National Academy for State Health Policy Conference Joan L. Erney, JD Chief Business Development and Public Policy Officer Community Care Behavioral Health Organization Kansas City, Missouri / October 5th, 2011

Today’s Discussion Introduction to Pennsylvania Medicaid and behavioral health landscape. PA Health Choices program performance Overview of two physical health/behavioral health projects in Pennsylvania. Lessons learned. 2 Earney

Pennsylvania Quick Facts 12 million residents. 2.2 million projected Medicaid members (FY11-12). 2 urban centers (Philadelphia, Pittsburgh = 38% MA members). Department of Public Welfare (DPW) is single state agency for Medicaid –Office of Medical Assistance => physical health system –Office of Mental Health and Substance Abuse Services => behavioral health system County-based system for human services. –Organized as 49 county joinders for mental health & drug and alcohol services. –County government plays significant role in Behavioral Health HealthChoices program; 43 of 67 counties contract for Medicaid. 3 Earney

HealthChoices Overview CMS Waiver Authority: 1915 (b) Waiver 25 County Waiver (3 zones) –Physical health: Choice of HMOs. –Behavioral health: 24 contracts with counties, 1 direct contract (Greene). 42 County Waiver –Physical health: Access Plus (PCCM); voluntary HMO. –Behavioral health: 19 counties; 1 direct state contract for 23 counties (Community Care). 4 Earney

5 Erie WarrenMcKean Tioga Bradford Susquehanna Wayne Cambria Huntingdon Blair Forest Venango Mercer Lawrence Butler Clarion Crawford Jefferson Clearfield Centre ElkCameron Potter Northampton Lebanon Cumberland York Adams Lancaster Perry Juniata Mifflin Dauphin Schuylkill Montgomery Chester Delaware Philadelphia Berks Bucks Lehigh Columbia Montour Snyder Union Northumberland Lycoming Sullivan Pike Carbon Luzerne Monroe Wyoming SOUTHEAST Implemented February 1997 SOUTHWEST Implemented January 1999 LEHIGH/CAPITAL Implemented October 2001 NORTH/CENTRAL STATE OPTION Implemented January 2007 NORTH CENTRAL COUNTY OPTION Implemented July 2007 NORTHEAST Implemented July 2006 Lackawanna HealthChoices Zones Earney

Key Features County Right of First Opportunity: Sole Source Contract - County options for acceptance of risk. Consumer choice for in-plan services. ─All MA Providers in initial year. ─Choice of two providers each level of care within access standards; reviewed annually. Includes all state and federal eligibility categories of Medicaid. Includes special populations, children and youth, and persons with intellectual disabilities. 6 Earney

Key Features Pharmacy benefits (with the exception of Methadone) paid for by physical health or FFS. State Plan services, cost-effective alternatives, and supplemental services available. Consumer/Family Satisfaction Team (C/FST) in every contract. Reinvestment of savings at the local level; must be targeted to behavioral health. Performance measurement system. 7 Earney

HealthChoices Today Began in the Southeast Region and is now statewide BH program began in 1997; phased in through 2007 ─43 counties (joinders/multi-counties) accepted the right of first opportunity; mixture of ASO (administrative services organization) and county risk-sharing arrangements. ─23 counties (rural): state contract; 1 county (southwest zone): state contract. 8 Earney

HealthChoices Highlights $4-5 billion in savings due to the Behavioral Health program. Access to services and variety of services have both increased. Increased access to drug and alcohol providers to a significant degree. Reinvestment opportunities sparked innovative practices and cost-effective alternatives to current practices. 9 Earney

More HealthChoices Highlights Improved quality standards and outcomes. –Significant change in performance from –Utilization Changes reflect commitment to less restrictive services Design provides opportunities for innovative physical health and behavioral health initiatives. Unified systems and funding; maximized fiscal resources at state and local level to support major initiatives include closing of state facilities; enhanced access for high need dependent children. 10 Earney

% Change in HealthChoices Performance Measure: 2003 to 2008 Access Performance Indicators (Penetration Rate) All PI #1a, SMI and No Substance Abuse, Ages % PI #1b, SMI and Substance Abuse, Ages % PI #2.1, Mental Health Service, Ages 18-64, African American33% PI #2.2, Substance Abuse Service, Ages 13-17, African American41% PI #2.3, Substance Abuse Service, Ages 18-64, African American27% PI #2.4, Mental Health Service, Ages % PI #2.5, Substance Abuse Service, Ages % PI #2.6, Substance Abuse Service Ages % Quality/Process Performance IndicatorsAll PI #3a, At Least One Day in a Residential Treatment Facility, Under Age 21, Mental Health 35% PI #3b, Cumulative RTF Bed Days 120 or Greater, Under Age 21, Mental Health 1% PI #4a, Psychiatric Inpatient Readmitted Within 30 Days Post-Discharge, Under Age 21 5% PI #4b, Psychiatric Inpatient Readmitted Within 30 Days Post-Discharge, Ages % PI #4c, Psychiatric Inpatient Readmitted Within 30 Days Post-Discharge, Ages 65+ PI #5a, Discharged from RTF With Follow-Up Service(s) Within 7 Days Post-Discharge -3% PI #5b, Discharged From Psychiatric Inpatient With Follow-Up Service(s) Within 7 Days Post-Discharge, Under Age 21 19% PI #5c, Discharged From Psychiatric Inpatient With Follow-Up Service(s) Within 7 Days Post-Discharge, Ages % PI #5d, Discharged From Psychiatric Inpatient With Follow-Up Service(s) Within 7 Days Post-Discharge, Ages 65+ NC PI #5e, Discharged From Non-Hospital Residential Detox, Rehabilitation and Halfway House Services for D&A Dependency or Addiction with Follow-Up Services Within 7 Days Post-Discharge, Under Age 65 9% 11 Earney

Utilization Rate Changes by Service Category : Earney

Systems Redesign: Move to Less Restrictive Care Settings 13 Earney

PA Physical Health/ Behavioral Health Landscape Projects supporting integration of services and supports for individuals with physical health (medical) and behavioral health needs happening across the state in urban, rural, and suburban settings. Co-locations; collaborations; shared staff models; health home development; shared health records. This presentation will focus on two Pennsylvania initiatives involving Community Care, a behavioral health managed care organization serving in Pennsylvania’s Medicaid managed care program. (Health Choices) 14 Earney

About Community Care 15 Behavioral health managed care company; part of UPMC; headquartered in Pittsburgh, PA; founded in 1996 Federally tax exempt non-profit 501(c)3 Major focus is publicly-funded behavioral health care; currently doing business in PA and New York Licensed as a Risk-Assuming PPO in PA; NCQA accredited Serving over 100,000 individuals in 36 PA counties through a statewide provider network of over 1700 Earney

Connected Care™ Program Initiative to improve the connection and coordination of care for those with Serious Mental Illness among health plans, PCPs, and behavioral health providers in outpatient, inpatient, and ED settings Based on Patient-Centered Medical Home model –integrated care team and care plan to address medical, behavioral, and social needs Partnership between: –Center for Health Care Strategies (CHCS) –Department of Public Welfare (DPW) –UPMC for You and UPMC for Life Specialty Plan –Community Care Behavioral Health –Allegheny County Department of Human Services 16

Services in PA and NY City Erie Allegheny Clarion Forest Warren McKean Potter CameronElk Jefferson Clearfield Centr e Clinton Adams Unio n Lycoming TiogaBradford Columbia Northumberla nd York Chester Berks Schuylkill Luzerne Wyoming Susquehanna Lackawanna Wayne Pike Monroe Carbon Juniat a Sulliv an Huntingdo n Miffli n Snyd er Monto ur Southwest Region Lehigh-Capital Region Northeast Region Erie County Region Community Care Office Serving individuals in 36 PA Counties and 5 New York City Boroughs Chester County Region North Central Region County Option North Central Region State Option 17

Connected Care™ Guiding Principles Behavioral health is part of overall health; good health outcomes are important to an individual’s recovery. Integration of good health habits, prevention activities, and specific physical health interventions are best achieved through local collaborations and navigator systems. Good health outcomes can be achieved within the existing physical health and behavioral health managed care design. 18 Earney

Connected Care™ Expected Outcomes –Decreased Inpatient utilization (both PH/BH). –Decreased Utilization of emergency room usage and crisis services. –Reductions in readmission rates for PH/BH. –Increase in preventive and routine health care. –Increase in satisfaction and quality of life. Members qualify for Connected Care™ if they: –Are a UPMC for You and a Community Care member. –Are age 18 or older. –Live in Allegheny County. –Have Serious Mental Illness (SMI)*. * SMI is defined as individuals who have been diagnosed with schizophrenic disorders, episodic mood disorders, or borderline personality disorder. 19

Member Stratification High PH needs defined as: –3 or more ED visits in past 3 months, or –3 or more inpatient admissions in the past 6 months. High BH needs defined as: –Discharged from, history of being served, or diverted from a State mental hospital. –5 or more admissions to most restrictive level of care, or readmitted within 30 days. –4 or more admissions to most restrictive level of care and inpatient or RTF or CTT admission. –3 or more admissions to the most restrictive level of care and inpatient or 2 admissions to most restrictive level and inpatient and an open authorization for certain services. 20 Earney

Joint training sessions on program design and work flows with care managers Consumer group input on program design and materials. Use of BH providers to help obtain consent Incentives to Medicaid members –2009- $25 gift cards for visiting PCP –2010- $25 gift cards for completing consent and enrolling Approximately 250 new Medicaid members identified monthly Consumer Engagement 21 Earney

UPMC for You and Community Care coordination: Focus on Tier 1 members and those admitted or seen I the ED Use of integrated care plan Weekly multi-disciplinary care team meetings Daily identification of members with PH or BH admission, and ED visits from key UPMC hospitals Concurrent case discussions 24 hour/day phone line managed by Community Care to answer member questions Care Management Activities 22 Earney

Mathematica Review: Summary of Outcomes After Year 1, no evidence suggested program had effect on changes in aggregate rates of hospitalizations or ED visits –For example, average number of PH hospitalizations per 1,000 members per month: Study group dropped 11 percent from 31.6 to 28.2 Comparison group dropped 17 percent from 30.3 to 25.2 Difference in differences was not statistically significant (p=0.449) No statistically significant differences in rates among those who consented to participate 23 Earney

Mathematica Review: Conclusion After the first year, it was too early to identify improvements in health care utilization Both regions faced enrollment challenges and spent parts (or most) of the first year finalizing implementation issues Several promising strategies emerged –Member and provider engagement through existing relationships –Nurses as a central component of a multidisciplinary care team for BH-led integration efforts –Shared information tool merging PH and BH information 24 Earney

Connected Care: Behavioral Health Home Plus Designed to demonstrate the efficacy of care coordination of PH/BH services for individuals with SMI and co-occurring medical conditions in a Medicaid and dual-eligible BH carve-out –Combines technological infrastructure, data management, and clinical expertise of a BH-MCO and a BH provider-based care coordination model. Expands on Community Care’s Allegheny County Connected Care program. –Effectively reduced both physical and psychiatric hospital readmission rates & emergency room use –Improved quality indicators for individuals with physical co- morbidities 25 Earney

North Central State Option Medicaid Members and Expenditures – 2009 Profile * Total Member Months: 1,749,129; Average Member Months: 145,761 Unique Users159,251CDPS Profile Total BH Spending$192,206,453BH $/User$1,207ConditionUsersPercent Total PH Spending$572,917,158PH $/User$3,598Diabetes12,104 8% Inpatient Util000Pulmonary78,53349% BH2763+ co-morbidities92,47958% PH1,5325+ co-morbidities68,40043% Population Characteristics 26 Earney

Connected Care: Behavioral Health Home Plus Identify multiple sites within 23 county rural contracts in North Central Pennsylvania –Rural communities build on existing relationships; enhance with nursing competencies Early Adopter includes 5 county programs who operate services, partnering with local practices, Geisinger Health Systems Health Care Quality Unit (HCQU) for persons with Intellectual Disabilities and other behavioral health supports including peer specialists and psych rehabilitation. Member Portal and Other IT innovations Implementation manual will detail “how to” Evaluation Opportunity 27

Lessons Learned Integration of physical health and behavioral health happens locally, building on the strengths of community infrastructure Real time notice of inpatient stays and ER visits has had impact on follow-up and engagement of individuals Nurses play a key role in the program and appear to interface more successfully with PCPs and specialists in accessing treatment for persons with SMI Certified Peer Specialists, and consumer tools such as WRAP ( Wellness Recovery Action Plan) planning and shared-decision making, are key in assisting in recovery and engagement in healthcare 28 Earney

Lessons Learned IT Infrastructure of systems is challenging, but interfacing systems capacity can be built over time Investment of key PH and BH systems for at all stakeholder levels critical to success of collaboration CHCS played important role in providing support and technical assistance to the projects Having financial resources to assist in start-up and pooled resources for shared savings provided greater incentives for collaboration Identification of outcomes and performance expectations assists in focusing work 29 Earney

For Our Consideration… Integration with physical health is important; however, also equally important for persons with serious mental illnesses are supports outside of medical care that encourage community integration and recovery. Issues of poverty, and real life challenges, such as transportation, access to healthy food, and stigma need to be incorporated into our solutions for individuals. Access to behavioral health treatment for persons with situational and short-term needs must be available in a timely way; barriers to co-location, payment constraints, and regulatory challenges continue to need to be addressed. Continued evaluation for financial impact of collaboration is needed. Opportunity to include Medicare resources will be of great benefit for persons with serious mental illnesses and chronic conditions. Careful consideration and best practices continue to need to be developed for substance use and physical health integration, including pain management strategies. Health Homes and ACOs offer opportunities; however, thought should be given as to how to build from, not create separate and distinct structures, from local communities strengths. Build on Success! 30 Earney

Contact Information Joan L. Erney, JD Chief Business Development and Public Policy Officer Community Care Behavioral Health Organization Former Deputy Secretary OMHSAS ( ) Community Care Behavioral Health Organization One Chatham Center, Suite Washington Place Pittsburgh, PA Earney