Transcript Community Care A Non-profit Behavioral Health Managed Care

National Academy for State Health Policy
Conference
Joan L. Erney, JD
Chief Business Development and Public Policy Officer
Community Care Behavioral Health Organization
Kansas City, Missouri / October 5th, 2011
Today’s Discussion
• Introduction to Pennsylvania Medicaid and
behavioral health landscape.
• PA Health Choices program performance
• Overview of two physical health/behavioral
health projects in Pennsylvania.
• Lessons learned.
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Pennsylvania Quick Facts
• 12 million residents.
• 2.2 million projected Medicaid members (FY11-12).
• 2 urban centers (Philadelphia, Pittsburgh = 38% MA
members).
• Department of Public Welfare (DPW) is single state
agency for Medicaid
– Office of Medical Assistance => physical health system
– Office of Mental Health and Substance Abuse Services =>
behavioral health system
• County-based system for human services.
– Organized as 49 county joinders for mental health & drug and
alcohol services.
– County government plays significant role in Behavioral Health
HealthChoices program; 43 of 67 counties contract for Medicaid.
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HealthChoices Overview
CMS Waiver Authority: 1915 (b) Waiver
• 25 County Waiver (3 zones)
– Physical health: Choice of HMOs.
– Behavioral health: 24 contracts with counties,
1 direct contract (Greene).
• 42 County Waiver
– Physical health: Access Plus (PCCM); voluntary HMO.
– Behavioral health: 19 counties; 1 direct state contract for 23
counties (Community Care).
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HealthChoices Zones
Erie
Warren
Crawford
Forest
Venango
McKean
Elk
Potter
Cameron
Sullivan
Mercer
Clinton
Jefferson
Clearfield
Armstrong
Beaver
Centre
Union
Snyder
Indiana
Mifflin
Cambria
Juniata
Allegheny
Blair Huntingdon Perry
Westmoreland
Washington
Greene
Pike
Luzerne
Columbia
Monroe
Montour
Carbon
Northumberland
Northampton
Lehigh
Schuylkill
Dauphin
Somerset Bedford Fulton
Berks
Lebanon
Cumberland
Fayette
Wyoming
Lackawanna
Lycoming
Clarion
Lawrence
Butler
Susquehanna
Wayne
Bradford
Tioga
Bucks
Montgomery
Lancaster
Chester
Franklin Adams
York
Philadelphia
Delaware
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SOUTHEAST
Implemented February 1997
SOUTHWEST
Implemented January 1999
LEHIGH/CAPITAL
Implemented October 2001
NORTHEAST
Implemented July 2006
NORTH/CENTRAL STATE OPTION
Implemented January 2007
NORTH CENTRAL COUNTY OPTION
Implemented July 2007
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Key Features
• County Right of First Opportunity: Sole Source
Contract - County options for acceptance of risk.
• Consumer choice for in-plan services.
─ All MA Providers in initial year.
─ Choice of two providers each level of care within access
standards; reviewed annually.
• Includes all state and federal eligibility categories of
Medicaid.
• Includes special populations, children and youth, and
persons with intellectual disabilities.
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Key Features
• Pharmacy benefits (with the exception of Methadone)
paid for by physical health or FFS.
• State Plan services, cost-effective alternatives,
and supplemental services available.
• Consumer/Family Satisfaction Team (C/FST) in every
contract.
• Reinvestment of savings at the local level; must
be targeted to behavioral health.
• Performance measurement system.
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HealthChoices Today
• Began in the Southeast Region and is now
statewide
• BH program began in 1997; phased in through 2007
─ 43 counties (joinders/multi-counties) accepted the right of first
opportunity; mixture of ASO (administrative services
organization) and county risk-sharing arrangements.
─ 23 counties (rural): state contract; 1 county (southwest zone):
state contract.
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HealthChoices Highlights
• $4-5 billion in savings due to the Behavioral Health
program.
• Access to services and variety of services have both
increased.
• Increased access to drug and alcohol providers to a
significant degree.
• Reinvestment opportunities sparked innovative practices
and cost-effective alternatives to current practices.
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More HealthChoices Highlights
• Improved quality standards and outcomes.
– Significant change in performance from 2003- 2008
– Utilization Changes reflect commitment to less restrictive
services
• Design provides opportunities for innovative physical
health and behavioral health initiatives.
• Unified systems and funding; maximized fiscal resources
at state and local level to support major initiatives include
closing of state facilities; enhanced access for high need
dependent children.
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% Change in HealthChoices
Performance Measure: 2003 to 2008
Access Performance Indicators (Penetration Rate)
PI #1a, SMI and No Substance Abuse, Ages 18-64
PI #1b, SMI and Substance Abuse, Ages 18-64
PI #2.1, Mental Health Service, Ages 18-64, African American
PI #2.2, Substance Abuse Service, Ages 13-17, African American
PI #2.3, Substance Abuse Service, Ages 18-64, African American
PI #2.4, Mental Health Service, Ages 18-64
PI #2.5, Substance Abuse Service, Ages 13-17
PI #2.6, Substance Abuse Service Ages 18-64
Quality/Process Performance Indicators
PI #3a, At Least One Day in a Residential Treatment Facility, Under Age 21, Mental Health
PI #3b, Cumulative RTF Bed Days 120 or Greater, Under Age 21, Mental Health
PI #4a, Psychiatric Inpatient Readmitted Within 30 Days Post-Discharge, Under Age 21
PI #4b, Psychiatric Inpatient Readmitted Within 30 Days Post-Discharge, Ages 21-64
PI #4c, Psychiatric Inpatient Readmitted Within 30 Days Post-Discharge, Ages 65+
PI #5a, Discharged from RTF With Follow-Up Service(s) Within 7 Days Post-Discharge
PI #5b, Discharged From Psychiatric Inpatient With Follow-Up Service(s) Within 7 Days
Post-Discharge, Under Age 21
PI #5c, Discharged From Psychiatric Inpatient With Follow-Up Service(s) Within 7 Days
Post-Discharge, Ages 21-64
PI #5d, Discharged From Psychiatric Inpatient With Follow-Up Service(s) Within 7 Days
Post-Discharge, Ages 65+
PI #5e, Discharged From Non-Hospital Residential Detox, Rehabilitation and Halfway
House Services for D&A Dependency or Addiction with Follow-Up Services Within 7 Days
Post-Discharge, Under Age 65
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All
52%
65%
33%
41%
27%
46%
-1%
30%
All
35%
1%
5%
12%
-3%
19%
20%
NC
9%
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Utilization Rate Changes by Service
Category : 2003- 2008
450%
400%
350%
300%
250%
200%
150%
100%
50%
0%
-50%
-100%
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Systems Redesign: Move to Less
Restrictive Care Settings
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PA Physical Health/ Behavioral Health
Landscape
• Projects supporting integration of services and supports
for individuals with physical health (medical) and
behavioral health needs happening across the state in
urban, rural, and suburban settings.
• Co-locations; collaborations; shared staff models; health
home development; shared health records.
• This presentation will focus on two Pennsylvania
initiatives involving Community Care , a behavioral
health managed care organization serving in
Pennsylvania’s Medicaid managed care program.
(Health Choices)
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About Community Care
• Behavioral health managed care company; part of
UPMC; headquartered in Pittsburgh, PA; founded in
1996
• Federally tax exempt non-profit 501(c)3
• Major focus is publicly-funded behavioral health care;
currently doing business in PA and New York
• Licensed as a Risk-Assuming PPO in PA; NCQA
accredited
• Serving over 100,000 individuals in 36 PA counties
through a statewide provider network of over 1700
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Connected Care™ Program
• Initiative to improve the connection and coordination of
care for those with Serious Mental Illness among health
plans, PCPs, and behavioral health providers in
outpatient, inpatient, and ED settings
• Based on Patient-Centered Medical Home model
– integrated care team and care plan to address medical,
behavioral, and social needs
• Partnership between:
–
–
–
–
–
Center for Health Care Strategies (CHCS)
Department of Public Welfare (DPW)
UPMC for You and UPMC for Life Specialty Plan
Community Care Behavioral Health
Allegheny County Department of Human Services
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Services in PA and NY City
Serving individuals in 36 PA Counties and 5 New York City Boroughs
Erie
Bradford Susquehanna
Potter
Wayne
Wyoming
Forest Elk Cameron
Lackawanna
Lycoming Sulliv
Pike
an
Clinton
Luzerne
Columbia
Clarion
Monroe
Monto
Clearfield Centr
Jefferson
Carbon
ur
Unio
Northumberla
e
n nd
Miffli Snyd
Schuylkill
er
n
Allegheny
Berks
HuntingdoJuniat
a
n
Warren
McKean
Tioga
Community Care Office
Chester
Adams York
Erie County Region
Southwest Region
Northeast Region
Lehigh-Capital Region
Chester County Region
North Central Region
State Option
North Central Region
County Option
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Connected Care™
Guiding Principles
• Behavioral health is part of overall health; good
health outcomes are important to an individual’s
recovery.
• Integration of good health habits, prevention activities,
and specific physical health interventions are best
achieved through local collaborations and navigator
systems.
• Good health outcomes can be achieved within the
existing physical health and behavioral health
managed care design.
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Connected Care™
• Expected Outcomes
– Decreased Inpatient utilization (both PH/BH).
– Decreased Utilization of emergency room usage and crisis
services.
– Reductions in readmission rates for PH/BH.
– Increase in preventive and routine health care.
– Increase in satisfaction and quality of life.
• Members qualify for Connected Care™ if they:
–
–
–
–
Are a UPMC for You and a Community Care member.
Are age 18 or older.
Live in Allegheny County.
Have Serious Mental Illness (SMI)*.
* SMI is defined as individuals who have been diagnosed with schizophrenic
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disorders, episodic mood disorders, or borderline personality disorder.
Member Stratification
• High PH needs defined as:
– 3 or more ED visits in past 3 months, or
– 3 or more inpatient admissions in the past 6 months.
• High BH needs defined as:
– Discharged from, history of being served, or diverted from a
State mental hospital.
– 5 or more admissions to most restrictive level of care, or
readmitted within 30 days.
– 4 or more admissions to most restrictive level of care and
inpatient or RTF or CTT admission.
– 3 or more admissions to the most restrictive level of care and
inpatient or 2 admissions to most restrictive level and inpatient
and an open authorization for certain services.
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Consumer Engagement
• Joint training sessions on program design and work
flows with care managers
• Consumer group input on program design and materials.
• Use of BH providers to help obtain consent
• Incentives to Medicaid members
– 2009- $25 gift cards for visiting PCP
– 2010- $25 gift cards for completing consent and enrolling
Approximately 250 new Medicaid members identified
monthly
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Care Management Activities
UPMC for You and Community Care coordination:
• Focus on Tier 1 members and those admitted or seen I
the ED
• Use of integrated care plan
• Weekly multi-disciplinary care team meetings
• Daily identification of members with PH or BH admission,
and ED visits from key UPMC hospitals
• Concurrent case discussions
• 24 hour/day phone line managed by Community Care to
answer member questions
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Mathematica Review: Summary of
Outcomes
• After Year 1, no evidence suggested program had effect
on changes in aggregate rates of hospitalizations or ED
visits
– For example, average number of PH hospitalizations per 1,000
members per month:
Study group dropped 11 percent from 31.6 to 28.2
Comparison group dropped 17 percent from 30.3 to 25.2
Difference in differences was not statistically significant
(p=0.449)
• No statistically significant differences in rates among
those who consented to participate
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Mathematica Review: Conclusion
• After the first year, it was too early to identify
improvements in health care utilization
• Both regions faced enrollment challenges and spent
parts (or most) of the first year finalizing
implementation issues
• Several promising strategies emerged
– Member and provider engagement through existing
relationships
– Nurses as a central component of a multidisciplinary care team
for BH-led integration efforts
– Shared information tool merging PH and BH information
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Connected Care:
Behavioral Health Home Plus
• Designed to demonstrate the efficacy of care
coordination of PH/BH services for individuals with SMI
and co-occurring medical conditions in a Medicaid and
dual-eligible BH carve-out
– Combines technological infrastructure, data management, and
clinical expertise of a BH-MCO and a BH provider-based care
coordination model.
• Expands on Community Care’s Allegheny County
Connected Care program.
– Effectively reduced both physical and psychiatric hospital
readmission rates & emergency room use
– Improved quality indicators for individuals with physical comorbidities
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North Central State Option Medicaid
Members and Expenditures – 2009 Profile
Population Characteristics
Unique Users
159,251
CDPS Profile
Total BH Spending $192,206,453
BH $/User
$1,207
Total PH Spending $572,917,158
PH $/User
$3,598
Inpatient Util000
Condition
Users
Percent
Diabetes
12,104
8%
Pulmonary
78,533
49%
BH
276
3+ co-morbidities
92,479
58%
PH
1,532
5+ co-morbidities
68,400
43%
* Total Member Months: 1,749,129; Average Member Months: 145,761
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Connected Care:
Behavioral Health Home Plus
• Identify multiple sites within 23 county rural contracts in
North Central Pennsylvania
– Rural communities build on existing relationships; enhance with
nursing competencies
• Early Adopter includes 5 county programs who operate
services, partnering with local practices, Geisinger Health
Systems Health Care Quality Unit (HCQU) for persons with
Intellectual Disabilities and other behavioral health supports
including peer specialists and psych rehabilitation.
• Member Portal and Other IT innovations
• Implementation manual will detail “how to”
• Evaluation Opportunity
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Lessons Learned
• Integration of physical health and behavioral health
happens locally, building on the strengths of community
infrastructure
• Real time notice of inpatient stays and ER visits has had
impact on follow-up and engagement of individuals
• Nurses play a key role in the program and appear to
interface more successfully with PCPs and specialists in
accessing treatment for persons with SMI
• Certified Peer Specialists, and consumer tools such as
WRAP ( Wellness Recovery Action Plan) planning and
shared-decision making, are key in assisting in recovery
and engagement in healthcare
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Lessons Learned
• IT Infrastructure of systems is challenging, but
interfacing systems capacity can be built over time
• Investment of key PH and BH systems for at all
stakeholder levels critical to success of collaboration
• CHCS played important role in providing support and
technical assistance to the projects
• Having financial resources to assist in start-up and
pooled resources for shared savings provided greater
incentives for collaboration
• Identification of outcomes and performance expectations
assists in focusing work
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For Our Consideration…
•
Integration with physical health is important; however, also equally important for
persons with serious mental illnesses are supports outside of medical care that
encourage community integration and recovery.
•
Issues of poverty, and real life challenges, such as transportation, access to healthy
food, and stigma need to be incorporated into our solutions for individuals.
•
Access to behavioral health treatment for persons with situational and short-term needs
must be available in a timely way; barriers to co-location, payment constraints, and
regulatory challenges continue to need to be addressed.
•
Continued evaluation for financial impact of collaboration is needed.
•
Opportunity to include Medicare resources will be of great benefit for persons with
serious mental illnesses and chronic conditions.
•
Careful consideration and best practices continue to need to be developed for
substance use and physical health integration, including pain management strategies.
•
Health Homes and ACOs offer opportunities; however, thought should be given as to
how to build from, not create separate and distinct structures, from local communities
strengths.
•
Build on Success!
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Contact Information
Joan L. Erney, JD
Chief Business Development and Public Policy Officer
Community Care Behavioral Health Organization
Former Deputy Secretary OMHSAS (2003-2010)
Community Care Behavioral Health Organization
One Chatham Center, Suite 700
112 Washington Place
Pittsburgh, PA 15219
www.ccbh.com
412-454-2120
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