Making Data MeaningfulA Provider’s Experience in Selection, Collection and Analysis of Metrics

Featuring Acacia Network

National Council for Behavioral HealthMontefiore Medical Center

Northwell HealthNew York State Office of Mental Health

Netsmart Technologies

Today’s Presenters

Samantha HolcombeDirector, Practice ImprovementNational Council for Behavioral Health

Stephanie CurryProgram Director for Amanecer Recovery Center (Detox and Rehab), Acacia Network

Stephanie NietoAdministrator for Health Homes Care Management Agency Serving Adults and Children, Acacia Network

The Shift to Value-Based Care

A healthcare delivery model in which providers arepaid based on patient health outcomes.

Value =Health Outcomes

Cost of Delivery

Need to be able to

measure

What This Means for Providers

Providers need to:• Identify the measures and outcomes most relevant to their patient

populations• Know and understand performance against these metrics• Speak to what your organization is doing to drive that performance • Have the ability to collect and analyze performance

Challenges

Quality Measures Not Standardized Across Markets

Over 1,600 federal quality measures

spread out over 33programs

Over 500 measures across state/regional programs, only 20% used by more than

one

29 private health plans identified

approximately 550 distinct measures

https://www.psychu.org/are-you-suffering-from-measurement-fatigue/

Challenges

https://www.psychu.org/are-you-suffering-from-measurement-fatigue/

Data collectionData reporting

Optimizing EHRs

Data sharing

Data analysis

Where to Begin?

https://www.psychu.org/are-you-suffering-from-measurement-fatigue/

Be Strategic and Realistic. Ask yourself:

• Who is your population?• What physical and behavioral health conditions do they have?• What services do you offer to address those conditions?• How are you measuring improvement or adherence to recommended

guidelines?• Who are your payers?

• What are their pain points?• What are their most important measures?• What concerns may they have around your population?

Metric NQF HEDIS QPP DSRIP CCBHC

All-cause 30-day readmission rate following MH inpatient discharge x x x

Follow-Up After Hospitalization for Mental Illness (FUH) x x x x xDiabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medication

x x x x

Preventive Care and Screening: Screening for Depression and Follow-Up Plan x x x x

Preventive Care and Screening: Body Mass Index Evaluation and Follow-Up x xAdult Major Depressive Disorder (MDD): Suicide Risk Assessment x xDepression Remission (6- and 12-months) x x x

Adherence to Antipsychotic Medications For Individuals with Schizophrenia x x x x x

Anti-Depressant Medication Management x x x x

Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

x x x

Initiation/engagement of alcohol and other drug (AOD) dependence treatment

x x x x x

Selecting Meaningful Measures

https://www.psychu.org/wp-content/uploads/2018/09/An-Update-From-NCQA-Focusing-On-HEDIS-Behavioral-Health-Measures.pdf

Relevance• Meaningful to stakeholders• Important to enhance

health• Controllable• Potential for improvement

– substantial variation

Scientific Soundness• Based on best available

evidence• Linked to outcomes• Valid and reproducible

Feasible• Precisely specified• Needed data available• Cost of data collection is

reasonable

Process Measures

Provider Actions

What are we doing?

Outcome Measures

Consumer Impact

Is it working?

Ensuring The Right Mix

Operationalizing

https://www.psychu.org/are-you-suffering-from-measurement-fatigue/

What is your current

performance?Quality

improvement opportunities

Where are there gaps?

Longer term needs

What data do you already

collect?Low hanging fruit

• Stephanie Curry, AmanacerProgram Director

• Jordania Estrella, Sr. Administrator of Outpatient and MAT Programs

• Yaberci Perez-Cubillan, VP Behavioral Health Services

• Stephanie Nieto, Administrator Health Homes

• Irene Ceregnul, Medical Director• Bright Akhere, Director of Revenue

Cycle

• Gabriela Marinescu, Asst. Manage Care Director

• Rebecca Arce, Care Manager• Tony Curry, Care Manager

Acacia VBP Work Team

The Acacia Network value-based payment transformation project to reduce re-admissions for high risk patients in detoxification has substantially redesigned the care pathway utilizing data driven risk stratification, enhanced staffing patterns, and improved clinical and social programming.

Specific objectives are outlined on the following slides.

Project Overview

• Updated data entry at intake; implementation of Risk Assessment in Y1• Reduced admission paperwork• Established performance variables is at 12 based on Y2 data

• Y1: Measuring at 2 weeks intervals • Y2: Measuring at monthly intervals

• Produced 3 years of readmission report for analysis - changed to 1 year analysis

• Identified high utilizers - identification of 5X re-admission • Implemented Tableau • Implementing electronic medical record

Accomplishments: Data Collection

Y1 INDICATORS Pilot 1 Pilot 2 Pilot 3 Pilot 4 Pilot 5 Pilot 6 Pilot 7 Pilot 8 Trend PCP Confirmed 56% 82% 73% 58% 69% 64% 65% 77% ↑

Pending PCP 43% 18% 27% 42% 31% 35% 35% 23% ↑

Against Medical Advice 35% 10% 23% 27% 19% 21% 24% 33% ↓

Decreased Dosage 31% 51% 57% 56% 42% 47% 44% 41% ↑

Rehab Admission 10% 13% 27% 23% 23% 20% 29% 29% ↑

Confirmed 27% 40% 58% 42% 32% 50% 59% 51% ↑

Confirmed & Kept Appts.

N/A 23% 36% 30% 49% 39% 50% 49% ↑

PCP Appt. N/A N/A N/A N/A N/A N/A N/A N/A N/A

Risk Assessment Low N/A 24% 15% 15% 15% 19% 16% 16% N/A

Risk Assessment Med N/A 41% 46% 54% 35% 46% 39% 16% N/A

Risk Assessment High N/A 12% 16% 18% 32% 24% 38% 40% N/A

Metric Sample Report: 2-week Intervals

Outcome• Maintain AMA at 25% • Maintain Re-Admission Rate Comparable to Manage Care• Admission to Amanecer Rehab • Medication Assistant Treatment (MAT)

ProcessCoordinated Care• Identification of PC/MH Professional• PCP Confirmed• PCP Re-Scheduled• PCP Kept.• Health Home enrollments

Y2 Performance Indicators

Screening/Risk Assessment• Behavioral Health Risk Assessment-

High rating• PHQ2/9-High rating• Homelessness

Y1 INDICATORS Cycle 1-Mar

Cycle 2-Apr

Cycle 3-May

Cycle 4-Jun

Cycle 5-Jul

Cycle 6-Aug

Cycle 7-Sep

Cycle 8- Oct

Admissions 156 188 186 162 168 189 161 163

AMA 33% 30% 24% 25% 21% 19% 24% 25%

Readmission 2% 2% 2% 2% 2% 1% 0.6%

Admission to AmanecerRehab

19% 21% 21% 27% 19% 22% 19% 21%

MAT Program 25% 12% 13% 2% 2% 8% 14% 10%

PCP Confirmed 66% 85% 81% 86% 74% 96% 75% 69%

PCP Appt. Rescheduled 12% 32% 90% 40% 35% 30% 34% 44%

PCP Attended 2% 2% 2% 2% 2%

Risk Assessment High 37% 45% 46% 53% 62% 58% 58% 47%

PHQ2/9 High 41% 43% 42% 43% 33% 38% 31%

Homeless 46% 43% 47% 51% 44% 46% 46% 39%

HH Enrolled 35% 34% 58% 66% 68% 71% 64% 74%

Metric Sample Report: Y2 1-month Intervals

• In Y1, implemented health risk assessment to determine low, medium, high risk• The Y2 Risk Assessment process evaluates primary care needs, mental health needs (PHQ 2/9),

confirms diagnoses, identifies social determinants of health (access to food, housing), and screens for HH

• Identification/Referral to Medical/Mental Health Provider• Schedule appointments to Medical/Mental Health Provider and follow-up to monitor• Identification/Referral to HH

• Designed person centered risk stratified care planning-based on risk assessment score • Y1: Implemented daily huddles to review high risk patients and participated in collaborative case

conferences with St. Barnabas Hospital • Y2: Collaborative Case Conference with St. Barnabas have continued; providing intensive case

management via team case conferences• Receive alerts when patients present for admission for Detox services from St. Barnabas Hospital -

developed consent for patient to participate in collaborative case conferencing

Risk Stratification

• Improved patient flow from intake through room assignment• Redefined staff roles and responsibilities• Prioritized PCP notification and communication; PCP Referrals (and MH referrals,

if applicable); • PCP confirmed• PCP appointment re-scheduled• PCP attended

• Updated medication protocols and outcomes• Enhanced clinical and social programming • Revised analysis of key indicators as part of quality improvement

Accomplishments - Clinical & Care Transitions Pathways

• Established joint care planning for high utilizers using Acacia Network and local hospital St. Barnabas detox units. The goal is to reduce revolving door re-admissions.

Accomplishments - Care Transition with Hospital Detox

• Repainted, office upgrades, and established care management drop in office

• Provide admission brochure for treatment expectations and continuing care poster for patient decision making

• Added patient into case conferences• Added social and creative arts activities- Music and Dance Therapy

Accomplishments – Patient Experience

• Re-instituted Nursing Supervisor• Decrease caseload by adding counselor• Shifted Program Manager position to Asst. Clinical Director position• Embedded health home care managers and heath navigators; placing

emphasis on care management support

Accomplishments – Staffing Pattern

• Engaged with one managed care plan on readmission VBP to start Q1 2019

• Monthly Meetings with Personnel from select MCO; Options to discussions Initial Engagement Treatment (IET measures) for High Utilizers

• Currently in conversation with additional MCO’s to start receiving/reviewing claim data

Accomplishments – Monitor & Evaluate Cost of Care

We continue to apply these key areas for future value-based payment practice transformation efforts:

• Data Driven Decision Making• Staff Engagement and Critical Thinking• Workflow Optimization• Person Centered Risk Stratification

Lessons Learned

Establish User Friendly Data Collection and Analysis System:

• Support follow-up, monitoring and uncovering trends. • Keep the momentum for quality activities • Reveal new areas to explore• Highlight gaps in thinking and actions

Lessons Learned – Data Driven Decision Making

• Fundamental for understanding, buy in and transparency• Value of walk-throughs and workflow mapping • Impact of collaborative case management• Prioritize lean process to invest time in valuable activities• Driving forward needs breathers• Frequently celebrate small wins• Reinforced team approach

Lessons Learned – Workflow Optimization

• Risk stratification focused the clinical dialogue• Patient felt respected and appreciated that their situation was being

carefully reviewed• Maximizing the patient experience makes the difference with their

voice heard with serious intent • Patient value the objectivity of the score• The risk score drives the care plan

Lessons Learned – Person Centered Risk Stratification

• Consulting with national health care consultants for corporate wide VBP readiness

• Information technology• Clinical Pathways• Financial

• Complete joint care planning with hospital.• Measure performance with MCO’s• Incorporate additional social determinants of health (job security,

education, etc.)• Implement referral tracking system such as “Referral MD”

Next Steps for Continued Transformation –Sustainability Plan

Y3: To Begin 2019 (Follow-Ups)

• 14 Day Follow-Up with Licensed Professional (Internal/External)• 34 Day Follow-Up with Licensed Professional (Internal/External)• Any Re-Admission post 90 days would be considered a new

event (new episode of treatment).

Next Steps for Continued Transformation –Initiation and Engagement Treatment (IET)

Measures

Questions?

Thank you!www.CareTransitionsNetwork.org

CareTransitions@TheNationalCouncil.org

The project described was supported by Funding Opportunity Number CMS-1L1-15-003 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. Disclaimer: The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.