Community Care A Non-profit Behavioral Health Managed Care Company

1
National Academy for State Health Policy
Conference

• Joan L. Erney, JD
• Chief Business Development and Public Policy
  OfficerCommunity Care Behavioral Health
  Organization
• Kansas City, Missouri / October 5th, 2011

2
Todays Discussion

• Introduction to Pennsylvania Medicaid and
  behavioral health landscape.
• PA Health Choices program performance
• Overview of two physical health/behavioral health
  projects in Pennsylvania.
• Lessons learned.

3
Pennsylvania Quick Facts

• 12 million residents.
• 2.2 million projected Medicaid members (FY11-12).
• 2 urban centers (Philadelphia, Pittsburgh 38
  MA members).
• Department of Public Welfare (DPW) is single
  state agency for Medicaid
• Office of Medical Assistance gt physical health
  system
• Office of Mental Health and Substance Abuse
  Services gt behavioral health system
• County-based system for human services.
• Organized as 49 county joinders for mental health
  drug and alcohol services.
• County government plays significant role in
  Behavioral Health HealthChoices program 43 of 67
  counties contract for Medicaid.

4
HealthChoices Overview

• CMS Waiver Authority 1915 (b) Waiver
• 25 County Waiver (3 zones)
• Physical health Choice of HMOs.
• Behavioral health 24 contracts with counties,1
  direct contract (Greene).
• 42 County Waiver
• Physical health Access Plus (PCCM) voluntary
  HMO.
• Behavioral health 19 counties 1 direct state
  contract for 23 counties (Community Care).

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HealthChoices Zones
Erie
Susquehanna
Warren
McKean
Bradford
Tioga
Wayne
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Key Features

• County Right of First Opportunity Sole Source
  Contract - County options for acceptance of risk.
• Consumer choice for in-plan services.
• All MA Providers in initial year.
• Choice of two providers each level of care within
  access standards reviewed annually.
• Includes all state and federal eligibility
  categories of Medicaid.
• Includes special populations, children and youth,
  and persons with intellectual disabilities.

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Key Features

• Pharmacy benefits (with the exception of
  Methadone) paid for by physical health or FFS.
• State Plan services, cost-effective
  alternatives,and supplemental services
  available.
• Consumer/Family Satisfaction Team (C/FST) in
  every contract.
• Reinvestment of savings at the local level
  mustbe targeted to behavioral health.
• Performance measurement system.

8
HealthChoices Today

• Began in the Southeast Region and is now
  statewide
• BH program began in 1997 phased in through 2007
• 43 counties (joinders/multi-counties) accepted
  the right of first opportunity mixture of ASO
  (administrative services organization) and county
  risk-sharing arrangements.
• 23 counties (rural) state contract 1 county
  (southwest zone) state contract.

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HealthChoices Highlights

• 4-5 billion in savings due to the Behavioral
  Health program.
• Access to services and variety of services have
  both increased.
• Increased access to drug and alcohol providers to
  a significant degree.
• Reinvestment opportunities sparked innovative
  practices and cost-effective alternatives to
  current practices.

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More HealthChoices Highlights

• Improved quality standards and outcomes.
• Significant change in performance from 2003- 2008
• Utilization Changes reflect commitment to less
  restrictive services
• Design provides opportunities for innovative
  physical health and behavioral health
  initiatives.
• Unified systems and funding maximized fiscal
  resources at state and local level to support
  major initiatives include closing of state
  facilities enhanced access for high need
  dependent children.

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Change in HealthChoices Performance Measure
2003 to 2008
Access Performance Indicators (Penetration Rate) All
PI 1a, SMI and No Substance Abuse, Ages 18-64 52
PI 1b, SMI and Substance Abuse, Ages 18-64 65
PI 2.1, Mental Health Service, Ages 18-64, African American 33
PI 2.2, Substance Abuse Service, Ages 13-17, African American 41
PI 2.3, Substance Abuse Service, Ages 18-64, African American 27
PI 2.4, Mental Health Service, Ages 18-64 46
PI 2.5, Substance Abuse Service, Ages 13-17 -1
PI 2.6, Substance Abuse Service Ages 18-64 30

Quality/Process Performance Indicators All
PI 3a, At Least One Day in a Residential Treatment Facility, Under Age 21, Mental Health 35
PI 3b, Cumulative RTF Bed Days 120 or Greater, Under Age 21, Mental Health 1
PI 4a, Psychiatric Inpatient Readmitted Within 30 Days Post-Discharge, Under Age 21 5
PI 4b, Psychiatric Inpatient Readmitted Within 30 Days Post-Discharge, Ages 21-64 12
PI 4c, Psychiatric Inpatient Readmitted Within 30 Days Post-Discharge, Ages 65  
PI 5a, Discharged from RTF With Follow-Up Service(s) Within 7 Days Post-Discharge -3
PI 5b, Discharged From Psychiatric Inpatient With Follow-Up Service(s) Within 7 Days Post-Discharge, Under Age 21 19
PI 5c, Discharged From Psychiatric Inpatient With Follow-Up Service(s) Within 7 Days Post-Discharge, Ages 21-64 20
PI 5d, Discharged From Psychiatric Inpatient With Follow-Up Service(s) Within 7 Days Post-Discharge, Ages 65 NC
PI 5e, Discharged From Non-Hospital Residential Detox, Rehabilitation and Halfway House Services for DA Dependency or Addiction with Follow-Up Services Within 7 Days Post-Discharge, Under Age 65 9
12
Utilization Rate Changes by Service Category
2003- 2008
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Systems Redesign Move to Less Restrictive Care
Settings
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PA Physical Health/ Behavioral Health Landscape

• Projects supporting integration of services and
  supports for individuals with physical health
  (medical) and behavioral health needs happening
  across the state in urban, rural, and suburban
  settings.
• Co-locations collaborations shared staff
  models health home development shared health
  records.
• This presentation will focus on two Pennsylvania
  initiatives involving Community Care , a
  behavioral health managed care organization
  serving in Pennsylvanias Medicaid managed care
  program. (Health Choices)

Earney 10.5.11
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About Community Care

• Behavioral health managed care company part of
  UPMC headquartered in Pittsburgh, PA founded in
  1996
• Federally tax exempt non-profit 501(c)3
• Major focus is publicly-funded behavioral health
  care currently doing business in PA and New York
• Licensed as a Risk-Assuming PPO in PA NCQA
  accredited
• Serving over 100,000 individuals in 36 PA
  counties through a statewide provider network of
  over 1700

Earney 10.5.11
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Connected Care Program

• Initiative to improve the connection and
  coordination of care for those with Serious
  Mental Illness among health plans, PCPs, and
  behavioral health providers in outpatient,
  inpatient, and ED settings
• Based on Patient-Centered Medical Home model
• integrated care team and care plan to address
  medical, behavioral, and social needs
• Partnership between
• Center for Health Care Strategies (CHCS)
• Department of Public Welfare (DPW)
• UPMC for You and UPMC for Life Specialty Plan
• Community Care Behavioral Health
• Allegheny County Department of Human Services

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Services in PA and NY City
Serving individuals in 36 PA Counties and 5 New
York City Boroughs
Community Care Office
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Connected Care

• Guiding Principles
• Behavioral health is part of overall health good
  health outcomes are important to an individuals
  recovery.
• Integration of good health habits, prevention
  activities, and specific physical health
  interventions are best achieved through local
  collaborations and navigator systems.
• Good health outcomes can be achieved within the
  existing physical health and behavioral health
  managed care design.

Earney 10.5.11
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Connected Care

• Expected Outcomes
• Decreased Inpatient utilization (both PH/BH).
• Decreased Utilization of emergency room usage and
  crisis services.
• Reductions in readmission rates for PH/BH.
• Increase in preventive and routine health care.
• Increase in satisfaction and quality of life.
• Members qualify for Connected Care if they
• Are a UPMC for You and a Community Care member.
• Are age 18 or older.
• Live in Allegheny County.
• Have Serious Mental Illness (SMI).
• SMI is defined as individuals who have been
  diagnosed with schizophrenic disorders, episodic
  mood disorders, or borderline personality
  disorder.

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Member Stratification

• High PH needs defined as
• 3 or more ED visits in past 3 months, or
• 3 or more inpatient admissions in the past 6
  months.
• High BH needs defined as
• Discharged from, history of being served, or
  diverted from a State mental hospital.
• 5 or more admissions to most restrictive level of
  care, or readmitted within 30 days.
• 4 or more admissions to most restrictive level of
  care and inpatient or RTF or CTT admission.
• 3 or more admissions to the most restrictive
  level of care and inpatient or 2 admissions to
  most restrictive level and inpatient and an open
  authorization for certain services.

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Consumer Engagement

• Joint training sessions on program design and
  work flows with care managers
• Consumer group input on program design and
  materials.
• Use of BH providers to help obtain consent
• Incentives to Medicaid members
• 2009- 25 gift cards for visiting PCP
• 2010- 25 gift cards for completing consent and
  enrolling
• Approximately 250 new Medicaid members identified
  monthly

22
Care Management Activities

• UPMC for You and Community Care coordination
• Focus on Tier 1 members and those admitted or
  seen I the ED
• Use of integrated care plan
• Weekly multi-disciplinary care team meetings
• Daily identification of members with PH or BH
  admission, and ED visits from key UPMC hospitals
• Concurrent case discussions
• 24 hour/day phone line managed by Community Care
  to answer member questions

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Mathematica Review Summary of Outcomes

• After Year 1, no evidence suggested program had
  effect on changes in aggregate rates of
  hospitalizations or ED visits
• For example, average number of PH
  hospitalizations per 1,000 members per month
• Study group dropped 11 percent from 31.6 to
  28.2Comparison group dropped 17 percent from
  30.3 to 25.2
• Difference in differences was not statistically
  significant (p0.449)
• No statistically significant differences in rates
  among those who consented to participate

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Mathematica Review Conclusion

• After the first year, it was too early to
  identify improvements in health care utilization
• Both regions faced enrollment challenges and
  spent parts (or most) of the first year
  finalizing implementation issues
• Several promising strategies emerged
• Member and provider engagement through existing
  relationships
• Nurses as a central component of a
  multidisciplinary care team for BH-led
  integration efforts
• Shared information tool merging PH and BH
  information

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Connected Care Behavioral Health Home Plus

• Designed to demonstrate the efficacy of care
  coordination of PH/BH services for individuals
  with SMI and co-occurring medical conditions in a
  Medicaid and dual-eligible BH carve-out
• Combines technological infrastructure, data
  management, and clinical expertise of a BH-MCO
  and a BH provider-based care coordination model.
• Expands on Community Cares Allegheny County
  Connected Care program.
• Effectively reduced both physical and psychiatric
  hospital readmission rates emergency room use
• Improved quality indicators for individuals with
  physical co-morbidities

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North Central State Option Medicaid Members and
Expenditures 2009 Profile
Population Characteristics
Unique Users 159,251 CDPS Profile CDPS Profile CDPS Profile
Total BH Spending 192,206,453 BH /User 1,207 Condition Users Percent
Total PH Spending 572,917,158 PH /User 3,598 Diabetes 12,104 8
Inpatient Util000 Pulmonary 78,533 49
BH 276 3 co-morbidities 92,479 58
PH 1,532 5 co-morbidities 68,400 43

• Total Member Months 1,749,129 Average Member
  Months 145,761

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Connected Care Behavioral Health Home Plus

• Identify multiple sites within 23 county rural
  contracts in North Central Pennsylvania
• Rural communities build on existing
  relationships enhance with nursing competencies
• Early Adopter includes 5 county programs who
  operate services, partnering with local
  practices, Geisinger Health Systems Health Care
  Quality Unit (HCQU) for persons with Intellectual
  Disabilities and other behavioral health supports
  including peer specialists and psych
  rehabilitation.
• Member Portal and Other IT innovations
• Implementation manual will detail how to
• Evaluation Opportunity

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Lessons Learned

• Integration of physical health and behavioral
  health happens locally, building on the strengths
  of community infrastructure
• Real time notice of inpatient stays and ER visits
  has had impact on follow-up and engagement of
  individuals
• Nurses play a key role in the program and appear
  to interface more successfully with PCPs and
  specialists in accessing treatment for persons
  with SMI
• Certified Peer Specialists, and consumer tools
  such as WRAP ( Wellness Recovery Action Plan)
  planning and shared-decision making, are key in
  assisting in recovery and engagement in healthcare

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Lessons Learned

• IT Infrastructure of systems is challenging, but
  interfacing systems capacity can be built over
  time
• Investment of key PH and BH systems for at all
  stakeholder levels critical to success of
  collaboration
• CHCS played important role in providing support
  and technical assistance to the projects
• Having financial resources to assist in start-up
  and pooled resources for shared savings provided
  greater incentives for collaboration
• Identification of outcomes and performance
  expectations assists in focusing work

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For Our Consideration

• Integration with physical health is important
  however, also equally important for persons with
  serious mental illnesses are supports outside of
  medical care that encourage community integration
  and recovery.
• Issues of poverty, and real life challenges, such
  as transportation, access to healthy food, and
  stigma need to be incorporated into our solutions
  for individuals.
• Access to behavioral health treatment for persons
  with situational and short-term needs must be
  available in a timely way barriers to
  co-location, payment constraints, and regulatory
  challenges continue to need to be addressed.
• Continued evaluation for financial impact of
  collaboration is needed.
• Opportunity to include Medicare resources will be
  of great benefit for persons with serious mental
  illnesses and chronic conditions.
• Careful consideration and best practices continue
  to need to be developed for substance use and
  physical health integration, including pain
  management strategies.
• Health Homes and ACOs offer opportunities
  however, thought should be given as to how to
  build from, not create separate and distinct
  structures, from local communities strengths.
• Build on Success!

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Contact Information

• Joan L. Erney, JD
• Chief Business Development and Public Policy
  OfficerCommunity Care Behavioral Health
  Organization
• Former Deputy Secretary OMHSAS (2003-2010)
• Community Care Behavioral Health Organization
• One Chatham Center, Suite 700
• 112 Washington Place
• Pittsburgh, PA 15219
• www.ccbh.com
• 412-454-2120