1. Connecting Payment And Performance To Achieve Results California Summit March 20-21, 2008

2. Leadership Woes The trouble with being a leader today is that you can’t be sure whether people are following you or chasing you. The trouble with doing something right the first time is that nobody appreciates how difficult it was. If at first you don’t succeed, skydiving is definitely not for you.

3. IOM Report Recommendation 8-4. State and local governments should reduce the emphasis on the grant-based systems of financing that currently dominate public M/SU treatment systems and should increase the use of funding mechanisms that link some funds to measures of quality. (317)

4. IOM Report “... redesign grant-based systems incrementally so as to incorporate some simple and meaningful performance indicators.” “... initial efforts tie either new funds or a small percentage of existing budgets to performance indicators as means of reorienting the management of public M/SU treatment provision toward quality improvement.” (more)

5. IOM Report “Over time, as performance measures, improved and providers altered their management practices, performance measures might be given greater weight in budget allocations.”

6. Rewarding Good Performance Wait staff Bridge Construction

7. Context For PBC Enhance, expand existing services Create new programs Quality improvement initiatives Increasing accountability Keeping spotlight on results Using data supported information to make decisions on an on-going basis

8. Overarching Principles Use “real time” data to inform management and clinical decision making Financial rewards motivate performance Rewards are more effective when received shortly after successful achievement Use “real time” data to reward the results you want to achieve

9. How To – The Process Design the program, service Agree on what you want to reward Use data to determine realistic performance targets Agree on rates and payment mechanism Issue Request for Proposal Negotiate details in contract process and include specifics in contracts Meet regularly with contractors to review, discuss success and problems, identify barriers, etc. Evaluate & use data as basis for revisions/modifications

10. Some Delaware Applications and Examples

11. Random Thoughts Why is there an expiration date on sour cream? Do Roman nurses refer to IVs as 4s? You go to a ballet and you see girls dancing on their toes? Why don’t they just get taller girls? Did you know that half of all people are below average?

12. Evidence Based Practice and Practice Based Evidence Length of time in treatment is associated with successful outcomes. Amount of treatment makes a difference. Evidence based techniques and strategies produce better results. Continuity of care is essential. Detoxification and treatment programs have a responsibility to assist clients to successfully engage in the next level of care.

13. What To Reward Outpatient - Engagement/Utilization, Active Participation, Program Completion Residential - Engagement/Utilization, Retention, Completion Detoxification – Placement in Treatment, Case Management/Placement for Repeat Clients

14. Detox PBC Example Improve rate of successful connection with treatment after completion of detox –Data: identified the % in the last year Reduce number of clients with 3+ admissions –Data: identified the specific clients with 3+ admissions (more)

15. Detox PBC Example Write the RFP: –TIP 45 –TRI Study in Philadelphia Decide on targets for key results: –25% connected to treatment within 7 days –3+ to be case managed until successfully engaged in treatment (30 days OP, 60 days residential) (more)

16. Detox PBC Example Work out payment mechanism and incentive –Base (1/12th of annual contract paid each month as follows): 1% of negotiated contract base amount (i.e., the approved operating cost for the program) to be paid for each 1% of monthly utilization rate (determined by average daily census for the month) up to a maximum of 90% each month (23.4 avg. daily census = 90%). (more)

17. Detox PBC Example Other 10% of base amount to be paid for achieving placement target of 25%* for clients who successfully complete detoxification and: –are admitted to a licensed residential treatment program or Chance House within 7 days of detox completion -or- –complete an intake session and attend one treatment session in a licensed SA outpatient treatment program within 7 days of detox completion (OK to complete intake session prior to discharge from detox) * The placement target will be raised in subsequent years of the contract. After the first year, the specific placement target will be negotiated with the provider. (more)

18. Detox PBC Example B. Performance Incentives (above base amount): –Applies only to clients with a combined total of 3 or more admissions to New Castle Detox and/or Kent-Sussex Detox in the previous 12 months (more)

19. Detox PBC Example –$500 for each client (up to a contracted annual ceiling amount) who successfully completes detoxification, enters the next level of care within 7 days of discharge and completes : 30 days in a DSAMH funded SA residential treatment program or Halfway House –OR- Chance House and 15 days in a DSAMH funded SA residential treatment program –OR- 60 days in a DSAMH funded SA outpatient treatment program.

20. Preliminary 6 Month Results Generally seems to be working Some positives: –More clients served –More clients and higher percentage getting to treatment –Management paying attention –Closer working relationships between detox and treatment providers (more)

21. Preliminary 6 Month Results –New initiatives to connect with treatment prior to leaving detox –Improved collaboration between state and detox –Evaluation data being used to inform decisions (more)

22. Preliminary 6 Month Results Some Issues and Questions: –Incentives having more impact on management than clinicians –Definition of “admission” to treatment –Are incentives in the right place –Too early to tell about 3+ –AMA rate (why do people leave detox early?)

23. Tips For Making PBC Work 1) Meet regularly with providers, especially in the early stages: Meet as a group Create atmosphere of sharing Build partnership – state/county and providers and among providers themselves Be supportive, be flexible when appropriate, be firm with PBC

24. Tips For Making PBC Work 2) Incorporate NIATx: Process and performance improvement for access, engagement and retention 3) Praise successes

25. To Conclude... I don’t do drugs anymore because I find I can get the same effect just standing up really fast. Seen it all, done it all, can’t remember most of it. I intend to live forever – so far, so good.

26. Contact Information Jack Kemp Treatment Research Institute jkemp@tresearch.org 215-399-0980