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System Activity

Plan to Improve (QI Work Plan). Need / Demand Analysis. System Activity. Vision & Mission. Design & Redesign Processes and Services. Measurement & Feedback. Outcomes :. Sources :. Core System Processes :. UNDERSTAND WHOLE PERSON: Put clients’ strengths, assets and goals into usable form.

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System Activity

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  1. Plan to Improve (QI Work Plan) Need / Demand Analysis System Activity Vision & Mission Design & Redesign Processes and Services Measurement & Feedback Outcomes: Sources: Core System Processes: UNDERSTAND WHOLE PERSON: Put clients’ strengths, assets and goals into usable form Client Wellness & Recovery Community Schools Client Independence from PMH WELCOME: Provide accessible, appropriate and welcoming points of entry ENGAGE: Build clients’ hope and belief ASSESS: Discover clients’ strengths, assets, goals and other whole health needs PLAN & COORDINATE: Create or update clients’ txplan with usable strengths, assets goals and other whole health needs and share it TRANSITION: Support clients’ discharge to new programs and from public mental health services PREVENTION: Education in the Community Juv. Justice, Corrections Healthier Community TREAT & TEAM UP ON CARE: Provide tx in collaboration with others to support clients’ goal attainment and advance their recovery IMDs & Acute Hosp Improved Public Support Primary Care Other Programs & Agencies No Disparities System Supports: Contractual Relationships Development & Supervision Documentation & Reimbursement Auditing & Compliance External/Community Resources

  2. System Activity Vision & Mission Outcomes: Sources: Core System Processes: UNDERSTAND WHOLE PERSON: Put clients’ strengths, assets and goals into usable form Client Wellness & Recovery Community Schools Client Independence from PMH WELCOME: Provide accessible, appropriate and welcoming points of entry ENGAGE: Build clients’ hope and belief ASSESS: Discover clients’ strengths, assets, goals and other whole health needs PLAN & COORDINATE: Create or update clients’ txplan with usable strengths, assets goals and other whole health needs and share it TRANSITION: Support clients’ discharge to new programs and from public mental health services PREVENTION: Education in the Community Juv. Justice, Corrections Healthier Community TREAT & TEAM UP ON CARE: Provide tx in collaboration with others to support clients’ goal attainment and advance their recovery IMDs & Acute Hosp Improved Public Support Primary Care Other Programs & Agencies No Disparities System Supports: Contractual Relationships Development & Supervision Documentation & Reimbursement Auditing & Compliance External/Community Resources

  3. Change to the System Vision & Mission TCP: Redesign processes to assess, understand and plan; develop person-centered skills Outcomes: Sources: Core System Processes: UNDERSTAND WHOLE PERSON: Put clients’ strengths, assets and goals into usable form Client Wellness & Recovery Community Schools Client Independence from PMH WELCOME: Provide accessible, appropriate and welcoming points of entry ENGAGE: Build clients’ hope and belief ASSESS: Discover clients’ strengths, assets, goals and other whole health needs PLAN & COORDINATE: Create or update clients’ txplan with usable strengths, assets goals and other whole health needs and share it TRANSITION: Support clients’ discharge to new programs and from public mental health services PREVENTION: Education in the Community Juv. Justice, Corrections Healthier Community TREAT & TEAM UP ON CARE: Provide tx in collaboration with others to support clients’ goal attainment and advance their recovery IMDs & Acute Hosp Improved Public Support Primary Care Other Programs & Agencies No Disparities System Supports: Contractual Relationships Development & Supervision Documentation & Reimbursement Auditing & Compliance External/Community Resources

  4. Change to the System Vision & Mission Access and Capacity Management: Improve flexibility of programs, contractual structure and referral processes (AB109, access points, LOCs) and customer services Outcomes: Sources: Core System Processes: UNDERSTAND WHOLE PERSON: Put clients’ strengths, assets and goals into usable form Client Wellness & Recovery Community Schools Client Independence from PMH WELCOME: Provide accessible, appropriate and welcoming points of entry ENGAGE: Build clients’ hope and belief ASSESS: Discover clients’ strengths, assets, goals and other whole health needs PLAN & COORDINATE: Create or update clients’ txplan with usable strengths, assets goals and other whole health needs and share it TRANSITION: Support clients’ discharge to new programs and from public mental health services PREVENTION: Education in the Community Juv. Justice, Corrections Healthier Community TREAT & TEAM UP ON CARE: Provide tx in collaboration with others to support clients’ goal attainment and advance their recovery IMDs & Acute Hosp Improved Public Support Primary Care Other Programs & Agencies No Disparities System Supports: Contractual Relationships Development & Supervision Documentation & Reimbursement Auditing & Compliance External/Community Resources

  5. Change to the System Vision & Mission Client Measurement: Increase measurement of community and client needs, quality of life indicators and other outcome measures:Client Outcomes , CANS (F&C0, Demand analysis Outcomes: Sources: Core System Processes: UNDERSTAND WHOLE PERSON: Put clients’ strengths, assets and goals into usable form Client Wellness & Recovery Community Schools Client Independence from PMH WELCOME: Provide accessible, appropriate and welcoming points of entry ENGAGE: Build clients’ hope and belief ASSESS: Discover clients’ strengths, assets, goals and other whole health needs PLAN & COORDINATE: Create or update clients’ txplan with usable strengths, assets goals and other whole health needs and share it TRANSITION: Support clients’ discharge to new programs and from public mental health services PREVENTION: Education in the Community Juv. Justice, Corrections Healthier Community TREAT & TEAM UP ON CARE: Provide tx in collaboration with others to support clients’ goal attainment and advance their recovery IMDs & Acute Hosp Improved Public Support Primary Care Other Programs & Agencies No Disparities System Supports: Contractual Relationships Development & Supervision Documentation & Reimbursement Auditing & Compliance External/Community Resources

  6. Change to the System Vision & Mission Outcomes: Sources: Core System Processes: UNDERSTAND WHOLE PERSON: Put clients’ strengths, assets and goals into usable form Client Wellness & Recovery Community Schools Client Independence from PMH WELCOME: Provide accessible, appropriate and welcoming points of entry ENGAGE: Build clients’ hope and belief ASSESS: Discover clients’ strengths, assets, goals and other whole health needs PLAN & COORDINATE: Create or update clients’ txplan with usable strengths, assets goals and other whole health needs and share it TRANSITION: Support clients’ discharge to new programs and from public mental health services PREVENTION: Education in the Community Juv. Justice, Corrections Healthier Community TREAT & TEAM UP ON CARE: Provide tx in collaboration with others to support clients’ goal attainment and advance their recovery IMDs & Acute Hosp Improved Public Support Primary Care Supervision: Improve capacity to support staff in their work to advance client outcomes Other Programs & Agencies No Disparities System Supports: Contractual Relationships Development & Supervision Documentation & Reimbursement Auditing & Compliance External/Community Resources

  7. Change to the System Vision & Mission Outcomes: Sources: Core System Processes: UNDERSTAND WHOLE PERSON: Put clients’ strengths, assets and goals into usable form Client Wellness & Recovery Community Schools Client Independence from PMH WELCOME: Provide accessible, appropriate and welcoming points of entry ENGAGE: Build clients’ hope and belief ASSESS: Discover clients’ strengths, assets, goals and other whole health needs PLAN & COORDINATE: Create or update clients’ txplan with usable strengths, assets goals and other whole health needs and share it TRANSITION: Support clients’ discharge to new programs and from public mental health services PREVENTION: Education in the Community Juv. Justice, Corrections Healthier Community TREAT & TEAM UP ON CARE: Provide tx in collaboration with others to support clients’ goal attainment and advance their recovery IMDs & Acute Hosp Streamline Documentation: Streamline documentation requirements to reduce burden on staff, improve usefulness for clients Improved Public Support Primary Care Other Programs & Agencies No Disparities System Supports: Contractual Relationships Development & Supervision Documentation & Reimbursement Auditing & Compliance External/Community Resources

  8. Change to the System Vision & Mission Clients Transitions: Improve transitioning to/from FQHCs, IMDs, etc. – and into the community Outcomes: Sources: Core System Processes: UNDERSTAND WHOLE PERSON: Put clients’ strengths, assets and goals into usable form Client Wellness & Recovery Community Schools Client Independence from PMH WELCOME: Provide accessible, appropriate and welcoming points of entry ENGAGE: Build clients’ hope and belief ASSESS: Discover clients’ strengths, assets, goals and other whole health needs PLAN & COORDINATE: Create or update clients’ txplan with usable strengths, assets goals and other whole health needs and share it TRANSITION: Support clients’ discharge to new programs and from public mental health services PREVENTION: Education in the Community Juv. Justice, Corrections Healthier Community TREAT & TEAM UP ON CARE: Provide tx in collaboration with others to support clients’ goal attainment and advance their recovery IMDs & Acute Hosp Improved Public Support Primary Care Other Programs & Agencies No Disparities System Supports: Contractual Relationships Development & Supervision Documentation & Reimbursement Auditing & Compliance External/Community Resources

  9. Change to the System Vision & Mission Outcomes: Sources: Core System Processes: UNDERSTAND WHOLE PERSON: Put clients’ strengths, assets and goals into usable form Client Wellness & Recovery Community Schools Client Independence from PMH WELCOME: Provide accessible, appropriate and welcoming points of entry ENGAGE: Build clients’ hope and belief ASSESS: Discover clients’ strengths, assets, goals and other whole health needs PLAN & COORDINATE: Create or update clients’ txplan with usable strengths, assets goals and other whole health needs and share it TRANSITION: Support clients’ discharge to new programs and from public mental health services PREVENTION: Education in the Community Juv. Justice, Corrections Healthier Community TREAT & TEAM UP ON CARE: Provide tx in collaboration with others to support clients’ goal attainment and advance their recovery IMDs & Acute Hosp Linkages: Reduce preventable readmissions to acute/ED services, improve linkage to 24 hour care, create drop-in services Improved Public Support Primary Care Other Programs & Agencies No Disparities System Supports: Contractual Relationships Development & Supervision Documentation & Reimbursement Auditing & Compliance External/Community Resources

  10. Change to the System Vision & Mission Outcomes: Sources: Core System Processes: UNDERSTAND WHOLE PERSON: Put clients’ strengths, assets and goals into usable form Client Wellness & Recovery Community Schools Client Independence from PMH WELCOME: Provide accessible, appropriate and welcoming points of entry ENGAGE: Build clients’ hope and belief ASSESS: Discover clients’ strengths, assets, goals and other whole health needs PLAN & COORDINATE: Create or update clients’ txplan with usable strengths, assets goals and other whole health needs and share it TRANSITION: Support clients’ discharge to new programs and from public mental health services PREVENTION: Education in the Community Juv. Justice, Corrections Healthier Community TREAT & TEAM UP ON CARE: Provide tx in collaboration with others to support clients’ goal attainment and advance their recovery IMDs & Acute Hosp Improved Public Support Primary Care EBPs: Increase therapeutic skills and capabilities of staff (expand range of EBPs) Other Programs & Agencies No Disparities System Supports: Contractual Relationships Development & Supervision Documentation & Reimbursement Auditing & Compliance External/Community Resources

  11. Change to the System Vision & Mission Advance Recovery: Improve ability to keep treatment plan current, relevant and effective (MORS 5, Older Adult, ARP) Outcomes: Sources: Core System Processes: UNDERSTAND WHOLE PERSON: Put clients’ strengths, assets and goals into usable form Client Wellness & Recovery Community Schools Client Independence from PMH WELCOME: Provide accessible, appropriate and welcoming points of entry ENGAGE: Build clients’ hope and belief ASSESS: Discover clients’ strengths, assets, goals and other whole health needs PLAN & COORDINATE: Create or update clients’ txplan with usable strengths, assets goals and other whole health needs and share it TRANSITION: Support clients’ discharge to new programs and from public mental health services PREVENTION: Education in the Community Juv. Justice, Corrections Healthier Community TREAT & TEAM UP ON CARE: Provide tx in collaboration with others to support clients’ goal attainment and advance their recovery IMDs & Acute Hosp Improved Public Support Primary Care Other Programs & Agencies No Disparities System Supports: Contractual Relationships Development & Supervision Documentation & Reimbursement Auditing & Compliance External/Community Resources

  12. Plan to Improve (QI Work Plan) Need / Demand Analysis System Activity Vision & Mission Design & Redesign Processes and Services Measurement & Feedback System for Improvement Outcomes: Sources: Core System Processes: UNDERSTAND WHOLE PERSON: Put clients’ strengths, assets and goals into usable form Client Wellness & Recovery Community Schools Client Independence from PMH WELCOME: Provide accessible, appropriate and welcoming points of entry ENGAGE: Build clients’ hope and belief ASSESS: Discover clients’ strengths, assets, goals and other whole health needs PLAN & COORDINATE: Create or update clients’ txplan with usable strengths, assets goals and other whole health needs and share it TRANSITION: Support clients’ discharge to new programs and from public mental health services PREVENTION: Education in the Community Juv. Justice, Corrections Healthier Community TREAT & TEAM UP ON CARE: Provide tx in collaboration with others to support clients’ goal attainment and advance their recovery IMDs & Acute Hosp Improved Public Support Primary Care Other Programs & Agencies No Disparities System Supports: Contractual Relationships Development & Supervision Documentation & Reimbursement Auditing & Compliance External/Community Resources

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