1. copyright © 2012 How Data & Analytics are Changing Payer Expectations & Shaping the Delivery of Services Children’s Mental Health Services Staff Development Training Forum November 27, 2012

2. copyright © 2012 About Community Care Behavioral Health Managed Care Company Founded in 1996 Federally tax exempt non-profit 501(c)3 Sole member corporation (UPMC) – provider owned Licensed as a Risk-Assuming PPO Major focus: publicly funded behavioral health care system

3. copyright © 2012 About Community Care Medicaid/HealthChoices membership: 700,000 Commercial/Medicare membership: 600,000 Statewide HealthChoices presence – 36 of 67 Pennsylvania counties 8 offices across the Commonwealth Over 500 employees Approximately 110,000 people served Statewide provider network of 1800+ Also serving as a BHO in Hudson River region of New York

4. copyright © 2012 Our Origins Pennsylvania HealthChoices Program Medical Assistance (Medicaid) managed care program Department of Public Welfare Office of Mental Health and Substance Abuse Services oversight Statewide behavioral health carve out – 1915b federal waiver – County government is the recipient of funds – County government contracting models vary

5. copyright © 2012 Mission and Vision To improve the health and well-being of the community through the delivery of effective and accessible behavioral health services To improve the quality of services for members through a stakeholder partnership focused on outcomes To support high quality service delivery through a not-for-profit partnership with public agencies, experienced local providers, and involved members and families

6. copyright © 2012 Focus Recovery transformation Peer and family involvement Respecting individual differences Community partnership Systems integration (children and youth) Focused care management model Physical/behavioral health integration Fiscal responsibility

7. copyright © 2012 Membership Trend 2001402,369 2002476,020 2003 520,152 2004 587,162 2005 597,011 2006 697,676 2007 998,908 2008 1,043,125 2009 1,097,645 2010 1,297,458 2011 1,377,419 2012 1,470,927

8. copyright © 2012 Services in Pennsylvania & New York Serving 36 PA counties & NY’s Hudson River Region Southwest Region Lehigh-Capital Region Chester County Region Northeast Region North Central Region County Option North Central Region State Option Erie County Region Community Care Office Erie Allegheny Clarion Forest Warren McKean Potter CameronElk Jefferson Clearfield Centre Clinton Adams Union Lycoming TiogaBradford Columbia Northumberlan d York Chester Berks Schuylkill Luzerne Wyoming Susquehanna Lackawanna Wayne Pike Monroe Carbon Juniata Sullivan Huntingdon Mifflin Snyde r Monto ur Hudson River Region

9. copyright © 2012 UPMC Insurance Services Division Operating Structure University of Pittsburgh Medical Center (UPMC) UPMC Insurance Services Division UPMC Health Plan Askesis Development Group, Inc. Medical Assistance Community Care

10. copyright © 2012 Accreditations and Commendations NCQA Full accreditation status (3 years) MBHO and DM Moffic Award–American Association of Community Psychiatrists ESPRIT Award–Mental Health Association of Allegheny County Corporate Award National Alliance for Autism Research (NAAR)-Appreciation Award Certificate of Recognition for Contribution to Western Pennsylvania Autism Community

11. copyright © 2012 Community Care’s Utilization of Data System Redesign Care Management Quality PH/BH Integration Provider Collaborations Highlights

12. copyright © 2012 Before We Look at the Data What are we interested in? What is the specific question? How can we frame the data? How do we improve our interpretation of data over time?

13. copyright © 2012 What Are We Interested In? There are many questions to ask, but we need to clarify what our goal/area of focus is – Admission data can be important to understanding the rates of admission, readmissions, and follow up after discharge. – Length of stay data might be related to quality of care, discharge options, or other characteristics of the population – “Data mining” without an area of focus could lead you off course

14. copyright © 2012 What is our Expectation of the Answer? Data alone can give answers that are correct, but not necessarily meaningful – Medication effects that are statistically significant, but not often clinically relevant – Information can reinforce existing beliefs (e.g. global warming) – Predictions and assessments based on data are always tainted by our subjective perspective Silver, Nate: The Signal and the Noise. New York: Penguin Press, 2012

15. copyright © 2012 Available Data Sources Authorizations Claims Enrollment data including basic demographic information Eligibility data including all coverage in addition to Medicaid Pharmacy Physical health from physical health plans Limited laboratory results (ordered by psychiatrists) Care management information entered into PsychConsult Member and provider satisfaction results Complaints and grievances Significant member incidents

16. copyright © 2012 Reducing Readmissions Case Study Allegheny County Readmission rate was one of the highest in the state Used data analysis to identify members at high risk for readmission: – Concurrent substance use – Homelessness – Lack of social supports – Multiple readmissions

17. copyright © 2012 Preliminary Questions What are we interested in? – Decreasing Rate of Readmissions What is our expectation of the answer? – There are patient specific factors that can help us identify what specific members to provide additional resources for – There are process related factors that contribute to many readmissions

18. copyright © 2012 Analysis of Readmission Data Length of Stay The Length of Stay for the Index Event is significant as an indicator for a member having a readmission following the index admission event.

19. copyright © 2012 Age Group Member’s age was not significant as an indicator for a member having a readmission following an index admission event.

20. copyright © 2012 Day of the Week Days of the week for index discharge date are not significant as an indicator for a member having a readmission.

21. copyright © 2012 Diagnosis Group Diagnosis groups are significant as an indicator for readmission.

22. copyright © 2012 Our Understanding of these Analyses Serious mental illness significantly contributes to readmissions Many people who are readmitted have concurrent substance abuse Lack of necessary community resources for many individuals contribute to readmissions

23. copyright © 2012 Activities to Improve Readmission Rates High risk care management focus on multiple readmissions – Care managers complete telephonic continued stay and discharge reviews for acute levels of care and specialized services – Care managers attend multiple community meetings, i.e. disposition, treatment team, interagency, to help with discharge planning New services to address members’ needs – Acute case management service focused on immediate engagement and support – Imbedded evidence based practice, Brief Critical Time Intervention (BCTI) in ACM; designed to link individuals to community based services and resources based on need during times of transition in care – Enhanced crisis residential services – Enhanced access to substance abuse services

24. copyright © 2012 Additional Service Development To ensure individuals receive the treatment needed in their home communities, system redesign and enhancements included: Peer Support Services, help individuals establish ongoing relationships in the community and provide support during transition out of hospital Crisis Services, including mobile teams, walk-in services and residential alternatives Case Management, Service Coordination, and Community Treatment Teams Health care integration to address physical and behavioral health care needs Enhanced housing program Development of acute case management program

25. copyright © 2012 Acute Case Management Intensive outreach and extended case management engagement period for individuals in inpatient settings Case Management providers condensed existing case lists to free up resources for enhanced service Higher rate paid for the enhanced service which was used to increase reimbursement for staff Initial length of service of 6-8 weeks

26. copyright © 2012 Acute Case Management Impact on the following outcomes: – 60 day readmission rates – 60 day inpatient days and costs – 7 and 30 day follow up rates – 60 day total behavioral health care cost – 60 day total inpatient stay cost prevented Explored variation for the four largest volume providers What We Examined

27. copyright © 2012 Acute Case Management What We Examined 60 Day Readmission Rate 0 10 20 30 40 50 60 70 Comparison ACM Rate (No ACM)

28. copyright © 2012 Acute Case Management What We Examined

29. copyright © 2012 Acute Case Management What We Examined 7-day follow-up rate post discharge 0 10 20 30 40 50 60 Comparison ACM Rate (No ACM) 30-day follow-up rate post discharge 0 10 20 30 40 50 60 Comparison ACM Rate (No ACM)

30. copyright © 2012 Acute Case Management What We Examined

31. copyright © 2012 Acute Case Management What We Examined

32. copyright © 2012 Acute Case Management What We Examined Total cost accrued in the 60 days post discharge 0 2000 4000 6000 8000 10000 12000 Comparison ACM Dollars IP MHACMRehab/PartialOther (No ACM)

33. copyright © 2012 Acute Case Management What We Examined Total Cost/IP MH Day Prevented 0 200 400 600 800 1000 1200 Pre tool Post tool implementation

34. copyright © 2012 Acute Case Management What We Examined 60 day readmission rate by provider 0 10 20 30 40 50 60 70 80 90 100 Comparison ACM Rate (No ACM)

35. copyright © 2012 Acute Case Management What We Examined Number of Inpatient Days accrued in the 60 days post discharge by provider 0 2 4 6 8 10 12 Comparison ACM Days (No ACM)

36. copyright © 2012 Acute Case Management What We Examined 7-day follow-up rate post discharge by provider 0 10 20 30 40 50 60 70 Comparison ACM Rate (No ACM)

37. copyright © 2012 Readmission Results in Allegheny County YearAdmissions Readmissions within 30 Days 30 Day Readmission Rate 2006632799015.6% 2007553777614.0% 2008529281415.4% 2009514064612.6% 2010477362013.0%

38. copyright © 2012 Use of Data in Care Management Data is used to identify high service utilization – High risk care managers routinely participate in interagency service planning teams (ISPT) meetings – ISPT meetings are a collaborative effort of the county administrative staff, individual support coordinators, case managers, peer specialists and members to problem solve issues and develop comprehensive relapse prevention plans

39. copyright © 2012 Use of Data in Care Management Care management staff collect critical data though utilization review protocols – During telephonic review for service authorization, care managers routinely collect information on the services the member is involved with at the current time (including those not funded by Medicaid) – If a member with complex needs is not involved with in case management, a referral is made continued

40. copyright © 2012 Sample Care Management Monitoring Reports Census data by level of care and by provider to allow for targeted interventions Inpatient mental health and inpatient drug and alcohol admissions by provider Report of members holding for another level of care Length of stay by provider

41. copyright © 2012 Residential Facility Utilization

42. copyright © 2012 Use of Data in Quality Activities Cost Drivers Member and Provider Satisfaction Quality Improvement Activities Provider Incentive Programs Comprehensive Provider Evaluations and Provider Benchmarking Adherence Monitoring of Practice Guidelines and Performance Standards

43. copyright © 2012 Cost Driver Analysis Extreme outliers identified as 30% higher utilization than the statewide average In one county, Family Based Services were an outlier and a root cause analysis conducted Community Care utilized a clinical monitoring authorization process and promoted adherence to the family based performance standards Measures planned to determine effectiveness include family based penetration, pmpm, and length of stay

44. copyright © 2012 Member and Provider Satisfaction Provider and member satisfaction surveys are administered annually Member satisfaction: adult response rate 31% in 2011, child response rate 33.4 in 2011, utilizing a 7-wave mailing process with follow up calls Provider satisfaction: response rate 40.7% in 2011 utilizing a 2-wave mailing process Analysis of the results is conducted and opportunities for improvement identified

45. copyright © 2012 Member Satisfaction Urgent Service Access: – When you needed counseling or treatment right away, how often did you see someone as soon as you wanted? (usually, always) 2011: 68.4%2012: 70.7% – When you needed to get counseling or treatment right away, how long did you usually have to wait between trying to get care and actually seeing someone? (same day, one day 2011: 45.4%2012: 52.3% Quality Improvement Activity

46. copyright © 2012 Member Satisfaction The availability of crisis services is more widely promoted for those members feeling they need to be seen right away The development of a specialized adult outpatient service which is a step down option for members being discharged from inpatient mental health Implementation of an enhanced rate initiative for providers of outpatient mental health services for the first appointment following an inpatient Implementation of mobile and walk in crisis services Service Access Interventions

47. copyright © 2012 Provider Satisfaction Timeliness of Claims Payments: – How would you rate the timeliness of the claims payments made to you/your practice? (good, very good) 2011: 69.8%2012: 77.2% Interventions: Community Care works with individual providers who are identified as having difficulty or any provider requesting assistance or training Development and ongoing encouragement to utilize the Provider Online tool for claims submission and review of claims status Quality Improvement Activity

48. copyright © 2012 Quality Improvement Activities Identified as an ongoing opportunity for improvement based on claims data monitoring Member identified barriers: – Member feels better after the inpatient stay and refuses follow up – Barriers to keeping the follow up such as transportation or child care Provider identified barriers: – High volume of cancellations and no shows – Lack of timely discharge planning Interventions implemented: – An enhanced outreach team contacts members following discharge to remind them of the follow up appointment and utilize active problem solving techniques – An enhanced rate is offered to the outpatient provider for the first appointment after inpatient – Several in plan services are developed including mobile mental health services, certified peer specialists, mobile medication, assertive community treatment teams and telepsychiatry Follow Up After BH Hospitalization

49. copyright © 2012 Follow Up Results

50. copyright © 2012 Comprehensive Provider Evaluation Real time, ongoing performance monitoring Data is collected and evaluated in total to present a multifaceted picture of provider performance Comprised on more than 20 elements of performance including: – Compliance with performance standards – Follow up on significant member incidents – Quality record review results – Compliance audits – Complaints – Changes in licensure status – Review and follow through with corrective action plans

51. copyright © 2012 Provider Benchmarking Claims based reporting distributed to high volume providers annually Comprised of utilization and quality indicators Quality Improvement Plans are requested from providers not meeting expectations The goal of provider benchmarking is to improve the practice standards of the provider by sharing comparative data

52. copyright © 2012 Benchmarking Indicators Inpatient admission rate during the treatment period Distinct number of discharges Median length of stay Length of stay over 365 days 7 day follow up after inpatient Residential Treatment Facilities

53. copyright © 2012 Provider Benchmarking Blended Case Management

54. copyright © 2012 Paying for Performance Pay for Performance projects for the following levels of care: – Blended Case Management and Specialty Case Management services – Family Based Mental Health Services – Outpatient Services – Preferred Providers for Best Practice Evaluations – Alternative Payment Arrangements tied to quality indicators

55. copyright © 2012 Pay for Performance Initiatives TCM/ICM – P4P Initiative – Set performance improvement targets to improve quality of care in TCM/ICM. Providers earned prospective rate increases based on their achievement of goals established to improve OPMH follow-up rates post IPMH, insure TCM/ICM contact before and during IPMH admission and increase the frequency of TCM/ICM contact in the 30 days following IPMH discharge. Measures drawn from TCM/ICM Performance Standards developed with stakeholders. – Initiative successful in improving network wide performance on selected indicators – Set the foundation for the Single Point of Accountability project in Allegheny

56. copyright © 2012 Pay for Performance Initiatives CCT/ACT – P4P Initiative – Supported/Competitive Employment Initiative – Following intensive training and technical assistance in the evidence-based practice of Supported Employment, performance improvement targets set to improve SE rates among CTT/ACT recipients to 20%. – Providers who meet the target can earn a $1000 per employed member bonus payment at the end of the year.

57. copyright © 2012 Pay for Performance Initiatives CTT/ACT APA – P4P Initiative – Alternative Payment Arrangement – Utilizes a risk sharing methodology developed to incent CTT/ACT providers to decrease IPMH utilization among CTT/ACT recipients.

58. copyright © 2012 Clinical Practice Guidelines Community Care adopts evidence based clinical practice guidelines – American Psychiatric Association Guideline for the Treatment of Patients with Major Depressive Disorder – The National Institute of Drug Abuse Principles of Drug Addiction Treatment: A Research Based Guide Claims based measures used to monitor practitioner adherence to treatment guidelines – Member newly diagnosed with depression and treated with an antidepressant who filled a sufficient number of prescriptions to allow for 84 days of continuous therapy – Members that initiate follow up chemical dependency treatment after detoxification Monitoring Adherence

59. copyright © 2012 Physical/Behavioral Health Initiatives Pharmacy data for all members Collaborations with all physical health plans to develop joint data bases for specific projects (routine PH data feeds expected soon). Creation of integrated data warehouse with some plans that includes pharmacy and physical health elements Creation of fields in PsychConsult for pharmacy and other physical health items, including member release of information forms Use of Data

60. copyright © 2012 Connected Care Program Collaboration between Community Care and UPMC for You Involved members with serious mental illness in Allegheny County enrolled in both Community Care and UPMC for You Created shared data document for care management staffs Shared key data items (e.g. readmissions, adherence to preventive care items) with both PH and BH providers Program demonstrated a positive effect on indicators such as mental health hospitalizations (12% decline) and overall readmission rates (10% decline; more info available at http://www.chcs.org/info-url3969/info- url_show.htm?doc_id=1261430)http://www.chcs.org/info-url3969/info- url_show.htm?doc_id=1261430

61. copyright © 2012 Behavioral Health Homes Building on lessons learned in Connected Care, Behavioral Health Home Plus Program implemented in several counties in central PA Goal of building virtual teams for adults with SMI and other chronic physical conditions Training of care managers and peer specialists as health navigators Funding of nursing positions focused on wellness and PH in case management settings Involves sharing data about BH and PH activities with BH providers so that they can better coordinate care

62. copyright © 2012 Summary Multiple data sources available Data can be used to create value, but requires substantial prospective planning and iterative analysis (separating the “signal” from the “noise”) Possibilities exist to use data to enhance service efficacy and cost-effectiveness Many opportunities for payer provider collaborations