Care Coordination and Transitions in Behavioral Health

Care Coordination and Transitions in Behavioral Health Pam Pietruszewski Integrated Health Consultant The National Council for Behavioral Health This product is supported by the Florida Department of Children and Families Substance Abuse and Mental Health Program Office funding.

The National Council for Behavioral Health 2500+ member organizations that provide safety net mental health, primary care and substance abuse treatment services. National voice for legislation, regulations, policies, and practices that protect and expand access to effective mental health and addictions services.

Coordination in Context Depression Improvement Across MN Offering a New Direction (DIAMOND) Care of Mental, Physical and Substance Use Syndromes (COMPASS) Reducing Avoidable Readmissions Effectively (RARE) Reducing Adolescent Substance Abuse Initiative (RASAI) Center for Integrated Health Solutions (CIHS) MN Practice Facilitation Program Motivational Interviewing 2

Today s Objectives Describe the status of care transitions and the current state of care. Define existing care transition models and their application to mental health. Assess quality strategies to support changes in the policy landscape.

Consequences of Inadequate Transitions to Patients and Families Poor health outcomes 1,2 Unnecessary disruptions and stress to families and patients 2 1. American Geriatrics Society Position Statement 2007 2. Coleman, E.A., J Am Geriatr Soc 51:549 555 (2003). January 2015 018749-141219 4

Consequences of Inadequate Transitions to The Medical System Based on an analysis of Medicare claims data between 2003 2004: Almost20% of total Medicare beneficiaries were rehospitalized within 30 days, and 34% within 90 days 1 Unplanned rehospitalizations in 2004 cost $17.4 billion Medicare and Medicaid: 50% of total rehospitalizations within 30 days of discharge showed no bills for physician visits between discharge and rehospitalization 1,2 1 1. Jencks SF et al. N Engl J Med. 2009 2. Gilmer T, Center for Health Care Strategies, Inc. 2010 January 2015 018749-141219 5

Consequences of Inadequate Transitions to The Behavioral Health System Up to 50% of all patients discharged from psychiatric hospitals are readmitted within 1 year 1 Medicare: Readmission rates increase with number of chronic conditions, including schizophrenia 2 One in 5 people with schizophrenia and other psychotic disorders has a hospitalization readmission within 30 days of hospital discharge 3 1. Vigiano T. Clinical Therapeutics, 2012. 2. Gilmer T. Center for Health Care Strategies, Inc. 2010. 3. Elixhauser A. HealthcareCost and Utilization Project, 2013. January 2015 018749-141219 6

Care Coordination The deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient s care to facilitate the appropriate delivery of health care services. AHRQ 2007

Critical Components Care Coordination Project Team, FL Dept. of Children & Families Assessment and standardized level of care determination Knowledge of community resources Shared decision making Single point of accountability Family and person centered plan of care Family and individual choice and needs drive care Coordination across the spectrum of health services (physical & behavioral health) & social services, housing, education, & employment Information sharing Health Information Technology (HIT) Effective transitions and warm hand offs Goal of wellness and recovery

Poll Question #1 As of today, which of the Critical Components do you feel most confident about being able to implement? Level of care determination Community resources Shared decision making Single point of accountability Family and person centered choice, needs; plan of care Coordination across the spectrum of services Health Information Technology & data sharing Transitions and warm hand offs Goal of wellness and recovery

Poll Question #2 As of today, which of the Critical Components do you feel least confident about being able to implement? Level of care determination Community resources Shared decision making Single point of accountability Family and person centered choice, needs; plan of care Coordination across the spectrum of services Health Information Technology & data sharing Transitions and warm hand offs Goal of wellness and recovery

Few models specifically address the population of people with Serious Mental Illness, but there are several well-researched and widely known care transition models. 1 Care Transitions Intervention Transitional Care Model 1. Health Affairs/Robert Wood Johnson Foundation. Health Policy Brief, 2012. January 2015 018749-141219 11

Care Transitions Intervention (CTI) Developed by Eric Coleman, MD, MPH, University of Colorado Key components 1 Patient-centered record, or Personal Health Record Structured checklist of critical activities to empower patients pre-discharge Patient self-activation and management session with a Transitions Coach in the hospital Transitions Coach follow-up visits and phone calls Outcomes 30% reduction in hospital readmissions 2 Follow-up pilot showed 36% reduced readmission rate 3 1. Parry, et al. Home Health Care Serv. Q. 2003 2. Coleman, et al. Arch Intern Med 2006. 3. Voss et al. Arch Intern Med 2011 January 2015 018749-141219 12

Transitional Care Model (TCM) Developed by Mary Naylor, University of Pennsylvania Studied on older adults, but has good lessons for other populations as well Key components 1 Transition support begins in the hospital Heavy emphasis on patient education/activation Home-visiting component Accompany consumer to appointments Different from traditional case management Outcomes 1,2 Reduced readmission rates, and shorter stays & longer time between first and second admissions Improved physical health, functional status & quality of life Increased patient and family caregiver satisfaction Reduction in total and average costs per patient (mean savings of approximately $5000 after accounting for cost of the intervention) 1. Transitional Care Model, http://www.transitionalcare.info/ 2. Naylor MD et al. J Am Geriatr Soc. 2004 January 2015 018749-141219 13

Common Model Elements Time-limited supports Heavy investment in education and patient activation Assigned person to support patient and family pre- and posttransition January 2015 018749-141219 14

Other Adaptations & Initiatives Re-engineering Discharge (RED) Better Outcomes for Older Adults through Safe Transitions (BOOST) Reducing Avoidable Readmissions Effectively (RARE) Geriatric Resources for Assessment and Care of Elders (GRACE) Availability, Responsiveness and Continuity (ARC)

Components of High Quality Care Coordination Relationships Recognizing Risk Education & Empowerment Systematic Follow up

Relationships Relationships with team members, community partners Key contacts Clear workflows with warm hand offs Shared records, release of information Written policies/protocols

Social worker Physician patient Peer specialist Nurse Care Coordinator Psychologist consumer Physician Housing coordinator Psychiatrist Pharmacist

Team-Based Care More than just adding a care coordinator Share vision of care team Reconfiguring front-back office functions Cross-training Time, effort, trust building Standing orders, protocols Nutting, Annals of Family Medicine 2010

Questions to Ask When Developing your Process 1. What are my resources and is my knowledge current? 2. Where do I look for other resources? 3. What does this resource provide? 4. Who is my contact? 5. How do we exchange information? 6. How can I build bridges?

Recognizing Risk Risk prediction, stratification Diagnoses and comorbidities History of hospitalizations Cultural barriers Level of Care Utilization System (LOCUS) http://www.dbhn.com/ Patient Centered Assessment Method Maxwell, Hibberd, Pratt, Peek and Baird 2013 www.pcamonline.org The 8P s - Project BOOST Society of Hospital Medicine

Risk Assessment 8P - Project BOOST 1. Problems with medications 2. Psychological 3. Principal diagnosis 4. Physical limitations 5. Poor health literacy 6. Poor social support 7. Prior hospitalization 8. Palliative care http://www.hospitalmedicine.org/web/quality_innovation/implementation_t oolkits/project_boost/web/quality Innovation/Implementation_Toolkit/B oost/boost_intervention/tools/risk_assessment.aspx

Education & Empowerment Prevention System navigation Motivational Interviewing, teach back, health literacy, self-management skill building Chronic care management Partnership Acceptance Evocation Compassion The spirit of Motivational Interviewing

Actual Discharge Form Example from Project RED: The ReEngineered Discharge

Who has influence? Every touch point = opportunity

Open-Ended Inquiry Instead of 1. Can you cut back on your smoking? 2. Are you taking your medication? Try 1. What are the good things, and the not so good things about smoking for you? 2. How are you taking your medication? 3. Why haven t you followed up with your case worker? 3. Tell me about your case worker and the expectations for follow up.

Readiness Rulers On a scale of 0 to 10, how important is it for you to do something different? On a scale of 0 to 10, how confident are you that you can do something different?

Achievable Goals

Conversation Starting Points 1. What is most important to you? 2. Where would you like to start? 3. What could you do differently? 4. How might you make the best of it? 5. What is your next step?

Systematic Follow up Follow up protocols Opportunity for step-down services Relapse prevention Celebrating accomplishments

1. Goal or Action Self-Care Plan Elements 2. Reason(s) to focus on this goal/action 3. First steps 4. Potential challenges 5. People who support me 6. I will know that my plan is working if: 7. Actions I will take if this plan isn t working

Systematic Case Review Patient ID Discharge date Primary diagnosis Primary provider Short term health goals Current level of care 48726 9/22/15 Bipolar disorder Wong, T. Find stable housing within 3 months 3 49399 8/20/15 Substance use disorder 274761 8/31/15 Congestive heart failure Etc. Etc. Clarkson, J. Kaner, L. Continued sobriety 1 Eliminate fried foods 4

Change in the Policy Landscape Hospital Readmission Penalties Built-in Expectations for Improved Care Transitions Focus on Quality January 2015 018749-141219 35

Focus on Quality: Hospital Readmissions Hospital Readmission Penalties Reporting on quality measurements developed and approved by National Quality Forum required by 1 : Deficit Reduction Act Hospital Inpatient Quality Reporting Program Affordable Care Act established Hospital Readmission Reduction Program 2 Allows Medicare to reduce payments to certain applicable hospitals for excess readmissions related to specific health conditions 1. Deficit Reduction Act of 2005, Pub. L. No. 109-171, 5001, 120 Stat. 4, 28 (2006). 2. Patient Protection and Affordable Care Act, Pub. L. 111-148, 3025, 124 Stat. 119, 408-12 (2010). January 2015 018749-141219 36

Focus on Quality: Hospital Readmissions Hospital Readmission Penalties 1 For FY 2015, the applicable conditions for which hospitals are penalized for readmission are: Heart Failure Acute Myocardial Infarction Pneumonia Chronic Obstructive Pulmonary Disease (COPD) New! Total Hip and Total Knee Replacement New! Additional conditions will be considered for future years 1. CMS, Readmissions Reduction Program, http://www.cms.gov/medicare/medicare-fee-for- Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html January 2015 018749-141219 37

Focus on Quality: Concentrated Care Expectations for Improved Care Transitions in Other Programs Examples of Medicaid Health Home Core Measures 1 Care transition transition record transmitted to healthcare professional Follow-up after hospitalization for mental illness All-cause readmission Accountable Care Organizations 2 Outpatient and inpatient providers work together CMS Bundled Payments for Care Initiative 3 Incentivizes closely coordinated care for certain conditions 1. Centers for Medicare and Medicaid Services. State Medicaid Director Letter, Health Home Core Quality Measures. January 15, 2013. 2. Centers for Medicare and Medicaid Services. Medicare.gov, Accountable Care Organizations, http://www.medicare.gov/manage-your-health/coordinating-your-care/accountable-care-organizations.html. 3. Centers for Medicare and Medicaid Services. Bundled Payments for Care Improvement (BPCI) Initiative. http://innovation.cms.gov/initiatives/bundled-payments January 2015 018749-141219 38

National Quality Measures Nationally Developed or Endorsed HEDIS Effectiveness of Care: Chronic Conditions, Follow-Up After Hospitalization for Mental Illness Percentage of patients hospitalized for certain mental health disorders AND Had a follow-up visit after discharge either outpatient, intensive outpatient, or partial hospitalization with a mental health practitioner within a certain time frame (7 days) 1 Required reporting by all NCQA-accredited health plans 2 Recommended Medicaid health home core measure 1 1. Centers for Medicare and Medicaid Services. State Medicaid Director Letter #13-001, Health Home Core Quality Measures. January 15, 2013. 2. NCQA Health Plan Accreditation Requirements. http://www.ncqa.org/portals/0/programs/accreditation/2012%20ncqa%20health%20pl an%20accreditation%20requirements%20and%20hedis%20measures.pdf. January 2015 018749-141219 39

National Quality Measures Nationally Developed or Endorsed CMS/NCQA Structure and Process Measures, Care Transitions 1 The organization manages the process of care transitions, identifies problems that could cause transitions, and where possible prevents unplanned transitions. Element A: Managing Transitions Element B: Supporting Members Through Transitions Element C: Analyzing Performance Element D: Identifying Unplanned Transitions Element E: Analyzing Transitions Element F: Reducing Transitions 1. National Committee for Quality Assurance. Special Needs Plans Structure & Process Measures (2012). http://www.ncqa.org/tabid/1434/default.aspx. January 2015 018749-141219 40

National Quality Measures Hospital-Based Inpatient Psychiatric Services 1 : Admission screening for violence risk, substance use, psychological trauma history, and patient strengths completed Hours of physical restraint use Hours of seclusion use Patients discharged on multiple antipsychotic medications Patients discharged on multiple antipsychotic medications with appropriate justification Post-discharge continuing care plan created Post-discharge continuing care plan transmitted to next level of care provider upon discharge CMS- Mandated for Reporting Payment now dependent on reporting future on performance? 1. The Joint Commission Core Performance Measures. Hospital-Based Inpatient Psychiatric Services. May 5, 2014. January 2015 018749-141219 41

How Can We Best Respond to a Changing Environment? January 2015 018749-141219 42

Focus on Quality Expectations for Improved Care Transitions in Other Programs Medicaid Health Homes Core Measures Care transition transition record transmitted to healthcare professional Follow-up after hospitalization for mental illness Accountable Care Organizations Outpatient and inpatient providers work together CMS Bundled Payments for Care Initiative Incentivizes closely coordinated care for certain conditions January 2015 018749-141219 43

Poll Question #3 Which of the following do you participate in, or plan to by this time next year? (Select all that apply) Medicaid Health Home Accountable Care Organization CMS Bundled Payments for Care

Use of Technology Information sharing between hospital and community providers Remote monitoring/engagement technologies January 2015 018749-141219 45

Poll Question #4 Is your EHR system linked up with your area hospitals? Yes No No but in development

Changing Reimbursement Mechanisms Medicaid Health Homes Significant focus on care coordination of all services and supports Target population is people with chronic illness, often behavioral health Medicare Transitional Care Management Codes 1, 2 Includes services provided to a patient whose medical and/or psychosocial problems require moderate or high-complexity medical decision making during transitions in care Communication and face-to-face visit within specified timeframes post-discharge CPT Codes 99495 and 99496 1. American Medical Association, CPT 2013: Professional Edition (2012). 2. Centers for Medicare and Medicaid Services: Frequently Asked Questions About Billing for Medicare for Transitional Care Management Services (August 2013) January 2015 018749-141219 47

Staff Considerations Case managers vs. care managers Culture shifting inherent in multispecialty work

Emerging Collaborations in Health Care Partnerships with hospitals and medical homes Environmental scan: Where are ACOs and bundled payment initiatives unfolding in your area?

National Transitions of Care Coalition http://www.ntocc.org/ Recommended Actions for Improved Care Transitions: Mental Illnesses and/or Substance Use Disorders http://www.rarereadmissions.org/ Joint Commission Core Performance Measures http://www.jointcommission.org/hospital-based_inpatient_psychiatric_services/. Health Home Core Quality Measures http://www.medicaid.gov/federal-policy-guidance/downloads/smd-13-001.pdf.

Questions or Comments? Pam Pietruszewski pamp@thenationalcouncil.org