ACA Readiness: Making Change a Reality

Transcription

1 ACA Readiness: Making Change a Reality Presented by: MTM Services P. O. Box 1027, Holly Springs, NC Phone: Fax: Scott.Lloyd@mtmservices.org Web Site: wwww.mtmservices.org MTM Publication Ordering Information: or Call (202) A Roadmap for Impactful Change! Operationalizing Health Reform was written by the entire MTM Services Team to be an up to date view of what we have learned working to help hundreds of organizations across the country and abroad make the changes necessary to be successful in today s ever changing environment of health reform. Each of the 14 chapters deal with a specific change focus required to help vision based leaders improve their organization s quality of care, efficiency, and the compliance of their service delivery system! To Order or for more information visit: or If preferred call (202)

2 Experience Improving Quality in the Face of Healthcare Reform MTM Services has delivered consultation to over 700 providers (MH/SA/DD/Residential) in 45 states and 2 foreign countries since MTM Services Access Redesign Experience (Excluding individual clients): 5 National Council Funded Access Redesign grants with 200 organizations across 25 states 6 Statewide efforts with 140 organizations Over 1,500 individualized flow charts created Over $16,000,000 in Annual Savings generated thus far A lot of happy staff and consumers 4 Access Redesign Experience - Improving Quality in the Face of Healthcare Reform David Lloyd, Founder of MTM Services and Senior Consultant for the National Council Scott Lloyd, President of MTM Services and Senior Consultant for the National Council Randy Love, Chief Information Officer for SPQM Data Reporting Services Willa Presmanes, M.Ed., M. A., Medical Necessity/Utilization Management Expert and Co-Author of the DLA-20 (Daily Living Activities) functionality scale Bill Schmelter, Ph.D., Lead Clinical & Collaborative Documentation Consultant for MTM Services and Consultant for the National Council Michael Flora, M.B.A., M.A.Ed., L.P.C.C., L.S.W., Lead Operations Consultant for MTM Services, CEO of the Ben Gordon Center in DeKalb, IL, and Consultant for the National Council David Swann, MA, LCAS, CCS, LPC, NCC M.T.M. Services Senior Integrated Healthcare Consultant, CEO of a public Local Management Entity in North Carolina, and Consultant for the National Council Joy Fruth, M.S.W., Lead Process Change Consultant for M.T.M. Services and Consultant for the National Council Katherine Hirsch, MSW, LCSW, Collaborative Documentation Consultant Specializing in Collaborative Documentation with Children and Consultant for the National Council John Kern, MD - Collaborative Documentation Consultant for M.T.M. Services and Consultant for the National Council Annie Jensen, MSW, LCSW - Process Change Consultant for MTM Services, Vice President of Operations/ Burrell Behavioral Health, and Consultant for the National Council Justin Senechal - Database Developer/Data Analyst for MTM Services Jennifer Senechal Financial Controller and Cost & Revenue Analyst for M.T.M. Services 5 The National Landscape / Today s Reality What can you do about the changes we face Besides Panicking? 6 2

3 The National Landscape So tell me, How bad is it? State Funding Issues Federal Issues: Office of Inspector General Obstacles to Integrated Care Are future rule changes holding you hostage now? Focus on what you can control Agenda Item: It s so awful time Move now, not after the challenges come about. 7 The National Landscape 8 The National Landscape Federal O.I.G. The Office of Inspector General -Do you know about the Exclusion s Database? -Do you know about RAC teams? -A lot of states are the passing the compliance responsibilities to the providers. -Do you know why Money is being taken back? -Increased audits with an emphasis on Medical Necessity Linkage and The Rehabilitation Model. 9 3

4 Quantitative Vs. Qualitative Historically, State MH/DD/SA Departments have focused on quantitative review it is there and is it signed/dated CMS has moved to a qualitative review standard does the documentation quality justify the intensity, duration and frequency of services? Qualitative reviews require demonstration of the Golden Thread. 10 The National Landscape 11 The National Landscape The Compliance Officer is accountable for the organization s compliance program, not the organization s compliance. Everyone is accountable for the latter by either their own conduct or staff or activity overseen. Source: Adam J. Falcone ( 12 4

5 What data is needed for the decision, and how to attain it! 13 Redesign - Improving Quality in the Face of Healthcare Reform What are your Teams Roadblocks? Team members with differing opinions Teams who setup their systems to the Exceptions. 14 Process Redesign Review Get Past Emotion with the use of Data: Organizations that have continued forward without fully addressing the questions around the creation and use of data reports as part of their decision making process often face some historical management philosophies/challenges that cannot be overcome because they exist in the emotional realm: A lack of data leads to a Retreat Culture Lack of leadership through data opens the door for Passionate Staff 15 5

6 Process Redesign Review Data is the Key! Without data, teams set up to their exceptions. What is the best way to Present it to staff? What data do you need an how do you get it? 16 No Show/ Cancellation Holiday Sick Leave Vacation Leave Travel Training Typical Center Staff Resource Utilization Billable Service Meetings Paperwork Non-Billable Service 17 How We Arrived Here Assessment Appointment Wait Time Documentation Concerns Repetitive Data Collection Overly Extensive Narratives Post Session Documentation Time Leads to holding back time Capacity Issues Caseloads Full Staff Short on Direct Service Expectations No Show Issues Leads to double booking Generates Staff Anxiety 18 6

7 What we do About it! Collaborative Documentation Same Day Access No Show Management Utilization Review/Utilization Management EOC/LOC Without the right costing data 19 Process Redesign Review RESULTS 20 Process Redesign Review 21 7

8 A Standardized Solution Presented by: M.T.M. Services, LLC P. O. Box 1027, Holly Springs, NC Phone: Fax: Web Site: wwww.mtmservices.org Costing based upon the different types of Integrated health care models, benefit and concerns. 23 Different types of Integrated health care models, benefit and concerns. 1. Accountable Care Organizations (ACOs) Model of Service Delivery 2. Primary Care Practice Medical Homes Integration of primary care, and behavioral health needs available through and coordinated by the PCP 3. CBHO Health Homes/ Person-Centered Medical Homes - Integration of primary care, and behavioral health needs available through and coordinated by the CBHO 4. Federally Qualified Health Centers (FQHCs) - Integration of primary care, oral health, and behavioral health needs) 5. Multi Agency Health Homes Integrates medical, behavioral, social services, etc. 6. FQBHC? To be seen, currently being proposed in DC, with the hope to be online within 1 to 2 years. 24 8

9 How to decide which model is the best for your organization's situation Clinical Integration - what is experienced by the consumer in relationship to the providers - is the goal. To achieve that goal, it is important to be clear about which integration mechanisms are being selected and why... mechanisms promoting the goal of clinical integration include: Clinical integration: dually trained clinicians or interdisciplinary teams Clinical practice integration: formal collaboration and consultation mechanisms, required screening practices, collaboration practices built into service protocols Programmatic integration: incorporating health education into psychiatric rehabilitation or incorporating behavioral health (BH) intervention into diabetes management Physical integration: Co-location of services in either direction Structural integration: BH and primary care services under a common administrative authority, which can create standards for collaboration and clinical integration Fiscal integration: mental health (MH) and primary care services under a common funding stream which can potentially be utilized to promote any of the other activities... This is an excerpt from a paper titled "Behavioral Health/Primary Care Integration Models, Competencies, and Infrastructure" by the National Council for Community Behavioral Healthcare Most Organizations Perform Costing Efforts Preparing for Integrated Care, Open Access, etc. to Answer the question, Do We Need to Adjust our Staffing/Have a Workforce Expansion? Here are the Questions you need to ask before hiring anyone! Steps to Reduce Wait Time or Clear a Waiting List Productivity = Service Capacity ACTUAL FACE-TO-FACE Billable Time Collaborative Documentation 250 Hours per year No Show Rates How much capacity is lost to No Shows? EOC/LOC Management Appropriately cleaning caseloads Adjust Episodes of Care expectations Hire new staff or turn away clients 27 9

10 1. What Costing Elements Need to Be Reviewed? 2. Establishing Service Capacity. 3. Establishing Case Load Sizes. 4. Proactive No Show Management. 5. Incentive Pay Models What Cost Elements Need to Be Reviewed? Cost Per Service (Event, Day, Hour, Etc.) The Impact of Overhead/Non-Direct Costs Access Costing (First Call through the Client being Open for Services) Your Costs Versus Statewide Averages Tie to the CPT codes % Versus Direct Service Costing Hours Per Day 8 Direct Service % 57.70% Work Days Per Year 260 Avg. Revenue PH $85.00 Costing Model Salary Fringe Benefit Salary & FB Overhead % Salary + FB + OH Hours Cost Per Hour Revenue PH Margin 100% Costing $40, % $52, % $75, $36.25 $85.00 $48.75 Direct Service $40, % $52, % $75, $62.82 $85.00 $22.18 Revenue Model Hours Revnue PH Gross Revenue Salary + FB + OH Net Revenue Check 100% Costing 2080 $85.00 $176, $75, $101, FALSE Direct Service 1200 $85.00 $102, $75, $26, TRUE 30 10

11 Cost Per Service (Event, Day, Hour, Etc.) 31 Workforce Expansion? Productivity = Service Capacity ACTUAL FACE-TO-FACE Billable Time 32 The Importance of knowing your organization's real costs situation 33 11

12 Knowing Your Real Costs 34 Your Costs Versus Statewide Averages $300 $ $200 $150 $100 $ Current Cost Per Hour Statewide Avg. Cost PH Cost PH at 60% Productivity Statewide Avg. Cost PH at 60% Current Actual Reimbursement PH $0 Statewide Avg. Reimbursement PH Bachelors Level Below Bachelors Level Masters Level & Above Psychiatrist & ARNPs 35 Your Costs Versus Statewide Averages 36 12

13 Your Costs Versus Statewide Averages 37 The Impact of Overhead $800 $700 $600 $500 $400 $601 $300 $200 $100 $0 $184 $66 $81 $93 $27 $115 $115 $115 $115 $115 $115 Bachelors Level Below Bachelors Level Masters Level & Above Nurses Psychiatrist & ARNPs Dedicated Crisis Staff Sum of Avg. Base Cost PH Sum of Avg. OH Cost Per Hour Treat to Target System The Reality! - 60% of the average clinician s caseload is made up of clients that chronically no show and/or have a level of functioning that we cannot justify why they are still in treatment! EOC/LOC Management are Needed to Appropriately cleaning caseloads Adjust Episodes of Care expectations 39 13

14 Treat to Target System EOC/LOC Management Appropriately cleaning caseloads 40 Treat to Target System EOC/LOC Management Appropriately cleaning caseloads 41 No Show Management 1. Same Day Access Eradicates No Shows in the Intake Process 2. On Going No Shows Target of 10% or less Defining No Shows The Individual Served either misses the appointment without notifying us, or notifies us less than 24 hours before their appointment, making it difficult for the provider to arrange another productive use of the appointment time. Setting a Trigger When does the policy kick in? 3. Centralized Scheduling A Must! 42 14

15 No Show Management 1. Reminder/Back Fill Calls Sample Script: Hello, you have an appointment scheduled on (Day) at (Time). Does this appointment time still work for you, or do we need to reschedule you? 43 Incentive Pay Models: Pay Per Hour Over Standard d Pay Tied to Productivity Part Time vs. Full Time 44 Next Steps Questions and Answers? Resources Needed? Thank You 45 15