RTFs in TransitionPlanning to Avoid an Access Crisis,

Address Community Needs, and End Financial Distress

Three Key Components

• Access to Care: PACC process, families with commercial insurance, facility closures and downsizing (planning for adequate access)

• Capital and Debt Restructuring: revising rate methodology to address paying capital expenses, retiring debt associated with bed transformation, retirement (20% rule retained in residual rates)

• Services Redesign: staffing for more intensive services, higher turnover

PACC Performance

Current PACCs Practices and Productivity:

“In practice, according to RTF providers, each of the PACCs operates somewhat differently, particularly in the experience of those RTFs that relate to more than one.” – 2013 Manatt Report

Under managed care, standardized practices will be a key element in developing trust about the clinical appropriateness of placements. The PACC process must reflect decision “parity.”

Regional PACC Approval Rate Comparison

Average Length of Stay by Region

Bed Downsizing

Facility

2009 2010 2011 2012 2013 2014 2015^ Total

BVS -5

HGS -4

CV -14

SCO -6

GC -14

HR -6-8^ ^TBD

Total -49-51

• Nurse, OT, Physician, Psychiatrist, Rehab counselor, Social worker, Teacher, Therapeutic Specialist, Speech pathologist, Dietitian (consult)

• Transition Coordinator

RTFs-Intensive Treatment• More discharge, admission staff

• More clinical staff, specialty trained clinicians

• More permanency and outreach staff

Modernizing Staffing to Meet Current Needs, Shorter LOS and More Intensive Treatment

30-year old RTF Model

Establish Principles for Bed Downsizing/Conversions

• Retain 20% rule: if facilities reduce capacity by at least 20% they can maintain existing rate

• Allow flex capacity at any facilities that take advantage of RFI – use annual average census to respond to actual community need for RTF services

• How shall we establish principles?

Capital and Debt Restructuring-Precedent in Nursing Home Industry

Nursing Home Capital Component• Capital component guaranteed

• Disconnected capital from Medicaid occupancy

• DOH will calculate the capital component and will require payment via contract with the Plans that they will pay the rate to homes w/in their network

• Future Modifications may come from NH Capital Work Group

NH Debt Restructuring• DOH worked collaboratively with Nursing

Home industry; Recognized outstanding debt as a liability

• Developed and proposed for inclusion in the 2015-16 Budget, but was not included, but would have affected over 600 facilities

• Approach to reduce mortgage costs through refinancing and debt retirement

PACC Reforms to Consider• Amend MHL 9.51 to limit number of regional PACCs to 3 and have them meet every 3 weeks

• Amend MHL 9.51 to have 1 statewide “Advisory” Committee and remove mandate to include SED and OCFs reps (violating law now)

• Centralize “District 97” eligibility at Central Office level

• Formalize expedited review process in regulation and allow psych nurse practitioner, psychologist or physician

• Allow PACC to use psychiatrists or other licensed professionals affiliated with RTFs or agencies as long as the placement is not to the facility of affiliation

• Amend 2004 directive by OMH for SPOA to screen RTF PACC candidates to allow MCOs to takeover that role

PACC Materials Reforms to Consider

• Streamline or eliminate – Ed/Voc summary; Recreational Summary

• Allow documentation of “other observed behaviors” to override complete packet preparation

• Offer alternatives to psychiatric summary, physical exam, psychological

• existing treatment plans with psychiatrist signature;

• general physical exam without dental/vision within the past 12 months or 90 days if medical condition is present;

• psycho-social status report

A Service Type Seeking a Planned Transition –Previous Effort/Proposed Effort

• Building Bridges; Planning for Future Residential Needs – 2008

• Redesigning RTFs Report - 2013

• PACC Reform LSS - 2014

• RFI – May 2015

• Rate Methodology Amendments – July 2015 (capital, staffing)

• PACC Reform - 2015

RFI Proposal Under Development

Associate Commissioner Donna Bradbury

Actions to Address Concerns ~ 2015

• Quarterly Meeting with Commissioner Sullivan – February 6, 2015

• Coalition Follow-up on Workgroup Proposal – February 20, 2015

• OMH Shared RFI concept with Coalition – Feb 20, 2015

• Coalition Scheduled Webinar – Feb 25, 2015

• Webinar – March 17, 2015

• Internal Review of RFI (3.18.15) and Internal OMH planning – Feb-April 2015

Conceptual Design of RTF Bed Repurposing

Challenges the RFI approach may address:

• Immediate option for RTFs ready to downsize beds

• Transformation of service ahead of Medicaid managed care implementation

• Development of new services to market to Medicaid managed care organizations

• Retention of some traditional RTF services

• Practice model changes

• Data collection and analysis

RTF Bed Repurposing Planned Supports

• Dovetail effort with CTAC training and TA

• Building Bridges Initiative

• Save the Date: Aug 5-7, 2015 in Andover, MA “Building Bridges Initiative 2015” Training Event

• Support for three sets of services:

• Crisis management and stabilization

• Family-centered care planning

• Community-based clinical services

Draft of RFI Repurposing Services

• Crisis Respite

• Hospital diversion

• Clinical observation

• Family Support Services

• Evidence-based family therapy – with possible no-cost training opportunities

Coalition Discussion

• Thanks to Commissioner Anne Sullivan and Associate Commissioner Donna Bradbury for responding quickly to our February 6, 2015 request for attention to the RTF situation

• We will open the phones for a Coalition-only discussion and Andrea will provide some feedback to Donna Bradbury prior to her meeting tomorrow (March 18) with OMH-wide review of the RFI proposal.