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Health Plan of Nevada
Behavioral Healthcare Options, Inc. (BHO)
Medicaid Programs – May 2017
Michelle Guerra, CPC, LCADC
Health Plan of Nevada
Behavioral Healthcare Options
Behavioral Healthcare Options (BHO) is the department
within Health Plan of Nevada (HPN) that supports all
of the responsibilities of mental health and substance
abuse benefits for assigned HPN Medicaid recipients.
BHO employs a full intake behavioral health call center,
and a complete clinical behavioral health team
including complex case management.
Within the responsibilities of the department, BHO
maintains URAC Accreditation and is subject to all
health plan requirements for State, CMS and NCQA.
Health Plan of Nevada
Behavioral Healthcare Options
----We are Advocates---
We speak up for people struggling with mental illness and substance use disorders. We understand the fear, stigma
and impact the illness has on the individual, family and friends. Our solution-focused approach promotes
evidence-based best practices, improves coordination of care and results in development of specialized programs to
remove barriers.
Our staff of clinicians and nurses have extensive experience in all levels of care. Our rigorous credentialing process, ensure that services are provided by a qualified
network of providers. Our experienced and qualified clinical staff and providers assure those we advocate for are
getting the best care possible at the right time.
Utilization Management
Licensed Clinical Staff
MD
LMSW
LMFT
CPC
RN
Care Coordination
Clinical Review
Peer Review
Authorization, Billing, Claims
Provider Relations
Credentialing
Education
Contracting
Care Management
ACCESSING PROVIDERS (Staff Training & Experience)
Crisis Immediate (Same Day)
Member Request:
Near bus route
Near work or relative
Near home
All members are given appointments with a provider based on need or request
Monthly oversight review of capitated provider access and availability
Member has medications for next 60 days
Member special time or day request
Needs Considered
6
Service Standard
Routine Behavioral Health Care "Routine" Within 10 business days
Urgent Care "At Risk" Within 48 hours
Crisis-Non-Life Threatening Emergency
Services “Expedited”Within 6 hours
Life Threatening Emergency Services
"STAT"Immediately
Access & Availability Standards
Health Plan of Nevada Contracted Behavioral Health Providers
2013 - Total Providers 2014 - Total Providers YTD TOTAL PROVIDERS (04/27/2017)
SpecialtyNorthern
NV
Southern
NV
Northern
NV
Southern
NV
Northern
NV
Southern
NV
Total
Medicaid
All
Networks
Psychiatry MD/DO/PAC/APRN
11 21 11 13 68 135 203 228
Psychology PSYD/PHD
6 22 3 2 20 48 68 86
Marriage &
Family LMFT/MFT-I
7 25 9 15 64 167 231 297
Social Work LCSW, CSW-I
5 29 1 16 62 178 240 289
Counselor LCPC, CPC-I
0 2 2 2 4 48 52 59
SUD
Counselor LADC/CADC/LADC-I
5 14 9 8 27 78 105 144
34 113 35 56 245 654 899 1103
GEO ACCESS – .05% of members do not meet 25 mile rule for psychiatry
COMMUNITY ESSENTIAL PROVIDERSSAPTA PROVIDERS
ADELSON CLINIC LAS VEGAS, NVBRIDGE COUNSELING ASSOCIATES LAS VEGAS, NVBRISTLECONE FAMILY RESOURCES LAS VEGAS, NVCOMMUNITY COUNSELING LAS VEGAS, NVFAMILY COUNSELING NORTHERN NEVADA
RENO, NV
HELP OF SOUTHERN NEVADA LAS VEGAS, NVQUESTS COUNSELING & CONSULTING RENO, NVRIDGE HOUSE, INC. RENO, NVSTEP 2 RENO, NVWESTCARE NEVADA, INC. LAS VEGAS, NV/RENO, NV
FQHC PROVIDERS
CAMBRIDGE FAMILY HEALTH CENTER NEVADA HEALTH CENTERS INC
LAS VEGAS, NV
COMMUNITY HEALTH ALLIANCE RENO, NV
MARTIN LUTHER KING HEALTH CENTER NEVADA HEALTH CENTERS INC
LAS VEGAS, NV
NEVADA HEALTH CENTERS INC CARSON CITY, NV
NORTHERN NEVADA HOPES NORTHERN NEVADA HIV OUTPATIENT PROGRAM EDUCATION AND SERVICES RENO, NV
8
Essential Community ProvidersContracted Specifically for Behavioral Health
Attributes
Attributes of Medicaid Capitated Provider
Aggressive & Creative
Go the Extra Mile
Understands Managed Care
Quality Management
Perform home assessment (established pts)
Large central location or multiple smaller
locations in key geographic areas and on
bus route
Similar Clinical Model & Treatment Philosophies
URAC & NCQA Accredited
Knowledge of History of Area
Capacity to Handle Population
Community Partnerships
Ability to Create a Provider Network
Relationship with the State (a plus)
Willing to have a close collaborative
relationship with health plan
Respected in community
Ability to Develop (in partnership)
ER Assessment Team
Crisis Management
Centralized Intake & Triage
Utilization Management
Case Management
Authorization Process
Peer Review Protocols
Participates in Meetings
Joint Operations Meetings (JOC)
Large Case Management
Claim Reconciliation
Participates in Quality Initiatives
NCQA
HEDIS Measures
CMS Star Ratings
11
Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Collaborative Partnerships
Collaborate and educate network
providers
Attributes
Attributes of Medicaid Capitated Provider
Type 14 (not type 82)
Health Plan Oversight Program
Outpatient Based Services
Wrap Services (understands the value)
Collaboration
Flexibility to create based on demand
Home visits
Experience & Understanding of Medicaid Population
12
Cap Provider provides intensive case
management from the first contact until
discharge; clinicians work with the medical
physicians, psychiatric facilities & community
resources in order to service the member.
Case managers identify high-risk members
with severe mental health conditions with co-
morbid medical problems & coordinate care
with other providers & social services.
Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Innovative approach to care delivery
Focus on prevention
Focus on utilization review
Development of wrap services
Eliminate unnecessary services
Develop Collaborative Relationship with Cap Provider Meeting structure
Capitated Provider Oversight Program
Structure (who talks to whom)
Schedule frequent meetings
How do you handle urgent communication;
escalation process
15
Type and frequency
Policies & Procedures
All internal responsibilities will be
done differently
Staff understanding new role
Method to Identify Issues & Concerns
Keep open Issues Log (close when resolved)
Develop Corrective Action Plan process
Identify Staff Responsibilities with statistics & trends
What is required & who reviews
Complaints
Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Goal: Ensure capitated provider is providing appropriate care and appropriate quality care
Increase investigation of complaints
Track and trend all complaints
12
Southern NevadaROUTINE Access & Availability “Snap Shot” 4/27/17
SAME DAY Appointments AVAILABLE for CRISIS
Currently 88%
of Network
Providers are
ACCEPTING
NEW
PATIENTS
First Available Routine
Appointment
New
Patient
Existing
Patient
Medication
Management
Same day 2 2 2
1 -2 Days 1 1 none
1 week out 2 4 0
1-2 Weeks Out 1 2 1
2 Weeks Out 2 4 1
2-3 Weeks Out 3 3 none
3 Weeks Out 2 3 1
3-4 Weeks Out none none 1
1 Month out 1 2
4-6 Weeks Out none
Weekly appts. pre set 1
Not taking new pt 1
Service Not Offered 11
Pro
vid
er
Resp
on
ses
(HPN/BHO contacted 21 contracted providers at random)
"Snap Shot" 4/27/17
Southern Nevada Routine Access & Availability
*15 Random Providers
13
Northern NevadaROUTINE Access & Availability “Snap Shot” 4/27/17
SAME DAY Appointments AVAILABLE for CRISIS
Northern Nevada Routine Access & Availability
"Snap Shot" 4/27/17
(HPN/BHO contacted 15 contracted providers at random)
First Available Routine AppointmentNew
Patient
Existing
Patient
Medication
Management
Pro
vid
er
Re
sp
on
se
s
Same day 1 1 1
1 week out 2 2 0
1-2 Weeks Out 1 2 0
2 Weeks Out 2 5 2
2-3 Weeks Out 3 4 none
3 Weeks out 2 none none
1 Month out 1 none 2
4-6 Weeks Out none none 2
Not taking new pt 1
Service Not Offered2 2 9
Currently 88%
of Network
Providers are
ACCEPTING
NEW
PATIENTS
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ER ASSESSMENT – MOBILE RESPONSE TEAM
CRISIS MANAGEMENT
After Care Stabilization
Outpatient services
Home Assessment Team
Respond within 24 hours
IF POSSIBLE, DIVERT FROM INPATIENT
Crisis Stabilization Unit
Crisis Triage Center
Intensive Outpatient
Complex Case Management
Wrap Around Services
Temporary Housing
Sober Living
Transitional Care Program
Medical Necessity
Medication Management
Crisis Intervention/Management
Initiatives to Reduce Admission and
Readmission
Coordination of Care
Determines Safety
Develops Individualized Treatment Plans
Service Continuum
Intensity of Services Supporting Incentives and Initiatives Member Populations
Lowest Intensity • Open access to outpatient clinics
• 24-hour support through warm lines, health
plan crisis triage and 24 hours a day, seven
days a week availability of outpatient
behavioral health provider
Member who:
• Is not experiencing acute symptoms, and
understands and is adherent with the
treatment plan and/or medications.
• May have previously attended more acute
services
• Stepped down to these lower intensity
services
Moderate Intensity
Services will vary in
intensity & duration to
support the member’s
ability to use behavioral
health services, manage
functional difficulties and
otherwise realize recovery
goals
• Community-based case management
• Peers
• Temporary Placement
• Sober Living
• Aftercare for crisis stabilization
Member who:
• Continues to require support for some acute
symptomology, but can be safely returned to
the community.
• May have previously attended more acute
services,
• Stepped down to these lower intensity
services.
High Intensity
Services are designed to
reduce symptoms and
stabilize the individual so
that less intensive
supports can be used.
• Mobile assessment in ER
• Crisis Triage Center
• Crisis Stabilization Program
• Intensive case management
Members who:
• Are at immediate risk of harming themselves
or others or experiencing acute symptoms
• Requires intensive support before being
returned to the community or stepped down to
lower levels of care.
16
Crisis Intervention Services
Telephone Crisis Services
Outpatient Triage
Mobile Response Team
o Medication Consultation
Crisis Stabilization Unit
o 5 Day Outpatient Crisis
Complex Case Management
Collaborative Medication
Case Management
Family Support Resource
Program
Provider Community & Network
ER Diversion
Crisis Intervention
Wet Shelter (Sobering Unit)
Sub Acute Detox
Mobile Outreach Safety Team
Crisis Services
17
Inpatient Alcohol/Substance Abuse Services
Residential Treatment Center (RTC)
Outpatient Services
Rehabilitative Service
Evaluation or Assessment
Medication Management
Medication Assisted Therapy (MAT for SUD)
Individual/Family/Group Therapy
Neurotherapy
Behavioral Health Services
Intensive Outpatient Program
Partial hospitalization program
Psychological Evaluations & Testing
Neuro Coginitve/Neuropsychological/Neurobehavioral Testing
Psychiatric Acute Detox Rehabilitative
Under age 21
Basic skills training with limitations
Program for Assertive Community Training (PACT)
Day Treatment (provider approved by DHCFP)
Peer to Peer Support
Psychosocial Rehabilitation (PSR)
Crisis intervention
Community or In Home
Evaluation
EXAMPLES OF ADULT WRAP-AROUND SERVICES
18
General Group
Therapy
Inpatient Initial
Contact
Living in Balance with Co-
Occurring Disorders Workshop
SUD Programs
Intimate Partner Violence
Support Group
Care Coordination
Getting Around
(Learning to be
Independent)
Women’s Recovery Program
Aftercare Programs
Patient/Family/
Support System
SUD Groups
Walk-in Center
19
Outpatient therapy
Coordinated school based therapy
Home based case management
Telephonic case management
In home crisis stabilization training
Day treatment
Wrap around services
Maintains stability on an outpatient basis
Supports care plan initiated during inpatient care
Engages the family in ongoing treatment
Supports family with access to resources
Identifies and addresses environmental needs
Youth Services
Discipline through
Martial Arts
(Confidence Building)
EXAMPLES OF YOUTH WRAP-AROUND SERVICES
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General Group
Therapy for Children
& Adolescents
Parenting Classes
Anti-Bullying
Group (How to Handle
Bullies)
Addiction Programs
Confident Young Women Classes
Children of Divorced
Parents Group
Getting Around
(Learning to be
Independent)
Left Behind
(For Children-Parents Deported)
Children with Asperger’s
Group
Patient/FamilyAdolescent CD
Group
Healthy Bodies
Healthy Minds
Group
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Behavioral Health Home
Specialty Court Coordination
BHO Stat Line
PCP Stat Line
Assisted SMI Care Coordination Transition
Co-Morbid Disease Management Program
Depression Screening Program
Integrated Care
Integrated co-occuring
Peer Programs
Temporary Placement
Sober Living
Value Added Service Programs
22
Crisis Stabilization Unit
Crisis Triage Center
Temporary Placement
Sober Living
Behavioral Health
Additional Services
Available to members seen in ER, providers office and members discharged from inpatient psychiatric
hospital in need of additional support and services
Designed for members that are in need of a higher level of care than traditional outpatient services
Emphasis on stabilizing and increasing psychiatric treatment compliance
Focuses on the member’s needs and a proper course of medical action
Services range from detoxification to crisis stabilization
Short-term, immediate care and professional assessment with collaboration from first responders,
social service programs, and government agencies
Temporary Placement funded by HPN for members with Severe Mental Illness and readmission risk
Provides a safe environment, stability, opportunity for recovery, support for co-morbid issues
Increases treatment compliance
Case management to assist member in gaging resources to transition to self-sufficiency
Provides transitional alcohol and drug free living environments for members with severe substance
use disorders attempting to abstain from alcohol and drugs
Increases the likelihood of sobriety
Decreases the potential for relapse
23
High Risk Case Management
Complex Case Management
Case Management
Services for members with high incident of hospitalizations and poor adherence to treatment
Case manager is the single point of contact for all parties involved in a member’s well-being and care,
with the goal being to facilitate care coordination
Support mental health services and integrated substance abuse treatment, including medication
management, symptoms management, rehabilitation, crisis stabilization and psychosocial education
Arrange medical appointments, including transport
Perform administrative duties related to a client's care
Services members with high utilization of inpatient services and non adherence to treatment
Works to improve the continuity of care and quality of life for the serious mentally ill members
Participate in patient's treatment plan with other professionals working with member
Facilitates care coordination with all involved in the members care
Arranges medical appointments and transports
Perform administrative duties related to a client's care
24
NowClinic
Online access to a physician, clinician or specialist including
child/adolescent psychiatric consults for SMA pediatric members
Psychiatric consultation for Emergency Room physicians treating
members
At the members convenience and accessible from various locations
Case manager accessible for members living at home, in shelters or on
the streets
Closes the gap between patient demand and provider supply
Improved health outcomes
Simple care needs managed effectively and efficiently
Preventive actions and follow ups
Focus on continuity of care
TeleHealth Wellness
BEHAVIORAL HEALTHCARE OPTIONS (BHO)
Local: 702-364-1484
Toll-Free: 1-800-873-2246
Human Behavior Institute (HBI)
Local: 702-248-8866
Toll-Free: 1-800-441-4483
Nevada Behavioral Health Systems (NBH)
Local: 702-978-8100
Toll-free: 1-844-978-8100
Contact Information
26
Michelle Guerra, CPC, LCADC
HPN/BHO Medicaid Program Manager
(702) 242-7089
Questions?
