Partnering to Reduce Inpatient Utilization and Right-Size Community - PowerPoint PPT Presentation

An Innovative P4P Initiative: Partnering to Reduce Inpatient Utilization and Right-Size Community Services RCPA Conference September 27, 2016

Presenters  Deborah Duch, Community Care Behavioral Health Organization  Christine Gregor, Pittsburgh Mercy  Melissa Medice, Allegheny County Department of Human Services, Office of Behavioral Health  Kim Patterson, Allegheny HealthChoices, Inc.  Susan Wolfe, Western Psychiatric Institute and Clinic

Learning Objectives  Define components of successful system-level stakeholder collaboration around decision-making and quality improvement.  Describe elements of the Pay for Performance (P4P) model used in payment redesign.  Replicate practical strategies for attaining targeted system change (reduction of inpatient mental health utilization).

Assertive Community Treatment (ACT) in Pittsburgh, PA  8 teams, 4 providers  About 750+ individuals served (100/team capacity)  Funded through Medicaid (HealthChoices) and County- Based Funds  Expectations for high fidelity to the ACT model  Annual fidelity reviews occur using the TMACT  ACT is a licensed service in PA  State hospital is not an option

Multi-Level Partnering Level I: Leadership Team Office of Behavioral Health Managed Care Organization Monitoring Authority Level II: ACT Network Workgroup Above plus- ACT directors ACT team leaders Outcome/quality analysts Level III: Team Level ACT training/technical assistance staff ACT team leaders MULTI-LEVEL PARTNERING ALLEGHENY COUNTY, PA ACT staff 5

Multi-Level Partnering Level I: Leadership Team Activities:  Care management  Outcomes monitoring  Quality improvement  Fiscal analysis  Fidelity reviews and training

Multi-Level Partnering Level II: ACT Network Workgroup Activities:  Data review  Outcomes monitoring  Quality improvement  Networking  Problem solving

Multi-Level Partnering Level III: ACT Team Level Activities:  Fidelity reviews  Supervising by outcomes  Quality improvement  Training and skill development

Multi-Level Partnering Consumer Advisory Committee Activities:  Gathering of individual team advisory group representatives  Review data and trends  Quality improvement

Assertive Community Treatment Teams: An Overview  Interdisciplinary team approach : MDs, nurses, peer professionals, mental health professionals, employment specialists, and substance use specialists join together to provide services.  Community-wide service delivery : Services are provided where they are needed, such as a person’s home, place of employment, or other community settings.  Individualized services : Teams work with relatively small numbers of persons to provide individualized care (staff to member ratio of 10:1 with team supporting max of 100 persons).  Time-unlimited support : Teams provide whatever services and supports a person needs for as long as they need them.  Continuous, flexible, and comprehensive services : Several staff work regularly with each person served, providing an array of services at times convenient to the individual.  Round-the-clock service accessibility : Services are available 24 hours a day, 7 days a week, and someone is always available to handle emergent situations.  Utilization of multiple treatment models : Use of a variety of evidence-based practices within the ACT model (e.g., Supported Employment, Integrated Dual Disorders Treatment, etc.).

ACT Outcomes  Increase treatment adherence  Increase tenure in independent living  Increase those working in competitive employment  Improve wellness and health outcomes  Reduce, if not eliminate, psychiatric inpatient days

Why Pay for Performance? High Inpatient High Low Outpatient Outpatient

Baseline Data: 2012 Average IPMH Days, 2012 Provider # Members Days WPIC 126 15.1 Pittsburgh Mercy 224 16.8 Total 350 16.2

Baseline Data: 2012

Pay for Performance (P4P) Model Development  Goal: Reduction of inpatient mental health service utilization by ACT recipients by shifting dollars from inpatient mental health treatment to the community to sustain an adequate level of funding for Assertive Community Treatment (ACT) team supports.

Pay for Performance (P4P) Model Development  Collaborating partners included:  Two ACT providers (Pittsburgh Mercy and Western Psychiatric Institute and Clinic of UPMC)  Allegheny County Department of Human Services, Office of Behavioral Health  Allegheny HealthChoices, Inc. (AHCI)  Community Care Behavioral Health Organization (Community Care)

Pay for Performance (P4P) Model Development  To be included in the P4P project, consumers needed to be HealthChoices-eligible for at least 80% of the measurement year.  Model dashboard reports were developed so that providers could assess current performance and predict future P4P earnings based on various scenarios related to inpatient mental health services and ACT service utilization.

P4P Interactive Monitoring Tool

P4P Model Specifics  “Gate and Ladder” approach : Providers had to meet an established threshold of $10,000 per consumer for inpatient cost reduction in order to be eligible for any bonus earnings  Tiered earnings available from a bonus pool created by withholding 20% of the established ACT service rate  Providers could earn 20% withhold and up to 10% bonus amount if they met the overall target of reducing average inpatient mental health cost per person to $9,000 or less during the calendar year  Bonus earnings increase as inpatient costs decrease  Providers needed to stay under an established cap for total ACT service utilization cost per person for the year of $25,000

P4P Provider Experience: Pittsburgh Mercy  Partnering for People (P4P): Clinicians and leadership worked together in a focused way to empower the person served to choose a path of recovery — a path paved with logistical freedom, but far more cohesion in terms of treatment, care, and support.  Strategy framework based on belief that many readmissions are preventable.  Began by investigating precipitating factors for inpatient admissions and readmissions:  Understand fundamentals of behavioral principles and identify antecedents to readmissions & risk factors.  Review hospitalization histories of persons served (both over- and under- utilizers).  Focus on effectiveness of transitions of care.

Pittsburgh Mercy – Strategies & Interventions  Formulate Strategies Based on Data Analysis  Define goal of project and utilize a “top down” approach to disseminate information to agency employees, persons served and their supports, and internal/ external agency partners.  Use of a Risk Stratification Tool to allow for continual assessment of risk factors, supports, and interventions.  Create team-based approach to reviewing persons served who have been hospitalized or are at risk of hospitalization (the “War Room” ).  Institute cross-setting meetings with crisis services, residential providers, or other stakeholders.  Divert!

Pittsburgh Mercy – Strategies & Interventions  Implement Strategies to Address Inpatient Treatment and Care  Leadership-led training on assertive engagement for all staff.  Meet 5 days/week in the “War Room” to collaborate on high -risk cases.  Create positive behavioral support plans to include motivational incentives.  Enhance/increase informal and natural supports.  Invest more time in working with persons served around medication management.  Address risk factors of persons served on crisis plans and treatment plans.  Have team psychiatrist present within 24 hours of admission to speak with inpatient team.  Implement a best practice process in discharge planning, starting at admission.

Pittsburgh Mercy – Strategies & Interventions  Assess Effectiveness of Interventions and Maintain a Person-Centered Perspective  Ensure discharge plans are understood by persons served and shared with the team.  Provide persons served with education and self-management tools that will empower them to navigate their treatment.  Collaborate with physical health and other specialty providers to ensure overall health and wellness.  Constantly engage family/friends/other natural supports in the treatment of persons served.  Routinely inform agency leadership and direct care staff of project progress.

Pittsburgh Mercy: Case Study  A.R. is a male in his mid-30s diagnosed with schizoaffective disorder, bipolar type, and polysubstance dependence. He started with Pittsburgh Mercy’s ACT program in mid-2009 .  A.R.’s pre -ACT history:  Extensive history of psychiatric inpatient hospitalizations and D&A rehab stays  Chronic polysubstance use/abuse  Criminal justice system involvement  Medication non-adherence  No insight into his illness or understanding of his diagnosis or how his medications helped him  Exhibited symptoms of paranoia and delusions, and experienced auditory hallucinations