, DBHDD is working to expand the range of services available to children with autism payable by Medicaid. Thus far, policy changes have been made, and practitioners have been enrolled. This work is ongoing and includes plans for changes to psychiatric residential treatment facilities, crisis support homes, and mobile crisis response to accommodate individuals with autism. Additionally, work is underway on an autism crisis stabilization unit. Training of field office staff is complete and outward facing messaging is under construction.

Enterprise Priorities Realizing Benefits of ASO Currently underway is a Comprehensive Examination of the ASO Quality Review tools*. As our environment, policies, standards, and best practices continue to evolve, so too should our quality review tools. Statistical methods such as exploratory factor analysis, principal component analysis, confirmatory factor analysis and Item Response Theory are being employed to empirically study the instruments that form the basis for provider quality reviews. The desired outcome is to monitor and improve the effectiveness, efficiency, and validity of the survey instruments. Current work on this involves identifying areas of overlap and duplication between and among the tools that make up the intellectual and developmental disability portion of the quality review toolbox.
At the request of DBHDD, the ASO has performed a Quality Study of Supported Employment*. The ASO collects National Core Indicator (NCI) data as part of its quality review process. This nationally-normed information can be used to compare Georgia's performance with other states, and identify trends longitudinally within Georgia and cross-sectionally with other states

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to inform additional quality improvement activities. The analysis has been completed, and the study is in the final stages of review and confirmation before publication.

Defining DBHDD's Role in Child and Adolescent Mental Health Commissioner Fitzgerald serves as a co-chair of the Governor's Commission on Children's Mental Health. This facilitates DBHDD partnerships with representatives from the governor's office, other state agencies, and advocates to recommend initiatives to improve care and access for Georgia's children. Several of those initiatives have now been approved and funded.
Expansion of the Georgia Apex Program is in process and will increase access to a continuum of behavioral health care for children and families. This innovative program is a collaboration among school systems, providers and other community stakeholders.
Supported Employment/Supported Education Programs are in development and are designed to provide access to supports for employment and related recovery activities to children and young adults.
Telemedicine Infrastructure Capacity Building addresses a need to improve access to children's behavioral health services, especially for those in rural, underserved areas. This initiative is approaching completion.
Early Intervention and Prevention Opioid Crisis and Early Intervention and Prevention Suicide Prevention are both designed to be complex programs that use multi-pronged approaches and multiple intervention strategies to reduce rates of opioid use and suicides among Georgia's youth and emerging adults.
Targeted Training for the Child Serving-Workforce is in the planning stage and may encompass additional clinical training in evidence-based practices, including trauma-informed care, or administrative practices that support the delivery of high-quality behavioral health services across service settings.
High Fidelity Wraparound (HFW) is in process and seeks to address an identified need for guidance, evaluation, and training for providers to meet the growing demand for these services and support positive outcomes for children and youth.
Mortality Analysis and Response DBHDD prepares an Annual Mortality Report* that summarizes, analyses and trends consumer deaths occurring in the previous calendar year. Click here to see a copy of the most recent published Mortality Report. This report is very rich and robust and is a primary source for identifying and creating actionable intelligence useful in designing and performing QI projects. Informed by the mortality report, DBHDD has implemented several initiatives aimed at supporting the health and safety of the individuals we serve. Additionally, policy has been updated to include twice per year joint meetings of the Community Mortality Review Committee with the Office of Quality Improvement and other stakeholders to discuss system

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implications, review recommendations and progress toward implementation, and to discuss cross-functional interventions.
One of the challenges of meeting this goal is understanding the community physician perspective on, including barriers to, serving the intellectual and developmental disability population. The Physician Survey on Attitudes regarding Consumers with Developmental Disabilities* seeks to gather more information about the community physician's perspective on treating people with intellectual and developmental disabilities. It was first administered at the Health and Wellness Physician's Summit in November 2017, and additional venues for survey administration are being researched and vetted. Completed surveys from November 2017 have been tabulated and used to identify additional physician concerns. Practitioners in specialties such as psychiatry, neurology, gastroenterology, family practice and cardiology have all been identified as additional candidates for survey administration. These practitioners have been identified as especially critical to the health and wellness of the people we serve.
The Health and Wellness Physician's Summit is one component of the Special Medical Needs of Consumers with Intellectual and Developmental Disabilities Project*. This project seeks to provide educational opportunities about the sometimes-unique medical challenges faced by individuals with intellectual and developmental disabilities. The November 2017 summit addressed unusual medical presentations which may be incorrectly identified as behavioral health issues, such as common gastrointestinal issues, oral findings, neurological issues and special concerns of individuals with autism spectrum disorder. Additional symposiums targeting nurses, physicians, and ancillary disciplines have been scheduled for fall and winter 2018.
Because of the provision of clinical oversight, there has been, and continues to be the identification of incidents of withdrawal or requests to withdrawal clinical/medical support in circumstances of non-terminal diagnosis. The What's the Rush* brochure highlights actions that increase one's ability to make informed decisions and prevent premature withdrawal of clinical supports. The brochure offers information and recommended activities for families and support entities that result in assertive advocacy when faced with the difficult decisions related to withdrawal of care. The brochure has been finalized and printed, and efforts are now underway to confirm training materials and venues for education prior to distribution to DBHDD field offices and providers.
Implement Intellectual and Developmental Disability Provider Recruitment and Development Plan An important, enterprise-wide goal involves the development of the community provider network serving people with intellectual and developmental disabilities. Analysis suggests that both residential and community clinical services (e.g., occupational, speech, and physical therapy) are necessary to support individuals with complex medical or extensive behavioral support needs. Several initiatives are currently underway that serve this goal.

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Development of a Developmental Disability Residential Bed Board system to provide real-time access to residential service capacity and availability is underway. This foundational information will support and inform the strategic development of the service system throughout the state. DBHDD regional staff and support coordination staff will use this application to identify and connect community residential alternative (CRA) providers with families seeking services. The system will contain information about placement bed status, home accessibilities/modifications, gender preference and the ability to support individuals with behavioral challenges and or medical complexities that will be used to match individuals with providers.
IT Enablement The use of information technology continues to accelerate change and productivity. The Office of Information Technology is supporting many of the above initiatives through the development of web-based tools, databases, and reporting mechanisms. Other noteworthy projects include those listed below.
The Intellectual and Developmental Disability Case Management Information System is an integrated behavioral health/intellectual and developmental disability system supported by the Georgia Collaborative ASO. The system build is nearing completion, and current work is focused on planning the transition from the legacy system to the new system. Training and migration strategies are in development.
A main goal of the Supported Housing Project* is using IT resources to automate a manual process. Expectations are that thoughtful planning and implementation of automation will lead to greater process efficiency, easier tracking, and reporting of outcomes, and in partnership with the Department of Community Affairs (DCA), more individuals served. The initial computer application has been developed and is being used; enhancements to reporting, survey, DCA module and Georgia Housing Voucher module are underway.
Conclusion
This FY 2019 Community Quality Improvement Plan is a living document reflective of a dynamic process and describes the guiding principles, environment, philosophy, structure, and processes for DBHDD. This plan describes the major roles played by various individuals, teams, and councils in the deployment and conduct of QI initiatives. It also contains a brief synopsis of many current QI initiatives completed, occurring, and planned across the agency.

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