Transformational Perspectives from Oregon and Pennsylvania Susan Dreyfus President & CEO Alliance for Strong Families & Communities
TRILLIUM FAMILY SERVICES A Case Study in 4 Acts Critical decision points in response to system changes in Oregon Keith Cheng MD, Chief Medical Officer Trillium Family Services June 29 th & 30 th, 2015
Prologue Some History A Timeline Treading Water
History of Trillium Trillium Family Services was founded in 1998 Three historic Oregon agencies merged to create an array of children s services with statewide reach. Parry Center for Children Waverly Children s Home Children s Farm Home The original agencies were each founded in the late 1800s or early 1900s, and served Oregon s youth for a combined total of over 300 years.
The Move to Managed Care Before Managed Care Funding Patterns 2005 - Fee for Service changes to Managed Care System Change Initiative Mental Health Organizations (MHOs) decreased residential, more community-based treatments, evidence-based treatments, outcome data, more consumer engagement 2011 - Post system change initiative: Coordinated Care Organizations (CCOs) focused on population level health
Unhealthy Cycle Many MHOs: lowered rates, LOS limits, authorizations, increased paperwork, disempowering Cuts in funding Cuts in staffing Increases in holds and injuries Lower staff moral Increase in turnover
Crisis Red ink for 2 years Almost did not make payroll for several months Needed to take out a loan to pay employees
Act I Business Changes
Meeting the Bottom Line Better Billing Accounts Receivable, Collections Rate, Less billing lag time Better Rates Asking for better rates using (private insurance as fall back) EHR connected with billing for outpatient decreased time needed to send a bill
Negotiating for the True Cost of Care Know your value Know your true costs Diversify payors Be a skilled negotiator Be ready to walk
Act II Adopting Strategies for Transformation
Triple Aim
Sanctuary Seven Commitments: Leadership through Intentional Practice
Appreciative Inquiry
Act III New Strategies For New World Situations
Do what you do well Developed highly specialized and diverse inpatient services Integrated residential as part of home and community based system Adapted competencies for community-based services Deeper collaborations that help build community capacity
Secure Inpatient Service Then & Now Before TFS Average LOS 6-12 months 60 beds (40 adolescent, 20 child) Fewer Youth Treated even with more beds After TFS Average LOS 3-6 months 39 beds (28 adolescent, 11 child) More youth treated with less beds
Traditional Out Patient evolved to School-based Traditional out patient no-show rate up to 50% School-based appointments >90% kept Psychiatry appointments still at clinic Resultant efficiencies make program break even
Reactive vs Proactive Youth & Family Engagement Suggestions Box Family council Grievance process Youth council Hired a family liaison Peer to Peer Services
Evidence-based Treatments & collecting outcome data Oregon Contract Requirement Adopted several EBTs to meet unique needs of children and families Measuring Outcomes with ACORN (A Collaborative Outcome Resource Network) gave us stronger market position
Progress Toward Triple Aim Striving for patient centered staffing Enhancing family and youth involvement Developing the Behavioral Health Home in community
Act IV Transitioning to a Community Benefit Organization
Transitioning to a Community Benefit Organization Moving from acting upon community to acting within community Actively seeking collaborations to improve children s health TFS wanting to make our collaborators better the Magic Johnson agency
Concordia University Part of the Community CEO on the board Working with partners to provide a community for youth who are most vulnerable
Partnership with Oregon Health Sciences University (OHSU) Integration of Pediatrics and Mental Health Tele-psychiatry Emergency Dept. follow- up Research, Training Family Therapy Training Institute Sanctuary Partners
Partnership with Inter-Community Health Network (IHN) Co-location of services Collaboration in establishing Behavioral Health Homes» Hybrid (residential)» Co-location Model (community)» Mobile Model (schools)
Epilogue Lessons Learned Thoughts for New York Providers Thoughts for managed care Thoughts to Public Sector
Lessons Learned Need to have a compass Pick a strategy that changes culture because, Culture eats strategy for lunch Not us against them Collaborations are resource generating
Recommendations to Providers Be proactive not reactive Be collaborative not a silo Be flexible, be open to change Get a compass, determine how using existing strategies and models can help your program thrive in a time of change
Recommendations to Managed Care Organizations Look at the bigger bigger picture, not just saving money on an individual case Same billing form for all the MCOs Same admission criteria Same extension authorization criteria Treatment algorithms rather than formularies
Recommendations to Public Sector Facilitate Partnerships Facilitate continuums of care Provide technical assistance or grants for programs trying to make major culture changes
Keith Cheng MD Trillium Family Services Chief Medical Officer 503.205.3546 kcheng@trilliumfamily.org
A Case Study The Devereux Story Fran Wagner, CPA National Director of Contracts and Reimbursement Jamie Lyles, MA Director of Admissions Children s Behavioral Health Services
Neck Deep! https://www.youtube.com/watch?v=6vfnz20 yxo4
Our Mission Devereux changes lives and nurtures human potential. We inspire hope, ensure well-being, and promote meaningful life choices.
Locations And Services Devereux operates 15 centers in 13 states 30% of services are in Pennsylvania
Autism Services Our Specialties Intellectual/Developmental Disabilities Emotional and Behavioral Health Child Welfare Services/Lead Agency Case Management Resilience Resources and Training School-Based Prevention/Intervention Clinical & Professional Training & Research
The Devereux Continuum Campus Based Acute Inpatient Residential Vocational Community Based Foster Group Homes for Adult IDD Mental Health Services Other Children and Youth Case Management Training and Training Materials Consulting
Positive Collaboration is Key to Success A Brief History of Managed Care in Pennsylvania and Devereux s Experience
The Pennsylvania Story Managed Care in Pennsylvania Counties are responsible for over-sight of mental health and IDD programs Consumers are assigned to an MCO based on their county of residency The consumers selects their physical health manager from a handful of options
Devereux s Experience in Pennsylvania Initial Conversion to Managed Care Staff disbelief, denial, resistance Cash flow delays Billing File Issues- data entry errors, timely filing denial Authorization Issues-disputes over responsibility lapses, denials, appeal delays, no step down options Clerical backlogs-mco and Provider Limited service continuum for step down
Devereux s Experience in Pennsylvania Early Post Conversion Less authorization Issues Outcomes review and identification of data errors Staff turnover Underfunded levels of care (outpatient) Overuse of some levels of care Ongoing meetings mostly focused on billing and authorization Issues Bad debt
Devereux s Experience in Pennsylvania Moving to Stability Continued provider meetings focus on innovative programs Collaboration to implement evidence based services Higher payment levels for evidence based services Recognition of low funding levels in services most desired Positive outcomes and incentive payments Request to expand to a surrounding state Conflicting interpretation of Medicaid regulations MCO Contraction of some levels of care
Specific Results of Collaboration Transferred the adult services to another agency to focus on core competencies Expanded MH case management services under Medicaid to reduce administrative cost to public agency. Closed partial hospitalization services Worked with local school districts to provide mental health services in the school. Improved outcomes data by assisting with discharge plan compliance. Partnered to Implement evidence based services Interns from a local Medical College help collect and evaluate outcomes data
Recommendations
Provider Recommendations Focus on the revenue cycle to ensure financial health Expand education and communication throughout your organization Enhance ability for storage and retrieval of documents Diversify service lines based on consumer needs Quality data will be critical to sucess
MCO Recommendations Recognize the Administrative Burden that this conversion places on Providers and strive for policies that ease this. Implement Medical Necessity criteria that considers the readiness and availability of a step down level of care. Build outcomes data into the system and review it with providers regularly. Assist providers with compliance especially in areas where they have no control. Be fair in your negotiations and rule enforcement Ensure accuracy of your Data Base
Public Sector Recommendations Consider the value add of administrative burden Build Community Capacity alligned with program design Provide a resource for regulatory interpretation Provide for an independent, accessible and timely grievance process Clarify when MCO requirements are different than Medicaid Regulations
The Road Collaboration is the key to achieving the most important part of this work which is staying focused on better results for kids and their families. The end goal is more than getting things technically right. Each entity, the Public Sector, the MCO and an Individual Agency has to work together.
This is the Goal Improved services will lead to better outcomes and the CHILD AND FAMILY will GET WHAT THEY NEED