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1© 2017. All Rights Reserved.
www.openminds.com163 York Street, Gettysburg, Pennsylvania 17325Phone: 717-334-1329 - Email: [email protected]
The 2017 OPEN MINDS Strategy & Innovation Institute Tuesday, June 6, 2017 | 10:15am – 11:30am
Jim Gargiulo, Senior Associate, OPEN MINDS
Readmission Prevention Programs: Service Innovation In A Managed Care Environment
2© 2017. All Rights Reserved.
I. Readmission Rates: By The Numbers
II. Paul Duck, Vice President, Strategy & Development, Beacon Health Options
III. Melissa Larkin-Skinner, MBA, MA, LMHC, Chief Executive Officer, Centerstone of Florida
IV. Jennifer Garber, MA, LICSW, Director of Clinical Operations and Community Initiatives, Medica Behavioral Health
V. Questions & Discussion
Agenda
Readmission Rates: By The Numbers
4© 2017. All Rights Reserved.
Readmissions By Payer
21%
55%
19%
5%
30-DAY READMISSIONS BY PAYER, 2011
Mediciad Medicare Commercial Uninsured
18%
58%
20%
4%
30-DAY READMISSION HOSPITAL COSTS BY PAYER, 2011
Mediciad Medicare Commercial Uninsured
5© 2017. All Rights Reserved.
5 Most Common Causes 30-Day Readmissions
Medicare
• Congestive heart failure, non-hypertensive
• Septicemia, not including labor
• Pneumonia, not including that caused by STIs or tuberculosis
• Chronic obstructive pulmonary disease and bronchiectasis
• Cardiac dysrhythmias
Medicaid
• Mood disorders• Schizophrenia and
other psychotic disorders
• Diabetes mellitus with complications
• Complications of pregnancy, not including early or threatened labor
• Alcohol-related disorders
•Commercial
• Mood disorders• Alcohol-related
disorders• Diabetes mellitus
with complications• Pancreatic
disorders, not diabetes
• Skin and subcutaneous tissue infections
Uninsured
• Mood disorders• Alcohol-related
disorders• Diabetes mellitus
with complications• Pancreatic
disorders, not diabetes
• Skin and subcutaneous tissue infections
6© 2017. All Rights Reserved.
7© 2017. All Rights Reserved.
8© 2017. All Rights Reserved.
Key Issues Impacting Readmissions
Discharge & Care Transitions
Health Literacy & Consumer Education
Linkage To Primary Care
Social Determinants
Mental Health
Co-morbidities
Beacon Health Options Case Study
Paul Duck, Vice President, Strategy & Development, Beacon Health Options
Readmission Prevention Programs
Paul M. DuckVice President, Strategy & Development
June 6, 2017
@paulduck
About Beacon Health Options
11
Headquartered in Boston; more than 70 locations in the US and UK
5,000 employees nationally and in the UK serving 50 million people
200+ employer clients, including 45 Fortune 500 companies
Programs serving Medicaid recipients in 27 states and the District of Columbia
Serving 8.5 million military personnel, federal civilians and their families
Partnerships with 100 health plans
NCQA and URAC accredited
12
Readmissions Discussion Value Based Payments
Behavioral health is playing a very small role in therecent wave of value-based payments (VBP)
13
Behavioral health’s historical role has minimized participation to date
A majority of ACO-like entities and energy are related to Medicare, where BH spending is lowest as a percent of total spending
BH as a “second class citizen” in VBPs is not limited to Medicare. Same goes for Commercial; and we have no scaled Medicaid example (excluded from Oregon and Colorado) and Massachusetts and New York have yet to determine their approach. Data and evidence are thin
Lack of strong outcomes measurement regimes that definitively identify best-in-class provision of BH services
BH service provision lacks the diagnostic clarity and robust evidence base that physical health VBP has been built on in medical care (e.g. knee replacement)
BH providers, while interested in VBP, have small balance sheets and most have no experience managing VBP risk, so the first project will be a leap of faith and an exercise in planning
14
Texas: Outpatient Case Rates
Florida: Provider Sub-cap
Colorado: Provider Partner Sub Cap
California: Case Management Bundle
Illinois: Complex mental illness case rate
Beacon has a number of large-scale VBP deals, but the total is still small
New Hampshire: Sub-cap for complex mental illness
Beacon has implemented ambitious value-based payment programs in Colorado, Texas, Florida, California, and more
15
RFPs and ensuing contracts include commitments to VBPs strategies, including numeric targets (even if they are not well thought out)
• NY – glide path to having 85% of payments through VBP structures
• MA is ending its managed care program
• Oregon, Colorado, Alabama are all Medicaid programs organized around provider-led structures
Those providers with real VBP experience actually like them
• Cash flow, predictability, flexibility, clinical innovation, etc.
For BH specifically, lack of evidence notwithstanding, providers and payers both believe that more good than harm is occurring
Washington remains a wildcard, but I would bet on continued growth of VBPs
The emphasis on VBPs is unlikely to ebb any time soon
16
Overtreatment Under-treatment
INCENTIVE-BASED TREATMENT RISK
CO
MPL
EXIT
Y
VALUE-BASED PURCHASING OPTIONS
VBPs are a spectrum of options; we must get the right mix of incentives and complexity to get desired outcomes
Behavioral Health Capitation• Risk for providers• Full behavioral health
payment• Defined coverage set
Fee-for-service• One service• One payment
Case Rate• Group of services• Combined payment• Monthly/weekly payment
Episode Bundle• Group of services• Combined payment• Quality goals• Defined time period
Total Health Outcomes• Shared risk on total member experience
Pay for Performance (P4P)• “Upside only”• Key process measures
17
Value is defined as outcomes relative to the real costs
Outcome improvement without understanding the true cost of care is unsustainable and does not help effective allocation of limited resources
Cost reduction / revenue increase without regard to outcomes is not value
HEALTH OUTCOMESCOST
VALUE =
More emphasis on “PAYMENT” than “VALUE”
Proprietary and Confidential
Negotiations are overly focused on the financial envelope (bottom half of the value equation)
VBPs without changing outcomes is a very expensive way to lower cost
Too often in healthcare organizations, the clinical leads are not well coordinated with the contracting leads (both payers and providers)
• Leads to an organizational disconnect: Price changed, but things aren’t really going to be that different
18
Beacon Readmission Prevention Collaboration
Intervention Component and Approach Evidence Base Current Status
In-hospital care processesRisk stratification (use of clinical risk score) and “measurement based care” (routine use of validated BH outcome measures)
Models predicting BH readmission risk validated but not widely tested in practice; routine use of validated BH outcome measures to guide care improved outcomes in some settings
Routine assessment with validated BH outcome measures; data not used in systematic way to guide care
Structured discharge planning (structured summary, planning meeting with all parties, family involvement, communication of plan to community caregivers)
Reduces readmission & improves aftercare adherence (11 studies); mixed effect (1/3 studies); no effect among high utilizers (1 study)
Narrative discharge plan; no systematic implementation process across hospitals
Medication management (reconciliation, education, coordination with community providers)
Borderline significant; reduces medication discrepancies when supported by electronic tool
Medications assessed on admission and discharge; some hospitals have medication management education
Assessment of medical or BH needs (medical team or medical consults in psych units, psych in person or tele-consults in ERs or medical units
Adding primary care clinician to psychiatric team can improve processes of careMore evidence
Pilot psychiatrist tele-consult service for ER patients in some hospitals; process for medical referrals varies widely
Bridging transition to communityTelephone outreach calls (efforts to ensure timely follow-up, identify aftercare problems)
Can be effective, especially when used with transition manager and with 90-day post-discharge outreach
Nurse outreach call and assessment within 72 hours
Transition managers (regular follow-up, home visits, problem solving, psychoeducation, peer support)
Mixed significance, but significant with home visits or peer support
Some hospitals have peer navigator program, but no systematic use of transition managers
Patient and family skills training(psychoeducation, coping skills, living skills)
Consistently significant Used in several hospital settings, but no systematic approach
Inpatient-outpatient provider communication(scheduling, timely communication of plan)
Weak significance No systematic approach, varies by hospital and setting
19
MachineLearning
Partners in Data-Driven Care ManagementThe success of organizations responsible for managing chronic / complex conditions is dependent on their ability to: 1. Identify those most likely to benefit from more intensive care management2. Secure resources required to keep members healthy3. Maintain enrollment of members after their health has been stabilized.
• Care Management with a focus on SMI• Rather than using risk scores or past TME, focus on “hidden data”
• Health risk assessments• Care management notes
Cyft uses machine learning and natural language processing to leverage all the information in both clinical and administrative healthcare data, including HRAs and notes.
20
http://healthitanalytics.com/news/using-machine-learning-to-target-behavioral-health-interventions
21
7 days and 30 days Follow-up After Hospitalization for Mental Illness (FUH)
22
1. Develop your program focused on hospitals readmissions.
2. Partner / Pilot with local hospital.
3. Partner with specialty managed care company.
4. Measure.
5. Measure.
6. Measure.
7. If you build it they will come is NOT a business plan!
To-Do’s
Centerstone Case Study
Melissa Larkin-Skinner, MBA, MA, LMHC, Chief Executive Officer, Centerstone of Florida
Care ModelsMelissa Larkin-Skinner, MA, MBA, LMHC
Chief Executive Officer, Centerstone of Florida
Centerstone at a glance
Outpatient Models
Inpatient Approaches
Themes
Centerstone at a Glance
National, private, not-for-profit 501(c)(3) healthcare organization 60+ years in operation Specializing in the treatment and rehabilitation of individuals with
mental illness, addictions, traumas, and intellectual/developmental disabilities
Five state primary footprint; specialized services spanning all 50 states CARF and Joint Commission Accredited
• Including specialized CARF Accreditation – Adult and Children & Youth Health Home
In FY 2016
People Served 172,000+49%-Male| 51%-FemaleAll ages served
Services Provided2,781,000+
Staff5,000+ clinical and administrative staff and a national network of over 700 contract therapists
Signature Service Lines
• Health Homes• Integrated Primary Care• MAT/Addiction Services• Hospital and Crisis Services• Active Military and Veterans• Intellectual and Developmental
Disabilities
Centerstone’s Reach
Centerstone’s psychiatric inpatient unit in Florida and addiction centers in Florida and Kentucky draw patients from across the nation
Centerstone’s reach is spread across the United States with concentration in five states: TN, KY, IN, IL and FL
Our Capabilities150 Conveniently
Located, Commercially-
Ready Outpatient Sites160 Medical
Providers 380 Masters/PHD
Licensed, Credentialed
Clinicians
Fully Integrated & Interoperable EHR
Electronic Claims Submission
Integrated Medical/Behaviora
l Care
Easy Access & Referral
Management
Outcome-Driven Service System
Evidence-Based Practices
Value-Based Contracting
7
Centerstone Brand Promises
Delivering care that changes people’s lives________________________________________________
30
BRAND PROMISES
Access Clients access treatment quickly and easily.
Personalized Care Treatment is tailored to individual needs, goals and life.
Treat to Target The success of treatment is measured according to the individual goals that clients set with their treatment team.
Innovation & Value Individuals and payers know Centerstone for cutting edgeand high value clinical care.
Care Models
Assertive Community Treatment TeamChildren’s Community Action Treatment Team
Health HomeIntensive Outpatient Treatment TeamCommunity
Paramedicine
Long term
Short term
Assertive Community Treatment (ACT)
Service Delivery:High
Complexity: HighComorbid medical issues – obesity, COPD, CHF,
hypertension, diabetes; Comorbid substance use; Challenging social determinants of health.
Severity: HighSchizophrenia, Bipolar Disorder, Major Depressive
Disorder, Schizoaffective Disorder, Obsessive Compulsive Disorder, Personality Disorders;
multiple hospitalizations including state facilities; suicidal ideation and attempts
OutcomesDecreased hospital days; lower length of stay; decreased readmissions within 30, 90, 180 days; decreased use of EDs
Interventions up to 3 x daily; most services provided by the multidisciplinary team; long-term
Children’s Community Action Treatment Team (CAT)
Service Delivery:High
Complexity: HighComorbid medical issues – obesity, diabetes;
Comorbid substance use; academic difficulties; child welfare involvement; challenging social
determinants of health
Severity: HighSuicidal ideation and attempts; trauma; behavioral
difficulties; autism; any diagnoses
OutcomesDecreased hospital days; lower length of stay; decreased readmissions within 30, 90, 180 days; decreased residential admissions
Interventions up to 3 x daily; most services provided by the multidisciplinary team; long-term; coordination of services; time-limited to resolution of issues
Centerstone Health Home
Service Delivery:Moderate
Complexity: HighComorbid medical issues – obesity, COPD, CHF,
hypertension, diabetes; Comorbid substance use; Challenging social determinants of health
Severity: HighAny diagnoses; recent and historical hospitalizations
OutcomesDecreased hospital days; decreased readmissions within 30, 90, 180 days; decreased unnecessary use of EDs
Services coordinated by the health home; sharing claims data; predictive analytics; daily coaching
Intensive Outpatient Treatment Team
Service Delivery:High
Complexity: HighComorbid medical issues – obesity, diabetes;
Comorbid substance use; academic difficulties; challenging social determinants of health
Severity: HighAny diagnoses; recent hospitalizations, suicidal
ideation, suicide attempts, trauma
OutcomesDecreased hospital days; lower length of stay; decreased readmissions within 30, 90, 180 days; decreased use of EDs
Most services provided by the multidisciplinary team; intervention available up to 2 x daily; coordination of services; time limited to crisis episode
Community Paramedicine
Service Delivery: Mod - High
Complexity: HighComorbid medical and behavioral health issues;
challenging social determinants of health; multiple mediations from multiple prescribers
Severity: HighMultiple ED visits and/or hospital admissions; CHF
and respiratory diagnoses, high fall risk, diabetes, mental and substance use disorders,
OutcomesDecreased hospital days; decreased readmissions within 30, 90; decreased unnecessary use of emergency services (911, EMS)
Most services provided by the multidisciplinary team; intervention available daily (phone and face to face); behavioral heath and pharmacy interventions available as needed; coordination of services; time-limited to resolution of concerns
Hospital-based Approach
Service Delivery: Low - High
Complexity: HighComorbid medical and behavioral health issues;
challenging social determinants of health
Severity: HighAll diagnoses; recent psychiatric hospital admission
OutcomesDecreased hospital days; decreased readmissions within 30, 90; increase likelihood of follow-up with outpatient appointments
Adequate length of stay; bridge appointment; multidisciplinary team to provide community-based services; intervention available daily (phone and face to face); coordination of services; time-limited to follow-up with outpatient services
Models of CareCommon Themes
Multidisciplinary Teams
On-demand
Eligibility criteria
Flexibility & Intensity
Whatever it takes
Themes8
Challenges
• Identifying target population• EHR and analytics• Calculating and measuring desired ROI• Service limitations• Allowing flexibility to do “whatever it takes”
Optum Case Study
Jennifer Garber, MA, LICSW, Director of Clinical Operations and Community Initiatives, MedicaBehavioral Health
New Orleans, LA June 6 & 7, 2017
Open Minds Strategy and Innovation Institute
Jennifer J. Garber, MA, LICSWJune 6, 2017
AvoidingRe-hospitalizations and Improving Quality of Life
A UnitedHealth Group Company
Clinical Insight
F O U N D AT I O N A L C O M P E T E N C I E S
Data & InformationTechnology
Complementary but Distinct Business
PlatformsHEALTH BENEFITS HEALTH SERVICES
OPTUM Management of Complex/Multi-occurring Conditions
Focusing both internal and external resources to meet the unique needs of these members.
Specialized Projects Targeting Reduction in Re-hospitalizations
45
• Integrated Solutions–Telephonic Program –Internal to the
Health Plan
• Integrated Care Coordination –In Person –Internal to the Health Plan
• Substance Abuse Pilot Projects –In Person –Contract with Provider
• Intensive Behavioral Community Services –In Person–Contract with provider
Internal Programs: Integrated Solutions (ISOL)
46
Complex and Multi-occurring Conditions: Integrated Solutions
Telephonic Support
Members who have Complex Situations
Working Together to
Address Barriers
Working with the Member & Providers
Member Using Multiple Services
48
• Initiated in 2010• Intervention
– Telephonic Care Coordination– Work with Members and/or Providers, either or both– Person-Centered
• Target Population– Commercial and Medicaid – 18+ (occasionally a late adolescent)– High Complexity
• Chronically unstable BH conditions• Complex comorbid BH and medical conditions• May also have challenging social or socioeconomic
needs.
– High Risk for Continued High Costs
Background: Integrated Solutions
49
Program Process
Case Initiation
• Algorithm to identify members
• Direct Referral from Health Plan Behavioral Health Staff
• Direct Referral from Health Plan Management Staff
Identification
• Clinical screening• Review current services• Determination of approach
(Provider and/or Member)
Clinical Review
• Telephonic outreach• Person centered
assessment and treatment plan
• Coordination plan with all involved
• Coordination with UM determinations
Intervention
There are a combination of things that get considered for a member to meet the thresh hold to qualify for Integrated Solutions. They fall into the following categories:
Emergency Room Visits driven by BH condition
Detox Admissions
Inpatient Behavioral Health Admissions
Residential Treatment Stays
Program Criteria
51
• Interventions:– Development of trust– Identify and address patterns of behavior
with negative outcomes– Offer hope for self-identified needs– Collaboration with providers, family
members, community workers– Guide to appropriate treatment options
• Goal:– Increased internal and external stability– Decrease in use of acute services
Key Interventions and Goals: Identified by Staff
Sample 84 members Started ISOL program between 3/1/12 and 6/24/13
Engagement Levels Member/member and provider engaged Provider engaged Neither engaged
Data Program and member metrics using Summary of Care reports for all cause claims data OPTUM Claims Reports for Behavioral Health claims Short (90 days pre and post ISOL start date) and long (180 days pre-, post-enrollment)
term time frames evaluated
Data and Methodology
53
Outcomes
• Members identified between 3/1/12 and 6/24/13• Engagement Levels
– Member/Member and provider engaged– Provider engaged– Neither engaged
*5 members in the neither engaged group were referred for ER use and did not have MH claims pre enrolment or post enrollment. TheN for this group was small due to this and the distribution of changes was very wide.
PMPM ChangeMember/Member
and Provider Engaged (N=30)
Provider Engaged (N=33)
Neither Engaged (N= 21)
Combined BH/PH Claims 90 Days Pre/Post ID ($5,416.96) ($3,484.76) $498.91
Combined BH/PH Claims 180 Days Pre/Post ID ($2,348.18) ($2,416.55) ($835.04)
BH Claims Only 90 Days Pre/Post ID ($3,782.09) ($719.27) ($913.32)
Results
The changes in both utilization and cost showed strong results.
Utilization Changes from start date in the
program
Member/ Member and
Provider Engaged (N=30)
Provider Engaged (N=33) Neither
Engaged (N=21)
Total Change between member engaged and not
engaged
Short Term All-Cause ER Visits -32% -30% 4% -36%
Long Term All-Cause ER Visits -57% -19% 30% -87%
Short Term All-Cause Hospitalizations -63% -45% -19% -44%
Long Term All-Cause Hospitalizations -61% -52% -25% -36%
Members engaged in ISOL care coordination showed significant decrease in all-cause ER and Hospitalizations
Members and Providers engaged showed significant decrease in combined claims costs both short and long term.
$340,388.01 savings on short term BH costs for engaged members and $71,207.52 for provider only engagement
$487,526.55 savings on short term combined BH/PH for engaged members and $344,991.24 for provider only engagement
Long term combined BH/PH PMPM change of -$2,348.18 for member engaged and -$2,416.55 for provider engaged
Conclusion
Quote from an I-Solutions Care AdvocateI have worked with many members who have had lifelong mental health, substance use and, in some cases, medical issues. For many of these members there are additional challenges, for example homelessness, food instability, unemployment isolation.
Engagement with these members who have complex needs starts the moment I have contact with them. I am aware this is a vulnerable time in their life, a vulnerability for some that has gone on for many years.
Earning their trust requires a demonstration of respect and interest in them while recognizing the emotional impact of their life’s journey up to this point.
The reward for me with this program is that it focuses on helping members identify their needs in order to make a step by step plan to attain their short-and long-term goals, based on a belief that members have the strength, skills, and resiliency to be successful.
#2 Quote from I-Solutions Care Advocate
Looking at comprehensive service summaries we are able to explore members’ patterns of seeking frequent and repeated high levels of care. We talk with members to find out if their needs are met by these services. Most often they admit their needs are not met.
ISOL staff identify which patterns of behaviors are not working to meet mental, substance, and medical needs. And further, offer hope and other ways to effectively meet the member’s self-identified needs. Frequently we are talking with members about their addictive patterns, distress tolerance issues, and ineffective interpersonal behaviors.
Through regular phone contact with members we guide and accompany them on reaching goals and completing tasks – like scheduling and attending psychiatry, therapy, primary care, and methadone appointments. The over-arching goal is to build stability within the member, their immediate environment, and their care team.
External Programs: Intensive Community Based Services (ICBS)
58
Intensive Community Based Services
Initially developed as a collaboration between OPTUM, a county, MN Department of Human Services & 2 Community Mental Health Centers
Short term (6 months or less), it is an intensive program provided by community mental health providers serving Health Plan members with complex conditions
Provides both direct care and case management to address the specific barriers facing individuals whose needs often include mental and chemical health, psychosocial, housing & medical issues
Available to members on both Commercial and Government Programs products
59
Innovative Partnerships to Meet Member Needs
Intensive Community Based Services (ICBS): Intensive program provided by community mental health
providers Provides case management and direct care Address barriers to care and quality of life Address all health needs: medical, behavioral health, &
psychosocial issues
Substance Use Disorder (SUD) pilots: Serve adult members with chronic substance use disorders
who have had repeated higher levels of care. Program provides care coordination and direct care Address barriers to care and quality of life Address all health needs: medical, behavioral health, &
psychosocial issues Coordinate with providers including members on Restricted
Recipient Program Support of Medication Assisted Therapies
•Intensive outreach to clients in their living environments that is flexible based on client need
•Skills development/reinforcement for managing both MH and SUD
•Services that include health assessment and primary care coordination
•Medication monitoring
•Engagement into OP services when indicated
Examples of Services Being Offered
•Coordination with existing crisis services and development of crisis plans
•Assistance with daily living needs, housing support, benefits assistance,
•Recovery oriented activities – connect to community resources, vocational assistance, building natural/peer supports
•Transportation assistance
Examples of Services Being Offered (cont’d)
ICBS Innovation Award by Nat’l Business Coalition on Health
63
Intensive Community Based Services: Return on Investment
64
Per Member Population
Average BH Cost before ICBS $12,310 $3,163,819
Average BH Cost after ICBS $8,749 $2,248,609
BH Savings = (# of months eligon avg after ICBS x change in cost per month) – cost of ICBS
$2,998 $770,494
Measurement Period: 2011 Number of Members: 257 Age Group: Adult
BH Costs Decreased by 30% following ICBS services!
Continuation & Expansion of this Service
Currently this service is available in 23 counties in Minnesota through partnership with 7 different Community Mental Health Centers
The activities are both of facilitation, & connecting the member to services that will serve them over a longer period of time
The program was so effective that the MN Dept of Human Services set up a similar service for Medicaid members on Fee for Service plans
Goals include ensuring that there is connection with health care services in their local area, for all health needs, including medical, & behavioral health, as well as addressing psychosocial issues
65
Contact me:Jennifer Garber
Director of Clinical Operations and Community Initiatives
OPTUM 952-205-2798
Thank You!
Questions & Discussion
67
www.openminds.com 163 York Street, Gettysburg, Pennsylvania 17325 717-334-1329 [email protected]
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