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Family Resource NetworkApril 26, 2014
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Overview: Philadelphia’s Profile
Population: 1,547,607 (6th Largest City in the USA)– 42% African American– 13% Hispanic– 8% Asian or other
51% of individuals make less than $35,000 per year– 28% (3 of 10) of all Philadelphians are below the poverty line– In the first half of 2012, Medicare and Medicaid paid for 72.8% of all
city residents treated in hospitals– 15% of adults and 5% of children were uninsured
2nd highest unemployment rate in US in 2012 - Detroit has higher unemployment
Highest homicide rate among 10 largest cities High School graduation rate was 64% in 2012 , rising from 52%
in 2005
Overview of Philadelphia’s Racial & Ethnic Make up
Diversity varies widely from neighborhood to neighborhood.
In half of the city’s 46 residential zip codes, the largest group, (African Americans & Caucasians) account for more than 75% of the population.
In eight zip codes no majority group exists.
In one particular zip code, there is representation of 10% of African Americans, Caucasians, Hispanics and Asians.
SOURCE: Philadelphia 2013 The State of the City, Pew Charitable Trusts, www.pewtrusts.org/philaresearch
ACES in Philadelphia
Among those with >4 ACEs, increased number of: •multiple sexual partners• suicide attempts• substance abuse
>4 reported ACES also correlated to poor health outcomes which include higher rates of•Cancer•Diabetes•Severe Obesity•Asthma
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Department of Behavioral Health Intellectual disAbility Services
Department of Behavioral Health Intellectual disAbility Services
Office of Mental Health(OMH)
Office of Mental Health(OMH)
Office of Addiction Services
(OAS)
Office of Addiction Services
(OAS)
Office of Intellectual disAbility Services
(IdS)
Office of Intellectual disAbility Services
(IdS)
Community Behavioral Health(CBH)
Community Behavioral Health(CBH)
HealthChoices Administrative Services Organization (ASO)
Medicaid Managed Care
Community Behavioral Health Board of Directors•Arthur C. Evans, Jr., Ph.D., Commissioner/DBHIdS President•Roland C. Lamb, Director/Office of Addiction Services – Vice President•David T. Jones, Deputy Commissioner- Finance and Administration/DBHIdS Secretary/Treasurer•Anne Marie Ambrose, Commissioner/DHS Member•Sandy Vasco, Director/Office of Mental Health•Marquita Williams, Deputy Commissioner-Strategic Planning/DBHIdS - Member•Donald F. Schwarz, M.D., Deputy Mayor/Office of Health and Opportunity - Member•Karen Garrison, Consumer & Family Task Force Representative - Member
Community Behavioral Health Board of Directors•Arthur C. Evans, Jr., Ph.D., Commissioner/DBHIdS President•Roland C. Lamb, Director/Office of Addiction Services – Vice President•David T. Jones, Deputy Commissioner- Finance and Administration/DBHIdS Secretary/Treasurer•Anne Marie Ambrose, Commissioner/DHS Member•Sandy Vasco, Director/Office of Mental Health•Marquita Williams, Deputy Commissioner-Strategic Planning/DBHIdS - Member•Donald F. Schwarz, M.D., Deputy Mayor/Office of Health and Opportunity - Member•Karen Garrison, Consumer & Family Task Force Representative - Member
City of PhiladelphiaCity of Philadelphia
PhiladelphiaBehavioral Health System
PHILADELPHIABEHAVIORAL
HEALTHCHOICESPROGRAM
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CBH Introduction
Philadelphia created Community Behavioral Health (CBH) in 1997 to provide administrative services for the HealthChoices Behavioral Health Program. It is unique in the State of PA, as the only county operated BH-MCO.
CBH is a 501 C-3 Non-Profit with a majority County Board. One external advocate also sits on the Board of Directors.
CBH sits within the Department of Behavioral Health and Intellectual Services (DBHIDS) which falls under the Deputy Mayor for Health & Opportunity
The City of Philadelphia assumes full risk for the HealthChoices behavioral Health , maintaining reserves and risk protections consistent with commercial insurersAs of 2014, CBH contracts with 228 providers, and serves aproximately 100,000 members annually.
As an ASO, CBH manages the full spectrum of behavioral services with the exclusion of case management and ACT
Historically, CBH has low administrative expenses.
Overview: Administrative Expenses
Medicaid Managed Care Administrative Costs as a Percentage of Net Revenue– National - 12%– Pennsylvania - 8.7%
(estimated)– Philadelphia – 5.77%
• (included in the 2013 capitation rate)
National Pennsylvania Philadelphia0%
2%
4%
6%
8%
10%
12%
14%12.00%
8.70%
5.77%
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HealthChoices Program Goals
To improve access to health care services for Medical Assistance recipients
To improve the quality of health care available to Medical Assistance recipients
To stabilize Pennsylvania’s Medical Assistance spending
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Data & Performance Metrics
Access– Penetration rates– Engagement– Network Capacity
Quality– Complaints and Grievances– Consumer Satisfaction Team– Provider Profiles/ P4P– NIAC – Compliance
Fiscal Accountability– Utilization by LOC– Cost per User– LOS
Data and Performance Metrics help us to confirm if we are meeting the Health Choices Goals. Metrics also assist us in determining if we are making a positive
difference in the lives of our members as well as
contributing to the well being of our community
SMI & No SA 18-64
SMI & SA 18-64
Any MH Svc 18-64
African Amer w/MH
Svc 18-64
Hispanic w/ MH Svc
SA Svc 13-17
SA Svc 18-64
SA Svc African
Amer 13-17
SA Svc African
Amer 18-64
SA Hispanic 21-64
CBH 7 3 29 25 70 2 9 2 8 6
HC Av-erage
7 3 28 24 65 2 8 2 7 6
5.0
15.0
25.0
35.0
45.0
55.0
65.0
Perc
ent
*Note: Hispanic with mental health service is for Adults only. Source: Commonwealth of Pennsylvania HealthChoices Behavioral Health Performance Report CY 2010
Comparative Penetration Rates by OMHSAS Category HealthChoices Behavioral Health Performance-based Contracting Report 2011
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Number Served by Adults & Children
2011 Total: 108,001 2012 Total: 110,456 2013 Total: 107,563 -
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
31,829 32,663 32,500
77,264 78,824 76,126
ChildAdult
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Quality
Consumer Satisfaction
During 2012 – 2013, CST encountered over 10,000 individuals (adults, youth and family members) through:– Face-to-face interviews – Consumer representation on the CBH Board of Directors– Presentations, conferences, trainings and community/provider
events– Special projects with service recipients– Complaint/Problem resolution
Reports are shared with DBHIDS leadership, and incorporated in overall provider monitoring
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PCOMS Summary
Partners for Change Outcome Management System (PCOMS) is a SAMHSA-recognized evidence-based, feedback informed treatment program aimed at improving outcomes.
PCOMS enhances treatment by incorporating robust predictors of therapeutic success into an outcome management system that includes a transparent discussion of the feedback with the client.
PCOMS was initiated in December 2013 for use in the CIRC agencies.
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Provider Satisfaction Survey
Agencies 2012 n= 29
Agencies 2013 n=75
3.4%
48.3%48.3%
2012
Never RarelySometimesUsuallyAlways
2.7% 2.7%
5.3%
42.7%
46.7%
2013
Never RarelySometimesUsuallyAlways
Question: Overall, we are satisfied with our agency being a provider for CBH
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Provider Assessments
NIAC: Network Improvement and Accountability Collaborative– NIAC Highlights between January – July 2013
Total # of site visits conducted (Pre-Network Inclusion Criteria- NIC)31
Total # of programs that received a 3 year status15
Total # of programs that received a 2 year status44
Total # of programs that received a 1 year status9
Total # of programs that received initial credentialing status24
NIAC has expanded scope of credentialing to follow the Practice Guidelines, to include interviews with members receiving services, and to differentiate staff file reviews from clinical/policy reviews
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Provider Assessments NIAC has incorporated a variety of measures to assess family involvement; Appendix B of the NIC contains a glossary of terms, which defines family-to-family peer
support and FRN Best Practice Guidelines; Appendix J of the NIC tool is the Family Resource Network Best Practice Standards
Involving Participant-Identified “Significant People” In Mental Health Treatment and Recovery Programs;
The NIC specifically scores how staff and peers partner with individuals to assist them in connecting and engaging with resources;
The NIC also scores how the program demonstrates the development of family-to-family peer support through planned activities (open houses, meetings with families of choice, behavioral health education, support groups, use of the Family Resource Network, etc)
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Provider Profiles/Pay-For-Performance
Contracted with 228 Providers in 2013
$12.9M $13.4M $16.2M $9.5M
1st Provider Profile Released for Inpatient
Psychiatry
2007 Rehab and Children’s RTF
Profiled
2009P4P for Inpatient
Psychiatry, Rehab, and RTF
2010
2011
P4P for CIRCs, RTFA, BHRS, and
TCM2012
P4P for Outpatient for Mental Health
and Drug & Alcohol 2013
P4P for Drug & Alcohol Intensive
Outpatient
Provider Profiles and Pay-for-Performance•Provider profiling is required by the HealthChoices contract•Results are used to determine Pay-for-Performance awards•Every eligible provider receives a report of their performance, regardless of whether they receive an award•Awards are based on a percentage of provider dollars determined by CBH and DBH based on budgetary considerations, multiplied by the provider’s weighted score
30 Day Post Hospitalization Follow-Up
2006 2007 2008 2009 2010 2011 20120.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
30 Day HEDISLinear (30 Day HEDIS)30 Day + PA
National Gold Standard
National Medicaid Average, HEDIS
This graph shows CBH’s performance on the HEDIS and State (HEDIS + PA) measures of 30-day follow-up after Inpatient. We can see steady improvement on this measure, particularly after 2007, when provider profiling began for this level of care. 7 Day Follow-Up also showing positive trending
FY 2010 FY 2011 FY 20120.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00% Assessment and Service Planning & Delivery: Percent Having 1st LC
Claim Within 5 Days of Auth Open Date
REPORTING YEAR PERCENTAGE2010-2011 65.15%2011-2012 78.60%2012-2013 88.33%
BHRS: Assessment and Service Planning/DeliveryPercent Having 1st LC Claim Within 5 Days of Auth Open Date
Fiscal Years 2010-2012
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Pay-for-Performance ImpactMeasure Performance Time Frame
Readmission rates to Children’s RTF Below 4% - Gold Standard Performance! Consistently since 2009
30-day readmission outcomes for Inpatient for children under 18
Less than one point away from the national gold standard of 10% 2012
Percent of children’s Outpatient appointments available within 7 days of referral
12-point increase Between 2011 and 2012
Percent of cases staffed within five days of authorization for children’s school-based BHRS
23-point increase Between 2010 and 2012
Dropout from D&A Outpatient services after only 1 or 2 appointments
21-point decrease Between 2011 and 2012
Case management contacts within 48 hours for case-managed individuals admitted to Inpatient Psychiatric
20-point increase Between 2010 and 2012
Service gaps for children with Autism who receive BHRS Wraparound 17-point reduction Between 2010 and 2012
Follow-up rates for adults discharged from long-term D&A Rehab 17-point increase Between 2010 and 2012
Public Health Initiatives
Mental Health First Aid Behavioral Health Screenings Beating the Blues
Mental Health First Aid Mental Health First Aid teaches community members
and city partners, including public safety, the skills needed to identify, understand, and respond to signs of behavioral health challenges or crises.
Early intervention and public education program that teaches community members how to assist a person experiencing a behavioral health problem.
Teaches the basic skills needed to identify, understand, and respond to signs and symptoms of behavioral health challenges or crises.
As of March 31, 2014, 3,228 local individuals have received MHFA training, and 126 individuals have achieved instructor status.
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Behavioral Health Screening The Behavioral Health Screening is a public health priority initiative
supported by the Department of Behavioral Health and Intellectual disAbility Services (DBHIDS).
It was developed to be quick, free and anonymous to help assess for symptoms of Depression, Post-traumatic Stress Disorder, Bipolar Disorder, Generalized Anxiety Disorder, Alcohol and Eating Disorders.
Additionally, two large-scale in-person screening events are held each year. It is available in English and Spanish. To date, over 1,500 screenings have been administered, resulting in earlier detection of behavioral health challenges and quicker access to available services.
National Depression Screening Day was operationalized in 2012 in partnership with Screening for Mental Health, the Screening is available online (www.healthymindsphilly.org).
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Beating the Blues In May 2013, BtB developer, U Squared Interactive and
Mental Health America (MHA) partnered with CBH to implement Beating the Blues across Philadelphia.
Beating the Blues is a computerized Cognitive Behavioral Therapy (CBT) treatment program lasting eight sessions to help people suffering from mild to moderate depression and anxiety.
It is an evidence-based self-care technology that makes treatment accessible, and low-cost. If weekly sessions are attended, it can be completed in two months.
Currently in pilot phase.
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Physical Health/Behavioral HealthIntegrationHigh Access of Physical HealthExpansion in FQHCSpecial Needs Team
Do Behavioral Health Clients Access Physical Health? YES!
Types of Visits and Number of Visits A review of integrated PH/BH Claims for 2009 and 2010 show high levels of
CBH/BH members accessing Physical Health. Out of 35, 189 children aged 0-17, 95% had a PH Health Claim Out of 76, 187 adults aged 18-65, 93% had a PH Health Claim. Next Steps: Correlate PH Engagement with case management.
Specialty
Children (age 0-17) N = 19,943
Claims Per
Person
Adults (ages 18-65) N=43,536
Claims per
Person
Pediatrics 76.7% 7.1 7.6% 6.2
Family Practice 22.3% 4.4 48.5% 5.2
Internal Medicine 10.8% 3.5 53.6% 6.7
General Practioner 4.6% 3.7 12.0% 4.2
Specialty
Children (age 0-17) N = 19,943
Claims Per
Person
Adults (ages 18-65) N=43,536
Claims per
Person
Other Specialty 79.2% 7.2 39.1% 5.6
Obstetrics 6.4% 6.9 31.0% 5.5
Primary Care Specialty Care
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Comparison of Prevalence Rates Treated Prevalence of Three Chronic Co-morbid Conditions
By Behavioral Health ClassificationPhiladelphia MA Adult Enrollees 18-75 (N=355,856)
FY 2010
BHN=72,857
Non-BHN=282,999
SMI*N=31,040
Any Physical Health Claim
92.5% 59.7% 92.7%
Diabetes (n=21,015) 9.7% 4.9% 13.2% Inpatient 19.8% 23.9% 18.2% Outpatient 41.6% 30.3% 38.0% EDHepatitis C (n= 4,496) 3.7% 0.7% 2.9% Inpatient 25.6% 25.0% 22.2% Outpatient 85.1% 78.2% 86.6% ED 9.65% 5.6% 9.0%COPD (n=5,619) 3.0% 1.2% 3.6% Inpatient 40.8% 42.1% 38.6% Outpatient 58.9% 56.9% 62.2% ED 25.3% 21.4% 22.7%
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Quality of Care for Adult Patients with Diabetes
Note: The 310 clients missing from this sample were involved with an unaccounted health facility.
Quality of Care for Adult Patients with DiabetesBy Behavioral Health Classification
(N=21,015) FY 2010
BHN=7,061
Non-BHN=13,954
SMI*N=4,097
Received Recommended Test
HbA1c 82.5% 67.2% 83.7%
LDL-C Screening 80.3% 63.6% 81.7%
Nephropathy Screening 56.1% 45.2% 57.6%
Retinal Eye Exam 96.3% 89.3% 96.2%
Any Test 97.3% 90.5% 97.3%
All Tests 53.3% 41.7% 55.1%
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Expansion of Integrated Care via FQHC
Consultation model and co-location with FQHCs.– 21 FCQH’s in total:
• In 2013, four FQHCs were added to the Network.
• A fifth FQHC targeted towards the Latino population will be added in 2014.
CY-2008 CY-2009 CY-2010 CY-2011 CY-2012
Unique Clients Served
1970 4497 5565 6007 7453
5001500250035004500550065007500
FQHC Unique Clients ServedFrom Calendar Years 2008 to 2012
Uniq
ue C
lient
s Ser
ved
Overview of Special Needs Team The Special Needs Team has been operating since CBH’s inception in 1997 The Team aims to meet monthly with representatives from the following
HealthChoices physical health MCO’s in Philadelphia County. – Aetna Better Health– Coventry Cares– Health Partners– Keystone First– United Healthcare
The goal is to coordinate care for members with co-occurring physical and behavioral health care needs that may complicate their ability to successfully access and utilize treatment services.
This initiative is set to continue throughout 2014. Most recently its focus has expanded to include high utilizers (anyone
requiring 3 or more acute inpatient hospitalizations within a 6 month period)
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Special Needs Cross Systems Interface
Fetal Infant Mortality Review/HIV Community Health Education Advisory Committee
Meeting Southeast Regional PH/BH MCO Coordination of
Care/Steering Committee Safe Start Advisory Committee Cigna-Health Spring Pilot
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Key Initiatives
Evidenced Based Practices Children’s system transformation
EBP Support for the Network
Continued to support funding, training and implementation support to approximately 500 therapists at over 60 programs for the following evidence-supported treatments:– Cognitive Behavioral Therapy (Beck Initiative) – Prolonged Exposure– Dialectical Behavioral Therapy– Trauma-Focused Cognitive Behavior Therapy– Child and Family Traumatic Stress Intervention – Ecosystemic Structural Family Therapy (ESFT)– Partners in Change Outcomes Management System
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Promotion of Evidence Based Practices
• CBH enhancing capacity for EBPs:• Parent Child Interaction Therapy (PCIT)• Multi-Systemic Therapy (MST-PSB)• Multi-Dimensional Treatment Foster Care (MTFC)• Child Parent Psychotherapy (CPP)• PACTS grant:
– Trauma- Focused Cognitive Behavior Therapy (TF-CBT)– Child and Family Traumatic Stress Intervention (CFTSI)
• Evidence-Based Programs:– Philadelphia Intensive In-home Child and Adolescent Psychiatry
Service (PHIICAPS)
Streamlined referrals to EBPs:• Cross-system work with FFT, PCIT
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Enhancing Cross-System Efforts Between DHS and CBH
DHS Child Welfare Transformation:• Improving Outcomes for Children• Development of Community Umbrella Agencies (CUAs)
• Located in 10 Police Districts• Goal is One Family One Plan• Community Based to Strengthen Families
• Congregate Care Rightsizing• Title IV-E Waiver
• More Flexibility in Providing Services Directly to Support Families Instead of Placement• In PA, the funding is to be used for assessment, family engagement, use of evidence-
based practices rather than placement of children.
CBH cross-system efforts• Consent Procedures• Development of CBH CUA Care Management Team• Assessment of shared population
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DHS Congregate Care Rightsizing• CBH Collaboration:
– Participation in Teaming Processes for youth with consent and identified behavioral health histories
– CBH Participates in the EPM Process to ensure access to BH services
– CBH Participation in Transitional Planning Meetings
– Ongoing support of CBH CUA Team
DHS Strategies:– Expedited Permanency Planning
(EPM) Meetings• Annie E. Casey Best Practice
adopted by DHS– Transitional Planning Meetings held
at Juvenile Law Center with DHS, School District, Family, Provider, Advocates, CBH, IDS and youth for:
• Aging Out Youth with Intellectual Disabilities
• Aging Out involved in Multiple Systems of Care
• Life Share, Dom Care, Community Supports with Housing Voucher, SSI Referral through SSI Outreach, Access and Recovery Program
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New Centers of Excellence for Autism In July 2012, the COEs began accepting referrals and providing
services Based on current available data, between July 2012-December 2013,
727 children and families have received at least one type of service from an Autism Center of Excellence. – Of these, 55% are new to receiving services through CBH– Younger cohort of youth receiving early diagnosis
FY14 program development– Implementation of Afterschool Programs
COEs have developed relationships with community stakeholders including: academic centers, the School District of Philadelphia, parent and advocacy groups, and the Eastern Region Autism Services, Education, Resources and Training (ASERT) collaborative (a statewide initiative funded by the Bureau of Autism Services, PA Department of Public Welfare).
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School-based Service Collaboration Serving Children in the Community Continual Collaboration with the school district with
co-locating providers in the schools in addition to traditional wrap-around• Transition support provided for CBH members impacted
by district-wide school closures in 2013 in both traditional BHRS and STS;
• The Care Management Team worked with Agency and School Central office staff to transition care (traditional BHRS, STS or other need) to children in their receiving schools including re-location of 11 STS programs
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2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Unique Clients Served 3176 3063 3214 3381 3608 3859 4413 4763 5273 5525 5810 6084
2250
2750
3250
3750
4250
4750
5250
5750
6250
Unique Clients Served In the School SettingTraditional Wraparound & School-Based Programs (Calendar Years
2002-2013)
Uniq
ue C
lient
s Ser
ved
Enhanced Supports for Homeless and Housing Transformation Housing Stability among
Persons who were formerly Chronically Homeless
Average Cost
City Partnerships to End Homelessness
DBHIDS, CBH, Deputy Mayor’s Office of Health & Opportunity, Philadelphia Housing Authority and Office of Supportive Housing have a long history of collaborative work for those who are homeless, have housing needs, and behavioral health needs
Due to the relative success in reducing street homelessness and shelter stays in other cities, Philadelphia incorporated a Permanent Supportive Housing (PSH) model in 2008 – The hardest-to-serve homeless were matched to housing and case
management services using a scattered-site model– We will highlight the outcomes of the first three years of the Collaborative
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Housing Stability Outcomes Years July 2008 – December 2012
Philadelphia Housing Authority provided Blueprint Vouchers to enable DBHIDS to access stable housing and to allow for transformation of the DBHIDS County-Housing slots
587 Individuals receiving vouchers came from:– Transitional (OMH-County-Housing-Slots)– Safe Havens (HUD & OMH)– Treatment (i.e.: CBH/BHSI Journey of Hope)– Permanent Supportive Housing (HUD, OMH, OAS)– Emergency Housing/Shelters (OSH)– High percentage were MA recipients (67.9%)
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Housing Stability Outcome Summary
Findings reveal an overall retention rate of 84%, thus reducing the number of chronically homeless individuals in Philadelphia by assisting these individuals attain housing.
The Housing Choice Voucher program was associated with achieving long-term housing stability for this population, with an average length of stay in their housing of over 2.5 years after lease-up.
Average cost per person per day for behavioral health services one year before voucher receipt were lower than found during the time spent looking for an apartment; one year after lease-up showed the lowest average cost.
Resources
DBHIDS/CBH Member Services 24/7/365(1-888-545-2600)
Crisis Response Centers (CRC)Einstein CRC (only CRC for children) Hall Mercer CRCTemple/Episcopal CRC Mercy CRC
Friends CRC
Philadelphia Network of Care (philadelphia.pa.networkofcare.org)
Healthymindsphilly. org
