2018 Consumer Perception of Care Survey Detailed Report

1. 2018 Consumer Perception of Care Survey Detailed Report Adult and Child Caregiver Survey Results September 2019

2. Table of Contents

3. Survey Background

4. Background Survey Background • The Maryland Department of Health (MDH) launched Maryland’s Public Mental Health System (PMHS) in July 1997 as part of the state’s Medicaid 1115 waiver reform initiative. The 1115 waiver created a system whereby specialty mental health (MH) services are delivered through a “carve-out” arrangement that manages public mental health funds under a single payer system. • Since the creation of the “carve-out,” two additional major changes to the public system have occurred. • The first was the formal merger of the Mental Hygiene Administration (MHA) with the Alcohol and Drug Abuse Administration (ADAA) in July 2014, creating an integrated Behavioral Health Administration (BHA). • The second major change was the shift of substance use disorder (SUD) services from a managed care system to the “carve-out” system in January 2015, which is now referred to as the Public Behavioral Health System (PBHS).

5. Background (continued) Survey Background • The PBHS continues to serve Medicaid recipients and a subset of uninsured individuals eligible for public behavioral health services due to severity of illness and financial need. As a result of the aforementioned changes, individuals treated primarily for a substance use disorder have also been included in this survey, starting with the 2016 Consumer Perception of Care (CPOC) survey. • Medicaid currently contracts with Beacon Health Options (Beacon) to provide administrative services, including evaluation activities, for the PBHS. One of the evaluation activities is the administration of consumer surveys to assess perception of care, including satisfaction with and outcomes of behavioral health services provided by the PBHS. • In 2018, Beacon subcontracted with Morpace, Inc., an independent market research firm, to conduct data collection for this survey using mail, online, and phone methods, to analyze this survey’s data and to document the findings. • This report summarizes the findings of the 2018 Consumer Perception of Care Survey, which is the eighteenth systematic, statewide Consumer Perception of CareSurvey since the inception of the Public Mental Health System (PMHS), now the Public Behavioral Health System (PBHS).

6. Survey Methodology

7. Survey Population Survey Methodology Adult recipients of outpatient Mental Health (MH) treatment services and/or outpatient Substance Use Disorder (SUD) treatment services • Child recipients of outpatient Mental Health treatment services and • The eligible population includes individuals for whom Public Behavioral Health System claims were received for outpatient behavioral health services rendered between January and December 2017. • The sample was stratified by age group and region of residence and individuals were randomly selected from these groups for inclusion in the survey sample (see next slide). The sample included: • Individuals 16 years of age or older at the time of service responded to the adult survey on their own behalf, while parents or caregivers responded to the child survey on behalf of children and adolescents under the age of 16.

8. Survey Stratification Survey Methodology Note: PBHS Outpatient Recipients: Includes individuals for whom Public Behavioral Health System claims were received for outpatient behavioral health services rendered between January 1, 2017-December 31, 2017. *Sample selection: Sample was stratified by age and region of residence, and individuals were then randomly selected from among the eligible sample for inclusion in the survey outreach. • Survey samples were stratified by age of individuals and geographic region of residence based on service claims data. The regional breakdown of the survey sample and the final distribution of survey respondents are shown in the table below. • The geographic distribution of survey respondents closely aligned with the overall distribution of all PBHS outpatient service recipients.

9. Survey Procedure Survey Methodology Note: Survey procedural documents, including copies of survey questionnaires, cover letter, and follow-up correspondence will be made available in a companion document posted to the BHA and Beacon Health Options web-sites. • The survey was administered by mail, online, and by telephone. • A first survey mailing, consisting of a two-page cover letter, four-page survey booklet, and business return envelope was sent to 28,000 individuals in September, 2018. A second mailing was sent to 26,027 non-responders in October, 2018 (detail on those excluded from the second mailing is shown in the table below). Those who did not respond to either mailing were contacted by telephone from October to November, 2018, until the target numbers were achieved

10. Survey Procedures (continued) Survey Methodology • The cover letter included the following information: • An introduction to the survey and instructions on how to complete the survey online if desired (URL with username and password was provided). • A toll-free telephone number for those who wanted to receive more information about the survey, ask questions, or provide notification of willingness to participate. A voicemail captured calls made after business hours (messages were checked daily). • Answers to frequently asked questions. • Of the 28,000 individuals in the selected sample, surveys were mailed to: • 8,000 adult recipients of Mental Health services to achieve a target of 500 completed surveys. • 12,000 adult recipients of Substance Use Disorder services to achieve a target of 500 completed surveys.* • 8,000 Caregivers of Child recipients of Mental Health services to achieve a target 500 completed surveys. * Historically adult recipients of SUD services have had a lower response rate; therefore, a larger sample was drawn to achieve the target number.

11. Survey Questionnaires Survey Methodology • Separate survey instruments were used for adults and child caregivers. Surveys were adapted from a Federal initiative, the Mental Health Statistics Improvement Program (MHSIP) - Consumer Surveys. • Items from these surveys are incorporated into the Center for Mental Health Services Uniform Reporting System (URS) for Federal Block Grant reporting. • The Maryland Adult Perception of Care Survey is based on the MHSIP Adult Consumer Survey. The Maryland Child and Family Perception of Care Survey is based on the MHSIP Youth Services Survey for Families (YSS-F). • In addition to the MHSIP items, both survey instruments included other selected items of interest.

12. Survey Responses Survey Methodology Completed Surveys by Population Survey Method by Population

13. Survey Domains Survey Methodology • Survey domains presented in this report are described on the following slide. • Definition of domains and calculation methodology can be found at http://www.nri-inc.org/media/1322/2017-urs-table-instructions.pdf, pages 20-22 and 24-28. • Where appropriate, statistically significant differences in domain ratings between sub-groups are noted (based on z-tests for proportions at a 95% confidence level). • Statistical significance indicates whether or not the difference between two groups reflects an actual difference in the population from which the groups were sampled.

14. Adult MH/SUD Survey Domains Survey Methodology • I liked the services that I received here • If I had other choices, I would still get services from this provider • I would recommend this provider to a friend or a family member • Staff were sensitive to my cultural or ethnic background • Staff respected my family’s religious or spiritual views • Staff treated me with respect • Staff spoke with me in a way that I understood • The location of services was convenient • Staff were willing to see me as often as I felt was necessary • Staff returned my calls in 24 hours • Services were available at times that were good for me • I was able to get all of the services I thought I needed • I was able to see a psychiatrist when I wanted to • I deal more effectively with daily problems • I am better able to control my life • I am better able to deal with crisis • I am getting along better with my family • I do better in social situations • I do better in school and/or work • My housing situation has improved • My symptoms are not bothering me as much • I felt comfortable asking questions about my treatment and medications • I, not staff, decided my treatment goals • I am happy with the friendships I have • I have people with whom I can do enjoyable things • I feel I belong in my community • In a crisis, I would have the support I need from family or friends • My symptoms are not bothering me as much • I do things that are more meaningful to me • I am better able to handle things when they go wrong • I am better able to do things that I want to do • I am better able to take care of my needs *Note: The original MHSIP adult Survey does not include the Cultural Sensitivity Domain. Maryland elected to add this domain from the MHSIP Youth Services Survey for Families.

15. Child Mental Health Survey Domains Survey Methodology • Overall, I am satisfied with the services that my child received • The people helping my child stuck with us no matter what • I felt my child had someone to talk to when he or she was troubled • The services my child and/or family received were right for us • My family got the help we wanted for my child • My family got as much help as we needed for my child • Staff were sensitive to my cultural or ethnic background • Staff respected my family’s religious or spiritual beliefs • Staff treated me with respect • Staff spoke with me in a way that I understood • My child is better at handling daily life • I am satisfied with our family life right now • My child is better able to cope when things go wrong • My child gets along better with family members • My child gets along better with friends and other people • My child is doing better in school and/or work • The location of services was convenient for us • Services were available at times that were convenient for us • I helped choose my child’s services • I helped choose my child’s treatment goals • I participated in my child’s treatment • I know people who will listen and understand me when I need to talk • I have people with whom I can do enjoyable things • I have people that I am comfortable talking with about my child’s problems • In a crisis, I would have the support I need from family or friends Domain not included in the Child and Family Perception of Care Survey • My child is better able to do things he or she wants to do • My child is better at handling daily life • My child is better able to cope when things go wrong • My child gets along better with family members • My child gets along better with friends and other people • My child is doing better in school and/or work

16. Survey Results

17. Adult Mental Health: Nearly two-thirds of adults who received mental health services were between the ages of 35-64 (64%), one-half (54%) were white, and most (69%) were female. Nearly one-half (48%) report 14 or more days of poor mental health while more than one-third (36%) report 14 or more days of poor physical health. Adult Substance Use Disorder: Most adults receiving substance use services were between the ages of 35-64 (73%), nearly two-thirds (63%) were white, and just over one-half (51%) identified as male. Two out of every five adult SUD recipients reported 14 or more days of poor mental or physical health over the past 30 days. Child Mental Health: The age of child service recipients were evenly distributed across all age groups (<10; 10-12; 13-15). More than one-half (57%) of children who received mental health services were male, 52% were white and 14% of the population identified as Hispanic. Survey Results Respondent Profile

18. Adult MH/SUD Experiences of Care by Domain Survey Results • Adult survey recipients were most likely to report positive experiences in the areas of cultural sensitivity of providers, quality and appropriateness of services and overall satisfaction with services, and were least likely to report positively about improvement in outcomes and functioning as a result of services. Note: Percentages are based on calculations for number of positive responses in each domain. Definition of domains and calculation methodology can be found at http://www.nri-inc.org/media/1322/2017-urs-table-instructions.pdf, pages 20-22 and 24-28. Not all individuals responded to all questions.

19. Child MH Experiences of Care by Domain Survey Results Note: Percentages are based on calculations for number of positive responses in each domain. Definition of domains and calculation methodology can be found at http://www.nri-inc.org/media/1322/2017-urs-table-instructions.pdf, pages 20-22 and 24-28. Not all individuals responded to all questions. • Child caregivers were most likely to report positive experiences with the cultural sensitivity of providers, participation and engagement in their child’s treatment, and in their social connectedness to family, friends and community, and were least likely to report positively about improvement in their child’s functioning and outcomes as a result of services.

20. Adult Behavioral Health Service Utilization Survey Results * Psychiatric rehabilitation includes educational and support services that assist adults with chronic mental health issues in developing independent living skills to better function in the community. • One-third of adult recipients of MH and SUD services reported receiving Psychiatric Rehabilitation services.* • Two-thirds of adult recipients of SUD services reported that they participated in self-help or support groups, while less than one-third of those who received MH services reported participation.

21. Child Behavioral Health Service Utilization Survey Results • Nearly two-thirds (64%) of child caregivers reported that their child saw a pediatrician or other professional for emotional/behavioral problems. • More than half (54%) of all caregivers reported their child participated in psychiatric family support services, while 31% reported their child participated in self-help groups.

22. Adult MH/SUD Physical Health Services and Care Coordination Survey Results • Most adults (94% MH, 89.3% SUD) reported having a primary care provider. • Adult recipients of MH services (89.5%) were more likely to report they saw a medical professional for a check-up or illness in the past 12-months compared to adult recipients of SUD services (79.1%). • Nearly one-third of all adult recipients of MH or SUD services reported that their primary care provider (PCP) and MH or SUD provider have spoken with each other about their treatment.

23. Child Physical Health Services and Care Coordination Survey Results • Most child caregivers (95.7%) reported that their child has a primary care provider and three quarters (76%) reported that their child saw a medical professional for a check-up or illness in the past 12-months. • Nearly one-third of child caregivers reported that their child’s primary care provider and mental health provides have communicated about their child’s treatment.

24. Adult MH Experiences of Care by Domain and Gender Survey Results • Among adult recipients of MH services, males were more likely than females to report positive experiences relating to service outcomes. • There were no significant gender differences in adult MH recipient experiences of care across all other domains. * *Asterisk indicates % is significantly higher than corresponding sub-group. Percentages are based on calculations for number of positive responses in each domain. Definition of domains and calculation methodology can be found at http://www.nri-inc.org/media/1322/2017-urs-table-instructions.pdf, pages 20-22 and 24-28.

25. Adult SUD Experiences of Care by Domain and Gender Survey Results • There were no significant gender differences in Adult SUD recipient experiences across all domains. Note: Percentages are based on calculations for number of positive responses in each domain. Definition of domains and calculation methodology can be found at http://www.nri-inc.org/media/1322/2017-urs-table-instructions.pdf, pages 20-22 and 24-28.

26. Child MH Experiences of Care by Domain and Gender Survey Results • Among caregivers of child recipients of mental health services, those with female children reported more positive experiences with participation in treatment than those with male children. • There were no significant gender differences in caregiver experiences across all other domains. *Asterisk indicates % is significantly higher than corresponding sub-group. Percentages are based on calculations for number of positive responses in each domain. Definition of domains and calculation methodology can be found at http://www.nri-inc.org/media/1322/2017-urs-table-instructions.pdf, pages 20-22 and 24-28.

27. Adult MH Experiences of Care by Domain and Employment Survey Results • Among adult recipients of MH services, those who were employed reported more positive experiences of care in outcomes, social connectedness and functioning compared to those who were unemployed. * Note: Graph excludes respondents who identified their employment status as disabled or other. *Asterisk indicates % is significantly higher than corresponding sub-group. Percentages are based on calculations for number of positive responses in each domain. Definition of domains and calculation methodology can be found at http://www.nri-inc.org/media/1322/2017-urs-table-instructions.pdf, pages 20-22 and 24-28.

28. Adult SUD Experiences of Care by Domain and Employment Survey Results • Among adult recipients of SUD services, those who were employed reported more positive experiences of care in participation in treatment planning, quality and appropriateness of services, outcomes, social connectedness and functioning compared to those who were unemployed. * Note: Graph excludes respondents who identified their employment status as disabled or other. *Asterisk indicates % is significantly higher than corresponding sub-group.Percentages are based on calculations for number of positive responses in each domain. Definition of domains and calculation methodology can be found at http://www.nri-inc.org/media/1322/2017-urs-table-instructions.pdf, pages 20-22 and 24-28.

29. Adult MH Experiences of Care by Domain and Mental Health Quality of Life Survey Results • Among adult recipients of mental health services, those who reported fewer days of poor mental health, reported more positive care experiences across all domains. * * * * *Asterisk indicates % is significantly higher than corresponding sub-group. Percentages are based on calculations for number of positive responses in each domain. Definition of domains and calculation methodology can be found at http://www.nri-inc.org/media/1322/2017-urs-table-instructions.pdf, pages 20-22 and 24-28.

30. Adult SUD Experiences of Care by Domain and Mental Health Quality of Life Survey Results • Among adult recipients of SUD services, those who reported fewer days of poor mental health, reported more positive care experiences across all domains. * * * * * *Asterisk indicates % is significantly higher than corresponding sub-group. Percentages are based on calculations for number of positive responses in each domain. Definition of domains and calculation methodology can be found at http://www.nri-inc.org/media/1322/2017-urs-table-instructions.pdf, pages 20-22 and 24-28.

31. Adult MH Experiences of Care by Domain and Physical Health Quality of Life Survey Results • Among adult recipients of MH services, those individuals who reported fewer days of poor physical health reported more positive experiences related to improved outcomes, social connectedness and functioning as a result of services. * * *Asterisk indicates % is significantly higher than corresponding sub-group. Percentages are based on calculations for number of positive responses in each domain. Definition of domains and calculation methodology can be found at http://www.nri-inc.org/media/1322/2017-urs-table-instructions.pdf, pages 20-22 and 24-28.

32. Adult SUD Experiences of Care by Domain and Physical Health Quality of Life Survey Results • For adult recipients of SUD services, individuals who reported fewer days of poor physical health, reported more positive care experiences related to the quality of services provided, cultural sensitivity of providers, outcomes, social connectedness and functioning. * *Asterisk indicates % is significantly higher than corresponding sub-group. Percentages are based on calculations for number of positive responses in each domain. Definition of domains and calculation methodology can be found at http://www.nri-inc.org/media/1322/2017-urs-table-instructions.pdf, pages 20-22 and 24-28.

33. Conclusions

34. Summary of Results for Adult MH/SUD Population Conclusions • Adult recipients of outpatient behavioral health services generally reported being satisfied with the services that they received. • Adults were most likely to report positive experiences in the areas of cultural sensitivity of providers and quality and appropriateness of services, and least likely to report positive experiences regarding improvement in outcomes and functioning as a result of services. • Those adults who experienced fewer (<14) “poor mental health days” and/or “poor physical health days” in a month reported more positive experiences related to services and outcomes than those experiencing 14 or more days of poor mental or physical health. • More than one-third of adult MH/SUD participants reported being in poor physical health 14 or more days in the past month. • Adults with 14 or more days of poor physical health were less likely to report satisfaction across all domains, but particularly with perceived outcomes, such as getting along with family and friends, handling daily problems and doing better at work, and improvement in functioning as a result of services received. • The majority of adults report having a PCP and seeing a medical provider for a check-up or illness in the past 12-months, however less one-third report that their PCP and mental health providers have communicated about their treatment.

35. Summary of Results for Child MH Population Conclusions • Child caregivers report being generally satisfied with the outpatient services that their child received. • Caregivers were most likely to report positive experiences with the cultural sensitivity of providers, participation and engagement in their child’s treatment, and in their social connectedness to family, friends and community, and least likely to report positive experiences with outcomes and functioning as a result of services. • The majority of caregivers report that their child has a PCP and has seen a medical provider for a check-up or illness in the past 12-months, however less one-third report that their child’s PCP and mental health provider have communicated about their child’s treatment.