1. Critical Time Intervention as a Means of Exposing Community-Based Organizations to Value-Based Payment Arrangements
April 28th 2017

2. Bronx Partners for Healthy Communities
Our largest 7 primary care partners
BPHC is implementing the DSRIP initiative. Short overview – review of DSRIP. And our goals…
Our DSRIP Goals:
Achieve the Triple Aim: Better Health, Better Patient Experience, Lower Cost
Reduce avoidable ED visits and hospital admissions by 25% by 2020
357,424 total attributed patients

3. SMI, Homelessness & Hospitalization
Homelessness among people with Serious Mental Illness (SMI) is an important and unaddressed issue – contributes to avoidable hospitalization*
Traditional telephonic care-transitions programs rarely work for the precariously-housed with SMI
Recent data* has shown:
Psychiatric hospitalizations among these adults accounted for 26% of all psychiatric hospitalizations in NYC
~33% of US homeless population includes individuals with SMI
Hospital used as shelter. Explain precariously-housed as couch surfing. Transience makes it difficult to reach them with continuous services.
*Treatment Advocacy Center and National Coalition on the Homeless

4. Critical Time Intervention (CTI) Model
Housing Crisis Prevention
Life Skills Training
Substance Abuse Treatment
Psychiatric Treatment and Med Management
Money Management
Family Intervention
Cost-effective, evidence-based practice proven to reduce recurrent homelessness
Developed in early 1980s in NYC, due to rise in homelessness among people with SMI
Supports clients in building community ties and ensuring continuity of care
Time-limited: 9 months, 3 phases
Phase 1: Transition
Phase 2: Try-Out
Phase 3: Transfer of Care
CTI has been applied with veterans, people with mental illness, people who have been homeless or in prison, and many other groups
Phase 1: Transition (high intensity, high touch)
Phase 2: Try-Out (gradual reduction in intensity, move towards monitoring)
Phase 3: Transfer of Care (lowest intensity, support network in place
Limited areas of focus (6)
Front loaded. Peaks in frequency. A lot of attention
Phase 1: Transition - Provide support & begin to connect client to people and agencies that will assume the primary role of support
Phase 2: Try-Out - Monitor and strengthen support network and client’s skills.
Phase 3: Transfer of Care - Terminate CTI services with support network safely in place
To test the effectiveness of CTI, the first clinical trial ( ) focused on clients in the New York City men’s shelter who were also enrolled in the onsite mental health program.
After placement from a shelter clients received a CTI specialist to provide case management
BPHC chose CTI to address hospital utilization

5. BPHC’s Rationale For Selecting CTI
Bronx Community Needs Assessment, conducted in the DSRIP context, showed homeless New Yorkers tend to be:
Under utilizers of primary care and Health Homes
Frequent users of Emergency Departments
More pronounced amongst the SMI population.*
BPHC estimated ~400 patients with probable homelessness and 4+ visits to ED and/or inpatient setting (10/2013 – 10/2014).
SMI population requires community support to bridge the transition from facility to community and to ensure enduring linkages.
CTI bridges the gap by addressing transitional needs while the patient is still in the hospital, extending the reach of licensed community mental health providers.
*National Coalition on the Homeless and NYCDOHMH data

6. BPHC CTI Program Model Eligibility Criteria Diagnosis of a SMI
Hospital stay or ED visit in past 6 months
Eligible for Health Home (HH)
Precariously Housed
Locations of Client Identification
Psychiatric inpatient units
Medical inpatient units
Other programs (HHs, shelters, detox, etc.)
Phase
Fidelity Model
BPHC Model 1
Months 1-3
Intensive support to implement transition plan
CTI worker makes home visits and
accompanies clients to community providers
Identical to Fidelity 2
Months 4-6
Build and test problem-solving skills
CTI worker observes client’s support network and helps to modify to meet needs
Begin warm hand-off to HH Care Manager 3
Months 7-9
Solidify network and complete CTI services
CTI Worker develops and sets in motion
client’s plan to meet long-term goals
(e.g., employment, education, or family reunion)
Complete hand-off to traditional HH model of care.

7. BPHC CTI RFP and Provider Selection
RFP issued to network behavioral health providers
Incorporated value-based arrangement – downside risk tied to failure to achieve reduction in hospital use.
Four organizations selected to each enroll ~ 80 individuals in CTI program:
Coordinated Behavioral Care IPA (CBC)
Visiting Nurse Service of New York (VNSNY)
Riverdale Mental Health Association (RMHA)
SCO Family of Services (SCO)
Organizations hired caseworkers to perform the intervention – providing new job opportunities in the Bronx
Began enrolling patients in January 2017, will continue through end of the year.
Offered with two options: organizations with an existing CTI program and organizations with no existing CTI program.
Organizations were selected using a weighted scoring methodology.
BPHC sponsored training.

8. CTI and Health Home Collaboration
CTI extends intensive, high-touch care coordination into the community
Promotes successful transition
Complements the HH model during a critical period
Case workers are non-clinical coordinators supervised by a licensed professional
HH care coordinator is encouraged to collaborate with the CTI worker from the beginning. Interactions and billing for HH remains unchanged
CTI worker transitions out in Phase 3 and the HH care coordinator continues to work with the client on outstanding and/or new interventions.

9. DSRIP P4P Measures CTI Can Impact
Measure Name
Maximum P4P
Dollar Value
Potentially Preventable Visits (PPV) to ED
$5,257,927
Potentially Preventable Readmissions (PPR) to Hospital
Potentially Preventable Visits to the ED
(for patients with a BH diagnosis)
$2,785,879
F/U visit after hosp. for Mental Illness – 30 days
$2,355,465
F/U visit after hosp. for Mental Illness – 7 days
Initiation of Alcohol and Other Drug Dependence Treatment
(1 visit within 14 days)
$453,311
Engagement in Alcohol and Other Drug Dependence Treatment
(Initiation and 2 visits within 44 days)
Total Potential Earnings
$18,919,285
P4P = Pay for Performance

10. CTI Implementation – Early Challenges
Referral frequency and quality
Relationship between CTI and Health Home
Shelter system and the transience of the target population
Incentive payments and the potential for cherry picking clients

11. CTI as a Microcosm for VBP Challenges
CTI supports VBP goals
Integrating care services and measuring quality outcomes.
Emphasis on community-based care.
Associated challenges
How to measure / reward outcomes for this population beyond utilization.
How to account for the contribution of each provider or intervention, particularly non-clinical CBO services.
How to maintain a focused attribution with such a transient population.
How to remain patient-centric in a VBP arrangement.
Hospital
Health Homes
Social Services
Outpatient Physical & Behavioral Health
CTI

12. Thank you!

13. References
How Many People with Serious Mental Illness are Homeless? Retrieved from: with-serious-mental-illness-are-homeless
Bronx Community Needs Assessment Report November, 2014 Retrieved from: sp_dba_sbh_health_system/3.4_st_barnabas_cna.pdf
Epi Data Brief. New York City Department of Health and Mental Hygiene. June 2016, No 71. Retrieved from:
Mental Illness and Homelessness. National Coalition for the Homeless, July Retrieved from:
Homelessness and Housing Retrieved from:
Critical Time Intervention: Preventing Homelessness in the Transition from Institution to Community Retrieved from:
CUCS Institute, Critical Time Intervention (CTI) Presentation Retrieved from:
CUCS Institute, Critical Time Intervention Overview Retrieved from: