1. HARP Lessons Learned: We are all in it together!
Bob Holtz, Capital District Physicians’ Health Plan, Inc. (CDPHP®)
Kelly Lauletta, Community Care Behavioral Health

2. CDPHP: Who We Are

3. Who We Are
Established in 1984, CDPHP is a physician-founded, member-focused, and community-based nonprofit health plan that serves more than 430,000 members in 24 counties in New York state.
CDPHP continues to distinguish itself by the quality of its service and care management programs, the caliber of its physician network, and the excellence of its workplace climate.
We pride ourselves on meeting or exceeding widely accepted benchmarks for quality on a number of fronts and have been recognized for our efforts with several awards.
CDPHP Select Plan (Medicaid) is top-rated in New York state, according to NCQA’s Medicaid Health Insurance Plan Ratings  

4. CDPHP Coverage Area The CDPHP mainstream product is called Select Plan
We have elected not to use a product name for our HARP product
We currently offer Select Plan and HARP in 12 counties
85% of total Medicaid enrollment is in the northeast region, with 75% of this regional total centered in the four-county Capital Region of Albany, Schenectady, Rensselaer, and Saratoga

5. The Population We Serve
CDPHP serves 59% of the managed Medicaid population in the Capital Region
CDPHP serves a significant majority of SSI recipients (67%) in the Capital Region
The bulk of enrollment (88%) is in the SSI eligibility group; 12% are TANF adults
• 85.2% are in the Capital Region

6. Behavioral Health Mission
To implement a cost-effective, integrated model of managing behavioral health services within CDPHP. This includes assessment, triage, referral, clinical review, and decision-making tools to promote utilization of appropriate behavioral health care resources, as well as care coordination, discharge and aftercare planning, intensive case management, medical and wellness interfaces, a highly accessible delivery system, network management, quality management, data analysis, and ongoing evaluation.

7. Behavioral Health Access Center for Mainstream and HARP
Serves as the front line for clinical inquiries for CDPHP behavioral health services
Verifies the member’s current coverage and eligibility status; determines if the requested or necessary services are a covered benefit
Begins initial screening to determine if the call is emergency or routine for purposes of making triage decisions
Matches problem type with most appropriate provider of service using geographical, clinical information and member choice
Provides concierge referral services for EPC practices
Contacts providers and obtains appointments for members when necessary
Provides ambulatory quality review
Provides neuropsychiatry and psychological testing review
Provides crisis services

8. Behavioral Health Care Coordination - Mainstream and HARP
Licensed clinicians review requests for inpatient mental health and substance abuse services
Follows patients clinically to monitor medical necessity and ensure quality assurance
Travels to inpatient facilities to do on-site review and collaborate with inpatient BH hospital staff in length-of-stay meetings
Works collaboratively with medical inpatient care coordinators to assist with cases that involve a medical condition and a behavioral health condition
Works collaboratively with hospital staff and BH case management on discharge planning and comprehensive discharge planning
Notifies members and providers telephonically and in writing when care has been either approved or denied according to all regulatory timelines

9. Behavioral Health Case Management Mainstream
Contacts members after behavioral health hospitalization to establish a supportive “coaching relationship” that will help the member with treatment compliance and recovery
Provides short-term intensive assistance to members with behavioral health disorders to problem solve and eliminate barriers to care
Provides education and compliance encouragement on medication management
Collaborates with outpatient behavioral health providers to help the member avoid admissions into hospital levels of care
Reviews health risk assessment forms and makes follow-up phone calls to assist member with getting necessary behavioral health care
Works closely with case managers to coordinate chronic medical conditions
Reviews emergency room admissions for behavioral health-related disorders for follow-up assistance

10. Behavioral Health EPC Management Mainstream and HARP
Works on-site at the primary EPC practice to accept referrals from physicians, assess members on-site to help them obtain access to behavioral health care, and provide case-management services
Maintains registry of members engaged in case management
Coordinates mental health and substance abuse referral and care
Participates in medical practice huddles and provides physician consultations
Provides member education on medication management and encourages compliance
Collaborates with outpatient behavioral health providers to help the member avoid admission into a hospital level of care
Works closely with medical case managers to provide care for members with comorbid medical and behavioral health issues
Uses predictive modeling to identify members in the EPC practice who may be high risk for mental health/substance abuse problems

11. Our Partner: Community Care Behavioral Health

12. Community Care Behavioral Health
Incorporated in 1996 primarily to support Pennsylvania
Part of the UPMC Insurance Services Division
501(c)(3) nonprofit behavioral health managed care organization
20-year history of managing the behavioral health benefits for members in 39 out of the 67 counties in Pennsylvania
Recipient of two Patient-Centered Outcomes Research Institute (PCORI) grants studying shared decision making, as well as exploring member response to traditional nursing care management vs. peer lead wellness coaching

13. Community Care’s Work in NY
Implemented a care monitoring initiative in New York City (2009)
New York State Office of Mental Health (OMH)
New York City Department of Health & Mental Hygiene (DOHMH)
Awarded 16-county Hudson River Region in Behavioral Health Organization (BHO) Initiative (2012)
New York Office of Mental Health (OMH)
New York State Office of Alcoholism and Substance Abuse Services (OASAS)
Partnered with CDPHP to serve HARP members beginning July 1, 2016

14. Community Care’s Role So, they’re your BHO?
No. Community Care is providing on-the-ground care management solutions for HARP members. CDPHP retains the network and all utilization management functions.
Well then, they MUST be your health home.
No. Statewide, approximately 35% of all HARP members are enrolled with health homes. Community Care will facilitate the health home enrollment of HARP members whenever a member requests ongoing care coordination services.

15. How Do You Stratify Outreach?
Who do you outreach first?
Individuals who have been admitted to PH or BH units
Critical time interventions represent opportunities for engagement.
Community Care works closely with the CDPHP medical and behavioral health UM departments to identify when HARP members have been admitted.
Whenever possible, Community Care CMs coordinate visits while the member is inpatient to assess post-discharge needs.

16. How Do You Stratify Outreach?
Members triggering BH flags in PSYCKES
Members identified as HARP enrolled are run through PSYCKES to identify those who may meet the criteria for one or more of the following flags:
Medication-Related
Polypharmacy
High dose
Acute Care Utilization
High utilization
Readmission
Health Promotion and Care Coordination
Behavioral health
Medical

17. How Do You Stratify Outreach?
Members meeting PH flags in PSYCKES
When a HARP member triggers medical flags in PSYCKES, the CCBH CMs work closely with CDPHP medical CMs to assess the member’s needs and determine which team will take the lead in coordinating the member’s care.
If a member is exhibiting significant needs, the member may be switched to a co-managed status.

18. How Do You Locate Members?
Once members are stratified using PSYCKES data, the outreach begins!
CMs begin with the contact information contained in:
The state data feed
Other data platforms, including HIXNY and MAPP
Providers on recent claims

19. Community Engagement

20. Stakeholder Engagement
Who should be at the table?
Local governing units (LGUs)
Mental health providers
Substance use providers
Peer organizations
Health homes
Care management agencies

21. Communications and Consent The Struggle is Real
Who can the CDPHP/CCBH communicate openly with?
CDPHP can communicate openly with providers who have completed the contracting and credentialing process regarding shared member care.
CCBH is a business associate of CDPHP and can also talk with contracted providers to coordinate member care.
Who requires an executed Release of Information (ROI)?
Care management agencies (CMAs)
AOT teams
Single point of access (SPOA)

22. Barriers and Interventions

23. Barriers and Interventions
Barrier: Inability to communicate with CMAs Intervention: CDPHP is working to enter into BAAs through the health home to ensure ongoing coordination Barrier: Health home assessments and plans of care Intervention: CDPHP/CCBH are working closely with health homes and CMAs to assess readiness to perform assessments and complete POCs, as well as HCBS provider readiness to accept referrals Barrier: Health home assessments are deficit-based and engagement-averse - too may assessments asking the same questions Intervention: Use peer organizations to assist with moving questions to a strengths-based perspective; review and align existing assessments and share collected information across providers
Disease specific education- CM’s work to ensure members understand conditions by addressing barriers, health literacy issues, etc.

24. Subscribe to the PDSA!
PLAN – Work with the existing provider system to develop a plan that is sensitive to the needs and resources
DO – Give it a try! (Recognize that it won’t be pretty)
STUDY – Review – are the processes in place meeting the overall need?
ACT – Regroup – find out what is working and not working and make adjustments accordingly

25. Questions?

26. Contact Information
Bob Holtz
VP of Behavioral Health
CDPHP
Kelly Lauletta, LCSW
Regional Director
Community Care Behavioral Health