The Care Transitions Network

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Ilene Smith
6 years ago
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Making the move to Value Based Reimbursement/Payment/Purchasing

Organizations Performance The Care Transitions Network Presented

Box 1027, Holly Springs, NC 27540 Phone: 919-395-5911 Fax:

1 Making the move to Value Based Reimbursement/Payment/Purchasing (VBR/P 2 ): Using Data to Improve Care Delivery and Your Organizations Performance The Care Transitions Network Presented by: Scott C. Lloyd, President M.T.M. Services P. O. Box 1027, Holly Springs, NC Phone: Fax: scott.lloyd@mtmservices.org Web Site: Scott Lloyd, President 1

2 Experience Improving Quality in the Face of Healthcare Reform MTM Services has delivered consultation to over 800 providers (MH/SA/DD/Residential) in 46 states, Washington, DC, and 2 foreign countries since MTM Services Access Redesign Experience (Excluding individual clients): 5 National Council Funded Access Redesign grants with 200 organizations across 25 states 7 Statewide efforts with 176 organizations Over 5,000 individualized flow charts created Leading CCBHC Set up and/or TA efforts in 5 states Scott C. Lloyd, President 2

4 Shift in Payment Model 1. As parity and national integrated healthcare provided under the Affordable Care Act (ACA) are implemented, new models of shared risk funding are being introduced. 2. A shift by payers such as Medicaid, Medicare and Third Party Insurance from paying for volume to paying for value provides a significant challenge for CBHOs. 3. Ability of all staff to develop a dynamic tension between quality and cost as if they are on a pendulum 4. A large majority of CBHOs do not have an ongoing awareness of their cost of services or cost of processes involved in the delivery of services (i.e., What is your cost and time to treatment? ) Scott Lloyd, President 4

5 The Values that Community BH Clinics Now Need Community Behavioral Health Clinics (CBHCs) have an excellent opportunity to be helpful partners in the new integrated healthcare system if they can display the following specific values: 1. Be Accessible (Provide fast access to all needed services). 2. Be Efficient (Provide high quality services at lowest possible cost). 3. Be Connected (Have the ability to share core clinical information electronically). 4. Be Accountable (Produce measurement information about the clinical outcomes achieved). 5. Be Resilient (Have ability or willingness to use alternative payment arrangements). Scott Lloyd, President 5

6 Value of Care Equation 1. Services provided Timely access to clinical and medical services, service array, duration and density of services through Level of Care/Benefit Design Criteria and/or EBPs that focuses on population based service needs 2. Cost of services provided based on current service delivery processes by CPT/HCPCS code and staff type 3. Outcomes achieved (i.e., how do we demonstrate that people are getting better such as with the DLA-20 Activities of Daily Living) 4. Value is determined based on can you achieve the same or better outcomes with a change of services delivered or change in service process costs which makes the outcomes under the new clinical model a better value for the payer. Scott Lloyd, President 6

7 Value of Care Equation Scott Lloyd, President 7

8 Redesign - Improving Quality in the Face of Healthcare Reform Scott C. Lloyd, President 8

9 Redesign - Improving Quality in the Face of Healthcare Reform What are your Teams Roadblocks? Team members with differing opinions Scott C. Lloyd, President 9

10 Process Redesign Review Data is the Key! Without data, teams set up to their exceptions. What is the best way to Present it to staff? What data do you need and how do you get it? Scott C. Lloyd, President 10

11 Process Redesign Review Scott C. Lloyd, President 11

12 Client Definition of Access Client Calls for Help Wait Time # 1 Assessment Appointment Wait Time # 2 Treatment Planning Appointment Wait Time # 3 Client Arrives for an Open Session Scott C. Lloyd, President 12

13 How did We Get to Here? System Noise Anything that keeps staff from being able to do the job they want to do: Helping consumers in need! Scott C. Lloyd, President 13

14 Value of Care Equation Services Provided: Timely access to clinical and medical services, service array, duration and density of services through Level of Care/Benefit Design Criteria and/or EBPs that focuses on population based service needs Scott Lloyd, President 14

15 Engagement Based Level of Care Criteria Example Scott Lloyd, President 15

16 Engagement Based Level of Care Criteria Example Scott Lloyd, President 16

17 Sample Data Scott Lloyd, President 17 17

18 Scott Lloyd, President 18

19 Value of Care Equation Cost of services provided based on current service delivery processes by CPT code and staff type Scott Lloyd, President 19

20 Sustainability: Uncovering the Actual Cost of Care Scott Lloyd, President

It s Not About the Nail Are you in De-Nail?

21 It s Not About the Nail Are you in De-Nail? (Intentionally misspelled) Our system can t do that. We can t pull the data the way you need it. We have always done it this way. We are understaffed. What it feels like to be a Consultant. It s Not About the Nail! (Source Scott Lloyd, President

22 Sustainability: Uncovering the Actual Cost of Care Top Costing Fails! Dividing costs by 2080 hours Not including all of your costs Using overhead percentages instead of actual costs Looking at expected revenue instead of actual revenue Including monies outside of At Risk Funding Scott Lloyd, President

23 Sustainability: Uncovering the Actual Cost of Care At Risk Funding Includes funding that comes from the following payment types: Medicaid & Medicare funding that is paid by the state or the state s representatives (MCOs) Federal, State, County & City grant funds Private Insurance, Self Pay & Sliding Fee Scale What is not included Private funding coming from donations, fund raising events, and/or social entrepreneurship that organizations have generated on their own to overcome the losses that they are facing in their at risk funding. As these funding sources are not guaranteed and often fluctuate greatly, relying on them to provide the safety net services that states desire is not a long term sustainable model. Scott Lloyd, President

24 Sustainability: Uncovering the Actual Cost of Care Scott Lloyd, President

25 Sustainability: Uncovering the Actual Cost of Care Sample size of over 13,000 staff members Scott Lloyd, President

26 Sustainability: Uncovering the Actual Cost of Care Breakout of the Cost Per Hour Sample size of over 13,000 providers Scott Lloyd, President

27 Sustainability: Uncovering the Actual Cost of Care Statewide Comparisons for Context Scott Lloyd, President

28 Sustainability: Uncovering the Actual Cost of Care Breaking down cost versus revenue by modified code Crucial for CCBHC rate setting Scott Lloyd, President

29 Sustainability: Uncovering the Actual Cost of Care

30 Sustainability: Uncovering the Actual Cost of Care Unrealized Service Capacity

31 Sustainability: Uncovering the Actual Cost of Care Productivity Standard Unrealized Service Capacity Productivity Standard Definition: Billable hours or face to face encounters by each provider for authorized services. Standard: Staff has delivered the total productivity standard as it is defined their Position Description. Source: SPQM Staff Production Report Compliance Rating: 100% = Compliance. Below 100% = noncompliance. Solution Plan: If the provider is non compliant despite having supervision and managerial feedback during the previous quarter, then they will be put onto a 60/90** corrective action plan with monthly monitoring targets. If this corrective action plan is successfully completed then the provider will return to normal status, however failure to successfully complete this action plan will result in loss of employment/move to a part time status/other** (** = You pick)

32 Sustainability: Uncovering the Actual Cost of Care System Noise Anything that keeps staff from being able to do the job they want to do: Helping consumers in need! Scott Lloyd, President

33 Sustainability: Uncovering the Actual Cost of Care Areas of System Noise 1. Dealing with consumers angry about the wait 2. Dealing with a poorly functioning EMR 3. Dealing with No Shows/Late Cancellations 1. Medication Call Ins 2. Rescheduling/Crisis Events 3. Direct Service Production Hits 4. Naturally Occurring vs. Structured Downtime

Sustainability: Uncovering the Actual Cost of Care What we do About System Noise Collaborative Documentation Documentation Redesign Same Day Access

34 Sustainability: Uncovering the Actual Cost of Care What we do About System Noise Collaborative Documentation Documentation Redesign Same Day Access JIT Prescriber Scheduling No Show Management Utilization Review/Utilization Management Episode of Care (EOC) / Level of Care (LOC) Scott Lloyd, President

35 What We Do To Help Teams Collaborative Documentation MTM has trained over 500 teams on this concept that utilizes documentation in session to better engage the consumer and confirm that the service provider and recipient are on the same page in regard to the direct and progression of the services being delivered. This process boasts a 97% approval rating from consumers and care providers, and works for all types of services including med team services. Same Day Access MTM has moved more than 500 teams through this process that allows teams to offer assessments on the same day they are requested, without a scheduling delay or waitlist. This process greatly improves consumer satisfaction and engagement, while also eradicating no shows in the assessment process! JIT Prescriber Scheduling An offshoot of Same Day Access now implemented with teams in more than 10 different states, this process allows teams to move a consumer from their diagnostic assessment to a psychiatric evaluation within 3 to 5 days, greatly increasing engagement and reducing no shows and cancellations. This move improves that consumer's experience and the staff member's quality of life by removing obstacles like non-billable med call-ins that generate high levels of frustration. A properly set up JIT program will generate positive clinical and financial results within the first few months, one of our teams saw a 10 to 1 return on their investment in the first 90 days of operation! Scott Lloyd, President

36 Statewide Measurement Reporting Scott Lloyd, President 36

37 Statewide Measurement Reporting Scott Lloyd, President 37

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38 Scott Lloyd, President 38

39 SED Waiver Services Applied Costs and Net Medicaid Revenues Scott Lloyd, President 39

40 Value of Care Equation Outcomes achieved (i.e., how do we demonstrate that people are getting better Scott Lloyd, President 40

41 How to Support Statewide Measurement of Outcomes Achieved The ability of all CBHC members of a state association to use an state-wide standardized outcome tool for all ages and diagnostic groups that can objectively measure, record and report in a user friendly format how clients are getting better based on the services that they have received. One of the blessings that CBHCs have is an abundance of different outcome tools that seem to proliferate on a regular basis. A key challenge that CBHCs have is the abundance of different outcome tools that are being used within each center, each state across all CBHCs and nationally. David Lloyd, Founder, MTM Services 41 Scott Lloyd, President 41

42 Statewide Adoption of the DLA-20 Missouri Utah North Dakota Western New York Kansas South Carolina Mississippi Maryland (statewide use of the DLA20 that will be made available to CBHCs through its contract with ValueOptions/Beacon) Rhode Island Alaska (proposed by Alaska BH Providers Association) Georgia (Pilot Program with 10 CSBs) Over 10 Electronic Clinic Record Vendors have licensed the DLA- 20 to integrate into their software David Lloyd, Founder, MTM Services 42 Scott Lloyd, President 42

43 DLA-20 Crosswalk to Severity Levels in the DSM-5 and ICD 10 >= 6.0 (>60) = Adequate Independence; No significant to slight impairment in functioning mgaf tallies # symptoms few and mild (51 60) = Mild impairments, minimal interruptions in recovery ICD 10 4 th digit modifier = (41 50) = Moderate impairment in functioning ICD 10 4 th digit modifier = 1 mgaf tallies number of symptoms = (31 40) = Serious impairments in functioning ICD 10 4 th digit modifier = 2 mgaf tallies number of symptoms = (21 30) = Severe impairments in functioning ICD 10 4 th digit modifier =3 mgaf tallies number of symptoms = (20 or less) = Extremely severe impairments in functioning ICD10 4 th digit modifier = 3 mgaf identifies intensely high-risk symptoms Presented Scott By: Lloyd, David Lloyd, President Founder, MTM Services 43 43

44 Treat to Target Clinical Approach Needed for Medicaid Reform Model and Authorization Levels Identified 1. Most of our clinicians use a treat to target approach to planning, service delivery, and adjusting the care plan if it s not working. 2. The majority of clinicians and supervisors have studied the treat to target literature and develop care plans that include measureable targets (e.g. 25% improvement in DLA-20 aggregate score, 50% reduction in PHQ-9 scores within 12 weeks), measure progress at least monthly, and work with consumers to adjust the care plan if targets are not being met. 3. Part of this process includes the use of clinical tools that measure improvement in symptomology, functional status, and recovery and resilience-building for the children, families and adults we serve. Scott Lloyd, President 44

45 Value of Care Determination After implementation of the essential performance indicators for the above three components of Value of Care have been completed the individual results need to be integrated so that the resulting data from each of the components supports an objective determination of the level of value that your CBHC is providing. This level of objectivity can be very helpful to support individual CBHC and state association s business case to differentiate member CBHCs from other providers Scott Lloyd, President 45

46 DLA-20 Statewide Use Supports Delta Score Based Outcome Measurement Scott Lloyd, President 46

47 Sample Data Scott Lloyd, President 47

48 Sample Data Scott Lloyd, President 48

49 Measuring Value of Care (Services Provided, Cost of Services and Outcomes Achieved= VALUE Scott Lloyd, President 49

50 Sample Data Scott Lloyd, President 50

51 Sample Data Scott Lloyd, President 51

52 Questions and Feedback Questions? Feedback? Next Steps? Contact Information: Scott Lloyd, President M.T.M. Services, LLC P. O. Box 1027, Holly Springs, NC Phone: Fax: Web Site: Scott Lloyd, President 52

53 Scott Lloyd, President 53

The Care Transitions Network

Making the move to Value Based Reimbursement/Payment/Purchasing (VBR/P 2 ): Using Data to Improve Care Delivery and Your Organizations Performance The Care Transitions Network Presented by: Scott C. Lloyd,