Pilot Project update VACBP- October 29,2015 Case Management

The State of Case Management Services in VA VA STANDARDS:  Designated by DBHDS, as a CSB- only service  Reimbursable service is only recognized when provided by a CSB employee  CSBs across the state qualify bachelor and/or Masters trained human service professionals to provide service  All Case Managers must successfully complete the state “Case Management training” REGIONAL STANDARDS:  Most states recognize and reimburse case management services provided by private and non profit entities.  Qualified behavioral health care professionals (Mastered or exam certified) are eligible to provide case management services that are reimbursed by Medicaid.  Current case management case load sizes (non Intensive Case Management/ICM) range between individuals.

The State of Case Management Services in VA VA STANDARDS:  Designated by DBHDS, as a CSB- only service  Reimbursable service is only recognized when provided by a CSB employee  CSBs across the state qualify bachelor and/or Masters trained human service professionals to provide service  All Case Managers must successfully complete the state “Case Management training” REGIONAL STANDARDS:  Most states recognize and reimburse case management services provided by private and non profit entities.  Qualified behavioral health care professionals (Mastered or exam certified) are eligible to provide case management services that are reimbursed by Medicaid.  Current case management case load sizes (non ICM) range between individuals.

Case Management Defined VA State Core Service Taxonomy 7.3 defines Case Management as: “services that assist individuals and their family to access needed services that are responsive to the individual’s needs. Services include identifying and reaching out to individuals in need of services, assessing needs and planning services, linking the individual to services and supports, assisting the individual directly to locate, develop, or obtain needed services and resources, coordinating services with other providers, enhancing community integration, making collateral contacts, monitoring service delivery, and advocating for individuals in response to their changing needs.”

Emerging challenges: The accountability of case managers for CM outcomes will be strengthened by improving the clarity in the differences of caseloads. To a large extent, clarifying the differences in caseloads is based on the differences in the weights of activities, interventions, encounters, and responsibilities, as well as frequency. Future development efforts will be to support the “enhanced case management pilot” caseload by adhering to best practice CM calculators to establish the underlying algorithms, based on current evidence and a series of clinical criteria and behavioral healthcare business acumen.

Case Management Reimbursable Activity Defined  FACE-TO-FACE SERVICES:  F to F case management provided by a service licensed by the Department  Individual served must be present (i.e. case management, discharge planning)  NON-FACE-TO-FACE:  All other case management services licensed by the Department including: telephone contacts with the individual, any contacts with the individual’s family members or authorized representative or any contacts (f to f or otherwise) about the individual with other CSB staff or programs or other providers or agencies such as: phone consultation with individual, report writing re: indiv, individual- related staff travel, and discharge planning, individual not present.

Reimbursement for Case Management Services Currently Case Management is reimbursed by Medicaid at a rate of $ monthly for: 1 F to F case management contact within 90 days plus non face-to-face activities documented on a monthly basis

Duplication of Services  Case management services are currently provided by both CSB, private non profit, and private providers.  Private and public providers report providing majority of case management activities for consumers they share with the CSB.  Concern about split treatment policies by some VA CSBs.

The CSB system is stressed System Stress results in: 1. Large case load sizes 2. Current wait lists for services 3. Recent IIH and ICT changes require additional manpower for case management services (non recovery based) 4. Budget reductions result in doing more with less

VA deserves the most efficient, effective, and quality system of care Effective: addresses the quality of care given by measuring change over time (how is my life better as a result?) e.g. maintenance of abstinence, reduction of hospitalization rates, employment status etc. Efficient: usually administratively oriented (how well do we do what we do? i.e. input versus output) e.g. occupancy rates, length of stay, service utilization, retention rates, $ saved, etc. CARF 2015 Behavioral Health Standards Manual

Case Management Enhanced- A Pilot towards System Recovery Satisfaction Measures :  Hope and empowerment  Improved quality of care: access to clinician when needed  Increased consumer choice  Mobile services: provided in community close to home regardless of geographic location

“Case Management Enhanced”- A Pilot towards System Recovery  F to F case management provided on a monthly basis, with a minimum of weekly non F to F case management provided as needed  F to F case management provided in the home and/or community where the individual served resides (not in the office without consideration of consumer location or travel time)  Providers of Case Management provide access to staff with higher qualifications to include Case Managers certified through existing training-Case Management Certified/Masters level/ or Licensed eligible clinicians to enhance quality of service delivery  Maintain best practice case load sizes – high fidelity model  Comply with current state case management certification standards  Maintain Department license and/or CARF accreditation

Case Management Enhanced- A Pilot towards System Recovery Return on Investment (ROI)  Private and public providers can provide case management services with a higher quality of service delivery  No split treatment policy. Consumer choice (recovery based  Enhanced access to preventative psychiatric services  More frequent contact allow for early intervention/prevention of more costly services (i.e. jail, hospital)  27% Decrease in cost of current targeted case management services from $ monthly to $240.00

Pilot Project  Propose that 4 pilot projects be initiated throughout the state of VA.  Pilot awards would be selected through RFP/RFI process initiated by the state.  Guarantees verifiable ROI.

What do we know now? DMAS is requesting information about the VACBP’s proposed Private Provider Case Management Pilot Program

What do we know now? DMAS and DBHDS will entertain and respond to: Exploring ways to recognize and showcase excellence in the provision of services to help promote awareness and high achievement in the delivery of services A pilot that presents a high fidelity model to increase investment and responsiveness to the existing community need is now postured for strong consideration

SUMMARY  The State of Virginia is currently 48 th in the nation in mental health care.  Emergency room visits are increasing. Jails are full of inmates with mental health issues.  The “recovery model” should be supported as a best practice in ensuring consumer choice.  Local CSB’s are now partnering with Sheriffs departments to create diversion projects that need case management  Psychiatric hospitals are increasing patient admissions.  We know that early invention and prevention is the most proven model to prevent the above situations.  Private providers have been providing case management for years and have hundreds of qualified counselors that fit meet the requirement to provide case management.  VACBP is proposing a plan that would save millions of dollars a year by being able to share case management duties with the CSB so more clients can be served to prevent and provide early intervention to keep them out of hospitals and jails.

SUMMARY  Our system now tries to regulate costs by changing regulations to make it more difficult for clients to receive care, which results in more costly care to other institutions.  Think about this: every counselor has at the end of their voice mail message, “if this is an emergency please call 911.”  If clients are being case managed in their own environment in the community, at a lower cost it is a no brainer!  It is time to be creative and innovative in combating rising costs by allowing private providers to share some of this burden to relieve the CSB of a stressed system and overwhelmingly high case loads.