From HARPs to DSRIP to VBP: Promise or Peril?

1. From HARPs to DSRIP to VBP:Promise or Peril? Evolving Strategies for the Delivery and Payment of Mental Services MHA Regional Policy Council February 19, 2016 Harvey Rosenthal NYAPRS Executive director

2. New York Association of Psychiatric Rehabilitation Services (NYAPRS) A peer-led statewide coalition of people who use and/or provide community mental health recovery services and peer supports that is dedicated to improving services, social conditions and policies for people with psychiatric disabilitiesby promoting their recovery, rehabilitation, rights and community integration and inclusion. harveyr@nyaprs.orgwww.nyaprs.org

3. Impact of a Broken System Very high health, social and criminal justice costs with very low outcomes Early mortality: cardiovascular, respiratory and infectious diseases, diabetes and hypertension Highest rates of avoidable readmissions High rates of violence victimization, incarceration, homelessness and suicide

4. Impact of a Broken System High rates of poverty: unemployment and idleness Stigma and discrimination: isolation Loss of hope, purpose, dignity Magnified exponentially for communities of color and other underserved groups

5. Elements of a Broken System Fragmented, Siloed and Uncoordinated Unresponsive: Reactive vs Preventive and Diversionary Unaccountable: who can we turn to? Wrong Incentives: volume over value Illness over Wellness? Wellness over Illness? ‘Chronic’ Patienthood over Personhood

6. Affordable Care Act:National Healthcare Reform TheTriple Aim: improving outcomes, improving quality, reducing cost Key features: expansion of Medicaid and managed care, behavioral health parity, home and community based services including self-directed care

7. Affordable Care ActState Healthcare Reform • Focus on • Coordination • Integrated physical and behavioral healthcare • Outcomes • Prevention • Wellness • Hospital diversion • Individualized care

8. New York State’s Challenge • $54 billion Medicaid program with 5 million beneficiaries • 20% (1 million beneficiaries) use 80% of these dollars: hospital, emergency room, medications, longtime “chronic” services • Over 40% with behavioral health conditions • 20% of those discharged from general hospital BH units are readmitted within 30 days: NYS avoidable Medicaid hospital readmissions: $800 million to $1 billion annually • 70% with behavioral health conditions; 3/5 of these admissions for medical reasons

9. NYS Medicaid Waiver • Health and Recovery Plans • Health Homes • Home and Community Based Services • Delivery System Reform Incentive Payment • Performing Provider Systems • Value Based Payment • Eliminate racial disparities in healthcare

10. The Mantras of the MRT From fee for service to outcome based care Diversion from emergency room and inpatient hospital use Surprise! We are healthcare providers

11. NYS Medicaid Redesign Managed Care for All Universal Access to High Quality Primary Care; Integrate physical and BH services Targeting the Social Determinants of Health Health Homes: Teams of providers working together to coordinate care for Medicaid consumers who use lots of services

12. Managed Care Plans Now Offer Medicaid funded BH Services Inpatient - SUD and MH Clinic – SUD and MH Personalized Recovery Oriented Services Assertive Community Treatment Partial Hospitalization Comprehensive Psychiatric Emergency Program Targeted Case Management Opioid treatment Outpatient chemical dependence rehabilitation Rehabilitation supports for Community Residences (phased in in 2016)

13. Health and Recovery Plans • Designed for people with more extensive mental health and/or substance use related conditions • Covers all benefits provided by Medicaid Managed Care Plans, including expanded behavioral health benefits • Also provides additional Home and Community Based Services to help people live better, go to school, work and be part of the community

14. Who’s Eligible for a HARP? SSI Recipient ACT, TCM, PROS, PMHP in past year 30+ days of psych hospitalization, 3+ admissions or 3+ month stays in OMH housing over the past 3 years 60+ days in OMH psych center Incarceration w BH treatment past 4 years 2+ SUD ER visits, detox stays for SU related inpatient stays

15. Who’s Not Eligible for HARPs? Have both Medicaid and Medicare Live in a nursing home Are in a Managed Long Term Care Plan Are under age 21 Have services from the Office for People with Developmental Disabilities (OPWDD)

16. Health Plans in Broome County Aetna Capital District Physicians Health Plan Excellus Health Plan. Fidelis Care New York MVP Health Care

17. HARP Beneficiaries’ Care is Managed via Health Homes • Health homes are ‘a home for your healthcare” • Everyone gets a care coordinator who conducts an assessment and works with each individual to develop their own goal and service plan which are intended to be shared electronically with all providers and social services that support them • Health home responsibilities include: • Active engagement • 24-7 response • Focus on well coordinated discharge and treatment planning What are your experiences with Health Home Care Management?

18. NYS Health Home Model Managed Care Organizations (MCOs) New York State Designated Lead Health Home Administrative Services, Network Management, Health IT Support/Data Exchange • Health Home Care Management Network Partners (includes former Total Care Management Providers) • Comprehensive Care Management • Care Coordination and Health Promotion • Comprehensive Transitional Care • Individual and Family Support • Referral to Community and Social Support Services • Use of Health Information Technology to Link Services (Electronic Care Management Records) Medicaid Analytics Performance Portal (MAPP) Regional Health Information Organizations (RHIOs) Access to Required Primary and Specialty Services (Coordinated with MCO) Physical Health, Behavioral Health, Substance Use Disorder Services, HIV/AIDS, Housing, Social Services and Supports

19. Catholic Charities of Broome County Greater Binghamton Health Center Endwell Family Physicians The Family & Children's Society Catholic Charities Of Broome County The Addiction Center Of Broome County Southern Tier Independence Center Mental Health Association Of Southern Tier

20. Catholic Charities of Broome County Broome County Mental Health Department Our Lady of Lourdes Memorial Greater Binghamton Health Center Conifer Park Samaritan Counseling Center Of The Southern Tier LB Prescription Enterprises

21. Catholic Charities of Broome County United Cerebral Palsy Association of NYS Broome County Health Department Broome County Mental Health Community Options United Health Services Hospital Greater Binghamton Health Center NYS Office Of Mental Health United Health Services Hospitals

22. United Health Services Arms Acres Conifer Park Greater Binghamton Health Center Arms Acres Southern Tier Aids Program United Health Services The Family And Children's Society Conifer Park United Health Services

23. United Health Services Broome County Mental Health Department Volunteers Of America YMCA Twin Tier Home Health Binghamton Housing Authority Broome County Council Of Churches Broome County Department Of Social Services Broome County Lift Broome County Office For The Aging

24. United Health Services CASA Community Hunger Outreach Warehouse Mental Health Association Of Southern Tier Professional Home Care Addictions Center Of Broome County Alcoholics Anonymous American Cancer Society Fairview Recovery Services Holliswood Hospital

25. United Health Services Mothers And Babies Perinatal Association Narcotics Anonymous Opportunities For Broome Rehabilitation Support Services Retired And Senior Volunteer Program Salvation Army Serafini Transportation Corporation SOS Shelter Southern Tier Healthlink

26. NYS Home and Community Based Services Option Medicaid Will Now Pay for: Support Services Family Support and Training Non- Medical Transportation Individual Employment Support Services Prevocational Transitional Employment Support Intensive Supported Employment On-going Supported Employment Peer and Family Supports Self Directed Services Rehabilitation Psychosocial Rehabilitation Community Psychiatric Support and Treatment (CPST) Residential Supports/Supported Housing Habilitation Crisis Intervention Short-Term Crisis Respite Intensive Crisis Intervention Mobil Crisis Intervention Educational Support Services

27. Beyond HEDIS Outcome Measures 7 days from inpatient discharge to outpatient appointment 30 days to filled prescription Depression screening and follow up

28. HCBS Outcome Measures:Social Determinants of Care • Participation in employment • Enrollment in vocational rehabilitation services and education/training • Improved or Stable Housing status • Access to and use of Peer Support • Longer Community tenure, Decreased Hospital Readmissions • Decreased Criminal justice involvement • Improvements in functional status • Cultural & Linguistic Competence, Engagement

29. NYS Medicaid Redesign Response: Managed Integrated BH & Medical Care STATE MEDICAID AGENCY DOH OASAS OMH Health and Recovery Plan (HARP) Payers Health and Recovery Plan (HARP) Health and Recovery Plan (HARP) Health Home Team: Provider Network Health Home Team Health Home Team Health Home Team = Physical and/or behavioral health care provider 29

30. NYS Medicaid Waiver $7.1 billion over 5 years for DSRIP $650 million to play for Home and Community Based Services

31. Delivery System Reform Incentive Payment Program (DSRIP) Promotes community-level collaborations that improve the quality and outcomes of care, while achieving a 25% reduction in avoidable hospital use from 2015-20. Safety net providers are expected to collaborate to implement innovative projects focusing on system transformation and population health improvement. All DSRIP funds will be based on performance linked to achievement of project milestones.

32. 25 Performing Provider Systems Community health care needs assessment based on multi-stakeholder input and objective data Building and implementing a DSRIP Project Plan based upon the needs assessment in alignment with DSRIP strategies Meeting and Reporting on DSRIP Project Plan process and outcome milestones • Performing Provider Systems are networks of providers that collaborate to implement DSRIP projects • Each PPS must include providers to form an entire continuum of care • Hospitals • Health Homes • Skilled Nursing Facilities (SNF) • Clinics & FQHCs • Behavioral Health Providers • Home Care Agencies • Other Key Stakeholders

33. Key Mental Health Projects in DSRIP

34. Care Compass Network Also known as: Southern Tier Rural Integrated Performing Provider System, Inc., STRIPPS, United Health Services Hospitals, Inc. Counties served: Broome, Chemung, Chenango, Cortland, Delaware, Schuyler, Steuben, Tioga, Tompkins Attribution for Performance:         102,386 Total Award Dollars:                      $224,540,275

35. Provider Groups Home Care Independent Living Center Addiction Center Nursing and Rehabilitation Center Primary Care County Health Departments County Office for Aging Hospice and Palliative Care

36. Provider Groups Hospitals Vocational Rehabilitation Services for People w Developmental Disabilities Health Homes Compeer Pharmacies

37. Provider Groups Hospice and Palliative Care Therapeutic Communities Senior Living Center Suicide Prevention And Crisis Service United Cerebral Palsy Association Visiting Nurse Service YMCA

38. Behavioral Health Projects Integration of primary care and behavioral health services (required of all 25 PPSs) 16 PPSs also included: Community crisis stabilization services Transitional Supports Activation Medication adherence programs Withdrawal Management Behavioral Interventions in Nursing Homes

39. Behavioral Health Providers Lakeview Mental Health Services, Liberty Resources Mental Health Association Of The Southern Tier Northeast Parent And Child Society Onondaga Case Management Services Parsons Child And Family Center Phoenix Houses Planned Parenthood Rehabilitation Support Services

40. Projects Integrated Delivery System Development of Community Based Health Navigation Services Patient Activation Evidence-Based Strategies for Disease Management COPD Preventative Care and Management

41. Projects 30 Day Care Transitions for Chronic Diseases, including BH Conditions Integration of Behavioral Health and Primary Care Strengthen Mental Health and Substance Abuse Infrastructure, Prevention and Targeted Interventions Crisis Stabilization

42. Value Based Payment • What are Value Based Payments (VBPs)? • An approach to Medicaid reimbursement that rewards value over volume • Incentivizes providers through shared savings and financial risk • Directly ties payment to providers with quality of care and health outcomes • A component of DSRIP that is key to the sustainability of the Program

43. Value-Based Payment Reform Required to ensure ‘long term sustainability of DSRIP investments” By waiver Year 5 (2019), all MCOs must employ non-fee-for-service payment systems that reward value over volume for at least 80-90% of their provider payments

44. Value-Based Payment Reform Required to ensure that “value-destroying care patterns” (avoidable admissions, ED visits, etc) do not simply return when the DSRIP funding stops in 2020 If VBP goals are not met, overall DSRIP dollars from CMS to NYS will be significantly reduced

45. VBP: Sharing in the Savings To share in savings, you eventually need to take on risk… Partnering with other providers is essential to being able to take on risk We need to join forces with other providers to have enough cash reserves to take on Level 2 risk, which applies 90% of the savings to reward effective providers.

46. Value-Based Propositions • Proposals to: • Integrate physical and behavioral healthcare • get ahead of relapse and readmissions and support crisis stabilization • promote mental, emotional and behavioral (MEB) well-being in communities; prevention and strengthening MH/SA infrastructure across system

47. Value-Based PropositionsAn example • NYAPRS proposed to provide peer bridger services aimed at helping people with ‘serious’ mental health and addiction related conditions to: • Reduce avoidable emergency room and inpatient visits by 40% • Increased self-management and participation with chosen medications, services and supports NYAPRS has successfully applied this model within a managed care contract to reduce hospital use by 48% and Medicaid spend by 47%

48. NYAPRS Advocacy on Value Based Payment Work Groups We helped see that OMH HCBS services were added to the list of SDH interventions All Level 2 and 3 plans or providers must address at least one social determinant and contract with at least 1 CBO We’ve pushed for the state to provide infrastructure dollars and technical assistance for community based providers

49. NYAPRS Advocacy on Value Based Payment Work Groups • We’ve insisted that VBP outcomes include recovery and social determinant related ones (beyond HEDIS) • Ex: maintenance of housing stability • Strong emphasis on cultural competence • Buy not Build • Position our members for gain sharing

50. NYAPRS VBP Advocacy:Advocacy and Engagement Development of Member Incentive Programs Creation of an Expert Group for Achieving Cultural Competence in Incentive Programs Use of Patient Reported Outcomes (PRO) Expansion of ombuds program Plan for how best to communicate VBP to consumers/members