Title: Community Care A Non-profit Behavioral Health Managed Care Company
1National 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
2Todays 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.
3Pennsylvania 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.
4HealthChoices 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).
5HealthChoices Zones
Erie
Susquehanna
Warren
McKean
Bradford
Tioga
Wayne
Earney 10.5.11
6Key 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.
7Key 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.
8HealthChoices 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.
9HealthChoices 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.
10More 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.
11 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
12Utilization Rate Changes by Service Category
2003- 2008
13Systems Redesign Move to Less Restrictive Care
Settings
14PA 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
15About 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
16Connected 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
17Services in PA and NY City
Serving individuals in 36 PA Counties and 5 New
York City Boroughs
Community Care Office
18 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
19Connected 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.
20Member 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.
21Consumer 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
22Care 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
23Mathematica 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
24Mathematica 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
25Connected 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
26North 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
27Connected 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
28Lessons 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
29Lessons 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
30For 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!
31Contact 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