Transcript Chronic Health Homes DRAFT Criteria Opioid Maintenance Therapy Providers Webinar December 5, 2012 1:30-3:30pm.

Chronic Health Homes
DRAFT Criteria
Opioid Maintenance Therapy Providers Webinar
December 5, 2012
1:30-3:30pm
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Agenda
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Program Objectives
Review Draft Health Home Criteria
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Participant Eligibility
Health Home Services
Provider Qualifications
HIT Linkages
Payment Methodology
Evaluation
Next Steps
Questions/Discussion
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Chronic Health Home Objectives
Chronic Health Homes aim to:
• Further integration of behavioral and somatic
care through improved care coordination;
• Improve patient outcomes, experience of care,
and health care costs among individuals with
chronic conditions; and
• Enable Health Homes to act as locus of
coordination for SPMI and OMT populations
through provision of additional care
coordination services.
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Participant Eligibility Criteria
• The individual has been diagnosed with:
– a serious and persistent mental illness in combination
with meeting the medical necessity criteria for PRP
services, OR
– an opioid substance use disorder that is being treated
with methadone, AND one other qualifying chronic
condition.
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Participant Eligibility Criteria:
Qualifying Chronic Conditions
• Eligible chronic conditions among OMT population:
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Mental health condition
Substance use disorder
Asthma
Diabetes
Heart disease
Overweight (BMI> 25)
Hypertension
Infectious disease (HIV/AIDS, Viral Hepatitis)
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Health Home Assignment
• Assignment to Health Home based on current
provider
– OMT providers must confirm and report qualifying
chronic condition during intake
– Provider may add new HH consumers as they initiate
care after initial enrollment
• Potentially-eligible consumers in hospital or ED
notified of Health Home based on provider
history, county of residence
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Health Home Services
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Comprehensive Care Management
Care Coordination
Health Promotion
Comprehensive Transitional Care
Individual and Family Support
Referral to Community and Social Support
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Health Home Services:
Comprehensive Care Management
• Comprehensive assessment of preliminary service needs,
including screening for co-occurring behavioral and
somatic health needs
• Development of consumer-centered ITPs
• Development of treatment guidelines
• Monitoring of individual and population health status and
service use to determine adherence to treatment
guidelines
• Reporting of progress toward outcomes for consumer
satisfaction, health status, service delivery, and costs
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Health Home Services:
Care Coordination
Implementation of the consumer-centered ITP, including:
– appointment scheduling;
– conducting referrals and follow-up monitoring,
including long-term services and peer-based
support;
– participating in hospital discharge processes; and
– communicating with other providers and
consumers/family members, as appropriate.
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Health Home Services:
Health Promotion
• Health education, specific to chronic conditions
• Development and follow-up of self-management plans
emphasizing person-centered empowerment
• Education regarding immunizations and screenings
• Health promoting lifestyle interventions, such as:
– Substance use prevention
– Tobacco prevention and cessation;
– Nutritional counseling, obesity reduction and
prevention; and
– Physical activity.
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Health Home Services:
Comprehensive Transitional Care
Comprehensive transitional care services aim to:
• streamline plans of care;
• ease the transition to long-term services and supports; and
• reduce hospital admissions and interrupt patterns of frequent
hospital emergency department use.
The Health Home Team will:
• collaborate with clinical, therapeutic, rehabilitative, and other
providers to implement the treatment plan;
• increase consumers’ and family members’ ability to manage care
and live safely in the community; and
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• emphasize proactive health promotion and self-management.
Health Home Services:
Independent & Family Support
• Advocacy for individuals and families
• Assistance with medication & treatment adherence
• Identification of resources to support reaching the
highest possible level of health and functioning,
including transportation to medically-necessary services
• Health literacy improvement
• Support for the ability to self-manage care
• Facilitation of consumer and family participation in
ongoing revisions of care/treatment plan.
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Health Home Services:
Referral to Community & Social Supports
Health Homes will provide assistance for
consumers to obtain and maintain eligibility for:
• health care services,
• disability benefits,
• housing,
• personal needs, and
• legal services, as examples.
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Provider Qualifications:
Provider Types
• Licensed as a Psychiatric Rehab Provider
OR
• Licensed as a Outpatient Methadone Treatment
Provider AND
– Be an enrolled Maryland Medicaid Provider
– Be accredited as a Health Home by CARF
– Provisional designation as Health Home for
providers in-process of accreditation
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Provider Qualifications:
CARF Accreditation
• Health Home accreditation under CARF’s
Behavioral Health standards manual
– Must complete sections 1 &2 of BH standards
manual and Health Home supplemental survey
• Cost
– $995 initial application fee
– $1475 per surveyor/per day
– Average survey requires 2 surveyors, 2 days
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Provider Qualifications:
Initial and Ongoing Requirements
• Cost-effective Health Home delivery model
• Substantial % of existing consumers MA
beneficiaries
• Ability to provide 24/7 coverage
• Ability to meet reporting requirements
• Enrollment with CRISP, pharmacy data access
• Ability to maintain required staffing
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Provider Qualifications:
Provider Staffing Ratios
• Nurse Care Manager: .5 full-time equivalent (FTE)
per 125 Health Home enrollees
• Health Home Director: .5 FTE per 125 Health Home
enrollees
• Physician or Nurse Practitioner: 1 or 2 hours per
Health Home enrollee per 12 month period
• Administrative Support Staff: .25 FTE per 125
Health Home enrollees
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HIT Linkages
• eMedicaid online portal
– Providers submit initial intake and monthly report of
Health Home services provided and relevant
participant outcomes
– Will ultimately populate with individual participant
claims data
• CRISP notification of hospital encounters
• Real-time pharmacy data
• Provider HIT system capabilities
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Payment Methodology
• Flat per member/per month (PMPM) rate based
on cost, actuarial soundness
• Comparable to other states’ rates at $75-100
PMPM
• Dependent on compliance with ongoing
requirements
– Maintain staffing, accreditation, compliance with all
requirements and regulations
– Documentation of minimum monthly HH service(s)
per participant
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Evaluation
• Evaluation will be based on provider reports; claims,
hospital, and pharmacy data; and participant surveys.
• This includes, but is not limited to, a review of:
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hospital admissions;
chronic disease management;
coordination of care;
program implementation;
processes and lessons learned;
quality improvements & clinical outcomes; and
cost savings.
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Evaluation: Quality Measures
• Examples of quality measures include:
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avoidable hospital readmissions;
medication compliance;
preventive care delivery;
patient experience of care; and
medical outcomes specific to participants’ targeted
chronic conditions.
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Next Steps
1) DHMH consultation with SAMHSA
2) Continued stakeholder outreach
3) Finalize state plan amendment (SPA), set golive date
4) Provider outreach, training & enrollment
5) Participant enrollment
6) SPA goes into effect, service provision begins
7) Ongoing participant outreach & enrollment
8) Continued development of eMedicaid
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Points to Consider
• Start-Up/Training Costs
• Ongoing ability to deliver mandated services with
continuous improvement
• Data Collection/Reporting
– Health IT
• Sustainability/Economies of Scale
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Questions
You may send additional questions to
[email protected]
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