11/18/2016. A Regional Medicaid Accountable Care Organization (ACO) that would leverage the existing behavioral health managed care foundation.

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Ashlyn White
5 years ago
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This collaborative effort gained momentum and resulted in the

vision of the Governor and General Assembly for integrated

2 PROPOSED SOLUTION: A Regional Medicaid Accountable Care

1 This collaborative effort gained momentum and resulted in the release of a white paper, which proposed a solution to the vision of the Governor and General Assembly for integrated care in a capitated environment. 2 PROPOSED SOLUTION: A Regional Medicaid Accountable Care Organization (ACO) that would leverage the existing behavioral health managed care foundation. 3 1

MSSP TRACK 1 BENEFICIARIES 47,000 Medicare 9,300 Humana 17,200 Mission Health

State 4 Total physicians: 1,100 Approaching 300 primary care More than half of

Three hospital systems Eight hospitals 15+ EHRs 5 Improving health care outcomes

2 MSSP TRACK 1 BENEFICIARIES 47,000 Medicare 9,300 Humana 17,200 Mission Health (self-insured) 2,500 Uninsured GROWTH/EXPANSION United Medicare Advantage Healthy State 4 Total physicians: 1,100 Approaching 300 primary care More than half of the primary care physicians are independent Large multispecialty employed group Three hospital systems Eight hospitals 15+ EHRs 5 Improving health care outcomes in WNC through work force education We are passionate about excellence in health care 6 2

Advocate for and innovator of integrated care and care coordination models in western North Carolina Integrated behavioral health practice for 30 years I/DD

suboxone treatment program and work force training Community-centered Medical Home model project funded by BCBS NC 7 Totally awesome LME/MCO formerly known

3 Advocate for and innovator of integrated care and care coordination models in western North Carolina Integrated behavioral health practice for 30 years I/DD clinic in partnership with Vaya Health Model chronic pain program and leaders of Mission Health System s chronic pain Care Process Model (CPM) Certified suboxone treatment program and work force training Community-centered Medical Home model project funded by BCBS NC 7 Totally awesome LME/MCO formerly known as Smoky Budget: $420 million Serves 23 counties in western NC General population: 1.2 million 170,000 covered Medicaid lives 140,000 uninsured and underinsured 8 9 3

10 From the 1115 Medicaid Waiver: Behavioral Health integration is the care that results from a practice team of primary care and behavioral health clinicians.

4 10 From the 1115 Medicaid Waiver: Behavioral Health integration is the care that results from a practice team of primary care and behavioral health clinicians... This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization. 11 The Waiver suggests several pilots, including: 1. Promoting primary care integration models that support behavioral health screening, behavioral health supports in a primary care setting and coordination with specialty behavioral health and I/DD system 2. Introducing multiple levels of behavioral health integration by primary care physicians with payment structure 12 4

5 Mission Health Partners, MAHEC and Vaya Health bring an unparalleled level of expertise and partnership: Largest Medicare ACO in North Carolina More than 270 primary care physicians enrolled Teaching environment of joint residency between primary care and psychiatry Joint training efforts for integrated care leveraging resources between Vaya and MAHEC 13 The partnership will: Build on the expertise and experiences of the 1915 (b)/(c) waiver implementation Expand from a demonstration site to full implementation Serve those with the highest levels of need, super-utilizers and dual eligibles

Development of problems, goals and interventions specifically around behavioral health and developmental disabilities Health risk assessment

CCP chosen to complement existing work flow HELPS ASAM PSC CA/LOCUS 20 ICT members are responsible for sending data back on patients Shared care

7 Development of problems, goals and interventions specifically around behavioral health and developmental disabilities Health risk assessment Comprehensive assessment that drives workflow Addresses clinical, support and social determinate needs 19 Screening and assessments utilized in the CCP chosen to complement existing work flow HELPS ASAM PSC CA/LOCUS 20 ICT members are responsible for sending data back on patients Shared care plan that reflects all services and supports Work flow is directed to ICT members Specific providers have access to the integrated care portal to view data 21 7

22 A limited number of outcomes have been selected to determine the benefit of care coordination supported by

The outcomes that have been chosen are directly related to required Demonstration Initiatives included in the

23 What is the impact of care coordination supported by data exchange between clinical partners on Health

8 22 A limited number of outcomes have been selected to determine the benefit of care coordination supported by data exchange between clinical partners. The outcomes that have been chosen are directly related to required Demonstration Initiatives included in the 1115 Waiver submission. 23 What is the impact of care coordination supported by data exchange between clinical partners on Health care outcomes? Quality of care? Utilization and cost of care? What are the specific care coordination interventions that make a difference? With which populations? Can elements of care coordination best practices be identified and implemented to replicate results? 24 8

Population health quality of care outcomes (Demonstration Initiative #1*) Goal is to improve preventive and chronic care outcomes and member quality of life Blood Pressure control A1C control Rates

edition 25 Intervention process outcomes (Demonstration Initiative #2*) Goal is system reliability Health-related member data will be entered into system within three business days Assessments

(MH/SU/IDD and medical) *Cited in North Carolina 1115 Demonstration Waiver Application, June 1, 2016 edition 26 Utilization patterns (Demonstration Initiative #2*) Goal is appropriate utilization

9 Population health quality of care outcomes (Demonstration Initiative #1*) Goal is to improve preventive and chronic care outcomes and member quality of life Blood Pressure control A1C control Rates of influenza vaccination Engagement with primary care Quality of life assessment using patient reported outcome survey *Cited in North Carolina 1115 Demonstration Waiver Application, June 1, 2016 edition 25 Intervention process outcomes (Demonstration Initiative #2*) Goal is system reliability Health-related member data will be entered into system within three business days Assessments triggered by the Care Coordination Platform (CCP) will be completed Follow-up appointments identified in care plan are kept (medical, behavioral health, social determinants) Clinical pathways closed (MH/SU/IDD and medical) *Cited in North Carolina 1115 Demonstration Waiver Application, June 1, 2016 edition 26 Utilization patterns (Demonstration Initiative #2*) Goal is appropriate utilization Reduce Emergency Department visits Avoidable inpatient admissions Inpatient readmissions at 30/60/90 days and annually Emergency Department readmission rates at 30/60/90 days and annually Increase engagement with PCP *Cited in North Carolina 1115 Demonstration Waiver Application, June 1, 2016 edition 27 9

Provider and member experience outcomes (Demonstration Initiative #2*) Goal is high level of customer satisfaction Increase over baseline for member experience Qualitative analysis of provider

develop and select providers who can meet member and system needs.

10 Provider and member experience outcomes (Demonstration Initiative #2*) Goal is high level of customer satisfaction Increase over baseline for member experience Qualitative analysis of provider experience *Cited in North Carolina 1115 Demonstration Waiver Application, June 1, 2016 edition 28 Network adequacy and access standards outcomes (Demonstration Initiatives #2, #3 and #4*) Goal is to develop and select providers who can meet member and system needs. Providers will be selected based on ability to deliver quality services and utilize an EHR to generate data analytics capable of delivering, at a minimum, clinical summaries upon each visit *Cited in North Carolina 1115 Demonstration Waiver Application, June 1, 2016 edition 29 Costs at baseline and at other phases of the project (actual cost of care and identification of potentially avoidable cost) (Demonstration Initiative #5*) Goal is to understand the financial impact of the pilot--the return on investment. An overall PMPM will be calculated PMPM by specialist, program and provider will be calculated *Cited in North Carolina 1115 Demonstration Waiver Application, June 1, 2016 edition 30 10

Clinicians 32 Admission Discharge Transition (ADT) Types: ED Admission / Discharge Hospital Admission / Discharge Format - HL-7

11 31 Medicaid medical claims data (one year) Medicaid medication claims data (one year) MH/SA/ DD claims data (one year) Medicaid/ State eligibility data Including Coordination of Benefits Medicaid provider data MCO/NCTracks/ NPPES NPIs for Facility, Site and Clinicians 32 Admission Discharge Transition (ADT) Types: ED Admission / Discharge Hospital Admission / Discharge Format - HL-7 V2 Messages Consolidated Clinical Document Architecture (CCDA) Types: Clinical Summary of Care Care Transition Format XML 33 11

the clinical work flow Other Assessment Tools PHQ-2

12 Health Risk Assessment Comprehensive assessment SIS Assessment Data (in development) Incorporate into the clinical work flow Other Assessment Tools PHQ-2 and PHQ-9 ASAM LOCUS and CALOCUS SBIRT DIRE

13 37 Risk Stratification Health Risk Assessment (HRA) Care Plan Problems, Goals, Interventions, Measures Clinical Dashboard Assessments Work flow triggers Integrated Care Team Portal

The Basics of LME/MCO Authorization and Appeals

The Basics of LME/MCO Authorization and Appeals Tracy Hayes, JD General Counsel and Chief Compliance Officer July 17, 2014 DSS Attorneys Summer Conference Asheville, NC What is Smoky Mountain? Area Authority