1 Ohio s Community Behavioral Health Center Health Homes: A New Service Delivery Model 1 C E N T E R F O R E V I D E N C E - B A S E D P R A C T I C E S A T C A S E W E S T E R N R E S E R V E U N I V E R S I T Y - C O N F E R E N C E O C T O B E R 2 3, A N G I E B E R G E F U R D, A F E T K I L I N C, PH.D., P C C -S O H I O D E P A R T M E N T O F M E N T A L H E A L T H
2 A Health Home is A new service delivery model for Medicaid consumers with uncoordinated care Whole person care coordination / care management for consumers with complex conditions Person-centered planning approach to identify needed services and supports Consideration of the needs of the person without compartmentalizing aspects of the person, his/her health, or his/her well-being Providing care and linkages to care that address all of the clinical and non-clinical needs 2
3 Related to, but Not the Same as, the Patient-Centered Medical Home 3 Use Patient-Centered Medical Home (PCMH) as foundation for Medicaid Health Homes Medicaid Health Homes expand on PCMHs by: Focusing on patients with multiple chronic and complex conditions; Coordinating across medical, behavioral, and long-term care; and Building linkages to community, social supports, & recovery services Focus on outcomes reduced ED & hospital admissions & readmissions, reduced reliance on LTC facilities, improved experience of care and quality of care
4 Ohio s CBHC Health Homes: Background & Overview 4 Affordable Care Act of 2010, Section 2703 Budget bill authorized Ohio Medicaid to design a health home model and implementation strategy Ohio Medicaid teamed up with Ohio Department of Mental Health to focus first on persons with serious & persistent mental illness Ohio s State Plan Amendment (SPA) was approved by the Federal government on September 17, 2012 Health Homes for people with SPMI were implemented initially on 10/1/2012
5 Ohio Medicaid Health Homes Service Delivery Model Organizational Transformation CBHC Health Home Family Enhanced Access Patient Person Natural Supports Care Coordination Person-Centered Care Plan DRAFT Health Information Technology ODJFS, OHP, BHSR, 1/24/2012
6 Ohio Health Home Goals are Improve care coordination Improve integration of physical and behavioral health care Improve health outcomes Lower rates of hospital emergency department use Reduce hospital admissions and readmissions Decrease reliance on long-term care facilities Improve the experience of care and quality of life for the consumer Reduce healthcare costs 6
7 Health Home Consumers 7
8 Eligible Health Home Consumers Are Adults and children with Medicaid who have: Serious and Persistent Mental Illness Serious Mental Illness Serious Emotional Disturbance Eligible consumers include: Persons currently receiving services at the community mental health agency Persons referred to health home from hospitals, specialty providers, MCP or other referral sources Eligibility will be determined at the health home 8
9 Health Home Population Criteria: Serious and Persistent Mental Illness 9 Serious and Persistent Mental Illness (SPMI): Must be 18 years of age or older Must meet criteria for any of the DSM-IV TR diagnoses, except the exclusionary diagnoses (DD, AOD, V Codes & Dementia) Treatment history criteria Global Assessment of Functioning scale (GAF) Score of 50 or below
10 Health Home Population Criteria: Serious and Persistent Mental Illness Treatment history criteria 10 Continuous treatment of 12 months or more, or a combination of, the following treatment modalities: inpatient psychiatric treatment, partial hospitalization or 12 months continuous residence in a residential program (e.g., supervised residential treatment program, or supervised group home); or Two or more admissions of any duration to inpatient psychiatric treatment, partial hospitalization or residential programming within the most recent 12 month period; or A history of using two or more of the following services over the most recent 12 month period continuously or intermittently (this includes consideration of a person who might have received care in a correctional setting): psychotropic medication management, behavioral health counseling, CPST, crisis intervention. Previous treatment in an outpatient service for at least 12 months, and a history of at least two mental health psychiatric hospitalizations; or In the absence of treatment history, the duration of the mental disorder is expected to be present for at least 12 months.
11 Health Home Population Criteria: Serious Mental Illness 11 Serious Mental Illness (SMI) : Must be 18 years of age or older Must meet any of the DSM-IV TR diagnoses, except the exclusionary diagnoses (DD, AOD, V Codes & Dementia) Assessment of impaired functioning measured by the GAF (score of 40 to 60) Treatment history criteria
12 Health Home Population Criteria: Serious Mental Illness Treatment history criteria Continuous treatment of 6 months or more, or a combination of, the following treatment modalities: inpatient psychiatric treatment, partial hospitalization or six months continuous residence in a residential program (e.g., supervised residential treatment program, or supervised group home); or Two or more admissions of any duration to inpatient psychiatric treatment, partial hospitalization or residential programming within the most recent 12 month period; or A history of using two or more of the following services over the most recent 12 month period continuously or intermittently (this includes consideration of a person who received care in a correctional setting): psychotropic medication management, behavioral health counseling, CPST, crisis intervention; or Previous treatment in an outpatient service for at least six months, and a history of at least two mental health psychiatric hospitalizations; or In the absence of treatment history, the duration of the mental disorder is expected to be present for at least 6 months. 12
13 Health Home Population Criteria: Serious Emotional Disturbance o Serious Emotional Disturbance (SED): 13 Must be 17 years of age or younger Must meet criteria for any of the DSM-IV TR diagnoses, except the exclusionary diagnoses (Developmental disorders, Substance use disorders, and V Codes) Duration of the mental health disorder has persisted or is expected to be present for 6 months or longer Assessment of impaired functioning as measured by the Global Assessment of Functioning scale (GAF Score of below 60)
14 HEALTH HOME SERVICE 14
15 Health Home Service Components 15 Health home service providers are required to have the capacity to provide all components of the health home service as described in the health home service rule.
16 Health Home Service Delivery Format Health home service may be: 16 Provided to the consumer and any other individuals who will assist in the consumer's treatment; Delivered face-to-face, by telephone, and/or by video; Delivered in individual, family and group format; Performed in locations and settings that meet the needs of the health home consumer.
17 Health Home Service Components: Comprehensive Care Management Identification of consumers who are SPMI and potentially eligible for health home services; Recruit and engage consumers through discussing the benefits and responsibilities of participating and any incentives for active participation and improved health outcomes; Conduct comprehensive health assessment; form a team of health care professionals to deliver health home services based on the consumer s needs; establish and negotiate roles and responsibilities, including the accountable point of contact; Develop, review and update the care plan Develop Crisis and Contingency Plan Develop Communication Plan 17
18 Health Home Service Components: Care Coordination Implementation of individualized treatment plan; Assist consumer in obtaining health care, including mental health, substance abuse services and developmental disabilities services, ancillary services and supports; Medication management, including medication reconciliation; Track tests and referrals and follow-up as necessary; 18 Coordinate, facilitate and collaborate with consumer, family, team of health care professionals, providers; Monitor care plan and the individual s status in relation to his or her care plan goals; Provide clinical summaries and consumer information along with routine reports of treatment plan compliance to the team of health care professionals, including consumer/family.
19 Health Promotion Health Home Service Components: Health Promotion Provide education to the consumer and his or her family /guardian/significant other that is specific to his/her needs as identified in the assessment; Assist the consumer to acquire symptom self-monitoring and management skills so that the consumer learns to identify and minimize the negative effects of the chronic illness that interests with his/her daily functioning; Provide or connect the consumer with the services that promote healthy lifestyle and wellness and are evidence based; Actively engage the consumer in developing and monitoring the care plan; Connect consumer with peer supports including self-help/self-management and advocacy groups; Develop consumer specific self-management plan anticipating possible occurrence or re-occurrences of situations required an unscheduled visit to health home or emergency assistance in a crisis; Population management through use of clinical and consumer data to remind consumers about services need for preventive/chronic care; Promote health behavioral and good lifestyle choices; Educate consumer about accessing care in appropriate settings. 19
20 Health Home Service Components: Comprehensive Transitional Care and Follow-up 20 Facilitate and manage care transitions (inpatient to inpatient, residential, community settings, pediatric to adult) to prevent unnecessary inpatient admissions, inappropriate emergency department use and other adverse outcomes such as homelessness; Develop a comprehensive discharge and/or transition plan with short-term and long-term follow-up; Conduct or facilitate clinical hand-offs as face-to-face interactions between providers to exchange information and ask questions;
21 Health Home Service Components: Individual and Family Support 21 Provide expanded access and availability; Provide continuity in relationships between consumer/family with physician and care manager; Outreach to the consumer and their family and perform advocacy on their behalf to identify and obtain needed resources such as medical transportation and other benefits to which they may be eligible; Educate the consumer in self-management of their chronic condition; Provide opportunities for the family to participate in assessment and care plan development; Ensure that health home services are delivered in a manner that is culturally and linguistically appropriate; Referral to community supports; assist with natural supports; Promote personal independence; empower consumer to improve their own environment; Include the consumer family in the quality improvement process including surveys to capture experience with health home services; use of a patient/family advisory council at the health home site; Allow consumers/families access to electronic health record information or other clinical information.
22 Health Home Service Components: Referral to Community & Social Support Services Provide referrals to community/social/recovery support services; 22 Assist consumers in making appointments and validating that the consumer attended the appointment and the outcome of the visit and any needed follow-up.
23 Behavioral and Physical Health Integration 23
24 Behavioral and Physical Healthcare Integration 24 A health home provider must demonstrate integration of physical and behavioral health care by either achieving: o successful implementation of accrediting body integrated physical health/primary care standards during its next accreditation survey process following the health home service certification; or o recognition as a Patient Centered Medical Home within 18 months of being certified to provide health home service.
25 Person-Centered Care 25
26 Health Homes and Person-Centered Care 26 A health home provider must support delivery of person-centered care by: Expanded, timely access Orientation of the patient to Health Home services Services in a culturally and linguistically appropriate manner A multi-disciplinary team based approach for the delivery of Health Home services through the continual use of an established team of core members defined by the state
27 Health Homes and Person-Centered Care-cont. Support the delivery of person-centered care by also providing: A single, integrated, and person-centered care plan that coordinates all of the clinical and non-clinical needs. The ability to track tests and referrals for health care services, and coordinate follow up care as needed. 27 Point of care reminders for patients about services needed for preventive care and/or management of chronic conditions by using patient information and clinical data.
28 Health Home Team Composition 28
29 Health Home Team Composition 29 A health home provider shall utilize an integrated, multidisciplinary team to deliver health home service. Licensed, certified or registered individuals shall comply with current, applicable scope of practice and supervisory requirements identified by appropriate licensing, certifying or registering bodies.
30 Health Home Team Composition Health Home Team Leader o o o o 30 Minimum qualifications: o Licensed independent social worker, professional clinical counselor, independent marriage and family therapist, registered nurse with a master of science in nursing, certified nurse practitioner, clinical nurse specialist, psychologist or physician. Supervisory, clinical and administrative leadership experience. Health management experience, and competence in practice management, data management, managed care and quality improvement. Responsibilities: o Provide administrative and clinical leadership and oversight to the health home team, and monitor provision of health home service. o Monitor and facilitate consumer identification and engagement, completion of comprehensive health and risk assessments, development of care plans, scheduling and facilitation of treatment team meetings, provision of health home service, consumer status and response to health coordination and prevention activities, and development, tracking and dissemination of outcomes.
31 Health Home Team Composition Embedded Primary Care Clinician o Qualifications: o Primary care physician, internist, family practice physician, pediatrician, gynecologist, obstetrician, certified nurse practitioner with primary care scope of practice, clinical nurse specialist with primary care scope of practice, or physician assistant. 31 o Responsibilities: o Provide health home service including identification of consumers, assessment of service needs, development of care plan and treatment guidelines, and monitor health status and service use. o Provide education and consultation to the health home team and other team members regarding best practices and treatment guidelines in screening and management of physical health conditions as well as engage with, and act as a liaison between, the treating primary care provider and the team. o Meet individually as needed with care managers to review challenging and complex cases. o It is preferred, but not required, that the embedded primary care clinician also functions as the treating primary care clinician and thus may hold dual roles on the health home team.
32 Health Home Team Composition 32 Care Manager o Minimum qualifications: o Licensed social worker, independent social worker, professional counselor, professional clinical counselor, marriage and family therapist, independent marriage and family therapist, registered nurse, certified nurse practitioner, clinical nurse specialist, psychologist or physician. o Possess core and specialty competencies and skills in working with persons with SPMI, including assessment and treatment planning. o Demonstrate either formal training or a strong knowledge base in chronic physical health issues and physical health needs of persons with SPMI and be able to function as a member of an inter-disciplinary team. o Knowledge of community resources and social support services for persons with SPMI. o Responsibilities: o Accountable for overall care management and care coordination, and both provide and coordinate all of the health home service. o Responsible for overall management and coordination of the consumer's care plan, including physical health, behavioral health, and social service needs and goals. o Conduct comprehensive assessments and develop care plans. o Conduct case reviews on a regular basis.
33 Health Home Team Composition Qualified Health Home Specialist Minimum qualifications: Pharmacist, licensed practical nurse; qualified mental health specialist with a four-year degree, two-year associate degree or commensurate experience; wellness coach; peer support specialist; certified tobacco treatment specialist, health educator or other qualified individual (e.g., community health worker with associate degree). Responsibilities: 33 Assist with care coordination, referral/linkage, follow-up, consumer, family, guardian and/or significant others support and health promotion services.
35 Health Homes and HIT 35 Within 12 months of receiving designation as a Health Home provider, the CBHC must acquire (or adopt) an electronic health record product that is certified by the Office of the National Coordinator for Health Information Technology. Within 24 months of receiving designation as a Health Home provider, the CBHC must demonstrate that the electronic health record is used to support all Health Home services, including population management. The CBHC must also participate in any statewide Health Information Exchange.
36 Health Home and Other Providers 36
37 Health Homes and Medicaid Managed Care CBHCs must establish relationships with managed care plans: Ensuring all needs of health home members are met Ensuring clear delineation of service delivery responsibilities ALL health home services will be provided by the CBHC Health Home Work with a designated single point of contact assigned by MCP Collaborate with MCP panel providers and clinicians 37 Foster relationships with MCP that encourage bi-directional free flow of data gathering and reporting
38 Health Homes and Community Providers To facilitate health home beneficiaries access to needed services, CBHCs must also establish relationships with: Specialty (including substance abuse) care providers Long-term care providers Hospitals (including emergency departments) Other community providers (e.g., nutritionists, housing, etc.) 38
39 Data/Information Exchange 39
40 Health Home and Data Sharing Patient Profile Utilization data set includes: Demographics Affiliation with MCP and PCP 24 months of summary level data Data sources would include FFS and MCP Encounter level data 40 For each Service and/or drug
41 Health Home and Data Sharing Real time data exchange Health homes and psychiatric hospitals Health homes and general hospitals (inpatient and emergency department) Health homes and MCPs Integrated Care Plan 41
42 Health Home Quality Measures 42
43 Health Home Service: Quality Improvement Requirements 43 Health Home provider must have existing capacity to collect and report data and meet health home performance measurement requirements which consist of mandatory Centers for Medicare and Medicaid Services core measures and measures established by the Ohio department of mental health in conjunction with stakeholder input.
44 Health Home Quality Measures 44 CMS Core Measures State Selected Measures 1. Timely Transmission of Transition Record 2. Screening for Clinical Depression and Follow-up Plan 3. Adult BMI Assessment 4. Initiation and Engagement of Alcohol and Other Drug (AOD) Dependence Treatment 5. Ambulatory Care Sensitive Conditions Hospitalization Rate 6. All-Cause Readmissions 7. Follow-Up After Hospitalization for Mental Illness 1. Cholesterol Management for Patients With Cardiovascular Conditions 2. Controlling High Blood Pressure 3. Reconciled Medication List Received by Health Home 4. Comprehensive Diabetes Care: HbA1c level Less Than 7.0% 5. Comprehensive Diabetes Care: LDL-C Screening and LDL-C Less Than 100 mg/dl 6. Use of Appropriate Medications for People with Asthma
45 Health Home Quality Measures- continued 45 CMS Core Measures State Selected Measures 1. Timely Transmission of Transition Record 2. Screening for Clinical Depression and Follow-up Plan 3. Adult BMI Assessment 4. Initiation and Engagement of Alcohol and Other Drug (AOD) Dependence Treatment 5. Ambulatory Care Sensitive Conditions Hospitalization Rate 6. All-Cause Readmissions 7. Follow-Up After Hospitalization for Mental Illness 7. Annual Assessment of Body Mass Index, Glycemic Control, and Lipids for People with Schizophrenia Who Were Prescribed Antipsychotic Medications 9. Annual Assessment of Body Mass Index, Glycemic Control, and Lipids for People with Bipolar Disorder Who Were Prescribed Mood Stabilizer Medications 10. Percent of Live Births Weighing Less than 2,500 grams 11. Prenatal and Postpartum Care 12. Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents
46 Health Home Quality Measures-continued 46 CMS Core Measures State Selected Measures 1. Timely Transmission of Transition Record 2. Screening for Clinical Depression and Follow-up Plan 3. Adult BMI Assessment 4. Initiation and Engagement of Alcohol and Other Drug (AOD) Dependence Treatment 5. Ambulatory Care Sensitive Conditions Hospitalization Rate 6. All-Cause Readmissions 7. Follow-Up After Hospitalization for Mental Illness 12. Adolescent Well-Care Visits 14. Adults' Access to Preventive/Ambulatory Health Services 16. Appropriate Treatment for Children with Upper Respiratory Infections 17. Annual Dental Visit 20. Smoking and Tobacco Use Cessation 22. Inpatient and Emergency Department (ED) utilization Rate 24. Client Perception of Care - National Outcome Measure (SPMI Health Home) 26. Proportion of Days Covered of Medication
47 Health Services Advisory Group (HSAG) Health Services Advisory Group, Inc. (HSAG) is a health care quality improvement and quality review organization. HSAG offers outcomes measurement and quality improvement interventions. ODJFS is considering contracting with HSAG to: Conduct quarterly analyses of Health Home Quality Measures data; Produce quarterly reports on Health Home Quality Measures; Disseminate the reports/results in Excel spreadsheets; and Provide technical assistance to the Health Homes. 47
48 Health Home Payment Approach 48
49 Health Home Payment Approach 49 State pays for health home services based on submission of fee-for- service (FFS) monthly claim (HCPCS code S0281) Monthly case rate covers ALL health home service components CBHC can bill for health home services for clients on spend-down as soon as spend-down is met
50 Payment Approach, cont. 50 Separate payments continue for o Community BH services treatment services (e.g., counseling) o Other treatment services (e.g., primary care & specialty services) through existing Medicaid payment mechanisms (MCPs or FFS). Case management or other types of coordination services are not reimbursed for clients receiving health home services such as ODMH CPST, ODADAS Case Management, Help Me Grow Targeted Case Management, MCP care management
51 Health Home Implementation Regions and Schedule 51
52 Health Home Regional Implementation Schedules Are 52 Phase I: Implementation Date is October 1, 2012 Regions are Scioto, Adams, Lawrence, Butler and Lucas Counties Phase II: Tentative Implementation Date is April, 2013 Regions are 30 additional counties Phase III: Tentative Implementation Date is July, 2013 Regions are remaining 53 Counties
53 Health Home for SPMI Implementation Schedule based on Letters of Intent* Recommended Implementation Schedule Green - October 2012 Blue - April 2013 Yellow - July 2013 * Non-binding letters of intent as submitted by CBHCs 53
54 Application & Certification Process Qualifying community mental health agencies (CMHA) may submit health home service provider supplemental application effective October 1, 2012 ODMH Licensure and Certification Office reviews applications and notifies applicants via mail A list of certified community mental health agencies can be obtained on the ODMH health home website Approved phase I health homes in Lucas, Butler, Adams, Lawrence and Scioto Counties 54
55 Early Implementation and Lessons Learned 55
56 Early Implementation and Lessons Learned 56 Provider Application and certification process Multi-pronged and robust communication strategy Engagement of key stakeholders and partners Legal, systems and data infrastructure requirements Provider training and orientation Program and clinical implementation Flexibility and creativity is KEY!
57 57 For a complete list of Health Home documents, please visit the following link: Questions to