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Proprietary and Confidential
Mercy Maricopa Integrated CareProvider Leadership Meeting
February 4, 2016
Proprietary and Confidential
Eddy D. Broadway, Chief Executive Officer
Welcome
Proprietary and Confidential
Mercy Maricopa Integrated CareProprietary and Confidential
Meeting Overview
• Welcome
• CEO Update
• Topic Highlight: Neonatal Abstinence Syndrome
• Medical Management & Systems of Care Updates
• Operations Update
• Finance Update
• Q & A Session
• Adjourn
3
Mercy Maricopa Integrated Care Strictly Confidential
Populations Served
Population Program Eligible
Medicaid eligible individuals with a Serious Mental Illness
Integrated physical, behavioral health, and substance abuse services
19,926
Medicare-Medicaid eligible individuals with a Serious Mental Illness
Integrated physical, behavioral health, and substance abuse services
1,099
Medicaid eligible individuals with general mental health/substance abuse needs
Behavioral health and substance abuse services 415,168
Medicaid eligible children Behavioral health and substance abuse services, case management for high needs children
443,469
Total Medicaid Eligible Members 878,563
Non-Medicaid eligible individuals with a Serious Mental Illness
Behavioral health and substance abuse services, housing, and supported employment
5,717
Any of the 4M Maricopa County residents may access the RBHA for crisis services
Updated December 2015
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Mercy Maricopa Integrated Care Strictly Confidential
CEO Update
• DBHS transition to AHCCCS
• Services to foster children and working with foster parents (HB 2442)
• Services for justice system-involved populations
• Substance abuse services and AHCCCS-led workgroup
• RFI for in-state residential targeting complex needs youth
• Mercy Maricopa strategic plan
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Mercy Maricopa Integrated CareProprietary and Confidential
Mercy Maricopa Strategic Plan
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Mercy Maricopa Integrated CareProprietary and Confidential
Mercy Maricopa: Strategic Plan Pillars
Right Care,
Right Place,
Right Time
GOAL: To enhance the system’s ability to serve members
in community-based settings, promoting greater
independence, health, and well-being.
Culture
Transformation
GOAL: To create an internal and external culture that
creates a service delivery system that is transparent and
responsive to the physical, behavioral, and social needs of
our members, state customers, and stakeholders;
supports professional capacity-building of employees and
providers; and promotes compliance with contractual
requirements and stakeholders expectations.
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Mercy Maricopa Integrated CareProprietary and Confidential
Mercy Maricopa: Strategic Plan Pillars
Integrated Care
GOAL: To implement a fully integrated program for individuals
determined to have a serious mental illness and to expand
integrated care to children and members with general mental
health and substance abuse needs.
Value-based
Purchasing
GOAL: To align payment methodologies to system goals by
compensating providers for delivering services that meet
performance standards related to access, quality, and member
outcomes.
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Topic Highlight: Neonatal Abstinence Syndrome
Dr. Ann Negri, Adult Medical Director
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Ann Negri, MD, FAPA, DFAPA
Robin S. Richardson, RN
Carolyn C. Lengua, RN, BSN
NAS Prevention Treatment Efforts and Preliminary Outcomes Data
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Mercy Maricopa Integrated CareProprietary and Confidential
Neonatal Abstinence Syndrome (NAS)NAS is when a newborn baby has withdrawal signs from certain prescription medications or street drugs used by the mother during pregnancy.
The baby may have withdrawal symptoms because he or she is no longer getting the drugs or medications from their mother’s womb. NAS symptoms can start within hours to a few days to a few weeks following birth.
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Common drugs or medications that can cause NAS include:Prescription Medication:• Methadone
• Oxycodone (Percocet)
• Hydrocodone (Vicodin)
• Suboxone
• Fentanyl
• Ativan (lorazepam)
• Xanax (alprazolam)
• and Alcohol
Illicit Drugs Such As:• Heroin• Methamphetamine• Amphetamine• Cocaine • Cannabis/marijuana• Crack• Bath salt
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Mercy Maricopa Integrated CareProprietary and Confidential
Use of opioids during pregnancy
In 2013, 645 newborns were positive for the presence of narcotics.
This same analysis found that newborns in AZ with NAS were:
• 3 times more likely to be low birth weight
• 3 times more likely to have respiratory symptoms
• 17 more likely to have seizures
• 5 times more likely to have feeding difficulties compared to those with out NAS
An Arizona newborn with NAS has a median length of stay of 13 days in the hospital compared to non-NAS with a median length of stay of 2 days
Source: Arizona Statewide Task Force on Preventing Prenatal Exposure to Alcohol and
Other Drugs Strategic Plan 2015-2010
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NAS-Neonatal Abstinence Syndrome Program Objectives
• Identify pregnant women with substance
use and abuse issues risks and effects of
prenatal exposure to alcohol and others.
• Provide NAS education and discuss treatment options. For opiate use, replacement therapy is recommended and has been shown to reduce NAS symptoms.
• Talk with members addicted to opioids about a management plan and how prescribing of opioids will be handled during the pregnancy.
• Emphasize the continued need for regular visits to the obstetrician.
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NAS-Neonatal Abstinence Syndrome Program Objectives • Support the mother's adherence to treatment
prenatally and after delivery.
• Reduce neonatal intensive care unit (NICU) admissions and hospital stays from NAS complications.
• Initiate care management for the hospitalized infants to improve discharge planning and parent/guardian training during the infant's hospital stay.
• Screen for depression during pregnancy and post-partum
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Mercy Maricopa NAS ProjectIntegrated Care Management Schematic
Member
Identification
Ongoing Assessment
and Evaluation
Monitoring and
Intervention
Coordination
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Providers Collaboration Treating Pregnant Women Using Substances/Opioids
Behavioral Health and Addiction
Services
Medical specialists, endocrinologists, Pulmonologist
Pain managements specialists
OB/ neonatologists Pediatricians
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Provider Fact Sheet
CONSIDER substance issues with all pregnant
women
DISCUSSsubstance issues with all pregnant
women
COORDINATE substance issues with all providers
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Mercy Maricopa Integrated CareProprietary and Confidential 19
Mercy Maricopa Integrated CareProprietary and Confidential
Number of Births by Month (353 total) April 2015 to October 2015
2123
19
26
22
12
25
12
21
0 0 0
1719
2022
13
20
4
0 0
1917
21
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2014 2015
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Mercy Maricopa Integrated CareProprietary and Confidential
Mercy Maricopa preliminary NAS data Total Births
353
229
124
Total Births Non-Substance Use Any Substance Use
65%
35%
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Mercy Maricopa Integrated CareProprietary and Confidential
Mercy Maricopa preliminary NAS data Type of Substance Use (124 of 353 births)
35% or 124
14% or 49
10% or 38
1% or 5
17% or 59
*IdentifiedSubstance Use
*Other SubstanceUse
*Opiate Use *Alcohol Use Tobacco withOther Use
124 Births
*124 identified prenatal substance use*Other Substance use –meth/amphetamine,
benzos, Adderall, cocaine, cannabinoid
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Mercy Maricopa Integrated CareProprietary and Confidential
Mercy Maricopa preliminary NAS data Type of Delivery
Vaginal Delivery47% or 166
C-Section29% or 102
Unknown 4% or 14
*Other20% or 71
Total = 353
*miscarriage, ectopic pregnancy, abortion, fetal demise
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Mercy Maricopa Integrated CareProprietary and Confidential
MMIC preliminary NAS data Type of Delivery - Any Substance Use
Vaginal Delivery49% or 60
C-Section28% or 35
Unknown 3% or 4
*Other20% or 25
Total = 124
*miscarriage, ectopic pregnancy, abortion, fetal demise
• CDC statistics average C Section rate is 32.7% as of 2013• CDC miscarriage rate loss of fetus before 20th week of gestation is 15-20% in the US
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Mercy Maricopa Integrated CareProprietary and Confidential
Mercy Maricopa preliminary NAS data Average prenatal visits for all births based on substance use
12
109
10 10
Non-SubstanceUse
Opiate Use *Other SubstanceUse
Alcohol Use Tobacco withOther Use
*Other Substance use –meth/amphetamine, benzos, Adderall, cocaine, cannabinoid
Average prenatal visits for a normal pregnancy is 10-15
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Mercy Maricopa Integrated CareProprietary and Confidential
Mercy Maricopa preliminary NAS data Average Birth Weight
31573182
3011
2831
2996
Non-SubstanceUse
Opiate Use Other SubstanceUse
Alcohol Use Tobacco withOther Use
OB statistics from American Journal of Obstetrics ad Gynecology
Average birth weight for a normal pregnancy is 5.5 lbs or 2.5 to 4.5 KG
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Mercy Maricopa Integrated CareProprietary and Confidential
Mercy Maricopa preliminary NAS data Newborn disposition as mothers used multiple substances
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Mercy Maricopa Integrated CareProprietary and Confidential
Mercy Maricopa preliminary data of the 353 births Baby disposition related to NICU admission for any cause and for NAS
Reference : The New England Journal of Medicine May 28, 2015 - ..
From 2004 through 2013, the rate of NICU admissions for the NAS
nationwide that were attributed to the more than 20% of all NICU days 2013.28
Mercy Maricopa Integrated CareProprietary and Confidential
Mercy Maricopa preliminary NAS data Post-Partum Depression Screening
Total Screened186 of the 353
Referred157%
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Program Evaluation: Key Points and Next Steps • Evaluate if the program improved identification of pregnant women using
substances
• Ongoing monitoring
• Evaluate if the program improved identification of infants with NAS and trend data
• Development and implementation of a new pilot program with SW human development for referral of Infants to 0-5 program
• Evaluate effectiveness of interventions and referrals of members to chemical dependency programs through the integrated intensive care management
• Screening for postpartum depression
• Track and document identified barriers to care
• Highlight “what works” along the way and success stories
• Identify areas for provider education and program change
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Questions?
Thank you
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Dr. Sandra Zebrowski, Chief Medical Officer
Tad Gary, Chief Clinical Officer
Medical Management and Systems of Care Updates: Inpatient and Residential Utilization
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Crisis System
Crisis System
Warm Line
Crisis Line
Transition Points
Access Points
Inpatient Hospitalizations
Mobile Team
Psychiatric Urgent Care
Emergency Department
Potential Services Post Crisis
ResidentialTransitional
Living
Permanent Supportive
Housing Services
Assertive Community Treatment
Home Environment with Outpatient
Supports and Services
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Mercy Maricopa Integrated CareProprietary and Confidential
Inpatient and Residential Utilization Rates
0
20000
40000
60000
80000
100000
120000
Per 1 Per 2 Per 3 Per 4
Inpatient Utilization Residential Utilization
*Measurements reported in Units/Bed Days
12 month period – 9/14-8/15
130000
135000
140000
145000
150000
155000
160000
165000
170000
175000
180000
Per 1 Per 2 Per 3 Per 4
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Mercy Maricopa Integrated CareProprietary and Confidential
Inpatient Activities
AdultCurrent Activities
• Alerting SMI clinics of member admission to inpatient care
• Have hired discharge coordinators to assist inpatient facilities and outpatient teams with discharge planning
• Intensive care management for members with complex medical conditions
• Developed provider education regarding available housing services and supports
• Increased availability of comprehensive community based services
Upcoming Activities
• Process to enhance SMI clinic involvement in member transition planning (reduce barriers to discharge and increase accountability with new workflows)
• Expansion of comprehensive community based services
• Assertive Community Treatment
• Permanent Supportive Housing Services
• Continued expansion of housing supports and services for adults within the GMH/SA and SMI system
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Mercy Maricopa Integrated CareProprietary and Confidential
Residential ActivitiesAdultCurrent Activities
• Updating the scopes of work for basic residential, co-occurring and personal care residential treatment settings
• Creating criteria sets for prior authorization, continued stay and discharge for basic residential, co-occurring and personal care residential treatment settings
• AHCCCS criteria review in process
Upcoming Activities
• Plan to Implement a prior authorization process for new admits to residential treatment
• Monitoring member progress in residential treatment through concurrent review and transition of care planning
• Reviewing current residential providers to ensure service alignment with updated scopes of work
• Engagement of SMI clinics to decrease residential utilization and increase community based supportive housing
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Mercy Maricopa Integrated CareProprietary and Confidential
Inpatient Activities
ChildrenCurrent Activities
• Notification process to alert providers of inpatient admissions
• Requirement for outpatient child providers to complete the level 1 discharge form within 24 hours of discharge
• Have hired discharge coordinators to assist inpatient facilities and outpatient teams with discharge planning
• Infused system with funding to support additional community based stabilization services to decrease length of stay and utilization of out of home treatment services
Upcoming Activities
• Process to enhance Children’s outpatient provider involvement in member transition planning (reduce barriers to discharge and increase accountability with new workflows)
• Continue to expand community based services
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Residential Activities
ChildrenCurrent Activities
• Conducting prior authorization and concurrent reviews for Behavioral Health Inpatient Facility (BHIF), Behavioral Health Residential Facility(BHRF) and Home Care Training to the Home Care Client (HCTC)
• Training High Needs Case Managers (HNCMs) in levels of care utilization and medical necessity criteria
• Providing “train the trainer” opportunities for supervisors of HNCM’s
• Monitoring member progress in residential treatment through concurrent review and transition of care planning
Upcoming Activities
• Creating more training opportunities to include increased use of community supports, developing targeted treatment goals and discharge planning
• Expansion of community based services to decrease out of home placement, utilization, readmission rates and improve outcomes.
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Mercy Maricopa Integrated CareProprietary and Confidential
Operations Updates
Angelo Edge, Chief Operating Officer
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Administrative Efficiency Initiative
Goal: Evaluate options to align select requirements in the RBHA contracts with those of acute plans to reduce the administrative burden on contracted BH providers.
Steering Committee formed by AHCCCS in December 2015
• Chaired by Tom Betlach at AHCCCS
• Mercy Maricopa is collaborating with AHCCCS, Arizona Council, Greater AZ RBHAs and select providers as committee members
• Committee considering policy changes that would reduce the administrative burden and associated cost related to the following areas:
‒ BH Provider Training Requirements and Workforce Development
‒ Demographics and Episode of Care data submission
‒ RBHA Reporting Requirements and Provider Deliverables
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BH Provider Training Requirements
Workgroup formed to modify Policy 403 governing Arizona’s fundamental approach to mandating, planning, evaluating the proficiency of the contracted BH workforce.
• Workgroup participants include AHCCCS/DBHS, RBHAs, TRBHAs and BH Providers
• Move from a mandatory one size fits all approach to individualized competency assurance approach based on the employee’s skills and experience (BHTs & BHPPs)
• Shift from training completion report requirements to provider record retention onsite reviews
• Workgroup is working on a Job Competency Development Matrix
• Workgroup has recommended the use of Relias Learning Management System to share training records between the RBHAs
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Episode of Care (EOC) and Demographics
Workgroup formed to improve the efficiency by examining the administrative demands of the demographic submission process and pursuing opportunity for improvement.
• Workgroup participants include AHCCCS/DBHS, RBHAs, TRBHAs, AZ Council
• Workgroup has recommended the elimination of the EOC construct:
‒ Relax the edits related to the EOC by 2/15/2016 (target)
‒ Remove unnecessary data fields during the next software update by focusing on fields in which the data can be pulled form other sources such as enrollment and claims.
‒ Mercy Maricopa is evaluating the IT system impact and will develop a schedule for implementing the required changes.
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Reporting Requirements and Provider DeliverablesWorkgroup formed to review and assess the value and benefit of all provider report deliverables to eliminate outdated , duplicative or non beneficial reports from the RBHA contracts.
• Workgroup participants include AHCCCS/DBHS, RBHAs, AZ Council
• Current review of report inventory is underway
• Targeting 7/1/16 timeframe for first round of changes
• Provider Notice will be posted to announce the official change and, the provider manual will be updated with the revised requirements.
• Design of a Provider “Deliverables Manager” application is underway that will improve the submission, collection, tracking and utilization of provider submitted deliverables.
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Landing Page
44
Mercy Maricopa Integrated CareProprietary and Confidential 45
Document LibrarySelecting a Deliverable
Mercy Maricopa Integrated CareProprietary and Confidential 46
Document LibraryDeliverable Details
Mercy Maricopa Integrated CareProprietary and Confidential 47
Document LibraryDeliverable Details
Mercy Maricopa Integrated CareProprietary and Confidential 48
Enter/Upload DeliverableSelecting a Deliverable, Submission Type & Date/Period
Mercy Maricopa Integrated CareProprietary and Confidential 49
Enter/Upload DeliverableDirect Entry Option
Mercy Maricopa Integrated CareProprietary and Confidential 50
Enter/Upload DeliverableDirect Entry Option - Attestation
Mercy Maricopa Integrated CareProprietary and Confidential 51
Enter/Upload DeliverableDirect Entry Option - Validation
Mercy Maricopa Integrated CareProprietary and Confidential 52
Enter/Upload DeliverableDirect Entry Option - Results
Mercy Maricopa Integrated CareProprietary and Confidential 53
Enter/Upload DeliverableSelecting a Deliverable, Submission Type & Date/Period
Mercy Maricopa Integrated CareProprietary and Confidential
System Updates Improve Claims Submission and Processing• Enrollment Update Nov. 2015 – Updates to Enrollment Application were
deployed to improve the loading of both enrollment and demographic data provided in the states 834 transactions.
‒ Enables members to have immediate access to their prescriptions, medical and behavioral services
‒ Improves the providers ability to receive reimbursement on claims more timely while reducing the rework required with encounter submissions due to faulty enrollment data.
• New Benefit Plan – NTXIX Crisis – aligns benefits more closely to those for that segment of the population.
• Realigned ICD10 mapping to alleviate incorrect claims denials for NTXIX and GMHSA.
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Psychiatric Rate Increase
• Rate increase implemented on 10/1/15 but some providers reports lower than expected encounter value.
• Mercy Maricopa IT identified the issue related to system scoring for the 20% encounter value.
• A solution has been developed and is in the final stages of testing.
• Providers notice will be issued when testing has completed and update is ready for deployment
• Adjustment will be automatically applied by Mercy Maricopa to historical claims.
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Finance Updates
Ramon Dominguez, Chief Financial Officer
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Finance Update
• Value-based purchasing
• Behavioral health fee schedule
• Encountering
• NTXIX – adjustments
• Submission timing
• Contract year ending 09/30/2015
• Provider financial reporting guide updates
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Q & A Session
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Thank You!