Organizational Assessment Toolkit Oati National Council

Summary

ORGANIZATIONAL ASSESSMENT TOOLKIT
FOR PRIMARY AND BEHAVIORAL HEALTH
CARE INTEGRATION
SEPTEMBER 2014
SAMHSA-HRSA C E NTE R F O R I NTE G RATE D H E A LTH S O LU TI O NS
ACKNOWLEDGEMENTS
This document was prepared for the SAMHSA-HRSA Center for Integrated Health Solutions with funds under grant number
1UR1SMO60319-01 from SAMHSA-HRSA, U.S. Department of Health and Human Services. The statements, findings, conclusions,
and recommendation are those of the author(s) and do not necessarily reflect the view of SAMHSA, HRSA, or the U.S. Department
of Health and Human Services

Special thanks to Ken Minkoff, ZiaPartners, Inc.; David Lloyd, MTM Associates, LLC.; and Jeff Capobianco and Kathleen Reynolds,
CIHS, for the development of this toolkit as a whole, and for the creation and testing of specific assessment tools

SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS
The SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) promotes the development of integrated primary and behavio-
ral health services to better address the needs of individuals with mental health and substance use conditions, whether seen in
specialty behavioral health or primary care provider settings. CIHS is the first “national home” for information, experts, and other
resources dedicated to bidirectional integration of behavioral health and primary care

CIHS is funded jointly by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and
Services Administration (HRSA), and run by the National Council for Behavioral Health. CIHS provides training and technical as-
sistance to community behavioral health organizations that received Primary and Behavioral Health Care Integration (PBHCI) grants
as well as to community health centers and other primary care and behavioral health organizations. The PBHCI Grant program is
part of an unprecedented push by Congress and the Health and Human Services Administration to help prevent and reduce chronic
disease and promote wellness by treating behavioral health needs on an equal footing with other health conditions

CIHS’ array of training and technical assistance helps improve the effectiveness, efficiency, and sustainability of integrated ser-
vices, which ultimately improves the whole health and wellness of individuals living with behavioral health disorders

1701 K Street NW, Suite 400
Washington, DC 20006
202.684.7457
[email protected]
www.integration.SAMHSA.gov
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INTRODUCTION
Designed by a team of integration experts, the Organizational Assessment Toolkit for primary and behavioral health care Integration
(OATI) provides a compendium of tools that lay out a path for organizations to assess their readiness for integration, as well as
benchmarking opportunities for those organizations well down the line in integration efforts

Bidirectional integration1 is the systematic coordination of mental health and substance use care (i.e., behavioral health care)
with physical health care services (i.e., primary care). Since physical and behavioral health problems often occur simultaneously,
integrating services to treat the whole health of individuals achieves the best results. People who receive integrated care prefer this
approach, finding it the most acceptable, convenient, and effective approach to obtaining care.2
Organization-wide bidirectional primary and behavioral health care integration involves two simultaneous processes:
1. The ongoing development of an organizational culture centered around high quality customer service that ensures every staff
member’s focus remains on the experiences and outcomes of customers with both physical and behavioral health needs

2. A comprehensive, system-level transformation of different aspects of the organizational process, structure, programming,
practice, and financing that ensures the provision of seamless integrated care

Successful integration requires a complete review and redesign of an organization’s service delivery. Assuming that most of the
people you serve have both physical and behavioral health needs, you will need to review every program, policy, procedure, prac-
tice, and staff member to implement integrated services that achieve the best outcomes at the lowest cost

Hallmarks of Integration:
8 Integration is a process that occurs over time in the entire organization

8 Integration activities create a system of care in which your organization
operates

8 Integration is more than having a good referral partner, care capacity, or
a co-located site. It is more than a behavioral health center becoming or
acquiring a federally qualified health center (FQHC). It is more than an FQHC hiring mental health and substance use
specialists or becoming certified as a community mental health center or substance abuse clinic. It is more than achiev-
ing certification as a person-centered medical home/health home (see below)

8 Integration is more than a particular tool (e.g., PHQ 9), diagnostic combination (e.g., depression and diabetes), process
(e.g., SBIRT), or evidence-based program (e.g., IMPACT)

8 Integration involves multiple organizational components changing simultaneously in different timeframes. While some
change process is linear, it also involves working through a series of rapid-cycle changes as you progress

8 Integration is a fully articulated “customer-oriented continuous quality improvement process,” not a time-limited project

The integration journey never ends because there are always new challenges, new populations, new improvement oppor-
tunities, and new partners

1 Throughout this toolkit, the word “integration” pertains to the bidirectional model of integration
2 Lopez, M., et. al. (2008). Connecting Mind and Body: A Resource Guide to Integrated Healthcare in Texas and the United States. Hogg Foundation. Austin, Texas

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THE FOUR MAJOR SELF-ASSESSMENT TOOLS
This toolkit provides four organizational integration readiness and capability self-assessment tools. The four tools can be used in
order, or can stand alone as an integration aid (or benchmarking tool)

The four major building blocks for assessing organizational capability and readiness are:
1. The Partnership Checklist
2. The Executive Walkthrough
3. The Administrative Readiness Tool (ART) for Primary Health Behavioral Health
Integration
4. The COMPASS-Primary Health and Behavioral HealthTM
Originally conceptualized as a single tool to be used in in totality, in testing in the field,
the individual tools were each found to be effective at self-assessment of key integra-
tion infrastructure areas. Key questions answered through the assessments include:
8 Do we need a partner to do integration and, if so, how do I select a partner?
Centers working toward
(Partnership Checklist)
Patient-Centered Medical
8 Is the organization welcoming to customers and what’s it like to secure access
to our services? (The Executive Walkthrough and COMPASS – Primary and Be- Home (PCMH) certification
havioral Healthcare)
can easily locate PCMH
8 Does the organization’s administrative infrastructure support key elements of
certification criteria within
integration success such as health information technology (HIT), billing and
coding, costing, policies and procedures, and human resource functions? (The the toolkit

Administrative Readiness Tool and COMPASS – Primary and Behavioral Health-
care) Each item that specifically
8 Are clinical services infused with integration language and processes includ- relates to PCMH certification
ing medication management, person centered planning, documentation, and
is flagged as “PCMH”
professional competencies and training? (COMPASS – Primary and Behavioral
Healthcare)
8 Does the organization’s quality improvement process include rapid-cycle change models and action plans that support im-
plementation and improvement? (The Administrative Readiness Tool and COMPASS – Primary and Behavioral Healthcare)
The answers to these and many more core questions regarding successful integration are identified and supported through the use
of the tools in OATI. The goal is progress, not perfection. Organizational change often proceeds most successfully by simply find-
ing the best next step that the organization, its partners, and each of its programs can and will take. A key element of continuous
quality improvement is to acknowledge and measure these small steps of success

It is common that different parts of the organization or the organizational partnership will be in different stages of readiness to
proceed. It is recommended, but not required, to use the tools in the sequence listed. Organizations and programs can review the
description, desired outcomes, and best way to use each of the tools below, and then may choose which tool (or tools) is most
useful as a starting place

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TOOL 1: Partnership Checklist
The Partnership Checklist can assist organizations in determining the need for a partner, assessing a partner’s potential contribu-
tions to the partnership, and identifying next steps for how to develop more effective partnerships

Organizations using the partnership checklist will be able to:
8 Identify if they need a partner to pursue integration
8 Examine core elements in selecting a potential partner
8 Identify their strengths and weaknesses in a partnership
8 Identify potential partners for integration
Best Way to Use the Partnership Checklist: The Partnership Checklist is designed as a discussion guide for team
based projects to use in determining if the partnership model is the best choice for organizational integration efforts. Through dis-
cussion, senior leadership teams, special integration discussion teams or multi-organizational planning teams review each element
and identify strengths, weaknesses and needs for successful integration efforts. Each task can be discussed and/or assignments
can be made for individuals to complete and bring the information back to the group for discussion. The key element is: this is not
a task that should be assigned to one person – it’s a group task within and/or across organizations

TOOL 2: Executive Walkthrough
This tool can help leadership see the organization(s) through a customer’s eyes. It is helpful to do this for both your and your
partner’s organization. To help your senior management team, and that of your organization’s partners, evaluate the current level of
customer service, it is important to move beyond anecdotal information and to experience firsthand the level of customer service
actually provided. This tool can assess the customer service levels your organization has achieved through the use of objective data
and lay out a path for improving the “customer experience” of individuals who have health and behavioral health needs

What’s the difference between client, consumer, and customer focused philosophies?3
Client Focus Consumer Focus Customer Focus
They are not empowered They are somewhat empowered They are fully empowered
They usually don’t know what they need They tend to know what they need They know what they want
They have little or no choice They have choices They have choices
They usually don’t know what they need They tend to know what they need They know what they want
They are here to receive treatment They are here to utilize service They are here to participate
opportunities in their recovery
They Need Us! They Choose Us! We Choose Each Other!
Outcomes:
8 Customer-centered service orientation within delivery processes
8 Customers are viewed as essential partners in the change process

8 Welcoming, efficient, and effective customer experiences
3 Lloyd, D. (2002). How to Deliver Accountable Care. Washington, DC: The National Council for Community Behavioral Healthcare

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Best Way to Use the Executive Walkthrough: A helpful starting place is to engage clinical and support staff in
a conversation about their “customer service philosophy.” Ask them how they view the organization’s customer service philosophy

There are typically three customer service philosophies in use: client focus, consumer focus, and customer focus. When your staff
begins discussing and defining each term, it invites exploration of current attitudes and helps your organization move from a client
focus to a customer focus

TOOL 3: The Administrative Readiness Tool (ART) for Primary
Health Behavioral Health Integration
The Administrative Readiness Tool (ART) for Primary Health Behavioral Health Integration assesses the core administrative pro-
cesses and practices needed most to support successful delivery of integrated care

Organization of the ART Sections: (Sections A-G, K, M: PCMH*)
A. Clinic has a time and cost effective access to treatment process
B. Clinic has Centralized Electronic schedule management system
C. Clinic has implemented caseload management to support appropriate utilization levels
D. Clinic has re-engagement/transition procedures for current cases not actively in treatment

E. Clinic has real time documentation support processes
F. Clinic has cost based key performance indicators (KPIs) for all staff and a measurement capacity to support coaching/
mentoring activities by supervisors/managers
G. Clinic has integrated KPIs into the job descriptions of all staff and into the performance evaluation model used
H. Clinic has implemented internal utilization management functions including credentialing support for clinical staff;
pre-certs, authorizations and re-authorizations; and referrals to clinicians credentialed on the appropriate third party/
ACO/Medical Home/Health Home panels
I. Clinic has a diversified payer mix
J. Clinic has appropriate revenue cycle management including co-pay collections and claim submission
K. Clinic has outcome assessment capacity and measurement tools to integrate achieved outcomes into support service
delivery process change
L. Community Awareness, Branding and Market Share
M. Clinic has decision making and change management capacity including the use of Rapid Cycle Change models
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Outcomes:
8 Assessment of the data available within your organization to continually make data based decisions around effective ad-
ministrative procedures
8 Assessment of ability to participate in bundled/shared risk payment models

8 Assessment of ability to focus on episodic care needs and treat to target models
8 Assessment of electronic health record capacity
8 Assessment of ability to provide high quality services at the lowest possible cost
8 Assessment of ability to produce measureable outcomes
Note that this tool will not just ask you if you believe you can collect the data. It will actually ask you to find the data. That may seem
challenging, but it is best to start building your foundation early so it is ready when you need it

Best Way to Use the ART: A self-assessment tool, the ART requires your management team to schedule time to meet
and work through the sections. Typically, the assessment takes 6-8 hours to complete

As your management team prepares to use ART, consider the following:
1. It is important for your team to move away from anecdotal responses to the questions such as “I think the rate is…” and to
understand the actual rate or data point

2. If there are significant variances in response levels or service process data among the management team members, it is
important to identify if an ART needs to be completed for specific programs or locations (e.g., children/adolescent/pedi-
atric vs. adult/geriatric) to identify process variances with the clinic. If it is determined that multiple ART forms are needed
to assess the organization’s components, add and average the question and section scores to generate an overall score
for the organization as a whole

3. If the question and section scores have more than a one point difference, the key issue to identify is if your organization
is operating coherently as a “group practice” or “program team” rather than as a “loosely held federation of individual
practices.”
If variance is found within program practice, integrating primary care services will be more difficult. Therefore, the ART
should be used to identify internal practice and administrative support variance to reduce the time and cost of service
delivery processes prior to starting integrated care efforts

4. The self-assessment scoring model for each question and section of the ART is based on a five point scale:
5 4 3 2 1
Not a Challenge Small Concern Moderate Concern Quite a bit of Concern Serious Challenge
At the end of each section of the ART, there is a “total cumulative score” indicator that will allow your team to total all individual
question scores in a section. Also, at the end of the ART, there is a scoring sheet that provides for transferring the sections’ cumula-
tive scores to an overall score summary with recommendations for next steps

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TOOL 4: COMPASS-Primary Health and Behavioral Health™
The COMPASS-Primary Health and Behavioral Health™ (COMPASS-PH/PC) is a continuous quality improvement tool for clinics
and treatment programs, whether working in their own integration process or in partnership with others, to organize themselves
to develop core integrated capability to meet the needs of service populations with physical health and behavioral health issues

Outcomes:
8 Empowers organizations and staff to accomplish step-by-step goals to create integrated care for people and families with
complex needs

8 Communicates a common language and understanding of integrated primary health and behavioral health capable ser-
vices

8 Establishes an organizational baseline of integrated primary health and behavioral health capability so there is a rational
foundation for a change process

8 Creates a shared process using a common tool that can be used in any system for an array of diverse programs working in
partnership on integrated primary health and behavioral health capability development

8 Produces a universal continuous quality improvement framework for all types of programs in any system of care that serves
individuals and families with complex lives

Companion Tools
COMPASS-PH/PC™ also has companion tools that are tailored to meet the needs of a variety of partner programs working on vari-
ous aspects of integrated co-occurring capability. Examples are:
8 COMPASS-Prevention™ for prevention and early intervention programs

8 COMPASS-EZ™ for mental health and substance abuse treatment programs working on integrated mental health/ sub-
stance abuse co-occurring capability development

8 COMPASS-ID™ for providers serving people with intellectual disabilities working on integrated ID/BH co-occurring capabil-
ity development

CUSTOMER-ORIENTED CONTINUOUS QUALITY IMPROVEMENT
Organization-wide change may seem daunting in complex organizations facing multiple clinical, organizational, and financial chal-
lenges. Fortunately, there is a well-established organizational process, termed customer-oriented continuous quality improvement,
which organizations of any size can — and should — use to make progress within base resources. Further, development of broad ca-
pability for using continuous quality improvement strategies to improve care is a core feature of acquiring person-centered medical
home certification, as well as a core feature of the national movement to achieve the ‘triple aim’ of improved customer experience,
improved cost, and improved health, as defined by the Institute for Healthcare Improvement

The OATI is designed to help any organization or organizational partnership (and any program within that organization or partner-
ship) to make progress by using customer-oriented continuous quality improvement strategies and techniques to improve inte-
grated care delivery. Each of the four tools in the OATI provides an opportunity for an “improvement team” to perform a baseline
self-assessment to “study the process” of how care is delivered for individuals with both primary health and behavioral health
needs. Once that baseline is established, the improvement team can then select improvements to target, engage in plan-do-study-
act rapid change cycles, and identify measurable indicators of progress to demonstrate success. The core elements of customer-
oriented continuous quality improvement help to keep the process grounded and achievable are:
8 Customer First: Always focus on improving the customer experience for individuals who present with co-occurring health
and behavioral health needs. This approach helps to stay on track when there are many competing priorities

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8 Progress Not Perfection: The initial goal is not to improve everything at once. Continuous quality improvement is not a
compliance audit. The initial goal is to select achievable improvements that can be accomplished within available re-
sources in a reasonable time frame. Further, in a complex organization or system, each program can be working on its own
improvements. This results in significant progress across the whole organization even though each program may only be
making small steps

8 Continuous Cycles of Change: Finally, progress is achieved by continuous improvement over time. Once each rapid change
cycle is completed, the organization (and its programs) then can choose the next improvement targets based on their self-
assessments, develop new rapid change cycles with new indicators of progress, and keep going

The tools in the OATI prepare and inform organizations about their readiness and needed steps to integrate primary and behavioral
health. From there, organizations seeking to boost their overall capability for using customer-oriented continuous quality improve-
ment to manage significant change can delve deeper into these core elements with other existing tools (such as the QI-IQ) or review
a basic approach to plan-do-check-act cycles and/or rapid cycle change

Based on what is learned during the self-assessment process using the four major self-assessment tools, organizations can then
develop a successful, achievable, and measurable improvement plan

For more information and assessments related to successful implementation of integrated primary and behavioral health care, visit
www.integration.SAMHSA.gov/operations-administration/assessment-tools
For further information on the toolkit, or to explore the availability of technical assistance in using the tools, please contact:
The SAMHSA-HRSA Center for Integrated Health Solutions
www.integration.samhsa.gov
[email protected]
202.684.7457
SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS 9

This toolkit provides four organizational integration readiness and capability self-assessment tools. The four tools can be used in order, or can stand alone as an integration aid (or …

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Frequently Asked Questions

What is an organizational assessment?

Self-assessments are typcially used in conjunction with annual/regular performance evaluations. But the type of organizational assessment we are focusing on here is a process that a nonprofit may use to evaluate the nonprofit’s progress towards its goals. Assessments are common throughout the nonprofit sector.

What are the best self assessment tools for nonprofit organizations?

Nonprofit Organization Self-Assessment tools from the Nonprofit Association of Oregon include a 360 degree self-assessment, a financial self-assessment tool, and a general self-assessment tool that includes questions addressing nonprofit accountability. Organizational capacity assessment tool (Marguerite Casey Foundation)

What are organizational self assessments?

Organizational Self-Assessments. Self-assessments are often the first step in an organization’s journey towards effective outcomes. The goal of assessments is to collect data that can help the nonprofit evaluate whether or not it is making progress towards various goals, including whether the nonprofit can demonstrate that it is making progress...