an innovative p4p initiative: partnering to reduce ... · rcpa conference september 27, 2016 ....
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An Innovative P4P Initiative:
Partnering to Reduce Inpatient
Utilization and Right-Size
Community Services
RCPA Conference
September 27, 2016
Presenters
Deborah Duch, Community Care Behavioral Health Organization
Christine Gregor, Pittsburgh Mercy
Melissa Medice, Allegheny County Department of Human Services, Office of Behavioral Health
Kim Patterson, Allegheny HealthChoices, Inc.
Susan Wolfe, Western Psychiatric Institute and Clinic
Learning Objectives
Define components of successful system-level stakeholder
collaboration around decision-making and quality
improvement.
Describe elements of the Pay for Performance (P4P)
model used in payment redesign.
Replicate practical strategies for attaining targeted
system change (reduction of inpatient mental health
utilization).
Assertive Community Treatment (ACT) in Pittsburgh,
PA
8 teams, 4 providers
About 750+ individuals served (100/team capacity)
Funded through Medicaid (HealthChoices) and County-
Based Funds
Expectations for high fidelity to the ACT model
Annual fidelity reviews occur using the TMACT
ACT is a licensed service in PA
State hospital is not an option
Multi-Level Partnering
5
Level I: Leadership Team Office of Behavioral Health Managed Care Organization Monitoring Authority Level II: ACT Network Workgroup Above plus- ACT directors ACT team leaders Outcome/quality analysts Level III: Team Level ACT training/technical assistance staff ACT team leaders ACT staff
MULTI-LEVEL PARTNERING
ALLEGHENY COUNTY, PA
Multi-Level Partnering
Level I: Leadership Team
Activities:
Care management
Outcomes monitoring
Quality improvement
Fiscal analysis
Fidelity reviews and training
Multi-Level Partnering
Level II: ACT Network Workgroup
Activities:
Data review
Outcomes monitoring
Quality improvement
Networking
Problem solving
Multi-Level Partnering
Level III: ACT Team Level
Activities:
Fidelity reviews
Supervising by outcomes
Quality improvement
Training and skill development
Multi-Level Partnering
Consumer Advisory Committee
Activities:
Gathering of individual team advisory
group representatives
Review data and trends
Quality improvement
Assertive Community Treatment Teams: An
Overview
Interdisciplinary team approach: MDs, nurses, peer professionals, mental health professionals, employment specialists, and substance use specialists join together to provide services.
Community-wide service delivery: Services are provided where they are needed, such as a person’s home, place of employment, or other community settings.
Individualized services: Teams work with relatively small numbers of persons to provide individualized care (staff to member ratio of 10:1 with team supporting max of 100 persons).
Time-unlimited support: Teams provide whatever services and supports a person needs for as long as they need them.
Continuous, flexible, and comprehensive services: Several staff work regularly with each person served, providing an array of services at times convenient to the individual.
Round-the-clock service accessibility: Services are available 24 hours a day, 7 days a week, and someone is always available to handle emergent situations.
Utilization of multiple treatment models: Use of a variety of evidence-based practices within the ACT model (e.g., Supported Employment, Integrated Dual Disorders Treatment, etc.).
ACT Outcomes
Increase treatment adherence
Increase tenure in independent living
Increase those working in competitive
employment
Improve wellness and health outcomes
Reduce, if not eliminate, psychiatric inpatient days
Why Pay for Performance?
High
Outpatient
Low
Outpatient
High
Inpatient
Baseline Data: 2012
Provider # Members Days
WPIC 126 15.1
Pittsburgh Mercy 224 16.8
Total 350 16.2
Average IPMH Days, 2012
Baseline Data: 2012
Pay for Performance (P4P) Model
Development
Goal: Reduction of inpatient mental health
service utilization by ACT recipients by shifting
dollars from inpatient mental health treatment
to the community to sustain an adequate
level of funding for Assertive Community
Treatment (ACT) team supports.
Pay for Performance (P4P) Model
Development
Collaborating partners included:
Two ACT providers (Pittsburgh Mercy and
Western Psychiatric Institute and Clinic of UPMC)
Allegheny County Department of Human
Services, Office of Behavioral Health
Allegheny HealthChoices, Inc. (AHCI)
Community Care Behavioral Health Organization
(Community Care)
Pay for Performance (P4P) Model
Development
To be included in the P4P project, consumers
needed to be HealthChoices-eligible for at least
80% of the measurement year.
Model dashboard reports were developed so that
providers could assess current performance and
predict future P4P earnings based on various
scenarios related to inpatient mental health
services and ACT service utilization.
P4P Interactive Monitoring Tool
P4P Model Specifics
“Gate and Ladder” approach: Providers had to meet an established threshold of $10,000 per consumer for inpatient cost reduction in order to be eligible for any bonus earnings
Tiered earnings available from a bonus pool created by withholding 20% of the established ACT service rate
Providers could earn 20% withhold and up to 10% bonus amount if they met the overall target of reducing average inpatient mental health cost per person to $9,000 or less during the calendar year
Bonus earnings increase as inpatient costs decrease
Providers needed to stay under an established cap for total ACT service utilization cost per person for the year of $25,000
P4P Provider Experience: Pittsburgh Mercy
Partnering for People (P4P): Clinicians and leadership worked together in a focused way to empower the person served to choose a path of recovery—a path paved with logistical freedom, but far more cohesion in terms of treatment, care, and support.
Strategy framework based on belief that many readmissions are preventable.
Began by investigating precipitating factors for inpatient admissions and readmissions:
Understand fundamentals of behavioral principles and identify antecedents to readmissions & risk factors.
Review hospitalization histories of persons served (both over- and under-utilizers).
Focus on effectiveness of transitions of care.
Pittsburgh Mercy – Strategies & Interventions
Formulate Strategies Based on Data Analysis
Define goal of project and utilize a “top down” approach to disseminate information to agency employees, persons served and their supports, and internal/ external agency partners.
Use of a Risk Stratification Tool to allow for continual assessment of risk factors, supports, and interventions.
Create team-based approach to reviewing persons served who have been hospitalized or are at risk of hospitalization (the “War Room”).
Institute cross-setting meetings with crisis services, residential providers, or other stakeholders.
Divert!
Pittsburgh Mercy – Strategies & Interventions
Implement Strategies to Address Inpatient Treatment and Care
Leadership-led training on assertive engagement for all staff.
Meet 5 days/week in the “War Room” to collaborate on high-risk cases.
Create positive behavioral support plans to include motivational incentives.
Enhance/increase informal and natural supports.
Invest more time in working with persons served around medication
management.
Address risk factors of persons served on crisis plans and treatment plans.
Have team psychiatrist present within 24 hours of admission to speak with
inpatient team.
Implement a best practice process in discharge planning, starting at admission.
Pittsburgh Mercy – Strategies & Interventions
Assess Effectiveness of Interventions and Maintain a Person-Centered
Perspective
Ensure discharge plans are understood by persons served and shared with the
team.
Provide persons served with education and self-management tools that will
empower them to navigate their treatment.
Collaborate with physical health and other specialty providers to ensure overall
health and wellness.
Constantly engage family/friends/other natural supports in the treatment of
persons served.
Routinely inform agency leadership and direct care staff of project progress.
Pittsburgh Mercy: Case Study
A.R. is a male in his mid-30s diagnosed with schizoaffective disorder, bipolar type, and polysubstance dependence. He started with Pittsburgh Mercy’s
ACT program in mid-2009.
A.R.’s pre-ACT history:
Extensive history of psychiatric inpatient hospitalizations and D&A rehab
stays
Chronic polysubstance use/abuse
Criminal justice system involvement
Medication non-adherence
No insight into his illness or understanding of his diagnosis or how his
medications helped him
Exhibited symptoms of paranoia and delusions, and experienced
auditory hallucinations
Pittsburgh Mercy: Case Study
After A.R. started with ACT, but prior to the P4P project:
Continued to experience crisis situations at least once a year, resulting in 6
community psych hospital admissions and 1 inpatient extended acute unit
admission (LOS = 396 days), and 5 DAS admissions (LOS = 24 days)
Continued to use drugs and alcohol, including marijuana and K2
Continued to be non-adherent on his oral medications and required daily
med observation by ACT staff
Continued to have poor insight into his mental health and substance use
issues
Had issues with housing and experienced multiple evictions and several
bouts of homelessness
Pittsburgh Mercy: Case Study
A.R.’s progress after implementation of P4P interventions…
Zero IP admissions in 2015 and 2016!
Stable on his medications – now on a long-acting injectable antipsychotic
(administered monthly) and an antidepressant (delivered weekly by ACT staff),
with subsequent decrease in symptomology
Has been working at the same job since October 2015
Attended school / classes to learn how to become an electrician
Has stable housing – living independently in his own apartment
No arrests
Working on becoming his own payee
More family involvement in his treatment
Decrease in drug use, but further reduction continues to be a treatment goal
P4P Provider Experience: Western
Psychiatric Institute and Clinic (WPIC)
Barrier-breaking model which required increased collaboration between ACT teams and the following
entities of a large urban academic medical center:
Primary Care
Psychiatric Emergency Rooms
Medical Emergency Rooms
Care Management
Crisis Services
P4P Provider Experience: Western
Psychiatric Institute and Clinic (WPIC)
Provided training on health care reform and project specifics to
essential groups:
ACT teams
High-level administration
Persons served
Psychiatric ER
Psychiatric inpatient services
Primary care
Training included didactic sessions and individual case consultations
WPIC – Strategies & Interventions
Paradigm shift for clinical services to a focus on person-centered planning
process resulted in:
Increased buy-in from persons served and staff and understanding of the “Risk
and Responsibility” of mental health recovery
Clinical review of highest utilizers and brainstorming to develop alternatives to
long inpatient stays
Collaboration with all stakeholders
Increased development and use of MH recovery tools such MHAD, crisis
recovery plans, and integrated care with physical health providers
Participation in “Positive Deviance” project and increased use of person served
feedback
Adoption of a “work is treatment” philosophy
WPIC – Strategies & Interventions
Revamped supervision
Person-centered planning seen as “core” instrument to inform supervision
sessions
Outcomes based supervision with emphasis on real time and historical data
Core requirement for staff to participate in continuing education that focuses
on evidence-based therapy models
Utilization of technical tools
Revise existing internal data and tracking reports
Use of a data dashboard
Electronic record treatment plan revised to include crisis and diversion planning
P4P Project Outcomes
In 2014, both providers earned the full 20% withhold amount and
the maximum bonus earnings of 10% under the P4P model
(increased revenue for ACT teams)
Pittsburgh Mercy achieved a 64% reduction in the average inpatient
cost per person per year
WPIC achieved a 28% reduction in the average inpatient cost per
person per year
In 2015, both providers further reduced the average inpatient cost
per person per year!
Pittsburgh Mercy achieved a 76% reduction from the baseline year
measure
WPIC achieved a 72% reduction from the baseline year measure
P4P Project Outcomes
Other positive outcomes of the P4P project included:
Improved program efficiencies
Increased community tenure for ACT recipients
Increased satisfaction for ACT recipients
Success!
Provider 2012 2014 2015
WPIC 15.1 10.5 6.6
Pittsburgh Mercy 16.8 8.7 6.9
Both Providers 16.2 9.3 6.8
Average IPMH Days
Success!
Provider 2012 2014 2015
WPIC:
billed ACT $/member
$15,835 $16,215 $18,477
WPIC:
billed inpatient $/member
$12,413 $8,979 $3,486
Pittsburgh Mercy:
billed ACT $/member
$24,260 $19,321 $18,182
Pittsburgh Mercy:
billed inpatient $/member
$9,911 $3,573 $2,364
Average Cost of Outpatient & Inpatient Services
Next Steps – Updates to Model and
Sustaining Performance
Maintain results in inpatient savings
Add targets and P4P earning opportunity for
Supported Employment Outcomes
Add two additional ACT Providers
Questions?
Presenter Contact Information Debbie Duch, MPH
Associate Regional Director
Community Care Behavioral Health
Christine Gregor, LSW, CCDP-D
Component Services Director, Community Support Services
Pittsburgh Mercy
Melissa Medice, BA
Supervisor, Adult Mental Health Operations
Allegheny County Department of Human Services, Office of Behavioral Health
Kim Patterson, MSW, LSW
Senior Clinical Consultant
Allegheny HealthChoices, Inc.
Susan Wolfe, MA
Program Director, Community Treatment Teams
Western Psychiatric Institute and Clinic