Planning Effective. Workflows & Payment Models

Transcription

1 Planning Effective Collaborative Care Workflows & Payment Models Virna Little, PsyD, LCSW r, SAP

2 TWO PROCESSES 1. Systematic diagnosis and outcomes tracking e.g., PHQ 9 to facilitate diagnosis and track depression outcomes TWO NEW TEAM MEMBERS collaborate with PCPs Care Manager age Consulting Psychiatrist st Patient education / selfmanagement support Close follow up to make sure patients don t fall through the cracks 2. Stepped Care Support anti depressant Rx by PCP a) Change treatment according to evidence based algorithm if patient is not improving b) Relapse prevention once patient is improved Brief counseling (behavioral activation, PST PC, CBT, IPT) Facilitate treatment change / referral to mental health Relapse prevention Caseload consultation for care manager and PCP (population based) Diagnostic consultation on difficult cases Consultation focused on patients not improving as expected Recommendations for additional treatment / referral according to evidence based guidelines

3 Workflows Why workflows Workflows after financing Detail Training New providers

4 Patient Presents for Medical Care PHQ 2 BPA Fires OR Patient presents with Depressive Symptoms, including Sadness, feelings of Helplessness/Hopelessness, Fatigue, Chronic body or headaches PHQ 2 Administered Utilize PHQ 2 SmartSet to document result Who: Nursing Patient Scores Negatively (No yes ) Patient Scores Positively (one or more yes ) Administer GAD 7 Who: Nursing Administer PHQ 9 Who: Nursing

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7 Who are You? FQHC Article 28 primary care Article il 31 mental health h( APG and non APG) Article 28 Hospital Outpatient

8 Article 28 Mental Health FQHC have behavioral health billing Article 28 has limits in New York Care management is not billable bl Case management is not billable CCI care management services are not billable in article 28 non fqhc centers

9 What to do? Integrated licensure Article 31 on premises or within organization Adding to provider visit ii complexity

10 Review Payer Mix What payers does your organization or BH services get reimbursement from Review guidelines for each payer are services part of the contract or do they need to be added Does the payer reimburse for all credentials, i.e. social workers vs. counselors

11 Make A Grid What payers are involved List all of your payers Individually remember some have more then one plan List all of your billable staff Leave space for contracting possibilities

12 ORG NAME Individual Psychotherapy payor mix LCSW LMSW LMHC LPC PCP Psycho Psychi RN NP/PA MA Ph.D Medicare Medicaid Empire

13 Contracts Can be second source if a provider or code is not billable Contrary to popular blifth belief they are negotiable If you don t ask (is this the best rate you are offering in this state?) Check with other CCI project members Medicare Advantage

14 Credentialing Not to be confused with professional appointments Why should I bother if most of our patients are Medicaid? What if my organization doesn t credential behavioral health hproviders? Subject to reviews by credentialing organizations Takes a long time Delegated credentialing is a goal

15 Abstract Dollars Can help support IMPACT work Will vary by organization/setting/payer mix Time spent with PCP No show rates for PCP, specialty care Medication adherence Emergency room visits/utilization Productivity for behavioral health

16 Quality Dollars Disease Management industry Potential to have care management paid for ( at your site vs. by phone ) Brings in additional dollars above wrap Showcases your program/project Offer to be a pilot Gain sharing agreements Health Home or ACO

17 Optimize By Knowing what you should be paid for all services Reviewing work flows, opportunities to maximize revenue Review same day billing, services

18 Medicare Does Pay For Two Visits on the same day Incident too visits Behavioral health providers in health centers

19 Getting Paid What You re Due Look closely at EOB s Not all payments are correct Review and Track your Denials May see PCP denials for depression dx Review: Payer contracts

20 Behavioral Health Billable Documentation Progress notes vs psychotherapy py pynotes Included in compliance Many have not billed before or have not had oversight in article 28 settings Clear meaningful progression Treatment plans Quantifiable outcomes

21 The Documentation Linkage Psychosocial Assessment Treatment Plan Progress Notes

22 The Documentation Linkage Psychosocial Diagnoses Strengths/Challenges Assessed Needs/Personal Goals Treatment Plan Goals and Objectives Should link to assessed needs and goals from initial assessment Progress Notes Interventions Clinical progress

23 Most Common Deficiencies* Psychosocial Assessments: Not enough symptom information in assessment to support diagnosis Not capturing clinical baselines No documentation that clients were given the opportunity to identify their own goals for treatment *Basedon NYSCRI regulatory review

24 Continued Treatment Plans Not completed within required timeframes (90 days) Goals are not clearly related to assessed needs Interventions not included Evidence Based Interventions Goals and Objectives Measurable

25 Contents of Behavioral Health Notes Reason for visit Review of symptoms Clinical Interventions Plan progress towards treatment plan goals

26 Questions i