Connecting Payment And Connecting Payment And Performance To Achieve Performance To Achieve

ResultsResults

California SummitCalifornia Summit

March 20-21, 2008March 20-21, 2008

Leadership WoesLeadership Woes

The trouble with being a leader today is The trouble with being a leader today is that you can’t be sure whether people are that you can’t be sure whether people are following you or chasing you.following you or chasing you.

The trouble with doing something right the The trouble with doing something right the first time is that nobody appreciates how first time is that nobody appreciates how difficult it was.difficult it was.

If at first you don’t succeed, skydiving is If at first you don’t succeed, skydiving is definitely not for you.definitely not for you.

IOM ReportIOM Report

Recommendation 8-4.Recommendation 8-4. State and local State and local governments should reduce the emphasis governments should reduce the emphasis on the grant-based systems of financing on the grant-based systems of financing that currently dominate public M/SU that currently dominate public M/SU treatment systems and should increase treatment systems and should increase the use of funding mechanisms that link the use of funding mechanisms that link some funds to measures of quality. some funds to measures of quality. (317)(317)

IOM ReportIOM Report

““. . . redesign grant-based systems incrementally . . . redesign grant-based systems incrementally so as to incorporate some simple and so as to incorporate some simple and meaningful performance indicators.”meaningful performance indicators.”

““. . . initial efforts tie either new funds or a small . . . initial efforts tie either new funds or a small percentage of existing budgets to performance percentage of existing budgets to performance indicators as means of reorienting the indicators as means of reorienting the management of public M/SU treatment provision management of public M/SU treatment provision toward quality improvement.” toward quality improvement.” (more)(more)

IOM ReportIOM Report

““Over time, as performance measures, Over time, as performance measures, improved and providers altered their improved and providers altered their management practices, performance management practices, performance measures might be given greater weight in measures might be given greater weight in budget allocations.”budget allocations.”

Rewarding Good PerformanceRewarding Good Performance

Wait staffWait staff

Bridge ConstructionBridge Construction

Context For PBCContext For PBC

Enhance, expand existing servicesEnhance, expand existing services

Create new programsCreate new programs

Quality improvement initiativesQuality improvement initiatives

Increasing accountability Increasing accountability

Keeping spotlight on resultsKeeping spotlight on results

Using data supported information to make Using data supported information to make decisions on an on-going basisdecisions on an on-going basis

Overarching PrinciplesOverarching Principles

Use “real time” data to inform Use “real time” data to inform management and clinical decision makingmanagement and clinical decision making

Financial rewards motivate performanceFinancial rewards motivate performance

Rewards are more effective when received Rewards are more effective when received shortly after successful achievementshortly after successful achievement

Use “real time” data to reward the results Use “real time” data to reward the results you want to achieveyou want to achieve

How To – The ProcessHow To – The Process

Design the program, serviceDesign the program, serviceAgree on what you want to rewardAgree on what you want to rewardUse data to determine realistic performance targetsUse data to determine realistic performance targetsAgree on rates and payment mechanismAgree on rates and payment mechanismIssue Request for Proposal Issue Request for Proposal Negotiate details in contract process and include Negotiate details in contract process and include specifics in contractsspecifics in contractsMeet regularly with contractors to review, discuss Meet regularly with contractors to review, discuss success and problems, identify barriers, etc.success and problems, identify barriers, etc.Evaluate & use data as basis for revisions/modificationsEvaluate & use data as basis for revisions/modifications

Some Delaware Applications Some Delaware Applications and Examplesand Examples

Random ThoughtsRandom Thoughts

Why is there an expiration date on sour Why is there an expiration date on sour cream?cream?

Do Roman nurses refer to IVs as 4s?Do Roman nurses refer to IVs as 4s?

You go to a ballet and you see girls You go to a ballet and you see girls dancing on their toes? Why don’t they just dancing on their toes? Why don’t they just get taller girls?get taller girls?

Did you know that half of all people are Did you know that half of all people are below average?below average?

Evidence Based Practice and Evidence Based Practice and Practice Based EvidencePractice Based Evidence

Length of time in treatment is associated with Length of time in treatment is associated with successful outcomes.successful outcomes.

Amount of treatment makes a difference.Amount of treatment makes a difference.

Evidence based techniques and strategies Evidence based techniques and strategies produce better results.produce better results.

Continuity of care is essential.Continuity of care is essential.

Detoxification and treatment programs have a Detoxification and treatment programs have a responsibility to assist clients to successfully responsibility to assist clients to successfully engage in the next level of care.engage in the next level of care.

What To RewardWhat To Reward

Outpatient - Engagement/Utilization, Outpatient - Engagement/Utilization, Active Participation, Active Participation, Program CompletionProgram Completion

Residential - Engagement/Utilization, Residential - Engagement/Utilization, Retention, Retention, CompletionCompletion

Detoxification – Placement in Detoxification – Placement in

Treatment, Case Treatment, Case

Management/Placement Management/Placement

for Repeat Clientsfor Repeat Clients

Detox PBC ExampleDetox PBC Example

Improve rate of successful connection with Improve rate of successful connection with treatment after completion of detoxtreatment after completion of detox– Data: identified the % in the last yearData: identified the % in the last year

Reduce number of clients with 3+ Reduce number of clients with 3+ admissionsadmissions– Data: identified the specific clients with 3+ Data: identified the specific clients with 3+

admissionsadmissions(more)(more)

Detox PBC ExampleDetox PBC Example

Write the RFP:Write the RFP:– TIP 45TIP 45– TRI Study in PhiladelphiaTRI Study in Philadelphia

Decide on targets for key results:Decide on targets for key results:– 25% connected to treatment within 7 days25% connected to treatment within 7 days– 3+ to be case managed until successfully 3+ to be case managed until successfully

engaged in treatment (30 days OP, 60 days engaged in treatment (30 days OP, 60 days residential) residential)

(more)(more)

Detox PBC ExampleDetox PBC Example

Work out payment mechanism and Work out payment mechanism and incentiveincentive– BaseBase (1/12th of annual contract paid each (1/12th of annual contract paid each

month as follows):month as follows):1% of negotiated contract base amount (i.e., the 1% of negotiated contract base amount (i.e., the approved operating cost for the program) to be approved operating cost for the program) to be paid for each 1% of monthly utilization rate paid for each 1% of monthly utilization rate (determined by average daily census for the (determined by average daily census for the month) up to a maximum of 90% each month (23.4 month) up to a maximum of 90% each month (23.4 avg. daily census = 90%).avg. daily census = 90%). (more)(more)

Detox PBC ExampleDetox PBC Example

Other 10% of base amount to be paid for achieving Other 10% of base amount to be paid for achieving placement target of 25%* for clients who placement target of 25%* for clients who successfully complete detoxificationsuccessfully complete detoxification and:and:

– are admitted to a licensed residential treatment program are admitted to a licensed residential treatment program or Chance House within 7 days of detox completionor Chance House within 7 days of detox completion

-or--or-– complete an intake session and attend one treatment complete an intake session and attend one treatment

session in a licensed SA outpatient treatment program session in a licensed SA outpatient treatment program within 7 days of detox completion (OK to completewithin 7 days of detox completion (OK to complete intake intake session prior to discharge from detox)session prior to discharge from detox)

* The placement target will be raised in subsequent years of the contract. After the first year, * The placement target will be raised in subsequent years of the contract. After the first year, the specific placement target will be negotiated with the provider.the specific placement target will be negotiated with the provider.

(more)(more)

Detox PBC ExampleDetox PBC Example

B. Performance IncentivesB. Performance Incentives (above base (above base amount):amount):

– Applies only to clients with a combined total of Applies only to clients with a combined total of 3 or more admissions to New Castle Detox 3 or more admissions to New Castle Detox and/or Kent-Sussex Detox in the previous 12 and/or Kent-Sussex Detox in the previous 12 monthsmonths

(more)(more)

Detox PBC ExampleDetox PBC Example

– $500 for each client (up to a contracted $500 for each client (up to a contracted annual ceiling amount) who annual ceiling amount) who successfully successfully completes detoxification, enters the next level completes detoxification, enters the next level of care within 7 days of dischargeof care within 7 days of discharge and and completes :completes :

30 days in a DSAMH funded SA residential 30 days in a DSAMH funded SA residential treatment program or Halfway House –OR-treatment program or Halfway House –OR-Chance House and 15 days in a DSAMH funded Chance House and 15 days in a DSAMH funded SA residential treatment program –OR-SA residential treatment program –OR-60 days in a DSAMH funded SA outpatient 60 days in a DSAMH funded SA outpatient treatment program.treatment program.

Preliminary 6 Month ResultsPreliminary 6 Month Results

Generally seems to be workingGenerally seems to be working

Some positives:Some positives:– More clients servedMore clients served– More clients and higher percentage getting to More clients and higher percentage getting to

treatmenttreatment– Management paying attentionManagement paying attention– Closer working relationships between detox Closer working relationships between detox

and treatment providersand treatment providers (more)(more)

Preliminary 6 Month ResultsPreliminary 6 Month Results

– New initiatives to connect with treatment prior New initiatives to connect with treatment prior to leaving detoxto leaving detox

– Improved collaboration between state and Improved collaboration between state and detoxdetox

– Evaluation data being used to inform Evaluation data being used to inform decisionsdecisions

(more)(more)

Preliminary 6 Month ResultsPreliminary 6 Month Results

Some Issues and Questions:Some Issues and Questions:– Incentives having more impact on Incentives having more impact on

management than cliniciansmanagement than clinicians– Definition of “admission” to treatmentDefinition of “admission” to treatment– Are incentives in the right place Are incentives in the right place – Too early to tell about 3+Too early to tell about 3+– AMA rate (why do people leave detox early?)AMA rate (why do people leave detox early?)

Tips For Making PBC WorkTips For Making PBC Work

1)1) Meet regularly with providers, especially Meet regularly with providers, especially in the early stages:in the early stages:

Meet as a group Meet as a group

Create atmosphere of sharingCreate atmosphere of sharing

Build partnership – state/county and providers Build partnership – state/county and providers and among providers themselvesand among providers themselves

Be supportive, be flexible when appropriate, be Be supportive, be flexible when appropriate, be firm with PBCfirm with PBC

Tips For Making PBC WorkTips For Making PBC Work

2)2) Incorporate NIATx:Incorporate NIATx:Process and performance improvement for Process and performance improvement for access, engagement and retentionaccess, engagement and retention

3)3) Praise successesPraise successes

To Conclude . . .To Conclude . . .

I don’t do drugs anymore because I find I I don’t do drugs anymore because I find I can get the same effect just standing up can get the same effect just standing up really fast.really fast.

Seen it all, done it all, can’t remember Seen it all, done it all, can’t remember most of it.most of it.

I intend to live forever – so far, so good.I intend to live forever – so far, so good.

Contact InformationContact Information

Jack KempJack Kemp

Treatment Research InstituteTreatment Research Institute

jkemp@tresearch.orgjkemp@tresearch.org 215-399-0980215-399-0980