Oregon’s Health System Transformation

1. Oregon’s Health System Transformation Dan Reece, LCSW Oregon Health Authority, Transformation Center June 2, 2015

2. Agenda • Oregon’s Coordinated Care Model • Behavioral Health Integration with Primary Care in Oregon • Behavioral Health Homes

3. Oregon • 3.9M pop. (27th) • 98M sq. mi. (9th) • 2.3M metro area to 0.7 per sq. mile in Harney Co. (frontier)

4. The Oregon Health Plan and the Coordinated Care Model

5. The Burning Platform In 2011, Oregon faced a $2 billion hole in the Medicaid budget. Traditional budget balancing: • Cut people from care • Cut provider rates • Cut services The 4th way: Change how care is delivered.

6. Key Levers for Transforming Health Care Delivery

7. Coordinated Care Organizations • Implemented August 1, 2012 with Oregon’s Medicaid program. • There are 16 Coordinated Care Organizations (CCOs). Locally governed by a partnership between health care providers, community partners, consumers, and those taking financial risk. • Community Advisory Councils (CAC). • Multidisciplinary Clinical Advisory Panels (CAP). • Behavioral health, physical, dental care integrated global budget. • Responsible for health outcomes and receive incentives for quality.

8. CCO Accountability • CCOs are accountable for 33 measures of health and performance, 17 are linked to incentive payments • Results are reported regularly and posted on Oregon Health Authority website • CCO financial data posted regularly • Transformation Plans must address clinical integration, alternative payment models, shared EHRs and community health.

9. CCO’s Early Work… • Develop Patient Centered Primary Care Homes (PCPCH) • Reduce unnecessary Emergency Department visits. • Integrate mental and physical health care. • Develop a care management systems and strategies for patients with chronic and complex conditions. • Develop community health worker capacity to improve patient engagement and address social determinants of health

10. Oregon Health Authority Oregon Health Policy Board Health Evidence Review Commission Office of Health Analytics Metrics and Scoring Committee PCPCH Program: Three tier certification, Standards Advisory Committee Addictions and Mental Health Transformation Center Office of Health equity and Inclusion Public Health Link with State Early Learning System / Hubs

11. Technical Assistance StrategiesFunding in part by CMS State Innovations Model (SIM) Grant • PCPCH Institute • Learning collaboratives • Practice coaching /facilitation • Advisory work groups, e.g. information sharing, and billings • Technical Assistance Bank, i.e., for local consultation • HIT pilot grants • Innovator Agents • Webinars • Conferences: • Annual CCM Summit, • Complex Care Forums • Innovation Cafe

12. Oregon Health Plan Enrollment Oregonians on the Oregon Health Plan • As of May 4, 2015 • 95 % of Oregonians have health care coverage • Oregonians on the Oregon Health Plan: 1,055,000 • Enrollment growth since Jan. 1, 2014: 442,000 • About 90% of the OHP members are in a coordinated care organization, receiving care designed to bring better health, better care, lower costs. Extensive outreach efforts • Fast-track • OHA’s outreach team: • Trained over 2,300 individuals statewide, resulting in over 1,350 active assisters within 330 organizations • Managed 49 grants, 41 volunteer agreements, and hundreds of OHA contracted providers certified for application assistance

13. Coordinated care model continues to show improvements for Medicaid members • Decreased emergency department visits. • Decreased hospital admissions for short-term complications from diabetes. • Decreased hospital admissions for chronic obstructive pulmonary disease. • Increased enrollment in Patient-Centered Primary Care Homes.

16. Room for Improvement: SBIRT

17. Next steps for health system transformation • The coordinated care model has been implemented in the state’s public employees benefits program, PEBB • Aligning care models in Oregon Health Plan, PEBB, OEBB and private market • Leverage work to reduce costs, increase transparency in commercial market

18. Oregon Behavioral Health Integration:What we’ve heard, seen and learned

19. Integration Environmental Scan • OHSU qualitative research, five geographically dispersed CCO communities. • Additional 30+ site visits, CCO and provider interviews. • Informed by stakeholder groups NAMI, IBHAO, CHA, OPCA, BHH-LC,

20. Integration Initiatives Provider and Payer Initiatives OHA Initiatives PCPCH Institute CCO Oregon IBHAO Children’s Health Alliance & OPIP Tiger Teams Behavioral Health Home Learning Collaborative Project ECHO Local CCO Initiatives Youth Services WRAP CCI Fellow Projects OPCA SBIRT OHSU SBIRT OPAL-K SBIRT Consultation Q-Corp Payment Models QI Initiatives EnvironmentalScan

21. High Level Findings • Lives are being impacted and saved . • Some degree of implementation in most communities, but still limited population penetration. • Wide variability in the degree of implementation, from system-wide to beta testing. • Ongoing regulatory, reporting, and financial silos • Common set of barriers and requests for assistance. • Opportunities for much more shared learning

22. Challenges • Reimbursement / sustainability • Communications • Work Force • Project management capacity / Change fatigue • BH specialty care and BH Homes • Data and analytics • Health Neighborhoods

23. Reimbursement /Sustainability • Complexity and Confusion about billing rules • Continuing budget and regulatory silos • Codes and billing systems not integrated • BH vs. HB • Credentialing • Non-billable services (no codes) • CCM model needs to be adopted by commercial payers • Alternative payments models need to be accelerated

24. Communications • Confidentiality regulations • Misconceptions about confidentiality regulations • Less developed BH IT systems • Non-aligned EHR systems

25. Workforce • Practice cultures • Practice redesign and provider retraining • Provider capacity / access • Psychiatry gap (adult and child)

26. Data and Analytics • Dearth of integration metrics. • Tools to capture the value of integration. • Encounter-based data reporting requirements. • Burden of non-aligned reporting requirements.

27. Behavioral Health Home Learning Collaborative

28. Participating Project Sites OrganizationsLocations • Bridgeway Recovery Services Salem • Cascadia Behavior Health Portland • Lifeworks NW Portland/Hillsboro • Options for Southern OR Grants Pass • Eastern Oregon Alcoholism FND. Pendleton • Community Health Services Benton & Linn Co. • Community Health Alliance Roseburg • Old Town Recovery Center Portland • La Clinica Medford • Willamette Family Inc. Eugene • Center for Family Development Eugene • Mid-Columbia Center for Living Hood River

29. Project goals • Goal: Improve the health of persons with Severe and Persistent Mental Illness and Substance Use Disorders. • Methods: Training and on-site practice coaching. • Objectives: • Adopt & adapt PCPCH principles & practices in behavioral health settings. • Apply Continuous Quality Improvement tools to improve specific health conditions. • Examples: • Improve screening for unmet physical or behavioral health needs. • Create registries of clients in need of integrated care. • Promote team-based care across primary care, mental health and addictions treatment.

30. BHH Project Measures BHH project teams will link their quality improvement projects to Adult Medicaid Quality Grant Program core measures. Examples include: • Reduce Adult Body Mass Index (BMI) • Increase follow-up after hospitalization for mental illness • Reduce in all cause hospital readmissions • Increase screening for clinical depression and follow-up plans • Increase screening, initiation and engagement in alcohol and other drug dependence treatment. • Control High Blood Pressure • Control diabetes

31. Progress to-date: • All sites have begun providing primary care medical services for an identified population of behavioral health patients. • All project teams trained and using PDSA cycles focused on specific quality improvement objectives. Next steps: • Train project teams to use care management protocols and tools. • Site specific team work process flows • Create a BHH tool kit and resource guide to spread the model.