Health Care Reform & Integration In Maine. A Provider s Lessons Learned..

Transcription

1 Health Care Reform & Integration In Maine A Provider s Lessons Learned..

2 Catholic Charities Maine Who We Are One of the largest statewide social service agencies in Maine Operate 25 Programs in 15 sites throughout the state Serve over 55,000 people in Maine annually Serving those in need with special emphasis on Maine s most vulnerable populations-the poor, individuals with disabilities, seniors and children Our Mission Inspired by scripture and the Church s social teaching, Catholic Charities empowers and strengthens individuals and families of all faiths by providing innovative community-based social services throughout Maine.

3 About our Organization FY '15 Annual Budget of $29 Million, Funding Source by % Donations, Grants, Other, 5% Threads of Hope Thrift Operations, 4% Diocese of Portland, 2% United Way, 1% Fees for Service, 10% Government Resources, 78%

4 What We Do Where We Do It Behavioral Health Network Services Adult Mental Health Services Assertive Community Treatment Community Integration Behavioral Health Home 1 Addiction Treatment Services Outpatient Intensive Outpatient Suboxone 2 Medication Assisted Treatment DEEP Services DSAT Treatment Residential (Halfway house) Extended Shelter Children s Behavioral Health Services Targeted Case Management Wraparound Services Functional Family Therapy 6

5 Population density KEY DEMOGRAPHICS: o Geography o Population Density o Age o Socio-economics o Government, Politics o Weather

6 CMS Health Homes ACA Section 2703 Chronic conditions (per CMS): Mental health Substance abuse Asthma Diabetes Heart disease Overweight (BMI > 25) & Obesity Maine-specific Chronic Obstructive Pulmonary Disease (COPD) Hypertension Hyperlipidemia Tobacco use Developmental Disabilities & Autism Spectrum Acquired brain injury Cardiac & circulatory congenital abnormalities Seizure disorder

7 CMS Health Homes ACA Section 2703 Required Health Home services include: Comprehensive care management Care coordination and health promotion Comprehensive transitional care from inpatient to other settings Individual and family support Referral to community and social support services Use of health information technology (HIT) Prevention and treatment of mental illness and substance abuse disorders Coordination of and access to preventive services, chronic disease management, and long-term care supports

8 Why Health Homes Here? 20% of MaineCare members incur 87% of cost initially the target population for Maine Health Homes. This 20% often have more than one long-term condition, such as: COPD Diabetes Mental Illness Heart Disease Substance Abuse

9 The Overarching Goal

10 The Tools at Hand

11 Maine State Innovation Model (SIM) Initiative Our Mission Our Vision Our Strategy The Maine SIM initiative, through a collaborative process, will promote the alignment and acceleration of statewide innovations designed to improve health and health care and reduce health care costs for the people of Maine Working together to promote innovations which transform health care and make Maine the healthiest state in the nation We will achieve this vision by leading and aligning efforts to transform health care delivery and payment using the following primary innovations: Strengthen Primary Care Integrate Physical & Behavioral Health Care Develop New Workforce Models Develop New Payment Models Centralize Data & Analysis Engage People & Communities Primary Innovations Expand access to Patient Centered Medical Home (PCMH) / Health Home (HH) models Provide quality improvement support, recognition & rewards to PCMH/HH practices Provide leadership development opportunities for providers Provide learning collaborative & technical assistance to help BH organizations move to Health Homes model, and to improve integration of physical and BH Provide resources & assistance to BH providers for health information technology and interoperability Develop BH quality measures Develop Community Health Worker pilot in 5 communities Develop Diabetes Prevention Program Provide training for PCMH/HH practices to improve care for persons with developmental disabilities Support efforts to Align Long Term Care with PCMH/HH models Support the Improvement of care transitions Support development of Accountable Community Organizations (ACOs) Offer ACOs peerto-peer learning Develop common quality measures Engage employers, payers, and consumers Develop valuebased insurance & benefit design Support development & use of common quality & cost measures Support the development of standard cost & quality reporting Engage patients and families as active participants in their care Conduct consumer engagement campaign, with special focus on MaineCare members Promote Shared Decision Making, tools including Choosing Wisely Measure & publicly report patient experience Goals by 2017 The total cost of care per member per month in Maine will fall to the national average Maine will improve the health of its population in at least four categories of disease prevalence (ie diabetes, mental health, obesity, etc) Maine will improve targeted practice patient experience scores by 2% from baseline for practices that participated in the 2012 survey Maine will increase from 50% to 66% the number of practices reporting on patient experience of care

12 Maine Health Homes Stage A: Patient Centered Medical Home VS. Stage B: Behavioral Health Home High Need Individual Comprehensive and Coordinated Coaching Individual with SPMI/SED Community Care Team Med Mgt Behavioral Health & Subst. Abuse Treatment Care Mgt Medical Home Practice

13 The BHH Team Approach PCP and mental health services work together to provide better care Team-based, comprehensive approach: nurse care manager peer support specialist licensed clinical social worker health home coordinator Manage health, wellness, and prevention services Provide peer services and other supports Case management; help with housing, transportation, etc. 11

14 Concept Application

15 BHH and Primary Care Requirements BHH Requirements MH Licensure Provide OR have MOA with provider of medication management Have expertise in co-occurring disorders Utilize or adopt an EHR within 24 months of approval as BHH Participate in the Behavioral Health Home Learning Collaborative Comply with team-based care model Partner with at least one qualified practice Commit to meeting and reporting on ten (10) Core Expectations Primary Care Provider Requirements Utilize an Electronic Health Record (EHR) system. Provide Twenty-Four Hour Coverage Have received National Committee for Quality Assurance (NCQA) Patient- Centered Medical Home recognition by date determined by MaineCare Have established member referral protocols with area hospitals, which include coordination and communication on enrolled or potentially eligible HHP members. Must partner with a Behavioral Health Home provider Commit to Core Expectations for Health Home practices

16 1 5 Reimbursement for BHH Services Payment is structured to support both the PCP and the Behavioral Health Home provider to coordinate care: Primary Care practice $15/PMPM* Behavioral Health Organization PMPM = PER MEMBER PER MONTH $394.40/PMPM as of 1/1/16-Single Rate Originally: $322.00/PMPM for children $365.00/PMPM adults *PASS THROUGH FROM BHH TO PCP FOR SMALL ADMINISTRATIVE FEE TO COMPLY WITH CMS SINGLE PAYMENT REQUIREMENT

17 GO LIVE! Kick Off was April Month delay in implementation due to complexity of roll-out, lack of finalized rules, etc.

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19 Key Factors/Interventions

20 $160,000 Quarterly Financial Performance $140,000 $139,618 $120,000 $114,610 $104,025 $104,529 $100,000 $85,844 $80,000 $70,996 $76,408 BHH Revenue BHH Expenses BHH Net $60,000 $54,020 $40,000 $20,000 $0 $40,515 $40,650 $40,888 $29,819 $30,796 $35,708 $10,696 3rd Qtr FY14 $9,854 $5,179 4th Qtr FY14 1st Qtr FY15 $41,713 $46,819 $24,177 $18,181 $12,307 2nd Qtr FY15 3rd Qtr FY15 4th Qtr FY15 $38,202 $35,089 1st Qtr FY16 2nd Qtr FY16

21 Implement Challenges we faced early on 1. Enrollment Strategy th hour rule changes prior to GO LIVE 3. Universal Notification for all eligible clients originally planned 4. BHH Billing process design 5. Coordination and structure to MQC, MHMC and SIM 6. BHH training standards, resources 7. BHH Member restriction to ONLY partnered (MOU) PCPs originally planned

22 Evaluate What we learned following roll out 1. Utilization and Claims Data - Robust Data Pool 2. Training for BHH Staff Chronic Conditions 3. Competition/Collaboration Dynamic and Service Delivery Reform 4. Rate Setting 5. Differentiation of Services, Target population, goals and transition criteria/structure 5. The model works! Now we have proof of concept in our State.

23 Develop/Adapt The Present and Looking to the Future 1. Expansion 2. Implementation of formal BHH staff training curriculum 3. Marketing-Focus on Continuum of Care 4. Strengthening of our Peer Support role 5. Population Health Offering Wellness Workshops and Nurse Care Manager Role. 6. Snugging up how our interdisciplinary team, BHH members and community partners; work together to optimize the benefits of this model 7. Ongoing & enhanced leveraging of technology; Broad Reach through VTC, Clinical Decision Making, Key Performance Indicators, Real Time Utilization Notifications (HIE) 8. Continuing to advocate for system design improvements to achieve the Triple AIM

24 Questions, Comments?