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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.”
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
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.