Behavioral Health Integration Strategy: RAE 1 Care Coordination/ - - PowerPoint PPT Presentation

Behavioral Health Integration Strategy: RAE 1 Care Coordination/ Crisis System Louisa Wren - RAE 1

August 5th, 2020

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Crisis Services

Rocky Mountain Health Plans (RMHP) Crisis Services: RMHP is a part of Colorado Crisis Service System (CCS), which is a statewide behavioral health crisis response system

• ffering residents mental health, substance use or emotional

crisis help, information and referrals. RMHP manages mobile crisis, a walk-in clinic, a crisis stabilization unit and 2 respite programs throughout Region 1. RMHP is in a unique position, as both the RAE and Administrative Service Organization, to support members in crisis in Region 1 to get connected to behavioral health care.

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Care Coordination

Rocky Mountain Health Plans (RMHP) Care Coordination (CC) Approach: Outreach to all individuals referred to them to screen, assess and create care plans where indicated. Comprehensive assessments which cover: physical/behavioral health, social, cultural and linguistic issues. RMHP’s goal is to connect Members with the services to support them in overall health improvement

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How are you evaluating success when it comes to care coordination?

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LOG

We log all referrals from Community Mental Health Centers (CMHC) in Essette

TRACK EVALUATE CONTRACT REQUIREMENTS REFERRALS We track outreaches and connections Success can be evaluated by tracking successful outreaches

Our Crisis Services Partners (CS) must follow up within 24 hours of

• crisis. A quality follow-up includes: reassessing risk,

reviewing/updating safety plans, collaborating with immediate supports, support with making a behavioral health appointment.

Members who need further care referred to RMHP for food, housing, transportation, physical and dental health, HealthFirst enrollment

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How does RMHP’s Care Coordination approach differ with a Member who has received Crisis Services?

• RMHP’s Care Coordination team has a

consistent approach for all referrals.

• If the individual requires more

extensive/ongoing care coordination, they will be referred to RMHP Care Coordination

• Referrals from our Crisis Partners are put into

Essette campaigns.

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What is working well when coordinating the care between the two systems?

• Region 1 has the advantage that

the Crisis Services ASO is the RAE

• RMHP’s established relationships

with providers means:

• Many providers are already

aware of the referral process/programs

• Many providers have the

education and awareness around how RMHP’s Care Coordination team works.

• Longstanding relationship

between CMHC’s and RMHP started in July 2018 with RAE and then expanded in July 2019 (when RMHP took over as ASO for Crisis)

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Have best practices been developed?

I. After 24 hour follow up has

• ccurred, Members are

encouraged to seek ongoing treatment to avoid future crisis II. Aggregate data is reported to the ASO on a monthly basis; this

allows RMHP to analyze and give direction on how RHMP works and will inevitably inform the development of best practices

III. Data collection aids with alignment on other quality metrics and informs quality and Performance Outcome Plans (POP)

Crisis Care Coordination I. RMHP utilizes Essette to help close the loop on coordination of care for Members within 48 hours II. RMHPs Care Coordinators are local and know the resources within the communities they serve III. RMHP has integrated AHCM screenings with some of our providers which has helped us determine Member needs and connect them to appropriate services IV. Crisis contract managers have provided further education and awareness to internal staff, including care coordinators, about what CCS is and how it can be accessed in Region 1.

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What are future needs to help improve care coordination between the two systems?

• Targeted outreach with RMHP Crisis Providers about when

to refer individuals to RMHP Care Coordination and how.

• Continue bilateral discussions with RMHP Care

Coordination leadership and Crisis Providers about what high-risk populations would benefit from ongoing care- coordination.

• Increase number of CMHC’s who document in Essette to aid

with electronic referrals and a smoother transition of care coordination information for Members

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Gaps and Barriers

Potential duplication of services is a concern between the two systems. RMHP wants to ensure care coordination is appropriate and intentional.

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Specific transition of care strategies for Members being discharged from:

ATUs:

• CMHC in Durango

manages the ATU discharges there

• For any Member who

ends up in other ATUs, UM manages just like inpatient stays. We review them, typically, every two days for medical necessity. At discharge, they are referred to a discharge campaign and a CM follows up within 24 hours of discharge.

CSUs:

• We use the CSUs as

step down facilities when appropriate, but the CMHC manages the stay if the member is accepted there. Members being d/c from CSU receive a d/c plan with follow up appointments and assessments and resources for the Colorado crisis hotline. Residential: Short term residential: At discharge, cases are referred to a discharge campaign and a CM follows up within 24 hours. Long term residential cases are referred to CMs at discharge for follow up and wrap around services. MH residential: Our CMs would get involved at discharge from the residential facility.

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• RMHP has an established partnership with

Crisis providers as the ASO for Region 1.

• Required Data Sharing

How can RMHP coordinate efforts with the Crisis Services mobile response team?

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General Network Analysis

• All Crisis Service providers are contracted as a RAE

providers in Region 1 due to RMHP holding the ASO contract

• Due to the geographic size of Region 1, and limited

number of providers able to deliver these specialized services, we do have several gaps in mobile services."

• RMHP is working alongside our community partners

and the Office of Behavioral Health (OBH) to develop innovative ways to ensure these areas have coverage.

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What performance metrics (BHIP, KPI, PP) does RMHP feel have the greatest opportunity for improvement based on the work with the crisis service system (CCS)?

• Behavioral Health Incentive Program (BHIP):

– Opportunities for improvement align with Indicators 2 & 3: 7-day follow-ups for SUD ED Visits and MH Inpatient.

• Key Performance Indicators (KPI):

– Opportunities for improvement align with the BH Engagement and ED Visits measures.

• Performance Pool (PP):

– Opportunities for improvement align with the Inpatient Psychiatric Admissions and Department of Corrections (DOC) BH Engagement measures.

• The alignments identified within BHIP, KPI, and PP are being

worked through the CCS Performance Outcome Plans (POP).

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CCS Performance Outcome Plans (POP):

• POPs are

individualized for each contracted Crisis provider, based on their performance and target goals.

The following measures and

• bjectives are the

same across the 4 CCS modalities:

• Follow up within 24

hours

• Behavioral health
• utpatient

appointment scheduled within 7 days

• Crisis call volume

measured

• Episode volume

measured

Additional CCS modality specific measures are: Respite, Mobile, Walk In:

• Diversion Rate

CSU (Choice of):

• Readmission Rate
• Diversion Rate

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What specific strategies can RMHP implement with the help

• f the CCS to impact these performance metrics?
• RMHP is supporting providers on implementing and working their

individual POP plan

• The improvement measures were identified for the

POPs in effort to improve outcomes for CCS.

• CCS improved outcomes will improve measurement
• utcomes within the BHIP, KPI, & PP programs.
• FY20/21, Quarter 1 is being used to implement the POP

plans to ensure data is captured appropriately and accurately.

• FY20/21, Quarter’s 2, 3 & 4 will be measured on

performance against the stated measurement goals.

• RMHP is able to continue to conduct quantitative

/qualitative analysis on the data provided to help impact quality improvement within Crisis Services.

Questions ?