Region 1 IDN Integrated Delivery Network Region 1: Partnership for Integrated Care
Region 1 IDN Request For Proposal Process The Region 1 IDN following a community driven process has elected to open all DSRIP projects (B1, C1, D3, E5) to IDN partners through an RFP process for first round funding through the month of May, 2017. Deadlines for proposals are Monday, June 5 th Following proposal submission there will be a review within the Region 1 IDN Admin Lead Team, 5 days of review by a 9 person Independent Review Panel and finally a no contest approval by the Region 1 Executive Committee. Given this process and the timing of this presentation all of the components shared are driven from the C1 Project Team and Scope of Work developed to guide the RFP- No concrete details are yet known
Regional Target Populations/Institutions IDN-1 Providers Support 27,574 Medicaid Members in 61 Towns Target Population: Adults with serious mental illness. Target Participating Organizations: Hospitals (including New Hampshire Hospital), primary care providers, behavioral health providers, community-based social services organizations. Currently Involved on C1 Project Team: West Central Behavioral Health (CMHC) Monadnock Family Services (CMHC) Sullivan County Cheshire Medical Center Dartmouth Hitchcock Medical Center Servicelink Monadnock, Sulllivan Keene Housing Authority Alice Peck Day Hospital Crotched Mountain Services Home Healthcare Hospice and Community Services
Targeting/Screening & Enrollment Processes/Tools Likely the Region 1 C1 Project will start as a pilot based out of Cheshire Medical Center. The ED has been working with other organizations on co-located case management over the past 2 years. From that system the C1 project may build out to formalize screening, enrollment, and the support available to the CTI case manager Details of the screening tools and process steps for enrollment will be dependent on the organizations collaborating to apply for C1 funding Additionally all tools, screenings, and processes selected will be likely used as a foundation for the other replicated CTI implementation in other sub-regions of the IDN
Workforce Recruiting, Management & Development Plan Per the C1 scope of work developed: The intervention team encompasses A Bachelor s Degree level or Master s Level caseworker trained in CTI A licensed Master s Degree level clinical supervisor A lay professional or Bachelor s Degree level fieldwork coordinator Some organizations may choose to combine the clinical supervisor and fieldwork coordinator roles. More will be known on the institutional home, team structure, and supervision once the proposals are received
Project Implementation Timeline RFA Timeline Milestones RFP & Application Forms Released to Region 1 IDN Partners Region 1 Admin. Leads hold Office Hours and Q&A Webinars for RFP & Application Support Application Deadline for Submission Application Review Period by Admin. Leads Project Teams Independent Review Panel Date Thursday, May 4 th Weeks of May 8 th and 15 th Monday, June 5 th at 5:00 p.m. Weeks of June 5 th, 12 th and 19 th Final Approval by Executive Committee Week of June 26 th As of July 1 st the CTI team needs will be identified within the awarded organization Details on recruitment and implementation will be included with the RFP Through July, August continued coordination for statewide training on CTI July, August Development of process, case management and implementation framework for CY17 and CY18
Current Tracking, Monitoring & Evaluation Plan Per the RFP process proposals there will be submissions from organizations that will include their internal tracking, monitoring and evaluation frameworks
Gaps, Challenges, Unanswered Questions 1. How best can you integrate the CTI case manager into other system processes, team support etc.? Role of co-location Team Meetings Community Based Forums 2. How best can the system be structured for caseload support and the transition of clients through phases I-III? 3. General questions on feasible evaluation and tailoring if necessary
IDN 3: Nashua Region
Regional Target Populations/Institutions Target Population: Adults with a primary serious mental illness (SMI) or serious and persistent mental illness (SPMI) Not already connected to community-based care that currently meets their clinical needs Transition: Hospital Emergency Department and NH Hospital to the community
Targeting/Screening & Enrollment Processes/Tools Screening tools under consideration: Patient Health Questionnaire (PHQ) 2 & 9 or Mental Health Screening Form III (MHSF-III) Screens to identified functional impairments (screening tool(s) TBD) Referrals From ERs: through Transitional Care Coordinators From NH Hospital: through Discharge Planner and Social Workers To: CTI Clinical Supervisor or one of CTI Case Managers Conducts CTI Brief Assessment determining appropriateness to CTI Referrals to primary care physician (if lacking one)
Workforce Recruiting, Management & Development Plan Master s Level Licensed Clinical Supervisor (1 FTE) Caseload of up to 10 patients, depending upon CTI phase Weekly supervision of CTI staff Bachelor s Level Case Manager (2 FTEs) Caseload of maximum 20 patients each, depending upon CTI phase Fieldwork Coordinator (1 FTE) Could be Community Health Worker, Peer Support Worker, Navigator level Links patient to community resources and provides community education
Project Implementation Timeline July-August 2017: CTI team recruitment Agreements signed with NH Hospital, Southern NH Medical Center, St. Joseph Hospital Training/education for patient referrals and work flow protocols Set-up of HIT: Shared Care Plan (SCP), Electronic Notification Service (ENS), Data Aggregator September October 2017 CTI Supervisor/Program Fidelity and CTI Team Trainings CTI Community of Practice Kick-off October/November 2017 Full implementation of CTI Early 2018 CTI Train-the-Trainer to build in sustainability
Current Tracking, Monitoring & Evaluation Plan Use of Collective Medical Technology (CMT) Shared Care Plan Through Electronic Medical Records (EMR) and cloud-based platform Case management meetings: CTI team and other care team members Patient engagement and education about IDN s coordinated care model Evaluation: Reduction in repeat ER visits Yearly screening and referral protocols monitored for physical, mental and substance use, as well as for social determinants of health
Gaps, Challenges, Unanswered Questions Workflow for referral via EHRs? Via other means? Creating resource base/referral process with non-idn social service entities (e.g., Southern NH Services, DHHS, etc)
Region 4 IDN CTI Kickoff Event June 1, 2017 Co-lead: Susan Stearns Co-lead: Vic Topo Region Director: Peter Janelle Project Manager: Jennifer Turransky
Regional Target Populations/Institutions Transitions from Hospital to the Community Clients with either an ED visit or inpatient stay where either a primary or secondary diagnosis or comorbidity includes a behavioral health condition Transitions from Corrections to the Community Clients released from correctional facilities, including Sununu Youth Services Center, with an identified behavioral health condition Transitions from Youth Behavioral Health programming to Adult Services CTI Kickoff Event June 1, 2017 17
Screening & Enrollment Processes Referrals accepted from any N4H partnering organization Individual will be navigating 1 of the 3 critical transitions identified Eligibility criteria established Participate in N4H approved Core Standardized Assessment CTI Kickoff Event June 1, 2017 18
Workforce Management & Development Plan N4H Care Transitions Director/Clinical Supervisor Education Masters level experienced clinician Governance Reports to N4H Executive Director Care Transition Coach (5-6 FTEs) Education Bachelors level or lived experience Governance Reports to N4H Care Transitions Director CTI Kickoff Event June 1, 2017 19
Project Implementation Timeline May-June 2017 Kickoff event (Phase 1) Refine workforce needs (FTEs needed, job descriptions, salaries, hosting organizations) July-September 2017 Recruitment of staff Organization and DSRIP orientation September-October 2017 CTI Training to begin (Phase 2) October- December 2017 Monthly coaching for CTI staff (Phase 3) Identify staff for train-the-trainer training Begin accepting referrals January- February 2018 Train-the-Trainer training to begin (Phase 4) CTI Kickoff Event June 1, 2017 20
Monitoring & Evaluation Plan N4H Core Standardized Assessment performed upon referral Baseline assessment on admission and reassessment at 30, 60 and 90 days to identify: Hospital admissions Emergency room visits Utilization of crisis services Criminal justice system involvement and incarcerations CTI Kickoff Event June 1, 2017 21
Challenges Workforce Identifying organizational home Turnover Recruitment Capacity Unknown demand Education of referral sources High fidelity implementation CTI Kickoff Event June 1, 2017 22
Discussion Questions? Comments Follow-up Thank you CTI Kickoff Event June 1, 2017 23
Region 6
Regional Target Populations/Institutions Target Population >18yo Individuals/Head of Household Primary or co-occurring disorders SMI/SPMI; SUD; TBI Risk Factors (2-3): At risk of homelessness or homeless Lack of positive social support/natural supports network Inability to perform activities of daily living adequately Lack of basic subsistence needs (food stamps, benefits, medical care, transportation) Inability to manage money Unemployment/underemployed/lack of employment skills Probation/Parole Institutions Hospital (Frisbie Memorial) Crossroads Homeless Shelter Eventually Corrections and Residential Treatment
Targeting/Screening & Enrollment Processes/Tools Screening and Comprehensive Assessment TBD Combination of tools (10th Decile Approach) Diagnoses Housing Stability Crisis Service Utilization Social Supports ADLs Assessment of Needs/Strengths across categories Arizona Self Sufficiency Matrix Service Order/Authorization CTI Phase Planning
Workforce Recruiting, Management & Development Plan Contemplating one Full CTI Team comprised of: Masters level Team Leader 3 FTE CTI Workers (Bachelors Level-competencies composite) Team Leader located at Strafford County Complex One CTI Worker at Crossroads House Other two CTI Workers at partner organizations Weekly Case Conference/Supervision at County (with IDN Ops) Integration with Community Care Teams Continuous QI and Supplemental Trainings (offered across IDN)
Project Implementation Timeline June 30 Plan/Budget Finalized MOUs/Contracts finalized September 1 CTI Staff Hired; On-boarding (services orientation) October 15 Initial CTI Training complete (Team Leader; CTI Staff) Enrollment begins January 2018 Train-the-Trainer
Current Tracking, Monitoring & Evaluation Plan < Institutional Nights (Hospital, Corrections) < ED Utilization < Ambulance > Psychiatric stability, med management > Housing Stability (Days Housed) > Self Sufficiency > Linkage to Services/Benefits > Daily Life skills > Social Support Network > Community Involvement > Food Security > Mobility
Gaps, Challenges, Unanswered Questions All the usual challenges related to recruiting and retention Are any Regions contemplating in-reach to State Hospital? Process for making distinctions with existing services/resources i.e. ACT, Community Paramedicine, etc. (exclusion criteria, or supplemental?) Work Group: Frisbie Memorial Hospital Cornerstone VNA Tri-City Co-op Goodwin Community Health Community Partners CMHC Crossroads House
Region # Coos, Carroll and Northern Grafton Counties
Regional Target Populations/Institutions Medicaid recipients transitioning from hospitals, long term care, or incarceration Individuals with a primary diagnosis of SPMI/SMI Those not actively connected with ACT or ongoing programs that meet clinical needs Risk factors that include: homeless or risk of homelessness; lack of social or natural supports; daily living skills are compromised; lack connections to basic needs (medical, food, benefits); possible substance use; lack employment skills; challenged by daily functioning; inability to manage money. Navigating critical transitions without skills or clinical support
Targeting/Screening & Enrollment Processes/Tools Referral organizations Client is identified Enrollment Process Phase 1 Outreach and education (brochure) Meets eligibility criteria Signed Service Order Phase 1 Begins Understanding/ agreement Screening and Assessment Transition Plan created Individualized CTI Progress Notes Phase-Date Form CTI Referral Form Initial Risk Assessment Phase Plan Crisis P&I CTI Team Supervision Caseload Review Worker Self Assessment
Workforce Recruiting, Management & Development Plan Provider Organizations/Staffing Serve population Have complimentary positions Job Descriptions Clinical supervisor Create Regional Hubs Minimum of 4 staff Define maximum caseload Define regions Inclusive of Peer Specialists Workforce Development Outreach to Educational providers Educate Providers High schools Professional Development
Project Implementation Timeline CTI Kick Off- June 1, 2017 Program essentials are shared and will be incorporated into program components and processes Finalizing Program Components-June 2017 Design and Development of clinical services infrastructure Progress and Phase Reporting Discharge Process Evaluation, Tracking and Fidelity Project Budget-June 2017 Budget Projections reviewed and final budget determined.
Timeline Participating Providers Confirmed June 2017 CTI participating provider organizations complete agreements with referring organizations CTI Training- Fall 2017 CTI Training provided by CACTI 5 CTI Professionals Trained including a Clinical Supervisor, Case Managers and Peer Specialists. Implementation- Fall 2017 Participating providers identify eligible participants/referrals are made On-going additional trainings such as Person Centered Thinking; Motivational Interviewing
Timeline Technical Assistance and Mentoring Fall 2018 and ongoing CTI Trainer to provide TA and mentoring. Regional CTI Workgroup to share best practices and provide updates to current processes. CTI Trainer candidates are recruited. CTI Train the Trainer Jan/Feb 2018 CTI regional Trainer is trained. Regional Review- July 2018 Regional participating providers to meet for a review of the first 9 months of the program. Recommendations for improvements.
Current Tracking, Monitoring & Evaluation Plan Phase Plan Closing Plan Adherence Follow up Phase or PCP Plan Progress Notes Tracking tool Fidelity Assessment Staff self assessment
Gaps, Challenges, Unanswered Questions Has the program been started within a Jail setting? Recommended program exclusions- is the program ever used with a SUD primary diagnosis? Is eligibility criteria determined by region or does the CTI program define that?