MEDICAID COMPREHENSIVE WAIVER BEHAVIORAL HEALTH STAKEHOLDER STEERING COMMITTEE REPORT

Transcription

1 MEDICAID COMPREHENSIVE WAIVER BEHAVIORAL HEALTH STAKEHOLDER STEERING COMMITTEE REPORT CONVENED BY THE NEW JERSEY DEPARTMENT OF HUMAN SERVICES DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES AND DIVISION OF MENTAL HEALTH AND ADDICTION SERVICES June 15, Page

2 TABLE OF CONTENTS Acknowledgements... 3 Steering Committee Members...4 Executive Summary... 6 The Stakeholder Steering Committee... 9 Guiding Principles Recommendations Access Clinical Fiscal Outcomes Attachments Access Work Group Final Report Clinical Work Group Final Report Fiscal Work Group Final Report Outcomes Work Group Final Report Access Work Group Attachment - Access Work Group ASO Map Clinical Work Group Attachment I - Recommended Services Array Clinical Work Group Attachment II - Case Management Existing Services Clinical Work Group Attachment III - Case Management Proposed Services Outcomes Work Group Attachment I -Quality Improvement Framework Outcomes Work Group Attachment II Guiding Principles Related Web Links: Medicaid Comprehensive Waiver Steering Committee Meeting Summaries: January 20, 2012 March 2, 2012 March 16, 2012 March 30, Page

3 ACKNOWLEDGEMENTS The Division of Medical Assistance and Health Services and the Division of Mental Health and Addiction Services would like to take this opportunity to acknowledge those who have dedicated their time to provide input to the State concerning the changes to New Jersey s behavioral health system proposed through the Medicaid Comprehensive Waiver submitted on September 9, The Divisions would like to acknowledge the members of the Steering Committee who were selected based on their expertise and involvement in New Jersey s behavioral health system. The Steering Committee members were asked to give a significant time commitment to attend not only Steering Committee meetings but also participate in Work Group meetings. We want to take this opportunity to thank the Steering Committee members for their dedication and commitment to this process. In addition, the Divisions would like to recognize the Work Group Chairs who organized their Work Groups, met frequently with their assigned work groups in a condensed time frame and summarized their Work Group s recommendations. The Chairs are as follows: Access Tracy Maksel, New Jersey Association of County Mental Health Administrators; Clinical Evelyn Sullivan, Professional Advisory Committee; Fiscal - Dennis Lafer, Mental Health Association in New Jersey; and, Outcomes - Phillip Lubitz, New Jersey s National Alliance on Mental Illness (NAMI) and the New Jersey Mental Health Planning Council. Additionally, the Divisions would like to thank the stakeholders who participated in the Work Groups and dedicated their time and knowledge to this stakeholder input process. Members of each Work Group are identified in final Work Group Reports that are posted on the DHS website. The Divisions would like to acknowledge the Center for Health Care Strategies (CHCS) for providing technical assistance to the Steering Committee and the Divisions staff. In addition, CHCS organized and hosted the first meeting of the Steering Committee that took place on January 20, The expertise and knowledge provided to the State staff and Steering Committee by CHCS has been very useful. The Divisions would also like to acknowledge Mercer Government Human Services Consulting, a part of Mercer Health & Benefits, LLC, for providing technical assistance and support to the Steering Committee, Work Groups and State staff during this process. The Division of Mental Health and Addiction Services would like to take this opportunity to thank and acknowledge Gregory Hansch, an intern from Rutgers School of Social Work and the Fellow of the Eagleton Institute of Public Policy. Mr. Hansch observed several of the Steering Committee and Work Group meetings and assisted the State in compiling this document. Finally, we would like to acknowledge the State staff who participated in this process from the Department of Human Services and the Department of Health and Senior Services. We want to thank Commissioner Jennifer Velez, DHS, for her support of the Medicaid Comprehensive Waiver and ongoing dedication to obtaining stakeholder participation and feedback. 3 Page

4 STEERING COMMITTEE MEMBERS Carolyn Beauchamp, President and CEO Mental Health Association of New Jersey Ruth Cook, President New Jersey Psychiatric Rehabilitation Association Mary Ditri, Director New Jersey Hospital Association Ana Guerra, Member/Representative Citizens Advisory Council Donna Icovino Family Member Dan Keating, Executive Director Alliance for the Betterment of Citizens w/disabilities Dennis Lafer Mental Health Association of NJ Gail Levinson, Executive Director Supportive Housing Association of New Jersey Phil Lubitz, Chair National Alliance on Mental Illness and New Jersey Mental Health Planning Council Tracy Maksel, Chair New Jersey Association of County Mental Health Administrators Leslie Morris, Director of Community Relations New Jersey Primary Care Association Beverly Roberts, Program Director Arc of New Jersey Jim Romer, Chair Mental Health Emergency Screening Association Kevin Slavin, President & CEO East Orange General Hospital Deborah M. Spitalnik, Ph.D, Chair Medical Assistance Advisory Council (MAAC) Evelyn Sullivan, Chairperson Professional Advisory Committee Kim Todd, Chief Executive Officer New Jersey Association of Community Providers Maggie Vaughan, Chair County Drug & Alcohol Directors Association Wayne Vivian, President Coalition of Mental Health Consumer Organizations Linda Voorhis, Chair New Jersey Association for the Treatment of Opioid Dependence Debra Wentz, Executive Director New Jersey Association of Mental Health and Addiction Agencies Joseph Young, Executive Director Disability Rights New Jersey Allison Blake, Commissioner DCF Jennifer Velez, Commissioner DHS Steven Adams DMHAS Vicki Fresolone DMHAS Carol Grant DMAHS 4 Page

5 Mollie Greene DMHAS Valerie Harr, Director DMAHS Roxanne Kennedy DMAHS Lynn Kovich, Assistant Commissioner DMHAS Kathleen Mason DHSS Phyllis Melendez DMAHS Margaret Molnar DMHAS Jeanette Page-Hawkins, Director DFD Maribeth Robenolt DDD Liz Shea DDD Raquel Mazon Jeffers DMHAS 5 Page

6 Executive Summary In September 2011, the New Jersey Department of Human Services (DHS), in cooperation with the Department of Health and Senior Services (DHSS) and the Department of Children and Families (DCF), submitted a Comprehensive Medicaid Waiver application (Waiver) to the United States Department of Health and Human Services' Centers for Medicare and Medicaid (CMS) seeking a five-year Medicaid and Children's Health Insurance Program (CHIP) Section 1115 research and demonstration waiver that encompasses nearly all services and eligible populations served under a single authority. The Medicaid Comprehensive Waiver and Behavioral Health The Waiver application submitted to CMS by New Jersey details the State's plan to reform the entitlement program to preserve access and advance innovation in healthcare, and to secure flexibility to manage the State's programs more efficiently. The Waiver is a collection of reform initiatives designed to: sustain the program long-term as a safety-net for eligible populations rebalance resources to reflect the changing healthcare landscape prepare the State to implement provisions of the federal Affordable Care Act in 2014 The Waiver supports the following behavioral health system improvements and innovations: The integration of mental health and addictions services and behavioral health and primary care services through screening, intervention, and referral in both systems as well as the creation of behavioral health homes The development of innovative delivery systems through an Administrative Services Organization (ASO) and subsequent at-risk Managed Behavioral Health Organization (MBHO) to improve access, quality, and value within the State s behavioral health system of care The development of community alternatives to institutional placement The braiding of Federal block grant and State dollars with Medicaid resources to support a comprehensive array of treatment and recovery support services for qualified program participants Opportunities to maximize federal financial participation (FFP) and rebalance service rates while maintaining budget neutrality Promote service innovation and flexibility over time by transitioning from a no-risk to an at-risk managed care model Increased focus on populations with specific needs including the Substance Abuse Initiative (SAI) Welfare to Work Program, Medication Assisted Treatment Initiative (MATI), and consumers with intellectual and developmental disabilities The design and implementation of the Administrative Services Organization/Managed Behavioral Health Organization (ASO/MBHO) is intended as a vehicle to achieve these desired 6 Page

7 changes to promote improved access and quality, greater value, and sustainability for New Jersey s behavioral health system of care. The DHS Division of Mental Health and Addiction Services (DMHAS) and Division of Medical Assistance and Health Services (DMAHS) convened a Stakeholder Steering Committee in early 2012 with the goal of eliciting input from across consumer, provider, and advocacy communities and other constituencies with interests and investments in the design and implementation of the ASO/MBHO proposed in the Waiver. Key stakeholder representatives were invited to a Steering Committee Kick-Off meeting held on January 20, The Center for Health Care Strategies (CHCS) participated in the initial meeting and provided technical assistance in preparing the Steering Committee s final report. The Steering Committee was charged with providing recommendations to inform the State s plan to procure an ASO/MBHO to manage the Medicaid and State-funded behavioral health system of care. The Steering Committee formed four Work Groups and asked them to consider key questions and develop recommendations within four critical policy and operational domains: Access, Clinical, Fiscal and Outcomes. Each Work Group was charged with the task of developing specific recommendations to the Steering Committee in response to these questions. The Steering Committee members were asked to provide leadership through the Work Group process by chairing and participating in each of the Work Groups. They were also asked to identify additional Work Group members to ensure the active participation of a broad representation of stakeholders in the formulation of the Work Group recommendations. The Work Groups each met five to eight times throughout February and March Each Work Group included consumers, family members, providers, advocates, and other stakeholders with expertise in the four Work Group areas. The Work Groups each completed and presented a Work Group-specific set of guiding principles which were presented to the Steering Committee on March 2, The Work Groups continued to meet throughout March to draft their final recommendations for consideration by the Steering Committee. The Steering Committee met to review, revise, and endorse the Work Group Recommendations included in this report on March 30, Although each Work Group articulated specific recommendations relevant to the Group s area of focus, certain fundamental goals were expressed across all four Work Groups: Improve access to behavioral health care Integrate care for consumers with behavioral and physical health conditions Improve consumer health outcomes and satisfaction Maximize available resources to achieve the first three goals. This report is a summation of the Guiding Principles and Recommendations prepared by the Work Groups for consideration by the Steering Committee. At times the recommendations overlapped between the Work Groups, but all recommendations have been included in this document to maintain the integrity of each Work Group s recommendations. The State will take into consideration the guiding principles and recommendations approved by the Steering Committee when writing the Request for Proposals (RFP) to procure a contractor to serve as the 7 Page

8 ASO/MBHO. In addition, this information will be used as the State works with consumers, family members, providers and other stakeholders to improve New Jersey s behavioral health system of care, including those elements outside the scope of the ASO/MBHO. While the State values the input of the Steering Committee and Work Groups, it should be noted that not all of the recommendations advanced in this report may be reflected in the RFP for the ASO/MBHO. 8 Page

9 The Stakeholder Steering Committee The Stakeholder Steering Committee kickoff meeting was held on January 20, 2012 and was hosted by the CHCS on behalf of the New Jersey DMAHS and the DMHAS. DMAHS Director Valerie Harr and DMHAS Assistant Commissioner Lynn Kovich provided an overview of the purpose and goals of the Stakeholder Steering Committee: to inform the DHS values and vision regarding the design and implementation of the ASO/MBHO; to elicit broad stakeholder input regarding the design and development of the various components of the ASO/MBHO; to initiate a small group process to inform at a more detailed level the components of the ASO/MBHO; and to identify and leverage opportunities under Health Care Reform to support a transformed system. Four ASO/MBHO Work Groups were established and charged with facilitating the development of recommendations in response to specific questions regarding four core domains (Access, Clinical, Fiscal, and Outcomes) of the ASO/MBHO design and implementation. A member of the Steering Committee was appointed to chair each Work Group. The Work Groups were asked to embrace a consumer-centered, wellness and recovery orientation and to keep key consumerlevel and systems level considerations in mind as they engaged in their work. Each Work Group was asked to prepare a report that identified key issues for consideration, challenges and opportunities, and recommendations for the Steering Committee within their respective areas of focus. The charge to the Access Work Group was to describe ways the behavioral health system will provide better access to services within an ASO/MBHO, provide recommendations about using technology to improve access to behavioral health services, provide recommendations about ways that the behavioral health system can ensure consumer choice and a no wrong door approach within an ASO/MBHO, and to provide examples of a client walking through the recommended system design. The Clinical Work Group was asked to describe how the behavioral health system could ensure a uniform and consistent approach to screening, assessment, placement, and continuing care functions, prioritize strategies that the behavioral health system could use to increase system capacity to provide integrated care for consumers with co-occurring mental illness and substance use disorders, as well as behavioral and primary health care needs, describe ways the behavioral health system can utilize the ASO/MBHO to reduce the use of acute, high-cost services and increase the use of community-based services, and describe the specialized services that are needed for special populations within the behavioral health system and an ASO/MBHO. The Fiscal Work Group was asked to describe the critical components of a seamless, userfriendly service authorization and claims processing system, prioritize the services in the behavioral health system to target for rate rebalancing, describe reasonable options for a 9 Page

10 transition from cost reimbursement to fee-for-service provider contracts, and suggest payment strategies that will incentivize the provision of good care for a reasonable cost. The Outcomes Work Group was asked to identify the most effective and meaningful approach to monitoring/measuring outcomes to comply with national quality standards, provide recommendations for outcome measures that will demonstrate quality, value, appropriate level of care and consumer satisfaction, and prioritize performance outcomes and quality measures that should be used when looking to incentivize providers and the ASO/MBHO. The Work Group Chairs reported on their group s guiding principles and preliminary recommendations for the development of the ASO/MBHO at the March 2, 2012 Steering Committee. The Steering Committee had an opportunity to discuss the preliminary recommendations with the Work Group chairs and to provide additional suggestions for completion of the final reports. The Work Groups were asked to complete and submit their final reports to DMHAS and DMAHS so that the recommendations could be consolidated into a single document prior to and for consideration at the March 30, 2012 Steering Committee meeting. The consolidated report of the Guiding Principles and Recommendations from the four Work Groups was reviewed and discussed at the March 30, 2012 Steering Committee meeting. Stakeholders were given the opportunity to reflect upon and respond to the guiding principles and recommendations, and revisions were made. In addition to the recommendations developed and presented by the Work Groups, the March 2012 Stakeholder Committee meetings included opportunities for consideration of additional policy issues that the group identified as significant for the design and implementation of the ASO/MBHO. Consultants from Mercer Government Human Services Consulting, a part of Mercer Health & Benefits, LLC, presented information on and facilitated discussions about ASO/MBHO best practices and models implemented in other States, including examples of carve-in carve out arrangements and transitions from no-risk to at-risk fiscal models; ASO/MBHO functional requirements, including options for the alignment of State, vendor, service provider, and consumer roles and responsibilities; and regulatory and policy considerations for the design of services for consumers with intellectual and developmental disabilities. DMAHS staff provided information about and participated in a discussion regarding New Jersey s Dual Eligible Special Needs Plans (D-SNPs) and options for behavioral health consumers. 10 Page

11 11 Page Guiding Principles As described in the four Work Group summaries, a set of core values should inform the design and operation of the ASO/MBHO: First and foremost, the ASO/MBHO must be person-centered, reflecting the strengths, resources, challenges, and needs of consumers. The system needs to be easy for consumers and families to access and use. It is critical to ensure that the ASO/MBHO itself does not create additional barriers for consumers seeking to access services. The ASO/MBHO design should be informed by the fundamental belief that with services and supports consumers can manage their behavioral health conditions while regaining and sustaining purposeful and meaningful lives. This should be reflected in the system design by emphasizing the integration of primary and behavioral healthcare services managed by the ASO/MBHO and the Medicaid managed care organizations (MCOs) to promote holistic, community-based care for the purpose of overall consumer wellness and recovery. The transformation of the behavioral health system of care from an unmanaged, cost-related contracting system to a managed system that purchases services on a fixed-rate, fee-for-service basis is a challenging step towards creating an environment where consumers receive appropriate care and supports in a manner that is efficient, accountable, and affordable to the taxpayers. The State should pursue reimbursement rates at levels that will induce a sufficient number of providers to enter the marketplace to deliver necessary services to consumers, while meeting availability, access, geography and quality objectives and regulatory requirements. Financial and non-financial incentives need to be established to build a system that supports the over-arching principles of wellness and recovery, while tracking monitoring utilization and costs across the continuum of care to ensure that resources are expended efficiently and desired outcomes are achieved. While the implementation of the ASO/MBHO is anticipated to achieve improved behavioral health quality and outcomes while containing costs, government, community, and constituent stakeholders should be cognizant that many desirable outcomes will not be fully realized without a commitment to collaboration and accountability shared by other systems that also engage and serve behavioral health consumers including other programs administered by DHS (managed health care, family development, and developmental disabilities services), services administered by the Departments of Health and Senior Services and Labor and Workforce Development, as well as the judiciary and criminal justice systems. In addition to these guiding principles, the following were identified by the Work Groups as characteristics an ASO/MBHO should possess in order to reflect the values of New Jersey s behavioral health system. The ASO/MBHO needs to: Have the capacity to serve individuals with complex behavioral, medical, and/or social needs, including those with co-occurring mental illness, substance use disorders, and intellectual and developmental disabilities. These individuals should be provided with the support necessary to navigate the system in order to address all their needs.

12 Provide a seamless service delivery system that facilitates coordination, communication, and collaboration between partners. Utilize quality improvement strategies that interface between DHS, the ASO/MBHO, providers, and consumers and reflect consumer, family, and stakeholder participation. Ensure the delivery of high quality services under the ASO/MBHO by a trained and competent workforce. Easily exchange information and use that information to provide coordinated services. Support technological interoperability and quality improvement functions. Adhere to documentation requirements that inform clinical decision-making and support the clinical process. Maintain transparency with respect to data regarding both ASO/MBHO and provider performance. Recognize that the need to maintain safety is of paramount importance for consumers, families and staff. The ASO/MBHO should have a New Jersey location for all direct operations including care management, prior authorization, clinical, and phone/help desk operations. The State should establish a feasible timeline that takes into consideration operational, provider and system readiness pilots and reviews which are encouraged to take place prior to implementing the ASO/MBHO. Qualifying ASO/MBHO applicants must demonstrate interoperability of management information systems, data processing systems and health information technology. 12 Page

13 The Access Work Group 13 Page Recommendations from the Work Groups The Access Work Group developed a set of recommendations for access requirements to be included in the Request for Proposal (RFP) that will be issued to procure the ASO/MBHO. These recommendations describe what the ASO/MBHO should demonstrate and specify in their response to the RFP with respect to capacity and service delivery, care coordination and continuity of care, information and education, ease of initial access, geographic proximity, timeliness of access, and cultural and linguistic competence. Capacity and Service Delivery: Demonstrate that the ASO/MBHO will maintain and monitor an adequate network of appropriate providers that is sufficient to provide adequate access to all services covered under the contract. Demonstrate how the ASO/MBHO will predict the utilization of services, taking into consideration the characteristics and health care needs of consumers. Demonstrate how a second opinion from a qualified health care professional will be accessible within the network, or arrangements for the member to obtain one outside the network, at no cost to the member. Demonstrate how, if the network is unable to provide medically necessary services covered under the contract to a particular member, it will provide for adequate and timely coverage of these services out of network for the member, for as long as the ASO/MBHO is unable to provide them. Demonstrate maintenance plans for a network of providers that is sufficient in number, service mix, and geographic distribution to meet the needs of the anticipated number of members in the service area. Demonstrate how timely access to non-preferred drugs, when determined to be medically necessary, will be achieved. Demonstrate how authorizations will be issued for members living with serious mental illness to facilitate access to mental health specialty care services (i.e., issuing authorizations for encounters over a service period rather than for each individual encounter). Demonstrate how the ASO/MBHO will identify, define, and specify the amount, duration, and scope of each service that the ASO/MBHO is required to offer. Demonstrate how the ASO/MBHO will ensure that the services are sufficient in amount, duration, and scope to reasonably be expected to achieve the purpose for which the services are furnished. Articulate an authorization denial process in which the ASO/MBHO may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the beneficiary. Articulate a process the clearly defines how the ASO/MBHO may place appropriate limits on a service only after ensuring clinical and administrative determination has been achieved. Demonstrate how decisions to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested will be made by a

14 clinical professional who has appropriate clinical expertise in treating the member s condition or disease. Articulate parameters for standard authorization decisions and how notification will be provided as expeditiously as the member s health condition requires. Describe how the ASO/MBHO will make expedited authorization decisions and provide notification as expeditiously as the member s health condition requires for cases in which a provider indicates, or the ASO/MBHO determines, that a standard timeframe could seriously jeopardize the member s life or health or ability to attain, maintain, or regain maximum function. Care Coordination and Continuity of Care: Demonstrate how the ASO/MBHO will coordinate with other MCOs, including behavioral health benefits delivered through Managed Long-Term Services and Supports (MLTSS) to prevent duplication and fragmentation in service delivery. Demonstrate the ability to inform providers of the consumer s treatment plan through systems interoperability and electronic exchange of information and in accordance with confidentiality requirements. Demonstrate how coordinated care planning is member-driven (developed by members with assistance from care coordinators), built on member strengths, and reflects member preferences and needs of services and providers. Demonstrate how an information management decision support tool will be implemented and how screening and assessments will integrate into the tool for optimum output. Demonstrate how the ASO/MBHO will employ peers (e.g. peer specialists to provide care coordination and other services). Demonstrate how the ASO/MBHO will provide continued provision or gradual transition of a provider or service to prevent adverse effects for the member during the change. For mental health services, therapeutic alliance and treatment regimens require time to achieve effectiveness. Demonstrate how care coordinators will be trained to address the needs of, and work with, individuals with complex behavioral, medical and social needs, including specialty care coordinators assigned to work with specific member populations. Demonstrate how people living with substance use disorders and mental illness will be able to access a wide range of services and receive a coordinated warm transfer across services 1 Information and Education: Demonstrate a communication and education plan for providing in-depth information required for consumers, providers, families and community stakeholders to navigate the system, including use of free webinars. Describe the development and dissemination of consumer handbooks, pamphlets, and posters. Demonstrate how the ASO/MBHO will develop, implement, and maintain a network provider directory and a web-based provider database that is user-friendly, accessible, and searchable by location, name, service type, and hours of operation. 1 Recommendations in Italics are from other Work Groups 14 Page

15 Specify degree to which the state, the ASO/MBHO, or both, are responsible for ensuring availability of information to members, providers, and other parties. Require a guidance handbook for clinicians and provider organizations. Specify the type of information to be provided to members and provider organizations (rights, services covered, exclusions, etc.) Require easily accessed member services to provide information, answer questions, give recommendations, and resolve complaints. Ease of Initial Access: Specify mode of initial access to services managed by the ASO/MBHO. Specify that behavioral health care services can be accessed without a referral from a primary care provider. Require 24/7 toll-free service line provides information, assessment, and referral services with capacity to meet language needs. Establish how enrollees are able to access emergency services. Specify types of authorization (pre/post service authorization, no authorization) that are required, allowed, or disallowed. The ASO shall develop strategies to ensure that those eligible for Federal and State entitlements receive them in a timely manner. The ASO/MBHO should pay special attention to helping those most likely eligible for SSI/SSDI because of psychiatric and other disabilities. These consumers should receive support in completing applications and gathering health records within timeframes established by regulation to document consumer disability and their functional incapacity to work. Since current approaches used to apply for SSI/SSDI typically fail to meet timelines for providing health records, many consumers eligible for SSI/SSDI are forced to remain on State-funded General Assistance, resulting in a lower level of support for consumers and an unnecessary financial burden for the State taxpayer. Evidence-based methods for applying for SSI/SSDI, such as the SSI/SSDI Outreach, Access, and Recovery Technical Assistance (SOAR) program, should be employed. SOAR has been implemented on a small scale in New Jersey and has proven to be over three times more effective in securing benefits for participants, and doing so up to six times more quickly than other methods employed by behavioral health providers. 2 Geographic Proximity: Specify maximum allowable travel times and distances enrollees may be required to travel to receive specified levels of care and services. Require development of strategies for ensuring transportation services by providing these services directly, assigning transportation responsibility to network providers in specified circumstances, or subcontracting this service to a transportation firm. Establish special access standards for services that are highly specialized and/or for limited choice of providers. Establish access requirements for rural, suburban, and urban areas based on mileage, transportation schedules and other relevant variables including time, distance, and consideration that paratransit services do not cross county lines. 2 Recommendations in Italics are from other Work Groups 15 Page

16 Timeliness of Access: Require that urgent and emergency/crisis services be available within specified periods of time. Establish maximum times between initial telephone (or other contact) and first face-toface contact for routine, urgent, and crisis/emergency care. Establish maximum allowable times for authorizations and reauthorizations, or allow a certain level of service before continuing care authorizations must be obtained (e.g., eight outpatient visits). Demonstrate how provisions of services to all eligible individuals will be ensured without the establishment of waiting lists, including policies and protocols to support this process. Clarify access requirements for designated services (e.g., detoxification). Cultural and Linguistic Competence: Develop and maintain a culturally competent and representative provider network. Ensure and maintain a culturally competent workforce to serve and accommodate the diverse cultural and linguistic needs of enrollees. Demonstrate how the ASO/MBHO will ensure competence by employing staff that reflect the racial and ethnic composition of members. Create and maintain a comprehensive network provider directory to ensure appropriate referral, access and outreach. Complex Behavioral, Medical and Social Needs: Specify how the transition to the ASO/MBHO will occur for persons with complex behavioral, medical and social needs who are receiving mental health services from other MCOs. For example, how will transitions be effectuated for intellectually and developmentally disabled (I/DD) consumers currently receiving mental health services in the Medicaid managed care system. Demonstrate how mechanisms will be implemented to assess each member with complex behavioral, medical and social needs in order to identify any ongoing special conditions that require treatment or regular care monitoring. Demonstrate how quality and appropriateness of care provided to individuals with complex behavioral, medical and social needs will be assessed. Demonstrate how the ASO/MBHO will share with other MCOs serving the member with complex behavioral, medical and social needs the results of its identification and assessment of that member s needs to prevent duplication and fragmentation of those activities. 16 Page

17 The Clinical Work Group Ensure that we have prevention programs to reach people earlier in the disease and illness process. Access to care that includes early intervention and outreach to avoid hospitalization is critical. The ASO/MBHO must demonstrate the ability to help the behavioral health system reverse health disparities and the premature deaths of individuals with behavioral health conditions and untreated or under-treated chronic diseases whose life expectancy is years shorter than that of the general population. The ASO/MBHO must also ensure that the system has the capacity to divert consumers from high-cost emergency and inpatient care for both behavioral health and physical health problems. Diversion from high-cost hospital-based services is one of the most important guiding principles for the comprehensive waiver. The ASO/MBHO must demonstrate the ability to help the behavioral health system evolve into one where integrated care for both behavioral health and physical health needs represents standard and routine care for those with serious behavioral health problems. Although providers should not be expected to become expert in addressing all possible problems, they should receive training support and funding to function as generalists to support consumers in addressing their needs. This support may be either by providing services directly or, where needs are very complex, by helping consumers access services from specialty providers who are partners working under collaborative service agreements. These partnership agreements should be required as a means to ensure ongoing care coordination and adequate support for the consumer in navigating through the system. The design of the ASO/MBHO must be practical and user-friendly for consumers and providers. The management of services should not be a barrier for engagement but designed to promote engagement at every level. Effective and well delivered services are of little value if the consumer does not engage and participate. The ASO/MBHO should develop and manage a system of care that promotes and maintains consumer access and recovery and must also insure that: (1) services are available to those with behavioral health challenges when they need them and (2) that funding and service mechanisms support the engagement of individuals who are at risk but are not inclined to participate in services. Interventions should be based on sound research but should be practical to implement in the field with fidelity when adequate staff training is provided. Manualized approaches, tool kits, and fidelity instruments can be used to support quality outcomes. The appeals process needs to be defined with clear time frames and the provision of peer supports and advocacy during the process. Clarification needs to be made between the ASO/MBHO appeals process and the Medicaid Fair Hearing. The ASO/MBHO shall develop timelines for building capacity in the behavioral health system to prevent and/or delay the onset of chronic diseases and to ensure timely access to primary and specialty care. Deliverables with timelines for capacity-building for integrated care within behavioral health services shall include: o Physical and behavioral health problems identified and tracked by providers through integrated health records; 17 Page

18 o Incorporating treatment plan goals related to accessing primary and specialty care, and developing consumer skills for managing illnesses and maintaining health (e.g., proactive help-seeking skills, symptom-management skills, regular exercise, nutrition-conscious meal planning, shopping and food preparation skills, etc.); o On-going services to help consumers develop illness management and health maintenance skills, especially as part of programs serving persons in high-risk circumstances (e.g., PACT, ICMS, Supportive Housing, etc.); ongoing health coaching by direct service staff to help consumers learn illness management and health maintenance skills; o On-going monitoring and care coordination by direct service staff serving those at high risk of chronic diseases to ensure timely access to primary and specialty care; o On-going nursing support to identify potential health problems through nursing assessments; coordinating with direct service staff around health coaching and consumer skill development; coordinating with direct service staff and medical treatment providers to help consumers access primary and specialty care; coordinating with medical treatment providers to help consumers manage chronic diseases and support ongoing care; o Developing, in collaboration with DHS and community providers, staff training programs related to integrated care. Increase and fund the capacity for workforce development and training regarding evidence-based, emerging and promising practices (e.g. Cognitive-Behavioral Therapy (CBT), cognitive remediation, Integrated Dual Diagnosis Treatment (IDDT), Motivational Interviewing, trauma-informed care, and Medication-Assisted Treatment (MAT) through: o ASO/MBHO support for staff training and certification; o ASO/MBHO incentives and rewards for providers that demonstrate and maintain fidelity. Regulations across addictions, mental health and Medicaid should be consistent and aligned. Policies regarding assessment, treatment planning and continuing care approvals in the ASO/MBHO should be consistent with regulatory requirements. The ASO/MBHO shall ensure that every region and, where possible, every community has access to specialty services provided by experts, and that these specialty providers are integrated with all other providers in the behavioral health system through signed collaborative service agreements that specify roles and responsibilities related to access, system-navigation. and on-going care coordination for consumers with co-occurring and complex service needs, and shall ensure integration and collaboration by: o Developing, in consultation with DHS and providers, a template for inter-agency collaboration agreements to ensure integrated care coordination for consumers with co-occurring disorders/disabilities and complex service needs; o Rewarding integrated services and interagency collaboration throughout the continuum of care. Agencies cannot be expected to be expert in all areas but they must have the capacity to screen for behavioral and physical health conditions and intellectual and developmental disabilities. Agencies that cannot meet a consumer s need must facilitate an immediate referral to an appropriate provider and coordinate care. 18 Page

19 Eliminate restrictive, very specific eligibility requirements for substance use disorder treatment services. Utilize an information technology solution that allows for information sharing and that: o Avoids duplication; o Allows interoperability with the many electronic health record systems in place now; o Includes a consumer/family portal in any electronic information system and provider portal that includes ability to provide reports; o Supports data sharing between the MCO and the ASO/MBHO; o Supports data sharing from the MCO and ASO/MBHO with the providers. Establish minimum workforce core competencies and requirements that: o Align required credentials with core competencies; o Streamline and expedite the waiver process for qualified employees to allow providers to hire staff for non-clinical positions based on core competencies. Telehealth should be available to address shortages of highly trained professionals and consumer difficulties in accessing care. Telehealth can be used for consultations by specialists (e.g., addictions psychiatry) or for ongoing care when consumers have difficulty accessing office-based care. Use of peers should be developed in a very specific manner and include: defined roles, qualifications, and abilities, strong guidelines and requirements for accountability, and applicable accommodations to fund, hire, promote, and retain peer employees. Incorporate peer-delivered services throughout the continuum of services. The system should require the use of uniform tools for screening, assessment and placement regarding co-occurring disorders by the ASO/MBHO and all providers. The system should require a uniform placement tool that does not require a full summary for each continuing care request and addresses stages of readiness for change. The ASO/MBHO and all other points of access can screen consumers, but comprehensive assessments should only be provided by licensed provider agencies. Include a reimbursable engagement phase of services. Community providers should be funded and required to be accessible 24/7. Develop a comprehensive care and crisis plan that can move to and from agencies to follow the consumer through the system. This plan should include, but not be limited to, psychiatric advanced directives. The ASO/MBHO shall develop strategies and re-imbursement mechanisms to support providers in providing enriched services to those at risk of becoming a danger to self, others, and/or property. This would include, but not be limited to, the ability to dispatch staff in groups of two or more and/or the availability of 24/7 services. This is important to ensure providers are adequately funded to provide for the safety of staff and consumers. Ensure that providers receive adequate training in crisis prevention and de-escalation techniques, escape techniques, and support to develop safety and violence prevention procedures to ensure the safety of staff and other consumers. The ASO/MBHO must make provisions to provide funding to support the public safety goals of criminal court-mandated treatment and recognize the habilitation and rehabilitation needs of court-mandated consumers. 19 Page

20 The ASO/MBHO must facilitate encounter data collection and analyses of criminal courtmandated treatment episodes and identify utilization patterns that may not align with utilization patterns of non-mandated populations. Develop a statewide capacity-building and training initiative to ensure the capacity to implement the SOAR method advocated by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Department of Housing and Urban Development (HUD). Currently providers meet the basic needs of many consumers such as emergency medications, food and clothing through the use of contract funds. These critical services often divert a crisis for consumers. It is critical that a system is developed that allows providers to continue that practice in a fee-for-service system. Current case management has proven effective in New Jersey at decreasing the need for acute care services. A logical and needs-based system of case management should be developed that can complement the ASO/MBHO s care coordination role. A full chart of suggested case management services based on consumer acuity is attached as an appendix to this report. Provider admission, exclusionary and discharge polices and criteria should be standardized. The ASO/MBHO should monitor providers for adherence to these criteria to avoid discriminatory practices that results in adverse selection. Enhance targeted services for individuals with complex behavioral, medical and social needs that require specialized assistance (such as the aging-in population, consumers with I/DD, co-occurring disorders, or justice involvement). During start-up of adult managed behavioral health services, qualifying ASO/MBHO entities must demonstrate how they propose to administer and safeguard continuity of care for current Medicaid and other funded members. Screening centers crisis services need to be enhanced. Be innovative with advanced directives so that consumer wishes, desires, etc. are a real factor in service delivery. Ensure that universal consent for release of information forms are used in the advanced directive system. Advanced directives should be a part of the electronic health record. 3 3 Recommendations in Italics are from other Work Groups 20 Page

21 The Fiscal Work Group A seamless, user-friendly service authorization and claims processing system would include the following components: o Certain emergent and/or crisis services should be considered presumptively approved, such as screening and emergency services. Services rendered beyond an emergent or crisis episode could require prior authorization (PA); o Immediate access to crisis and emergency services. Non-emergent services including PACT, RIST, ICMS, residential services, and supportive housing that do not currently require PA should be considered for this requirement in the future; o Consider implementation of PA after 8-10 sessions similar to commercial plans for certain low-cost/low-intensity services such as outpatient services. Services to be delivered to the non-entitlement population would require PA to assure availability of resources; o The system needs to facilitate and not impede intake. Expedited triage can be performed by the ASO/MBHO to register initiation of an episode for entitlement program members. Non-entitlement program consumers would require authorization for all services to assure availability of funds prior to service provision; o The system should contain all attributes of the current Molina Medicaid claims processing system, i.e., electronic claims submission, no less frequently than weekly electronic payment cycles, the ability to provide cash advance and recovery, the ability to support differential rates, electronic remittance advices, etc.; o The ASO/MBHO must have a help desk to assist providers with claims processing; o Requirements for the amount of time that will be allowed for the managing entity to complete authorizations for care re: emergent, urgent and routine care; o Authorization requirements by a person and cases for warm transfer; o The RFP should specify credentials of staff able to provide authorizations, denials, reductions, and provision for physician involvement; o Claims adjudication requirements - X% clean claims paid within X days of submission - should be no less stringent than current Medicaid requirements; o Providers should have web-based access to provider account status information including PA information, claims in process, denied, pending and paid claims; o Blended funding so that the provider is not responsible for maintaining certain payer mix; o Authorization logic must include identification of payer -- providers would not have to distinguish authorizations by payer; o To the maximum extent practical, the scope of PA should cover the package of services needed by consumers based upon uniform objective criteria across all dimensions of care, including mental health, substance use disorders, and developmental disabilities. o There should be one system for all processes for entitlement as well as nonentitlement clients; The system needs to identify all potential payers for each client such that State funds are the payer of last resort. The vendor must develop processes for managing resources available statewide for non-entitlement populations and prioritizing service needs. 21 Page

22 22 Page o Eligibility criteria for services managed by the ASO/MBHO: Will require uniform income, asset, and population attribute criteria. Will need to consider to what degree there could be presumptive eligibility while full eligibility determination follows, for example as currently rendered in the state hospital interim assistance program. o A consumer and provider friendly process is needed to dispute denials, minimizing the volume that evolve to actual grievances; o Providers receive timely notification of changes in client eligibility; o Clinical determinations must be made by clinicians with relevant training regarding authorization approval or denial criteria and processes; o A summary of denials and recommendations for care reductions report should be provided to the State; o As the State develops network participation criteria, it needs to ensure uniform standards for the provision of each service type or, in the absence of uniform standards, ensure that rate differentials exist to address disparities in provider requirements. For example, independent practitioners such as Licensed Social Workers offering outpatient care would need to meet all of the network standards for providers such as community mental health centers rendering outpatient care. If different standards are maintained, such differences should be addressed in the rates; o Consideration should be given in rate development for an enhanced rate for providers for integrated care and coordination of medical and social services, including case management; o Rate setting exercises should take into account differences in client complexity to aid in preventing adverse selection. Rate differentials that are based on level of functioning and/or diagnosis should be considered. For example, the rate for individual counseling for situational depression should perhaps be less than counseling for a multi-system involved individual with schizophrenia, even if such services were provided by direct care clinicians with the same credentials; o Ensure that as the essential health benefits package is formulated, the State evaluates the impact on ASO/MBHO benefit packages and consumer eligibility in order to maximize coverage and non-state participation in the cost of care; o Ensure that the vision for the system is clearly articulated to stakeholders in as much detail as possible and as early as possible so that business practices can be realigned to maximize probability of success. Additionally, ensure that the ASO/MBHO passes a rigorous readiness test prior to going live and/or incrementally assuming more responsibility; o A subset of Work Group participants advocated for a go live date of January 1, 2014 to assess the impact of Federal Health Care Reform; o The ASO/MBHO should have a live help desk to aid consumers and providers to navigate issues (i.e. continuing authorizations/approvals, denials, pending claims, etc.); o Avoid multiple provider numbers that complicate the claiming process. The State should see if one provider number can be used with appropriate identification of all services for which a provider is allowed to bill;

23 o Providers should be able to access their individual prior authorization and claims status information at the ASO/MBHO or other applicable claims payment entity to facilitate their own internal administrative processes; o The State should frequently monitor available funds and outline process for reviewing utilization data to minimize disruption to service authorization process; Prioritize the services in the behavioral health system to target for rate rebalancing: o All rates that will be paid on a uniform non-cost related fee-for-service (FFS) basis by level of care really need to be evaluated for sufficiency to achieve the objective of ensuring inducement of sufficient provider participation to meet the access standards in terms of timeliness, quality and geographic standards; o A rate differential should be considered for complex cases such as multiple diagnoses; o Client attributes, including severity of need, to be considered in rate structure; o These rates should be market-based and periodically evaluated no less than biannually to assure continued sufficiency to achieve objectives identified above; o Community support and peer support services must be considered as part of rate review; o Some providers have waivers of regulatory staffing requirements which will need to be considered in rate setting and development of provider participation requirements. Current costs may be artificially low due to waivers and the rate setting exercise needs to consider this and provider participation standards need to consider availability of staff to comply with standards; o Rates must consider underlying licensure and regulatory standards, (i.e. ensure sufficiency of compensation in relation to requirements); Reasonable options for a transition from cost reimbursement to FFS provider contracts include: o Not all services that are currently purchased via cost-related contracts should be moved to FFS. Services such as advocacy and self-help centers, and possibly screening and affiliated emergency services, should remain cost-related; o The State must identify milestones for implementation of the transition (i.e., a rate analysis is needed well in advance of the initial transition of cost-related reimbursement to FFS); o Provider groups should facilitate training to assist in preparation for transition. This has been occurring; o The earlier rates can be developed and made known, the earlier providers will be able to determine if they can compete and if so what changes may be necessary to promote ability; o Simulations should be run to clearly demonstrate the effect of rate change at given volume levels by individual providers; o Consideration for infrastructure costs for residential and outpatient costs in rate setting and analysis should be based on the size of an agency; o Consideration should be given to commencement of transition before advent of the managing entity by using providers specific rates, but phasing in accountability for production of volume. Performance corridors could be established with no consequence at certain levels and varying consequences at fixed points thereafter and a method for additional compensation for additional performance. For example, there 23 Page

24 24 Page would be a reduction if 70% of anticipated volume was delivered and additional compensation (with approval) if over 110% of anticipated volume was delivered. Another option is to retain cost-related contracts for a period of time, paying the difference between cost and rates for actual volume delivered incrementally moving to no subsidization. A variation on this theme would be to have a volume subsidy as long as a certain minimums were provided (with restrictions on ability to make profit during period of subsidization); o Providers assert that a reasonable time transition from cost to FFS of 2-3 months is too rapid. Investigate the assertion that the New York Medicaid redesign held providers harmless for 2 years and evaluate feasibility of this strategy for New Jersey; o The State absolutely must have a vehicle to ensure cash flow for circumstances where the State and/or ASO/MBHO is the cause of delay in payments. Where the State/ ASO/MBHO is not the cause, develop objective criteria for limited provider assistance during the transition; o In order to ease provider movement into being compensated in advance of service delivery as is the case in large measure under the cost-related contracts, to after services are delivered as will be the case with FFS compensation, consider providing quarterly advances at the beginning of a quarter and recovering in the third month of the quarter. This should be based on uniform criteria to determine the need for some pre-defined limited period of time. A change in agency contracts from cost-based to FFS has major impact on an agency s business processes. Elimination of cost-based contracts has the potential to impact the available line of credit providers may have with their bank. The State must consider the cost of provider infrastructure in determining the transition process and provider cash flow needs. Another option could be to phase in FFS by service type; o Consideration could be given to phasing in ASO/MBHO responsibilities. They will need to pass readiness tests prior to assuming additional responsibilities; o Phase in could be by element of service or Medicaid covered individuals and services initially, expanding to other populations and services as additional demonstrations of system readiness are achieved; o Providers need to be afforded the maximum amount of time practical to develop information systems to conform with information requirements of the ASO/MBHO to maximize probability of success; o Transitional one-time assistance to develop information systems should be made available to the extent possible to maximize probability of provider success at transition; o It would be helpful if in addition to requirements enumerated in the RFP, there could be a demonstration of systems (billing and referral to ASO/MBHO) by the successful bidder some months in advance of implementation; o Publicize timeline for transition; o The needs of existing consumers in services undergoing transition should be considered if in the past these services did not need authorization and in the new system will require prior or continuing stay authorization; Consider presumptive authorization at current level for given period of time. Length of time may vary depending on level of care.

25 o It would be helpful for providers if flowcharts of how the new system is envisioned to function in terms of service authorization and payment were developed and disseminated; Suggested payment strategies that will incentivize provision of good care for reasonable cost: o Premium for coordination with physical health system and decreasing utilization/improving outcome; o Unified case planning with a negative financial consequence for non-compliance should be a contract requirement of both the MCOs and the ASO/MBHO; o Focus on high-cost utilizers and reducing utilization while concomitantly improving outcomes; o Reduction in inpatient utilization and recidivism; o Reduction in emergency room utilization; o Improve level of functioning as measured on standardized instruments; o Reduction in length of stay in residential care (as long as not mandated externally like by court order); o Incentivize ASO/MBHO to develop/assist the State to develop provider networks that are geographically balanced; o Increase community tenure (length of time out of hospital); o Realizing life goals related to employment, education, etc.; o Decrease individual risk level; o Abstinence for a specified period post treatment; o Abstinence for specified period during treatment; o Improvement in consumers quality of life following an episode of care (i.e., housing, employment, arrest); o Access - how quickly can an agency can provide services, particularly posthospitalization; o Engagement and retention - are consumers attending and actively participating in care on regular basis; o Incentives don t have to solely take the form of a payment. Lessening administrative burdens for high-performing providers would also be a form of incentive. Additionally, superior performance as evidenced on provider report cards should result in increased consumer selection; o Changing PA parameters in terms of length of authorization or services requiring PA before continuing authorization is required; o Providers identified as achieving positive outcomes could receive enhanced referrals in some manner that still preserves consumer choice; o As early as practical, given limitations of data regarding cost, utilization and outcomes, move from managed FFS compensation to case rates for providers. In this context, case rates are understood to be a payment to a provider of a flat amount, for a period of time, for a given consumer or each member of a population, in exchange for a particular outcome. For example, a rate per month to maintain a consumer out of inpatient psychiatric hospitalization and attain certain goals and a minimum level of consumer satisfaction. In this example, the provider is at risk to some or full degree for the cost of services needed to achieve the targets; 25 Page

26 o Movement to case rate compensation needs to be planned carefully and made only after sufficient data exists to develop case rates that are reasonable in terms of cost and in relation to the outcomes expected; Consideration should be given to one-time financial assistance as may be available to aid in developing systems necessary to participate in the network and accumulate and document outcomes that will ultimately be incented; 4 Work force development must be a priority in the development of the ASO/MBHO requirements, in the development of rate structures that allow for agencies to promote training, and ongoing supervision and a priority for State policies and programming; Build capacity in the system through rate setting and other targeted enhancement measures as a system that has an infrastructure deficiency can t be managed; Regional Liaison services should be funded under the ASO/MBHO to be present for local meetings and service coordination; Create IT system linkages for broad application of presumptive eligibility (PE) determinations (i.e. a child who is eligible for school lunches meet all PE program criteria). 4 Recommendations in Italics are from other Work Groups 26 Page

27 The Outcomes Work Group Consider the interrelationship of outcome and process measures to evaluate performance. Conduct a practical and meaningful consumer/family satisfaction/perception of care data collection and evaluation process. Evaluate and implement the use of incentives to promote performance improvement and penalties to mitigate substandard performance. Align outcome measures with requirements set forth in Federal guidelines and other regulatory bodies as well as outcomes measures utilized in other states. Performance benchmarks may be established from existing industry data but should not be used exclusively or without consideration for New Jersey specific data as the system matures. Existing or readily obtained data should be utilized, whenever possible, to limit the burden of data collection. Outcomes should reflect a wellness and recovery-based quality management approach. The implementation of evidence-based and emerging practices is reinforced through quality monitoring and quality improvement activities. The ASO/MBHO should collect and report on outcomes that reflect the Work Group s quality improvement framework (attached as an appendix to this report) and are available from already-existing and validated sources, i.e., National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set (HEDIS) measures, the Mental Health Statistics Improvement Program (MHSIP) consumer surveys, the National Quality Forum (NQF) measures and standards, and SAMHSA s National Outcomes Measures (NOMs) and National Registry of Evidence-Based and Promising Practices (NREPP) to provide a meaningful baseline upon which to build a dynamic, flexible, and iterative quality management program. Stakeholders (consumers, families, providers, and system partners) are engaged in and provide actionable recommendations in each step of the quality management process. Effective coordination of care is a desired outcome at the individual and the systems level. Quality improvement priorities are not static but may change over time due to emerging needs and unanticipated occurrences. Applicants must identify their strategy for selecting and testing variables for trending, statistical correlations, and determining statistically significant relationships among selected variables in the data sets. Applicants must detail how they engage stakeholders in the quality process and how they work as a partnership with stakeholders in the process of quality management and system redesign (rebalancing). Applicants should detail how they manage their quality programs, method, model, staffing, information technology, etc., as well as identify the percent of the operating budget dedicated to quality improvement activities and capacity to ensure meaningful data will be available in reasonable timeframes. Applicants should detail what software they will use and identify the skill/educational level of those who will be managing data analysis. 27 Page

28 Identify safeguards that assure the most effective treatment and not just the most inexpensive treatment is delivered. Recognize that some desirable outcomes, such as employment, may be outside the scope of the ASO/MBHO. Stakeholders must have input into the development of the data set for report cards, network participation criteria and public presentation. 5 Provider report cards should be made available to the public and used to allow consumers to make informed choices with regard to selection of service providers, subject to transportation issues. Positive outcomes, as well as a defined set of adverse incidents, should be included in the report card. The 2010 HMO Report Card should be examined as an example. An ASO/MBHO Report Card is needed as well. There should be provision for independent verification on a sampling basis of outcomes reported by providers as well as outcomes reported by the ASO/MBHO. There should be communication between the MCOs and ASO/MBHO to ensure uniform data integration with all the MCOs. De-identified data from the ASO/MBHO, as well as the MCOs, should be part of the public domain to the maximum extent practical to allow interested party analysis. There should be a study of the continuum of care in other states that have been developed to reduce deep-end care, such as extended acute care, and promote the development of a continuum of care that maximizes the probability of achieving superior outcomes. The RFP should require ASO/MBHO and State monitoring to correlate cost, utilization and outcome information to align resource utilization with services and providers producing superior outcomes for given compensation. Consider the use of service-specific outcomes linked to incentives. One example is to incentivize skill attainment for consumers engaged in partial care, which could be measured on pre and post-tests. Providers who deliver services within approved limits, and who exceed a target with regard to the proportion of consumers achieving in excess of a benchmark level of change, would qualify for an incentive. Enhance analysis of services that are costly and develop and invest in alternative services as appropriate. Build accountability for the ASO/MBHO and require reports on every call, referral, follow-up and linkage. Develop appeals, ombudsman and oversight mechanisms and protocols that include independent reviews, which is of particular concern in an at-risk model. Revisit existing oversight and monitoring mechanisms and consider replacing them with processes that engage in continual quality improvement and quality assurance activities. 5 Recommendations in Italics are from other Work Groups 28 Page

29 29 Page Attachments

30 Access Work Group Final Report Work Group: Access Work Group Work Group Chair: Tracy Maksel Work Group Members: Tracy Maksel, Roxanne Kennedy, Maggie Vaughan, Dan Keating, Joseph Young, Daniel Brewer, Mary Ditri, Beverly Roberts, Dan Martin, June Noto, Robert Davison, Kathleen Dobbs, Leslie Morris, Robin Weiss, Marilyn Goldstein, Richard Mingoia, Carolyn Beauchamp, Jeanette Page-Hawkins, Maribeth Robenolt, Lisa Ciaston, Harry Reyes, Loretta Hatez, Karin Burke, Kathleen Russo, Cathy Vahey, Karen McGraph, Carol Grant, Eileen Calabro 1. Guiding Principles: Provide a brief narrative summary of the guiding principles that should drive design and operation of the ASO/MBHO, with particular emphasis on the Work Group s area of focus (access, clinical, fiscal, outcomes). The Access Work Group met five times from 2/8/2012 through 3/7/2012. Through the use of small group activities, discussion and Q&A with a State and a national expert, the Work Group was able to complete their task and provide the Steering Committee with their stakeholder recommendations. Also, as part of the Work Group s effort to clearly understand the role of the ASO, the Work Group developed a flow chart that is included in the attachments on Page 58. The following guiding principles were developed early on in the Work Group s process and referred to throughout the subsequent meetings as the guide for making recommendations: Operability - A good system makes even complex processes simple for the user. This is especially true in regard to individuals with complex behavioral, medical and/or social needs. Therefore, User Operability means an easy to use system for consumers, families and providers that ultimately ensure simple, timely, and equitable access to needed services. Competence - A competent system, organization, or service is defined by adequacy; possession of required skill, knowledge, qualification, and importantly capacity. This is especially true in regard to serving individuals with complex behavioral, medical and/or social needs. Technological Interoperability - Interoperability is a property of a product or system, whose interfaces are completely understood to work with other products or systems, present or future, without any restricted access or implementation. Seamlessness - A seamless service delivery systems focus upon increasing the coordination amongst partners to develop a stronger collaborative and uniform focus on and approach to prevention, early intervention, treatment and support by increasing access to services by decreasing barriers. This is especially true in regard to serving individuals with complex behavioral, medical and/or social needs. 30 Page

31 2. Key Considerations: Provide a bulleted list of the key considerations identified by the Work Group, with particular emphasis on the Work Group s area of focus (access, clinical, fiscal, outcomes). Operability: Ensure consumers already engaged in services stay engaged in appropriate services Ensure a reasonably uniform screening tool promoting expeditious approvals Have navigation guided by competent staff who know their resources Have a virtual presence with online approvals complemented by web-based forms, online services, and updated resources Demonstrate follow up and technical assistance that is robust, consumer driven and wellness focused Competence: Clinically appropriate uniform screening and authorization completed in appropriate (defined) timeframes Accurate and dynamic resource and referral mechanisms the reflect the whole of what is truly available Ability to address complex cases through clinically appropriate experts on staff that work with community Consumer and family support, assistance, and navigation integrated within the system Peer supports readily and seamlessly available to consumers and families throughout the continuum of care Engage consumers and families by building relationships with them Clearly defined milieu/scope of services (essential benefits, referral sources, etc.) Sufficient provider base and capacity to meet the demonstrated demand in the community Wellness and Recovery oriented credentialed staff available 24/7 Community integration to build and sustain seamlessness The ASO should demonstrate its commitment to cultural competency for their consumer services Technological Interoperability: The ability of two or more systems or components to exchange information and to use the information that has been exchanged seamlessly The ability of systems, units, or forces to provide services to and accept services from other systems, units or forces and to use the services exchanged to enable them to operate effectively together The ability for two or more information collection mechanisms to be searched by a single query producing meaningful results Seamlessness: Ensure consumers already engaged in services stay engaged in appropriate services Include mechanisms to screen for eligibility for other programs that may support the consumer and their family in the community 31 Page

32 Develop a protocol for bridging silos in service delivery (i.e. DDD; Courts; DCBHS; etc.), to ensure consumers are not disengaged or neglected Have regional ASO/MBHO staff dedicated to building and sustaining community relationships with providers, consumers, families and counties Implement a plan to seamlessly integrate consumers transitioning from other existing systems Involve peers at ALL levels of service delivery Employ a universal release of information tool for all publicly funded programs and services Implement a plan to seamlessly integrate consumers transitioning from other existing systems Presumptive eligibility should be considered, especially for outpatient services inclusive of consumers currently receiving outpatient care, with determinations linked across all services/programs under the ASO Plan to use advanced directives more dynamically with a mechanism for universal releases of information 3. Challenges/Opportunities: Provide a bulleted list of the challenges and opportunities identified by the Work Group, with particular emphasis on the Work Group s area of focus (access, clinical, fiscal, outcomes). Challenges: Poor access to appropriate physical and behavioral health care services for individuals with mental illness or substance abuse disorders including those with specialty needs Inadequate access to community-based services and supports No management of total medical costs for individuals with co-occurring BH-PH conditions Poor health outcomes and insufficient consumer satisfaction High frequency of severity and duration of acute episodes Continued use of institutional care Opportunities: Increase integration between physical and behavioral health services Decreasing reliance on crisis/acute services as the primary point of care Enhance primary medical attention to address preventable and manageable conditions hopefully increasing life expectancy overall Increase coordination to bridge fragmented and uncoordinated service delivery systems Reduce overutilization of high cost services by developing, promoting and referring to alternatives Increase the underutilization of prevention, early intervention, treatment and community supports by rebalancing the system away from crisis driven approaches 4. Priority Recommendations specific to the Work Group: Provide a bulleted list of the Work Group s priority recommendations specific to the Work Group s area of focus (access, clinical, fiscal, outcomes). 32 Page

33 Capacity and Service Delivery: Demonstrate the ASO/MBHO will maintain and monitors an adequate network of appropriate providers that is sufficient to provide adequate access to all services covered under the contract. Demonstrate how the ASO/MBHO will predict the utilization of services, taking into consideration the characteristics and health care needs of consumers Demonstrate how second opinions from a qualified health care professional will be accessible within the network, or arrangements for the enrollee to obtain one outside the network, at no cost to the enrollee. Demonstrate how, if the network is unable to provide necessary services, covered under the contract, to a particular enrollee, it will provide for adequate and time coverage these services out of network for the enrollee, for as long as the ASO/MBHO is unable to provide them. Demonstrate maintenance plans for a network of providers that is sufficient in number, mix, and geographic distribution to meet the needs of the anticipated number of enrollees in the service area. Demonstrate how timely access to non-preferred drugs, when determined to be clinically necessary, will be achieved Demonstrate how authorization exceptions should be prescribed for enrollees living with serious mental illness to permit direct access to mental health specialty care services through standing referral (authorization granted for a period of time rather than for each visit). Demonstrate how the ASO/MBHO will identify, define, and specify the amount, duration, and scope of each service that the ASO/MBHO is required to offer. Demonstrate how ASO/MBHO will ensure that the services are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished. Articulate an authorization denial process in which the ASO/MBHO may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the beneficiary. Articulate a process the clearly defines how the ASO/MBHO may place appropriate limits on a service only after a process ensuring clinical and administrative determination has been achieved. Demonstrate how decisions to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested, be made by a clinical professional who has appropriate clinical expertise in treating the enrollee's condition or disease. Articulate parameters for standard authorization decisions and how notice will be provided as expeditiously as the enrollee's health condition requires Describe how the ASO/MBHO will make expedited authorization decisions and provide notice as expeditiously as the enrollee's health condition requires for cases in which a provider indicates, or the MCO determines, that a standard timeframe could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum function 33 Page

34 Care Coordination and Continuity of Care: Demonstrate how the ASO/MBHO will coordinate with other MCOs, PIHPs, and PAHPs serving the enrollee to prevent duplication and fragmentation in service delivery Demonstrate the ability, enhanced through EHR, to inform providers of the consumer s treatment plan, in accordance with confidentiality requirements Demonstrate how Coordinated Care Plans are member-driven (developed by members with assistance from Care Coordinators), build on member strengths and reflect member preferences and needs for services and providers Demonstrate how an information management decision support tool will be implemented and how screening and assessments will integrate into the tool for optimum output Demonstrate how the ASO will use peer supports (e.g. peer bridgers for care coordination, certified peer recovery specialists) Demonstrate how an ASO/MBHO will provide continued provision or gradual transition of a provider or service to prevent adverse effects for the member during the change. For mental health services, therapeutic alliance and treatment regimens require time to achieve effectiveness Demonstrate how Care Coordinators will be trained to address the needs of, and work with, individuals with complex behavioral, medical and social needs, including specialty care coordinators assigned to work with specific enrollee populations. Information and Education: Demonstrate a communication and education plan for providing in-depth information required for consumers, providers, families and community stakeholders to navigate the system inclusive of free webinars. Articulate the development and dissemination of consumer handbooks, pamphlets, and posters. Demonstrate how the ASO will develop, implement, and maintain a network provider directory and a web-based provider database that is user friendly, accessible, and searchable by location, name, service provision, and hours of operation. Specify degree to which purchaser, ASO, or both, are responsible for ensuring availability of information to enrollees, providers, and other parties Require a handbook guiding clinicians and provider organizations Specify type of information to be provided (rights, services covered, exclusions, etc.) Require easily accessed enrollee services to provide information, answer questions, give recommendations, and resolve complaints Ease of Initial Access: Specify mode of initial access to services to be used by the ASO Specify whether behavioral health care services can be accessed directly without going through a primary care provider Require 24/7 toll-free service line provides information, assessment, and referral services with capacity to meet language needs Establish how enrollees are to access emergency services Specify types of authorization (pre/post authorization, no authorization) that are required, allowed, or forbidden 34 Page

35 Geographic Proximity: Specify maximum allowable travel times and distances enrollees may be required to travel to specified levels of care and services Require development of strategies for ensuring transportation services by providing these services directly, assigning transportation responsibility to network providers in specified circumstances, or subcontracting this service to a transportation firm Establish special access standards for services that are highly specialized and/or for limited choice of providers Establish access requirements for rural areas based on mileage, time restrictions, or other relevant variables Timeliness of Access: Require urgent and emergency/crisis services available within specified periods of time Establish maximum times between initial telephone (or other contact) and first face-toface contact for routine, urgent, and crisis/emergency care Establish maximum allowable times for authorizations and reauthorizations, or allow a certain level of service before authorization must be obtained (e.g., eight outpatient visits) Demonstrate how provisions of services to all eligible individuals will be ensured without the establishment of waiting lists, including policies and protocols to support this process Clarify access requirements for designated services (e.g., detoxification) Cultural and Linguistic Competence: Develop and maintain a culturally competent and representative provider network Ensure and maintain a culturally competent workforce to serve and accommodate the diverse cultural and linguistic needs of enrollees Demonstrate how the ASO/MBHO will ensure competence by having a staff that reflects the racial and ethnic composition of the enrollees Create and maintain a comprehensive network provider directory to ensure appropriate referral, access and outreach Complex Behavioral, Medical and Social Needs: Specify how the transition to the ASO/MBHO will occur for persons with complex behavioral, medical and social needs who are receiving mental health services from other MCOs, PIHPs, and PAHPs. For example, I/DD consumers currently receiving mental health services in the Medicaid managed care system. Demonstrate how mechanisms to assess each enrollee with complex behavioral, medical and social needs in order to identify any ongoing special conditions that require treatment or regular care monitoring will be implemented Demonstrate how quality and appropriateness of care provided to individuals with complex behavioral, medical and social needs will be assessed Demonstrate how the ASO/MBHO will share with other MCOs, PIHPs, and PAHPs serving the enrollee with complex behavioral, medical and social needs the results of its identification and assessment of that enrollee s needs to prevent duplication and fragmentation of those activities 35 Page

36 5. Priority Recommendations for Development and Implementation of the ASO/MBHO: Provide a bulleted list of the Work Group s priority recommendations that that may not fall specifically within Work Group s area of focus but relate to the areas addressed by one or more of the other Work Groups. The State should establish a feasible timeline that takes into consideration operational, provider and system readiness pilots and reviews which are encouraged to take place prior to implementing care/enrollee management through an ASO/MBHO Establish mechanisms that ensure services to the uninsured and/or underinsured Establish mechanisms that promote utilization of community-based services (prevention, early intervention, treatment and supports) without inadvertently instituting barriers which diminish access to clinically appropriate/necessary inpatient treatment (short and/or long-term) Build capacity in the system through rate setting and other targeted enhancement measures as you can t manage a system that has an infrastructure deficiency Enhance targeted services for individuals with complex behavioral, medical and social needs that require specialized assistance (such as the aging in population, I/DD, Co-Occurring, Justice Involved) During start-up of adult managed behavioral health services, qualifying ASO entities must demonstrate how they propose to administer and safeguard continuity of care for current Medicaid and other funded enrollees. Qualifying ASO applicants must demonstrate interoperability of management information systems, data processing systems and health information technology Regional Liaison services should be funded under the ASO to be present for local meetings and service coordination Care management, at the community level, should be incorporated into the service delivery system Create system linkages for broad application of presumptive eligibility (PE) determinations (i.e. a child who is eligible for school lunches meets all PE program criteria) Screening centers crisis services need to be enhanced Enhance analysis of services that are costly and develop and invest in appropriate alternatives Build accountability for the ASO and require reports on every call, referral, follow up and linkage made ASO should provide care management, while case management of a different caliber must exist on a more personal and community based level Revisit existing oversight and monitoring mechanisms in place that engage in continual quality improvement and quality assurance activities Develop appeals, ombudsman and oversight mechanisms and protocols that include independent reviews, which is of particular interest in an at-risk model 36 Page

37 Ensure a competent communication plan is in place ensuring families, consumers and providers are educated in the community regarding the ASO and service delivery Be innovative with advanced directives so that consumer wishes, desires, etc. are a real factor in service delivery Ensure universal release of information forms are a part of the advanced directive system Advanced directives should be a part of the EHR 6. Attachments: Provide a brief description of any additional documents produced by the Work Group, as well as the specific attachments. A full report of the group s activities and outcomes are available at the following link: 37 Page

38 Clinical Work Group Final Report Work Group: Clinical Work Group Chair: Evelyn Sullivan* Professional Advisory Committee Work Group Members: State Staff: Vicki Fresolone* Natasha Johnson Nancy Hopkins George Mladenetz John White Annette Riordan Ana Guerra, Citizens Advisory Council Donna Icovino*, Family Advocate Kristen Creed*, ARC of Monmouth Kathy Bianco, Care Plus NJ John Monahan, Greater Trenton Behavioral Health Care Chris Mussell, Catholic Charities, Diocese of Trenton Earl Lipphardt, Integrity House Bill Sette, Preferred Behavioral Health Tom Rueben, Jewish Family Services of Atlantic County Angela Romano-Lucky, ICMS Provider Association Rosemarie Rosati, UMDNJ-UBHC Ruth Cook*, UMDNJ-SHRP Barbara Johnston, Mental Health Association in NJ Gail Levinson, Supportive Housing Association Angel Gambone, Citizen Ken Gill, UMDNJ-SHRP Russel Kormann, Rutgers University Lucille Esralew, SCCAT Jim Romer*, Ocean Screening Center Anthony DiFabio, Robin s Nest Manuel Guantez, Turning Point Wayne Vivian, COMCHO * Steering Committee Members Guiding Principles 1. Wellness and Recovery first and foremost the Administrative Services Organization (ASO) must be designed with wellness and recovery as the overarching guiding principle. This would include: 38 Page

39 Ensuring that the system is organized around promoting rehabilitation, resilience, and prevention, with use of acute services only as needed and with all services (acute, and longer-term) being evidence-based to the fullest extent possible. Ensuring that the service management does not create additional barriers for individuals in need. Ensuring a full continuum of behavioral health treatment services that produces quality outcomes while serving consumers in the lowest level of care clinically indicated. Ensuring that the ASO supports services designed to enhance clinical treatment by including access to support services and family involvement and promoting the use of natural supports. Ensuring that the ASO includes the use of adequately trained peers in both design and implementation of policies and procedures related to services, access and quality. Peer support is essential as peers can be a constant that people experience as they move between other points on the continuum of care (peer support and peer case management). Ensuring that access and management of services are designed in a culturally competent manner. Access, placement and continuing care decisions should include consumer choice whenever possible. Consumers have the choice of high quality, individualized and accessible services in the community. 2. No-wrong-door the system s interface with consumers should be based on a no-wrongdoor access model, where consumers receive concrete support in accessing services to address all their needs, and are not left on their own to negotiate solutions to complex service problems. 3. Integrated care integrated care addressing physical and behavioral health problems, mental health and substance use disorders, developmental disabilities, and other problems confronting consumers with co-occurring disorders/ disabilities and complex service needs. 4. Evidence based focuses on continually improving services by ensuring a full array of evidenced based and promising practices and promoting innovation and support pilot projects. Only within the context of a comprehensive array of evidence-based practices is the encouragement of consumer choice meaningful. 5. Service delivered by a trained and competent workforce the workforce is the foundation of care. A trained and competent work force is critical for the delivery of high quality services. The system will never achieve the care needed to promote outcomes and avoid the cycle of repeated acute care services without a trained and competent workforce. 6. Consumer and staff safety is paramount all behavioral health providers must have the capacity and support required to prevent and manage potentially dangerous situations, and to provide services to those who have demonstrated past dangerous behavior, and who are at-risk of dangerous behavior to self, others, and/or property without adequate support. 7. Comprehensive and efficient communication comprehensive and efficient communication across the system is critical to the desired goals of this system transformation. To improve 39 Page

40 consumer outcomes and increase effective use of the current system provides, the ASO and the service providers must have ready access to critical consumer information that can follow the consumer from provider to provider. 8. Documentation documentation requirements should be the minimum required to inform clinical decision-making, and remain subordinate to the clinical process. The provision of high quality services to consumers to improve the health of consumers is of paramount importance. 9. Quality Management continuous quality improvement should govern the interface between DHS, the ASO, providers, and consumers. 10. Mitigating the impact of poverty the majority of consumers served in the public system experience poverty and a paucity of resources that impede full integration into the community and recovery. To date, DHS has provided financial support in the form of flexible funds and emergency grants. It is critical to consumers recovery and decrease in use of acute care that this flexibility continues. 11. Consumer engagement is key consumers may be ambivalent about services and may require respectful processes to engage and ensure reasonable access to services. Challenges/Opportunities How to avoid the ASO/MBHO becoming an obstacle to engagement; Developing capacity in the system to meet consumer needs and ensure a continuum of care; Workforce shortages and retention; Lack of workforce competencies across the system; Developing outcomes tied to the consumers goals and desires; Dealing with statutory requirements and the justice system versus medically necessary and clinically appropriate care; Developing rates that allows for developing the system, i.e. incorporates ability to train and retain competent workforce, and provide critical services and care not yet billable (i.e. case management, outreach/engagement, clinical supervision); Ensuring inter-agency collaboration to the extent needed to develop seamless and integrated care; How to right-size the provider network to meet demand and enable a critical mass of consumers that allows agencies to continue to operate; Ensuring cross systems coordination among State agencies to lead from the State level; How to address the scarcity of specialists that accept Medicaid as a payer; Having the ability to pay for rehabilitation type services that will prevent crisis; Lack of capacity in primary care and other medical specialties that accept Medicaid; Manage dangerous behavior in community settings; 40 Page

41 Streamlining Medicaid and DMHAS regulations and compliance requirements, especially the clinical documentation requirements; Ensuring adequate assessment upon entry into a system to identify specific treatment needs (e.g., trauma history, substance abuse, emotional dysregulation; etc.); Developing provider readiness for ASO implementation; Maintaining service system infrastructure such as IT and vehicles; Priority Recommendations Specific to the Work Group Ensure that we have preventive programs to reach people earlier in the illness process. Access to care that includes early intervention and outreach to avoid hospitalization is critical. The ASO must demonstrate the ability to help the behavioral health system reverse the health disparities, where chronic diseases treated too late or not at all result in premature death years earlier than the general population. The ASO must also ensure that the system has the capacity to divert consumers from high-cost emergency and inpatient care for both behavioral health and physical health problems. Diversion from high-cost hospital-based services is one of the most important guiding principles for the comprehensive waiver. The ASO must demonstrate the ability to help the behavioral health system evolve into one where integrated care for both behavioral health and physical health needs is the standard of care for those with serious behavioral health problems. Although providers should not be expected to become expert in addressing all possible problems, they should receive training support and funding to function as generalists to support consumers in addressing their needs. This support may be either by providing services directly or, where needs are very complex, by helping consumers access services from specialty providers, who are partners working under collaborative service agreements. These partnership agreements should ensure ongoing care coordination and adequate support for the consumer in navigating through the system. The design of the ASO must be practical and user friendly for consumers and providers. The management of services should not be a barrier for engagement but designed to promote engagement at every level. Effective and well delivered services are of little value if the consumer does not engage and participate. The ASO should develop and manage a system of care that promotes and maintains consumer access and recovery and must also ensure that (1) services are available to those with behavioral health challenges when they need them and (2) that funding and service mechanisms support the integration of individuals who are at risk but are not inclined to participate in services. Interventions should be based on sound research but should be practical to implement in the field with fidelity when adequate staff training is provided. Manualized approaches, tool kits, and fidelity instruments support quality outcomes. The appeals process needs to be defined with clear time frames and provision of peer support and advocacy during the process. Clarification needs to be made between ASO appeals process and the Medicaid Fair Hearing. 41 Page

42 The ASO shall develop timelines for building capacity in the behavioral health system to prevent and/or delay the onset of chronic diseases and to ensure timely access to primary and specialty care. Deliverables with timelines for capacity-building for integrated care shall include: o Physical and behavioral health problems identified and tracked by providers through integrated health records; o Incorporating into treatment plans treatment goals related to accessing primary and specialty care, and developing consumer skills for managing illnesses and maintaining health (e.g., proactive help-seeking skills, symptom-management skills, regular exercise, nutrition-conscious meal planning, shopping and food preparation skills, etc.); o On-going program support by direct service staff to help consumers develop illness management and health maintenance skills, especially as part of programs serving persons in high-risk circumstances (e.g., PACT, ICMS, Supportive Housing, etc); ongoing health coaching by direct service staff to help consumers learn illness management and health maintenance skills; o On-going monitoring and care coordination by direct service staff serving those at high risk of chronic diseases to ensure timely access to primary and specialty care; o On-going nursing support to identify potential health problems through nursing assessments; coordinating with direct service staff around health coaching and consumer skill development; coordinating with direct service staff and medical treatment providers to help consumers access primary and specialty care; coordinating with medical treatment providers to help consumers manage chronic diseases and support ongoing care; o Develop in collaboration with DHS and community providers staff training programs related to integrated care; Increase and fund the capacity for evidence-based, emerging and promising practices (e.g. CBT, cognitive remediation, IDDT, Motivational Interviewing, trauma informed care, and MAT); o ASO to support staff training/certification o ASO to reward providers for obtaining and maintaining fidelity Regulations across addictions, mental health and Medicaid should be consistent; o Assessment, treatment planning and continuing care approvals in the ASO should reflect regulatory requirements. The ASO shall ensure that every region and, where possible, every community has access to specialty services provided by experts, and that these specialty providers are integrated with all other providers in the behavioral health system through signed collaborative service agreements that specify roles and responsibilities related to access, systemnavigation and on-going care coordination for consumers with co-occurring and complex service needs; o The ASO shall develop, in collaboration with DHS and providers, a template for inter-agency collaboration agreements to ensure integrated care coordination for consumers with co-occurring disorders/disabilities and complex service needs; 42 Page

43 o Reward integrated services and interagency collaboration throughout the continuum of care. Agencies cannot be expected to be expert in all areas but they must have the capacity to screen for BH/PH/DD. If they are not able to meet the consumer s needs they must facilitate an immediate referral and coordinate care; Eliminate restrictive, very specific eligibly requirements for substance abuse services; Utilize an IT system that allows for information sharing; o Avoids duplication; o Interoperability with the many Electronic Health Record systems in place now; o Include a consumer/family portal in any electronic information system and provider portal that includes ability to provide reports; o Data must be shared between the MCO and the ASO; o Data must be shared from the MCO and ASO with the providers. Establish minimum core competencies for workforce; o Align required credentials with core competencies; o Streamline and expedite waiver process for qualified employees to allow providers to hire for non-treatment positions based on core competencies. Telehealth should be used to address shortages in highly trained professionals and consumer difficulties in accessing care. Telehealth can be used for consultations by specialists (e.g., addiction psychiatry) or for ongoing care when consumers have difficulty accessing office based care; Use of peers should be developed in a very specific manner: Define roles, define qualifications/abilities: develop strong accountability, and applicable accommodations to fund, hire, promote and acquire peer employees; o Incorporate peers/peer supports throughout the continuum of services. System should require the use of uniform co-occurring tools for screening, assessment and placement for the ASO/MBHO and all providers; o System should require a uniform placement tool that does not require a full summary for each continuing care request and includes stage of readiness and change; o ASO/MBHO and all other points of access can screen consumer. Only licensed provider agencies can provide a full assessment. Include an engagement phase of services; Community providers should be funded to be accessible 24/7; Develop a comprehensive care and crisis plan that can move to and from agencies to follow the consumer through the system; The ASO shall develop strategies and reimbursement mechanisms to support providers in providing enriched services to those at risk of becoming a danger to self, others, and/or property; 43 Page

44 Ensure that providers receive adequate training in crisis prevention and de-escalation techniques, escape techniques, and support to develop safety and violence prevention procedures to ensure the safety of staff and other consumers; The ASO must make provisions for the support of public safety requirements due to extreme needs of habilitation and rehabilitation for those mandated to residential care in addiction and psychiatric settings; The ASO must allow for clear entry and tracking of documentation of legal mandates, especially when they contraindicate clinical assessment and prescribed treatment; Develop a state-wide capacity-building and training initiative to ensure the capacity to implement the SOAR method advocated by SAMHSA and HUD. Priority Recommendations for Development and Implementation of the ASO/MBHO [Priority recommendations that that may not fall specifically within Work Group s area of focus but relate to the areas addressed by one or more of the other Work Groups] The ASO shall develop strategies to ensure that those eligible for Federal and State entitlements receive them in a timely manner. The ASO should pay special attention to helping those most likely eligible for SSI/SSDI because of psychiatric and other disabilities. These consumers should receive support in completing applications and gathering health records within timeframes established by regulation to document consumer disability and their functional incapacity to work. Because current approaches used to apply for SSI/SSDI typically fail to meet timelines for providing health records, many consumers eligible for SSI/SSDI are forced to remain on State-funded General Assistance, resulting in a lower level of support for consumers and an unnecessary financial burden for the state taxpayer. Evidence-based methods for applying for SSI/SSDI, such as SOAR, should be employed. SOAR has been implemented on a small scale in New Jersey and has proven to be over three times more effective in securing benefits, and doing so up to six times more quickly than the current methods employed by behavioral health providers; Workforce development must be a priority in the development of the ASO requirements, in the development of rate structures that allow for agencies to promote training, and ongoing supervision and a priority for state polices and programming; Funding should be made available to support services for those consumers who are not Medicaid eligible or have no other payer source. Attachment I Attachment II Attachment III Attachments Recommended Services Array Case Management Existing Services Case Management Proposed Services 44 Page

45 Work Group Chair: Dennis Lafer Fiscal Work Group Final Report Work Group Members: Steve Adams, Joel Boehmler, Dan Burns, Julie Caliwan, Carmine Centanni, Jim Cooney, Stan Evanowski, Fonda Fonte, Jose Gonzalez, Roxanne Kennedy, Geralyn Molinari, Robert Nolan, Alan Oberman, Robert Parkinson, John Rios, Roger Sarao, Lou Schwarcz, Kevin Slavin, Kim Todd, Linda Voorhis, Debra Wentz, Colleen Woods, Annette Wright, Cheryl Young Guiding Principles: Provide a brief narrative summary of the guiding principles that should drive design and operation of the ASO/MBHO, with particular emphasis on the Work Group s area of focus (access, clinical, fiscal, outcomes). The fiscal Work Group considers the movement of the MH/SA system of care from a largely unmanaged, largely cost related contracting system to a managed system, employing fixed rates on a fee-for-service basis, to be a challenging, yet necessary step toward an environment where consumers receive appropriate care and supports in a manner that is efficient, accountable, and affordable to the taxpayers. A significant challenge will be to build a system that compensates providers for the level of care consumers require and can control resource consumption such that the entitlement as well as non-entitlement populations are sufficiently served. The State must also be mindful that as reimbursement rates are established, that they are set at levels that will induce a sufficient number of providers to enter the marketplace to deliver necessary services to consumers, while meeting all requirements in relation to availability, access, geography and quality. Financial and non-financial incentives need to be established to promote efficiency and a system that supports the over-arching principles of wellness and recovery, all while tracking consumer-specific utilization carefully in all programs on the clinical continuum of care to help insure resources are expended efficiently, and that stated outcomes are achieved. Key Considerations: Provide a bulleted list of the key considerations identified by the Work Group, with particular emphasis on the Work Group s area of focus (access, clinical, fiscal, outcomes). A. Describe the critical components of a seamless, user-friendly service authorization and claims processing system Key Issues for Consideration What do stakeholders like or not like about DAS, Medicaid and DCBHS authorization/claims processing and DCBHS systems and what strategies could be developed to ameliorate; 45 Page

46 The need to balance benefits of control through utilization management tools against clinical need for immediate access (emergent and urgent) and the cost of controls for the system (State and provider); Timeliness of authorization and payment; Need to consider how to promote preventive care and its relationship to authorization process; Consumers will continue to seek help until they receive services; this may be more costly if adequate access is not available at the community level; Lack of authorizations due to limited resources may create waiting lists and providers expressed concerns that there may be consumers who may not receive services; Consideration should be given to independent Ombudsmen to address consumer and provider inquiries; B. Prioritize the services in the behavioral health system to target for rate rebalancing Key Issues for Consideration What services for what populations will be included within the scope of the ASO/MBHO? Services where availability is being purchased such as screening and emergency are open questions as are self-help center services and intensive family support services; Question regarding management of State/county hospital resources; Services where model is still variable and not statewide (i.e. early intervention support services); Providers need sufficient time to ensure interoperability of EHR and IT systems being developed with requirements of ASO; What services, and to what degree, should be bundled in rate setting process? Will changes in rates potentially open bundling issue with CMS for services like ICMS, PACT, Adult Residential, etc.? Do current New Jersey limits on volume and consumption of service per day continue to be relevant if services are being managed? Rate development should consider differentials or add-ons for individuals who are dually diagnosed; Prospective system needs to address changes in cost/market conditions by some provision for rate adjustment or rebalancing; C. Describe reasonable options for a transition from cost reimbursement to fee for service provider contracts Key Issues for Consideration Is July 2013 a realistic goal to transition all services that will move from cost related to feefor-service (FFS); Success of transition paramount to ensure continuity of consumer care; 46 Page

47 There is wide variation in provider ability both financially and administratively to be successful in a system requiring authorization to serve consumers and provide payment after service is rendered as opposed to in advance; What should be the scope and duration of transitional assistance and/or hold harmless provisions; Existing consumers already enrolled and receiving services during transition need to be considered - i.e. if in the past did not need authorization and in the new system prior or continuing stay authorization is required; Education of State staff, providers, and clients is critical prior to implementation; DAS did a systems analysis to identify what was working well and what was not similar consideration should be given to the massive change envisioned by this initiative; Sufficient lead time will be necessary to ensure all required credentialing is completed; Auditing fees for providers may be reduced under FFS as providers may not be required to have A133 audits for services compensated in this manner vs. cost based reimbursement; Anything under cost reimbursement will still be subject to A133; With regard to resources for non-entitlement populations, consideration will need to be given to the development of sub-pools of resources by service type and potentially geography to promote assurance of availability of service array across the State; D. Suggest payment strategies that will incentivize provision of good care for reasonable cost Key Issues for Consideration State should strive to keep any system as simple and objective as possible and should consider starting small and building upon successes; Once applicable outcomes are selected for the ASO, service and consumer levels, baseline data needs to be collected to facilitate measurement of change; Need to ensure assessment through application of uniform instrument(s) to ensure clients with like attributes are aggregated and are measured against other like groups (i.e. in order to ensure fair application of incentives and avoid creaming, measurements must be objective and groups measured must be homogenous); Should the uniform assessment be conducted by providers who may ultimately deliver care or should assessment be independent? Once assessment is complete and quantities and types of services needed identified, need to ensure consumers are afforded reasonable informed choice based upon quantified published information such as provider report cards; Challenges/Opportunities: Provide a bulleted list of the challenges and opportunities identified by the Work Group, with particular emphasis on the Work Group s area of focus (access, clinical, fiscal, outcomes). A. Describe the critical components of a seamless, user-friendly service authorization and claims processing system 47 Page

48 Challenges and Opportunities DAS Current FFS system challenges New consumers labor intensive to secure authorization Difficult to predict availability of funds from provider perspective Managing situation with consumer when resources are not available Manage non-entitlement population to avoid starts and stops coordination with essential health benefits for non-entitlement consumers Current Medicaid billing system is being updated, next generation MMIS will not be available till 2015, making programming changes to current system is time-consuming EHR transition for individual agencies is costly and time consuming but required in under current law B. Prioritize the services in the behavioral health system to target for rate rebalancing Challenges and Opportunities Providers may have to add staff to manage consumer authorizations, billing and reimbursements Providers will have greater challenges managing cash flow in relation to varying volumes of services being authorized There are economies of scale that may adversely affect smaller providers State needs to ensure clear definition of services and ensure rates that reflect the level of credentialed staff that provide direct care services Various practitioner licensure boards have differing standards regarding qualifications for who can provide what services would be good if State ensures clarity in definitions when defining service requirements Consideration needed regarding the impact of capital funding provided through State on facilities costs and relationship to rates, particularly the room and board component of residential services Consideration necessary of which services or components of services should remain cost related such as perhaps new services without much track record re cost utilization and outcomes,? Rental subsidies? Capacity services? (i.e. screening) Providing services to dangerous individuals (not legal standard) or in dangerous areas and how to incorporate into rates Ensuring maximization of individuals covered via non-state sources such as Medicaid. How should benefit procurement be compensated in new system? C. Describe reasonable options for a transition from cost reimbursement to fee for service provider contracts Challenges and Opportunities Given wide variation in provider costs/financial stability / ability, the composition of provider pool may change 48 Page

49 Length of transitional assistance is an issue as the State needs to balance resources with the provider community s ability to conform business practices to new reality The conversion will likely be experienced differently for high volume, high turnover services, such as outpatient services, as opposed to longer term services like some types of residential services D. Suggest payment strategies that will incentivize provision of good care for reasonable cost Challenges and Opportunities Baseline data may or may not exist in a form accessible enough to facilitate analysis required to evaluate change and provide reward SRC may be a source of some baseline data to be explored Any incentive arrangement needs to be structured in such a way as to maximize opportunity for federal financial participation (FFP) in the incentive payment Given that consumers are starting at different points, need to measure progress against their individual starting point Need to be sure to measure against consumer articulated goals. For example, not every consumer may express desire for employment, so progress on outcome measure such as employment should only be measured for consumers expressing interest in employment vs. pursuing other activities Priority recommendations specific to the Work Group: Provide a bulleted list of the Work Group s priority recommendations specific to the Work Group s area of focus (access, clinical, fiscal, outcomes). A. Describe the critical components of a seamless, user-friendly service authorization and claims processing system Recommendations Certain emergent and/or crisis services should be considered presumptively approved such as screening and emergency services. Services beyond X immediate parameter require continuing authorization; Crisis and emergency immediate access. PACT, SH, Residential, RIST, ICMS do not currently require prior authorization but should be considered in the future; Consider implementation of prior authorizations (PA) after 8-10 sessions similar to commercial plans for certain low cost services such as outpatient services. Services to be delivered to the non-entitlement population would require PA to ensure availability of resources; System needs to facilitate, not impede, intake. Triage via ASO to register episode. Nonentitlement populations would require authorization even for intake evaluation to ensure availability of funds to ensure that intake is not performed when no funding is available for service; 49 Page

50 The system should contain all attributes of current Molina Medicaid claims processing system (i.e. electronic claims submission, no less frequently than weekly electronic payment cycles, ability to provide cash advance and recovery, ability for differential rates, electronic remittance advices, etc.). ASO must have help desk to assist processing of claims; Requirements for the amount of time that will be allowed for the managing entity to complete authorizations for care regarding emergent, urgent and routine care; Authorization requirements by a person and cases for warm handoff; RFP should specify credentials of staff able to provide authorizations, denials, reductions, and provision for physician involvement; Claims adjudication requirements - X% clean claims paid within X days of submission (no less stringent than current Medicaid requirement); Providers should have web based access to provider account status information including PA information, claims in process, denied, pending and paid claims; Blended funding so that provider is not responsible for maintaining certain payer mix; Authorization logic includes identification of payer -- providers would not have to distinguish; To the maximum extent practical the scope of PA should cover package of services needed by consumer based upon uniform objective criteria across all dimensions of BH care: o Mental health o Addiction o DD There should be one system for all processes, for entitlement as well as non-entitlement clients; System needs to identify all potential payers for each client such that state funds are source of last resort Vendor must develop process for managing resources available statewide for non-entitlement population and process to prioritize service need; Develop Eligibility Criteria; o Will need uniform income, asset, and population attribute criteria; o Consider to what degree there could be presumptive eligibility while full eligibility determination follows current example is State hospital interim assistance program; Need a consumer and provider friendly process to dispute denials minimizing volume that evolve to actual grievances; Client eligibility notification to provider; Clinical determination must be made by clinician with relevant training regarding authorization approval or denial; Summary of denials and recommendations for care reduction report should be provided to State; As State develops network participation criteria the State needs to ensure uniform standards for the provision of each service type, or in the absence of uniform standards, ensure that rate differentials exist to address disparities; o Example- will independent practitioners such as Licensed Social Workers be part of network and if so they would need to meet all of the standards developed for a provider like a community mental health center in order to provide outpatient counseling. If different standards such differences should be addressed in rates; 50 Page

51 Consideration should be given in rate development for an enhanced rate for providers for integrated care and coordination of medical and social services including case management; Rate setting exercise should take into account differences in consumer complexity to aid in preventing creaming. Consider rate differentials that are based on level of functioning and/or diagnosis; o Example - rate for individual counseling for situational depression should perhaps be less than counseling for multi system involved individual with schizophrenia even if such services were provided by direct care clinician with same credential; Ensure that as the essential health benefits package becomes concrete, State evaluates impact on ASO benefit package and consumer eligibility in order to maximize coverage and non- State participation in the cost of care; Need to ensure that system vision is clearly articulated to stakeholders in as much detail as possible as early as possible so that business practices can be realigned to maximize probability of success. Additionally, ensure that ASO passes a rigorous readiness test in advance of going live and/or incrementally assuming more responsibility; A subset of Work Group participants advocating a go live date of January 1, 2014 to assess impact of Federal Health Care Reform; The ASO should have a live help desk to aid consumers and providers to navigate issues (i.e. continuing authorizations/approvals, denials, pending claims, etc.); Multiple provider numbers for providers complicate claiming process. State should see if one provider number can be used with appropriate identification of all services for which a provider is allowed to bill; Providers should be able to access their individual prior authorization and claims status information at the ASO or other applicable claim payment entity to facilitate their own internal administrative processes; State should frequently monitor available funds and outline process for reviewing utilization data to minimize disruption to service authorization process; B. Prioritize the services in the behavioral health system to target for rate rebalancing Recommendations All rates that will be paid on a uniform non-cost related FFS basis by level of care really need to be evaluated for sufficiency to achieve the objective of ensuring inducement of sufficient provider participation to meet the access standards in terms of timeliness, quality and geographic standards; Rate differential should be considered for complex cases such as multiple diagnoses; Client attributes, severity of need to be considered in rate structure; These rates should be market based and periodically evaluated no less than bi-annually to ensure continued sufficiency to achieve above objectives; Community Support and Peer Support services must be considered as part of rate review; Some providers have waivers of regulatory staffing requirements which will need to be considered in rate setting and provider participation requirements that will be developed; Rates must consider underlying licensure and regulatory standards i.e. assure sufficiency of compensation in relation to requirements; 51 Page

52 C. Describe reasonable options for a transition from cost reimbursement to fee-forservice provider contracts Recommendations Not all services that are currently under cost related contracts will be moved to FFS. Our recommendation is that services such as advocacy and self-help centers, and possibly Screening and Affiliated Emergency Services remain cost related; State must identify milestones for transition for implementation of change (i.e. rate analysis needed well in advance of initial transition of cost related reimbursement to FFS); Provider groups should facilitate training to assist in preparation for transition. This has been occurring; Major issue will be the rates. The earlier the rates can be developed and made known the earlier providers will be able to determine if they can compete and if so what changes may be necessary to promote ability; Simulations should be run to clearly demonstrate effect of rate change at given volume levels by individual provider; Consideration for infrastructure costs for residential and outpatient costs in rate setting and analysis based on size of agency; Consideration should be given to commencement of transition before advent of the managing entity by using providers specific rates but phasing in accountability for production of volume. Performance corridors could be established with no consequence at certain levels and varying consequences at fixed points thereafter and method for additional compensation for additional performance; o Example: There would be a reduction if say 70% of volume were delivered and additional compensation (with approval) if over say 110% of volume were delivered; One option would be to retain cost related contracts for a period of X time, paying the difference between cost and rates for actual volume delivered incrementally moving to no subsidization. Variation on theme would be to have a volume subsidy as long as a certain minimums were provided (restrictions on ability to make profit during period of subsidization); Providers assert that reasonable time transition from cost to FFS of 2-3 months too rapid; o Investigating assertion that New York Medicaid redesign held providers harmless for 2 years. Evaluate comparability to New Jersey circumstances; State absolutely must have vehicle to ensure cash flow for circumstances where the State and/or ASO is cause of delay. Where State/ASO is not the cause, develop objective criteria for limited provider assistance during transition; In order to ease provider movement into being compensated in advance of service delivery as is the case in large measure under the cost related contracts, to after services are delivered as will be the case with FFS compensation, consider providing quarterly advances at the beginning of a quarter and recovering in the third month of the quarter. This should be based on uniform criteria to determine need for some pre-defined limited period of time; o Note: Change in agency contracts from cost-based to FFS has major impact on agencies business process. Elimination of cost based contract has potential to impact available line of credit providers may have with their bank. State must consider 52 Page

53 organization cost of provider infrastructure in determining transition process and provider cash flow needs; Another option could be to phase in FFS by service type; Consideration could be given to phasing in ASO responsibilities. They will need to pass readiness tests prior to assuming additional responsibilities; Phase in could be by element of service or Medicaid covered individuals and services initially, expanding broader as additional demonstrations of system readiness are achieved; Providers need to be afforded the maximum amount of time practical to develop information systems to conform with information requirements of ASO to maximize probability of success; It would be helpful if, in addition to requirements enumerated in the RFP, there could be demonstration of systems (billing and referral to ASO) by the successful bidder some months in advance of implementation; Publicize timeline for transition; Existing consumers in service transition needs to be considered - if in past did not need authorization and in the new system will require prior or continuing stay authorization; Consider presumptive authorization at current level for given period of time; Length of time may vary depending on level of care; Transitional one time assistance to develop information systems should be made available to the extent possible to maximize probability of provider success at transition; It would be helpful for providers if flowcharts of how the new system is envisioned to function in terms of service authorization and payment were developed and disseminated. D. Suggest payment strategies that will incentivize provision of good care for reasonable cost Recommendations: Premium for coordination with physical health system and decreasing utilization/improving outcome It should be a contract requirement of both the physical health side and behavioral health for unified case planning with a negative financial consequence for non-compliance; Focus on high cost utilizers and reducing utilization while concomitantly improving outcomes; Reduction in inpatient utilization and recidivism; Reduction in emergency room utilization; Improve level of functioning as measured on standardized instruments; Reduction in residential level of care required; (as long as not mandated externally like by court order); Incentivize ASO to develop/assist State to develop provider network that is geographically balanced; Increase community tenure (length of time out of hospital); Realizing life goals re employment, education, etc.; Decreasing individual risk level; Abstinence for X period post-treatment ; 53 Page

54 Abstinence for X period during treatment ; Improvement in consumers quality of life following episode of care (i.e. housing, employment, arrest); Access - how quickly can agency can provide services particularly post hospitalization; Engagement and retention - are consumers attending and actively participating in care on regular basis; Incentives don t have to solely take the form of a payment. Lessening administrative burdens for high performing providers would also be a form of incentive. Additionally, superior performance as evidenced on report card should result in increased consumer selection; Changing prior authorization parameters in terms of length of authorization or services requiring PA before continuing authorization is required; Providers identified as achieving positive outcomes could receive enhanced referrals in some manner that still preserves consumer choice; As early as practical, given limitations of data regarding cost, utilization and outcomes, move from managed FFS compensation to case rates for providers. In this context we are using case rate to mean payment to a provider of a flat amount, for a period of time, for a given consumer or each member of a population, in exchange for a particular outcome. o Example rate of X/month to maintain consumer out of inpatient psychiatric hospitalization and attain X goals and X level of consumer satisfaction. Provider is at risk to some or full degree for cost of services needed to achieve the objective; Movement to case rate compensation needs to be planned carefully and made only after sufficient data exists to develop case rates that are reasonable in terms of cost and in relation to the outcome expected; Priority Recommendations for Development and Implementation of the ASO/MBHO Provide a bulleted list of the Work Group s priority recommendations that that may not fall specifically within Work Group s area of focus but relate to the areas addressed by one or more of the other Work Groups. Outcomes need to be developed in terms of the MH/SA system, individual consumer selfidentified goal attainment and service element; An example of service element type outcome could be partial care, where the objective of the service is skill attainment, and for individuals can be measured on pre and post-tests. Providers whose caseload receiving services within approved limits, as measured over X period of time, who exceed a benchmark with regard to a proportion of consumers achieving in excess of a benchmark level of change, would qualify for incentive; Outputs which are believed to contribute to the production of desired outcomes could be incented as well as the outcome themselves (i.e. treatment retention and rapid access for clients with certain predefined attributes); Data (de-identified in terms of client) from ASO, as well as HMOs, should be part of the public domain to the maximum extent practical to allow interested party analysis; identifier for individuals that is anonymous but includes specific demographic client information; Consideration should be given to one time financial assistance as may be available to aid in developing systems necessary to participate in network and accumulate and document outcomes that will ultimately be incented; 54 Page

55 Stakeholders must have input into development of data set for report card, network participation criteria and public display; Publication of provider report card that is available to public and used to allow consumers informed choice with regard to selection of service provider, subject to transportation issues; o Publication of positive outcomes as well as a defined set of adverse incidents for inclusion in report card; o 2010 HMO Report Card example should be examined; o ASO Report Card needed as well as provider report cards; There needs to be provision for independent verification on sample basis of outcomes reported by providers as well as outcomes reported by ASO; To the maximum extent practical, outcomes should be based upon objective measurements using uniform instruments as well as consumer self-report in an independent manner to minimize potential bias; Is the New Jersey continuum currently developed with service array so as to maximize the probability of ensuring superior outcomes? There should be a study of the continuum of care in other states that have been developed to reduce deep end intrusive care such as extended acute care - is continuum set up to maximize the probability of ensuring superior outcomes? If new services are necessary what party is responsible for service system augmentation ASO vs. State vs. partnership? Ensure link to Essential Health Benefits package; There needs to be communication between HMOs and ASO to ensure integration with all HMO s in a uniform manner; RFP should require ASO monitoring as well as the State and correlation of cost, utilization and outcome information to align resource utilization with services and providers producing superior outcomes for given compensation; One additional tool to guard against creaming would be a no eject no reject policy; The ASO should have a New Jersey location for all direct operations to include care management, PA, clinical, and phone/help desk operations; Infrastructure includes (cost for EHR transition, rent, vehicle, benefits etc.) providers will be impacted must have vehicle to assure cash flow for circumstances where the State and/or ASO is cause of delay. 55 Page

56 Outcomes Work Group Final Report Work Group Chair: Work Group Members: Phillip Lubitz Phillip Lubitz, Mollie Greene, Annette Riordan, Deborah Splitalnik, Peggy Swarbrick, Joe Masciandaro, Shannon Brennan, Jim McCreath, Marie Verna, Deborah Megaro, Harry Marmorstein, Colleen Woods, Suzanne Borys, Donna Migliorino, Rosita Cornejo, Adam Bucon Guiding Principles: The Outcomes Committee envisions an ASO/MBHO for which outcomes are developed to reflect the effective delivery of consumer-centered, wellness and recovery-oriented system of services and supports where the hallmark of quality are the integration of physical and behavioral healthcare for all members. A recovery-oriented system of care supports the idea that people can regain and sustain purposeful and meaningful lives while managing behavioral health conditions. Specific measures should be multi-dimensional, demonstrating structure, process and results and provide data sets that are selected, integrated and synthesized to produce meaningful (consumer, practitioner, agency, ASO, system, community) actionable outcomes that promote accountability, quality and opportunity for systems and process improvements. Outcomes must address cultural competence and underserved populations. Data must be made available to all stakeholders in a timely, transparent and accessible presentation. To this end, the ASO/MBHO will implement a quality management infrastructure that includes broad stakeholder participation. Improvement priorities are not static but may change over time due to emerging needs and unanticipated occurrences. For this reason, flexibility is essential to create/develop new outcomes throughout the course of the contract that would encourage a movement towards a wellness and recovery-oriented system of care. Rather than propose an exhaustive list of specific measures that capture the multiple services to be managed and populations to be served by the ASO/MBHO, the Outcomes Committee recommends the strategic selection of outcomes that are consistent with the Committee s guiding principles (attached) from already existing and validated sources (i.e. HEDIS, MHSIP, NOMs, NCQA, NQF, and SAMHSA evidence-based and promising practices), to provide a meaningful baseline upon which to build a dynamic, flexible and iterative quality management program. For the purpose of illustration the document Quality Improvement Framework is attached. Key Considerations: The interrelationship of outcomes and process measures to evaluate performance Conduct a meaningful Consumer/Family Satisfaction/Perception of Care data collection and evaluation process Evaluate and implement the use of incentives to promote performance improvement and penalties for substandard performance Involve consumers, families providers and other stakeholders in the quality management process Align outcome measures with the requirements set forth in Federal guidelines and other regulatory bodies as well as outcome measures utilized in other States 56 Page

57 Identify safeguards that ensure the most effective treatment and not just the most inexpensive means of treatment Recognize that some desirable outcomes, such as employment, may be outside the purview of the ASO/MBHO Performance benchmarks may be established from existing industry data but should not be used exclusively or without consideration for NJ-specific data as the system matures Existing or readily obtained date should be utilized whenever possible to limit the burden of data collection Challenges/Opportunities: It is difficult to plan for every outcome that may be desired over time The structure of financial incentives and penalties may be constrained by the portion of funds available to implement Outcomes contingent upon key systems integration depend upon buy-in and participation from all systems and payers Relationships/affiliation agreements that the ASO establishes with providers part of the system but not paid or authorized through the ASO Potential selective choosing or creaming of consumers Transitions of consumers between the child and adult systems Ensuring secure information exchange in efforts to improve behavioral healthcare delivery ASO/MBHO data integration with other state information systems Priority Recommendations specific to the Work Group: Outcomes are developed to reflect a wellness and recovery-based process Evidence-based and emerging practices are valued Stakeholders (consumers, families, providers, system partners) are engaged and provide actionable recommendations in each step of the quality management process Effective coordination of care is a desired outcome at the individual and the systems level Quality improvement priorities are not static but may change over time due to emerging needs and unanticipated occurrences Applicants must identify their strategy for selecting and testing variables for trending, statistical correlations, and determining statistically significant relationships among selected variables in the data sets Applicants must detail how they engage stakeholders in the quality process and how they work as a partnership with stakeholders in the process of quality management and system redesign (rebalancing) Applicants should detail how they manage their quality programs, method, model, staffing, IT, etc, as well as identify the percent of the operating budget dedicated to CQI activities and capacity to ensure meaningful data will be available in reasonable timeframes Applicants should detail what software they will use and identify the skill/educational level of those who will be managing data analysis 57 Page

58 Priority Recommendations for Development and Implementation of the ASO/MBHO Develop and maintain a high quality workforce system for the purpose of enhancing care services to promote wellness and recovery, including Peer Specialists The ASO/MBHO should describe in detail how consumers will be integrated throughout the system of care, to include meaningful employment roles with the ASO/MBHO and as providers. People living with substance use and mental disorders are able to access a wide range of services and receive a coordinated warm transfer across services Services should be designed to be welcoming to all individuals and there is a low threshold for entry into care Attachments: Outcomes Guiding Principles Quality Improvement Framework Additional Resources SAMHSA Behavioral Health Quality Framework The Center for Quality Assessment and Improvement in Mental Health (CQAIMH) National Quality Measures Clearinghouse NCQA MBHO Accreditation Requirements NQF Endorsed Standards Competency Assessment Instrument The Personal Outcome Measures from the Center on Quality and Leadership Mental Health Statistics Improvement Program Recovery Oriented System Indicators (ROSI) Consumer Survey 58 Page

59 59 Page