Outcome Measures


Performance Analysis for Fiscal Year 2015


West Georgia Counseling and Assessment Services is a family focused community based social service agency that provides a variety of services to those with substance abuse, mental health and family issues. We seek out contractual relationships with those stakeholders who wish to purchase services to address these issues.   Over the last decade there has been an increased emphasis on having private social service providers compete with public, often government based providers that have traditionally been in the mental health and family service arena. Our services were established in 2000 with the intent of being a private provider in the west central Georgia geographic area.

The state of Georgia is the primary funder of our services through local Department of Family and Children’s Services (DFACS) offices. Through them we receive funding that originates from the Department of Human Services to provide specific services. In FY 2015 we were able to provide an extensive amount of service using our independent contractors. In April 2014 our agency implemented the use of CARF standards in our daily operations with a goal to have a survey by them in late 2015.  This is still a goal. The state of Georgia is encouraging its providers to become an accredited entity in order to provide services under Medicaid. Our agency’s strategic plan outlines our intent to be a provider under Medicaid and accreditation is a significant step toward this goal. Our agency felt that CARF was the best fit for the accreditation of the services we provide.

In calendar 2014 our agency changed leadership when the owner of the business at the beginning of the fiscal year sold the agency to its current owner.

One use of this performance analysis document is as a place to review CARF related conformance areas where specific annual reviews are required. However the parallel purpose of this document is to address the agency strategic plan and to perform an analysis of how WGCAS is performing against standards set by the agency.

Mission of the agency:

Our mission is stated as follows:

“To promote positive change by providing comprehensive assessment and therapeutic intervention services to all families and youth that we serve”. We affirm that this continues to be the mission of this agency and that it reflects the core values in which we believe. We will continually review our mission statement should the direction of services change.

Core Values of the agency:

WGCAS is dedicated to providing flexible, effective, and efficient services to its clients. We do this by emphasizing that staff must be flexible in terms of client service hours. Our agency is noted for its ability to perform duties for consumer outside of regular business hours and outside of office confines. We also believe in providing flexibility for our staff. Staff are never forced into providing services to those with whom they do not feel comfortable.

Agency Structure:

The agency is a sole proprietorship and uses a variety of independent contractors to meet the mission of the agency.  Management believes that there is a sufficient number of staff needed to maintain the mission of the agency and to provide an array of services.  The agency has physically moved 3 times since its inception. The business began on North Lewis Street in Lagrange in 2000. The agency moved to 98 Gordon Commercial Drive in the spring of 2008. In January 2015 the agency moved to its present location at 2233 West Point Road. Since moving to the present location there has been an increase in visibility to the general public as evidenced by increased drop in traffic asking about services. We believe that the current location is convenient to clients and families that we intend to serve.

The agency is still operated by the owner of the business. Assisting in the operation is a clinical supervisor and a part time clerical person. There is also a contractor who functions as the agency’s compliance officer. The agency also has a contractual relationship with a registered nurse for any direction needed in the medical area.

Accessibility status review:

The agency developed an accessibility plan for FY 2015.  Among the items noted in this plan are the following:

  • To refresh the accessibility parking sign area by January 2016. While the current sign and area is acceptable it would be an improvement to the agency to have the area refreshed. This item is not applicable currently as the agency moved to a new location.
  • By the end of FY 2015 WGCAS will have participated or attended at least 2 interagency council meetings and/or other community forums. The agency did participate in forums in FY 2015 in regard to establishing a community wide trauma based treatment protocol to be used with particular clients. All therapists at WGCAS completed training in Trauma-Focused Cognitive Behavioral Therapy.
  • By the end of FY 2016 WGCAS will have contacted a bilingual person who could assist in developing a brochure and/or informational material that is in Spanish. This has not occurred yet but on one occasion this year the agency used an interpreter to assist in a family assessment.

The agency has developed a subsequent accessibility plan that covers the year 2016 to 2020 and is kept on file with agency management reports.

Human Resources activities

The agency provided training during the year to the staff. Confidentiality was highlighted. Also distribution of cultural competence articles occurred.  The agency also provides various resources to staff including distribution of information involving domestic violence safety plans, car seat installation training, driver safety, and updates on suicide safety plans.  All therapists at WGCAS completed training in Trauma-Focused Cognitive Behavioral Therapy.  A part time clerical staff was hired as well as a clinical supervisor.

FY 2015 Input Review

WGCAS reviews input on an annual basis in order to determine if there are any changes needed to the strategic plan that directs our services. Input is obtained through a variety of means. A consumer satisfaction survey is conducted both with current and discharged consumers. The results of the discharge survey conducted and the current consumer satisfaction results are noted in this document. Additionally input from agency stakeholders was obtained and is noted in its own section in this document.

The agency also continued to have routine staff meetings. These meetings are a place for information, discussion and input on matters of importance to the agency or staff. Minutes are kept on file of the meetings and are used to adjust the strategic plan especially in regard to training and clinical issues. For example, issues from staff meetings resulted in training in confidentiality and in-home safety.

Additionally the agency has been involved in meetings with other local social service agencies in regard to trauma-based services. The Troup County juvenile court judge is a strong advocate and put together a coalition of providers to assure that service providers have training in trauma therapy and that consumer assessments address trauma issues.

FY 2015 Other Agency Stakeholder responses:

Input from stakeholders was requested from DFACS and the Juvenile Court system. In FY 2015 input from our service stakeholders revealed satisfaction with results that are received from us. On a 1 to 10 scale, our management of incoming referrals was graded as an 8. 67. Service Providers were graded 9.34 on their timeliness of responding to clients once referred to us. We were rated 9.00 regarding the effective and efficiency of our therapists that provide Outpatient Services. One responder noted that she is “happy with the services we receive”. And that “most times we are getting what we need in the documentation” that is provided to the referring party. One responder noted that they would like “to refer clients who have Medicaid to receive services”.

FY 2015 Discharged client’s responses:

The agency attempted to contact 23 clients who had received services in FY 15 and are now discharged from the program. The agency was able to reach nine clients. In response to the question if we began working with the family within the first 2 business days of initial contact, 5 clients stated that they would “strongly agree” with the remaining 4 clients stating that they would “agree”.

In response to whether the client “gained knowledge or skills by participating in this program, 8 client’s stated that they would “strongly agree” and one reported that they would “agree”.

Strategic Plan:

Our strategic plan is reviewed annually at the time of the performance measurement documents. The strategic plan was written in the spring of 2014 and is designed to guide services from FY 2014 to 2019. The plan was reviewed in May 2015 and was updated where necessary.

Policy Review:

We review our policy manual yearly and document that staff have had an opportunity to review the policy manual at the time of their performance review. This past fiscal year several updates were made to various policies in order to conform to CARF standards and regulatory and contractual issues.

Scope of Service Review:

West Georgia Counseling Services completed a scope of services review in August 2015. At that point in time our two Program Description documents were reviewed and revised. The review resulted in an updating of a current document that introduces consumers to the Outpatient Treatment program. This document is a letter that is provided by the service provider to the client who is entering this core service that explains the program in detail.

Additionally, the second “Corporate” program description was revised. This core program description is used for internal program purposes and assists in guiding the agency with its strategic planning for this core service.  This document describes the program, its philosophy, its program goals, treatment modalities to reach the program objectives and addresses mechanisms to address special populations and their needs.

Cultural Competency Plan:

The organization’s cultural competency plan was originally written in January 2009. The plan was reviewed in July 2015. In FY 2015 our services were provided by staff that were Black Female: 9, White Female: 7, White Male: 4

Technology: a 5 year technology plan was established for FY15-FY20. This year a corporate and secure internal email system was established that allows transmissions of document within its internal server. Prior to this, communication was occurring via normal email channels by various providers.

Additionally the agency established a website in order to provide accessibility to potential clients and to improve community presence. The address is www.westgeorgiacounseling.com. Additionally one new computer and one printer was purchased for the clinical supervisor.

Health and Safety reports: there were no incidents of health and safety issues in FY 15. The Fire department, building & zoning officer, as well as the agency’s insurance agent visited the facility in FY 2015 as part of the agency’s move in process.

Risk Management Plan:

The agency’s risk management plan was written in the spring of 2014 and is available for viewing. It is filed on a shelf in the building where other management reports are maintained. The plan continues to be relevant to today’s issues. Our insurance packet is adequate and meets the state of Georgia’s mandate of having 1 million/3 million in coverage to be a provider for them. Additionally, all of our transportation staff are required to have their own current insurance. MVR’s are reviewed annually to determine if any transportation staff have engaged in any at risk incidents. Additionally, the agency requires all staff to maintain professional liability insurance and this is paid for by the agency.

Critical Incident Review:

As part of risk management, all critical incidents that occur in a year are reviewed. In FY 2015 there were no critical incidents reported. Additionally there were no formal complaints lodged against our agency from clients or staff.

Field Trends: it is noted that the state of Georgia desires to have all of their providers be accredited. The agency began this process in April 2014 with the implementation of CARF standards.

Services Provided:

The agency provides a variety of services to the citizens and agencies of west Georgia. Among these are:

  • Outpatient treatment which is termed Homestead Counseling and Wrap- around Intensive Services.
  • Substance Abuse Assessments
  • Parental Fitness Assessments
  • Domestic Violence Assessments
  • Home Evaluations
  • Comprehensive Child and Family Assessments (CCFA)
  • Parent Aid
  • Early Intervention
  • Wrap-around in home case management
  • Safe Care

Most services are provided in community settings.

In Fiscal Year 2015 WGCAS provided the following:

  • 62 client’s vs 45 clients in Outpatient Services in FY 2014
  • 93 substance abuse assessments vs 74 in FY 2014
  • 40 Parental Fitness Assessments versus 44 in FY 2014
  • 31 ccfa’s vs 25 in FY 2014
  • 32 DV assessments in 2015 vs. 24 in FY 2014
  • 35 Parent Aide cases vs. 31 in FY 2014
  • 144 Wrap Around In home services vs. 113 in FY 2014

Program seeking accreditation: Outpatient Treatment

Objectives of Outpatient Treatment Services

WGCAS provides a variety of counseling services, including homestead counseling and parent educator services.  Participation in any or all of the counseling components is based on the reason for referral, assessment results, treatment recommendations, and the individual service plan. Each counseling modality is grounded in data driven, evidence-based techniques developed specifically for the target population. Durations of the counseling programs usually range from six to eighteen months.  While some individual counseling is provided in the WGCAS offices, the vast majority of the individual counseling occurs in the client’s home.

Personnel responsible for management measures and management: Andrea Malone, CEO, Ed Braik, compliance officer.


Service Outcome Measures Review

West Georgia Counseling and Assessment Services outcome measurement system consists of monitoring the effectiveness, efficiency, satisfaction, and access to services for our clients. For FY 2015 our agency monitored the services that we provide in our Outpatient Treatment program. In addition we monitored the number of services provided in a timely manner for a specific target group.

Outpatient Treatment Program

Our outpatient treatment core program includes the following services:

  1. Homestead Counseling
  2. Wrap around intensive services

Outpatient Treatment Demographics of persons served in FY 2015:

  • 62 total clients served in our outpatient program. This is an increase of 37 percent over the previous fiscal year (45 total in FY 14). For 2015, the agency served 34 white females, 8 white males, 17 black females, and 3 black males.

EFFECTIVENESS Performance Measure:

  • Goal: For 2015 the number of children and families referred for Homestead Counseling or intensive wraparound services that are maintained in the familial home or safety resource will not fall below 70% of the total number served.

Measurement Method: All clients in our homestead/wraparound program will be staffed monthly at the formal supervision meeting to address treatment interventions and progress on cases. Cases will be staffed with the CEO and with the clinical supervisor prior to closing the case to assure the family has met all goals. We will compare the number of out of home placements versus the total number of those who have been served through our homestead counseling program in the fiscal year.

Extenuating or influencing factors: We will not include families who are not willing to participate in home services. Only those who have been in home with parents that cooperate for at least 6 months will be counted.

Result: 99.5% were kept in home, more than meeting the established goal for the year.  The results were shown in that 1 family out of 21 total had their children removed from their care during our involvement.  In FY 2014 100 percent were kept in the home or familial resource.

Further data showed that 12% of families who were provided services through Wrap Around-In Home Intensive Services did not complete services successfully or were non-compliant.

14% of families who were provided services through Homestead did not complete services successfully or were non-compliant.

Action Plan for improvement: none, as measures were accomplished

EFFICIENCY Performance Measure:

   Goal 1) to have zero turnover in outpatient staff.

Measurement Method:  This measure will be applied to all independent contractors who provide outpatient services during fiscal year 2015. The data collection method will involve counting the number of independent contractors who are providing this service with our agency on July 1, 2014 against the number who are providing the services on June 30, 2015.

Extenuating or Influencing factors: The number of independent contractors working for the agency regardless of length of association with the agency.

Results:  At the beginning of the 2015 fiscal year our agency had 6 independent contractors providing outpatient service. Our agency had zero turnover in FY 2015. Additionally, the agency had zero turnover in FY 2014.

Action Plans for improvement: none as the goal was accomplished.



  • Goal: All Outpatient Services staff will have their first appointment with a consumer within 7 days of referral.

Measurement Method: Data collection will be the review of a client case note that will report the date client is first seen and compared to the date of referral on the service authorization document sent by referring agency.

Extenuating or Influencing factors: clients who were unable to be contacted during the authorization period.

Results:  29% of Outpatient referrals were seen within the seven day timeframe versus 42% in FY 14. We did not meet our goal in this area.

Action Plan for Improvement: The consensus at the agency is that staff are not documenting attempts to contact the clients and a renewed emphasis will be place on this with staff. Additionally, we are going to change the goal for FY 16 to give staff 12 days to contact clients. This seems reasonable for the clientele that we serve who often are economically challenged to get places and to maintain cell phone minutes. There have been no complaints about our services not being timely.

Consumer Satisfaction:

Goal: West Georgia Counseling and Assessment Center will achieve a 90% satisfaction rate with clients and families when surveyed.

Measurement Method: All open case clients seen by WGCAS in FY 2015 that had not been discharged at the time of the survey.

Extenuating or influencing factors: none noted

Results: 9 of the 10 consumers responded positively to the survey giving the agency a 4 or 5 on a scale of 1 to 5. This was in response to the question “do you think our services are helping you to improve your life”? This is a result of 90 percent. In FY 2014 the agency satisfaction rating was 95 percent. However, this rating of 90 percent does meet the agency’s overall goal.

Action Plan for Improvement: Our consumer satisfaction survey occurred during August 2015 for those clients seen during the time period of FY 2015 but not discharged from services. We attempted to contact 29 consumers who were open cases for the agency. We were able to contact 5 of these consumers. Four out of five stated that they would say our agency deserved a 5 on a scale of 1 to 5 in regard to helping them improve their life. Comments were made that included “just keep Miss Sharolette on board” and “everything is great” and that Savanna is “doing a great job. Very pleased from the beginning”. The dissatisfied consumer complained that staff gave no notice if their meeting had to be cancelled. The agency CEO has followed up with the provider regarding the consumer.

In FY 2015 West Georgia Counseling and Assessment services completed a survey of agency stakeholders to obtain their satisfaction with our services. We were able to receive a total of 3 responses, 3 of which were satisfied with services. In FY 2014 the agency received responses from 4 persons, 3 of whom were satisfied with services.

Supplemental Measures

Goal: to have at least 80% of all substance abuse assessments completed within 30 days of referral.

Measurement Method: at the end of FY 2015 a total of all substance abuse assessments completed in FY 15 will be noted. The agency will note how many of these assessments were completed within 30 days of receipt of referral.

Extenuating or influencing factors: none noted

Results. 86 of 93 substance abuse assessments were completed within 30 days of referral. This means that 92% of the assessments were completed within 30 days and that meets the goal. This result matches the result from FY 2014. In addition, during the year we began to track additional goals in this area regarding assessments within 30 days. The results were as follows:

  • Domestic Violence assessments: 18 out of 32 were within the 30 day mark for a 77 percent result.
  • Parental Fitness Assessments: 36 out of 40 were completed within the 30 day mark for an 89 percent success rate.
  • CCFA assessments: 21 out of 31 were completed within the 30 day standard for a 68 percent result. In FY 2014 88% of CCFA’s were completed within 30 days.

Actions Plan for improvement: none as the agency met this goal for its substance abuse assessments.

Areas needing performance improvement:

  1. We did not see or contact 100 percent of outpatient services referrals in the time frame of 7 days of the date of referral.

Action Plan: We will educate staff on this goal and continue to track our performance in this area and provide feedback to staff involved in this area. At the same time we are going to change the standard to 12 days as the consensus is that we are timely at contacting people but not as good at documenting our efforts.

  1. We did not reach our goal of having 90 percent of CCFA’s completed within the time frame set.

Action Plan: We will continue to monitor this performance and note issues that are inherent in the process to reaching this goal.