ValueOptions Spring Fever Feature Presentation. Webinar Event

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Kory Greer
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1 ValueOptions Spring Fever Feature Presentation Webinar Event March 26 th,

2 Segments: Suboxone Services for TennCare Members Grier PIN Process Updates ED Redirection Initiative Peer Support Services 2

3 What Does That Mean? VSHP? BCBST? ValueOptions? TennCare? BlueCare? TennCare Select? 3

4 TennCare Tennessee s Medicaid Waiver Program BCBST Blue Cross Blue Shield of Tennessee VSHP Volunteer State Health Plan, a government services division of BCBST BlueCare An at-risk TennCare network administered by VSHP TennCare Select A special populations TennCare network administered by VSHP ValueOptions a behavioral health company chosen by VSHP to manage delivery of behavioral health services for BlueCare and TennCare Select members 4

5 5 Suboxone Services for TennCare Members

6 Suboxone: a narcotic medication indicated for the treatment of opioid dependence, available only by prescription, and taken under a doctor's care as prescribed. SUBOXONE, which h contains buprenorphine and naloxone, was the first opioid medication approved under the Drug Addiction Treatment Act of 2000 (DATA 2000) for the treatment of opioid dependence in an office-based setting. 6

7 Suboxone Services are delivered by behavioral and non-behavioral physicians who have been certified to deliver the services, and there are restrictions on the number of Suboxone patients a physician can serve at any given time. More information about certification is available at Substance Abuse and Mental Health Services Administration at 7

8 Currently, there are approximately 310 certified Suboxone providers in Tennessee. Approximately 120 of these providers are psychiatrists. 8

9 9 Suboxone Services, inclusive of pharmacy and physician care, are TennCare reimbursable when determined to be Medically Necessary.

10 Based on anecdotes and pharmacy data available to VSHP related to BlueCare and TennCare Select members, we believe TennCare members are sometimes being charged for physician fees associated with the delivery of Suboxone services. TennCare members should not be charged for Medically Necessary Suboxone services, aside from applicable co-pays, deductibles, or exhaustion of benefits under the TennCare Program. 10

11 Providers who are certified to deliver Suboxone Services and who already participate in the BlueCare and TennCare Select networks have the ability to bill for Suboxone services utilizing i existing medication management codes (for behavioral health practitioners) or evaluation and management codes (non-behavioral health practitioners). While the medication itself requires prior authorization through the Pharmacy Benefit Manager (PBM), the physician billing codes do not require prior authorization unless the member has utilized services beyond certain benefit thresholds (see Provider Administration Manual). 11

12 Certified providers of Suboxone services who are not participating in the BlueCare or TennCare Select networks may contact the appropriate regional representative for information about joining the networks. Behavioral health practitioners should contact a ValueOptions regional representative. Nonbehavioral health practitioners should contact a BCBST/VSHP regional representative. Contact lists are available at the end of this presentation. 12

13 More to Come! As TennCare benefit changes are implemented, VSHP will evaluate the need for unique claims coding specific to delivery of Suboxone services. Any such changes will be communicated via direct outreach, Provider Alerts and via updates to the VSHP Provider Administration Manual. 13

14 14 More information about VSHP and ValueOptions is available at VSHPTN.com and ValueOptions.com

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17 17 [Reserve for VSHP/BCBST regional representative contact list]

18 18 Questions?

19 Grier Provider initiated Notice Process Update BlueCare/TennCare Select Behavioral Health

20 The Grier Consent Decree The consent decree provides a way for members to receive notice of adverse actions and the ability to appeal the decisions that providers and MCCs are making about their treatment. An adverse action is any Delay Suspension Reduction Discharge/Termination Adverse means the member will not be receiving the same amount or type of care that they were receiving previously.

21 Who Needs Notice? Every member who is discharging from Inpatient care Residential treatment Every member who is classified as SPMI/SED These members should be given notice every time there is an adverse action for any level of care.

Provider Initiated Notices (PINs) Inpatient Grier requires the member receives 2 business days notice of discharge These are faxed to your facility and mailed to the

22 Provider Initiated Notices (PINs) Inpatient Grier requires the member receives 2 business days notice of discharge These are faxed to your facility and mailed to the member Residential Grier requires the member is given 2 business days notice for provider initiated discharges. These are faxed to your facility and mailed to the member.

23 Inpatient and Residential PINs According to Grier Consent Decree, each member is entitled to a two days advance notice of any adverse action. This does not mean that each member can stay two days longer than the care is medically necessary members should receive notice of discharge 2 days prior to the probable discharge date. If member needs more service after PIN has been submitted, providers should contact BH UR and request a concurrent review. PIN will be voided and member should receive notice 2 business days prior to the new discharge date.

24 PINs for all Other Levels of Care To allow for mailing time, give 10 calendar days notice from when the letter was mailed. These are faxed to your facility and mailed to the member Please send these at least ten days in advance of discharge so the member can be discharged to the level of care they need as soon as possible.

25 To determine discharge date: Your Grier letter will state, Dear < Member's Name >: Starting <Discharge Date>, Dr. has decided to STOP this care you ve been getting from BlueCare: Receiving the PIN at least 2 days prior to discharge will ensure that members are discharged appropriately and providers are compliant with the notification process.

26 Aftercare Plans All provider initiated notices for discharges must have a complete aftercare plan before the letter can be completed. A complete discharge plan includes: The aftercare facility and/or provider name The phone number and address The date and time of the appointment Please do not send in a PIN notice form without a completed aftercare plan.

27 STOP WAIVER Members should not be discharged from their current level of care before they receive notice of the discharge, reduction, suspension or termination of services. Once the members receive the proper notice, the member can choose to stop service prior to the date on the Grier letter. If a member chooses to stop the service, the waiver form attached to the Grier notice should be completed and signed by the member or guardian. ALL signed waiver forms should be faxed to the same number as the PIN forms are faxed. WE MUST HAVE COPIES OF ALL SIGNED WAIVERS.

28 Waiver FORM here?

29 Aftercare delays Aftercare that is scheduled for a member when discharging from a higher level of care must also be done within the 7 or 14 day timeframe. If this care cannot be scheduled within 7 or 14 days of discharge, a Grier delay notice will be issued.

Delays It is in each provider s contract that you will be able to provide services for our members within seven days for case management and within fourteen

30 Delays It is in each provider s contract that you will be able to provide services for our members within seven days for case management and within fourteen days for other services (medication management, therapy, etc). The Grier consent decree states that notice of delays should be sent to the member immediately.

31 Aftercare Delays These are mailed to the member. BlueCare will call the discharging provider and request that the member be informed that they will be receiving a delay letter in the mail. Please continue to attempt to schedule these aftercare appointments within the appropriate timeframe.

32 Contact Information BlueCare Behavioral Health PIN fax East Region: West Region: Effective 9/1/09: TennCare Select PIN fax

Helpful Links Grier Consent Decree and letter templates http://www.tennessee.gov/tenncare/legal.

33 Helpful Links Grier Consent Decree and letter templates ml Volunteer State Health Plan website The most current PIN notice form can be found here.

34 ED Redirection / Medical Home Program Volunteer State Health Plan (VSHP) and BlueCross BlueShield of Tennessee (BCBST) are independent licensees of the BlueCross BlueShield Association. VSHP is a licensed HMO affiliate of BCBST.

35 ED Redirection / Medical Home Program Provides 24/7/365 nurse triage access through NurseLine call center Coordinates care of non-emergent patients by appropriately utilizing the Emergency Department (ED) with expedited PCP follow-up care PCP appointments are scheduled within 24 to 48 hours after being seen in the ED Patient is tracked and monitored from initial ED point-of-access through PCP follow-up. The purpose of this process is to solidify a Medical Home for the member as well as identify additional clinical needs including, but not limited to Case Management, Disease Management, and Behavioral Health concerns. 2

36 ED Redirection / Medical Home Program Places member health and safety first Respects the relationship between clinician and member Trusts in physicians judgment to direct patients Supports the roles of ED physicians and PCP s Expedites primary care for members Facilitates establishment of medical home for members 3

37 ED Redirection / Medical Home Program Patient receives education regarding appropriate ED utilization from NurseLine as well as Emergency Services Management (ESM) nurses within the health plan. Educational materials concerning proper ED use as well as other disease specific materials are mailed to the member s home Transportation is arranged as needed for ED members from the hospital, to the PCP, and home NurseLine is available anytime to assist members with additional health care concerns or questions BlueCare TennCareSelect Direct Line

38 Benefits to Members Provides expedited access to Primary Care Assists member in establishing a Medical Home and in navigating through the health care delivery system Access to a nurse for triage assessment, health advice and education through NurseLine Coordinates member clinical needs including case management, disease management, specialty referrals and transportation 5

39 Benefits to ED Physicians and Hospital Provides a coordinated system to assist members being redirected from the ED to primary care or urgent care Documents member activity from the ED to PCP follow-up visit, also includes member clinical assessment Provides monthly member tracking report to appropriate ED leadership Provides an integrated behavioral, physical, and social care coordination model 6

40 Benefits to ED Physicians and Hospital ED staff training is provided on an ongoing basis to both providers and ED clinical support teams ED is provided with a unique telephone number to reach the NurseLine team for patient care coordination ( One number to call, that s all. ) Mitigates risk to the hospital system by utilizing NurseLine as a safety net for post-visit tracking and outreach Decreases unnecessary treatment and cost of non-emergent visits Decreases overcrowding in ED by appropriately directing members to a Medical Home 7

41 Benefits to PCP / FQHC Enhances the Medical Home model and strengthens the relationship between the PCP and the member Increases patient volume and referrals to PCP Improved coordination of patient clinical activities and/or treatment in other care settings Minimizes duplication of unnecessary tests and procedures 8

42 Benefits to Health Plan Decreases inappropriate ED utilization and cost Helps to fulfill mission by ensuring access to quality health care in appropriate care settings Serves as a preferred safety model for the community and hospital systems 9

43 Phase 1 ~ Network Assessment Development Emergency Department Utilization Assessment to determine appropriate and inappropriate care rendered and to establish benchmarks and targets for improvement, year 1, year 2, and year 3 Emergency Department Physician Assessment to determine physician, other clinical and administrative support for the redirect program, by hospital Community Provider Assessment establishing primary care physicians willingness to receive referrals same day or next day for patient follow-up after initial ED medical screening 10

44 Phase 2 ~ Implementation Begin ED educational process with ED physicians, nursing staff, other clinical staff, clinical support staff, and hospital administration Engage NurseLine team for new client set up with centralized provider and patient communication, centralized patient appointments and daily tracking reports Establish referral provider network including private PCP offices, FQHC and urgent care clinics 11

45 Phase 3, Part 1 ~ Patient Referral Process Patient presents at a participating ED Patient is triaged and assessed by a physician to comply with Federal EMTALA guidelines Patient is determined non-emergent Patient payment method is identified Patient is placed on the telephone with NurseLine for coordination of care to a primary care physician, FQHC or urgent care clinic (UCC) 12

46 Phase 3, Part 1 ~ Patient Referral Process Appointment is made and communicated with the hospital ED team and the patient Patient is given an appointment slip to be presented at the PCP office, FQHC or UCC NurseLine informs PCP office of upcoming patient visit NurseLine provides a follow-up call to the patient after the visit to verify member received the help needed and satisfaction of care 13

47 Phase 3, Part 2 ~ Patient Referral Process Through the NurseLine, questions are asked to determine why the member chose the ED verses the physicians office and to see if a new PCP assignment is needed. All of this information is tracked in a database at NurseLine and sent to the Emergency Services Management (ESM) Team at VSHP. NurseLine provides weekly updates of patient/referral tracking report given to ED physicians and payer to ensure patient tracking and follow up is occurring. NurseLine provides monthly summary reports for payers to measure improvements in appropriate utilization. 14

48 Phase 3, Part 2 ~ Patient Referral Process ESM team assists members in establishment of a Medical Home with a primary care physician. ESM team educates members about calling the NurseLine for future medical questions and assistance in scheduling physician appointments as well as determining more appropriate use of the ED. NurseLine sends to the ESM team daily reports indicating additional services needed for the member. ESM then leads the member through a smooth transition to disease management or case management. 15

49 Patient Referral Flowchart Patient Presents to ED Triage Meets Emergent Criteria (level 1/2/3) Meets Non-emergent Criteria (level 4/5) Triage RN Follows Routine ED Process Pt. Placed in Holding / Counseling Room Qualified Medical Personal Completes Medical Screening Exam Emergent Condition Possible Non-emergent Condition Exists QMP Communicates to Triage Nurse Triage Nurse Follows Routine ED Process VSHP member placed on phone with NurseLine NurseLine assists member in coordinating follow-up appointment with PCP or urgent care center NurseLine coordinates patient visit with accepting clinic NurseLine will then follow up with member to determine provider satisfaction and additional member needs NurseLine provides VSHP with daily ED activity report ED report screened by ESM team ESM manager follows up with member to accomplish the following: 1. Identify barriers that prevent the member from receiving care by PCP 2. Assist member in establishing a medical home 3. Assist member in obtaining appointment with specialist, as needed 4. Identify community resources and support for member 5. Provides educational materials to member regarding appropriate use of ED 6. Refer member to health plan CM/DM as necessary 16

50 Peer Services Date: March 26, 2010 Directors of Recovery and Resiliency Clarence Jordan & Ron Morton BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association. This document has been classified as confidential proprietary information.

51 Increased Demand Disease Management / illness management and recovery WRAP Success stories Mutual Support Groups Consumer Demand Fiscal constraints Non-traditional care 2

52 Self Efficacy Enactive attainment Vicarious Experience Persuasion Physical Arousal 3

53 Why Peer Support? When it comes to combating stigma; there are three accepted, researched approaches with varying degrees of success: Protest generally effective at swaying the media, individual is left feeling worse than before Education produces change by challenging myths; limited effectiveness with a return to base line generally within a week Contact direct interaction and building interpersonal relationships is the most effective for both short term and long term change of views and behaviors, particularly among those who may be the focus of discrimination 4

54 Peer Centers / Self Help Practices Self-help is based on the principle of helping oneself and others at the same time. Thus, self-help is a mutual process, without a dichotomy between the helper and the person being helped. Membership in self-help is neither mandated nor charity. 5

55 What is Self-Help? Self-help groups include people with a common bond who voluntarily come together to share, reach out, and learn from each other in a trusting, supportive, and open environment. The common bond is defined as the collective experience related to being diagnosed as having a serious mental illness (such as bipolar illness, schizophrenia, or major depression) and receiving services from the mental health system. 6

56 Capacity Building VSHP is committed to lending expertise in pursuit of funding Opportunities, especially in the area of non-traditional approaches, through the American Recovery and Reinvestment Act of 2009 and other funding sources: Blue Cross Blue Shield Foundation SAMHSA Substance Abuse and Mental Health Services Administration NCMHD National Center on Minority Health and Health Disparities DREAM Disparities Research and Education Advancing Mission Small Business Research Funding (SBIR/STTR Programs) 7

57 Peer Run Organizations What is a Peer Run Organization? A Peer Run Organization is one that obtained nonprofit 501c3 status. It is an origanization with a board of directors made of peers and staffed from the top down by peers. The only one that exists in Tennessee right now is the Tennessee Mental Health Consumers' Association. Creating new Peer/Consumer Run Organizations will create more jobs for TCPS as well as expand access for services. 8

58 Peer Run Organizations, cont. How can we assist in creating new Peer Run Organizations? While there may be groups of consumers who would like to organize to provide services, they may lack the expertise and knowledge necessary to acquire a 501c3 certification. While the process is not difficult, the uninitiated may find it confusing. One of the responsibilities of Recovery as defined in our CRA is advocacy. This could include assisting consumers in the creation 501c3s 9

59 Community Linkages to Provide New Funding for Peer Services Discussion Can new funding be found through linking of programs with the same goals? Yes. SAMHSA requires community linkages in proposals submitted for new funding. Working affiliations that provide mutual support in communities are emphasized and when included in a proposal, generate a higher score. The key will be to work with providers to create new affiliations between organizations that have previously been seen as competitors. 10

60 Community Linkages to Provide New Funding for Peer Services, cont. What types of organizations might link up with each other to gain new funding? Currently, were are limited by being tied to old models where we see an organization of one type linking with an organization of the same type such as MHO with MHO. In a new model an MHO might link with a community medical facility to provide integrated health care, or with a faith based organization to provide assistance with food. It should be the task of MCCs to facilitate creating these new linkages. 11

61 Community Linkages to Provide New Funding for Peer Services, cont. How can MCCs facilitate creating linkages? Connecting with organizations that would typically be outside of our purview could be the way to begin. Discussion All of our communities in Tennessee are badly in need of funding to support providing services which may no longer be paid for by the State. Sponsoring forums where these linkages can be discussed can be facilitated by MCCs working with city and county governments to identify stakeholders. 12

62 Summary The findings from research on self-help groups for people with serious mental illness consistently show: reduced symptoms and substance abuse over time; concomitant reductions in crises, hospitalizations, and use of services; improved social competence and social networks; and increased healthy behaviors and perceptions of well being 13

63 Evidence of Benefit (references) 1. Magura S, Laudet A, Mahmood D, Rosenblum A, Knight E. Adherence to medication regimens and participation in dual-focus self-help groups. Psychiatric Services. 2002;53(3): Kurtz L. Mutual aid for affective disorders: The Manic Depressive and Depressive Association. Mutual aid for affective disorders: the manic depressive and depressive association. Am J Orthopsychiatry. 1988;58(1): Powell T, Hill E, Warner L, Yeaton W, Silk K. Encouraging people with mood disorders to attend a self-help group. Journal of Applied Social Psychology. 2000;30: Galanter M. Research on social supports and mental illness. American Journal of Psychiatry. 1988;145(10): Galanter M. Zealous self-help groups as adjuncts to psychiatric treatment: a study of Recovery, Inc. American Journal of Psychiatry. 1988;145(10): Kennedy, M. (1990).Psychiatric hospitalization of GROWers. Paper presented at the Second Biennial Conference on Community Research and Action; December 7, 1990; East Lansing, Michigan. 7. Edmunson E, Bedell J, Archer R.,Gordon R. (1982).Integrating skill building and peer support in mental health treatment: the early intervention and community network development projects. In: E.Jeger E, and R.Slotnick R (eds.) Community Mental Health and Behavioral Ecology. New York, NY: Plenum Press:

64 Questions?

Grier Provider initiated Notice Process Update. BlueCare/TennCare Select Behavioral Health

Grier Provider initiated Notice Process Update BlueCare/TennCare Select Behavioral Health The Grier Consent Decree The consent decree provides a way for members to receive notice of adverse actions and