Transitional Care and Diversion Workgroup December 21 st, 2017
Financial Sustainability through Value- Based Payment Workforce Systems for Population Health Management Initiative 1: Care Transformation Prevention & Health Promotion Care Delivery Redesign Domain 3: Prevention and Health Promotion Addressing the opioid use public health crisis Chronic disease prevention and control Domain 2: Care Delivery Redesign Bi-directional integration of physical and behavioral health through care transformation Community-Based care coordination Transitional Care Diversion interventions Domain 1: Health Systems and Community Capacity Building Financial sustainability through value-based payment Workforce Systems for population health management
Project Plan Application Summary Review of Preliminary Evidence Based Approach and Target Population Partnering with the other workgroups and projects (i.e. Whole Person Care Collaborative and Community Based Care Coordination) Health Equity Aspects of Project Monitoring and Continuous Improvement Sustainability
Evidence Based Approaches Quick Overview Transitional Care 1. Interventions to Reduce Acute Care Transfers, INTERACT 4.0 2. Transitional Care Model (TCM) 3. Care Transitions Intervention (CTI ) 4. Care Transitions Interventions in Mental Health 5. Transitional Care for People with Health and Behavioral Health Needs Leaving Incarceration Diversion Intervention 1. Emergency Department (ED) Diversion 2. Community Paramedicine Model 3. Law Enforcement Assisted Diversion (LEAD)
Funding the Demonstration Projects Each project involves metrics Funding will depend, in part, on our performance This is not a grant program. There will be up-front money for start-up, but much of the project funding must be earned by reaching performance targets. In the early years of the projects, we will be judged mainly on the progress we make in implementing project plans. In the later years of the projects, we will be judged mainly in terms of health care improvements such as reductions in unnecessary ER visits and hospitalization, percentage arrested, and homelessness. It will be a heavy lift to measurably improve Medicaid clinical quality by the end of 2021.
Transitional Care and Diversion Interventions Implementation Timeline 2017 DY1 2018 DY2 2019 DY3 2020 DY4 2021 DY5 By November 16 Preliminary Project Plan due to HCA Expected outcomes Preliminary Implementation approach and timing Partnering Providers Regional Assets, anticipated challenges and proposed solutions Monitoring and continuous improvement Sustainability By June 30 Nov 2017 Feb 2018 Assess current state capacity Select Target population Select Evidence-Based Approach March 2018 June 2018 Identify implementation partners and binding letters of intent Financial Sustainability, Workforce, Population Health Management strategies By September 30 Completed Implementation Plan (Prefer July 2018) By March 31 Adopt guidelines, policies, procedures, and protocols By June 30 Completed and Approved Quality Improvement Plan Begin reporting on QIP measures semi-annually By December 31 Implement Projects By December 31 Increase scope and scale by serving additional high-risk populations, adding partners, and spreading to additional communities Continuous quality improvement Provide ongoing training, technical assistance, and/or learning collaboratives to support continuation and expansion Identify and document the adoption by partnering providers of payment models that support transitional care, diversion activities, and the transition to value-based payment for services Goals: Ensure people are getting the right care in the right place by improving transitional care services. Promote more appropriate use of emergency care services through increased access to primary care and social services. P4R Payments March: Project Incentive November: DY2 P4R May: DY2 P4R November: DY3 P4R May: DY3 P4R November: DY4 P4R May 2021: DY4 P4R Nov. 2021: DY5 P4R May 2022: DY5 P4R P4P Measurement DY3 P4P Baseline DY4 P4P Baseline DY5 P4P Baseline DY3 P4P Meas. Year DY4 P4P Meas. Year DY5 P4P Meas. Year P4P Payments April 2021: DY3 P4P April 2022: DY4 P4P April 2023: DY5 P4P
Demonstration Project Stages STAGE 1: Planning (2018) STAGE 2: Implementation (2019) STAGE 3: Scale & Sustain (2020) This is a rough timeline as outlined by HCA but the sooner we implement, the better!
Key Questions by Stage STAGE 1 PLANNING QUESTIONS What evidence-based approaches should we select? What is the target population, and (how) will it change over time? Where do we begin and how might we scale? How do we identify early implementation partners? What does our funding process look like? How do providers apply for funding? How do we determine funding recommendations? What kind of training might partners need before launch? STAGE 2 IMPLEMENTATION QUESTIONS What does our reporting process look like? What data do we need to monitor progress and guide course correction? (qualitative and quantitative) What technical assistance can we recommend if partners encounter challenges? Now that we ve begun, how will we expand our project s reach? How do we fold in additional implementation partners? STAGE 3 SCALE & SUSTAIN QUESTIONS What will it take to implement our approaches region-wide? How can value-based payments sustain the good work we catalyzed? What other funding might sustain the good work we catalyzed?
PROJECT - PROPOSED PLANNING TIMELINE Dec-17 Jan-18 Feb-18 Mar-18 Exploration of Evidence Based Approaches Exploration of data gaps/needs Review and finalize selection of Evidence Based Approaches Initiate a current state assessment for projects Domain I linkages discussion Review draft Implementation Partner Application and scoring/funding criteria Finalize Current State Assessment Initiate project funds flow discussion Finalize Implementation Partner Application and scoring/funding criteria Continue funds flow discussion Apr-18 May-18 Jun-18 Jul-18 Distribute Implementation Partner Application to potential partners NCACH Whole Person Care Summit Final funds flow document created (and budget for 2018 year funding) Review draft LOI for partners Review and select successful Implementation Partner Applications Initiate process for binding LOIs for partners Approval of final funding document for 2018 funding Review received LOIs (LOIs from partners due June 8 th, 2018 Discuss gaps and develop plan to address them Initiate draft Implementation Plan Draft Implementation Plan (including partner LOIs) Initiate continuous monitoring and improvement discussion
Data Transitional Care & Diversion Intervention Workgroup 12/21/2017 Meeting
Feedback from CHIs Implications for Transition Care Release to homelessness (lack of affordable housing, rigid transitional housing, lack of wet/low barrier shelters) Need follow up post release (primary care, coaching, patient education, follow up phone calls) Referrals to other community resources (non-medical) need to match to biggest issue Legal barriers post incarceration Lack of interagency planning Lack of system supports (overwhelming, systems not well explained) Discharge instructions should be written at 3 rd grade level Implications for Diversion Interventions Ranked order of needs for client populations served by CHI members (both medical and social service providers) 1. Non-acute ER use (no same day appointments, nighttime access) 2. Mental health and substance abuse challenges a big issue 3. Inappropriate use of EMS Low health literacy No access to care (in clients minds) don t know how to access services, lack system navigator, transportation Lack of coordination of services Contact with law enforcement often symptom of lack of engagement with social service network
Emergency Department Data
ED Utilization Counts by Hospitals and Triage Levels 4000 3500 3000 2500 2000 1500 1000 500 0 Cascade Medical Center Central Washington Hospital Columbia Basin Hospital Coulee Medical Center Lake Chelan Community Hospital Mid Valley Hospital North Valley Hospital Quincy Valley Hospital Samaritan Hospital Three Rivers Hospital Level 1 Level 2 Level 3 Level 4 Level 5 Other Source: Health Care Authority (ED utilization by Facility data set) Data for North Central ACH (Measurement Period = Oct 1, 2015 - Sep 30, 2016) Note: Triage Levels based on CPT code groupings
Top Ten Most Common Causes of Outpatient ED Utilization Among Medicaid Recipients Rank Cause of ED Utilization Count % 1 Symptoms, signs & abnormal clinical and lab findings 8,007 24 2 Injury, poisoning, and certain other consequences of external 7,822 23 causes 3 Diseases of the respiratory system 3,860 11 4 Diseases of the digestive system 2,169 6 5 Diseases of the musculoskeletal system and connective tissue 1,635 5 6 Mental and behavioral disorders 1,554 5 7 Diseases of the skin and subcutaneous tissue 1,423 4 8 Diseases of the genitourinary system 1,352 4 9 Pregnancy, childbirth and the puerperium 1,195 4 10 Infectious and parasitic diseases 1,104 3 Source: Health Care Authority (ED Utilization by Facility data set) Data for North Central ACH (Measurement Period = Oct 1, 2015 - Sep 30, 2016)
ED Utilization by County and Diagnosis Grouping Top 10 Reasons (Counts) HCUP CCS Diagnosis Groupings (ICD10) Chelan Douglas Grant Okanogan Grand Total Other upper respiratory infections 673 311 1135 487 2606 Abdominal pain 802 431 900 352 2485 Superficial injury; contusion 413 240 789 420 1862 Sprains and strains 479 187 676 385 1727 Nausea and vomiting 365 206 516 155 1242 Headache; including migraine 359 153 397 213 1122 Nonspecific chest pain 318 115 374 185 992 Open wounds of extremities 237 118 403 231 989 Skin and subcutaneous tissue infections 261 119 339 217 936 Otitis media and related conditions 245 121 353 211 930 Source: Health Care Authority (ED Utilization Sensitive data set) Data for North Central ACH (Measurement Period = Calendar Year 2016)
ED Utilization by County and Diagnosis Grouping Top 10 Reasons (Rates per 1,000 member months) HCUP CCS Diagnosis Groupings (ICD10) Chelan Douglas Grant Okanogan Other upper respiratory infections 2.5 2.3 3.0 2.8 Abdominal pain 3.0 3.1 2.3 2.0 Superficial injury; contusion 1.6 1.8 2.1 2.4 Sprains and strains 1.8 1.4 1.8 2.2 Nausea and vomiting 1.4 1.5 1.3 0.9 Headache; including migraine 1.4 1.1 1.0 1.2 Nonspecific chest pain 1.2 0.8 1.0 1.0 Open wounds of extremities 0.9 0.9 1.1 1.3 Skin and subcutaneous tissue infections 1.0 0.9 0.9 1.2 Otitis media and related conditions 0.9 0.9 0.9 1.2 Source: Health Care Authority (ED Utilization Sensitive data set) Data for North Central ACH (Measurement Period = Calendar Year 2016)
ED Utilization by County and Diagnosis Grouping Behavioral Health Reasons (Counts) HCUP CCS Diagnosis Groupings (ICD10) Chelan Douglas Grant Okanogan Grand Total Anxiety disorders 159 79 182 95 515 Alcohol-related disorders 197 84 86 114 481 Substance-related disorders 98 53 116 73 340 Mood disorders 97 38 93 50 278 Suicide and intentional self-inflicted injury 104 43 69 51 267 Schizophrenia and other psychotic disorders 50 9 32 21 112 Source: Health Care Authority (ED Utilization Sensitive data set) Data for North Central ACH (Measurement Period = Calendar Year 2016)
ED Utilization by County and Diagnosis Grouping Behavioral Health Reasons (Rates) HCUP CCS Diagnosis Groupings (ICD10) Chelan Douglas Grant Okanogan Anxiety disorders 0.60 0.58 0.48 0.54 Alcohol-related disorders 0.75 0.61 0.22 0.65 Substance-related disorders 0.37 0.39 0.30 0.41 Mood disorders 0.37 0.28 0.24 0.28 Suicide and intentional self-inflicted injury 0.39 0.31 0.18 0.29 Schizophrenia and other psychotic disorders 0.19 0.07 0.08 0.12 Source: Health Care Authority (ED Utilization Sensitive data set) Data for North Central ACH (Measurement Period = Calendar Year 2016)
ED Utilization Resources ED Utilization Dashboard Can explore demographic breakout of ED utilizers by hospital (helpful to identify potential health equity issues) Age, gender, race/ethnicity, ED triage level https://public.tableau.com/profile/apde.datarequest#!/vizhome/medicaid_ed_visits /Frontpage Healthier Washington Dashboard Can explore ED Utilization metrics by ACH or county and see demographic breakout All-Cause ED Visits, per 1000 MM ED Utilization per 1,000 Members (aligns with HEDIS measures) Potentially Avoidable ED Visits https://fortress.wa.gov/hca/tableau/t/51/views/healthierwashingtondashboard/fro ntpage
Arrest/Incarceration Data
Arrest Data Measure Chelan Douglas Grant Okanogan NCACH WA State Arrests of adolescents ages 10-17 for alcohol violations, per 1,000 adolescents: 2015 Arrests of adolescents ages 10-17 for drug law violations, per 1,000 adolescents: 2015 Alcohol-related arrests for adults age 18+, per 1,000 adults: 2015 Drug law violation arrests for adults age 18+, per 1,000 adults: 2015 Violent crime arrests for adults age 18+, per 1,000 adults: 2015 Prisoners age 18+ in state correctional system, per 100,000 based on county of conviction: 2015 2.4 1.1 2.8 2.3 2.3 1.8 5.4 6 3.3 3.2 4.3 2.3 3.5 4.5 4.6 3.8 4.1 5.3 3.4 2.4 2.6 1 2.6 2.2 1.1 0.5 2 1.1 1.5 1411.8 67.7 720.9 1031 875.2 522.1 Source: DSHS Risk and Protection Profiles for Substance Abuse Prevention Planning https://www.dshs.wa.gov/sesa/research-and-data-analysis/county-and-state
Arrest Data Medicaid Adults Only Accountable Community of Health CY 2013 CY 2014 CY 2015 Statewide 7.2% 6.0% 6.5% Better Health Together 6.7% 6.0% 6.5% Cascade Pacific Action Alliance 6.3% 6.1% 6.9% Greater Columbia 8.3% 6.6% 7.4% King 7.7% 5.7% 6.1% North Central 7.9% 5.9% 6.7% North Sound 7.8% 6.3% 6.7% Olympic 7.0% 6.0% 5.9% Pierce 6.5% 6.0% 6.2% SW WA Regional Health Alliance 6.9% 5.9% 5.7% Source: DSHS Research and Data Analysis Division Cross System Outcome Measures for Adults Enrolled in Medicaid Dataset
Youth Detention Rates Source: Washington State Center for Court Research (Juvenile Detention 2016 Annual Report)
Accountability Measures Transitional Care & Diversion Interventions ACH Performance Statewide Follow-up After Discharge from ED for Mental Health (30 day) 70.2% 83.9% Follow-up After Discharge from ED for Mental Health (7 day) 58.7% 77.3% Follow-up After Discharge from ED for Alcohol or Other Drug Dependence (30 day) Follow-up After Discharge from ED for Alcohol or Other Drug Dependence (7 day) 30.6% 28.0% 24.5% 20.6% Follow-up After Hospitalization for Mental Illness (30 day) 79.8% 88.9% Follow-up After Hospitalization for Mental Illness (7 day) 65.8% 76.7% Percent Homeless (Narrow Definition) Plan All-Cause Readmission Rate (30 Days) Percent Arrested 2.7% 5.0% 10.0% 15.0% 7.0% 6.6% Source: Health Care Authority and DSHS-RDA Historical Toolkit Data Measurement periods vary by measure (CY2015 or CY2016)
EMS Data
EMS Data (2016) AERO METHOW OKANOGAN AMR GRANT BALLARD CHELAN/ DOUGLAS CASCADE EMS CHELAN LAKE CHELAN EMS CHELAN/ DOUGLAS MOSES LAKE FIRE GRANT Total calls 632-6,592 1,065 1,414 3,160 Non-emergent calls Non-emergent transports Total Opioid related calls 243-2,052 832 1,147 1,193 0-747 722 625 478-12 53 16 11 - Preliminary Data Does not include Life Line Ambulance (Okanogan & Chelan/Douglas) Some data is incomplete
EMS Data 2016 Preliminary Data Does not include Life Line Ambulance (Okanogan & Chelan/Douglas) Some data is incomplete
Evidence Based Approaches Detailed Conversation (See Spreadsheet) Transitional Care 1. Interventions to Reduce Acute Care Transfers, INTERACT 4.0 2. Transitional Care Model (TCM) 3. Care Transitions Intervention (CTI ) 4. Care Transitions Interventions in Mental Health 5. Transitional Care for People with Health and Behavioral Health Needs Leaving Incarceration Diversion Intervention 1. Emergency Department (ED) Diversion 2. Community Paramedicine Model 3. Law Enforcement Assisted Diversion (LEAD)
Next Steps Finalize Selection of Evidence Based Approaches (January 2018) WPCC selects approaches to incorporate in change plan Current State assessment (January/February 2018) Return signed member agreement to john.schapman@cdhd.wa.gov (ASAP) Next Meeting: January 18 th - 10:00-11:30 AM Location? Questions? Contact NCACH Transitional Care and Diversion Intervention Project Staff Lead: John Schapman john.schapman@cdhd.wa.gov