Welcome and Orientation Webinar

Transcription

1 Welcome and Orientation Webinar Care Transitions Network for People with Serious Mental Illness National Council for Behavioral Health Montefiore Medical Center Northwell Health New York State Office of Mental Health Netsmart Technologies

2 Libbi Ethier Program Assistant National Council for Behavioral Health Stacey Blase, PhD Psychologist Montefiore Health System Lauren Hanna, M.D. Psychiatrist Center for Psychiatric Neuroscience Northwell Health Elizabeth Arend, MPH Quality Improvement Advisor National Council for Behavioral Health

3 Please feel free to ask questions! Opening Your Line 1. Make sure Telephone is the option selected 2. Dial your Access Code 3. Enter your two-digit Audio PIN (unique to you!) Didn t work? Try putting # on either side of the PIN Your line will be muted Have a question? Please type in the chat box At the end of the webinar, we will unmute your lines and there will be an opportunity for questions

4 Introduction Transforming Clinical Practices Initiative Four-year Centers for Medicare and Medicaid Services (CMS) Cooperative Agreement Aims to help practices progress through the five phases of transformation using peer-based learning and achieve triple aim Intends to reach 140,000 clinicians nationwide Set Aims Use Data to Drive Care Achieve Progress on Aims Benchmark Status Thrive as a Business Through Pay-for- Value Approaches

5 Transforming Clinical Practice Initiative 29 Practice Transformation Networks (PTNs) The Care Transitions Network is: The only PTN focused on supporting clinicians who serve people with serious mental illness One the three project options for OMH s 2016 Continuous Quality Improvement Initiative

6 Moving toward Value over Volume in New York State

7 TCPI Goals 1. Practice Transformation: Evidence of a culture of quality where the vision is clear and data are used to drive continuous improvement to achieve triple aim 2. Effective Solutions Moving to Scale: Evidence of practice spreading effective improvement strategies to full scale for the entire population 3. High Clinical Effectiveness: Practice is effective in bringing all patient segments to their health status goal 4. Reduced Avoidable Hospital Use: Rates of readmission and unnecessary admissions for practice s patients have been reduced 5. Reduced Unnecessary Testing & Procedures: Practice demonstrates a reduction in unnecessary testing and in the use of the ED by its patient population 6. Reduced Costs: Practice controls its internal costs as well as other elements of total cost of care 7. Documented Value: Practice can articulate its value proposition and increases participation in available value-based payment agreements

8 Care Transitions Network Goal: To reduce all-cause rehospitalization rates by 50 percent for people with serious mental illness

9 Approach Targeted Coaching & Clinical Support Short-term Care Transitions Support Web-based Platforms to Track Progress Set Aims Use Data to Drive Care Achieve Progress on Aims Benchmark Status Thrive as a Payfor-Value Business

10 National Council Montefiore Netsmart Northwell Health Office of Mental Health Partner Roles Network Convener Enrollment National Policy Perspective Integration Patient Engagement Care Transitions Support Value-based Payment contracting Care Management Strategies QI Dashboards Care Manager platform for patient registry Best clinical practice support services Treatment and Relapse Prevention State Synchronization Quality Improvement

11 Benefits Individualized technical assistance and support to successfully transition from fee-for service to value-based payments under DSRIP--free and available to your entire workforce Up to $1000 incentive payment per eligible clinician Free contact hours that contribute to CMEs and CEUs for clinical staff Improved conversion rate for referrals from participating hospitals Practice support for managing the whole health treatment needs of people with SMI Best clinical practice support services to treat complex cases, provided by psychiatrists and internists with expertise in comorbid behavioral health and medical conditions

12 Welcome Packet 1. Review of the Practice Assessment Tool (PAT) and individualized goal setting call 2. Incentive payment made to organization 3. Individualized technical assistance provision Short-term care transitions support Best clinical practice support services Online, interactive learning opportunities 4. Dashboards

13 Practice Assessment Tool Results of the Practice Assessment Tool to help organizations assess preparedness for Value Based Payment Arrangements Submit Practice Assessment Tool within 30 days of execution of enrollment agreement Results of the Practice Assessment Tool will be reviewed with Care Transitions Network staff during initial Goal Setting phone call Set Aims Use Data to Drive Care Achieve Progress on Aims Benchmark Status Thrive as a Business Through Pay-for- Value Approaches

14 CMS Change Package: Primary and Secondary Drivers Patient and Family- Centered Care Design Continuous, Data- Driven Quality Improvement Sustainable Business Operations 1.1 Patient & family engagement 1.2 Team-based relationships 1.3 Population management 1.4 Practice as a community partner 1.5 Coordinated care delivery 1.6 Organized, evidence-based care 1.7 Enhanced access 2.1 Engaged and committed leadership 2.2 QI strategy supporting a culture of quality and safety 2.3 Transparent measurement and monitoring 2.4 Optimal use of HIT 3.1 Strategic use of practice revenue 3.2 Staff vitality and joy in work 3.3 Capability to analyze and document value 3.4 Efficiency of operation

15 Incentive Payments As a monetary support to help offset costs of resources needed to participate in QI activities: up to $1000 per eligible clinician Eligible professionals include: Physicians, NP s, PA s, PhD s/psyd s, LCSW s Enrollment Phase 1 $200 Phase 2 $200 Phase 3 $200 Phase 4 $200 Phase 5 $200 Enrollment Phase 3 $600 Phase 4 $200 Phase 5 $200

16 Care Transitions Support Inpatient Support with discharge planning, outpatient referrals, and post-discharge patient follow-up Improved patient connection with Health Home services Reduced readmission rates Access to outpatient attendance data following discharge Outpatient (behavioral and medical) Referrals of patients nearing discharge from psychiatric hospitalization Improved patient attendance at outpatient appointments following discharge Support with patient engagement in outpatient services following discharge

17 How to Access Care Transitions Managers Care Transitions Network at UBA Montefiore Phone: Fax: Program Director Trisha Blackburn, LCSW Phone: , ext

18 Best Clinical Practice Support Services Northwell Health faculty include psychiatrists and an internist who specialize in medical-smi co-morbidity Your enrolled clinicians can access information about best practices directly from the Care Transitions Network website, 24/7 Clinicians can also request individual consultations, which can take place over or telephone.

19 Training in Evidence-Based Treatments Available through webinars and the Care Transitions Network website Initial focus is upon optimal treatment of psychosis Clozapine and long acting injectable antipsychotics Prevention and management of adverse metabolic and other side effects Later, focus will include optimal use of antidepressants and mood stabilizers & approaches for substance misuse

20 Benefits for your Entire Workforce Webinars for administrative, support and clinical staff Teleconsultations with subject matter experts in workflow redesign, value based contracting and various evidencebased practices Content areas aligning with the Change Package include: PDSA / rapid cycle change Population management for people with serious mental illness Using health monitoring to improve outcomes Setting aim at tobacco cessation as a practice

21 Web-based Platform for Quality Improvement Regular dashboard reports on: Readmission rates (all-cause and psychiatric) Medication adherence and polypharmacy Preventive care screening and follow up (e.g., tobacco, BMI, depression) Data sources Data derived from Medicaid claims Participating organizations may submit additional data sources for a more complete QI picture (e.g., non-claims based measures that align with Meaningful Use, commercial, etc.)

22 Organizational Checklist Share information about the Network and its resources with staff! Instruct eligible clinicians to accept invite to Healthcare Communities Portal Complete Practice Assessment Tool within 30 days of executed agreement Schedule and participate in goal setting call

23 Open Your Line to Ask Questions! 1. Make sure Telephone is the option selected 2. Dial your Access Code 3. Enter your two-digit Audio PIN (unique to you!) Didn t work? Try putting # on either side of the PIN Your line will be muted Have a question? Please type in the chat box At the end of the webinar, we will unmute your lines and there will be an opportunity for questions CareTransitions@TheNationalCouncil.org

24 Thank you! The project described was supported by Funding Opportunity Number CMS-1L from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. Disclaimer: The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies