Sustaining Open Access

Transcription

1 Sustaining Open Access Annie Jensen MSW, LCSW MTM Services 0 Access Redesign Experience Improving Quality in the Face of Healthcare Reform David Lloyd, Founder of MTM Services and Senior Consultant for the National Council Scott Lloyd, President of MTM Services and Senior Consultant for the National Council Randy Love, Chief Information Officer for SPQM Data Reporting Services Willa Presmanes, M.Ed., M. A., Medical Necessity/Utilization Management Expert and Co-Author of the DLA-20 (Daily Living Activities) functionality scale Bill Schmelter, Ph.D., Lead Clinical & Collaborative Documentation Consultant for MTM Services and Consultant for the National Council Michael Flora, M.B.A., M.A.Ed., L.P.C.C., L.S.W., Lead Operations Consultant for MTM Services, CEO of the Ben Gordon Center in DeKalb, IL, and Consultant for the National Council David Swann, MA, LCAS, CCS, LPC, NCC MTM. Services Senior Integrated Healthcare Consultant for MTM Services, CEO of a public Local Management Entity in North Carolina, and Consultant for the National Council Joy Fruth, M.S.W., Lead Process Change Consultant for MTM Services and Consultant for the National Council Katherine Hirsch, MSW, LCSW, Collaborative Documentation (CD) Consultant Specializing in CD with Children and Consultant for the National Council John Kern, MD - Collaborative Documentation (CD) Consultant specializing in CD with Prescribers and Integrated Mental Health and Primary Care Services Consultant for MTM Services and Consultant for the National Council Annie Jensen, MSW, LCSW - Process Change Consultant for MTM Services and the National Council Jennifer Hibbard - Operations Consultant for MTM Services, CEO View Point Health in Georgia, and Consultant for the National Council Jennifer Senechal Financial Controller and Cost & Revenue Consultant for MTM Services 1 1

2 MTM Publication Ordering Information: Improving Quality in the Face of Healthcare Reform Experience- MTM Services has delivered consultation to over 700 providers (MH/SA/DD/Residential) in 45 states and 2 foreign countries since MTM Services Access Redesign Experience (Excluding individual clients): 5 National Council Funded Access Redesign grants with 200 organizations across 25 states 6 Statewide efforts with 140 organizations Over 1,500 individualized flow charts created Over $16,000,000 in Annual Savings generated thus far A lot of happy staff and consumers 3 2

3 Learning Objectives No Show Management Centralized Scheduling Levels of Care The system impacts that must be addressed to assure sustainability! 4 Access to Treatment As a Customer Service Focus The primary challenge facing almost every healthcare provider is having adequate service delivery capacity to support timely and effective access to treatment. In an era of integrated healthcare reform, access to treatment is even more critical. The historical three levels of access to care challenges have been Primary Access, Secondary Access, and Tertiary Access. 5 3

4 Three Levels of Access to Care Primary Access- Wait time from the initial call/walk in for routine help to the face to face initial intake/ assessment Same Day Access Secondary Access- Wait time from the initial face to face assessment to the next appointment with treating clinician 3 to 5 days but no longer than 7 days after intake assessment. Tertiary Access- Wait time from the intake/assessment date to an initial appointment for psychiatric services 3 to 5 days but no longer than 7 days after intake assessment. How much capacity is lost in no shows? What is your organization s no show rate for return appointments? How much additional capacity would you have if your organization s no show rate was below 10% for all return appointments for all services types? How much additional capacity would you have if your organization was able to successfully backfill 90% of all cancelled appointments? 7 4

5 Steps to Effective No Show Management Identify Appointment Types National Standard for appointment types: Appointment Kept No Show Appointment Cancelled by Consumer Appointment Cancelled by Staff Develop Definitions for all Appointment Types No show = Consumer either misses the appointment without notifying the organization or provides less than 24 hours notice. Appointment cancelled by consumer = Consumer notifies the organization at least 24 hours in advance they can not attend their appointment. 8 Steps to Effective No Show Management Develop and implement consumer no show standards No shows exceeds 20% or 2 events in a 90 day period Two consecutive no shows or Rate of cancellation exceeds 30% or 3 events in a 90 day period. Develop and implement provider kept appointments standards Provider kept appointment rate will average 90% during last 3 month time period Develop tracking and reporting tool 5

6 Responding to Missed Service Appointments After each missed appointment the service provider discusses reasons for missed appointment and identifies any barriers to treatment. Alternative scheduling plan if: no shows exceeds 20% or 2 events in a 90 day period Two consecutive no shows or Rate of cancellation exceeds 30% or 3 events in a 90 day period. 10 Alternative Scheduling Plans Schedule appointments during off peak hours only No Show Group Walk In Clinic Same Day Appointments initiated by the consumer calling to check availability for that day Medication Clinic 11 6

7 Shifting from Having a Schedule to Managing a Schedule Having a Schedule Model Schedule Out Assume Attendance Let No Show Occur Carry No Show Consumers in Caseload Managing a Schedule Model Negotiate Next Appointment Call and ask for commitment Back fill appointments at a rate of 90% Appropriately Transfer/Discharge Consumers 12 Measurement of Case Loads- The Answer Measurement of specific caseload members no showing/cancelling is a critical part of the ability to reduce rates Need information in clinical staffings and supervision in order to change our behavior Need agency protocol when staff are to begin action on no show/cancellation challenge that is case level specific 13 7

8 Centralized Scheduling The average staff member will spend 100 hours a year managing his or her schedule. The key concept is that schedules belong to the organization, not the provider. Organizations must hold staff and consumers accountable for appointments. Staff must meet specific scheduling rate expectations, and through appropriate attendance policies and engagement strategies, consumers are also held accountable for their participation in treatment. Centralized Scheduling When implementing centralized scheduling there are certain components that should be integrated into policies and protocols. The staffing template should include sufficient appointments each day to absorb each staff s noshow/cancellation rate and meet sustainability for production standards. Other items to include in the policy: Timeframe required for submitting changes to schedule Who approves changes to schedules How are changes communicated to centralized scheduling staff Who has access to schedules and can make changes 8

9 Centralized Scheduling Templates A staff scheduling template is built for a 90 day period. This template includes the clinicians availability and unavailability to provide clinical services during that time. Staff schedules should be blocked for supervision, team meetings, lunch and dinner breaks, holidays and trainings. Non emergency time off would be granted as long as consumers are not scheduled.. Centralized Scheduling Templates Clinicians provide their supervisor with the 90 days scheduling template for approval. Once approved the schedule for months one and two are open for scheduling and month three is in the scheduling system but not open to schedule. On the first day of month two, months two and three are open. Month four is in the system but not open for scheduling. By having two months live in the system and one inactive the clinician has some flexibility if needed to get approval to change the schedule before consumers are scheduled. 9

10 Centralized Schedulers are Responsible for Providing the ability to determine clinical capacity at any time and support just in time service delivery Completing the functions of scheduling new and return appointments Managing all backfilling of open appointment times Completing confirmation phone calls Providing consumers with an available contact person to coordinate their scheduling needs. Focus on Functioning New focus, new ACA law 1/2014: State and federal funding agencies have changed laws and standards that affect funding for services you provide How can you comply with state/federal regulations when billing Medicaid, Medicare, or any 3rd party payer? Establish medical necessity Make rehabilitation your treatment goal and your outcomes measureable. Both requirements can be addressed if you focus on assessed needs: Having the right tools makes it easier. Measure Impact of Symptom Severity on ADLs : Mild, Moderate, Serious, Severe, Extremely Severe Tie assessed needs to objectives! 10

11 Levels of Care Level of Functioning is best determined by assessing functional impairments in daily living activities based on symptoms, behaviors, developmental stage, cognitive abilities, and emotional abilities. Must be able to demonstrate medical necessity and functional impairments. Level of Care includes the scope of evidence based interventions including frequency and intensity. Length of Stay is the recommended length of time an individual can receive the services linked to each level of care. 20 Utilization Management Levels of Functioning (LOF) Require specific Levels of Care (LOC) Tied to Length of Stay (LOS) Provide services that appropriately match the assessed needs of consumers to help them achieve optimal functioning. Review frequently to ensure progress toward outcomes 21 11

12 Levels of Care Establish baseline measurement for consumers symptoms, behavior, and skill deficits and document how these impact consumers functioning is the basis for developing service/ recovery plans Standardized assessment tools and/or local or state mandated tools (ASI, LOCUS, CAFAS, DLA-20, etc.) used in conjunction with an initial assessment helps establish baseline functioning and helps justify continued medical necessity. Once the appropriate level of needed medical necessity is assessed the consumer can be placed in the appropriate level of care. 22 Levels of Care Each level of care would include: Indicator of the level of care that include the admission criteria for that level of care Descriptors of functional impairments to meet the level of care Length of Service which is typically a range of estimated length of treatment Types of Services offered in that level of care ( menu of services) Episode of Care including the frequency of each service type Add on Services Measureable Discharge Criteria 23 12

13 Levels of Care Level of Care # 3 Service Episode of Care Add-Ons Typical Length of Service 1 to 3 years (Reassess every 90 Days) Indicators of Level: 1. Prevention and DSM-IV Axis I Diagnosis. (V-codes Maximum of 2 contacts per wellness or excluded) or DSM-5, and episode of care (Initial Brief Diagnosis/Assessment self-help DLA-20 est.mgaf: for children Intake may require a resources second session) between 6 and 18 years of age with 1-3 areas of disturbance. 2. Hotline Crisis Interventions As needed, no maximum DLA-20 average (moderate to Services serious challenges in school, residence) Individual: Up to 12 CAFAS total score of individual sessions 3. Mental Health PECFAS total score of for children Counseling/Psychotherapy: Family Therapy: Up to 12 Education & under 6 years of age. sessions Referral CBCL 1 score > 64 Group: Up to 12 sessions Average Cost NOTE: When DLA-20 is below 50, complete Medication/Somatic Services CAFAS to further determine need and to determine need for Waiver/waiver services Program Specific Criteria: Evaluation for SEDCBS Psychiatric Rehab Services Psychiatric Evaluation/Med follow-up as needed CPST TCM Psychosocial Group Attendant Care Combination of up to 4-6 hours per week Discharge Criteria: NAMI 6. Families Together 7. KEYS for Networking 8. Self-help resources Possible Descriptors: Possible history of hospitalizations in past 2 years & may need stabilization Impaired structure and supports in his/her life, e.g., includes situational loss Everyday functioning in school or in residence is moderately to seriously impaired (e.g., school refusal/anxiety, unable to stay in school, or failing school, or unable to function safely) Serious impairment in relationships with friends (e.g., very few or no friends, or avoids current friends); Problems with the law (e.g., shoplifting, arrests) or frequent episodes of combative, aggressive, antisocial behavior. 1-3 Serious Symptoms from the following list: Serious impairment in judgment (incl. inability to make safe decisions, confusion, disorientation) Serious impairment in thinking (incl. ruminations, rituals, constant preoccupation w/ thoughts, distorted body image, paranoia) Serious impairment in mood (incl. constant depressed mood, passive suicidal ideation or agitation, or manic mood) Serious impairment due to anxiety (panic attacks, overwhelming anxiety). Other symptoms: delusions, or obsessional rituals Psychiatric symptoms & behavior & functioning have improved and a less intensive level of care is appropriate. Average DLA-20 functioning is >4.8 Improved in 8 out of 10 ADLs (Activities of Daily Living) from intake serious and moderate scores in Mood Management, Communication, Safety, Problem Solving, Nutrition, Family/Guardian relationships, Alcohol>Drugs, Coping Skills, Behavior Norms (court requirements) & Hygiene Satisfactory effectiveness with prescribed Medications Family/Self Administers Medications Private Means of obtaining medications if discharged School, Community integration/support Medical needs addressed Stabilized residence Client is goal directed; Attending school, work Family/Client has better understanding of illness Family provides improved structure and support 24 THANK YOU QUESTIONS???? 13