Joan L. Erney, JD

1. Improving Access and Quality Carefor Individuals with Behavioral Healthand Physical Healthcare Needs:Pennsylvania’s Rethinking Care Initiative Joan L. Erney, JD Chief Business Development and Public Policy OfficerCommunity Care Behavioral Health Organization

2. Today’s Discussion Introduction to Pennsylvania Medicaid and behavioral health landscape In the beginning: state role in program design and development Overview and initial outcomes from two physical health/behavioral health projects in Pennsylvania. Lessons learned. Next generation: Application of learning to rural communities. PH/BH opportunities: Health Homes, opportunity to serve individuals with dual eligibility; co-locations, collaborations (not duplications!).

3. Pennsylvania Quick Facts • 12 million residents. • 2.2 million projected Medicaid members (FY11-12). • 2 urban centers (Philadelphia, Pittsburgh = 38% MA members). • DPW is single state agency for Medicaid; Office of Medical Assistance oversees physical health managed care, disease management, and FFS programs. Office of Mental Health and Substance Abuse Services within Department of Public Welfare (DPW) oversees behavioral health system (Medicaid managed care and FFS and other state and federal funds for mental health and substance abuse). • County-based system for human services. • Organized as 49 county joinders for mental health and drug and alcohol services. • County government plays significant role in Behavioral Health HealthChoices program; 43 of 67 counties contract for Medicaid.

4. HealthChoices Overview • CMS Waiver Authority: 1915 (b) Waiver. • 25 County Waiver ( 3 zones) • Physical health: Choice of HMOs. • Behavioral health: 24 contracts with counties,1 direct contract (Greene). • 42 County Waiver • Physical health: Access Plus (PCCM); voluntary HMO. • Behavioral health: 19 counties; 1 direct state contract for 23 counties (Community Care).

5. HealthChoices Zones HealthChoices Zone

6. PA Physical Health/Behavioral Health Landscape Projects supporting integration of services and supports for individuals with physical health (medical) and behavioral health needs happening across the state in urban, rural, and suburban settings. Co-locations; collaborations; shared staff models; health home development; shared health records. Focus on this presentation on the PA collaboration with the Center for Health Care Strategies.

7. Getting Started Secretary of Welfare convened leadership team, including DPW policy director, Deputies from Medical Assistance (OMAP), Office of Mental Health and Substance Abuse Services (OMHSAS), and medical directors to discuss opportunities for physical health/behavioral health collaboration. Convened brainstorming sessions with Center for Health Care Strategies; Department policy director and Medical Assistance Medical Director took initial lead along with staff from OMHSAS. Identified two potential demonstration sites.

8. Guiding Principles Behavioral health is a part of overall health; good health outcomes are important to an individual’s recovery. Integration of good health habits, prevention activities, and specific physical health interventions are best achieved through local collaborations and navigator systems. Good health outcomes can be achieved within the existing physical health and behavioral health managed care design.

9. Program Design Two regional demonstration sites. Western Region: Connected Care™. UPMC for You, Allegheny County, and Community Care Southeast Region: HealthChoices Health Connections Keystone Mercy Health Plan; Bucks, Montgomery, and Delaware Counties; and Magellan Behavioral Health of PA Target Population Persons with Serious Mental Illness, Co-occurring D&A, with co-morbid health conditions. Expected Outcomes Decreased Inpatient utilization (both PH/BH). Decreased Utilization of emergency room usage and crisis services. Reductions in readmission rates for PH/BH. Increase in preventive and routine health care. Increase in satisfaction and quality of life.

10. Partnerships Department of Public Welfare Assisted with Program Design and Regional Development. Provided ongoing staff support to regional demonstration sites. Regular calls/face to face meetings during design. Issued clarification on confidentiality standards. Supported stakeholder feedback sessions. Provided financial resources for start- up activities. Incorporated performance standards into P4P initiative. Assisted with support for supplemental services design. Center For Health Care Strategies Provided Technical Assistance for both sites; both face-to-face and telephonic. Assisted in problem solving/bridging with and between systems. Assisted in development of performance/evaluation measures. Offered best practice for other sites. Physical Health Plan, County, Behavioral Health Plan Participated in development, implementation and evaluation of work. Developed integrated processes regarding sharing of information, case conferencing. Developed integrated care record. Developed educational materials for members, providers, etc. Stakeholder Community Advisory Roles and integral to consumer engagement and consent.

11. HealthChoicesHealth Connections Core Components: KMHP and Montgomery County. Consent and Engagement. Wellness Recovery Teams. Physical health professional (Registered Nurse). Behavioral health professional (Master degree in BH with co-occurring certification). Administrative navigator. Completed an approved integrated physical health/behavioral health certification. Collaborative Care Model. Recovery focused. Virtual Team - interface with supports. Member Profile. Data from KMHP and County/BHO. PH/BH provider contact information. PH and BH diagnosis, level of service, and claims information. Hospitalizations. Pharmacy data. Gaps in care. Delaware and Bucks County have similar core components, however, implemented differently based on unique aspects of their county’s system, e.g., self-directed care initiative in Delaware County.

12. HealthChoices Health Connections Pilot: Health Costs Offsets Source: Data from Bucks, Delaware, and Montgomery Counties in Pennsylvania

13. Connected Care™ Program • Initiative to improve the connection and coordination of care for those with Serious Mental Illness among health plans, PCPs, and behavioral health providers in outpatient, inpatient, and ED settings. • Based on Patient-Centered Medical Home model with integrated care team and care plan to address all medical, behavioral, and social needs. • Partnership between: • Center for Health Care Strategies (CHCS). • Department of Public Welfare (DPW). • UPMC for You and UPMC for Life Specialty Plan. • Community Care Behavioral Health. • Allegheny County Department of Human Services.

14. Target Population • Members qualify for Connected Care™ if they: • Are a UPMC for You and a Community Care member. • Are age 18 or older. • Live in Allegheny County. • Have Serious Mental Illness (SMI)*. * SMI has been defined as individuals who have been diagnosed with schizophrenic disorders, episodic mood disorders, or borderline personality disorder.

15. Member Stratification • High PH needs defined as: • 3 or more ED visits in past 3 months, or • 3 or more inpatient admissions in the past 6 months. • High BH needs defined as: • Discharged from, history of being served, or diverted from a State mental hospital. • 5 or more admissions to most restrictive level of care, or readmitted within 30 days. • 4 or more admissions to most restrictive level of care and inpatient or RTF or CTT admission. • 3 or more admissions to the most restrictive level of care and inpatient or 2 admissions to most restrictive level and inpatient and an open authorization for certain services.

16. Member Stratification • Members identified from medical and behavioral health claims data and stratified into 3 intervention levels. • Re-stratification performed monthly to identify new members and those who are at high-risk. • Members will not be “moved down” to a lesser level of stratification during the project.

17. Care Management Activities • UPMC for You and Community Care coordination includes: • Focus on Tier 1 members. • Integrated care plan. • Weekly multi-disciplinary care team meetings held. • Daily identification of members with PH or BH admission, and ED visits from key UPMC hospitals. • Concurrent case discussions. • 24 hour/day phone line managed by Community Care to answer member questions regarding the program. • Joint meetings with PH andBH providers to inform of the program. • Consumer group input on program design and materials. • Using BH providers to help obtain consents. • Approximately 250 new members identified monthly. • In 2009, provided $25 gift card incentive to 4,400 members who had a visit with their PCP. • 2010 incentive is $25 gift card to complete consent and enroll.

18. Provider Engagement • Mailing sent to PCPs and BH providers explaining Connected Care. • UPMC Health Plan and Community Care clinical leadership conducted joint on site visits to PCP Offices and BH Providers to explain Connected Care and shared materials consumers would be receiving. • In the first quarter 2010 Community Care met with the BH providers and shared the list of their members so that they could assist in informing them of the program and help in obtaining consents resulting in increased consents. • The member’s consent and specific engagement strategies are discussed at the weekly Connected Care case review meeting with the designated provider contacted by the lead care manager.

19. Preliminary Outcomes – Medicaid Members identified July-Dec 2009; Claims paid 07/01/09-06/30/10 *Statistically significant over baseline Baseline: Members with SMI identified 07/01/08-06/30/09 N = 4,953 6 months: Members with SMI identified 07/01/09-12/31/09 N = 5,463 Readmissions defined as within 30 days any diagnosis, any facility

20. Preliminary Outcomes – Medicaid Members identified July-Dec 2009; Claims paid 07/01/09-06/30/10 *Statistically significant over baseline Baseline: Members with SMI identified 07/01/08-06/30/09 N = 4,953 6 months: Members with SMI identified 07/01/09-12/31/09 N = 5,463

21. Lessons Learned • Integration of physical health and behavioral health happens locally, building on the strengths of community infrastructure. • Real time notice of inpatient stays and emergency room visits has had impact on follow-up and engagement of individuals participating in the program. • Nurses play a key role in the program and appear to interface more successfully with PCPs and specialists in accessing treatment for persons with serious mental illness. • Certified Peer Specialists, and tools such as WRAP planning and shared-decision making, are key in assisting in recovery and engagement in healthcare.

22. Lessons Learned • IT Infrastructure of systems is challenging, but interfacing systems capacity can be built over time. • Investment of key physical health and behavioral health systems at the state (county), MCO, provider, and stakeholder level critical to success of the collaboration. • CHCS played important role in providing support and technical assistance to the projects • Having financial resources to assist in start- up and pooled resources for shared savings provided greater incentive for collaboration • Identification of outcomes and performance expectations assists in focusing work.

23. Lets Talk about Drug & Alcohol • Pennsylvania Landscape: A little complicated! • Department of Health- Bureau of Drug and Alcohol Services- single state agencies for block grant, state only funds • Department of Public Welfare- Medicaid FFS, Behavioral Health HealthChoices Managed Care; Act 152 and BHSI state only funds for Drug & Alcohol • Department of Corrections, Department of Education administer some drug and alcohol funding • Proposal: Department of Drug & Alcohol • Pennsylvania’s Confidentiality Standard: • Pennsylvania’s Confidentiality Standard is more restrictive than Federal Rule • Only general and very limited information can be shared • Consent does not give rise to sharing of information • Strong stakeholder investment in current standard

24. Lets Talk about Drug & Alcohol • Problem Solving: Physical Health/Drug & Alcohol Issues & Opportunities: Work in Progress! • Opportunity to make a difference is substantial! • State provided guidance and additional training related to sharing of information and confidentiality standards • Sought consent and engagement with individuals participating in the projects • Recognized role of co-occurring and shared information as appropriate • Hard work but worth the investment of energy to work through barriers and create structures to support best practices!

25. Building on our foundation:PH/BH in Rural Pennsylvania • Building on the lessons learned in Connected Care, Community Care is developing a Connected Care: Behavioral Health Home Plus program for implementation in our state contract in concert with 23 rural counties in north central part of the state; the physical health services remain in FFS, with a contract for disease management for certain chronic conditions. • Implementation of disease management programs has begun, and we are in the process of implementing and evaluating a number of health homes, building virtual teams for adults with serious mental illness (SMI) and other chronic physical health conditions in several counties with very unique and different collaborations, including a county operated system collaborating with a local health center and ID nursing unit; and a community mental health center and local health center. • We expect to see increased access to and coordination with appropriate physical health and behavioral health services. • Virtual Teams will be built around existing resources! A primary lesson in rural settings!

26. For Our Consideration… • Integration with physical health is important; however, also equally important for persons with serious mental illnesses are supports outside of medical care that encourage community integration and recovery. • Issues of poverty, and real life challenges, such as transportation, access to healthy food, and stigma need to be incorporated into our solutions for individuals. • Access to behavioral health treatment for persons with situational and short term needs must be available in a timely way; barriers to co-location, payment constraints, and regulatory challenges continue to need to be addressed. • Continued evaluation for financial impact of collaboration is needed. • Opportunity to include Medicare resources will be of great benefit for persons with serious mental illnesses and chronic conditions. • Careful consideration and best practices continue to need to be developed for substance use and physical health integration, including pain management strategies. • Health Homes and ACOs offer opportunities; however, thought should be given as to how to build from, not create separate and distinct structures, from local communities strengths. • Build on Success!

27. Contact Information Joan L. Erney, JD Chief Business Development and Public Policy OfficerCommunity Care Behavioral Health Organization Former Deputy Secretary OMHSAS (2003-2010) Community Care Behavioral Health Organization One Chatham Center, Suite 700 112 Washington Place Pittsburgh, PA 15219 http://www.ccbh.com 412-454-2120