Embed Size (px)
Citation preview
copyright © 2012
How Data & Analytics are Changing Payer Expectations & Shaping the
Delivery of Services
Children’s Mental Health ServicesStaff Development Training Forum
November 27, 2012
copyright © 2012
About Community Care
• Behavioral Health Managed Care Company• Founded in 1996• Federally tax exempt non-profit 501(c)3 • Sole member corporation (UPMC)
– provider owned• Licensed as a Risk-Assuming PPO • Major focus: publicly funded behavioral
healthcare system
copyright © 2012
About Community Care
• Medicaid/HealthChoices membership: 700,000• Commercial/Medicare membership: 600,000• Statewide HealthChoices presence
– 36 of 67 Pennsylvania counties
• 8 offices across the Commonwealth• Over 500 employees• Approximately 110,000 people served• Statewide provider network of 1800+• Also serving as a BHO in Hudson River region
of New York
copyright © 2012
Our Origins
Pennsylvania HealthChoices Program
• Medical Assistance (Medicaid) managed care program
• Department of Public Welfare Office of Mental Health and Substance Abuse Services oversight
• Statewide behavioral health carve out– 1915b federal waiver– County government is the recipient of funds– County government contracting models vary
copyright © 2012
Mission and Vision
• To improve the health and well-being of the community through the delivery of effective and accessible behavioral health services
• To improve the quality of services for members through a stakeholder partnership focused on outcomes
• To support high quality service delivery through a not-for-profit partnership with public agencies, experienced local providers, and involved members and families
copyright © 2012
Focus
• Recovery transformation
• Peer and family involvement
• Respecting individual differences
• Community partnership
• Systems integration (children and youth)
• Focused care management model
• Physical/behavioral health integration
• Fiscal responsibility
copyright © 2012
Membership Trend
2001 402,369
2002 476,020
2003 520,152
2004 587,162
2005 597,011
2006 697,676
2007 998,908
2008 1,043,125
2009 1,097,645
2010 1,297,458
2011 1,377,419
2012 1,470,927
copyright © 2012
Services in Pennsylvania & New York
Serving 36 PA counties & NY’s Hudson River Region
Southwest Region
Lehigh-Capital Region
Chester County Region
Northeast Region
North Central Region
County Option
North Central Region
State Option
Erie County Region
Community Care Office
Erie
Allegheny
Clarion
Forest
Warren McKean Potter
CameronElk
JeffersonClearfield Centre
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
HudsonRiver Region
copyright © 2012
UPMC Insurance Services Division
Operating Structure
University of Pittsburgh Medical Center (UPMC)
UPMC Insurance Services Division
UPMC Health PlanAskesis
DevelopmentGroup, Inc.
Medical Assistance
Community Care
copyright © 2012
Accreditations and Commendations
• NCQA Full accreditation status (3 years) MBHO and DM
• Moffic Award–American Association of Community Psychiatrists
• ESPRIT Award–Mental Health Association of Allegheny County Corporate Award
• National Alliance for Autism Research (NAAR)-Appreciation Award
• Certificate of Recognition for Contribution to Western Pennsylvania Autism Community
copyright © 2012
Community Care’s Utilization of Data
• System Redesign• Care Management• Quality• PH/BH Integration• Provider Collaborations
Highlights
copyright © 2012
Before We Look at the Data
• What are we interested in?• What is the specific question?• How can we frame the data?• How do we improve our interpretation of
data over time?
copyright © 2012
What Are We Interested In?
• There are many questions to ask, but we need to clarify what our goal/area of focus is– Admission data can be important to
understanding the rates of admission, readmissions, and follow up after discharge.
– Length of stay data might be related to quality of care, discharge options, or other characteristics of the population
– “Data mining” without an area of focus could lead you off course
copyright © 2012
What is our Expectation of the Answer?
• Data alone can give answers that are correct, but not necessarily meaningful– Medication effects that are statistically
significant, but not often clinically relevant
– Information can reinforce existing beliefs (e.g. global warming)
– Predictions and assessments based on data are always tainted by our subjective perspective
Silver, Nate: The Signal and the Noise. New York: Penguin Press, 2012
copyright © 2012
Available Data Sources
• Authorizations• Claims• Enrollment data including basic demographic information• Eligibility data including all coverage in addition to Medicaid• Pharmacy• Physical health from physical health plans• Limited laboratory results (ordered by psychiatrists)• Care management information entered into PsychConsult• Member and provider satisfaction results• Complaints and grievances• Significant member incidents
copyright © 2012
Reducing Readmissions Case Study
Allegheny County
• Readmission rate was one of the highest in the state
• Used data analysis to identify members at high risk for readmission:– Concurrent substance use– Homelessness– Lack of social supports– Multiple readmissions
copyright © 2012
Preliminary Questions
• What are we interested in?– Decreasing Rate of Readmissions
• What is our expectation of the answer?– There are patient specific factors that
can help us identify what specific members to provide additional resources for
– There are process related factors that contribute to many readmissions
copyright © 2012
Analysis of Readmission Data
Length of Stay
The Length of Stay for the Index Event is significant as an indicator for a member having a readmission following the index admission event.
copyright © 2012
Age Group
Member’s age was not significant as an indicator for a member having a readmission following an index admission event.
copyright © 2012
Day of the Week
Days of the week for index discharge date are not significant as an indicator for a member having a readmission.
copyright © 2012
Diagnosis Group
Diagnosis groups are significant as an indicator for readmission.
copyright © 2012
Our Understanding of these Analyses
• Serious mental illness significantly contributes to readmissions
• Many people who are readmitted have concurrent substance abuse
• Lack of necessary community resources for many individuals contribute to readmissions
copyright © 2012
Activities to Improve Readmission Rates
• High risk care management focus on multiple readmissions– Care managers complete telephonic continued stay and
discharge reviews for acute levels of care and specialized services
– Care managers attend multiple community meetings, i.e. disposition, treatment team, interagency, to help with discharge planning
• New services to address members’ needs– Acute case management service focused on immediate
engagement and support– Imbedded evidence based practice, Brief Critical Time
Intervention (BCTI) in ACM; designed to link individuals to community based services and resources based on need during times of transition in care
– Enhanced crisis residential services– Enhanced access to substance abuse services
copyright © 2012
Additional Service Development
To ensure individuals receive the treatment needed in their home communities, system redesign and enhancements included:• Peer Support Services, help individuals establish ongoing
relationships in the community and provide support during transition out of hospital
• Crisis Services, including mobile teams, walk-in services and residential alternatives
• Case Management, Service Coordination, and Community Treatment Teams
• Health care integration to address physical and behavioral health care needs
• Enhanced housing program• Development of acute case management program
copyright © 2012
Acute Case Management
• Intensive outreach and extended case management engagement period for individuals in inpatient settings
• Case Management providers condensed existing case lists to free up resources for enhanced service
• Higher rate paid for the enhanced service which was used to increase reimbursement for staff
• Initial length of service of 6-8 weeks
copyright © 2012
Acute Case Management
• Impact on the following outcomes:– 60 day readmission rates– 60 day inpatient days and costs– 7 and 30 day follow up rates– 60 day total behavioral health care cost– 60 day total inpatient stay cost
prevented• Explored variation for the four largest
volume providers
What We Examined
copyright © 2012
Acute Case Management
What We Examined
• • 60 Day Readmission Rate
• 0
• 10
• 20
• 30
• 40
• 50
• 60
• 70
• Comparison ACM
•R
ate
• (No ACM)
copyright © 2012
Acute Case Management
What We Examined
Number of inpatient days accrued in the
60 days post discharge
0
2
4
6
8
Comparison ACM
Day
s
(No ACM)
copyright © 2012
Acute Case Management
What We Examined
7-day follow-up rate post discharge
0
10
20
30
40
50
60
Comparison ACM
Rat
e
(No ACM)
30-day follow-up rate post discharge
0
10
20
30
40
50
60
Comparison ACMR
ate
(No ACM)
copyright © 2012
Acute Case Management
What We Examined
Inpatient cost accrued in the 60 days post discharge
0
2000
4000
6000
8000
10000
12000
Comparison ACM
Do
llars
(No ACM)
copyright © 2012
Acute Case Management
What We Examined
Total cost accrued in the 60 days post discharge
0
2000
4000
6000
8000
10000
12000
Comparison ACM
Do
llars
(No ACM)
copyright © 2012
Acute Case Management
What We Examined
• • Total cost accrued in the 60 days post discharge
• 0
• 2000
• 4000
• 6000
• 8000
• 10000
• 12000
• Comparison ACM
•D
olla
rs
• IP MH• ACM• Rehab/Partial • Other
• (No ACM)
copyright © 2012
Acute Case Management
What We Examined
• Total Cost/IP MH Day Prevented
• 0
• 200
• 400
• 600
• 800
• 1000
• 1200
• Pre tool Post tool• implementation implementation
copyright © 2012
Acute Case Management
What We Examined•
• 60 day readmission rate by provider
• 0
• 10
• 20
• 30
• 40
• 50
• 60
• 70
• 80
• 90
• 100
• Comparison ACM
•R
ate
• (No ACM)
copyright © 2012
Acute Case Management
What We Examined
• Number of Inpatient Days accrued in the • 60 days post discharge by provider
• 0
• 2
• 4
• 6
• 8
• 10
• 12
• Comparison ACM
•D
ays
• (No ACM)
copyright © 2012
Acute Case Management
What We Examined•
• 7-day follow-up rate post discharge by provider
• 0
• 10
• 20
• 30
• 40
• 50
• 60
• 70
• Comparison ACM
•R
ate
• (No ACM)
copyright © 2012
Readmission Results in Allegheny County
Year AdmissionsReadmissions within 30 Days
30 DayReadmission Rate
2006 6327 990 15.6%
2007 5537 776 14.0%
2008 5292 814 15.4%
2009 5140 646 12.6%
2010 4773 620 13.0%
copyright © 2012
Use of Data in Care Management
• Data is used to identify high service utilization– High risk care managers routinely
participate in interagency service planning teams (ISPT) meetings
– ISPT meetings are a collaborative effort of the county administrative staff, individual support coordinators, case managers, peer specialists and members to problem solve issues and develop comprehensive relapse prevention plans
copyright © 2012
Use of Data in Care Management
• Care management staff collect critical data though utilization review protocols– During telephonic review for service
authorization, care managers routinely collect information on the services the member is involved with at the current time (including those not funded by Medicaid)
– If a member with complex needs is not involved with in case management, a referral is made
continued
copyright © 2012
Sample Care Management Monitoring Reports
• Census data by level of care and by provider to allow for targeted interventions
• Inpatient mental health and inpatient drug and alcohol admissions by provider
• Report of members holding for another level of care
• Length of stay by provider
copyright © 2012
Residential Facility Utilization
2010-Q
1
2010-Q
2
2010-Q
3
2010-Q
4
2011-Q
1
2011-Q
2
2011-Q
3
2011-Q
4
2012-Q
1
2012-Q
2
2012-Q
3
200
250
300
350
400
450
500
550
600
Units
Unit
s/1
000
copyright © 2012
Use of Data in Quality Activities
• Cost Drivers• Member and Provider Satisfaction• Quality Improvement Activities• Provider Incentive Programs• Comprehensive Provider Evaluations and
Provider Benchmarking• Adherence Monitoring of Practice
Guidelines and Performance Standards
copyright © 2012
Cost Driver Analysis
• Extreme outliers identified as 30% higher utilization than the statewide average
• In one county, Family Based Services were an outlier and a root cause analysis conducted
• Community Care utilized a clinical monitoring authorization process and promoted adherence to the family based performance standards
• Measures planned to determine effectiveness include family based penetration, pmpm, and length of stay
copyright © 2012
Member and Provider Satisfaction
• Provider and member satisfaction surveys are administered annually
• Member satisfaction: adult response rate 31% in 2011, child response rate 33.4 in 2011, utilizing a 7-wave mailing process with follow up calls
• Provider satisfaction: response rate 40.7% in 2011 utilizing a 2-wave mailing process
• Analysis of the results is conducted and opportunities for improvement identified
copyright © 2012
Member Satisfaction
Urgent Service Access:– When you needed counseling or treatment
right away, how often did you see someone as soon as you wanted? (usually, always)
2011: 68.4% 2012: 70.7%
– When you needed to get counseling or treatment right away, how long did you usually have to wait between trying to get care and actually seeing someone? (same day, one day
2011: 45.4% 2012: 52.3%
Quality Improvement Activity
copyright © 2012
Member Satisfaction
• The availability of crisis services is more widely promoted for those members feeling they need to be seen right away
• The development of a specialized adult outpatient service which is a step down option for members being discharged from inpatient mental health
• Implementation of an enhanced rate initiative for providers of outpatient mental health services for the first appointment following an inpatient
• Implementation of mobile and walk in crisis services
Service Access Interventions
copyright © 2012
Provider Satisfaction
Timeliness of Claims Payments:– How would you rate the timeliness of the claims
payments made to you/your practice? (good, very good)
2011: 69.8% 2012: 77.2%Interventions:• Community Care works with individual providers who
are identified as having difficulty or any provider requesting assistance or training
• Development and ongoing encouragement to utilize the Provider Online tool for claims submission and review of claims status
Quality Improvement Activity
copyright © 2012
Quality Improvement Activities
• Identified as an ongoing opportunity for improvement based on claims data monitoring
• Member identified barriers:– Member feels better after the inpatient stay and refuses follow up– Barriers to keeping the follow up such as transportation or child care
• Provider identified barriers:– High volume of cancellations and no shows– Lack of timely discharge planning
• Interventions implemented:– An enhanced outreach team contacts members following discharge to remind
them of the follow up appointment and utilize active problem solving techniques– An enhanced rate is offered to the outpatient provider for the first appointment
after inpatient– Several in plan services are developed including mobile mental health services,
certified peer specialists, mobile medication, assertive community treatment teams and telepsychiatry
Follow Up After BH Hospitalization
copyright © 2012
Follow Up Results
copyright © 2012
Comprehensive Provider Evaluation
• Real time, ongoing performance monitoring• Data is collected and evaluated in total to present a
multifaceted picture of provider performance• Comprised on more than 20 elements of performance
including:– Compliance with performance standards– Follow up on significant member incidents– Quality record review results– Compliance audits– Complaints – Changes in licensure status– Review and follow through with corrective action plans
copyright © 2012
Provider Benchmarking
• Claims based reporting distributed to high volume providers annually
• Comprised of utilization and quality indicators
• Quality Improvement Plans are requested from providers not meeting expectations
• The goal of provider benchmarking is to improve the practice standards of the provider by sharing comparative data
copyright © 2012
Benchmarking Indicators
• Inpatient admission rate during the treatment period
• Distinct number of discharges• Median length of stay• Length of stay over 365 days• 7 day follow up after inpatient
Residential Treatment Facilities
copyright © 2012
Provider Benchmarking
Blended Case Management
copyright © 2012
Paying for Performance
• Pay for Performance projects for the following levels of care:– Blended Case Management and
Specialty Case Management services– Family Based Mental Health Services– Outpatient Services– Preferred Providers for Best Practice
Evaluations– Alternative Payment Arrangements tied
to quality indicators
copyright © 2012
Pay for Performance Initiatives
• TCM/ICM – P4P Initiative
– Set performance improvement targets to improve quality of care in TCM/ICM. Providers earned prospective rate increases based on their achievement of goals established to improve OPMH follow-up rates post IPMH, insure TCM/ICM contact before and during IPMH admission and increase the frequency of TCM/ICM contact in the 30 days following IPMH discharge. Measures drawn from TCM/ICM Performance Standards developed with stakeholders.
– Initiative successful in improving network wide performance on selected indicators
– Set the foundation for the Single Point of Accountability project in Allegheny
copyright © 2012
Pay for Performance Initiatives
• CCT/ACT – P4P Initiative – Supported/Competitive Employment Initiative
– Following intensive training and technical assistance in the evidence-based practice of Supported Employment, performance improvement targets set to improve SE rates among CTT/ACT recipients to 20%.
– Providers who meet the target can earn a $1000 per employed member bonus payment at the end of the year.
copyright © 2012
Pay for Performance Initiatives
• CTT/ACT APA – P4P Initiative – Alternative Payment Arrangement
– Utilizes a risk sharing methodology developed to incent CTT/ACT providers to decrease IPMH utilization among CTT/ACT recipients.
copyright © 2012
Clinical Practice Guidelines
• Community Care adopts evidence based clinical practice guidelines– American Psychiatric Association Guideline for the
Treatment of Patients with Major Depressive Disorder– The National Institute of Drug Abuse Principles of Drug
Addiction Treatment: A Research Based Guide• Claims based measures used to monitor practitioner
adherence to treatment guidelines– Member newly diagnosed with depression and treated
with an antidepressant who filled a sufficient number of prescriptions to allow for 84 days of continuous therapy
– Members that initiate follow up chemical dependency treatment after detoxification
Monitoring Adherence
copyright © 2012
Physical/Behavioral Health Initiatives
• Pharmacy data for all members• Collaborations with all physical health plans to
develop joint data bases for specific projects (routine PH data feeds expected soon).
• Creation of integrated data warehouse with some plans that includes pharmacy and physical health elements
• Creation of fields in PsychConsult for pharmacy and other physical health items, including member release of information forms
Use of Data
copyright © 2012
Connected Care Program
• Collaboration between Community Care and UPMC for You
• Involved members with serious mental illness in Allegheny County enrolled in both Community Care and UPMC for You
• Created shared data document for care management staffs
• Shared key data items (e.g. readmissions, adherence to preventive care items) with both PH and BH providers
• Program demonstrated a positive effect on indicators such as mental health hospitalizations (12% decline) and overall readmission rates (10% decline; more info available at http://www.chcs.org/info-url3969/info-url_show.htm?doc_id=1261430)
copyright © 2012
Behavioral Health Homes
• Building on lessons learned in Connected Care, Behavioral Health Home Plus Program implemented in several counties in central PA
• Goal of building virtual teams for adults with SMI and other chronic physical conditions
• Training of care managers and peer specialists as health navigators
• Funding of nursing positions focused on wellness and PH in case management settings
• Involves sharing data about BH and PH activities with BH providers so that they can better coordinate care
copyright © 2012
Summary
• Multiple data sources available• Data can be used to create value, but
requires substantial prospective planning and iterative analysis (separating the “signal” from the “noise”)
• Possibilities exist to use data to enhance service efficacy and cost-effectiveness
• Many opportunities for payer provider collaborations
