Integrated Healthcare: Striving for Better Care

APP0040 (09/10)

A combined presentation from the MCO’s

Presented by Lynn Bradford, Ph. D., HSPPDirector of Behavioral HealthMDwise, Inc.

Purpose of today’s presentation

Philosophy Administration Integration MDwise Managed Health Services Anthem

Philosophy Integrated Care is one way to open up access to

behavioral health services of which the 7 day follow up is one.

Local management of behavioral health services. Improved coordination and collaboration between

medical and behavioral health providers (work in progress)

Utilization management and case management services are integrated, medical and behavioral health managers work together to manage members’ needs.

Building a “right sized” network of skilled providers, statewide.

Administration

MDwise medical and behavioral health case managers and utilization mangers work together to mange our members as a unified team at the Delivery Systems.

At the delivery system level of MDwise there is integrated staffing of member’s cases.

Integration Grant Project

MDwise is piloting metrics with our grant recipients who are implementing integrated care so that each recipient can present their projects to other providers in the State to further implement integrated care throughout the State.

The pilot participants will include:St. Vincent Primary CareMidtown CMHCGallahue CMHCSt. Francis Medical Group

Integration Grant Project A seminar is planned for November for primary

care and behavioral health providers; continuing education credit will be offered

A historical overview of integrated care will be presented

Grantees will present their projects and outcome metrics

National best practice will be discussed Next steps for Indiana so that integrated care can

move forward

Discharge PlanningTransition Planning

History of fragmentation in systems of care Not part of treatment planning Little communication between service

providers Interruption of care is among the most

significant obstacles to a stable recovery

Discharge Planning

In response, MDwise is moving towards transition planning AACP (2001,2009) developed “Best Practices for Managing Transitions

Between Levels of Care”. (www.communitypsychiatry.org) http://www.communitypsychiatry.org/publications/clinical_and_administrative_tools_guidelines/COG.doc

Guidelines developed through clinical experience and existing information Committee consensus determined each element Each element has an outcome indicator to measure adherence to the

principles 14 elements identified as best practices for transition planning Guidelines not yet considered evidence based

Bridge Appointments MDwise uses codes 99401 and 99402 billed on a CMS-

1500 claim form. Revenue Code 513 is paid on a UB form Code 99401 pays a flat fee of $25 (15 minutes) Code 99402 pays a flat fee of $50 (30 minutes) Rev. Code 513 pays a flat fee of $50

A prior authorization through the member’s Delivery System must be obtained prior to discharge. This can be done during the initial call for an inpatient authorization.

The progress report, after the Bridge Appointment is completed, is faxed to the MDwise Delivery System, the outpatient therapist, and the member’s case manager at MDwise.

Provider Education Network Improvement Program Team and

Provider Relations provide outreach and education to the Behavioral Health provider network.

Provide education on claims, PA, and billing guidelines.

Provide education on HEDIS and the quality measures.

Provide education on Case Management. Provide educational materials and reports. Provide materials to assist in meeting the 7-day

follow up standard.

Hoosier Alliance & Select Health – Case Management Case Study Kept Hoosier Alliance and Select Health have

increased case management efforts and tracking of inpatient discharges.

The following information is tracked: Inpatient facility, date of discharge, bridge appointment provided, outpatient appointment schedule and date, reminder call, bridge and/or outpatient appointment kept.

The case manager does not allow a discharge without the 7 day follow up appointment scheduled.

The case manager contacts the member to remind them of the appointment and follows up after the appointment to ensure the appointment was.

Administration MHS Case Managers, Cenpatico

Intensive Case Managers (ICM) and Utilization Managers work together as integrated teams to ensure a seamless delivery of services. Cases are staffed jointly to identify service gaps and develop an integrated plan to improve member outcomes.

Intensive Case Management Cenpatico Intensive Case Managers (ICMs)

start intervening as soon as we are notified of and inpatient event.

Outreach to the Hospital Social Worker, Discharge planner and family prior to discharge to coordinate community appointments.

Once discharged from an in-patient stay, each member is followed by an ICM for 6 months to help ensure that there are no barriers to follow up care.

Intensive Case Management Once discharged, ICMs contact the

member/parent to confirm appointment. If appointment falls outside the 7 day window assistance is provided to obtain an appointment with seven days.

Summary of discharge information is faxed to member’s PMP and outpatient behavioral health providers.

Perinatal Depression MHS/Cenpatico have worked to increase the

identification and treatment of pregnant or postpartum women with depression.

In an effort to better coordinate medical and behavioral health care, Intensive Case Managers notify the member’s medical provider when a member returns a depression screening tool that scored positive for signs of depression.

The Intensive Case Manager informs the medical provider that education will be provided to the member regarding depression, the available benefits to her under MHS and how to access these services.

Post Hospitalization Safety Incentive

An Incentive targeted at ensuring the 7 day follow up appointment for members discharged from Inpatient Hospitalization.

Target members: Ages 4 – 18 years of age. Members are informed during an Inpatient Hospitalization

and/or immediately following that if they complete their 7 day follow up appointment they will receive an incentive.

The incentive consists of a Build A Bear, a book on feelings and a $10.00 gift card to Wal-Mart.

January – September 2010 226 incentive packages have been mailed.

Caring Voices Intensive Case Managers identify high-risk members

who otherwise have little or no access to telephone service and provide free cell phones.

All Cenpatico Intensive Case Managers currently have a Caring Voices phone available to deliver to inpatient providers prior to discharge to aid in bridging the gap between member and provider, increasing member compliance and improving healthy outcomes.

Caring Voices phones allow outgoing calls only to preprogrammed numbers: Community Mental Health Centers, MHS/Cenpatico, Primary Medical Provider, transportation, pharmacy. Incoming calls are always open.

Provider Education EffortsThe Bridge Appointment

A detailed explanation of the HEDIS measure is provided to the provider

Discussions take place to ensure that the provider understands the value of ensuring that the member is assisted in making the transition back to their home, family and community

Informed that this is a “last resort” and not to take the place of a valid OP appointment

Primarily used when getting an appointment within 90 days is very difficult

Explanation of how to bill for the Bridge Appointment for IP Providers and list of other services that OP Providers can perform that count toward the HEDIS measure

Bridge Appointments Cenpatico has identified several High volume Hospitals to

provide Bridge appointments. The Bridge Appointment takes place on the day of

discharge. Demographic information, Community Provider information,

including date of next appointment is reviewed. Completed Bridge Appointment document is faxed to ICM

staff within 24 hours. ICM staff follow up with member/ parent to ensure 7 day

appointment is made and to assist with barriers in completing the appointment.

Bridge Appointment Cont..

If there is an appointment listed on the Bridge Appointment document outside of the 7 day expectation the ICM staff assist with rescheduling a more appropriate appointment.

No Prior Authorization is needed Bridge Provider will contact Cenpatico ICM’s via fax with

Bridge Appointment Documentation Bridge Provider will create a report with the names and

dates of those members that participated Revenue Code 513 will be used to process all Bridge

Appointment claims and will be billed on a separate claim

Bridge Appointments Cenpatico uses Revenue Code 513 to assist with

ensuring that members that are being discharged from an in-patient stay have an opportunity to meet with a behavioral health provider after discharge to the discharge plan and any post discharge information.

Revenue Code 513 should be billed on a UB Form. A prior authorization through the member’s Delivery

System must be obtained prior to discharge. This can be done during the initial call for an inpatient authorization.

The progress report, after the Bridge Appointment is completed, is faxed to the MDwise Delivery System, the outpatient therapist, and the member’s case manager at MDwise.

Managed Health Services

What is Cenpatico is doing to make integration easier?

No need to bill Cenpatico when billing 96150-96155 and billing under a PMP for health providers

PMP is allowed to supervise mid-level behavioral health providers

School-Based Health Care Services

MHS and Cenpatico also facilitates the planning, development, implementation, and evaluation of comprehensive integrated School-Based Health Centers (SBHCs).

What is a School-Based Health Center -- SBHC?

A SBHC is a “health center located in a school or on school grounds that provides school-aged children on-site comprehensive preventive and primary health services, including behavioral health, oral health, ancillary, and enabling services.”

Services provided in a SBHC:

General health assessments EPSDT screenings Laboratory and Diagnostic screenings Immunizations First Aid Family Planning and counseling Prenatal and postpartum care

Services Provided in a SBHC:

Dental Services Behavioral Health Services

o Billing codes: 96150-96155 Drug & Alcohol Abuse Services Prescription Drug Distribution &

management Patient Education & other services based

on student need

Anthem Blue Cross and Blue Shield Values and Beliefs Development of strong collaborative relationships with

our providers / partners in care Integration, coordination, and collaboration between

medical and behavioral health delivery systems / providers

Innovation- Advanced programs to provide proactive interventions geared to promote and improve better health

Timely follow up after hospitalization promotes sustained progress and longer community tenure

Anthem Blue Cross and Blue Shield Strategy One Team caring for the Whole Person

Collocated Behavioral Health and Medical Case Managers Shared medical information system Coordinated Care Conferences

• Case Managers work closely with the “clinical team” involving behavioral health / medical management case managers as well as the Primary Medical Provider and Behavioral Health Service Provider

Mutual referral processes State of the Art Disease Management Programs

Co-Existing Depression and Anxiety Program (CODA) Maternity Depression Program (MDP) Bipolar Disease Management Program Attention Deficit Hyperactivity Disorder

(ADHD) Program Autism Program

Anthem Blue Cross and Blue Shield Strategy Tiered Case Management Program

Members move between a three tier program based upon need and progress

Community Partnerships Maintenance and development of collaborative community

relationships, i.e. ASK (About Special Kids) Provider Collaboration and Education

Case Managers work with providers as team members and not “vendors”

Comprehensive educational seminars and opportunities geared toward integration of care and best practices

Anthem Blue Cross and Blue Shield Discharge Planning Comprehensive Discharge Planning is crucial to the

overall success of the member’s treatment Engages the member and his/her family in the ongoing

treatment plan Encourages member and PMP interaction and assists the

member in choosing a medical home if one has not been selected

Establishes a follow up appointment with an outpatient provider within 7 days of discharge

Transitions the member to a longer term provider along the continuum of care Alignment of the right care in the right setting

for the right amount of time

Anthem Blue Cross and Blue Shield Discharge Planning

Educates the member about their medications and the importance of compliance

Supports integrated and non-disrupted ongoing care Members who attend an outpatient appointment within

seven days of discharge have:

• Longer community tenure

• Increased commitment to treatment with fewer failed appointments

Anthem Blue Cross and Blue Shield

Transition Program Provides a seamless transition from inpatient to

outpatient care Facilitates integration of care through expedited

communication with the outpatient provider regarding the member’s history and treatment plan

Addresses barriers to continued treatment / medication compliance

Supports member engagement with their community provider

Demonstrated Results Increased follow up rate with community provider Decreased hospital readmissions

Anthem Blue Cross and Blue Shield Provider Outreach Provides educational opportunities and materials around

HEDIS, quality improvements, and billing tips Provides feedback on performance and opportunities for

improvement through Facility Report Cards Provides tips and tools to assist in improving ambulatory

care follow up Provides education on member outreach and Anthem’s

Case Management Programs Provides numerous webinars, seminars, and materials

for increased knowledge

Anthem Blue Cross and Blue Shield Transition Program Providers should bill Revenue Code 0513 along with the

accompanying CPT code of xxxxx Revenue Code 0513 is reimbursed at $70

Authorization is required at the time of the appointment and is obtained by sending the summary report via facsimile to Anthem’s case management staff

The summary report is sent to the outpatient provider via facsimile

Questions?????