Maryland Management Meeting Workshop December 13, 2010

1. Maryland Management Meeting WorkshopDecember 13, 2010 Jack Kemp* Treatment Research Institute (TRI) jkemp@tresearch.org *With a large tip of my Baltimore Ravens cap to Mady Chalk (TRI) and Richard Rawson (UCLA) for the use of their slides.

2. Workshop Overview • Integration with Healthcare • Health Homes • Preparing for Healthcare Reform

3. I. Integration with Healthcare

4. Substance Use Disorders Treatment under Health Care Reform: Welcome to the Healthcare System Richard Rawson, Ph.D.* Thomas E. Freese, Ph.D.* UCLA Integrated Substance Abuse Programs Pacific Southwest Addiction Technology Transfer Center ________________________________________ *Authors of the following 9 slides.

5. How will SUD services and MH services be integrated into primary care and other healthcare settings? 5

6. What is “Primary Care Integration”? Primary care integration is the collaboration between SUD service providers and primary care providers (e.g., FQHC’s, CHC’s) Collaboration can take many forms along a continuum* MINIMAL BASIC At a Distance BASIC On-Site CLOSE Partly Integrt CLOSE Fully Integrt Coordinated Co-located Integrated *Source: Collins C, Hewson D, Munger R, Wade T. Evolving Models of Behavioral Health Integration in Primary Care. New York: Millbank Memorial Fund; 2010.

7. Minimal Coordination The Primary Care System SUD Care System MH Care System • BH and PC providers • work in separate facilities, • have separate systems, and • communicate sporadically.

8. BH And PC providers Engage in regular communication about shared patients leading to improved coordination Basic AT A DISTANCE The Primary Care System SUD Care System MH Care System

9. BHand PC providers Still have separate systems Some services are co-located (e.g., screening, groups, etc). Basic On Site (co-location of services) The Primary Care System Referral SUDCareSystem SBI Counseling Counseling Referral MHCareSystem MHServices

10. BH and PC providers Still have separate systems Primary care services are integrated into BH Settings Basic On Site (reverse co-location) The Primary Care System Referral SUDCareSystem Medical Services MedicalServices Referral MHCareSystem

11. PC providers Develop and provide their own services Integrated Integrated Care System The Primary Care System SUDCareSystem MAT MHCareSystem

12. Primary Care Integration: A Growing Web of Confusion Coordination Disease Management Behavioral Health Integration Co-Location Integration SBIRT Medical Home Health Home Integrated EHRs Behavioral Health Consultant Behavioral Health Specialist Four Quadrant Model FQHC Integration Bi-Directional Care Care Team

13. Interactive Discussion Visualize yourself working in the post ACA service system in 2014. What will it be like? Discuss the following issues: What will be different about working in this new system? What new skills will you need to develop in order to be successful? What new systems (data, documentation, etc), will need to be developed in order to be successful? What will the benefit be for your clients?

14. II. Health Homes

15. History and Concept* • Patient centered primary care is a model of primary care where the relationship between a physician or other licensed health care practitioner and a patient ensures that appropriate care is structured, delivered and coordinated around the specific needs of each patient … • When a patient has this type of relationship with their health care practitioner and practice, they are considered to have a patient-centered medical home. ____________________________________ *Patient-Centered Primary Care Collaborative, “The Patient-Centered Medical Home, Quick Reference Home for Employers.”

16. History and Concept • Concept is not new – initially introduced in 1967 by the American Academy of Pediatrics • Concept evolved over time from a centralized medical record to a method of providing comprehensive primary care for children at the community level. • In 2007, the American College of Physicians, the American Academy of Family Physicians and the American Orthopedic Association issued the “Joint Principles of the Patient-Centered Medical Home.”

17. History and Concept • On November 11, 2008, the American Medical Association voted to adopt the Joint Principles. • To be able to deliver patient-centered primary care, primary care practitioners have to restructure their practices so that they are more accessible, promote prevention and wellness more effectively, proactively support patients with chronic illness rather than treat the symptoms of those illnesses, and, proactively support patients in self-management and decision making.

18. Seven Characteristics of PCMH from the Joint Principles • Personal Physician – ongoing relationship with a personal physician or other health care practitioner trained to provide first contact, continuous and comprehensive care. • Team Approach – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients. • Whole Person Approach – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals.

19. Seven Characteristics of PCMH from the Joint Principles • Coordination and Integration of Care – Care is coordinated across all elements of the complex health care system and the patient’s community facilitated by registries, information technology and other means to assure that the patient gets the indicated care when and where they want it.

20. Seven Characteristics of PCMH from the Joint Principles • Quality and Safety are hallmarks: • Advocate for their patients to support the attainment of optimal, patient-centered outcomes • Evidence based medicine and clinical decision support tools guide decision making • Patient, family and physician practice involvement in continuous quality improvement.

21. Seven Characteristics of PCMH from the Joint Principles • Expanded Access To Care – Enhanced access to care through systems such as open scheduling, expanded hours, and new options for communication between patients, their personal physician and practice staff.

22. Seven Characteristics of PCMH from the Joint Principles • Added Value Recognized – Payment appropriately recognizes the added value provided to patients. Payment should: • Reflect the value of physician and non-physician staff care management work that falls outside of the face-to-face visit. • Pay for services associated with coordination of care. • Support adoption and use of IT. • Support provision of enhanced communication and remote monitoring of clinical data via technology.

23. Recognize c Seven Characteristics of PCMH from the Joint Principles • Added Value Recognized (continued): • Recognize case mix differences. • Allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management • Allow for additional payments for achieving measurable and continuous quality improvement.

24. III. Preparing for Healthcare Reform

25. Preparing for Healthcare Reform We are about to discover what it is like to work with patients who are insured and who: • Want to make choices about their treatment • Want treatment that is in compliance with standards of care • Want treatment that is integrated with primary and other healthcare

26. Preparing for Healthcare Reform • It is no longer business as usual • We need to begin planning NOW at the state, county and provider levels if we hope to maximize what we can gain from healthcare reform

27. Payer Sources and Patients Medical Needs and Care Financing Use of Funding Streams Integration of Funding Medicaid Eligibility Benefit Design Performance, Quality, and Accountability Organization of Treatment Services Health Homes Integration with Primary Care Workforce Patient Choice Issues That Need to Be Addressed

28. Healthcare Reform and Treatment • We need to inform ourselves NOW about: • New payer sources • New patients • Medical needs and care of current and future patients

29. Payer Sources • We will have new payer sources that will have an impact on: • The organization and type of patient in our treatment programs • The entry of new organizations into treatment, and • The need for new types of professionals

30. Patients • SA leaders need to assess NOW the characteristics of the new types of patients who we think will be insured by Medicaid or commercial insurers that will need treatment, their stages of illness, and their treatment needs? • States and Jurisdictions need to begin planning with treatment providers how we will meet the needsof different populations in the same treatment program and balance financing, staffing, and organizational arrangements?

31. Medical Needs and Care • We need to learn where the patients in addiction treatment in your jurisdiction receive their medical care? And find out whether patients are loyal to specific medical providers? • We must know what combinations of substance use and other medical diagnoses patients currently in addiction treatment have? Are there clusters of diagnoses which have implications for interventions?

32. Medical Needs and Care • We need to answer the question: • Can treatment, without attention to other medical conditions, be considered to meet current standards of care and be SAFE and EFFECTIVE? • If not, what are the State and jurisdictions doing about it?

33. Financing and Reimbursement Use of Funding Streams: • What should State and Jurisdictions be doing to plan for the changes in the use of block grant funds and their possible reduction with the move toward increased insurance funding? • What do we know about what care gaps exist for the patients we treat now? Will these be different with the addition of insurances? How can new sources of financing and reimbursement be combined and used to fill gaps in care?

34. Financing and Reimbursement Integrated Financing: • What can the State and Jurisdictions plan for NOW to both integrate and differentiate uses of different funding streams, public and private to deliver care? • How will the States and Counties integrate health insurance exchanges and high-risk pools into their implementation strategies? • How will insurance change the types of patients entering treatment?

35. Medicaid Eligibility • What do you need to do NOW to work with Medicaid on treatment eligibility and approval for patients with substance use disorders? • What do the State and Jurisdictions need to do to assure a continuous flow of eligibility and enrollment information from Medicaid in order for providers to survive?

36. Benefit Design • What role are you playing NOW in assuring evidence-based benefit design under Medicaid and commercial insurance? • What are the States and Jurisdictions roles in working with providers to prepare to implement medical necessity and level of care guidelines required under by new benefits?

37. Performance and Quality • What are you doing NOW to begin work with providers to help them respond to quality incentive payments that will be included in Medicaid? • How will you help providers learn about and integrate standardized tools and guidelines to support quality improvement and meet performance expectations? • What are the States and Jurisdictions roles in benchmarking and feedback to providers about their performance and improving their performance?

38. Treatment Organization • Are there new organizational forms that will be needed to link treatment levels, to link treatment with continuing care and recovery supports, and/or different types of care in an episode? • What role does the State and Jurisdictions play in addressing the potential of new organizational forms as they emerge? • What do we think about “specialization” which may occur with new financing mechanisms and quality requirements?

39. Treatment Organization • How can we begin to anticipate what the organizational impact will be of financing that includes Medicaid, private insurance, and block grant funds and requires certified professionals? • Mergers, acquisitions, and increased competition • How will Medicaid managed care and “episode of care” payments for an array of services affect organization and use of treatment services? Are you anticipating the effects NOW?

40. Health Homes • What are the State, County and Providers’ roles in assuring that addiction is included as a chronic condition in the new health homes that are being created? • Are you at the table? If not, how do you get a seat?

41. Health Homes • What do you need to learn NOW about the designs of health homes including: • Use of dedicated care managers • Rapid access to health practitioners • Accessible, real time data to manage performance and track patients • Effective incentive payments

42. Health Homes • What is the role of specialty treatment in health care? • What do you know about the functions and designs of health homes? • Have you considered how specialty treatment programs will participate in primary care health homes? • Is there a role for a specialty care health home? What is it? How would it work?

43. Health Homes • Are there specialty staff that should be involved in staffing health homes? Who are they and how should they be used? • How will the State and Jurisdictions be involved in responding to health home certification criteria, e.g. care coordination, care planning, access and communication, practice level quality improvement?

44. Health Homes • What kind of partnerships do the State and Jurisdictions need to begin to develop NOW with health agencies responsible for primary care to implement an integrated care continuum with a range of primary and specialty care services? • Given advances in treatment methods such as MAT, what role does the State and Jurisdictions play in assuring that physicians and groups have the capacity to manage medications for addictions?

45. Integration with Primary Care • What resources do specialty programs need (staff, incentives) in order to support coordination and communication with primary care, i.e. with FQHCs and group practices? • What are the State’s and Jurisdiction’s roles in working NOW with treatment programs to identify and treat co-morbidities among their patients? And to provide access to healthcare for all patients with co-morbid medical conditions?

46. Integration with Primary Care • What role does the State and Jurisdictions play in working with treatment programs to be able to provide immediate access for primary care patients in need of specialty treatment? • What is their role in preparing for outplacement of treatment staff to provide services in primary care settings?

47. Workforce • What is the State and Jurisdictions role in developing a workforce for a mainstream illness that includes standards of care and is responsible for working with and communicating across systems of care? • What do treatment staff need to know about working with medical staff in medical settings? How will they learn what they need to know?

48. Workforce • As we expand the type of patient entering addiction treatment, what can you learn NOW about which combinations of professionals should treat which patients in our treatment programs? • As you think about the workforce, what is your role in helping providers consider shifting some job responsibilities to assist patients who are insured for the first time to help them understand and use their insurance benefits?

49. Workforce • How will you participate in workforce education, training, and credentialing that needs to change so that treatment programs can meet standards of care, include pharmacotherapy, and meet the performance requirements of new payers ? • What is the role of the State and Jurisdictions in assuring that the treatment workforce meets credentialing standards of Medicaid and other insurances?

50. Choice • As patients become better informed about standards of care and the characteristics of excellent treatment, what challenges do we face in transforming treatment programs? What is the State and Jurisdiction role in leading change? • What can the State and Jurisdictions do NOW to help providers improve their treatment services and the treatment system so that patients will CHOOSE to use our current treatment programs and services rather than potential new competitors?