January 11, 2012

1. PMHP Subgroup Analysis Activityfor the Seven Day Follow-up Collaborative PIPACCESS BEHAVIORAL HEALTH January 11, 2012

2. Intervention Peer Transition Liaison telephone calls Effectiveness: 2009 improvement in the PMHP’s rate of seven day follow-up was associated with implementation of this intervention However 2010 rate has dropped Dramatic impact on aftercare group attendance is a direct result of the intervention

3. Barriers • Barriers identified on the peer transition liaison call logs: • Transportation issues • Member needs to reschedule appointment • Member refuses to keep appointment • Follow-up appointment not clear on form • Follow-up appointment not within 7 days

4. Barriers Other barriers identified in the overall population for the seven day follow-up collaborative PIP include: Homeless No telephone Members whom we do not reach by phone

5. Subgroups Subgroups identified in the overall population for the seven day follow-up collaborative PIP are: Children vs Adults Inpatient Facilities

6. Subgroups Subgroups identified in the overall population for the seven day follow-up collaborative PIP are: Children vs Adults Follow-up within 7 days 38% of adult members 42% of child members

7. Subgroups Subgroups identified in the overall population for the seven day follow-up collaborative PIP are: Inpatient Facility 37% of Baptist Hospital discharges 68% of Bridgeway CSU discharges 35% of Emerald Coast Behavioral discharges 41% of Lakeview CSU discharges 16% of West Florida Hospital discharges

8. Availability of Data • Were the data for the identified subgroups available, complete, and accurate? • Encounter data • Peer Transition Liaison Activity Log data • ABH PTL Follow-up Form us being used only by the two CSUs (Bridgeway & Lakeview). • Hospitals are using other formats.

9. Availability of Data Approximate proportion of the subgroups to the overall population for the PIP: Baptist Hosp 71% Bridgeway CSU 10% Emerald Coast Behavioral 2% Lakeview CSU 15% West Florida Hosp 2% Adult 57% Child 43%

10. Analysis Results • disparities in the subgroups that were identified: • Only adults are admitted to the CSUs • All area children’s psych beds are in one hospital • Out of area children’s psych hospital used when necessary and appropriate • Most adults first appointment is a group • Most children’s first appointment is an individual appointment

11. Improvement Strategies • Do your identified subgroups have unique causes/barriers? • Children vs. Adults • More adults were given appointment within 7 days • PTL higher success rate reaching parents of children • Interventions that could be implemented to address the causes/barriers: • Bridgeway’s Psychiatric Aftercare day model • Impact children’s first appointment date

12. PMHP Subgroup Analysis Activityfor the Seven Day Follow-up Collaborative PIPJackson Public Health Trust / University of Miami Behavioral Health January 11, 2012

13. Subgroups • The subgroups identified in the overall population for the seven day follow-up collaborative PIP were: • Facilities with 50+ discharges • Length of Stay • Gender and Age Range

14. Availability of Data • Were the data for the identified subgroups available, complete, and accurate? • Yes • What was the approximate proportion of the subgroups to the overall population for the PIP? • Facilities with 50+ d/c: 92.4% • Age/Sex: 100% • Length of Stay: 100% • Was it adequate for analysis? • Yes

15. Analysis Results • Why did the subgroups make sense for your plan? • High SSI membership (longer LOS) • High number of contracted facilities • Representation of all age groups • Did the subgroups you originally selected require additional grouping? • Yes, original subgroups did not show disparities (i.e. DSM diagnostic categories) • Summarize the disparities in the subgroups that were identified. • See next 3 slides for charts

16. Gender and Age Range

17. Length of Stay

18. Facilities

19. Improvement Strategies • Do your identified subgroups have unique causes/barriers? • Discharge planners at low-performing facilities • Lack of facility “buy-in” for the importance of discharge planning • Perception that short MH hospital stays do not require follow-up • Men 65+ resistant/reluctant to attend f/u appointment • What interventions have been implemented or could be implemented to address the causes/barriers? • Additional education/training for discharge planners at low-performing facilities • Targeted intervention to emphasize f/u for men who are 65 and older • If applicable, discuss how the subgroups and/or barriers were or will be prioritized.

20. Lessons Learned • Has this exercise provided insight into your plan’s seven day follow-up PIP rates? Why or why not? • Yes • Future plans • Further drill-down to low-performing facilities and issues with discharge planning • Interviewing non-compliant men over 65 to determine specific reasons for non-compliance

21. PMHP Subgroup Analysis Activityfor the Seven Day Follow-up Collaborative PIPMagellan Behavioral Services January 11, 2012

22. Subgroups • The subgroups identified in the overall population for the seven day follow-up collaborative PIP were: • We identified subgroups for the PIP using the top five axis 1 diagnosis codes found in follow-up detail for the time period of 1/1/2011 to 9/30/2011 by quarter. We decided on this time period to see if there was a correlation between a change in medical necessity criteria that was implemented over the summer and follow-up rates.

23. The report is a combination of PMHP areas 2, 4, 9, & 11. The five diagnoses used were 295.34 295.70 296.90 311, and 314.01.

24. Availability of Data • Were the data for the identified subgroups available, complete, and accurate? Yes, the data is accurate and complete according to HEDIS requirements • Was it adequate for analysis? Yes

25. What was the approximate proportion of the subgroups to the overall population for the PIP? • The total % of the combined subgroups from the total population is 42%. • The 5 subgroup percentages are detailed in the results table.

26. • The total population denominator was considered anyone who was discharged from inpatient that fit the HEDIS requirements. • The total population numerator was anyone who had a follow-up appointment within 7 days of discharge that fit the HEDIS requirement.

27. • To determine the subgroup % of the population, the number of enrollees discharged with each diagnosis code was divided by the overall number of enrollees discharged (total population denominator).

28. Analysis Results • Why did the subgroups make sense for your plan? The Subgroups identified are plausible for this plan as there is a sufficient sample is each diagnosis subgroup.

29. • Did the subgroups you originally selected require additional grouping? We do not currently believe the subgroups require additional grouping. However, further research into the highest and lowest scoring subgroups may be needed as determined by the clinical team.

30. • Summarize the disparities in the subgroups that were identified.

32. Improvement Strategies • Do your identified subgroups have unique causes/barriers? • What interventions have been implemented or could be implemented to address the causes/barriers?

33. Causes/Barriers and Interventions by Diagnosis Members with thought disorders (295.34 and 295.70) have lower follow up rates. This is most likely due to the nature of these disorders. These members tend to be more disorganized in their thinking, have a lack of insight into their illness and therefore not acknowledging that follow up treatment is needed, and have less stable or no natural support systems.

34. Interventions for these subgroups (295.34 and 295.70) would be to involve any and all support systems in the discharge planning process, prior the member being discharged from the inpatient facility to better assist the member in complying with the discharge plan. Additionally, Magellan staff could provide added follow up assistance by care management staff, follow up specialists in the form of welcome home calls and appointment reminder calls. In some areas of the State of Florida, a field care worker or peer specialist may be available to assist in helping the member in reinforcing the discharge plan and linking with an outpatient provider.

35. Causes/Barriers and Interventions by Diagnosis • Members with mood disorders (296.9 and 311) had higher follow up rates than those with thought disorders. These members tend to have more insight into their illness, may have a support system in place, though may have apathy toward complying with follow up treatment.

36. Interventions for this subgroup (296.9 and 311) would entail more outreach efforts by care management staff with training in motivational interviewing to engage the member and encourage/support compliance with the discharge plan. Additionally, in areas of the State, a field care worker or peer specialist is available to provider added support and encouragement to comply with the discharge plan.

37. Causes/Barriers and Interventions by Diagnosis • Members with diagnosis code 314.01 had the highest follow up rate of the subgroups. This may be attributed to the fact that members with this diagnosis are mostly children and have a legal guardian/caretaker who can assist them in complying with the discharge plan. These support systems also have a vested interest in treatment.

38. Interventions for this subgroup, 314.01, would entail assistance in complying with the outpatient appointment. Reminder calls and assistance in rescheduling the follow up appointment due to schedule conflicts would yield the best results.

39. Improvement Strategies • If applicable, discuss how the subgroups and/or barriers were or will be prioritized. The subgroups are ranked in order of priority in #8 as are barriers for each subgroup.

40. Lessons Learned • Has this exercise provided insight into your plan’s seven day follow-up PIP rates? Why or why not? As expected, thought disorders have the lowest follow up rates. This exercise has allowed Magellan to focus on this (and other subgroups) upon admission to ensure discharge planning incorporates extra outreach attempts. • Future plans: Increase outreach and reminder calls to these populations.

41. Interventions (Optional) • Provide information on an intervention that your PMHP has implemented for the seven day follow-up collaborative PIP. • Why do you think that this intervention has been effective? • Has the effectiveness of this intervention been tested? • Was improvement in the PMHP’s rate of seven day follow-up attributed to this intervention?

42. Provide information on an intervention that your PMHP has implemented for the seven day follow-up collaborative PIP. During the years there has been many interventions to improve the follow up appointment rates in all areas. One of the most effective at the moment is the implementation of Bridge appointments which we started to work on in February 2011. We started to receive authorizations requests in March with the majority of them from Jackson Memorial Hospital.

43. Has the effectiveness of this intervention been tested? • In July 2011 Emerald Coast, from PMHP Area 2, agreed to participate in the Bridge Program and by August it has facilitated 29 appointments. This is more than all other providers year to date. • Area 2 increased the follow up rate from 43% in 2010 46% by June 30th, 2011 73% in August 70% in September and 84% in October. Area 2 has the biggest increase in rates

44. Why do you think that this intervention has been effective? • One of our biggest barriers is the lack of follow up from discharging providers. By implementing the Bridge program we have been able to increase the follow up rates in the areas where providers are participating by improving coordination of follow up appointments.

45. Was improvement in the PMHP’s rate of seven day follow-up attributed to this intervention? • It is clear that for PMHP Area 2 the Bridge Program has contributed to the increase in follow up rates. We are working to increase providers “enrollment" in this program in all areas, and to encourage providers that have agreed to participate to increase their activities.

46. Other Interventions • In 2011 we have instituted other interventions that have directly contributed to the increase in follow up rates by 14%: - - Welcome Calls to each discharged patient to ensure they have a follow up appointment and to encourage attendance to the appointment. - Outreach to transportation services in the areas of highest utilization of inpatient and crisis unit services.

47. - Follow up specialists are calling the CBC points of contacts regarding every child welfare admission to improve coordination of care and follow through with appointments.

48. PMHP Subgroup Analysis Activityfor the Seven Day Follow-up Collaborative PIPNFBHP & FHP January 11, 2012

49. Subgroups • The subgroups identified in the overall population for the seven day follow-up collaborative PIP were: • The five (5) distinct Contract Areas that make up NFBHP (A3) and FHP (A5, A6, A7, A8) • Adult vs. Children • Length of Stay (LOS) - <3 vs. >8 • Diagnosis (Dx) – the top three most common diagnoses associated with the discharge (Depressive Disorder NOS, Mood Disorder NOS and Schizoaffective Disorder)

50. Initial Study Population • Members assigned to the Medicaid PMHP for NFBHP (Contract Area 3) and FHP (Contract Areas 5, 6, 7 & 8) • All Members discharged from inpatient care during the time period under evaluation (CY 2010), and who were Medicaid PMHP enrolled at the time of their inpatient discharge • All age groups and PMHP covered diagnoses • Enrollment criteria included Client enrolled in PMHP at any time during the hospital stay and enrolled in PMHP at the time of discharge • Individuals continuously enrolled seven (7) days following discharge