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NORTHERN MICHIGAN REGIONAL ENTITY
DRAFT SNAPSHOT SATISFACTION SURVEY FEBRUARY 5TH – FEBRUARY 16TH, 2018
Purpose and Procedure Page 2
Instrumentation Page 3
Obstacles Page 3
Return Rates Page 4
Comprehensive Summary Page 6
Adult Case Management Page 11
Medical Services Page 14
Outpatient Therapy Page 17
Psychosocial Rehabilitation/Clubhouse Page 20
Youth Case Management Page 23
Assertive Community Treatment Page 26
Survey Evaluation Page 29
Strengths and Limitations Page 29
Next Steps Page 29
NMRE Snapshot Satisfaction Pre-planning Tool Attachment A
NMRE Snapshot Survey Procedures Attachment B
Adult Case Management Satisfaction Survey Attachment C
Medical Services Satisfaction Survey Attachment D
Outpatient Therapy Satisfaction Survey Attachment E
Psychosocial Rehabilitation/Clubhouse Satisfaction Survey Attachment F
Youth Case Management Satisfaction Survey Attachment G
Assertive Community Treatment (ACT) Satisfaction Survey Attachment H
NMRE Satisfaction Survey Tally Sheet Attachment I
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Purpose and Procedure
This is a report of consumer satisfaction for the Northern Michigan Regional Entity (NMRE), the Prepaid Inpatient Health Plan for the following 21 counties in northern Lower Michigan: Alcona, Alpena, Antrim, Benzie, Charlevoix, Cheboygan, Crawford, Emmet, Grand Traverse, Iosco, Kalkaska, Leelanau, Manistee, Missaukee, Montmorency, Ogemaw, Oscoda, Otsego, Presque Isle, Roscommon, and Wexford. The survey was conducted under the direction of the NMRE Quality Oversight Committee (QOC) which determined the timeframe, approved the survey tool and procedures, and set the rate of survey frequency at one time per year. The QOC of the NMRE includes quality improvement staff who share a collective focus on conducting quality and performance oversight of the service delivery systems. This is accomplished, in part, by collecting data on important processes or outcomes related to care, services, and delivery system functions and sharing the information with the Community Mental Health Services Programs (CMHSPs) quality improvement leaders. The data collection and information sharing are intended to both identify priorities and to analyze data over time in order to identify performance trends. The consumer satisfaction survey procedures established that six community mental health services programs would be evaluated by consumers over the same two-week timeframe across the NMRE region. The timeframe for the survey findings contained in the report was February 5, 2018 through February 16, 2018. The snapshot survey process was intended to aggregate consumer satisfaction among the five Member CMHSPs under contract with the NMRE: AuSable Valley Community Mental Health (AVCMH), Manistee-Benzie Community Mental Health d.b.a. Centra Wellness Network (CWN), North Country Community Mental Health (NCCMH), Northeast Michigan Community Mental Health (NEM), and Northern Lakes Community Mental Health (NLCMH). For the purposes of this report, a “consumer” is defined as an individual served by the CMHSP for the treatment of mental illness who meets the criteria of having received an initial assessment, and at least two ongoing face -to-face services. Prior to the start of the survey timeframe, pre-planning worksheets were sent to the CMHSPs for completion. (The pre-planning form is attached to this report as Attachment A.) Upon receipt of the pre-planning forms, color coded survey forms were produced for each program surveyed: Adult Case Management, Assertive Community Treatment, Medical Services, Outpatient Therapy Services, Psychosocial Rehabilitation (Clubhouse), and Youth Case Management. Once each program had been assigned a color for the surveys, the survey forms were coded at the bottom to indicate to which CMHSP, location, and clinician (if applicable) it corresponds. A packet was then generated for each program or clinician (if applicable) and forwarded to the QOC representative for each Member CMHSP. Each packet consisted of the requested number of survey forms (per the pre -planning worksheet), the survey procedures, a tally sheet, and return address labels. Pursuant to the survey procedures (Attachment B), staff from each of the six programs surveyed at each participating CMHSP was instructed to offer each consumer seen during the established snapshot timeframe, the opportunity to complete a satisfaction survey. Staff was instructed to emphasize that, while appreciated, participating in the snapshot survey was optional and would not impact the quality of care he or she receives. Consumers who agreed were given the survey form and an envelope in which to put the completed survey to maintain the anonymity of the respondent. Staff then asked the consumer whether he or she wished to complete the survey on site and place it in the collection box or mail the survey back to the NMRE. It the consumer indicated the latter, he or she was given a stamp and a label to return to the NMRE Customer Services. Staff was encouraged to stress that the envelope
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was used to maintain the confidentiality of his or her answers and would not be unsealed until the results were scored at the NMRE. Staff was encouraged to thank the consumers for participating in the survey and that the results would be used to measure and improve service quality. Completed surveys, in their sealed envelopes, were either routed to the NMRE via interoff ice or United States mail. For consumers who received services from more than one program surveyed (e.g. Adult Case Management and Medical Services), he or she was offered a survey for each program and instructed that responses should relate only to that program. The CMHSP staff was charged with maintaining accurate tally sheets to indicate to whom the survey was offered and whether each consumer: a) was given the survey, b) declined to participate, or c) had no face-to-face contact within the snapshot time frame. Staff was instructed to return tally sheets to the NMRE Customer Services at the close of the snapshot timeframe in order for return rates to be calculated.
Instrumentation The survey tool approved by the QOC and used during the snapshot survey process consisted of eleven quantitative questions scored on a four-point Likert scale. The six programs surveyed used the same first eleven quantitative statements with the addition of program-specific questions added to each corresponding survey tool. The survey tools used are included as Attachments C-I of this report. Consumers were also prompted to offer constructive comments or suggestions with regard to the services they had received. The survey tool listed the three qualitative questions: 1) “What did you like about CMH and think should be continued? 2) What did you not like, and think should be stopped? and, 3) Ideas to help the CMH improve. Responses were transcribed at the NMRE as stated and are provided as a companion to this report.
Obstacles
This was the fourth snapshot cycle conducted by the NMRE in which all five-member CMHSPs participated. The obstacles came after the survey process was underway. One CMH mailed surveys to clients that did not come into appointments during the two-week snapshot period, which is not part of the procedure. A second obstacle was identified during the data entry process. Tally sheets were not received from providers for two programs at one of the five CMHSPs. Without the tally sheets, reliable return rate cannot be calculated as that information provides the denominator, or number of surveys distributed. In these instances, NMRE removed the few surveys from the numerator and did not count them in the survey results in the return rate but did count the surveys in satisfaction measurement. The greatest obstacle, however, occurred during the time of Pre-Planning and the number of surveys requested from the NMRE. As illustrated in Figure 1, 6,032 surveys were requested and prepared by the NMRE Customer Services Specialist as indicated under “Purpose and Procedure.” Of those, only 1,878, or 31.13%, were actually distributed to services recipients. The NMRE will request that Boards use this report and the CMH-specific data supplied to them regarding the number of surveys requested, distributed, and returned for each program and clinician (if applicable) to provide more accurate Pre-Planning information for the FY19 Snapshot Survey. This survey report was prepared and presented to QOC on June 5, 2018. On July 3, 2018, the NMRE was notified by Northern Lakes CMH staff that an envelope containing 44 surveys and eight tally sheets had been discovered. Though NMRE staff considered not including those surveys in the results,
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the decision was made to honor the consumers who took the time to complete the surveys by adding their input into this report. The information was entered, and the data recalculated to provide this information.
Figure 1: FY18 Snapshot Survey Number of Surveys Requested vs. Number Distributed
Requested6,032
Distributed1,878
Extra4,154
NMRE FY19 Snapshot Satisfaction Survey - Number of Surveys Distributed vs. Number Requested per PrePlanning Forms
Return Rates
An overall return rate for the NMRE was calculated at 72.34%, a significant increase compared to FY17 rate of 60.62%. The return rate is increasing to be more consistent with historical return rates (76.82% in FY16). This calculation includes all clinicians across all five participating CMHSPs who provided services during the snapshot timeframe. The overall return rates per CMHSP were as follows: AuSable Valley CMH at 73.64% (FY17 74.74%), Centra Wellness Network at 61.97% (FY17 47.96 %), North Country CMH at 90.44% (FY17 79.10%), Northeast Michigan CMH at 51.36% (FY17 40.32%), and Northern Lakes CMH at 78.85% (FY17 56.18%). The return rate per CMHSP will be broken down by program under each program title within this report. Figure 1 illustrates the 2018 return rates for each program surveyed per CMHSP and trendlines for NMRE averages for 2017 and 2018. Figure 1 illustrates how each CMSP compared to the NMRE average for 2017 and 2018.
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Table 1: Return Rates for All Programs Surveyed sorted by CMHSP and Program
OUTPATIENT
ADULT
CSM
YOUTH
CSM MEDICAL CLUBHOUSE ACT TOTAL
AVCMH 63.89% 100.00% 80.82% 73.38% 90.00% 73.64%
CWN 56.30% 70.18% 50.00% 69.70% 86.96% 61.97%
NCCMH 95.83% 78.43% 46.67% 87.80% 97.06% 81.48% 90.44%
NEMCMH 35.53% 52.87% 61.22% 47.06% 72.73% 31.82% 51.36%
NLCMH 71.17% 78.26% 100.00% 79.35 100.00% 59.09% 78.85%
NMRE 69.51% 74.92% 68.53% 71.93% 93.50% 68.38% 72.34%
NMRE FY17 71.95% 45.97% 65.48% 68.42% 81.90% 36.36% 64.00%
Figure 2: FY18 Snapshot Survey Return Rates by CMHSP and Program
73.64%
61.97%
90.44%
51.36%
78.85%
72.34%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
AVCMH CWN NCCMH NEMCMH NLCMH NMRE
NMRE FY18 Snapshot Satisfaction Survey - Return Rates by Program ("n" = 1364)
OUTPATIENT ADULT CSM YOUTH CSM MEDICAL CLUBHOUSE
ACT TOTAL FY17 FY16
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Table 2 - AVG RATING RANGE by PROGRAM (Q1-Q11 only) HIGH QUESTION LOW QUESTION
ADULT CSM 3.78 staff treats me with dignity and respect 3.43 making progress toward goals
MEDICAL 3.74 staff treats me with dignity and respect 3.29 making progress toward goals
OUTPATIENT 3.86 staff treats me with dignity and respect 3.41 making progress toward goals
CLUBHOUSE 3.66 staff treats me with dignity and respect 3.37 receiving information about recovery
YOUTH SERVICES 3.85 staff treats me with dignity and respect 3.57 making progress toward goals
ACT 3.74 staff treats me with dignity and respect 3.35 deal better with problems
NMRE 3.77 staff treats me with dignity and respect 3.42 making progress toward goals
Comprehensive Summary The results suggest that individuals served by all of the six programs surveyed are satisfied with those services. For the NMRE, averages by program, based on a four-point scale, ranged from a low of 3.29 for Medical Services to a high of 3.85 for Youth Case Management and Outpatient Therapy. The range for FY17 was 3.48 to 3.7 with the low being Psychosocial Rehabilitation/Clubhouse and the high was with Youth Case Management. Table 2 shows the average rating range for each program and indicates which question scored on the high and low end of the scale. The question “Staff treats me with dignity and respect” scored the highest for every CMHSP. The ratings for the two questions: 1) “I am making progress toward goals” and 2) “Deal better with daily problems” were scored on the low end and should be considered as opportunities for improvement by each CMHSP. These results were consistent with the NMRE summary, as all programs at all participating CMHSPs scored above the 3.0 target set by the QOC. The percentage of favorable responses given by consumers ranged from 92.15% for Medical to 96.65% for Adult Case Management. Last year the favorable percentage was very similar and ranged from 90.48% to 97.34% for Clubhouse and Youth Case Management accordingly. A “favorable response” was defined as a score of “4” (Strongly Agree) or “3” (Agree) to the questions asked on the survey form. Figure 3 illustrates the average percent of favorable responses by program per CMHSP. It should be noted that AuSable Valley CMH and Centra Wellness Network do not offer Psychosocial Rehabilitation/Clubhouse programs; therefore, results are included only for the three CMHSPs indicated.
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Figure 3: Percentage of Favorable Responses by CMHSP and Program
95.88% 96.65% 95.67%
92.15% 93.73% 92.17%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
OUTPATIENT ADULT CSM YOUTH CMH MEDICAL CLUBHOUSE ACT
NMRE FY18 Snapshot Satisfaction Survey - Overall Percent Favorable ("n" = 1364)
AVCMH CWN NCCMH NEMCMH NLCMH NMRE
The total number of survey respondents for FY18 was 1364 compared to FY17 of 1150 which is a 15.68% increase. As illustrated in Figure 4, the Outpatient program represented the highest percentage at 35% and ACT reflected the lowest at 8%.
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Figure 4: Program Responses as Percentage of Total
OUTPATIENT474 (35%)
ADULT CSM237 (17%)
YOUTH CSM135 (10%)
MEDICAL310 (23%)
CLUBHOUSE115 (8%)
ACT93 (7%)
NMRE FY18 Snapshot Satisfaction Survey - Number and Percentage of Responses by Program ("n" = 1364)
Data has been aggregated for the NMRE and results summarized in Figures 5 through 7. The survey item that received the highest response percent was “Staff treats me with dignity and respect” at an NMRE average rating of 3.77 with the percentage of favorable responses calculated at 94.3%. Results indicated that the statements “I am making progress toward my treatment goals,” and “I deal better with daily problems because of the services” each received the lowest average at 3.42 and 3.43 with the percentage of favorable responses calculated at 85.51% and 85.74% respectively. Program specific data follows beginning on page 11 of this report.
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Figure 5: Percentage of Favorable Responses across Programs per CMHSP
94.30%
88.25%
85.51%
88.29%89.92%
88.45%92.03%
85.74%
90.55%89.60%
90.94%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
staff treats me with dignity and respect
had enough input into
treatment plan
making progress
toward goals
know what to do if concern or complaint
feel comfortable
asking questions
getting information to
help with recovery
staff supports recovery
deal better with daily problems
recommend services to
others
if greater choices still
come to cmh
appointments at times that
work best (excludes PSR)
AVCMH CWN NCCMH NEMCMH NLCMH NMRE
NMRE FY18 Snapshot Satisfaction Survey - Percent Favorable by Question by CMH ("n" = 1364)
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Figure 6: Average Responses across Programs per CMHSP
3.77
3.53
3.42
3.533.60
3.543.68
3.43
3.62 3.583.64
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
staff treats me with dignity and respect
had enough input into
treatment plan
making progress
toward goals
know what to do if concern or complaint
feel comfortable
asking questions
getting information to
help with recovery
staff supports recovery
deal better with daily problems
recommend services to
others
if greater choices still
come to cmh
appointments at times that
work best (excludes PSR)
NMRE FY18 Snapshot Satisfaction Survey - Average Scores by Question ("n" = 1364)
AVCMH CWN NCCMH NEMCMH NLCMH NMRE
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Figure 7: Percentage of Favorable Responses by Program
95.20%
89.69% 85.57%89.62% 91.70% 89.69%
92.38%
86.19%
90.82% 89.98%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
staff treats me with dignity and
respect
had enough input into
treatment plan
making progress toward goals
know what to do if concern or
complaint
feel comfortable
asking
questions
getting information to
help with
recovery
staff supports recovery
deal better with daily problems
recommend services to
others
if greater choices still
come to cmh
OUTPATIENT ADULT CSM YOUTH CSM MEDICAL CLUBHOUSE ACT AVERAGE
NMRE FY18 Snapshot Satisfaction Survey - Percent Favorable by Question by Program ("n" = 1364)
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Results
Adult Case Management
Adult Case Management services are offered at every CMHSP in the NMRE region. A total of 307 surveys were distributed to recipients of Adult Case Management services during the two-week snapshot timeframe, 230 of which were returned to the NMRE for inclusion in this report. This represents a regional return rate of 74.92%, an increase compared to 45.97% in FY17. Completed surveys for three providers from Northern Lakes* CMH were returned, but a tally sheet was not. The returned surveys were not counted in the numerator when calculating the return rate as it was unable to be determined how many surveys had been distributed. Table 3 displays the number of surveys distributed and returned per CMHSP with calculated return rates. The AuSable Valley program had the highest return rate for FY18 and FY17 (94.29%).
Table 3: Return Rates for Adult Case Management Program
AVCMH RETURNED DISTRIBUTED RETURN RATE
TOTAL 48 48 100%
CWN RETURNED DISTRIBUTED RETURN RATE
TOTAL 40 57 70.18%
NCCMH RETURNED DISTRIBUTED RETURN RATE
TOTAL 40 51 78.43%
NEMCMH RETURNED DISTRIBUTED RETURN RATE
TOTAL 46 87 52.87%
NLCMH* RETURNED DISTRIBUTED RETURN RATE
TOTAL 54 69 78.26%
TOTAL NMRE 230 307 74.92%
Adult Case Management services scored an overall high level of satisfaction with regional item means ranging from 3.43 to 3.78. The range of favorable responses fell between a low of 85.64% for “I am making progress toward my treatment goals,” and a high of 94.41% for “Staff treats me with dignity and respect.” Figure 8 and Table 4a detail the average scores per question for Adult Case Management services throughout the NMRE region and Table 4b shows the NMRE percentage of favorable responses. A trend line (dotted gray) for FY17 has been included. All averages are above the 3.0 target prescribed by the QOC.
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Figure 8: Average Responses per Question for Adult Case Management Program sorted by CMHSP
3.783.56 3.43 3.60
3.68 3.623.70
3.523.62 3.60 3.69 3.71 3.62 3.76
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
staff treats me with
dignity and respect
had enough input into treatment
plan
making progress
toward goals
know what to do if concern or complaint
feel comfortable
asking questions
getting information to help with
recovery
staff supports recovery
deal better with daily problems
recommend services to
others
if greater choices still
come to cmh
appointments at tmes that
work best
worker sees strengths, needs, and
abilities
get support in emergency or
crisis
if problems surface,
worker will help
NMRE FY18 Snapshot Satisfaction Survey - Adult Case Management ("n" = 237)
AVCMH CWN NCCMH NEMCMH NLCMH NMRE NMRE FY17
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Table 4a: Average Responses per Question for Adult Case Management Program sorted by CMHSP
staf
f tr
eats
me
wit
h di
gnit
y an
d re
spec
t
had
enou
gh
inpu
t in
to
trea
tmen
t pl
an
mak
ing
prog
ress
to
war
d go
als
know
wha
t to
do
if c
once
rn o
r co
mpl
aint
feel
com
fort
able
aski
ng q
uest
ions
gett
ing
info
rmat
ion
to
help
wit
h re
cove
ry
staf
f su
ppor
ts
reco
very
deal
bet
ter
wit
h
daily
pro
blem
s
reco
mm
end
serv
ices
to
othe
rs
if g
reat
er c
hoic
es
still
com
e to
CMH
appo
intm
ents
at
tim
es th
at w
ork
best
wor
ker
sees
stre
ngth
s, n
eeds
, an
d ab
iliti
es
get
supp
ort
in
emer
genc
y or
cr
isis
if p
robl
ems
surf
ace,
wor
ker
will
hel
p
AVCMH 3.75 3.60 3.40 3.69 3.71 3.64 3.69 3.44 3.56 3.55 3.69 3.65 3.60 3.74
CWN 3.85 3.58 3.50 3.55 3.65 3.73 3.75 3.69 3.62 3.77 3.74 3.75 3.72 3.85
NCCMH 3.73 3.46 3.44 3.54 3.63 3.59 3.68 3.56 3.66 3.61 3.68 3.71 3.66 3.68
NEMCMH 3.71 3.51 3.45 3.57 3.67 3.47 3.61 3.46 3.65 3.47 3.65 3.65 3.50 3.69
NLCMH 3.83 3.63 3.37 3.64 3.69 3.69 3.76 3.47 3.64 3.63 3.71 3.76 3.65 3.81 NMRE 3.78 3.56 3.43 3.60 3.68 3.62 3.70 3.52 3.62 3.60 3.69 3.71 3.62 3.76
Table 4b: Average Percentage of Favorable Responses for Adult Case Management Program
staf
f tr
eats
me
wit
h di
gnit
y an
d
resp
ect
had
enou
gh
inpu
t in
to
trea
tmen
t pl
an
mak
ing
prog
ress
to
war
d go
als
know
wha
t to
do
if c
once
rn o
r co
mpl
aint
feel
com
fort
able
aski
ng q
uest
ions
gett
ing
info
rmat
ion
to
help
wit
h re
cove
ry
staf
f su
ppor
ts
reco
very
deal
bet
ter
wit
h da
ily p
robl
ems
reco
mm
end
serv
ices
to
othe
rs
if g
reat
er c
hoic
es
still
com
e to
CMH
appo
intm
ents
at
tim
es th
at w
ork
best
wor
ker
sees
st
reng
ths,
nee
ds,
and
abili
ties
get
supp
ort
in
emer
genc
y or
cr
isis
if p
robl
ems
surf
ace,
wor
ker
will
hel
p
NMRE 94.34% 88.98% 85.64% 90.08% 91.88% 90.53% 92.51% 87.88% 90.60% 90.00% 92.31% 92.63% 90.57% 93.91%
FY17 94.13% 89.62% 85.90% 87.98% 90.83% 88.82% 91.27% 87.26% 89.29% 89.15% 90.02% 89.62% 88.88% 91.35%
Page 15 of 43
Medical Services
Medical Services are offered at every CMHSP in the NMRE region utilizing the professional services of medical doctors, physician assistants, nurse practitioners, and registered nurses (including telemed/telepsychiatry). A total of 431 surveys were distributed to recipients of Medical services during the two-week snapshot timeframe, 310 of which were returned to the NMRE for inclusion in this report. This represents a regional return rate of 71.93%, compared to FY17 of 68.42%. North Country and Northern Lakes CMH had the highest return rates in comparison to the other CMHSPs. Table 5 displays the number of surveys distributed and returned per CMHSP with calculated return rates.
Table 5: Return Rates for Medical Services Program
AVCMH* RETURNED DISTRIBUTED RETURN RATE
TOTAL 102 139 73.38%
CWN RETURNED DISTRIBUTED RETURN RATE
TOTAL 23 33 69.70%
NCCMH RETURNED DISTRIBUTED RETURN RATE
TOTAL 72 82 87.80%
NEMCMH* RETURNED DISTRIBUTED RETURN RATE
TOTAL 40 85 47.06%
NLCMH* RETURNED DISTRIBUTED RETURN RATE
TOTAL 73 92 79.35%
TOTAL NMRE 310 431 71.93%
Medical Services scored an overall high level of satisfaction with regional item means ranging from 3.29
to 3.74. The range of favorable responses fell between 82.17% for “I am making progress toward my
treatment goals” and 93.61% for “Staff treats me with dignity and respect.” Figure 8 and Table 6a detail the average scores per question for Medical Services throughout the NMRE region and Table 6b shows the NMRE percentage of favorable responses. A trend line (dotted gray) for FY17 has been included. All averages are above the 3.0 target prescribed by the QOC.
Page 16 of 43
Figure 9: Average Responses per Question for Medical Services Program sorted by CMHSP
3.74
3.48
3.29
3.443.56
3.483.61
3.33
3.513.44
3.553.44
3.523.44
3.53
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
staff treats me with
dignity and respect
had enough input into treatment
plan
making progress
toward goals
know what to do if concern or complaint
feel comfortable
asking questions
getting information to help with
recovery
staff supports recovery
deal better with daily problems
recommend services to
others
if other choices still
come to cmh
appointments at times that
work best
enough information
about medication
dr or nurse respects my choices and
opinions
receive feedback on lab results
dr or nurse takes time to
answer questions
NMRE FY18 Snapshot Satisfaction Survey - Medical Services ("n" = 310)
AVCMH CWN NCCMH NEMCMH NLCMH NMRE NMRE FY17
Page 17 of 43
Table 6a: Average Responses per Question for Medical Services Program by CMHSP
staf
f tr
eats
me
wit
h di
gnit
y an
d re
spec
t
had
enou
gh i
nput
int
o tr
eatm
ent
plan
mak
ing
prog
ress
tow
ard
goal
s
know
wha
t to
do
if
conc
ern
or c
ompl
ain
t
feel
com
fort
able
aski
ng q
uest
ions
gett
ing
info
rmat
ion
to
help
wit
h re
cove
ry
staf
f su
ppor
ts
reco
very
deal
bet
ter
wit
h da
ily
prob
lem
s
reco
mm
end
serv
ices
to o
ther
s
if g
reat
er c
hoic
es s
till
com
e to
CM
H
appo
intm
ents
at
tim
es
that
wor
k be
st
enou
gh i
nfor
mat
ion
abou
t m
edic
atio
n
Dr
or n
urse
res
pect
s m
y ch
oice
s an
d op
inio
ns
rece
ive
feed
back
on
lab
resu
lts
Dr
or n
urse
tak
es t
ime
to a
nsw
er q
uest
ions
AVCMH 3.72 3.47 3.26 3.46 3.55 3.51 3.58 3.35 3.49 3.31 3.56 3.42 3.45 3.39 3.45
CWN 3.91 3.55 3.26 3.61 3.78 3.61 3.70 3.52 3.82 3.91 3.83 3.70 3.70 3.70 3.78
NCCMH 3.78 3.46 3.41 3.40 3.52 3.47 3.61 3.44 3.46 3.35 3.44 3.44 3.49 3.52 3.58
NEMCMH 3.70 3.56 3.23 3.55 3.55 3.38 3.60 3.20 3.58 3.58 3.58 3.53 3.60 3.39 3.56
NLCMH 3.72 3.46 3.25 3.33 3.55 3.44 3.60 3.22 3.46 3.51 3.52 3.35 3.55 3.38 3.49
NMRE 3.74 3.48 3.29 3.44 3.56 3.48 3.61 3.33 3.51 3.44 3.55 3.44 3.52 3.44 3.53
Table 6b: Average Percentage of Favorable Responses for Medical Services Program
sta
ff t
rea
ts m
e w
ith
dig
nit
y a
nd
resp
ect
ha
d e
no
ug
h i
np
ut
into
tre
atm
ent
pla
n
ma
kin
g p
rog
ress
tow
ard
go
als
kno
w w
ha
t to
do
if c
on
cern
or
com
pla
int
feel
co
mfo
rta
ble
ask
ing
qu
esti
on
s
get
tin
g
info
rma
tio
n t
o
hel
p w
ith
reco
very
sta
ff s
up
po
rts
reco
very
dea
l b
ette
r w
ith
da
ily p
rob
lem
s
reco
mm
end
serv
ices
to
oth
ers
if o
ther
ch
oic
es
still
co
me
to c
mh
ap
po
intm
ents
at
tim
es t
ha
t w
ork
bes
t
eno
ug
h
info
rma
tio
n
ab
ou
t m
edic
ati
on
dr
or
nu
rse
resp
ects
my
cho
ices
an
d
op
inio
ns
rece
ive
feed
ba
ck
on
lab
res
ult
s
Dr
or
nu
rse
take
s ti
me
to a
nsw
er
qu
esti
on
s
NMRE 93.61% 87.09% 82.17% 86.00% 89.00% 86.92% 90.13% 83.36% 87.75% 86.10% 88.63% 86.11% 87.99% 86.12% 88.23%
FY17 95.67% 89.75% 84.96% 90.00% 90.69% 88.73% 92.17% 85.43% 91.12% 88.72% 91.37% 86.58% 91.26% 88.02% 91.70%
Page 18 of 43
Outpatient Therapy Services
Outpatient Therapy Services are offered at every CMHSP in the NMRE region. A total of 679 surveys were distributed to recipients of Outpatient Therapy Services during the two-week snapshot timeframe, 472 of which were returned to the NMRE for inclusion in this report. This represents the largest program surveyed and had a regional return rate of 69.51%, compared to 71.95% for FY17. Completed surveys for one providers from Northern Lakes* CMH were returned, but a tally sheet was not. The returned surveys were not counted in the numerator when calculating the return rate as it was unable to be determined how many surveys had been distributed. Table 7 displays the number of surveys distributed and returned per CMHSP with calculated return rates. North Country had the highest return rate of 95.83%.
Table 7: Return Rates for Outpatient Therapy Services Program
AVCMH RETURNED DISTRIBUTED RETURN RATE
TOTAL 115 180 63.89%
CWN RETURNED DISTRIBUTED RETURN RATE
TOTAL 67 119 56.3%
NCCMH RETURNED DISTRIBUTED RETURN RATE
TOTAL 184 192 95.83%
NEMCMH RETURNED DISTRIBUTED RETURN RATE
TOTAL 27 76 35.53%
NLCMH* RETURNED DISTRIBUTED RETURN RATE
TOTAL 79 111 71.17%
TOTAL NMRE 472 679 69.51%
Outpatient Therapy Services scored an overall high level of satisfaction with regional item means ranging from 3.41to 3.86. Figure 9 and Table 8a detail the average scores per question for Outpatient Therapy services throughout the NMRE region. Table 8b illustrates the range of favorable responses
which fell between 85.29% for “I am making progress toward my treatment goals ,” and 96.50% for “Staff treats me with dignity and respect.” A trend line (dotted gray) for FY17 has been included. All averages are above the 3.0 target prescribed by the QOC.
Page 19 of 43
Figure 10: Average Responses per Question for Outpatient Therapy Program sorted by CMHSP
3.86
3.61
3.41
3.61 3.68 3.64 3.75
3.43
3.68 3.663.67
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
staff treats me with dignity and respect
had enough input into
treatment plan
making progress
toward goals
know what to do if concern or complaint
feel comfortable
asking questions
getting information to
help with recovery
staff supports recovery
deal better with daily problems
recommend services to
others
if greater choices still
come to cmh
appointments at times that
work best
NMRE FY18 Snapshot Satisfaction Survey - Outpatient Services ("n" = 474)
AVCMH CWN NCCMH NEMCMH NLCMH NMRE NMRE FY17
Page 20 of 43
Table 8a: Average Responses per Question for Outpatient Therapy Services Program sorted by CMHSP
staf
f tr
eats
me
wit
h di
gnit
y an
d re
spec
t
had
enou
gh i
nput
in
to t
reat
men
t pl
an
mak
ing
prog
ress
to
war
d go
als
know
wha
t to
do
if
conc
ern
or c
ompl
aint
feel
com
fort
able
as
king
que
stio
ns
gett
ing
info
rmat
ion
to h
elp
wit
h re
cove
ry
staf
f su
ppor
ts
reco
very
deal
bet
ter
wit
h d
aily
pr
oble
ms
reco
mm
end
serv
ices
to
oth
ers
if g
reat
er c
hoic
es s
till
com
e to
CM
H
appo
intm
ents
at
tim
es th
at w
ork
best
AVCMH 3.90 3.63 3.47 3.65 3.77 3.73 3.79 3.45 3.69 3.68 3.74
CWN 3.81 3.60 3.38 3.58 3.66 3.66 3.77 3.44 3.70 3.70 3.67
NCCMH 3.82 3.64 3.43 3.59 3.62 3.59 3.71 3.43 3.71 3.64 3.59
NEMCMH 3.96 3.62 3.33 3.74 3.78 3.63 3.74 3.33 3.63 3.67 3.70
NLCMH 3.90 3.52 3.35 3.59 3.66 3.59 3.75 3.46 3.63 3.65 3.73
NMRE 3.86 3.61 3.41 3.61 3.68 3.64 3.75 3.43 3.68 3.66 3.67
Table 8b: Average Percentage of Favorable Responses for Outpatient Therapy Services Program
staf
f tr
eats
me
wit
h di
gnit
y an
d re
spec
t
had
enou
gh i
nput
in
to t
reat
men
t pl
an
mak
ing
prog
ress
to
war
d go
als
know
wha
t to
do
if
conc
ern
or c
ompl
aint
feel
com
fort
able
as
king
que
stio
ns
gett
ing
info
rmat
ion
to h
elp
wit
h re
cove
ry
staf
f su
ppor
ts
reco
very
deal
bet
ter
wit
h da
ily
prob
lem
s
reco
mm
end
serv
ices
to
oth
ers
if g
reat
er c
hoic
es s
till
com
e to
CM
H
appo
intm
ents
at
tim
es th
at w
ork
best
NMRE 96.50% 90.26% 85.29% 90.35% 91.91% 90.88% 93.67% 85.83% 92.09% 91.47% 91.68% FY17 96.16% 89.86% 86.52% 90.18% 91.54% 90.81% 93.85% 86.50% 91.84% 91.15% 91.62%
Page 21 of 43
Psychosocial Rehabilitation/Clubhouse
Psychosocial Rehabilitation/Clubhouse services are offered by five Clubhouse programs throughout the region. It should be noted that North Country CMH and Northern Lakes each offer two programs while AuSable Valley CMH and Centra Wellness Network do not offer Psychosocial Rehabilitation/Clubhouse services to consumers. This may become a topic for further discussion if the State continues to push for a consistent service array across the region. A total of 115 surveys, down from last year’s total of 163, were distributed to recipients of Psychosocial Rehabilitation/Clubhouse services during the two-week snapshot timeframe, 95 of which were returned to the NMRE for inclusion in this report. This represents a regional return rate of 81.90%. Table 9 displays the number of surveys distributed and returned per CMHSP with calculated return rates. Northern Lakes CMH has the highest return rate at 100%.
Table 9: Return Rates for Psychosocial Rehabilitation/Clubhouse Program
NCCMH RETURNED DISTRIBUTED RETURN RATE
TOTAL 66 68 97.06%
NEMCMH RETURNED DISTRIBUTED RETURN RATE
TOTAL 16 22 72.73%
NLCMH* RETURNED DISTRIBUTED RETURN RATE
TOTAL 33 33 100.00%
TOTAL NMRE 115 123 93.50%
Psychosocial Rehabilitation/Clubhouse services scored an overall high level of satisfaction with regional item means ranging from 3.37 to 3.66 (Figure 10 and Table 10a ). A dotted gray trendline has been included on Figure 10 to notate the ratings for FY 2017. The range of favorable responses fell between a
low of 84.13% for “I am getting the information I need to help me with my recovery” and a high of
91.45% for “Staff treats me with dignity and respect” and 91.52% for “The Clubhouse program offers a safe and friendly environment.” Table 10b details the average percentage of favorable responses per question for Psychosocial Rehabilitation/Clubhouse services throughout the NMRE region. All averages are above the 3.0 target prescribed by the QOC.
Page 22 of 43
Figure 11: Average Responses per Question for Psychosocial Rehabilitation/Clubhouse Program sorted by CMHSP
3.66
3.39 3.43 3.473.41
3.37
3.63
3.43
3.63 3.58 3.60
3.44
3.59 3.66
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
staff treats me with
dignity and respect
had enough input into treatment
plan
making progress
toward goals
know what to do if
concern or complaint
feel comfortable
asking questions
getting information to help with
recovery
staff supports recovery
deal better with daily problems
recommend services to
others
if greater choices, still come to cmh
offered meaningful tasks and activities
able to give input into
policies and procedures
able to build on skills
safe and friendly
environment
NMRE FY18 Snapshot Satisfaction Survey - Clubhouse Services ("n" = 115)
NCCMH NEMCMH NLCMH NMRE NMRE FY17
Page 23 of 43
Table 10a: Average Responses per Question for Psychosocial Rehabilitation/Clubhouse Program sorted by CMHSP
Table 10b: Average Percentage of Favorable Responses for Psychosocial Rehabilitation/Clubhouse Program
staf
f tr
eats
me
wit
h
dign
ity
and
resp
ect
had
enou
gh i
nput
into
tre
atm
ent
plan
mak
ing
prog
ress
to
war
d go
als
know
wha
t to
do
if
conc
ern
or
com
plai
nt
feel
com
fort
able
aski
ng q
uest
ions
gett
ing
info
rmat
ion
to h
elp
wit
h re
cove
ry
staf
f su
ppor
ts
reco
very
deal
bet
ter
wit
h da
ily p
robl
ems
reco
mm
end
serv
ices
to o
ther
s
if >
cho
ices
, sti
ll
com
e to
CM
H
offe
red
mea
ning
ful
task
s an
d ac
tivi
ties
able
to
give
inpu
t in
to p
olic
ies
and
proc
edur
es
able
to
build
on
skill
s
safe
and
fri
endl
y
envi
ronm
ent
NMRE 91.45% 84.77% 85.65% 86.74% 85.31% 84.13% 90.79% 85.87% 90.71% 89.60% 90.00% 86.09% 89.69% 91.52%
FY17 91.05% 84.57% 85.42% 85.37% 84.47% 85.11% 86.46% 83.68% 87.89% 87.63% 89.89% 86.29% 88.02% 91.15%
staf
f tr
eats
me
wit
h
dign
ity
and
resp
ect
had
enou
gh i
nput
into
tre
atm
ent
plan
mak
ing
prog
ress
tow
ard
goal
s
know
wha
t to
do
if
conc
ern
or
com
plai
nt
feel
com
fort
able
as
king
que
stio
ns
gett
ing
info
rmat
ion
to h
elp
wit
h re
cove
ry
staf
f su
ppor
ts
reco
very
deal
bet
ter
wit
h da
ily p
robl
ems
reco
mm
end
serv
ices
to o
ther
s
if >
cho
ices
, sti
ll
com
e to
CM
H
offe
red
mea
ning
ful
task
s an
d ac
tivi
ties
able
to
give
inpu
t in
to p
olic
ies
and
proc
edur
es
able
to
build
on
skill
s
safe
and
fri
endl
y en
viro
nmen
t
NCCMH 3.66 3.39 3.42 3.42 3.40 3.38 3.67 3.47 3.70 3.59 3.62 3.52 3.63 3.73
NEMCMH 3.69 3.50 3.38 3.50 3.44 3.19 3.67 3.38 3.56 3.50 3.50 3.25 3.44 3.63
NLCMH 3.64 3.34 3.45 3.55 3.42 3.42 3.55 3.39 3.52 3.61 3.61 3.39 3.58 3.55
NMRE 3.66 3.39 3.43 3.47 3.41 3.37 3.63 3.43 3.63 3.58 3.60 3.44 3.59 3.66
Page 24 of 43
Youth Case Management Services Youth Case Management Services are offered at every CMHSP in the NMRE region to consumers under the age of 18 years. A total of 197 surveys were distributed to recipients of Youth Case Management Services during the two-week snapshot timeframe, 135 of which were returned to the NMRE for inclusion in this report. This represents a regional return rate of 68.53%, an increase from 65.48% for FY17. Table 10 displays the number of surveys distributed and returned per CMHSP with calculated return rates. North Country CMH had the highest return rate for this program with a 91.67%.
Table 11: Return Rate for Youth Case Management Program
AVCMH RETURNED DISTRIBUTED RETURN RATE
TOTAL 59 73 80.82%
CWN RETURNED DISTRIBUTED RETURN RATE
TOTAL 2 4 50%
NCCMH RETURNED DISTRIBUTED RETURN RATE
TOTAL 7 15 46.67%
NEMCMH* RETURNED DISTRIBUTED RETURN RATE
TOTAL 60 98 61.22%
NLCMH RETURNED DISTRIBUTED RETURN RATE
TOTAL 7 7 100%
TOTAL NMRE 135 197 68.53%
Youth Case Management Services scored an overall high level of satisfaction with regional item means ranging from 3.57 to 3.85 as documented in Table 12a. The range of average favorable responses for Questions 1
through 10, fell between 87.69%% for “I deal better with daily problems because of the services.” and 96.30% for “staff treats me with dignity and respect.” (Table 11b). Figure 11 details the average scores per question for Youth Case Management Services throughout the NMRE region. All averages are above the 3.0 target prescribed by the QOC.
Page 25 of 43
Figure 12: Average Response per Question for Youth Case Management Program sorted by CMHSP
3.85
3.703.57
3.68 3.763.62
3.733.51
3.71 3.693.77 3.76
3.81
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
staff treats me with
dignity and respect
had enough input into treatment
plan
making progress
toward goals
know what to do if concern or complaint
feel comfortable
asking questions
getting information to help with
recovery
staff supports recovery
deal better with daily problems
recommend services to
others
if greater choices still
come to cmh
appointments at times that
work best
worker understands my strengths and abilities
worker will help if I have
a problem
NMRE FY18 Snapshot Satisfaction Survey - Youth Case Management ("n" = 135)
AVCMH CWN NCCMH NEMCMH NLCMH NMRE NMRE FY17
Page 26 of 43
Table 12a: Average Responses per Question for Youth Case Management Program by CMHSP
staf
f tr
eats
me
wit
h di
gnit
y an
d re
spec
t
had
enou
gh i
nput
in
to t
reat
men
t
plan
mak
ing
prog
ress
to
war
d go
als
know
wha
t to
do
if
conc
ern
or
com
plai
nt
feel
com
fort
able
aski
ng q
uest
ions
gett
ing
info
rmat
ion
to
help
wit
h re
cove
ry
staf
f su
ppor
ts
reco
very
deal
bet
ter
wit
h da
ily p
robl
ems
reco
mm
end
serv
ices
to o
ther
s
if g
reat
er c
hoic
es
still
com
e to
CM
H
appo
intm
ents
at
tim
es th
at w
ork
best
wor
ker
sees
st
reng
ths,
nee
ds,
and
abili
ties
if p
robl
ems
surf
ace,
wor
ker
will
hel
p
AVCMH 3.92 3.80 3.66 3.81 3.81 3.70 3.75 3.61 3.81 3.83 3.83 3.83 3.86
CWN 3.00 2.50 2.50 3.50 3.00 3.00 2.50 2.00 2.50 2.50 2.50 2.50 2.50
NCCMH 3.29 3.14 3.29 3.33 3.57 3.14 3.43 3.00 3.17 2.80 3.14 3.29 3.33
NEMCMH 3.88 3.68 3.55 3.59 3.78 3.62 3.81 3.53 3.73 3.69 3.79 3.78 3.83
NLCMH 3.86 3.86 3.57 3.71 3.57 3.50 3.40 3.29 3.57 3.57 4.00 3.86 4.00
NMRE 3.85 3.70 3.57 3.68 3.76 3.62 3.73 3.51 3.71 3.69 3.77 3.76 3.81
Table 11b: Average Percentage of Favorable Responses for Youth Case Management Program
staf
f tr
eats
me
wit
h di
gnit
y an
d re
spec
t
had
enou
gh i
nput
in
to t
reat
men
t
plan
mak
ing
prog
ress
to
war
d go
als
know
wha
t to
do
if c
once
rn o
r co
mpl
aint
feel
com
fort
able
aski
ng q
uest
ions
gett
ing
info
rmat
ion
to
help
wit
h re
cove
ry
staf
f su
ppor
ts
reco
very
deal
bet
ter
wit
h da
ily p
robl
ems
reco
mm
end
serv
ices
to o
ther
s
if g
reat
er c
hoic
es
still
com
e to
CM
H
appo
intm
ents
at
tim
es th
at w
ork
best
wor
ker
sees
st
reng
ths,
nee
ds,
and
abili
ties
if p
robl
ems
surf
ace,
wor
ker
will
hel
p
NMRE 96.30% 92.42% 89.18% 92.05% 94.03% 90.43% 93.22% 87.69% 92.86% 92.37% 94.17% 94.07% 95.34%
FY17 97.05% 91.98% 88.76% 90.14% 93.81% 93.29% 93.35% 89.22% 92.66% 90.60% 93.64% 93.86% 94.77%
Page 27 of 43
Assertive Community Treatment (ACT) ACT services are offered at every CMHSP in the NMRE region. A total of 136 surveys were distributed to recipients of Assertive Community Treatment services during the two-week snapshot timeframe, 93 of which were returned to the NMRE for inclusion in this report. This represents a regional return rate of 68.38%. This is a 32.02% increase over FY17 return rate of 36.36%. Table 13 displays the number of surveys distributed and returned per CMHSP with calculated return rates. AuSable CMH had the highest return rate for this program with a 90.00%.
Table 13: Return Rate for Assertive Community Treatment Program
AVCMH RETURNED DISTRIBUTED RETURN RATE
TOTAL 18 20 90.00%
CWN RETURNED DISTRIBUTED RETURN RATE
TOTAL 20 23 86.96%
NCCMH RETURNED DISTRIBUTED RETURN RATE
TOTAL 22 27 81.48%
NEMCMH* RETURNED DISTRIBUTED RETURN RATE
TOTAL 7 22 31.82%
NLCMH* RETURNED DISTRIBUTED RETURN RATE
TOTAL 26 44 59.09%
TOTAL NMRE 93 136 68.38%
ACT services scored an overall high level of satisfaction with regional item means ranging from 3. 35 to
3.74. The range of favorable responses fell between 83.79% for “I deal better with daily problems because of the services” and 93.55% for “Staff treats me with dignity and respect.” Figure 10 and Table 11 detail the average scores per question for Adult Case Management services throughout the NMRE region. All averages are above the 3.0 target prescribed by the QOC.
Figure 13: Average Response per Question for Assertive Community Treatment Program sorted by CMHSP
3.74
3.44 3.403.38
3.493.51 3.67
3.35
3.573.52 3.52 3.55
3.53
3.60
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
staff treats me with dignity and respect
had enough input into
treatment plan
making progress
toward goals
know what to do if concern or complaint
feel comfortable
asking questions
getting information to
help with recovery
staff supports recovery
deal better with daily problems
recommend services to
others
if greater choices still
come to cmh
appointments at times that
work best
staff willing to see meas often as I needed
get support I need in an
emergency or crisis
if problem, I feel ACT team will help me
NMRE FY18 Snapshot Satisfaction Survey - ACT Team Services ("n" = 93)
AVCMH CWN NCCMH NEMCMH NLCMH NMRE NMRE FY17
Table 14a: Average Responses per Question for Assertive Community Treatment Program by CMHSP
staf
f tr
eats
me
wit
h di
gnit
y an
d re
spec
t
had
enou
gh i
nput
in
to t
reat
men
t pl
an
mak
ing
prog
ress
tow
ard
goal
s
know
wha
t to
do
if
conc
ern
or c
ompl
aint
feel
com
fort
able
as
king
que
stio
ns
gett
ing
info
rmat
ion
to h
elp
wit
h re
cove
ry
staf
f su
ppor
ts
reco
very
deal
bet
ter
wit
h da
ily p
robl
ems
reco
mm
end
serv
ices
to
oth
ers
if g
reat
er c
hoic
es
still
com
e to
CM
H
appo
intm
ents
at
tim
es th
at w
ork
best
staf
f w
illin
g to
see
m
e a
s of
ten
as I
ne
eded
get
supp
ort
I nee
d in
an e
mer
genc
y or
cr
isis
if p
robl
em,
I fee
l ACT
te
am w
ill h
elp
me
AVCMH 3.61 3.39 3.28 3.44 3.44 3.33 3.56 3.33 3.47 3.47 3.44 3.44 3.28 3.50 CWN 3.45 3.30 3.50 3.00 3.35 3.55 3.37 3.06 3.47 3.21 3.25 3.40 3.35 3.25 NCCMH 3.91 3.67 3.57 3.36 3.59 3.55 3.82 3.41 3.68 3.68 3.77 3.68 3.68 3.77 NEMCMH 3.86 3.00 2.86 3.57 3.14 3.29 3.71 3.14 3.14 3.43 3.29 3.29 3.29 3.57 NLCMH 3.88 3.50 3.44 3.58 3.65 3.64 3.85 3.58 3.73 3.68 3.62 3.69 3.77 3.81 NMRE 3.74 3.44 3.40 3.38 3.49 3.51 3.67 3.35 3.57 3.52 3.52 3.55 3.53 3.60
Table 14b: Average Percentage of Favorable Responses for Assertive Community Treatment Program
staf
f tr
eats
me
wit
h di
gnit
y an
d re
spec
t
had
enou
gh i
nput
in
to t
reat
men
t pl
an
mak
ing
prog
ress
to
war
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NMRE 93.55% 85.99% 85.11% 84.51% 87.37% 87.77% 91.85% 83.79% 89.29% 88.06% 87.90% 88.71% 88.33% 90.05%
FY17 93.68% 88.51% 89.94% 87.21% 89.58% 88.79% 93.39% 89.12% 91.57% 91.57% 88.66% 89.94% 98.49% 93.60%
Survey Evaluation
Strengths and Limitations The preceding pages summarized the results of the fiscal year 2018 snapshot survey and included a description of the instrument used, procedures employed, and the level of satisfaction for the six programs surveyed. There are important strength and limitations to the methods followed that must be considered. As any attempt to measure satisfaction across a complex service array is met with strengths and limitations, it is important they be acknowledged and considered throughout the interpretation of the results. During the fiscal year 2018 survey process, limitations were identified with regard to the survey implementation procedures. As stated under the “Obstacles” heading, the process encountered some difficulties which were conveyed to the Member Boards and corrected or referred to their internal QI processes. Undoubtedly, identified limitations to the survey process must include the fact that the results of the survey are limited to those consumers who were actively engaged in services during the snapshot timeframe and may be more likely to respond favorably than individuals who have exited services. Individuals who either withdrew from services voluntarily, or whose cases were closed by the CMHSP, are potentially more likely to express dissatisfaction; therefore, losing the input of this population may skew the results to the positive. Historically, individuals with disabilities or who receive public services are influenced by their desire for the services to continue and tend to respond favorably to questionnaires. This may resu lt in inflated levels of satisfaction; however, levels should be consistent throughout the six programs surveyed. Next Steps As a result of what was learned during the fiscal year 2018 snapshot survey process, some steps will need to be taken to ensure the integrity of the fiscal year 2019 survey results. The NMRE Managing Director of Quality and Customer Services will work with CMHSP Quality Leaders to resolve the main concern raised in this report, namely the importance that all tally sheets be returned in order to have a legitimate number to use in calculating the return rates. It is expected that additional questions will be brought to the NMRE prior to the onset of the 2019 snapshot satisfaction survey timeframe in order to preempt any future misunderstanding of the process. No Plans of Correction were needed from the Member CMHSPs as no question received an aggregate score of less than the 3.0 benchmark. The NMRE does request, however, that any questions which received a score falling below that number when analyzing the data per location or clinician, be addressed by the internal processes of the quality improvement programs. This survey report will be reviewed by the QOC for comment and input. Once approved, the CMHSP Quality Leaders will be directed to share the report with their internal Quality Improvement Committees. A comprehensive review of the report should be conducted and reported in meeting minutes noting the resulting actions implemented to improve performance. The QOC will monitor the data for observable trends and/or potential problematic areas and convey its findings along with recommendations, if applicable, to the NMRE Operations Committee. The NMRE Managing Director of Quality and Customer Services will present the report with the regional consumer advisory committee, the Regional Entity Partners, for discussion. This report may also be shared with the NMRE Board of Directors and community stakeholders throughout the region.
Attachment A
[NAME OF PROGRAM]
NORTHERN MICHIGAN REGIONAL ENTITY
QUALITY OVERSIGHT COMMITTEE
SATISFACTION SNAPSHOP PLANNING PROTOCOL
Achieving the highest return rates possible requires adequate planning and coordination. The
committee will use this tool to document critical Board-specific programmatic descriptors to
efficiently coordinate affiliation snapshot surveys.
Service and Provider Level Information
1. Survey Timeframe: [date filled in by NMRE]
2. Board Name:
3. Number of Consumers Receiving these Services:
4. Who is the Program Supervisor at Your Agency?
5. In the spaces below, enter the names of all service providers, AVATAR ID numbers (or other
identifier), and the number of surveys needed for each provider:
LOCATION NAME ID # # OF SURVEYS
POPULATION
Attachment B
NORTHERN MICHIGAN REGIONAL ENTITY
SNAPSHOT SURVEY PROCEDURES
November 9, 2015 – November 20, 2015
The clinician or secretary will offer a survey to every consumer who has a face -to-face contact within the two-week time period indicated above IF the consumer has had at least an Intake, Plan of Service appointment, and one on-going service. Consumers may receive only one survey per program, but may receive a survey for each program they are involved in (e.g., outpatient + medical + clubhouse). When the consumer arrives for his/her appointment or when a contact is made with the CMH worker in the community: 1. Ask the consumer if they would please complete a short survey regarding the services received through
Community Mental Health. Please stress that the information is confidential and used to assist CMH in improving the quality of services it provides. However, do not pressure the consumer; his/her right to refuse must be respected.
2. If the consumer is unwilling to complete the survey, please write his/her name on the tally sheet to indicate that it was offered, and place a check mark in the “declined/refused” column.
3. If the consumer is willing to complete the survey, hand it to him/her to complete. If he/she needs
assistance reading the questions or filling in the responses, please offer to assist. The consumer may take the survey with him/her and mail it back, or may complete it on the spot and return to the designated location. Each site location will have a receptacle in which to keep the completed surveys.
4. The consumer will be provided an envelope in which to return the survey to ensure confidentiality is
maintained. If he/she chooses to mail the survey, a return address label will be put on the envelope and postage will be provided. Return address labels have been provided in the survey packets and postage will be paid by the individual CMH Boards.
5. The consumer’s name will be added to the tally sheet under the “survey distributed” column. This ensures
proper calculation of the return rate.
6. Thank the consumer for participating in the survey process and mention to him/her that he/she may receive additional surveys for other programs noting that the right to refuse any or all is always an option.
7. At the end of the survey process, please return all the completed surveys and all tally sheets to the
Northern Michigan Regional Entity (NMRE) Executive Assistant: [NMRE EXECUTIVE ASSISTANT] NORTHERN MICHIGAN REGIONAL ENTITY 1420 PLAZA DRIVE PETOSKEY, MI 49770
Attachment C
Adult Case Management Services Consumer Satisfaction Survey
All responses are confidential.
In order to improve services we need to know what you think. Your opinions, whether you agree or disagree, are important to us. Please fill out the circle under the category that best describes how you feel about the services received in the past 12 months. Please complete and return this survey in the
enclosed envelope. If you are a guardian or a parent completing this survey, please answer on behalf of the consumer.
Strongly
Agree Agree Disagree
Strongly
Disagree
Not
Applicable
CMH staff treats me with dignity and respect. ④ ③ ② ① ⃝I had enough input into the development of my
person centered plan/treatment plan. ④ ③ ② ① ⃝I am making progress toward my treatment goals. ④ ③ ② ① ⃝I know what to do if I have a concern or complaint about my treatment. ④ ③ ② ① ⃝I feel comfortable asking questions about my services, treatment, or medication(s). ④ ③ ② ① ⃝I am getting the information I need to help me
with my recovery. ④ ③ ② ① ⃝
I think staff supports my recovery. ④ ③ ② ① ⃝I deal better with daily problems because of the
services. ④ ③ ② ① ⃝I would recommend these services to a friend or relative. ④ ③ ② ① ⃝If I had other choices, I would still get services from this agency. ④ ③ ② ① ⃝Appointments/contacts are scheduled at times that work best for me. ④ ③ ② ① ⃝My worker understands my strengths, needs, and abilities. ④ ③ ② ① ⃝I get the support I need in an emergency or crisis. ④ ③ ② ① ⃝If I have a problem or need, I feel that my
worker will help me. ④ ③ ② ① ⃝
Please provide additional comments on the reverse side.
Please provide any comments you would like to make about the quality of CMH services below.
What did you like about CMH and think should be continued:
What did you not like and think should be stopped:
Ideas to help the CMH improve:
Thank you for your important feedback. The information you provide will be used to improve the quality of services provided by CMH.
Attachment D
BOARD/LOCATION/CLINICIAN ID#
Medical Services Consumer Satisfaction Survey
All responses are confidential.
In order to improve services we need to know what you think. Your opinions, whether you agree or
disagree, are important to us. Please fill out the circle under the category that best describes how you
feel about the services received in the past 12 months. Please complete and return this survey in the enclosed envelope. If you are a guardian or a parent completing this survey, please answer on behalf
of the consumer.
Strongly
Agree Agree Disagree
Strongly
Disagree
Not
Applicable
CMH staff treats me with dignity and respect. ④ ③ ② ① ⃝I had enough input into the development of my
person centered plan/treatment plan. ④ ③ ② ① ⃝
I am making progress toward my treatment goals. ④ ③ ② ① ⃝I know what to do if I have a concern or complaint
about my treatment. ④ ③ ② ① ⃝I feel comfortable asking questions about my services, treatment, or medication(s). ④ ③ ② ① ⃝I am getting the information I need to help me with my recovery. ④ ③ ② ① ⃝
I think staff supports my recovery. ④ ③ ② ① ⃝I deal better with daily problems because of the
services. ④ ③ ② ① ⃝I would recommend these services to a friend or relative. ④ ③ ② ① ⃝If I had other choices, I would still get services from this agency. ④ ③ ② ① ⃝Appointments are scheduled at times that work best for me. ④ ③ ② ① ⃝I feel that I have received enough information about
the benefits and side effects of my medication(s). ④ ③ ② ① ⃝I feel the doctor or nurse respects my choices and
opinions. ④ ③ ② ① ⃝I received notice or feedback on the results of my lab work at my medical appointment. ④ ③ ② ① ⃝I feel the doctor or nurse takes the time to answer my questions. ④ ③ ② ① ⃝
Please provide additional comments on the reverse side.
Please provide any comments you would like to make about the quality of CMH services below.
What did you like about CMH and think should be continued:
What did you not like and think should be stopped:
Ideas to help the CMH improve:
Thank you for your important feedback. The information you provide will be used to improve the quality of services provided by CMH.
Attachment E
BOARD/LOCATION/CLINICIAN ID#
Outpatient Therapy Services Consumer Satisfaction Survey
All responses are confidential.
In order to improve services we need to know what you think. Your opinions, whether you agree or
disagree, are important to us. Please fill out the circle under the category that best describes how you
feel about the services received in the past 12 months. Please complete and return this survey in the enclosed envelope. If you are a guardian or a parent completing this survey, please answer on behalf
of the consumer.
Strongly
Agree Agree Disagree
Strongly
Disagree
Not
Applicable
CMH staff treats me with dignity and respect. ④ ③ ② ① ⃝I had enough input into the development of my
person centered plan/treatment plan. ④ ③ ② ① ⃝I am making progress toward my treatment
goals. ④ ③ ② ① ⃝I know what to do if I have a concern or complaint about my treatment. ④ ③ ② ① ⃝I feel comfortable asking questions about my services, treatment, or medication(s). ④ ③ ② ① ⃝I am getting the information I need to help me
with my recovery. ④ ③ ② ① ⃝
I think staff supports my recovery. ④ ③ ② ① ⃝I deal better with daily problems because of the services. ④ ③ ② ① ⃝I would recommend these services to a friend or relative. ④ ③ ② ① ⃝If I had other choices, I would still get services from this agency. ④ ③ ② ① ⃝Appointments/contacts are scheduled at times
that work best for me. ④ ③ ② ① ⃝
Please provide additional comments on the reverse side.
Please provide any comments you would like to make about the quality of CMH services below.
What did you like about CMH and think should be continued:
What did you not like and think should be stopped:
Ideas to help the CMH improve:
Thank you for your important feedback. The information you provide will be used to improve the quality of services provided by CMH.
Attachment F
BOARD/LOCATION/CLINICIAN ID#
Psychosocial Rehabilitation Services (Clubhouse) Consumer Satisfaction Survey
All responses are confidential.
In order to improve services we need to know what you think. Your opinions, whether you agree or
disagree, are important to us. Please fill out the circle under the category that best describes how you
feel about the services received in the past 12 months. Please complete and return this survey in the enclosed envelope. If you are a guardian or a parent completing this survey, please answer on behalf
of the consumer.
Strongly
Agree Agree Disagree
Strongly
Disagree
Not
Applicable
CMH staff treats me with dignity and respect. ④ ③ ② ① ⃝I had enough input into the development of my
person centered plan/treatment plan. ④ ③ ② ① ⃝I am making progress toward my treatment
goals. ④ ③ ② ① ⃝I know what to do if I have a concern or complaint about my treatment. ④ ③ ② ① ⃝I feel comfortable asking questions about my services, treatment, or medication(s). ④ ③ ② ① ⃝I am getting the information I need to help me
with my recovery. ④ ③ ② ① ⃝
I think staff supports my recovery. ④ ③ ② ① ⃝I deal better with daily problems because of the services. ④ ③ ② ① ⃝I would recommend these services to a friend or relative. ④ ③ ② ① ⃝If I had other choices, I would still get services from this agency. ④ ③ ② ① ⃝I am offered meaningful tasks and activities at
the Clubhouse. ④ ③ ② ① ⃝I am able to give input into Clubhouse
procedures & policies. ④ ③ ② ① ⃝I feel that I am able to build on skills that I desire, including employment, independence,
and socialization. ④ ③ ② ① ⃝
The Clubhouse program offers a safe and
friendly environment. ④ ③ ② ① ⃝
Please provide additional comments on the reverse side.
Please provide any comments you would like to make about the quality of CMH services below.
What did you like about CMH and think should be continued:
What did you not like and think should be stopped:
Ideas to help the CMH improve:
Thank you for your important feedback. The information you provide will be used to improve the quality of services provided by CMH.
Attachment G
Youth Case Management Services Consumer Satisfaction Survey
All responses are confidential.
In order to improve services we need to know what you think. Your opinions, whether you agree or
disagree, are important to us. Please fill out the circle under the category that best describes how you
feel about the services received in the past 12 months. Please complete and return this survey in the enclosed envelope. If you are a guardian or a parent completing this survey, please answer on behalf
of the consumer.
Strongly
Agree Agree Disagree
Strongly
Disagree
Not
Applicable
CMH staff treats me with dignity and respect. ④ ③ ② ① ⃝I had enough input into the development of my
person centered plan/treatment plan. ④ ③ ② ① ⃝I am making progress toward my treatment
goals. ④ ③ ② ① ⃝I know what to do if I have a concern or complaint about my treatment. ④ ③ ② ① ⃝I feel comfortable asking questions about my services, treatment, or medication(s). ④ ③ ② ① ⃝I am getting the information I need to help me
with my recovery. ④ ③ ② ① ⃝
I think staff supports my recovery. ④ ③ ② ① ⃝I deal better with daily problems because of the services. ④ ③ ② ① ⃝I would recommend these services to a friend or relative. ④ ③ ② ① ⃝If I had other choices, I would still get services from this agency. ④ ③ ② ① ⃝Appointments/contacts are scheduled at times
that work best for me. ④ ③ ② ① ⃝My worker understands my strengths, needs,
and abilities. ④ ③ ② ① ⃝If I have a problem or need, I feel that my worker will help me. ④ ③ ② ① ⃝
Please provide additional comments on the reverse side.
Please provide any comments you would like to make about the quality of CMH services below.
What did you like about CMH and think should be continued:
What did you not like and think should be stopped:
Ideas to help the CMH improve:
Thank you for your important feedback. The information you provide will be used to improve the quality of services provided by CMH.
Attachment H
NORTHERN MICHIGAN REGIOAL ENTITY SNAPSHOT SATISFACTION SURVEY TALLY SHEET
(PROGRAM) SERVICES
CMHSP: LOCATION:
PROVIDER PROVIDER ID#:
CONSUMER NAME SURVEY
DISTRIBUTED DECLINED OR
REFUSED NO FACE-TO-
FACE CONTACT
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
30.