cms/cmmi cooperative agreement to advance integrated...
TRANSCRIPT
CMS/CMMI Cooperative Agreement to Advance Integrated Care: Essential to Payment for Quality and Outcome
• W. Douglass Tynan, PhD, ABPP; Director of Integrated Care, American Psychological Association
• Elena J. Eisman, EdD, ABPP; Director – Center for Psychology & Health, American Psychological Association
• Christopher D. Nettles, PhD, Project Director – Integrated Health Care Alliance, American Psychological Association
Session # D4
CFHA 19th Annual ConferenceOctober 19-21, 2017 • Houston, Texas
Faculty Disclosure
The presenters of this session have NOT had any
relevant financial relationships during the past 12
months.
Conference Resources
Slides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2017
Slides and handouts are also available on the mobile app.
Learning Objectives
At the conclusion of this session, the participant will be able to:
Describe the essential common elements of effective primary care behavioral health models.
Define the role of integrated behavioral health within the context payment for value and outcome.
Describe development of integrated teams compared to coordinating existing services.
Discuss the workforce issues associated with transition to integrated care models
Identify the goals and change processes associated with the Transforming Clinical Practice Initiative.
1. Tice, J.A., Ollendorf, D.A., Reed, S.J., Shore, K.K., Weissberg,J., & Pearson, S.D. (2015). Integrating Behavioral Health into Primary Care: A Technology Assessment. Retrieved from Institute for Clinical and Economic Review website: https://icer-review.org/wp-content/uploads/2016/01/BHI_Final_Report_0602151.pdf
2. McDaniel, S. H., & deGruy, F. V., III. (2014). An introduction to primary care and psychology. American Psychologist, 69, 325–331. http://dx.doi.org/10.1037/a0036222
3. Bachrach, D., Anthony, S., & Manatt, A D. (2014). State Strategies for Integrating Physical and Behavioral Health Services in a Changing Medicaid Environment. Retrieved from The Commonwealth Fund website: http://www.commonwealthfund.org/~/media/files/publications/fund-report/2014/aug/1767_bachrach_state_strategies_integrating_phys_behavioral_hlt_827.pdf
4. American Psychological Association. (2016). 2015 survey of psychologist health providers. Retrieved from http://www.apa.org/workforce/publicaitons/15-health-service-providers/index.aspx
5. Kearney, L. K., Post, E. P., Pomerantz, A. S., & Zeiss, A. (2014). Applying the interprofessional aligned care team in the Department of Veterans Affairs: Transforming primary care. American Psychologist, 69(4), 399-408.
6. McDaniel, S. /H., Grus, C. L., Cubic, B. A., Hunter, C. L., Kearney, L. K., Schuman, C. C., . . . Johnson, S. B. (2014). Competencies for psychology practice in primary care. American Psychologist, 69(4), 409-429. http://dx.doi.org/10.1037/a0036072
7. Robinson, P. J. & Reiter, J. T. (2007). Behavioral Consultation and Primary Care: A guide to Integrating Services. Springer Science+ Business Media, LLC
8. William N. Robiner, PhD, & John A. Yozwiak, PhD (2013). The Psychology Workforce: Trials, Trends, and Tending the Common. The National Register Report. Retrieved from https://www.nationalregister.org/pub/the-national-register-report-pub/spring-2013-issue/the-psychology-workforce-trials-trends-and-tending-the-commons
Bibliography / Reference
Learning Assessment
A learning assessment is required for CE credit.
A question and answer period will be conducted
at the end of this presentation.
Integrated Care: Increasing Value
W. DOUGLAS TYNAN, PHD, ABPP
DIRECTOR, OFFICE OF INTEGRATED HEALTHCARE
AMERICAN PSYCHOLOGICAL ASSOCIATION
Healthcare reform: Changes in PaymentEmphasis on quality
- Payment for Services
- Patient Improvement
- Patient and Family Satisfaction
Emphasis on outcome
-Utilization
-Reduced hospitalizations
-Medication adherence
De-Emphasis on services provided
- Fee-for-Service
Meeting Quality Goals for Depression
Meeting Depression Screening example:
Choose screener – PHQ 9, Other screen.
Imbed within Electronic Health Record
Build into workflow –by office staff.
Emotional / Behavioral screener - 96127
Establish disposition for patients
Meeting Quality Goals in Screening: Example
Four Offices, 20000 patients:
1. 70% goal, 14,000 screened
2. 8.0% screen positive, 1100 – disposition plans.
3. $70,000 collected for screening.
For the patient: Early Screen, services to address needs
Meeting Efficiency Goals in Primary Care: Gouge N, Polaha J, Rogers R, Harden A. (2016)
• On days when an integrated behavioral health consultant (BHC)◦ was present, medical providers spent 2 fewer minutes on average
◦ for every patient seen in comparison to days when the consultant
◦ was not available.
On days when an integrated BHC was available, medical◦ providers saw 42% more patients than they did on days when
◦ no consultant was available.
• The practice generated $1142 more in revenue on days with BHC◦ integration as compared with non-BHC days.
Reviewing Revenue
Help meet goals for Quality Payment.
Develop a system for billing of behavioral screens◦ Can use a similar system for developmental behavioral screens, screens.
◦ This generates additional revenue.
Makes Primary care provider more efficient – see more patients.◦ Likely reduces stress on PCP.
You have increased revenue, improved efficiency, in addition, factor in your fee for service billing.
The Workforce to move-demographics106,000 licensed psychologists in the US
Approximately 16% of behavioral and social science workforce were psychologists
Added health to mission statement
Competencies for work in integrated primary care
http://www.apa.org/Images/15-hsp-figure-2a_tcm7-207971.png
http://www.apa.org/workforce/publications/15-health-service-providers/index.aspx
Employment Characteristics of Psychologists: setting, Arrangement, Status
Goal of TransitioningPsychologists move up the ramp from independent practice through coordination, colocation to integration
Develop skills in addressing/treating:
health related behaviors
team practice
brief interventions
brief assessments
system based record keeping
system based approach to outcome measurement
healthcare economics
management and leadership skills
Six levels of integrated primary care
Minimal collaboration Communicate rarely
Collaboration at a distanceCommunicate periodically about shared patients
Collaboration onsiteCommunicate regularly about patients; share referrals
Close collaboration onsiteCollaborate on treatment plans for some patients, communicate regularly
Approaching an integrated practiceCollaborate on overall care and coordinate treatment for some patients
Full collaborationCommunicate at all levels, provider roles blended, business systems integrated
Source: Derived from A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C. SAMHSA-HRSA Center for Integrated Health Solutions. March 2013
Barriers to TransitioningIndependent practice system-historically separate from medical community
MH carve-outs
Health condition knowledge and credentialing
HiTech exclusion
PQRS, MIPS and MACRA non-participation
Confidentiality principles
Stigma
Lack of integration in medical neighborhood
Confusion about scope
Few appropriate billing codes
Confusing political climate
Lack of access to physical health metrics
Strategies for TransitionCMMI ◦ Online and face to face training
◦ Referral for continued training and skill development
◦ stages of practice transformation
◦ Strategic alignment networks
Focus on QI
Outcomes measurement
Connections with medical community◦ State Psychological Association joint meeting
◦ Joint training opportunities
◦ On-line “matching service”
Advocacy opportunity
Taking The Transformation Journey
CHRISTOPHER D. NETTLES, PHD
PROJECT DIRECTOR - INTEGRATED HEALTH CARE ALLIANCE
AMERICAN PSYCHOLOGICAL ASSOCIATION
CMMI’s Transforming Clinical Practice Initiative
Support more than 140,000 clinicians in their practice transformation work
Improve health outcomes for millions of Medicare, Medicaid and CHIP beneficiaries and other patients
Reduce unnecessary hospitalizations for 5 million patients
Generate $1 to $4 billion in savings to the federal government and commercial payers
Sustain efficient care delivery by reducing unnecessary testing and procedures
Transition 75% of practices completing the program to participate in AlternativePayment Models
Build the evidence base on practice transformation so that effective solutions can be scaled
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Transforming Psychology Clinical Practice
The Integrated Health Care Alliance (IHCA) is funded by CMMI/CMS as part of their Transforming Clinical Practice Initiative.
Project goals include developing, sharing, and adapting comprehensive quality improvement strategies in conjunction with other healthcare and professional organizations
Plan to engage more than 6k providers
For psychologists we will provide training, tools, and technical assistance in:
The basics of integrated care from both the practice and business perspectives
Value-based Payment Models
Measuring Quality and Outcome
Participating in a broad network of thought-leader clinicians dedicated to integrated care.
Practice
TransformationPhase 2:
Use Data
to Drive
Care
Phase 3:
Achieve Progress on
Aims
Phase 4:
Achieve
Benchmark
Status
TCPI Ch. Pkg.
Driver 2:
Continuous, Data-Driven
Quality Improvement
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3
4
5
2
Phase 1. Setting aims
Practice has developed and shared a vision and detailed plan that addresses goals of transformation with specific clinical outcomes and utilization aims along with the detail on how each of the aims will be addressed.
Phase 2. Use Data to Drive Care
18. Using sound business practices
16. Produces reports …follow up system
10. Account-ability for care management
15. Building QI capability …
14. Regular Improvement method …
8. Referral to community resources
Implementation Activities
Service Delivery System
Practice Aims TCPI Aims
TCPI Enrolled PracticeDeveloping Implementing Performing
7. ID high risk patients …
1. Monitor metrics on TCPI aims …
4. Training in patient shared decision making …
19. Improve experience …joy in work
Administrative Staff
Clinical Staff
New Capabilities:Use of data to
drive care
Phase 3. Achieve Progress on Aims1. Practice has shown improvement in metrics related to TCPI aims but has not reached its targets or improvement is not yet sustained.
2. Practice has a formal system for obtaining patient and family feedback but does not consistently incorporate the information received into the QI and overall management systems of the practice.
3. The practice has documented each team member’s role and accountability lanes and each team member works to the maximum of his skill set and credentials in order to optimize efficiency and outcomes.
4. Practice has collaborated with the primary care practices in its medical neighborhood and has jointly developed criteria for referrals for episodic care, co-management, and transfer of care but processes have not yet been implemented.
Phase 3. Achieve Progress on Aims (cont)5. Practice has a reliable system in place to identify the primary care provider of each patient and to communicate with the primary care team about each visit or encounter.
6. Practice has developed or identified evidence -based protocols or care maps to use but these have not yet been implemented consistently within the practice.
7. Practice has a clinician available from the practice or on contract who can speak to patients after hours while being able to access the patient’s record.
8. Practice has developed QI capability within the practice and empowers staff/ providers to participate in QI activities by allocating time for QI activities, including QI within defined job duties, recognizing and rewarding innovation and improvement.
9. Practice is developing its internal capability to success in an alternative payment system and a date has been set for this migration has been set within the TCPI timeframe.
10. Practice has worked to streamline a number of its work flows by reviewing the steps and eliminating waste and rework, but the concept of value is not consistently considered during these efforts.
Phase 4. Achieve Benchmark status • Practice has met at least 75% of its targets and sustained improvements in practice-identified metrics for at
least one year.
• Practice has demonstrated improvement in reducing unnecessary tests.
• Practice has implemented and documented a tested process and has demonstrated a reduction in unnecessary
hospitalizations from its baseline.
• Practice can demonstrate that patients and families are collaborating in goal setting, decision making and self-
management (e.g. shared care plans, documentation of self- management goals, compacts, etc.).
• Practice has a formal system for obtaining patient and family feedback and can document operational or
strategic decisions made in response to this feedback.
• Practice has successfully implemented and documented a tested process that identifies patient risk level and
includes follow up with care appropriate to the risk level identified, including ensuring that those at highest risk
receive care management services or have a care plan in place that the practice is following.
• Practice has completed its resources inventory and consistently links patients with appropriate community
resources and follows up on referrals made.
Phase 4. Achieve Benchmark status (cont)
• Practice has collaborated with the primary care practices in its medical neighborhood and has jointly
developed and implemented criteria for referrals for episodic care, co-management, and transfer of care/
return to primary care, processes for care transition, including communication with patients and family.
• Practice consistently uses evidence -based protocols or care maps where appropriate to improve patient care
and safety.
• The practice fully incorporates regular improvement methodology to execute change ideas in the practice
setting.
• Practice offers multiple forms of alternative visit types (e.g. email, Skype, or tele-visits) or communication
media (e.g. portal, texting) and has integrated these alternatives into regular practice.
• Practice has implemented strategies to support joy in work and can demonstrate the results through metrics
such as staff survey results, high retention rates, or low turnover rates.
• Practice uses an organized approach (e.g. lean, process mapping) to reviewing its processes, eliminating or
reducing waste in the process, and understanding the value of each process step to the patient and other
customers.
Phase 5. Thrive as a pay-for-value business
• Practice is providing education and practice data on business metrics to staff at all levels across the organization.
• Specialized training is being provided to those at the practice level that may be involved in analysis of alternative payment arrangements and in contracting for services.
• Practice is confident of its readiness for migrating into alternative payment approaches.
Benefits of Enrollment
Free subscription to Clinical Quality Outcome Reporting Registry
Use current expertise in new ways while developing new & in-demand skills
Advocate for psychology by providing data and feedback specific to psychologists to health care leaders
Earn up to 8 hours of CE credit** at no cost to you
**Continuing Education credits are sponsored by the APA Office of Continuing Education in Psychology (CEP). The APA CEP Office has reviewed and approved the programs to offer CE credits for psychologists. The APA CEP Office maintains responsibility for the content of the programs.