Oregon Performance Plan
Semi-Annual Narrative Report
January 2019

The Oregon Performance Plan (OPP) requires that Oregon Health Authority
(OHA) provide data to USDOJ on a quarterly basis and a narrative report about the
data every six months. This is the fourth semi-annual report about data.
For each of the data metrics, this report will describe the calendar year 2015
Baseline Data (if applicable and available), the target for the time period reported
(if applicable), the methodology for collecting the data, and the progress of each
metric for the quarter ending 06/30/18. At the end of each section, this report will
describe the activities associated with the metric(s) in that section. This report does
not review or discuss requirements related to OHA’s implementation of various
processes. However, those processes may be referenced if related to the data
metrics. Some of the metrics in the OPP require baselines to be established since
there are percentage improvement targets. The other metrics have baselines to
inform the review of progress, and numeric annual targets are provided for a
number of the metrics. While OHA has detailed implementation plans associated
with the OPP, only some of the implementation activities are highlighted in this
report.
This report includes graphs for those metrics that have established targets. Further
information about the metrics is provided in Appendix A. All metrics are
summarized in the attached Data Report in Appendix B.

 Assertive Community Treatment (ACT)
#1 (a-b) Number Served with ACT

Baseline (Calendar Year 2015)
As of the end of calendar year 2015, 815 individuals were being served by ACT.
Comments on Methodology
The data regarding ACT services is received via quarterly reports from providers,
via the Oregon Center of Excellence for ACT (OCEACT). OHA will identify the
number of individuals served at the end of each fiscal year to determine if the
performance outcome has been achieved.
Comment on Progress
Pursuant to the OPP, OHA will increase the number of individuals with SPMI
served by ACT teams. OHA will provide ACT services to everyone who is
referred to and eligible for ACT and will meet a metric so that 2,000 individuals
will be served by the end of fiscal year two (June 30, 2018). As of 6/30/18, a total
of 1,248 individuals were being served by ACT, an increase of 50% over the
baseline year, but short of the year two target by 752. Growth in ACT numbers has
remained level for the last four quarters of reporting.

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 Activities Associated with Metric
OHA has taken several steps to address growth in ACT numbers. OHA is
partnering with OCEACT to ensure individuals eligible for ACT services receive
ACT services.
The Coordinated Care Organization 2019 Contract, effective January 1, 2019,
better identifies CCO responsibilities regarding providing ACT to all eligible
individuals. It reads:
Contractor shall:
(1) Ensure Members with SPMI are assessed to determine
eligibility for ACT.
(2) Ensure ACT services are provided for all adult Members with
SPMI who are referred to and eligible for ACT services.
Related provisions: OAR 309-019-0105 and 309-019-0225
through 309-019-0255.
(3) Ensure additional ACT capacity is created to serve adult
Members with SPMI as services are needed. When ten (10) or
more of Contractor’s adult Members with SPMI in
Contractor’s Service Area are on a waitlist to receive ACT for
more than thirty (30) days, without limiting other Contractor
solutions, additional capacity may be created by either
increasing existing ACT team capacity to a size that is still
consistent with Fidelity standards or by adding additional ACT
teams. If contractor lacks qualified providers to provide ACT
services, Contractor shall consult with OHA and develop a plan
to develop additional qualified providers.
(4) Ensure all denials of ACT services for all adult Members with
SPMI are based on established criteria and are recorded and
compiled in a manner that allows denials to be accurately
reported out.
(5) Follow the Notice of Adverse Benefit Determination process for
all denials of ACT services for adult Members with SPMI.
OHA has worked with the CCOs in understanding this responsibility by revising
Oregon Administrative Rules, speaking specifically about ACT at the Rules
Advisory Committee which included CCOs, and discussion during the CCO
Behavioral Health Directors quarterly meeting. OHA will continue to work with
CCOs and will be providing additional guidance documents in the coming weeks.

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 Crisis Services
#7 (a-b) Number Served with Mobile Crisis

Baseline (Calendar Year 2015)
As of the end of calendar year 2015, a total of 3,150 individuals received mobile
crisis services.
Comments on Methodology
OHA captured mobile crisis services through 3/31/1/, utilizing the Measures and
Outcomes Tracking System (MOTS). Beginning 4/1/18, OHA is collecting data for
mobile crisis via a quarterly reporting template. This allows for tracking response
times and dispositions. This also ensures we are counting only the data for mobile
crisis responses that occur in the community and not in Emergency Departments
(ED) or other settings not considered to be a mobile response. The number of
individuals receiving these services in both methodologies is unduplicated. For
instance, if the same individual received mobile crisis services multiple times
through the year, they are still only counted as one. The metric for individuals
receiving mobile crisis services is based on a rolling 12 month period, whereas the
response times and dispositions are reported quarterly.

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 Comment on Progress
Pursuant to the OPP, OHA will increase the number of individuals served with
mobile crisis services, so that during fiscal year two (July l, 2017 to June 30,
2018), 3,700 people will be served by mobile crisis. There were 7,270 individuals
who received mobile crisis services during the quarter ending 6/30/18. This is
3,570 over the target of 3,700.
Activities Associated with Metric
The 2017 Legislature allocated $15 million to OHA to address the goals of the
Oregon Performance Plan. OHA utilized $10 million of the $15 million to increase
mobile crisis services to address statewide coverage. The funding has been
allocated through the County Financial Assistance Agreement (CFAA). All
counties now have mobile crisis programs in place.
#8 (c) The Number of Dispositions resulting in Stabilization in a Community
Setting Rather than Arrest, ED, or Admission to Acute Care
Dispositions following a mobile crisis response for October 2017 through June
2018 are indicated in the graph below. The graph indicates a majority of
individuals are stabilized and remain in the community following a mobile crisis
service.
Mobile Crisis Dispositions ‐ October 2017‐June 2018
3000
2500
2000
1500
1000
500
0
Acute Care (#)

Oct‐Dec '17

Jan‐Mar '18

Apr‐Jun '18

169

205

105

Arrest (#)

22

26

31

Emergency Department (#)

349

270

454

Remained in Community (#)

2401

2014

2021

Other or N/A (#)

155

1038

113

Acute Care (#)

Arrest (#)

Remained in Community (#)

Other or N/A (#)

January 2019 OPP Narrative Report

Emergency Department (#)

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 Supported Housing
#14 (a-c) Number Living in Supported Housing

Baseline (Calendar Year 2015)
As of the end of calendar year 2015, there were 442 individuals living in Supported
Housing.
Comments on Methodology
Supported Housing is calculated using a combination of Supported Housing units
developed and occupied and individuals receiving rental assistance in existing
affordable housing units that meet the definition of Supported Housing. The Rental
Assistance provider reporting requirements were enhanced this year to distinguish
individuals in Supported Housing and those in Supportive Housing. For the Rental
Assistance Program, although data are collected on both Supported and Supportive
Housing, only the Supported Housing is counted. This is then combined with
additional units of Supported Housing that have been developed and in which
adults with SPMI are living for a combined overall count.
Comments on Progress
Pursuant to the OPP, OHA's housing efforts will include an increase in the number
of individuals with SPMI in Supported Housing, in fiscal year two (July 1, 2017 to
June 30, 2018), so that at least 1,355 individuals will live in Supported Housing.
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 As of 6/30/18 there were 1,036 individuals residing in Supported Housing. OHA is
319 short of the goal.
OHA also tracks the number of individuals with SPMI receiving Supportive
Housing, applying the definition for that term found in the November 2012 letter
of agreement with USDOJ. Supportive Housing is another form of housing support
provided for the SPMI population. As of 6/30/19, there were 1,415 individuals
with SPMI living in Supportive Housing in addition to those living in Supported
Housing.
OHA is also maintaining an inventory of affordable housing statewide, available at
http://www.oregon.gov/oha/amh/Pages/affordable_housing.aspx. As of the end of
calendar year 2018, there were 54.691 units of affordable housing throughout
Oregon.
Activities Associated with Metric(s)
OHA continues to work with Oregon Housing and Community Services (OHCS)
to increase Supported and Supportive Housing opportunities for both individuals
with SPMI and individuals with substance use disorder (SUD). Using competitive
funding rounds, as of July 2018, OHCS in collaboration with OHA has obligated a
total of $13.2 million of the $20 million provided to OHCS by the 2015 Legislature
for development of Supported and Supportive Housing. The most recent round of
Notice of Funding Availability was veteran focused. OHCS Mental Health
Housing Funds (MHHF) totaling $700,000 were awarded to three SUD projects
serving Veterans. However, no applications for projects to serve Veterans with
SPMI were submitted for consideration.
Additionally, OHA and OHCS brokered an agreement to braid $2.5 million of
OHCS’s MHHF into OHA’s Community Mental Health Housing Trust Funds and
Mental Health Services Funds to increase the supply of Supported and Supportive
Housing. OHA released two applications with the combined OHCS and OHA
funds in May 2018. A combined total of $5,060,000 was made available in two
separate applications, one for rental housing to serve individuals with SUD and one
for rental housing to serve people with SPMI. This application described the
importance of integrated (Supported) housing and incented it over Supportive
Housing by awarding a higher unit subsidy. In September 2018, OHA made
awards to eight housing development projects serving individuals with SPMI that
will offer 91 rental units. Awards were also made to three housing development
projects serving individuals with SUD that will offer ten rental units.

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 Peer Delivered Services (PDS)
#16 (a-b) Number Served with Peer Delivered Services

Baseline (Calendar Year 2015)
A total of 2,156 individuals received Peer Delivered Services (PDS) in the calendar
year 2015.
Comments on Methodology
OHA continues to capture PDS utilizing the Medicaid Management Information
System (MMIS) as agreed upon with USDOJ, and stated in the OPP.
Comments on Progress
Pursuant to the OPP, OHA will increase the availability of PDS, in that by the end
of fiscal year two (June 30, 2018), OHA will increase the number of individuals
who are receiving PDS by an additional 20% more than the actual number at the
end of fiscal year one, that is, the higher number of 3,456 individuals. As of
6/30/18, there were 3,775 individuals who received PDS. OHA has exceeded the
year two target by 319.
Activities Associated with Metric(s)
OHA continues to work across stakeholder groups to increase opportunities for
education regarding PDS and its outcomes.
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 Oregon State Hospital (OSH)
#20 (a-b) Percentage Discharged within Target of Ready to Transition

Baseline (Calendar Year 2015)
The cumulative percentage of civilly committed patients discharged within 30 days
of being placed on the Ready to Transition (RTT) list was 51.7% for the 12-month
period ending December 31, 2015. This includes one individual who was
discharged shortly after the 30 days due to a weekend/holiday.
Comments on Methodology
In order to provide the most accurate RTT data possible, a new tracking system
was developed and implemented as part of the OSH Electronic Health Record
(Avatar) on July 1, 2016.
Comments on Progress
The OPP goal is that by the end of fiscal year two (June 30, 2018), 85% of
individuals who are RTT will be discharged within 25 calendar days of placement
on that list. As of 6/30/18, the cumulative percentage of those discharged within 25
days of being placed on the RTT list was 48.4%.
Efforts to address the shortfall on OSH metrics are addressed below, in the section
“Activities Associated with Metric(s).”

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 There was one discharge that was extended to, and occurred on, the business day
following a weekend day or holiday.
#24 Percentage Discharged within 120 Days

Baseline (Calendar Year 2015)
For calendar year 2015, the percentage of discharges within 120 days of being
admitted to OSH was 37.9%.
Comments on Methodology
The percentage is calculated taking the number of individuals who are civilly
committed, pursuant to the OPP, who were discharged within 120 days of
admission, divided by the total number of individuals who are civilly committed
and were discharged.
Comments on Progress
As of 6/30/18, the cumulative percentage of discharges within 120 days of
admission was 54.1%.

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 Activities Associated with Metric(s)
OHA is taking many steps to address discharges.
On 01/04/19, OHA filed temporary Oregon Administrative Rules 309-091-0000
through 309-091-0050, State Hospital Admissions and Discharges. These rules will
ensure consistency in the application of criteria for admissions and discharges.
OSH and Health Systems Division (HSD) have been meeting directly with Acute
Care Hospitals since 11/08/18 to provide training on these rules. Specifically, to
assure the community and the hospital understand an OSH stay is an episode of
care only and that discharge is to be planned from the beginning, and the
community remains responsible for the individual’s care and discharge.
To date, there have been eight trainings across Portland, Salem, Eugene, and
Corvallis. There is another training scheduled for the end of February.
The CCO 2019 Contract, effective 1/1/19, better identifies CCO responsibilities
related to individuals at OSH. It reads:
Contractor shall:
(1) Coordinate with applicable Choice Contractors as needed
regarding Oregon State Hospital discharges for all adult
Members with SPMI.
(2) Coordinate care for members receiving behavioral health
treatment while admitted to the State hospital during discharge
planning for the return to Home CCO when the patient has
been deemed ready to transition.
(3) Provide access to evidence-based intensive services for adult
Members with SPMI discharged from Oregon State Hospital
who refuse ACT services.
OHA is currently revising the Choice contract for the 2019-2021 biennium to
include the OPP fiscal year three metric which reads 90% of individuals who are
RTT will be discharged within 20 calendar days of placement on that list.

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 As was provided in the January 2017 report, OHA is providing a “Point in Time”
count of all civilly committed individuals with SPMI residing in OSH on June 15,
2018. The breakdown for the number of days in OSH for the 97 individuals in
residence on June 15, 2018 is as follows:
 Less than 120 days: 56 persons, or 57.7% of all civilly committed
individuals residing at OSH on June 15, 2018.
 120-365 days: 27 persons, or 27.8% of all civilly committed individuals
residing at OSH on June 15, 2018.
 366 days to two years: 9 persons, or 9.3% of all civilly committed
individuals residing at OSH on June 15, 2018.
 Over two years: 5 persons, or 5.2% of all civilly committed individuals
residing at OSH on June 15, 2018.
OHA is consulting with Pam Hyde, the Independent Consultant to examine the
OSH metrics and look for opportunities to impact OSH utilization.
Acute Psychiatric Care
#29 Percentage Receiving Warm Handoff
Baseline (Calendar Year 2015)
This is a new process and metric, therefore there is no baseline information
available for calendar year 2015.
Comments on Methodology
OHA has contracted with Health Insights to gather data to determine the number of
warm handoffs that are occurring for individuals with SPMI in Acute Care. The
contractor is reviewing records for all Acute Care discharges within each quarter to
determine if a warm handoff occurred. This process will also identify any refusals
for a warm handoff.
Comments on Progress
Pursuant to the OPP, by the end of fiscal year two (June 30, 2018), 75% of
individuals discharged from an Acute Care Psychiatric Facility will receive a warm
handoff to a community case manager, peer bridger, or other community provider.
As of 6/30/18, the cumulative percentage of those who received a warm handoff
was 27.7%. The hospital association believes the numbers are low due to
documentation issues and that there are actually more warm handoffs occurring.
OHA is below the year two percentage for this metric. Steps being taken to address
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 this are described below in the section for “Activities Associated with Metric(s).”
#30 Percentage Receiving Follow-up within 7 Days of Discharge
Baseline (Calendar Year 2015)
For calendar year 2015, the percentage of follow up visits within seven days of
discharge was 79.4%.
Comments on Methodology
The methodology to collect this data aligns with the methodology for reporting on
other Coordinated Care Organizations (CCO) metrics.
Comments on Progress
The OPP provides that OHA will continue to require that individuals receive a
follow-up visit with a Community Mental Health Provider within seven days of
discharge, and that OHA will report this data. As of 6/30/18, the percent of
individuals receiving follow up within seven days was 76.7%. Oregon continues to
do well as compared to other states. According to the 2015 Benchmarks and
Thresholds Report by the National Center for Quality Assurance (NCQA), the
Medicaid national 90th percentile was 70%. Oregon’s numbers continue to be
above the 90th percentile.
#31 (a) Readmission Rates
Baseline (Calendar Year 2015)
The cumulative 30-day readmission rate to Acute Care Psychiatric Facilities for
calendar year 2015 was 9.23%. The cumulative 180-day readmission rate to Acute
Care Psychiatric Facilities for calendar year 2015 was 21.35%.
Comments on Methodology
Pursuant to the OPP, OHA will monitor and report the percentages of discharges
with readmissions to Acute Psychiatric Care hospitals within 30 and 180 days of
discharge from hospitalizations for a psychiatric reason. The Data Specification
Sheet has been updated to provide the methodology for collecting the readmission
rate data by hospital. The readmission rate by hospital was reported based on the
hospital where the first admission occurred. The second admission may have
actually occurred at another hospital. This creates challenges in how the data by
hospital is interpreted.

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 Comments on Progress
As of 6/30/18, the cumulative percentage rates of readmission at 30 and 180 days
were 12.2% and 24.0% respectively. See Appendix C for the breakout by hospital.
#35 Average Length of Stay
Baseline (Calendar Year 2015)
The cumulative average length of stay for Acute Psychiatric Care Facilities, for
calendar year 2015, is 8.89 days. For calendar year 2015, there were 4,431
discharges; 385 (8.7%) of them exceeded 20 days.
Comments on Methodology
The OPP provides that OHA will provide the cumulative average length of stay of
individuals with SPMI for all hospitals, as well as the average length of stay by
hospital. OHA will also provide a count of the number of individuals with a length
of stay longer than 20 days.
Comments on Progress
As of 6/30/18, the cumulative average length of stay of individuals with SPMI
discharged from Acute Care Psychiatric Facilities was 11.16 days. When broken
down by hospital, the range of length of stays at the Acute Care Psychiatric
Facilities (see Appendix D ranges from 8.0 to 15.1 days. Of the 3,907 discharges,
the length of stay for 518 (13.3%) exceeded 20 days. Of the 518 individuals, 138
were on the OSH Waitlist. See Appendix D for the detail by hospital.
Activities Associated with Metric(s)
OHA continues to work with the Oregon Association of Hospitals and Health
Systems (OAHHS) to assure performance of warm handoffs and documentation of
any warm handoff activity improves over time.
The CCO 2019 Contract, effective 1/1/19, better identifies CCO responsibilities
regarding Acute Care, including warm handoffs and links to housing agencies. It
reads:
Contractor shall:
(1) Ensure all adult Members with SPMI discharged from Acute
Care Psychiatric Hospitals are provided access to a Warm
Handoff to a community case manager, peer bridger, or other
community provider prior to discharge.
(2) Ensure that all Members discharged from Acute Care
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 (3)
(4)
(5)

(6)

(7)

Psychiatric Hospitals have documentation of linkages to timely,
appropriate behavioral and primary health care in the
community prior to discharge. Related OAR provision: 309032-0850 through 309-032-0870.
Ensure all adult Members with SPMI receive a follow-up visit
with a community mental health provider within seven (7) days
of their discharge from an Acute Care Psychiatric Hospital.
Reduce readmissions of adult Members with SPMI to Acute
Care Psychiatric Hospitals.
Work with system partners to ensure adult Members with SPMI
who are homeless and who have had two or more readmissions
to an Acute Care Psychiatric Hospital in a six-month period
are connected to a housing agency or mental health agency to
ensure these adult Members are linked to housing in an
integrated setting, consistent with the individual’s treatment
goal, clinical needs and the individual’s informed choice.
Work with OHA and the CMHPs to ensure that adult Members
with SPMI who are discharged from Acute Care Psychiatric
Hospitals are discharged to housing that meets the individuals’
immediate need for housing and shall work with Acute Care
Psychiatric Hospitals in the development of each individual’s
housing assessment. The housing assessment will be
documented in a plan for integrated housing that is part of the
individual’s discharge plan, and will be based on the
individual’s treatment goals, clinical needs, and the
individual’s informed choice. Contractor shall notify, or have
the Acute Care Psychiatric Hospital notify, the community
provider to facilitate the implementation of the plan for
housing.
Develop and upon request, provide to OHA a management plan
for contacting and offering services to each adult Member with
SPMI who has two (2) or more readmissions to an Acute Care
Psychiatric Hospital in a six-month period. The management
plan will describe how it will assist the Member in avoiding
unnecessary readmissions to acute care hospitals.

OHA is engaging with Health Insights, the contractor determining if warm
handoffs are occurring, to better understand the barriers. OHA has developed
guidance documents regarding warm handoffs. They will be distributed to system
partners in the coming weeks.
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 Emergency Departments (ED)
#40 (a) Number Readmitted Two or More Times within 6 Months
Baseline (Calendar Year 2015)
During calendar year 2015, 1,067 individuals with SPMI were re-admitted to an
emergency department (ED) two or more times in a six-month period.
Comments on Methodology
The OPP provides that OHA will count individuals with three or more visits
(admissions) to an ED (which is equal to two readmissions) within a six-month
period of time. As previously discussed with Pam Hyde, the Independent
Consultant, and as discussed with USDOJ during the November 2, 2017 meeting,
OHA is providing this breakout by CCO. See Appendix E for the detail by CCO.
Comments on Progress
As of 6/30/18, a total of 622 individuals with SPMI were readmitted to an ED two
or more times in a six-month period. There is no target associated with this metric,
although the data is relatively unchanged over the last four quarters.
#41(a-b) Rate of ED Mental Health Visits

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 Baseline (Calendar Year 2015)
During calendar year 2015, the rate was 1.54 persons per 1000 Oregon Health Plan
(OHP) members who visited the ED for psychiatric reasons.
Comments on Methodology
The OPP provides that OHA will reduce the rate of visits to general emergency
departments by individuals with SPMI for mental health reasons, and that by the
end of fiscal year two (June 30, 2018), there will be a 20% reduction from the
baseline. The rate of ED visits for mental health reasons is the number of
individuals with SPMI who had an ED visit for psychiatric reasons per 1,000
persons enrolled in Medicaid. The MMIS system does not have diagnostic
information for everyone enrolled in Medicaid. However, OHA will review the
methodology for possible narrowing of the patients in the denominator to
individuals with SPMI.
Comments on Progress
As of 6/30/18, 1.79 individuals per 1,000 OHP members with SPMI visited the ED
for mental health reasons. This rate has been trending down over this second fiscal
year.
Activities Associated with Metric(s)
Steps taken by OHA to address the rate of ED visits include contract
modifications. The CCO 2019 Contract, effective 1/1/19, better identifies CCO
responsibilities regarding providing a management plan for individuals with 2 or
more readmissions to an emergency department in a six-month period. It reads:
Contractor shall develop a management plan for contacting and
offering services to each adult Member with SPMI who has two (2) or
more readmissions to an emergency department in a six-month
period. The management plan will describe how it will assist
Members in avoiding unnecessary readmissions. Contractor shall
collaboratively work with OHA and CMHPs to develop and
implement plans to better meet the needs of Members in less
institutional community settings and to reduce recidivism to
emergency departments for mental health reasons.
OHA will continue to monitor the other services in the OPP that affect the rate of
ED utilization.

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 Supported Employment
#45 (a-b) Individuals Served with Supported Employment
Baseline (Calendar Year 2015)
The two Supported Employment data points being collected regarding Supported
Employment are new data points; therefore, baseline data is not available.
Comments on Methodology
The data regarding Supported Employment services is received via quarterly
reports. OHA will identify the number of individuals receiving Supported
Employment who are employed in Competitive Integrated Employment (CIE), and
the number of individuals who no longer receive Supported Employment services
and are employed in CIE without receiving supportive services from a Supported
Employment specialist at discharge.
Comments on Progress
Pursuant to the OPP, OHA will report the number of persons receiving Supported
Employment who are employed in CIE and the number of individuals who no
longer receive Supported Employment and are employed in CIE. As of 6/30/18, a
total of 762 individuals were receiving Supported Employment services and
employed in CIE. There were 137 individuals who no longer receive Supported
Employment and are employed in CIE without currently receiving supportive
services from a Supported Employment specialist. The number of individuals
receiving SE services as well as the number of individuals employed in CIE
without receiving supportive services has increased since the end of year one
(6/30/17).
Activities Associated with Metric(s)
OHA will continue to work with the Oregon Supported Employment Center of
Excellence to monitor fidelity and provide technical assistance.
The CCO 2019 Contract, effective 1/1/19, better identifies CCO responsibilities
regarding Supported Employment. It reads:
Contractor shall ensure access to supported employment services for
all adult Members with SPMI seeking these services, in accordance
with OAR 309-019-0275 through 309-019-0295. “Supported
employment services” means the same as “Individual Placement and
Support (IPS) Supported Employment Services” as defined in OAR
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 309-019-0225.
Secure Residential Treatment (SRTF)
#49 (b) (i-ii) Average Length of Stay in SRTFs

Baseline (Calendar Year 2015)
As of the end of calendar year 2015, the average length of stay for an individual
who was civilly committed and in a Secure Residential Treatment Facility (SRTF)
was 638 days.
Comments on Methodology
The baseline data is calculated by dividing the total days by the number of
individuals with SPMI civilly committed who have been discharged from SRTFs.
Comments on Progress
Pursuant to the OPP, OHA will seek to reduce the length of stay of civilly
committed individuals in SRTFs, in that by the end of fiscal year two (June 30,
2018), there will be a 20% reduction from the baseline. As of 6/30/18, the average

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 length of stay for an individual who was civilly committed and discharged from an
SRTF was 676 days. While the length of stay based on discharge has increased, it
is still significantly below baseline.
This increase may in part reflect efforts to assure that those who can be served in
more integrated settings have been transitioned to other settings or are no longer
being admitted to SRTFs. That is, individuals now being admitted to SRTFs may
have higher or more intense needs on average than before.
The other factor resulting in an increase is that in CY 2018 Q1, there were
discharges of individuals with longer lengths of stay. The data represents a rolling
12 month reporting period, so it will take some time for the average to level back
out.
The 15 discharges occurred within the following timeframes:
 Less than one year: two individuals discharged
 366 days to two years: 3 individuals discharged
 Two plus to three years: four individuals discharged
 Three plus to four years: one individual discharged
 Four plus to five years: one individual discharged
 Five plus to six years: one individual discharged
 Six plus to seven years: one individual discharged
 Seven plus to eight years: two individuals discharged
Activities Associated with Metric(s)
The CCO 2019 Contract, effective 1/1/19, better identifies CCO responsibilities
regarding SRTFs. It reads:
Contractor shall work with SRTFs to expeditiously move civilly
committed adult Members with SPMI who no longer need placement
in an SRTF to a community placement in the most integrated setting
appropriate for that person.
OHA’s contractor (KEPRO) continues to perform prior authorizations for
individuals referred to SRTFs from OSH as well as the continued stay reviews for
individuals receiving treatment in an SRTF. OHA is working with its contractors to
assure only those who need this intensive level of care are admitted and to promote
timely discharge from SRTFs for those who can transition safely to more
integrated settings.
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 As was provided in the January 2017 report, OHA is providing a “Point in Time”
count of all civilly committed individuals with SPMI residing in SRTFs on June
15, 2018. The breakdown for the number of days in SRTFs for the 53 individuals
in residence on June 15, 2018 is as follows*:
 Less than 120 days: 19 persons or 35% of all civilly committed individuals
with SPMI residing in SRTFs on June 15, 2018.
 120-365 days: 10 persons or 19% of all civilly committed individuals with
SPMI residing in SRTFs on June 15, 2018.
 366 days to two years: 11 persons or 20% of all civilly committed
individuals with SPMI residing in SRTFs on June 15, 2018
 Over two years: 13 persons or 24% of all civilly committed individuals with
SPMI residing in SRTFs on June 15, 2018.
*The percentage only adds up to 98% due to decimal rounding.
Criminal Justice Diversion (CJD)
#52 (a) Numbers Served with Jail Diversion
Baseline (Calendar Year 2015)
In the last quarter of calendar year 2015, there were 1,409 individuals who
received Jail Diversion services. The number of individuals reported by jail
diversion contractors as receiving services pre-arrest was 499 and the number postarrest was 910.
Comments on Methodology
The data regarding Jail Diversion services is received via Quarterly Reports from
jail diversion contractors. OHA will identify the number of individuals receiving
Jail Diversion services as well as the number that were pre-arrest and post-arrest.
Comments on Progress
Pursuant to the OPP, OHA will continue to report the number of individuals with
SPMI receiving Jail Diversion services and the number of reported diversions. As
of 6/30/18, a total of 2,086 individuals received Jail Diversion services, an increase
over the baseline year of 677 individuals. Of these 2,086 individuals, 502 were prebooking and 1,574 were post-booking.

January 2019 OPP Narrative Report

Page 21

 #52 (d) Number of Individuals Receiving Mental Health Services and Arrested
OHA has been keeping Pam Hyde, the Independent Consultant apprised of the
challenges in collecting this data. During the November 2017 annual meeting
between OHA and USDOJ, OHA shared the challenges in collecting the data
directly with USDOJ. The collection of this data is a complex process requiring
data from both OHA and the Criminal Justice Commission (CJC). OHA continues
to work with Oregon DOJ regarding establishing a partnership between OHA and
the CJC so that data can be shared. OHA is encountering new barriers in obtaining
this information.
Based on data and through Pam Hyde, the Independent Consultant’s June 2018
Site Visit, we are assured that there is a great deal of work occurring to divert
individuals with SPMI from being arrested. There is a lot of diversion occurring in
the Mobile Crisis services rather than just in the Criminal Justice Diversion
programs.
Activities Associated with Metric(s)
The CCO 2019 Contract, effective 1/1/19, better identifies CCO responsibilities
regarding Criminal Justice. It reads:
Contractor shall work with local law enforcement and jail staff to
develop strategies to reduce contacts between adult Members with
SPMI and law enforcement due to mental health reasons, including
reduction in arrests, jail admissions, lengths of stay in jails and
recidivism. Contractor will work with local jurisdictions to share
information with jails regarding the mental health diagnosis, status,
medication regimen, and services of adult Members with SPMI who
are incarcerated.

January 2019 OPP Narrative Report

Page 22

 APPENDIX A
Many of the metrics identified refer to a rolling one-year period. This information
is identified in the Data Table in Appendix B – see the footnote marked with an
asterisk (*). A rolling one-year period means the analyst looks at 12 months of
data for each quarterly report. In the current report, three quarters of data from the
previous report are included along with one new quarter for a full 12 months of
data. Doing this ensures adequate sample size for analysis, especially when there
are small samples. The table below shows a rolling one-year schedule with a sixmonth lag period to ensure complete data submission.
Report Quarter
Q1 (January)
Q2 (April)
Q3 (July)
Q4 (October)

Previous Rolling One-Year Period
July 1 to June 30 of the previous year
October 1 to September 30 of the previous year
January 1 to December 31 of the previous year
April 1 to March 31 of the previous year

January 2019 OPP Narrative Report

Page 23

 Appendix B
Oregon Performance Plan
January 2019 Data Report
Note: Light yellow shading indicates Year 2 data.

Metric Metric
Category Number

Performance Outcome

ACT*

1a

OHA will increase the number of individuals with
SPMI served by ACT teams.

Crisis

1b
7a

2,000 individuals will be served by the end of year two (June 30, 2018).
OHA will increase the number of individuals with During year one (July 1, 2016 to June 30, 2017), 3,500 people will be
mobile crisis services, as follows:
served by mobile crisis.
During year two (July 1, 2017 to June 30, 2018), 3,700 people will be
served by mobile crisis.
OHA will track and report the number of
By the end of year two (June 30, 2018), Oregon will report the number of
individuals receiving a mobile crisis contact.
individuals whose dispositions after contact with mobile crisis result in:
stabilization in a community setting rather than arrest
presentation to an emergency department
admission to an acute care psychiatric facility
OHA's housing efforts will include an increase in
In year one (July 1, 2016 to June 30, 2017), at least 835 individuals will
the number of individuals with SPMI in supported live in supported housing.
housing, as follows:
In year two (July 1, 2017 to June 30, 2018), at least 1,355 individuals will
live in supported housing.
In year three (July 1, 2018 to June 30, 2019), at least 2,000 individuals will
live in supported housing.
OHA will increase the availability of peer-delivered By the end of year one (June 30, 2017), OHA will increase the number of
services, as follows:
individuals who are receiving peer-delivered services by 20%.
By the end of year two (June 30, 2018), OHA will increase the number of
individuals who are receiving peer-delivered services by an additional

7b
Crisis*

SH*

8c

14a
14b
14c

PDS

16a
16b

1,050 individuals will be served by the end of year one (June 30, 2017).

Baseline
2015
815

3,150

442

Target
Target
Year 1
Year 2
6/30/2017 06/30/18
1,050

Quarter
Quarter
Quarter
Quarter
Ending
Ending
Ending
Ending
Sept 30
Dec 31
March 31 June 30
of each FY of each FY of each FY of each FY
1,098

1,120

1,140

2,000

1,280
3,587

1,260
3,472

1,226
3,564

1,170
1,248
3,832

3,700

4,208

5,027

6,983

7,270

n/a
n/a
n/a
767

2,401
349
169
834

2,041
270
205
876

2021
454
105
966

1,008

1,002

1,026

1,036

3,500

835
1,355

Year Three Deliverable
2,156

2,587
3,456

2,434

2,461

2,538

2,880

3,022

3,289

3,522

3,775

* Quarterly data for metrics marked with a "*" reflect 3 months of data for a given quarter. Quarterly data for other metrics are based on the past year's worth of data, reported on a rolling basis through the end of a given quarter.

Page 1

 Appendix B
Oregon Performance Plan
January 2019 Data Report
Note: Light yellow shading indicates Year 2 data.

Metric Metric
Category Number
OSH

20a

20b

20c

20e

OSH

ACUTE

24

29a

29b

29c

Performance Outcome

Discharge from OSH will occur as soon as an
individual is ready to return to the community, as
follows:

By the end of year one (June 30, 2017), 75% of individuals who are Ready
to Place/Ready to Transition will be discharged within 30 calendar days of
placement on that list.
By the end of year two (June 30, 2018), 85% of individuals who are Ready
to Place/Ready to Transition will be discharged within 25 calendar days of
placement on that list.
By the end of year three (June 30, 2019), 90% of individuals who are
Ready to Place/Ready to Transition will be discharged within 20 calendar
days of placement on that list.
OSH will track and report discharges that are extended to and occur on the
business day following a weekend day or holiday. (FY1)

Baseline
2015

Target
Target
Year 1
Year 2
6/30/2017 06/30/18

51.7%

75.0%

61.3%

n/a

85.0%

Quarter
Quarter
Quarter
Quarter
Ending
Ending
Ending
Ending
Sept 30
Dec 31
March 31 June 30
of each FY of each FY of each FY of each FY
55.4%

59.6%

61.6%

61.3%

53.9%

49.0%

47.1%

48.4%

57.7%

Year Three Deliverable

Baseline Measure
Not
without
Applicable Target

OSH will track and report discharges that are extended to and occur on the
business day following a weekend day or holiday. (FY2)
At the end of year one (June 30, 2017), OSH will discharge 90% of
37.8%
individuals within 120 days of admission.(FY1)
At the end of year one (June 30, 2017), OSH will discharge 90% of
individuals within 120 days of admission.(FY2)
By the end of year one, (June 30, 2017), 60% of individuals discharged
Baseline
from an acute care psychiatric facility will receive a warm handoff to a
Not
community case manager, peer bridger, or other community provider.
Applicable
By the end of year two, (June 30, 2018), 75% of individuals discharged
from an acute care psychiatric facility will receive a warm handoff to a
community case manager, peer bridger, or other community provider.
By the end of year three, (June 30, 2019), 85% of individuals discharged
from an acute care psychiatric facility will receive a warm handoff to a
community case manager, peer bridger, or other community provider.

90.0%
90.0%

0

1

1

1

5

2

3

3

41.5%

41.7%

46.4%

46.9%

46.5%

47.8%

48.6%

54.1%

60%

Not Available

75.0%

21.4%

27.7%

29.6%

27.7%

Year Three Deliverable

* Quarterly data for metrics marked with a "*" reflect 3 months of data for a given quarter. Quarterly data for other metrics are based on the past year's worth of data, reported on a rolling basis through the end of a given quarter.

Page 2

 Appendix B
Oregon Performance Plan
January 2019 Data Report
Note: Light yellow shading indicates Year 2 data.

Metric Metric
Category Number
ACUTE

ACUTE

30

31a

Performance Outcome

OHA will continue to require that individuals receive a follow up visit
with a community mental health provider within 7 days of discharge, and
OHA will report this data. (FY1)
OHA will continue to require that individuals receive a follow up visit
with a community mental health provider within 7 days of discharge, and
OHA will report this data. (FY2)
OHA will monitor and report the 30 day rates of readmission, by acute
care psychiatric facility. (FY1)

Baseline
2015
79.4%

n/a

9.2%

Target
Target
Year 1
Year 2
6/30/2017 06/30/18
Measure
without
Target
n/a

Measure
without
Target

OHA will monitor and report the 30 day rates of readmission, by acute
care psychiatric facility. (FY2)
OHA will monitor and report the 180 day rates of readmission, by acute
care psychiatric facility. (FY1)

Measure
without
Target
21.3%

Measure
without
Target

OHA will monitor and report the 180 day rates of readmission, by acute
care psychiatric facility. (FY2)
ACUTE

31b
32

Two or more readmissions to acute care psychiatric hospital in a six month
period. (FY1)
Two or more readmissions to acute care psychiatric hospital in a six month
period. (FY2)

Measure
without
Target

Measure
without
Target
Baseline Data for
Not
Process
Applicable Measure
Data for
Process
Measure

Quarter
Quarter
Quarter
Quarter
Ending
Ending
Ending
Ending
Sept 30
Dec 31
March 31 June 30
of each FY of each FY of each FY of each FY
71.5%

72.0%

73.0%

74.20%

75.7%

77.8%

77.2%

76.7%

10.9%

11.1%

10.3%

10.60%

11.0%

10.8%

11.8%

12.2%

22.6%

22.6%

22.7%

22.80%

23.8%

22.9%

23.4%

24.0%

n/a

346

280

284

305

314

291

302

* Quarterly data for metrics marked with a "*" reflect 3 months of data for a given quarter. Quarterly data for other metrics are based on the past year's worth of data, reported on a rolling basis through the end of a given quarter.

Page 3

 Appendix B
Oregon Performance Plan
January 2019 Data Report
Note: Light yellow shading indicates Year 2 data.

Metric Metric
Category Number
ACUTE

35

35

Performance Outcome

Baseline
2015

OHA will measure the average length of stay of individuals with SPMI in
acute care psychiatric facilities, by hospital. (FY1)

8.9

OHA will measure the average length of stay of individuals with SPMI in
acute care psychiatric facilities, by hospital. (FY2)

n/a

OHA will also report the number of individuals with SPMI in each facility
whose length of stay exceeds 20 days. (FY1)

385

Target
Target
Year 1
Year 2
6/30/2017 06/30/18
Measure
without
Target
n/a

Measure
without
Target

OHA will also report the number of individuals with SPMI in each facility
whose length of stay exceeds 20 days. (FY2)
ED

ED

40a

41a
41b

ED

43

OHA will reduce recidivism to emergency
OHA will monitor the number of individuals with SPMI with two or more
departments for the psychiatric purposes, by taking readmissions to an emergency department for psychiatric reasons in a six
month period, by CCO (previously stated by hospital). (FY1)
the following steps:
OHA will monitor the number of individuals with SPMI with two or more
readmissions to an emergency department for psychiatric reasons in a six
month period, by CCO (previously stated by hospital). (FY2)
OHA will reduce the rate of visits to general
By the end of year one (June 30, 2017), there will be a 10% reduction from
emergency departments by individuals with SPMI the baseline.
for mental health reasons, as follows:
By the end of year two (June 30, 2018), there will be a 20% reduction
(excludes Unity)
from the baseline.
OHA is working with hospitals to determine a
OHA will begin reporting this information in July 2017, and will provide
strategy for collecting data regarding individuals
data by quarter thereafter. OHA will report this information by region.
with SPMI who are in emergency departments for OHA will pursue efforts to encourage reporting on a hospital-by-hospital
longer than 23 hours.
basis.

Measure
without
Target

Measure
without
Target
1,067

n/a

Measure
without
Target
n/a

1.5

1.4

Measure
without
Target

1.3

Quarter
Quarter
Quarter
Quarter
Ending
Ending
Ending
Ending
Sept 30
Dec 31
March 31 June 30
of each FY of each FY of each FY of each FY
9.6

9.6

11.0

11.24

11.5

11.4

11.2

11.16

435

423

459

475

534

529

509

518

924

919

865

834

828

935

838

622

2.0

2.1

2.0

2.0

1.97

1.9

1.82

1.79

Not Available

* Quarterly data for metrics marked with a "*" reflect 3 months of data for a given quarter. Quarterly data for other metrics are based on the past year's worth of data, reported on a rolling basis through the end of a given quarter.

Page 4

 Appendix B
Oregon Performance Plan
January 2019 Data Report
Note: Light yellow shading indicates Year 2 data.

Metric Metric
Category Number
SE*

SE*

SRTF

SRTF

45a

Performance Outcome

Baseline
2015

Target
Target
Year 1
Year 2
6/30/2017 06/30/18

The number of individuals with SPMI who receive supported employment Baseline Measure
services who are employed in competitive integrated employment… (FY1)
Not
without
Applicable Target
The number of individuals with SPMI who receive supported employment
services who are employed in competitive integrated employment… (FY2)

The number of individuals with SPMI who no longer receive supported
Baseline Measure
employment services and are employed without currently receiving
Not
without
supportive services from a supported employment specialist (but who may Applicable Target
rely upon natural and other supports). (FY1)
The number of individuals with SPMI who no longer receive supported
employment services and are employed without currently receiving
supportive services from a supported employment specialist (but who may
rely upon natural and other supports). (FY2)
638.0
574.2
49b (i) OHA will seek to reduce the length of stay of civilly By the end of year one (June 30, 2017), there will be a 10% reduction from
committed individuals in secure residential
the baseline. (Mean)
By the end of year two (June 30, 2018), there will be a 20% reduction
49b (ii) treatment facilities, as follows:
from the baseline.
OHA will regularly report on the number of civilly Starting with year two of this Plan (July 1, 2017), OHA will collect data
49c
committed individuals in SRTFs, their lengths of
identifying the type of, and the placement to which they are discharged.
stay, and the number of individuals who are
discharged.

Measure
without
Target

45b

Measure
without
Target

510.2

Quarter
Quarter
Quarter
Quarter
Ending
Ending
Ending
Ending
Sept 30
Dec 31
March 31 June 30
of each FY of each FY of each FY of each FY
680

697

628

757

749

756

731

762

114

115

164

110

121

127

139

137

409.1

552.8

543.5

553

449.7

501.8

663.2

676.0

Not Available

* Quarterly data for metrics marked with a "*" reflect 3 months of data for a given quarter. Quarterly data for other metrics are based on the past year's worth of data, reported on a rolling basis through the end of a given quarter.

Page 5

 Appendix B
Oregon Performance Plan
January 2019 Data Report
Note: Light yellow shading indicates Year 2 data.

Metric Metric
Category Number
CJD*

52a

52a

Performance Outcome

OHA will work to decrease the number of
individuals with serious and persistent mental
illness who are arrested or admitted to jail based on
a mental health reason, by engaging in the following
strategies:

OHA will continue to report the number of individuals with SPMI
receiving jail diversion services. (FY1)
OHA will continue to report the number of individuals with SPMI
receiving jail diversion services. (FY2)
OHA will continue to report the number of reported diversions. (PreBooking) (FY1)
OHA will continue to report the number of reported diversions. (PreBooking) (FY2)

52a

OHA will continue to report the number of reported diversions. (PostBooking) (FY1)
OHA will continue to report the number of reported diversions. (PostBooking) (FY2)

52d

As of July 2016, OHA will track arrests of individuals with SPMI who are
enrolled in services and will provide data by quarter thereafter.

Baseline
2015

Target
Target
Year 1
Year 2
6/30/2017 06/30/18

Baseline Measure
Not
without
Applicable Target
n/a
n/a

Baseline Measure
Not
without
Applicable Target
n/a
n/a

Baseline Measure
Not
without
Applicable Target
n/a
n/a

Measure
without
Target

Measure
without
Target

Measure
without
Target

Quarter
Quarter
Quarter
Quarter
Ending
Ending
Ending
Ending
Sept 30
Dec 31
March 31 June 30
of each FY of each FY of each FY of each FY
1,553

1,610

1,736

2,499

1,822

1,766

1,884

2,086

284

385

346

515

356

350

393

502

1,269

1,225

1,390

1,984

1,466

1,416

1,491

1,574

Baseline
Not
Applicable

* Quarterly data for metrics marked with a "*" reflect 3 months of data for a given quarter. Quarterly data for other metrics are based on the past year's worth of data, reported on a rolling basis through the end of a given quarter.

Data Not Available

Page 6

 Appendix C
Rates of Readmission by Acute Care Facility (31a-b)
2018 Q2 (July 1, 2017 – June 30, 2018)

Acute Care Psychiatric Hospital

Location

30-day

180-day

Asante Rogue Regional Medical Center
(Rogue Valley)

Medford

12.0%

21.9%

Bay Area Hospital

Coos Bay

13.9%

25.2%

Good Samaritan Regional Medical Center

Corvallis

6.7%

15.8%

Unity/Legacy Emmanuel Medical Center

Portland

13.9%

27.3%

Peace Health - Sacred Heart Medical Center

Eugene

12.3%

24.9%

Providence Portland Medical Center

Portland

13.4%

24.4%

Providence St. Vincent Medical Center

Portland

12.0%

26.0%

Salem Hospital

Salem

11.6%

20.5%

St Charles Health System Sage View

Bend

10.3%

19.4%

Portland

10.2%

22.3%

12.2%

24.0%

UBH of Oregon (Cedar Hills)

Total:

 Appendix D
Average Length of Stay in Acute Care Facilities, by Facility (35)
2018 Q2 (July 1, 2017 – June 30, 2018)

Acute Care Psychiatric Hospital

Location

Number of
Individuals
Average
whose
Length
Length of
of Stay
Stay
exceeds 20
days
9.2
29

Asante Rogue Regional Medical Center
(Rogue Valley)

Medford

Bay Area Hospital

Coos Bay

8.0

17

Good Samaritan Regional Medical Center

Corvallis

15.1

48

Unity/Legacy Emmanuel Medical Center

Portland

12.1

180

Peace Health - Sacred Heart Medical Center

Eugene

11.9

62

Providence Portland Medical Center

Portland

13.0

67

Providence St. Vincent Medical Center

Portland

9.8

36

Salem Hospital

Salem

12.3

43

St Charles Health System Sage View

Bend

8.0

16

UBH of Oregon (Cedar Hills)

Portland

9.5

20

11.2

518

Total:

 Appendix E
Count of Individuals with 2+ Readmissions to ED in 6 Months (40a)
2018 Q2 (July 1, 2017 – June 30, 2018)

Coordinated Care Organization
AllCare CCO Inc

2+ Readmissions
within a Six Month Period
18

Cascade Health Alliance LLC

4

Columbia Pacific CCO LLC

10

Eastern Oregon CCO LLC

10

FamilyCare CCO

59

Health Share of Oregon

178

Intercommunity Health Network

21

Jackson Care Connect

15

PacificSource Community Solutions Gorge

0

PacificSource Community Solutions Inc

17

PrimaryHealth Josephine County CCO

4

Trillium Community Health Plan

61

Umpqua Health Alliance DCIPA

17

Western Oregon Advanced Health

6

Willamette Valley Community Health

31

Yamhill Community Care

13

Fee-for-Service

136

Total

600