This is simple demographic data that provides

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STEP-BY-STEP ILLUSTRATION FOR PREPARING A
MORTALITY REPORT
The Connecticut report is very visual, relying
on a lot of graphs to illustrate patterns and
trends. This approach was used as opposed to a
narrative dense format to make it easier for
general readers to understand the data. Such an
approach does, however, take a bit more time to
prepare, and requires setting up complimentary or
linked excel charts and graphs. The report is
published in powerpoint (only because I find that
easier to work in than word). It can be prepared
with almost any publishing software, as long as
you can easily import tables and graphs. The
following pages present a step-by-step
illustration of how to set up and prepare the
report. Obviously, available data and areas of
interest will determine the exact format and
information that is included in your report.
This is simple demographic data that provides a
general overview of the population served by the
agency. It can be configured in any way that
makes sense for your agency.
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This data simply reflects the no. and percent of
deaths by where people lived (categories). You
can configure any way you want (usually it is
helpful to distinguish between persons who
receive direct residential services from those
who do not and from those for whom another agency
may have responsibility (e.g., LTC).
Health Mortality Review ANNUAL REPORT September
2002
Mortality Trends
An important component of the risk management
systems present within DMR involve the analysis
and review of deaths to identify important
patterns and trends that may help increase
knowledge about risk factors and provide
information to guide system enhancements.
Consequently, DMR collects information on the
death of all individuals served by the
department. The following section provides a
general description of the results of this
analysis for Fiscal Year 2002 (July 2001 through
June 2002).
Excel chart set up as follows
Type of Residential Support At Time of Death
Mortality and Residence During the 12 month time
period between July 1, 2001 and June 30, 2002 a
total of 178 out of the 19,500 individuals
served by DMR passed away. As can be seen in
the graph to the right approximately half died
while being served in a residential setting
operated, funded or licensed by DMR (blue
section). The other half were living at home
(family home or independently), in a
long-term care facility (e.g., nursing home), or
other non-DMR setting . This general pattern is
consistent with that observed last fiscal year,
although there was a slight reduction in the
relative percentage of deaths that occurred in
CLAs, Supported Living and Long-Term Care
facilities. The average Death Rate is expressed
as the no. of deaths per 1000 people served. It
compares the number of deaths to the number of
persons served in each type of setting (no.
deaths /population X1000), and continues to show
a predictable pattern In general, the higher
need for specialized care, the higher the average
rate of death.
This data represents death RATE, with table set
up so that it moves from lowest to highest. Rate
is a good indicator since it allows general
comparisons that compensate for differences in
the population size. (If you use similar
groupings you will have CT and MA data as a
benchmark.)
This graph shows the number of people who died
for every 1000 people served in each type of
setting. The settings to the left tend to
provide less comprehensive care and support than
the settings to the right. This often reflects
the level of disability and specialized care
needs of the people who generally live in each
type of setting. For example, persons living in
LTC (nursing homes) tend to be older than other
people served by DMR, and, usually went to a
nursing home because they needed skilled
nursing care. Their death rate is much
higher than for other people served by DMR.
Excel chart set up as follows
In this report we use the term average death
rate to reflect what is more commonly referred
to as the crude death rate in mortality and
epidemiological research.
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Home people living with families or
independently SL supported living CTH
Community Training Home (foster care)
CLA Community Living Arrangement (group home)
Campus regional centers and STS (institutions)
LTCLong Term Care (Nursing Homes, SNFs, etc.)
Other Everything else.
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This data simply compares the past two years in
terms of the total no. deaths and the death
rates. As time goes on, additional years
(reflecting trends) will be included.
Health Mortality Review ANNUAL REPORT September
2002
Health Mortality Review ANNUAL REPORT September
2002
Excel chart set up as follows
The two graphs to the right compare the number of
deaths within the population served by DMR and
the average death rate for fiscal years 2001 and
2002. As can be seen, FY02 experienced a slight
decrease in both measures.
This graph compares the death rate (the
number deaths per 1000 persons served) for
fiscal year 2002 with that for last fiscal year
(FY2001) by type of residential setting. Small
differences can be seen, with the rate
decreasing for persons living in CLAs (group
homes) and in Campus settings (STS and regional
centers). The most pronounced decrease
occurred for persons receiving Supported Living
services. Slight increases in the mortality
rate occurred for persons living in
Long-Term-Care facilities and their family homes
Rate by residential setting across the two years
is shown here. This is useful to identify any
emerging trends.
Uses same excel chart as above
Caution must be exercised in reviewing this data
since the actual number of deaths in each of
these settings was relatively small. The
differences across this time period are therefore
most likely not statistically significant.
Comparison of death rate by gender is a common
(and almost expected) type of analysis. It is
useful since there is a lot of data of
differential rates (e.g., CDC). Make sure you
also look at age higher death rates for women
may be reflective of the fact that their average
age is higher.
Gender and Mortality During Fiscal Year 2002 a
little over half (52) of the 178 individuals who
passed away were men. However, DMR serves more
men than women. The No. Deaths per 1000 people
served shows that women tend to have a higher
death rate. It is important to note, however,
that the average age of women served by DMR is
greater than the age of men, with almost two
times as many females over the age of 85-yrs than
males. Thus, a higher death rate for women would
be expected since they are, as a group, older
than the men served by the department.
Excel chart set up as follows
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Age is probably the most common type of analysis
for mortality since it is the strongest predictor
of death and there are numerous benchmarks you
can look at (including data specific to a given
state). Data reflects a basic frequency
distribution, converted to rates (no. divided by
total no. served in the age range). You can
expand or compress the age ranges to best reflect
the population you serve or specific
program/service categories.
Health Mortality Review ANNUAL REPORT September
2002
Age and Mortality
Excel chart set up as follows
The relationship between age and mortality shows
the expected trend, with the mortality rate
increasing as people served by DMR get older. As
seen here, at around 70 -yrs of age there is a
dramatic rise in mortality, again, in line with
expectations and the trends observed in the
general population.
Individuals living at home (especially those
living with their family) are younger than the
other persons served by DMR. They also have a
much younger average age at death. The oldest
group served by DMR are living in LTC facilities.
They have the highest average age at death.
This table is a summary of above data used for
direct import into the report.
As can be seen in this graph there is a
relatively strong relationship between the
average age of the population living in each type
of residential setting and their average age at
death. The largest difference between the two
variables exists in CLAs, where the average age
of death is 13-yrs higher than the average age of
the population living in this type of setting.
This analysis may not be necessary. It was
included due to erroneous reporting by the
Hartford Courant and to illustrate that there is
NOT any adverse risk for people living in CLAs.
If you decide to include something like this, it
will be necessary to compute the average age of
persons in each type of residential setting and
the average age of death for people in those
settings.
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This data simply reflects the relationship
between MR level and mortality rate. You can do
something very similar with any data re client
characteristics as long as you can group your
population according to the variable (e.g., ICAP
scores on selected functional or diagnostic
categories/levels). The average rate is
illustrated by the dashed line (to allow easy
identification of levels above and below the
average).
Health Mortality Review ANNUAL REPORT September
2002
Level of Disability and Mortality
In addition to age and gender, the level of
mental retardation is another factor that affects
a persons life expectancy. Persons with more
severe levels of disability typically have many
co-morbid conditions (other medical diagnoses
such as epilepsy, cerebral palsy, etc.),
including mobility and eating impairments. These
disabilities have a significant effect on
morbidity (illness) and mortality. As can be seen
in this graph, the relationship between level of
mental retardation and mortality shows the
expected trend. Persons with the most
significant levels of mental retardation (severe
and profound) have a much higher rate of
mortality.
Excel chart set up as follows
No MR or ND category Includes children receiving
DMR services through the Birth-to-Three system
who are too young to test for mental retardation
and adults for whom the DMR has limited
responsibility under the Federal Nursing Home
Reform Act (OBRA 87) who do not have mental
retardation. It may include some DMR clients who
were DMR clients prior to Connecticuts current
statutory definition of mental retardation.
During FY 2002 (July 1, 2001 to June 30, 2002)
123 cases were formally reviewed by DMR
Mortality Review Committees. The information
presented in the next section summarizes ONLY
those deaths that were reviewed and will
therefore be different from the numbers discussed
in the preceding section. Information regarding
FY02 reviews will be presented for ALL CASES
REVIEWED and for only those deaths that OCCURRED
DURING FY02.
The following sections of the report require
additional data that may not be readily available
without a specific database associated with the
process of mortality review. You do have data on
whether the death was natural or accidental
as well as a few other very general categories.
(Recommend you decide what type of information
you want to report on and then incorporate into
your reporting format and process.)
DMR Mortality Review DMR policy establishes
formal mechanisms for the careful review of
consumer deaths by local regional Mortality
Review Committees and a central Medical Quality
Assurance Board. This latter entity, modified by
the Governors Executive Order No. 25, is now
called the Independent Mortality Review Board
(IMRB) and includes representation from a number
of outside agencies as well as a consultant
physician. During FY02 a total of 123 cases were
reviewed by these local committees and the
central IMRB. Of these, 58 cases were referred
by local committees to the IMRB, and an
additional 14 (11) cases of the 65 closed at the
local level were reviewed centrally as a quality
assurance audit. Of the 123 cases that were
reviewed, 41 represented deaths that occurred
during FY02. Information regarding these deaths
is summarized separately below. IMPORTANT
FINDINGS From Mortality Reviews
This data reflects deaths associated with hospice
(and therefore expected.
Community Hospice Support is routinely provided
for persons served by DMR in all types of
residential settings, including regional centers
and STS, CLAs, CTHs, and for individuals
receiving supported living services when death is
anticipated, usually due to a terminal
illness. ALL CASES REVIEWED Hospice support
was provided in 24 of the 123 cases reviewed
(20) FY02 DEATHS ONLY Hospice support was
provided for 14 of the 41 individuals who died
(34)
Excel chart set up as follows
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All of this data had to be reported in two
different ways since the mortality review process
is always a bit behind the actual fiscal year,
and, given the heightened attention to death that
year, it was important to present info on both
the total no. of reviews as well as only those
deaths that occurred in that year. Most of the
data is self-explanatory. The categories chosen
for inclusion tended to be hot button issues
where real objective information can calm the
storm.
Health Mortality Review ANNUAL REPORT September
2002
Autopsies are performed by the Office of the
Chief Medical Examiner for those cases in which
the OCME accepts jurisdiction or by private
hospitals when DMR requests and the family
consents to the autopsy. ALL CASES REVIEWED
Of the 123 individuals reviewed, autopsies had
been requested for 48 (or 39 of the sample),
and consent was obtained and autopsies performed
for 26 (21 of the sample). The OCME accepted
jurisdiction and performed autopsies for 15 of
these cases, and private autopsies were
conducted for 11. FY02 DEATHS ONLY Of the 41
deaths that occurred during FY02, autopsies were
requested for 22 (54). A total of 8 autopsies
were performed (20), 5 of which were conducted
by the OCME. Special Note A recent report by
the Columbus Organization found that the average
rate of autopsy for persons served by those state
MR/DD agencies they surveyed was 11.7. This
compares to the 20-21 rate noted above for cases
reviewed by mortality review committees in
Connecticut during FY02. Predictability. ALL
CASES REVIEWED In 64 of the cases reviewed
(n79), the death was anticipated and related to
the diagnosis. In another 24 of the cases
(n29) the death was not anticipated, but was
directly related to the existing diagnosis. In
12 (n15) the death was not anticipated and
not related to the diagnosis, as follows 1
heart anomaly 2 asphyxia (drowning) 3
cardiovascular disease 1 subdural hematoma 1
adverse drug reaction 1 stroke 2
pulmonary embolism (1 following surgery) 1
pneumonia 2 inhalation of food 1 cause
undetermined by OCME FY02 DEATHS ONLY
Of the 41 deaths reviewed that occurred in FY02,
56 (n23) were anticipated and related to the
known diagnosis, 32 (n13) were not anticipated
but were related to the existing diagnosis, and
12 (n5) were not anticipated and not related to
the diagnosis, as follows (also included
above) 1 cardiovascular disease 1
stroke 1 adverse drug reaction 1
pulmonary embolism following orthopedic
surgery 1 cause undetermined by OCME DNR.
Do Not Resuscitate (DNR) orders are sometimes
utilized when individuals reach the terminal
phase of an illness. DMR has an established
policy that includes specific criteria that must
be met along with a review process for all DNR
orders issued for persons served by the
department. ALL CASES REVIEWED Of the 123
cases reviewed, 71 people (or 58) had DNR
orders, indicating that their condition was
terminal. Of these, 67 were formally reviewed by
DMR. For the remaining four individuals, DMR was
not notified as required by policy, but in all
cases the DNR was appropriate and would have met
established criteria. Of these four, two occurred
at a LTC facility, one at an acute care hospital
, and the fourth at a Hospice facility. All
facilities received additional training regarding
required notification to DMR. FY02 DEATHS ONLY
Of the 41 deaths that occurred in FY02, 15 had
DNR orders (37). All met DMR policy
requirements (met criteria, and both notification
and review took place as required). Risk.
Mobility impairments and need for special
assistance eating are two factors that place
individuals at significantly higher risk of
death. The mortality review process therefore
looks carefully at the presence of these two
personal characteristics. ALL CASES REVIEWED
Of the 123 individuals reviewed, 54 or 44 were
non-ambulatory. 62, or 50, were not able to
eat independently. FY02 DEATHS ONLY Of the 41
FY02 deaths reviewed, 18 (44) had mobility
impairments (non- ambulatory) and 10 (24) were
not able to eat independently.
Excel charts set up as follows
Note your mortality review process will need to
be structured to generate specific kinds of data
and conclusions in order to provide this type of
data for a report.
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Context is similar to the data you collect.
(Recommend you carefully review the reliability
of the reporting, especially to see if later
review causes changes to be made.)
Health Mortality Review ANNUAL REPORT September
2002
SUMMARY Deaths that Occurred and Were Reviewed
between 7/1/01 6/30/02
Context. ALL DEATHS REVIEWED The vast
majority over 90 - of all deaths reviewed were
classified as due to Natural Causes. Six
(6)deaths were associated with an Accident. Of
these, 2 were related to choking, 2 were related
to drowning, and 2 appear to be related to a
fall. One case was a Homicide and in one case
the context was not able to be determined by the
OCME. FY02 DEATHS ONLY 39 deaths or 95 - of
the 41 reviewed were related to natural causes.
1 death was accidental and 1 was not able to be
determined by the OCME. The accidental death was
related to a fall. Neglect. ALL DEATHS
REVIEWED There were a total of 18 allegations
of abuse or neglect that occurred within 6 months
of death for the cases reviewed. Of these, 2
were not substantiated, 8 are still under
investigation, and 8 were substantiated. In 4 of
these latter cases, the neglect appeared to be
related to the cause of death, as follows 2 -
asphyxia resulting from drowning (private CLAs)
1- anoxia, associated with nursing failure to
properly assess (LTC) 1 - anoxia resulting
from choking on food (private day program)
Enforcement action was taken in 3 of the 4 cases
and included 2 dismissals from service by the
provider with arrest by police and 1 citation
with monetary fine by DPH (1). In the fourth
case there were inconsistent findings regarding
the culpability of the involved staff member.
In all four instances family members were
notified of findings. FY02 DEATHS ONLY Of the
41 deaths that occurred in FY02 there were a
total of 8 that included an allegation of abuse
or neglect within 6-months of death. Of these, 1
was not substantiated, 5 are still under
investigation, and in two cases the neglect was
substantiated. In both of these latter two cases
it was not possible to determine if the neglect
was the direct cause of the deaths. Both cases
involved nursing personnel where enforcement
action included appropriate reporting to the
Department of Public Health and Nursing Board.
Excel chart set up as follows

• 34 of the people had Hospice support.
• 20 had an Autopsy.
• 56 of the deaths were Anticipated and
  related to the existing diagnosis. In 12 the
  death was not anticipated and not related to
  the existing diagnosis.
• 37 had a DNR order. All met DMR criteria.
• 44 of the people could Not Walk (i.e., were
  non-ambulatory).
• 24 could Not Eat without assistance.
• 95 of all the deaths reviewed were due to
  Natural causes.
• 1 death was classified as Accidental.
• 2 cases involved Neglect that was
  substantiated. In both cases it was not
  possible to determine if the neglect was related
  to the cause of death.

Neglect data reflects whether or not there was an
allegation of abuse or neglect within 6 mo. of
the death. Therefore, it was important to also
note whether or not the neglect was related to
the death (which only an investigation or
mortality review process can determine)
Excel chart set up as follows
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Location at time of death may be important to
look at, particularly if questions get raised
about the care being provided within programs
operated or funded by your agency. It can be
useful to show that a majority of deaths take
place within hospitals and LTC (as would be
expected). However, to do this, you will need to
capture that data either on the IR form or
through mortality review.
Health Mortality Review ANNUAL REPORT September
2002
Location at Time of Death As can be seen in this
graph over 60 of the individuals reviewed by the
mortality review committee in FY02 passed away
outside of a DMR - operated or funded residential
setting. Most died in the hospital or long term
care facility. The table below shows both the
number of individuals who died by location as
well as the relative percentage by location.
Excel chart set up as follows
Where People Died FY 2002 Mortality Reviews
LEADING CAUSES OF DEATH A review of data from
Connecticut and two other New England states
suggests that the leading causes of death for
people with mental retardation are somewhat
different than for the general population. Heart
disease is the no. 1 cause of death for all
groups. However, unlike the general population,
deaths due to respiratory conditions are the
second leading cause of death for individuals
served by DMR. This is expected due to the high
percentage of deaths for persons with severe and
profound mental retardation and the high
incidence of co-morbid conditions in that group,
including conditions such as cerebral palsy,
dysphagia, gastro-esophageal disorders, all of
which carry a heightened risk of aspiration
pneumonia. It should be noted that increasing
age is an important factor that increases risk
for aspiration pneumonia as documented in the
National Vital Statistics Report published by the
CDC.1 This report states that a major cause of
death concentrated among the elderly, is a
pneumonia resulting from aspirating materials
into the lungs. Diseases of the nervous
system are the third leading cause of death for
DMR consumers. These include Alzheimers
Disease which has a very high incidence in
people with Down Syndrome - and Seizure
Disorders, again a condition that has a much
higher incidence in people with mental
retardation. Interestingly, deaths due to
accidents are much lower for people with mental
retardation than for the general U.S. or
Connecticut population. Deaths due to injuries or
accidents are the 5th leading cause of death in
the general population , but are only the 8th
highest cause of death for people reviewed by
DMRs mortality review committees.
Leading causes of death is VERY important. IT is
also a variable that has ample benchmarks. You
can use SD data as well as national data (for
both the general population and, given published
mortality reports, for the MR/DD population as
well just make sure there is an ability to
directly compare DD populations since some states
only serve MR, some report only on adults, etc.).
Leading Causes of Death
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Health Mortality Review ANNUAL REPORT September
2002
Benchmarking is becoming more and more critical
since it provides a means to assess whether or
not your state is typical or an outlier. It
will be important to scan the web and stay in
touch with other states to get copies of
mortality data and reports as they become
available. Be very CAREFUL, however not all
data is comparable. CT and MA have similar
systems communicate a lot and therefore can
usually use one another as a benchmark. (Check
with Wanda to see if she was able to get the
report from Gerry Morrisey.)
BENCHMARKS While there is a dearth of objective
information regarding mortality in persons with
mental retardation being served by state agencies
from across the country, this section will
provide comparative analysis when appropriate
benchmarks do become available.
Massachusetts DMR The Massachusetts Department of
Mental Retardation has recently enhanced and
expanded its mortality reporting requirements and
has issued an annual report. This 2000
Mortality Report was prepared by the University
of Massachusetts Medical School/Shriver, Center
for Developmental Disabilities Evaluation and
Research2. The report covers the calendar year
January 1 through December 31, 2000. Mortality
statistics pertaining to persons 18-years and
older served by DMR were analyzed according to a
number of variables not dissimilar from many of
those contained in the first part of this report.
Consequently, it is possible to use some of the
Massachusetts data for comparative purposes. It
should be noted that the Massachusetts DMR
system, although larger, is very similar to
Connecticuts (e.g., population served, type of
services and supports, organization). However,
there are differences in reporting requirements,
age limits, and and categorization of service
types. It is therefore important that readers
exercise caution when reviewing comparative
information.
Overall Death Rate A comparison of the overall
death rate for persons served by the Connecticut
DMR with similar rates for the general population
in the U.S. and the DMR population in
Massachusetts are presented in this graph. The
overall Connecticut DMR death rate of 12.1 deaths
per thousand people is higher than the rate of
8.7 deaths per thousand people in the general
population, as would be expected due to the many
health and functional complications associated
with disability and mental retardation. A
comparison of the Connecticut DMR with
Massachusetts DMR shows a slightly higher death
rate in Connecticut for the adult population
(people older than 18-yrs of age.) of 0.8 deaths
per thousand people served. This difference does
not appear to be significant and may be a
reflection of the aforementioned differences in
the populations being served.
Excel charts set up as follows
Residential Analysis A comparison of average
death rates by where people live is presented
here. The general pattern for rates by type of
setting is quite similar across the two states,
with the exception of the Other category. This
is most likely a reflection of differences in the
populations included in this cluster.
Death rates in DMR would therefore appear to be
very consistent with an available benchmark as
reported in Massachusetts.
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This page is purely optional. Including it shows
that the department is paying attention to what
is happening nationally, and in a way forces
staff to take time to scan national literature.
If you conduct any statistical studies (e.g.,
relationship between ICAP and mortality, or other
types of incidents and mortality) it would be
most beneficial to summarize findings in this
section of the report.
Health Mortality Review ANNUAL REPORT September
2002
RESEARCH REPORTS OF INTEREST This section will
report on selected research, reviews, and other
information from Connecticut and around the
country that is related to mortality and health
care in mental retardation and developmental
disabilities systems.

• Connecticut DMR Independent Study on Mortality
• The Connecticut DMR retained the services of two
  outside consultants to conduct a comprehensive
  analysis of mortality and basic demographic
  trends from 1997 to 2002 within the population of
  individuals served by DMR. The study was
  designed to provide
• Descriptive Overview of People Served by DMR
• Predictive Mortality Analysis
• Cross-sectional Analysis of People Served
• Longitudinal Analysis (Changes over Time)
• Using sophisticated statistical procedures the
  study authors found that
• Changes in mortality rates over time are not
  significant
• As expected, mortality is highly related to
  client age
• Women served by DMR are older than men, and hence
  have a higher mortality rate
• Increased levels of disability are inter-related
  and correlated with higher risk of mortality
• The strongest predictors of mortality are age,
  mobility status, and amount of supervision
  provided
• The aging in place phenomenon is leading to
  increased risk of mortality since individuals
  served by DMR are becoming older and more
  disabled over time.
• Copies of the report3 and a graphical summary can
  be obtained by contacting

DMR Strategic Leadership Center 860-418-6163 or
steven.staugaitis_at_po.state.ct.us

• California Study of National Mortality Review
  Systems
• The Columbus Organization conducted a survey of
  national mortality review practices in MR/DD
  systems for the California DDS4. Survey findings
  indicate that
• The majority of states require reporting of
  deaths for persons served by state DD agencies at
  both the local and statewide level.
• In most instances the determination to perform an
  autopsy is based upon the unique circumstances of
  each case, with an average of 11.7 of all cases
  having an autopsy.
• About half of the states use a set of
  standardized criteria to review deaths.
• The majority of states have established databases
  to track mortality information.
• The Columbus report was published in May of 2002.
  Copies can be obtained by contacting Columbus at
  
• 800-229-5116.

References 1 Minino, M.P.H., Arialdi, M. and
Smith, Ed., S.B., CDC National Vital Statistics
Reports National Vital Statistics System,
Deaths Preliminary Data for 2000, Volume 49,
Number 12, October 9, 2001. 2 2000 Mortality
Report A Report on DMR Deaths January 1
December 31, 2000. Prepared for the
Massachusetts Department of Mental Retardation
by the Center for Developmental Disabilities
Evaluation and Research at the University of
Massachusetts Medical School/Shriver. March 4,
2002. 3 Gruman, C. Fenster, J. A Report to
the Department of Mental Retardation 1996
through 2002 Data Overview Completed April
2002. 4 The Columbus Organization. Mortality
Review Survey Survey of the States. Submitted
to the California Department of Developmental
Services. May, 2002.
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Health Mortality Review ANNUAL REPORT September
2002
This section of the report is also optional. It
does, however, allow the agency to publicize new
initiatives and efforts to enhance services and
systems that reduce risk (e.g., improving your IR
and MR system).
ENHANCEMENTS Executive Order No. 25 A number
of important enhancements to the risk management
and mortality review systems in DMR are being
implemented in response to Governor Rowlands
Executive Order No. 25. All of these changes are
designed to improve communication with families,
assure that a rigorous and objective evaluation
and review of circumstances surrounding untimely
deaths takes place,and to make sure that the
review process is independent and free from the
potential for conflict of interest. Some of
these enhancements include
Stronger Role for Investigations Unit The
Connecticut DMR has a unique relationship with
the State Police that includes the assignment of
a senior Officer to oversee and manage the
Investigations Unit. Two trained clinical nurse
investigators have joined the units staff and
are conducting preliminary screening on all
deaths that occur in DMR operated or funded
settings to immediately assess the need for a
complete A/N investigation. In addition, a
Special Investigative Assistant has been
appointed to oversee and monitor investigations
conducted within the private sector. New
Independent Mortality Review Board The Medical
Quality Assurance Board has been transformed into
a new Independent Mortality Review Board that
increases outside representation. The
Chairperson was appointed by the Commissioner of
DMR, in consultation with the Director of the
Office of Protection and Advocacy (OPA). The
independent medical professional (physician)and
an independent representative from a private
sector agency were jointly appointed by the DMR
Commissioner and OPA Director. In addition, OPA
now has two members. The new IMRB began meeting
in March, 2002. Increased Communication with
OPA The department is notifying the Executive
Director of the Office of Protection and Advocacy
of all deaths that occur for persons served by
DMR. The Director may request an expedited
review by the IMRB, or, may direct that an
abuse/neglect investigation be initiated for any
case. Consistent Notification of Families New
policies and procedures have been implemented to
assure that families and guardians are
consistently notified of all deaths and the
results of investigations and mortality reviews.
Families are provided with an opportunity to meet
with DMR personnel to review all
findings. Posting of Licensing Inspection
Reports The department is now requiring visible
notice to consumers, families and guardians that
the results of DMR licensing inspections are
available for review. In addition, DMR is
posting summary reports of inspections on the DMR
website in order to make access to the
information much easier and more widely available
to the public. Results of licensing inspections
can be viewed at www.dmr.state.ct.us/license.htm.
The Next Health and Mortality Review UPDATE
Will be issued in March of 2003. For more
information or to contact DMR please visit us at
www.dmr.state.ct.us
Prepared by Steven Staugaitis, Director,
Strategic Leadership Center Marcia Noll,
Director, Health and Clinical Services
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