Care Coordination Collaborative -Learning Session 1 Leadership Break Out: Identifying Shared Goals between MCPs and MHPs

Topics A cross walk- core care coordination functions needed to manage spectrum of behavioral health needs Building relationships between MCPs, MHPs, and Partners to address common problems Discussion- “How can CCC Executive Leaders and their Health Plan Partners Plan for Integration of Behavioral Health in their Counties?” 2

Description of the Cross Walk Maps the common elements in: 1.DHCS APLs- MOU and SBIRT (reviewed and approved by DHCS) 2.Care Coordination Collaborative Clinical and System Changes to be tested 3.Key Elements of Care Coordination identified in variety of national research articles/CMS initiatives 3

INTEGRATION: ONE HEALTH PLAN’S EXPERIMENT PETER CURRIE, PH.D CLINICAL DIRECTOR OF BEHAVIORAL HEALTH IEHP is a Non-profit public health plan, serving low-income families and individuals in two of the largest counties in the country. Today IEHP serves over 680,000 members in government- sponsored programs compared to 400,000 in With Health Care Reform and the Cal Medi Connect, IEHP is projected to grow to over 900,000 members by 2015.

604, 862 current IEHP Medi-Cal members (including children under the age of 21). 53,000 LIHP Transition members to IEHP in January Medi-Cal also expanded Medi-Cal eligibility criteria, which increases the number of Medi-Cal eligible beneficiaries. It is anticipated that that there will be 4,100 new IEHP members per month for the first 6 months. For the remaining 4 ½ years, it is expected that there will be an increase of 2,050 members per month. IEHP Medi-Cal Growth

Why IEHP Integrated BH: MBHO Sub-Cap model not aligned with IEHP’s Mission  Clarification:  This Evaluation pertained only to the Health Plan’s Carve Out relationship with a private sector MBHO for the Dual Eligible and HF members  “Carve Out” refers to the Sub-Capitated arrangement with a Managed Behavioral Health Organization (MBHO); Not to the Medi-Cal carve out to County MHPs  Physical Health and Behavioral Health (BH) care were Separate and Disconnected  Outpatient Mental Health Services Under Utilized & Substance Abuse Treatment was Nil  IEHP had no influence over the BH Network  Coordination of Care – PCPs describe referring into the “Black Hole” for Behavioral Health Services.  BH Administrative Services were expensive: 50% of BH dollars reached the MBHO’s Providers (2009) (Context – 93% of Dollars paid to IEHP reach IEHP Providers)

The BH Integration Plan  Fully Integrated BH Program – “In House”  Streamline the coordination of physical and mental health benefits - one fully integrated system of care  Redirect MBHO Admin/Profit (50% of the BH Cost) to fund Expanded BH Services  Directly Contracted BH Network – Identify and Support Best Practices  Eliminate Reliance on Vendor (MBHO) for all BH Expertise including NCQA Compliance

Preparation for Integration  Infusing BH Competency in all IEHP departments  In-House Clinical Expertise – Clinical Director, Consulting Psychiatrist & BH Care Managers (LCSWs)  Directly contract the BH Network to ensure access  Leveraging Web Based Technology to enable Virtual Integration where Co-Location was not possible  Online EHR available to all BH providers  Required BH assessment/treatment plan instantly and securely sent to IEHP BH Care Manager and the PCP

The Launch – Feb 1, 2010  Call Center: triage and referral by Licensed BH Care Managers  “No Gate Keeper” model – PCP referral is not required  One phone # access at IEHP for physical and mental healthcare  Higher than average rate of pay for the initial assessment:  Incentivize prompt Access  Payment triggered by Coordination of Care Report Web Form – eliminating the “Black Hole”  Added new BH services - wrap around & intensive outpatient (IOP)  Direct Partnership with SBDBH & RCMHD - Improving Coordination of Care

BH Integration Results  Increased access to BH services – No increased Cost to Plan  Improved coordination of physical and behavioral healthcare:  BH providers must submit Tx Plan (COC) Web Forms  78 % of COCs passed on to the member’s PCP (with release)  75 % of PCPs used web portal to access these BH Tx reports  Medical Cost-Offsets from BH services for high-risk/high-cost populations – Dual Eligible's & SPDs  Infusing BH expertise within IEHP to respond to crisis calls  Met 100% of the NCQA requirements for BH in 2012  IEHP’s BH network - Private Sector, FQHCs, MHP & CBOs

Inland Empire Health Plan – Medical Operations Outpatient Mental Health Visits per 1000

Inland Empire Health Plan – Medical Operations Outpatient Chemical Dependency (SA & Dual Diagnosis) Visits per 1000

Inland Empire Health Plan – Medical Operations Inpatient Days per 1000

Inland Empire Health Plan – Medical Operations Inpatient Readmissions per 1000

Current Status  Meaningful collaboration with our County Mental Health Plans including:  New Eating Disorder Program  New Teen Depression Screening and Referral program  Care Integration Collaborative: Co-Location of Mental Health, Substance Abuse and Primary Care  Adoption of County Proven Wrap Around Program for Dual Eligible SMI group – Big ROI for IEHP  Autism Collaborative with a Mission to develop an Inland Empire ASD Center of Excellence  “Warm Hand Off” Referrals between County Specialty Mental Health and Health Plan for Medi Cal Expansion

Example #1: IEHP Implements SBDBH Proven Wrap Around Program For each Member information was collected six (6) months prior to TeleCare enrollment up May 29, 2013

Reduction in Psych Bed Days For each Member information was collected six (6) months prior to TeleCare enrollment up May 29, 2013

Medical Cost Offset: ED Utilization

Psychiatric Wrap Around Services Bring Down ED Costs by 74% Visits Months Reflected ED Visits PMPM Pre TelecarePost Telecare Pre TelecarePost Telecare Pre TelecarePost Telecare Average ED Cost per Visit is $510 ($110 for the professional component and $400 for the facility) - [Information Provided by IEHP's Provider Contracting Department]

Control Group – Increasing Psychiatric Hospital Costs

Control Group: ED Cost - Minimal Change Over Time

25% Return on Investment for IEHP For each Member information was collected six (6) months prior to TeleCare enrollment up May 29, 2013

Example # 2: From ADHC to CBAS- From State to Health Plan as Payer  What Happened to Adult Day Health Care?: State assigned responsibility to Local Health Plans and changed them into Community Based Adult Services (CBAS)  CBAS and Health Plans got to know each other out of necessity  CBAS Programs learned how to obtain Authorizations and Payment  End Result: Local Collaboration Improved Coordination of Care, Cost Effective for SMIs

Example # 3: IEHP Launches Navigator Program  Spanish Speaking Membership  Misuse of Health Care System  Low rate of Well Child Utilization/Immunizations  Uneven use of Primary Care  Over use of Emergency Department for Routine Care  Solution: Implementing a “Social” Model Intervention in a “Medical” Model Health Plan

The Health Plan’s Problem  Very high Emergency Department (ED) utilization  655 Per Thousand Members Per Year (2009)  23% for “avoidable” visits  California Department of Health Care Services Statewide ED Collaborative definition (2009)  Significant ED utilization for those 2 years old and younger for non-emergent visits  Medi-Cal: No ED co-payment

Member UtilizationRate Change Avoidable Emergency Room-39% Nurse Advice Line51% Urgent Care44% Utilization data based on the family linked to the Member visited by the Health Navigators with a middle visit between 06/15/2010 and 02/29/2012 Rates based on Per 1000 Members 26 Navigator Program Results

Example # 4 Autism Collaborative Kids with Autism Deserve an Answer!  1 in 50 children have ASD (CDC)  Lack of clinical criteria  Behavioral treatments:  Not well understood or coordinated  $40,000 to $120,000 per child per year = treatment authorization decisions based on cost rather than clinical criteria  Who is responsible?  Fragmented System

The Problem: Late Intervention = Diminished Quality of Life & Higher Life-Long Care Cost  Disparity in the Inland Empire (IE)  Average age of diagnosis of ASD in the IE –  All Children - age 5  Latino children - age 7  Scarce resources essential for the assessment of ASD such as Pediatric Neurology - typically not accessible in the IE

The Solution for the IE: Collaboration Stimulated by IEHP “In-House” BH The Inland Empire ASD Collaborative  Autism Society of the Inland Empire  Children’s Network  Dept of Pediatrics Loma Linda University  Desert Mountain Special Education LPA  First 5 Riverside and First 5 San Bernardino Counties  Inland Empire Health Plan (IEHP)  Inland Regional Center  Riverside County Mental Health Department  Riverside County Office of Education  San Bernardino Department of Behavioral Health

Inland Empire (IE) ASD Collaborative: Establishing ASD Assessment Center  Vision: “Every child in the Inland Empire will have access to a collaborative, organized, integrated and Trans-Disciplinary Assessment/treatment resource for Autism.”

AACE Clinic: Integrated & Child-Centric  Inter-agency collaboration will improve referrals as well as align providers and educators  Wasted time, duplicative assessments eliminated  Reduce the Parent’s burden of having to advocate and coordinate across multiple agencies  Provide families and providers with useful, appropriate and actionable treatment recommendations, referrals and resources  Be financially self-sustaining 2 years after start-up

Last Thoughts: What Works  Integration of Behavioral & Physical Health Care is the “Best Practice”  Separate is not Equal  Parity is not enough: Parity is a mandate, Integration is the Work to be done  Coordination of Care in not Sufficient: just a stepping stone toward integration  Health Plans Need to develop direct relationships with BH Providers in private practice, County BH programs and CBOs to meet the need  Direct Relationships are best: Minimize use of Sub-Capitated Middle Men that limit access  Health Plans must bring BH expertise “In House” to ensure Quality BH Care  Providers should contract at the highest possible level of the Funding Stream - Directly with Health Plans when possible  In a well integrated Model of Care, Open Access to BH Services pays for itself in Medical Cost Offsets  Not treating BH conditions drives up Medical & Social Costs  BH Providers need to demonstrate Value by Measuring Results and prove to Health Plans the return on investment (ROI) BH services yield

MCP services to be carved-in effective 1/1/14* Individual/group mental health evaluation and treatment (psychotherapy) condition Psychological testing when clinically indicated to evaluate a mental health condition Psychiatric consultation for medication management Outpatient laboratory, supplies and supplements Screening and Brief Intervention (SBI) (new service not currently offered) Drugs, excluding anti-psychotic drugs (which are covered by Medi-Cal FFS) MCP services to be carved-in effective 1/1/14* Individual/group mental health evaluation and treatment (psychotherapy) condition Psychological testing when clinically indicated to evaluate a mental health condition Psychiatric consultation for medication management Outpatient laboratory, supplies and supplements Screening and Brief Intervention (SBI) (new service not currently offered) Drugs, excluding anti-psychotic drugs (which are covered by Medi-Cal FFS) IEHP Responsibility San Bernardino County DBH Riverside County MHD San Bernardino County DBH Riverside County MHD Outpatient Services Mental Health Services (assessments plan development, therapy, rehabilitation and collateral) Medication Support Day Treatment Services and Day Rehabilitation Crises Intervention and Crises Stabilization Targeted Case Management Therapeutic Behavior Services Residential Services Adult Residential Treatment Services Crises Residential Treatment Services Inpatient Services Acute Psychiatric Inpatient Hospital Services Psychiatric Inpatient Hospital Professional Services Psychiatric Health Facility services Outpatient Services Mental Health Services (assessments plan development, therapy, rehabilitation and collateral) Medication Support Day Treatment Services and Day Rehabilitation Crises Intervention and Crises Stabilization Targeted Case Management Therapeutic Behavior Services Residential Services Adult Residential Treatment Services Crises Residential Treatment Services Inpatient Services Acute Psychiatric Inpatient Hospital Services Psychiatric Inpatient Hospital Professional Services Psychiatric Health Facility services Target Population: Children and adults in Managed Care Plans who meet medical necessity or EPSDT for Mental Health Services Target Population: Children and adults who meet medical necessity or EPSDT criteria for Medi-Cal Specialty Mental health Services County Alcohol and Other Drug Programs (AOD) Outpatient Services Outpatient Drug Free Intensive Outpatient (newly expanded to additional populations) Residential Services (newly expanded to additional populations) Narcotic Treatment Program Naltrexone New Services Voluntary Inpatient Detoxification Services (Administrative linkage to County AOD still being discussed) Outpatient Services Outpatient Drug Free Intensive Outpatient (newly expanded to additional populations) Residential Services (newly expanded to additional populations) Narcotic Treatment Program Naltrexone New Services Voluntary Inpatient Detoxification Services (Administrative linkage to County AOD still being discussed) Target Population: Children and adults who meet medical necessity or EPSDT criteria for Drug Medi-Cal Substance Use Disorder Services As of October 11, 2013 * MCP carve-in services, except for SBI, are currently offered through Medi-Cal FFS

Discussion How can CCC Executive Leaders and their Health Plan Partners Plan for Integration of Behavioral Health in their Counties? 1.What are your shared risks? 2.What are your shared end goals? 3.How can the process and structure of the Care Coordination Collaborative (CCC) help you to achieve your shared end goals? Can CCC serve as an incubator? 34