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From HARPs to DSRIP to VBP:Promise or Peril?

Evolving Strategies for the Delivery and Payment of

Mental ServicesMHA Regional Policy

CouncilFebruary 19, 2016

Harvey Rosenthal NYAPRS Executive director1

A peer-led statewide coalition of people who use and/or provide community mental health recovery services and peer supports that is dedicated to improving services, social conditions and policies for people with psychiatric disabilities by promoting their recovery, rehabilitation, rights and community integration and inclusion.

[email protected] www.nyaprs.org

2

New York Association of Psychiatric Rehabilitation Services (NYAPRS)

mailto:[email protected]

http://www.nyaprs.org/

Very high health, social and criminal justice costs with very low outcomes

Early mortality: cardiovascular, respiratory and infectious diseases, diabetes and hypertension

Highest rates of avoidable readmissions

High rates of violence victimization, incarceration, homelessness and suicide

Impact of a Broken System

High rates of poverty: unemployment and idleness

Stigma and discrimination: isolationLoss of hope, purpose, dignityMagnified exponentially for communities of color and other underserved groups

Impact of a Broken System

Fragmented, Siloed and Uncoordinated

Unresponsive: Reactive vs Preventive and Diversionary

Unaccountable: who can we turn to?Wrong Incentives: volume over value Illness over Wellness? Wellness over

Illness? ‘Chronic’ Patienthood over

Personhood

Elements of a Broken System

The Triple Aim: improving outcomes, improving quality, reducing cost

Key features: expansion of Medicaid and managed care, behavioral health parity, home and community based services including self-directed care

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Affordable Care Act:National Healthcare Reform

Focus on Coordination Integrated physical and behavioral healthcare Outcomes Prevention Wellness Hospital diversion Individualized care

7

Affordable Care ActState Healthcare Reform

$54 billion Medicaid program with 5 million beneficiaries

20% (1 million beneficiaries) use 80% of these dollars: hospital, emergency room, medications, longtime “chronic” serviceso Over 40% with behavioral health

conditions 20% of those discharged from general hospital

BH units are readmitted within 30 days: NYS avoidable Medicaid hospital readmissions: $800 million to $1 billion annually 70% with behavioral health conditions;

3/5 of these admissions for medical reasons8

New York State’s Challenge

Health and Recovery Plans Health Homes Home and Community Based Services Delivery System Reform Incentive

Payment Performing Provider Systems

Value Based Payment Eliminate racial disparities in healthcare

NYS Medicaid Waiver

From fee for service to outcome based care

Diversion from emergency room and inpatient hospital use

Surprise! We are healthcare providers

10

The Mantras of the MRT

Managed Care for All Universal Access to High Quality Primary Care; Integrate physical and BH services

Targeting the Social Determinants of Health

Health Homes: Teams of providers working together to coordinate care for Medicaid consumers who use lots of services

NYS Medicaid Redesign

Inpatient - SUD and MH

Clinic – SUD and MH Personalized Recovery

Oriented Services Assertive Community

Treatment Partial Hospitalization Comprehensive

Psychiatric Emergency Program

Targeted Case Management

Opioid treatment Outpatient chemical

dependence rehabilitation

Rehabilitation supports for Community Residences (phased in in 2016)

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Managed Care Plans Now Offer Medicaid funded BH Services

• Designed for people with more extensive mental health and/or substance use related conditions• Covers all benefits provided by Medicaid Managed Care Plans, including expanded behavioral health benefits• Also provides additional Home and Community Based Services to help people live better, go to school, work and be part of the community

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Health and Recovery Plans

Who’s Eligible for a HARP?

SSI Recipient ACT, TCM, PROS, PMHP in past year 30+ days of psych hospitalization,

3+ admissions or 3+ month stays in OMH housing over the past 3 years

60+ days in OMH psych center Incarceration w BH treatment past 4

years 2+ SUD ER visits, detox stays for SU

related inpatient stays

Have both Medicaid and Medicare Live in a nursing home Are in a Managed Long Term Care Plan Are under age 21 Have services from the Office for

People with Developmental Disabilities (OPWDD)

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Who’s Not Eligible for HARPs?

AetnaCapital District Physicians Health Plan

Excellus Health Plan.Fidelis Care New York MVP Health Care

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Health Plans in Broome County

Health homes are ‘a home for your healthcare” Everyone gets a care coordinator who conducts an

assessment and works with each individual to develop their own goal and service plan which are intended to be shared electronically with all providers and social services that support them

Health home responsibilities include: Active engagement 24-7 response Focus on well coordinated discharge and treatment

planningWhat are your experiences with Health Home Care Management?17

HARP Beneficiaries’ Care is Managed via Health Homes

October 23, 2015

New York State Designated Lead Health Home

Administrative Services, Network Management, Health IT Support/Data Exchange

Health Home Care Management Network Partners (includes former

Total Care Management Providers)

Comprehensive Care ManagementCare Coordination and Health

PromotionComprehensive Transitional Care

Individual and Family Support Referral to Community and Social

Support ServicesUse of Health Information

Technology to Link Services (Electronic Care Management Records)

Managed Care Organizations (MCOs)

Access to Required Primary and Specialty Services

(Coordinated with MCO)Physical Health, Behavioral Health, Substance Use

Disorder Services, HIV/AIDS, Housing, Social Services and Supports

Medicaid

Analytics

Performance Portal

(MAPP)

Regional Health

Information

Organizations

(RHIOs)

NYS Health Home Model

Greater Binghamton Health Center Endwell Family Physicians The Family & Children's Society Catholic Charities Of Broome County The Addiction Center Of Broome County Southern Tier Independence Center Mental Health Association Of Southern Tier

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Catholic Charities of Broome County

Broome County Mental Health Department

Our Lady of Lourdes Memorial Greater Binghamton Health Center Conifer Park Samaritan Counseling Center Of The

Southern Tier LB Prescription Enterprises

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United Cerebral Palsy Association of NYS Broome County Health Department Broome County Mental Health Community Options United Health Services Hospital Greater Binghamton Health Center NYS Office Of Mental Health United Health Services Hospitals

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Arms Acres Conifer Park Greater Binghamton Health Center Arms Acres Southern Tier Aids Program United Health Services The Family And Children's Society Conifer Park United Health Services

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United Health Services

Broome County Mental Health Department

Volunteers Of America YMCA Twin Tier Home Health Binghamton Housing Authority Broome County Council Of Churches Broome County Department Of Social

Services Broome County Lift Broome County Office For The Aging23


CASA Community Hunger Outreach Warehouse Mental Health Association Of Southern Tier

Professional Home Care Addictions Center Of Broome County Alcoholics Anonymous American Cancer Society Fairview Recovery Services Holliswood Hospital

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Mothers And Babies Perinatal Association Narcotics Anonymous Opportunities For Broome Rehabilitation Support Services Retired And Senior Volunteer Program Salvation Army Serafini Transportation Corporation SOS Shelter Southern Tier Healthlink

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RehabilitationPsychosocial RehabilitationCommunity Psychiatric Support and Treatment (CPST)Residential Supports/Supported Housing

HabilitationCrisis Intervention

Short-Term Crisis RespiteIntensive Crisis InterventionMobil Crisis Intervention

Educational Support Services

NYS Home and Community Based Services Option

Medicaid Will Now Pay for:

Support Services Family Support and Training Non- Medical TransportationIndividual Employment Support Services Prevocational Transitional Employment Support Intensive Supported Employment On-going Supported EmploymentPeer and Family SupportsSelf Directed Services

7 days from inpatient discharge to outpatient appointment

30 days to filled prescriptionDepression screening and follow up

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Beyond HEDIS Outcome Measures

Participation in employment Enrollment in vocational rehabilitation

services and education/training Improved or Stable Housing status Access to and use of Peer Support Longer Community tenure, Decreased

Hospital Readmissions Decreased Criminal justice involvement Improvements in functional status Cultural & Linguistic Competence,

Engagement

HCBS Outcome Measures:Social Determinants of Care

= Physical and/or behavioral health care provider

Health and Recovery Plan (HARP)

Health and Recovery Plan

(HARP)Payers

Health and Recovery Plan (HARP)

Health Home Team

OMH

Health Home Team: Provider

Network

Health Home Team

Health Home Team

NYS Medicaid Redesign Response: Managed Integrated BH & Medical Care

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STATE MEDICAID AGENCY DOHOASAS

$7.1 billion over 5 years for DSRIP

$650 million to play for Home and Community Based Services

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NYS Medicaid Waiver

Promotes community-level collaborations that improve the quality and outcomes of care, while achieving a 25% reduction in avoidable hospital use from 2015-20.

Safety net providers are expected to collaborate to implement innovative projects focusing on system transformation and population health improvement.

All DSRIP funds will be based on performance linked to achievement of project milestones.

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Delivery System Reform Incentive Payment Program (DSRIP)

Performing Provider Systems are networks of providers that collaborate to implement DSRIP projects

Each PPS must include providers to form an entire continuum of care Hospitals Health Homes Skilled Nursing Facilities

(SNF) Clinics & FQHCs Behavioral Health

Providers Home Care Agencies Other Key Stakeholders October 23, 2015

Community health care needs assessment based on multi-stakeholder input and objective data

Building and implementing a DSRIP Project Plan based upon the needs assessment in alignment with DSRIP strategies

Meeting and Reporting on DSRIP Project Plan process and outcome milestones

25 Performing Provider Systems

Project

Description PPSs Involved

3.a.i Integration of primary care and behavioral health services 253.a.ii Behavioral health community crisis stabilization services 113.a.iii Implementation of Evidence-Based Medication Adherence

Program (MAP) in Community Based Sites for Behavioral Health Medication Compliance

2

3.a.iv Development of Withdrawal Management (e.g. ambulatory detoxification, ancillary withdrawal services) capabilities and appropriate enhanced abstinence services within community-based addiction treatment programs

4

3.a.v Behavioral Interventions Paradigm (BIP) in Nursing Homes 14.a.i Promote mental, emotional and behavioral (MEB) well-being

in communities 2

4.a.ii Prevent Substance Abuse and other Mental Emotional Behavioral Disorders 1

4.a.iii Strengthen Mental Health and Substance Abuse Infrastructure across Systems 13

October 23, 2015

Key Mental Health Projects in DSRIP

Also known as: Southern Tier Rural Integrated Performing Provider System, Inc., STRIPPS, United Health Services Hospitals, Inc.

Counties served: Broome, Chemung, Chenango, Cortland, Delaware, Schuyler, Steuben, Tioga, Tompkins

Attribution for Performance: 102,386

Total Award Dollars: $224,540,27534

Care Compass Network

Home Care Independent Living Center Addiction Center Nursing and Rehabilitation Center Primary Care County Health Departments County Office for Aging Hospice and Palliative Care

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Provider Groups

Hospitals Vocational Rehabilitation Services for People w Developmental

Disabilities Health Homes Compeer Pharmacies

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Provider Groups

Hospice and Palliative Care Therapeutic Communities Senior Living Center Suicide Prevention And Crisis Service United Cerebral Palsy Association Visiting Nurse Service YMCA

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Provider Groups

Integration of primary care and behavioral health services (required of all 25 PPSs)

16 PPSs also included: Community crisis stabilization services Transitional Supports Activation Medication adherence programs Withdrawal Management Behavioral Interventions in Nursing Homes

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Behavioral Health Projects

Lakeview Mental Health Services, Liberty Resources Mental Health Association Of The Southern

Tier Northeast Parent And Child Society Onondaga Case Management Services Parsons Child And Family Center Phoenix Houses Planned Parenthood Rehabilitation Support Services

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Behavioral Health Providers

Integrated Delivery SystemDevelopment of Community

Based Health Navigation ServicesPatient ActivationEvidence-Based Strategies for

Disease ManagementCOPD Preventative Care and

Management40

Projects

30 Day Care Transitions for Chronic Diseases, including BH Conditions

Integration of Behavioral Health and Primary Care

Strengthen Mental Health and Substance Abuse Infrastructure, Prevention and Targeted Interventions

Crisis Stabilization41

Projects

What are Value Based Payments (VBPs)? An approach to Medicaid

reimbursement that rewards value over volume

Incentivizes providers through shared savings and financial risk

Directly ties payment to providers with quality of care and health outcomes

A component of DSRIP that is key to the sustainability of the Program

Value Based Payment

Required to ensure ‘long term sustainability of DSRIP investments”

By waiver Year 5 (2019), all MCOs must employ non-fee-for-service payment systems that reward value over volume for at least 80-90% of their provider payments

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Value-Based Payment Reform

Required to ensure that “value-destroying care patterns” (avoidable admissions, ED visits, etc) do not simply return when the DSRIP funding stops in 2020

If VBP goals are not met, overall DSRIP dollars from CMS to NYS will be significantly reduced

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Value-Based Payment Reform

To share in savings, you eventually need to take on risk…

Partnering with other providers is essential to being able to take on risk

We need to join forces with other providers to have enough cash reserves to take on Level 2 risk, which applies 90% of the savings to reward effective providers.

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VBP: Sharing in the Savings

Proposals to: Integrate physical and behavioral

healthcare get ahead of relapse and

readmissions and support crisis stabilization

promote mental, emotional and behavioral (MEB) well-being in communities; prevention and strengthening MH/SA infrastructure across system

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Value-Based Propositions

NYAPRS proposed to provide peer bridger services aimed at helping people with ‘serious’ mental health and addiction related conditions to: Reduce avoidable emergency room and

inpatient visits by 40% Increased self-management and participation

with chosen medications, services and supportsNYAPRS has successfully applied this model within a managed care contract to reduce hospital use by 48% and Medicaid spend by 47%

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Value-Based PropositionsAn example

We helped see that OMH HCBS services were added to the list of SDH interventions

All Level 2 and 3 plans or providers must address at least one social determinant and contract with at least 1 CBO

We’ve pushed for the state to provide infrastructure dollars and technical assistance for community based providers

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NYAPRS Advocacy on Value Based Payment Work Groups

We’ve insisted that VBP outcomes include recovery and social determinant related ones (beyond HEDIS) Ex: maintenance of housing stability

Strong emphasis on cultural competenceBuy not BuildPosition our members for gain sharing

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NYAPRS Advocacy on Value Based Payment Work Groups

Development of Member Incentive Programs

Creation of an Expert Group for Achieving Cultural Competence in Incentive Programs

Use of Patient Reported Outcomes (PRO)

Expansion of ombuds program Plan for how best to communicate VBP

to consumers/members50

NYAPRS VBP Advocacy:Advocacy and Engagement

NYAPRS and MHANYS: partnerships that advocate for recovery outcomes, services and providers and for consumer rights and choice protections

Our member agencies: attain good positioning in health home and DSRIP networks, offer relevant and reliable value propositions, raise level of infrastructure (contracting, billing, compliances) and workforce

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Homework

Recovering people: be prepared to make informed choices!New health home assessment, plan

and selection of recovery and HCBS services

Use of self-directed care dollars and ‘patient incentives’

Assume responsibility for health literacy, improved wellness self management and health outcomes

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Homework

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Documents