Partnering to Reduce Inpatient Utilization and Right-Size Community - - PowerPoint PPT Presentation

An Innovative P4P Initiative: Partnering to Reduce Inpatient Utilization and Right-Size Community Services

RCPA Conference September 27, 2016

Presenters

 Deborah Duch, Community Care Behavioral Health Organization  Christine Gregor, Pittsburgh Mercy  Melissa Medice, Allegheny County Department of Human Services, Office of Behavioral Health  Kim Patterson, Allegheny HealthChoices, Inc.  Susan Wolfe, Western Psychiatric Institute and Clinic

Learning Objectives

 Define components of successful system-level stakeholder collaboration around decision-making and quality improvement.  Describe elements of the Pay for Performance (P4P) model used in payment redesign.  Replicate practical strategies for attaining targeted system change (reduction of inpatient mental health utilization).

Assertive Community Treatment (ACT) in Pittsburgh, PA

 8 teams, 4 providers  About 750+ individuals served (100/team capacity)  Funded through Medicaid (HealthChoices) and County- Based Funds  Expectations for high fidelity to the ACT model  Annual fidelity reviews occur using the TMACT  ACT is a licensed service in PA  State hospital is not an option

Multi-Level Partnering

5

Level I: Leadership Team Office of Behavioral Health Managed Care Organization Monitoring Authority Level II: ACT Network Workgroup Above plus- ACT directors ACT team leaders Outcome/quality analysts Level III: Team Level ACT training/technical assistance staff ACT team leaders ACT staff

MULTI-LEVEL PARTNERING ALLEGHENY COUNTY, PA

Multi-Level Partnering

Level I: Leadership Team

Activities: Care management Outcomes monitoring Quality improvement Fiscal analysis Fidelity reviews and training

Multi-Level Partnering

Level II: ACT Network Workgroup

Activities: Data review Outcomes monitoring Quality improvement Networking Problem solving

Multi-Level Partnering

Level III: ACT Team Level

Activities: Fidelity reviews Supervising by outcomes Quality improvement Training and skill development

Multi-Level Partnering

Consumer Advisory Committee

Activities: Gathering of individual team advisory group representatives Review data and trends Quality improvement

Assertive Community Treatment Teams: An Overview

 Interdisciplinary team approach: MDs, nurses, peer professionals, mental health professionals, employment specialists, and substance use specialists join together to provide services.  Community-wide service delivery: Services are provided where they are needed, such as a person’s home, place of employment, or other community settings.  Individualized services: Teams work with relatively small numbers of persons to provide individualized care (staff to member ratio of 10:1 with team supporting max of 100 persons).  Time-unlimited support: Teams provide whatever services and supports a person needs for as long as they need them.  Continuous, flexible, and comprehensive services: Several staff work regularly with each person served, providing an array of services at times convenient to the individual.  Round-the-clock service accessibility: Services are available 24 hours a day, 7 days a week, and someone is always available to handle emergent situations.  Utilization of multiple treatment models: Use of a variety of evidence-based practices within the ACT model (e.g., Supported Employment, Integrated Dual Disorders Treatment, etc.).

ACT Outcomes

Increase treatment adherence Increase tenure in independent living Increase those working in competitive employment Improve wellness and health outcomes Reduce, if not eliminate, psychiatric inpatient days

Why Pay for Performance?

High Outpatient Low Outpatient High Inpatient

Baseline Data: 2012

Provider # Members Days WPIC 126 15.1 Pittsburgh Mercy 224 16.8 Total 350 16.2

Average IPMH Days, 2012

Baseline Data: 2012

Pay for Performance (P4P) Model Development

Goal: Reduction of inpatient mental health service utilization by ACT recipients by shifting dollars from inpatient mental health treatment to the community to sustain an adequate level of funding for Assertive Community Treatment (ACT) team supports.

Pay for Performance (P4P) Model Development

Collaborating partners included:

Two ACT providers (Pittsburgh Mercy and Western Psychiatric Institute and Clinic of UPMC) Allegheny County Department of Human Services, Office of Behavioral Health Allegheny HealthChoices, Inc. (AHCI) Community Care Behavioral Health Organization (Community Care)

Pay for Performance (P4P) Model Development

 To be included in the P4P project, consumers needed to be HealthChoices-eligible for at least 80% of the measurement year.  Model dashboard reports were developed so that providers could assess current performance and predict future P4P earnings based on various scenarios related to inpatient mental health services and ACT service utilization.

P4P Interactive Monitoring Tool

P4P Model Specifics

 “Gate and Ladder” approach: Providers had to meet an established threshold of $10,000 per consumer for inpatient cost reduction in

• rder to be eligible for any bonus earnings

 Tiered earnings available from a bonus pool created by withholding 20% of the established ACT service rate  Providers could earn 20% withhold and up to 10% bonus amount if they met the overall target of reducing average inpatient mental health cost per person to $9,000 or less during the calendar year  Bonus earnings increase as inpatient costs decrease  Providers needed to stay under an established cap for total ACT service utilization cost per person for the year of $25,000

P4P Provider Experience: Pittsburgh Mercy

 Partnering for People (P4P): Clinicians and leadership worked together in a focused way to empower the person served to choose a path of recovery—a path paved with logistical freedom, but far more cohesion in terms of treatment, care, and support.  Strategy framework based on belief that many readmissions are preventable.  Began by investigating precipitating factors for inpatient admissions and readmissions:

 Understand fundamentals of behavioral principles and identify antecedents to readmissions & risk factors.  Review hospitalization histories of persons served (both over- and under- utilizers).  Focus on effectiveness of transitions of care.

Pittsburgh Mercy – Strategies & Interventions

 Formulate Strategies Based on Data Analysis

 Define goal of project and utilize a “top down” approach to disseminate information to agency employees, persons served and their supports, and internal/ external agency partners.  Use of a Risk Stratification Tool to allow for continual assessment of risk factors, supports, and interventions.  Create team-based approach to reviewing persons served who have been hospitalized or are at risk of hospitalization (the “War Room”).  Institute cross-setting meetings with crisis services, residential providers, or

• ther stakeholders.

 Divert!

Pittsburgh Mercy – Strategies & Interventions

 Implement Strategies to Address Inpatient Treatment and Care

 Leadership-led training on assertive engagement for all staff.  Meet 5 days/week in the “War Room” to collaborate on high-risk cases.  Create positive behavioral support plans to include motivational incentives.  Enhance/increase informal and natural supports.  Invest more time in working with persons served around medication management.  Address risk factors of persons served on crisis plans and treatment plans.  Have team psychiatrist present within 24 hours of admission to speak with inpatient team.  Implement a best practice process in discharge planning, starting at admission.

Pittsburgh Mercy – Strategies & Interventions

 Assess Effectiveness of Interventions and Maintain a Person-Centered Perspective

 Ensure discharge plans are understood by persons served and shared with the team.  Provide persons served with education and self-management tools that will empower them to navigate their treatment.  Collaborate with physical health and other specialty providers to ensure overall health and wellness.  Constantly engage family/friends/other natural supports in the treatment of persons served.  Routinely inform agency leadership and direct care staff of project progress.

Pittsburgh Mercy: Case Study

 A.R. is a male in his mid-30s diagnosed with schizoaffective disorder, bipolar type, and polysubstance dependence. He started with Pittsburgh Mercy’s ACT program in mid-2009.

 A.R.’s pre-ACT history:

 Extensive history of psychiatric inpatient hospitalizations and D&A rehab stays  Chronic polysubstance use/abuse  Criminal justice system involvement  Medication non-adherence  No insight into his illness or understanding of his diagnosis or how his medications helped him  Exhibited symptoms of paranoia and delusions, and experienced auditory hallucinations

Pittsburgh Mercy: Case Study

 After A.R. started with ACT, but prior to the P4P project:

 Continued to experience crisis situations at least once a year, resulting in 6 community psych hospital admissions and 1 inpatient extended acute unit admission (LOS = 396 days), and 5 DAS admissions (LOS = 24 days)  Continued to use drugs and alcohol, including marijuana and K2  Continued to be non-adherent on his oral medications and required daily med observation by ACT staff  Continued to have poor insight into his mental health and substance use issues  Had issues with housing and experienced multiple evictions and several bouts of homelessness

Pittsburgh Mercy: Case Study

 A.R.’s progress after implementation of P4P interventions…  Zero IP admissions in 2015 and 2016!

 Stable on his medications – now on a long-acting injectable antipsychotic (administered monthly) and an antidepressant (delivered weekly by ACT staff), with subsequent decrease in symptomology  Has been working at the same job since October 2015  Attended school / classes to learn how to become an electrician  Has stable housing – living independently in his own apartment  No arrests  Working on becoming his own payee  More family involvement in his treatment  Decrease in drug use, but further reduction continues to be a treatment goal

P4P Provider Experience: Western Psychiatric Institute and Clinic (WPIC)

 Barrier-breaking model which required increased collaboration between ACT teams and the following entities of a large urban academic medical center:

 Primary Care  Psychiatric Emergency Rooms  Medical Emergency Rooms  Care Management  Crisis Services

P4P Provider Experience: Western Psychiatric Institute and Clinic (WPIC)

 Provided training on health care reform and project specifics to essential groups:

 ACT teams  High-level administration  Persons served  Psychiatric ER  Psychiatric inpatient services  Primary care

 Training included didactic sessions and individual case consultations

WPIC – Strategies & Interventions

Paradigm shift for clinical services to a focus on person-centered planning process resulted in:

 Increased buy-in from persons served and staff and understanding of the “Risk and Responsibility” of mental health recovery  Clinical review of highest utilizers and brainstorming to develop alternatives to long inpatient stays  Collaboration with all stakeholders  Increased development and use of MH recovery tools such MHAD, crisis recovery plans, and integrated care with physical health providers  Participation in “Positive Deviance” project and increased use of person served feedback  Adoption of a “work is treatment” philosophy

WPIC – Strategies & Interventions

 Revamped supervision

 Person-centered planning seen as “core” instrument to inform supervision sessions  Outcomes based supervision with emphasis on real time and historical data  Core requirement for staff to participate in continuing education that focuses

• n evidence-based therapy models

 Utilization of technical tools

 Revise existing internal data and tracking reports  Use of a data dashboard  Electronic record treatment plan revised to include crisis and diversion planning

P4P Project Outcomes

 In 2014, both providers earned the full 20% withhold amount and the maximum bonus earnings of 10% under the P4P model (increased revenue for ACT teams)

 Pittsburgh Mercy achieved a 64% reduction in the average inpatient cost per person per year  WPIC achieved a 28% reduction in the average inpatient cost per person per year

 In 2015, both providers further reduced the average inpatient cost per person per year!

 Pittsburgh Mercy achieved a 76% reduction from the baseline year measure  WPIC achieved a 72% reduction from the baseline year measure

P4P Project Outcomes

Other positive outcomes of the P4P project included:

Improved program efficiencies Increased community tenure for ACT recipients Increased satisfaction for ACT recipients

Success!

Provider 2012 2014 2015 WPIC 15.1 10.5 6.6 Pittsburgh Mercy 16.8 8.7 6.9 Both Providers 16.2 9.3 6.8

Average IPMH Days

Success!

Provider 2012 2014 2015 WPIC: billed ACT $/member $15,835 $16,215 $18,477 WPIC: billed inpatient $/member $12,413 $8,979 $3,486 Pittsburgh Mercy: billed ACT $/member $24,260 $19,321 $18,182 Pittsburgh Mercy: billed inpatient $/member $9,911 $3,573 $2,364 Average Cost of Outpatient & Inpatient Services

Next Steps – Updates to Model and Sustaining Performance

Maintain results in inpatient savings Add targets and P4P earning opportunity for Supported Employment Outcomes Add two additional ACT Providers

Questions?

Presenter Contact Information

 Debbie Duch, MPH Associate Regional Director Community Care Behavioral Health duchd@ccbh.com  Christine Gregor, LSW, CCDP-D Component Services Director, Community Support Services Pittsburgh Mercy cgregor@pittsburghmercy.org  Melissa Medice, BA Supervisor, Adult Mental Health Operations Allegheny County Department of Human Services, Office of Behavioral Health Melissa.Medice@AlleghenyCounty.US  Kim Patterson, MSW, LSW Senior Clinical Consultant Allegheny HealthChoices, Inc. kpatterson@ahci.org  Susan Wolfe, MA Program Director, Community Treatment Teams Western Psychiatric Institute and Clinic wolfesk@upmc.edu