Promise or Peril Evolving Strategies for the Delivery and Payment of Mental Services MHA Regional Policy Council February 19 2016 Harvey Rosenthal NYAPRS Executive director 1 A peerled statewide coalition of people who use andor provide community mental health recovery services and pe ID: 712345
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From HARPs to DSRIP to VBP:Promise or Peril?
Evolving Strategies for the Delivery and Payment of Mental ServicesMHA Regional Policy CouncilFebruary 19, 2016Harvey Rosenthal NYAPRS Executive director
1Slide2
A peer-led statewide coalition of people who use and/or provide community mental health recovery services and peer supports that is dedicated to improving services, social conditions and policies for people with psychiatric disabilities
by promoting their recovery, rehabilitation, rights and community integration and inclusion. harveyr@nyaprs.org www.nyaprs.org
2
New York Association of Psychiatric Rehabilitation Services
(NYAPRS)Slide3
Very high health, social and criminal justice costs with very low outcomesEarly mortality: cardiovascular, respiratory and infectious diseases, diabetes and hypertensionHighest rates of avoidable readmissions
High rates of violence victimization, incarceration, homelessness and suicideImpact of a Broken SystemSlide4
High rates of poverty: unemployment and idleness
Stigma and discrimination: isolationLoss of hope, purpose, dignityMagnified exponentially for communities of color and other underserved groups
Impact of a Broken SystemSlide5
Fragmented, Siloed and UncoordinatedUnresponsive: Reactive vs Preventive and DiversionaryUnaccountable: who can we turn to?Wrong Incentives: volume over value
Illness over Wellness? Wellness over Illness?‘Chronic’ Patienthood over PersonhoodElements of a Broken SystemSlide6
The Triple Aim: improving outcomes, improving quality, reducing cost Key features: expansion of Medicaid and managed care, behavioral health parity, home and community based services including self-directed care
6
Affordable Care Act:
National Healthcare ReformSlide7
Focus on Coordination
Integrated physical and behavioral healthcareOutcomesPreventionWellness
Hospital diversion
Individualized care
7
Affordable Care Act
State Healthcare ReformSlide8
$54 billion Medicaid
program with 5 million beneficiaries20% (1 million beneficiaries) use 80% of these dollars: hospital
, emergency room, medications, longtime
“chronic”
servicesOver 40% with behavioral health conditions
20% of those discharged from general hospital BH units are readmitted within 30 days: NYS
avoidable Medicaid hospital readmissions: $
800 million
to
$
1 billion annually
70% with
behavioral health
conditions;
3/5
of these admissions
for
medical
reasons
8
New York State’s ChallengeSlide9
Health and Recovery PlansHealth Homes
Home and Community Based ServicesDelivery System Reform Incentive PaymentPerforming Provider Systems
Value Based Payment
Eliminate racial disparities in healthcare
NYS Medicaid WaiverSlide10
From fee for service to outcome based careDiversion from emergency room and inpatient hospital useSurprise! We are healthcare providers
10
The Mantras of the MRTSlide11
Managed Care for All Universal Access to High Quality Primary Care; Integrate physical and BH services Targeting the Social Determinants of Health
Health Homes: Teams of providers working together to coordinate care for Medicaid consumers who use lots of servicesNYS Medicaid RedesignSlide12
Inpatient - SUD and MH
Clinic – SUD and MHPersonalized Recovery Oriented ServicesAssertive Community Treatment
Partial
Hospitalization
Comprehensive Psychiatric Emergency Program
Targeted Case Management
Opioid treatment
Outpatient chemical dependence rehabilitation
Rehabilitation supports for Community Residences
(phased in in 2016)
12
Managed Care Plans Now
Offer Medicaid funded BH ServicesSlide13
• Designed for people with more extensive mental health and/or substance use related conditions• Covers all benefits provided by Medicaid Managed Care Plans, including expanded behavioral health benefits
• Also provides additional Home and Community Based Services to help people live better, go to school, work and be part of the community
13
Health and Recovery PlansSlide14
Who’s Eligible for a HARP?SSI Recipient ACT, TCM, PROS, PMHP in past year
30+ days of psych hospitalization, 3+ admissions or 3+ month stays in OMH housing over the past 3 years60+ days in OMH psych centerIncarceration w BH treatment past 4 years2+ SUD ER visits, detox stays for SU related inpatient staysSlide15
Have both Medicaid and Medicare Live in a nursing home Are in a Managed Long Term Care Plan Are under age 21
Have services from the Office for People with Developmental Disabilities (OPWDD)15
Who’s Not Eligible for HARPs?Slide16
AetnaCapital District Physicians Health PlanExcellus Health Plan.Fidelis Care New York
MVP Health Care16
Health Plans in Broome CountySlide17
Health homes are ‘a home for your healthcare”
Everyone gets a care coordinator who conducts an assessment and works with each individual to develop their own goal and service plan which are intended to be shared electronically with all providers and social services that support them
Health home responsibilities include:
Active engagement
24-7 responseFocus on well coordinated discharge and treatment planning
What are your experiences with
Health Home Care Management?
17
HARP Beneficiaries’ Care is
Managed via Health HomesSlide18
October 23, 2015
New York State Designated Lead Health Home
Administrative Services, Network Management,
Health IT
Support/Data Exchange
Health Home Care Management Network Partners
(includes former
Total Care Management
Providers)
Comprehensive Care Management
Care Coordination and Health Promotion
Comprehensive Transitional Care
Individual and Family Support
Referral to Community and Social Support Services
Use of Health Information Technology to Link Services
(Electronic Care Management Records)
Managed Care Organizations (MCOs)
Access to Required Primary and Specialty Services
(Coordinated with MCO)
Physical Health, Behavioral Health, Substance Use Disorder Services, HIV/AIDS, Housing, Social Services and Supports
Medicaid Analytics Performance Portal (MAPP)
Regional Health Information Organizations
(RHIOs)
NYS Health Home ModelSlide19
Greater Binghamton Health Center Endwell Family PhysiciansThe Family & Children's Society Catholic Charities Of Broome County The Addiction Center Of Broome County
Southern Tier Independence CenterMental Health Association Of Southern Tier
19
Catholic Charities of Broome CountySlide20
Broome County Mental Health Department Our Lady of Lourdes Memorial Greater Binghamton Health Center Conifer Park Samaritan Counseling Center Of The Southern Tier
LB Prescription Enterprises
20
Catholic Charities of Broome CountySlide21
United Cerebral Palsy Association of NYS Broome County Health Department Broome County Mental Health Community Options United Health Services Hospital
Greater Binghamton Health Center NYS Office Of Mental Health United Health Services Hospitals
21
Catholic Charities of Broome CountySlide22
Arms Acres Conifer Park Greater Binghamton Health Center Arms Acres Southern Tier Aids Program
United Health Services The Family And Children's SocietyConifer ParkUnited Health Services
22
United Health ServicesSlide23
Broome County Mental Health Department Volunteers Of America YMCA Twin Tier Home Health Binghamton Housing Authority
Broome County Council Of Churches Broome County Department Of Social Services Broome County Lift Broome County Office For The Aging
23
United Health ServicesSlide24
CASACommunity Hunger Outreach WarehouseMental Health Association Of Southern Tier Professional Home Care
Addictions Center Of Broome County Alcoholics Anonymous American Cancer Society Fairview Recovery Services Holliswood Hospital
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United Health ServicesSlide25
Mothers And Babies Perinatal Association Narcotics Anonymous Opportunities For Broome Rehabilitation Support Services Retired And Senior Volunteer Program
Salvation Army Serafini Transportation Corporation SOS Shelter Southern Tier Healthlink
25
United Health ServicesSlide26
Rehabilitation
Psychosocial Rehabilitation
Community Psychiatric Support and Treatment (CPST)
Residential Supports/Supported Housing
Habilitation
Crisis Intervention
Short-Term Crisis Respite
Intensive Crisis Intervention
Mobil Crisis Intervention
Educational Support Services
NYS
Home and Community Based Services Option
Medicaid Will Now Pay for:
Support Services
Family Support and Training
Non- Medical Transportation
Individual Employment Support Services
Prevocational
Transitional Employment Support
Intensive Supported Employment
On-going Supported Employment
Peer and Family Supports
Self Directed Services Slide27
7 days from inpatient discharge to outpatient appointment
30 days to filled prescriptionDepression screening and follow up
27
Beyond HEDIS Outcome MeasuresSlide28
Participation in employment
Enrollment in vocational rehabilitation services and education/trainingImproved or Stable Housing statusAccess to and use of Peer Support
Longer Community tenure, Decreased Hospital Readmissions
Decreased Criminal
justice involvementImprovements in functional status
Cultural & Linguistic Competence, Engagement
HCBS Outcome Measures:
Social Determinants of CareSlide29
=
Physical and/or
behavioral health care provider
Health and Recovery Plan (HARP)
Health and Recovery Plan (
HARP)
Payers
Health and Recovery Plan (HARP
)
Health Home
Team
OMH
Health Home
Team: Provider Network
Health Home Team
Health Home Team
NYS Medicaid Redesign Response:
Managed Integrated BH & Medical Care
29
STATE MEDICAID AGENCY DOH
OASASSlide30
$7.1 billion over 5 years for DSRIP$650 million to play for Home and Community Based Services
30
NYS Medicaid WaiverSlide31
Promotes community-level collaborations that improve the quality and outcomes of care, while achieving a 25% reduction in avoidable hospital use from 2015-20. Safety net providers are expected to collaborate to implement innovative projects focusing on system transformation and population health improvement.
All DSRIP funds will be based on performance linked to achievement of project milestones.
31
Delivery System Reform Incentive
Payment Program (DSRIP)Slide32
Performing Provider Systems are networks of providers that collaborate to implement DSRIP projectsEach PPS must include providers to form an entire continuum of care
HospitalsHealth HomesSkilled Nursing Facilities (SNF)Clinics & FQHCsBehavioral Health Providers
Home Care Agencies
Other Key Stakeholders
October 23, 2015
Community health care needs assessment based on multi-stakeholder input and objective data
Building and implementing a DSRIP Project Plan based upon the needs assessment in alignment with DSRIP strategies
Meeting and Reporting on DSRIP Project Plan process and outcome milestones
25 Performing Provider SystemsSlide33
Project
DescriptionPPSs Involved3.a.i
Integration of primary care and behavioral health services
25
3.a.ii
Behavioral health community crisis stabilization services
11
3.a.iii
Implementation of Evidence-Based Medication
Adherence Program (MAP) in Community Based Sites for Behavioral Health Medication Compliance
2
3.a.iv
Development of Withdrawal Management (e.g. ambulatory detoxification, ancillary withdrawal services)
capabilities and appropriate enhanced abstinence services within community-based addiction treatment programs
4
3.a.v
Behavioral Interventions Paradigm (BIP) in Nursing
Homes
1
4.a.i
Promote mental, emotional
and behavioral (MEB) well-being in communities
2
4.a.ii
Prevent Substance Abuse and other Mental Emotional Behavioral Disorders
1
4.a.iii
Strengthen Mental Health and Substance Abuse Infrastructure across Systems
13
October 23, 2015
Key Mental Health Projects in DSRIP Slide34
Also known as: Southern Tier Rural Integrated Performing Provider System, Inc., STRIPPS, United Health Services Hospitals, Inc.Counties served: Broome, Chemung, Chenango, Cortland, Delaware, Schuyler, Steuben, Tioga, Tompkins
Attribution for Performance: 102,386Total Award Dollars: $224,540,275
34
Care Compass NetworkSlide35
Home CareIndependent Living CenterAddiction CenterNursing and Rehabilitation Center Primary Care
County Health DepartmentsCounty Office for AgingHospice and Palliative Care
35
Provider GroupsSlide36
HospitalsVocational RehabilitationServices for People w Developmental DisabilitiesHealth Homes
CompeerPharmacies
36
Provider GroupsSlide37
Hospice and Palliative CareTherapeutic CommunitiesSenior Living Center Suicide Prevention And Crisis Service
United Cerebral Palsy AssociationVisiting Nurse Service YMCA
37
Provider GroupsSlide38
Integration of primary care and behavioral health services (required of all 25 PPSs)
16 PPSs also included: Community crisis stabilization servicesTransitional Supports
Activation
Medication adherence programs
Withdrawal Management Behavioral Interventions in Nursing Homes
38
Behavioral Health ProjectsSlide39
Lakeview Mental Health Services, Liberty ResourcesMental Health Association Of The Southern Tier Northeast Parent And Child Society
Onondaga Case Management ServicesParsons Child And Family CenterPhoenix HousesPlanned ParenthoodRehabilitation Support Services
39
Behavioral Health ProvidersSlide40
Integrated Delivery SystemDevelopment of Community Based Health Navigation ServicesPatient ActivationEvidence-Based Strategies for Disease Management
COPD Preventative Care and Management40
ProjectsSlide41
30 Day Care Transitions for Chronic Diseases, including BH ConditionsIntegration of Behavioral Health and Primary CareStrengthen Mental Health and Substance Abuse Infrastructure, Prevention and Targeted Interventions
Crisis Stabilization41
ProjectsSlide42
What are Value Based Payments (VBPs)? An approach to Medicaid reimbursement that rewards value over volume
Incentivizes providers through shared savings and financial risk Directly ties payment to providers with quality of care and health outcomesA component of DSRIP that is key to the sustainability of the ProgramValue Based PaymentSlide43
Required to ensure ‘long term sustainability of DSRIP investments”By waiver Year 5 (2019), all MCOs must employ non-fee-for-service payment systems that reward value over volume for at least 80-90% of their provider payments
43
Value-Based Payment ReformSlide44
Required to ensure that “value-destroying care patterns” (avoidable admissions, ED visits, etc) do not simply return when the DSRIP funding stops in 2020 If VBP goals are not met, overall DSRIP dollars from CMS to NYS will be significantly reduced
44
Value-Based Payment ReformSlide45
To share in savings, you eventually need to take on risk…Partnering with other providers is essential to being able to take on riskWe need to join forces with other providers to have enough cash reserves to take on Level 2 risk, which applies 90% of the savings to reward effective providers.
45
VBP: Sharing in the SavingsSlide46
Proposals to: Integrate physical and behavioral healthcareget ahead of relapse and readmissions and support crisis stabilization
promote mental, emotional and behavioral (MEB) well-being in communities; prevention and strengthening MH/SA infrastructure across system
46
Value-Based PropositionsSlide47
NYAPRS proposed to provide peer bridger services aimed at helping people with ‘serious’ mental health and addiction related conditions to:
Reduce avoidable emergency room and inpatient visits by 40%Increased self-management and participation with chosen medications, services and supportsNYAPRS has successfully applied this model within a managed care contract to reduce hospital use by 48% and Medicaid spend by 47%
47
Value-Based
Propositions
An exampleSlide48
We helped see that OMH HCBS services were added to the list of SDH interventionsAll Level 2 and 3 plans or providers must address at least one social determinant and contract with at least 1 CBO We’ve pushed for the state to provide infrastructure dollars and technical assistance for community based providers
48
NYAPRS Advocacy on Value Based Payment Work GroupsSlide49
We’ve insisted that VBP outcomes include recovery and social determinant related ones (beyond HEDIS)
Ex: maintenance of housing stabilityStrong emphasis on cultural competenceBuy not BuildPosition our members for gain sharing
49
NYAPRS
Advocacy on Value Based Payment Work GroupsSlide50
Development of Member Incentive ProgramsCreation of an Expert Group for Achieving Cultural Competence in Incentive Programs Use of Patient Reported Outcomes (PRO)Expansion of ombuds program
Plan for how best to communicate VBP to consumers/members
50
NYAPRS VBP Advocacy:
Advocacy and EngagementSlide51
NYAPRS and MHANYS: partnerships that advocate for recovery outcomes, services and providers and for consumer rights and choice protectionsOur member agencies: attain good positioning in health home and DSRIP networks, offer relevant and reliable value propositions, raise level of infrastructure (contracting, billing, compliances) and workforce
51
HomeworkSlide52
Recovering people: be prepared to make informed choices!New health home assessment, plan and selection of recovery and HCBS services
Use of self-directed care dollars and ‘patient incentives’Assume responsibility for health literacy, improved wellness self management and health outcomes
52
Homework