Delivering Recovery-Focused Treatment Services in a Managed Care Environment

1. Delivering Recovery-Focused Treatment Services in a Managed Care Environment NYAPRS 7th Annual Executive Seminar on Systems Transformation April 27 - 28, 2011 Adele Gregory Gorges, Executive Director New York Care Coordination Program

2. www.carecoordination.org

3. New York Care Coordination Program

4. NYCCP Strategic Plan for System Transformation

5. ACT 1: Laying the Foundation • Transformation initiatives lay the foundation for recovery-focused managed care • Collaborative processes • Person-Centered Practice • Care Coordination • Health integration • Data driven to promote wellness

6. Guiding Principles for Person-Centered, Recovery-Focused Services, Developed by the Peer and Family Advisory Group of the WNYCCP, 2007

7. Guiding Principles (cont.)

8. Creating a Person-Centered, Recovery-Focused System of Care

9. Care Coordination

10. Person-Centered, Recovery-Focused Care Coordination adds value * 2009 Periodic Reporting Form Analysis

11. ACT • ICM • SCM DATA DRIVEN: Medicaid claims analysis shows need to refocus community care coordination on the right MH consumers Of Erie and Monroe mental health users, the “top 10% in total cost” represent 63% of Medicaid hospital and residential spending… …yet only a quarter of the “top 10%” were enrolled in available Care Coordination programs Note: Analysis of all 2007 claims for Medicaid recipients 18 or over, with any mental health claim, excluding individuals with any OMRDD or nursing home claim. 11

12. ACT 2: NYCCP in Partnership with Beacon Health Strategies, LLC for Managed Fee for Service • Complex Care Management • Intensive, short-term service for individuals with highest needs -- serious mental illness, complex medical needs, top 10% in total costs. Average length of stay of 6 months. • Melds Person-Centered Practice as an underpinning for the initiative AND a managed care focus on an episode of care and movement to recovery. • Teams provider-based Complex Care Coordinators (ICM) with MBHO based Complex Care Managers. • Identified care coordinators are trained for delivery of care coordination in a short term model with a focus on physical as well as behavioral health care • Identified MBHO care management staff required to be trained in Person- Centered Practices • On the ground, in the community Care Coordinators plus office based CMSA-lead, office based Care Managers with significant physical health and behavioral health experience

13. Complex Care Management (cont.) • Grounded in supporting individuals to attain recovery goals related to life objectives – living, working, socializing. • Empowers individuals through development of skills for self-management of physical and behavioral health symptoms • Supports individuals in building an integrated, coordinated team of providers of choice • Enhances the use of Peer Support services and other natural supports in the community. As generally available in the community, but also purchased using wrap around dollars if necessary for program enrollees. (e.g. Compeer Peer Wellness Coaches for the Well Balanced Program)

14. Learning through Collaboration • Managed care learned about person-centered practice • NYCCP providers, peers and counties learned that the managed care tools and skills are helpful in promoting recovery • Focusing efforts on high cost/high need individuals can produce dramatic outcomes

15. ACT 3: Managed Care and Health Homes • NYCCP wants to build on what we have learned about the effectiveness of: • Collaborative processes • Person-centered, recovery-focused approaches • Complex Care Management in collaboration with Beacon Health Strategies • Can be an effective core for Specialty Behavioral Health Homes • Focuses HR/HN populations and episodes of care • Can be expanded through “repurposing” of care coordinators/targeted case managers and added MBHO capacity • Maximizes resources through shorter lengths of stay in care coordination and effective linkage with providers of choice • Effective linkage to a provider of choice for a “health home” can lead to enhanced self management skills, timely health promotion and prevention services, early intervention, and mind-body health

16. NYCCP RBHO/Health Home Vision Provider A Provider B Provider C

17. Functions of RBHO as ‘superstructure” • Develop/coordinate health homes throughout the designated region. • Coordinate care and manage utilization for Medicaid behavioral health services delivered throughout the region. • Approve, coordinate & facilitate continuity and integration of behavioral health/physical health services within Health Homes and between Health Homes in the region. • Provide “back office” functions (e.g. data analysis) for the network of affiliated health homes. • Functional overlap comparison:

18. Functional Overlap Comparison

19. Comparison of Functions (cont.)

20. Comparison of Functions (cont.)

21. Target Populations for Specialty Behavioral Health Homes • Adults with Serious Mental Illness • Children with Serious Emotional Disturbance • Adults and Children with Serious Chemical Dependency + Co-Occurring Chronic Physical Illness

22. Model for Direct Services to Specialty Behavioral Health Home Enrollees • Health Home Services: • Care Coordination will be provider-based and include working with individuals to develop a comprehensive person-centered service plan. As necessary, it will include coordinating comprehensive transitional care from inpatient to other settings, including appropriate follow-up; arranging individual and family support; and arranging referral to community and social support services. The RBHO based Comprehensive Care Manager will provide consultation as appropriate.

23. Model for Direct Services to Specialty Behavioral Health Home Enrollees • Levels for designated Health Home services • Basic Level Care Coordination Services - all individuals identified as meeting the criteria for SMI/SED or Serious Chemical Dependency established by NYS OMH, OASAS, and DOH. Likely provided within Clinic Regulations, not requiring discrete care coordinators. Facilitates flow. • Intensive Care Coordination Services • Intensive Care Coordinators will provide time limited services, for the sub-set of individuals needing more intense service at a point in time. • Criteria for this level will take into account multiple factors including service utilization and costs. • Additional to care coordination provided as part of the Basic Level Care Coordination Services specified above. • Data analysis suggests an ability to meet the need for Intensive Care Coordination Service through repurposing existing TCM dollars.

24. Model for Direct Care Services: Treatment, Health Promotion, Community Support • The Behavioral Health Home Provider provides behavioral health services, and a basic level of Physical Health services on site, in close collaboration with the individual’s Primary Care Physician. • Specialty Behavioral Health Home Core Team • Mental Health or Chemical Dependency Primary Therapist (PT) • Nurse Practitioner or Primary Care Physician onsite at Specialty Behavioral Health Home • Care Coordinator (CC) -with appropriate qualifications and training for integrated, person-centered work and a team reflecting the need for peer experience and cultural and linguistic competency

25. Model for Direct Care Services: Treatment, Health Promotion, Community Support • Behavioral Health Treatment Providers will contract with Primary Care Providers, particularly FQHC’s with NCQA Level 3 Certification as Person-Centered Medical Homes. They will also collaborate with independent Primary Care Physician practices serving individuals in the Health Home. • Health Promotion, Inpatient, Pharmacy, Specialist, Rehabilitation as referred and per the Person-Centered Service Plan • Communication will be supported by Beacon IT and RHIO’s and facilitated by the Care Coordinator • Community Supports • Peer support services • Housing, social services and community supports will be provided as specified in the Person-Centered Treatment Plan

26. For more information • Adele Gregory Gorges • Executive Director, New York Care Coordination Program • C/O Coordinated Care Services, Inc. • 1099 Jay Street, Building J, Rochester, NY 14611 • 585-613-7656 • agorges@ccsi.org • www.carecoordination.org