Behaviora Heath Centers of Exceence The Future of Heath Written by: Dae Jarvis, Jarvis and Associates Written for: Nationa Counci for Behaviora Heath Apri 30, 2014
Behaviora Heath Centers of Exceence: The Future of Heath Heathcare reform is creating tremendous disruption in neary a aspects of the heathcare fied. As many other industries have aready experienced, disruption and chaos mask innovations that fundamentay change the heathcare andscape and provide competitive advantages for handfus of forward thinking organizations. How do behaviora heath organizations use this chaotic time to not ony survive but thrive? Overview This paper begins by exporing the survive and thrive question with a discussion of the future of heath, which eads to an overview of Centers of Exceence and their appication as Behaviora Heath Centers of Exceence. From there, it reviews a behaviora heath center of exceence definition: A Behaviora Heath Center of Exceence is known by the entire community as a great pace to get care and a great pace to work. With that definition in mind, the paper deves into five key eements: Eement 1: Easy Access Eement 2: Word Cass Customer Service Buit on a Cuture of Engagement and Weness Eement 3: Comprehensive Care Eement 4: Exceent Outcomes Eement 5: Exceent Vaue The ast sections examine the importance of Performance Measurement and a soid Infrastructure that can be supported by the Exceence in Menta Heath Act of 2014 and Certified Community Behaviora Heath Cinic designation. The concepts expored beow wi be vita to the success of behaviora heath organizations and the individuas they serve. The Future of Heath Michae Porter, a professor at the Harvard Business Schoo and eading authority on competitive strategy, has considered the future of heath since he began work on his 2006 book, Redefining Heath Care: Creating Vaue-Based Competition on Resuts. Porter has become convinced that in heath care, the days of business as usua are over. [ ] It s time for a fundamentay new strategy. [ ] We must move... toward a patient-centered system organized around what patients need. We must shift the focus from the voume and profitabiity of services provided physician visits, hospitaizations, procedures, and 2
tests to the patient outcomes achieved and repace today s fragmented system... with a system in which services for particuar medica conditions are concentrated in heath-deivery organizations. 1 Take specia note of the ast phrase heath-deivery organizations. Notice he doesn t say heathcare deivery organizations. That one word fundamentay changes the meaning from organizations that treat medica conditions after you get sick or injured to organizations that address the fu spectrum of heath and weness. This is consistent with the transformation driven by the Affordabe Care Act, the empoyer community, and the miennia generation. We are seeing the evoution of primary care cinics into patient-centered medica homes, soon to be foowed or accompanied by one-stop heath and weness centers with each customized to meet the whoe heath needs of the communities they serve. This evoving mode of primary care is supported by speciaty centers of exceence that provide word cass inpatient and speciaty care to compement new primary care modes. There is a growing awareness that medica and behaviora heathcare is not enough to address the socia determinants of heath and sowy but surey denta, pubic heath, socia services, housing supports, and other important services and supports are being foded in. Athough we cannot predict with precision how this wi unfod, the future of heath wi be personaized, proactive, integrated, and efficient. The New Mindset Centers of Exceence We can no onger afford to make referras to speciaty providers As medica homes and other integrated heath systems expand their footprint, acking outcomes data or that supported by payment reform, emerging evidence shows that cinicians are you know to be poor performers becoming more thoughtfu about speciaist referras. For exampe, imagine being with high error rates, high costs, a physician in a medica home, treating a patient who has a serious heart condition or a major menta iness beyond the scope of what you can treat at your and poor outcomes. cinic. You can no onger afford to make referras to speciaty providers acking outcomes data or that you know to be poor performers with high error rates, high costs, and poor outcomes. Instead, you must become meticuous about buiding reationships with high-performing speciaists to support your patients whoe heath. In other words, you are ooking for speciaty centers of exceence. Professor Porter pushes the center of exceence concept to the next eve, caing for the deveopment of Integrated Practice Units organized to provide integrated, comprehensive, and team-based whoe heathcare to patients with compex conditions. For exampe, at Virginia Mason Medica Center in Seatte, individuas with ower back pain can get a same-day/next day appointment with a spine team that competes a fu assessment, identifies the most effective intervention, and in most cases begins treatment that day. This approach reduces missed days from work, owers cost, and resuts in outcomes that are meaningfu to the patient back pain reief and improved functioning. 1. Michae E. Porter and Thomas H. Lee. The Strategy That Wi Fix Heath Care. Harvard Business Review. October 201 3
Virginia Mason is one of many speciaty organizations taking up Porter s high-vaue heathcare deivery system chaenge: organizing around patients medica conditions rather than discreet medica speciaties, measuring costs and outcomes for each patient, deveoping bunded prices for the fu care cyce, integrating across separate faciities, expanding geographic reach, and buiding an enabing IT patform. (Porter, Redefining Heath Care) This is aso occurring in the empoyer community. Companies ike Boeing, Lowe s, and Wamart contract directy with centers of exceence, ike the Mayo Cinic, Ceveand Cinic, and Virginia Mason Medica Center to provide compex speciaty care to their empoyees, even if they ive hundreds of mies away. Why? Because those organizations provide word cass care for specific conditions at a fixed price (bunded payment) with a warranty. If they do not address the probem the first time (a rare occurrence), they wi fix it for free. Behaviora Heath Centers of Exceence The Nationa Counci for Behaviora Heath began in December 2013 a six-month crowdsourcing project to refine these ideas into a framework reevant for behaviora heath provider organizations that can then be transated into action through behaviora heath centers of exceence (BHCOEs). Crowdsourcing uses the Internet to channe the wisdom of a arge group of peope to sove a probem. In this case, the channe was the Nationa Counci s socia and digita media toos: the Nationa Counci website, bogs, webinars, Facebook, Twitter, LinkedIn, and emai communication. The project began with a draft concept paper and webinar, foowed by 10 bog posts and a mid-project webinar. The Nationa Counci and Dae Jarvis and Associates received feedback from dozens of individuas, which was integrated into this paper. On March 31, 2014, during the midde of the project, Congress passed the Exceence in Menta Heath Act, which incudes the argest singe federa investment ($900 miion) in community-based menta heath and substance use treatment in over a generation. The aw wi expand services to as many as 240,000 peope and cas for an eight state piot of Certified Community Behaviora Heath Cinics (CCB- HCs), entities that wi access a prospective payment system (PPS) simiar to that of Federay Quaified Heath Centers (FQHCs) and Rura Heath Cinics (RHCs). In return, these entities face new opportunities and expectations to provide care coordination and comprehensive treatment services to individuas with menta inesses and substance use disorders. CCBHCs wi ikey be one manifestation of a BHCOE, supported by federa doars. This CCBHC-BHCOE connection is expored further in the Concusion. But first, et s tak about a BHCOE definition, five BHCOE eements, BHCOE performance measurement, and the infrastructure needed to support its success. 4
BHCOE Definition Like a things reated to BHCOEs, the foowing definition is a work in progress that wi evove over time as the behaviora heath deivery system evoves. A Behaviora Heath Center of Exceence is known by the entire community as a great pace to get care and a great pace to work. A BHCOE offers easy access to affordabe, comprehensive care for persons experiencing behaviora heath issues. Cients experience respectfu, sef-directed, team-based, and hoistic care that addresses their probems and achieves outcomes important to them. Exceence is created by each staff member who has a heartfet connection to their community and the peope they serve, based on a deep understanding of trauma, best cinica practices, and an unshakabe commitment to resiiency and recovery. Meeting this definition is a high bar. It is not something that comes from passing a written test or a surveyor s review. It begins with buiding a great team that is abe to achieve high marks on a set of core eements, which eads to recognition by the community as a great pace to get care and a great pace to work. BHCOE Draft Eements Again, as with a things reated to BHCOEs, the foowing eements wi evove over time. This is not an exhaustive ist, but organizations wi not be viewed by the community as a great pace to get care and a great pace to work without getting high marks in a of the foowing areas: Eement 1: Easy Access Eement 2: Word Cass Customer Service Buit on a Cuture of Engagement and Weness Eement 3: Comprehensive Care Eement 4: Exceent Outcomes Eement 5: Exceent Vaue >> Eement 1: Easy Access Be there when I need you. (Oregon Patient-Centered Primary Care Home Principes) A BHCOE is known for ensuring new and existing cients can get the right care, at the right time, in the right setting, and with the right provider. Work processes have been reengineered to support same-day/ next day appointments and open access scheduing. The organization effectivey manages no shows and canceations, eiminates redundant information coection, and reduces the time from first appointment to competed treatment pan. One exampe of success in this area is heathcare providers abiity to get their patients into speciaty behaviora heathcare with same-day/next day access for high-risk, high-need patients. 5
This eement demonstrates the interconnected nature of the five eements. Easy access is instrumenta to great customer service (Eement 2). If you do not track mutipe access measures, you cannot improve your outcomes (Eement 4). This may incude ength of time to first service; ength of time to compete the intake process; ength of time to begin the treatment/recovery process; ength of time to see a provider with prescribing authority; and ength of time to get back into care. >> Eement 2: Word Cass Customer Service Buit on a Cuture Engagement and Weness Kind words can be short and easy to speak, but their echoes are truy endess. (Mother Theresa) A BHCOE is known by the community, cients, and staff for going the extra mie. Think Nordstrom, Amazon, Starbucks, Appe, and UPS. A create extraordinary experiences for customers by achieving a seamess service experience provided by caring empoyees who provide a persona touch, and are empowered to resove any probems that arise. Behaviora heath organizations are abe to achieve word cass customer services ony if they are great paces to work and are staffed with individuas who have a heartfet connection to their community and the peope they serve, based on a deep understanding of trauma, best cinica practices, and an unshakabe commitment to recovery and resiiency. These characteristics, skis, and knowedge are grown over time with the support of eaders who prioritize cient and staff engagement and weness. In a BHCOE, staff members fee what they do is meaningfu and they have a way of measuring their own success. Their opinions count, their co-workers are committed to doing quaity work, and there is someone at work who encourages their growth and deveopment. Leaders in these organizations engage and empower consumers and staff, and they empoy consumers at a eves (incuding eadership). Cients experience word cass customer service at the front door, supported by wak-in access and programs convenienty ocated in the community. They aso experience this eve of customer service during the treatment/recovery process, as we as after their care pan is competed and they wish to have periodic check-backs or need to access crisis services or additiona panned care, shoud their needs change. >> Eement 3: Comprehensive Care Provide or hep me get the heath care and services I need. (Oregon Patient-Centered Primary Care Home Principes) A BHCOE is known for offering a broad scope of menta heath, substance use, and co-occurring disorder treatment services that are integrated with medica care and other services and supports. Each person or famiy has a singe care pan that incudes what is needed to move toward whoe heath, supported by a mutidiscipinary care team, sometimes representing staff from mutipe organizations, connected by an eectronic care pan or cient registry. 6
A BHCOE has a deep understanding of the popuation it serves and is abe to offer a taiored version of SAMHSA s nine categories of care for individuas with behaviora heath disorders: 1. Heathcare home/physica heath 2. Prevention and weness 3. Engagement services 4. Outpatient and medication services 5. Community and recovery support (rehabiitative) 6. Other supports (habiitative) 7. Intensive support services 8. Out-of-home residentia services 9. Acute intensive services Care management is a critica activity that overaps and connects a nine categories. BHCOE care managers work with cients to manage care across the care continuum, throughout various settings, working with the person, providers, payors, and others to improve outcomes and make best use of the fu range of avaiabe resources. The abiity to achieve this eve of integration and comprehensiveness, combined with the other four eements, represents significant progress toward Michae Porter s definition of an Integrated Practice Unit. (Attachment A describes the continuum of care that aigns with this eement.) >> Eement 4: Exceent Outcomes Take responsibiity for making sure I receive the best possibe heath care. (Oregon Patient-Centered Primary Care Home Principes) A BHCOE is known for achieving resuts for cients. It can measure what is important to cients and achieves exceent outcomes on those measures. The organization has aso done its homework and has deveoped a measurement framework that draws on existing process and outcome measures. One exampe is a comprehensive framework deveoped by Richard Hermann, MD and his coeagues at the Center for Quaity Assessment and Improvement in Menta Heath, Tufts-New Engand Medica Center. Based on the identification of more than 300 behaviora heath measures drawn from over 20 measure deveopers, they identified seven behaviora heath domains: prevention, access, assessment, treatment, continuity, coordination, and safety. 2 Of particuar importance is the emergence of a treat-to-target, team-based care approach to achieving success at the cient eve. The cient, with support of their care team, identifies their care goas at east 2. Richard C. Hermann, MD, MS. Improving Menta Heathcare: A Guide to Measurement-Based Quaity Improvement. American Psychiatric Pubishing, Inc. 2005. 7
one cinica and one persona. Outcome toos reevant to the cinica goas are used to coect baseine information and measurabe targets are set. Professiona and sef-care pans are deveoped, drawing from scientific evidence about the cient s background, conditions, and goas. Frequent measurement is made and if a cient is not reaching their targets, the care pan and sef-care pan are changed. Cient-eve outcome data are coected in a centra repository, evauated on a reguar basis, and used to continuousy improve care. Equay important is the need to identify performance measures reevant to partner organizations such as medica homes and heath pans. Both groups are increasingy under the microscope to demonstrate exceent outcomes and BHCOEs can position themseves to hep their partners and payors succeed. (See additiona discussion of this topic in the BHCOE Performance Measurement section.) >> Eement 5: Exceent Vaue We are accountabe for both the cost and quaity of care. (Anonymous) A BHCOE is known for providing high vaue. This means the organization achieves improved heath outcomes that matter to cients reative to the cost of achieving those outcomes. In speciaty care, incuding behaviora heath, this move to high-vaue care is accompanied by a move away from fee-for-service and a move toward bunded payments/case rates. High vaue services have three characteristics: 1) The services are effective in achieving individua outcomes or system-wide outcomes; 2) The services are more cost-effective than aternatives that may have been seected; and 3) The service are ean, meaning waste (i.e., excess costs) have been removed through process improvement activities. The first two characteristics reate to the achievement of outcomes-based care (Eement 4) with the addition of thinking about the cost effectiveness of aternatives. The third characteristic requires that a defined approach to quaity improvement, generay ean, is used throughout the organization. Organizations that provide high vaue services can provide higher quaity care and ower costs than their peers, and they can offer competitive prices under aternative payment modes such as bunded payments/case rates. BHCOE Performance Measurement The discussion of performance measurement began with Eement 4: Exceent Outcomes, but there is more to say in order to achieve true exceence. When it comes to outcomes-based care and performance measurement, the behaviora heath fied has often been eft on the outside ooking in. The excusion of community behaviora heath centers from Meaningfu Use funding is a prime exampe. A second major probem is the fied s inabiity to reach consensus on what outcomes are most important and what toos to use. 8
BHCOEs wi need to update their views on this topic and move forward, regardess of outside funding opportunities. And they aready have a great dea of hep from many organizations. A partia ist of these organizations and their roes is incuded in Attachment B. The foowing diagram iustrates a six-step action pan for getting into the performance measurement game reevant for any federa, state, or payor reporting initiatives. 3 Determine the Reporting Vehice Deveop an Interna Reporting System 4 2 Seect Measures to Report Identify a Standing Group to Anayze the Data 5 1 Identify Eigibe Providers Participate in Performance Measurement Design and Impement Rapid Cyce Improvements 6 BHCOE Infrastructure It wi be cear that BHCOEs make substantia infrastructure investments as a prerequisite to achieving high marks on the five eements. At a minimum this wi incude: Information Technoogy, incuding eectronic heath records, patient registries, and participation in heath information exchanges. Quaity Improvement Framework with a we-deveoped quaity management process that addresses quaity assurance, quaity improvement, risk management, utiization and resource management, utiization review, credentiaing, and performance contracting. (This is not the same as compiance.) Supervision and Training Pan that supports reguar and timey training, supervision, coaching, and performance evauations to support a staff in maximizing their potentia and effectiveness. Revenue Cyce Management that effectivey addresses every step in the process incuding payor contract management, cient scheduing, financia counseing, service pre-authorization, charge capture, utiization management, caims submission, third-party foow-up, and denias management and appeas. 9
Vaue-Based Purchasing, incuding the abiity to integrate cinica, quaity, and financia information to anayze cost and outcomes by cient, provider, team, program, and payor, and to operate under a variety of payment modes. Compiance Pan ed by a designated compiance officer that ensures appropriate training on robust compiance practices and standards supported by interna monitoring and auditing. (This is not the same as quaity Improvement.) Concusion Speciaty heathcare, incuding behaviora heath, is in the midst of a major transformation that wi fundamentay redefine the fied. Michae Porter suggests Integrated Practice Units, organized around peope s medica conditions is the future. This is potentiay good news for the nation s network of community behaviora heathcare organizations because of their ong history of working with a psychosocia rehabiitation mode that addresses behaviora heath disorders, as we as socia determinants of heath. With the fu roout of the Affordabe Care Act and an expanding research base teing us that effectivey integrated behaviora heathcare improves outcomes and saves money, there is aready more demand for propery trained behaviora heath professionas and paraprofessionas. There is aso a rapidy expanding expectation that organizations empoying these individuas must perform as high-vaue heath deivery organizations. The recenty enacted CCBHC Program has the potentia to create a Good Housekeeping Sea of Approva for centers that are abe to pass muster, supported by additiona doars that wi fund comprehensive and outcomes based care. By September 1, 2015, the Secretary of Heath and Human Services wi pubish criteria for an organization to be certified by a state as a CCBHC, aong with guidance on estabishing a new prospective payment system mode. By January 1, 2016, the Secretary wi award panning grants to states that wish to appy to participate in the CCBHC demonstration program. By September 1, 2017, the Secretary wi seect eight states to participate in a two-year piot of the CCBHC program, where each state wi receive 90 percent federa funding for a of the required services provided by the CCBHCs. The time has arrived for behaviora heath providers to up their game, moving toward exceence today and CCBHC status tomorrow to become an integra part of the new heath ecosystem. 10
Attachment A The Continuum of Care Aigned with Eement 3: Comprehensive Care Description of a Modern Addictions and Menta Heath Service System (SAMHSA) Heathcare Home / Physica Heath Prevention and Weness Engagement Services Outpatient & Medication Services Community and Recovery Support (Rehabiitative) Other Supports (Habiitative) Intensive Support Services Out-of-Home Residentia Services Acute Intensive Services Screening, brief intervention & referra Acute primary care Genera heath screens, tests & immunization Comprehen-sive care management Prevention programs Weness programs Smoking cessation education session on MI/SUD Heath promotion Brief interviews Warm ine Assessment Speciaized evauations (psychoogica, neuroogica) Service panning (incuding crisis panning) Consumer/ famiy education Outreach Individua evidenced based therapies * Group therapy Famiy therapy Muti-famiy counseing Medication management Pharmacotherapy (incuding Opiod maintenance therapies) Laboratory services Speciaized consutation Peer supports Recovery support services* Famiy training & support Ski buiding (socia, daiy iving, cognitive) Case management Continuing care Behaviora management Supported empoyment Permanent Supportive housing Recovery housing Therapeutic mentoring Traditiona heaing services Persona care Homemaker Respite Educationa services Transportation Assisted iving services Recreationa services Other goods & services* Trained behaviora heath interpreters Substance abuse intensive outpatient services Partia hospita Assertive community treatment Intensive home based treatment/ Muti-systemic therapy Crisis residentia/ stabiization Residentia services* Supports for chidren in foster care Mobie crisis services Urgent care services 23 hour crisis stabiization service Psychiatric inpatient & medica detoxification services 24/7 crisis hotine services 11
Attachment B Performance Measurement Organizations The foowing is a partia ist of key organizations that have been invoved in the deveopment and promugation of behaviora heath performance measures. The Nationa Quaity Forum (NQF) is the nationa measurement vaidation engine for the federa government and numerous other organizations. Currenty the NQF has endorsed severa dozen behaviora heath measures. (www.quaityforum.org) The Centers for Medicare & Medicaid Services (CMS), the argest purchaser of heathcare in the United States, has 26 separate CMS quaity initiatives under way, tracking 971 measures that incude 60 unique behaviora heath measures. The CMS measurement framework is part of a arger federa structure containing 2,179 tota measures incuding 179 behaviora heath measures. (www.quaitymeasures.ahrq.gov/hhs/inventory.aspx#browsetype=current) The Center for Quaity Assessment and Improvement in Menta Heath (CQAIMH), consisting of facuty and staff from Tufts and Harvard, have deveoped a quaity measure inventory consisting of more than 300 behaviora heath measures drawn from more than 20 measure deveopers. (www.cqaimh.org) The Substance Abuse and Menta Heath Services Administration (SAMHSA) has worked on severa projects, incuding their ongoing project to create a Nationa Behaviora Heath Quaity Framework, a joint project with the Office of the Nationa Coordinator (ONC), and a joint project with the Assistance Secretary for Panning and Evauation (ASPE). (http://store.samhsa.gov/draft/nbhqf_draft_082613.pdf?wt.mc_id=eb_20130827_nbhqdraft) CMS Physician Quaity Reporting System (PQRS) is a reativey new program open to a behaviora heath providers that bi Medicare Part B with an individua provider identifier. This is an idea vehice for potentia BHCOEs to jump into federa quaity reporting, especiay because providers that do participate wi receive a 0.5 percent incentive bonus if they participate in 2014, and wi be subject to a 2 percent penaty beginning in 2016 for those that fai to report into the PQRS beginning in 2014. (www.cms.gov/medicare/quaity-initiatives-patient-assessment-instruments/pqrs/?gcid=cmd-o4cu6l- 0CFY17fgodHTcATQ) 12