Building Capacity fr Transfrmatin Regin 7 IDN Executive Summary Backgrund Nrth Cunty Health Cnsrtium (NCHC) is the Administrative Lead Agency fr Regin 7 Integrated Delivery Netwrk (IDN), which cvers all f Cs, Carrll, and Nrthern Graftn Cunty. Regin 7 IDN jins 6 ther IDNs acrss the state which are all part f New Hampshire s Delivery System Refrm Incentive Payment (DSRIP) prgram. The DSRIP prgram is utilizing a Medicaid 1115 waiver t incentivize netwrks f prviders t be innvative and transfrm the way mental health care is delivered by getting mental health, substance use disrder and healthcare systems wrking tgether t make it easier fr peple t get the care they need and cnnect with helpful resurces in the cmmunity. These changes will help make peple healthier, save mney and be mre effective fr thse wh have multiple healthcare needs. Regin 7 IDN has the ptential t earn up t a ttal f $14,178,458 ver the curse f the five year demnstratin which ends n December 31, 2020. These funds are based n the attributed Medicaid ppulatin in the regin, which was set at 19,138. While the main bjective f the prject is t imprve the ttal health care f Medicaid recipients, changes ahead will have a psitive impact fr everyne wh uses any type f health care. Regin 7 IDN partners include hspitals, primary care, mental health and substance use disrder treatment prviders, Department f Crrectins, Public Health and scial service rganizatins. These partners are cllabrating with ne anther t meet the DSRIP gals: Delivering integrated physical and behaviral health care Expanding capacity t address behaviral health needs and substance use disrders Reducing gaps in care during transitins acrss care settings Transitining t Alternative Payment Mdels (APMs) NCHC submitted Regin 7 IDN s prject plan n Octber 30, 2016, which was apprved at the end f 2016. The first six mnths f 2017 fcused n creating an extensive implementatin plan utlining the wrk f the regin thrugh 2020. This plan was submitted n July 31, 2017, and is currently underging review by NH DHHS. Regin 7 IDN partners will be implementing six prjects ver the remainder f the demnstratin, and belw are highlights n hw each prject will be executed.
Summary f Regin 7 IDN Implementatin Plan Behaviral Health Wrkfrce Capacity Develpment Grw ur wn mental health prviders pll existing Licensed Alchl and Drug Cunselrs (LADCs) in the area t identify the unmet training needs related t btaining Masters LADC licensure identify lcal mental health subject matter experts in the regin wh wuld be willing t utilize these skills fr training purpses wrk with area academic institutins t find innvative ways t expand behaviral health wrkfrce capacity expand Live, Learn, Play in Nrthern NH t include mental health prfessinal students Petitin NH Bard f Mental Health Practice regarding supervisin rules Ask fr a waiver t pilt a mdel f lng-distance supervisin n a limited basis Request fr experienced staff t be grandfathered in as supervisrs, and t allw fr shared grup supervisin Shared use f existing mental health prfessinals Create prcess t share staff resurces when feasible, including deplyment f mbile Licensed Drug and Alchl Cunselrs Explre creatin f clearinghuse t cllect requests fr shared staff, and deply the shared resurces t the mst apprpriate place. The clearinghuse wuld als serve as a mechanism t help with sme cst sharing f staff Create a central crdinating agency fr recvery supprt services Offer at least 2 Peer Recvery Cach Academy trainings per year Create infrastructure fr crdinated effrts related t peer supprt recvery services Health Infrmatin Technlgy Institute a secure, EHR-cmpatible electrnic shared care plan tl fr all direct service prviders (bth physical and behaviral health, regin-wide, t better enable crss-site care crdinatin) Cllective Medical Technlgies (CMT) is the shared care plan vendr Shared care plan will be rlled ut in 3 phases acrss the regin; March 2018, June 2018, and September 2018 Enable event ntificatin, triggered by specific patient actins, t facilitate care crdinatin and apprpriate use f services acrss a wide regin Cllective Medical Technlgies (CMT) is the event ntificatin system vendr Hspitals will prvide Admissin, Discharge, Transfer (ADT) feeds Assist all agencies wh culd be invlved in a patient's care in acquiring a direct secure messaging service allwing fr secure transmissin f apprpriate infrmatin, when enabled by patient cnsent Use data warehuse/data aggregatin technlgies t satisfy all internally-derived and statedirected reprting requirements f the prject
04/01/2018 first deadline fr reprting n statewide utcme measures Use data aggregatin tls t enable ppulatin health management and imprve utcmes thrugh better directin f resurces, in preparatin fr alternative payment mdels Integrated Health Care (Cre Cmpetency Prject) The center f the DSRIP prgram is the required Cre Cmpetency Prject which fcuses n the integratin f care acrss primary care, behaviral health (mental health and substance misuse/substance use disrder (SUD) and scial supprt service prviders. This prject, in cnjunctin with wrking t imprve care transitins, enhance care crdinatin fr the high needs ppulatin, and expand SUD treatment ptins, will lead t an integrated behaviral health delivery system. Crdinated Care Requirements: primary care and behaviral health practices will wrk t attain Crdinated Care Practice designatin by December 2018. Crdinated Care Designatin requirements include: Primary care and behaviral health prviders need t have a Cmprehensive Cre Standardized Assessment (CCSA) prcess in place which can capture infrmatin abut all f the required dmains including demgraphic infrmatin, physical health review, substance use review, husing assessment, family and supprt services, educatinal attainment, emplyment r entitlement, access t legal services, suicide risk assessment, functinal status assessment, universal screening using depressin screening (PHQ 2 & 9) and universal screening using SBIRT Regin 7 IDN Clinical Wrkgrup will apprve the Regin 7 Integrated Care Tlkit which will cntain a sample CCSA, sample cnsents, frms, assessment tls and prtcls Regin 7 IDN Quality Imprvement team will wrk with practice sites t share best practices related t the DSRIP requirements, and help sites advance alng the cntinuum f integrated healthcare Use f a Multi-Disciplinary Cre Teams (MDCT) MDCT must cntain a psychiatrist NCHC is explring the ptins related t this requirement, including cntracting with entities t prvide cnsulting psychiatric services t the MDCT Infrmatin sharing: care plans, treatment plans, case cnferences Reginal apprach fr mnthly multi-disciplinary case cnferences which will be rlled ut in a phased apprach t g alng with the shared care plan 1 MDCT will be frmed within each cunty f Regin 7 IDN, fllwing the phased rllut f the shared care plan Standardized wrkflws and prtcls Regin 7 Integrated Care Tlkit will have sample frms Assessment f level f integratin in Regin 7 IDN: NCHC has cntracted with Citizens Health Initiative t measure the IDNs prgress alng the cntinuum f integrated healthcare. Practice sites cmpleted surveys in June f 2017 t establish a baseline related t the level f integratin. Fllw up surveys will be cmpleted in December
and June 2018 and then n a yearly basis t quantitatively and qualitatively measure the prgress f IDN practices as they mve alng the cntinuum f integrated healthcare. Baseline results shw the regin needs t fcus n imprvements related t levels f integratin f primary care and mental/behaviral health care; patient care teams fr implementing integrated care; patient/family integratin management; and physician, team and staff educatin and training fr integrated care. IDN Quality Imprvement Cach and Health Infrmatin Technlgy Cach will wrk with prvider agencies t implement wrkflws and prtcls t address these weaknesses and psitin practice sites t imprve these scres when taking the same survey ver the curse f the DSRIP demnstratin. Multi-agency cnsent frm: create a frm and prcess s a patient des nt need t fill ut a cnsent frm each time they are referred t anther rganizatin Required Trainings cre multi-disciplinary care team members (PCPs, behaviral health prviders (including a psychiatrist), assigned care managers r cmmunity health wrkers are required t have the fllwing trainings: chrnic disease management training related t hyperglycemia, dyslipidemia, and hypertensin Mental Health Disrder Recgnitin, Treatment, Management, and Specialty Referral Substance Use Disrder Recgnitin, Treatment, Management, and Specialty Referral Wrking as a Care Team practice staff wh are nt invlved in direct care need t receive training in knwledge and beliefs abut mental disrders that can aid in recgnitin and management in special situatins 2 Mental Health First Aid trainings befre the end f 2017, ne in the Littletn area and ne in the Nrth Cnway area 4 Mental Health First Aid trainings in 2018, 4 in 2019, and 4 in 2020 NCHC has assessed training needs and will cntinue this prcess t determine the training needs f IDN partners and will wrk with partners t develp a training plan fr their rganizatin. variety f training mdalities will be used t meet the needs f IDN partners NCHC will create a reginal training plan t meet the training gals f the DSRIP demnstratin, and share this plan with all IDN members NCHC will develp schedule f required trainings befre the end f 2017. Trainings cnducted at a reginal level will be free t participating IDN members IDN partners will need t use the sub-recipient prpsal prcess r the IDN Training & Technlgy frm t apply fr funds t supprt practice specific trainings
Care Transitin Teams Regin 7 IDN will be wrking with 4 ther IDNs acrss the state t use the Critical Time Interventin (CTI) mdel which is an evidence based, time-limited case management mdel designed t prevent hmelessness and ther adverse utcmes in peple with mental illness fllwing discharge frm hspitals, shelters, prisns and ther institutins. Trainings CTI Wrker Training in NH #1- Nvember 2017 CTI Supervisr Training #1 in NH- December 2017 CTI Wrker Training in NH #2 February/March 2018 Train the Trainer in NH- August/September 2018 CTI Supervisr Training #2 in NH- Nvember 2018 CTI Wrker Training #3 Nvember 2018 CTI Supervisr Training #3 December 2018 One CTI Wrker in bth Nvember 2019 and Nvember 2020 One CTI Supervisr Training in bth December 2019 and December 2020 Mnthly Cmmunity f Practice Meetings Caching Supprt available Phased rll-ut f the prgram by sub-regins within Regin 7 IDN CTI tlkit will be develped which will cntain the dcuments necessary t implement the Critical Time Interventin mdel, including prtcls fr patient assessment, treatment, management, and referrals Prgram targets: 120 individuals served by CTI by December 31, 2018 3 partner rganizatins implementing CTI by December 31, 2018 15 CTI wrkers psitined in Regin 7 IDN by December 31, 2018 Expansin in Intensive Substance Use Disrder (SUD) Treatment Optins Regin 7 IDN will wrk t expand access t substance use disrder treatment ptins by addressing the fllwing: add additinal Medicatin Assisted Treatment (MAT) prgrams in the regin increase supprtive behaviral therapy by expanding behaviral health wrkfrce capacity, build and rganize peer supprt services; utilize technlgy t enable behaviral health therapies t be mre accessible deplyment f mbile Licensed Drug and Alchl Cunselrs Expanding Intensive Outpatient Prgrams (IOP) in the regin Cmmunity, patient and family educatin n mental health and substance use disrders listening sessins, educatinal utreach articles, and wrk with existing cmmunity resurce grups
Create tlkit which will cntain tls related t care transitins fr SUD treatment plicies, tracking and mnitring Systems, assessments arund transitin readiness, planning guides fr the transitin and hw t cmplete a transitin. Prject targets: 3 new MAT services in Regin 7 by December 31, 2018 35 individuals t be served with new MAT services in Regin 7 by December 31, 2018 1 new site ffering intensive utpatient (IOP) services by December 31, 2018 6 trained Peer Recvery Caches by December 31, 2018 50 individuals served by Peer Recvery Caches by December 31, 2018 3 existing IOP prviders expanding IOP services by December 31, 2018 NCHC assumes peratins f Tri-Cunty Cmmunity Actin s Alchl and Other Drug (AD) prgrams, including Friendship Huse n Octber 1, 2017 Enhanced Care Crdinatin in High Needs Ppulatin Regin 7 IDN will prmte a reginal care crdinatin apprach by training Care Advcates acrss the regin. These Care Advcates can be existing care crdinatrs, r new staff. This training mdel will be a phased apprach and will be rlled ut n a reginal level at the same time as the shared care plan. Prject targets: 15 Care Advcates trained by December 31, 2018 1 Reginal Care Advcate supervisr trained by December 31, 2018 45 individuals will be served by Care Advcates by December 31, 2018 20% decrease in annual 30 day hspital readmissins rate fr patients with behaviral health indicatrs rate per 1,000 ppulatin frm 9.1 in 2015 t 7.2 by 2020 20% decrease in annual emergency department visits fr patients with behaviral health indicatrs rate per 1,000 frm 1073 in 2015 t 858 by 2020 4 partner rganizatins will have frmal agreements in place fr referral prcess by December 31, 2018 Regin 7 Care Advcate Wrkgrup will prvide expertise t help develp tlkit which will cntain care transitin risk assessments, screening tls, management and referral prtcls, and mechanisms t track and mnitr individuals served by the prgram, adherence, impact measures, and fidelity t evidence-supprted prject elements