Rhode Island SPMI Health Homes Overview CSI Integrated Behavioral Health Network November 21, 2013. Michael S. Varadian, JD, MBA Executive Director, Operations and Policy RI Department of Behavioral Healthcare Developmental Disabilities & Hospitals. 1. - PowerPoint PPT Presentation
1 1 Rhode Island SPMI Health Rhode Island SPMI Health Homes Homes Overview Overview CSI Integrated Behavioral Health CSI Integrated Behavioral Health Network Network November 21, 2013 November 21, 2013 Michael S. Varadian, JD, MBA Michael S. Varadian, JD, MBA Executive Director, Operations and Policy Executive Director, Operations and Policy RI Department of Behavioral Healthcare RI Department of Behavioral Healthcare Developmental Disabilities & Hospitals Developmental Disabilities & Hospitals
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Rhode Island SPMI Health HomesRhode Island SPMI Health HomesOverviewOverview
CSI Integrated Behavioral Health NetworkCSI Integrated Behavioral Health Network
November 21, 2013November 21, 2013
Michael S. Varadian, JD, MBAMichael S. Varadian, JD, MBA Executive Director, Operations and PolicyExecutive Director, Operations and PolicyRI Department of Behavioral Healthcare RI Department of Behavioral Healthcare Developmental Disabilities & HospitalsDevelopmental Disabilities & Hospitals
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Health Homes Service Model Health Homes Service Model Development PrinciplesDevelopment Principles
1.1. Person/Family Centered Care CoordinationPerson/Family Centered Care Coordination2.2. Comprehensive Whole Person CareComprehensive Whole Person Care3.3. Evidenced-Based (Self Management Goal)Evidenced-Based (Self Management Goal)4.4. Accountable (HH fixed point of responsibility)Accountable (HH fixed point of responsibility)5.5. Continuity and Transition ManagementContinuity and Transition Management6.6. Proactive Outreach/EngagementProactive Outreach/Engagement7.7. Data-Driven Outcome-based Approach (to Data-Driven Outcome-based Approach (to
customize ongoing treatment plans)customize ongoing treatment plans)8.8. Community Provider Engagement/Collaboration Community Provider Engagement/Collaboration
StrategyStrategy
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BHDDH MEDICAID HEALTH HOMESBHDDH MEDICAID HEALTH HOMES RI BHDDH has implemented a statewide Medicaid RI BHDDH has implemented a statewide Medicaid
SPMI Health Home program, and is currently SPMI Health Home program, and is currently applying for second:applying for second:
Community Mental Health Organizations Community Mental Health Organizations (CMHOs)(CMHOs)
– 7 CMHOs and 2 Specialty MH Centers7 CMHOs and 2 Specialty MH Centers– Approximately 5,200 SMPI enrolleesApproximately 5,200 SMPI enrollees
RI Opioid Treatment Program Health Home RI Opioid Treatment Program Health Home Services- (pending approval from CMS)Services- (pending approval from CMS)
– 1,500 individuals and 6 agencies (12 sites)1,500 individuals and 6 agencies (12 sites)
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Target PopulationTarget Population In 2010, CMHOs served 7,490 persons w/SPMI:In 2010, CMHOs served 7,490 persons w/SPMI:
In RI, all Medicaid-only individuals are auto-In RI, all Medicaid-only individuals are auto-enrolled in Managed Care with BH-carve out for enrolled in Managed Care with BH-carve out for persons with SPMI.persons with SPMI.
Current RI SPMI Health Home enrollment is over Current RI SPMI Health Home enrollment is over 5,200 individuals (approximately5,200 individuals (approximately 26 teams) 26 teams)
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THE CMHO HEALTH HOME TEAMTHE CMHO HEALTH HOME TEAM
Master’s Level Team Coordinator (1 FTE)Master’s Level Team Coordinator (1 FTE) Psychiatrist (0.5 FTE)Psychiatrist (0.5 FTE) Registered Nurse (2.5 FTE)Registered Nurse (2.5 FTE) Licensed and Master’s prepared mental health Licensed and Master’s prepared mental health
professional (0.5 FTE)professional (0.5 FTE) Community Support Professionals – Hospital Community Support Professionals – Hospital
Liaison (1 FTE); Community Support Care Liaison (1 FTE); Community Support Care Coordinators (5.5 FTE); Peer Specialist (0.25 FTE) Coordinators (5.5 FTE); Peer Specialist (0.25 FTE)
Total of up to 11.25 FTEs per 200 clientsTotal of up to 11.25 FTEs per 200 clients
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SUPPLEMENTALSUPPLEMENTAL TEAM TEAM PARTICIPANTSPARTICIPANTS
Other health team members may Other health team members may include, but are not limited to: include, but are not limited to: – Primary Care Physicians Primary Care Physicians – Pharmacists Pharmacists – Substance Abuse Specialists Substance Abuse Specialists – Vocational/Employment Specialists Vocational/Employment Specialists – Community Integration Specialists Community Integration Specialists – Housing Facilitators Housing Facilitators
Almost 70% of RI SPMI Health Home clients have substance Almost 70% of RI SPMI Health Home clients have substance abuse, homelessness or unemployment issuesabuse, homelessness or unemployment issues
Many of these issues were not being dealt with effectively Many of these issues were not being dealt with effectively and they directly affect clinical outcomesand they directly affect clinical outcomes
It is challenging to separate care coordination from It is challenging to separate care coordination from treatment when (necessarily) occurring in the same time treatment when (necessarily) occurring in the same time period to address all of these issuesperiod to address all of these issues
It is challenging to separate populations between eligible It is challenging to separate populations between eligible Health Home clients and non-eligible clients who must be Health Home clients and non-eligible clients who must be treated (differently) by the same stafftreated (differently) by the same staff
10-20% of Health Home dual eligible clients lose their 10-20% of Health Home dual eligible clients lose their Medicaid eligibility (spend down/flex off) at some point and Medicaid eligibility (spend down/flex off) at some point and it may take 3-6 months to re-enroll, disrupting clinical it may take 3-6 months to re-enroll, disrupting clinical outcomes (loss of access to primary care and medications outcomes (loss of access to primary care and medications because of no coverage or unaffordable deductibles)because of no coverage or unaffordable deductibles)
Need a less intensive level of care to support recoveryNeed a less intensive level of care to support recovery
– Transition from blended fee for service and per diem rate to Transition from blended fee for service and per diem rate to case rates were both favorable to some and unfavorable to case rates were both favorable to some and unfavorable to other agenciesother agencies
– Changes in rules and reporting (minimums) negatively Changes in rules and reporting (minimums) negatively affected revenue streams in most agenciesaffected revenue streams in most agencies
– New payment methodology provided reimbursement for care New payment methodology provided reimbursement for care coordination activities that were not funded or provided coordination activities that were not funded or provided uniformly (thus new encounter reporting)uniformly (thus new encounter reporting)
– Enrollees were going in and out of Medicaid eligibility which Enrollees were going in and out of Medicaid eligibility which created vacuums in reimbursement and coveragecreated vacuums in reimbursement and coverage
– Staff report that there should be a group home facility for Staff report that there should be a group home facility for more intensive SPMI clients that don’t do well in a nursing more intensive SPMI clients that don’t do well in a nursing home care as a more cost and clinically effective setting home care as a more cost and clinically effective setting
– Some hospital admissions have increased with coordinated Some hospital admissions have increased with coordinated access to needed medical/surgical care and better educated access to needed medical/surgical care and better educated consumerconsumer
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RI Health Homes:RI Health Homes: 1 Year Program Audit 1 Year Program Audit
Audit Tool/Certification ProcessAudit Tool/Certification Process
– Based on Person Centered Health Home Best Based on Person Centered Health Home Best Practice Standards issued in September 2012Practice Standards issued in September 2012
– Covers all six key Health Home categoriesCovers all six key Health Home categories– Utilizes multiple sources of information- Utilizes multiple sources of information-
Chart reviewsChart reviews Interviews with staffInterviews with staff Observation of team meetingsObservation of team meetings Agency’s own self rating scores compared to BHDDH Agency’s own self rating scores compared to BHDDH
resultsresults Discussions of pathways to goals and outcomesDiscussions of pathways to goals and outcomes
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RI Health Home Program AuditRI Health Home Program AuditPreliminary FindingsPreliminary Findings
Comprehensive Care ManagementComprehensive Care Management– Focus on key areas of medical discharge and urgent care Focus on key areas of medical discharge and urgent care
follow-upfollow-up– Management of prescriptions and complianceManagement of prescriptions and compliance– Develop system to stratify client needs/supportsDevelop system to stratify client needs/supports– Refine team communication processRefine team communication process– Strengthen liaison with primary care provider staff Strengthen liaison with primary care provider staff
(education, data, collaboration, care coordination)(education, data, collaboration, care coordination)– Develop comprehensive and culturally appropriate health Develop comprehensive and culturally appropriate health
assessment- nurses are critical team membersassessment- nurses are critical team members– Develop training on key areas of medical interface, Develop training on key areas of medical interface,
standardized assessment, medication management, data standardized assessment, medication management, data collectioncollection
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RI Health Home Program AuditRI Health Home Program AuditPreliminary FindingsPreliminary Findings
Care Coordination and Health PromotionCare Coordination and Health Promotion– Caseload size (<30) and turnover key factors of Caseload size (<30) and turnover key factors of
effectiveness effectiveness – Training needs (stage of client’s health, motivational Training needs (stage of client’s health, motivational
interviewing, health coaching, knowledge of chronic interviewing, health coaching, knowledge of chronic disease management)disease management)
– Lack of evidenced based guidelines (integrated Lack of evidenced based guidelines (integrated assessment/screening, interface with primary care, assessment/screening, interface with primary care, medical discharge planning, medication reconciliation)medical discharge planning, medication reconciliation)
– HIT capacity needed for team data sharing (medical data, HIT capacity needed for team data sharing (medical data, comprehensive assessment, lab results, treatment comprehensive assessment, lab results, treatment regimen, appointments, tracking, etc.) regimen, appointments, tracking, etc.)
– CurrentcareCurrentcare (RI statewide HIE) participation and (RI statewide HIE) participation and challengeschallenges
– MOUs needed beyond behavioral/primary care to include MOUs needed beyond behavioral/primary care to include secondary level care providers and local institutions secondary level care providers and local institutions (schools, police, churches, community agencies and (schools, police, churches, community agencies and recreational programs, support groups, etc.)recreational programs, support groups, etc.)
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RI Health Home Program AuditRI Health Home Program AuditPreliminary FindingsPreliminary Findings
Comprehensive Transitional CareComprehensive Transitional Care– Health Home client medical hospital admission notification Health Home client medical hospital admission notification
to agencies is still a challenge because of privacy, HIPAA to agencies is still a challenge because of privacy, HIPAA rules, hospital regulations and medical clinical territorial rules, hospital regulations and medical clinical territorial issuesissues
– Transitions (discharge planning, post discharge care, Transitions (discharge planning, post discharge care, follow-up tracking, medication reconciliation) worked follow-up tracking, medication reconciliation) worked more effectively with psychiatric hospital admissions more effectively with psychiatric hospital admissions based on past practices- based on past practices- role of hospital liaisonsrole of hospital liaisons
– Current process involves notification from insurers vs. Current process involves notification from insurers vs. providers: (Insurers have financial incentives)providers: (Insurers have financial incentives)
– Hospital liaisons and pharmacy are critical to this areaHospital liaisons and pharmacy are critical to this area– Transitions to/from other facilities (LTC, rehab, day Transitions to/from other facilities (LTC, rehab, day
treatment, corrections, community services) better treatment, corrections, community services) better networked and managednetworked and managed
– Identify and address consumer’s barriers to self Identify and address consumer’s barriers to self management and understanding of post hospital caremanagement and understanding of post hospital care
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RI Health Home Program AuditRI Health Home Program AuditPreliminary FindingsPreliminary Findings
Referral to/Mobilizing Community and Social Referral to/Mobilizing Community and Social Support ServicesSupport Services
Variable effectiveness in focus on self-management and Variable effectiveness in focus on self-management and addressing risk factors of heart disease, obesity, diabetes, addressing risk factors of heart disease, obesity, diabetes, hypertension, and circulatory conditions (lack of training, hypertension, and circulatory conditions (lack of training, consumer desire, fear)consumer desire, fear)
Key areas to emphasize: support skills/techniques to deal Key areas to emphasize: support skills/techniques to deal with frustration, fatigue, pain and isolationwith frustration, fatigue, pain and isolation
Appropriate use of medication (filling prescriptions and Appropriate use of medication (filling prescriptions and compliance, etc.) as well as discontinuation notificationscompliance, etc.) as well as discontinuation notifications
Nutrition and decision making regarding new self-Nutrition and decision making regarding new self-management goalsmanagement goals
Need to address functional impairment (thinking and Need to address functional impairment (thinking and planning, sociability/emotional expression, activity/interest planning, sociability/emotional expression, activity/interest and anxiety management)and anxiety management)
Re-evaluate composition and effectiveness of networkRe-evaluate composition and effectiveness of network
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RI Health Home Program AuditRI Health Home Program AuditPreliminary FindingsPreliminary Findings
Use of Health Information Technology to Link Use of Health Information Technology to Link ServicesServices
– The barrier of information sharing will be the major The barrier of information sharing will be the major factor limiting the effectiveness of care factor limiting the effectiveness of care coordinationcoordination
– BH Agency MIS systems are challenged to incorporate BH Agency MIS systems are challenged to incorporate medical disorders, screenings, health risks, expanded medical disorders, screenings, health risks, expanded medications, etc., into behavioral health software medications, etc., into behavioral health software programsprograms
– Health Home field needs technical support to aid Health Home field needs technical support to aid standardization of integrated care data collection and standardization of integrated care data collection and reporting componentsreporting components
– Need process to interface medical records with hospitals, Need process to interface medical records with hospitals, primary care, laboratories, pharmacies, etc., and data primary care, laboratories, pharmacies, etc., and data sharing featuressharing features
– MCOs need to share claims data and reporting with MCOs need to share claims data and reporting with CMHOs for Health Home clients (set timelines, reporting CMHOs for Health Home clients (set timelines, reporting requirement, etc.)requirement, etc.)
– Tracking, follow-up, notifications, and client and team Tracking, follow-up, notifications, and client and team communication must be features of MIS systemcommunication must be features of MIS system
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HEALTH INFORMATION TECHNOLOGYHEALTH INFORMATION TECHNOLOGY
Medicaid MCOs providing CMHOs with quarterly Medicaid MCOs providing CMHOs with quarterly claims data for the 35% of Medicaid Health Home claims data for the 35% of Medicaid Health Home recipients enrolled in MCOs, including health recipients enrolled in MCOs, including health utilization profiles:utilization profiles:– Hospital admissionsHospital admissions– # Emergency Room Visits# Emergency Room Visits– Last ER Visit DateLast ER Visit Date– Last ER Visit Primary DiagnosisLast ER Visit Primary Diagnosis– # Urgent Care Visits# Urgent Care Visits– PCP site and date of last PCP visit, etc.PCP site and date of last PCP visit, etc.
The state has still not been able to obtain The state has still not been able to obtain Medicare utilization and cost data Medicare utilization and cost data (hospitalization, primary care services, ER visits, (hospitalization, primary care services, ER visits, etc.) for 33% of Health Home population that is etc.) for 33% of Health Home population that is dual eligible dual eligible
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HEALTH INFORMATION TECHNOLOGYHEALTH INFORMATION TECHNOLOGY
The state currently collects a great deal of self The state currently collects a great deal of self report data on the state RIBHOLD (RI Behavioral report data on the state RIBHOLD (RI Behavioral Healthcare On-Line Database) system including Healthcare On-Line Database) system including commonly co-occurring conditions such as:commonly co-occurring conditions such as:– MH/SA, Developmental Disabilities, Pregnancy, Smoking, MH/SA, Developmental Disabilities, Pregnancy, Smoking,
Hypertension, Hepatitis, Life Threatening Viral Illness, Hypertension, Hepatitis, Life Threatening Viral Illness, Hypercholesterolemia, Obesity, Diabetes, Asthma and Hypercholesterolemia, Obesity, Diabetes, Asthma and Chronic Obstructive Pulmonary DiseaseChronic Obstructive Pulmonary Disease
Agencies report monthly on, for example: # of HH Agencies report monthly on, for example: # of HH clients served, # newly admitted HH clients, # of clients served, # newly admitted HH clients, # of clients receiving face to face services within 10 clients receiving face to face services within 10 days of hospital discharge, # of psychiatric days of hospital discharge, # of psychiatric admissions and other encounter data detailing admissions and other encounter data detailing type of contact and durationtype of contact and duration
Agencies also report HH FTE team composition Agencies also report HH FTE team composition and vacancies monthlyand vacancies monthly
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Outcome TrendsOutcome Trends
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Outcome TrendsOutcome Trends
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Outcome TrendsOutcome Trends
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QUESTIONS AND CONTACTSQUESTIONS AND CONTACTS
RI DEPARTMENT OF BEHAVIORAL RI DEPARTMENT OF BEHAVIORAL HEALTHCARE, DEVELOPMENTAL HEALTHCARE, DEVELOPMENTAL
DISABILITIES AND HOSPITALSDISABILITIES AND HOSPITALS
Michael S. Varadian: 401-462-0917 Michael S. Varadian: 401-462-0917
