BEHAVIORAL HEALTH HOMES Rhode Island and Missouri Models CT Behavioral Health Partnership Oversight Council Adult Quality, Access and Policy Committee BHH Workgroup October 17, 2012
Agenda Rhode Island BHH Model Missouri BHH Model Comparison of Models Next Steps
Rhode Island BHH Model Representatives from DMHAS and DSS met with officials from RI s Department of Behavioral Healthcare, Development Disabilities and Hospitals in September 2012 to gather information and garner lessons learned on their BHH model
Rhode Island Behavioral Health Home (BHH) Model 9 state designated private non-profit Community Mental Health Organizations (CMHOs) operating statewide Serve adults diagnosed with Severe and Persistent Mental Illness (SPMI) Approximately 5000 Medicaid clients eligible About 1/3 of CMHO BHH consumers have both Medicare and Medicaid (not included in RI s MME Proposal) 2 sites have SAMHSA Primary Care Integration Grants
Why Did RI Develop Behavioral Health Homes? SPMI have complex medical, behavioral health and psychosocial needs Built upon CMHO infrastructure already in place Harness unique capabilities of CMHOs boots on the ground Used 90% match to absorb $13M cut to BH services
Attribution to BHHs Universal eligibility criteria no enrollment process Individuals receiving services from a CMHO who meet the HH criteria are deemed HH clients No opt-out, but clients can choose to stop receiving services from CMHO
BHH Team Each team must have a caseload of at least 200 Each team is comprised of a multi-disciplinary group of professionals and peers (11.25 FTEs) which include: Master s Team Coordinator 1FTE Psychiatrist -.5 FTE Registered Nurse 2.5 FTE MA Level Clinician.5 FTE Community Psychiatric Supportive and Treatment Specialist (CPST) 5.5 FTE CPST Specialist Hospital Liaison 1FTE Peer Specialist -.25 FTE (phased in as resources available)
BHH Team Roles Health Home Service Care Management Primary Team Member Master s Level Team Coordinator Primary Care Coordination CPST Specialist Health Promotion Nurses and Psychiatrist Transitional Care CPST Hospital Liaisons Family Psycho-education CPST Specialists Referral to Community and Social Support Services CPST Specialists
Goals for RI BHH 1. Improve Care Coordination 2. Reduce Preventable ED visits 3. Increase Use of Preventative Services 4. Improve Management of Chronic Conditions 5. Improve Transitions to CMHO Services 6. Reduce Hospital Admissions
Data Reporting There is no standardized assessment, but CMHOs are responsible to report data to the state on HH outcome measures Outcome data is collected by BHHs and the state and combined within an aggregate outcome reporting spreadsheet Outcomes are based on a combination of claims data and chart audits Providers report encounter data in 5 minute increments The state originally posited 15 minute increments but Providers voiced concern about losing credit
Data Sharing MCOs give admission data to CMHOs within 2 days of hospital admit as the MCOs preauthorize the hospital stay MCOs give other medical data to CMHOs on a quarterly basis
Financing BHH services paid on a Per Member Per Month (PMPM) basis There were no start up payments and are no performance incentive payments CMHOs bill for 1 code for all health home activities and use FFS codes for all other Medicaid covered services Some FFS codes were transitioned to the all inclusive HH code In order to bill, BHHs must provide: at least 1 hour of service per month At least 1 hour of face to face per quarter At least 3 hours of service per month in aggregate for all clients
Lessons Learned Build upon existing infrastructure Be data informed RI implemented BHHs to avoid budget cuts (by securing 90% match) needed to be cost neutral RI overestimated the number of individuals that were eligible for BHHs (CMHOs) RI did not account for individuals on spend down Long-term cost neutrality or savings may not be guaranteed is case load growth occurs Medicare data is needed and is hard to secure
Lessons Learned Cost savings May not be realized in the sort-term but believe that the BHH model will improve care for clients Accountability Increased accountability for both state and providers CMHOs meeting new requirements Tracking and documenting HH activities Data/Outcomes Management CMS outcome measures difficult to track Build/purchase technology up front to manage and report data
Agenda Rhode Island BHH Model Missouri BHH Model Comparison of Models Next Steps
Missouri BHH Model Representatives from DMHAS and DSS held a teleconference with the Medical Director, Joe Parks, MD, from Missouri s Department of Mental Health in January 2012 to gather information and garner lessons learned from their BHH model which was the first one approved and implemented across the nation
Missouri BHH Model 28 State designated private non-profit Community Mental Health Centers (CMHCs) operating statewide (and affiliates) Serve adults and children diagnosed with MH+ another chronic condition or SUD+ another chronic condition Very few children fall into population based on data Population limited by severity (cost threshold established) MMEs included in population (MO s MME proposal is to use the existing HH model)
Why did MO Develop Behavioral Health Homes It was the next natural step: Build upon existing infrastructure (CMHC Psychiatric Rehabilitative Teams) Build upon existing integration initiatives (CMHC/FQHC collaborations) Increase wellness and prevention Would have to face additional reductions without implementation (assumed $7.8M in savings)
Attribution to BHHs Individuals who meet the cost threshold are auto-enrolled to the CMHC based on current source of care Individuals can choose to receive care elsewhere or can opt-out completely
BHH Team Health Home Director 1 FTE Nurse Care Manager 1 FTE per 250 Admin Support 1 FTE per 500 Physician Consultation 1 hour per enrollee per year Psychiatric Rehabilitation Team Members (funded separately): Psychiatrist, Behavioral Health Clinician, Community Support Specialist)
BHH Team Roles Health Home Service Care Management Primary Team Member Nurse Care Manager, HH Director Care Coordination Nurse Care Manager with assistance from Admin Support Health Promotion Nurse Care Manager, HH Director, Physician Consult Transitional Care Nurse Care Manager, HH Director, Physician Consult Family Psycho-education Nurse Care Manager Referral to Community and Social Support Services Nurse Care Manager with assistance from Admin Support
Goals for MO BHH Implement and evaluate the Health Home model as a way to achieve accessible, high quality primary health care and behavioral health care Demonstrate cost-effectiveness in order to justify and support the sustainability and spread of the model Support primary care and behavioral care practice sites by increasing available resources and improving care coordination to result in improved quality of clinician work life and patient outcomes.
Data Management and Analytics Uses 2 different contractors One manages EHR off of Medicaid claims The other manages data analytics: care management technologies, aggregate/benchmarking reporting, to-do lists, etc. Notification of Hospital Admit from Missouri Health Net (MHN) concurrent authorization system Care Coordination via CyberAccess Medication Adherence reports
Technological Tools CyberAccess: Web-based electronic health record (EHR) accessible to enrolled Medicaid providers, including CMHCs Direct Inform as EHR patient portal: A module of the MHN comprehensive, web-based EHR allows enrollees to look up their own healthcare utilization and receive the same content in laypersons terms The information facilitates self-management and monitoring necessary for an enrollee to attain the highest levels of health and functioning
Financing BHH services paid on a per member per month basis Providers are required to pay a small PMPM ($2-3) to vendors for data management, training, technical and administrative support Start up payments made to cover infrastructure costs: recruiting, training, IT changes, etc. MO may pursue incentive payments in the future based on shared savings and performance
Lessons Learned Build upon existing infrastructure Be data informed Data analytics should come first before defining population and providers Training via statewide learning collaboratives - just as important as data analytics Multiple data contractors creates productive competition
Agenda Rhode Island BHH Model Missouri BHH Model Comparison of Models Next Steps
Attribution Rhode Island Auto assignment based on current CMHO provider No opt out but may choose to stop receiving services or choose another provider Missouri Auto enrolled based on current CMHC provider May opt out or choose another provider
BHH Team Rhode Island The team will vary according to unique needs of individuals but will minimally consists of a Master s team coordinator who will serve as the central coordinator of health home services, psychiatrist, registered nurse, MA level clinician, CPST Specialist/hospital liaison, CPST Specialist and Peer Specialist Missouri Physician-led with health team of a health home director, a health home primary care physician consultant, nurse care manager(s) and health home administrative support staff Other team members may include: primary care physicians, pharmacists, substance abuse specialists, vocational and community integration specialists Optional staff include an individual s treating physician and psychiatrist, mental health case manager, nutritionist/dietician, pharmacist, peer recovery specialist CMHOs will participate in statewide learning activities to promote practice transformation CMHCs will be supported in statewide learning activities to promote practice transformation CMHOs as designated providers CMHCs as designated providers
Data Management Rhode Island Missouri No interoperable EHR Data collected and reported by both the state and BHHs via multiple methods MCOs provide admission information to BHHs Well developed web-based interoperable EHR information available to providers and members Extensive data analytics and information sharing Contracted with 2 data management vendors
Financing Rhode Island Missouri Monthly PMPM to BHH Monthly PMPM to BHH No start up or incentive payments Part of PMPM used for administrative costs of data vendors and learning collaboratives Infrastructure payments made and exploring incentive payments
Agenda Rhode Island BHH Model Missouri BHH Model Comparison of Models Next Steps
Next Steps State Partners Data Financial Model HIT BHH Workgroup Care Team Composition Provider Infrastructure Provider Credentials Outcome Measures