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2014 is Around the Corner: - Texas Council of Community Centers

2014 is Around the Corner: - Texas Council of Community Centers

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www.TheNationalCouncil.orgHypothesis…• American healthcare system isin era of “Dis ruptiveInnovation” to improve qualityand bend the cos t curve (33states propose cutting Medicaidprovider payments in 2012)• That will proceed, regardlessof what happens in theelections of 2012 and 2014• And parity, the ACA andtechnology are shapingchanges to the delivery ofhuman services.


www.TheNationalCouncil.orgA tul G awande: T es ting, T es ting• Insurance Reform andCoverage Expansion are“technical fixes”• Service Delivery Redesign andPayment Reform is now thefocus…4


www.TheNationalCouncil.orgChronic Conditions Among ChildlessAdults at or B elow 138% FPLSource: Holahan, et al. “The Health Status of New Medicaid Enrollees Under HealthReform.” The Urban Institute, August 2010.


www.TheNationalCouncil.orgCo-morbidities in the Adult PopulationSource: Druss & Walker. “Mental disorders and medical comorbidity.” The Robert WoodJohnson Foundation Synthesis Project, February 2011.


www.TheNationalCouncil.orgThe Task: Inverting the TriangleCurrent Resource AllocationIt’s all about Inverting theResource Allocation Triangleso that:• Primary Care budgets aredoubled• Inpatient and InstitutionalCare are limited• Prevention and healthpromotion activities arewidely deployedAll things Inpatient andInstitutionalPrevention,PrimaryCare,BHInpatient &InstitutionalPrevention, EarlyIntervention,Primary Care, andBehavioral HealthNeeded Resource Allocation9


www.TheNationalCouncil.orgHow will changes effect MemberOrganizations and Consumers?2,0001,8301,8001,6001,4001,2001,00080060040020002001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011YTD


www.TheNationalCouncil.orgS ervice Delivery R edesign and PaymentR eform…information• Public Policy Update and Alerts• National Council Magazine• Technical Assistance Newsletter• Addictions /Co-occurring Newsletter• J ournal of B ehavioral Health S ervices& R esearch• Policy briefs and papers• Annual Conference• Webinars – 1000+ lines• Print Media and social media – onlinecommunities, blogging, and tweeting


www.TheNationalCouncil.orgS ervice Delivery R edesign and PaymentR eform…initiatives• Health Promotion: Mental Health First Aid*• Collaborative Care: Healthcare Learning Communities*• Capacity: Access Initiatives*• Quality and Accountability: Standards of Care; DepressionCollaborative*, Trauma Informed Care*• Leadership: Middle Management Academy*; PsychiatricLeadership Project*; Health Disparities and Emerging Leadersand *; Association Executives Learning Community*


www.TheNationalCouncil.orgHealthcare Models of the Future• Coverage expansions are ONLYsustainable with delivery systemreform– Collaborative Care– Patient Centered HealthcareHomes– Accountable Care Organizations• C os t containment, accountability and qualityimprovement are hallmarks of the new healthcareecosystem


www.TheNationalCouncil.orgCollaborative Care for Co-morbidities• The Care Coordination Standard: When I need to see a specialist orget a test, including mental health or substance use help, I get what I needat your clinic whenever possible and you stay involved when I get careother places.• >30 randomized controlled trials have found collaborativecare improves quality/ outcomes• K ey “active ingredients” = care managers and stepped care• Collaborative care highly cos t effective• Variety of models , including:– F ully integrated– Partnership model– Facilitated referral model


www.TheNationalCouncil.orgNew Paradigm – Primary Care inB ehavioral Health OrganizationsF unding s tarting toopen up forembedding primarymedical care intoCBHOs, a criticalcomponent ofmeeting the needsof adults withserious mentalillnes sClinical Design for Adults with Lowto Moderate and Youth with Low toHigh BH Risk and ComplexityPrimary CareClinic withBehavioralHealthCliniciansembedded,providingassessment,PCPconsultation,caremanagementand directserviceFood CBHO MartPartnership/Linkage withSpecialty CBHOfor persons whoneed their carestepped up toaddressincreased riskand complexitywith ability tostep back toPrimary CareClinical Design for Adults withModerate to High BH Risk andComplexityCBHOFoodMartCommunity Behavioral HealthcareOrganization with an embeddedPrimary Care Medical Clinic withability to address the full range ofprimary healthcare needs ofpersons with moderate to highbehavioral health risk andcomplexity


www.TheNationalCouncil.orgThe S AMHS A/HR S A Center for IntegratedHealth S olutions• Purpose:– To serve as a national training and technicalassistance center on the bidirectional integration ofprimary and behavioral health care and relatedworkforce development (including healthcare homes)– To provide technical assistance to PB HCI grantees andentities funded through HR S A to address the healthcare needs of individuals with mental illnesses,substance use and co-occurring disorders***T ex as – Austin Travis, Lubbock, MontroseEmail: integration@thenationalcouncil.orgPhone: 202-684-7457Web:www.CenterforIntegratedHealthSolutions.org


www.TheNationalCouncil.orgPerson-Centered Healthcare Homes: Anew paradigm• Everyone has a health home practitioner and team• Patients can easily make appointments and select the dayand time.• Waiting times are short.• Email and telephone consultations are offered.• Systems support high-quality care, practice-based learning,and quality improvement.• Practices maintain patient registries; monitor adherence totreatment; have easy access to lab and test results; andconsumers receive reminders, decision support, andinformation/education on treatments and lifestyle.


www.TheNationalCouncil.orgHealth Homes S erving Individuals withS MI and S ubstance Use Disorders1. Assure regular health status screening andregistry tracking/outcome measurement2. Locate medical nurse practitioners/primary carephys icians in MH/S U facilities3. Identify a primary care s upervis ing phys ician4. E mbed nurse care managers5. Use evidence-based practices developed toimprove health s tatus6. Create wellness programs


www.TheNationalCouncil.orgAdditional Necessary Components• The health home is supported by a sustainablebusiness model & appropriately aligned incentives• The health home is accountable for achievingimproved clinical, financial, and patient experienceoutcomes


www.TheNationalCouncil.orgThe Money and the B usiness Model• Financial models (FFS, case rates, global payments) arecritical to selection of business models – how doesMedicaid reimburse for care?• In one FFS s tate, for ps ychiatric medication s ervice 90862– A university medical center clinic is reimbursed $12.50– The s ame vis it at a CMHC is reimburs ed $39.92– At an FQHC, the visit would be reimbursed at $80-88• In a nearby FFS and managed care state, for 90862:– A university medical center is reimbursed $19.53 (FFS )– The s ame vis it at a CMHC is reimburs ed $210.87 (FFS )– At an FQHC, the visit would be reimbursed $66.82-155.64(FFS)


www.TheNationalCouncil.orgPayment Models for Healthcare Homes• Fee for S ervice is headed towards extinction• Healthcare Home models are beginning with a 3-layer funding design with the goal of the FFSlayer s hrinking over time:Case Rate• Prevention, Early Intervention, CareManagement for Chronic Medical ConditionsFee for Service• Per Service (Fee for Service) Payments forservices provided by Primary Care ProvidersBonus• Share in Savings from Reduced TotalHealthcare Expenditures (bending thecurve)


www.TheNationalCouncil.orgMedicaid Healthcare Homes S tate Option• State plan option allowing Medicaid beneficiaries with or atrisk of two or more chronic conditions (including mentalillness or substance abuse) to designate a “health home”• Community behavioral health organizations are eligibleproviders• 90% Federal match rate for the following services during thefirst 8 fiscal year quarters when the program is in effect:• Provider organizations may work alone or as part of a team• 5 States have planning grants: WV, AR, MI, NV, AZ• SAMHSA/CIHS Discussions: MO, MN, NH, NY• No SPA approved


www.TheNationalCouncil.orgOn Y our Mark, G et S et, A C O…• Directed by a coordinated set ofproviders• Provides a full continuum of careto patients and populations• Hospital, healthcare homes,specialty care, carecoordination, transitionsbetween levels of care…• Financial incentives• Cost containment• Enhanced care quality, patientexperience and overall healthstatus


www.TheNationalCouncil.orgPartnering with Health Homes andAccountable Care Organizations• National Council reporthttp://www.thenationalcouncil.org/cs/acos_and_health_homes• Webinar with Dale Jarvis &Laurie Alexanderhttp://www.thenationalcouncil.org/cs/recordings_presentations• Live Blogchathttp://mentalhealthcarereform.org/aco-webchat/


www.TheNationalCouncil.orgWhat C ompetitive A dvantages andAchilles Heels do we bring to theparty?25


www.TheNationalCouncil.orgP ublic unders tands that…• Behavioral Health is Essential to Health• Prevention Works• Treatments are E ffective• People R ecoverAchieving equality – pas s age of parity and inclus ion in ACA


www.TheNationalCouncil.orgS ervices are Cost E ffectiveWe already know how to be hospital prevention organizations;we’ve been doing it for yearsState Hospital$175,000Jail Cell$85,000CommunityResidential Facility$65,000Single RoomOccupancy withServices$40,000Supportive Housingwith ACT$22,500$0 $50,000 $100,000 $150,000 $200,000


www.TheNationalCouncil.orgAchilles Heels• Our members are relatively disconnected from the rest of thehealthcare ecosystem• We aren’t often invited to the planning table• We haven’t done a great job demonstrating how we can helpthe healthcare system manage total healthcare expenditures• We have limited capital and health technology infrastructure• We have a perceived image of not having timely access tocare capacity• Question:– What other Achilles Heels do we need to get onthe table?28


www.TheNationalCouncil.orgApproach #129


www.TheNationalCouncil.orgApproach #2:Assume Magical Thinking Won’t Work…• And that the Texas Council and its members can play a hugerole in creating the healthcare system of tomorrow…Plan Do StudyEducationHow willHealthcareReform changeWhat we do andHow we do it?ReadinessAssessmentWhat Gaps existbetween What Isand Where WeNeed to Be?Planning &DesignWhat are ourRedesignPriorities/StrategicInitiatives (Who,What, When)?External WorkRelationshipbuilding andInfluencing PolicyMakers andFundersInternal WorkUsing RapidCycleImprovement(RCI) ProjectMethodsEvaluationAre weachieving ourdesiredobjectives?What’s our NextPhase ofRedesignPriorities/StrategicInitiatives?No or “NotQuite”Yes?No?YesAct3030


www.TheNationalCouncil.orgLooking E xternally –Leaders hip and R elations hip B uilding• Relationship Building– “We are actively pursuing relationship-buildingwith leaders in the healthcare community…”• Track down the movers and shakers in yourcommunity, not just the healthcare leaders• Be seen in your community as someone who clearlyexplains healthcare reform (not just the MH/SU stuff)• Build the business case for MH/SU services• You need a 30 second elevator speech, a 2 minutehallway speech, and a 20 minute Rotary Club talk• There’s a huge vacuum in many communities; if youdon’t do this, who will?31 31


www.TheNationalCouncil.orgK ey R elations hip B uilding Is s ueAccountable Care Organization• If you are operating in a state and community where integrationefforts are under way and the ACO model is being pushed, yourchoices are:• Become a Preferred Provider tothe ACO• Become a Memberof the ACO• Get in on the groundfloor and become aFounding Member/Owner of the ACOMedicalHomesMedicalHomesMedicalHomesHealthClinicFood MartSpecialty ClinicsClinicPlanAccountable Care OrganizationFood MartSpecialty ClinicsHospitalsHospitals3232


www.TheNationalCouncil.orgPitching the B usiness Case• First, the five second pitch:“We can help you manage your mostcomplex cases, reduce costs, and gethome to your family on time moreevenings of the week.”Quote from Brenda Reiss-Brennan, MS, APRN, CS,mental health integration leader of primary care clinicalprograms, Intermountain Health Care (IHC), Salt LakeCity, Utah3333


www.TheNationalCouncil.orgTools: Tool #1, the 2 Pager3434


www.TheNationalCouncil.orgTool #2:The 7Pager3535


www.TheNationalCouncil.orgTool #3:The 43Pager3636


www.TheNationalCouncil.orgLooking Internally…In the new healthcare ecosystem, the value of ourservices will depend on our ability to:1. Be accessible (fast access to all needed services)2. Be efficient (provide high-quality services at lowestpossible cost)3. Connect with other providers (via electronicinformation exchange)4. Focus on episodic care needs5. Produce outcomes37


www.TheNationalCouncil.org1. B e Acces s ibleCan schools, child welfare, ACOs and healthcare homes get theirclients/patients into specialty MH/SU care with same day/next dayaccess, especially for high risk, high need patients?New Patient’s firstVisit to PCP includesbehavioral healthscreeningPossibleBH Issues?YESBehavioral HealthAssessment by BHProfessional workingin primary careNeed BHSvcs?YESSuperbAccessto CareClients with Low to Moderate BH need enrolledin Level 1; to be case managed and served inprimary care by PCP and BH Care Coordinatorwith support from Consulting Psychiatrist andother clinic-based Mental Health ProvidersClients with Hi Moderate to High need referredto Level 2 specialty care; PCP continues toprovide medical services and BH CareCoordinator maintains linkage; this is a timelimitedreferral with expectation that care will bestepped back to primary careReferrals to other needed services and supports (e.g. CSO, Vocational Rehabilitation)38


www.TheNationalCouncil.orgP oll R es ults : 600+ P articipants for Webinar onHealthcare R eform by David Lloyd, MTM S ervices1. From the clinicians’ perspective, are the caseloads in your organization “full” at thistime?Yes = 74% No = 26%2. Do you know the cost and days of wait for your organization’s firs t c all to treatment plancompletion process?Yes = 41% No = 59%3. Indicate the no show/cancellation percentage last quarter in your organization for theintake/assessment appointments:A. 0 to 19% = 20%B . 20 to 39% = 42%C. 40 to 59% = 15%D. Not aware of percentage = 23%4. Indicate the no show/cancellation percentage last quarter in your organization for IndividualTherapy appointments :A. 0 to 19% = 24%B. 20% to 39% = 50%C. Not aware of percentage = 26%39


www.TheNationalCouncil.orgC arls bad Mental Health C enter’s S olution toS ame Day Access• Control the S chedule• Limit any approved meeting to 1 hour• Only schedule two appointments out• No-show groups for appointment wasters• Don’t schedule paper work time• R educe center cancellations - reminders• B ook 7 appointments a day


www.TheNationalCouncil.org2. B e E fficientDo you have the ability to identifypatients with MH/SUD who representthe top 5% to 10% of high costconsumers of health care and provideeffective care management servicesto help them manage their MH/SUdisorders AND their chronic healthconditions?CareCoordinationTeamCare41


www.TheNationalCouncil.orgCare Management: Missouri Example• Identified the cohort of MO HealthNet participantsfor whom care management offers the greatestopportunity• Program components:– Outreach and engagement (door-to-dooroutreach, collaboration with other healthproviders)– Care coordination by mental health case manager– Nurse training– Chronic disease training– Evaluating outcomes: both process indicators andclinical outcomes42


www.TheNationalCouncil.orgMO Program Outcomes• Actual pharmacy cost decreased 23%.• Actual general hospital cost decreased by 6.8%.• Actual primary care services increased by 21%.• Independent living increas ed by 33%.• Vocational activity increas ed by 44%.• Legal involvement decreased by 68%.• Ps ychiatric hos pitalization decreas ed by 52%.• Illegal substance use decreased by 52%


www.TheNationalCouncil.org3. Connect with Other Providers• Do you use a collaborative care approachto clinical services?• Are you actively pursuing bi-directionalinvolvement in your community as aperson-centered healthcare home?• Can you electronically collect and shareboth demographic and clinical-level datawith your partners in the healthcarecommunity?ClinicalInformationSystems44


www.TheNationalCouncil.orgIntegration, Healthcare Homes, andHealth IT• Stage 1 Meaningful UseObjectives include:• Recording patientinformation into EHRs, suchas gender, race, preferredlanguage, height, weight,smoking status, and bloodpressure• HIT and heart of ACOframework


www.TheNationalCouncil.orgThe B ehavioral Health InformationTechnology Act of 2011 – S . 539The Obama Administration made a “down payment” onhealthcare reform with the passage of the HITECH Act in2009, suppoting the adoption and meaningful use ofHealth Information Technology• Introduced by S enator Whitehouse (D-R I)• E xpands the HITE CH Act Incentives PaymentProgram to more comprehensively include B Hproviders .• T ake Action!http: //c apwiz.c om/thenationalc ounc il/is s ues /alert/? alertid=34706536&queueid=[capwiz:queue_id]


www.TheNationalCouncil.org4. Focus on E pisodic Care NeedsDo you have well defined assessment processes and defined levels ofcare based on clinical pathways, functionality in daily living activities,symptom severity indicators, service volumes, etc. to match clientneed with the type, location, and duration of evidence-based carethat increases the likelihood that consumers will get their needs met in atimely and effective manner?47


www.TheNationalCouncil.org5. Produce OutcomesDo you use standardized tools to measure improvement(or not) in symptomology, level of functioning, resilienceand recovery?48


www.TheNationalCouncil.orgS taff Mix• Are you assessing compatibility and capacity of clinical workforceto operate in environment of increased demand where mostconsumers have Medicaid or Insurance and Plans will contractwith high-performing Providers that can offer, in many cases,licensed professionals and certified peers?49


www.TheNationalCouncil.orgJ oin us in Washington, DC

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