National Academy for State Health Policy Conference

Joan L. Erney, JDChief Business Development and Public Policy Officer

Community Care Behavioral Health OrganizationKansas City, Missouri / October 5th, 2011

Today’s 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.

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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 => physical health system– Office of Mental Health and Substance Abuse Services =>

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.3Earney 10.5.11

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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Clinton

Armstrong

Indiana

Washington

GreeneFayette

Allegheny

Beaver

Westmoreland

BedfordSomersetFranklin

Fulton

5

Erie

Warren McKean Tioga BradfordSusquehanna

Wayne

Cambria

HuntingdonBlair

ForestVenango

Mercer

LawrenceButler

Clarion

Crawford

JeffersonClearfield Centre

Elk Cameron

Potter

Northampton

LebanonCumberland

YorkAdams

Lancaster

PerryJuniata

Mifflin

Dauphin

Schuylkill

Montgomery

Chester

Delaware

Philadelphia

BerksBucks

Lehigh

ColumbiaMontour

Snyder

Union

Northumberland

Lycoming

SullivanPike

Carbon

Luzerne

Monroe

Wyoming

SOUTHEASTImplemented February 1997

SOUTHWESTImplemented January 1999

LEHIGH/CAPITALImplemented October 2001

NORTH/CENTRAL STATE OPTIONImplemented January 2007

NORTH CENTRAL COUNTY OPTIONImplemented July 2007

NORTHEASTImplemented July 2006

Lackawanna

HealthChoices Zones

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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.

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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 AllPI #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 D&A Dependency or Addiction with Follow-Up Services Within 7 Days Post-Discharge, Under Age 65

9%

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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 Pennsylvania’s Medicaid managed care program. (Health Choices)

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About Community Care

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• 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

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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 16

Services in PA and NY City

Erie

Allegheny

Clarion

Forest

Warren McKean Potter

CameronElk

JeffersonClearfield Centr

e

Clinton

Adams

Union

Lycoming

Tioga Bradford

Columbia

Northumberland

York Chester

Berks

Schuylkill

Luzerne

Wyoming

Susquehanna

Lackawanna

Wayne

Pike

Monroe

Carbon

Juniata

Sullivan

Huntingdon

Mifflin

Snyder

Montour

Southwest Region

Lehigh-Capital Region

Northeast Region

Erie County Region

Community Care Office

Serving individuals in 36 PA Counties and 5 New York City Boroughs

Chester County Region

North Central RegionCounty Option

North Central Region State Option

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Connected Care™

Guiding Principles

• Behavioral health is part of overall health; good health outcomes are important to an individual’s 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.

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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. 19

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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• 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

Consumer Engagement

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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

Care Management Activities

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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 (p=0.449)

• 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 information24

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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 Care’s 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 25Earney 10.5.11

North Central State Option Medicaid Members and Expenditures – 2009 Profile

* Total Member Months: 1,749,129; Average Member Months: 145,761

Unique Users 159,251 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%

Population Characteristics

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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 Opportunity27

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! 30

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Contact Information

Joan L. Erney, JDChief Business Development and Public Policy Officer

Community Care Behavioral Health OrganizationFormer Deputy Secretary OMHSAS (2003-2010)

Community Care Behavioral Health OrganizationOne Chatham Center, Suite 700

112 Washington PlacePittsburgh, PA 15219

www.ccbh.com412-454-2120

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