Behavioral Health Integration Strategy: RAE 1 Care Coordination/ Crisis System Louisa Wren - RAE 1 August 5 th , 2020
Crisis Services Rocky Mountain Health Plans (RMHP) Crisis Services: RMHP is a part of Colorado Crisis Service System (CCS), which is a statewide behavioral health crisis response system offering residents mental health, substance use or emotional crisis help, information and referrals. RMHP manages mobile crisis, a walk-in clinic, a crisis stabilization unit and 2 respite programs throughout Region 1. RMHP is in a unique position, as both the RAE and Administrative Service Organization, to support members in crisis in Region 1 to get connected to behavioral health care. 2 rmhp.org
Care Coordination Rocky Mountain Health Plans (RMHP) Care Coordination (CC) Approach: Outreach to all individuals referred to them to screen, assess and create care plans where indicated. Comprehensive assessments which cover: physical/behavioral health, social, cultural and linguistic issues. RMHP’s goal is to connect Members with the services to support them in overall health improvement 3 rmhp.org
How are you evaluating success when it comes to care coordination? LOG We log all referrals from Community Mental Health Centers (CMHC) in Essette We track outreaches and connections TRACK Success can be evaluated by tracking EVALUATE successful outreaches Our Crisis Services Partners (CS) must follow up within 24 hours of CONTRACT crisis. A quality follow-up includes: reassessing risk, reviewing/updating safety plans, collaborating with immediate REQUIREMENTS supports, support with making a behavioral health appointment. Members who need further care referred to RMHP for food, REFERRALS housing, transportation, physical and dental health, HealthFirst enrollment 4 rmhp.org
How does RMHP’s Care Coordination approach differ with a Member who has received Crisis Services? • RMHP’s Care Coordination team has a consistent approach for all referrals. • If the individual requires more extensive/ongoing care coordination, they will be referred to RMHP Care Coordination • Referrals from our Crisis Partners are put into Essette campaigns. 5 rmhp.org
What is working well when coordinating the care between the two systems? • Region 1 has the advantage that the Crisis Services ASO is the RAE • RMHP’s established relationships with providers means: • Many providers are already aware of the referral process/programs • Many providers have the education and awareness around how RMHP’s Care Coordination team works. • Longstanding relationship between CMHC’s and RMHP started in July 2018 with RAE and then expanded in July 2019 (when RMHP took over as ASO for Crisis) 6
Have best practices been developed? Care Coordination Crisis I. RMHP utilizes Essette to help close I. After 24 hour follow up has the loop on coordination of care for occurred, Members are Members within 48 hours encouraged to seek ongoing II. RMHPs Care Coordinators are local treatment to avoid future crisis and know the resources within the II. Aggregate data is reported to communities they serve the ASO on a monthly basis; this III. RMHP has integrated AHCM allows RMHP to analyze and give screenings with some of our direction on how RHMP works providers which has helped us and will inevitably inform the determine Member needs and development of best practices connect them to appropriate III. Data collection aids with services alignment on other quality metrics and informs quality and IV. Crisis contract managers have Performance Outcome Plans provided further education and (POP) awareness to internal staff, including care coordinators, about what CCS is and how it can be accessed in Region 1. 7 rmhp.org
What are future needs to help improve care coordination between the two systems? • Targeted outreach with RMHP Crisis Providers about when to refer individuals to RMHP Care Coordination and how. • Continue bilateral discussions with RMHP Care Coordination leadership and Crisis Providers about what high-risk populations would benefit from ongoing care- coordination. • Increase number of CMHC’s who document in Essette to aid with electronic referrals and a smoother transition of care coordination information for Members 8 rmhp.org
Gaps and Barriers Potential duplication of services is a concern between the two systems. RMHP wants to ensure care coordination is appropriate and intentional. 9 rmhp.org
Specific transition of care strategies for Members being discharged from: ATUs: CSUs: Residential: • CMHC in Durango • We use the CSUs as manages the ATU Short term residential: At step down facilities discharges there discharge, cases are when appropriate, but referred to a discharge • For any Member who campaign and a CM follows the CMHC manages the ends up in other ATUs, up within 24 hours. UM manages just like stay if the member is inpatient stays. We accepted there. Long term residential review them, typically, Members being d/c from cases are referred to CMs every two days for at discharge for follow up CSU receive a d/c plan medical necessity. At and wrap around services. discharge, they are with follow up referred to a discharge appointments and campaign and a CM MH residential: Our CMs assessments and follows up within 24 would get involved at hours of discharge. discharge from the resources for the residential facility. Colorado crisis hotline. 10 rmhp.org
How can RMHP coordinate efforts with the Crisis Services mobile response team? • RMHP has an established partnership with Crisis providers as the ASO for Region 1. • Required Data Sharing 11 rmhp.org
General Network Analysis • All Crisis Service providers are contracted as a RAE providers in Region 1 due to RMHP holding the ASO contract • Due to the geographic size of Region 1, and limited number of providers able to deliver these specialized services, we do have several gaps in mobile services." • RMHP is working alongside our community partners and the Office of Behavioral Health (OBH) to develop innovative ways to ensure these areas have coverage. 12 rmhp.org
What performance metrics (BHIP, KPI, PP) does RMHP feel have the greatest opportunity for improvement based on the work with the crisis service system (CCS)? • Behavioral Health Incentive Program (BHIP): – Opportunities for improvement align with Indicators 2 & 3: 7-day follow-ups for SUD ED Visits and MH Inpatient. • Key Performance Indicators (KPI): – Opportunities for improvement align with the BH Engagement and ED Visits measures. • Performance Pool (PP): – Opportunities for improvement align with the Inpatient Psychiatric Admissions and Department of Corrections (DOC) BH Engagement measures. • The alignments identified within BHIP, KPI, and PP are being worked through the CCS Performance Outcome Plans (POP). 13 rmhp.org
CCS Performance Outcome Plans (POP): The following • POPs are Additional CCS measures and modality specific individualized objectives are the same across the 4 CCS measures are: for each modalities: contracted • Follow up within 24 Respite, Mobile, hours Crisis Walk In: • Behavioral health provider, • Diversion Rate outpatient based on their appointment performance scheduled within 7 CSU (Choice of): and target days • Readmission Rate goals. • Crisis call volume • Diversion Rate measured • Episode volume measured 14 rmhp.org
What specific strategies can RMHP implement with the help of the CCS to impact these performance metrics? • RMHP is supporting providers on implementing and working their individual POP plan • The improvement measures were identified for the POPs in effort to improve outcomes for CCS. • CCS improved outcomes will improve measurement outcomes within the BHIP, KPI, & PP programs. • FY20/21, Quarter 1 is being used to implement the POP plans to ensure data is captured appropriately and accurately. • FY20/21, Quarter’s 2, 3 & 4 will be measured on performance against the stated measurement goals. • RMHP is able to continue to conduct quantitative /qualitative analysis on the data provided to help impact quality improvement within Crisis Services. 15 rmhp.org
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