Measuring to improve quality June 29,

This presentation will: Provide an overview of the provider profile and pay- for-performance (P4P) process Invite discussion on proposed measures and the P4P process for BHRS Outline next steps after today 2

What is a Provider Profile Data-oriented report to measure change at the System and the Provider level Intended to profile a Provider in our network on their performance on key quality measures Include contextual data on who (e.g. demographic information) and how (e.g. length of stay) were served by said Provider Iterative process: may include new measures each year and or higher targets 3

What makes good performance measures? Central to our Shared Mission Important & Meaningful Feasible to Capture Accurate and Representative Leads to Improved Performance 4

What is Pay-for-Performance A payment model rewards providers for meeting certain performance measures for quality and efficiency Providers under this arrangement are usually rewarded for meeting pre-established targets for delivery of healthcare services 5

How is Philadelphia affected by P4P? HealthChoices Contract with State PA Department of Public Welfare pay-for- performance So far, focused on inpatient psychiatric hospitalization Received pay for 2008 performance 2009 performance probably will not as our Inpatient Outcomes did not keep up with other Counties 6

Purpose of Pay for Performance Focus attention on desired quality processes & outcomes Shared Focus What are the things DBH can do to improve and what are things Providers can do? Develop Shared Clarity about the direction we want to go 7

Timeline (abbreviated) of development of provider profile 2007 – Series of meetings with providers to introduce concept & start discussion 2008 – Preliminary data tabulations; internal sharing of results 2009 – Baseline reports on Inpatient Psychiatric Services (April) and Children’s Residential Treatment (Dec) nd series on IP & RTF; baseline report on D & A Residential Rehabilitation Services 2011 – Repeat others and Baseline for: BHRS, TCM, CIRC, Host Homes 8

Who gets a report? In-network providers Providers serving at least 20 youths Individualized reports Need to discuss dose within the year before expected improvement Providers with fewer than 20 discharges All CBH providers combined report or Letter of Intent for Continuous Quality Improvement? Similar to the OTIP process? Or Expanded Chart Reviews? 9

Types of Information in the Profiles Quantitative Outcomes – Inpatient/CRC Visits/RTF rates, Follow-up rates, AMA rates, etc. Contextual – Length of Stay – Cost Summaries – Avg Units per Child per Level of Care Contractual Oversight – Compliance and Credentialing Qualitative Measures (being piloted) – Agency and Individual Service Reviews (chart audits) 10

All reports have: Measures that compare to national and/or state standards or to local norms Thresholds for assessing good, adequate and poor performance (green, yellow and red) based on national and/or state standards or local norms Comparison to overall CBH statistics Blinded comparisons to other providers Multi-year trends for selected (not all) measures 11

How to use the reports Provide you with comparison benchmarks System as a whole and other providers Raise questions about care, expectations, and generate research about differences Generate discussion about system wide challenges Help to determine P4P measures Facilitate providers sharing information about practices with each other after receiving reports Inform the credentialing process 12

Purpose of Pay for Performance Focus attention on desired quality processes & outcomes Shared Focus What are the things DBH can do to improve and what are things Providers can do? Develop Shared Clarity about the direction we want to go? 13

P4P Methodology Criteria for being in P4P Pool each Year ◦ In Network Providers ◦ Adequate sample size for measuring said provider ◦ Top 2/3 of Aggregated Scores  Unless all are meeting national standards then possibly consider all as qualifying Scores/weights for each Measure used in P4P ◦ Weighting for specific measure and to population served – details available from CQI 14

2011 performance pay will be based on 2010 FY data for BHRS Measures from profiles used in all levels of care P4P Continuity of Care Readmission or alternately Not Readmission Compliance Measures used in some levels of care (not all) AMA Quality of Care Concerns Measures not used include Complaints 15

Sample of what CEO’s Received regarding D&A Residential Rehab P4P Scores 16

Performance Dollars are: Proportional to Volume Served Proportional to Weighted Scores 17

2010 Performance Pay Based on their weights/scores (which are based on how well they did in certain measures from the profiles), and how much services they had provided in 2009 some providers received performance pay some providers did not receive performance pay 18

Profiles reported on 5 domains System Transformation Access and Service Utilization Quality of Care Customer Service Contract Status 19

1. System Transformation Suggestions for measure includes: Peer Culture Development Family Involvement Recovery/Resilience Training 20

2. Access and Utilization What are we counting Those served Units per Child per Level of care Length of Stay Are membera having timely access? Do we have enough system capacity? Under and over utilization? 21

Utilization measures 22

3. Quality of Care Measures in the section of CBH Provider Profiles that focus on: Safety Clinical effectiveness Consumer-centered 23

Measures in Quality of Care How do we know that our members received quality care? – Members are doing better How measured? – Not returning to same or higher level of care – recidivism – Engagement in continuity of care – follow-up care in a lower level of care – Provider closed to admissions 24

Quality of Care (cont’d) Few DIRECT measures of quality of care We need to assess for indicators of quality care: ◦ Documentation of specific desirable (operationally defined) activities or events in client records (e.g. family meetings) ◦ Lack of undesirable events in client records or data sets (e.g. serious incidents, AMAs, restraints) ◦ Individual assessment tools (e.g. recovery tools, community participation scales). 25

Comparison of Providers to CBH System as a whole 26

Comparison to other providers – Adult Inpatient recidivism 27

One example measure of Significant Incident 28

Types of severe incidents 29

4. Customer Service Complaints “an issue, dispute, or objection presented by or on behalf of a member regarding a participating health care provider, or the coverage, operations or management policies of a managed care plan” 30

Complaints: what we report First-level complaints – Number of complaints per provider – Type of complaint E.g., consumer rights, treatment concerns – Rate per 1000 authorized units of service Blinded comparison across providers – How rate per 1000 authorizations compare to other providers in same level of care 31

5. Contract Status Rate Increase History Provider Volume Compliance Status and Audit Rate Credentialing History Refusal to Admit (proposed) Failure to Notify CBH of Closure (proposed) 32

Measurements to be reported by the categories Population/diagnostic cohorts ASD, ID or other Specific Level of Care Groupings STS CARE School-based Wrap-around Non-school based Wrap-around Group TSS Mobile Therapy Family Services 33

Breakout Group 1: Clinical Review of Agency Infrastructure and Chart Reviews A break-out group to review and discuss Proposed Self Audits and Cross-Validation What to do for small volume providers? Letter of Intent: Plan for Quality Improvement Processes regarding Practice Guidelines and measures that are included in the reports. Similar to OTIP along with quantitative measures..weigh quantitative measures less for these Additional chart reviews 34

Breakout Group 2: Access and Delivery of Service Average number of days between auth and date of first claim for new auths that year Paid to Auth Ratios to demonstrate delivery of service By 6-digit level of care Staffing Ratio based upon census submission Length of time between date of completion of evaluation and date of submission to CBH Avg Number of Units per youth per level of care 35

Breakout Group 3: Transitioning from BHRS to high intensity services or failure to transition % of (non ASD, non ID) youth receiving greater than 3 years of BHRS % of (non ASD, non ID) youth >= 14 receiving BHRS % of Children admitted to Inpatient, and CRC respectively Control for minimum dose: or two measures those with higher auth/paid ratio’s and those with lower auth/paid ratio Or Control by length of time with provider 36

Breakout Group 3: Successful Completion, Transition to Family or Lower Levels of Care, positive Outcome % Transitioned to Family Level of Care Family Based Services Family Focused Behavioral Health PHICAPS FFT Others? % Transitioned to any Outpatient Treatment % Listed as Successful Completion on Discharge Summaries % of Children with Improvement in School Attendance 37

Breakout Group 4: (3 topics) Support of Evidenced Informed Evaluations, Interpretation of Quality, and Compliance % Completion and Data Submission of ASEBA at Baseline and Follow-up % Submission of Census % Submission of Discharge Summaries Rate of Quality of Care Concerns Error Rates on Compliance 38

Report Back by Groups 39

Next Steps Summary to the Website Data and profile development Distribution of Reports Recommendations for Pay for Performance Pay for Performance Weights and Outcomes Pay Increase before 01/01/2012 for those deemed as receiving P4P 40