health homes are
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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, 2016
Harvey Rosenthal NYAPRS Executive director1
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.
[email protected] www.nyaprs.org
2
New York Association of Psychiatric Rehabilitation Services (NYAPRS)
Very high health, social and criminal justice costs with very low outcomes
Early mortality: cardiovascular, respiratory and infectious diseases, diabetes and hypertension
Highest rates of avoidable readmissions
High rates of violence victimization, incarceration, homelessness and suicide
Impact of a Broken System
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 System
Fragmented, Siloed and Uncoordinated
Unresponsive: Reactive vs Preventive and Diversionary
Unaccountable: who can we turn to?Wrong Incentives: volume over value Illness over Wellness? Wellness over
Illness? ‘Chronic’ Patienthood over
Personhood
Elements of a Broken System
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
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Affordable Care Act:National Healthcare Reform
Focus on Coordination Integrated physical and behavioral healthcare Outcomes Prevention Wellness Hospital diversion Individualized care
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Affordable Care ActState Healthcare Reform
$54 billion Medicaid program with 5 million beneficiaries
20% (1 million beneficiaries) use 80% of these dollars: hospital, emergency room, medications, longtime “chronic” serviceso Over 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 reasons8
New York State’s Challenge
Health and Recovery Plans Health Homes Home and Community Based Services Delivery System Reform Incentive
Payment Performing Provider Systems
Value Based Payment Eliminate racial disparities in healthcare
NYS Medicaid Waiver
From fee for service to outcome based care
Diversion from emergency room and inpatient hospital use
Surprise! We are healthcare providers
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The Mantras of the MRT
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 services
NYS Medicaid Redesign
Inpatient - SUD and MH
Clinic – SUD and MH Personalized Recovery
Oriented Services Assertive 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)
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Managed Care Plans Now Offer Medicaid funded BH Services
• 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
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Health and Recovery Plans
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 years
60+ days in OMH psych center Incarceration w BH treatment past 4
years 2+ SUD ER visits, detox stays for SU
related inpatient stays
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)
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Who’s Not Eligible for HARPs?
AetnaCapital District Physicians Health Plan
Excellus Health Plan.Fidelis Care New York MVP Health Care
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Health Plans in Broome County
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 response Focus on well coordinated discharge and treatment
planningWhat are your experiences with Health Home Care Management?17
HARP Beneficiaries’ Care is Managed via Health Homes
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 ManagementCare Coordination and Health
PromotionComprehensive Transitional Care
Individual and Family Support Referral to Community and Social
Support ServicesUse 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 Model
Greater Binghamton Health Center Endwell Family Physicians The Family & Children's Society Catholic Charities Of Broome County The Addiction Center Of Broome County Southern Tier Independence Center Mental Health Association Of Southern Tier
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Catholic Charities of Broome County
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
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Catholic Charities of Broome County
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
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Catholic Charities of Broome County
Arms Acres Conifer Park Greater Binghamton Health Center Arms Acres Southern Tier Aids Program United Health Services The Family And Children's Society Conifer Park United Health Services
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United Health Services
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 Aging23
United Health Services
CASA Community Hunger Outreach Warehouse Mental 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 Services
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
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United Health Services
RehabilitationPsychosocial RehabilitationCommunity Psychiatric Support and Treatment (CPST)Residential Supports/Supported Housing
HabilitationCrisis Intervention
Short-Term Crisis RespiteIntensive Crisis InterventionMobil 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 TransportationIndividual Employment Support Services Prevocational Transitional Employment Support Intensive Supported Employment On-going Supported EmploymentPeer and Family SupportsSelf Directed Services
7 days from inpatient discharge to outpatient appointment
30 days to filled prescriptionDepression screening and follow up
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Beyond HEDIS Outcome Measures
Participation in employment Enrollment in vocational rehabilitation
services and education/training Improved or Stable Housing status Access to and use of Peer Support Longer Community tenure, Decreased
Hospital Readmissions Decreased Criminal justice involvement Improvements in functional status Cultural & Linguistic Competence,
Engagement
HCBS Outcome Measures:Social Determinants of Care
= 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
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STATE MEDICAID AGENCY DOHOASAS
$7.1 billion over 5 years for DSRIP
$650 million to play for Home and Community Based Services
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NYS Medicaid Waiver
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.
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Delivery System Reform Incentive Payment Program (DSRIP)
Performing Provider Systems are networks of providers that collaborate to implement DSRIP projects
Each PPS must include providers to form an entire continuum of care Hospitals Health Homes Skilled Nursing Facilities
(SNF) Clinics & FQHCs Behavioral 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 Systems
Project
Description PPSs Involved
3.a.i Integration of primary care and behavioral health services 253.a.ii Behavioral health community crisis stabilization services 113.a.iii Implementation of Evidence-Based Medication Adherence
Program (MAP) in Community Based Sites for Behavioral Health Medication Compliance
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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
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3.a.v Behavioral Interventions Paradigm (BIP) in Nursing Homes 14.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
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: 102,386
Total Award Dollars: $224,540,27534
Care Compass Network
Home Care Independent Living Center Addiction Center Nursing and Rehabilitation Center Primary Care County Health Departments County Office for Aging Hospice and Palliative Care
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Provider Groups
Hospitals Vocational Rehabilitation Services for People w Developmental
Disabilities Health Homes Compeer Pharmacies
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Provider Groups
Hospice and Palliative Care Therapeutic Communities Senior Living Center Suicide Prevention And Crisis Service United Cerebral Palsy Association Visiting Nurse Service YMCA
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Provider Groups
Integration of primary care and behavioral health services (required of all 25 PPSs)
16 PPSs also included: Community crisis stabilization services Transitional Supports Activation Medication adherence programs Withdrawal Management Behavioral Interventions in Nursing Homes
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Behavioral Health Projects
Lakeview Mental Health Services, Liberty Resources Mental Health Association Of The Southern
Tier Northeast Parent And Child Society Onondaga Case Management Services Parsons Child And Family Center Phoenix Houses Planned Parenthood Rehabilitation Support Services
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Behavioral Health Providers
Integrated Delivery SystemDevelopment of Community
Based Health Navigation ServicesPatient ActivationEvidence-Based Strategies for
Disease ManagementCOPD Preventative Care and
Management40
Projects
30 Day Care Transitions for Chronic Diseases, including BH Conditions
Integration of Behavioral Health and Primary Care
Strengthen Mental Health and Substance Abuse Infrastructure, Prevention and Targeted Interventions
Crisis Stabilization41
Projects
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 outcomes
A component of DSRIP that is key to the sustainability of the Program
Value Based Payment
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
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Value-Based Payment Reform
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
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Value-Based Payment Reform
To share in savings, you eventually need to take on risk…
Partnering with other providers is essential to being able to take on risk
We 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.
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VBP: Sharing in the Savings
Proposals to: Integrate physical and behavioral
healthcare get 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
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Value-Based Propositions
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%
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Value-Based PropositionsAn example
We helped see that OMH HCBS services were added to the list of SDH interventions
All 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
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NYAPRS Advocacy on Value Based Payment Work Groups
We’ve insisted that VBP outcomes include recovery and social determinant related ones (beyond HEDIS) Ex: maintenance of housing stability
Strong emphasis on cultural competenceBuy not BuildPosition our members for gain sharing
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NYAPRS Advocacy on Value Based Payment Work Groups
Development of Member Incentive Programs
Creation 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/members50
NYAPRS VBP Advocacy:Advocacy and Engagement
NYAPRS and MHANYS: partnerships that advocate for recovery outcomes, services and providers and for consumer rights and choice protections
Our 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
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Homework
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
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Homework