Delivering Recovery-Focused Treatment
Services in a Managed Care Environment
NYAPRS 7th Annual Executive Seminar on
Systems Transformation
April 27 - 28, 2011
Adele Gregory Gorges, Executive Director
New York Care Coordination Program
2
www.carecoordination.org
New York Care Coordination Program
Multi-county, multi-stakeholder collaborative to
improve outcomes for those with serious behavioral
health issues
Formed in 2000, operational in mid-2002 – six
western and central counties, with support from
the NYS Office of Mental Health, project
management through Coordinated Care Services,
Inc. (CCSI). Partnership with Beacon Health
Strategies, LLC in 2009 for managed care.
Expanded in 2010 to include Westchester County
3,000 enrollees at any one time
3
NYCCP Strategic Plan for
System Transformation
• Participatory process for governance
• Data access, analysis and reporting capacity
Structures • Platform for disseminating best practices
Initiatives
4
• Culture change to a person-centered, recovery-focused system of
care
• Care coordination
• Physical health integration
• Finance reform
• Pay for performance
• Managed behavioral health
• Conserve dollars for behavioral health
• Use dollars flexibly
• Information
ACT 1: Laying the Foundation
 Transformation initiatives lay the foundation for
recovery-focused managed care
 Collaborative processes
 Person-Centered Practice
 Care Coordination
 Health integration
 Data driven to promote wellness
5
Guiding Principles for Person-Centered, Recovery-Focused
Services, Developed by the Peer and Family Advisory Group of the
WNYCCP, 2007
The goal is recovery, not just stabilization and maintenance.
Hope is necessary and recovery is possible for everyone.
Every individual is unique; every recovery different.
People have prompt access to compassionate care and services.
The system is flexible, wherever possible, to support the person’s
recovery.
Every plan for recovery is centered on the person’s goals, strengths,
and preferences -- not the availability of a particular program or
service.
6
Guiding Principles (cont.)
Natural supports, outside the mental health system, are explored and
encouraged.
Family support is valued and included when appropriate.
There is a partnership between individuals and their treatment team,
care coordinators, service providers, and their peers and family
members, when appropriate.
Individuals are educated to make informed choices about their health
care and recovery.
Peers (people in recovery) are included and involved at all levels in the
organization.
Everyone is treated with dignity and respect; differences in culture,
belief, or language are valued.
7
Creating a Person-Centered, Recovery-Focused
System of Care
8
Education
and
training
Monitoring
Onsite
mentoring
Focused
modules
Online resources
recoveryskillbuilder.com
Webinars
Incentives
Care Coordination
• From traditional Case Management to new Care
Coordination practice with recovery focus, personcentered tools, methods, approaches
• Pilots of care coordination with varying intensity
and duration, in varying settings, and in
partnership with Managed Medicaid HMO’s
• Additional competencies: for integrated care
coordination for persons with complex needs
9
Person-Centered, Recovery-Focused
Care Coordination adds value
Better quality
• 46% decrease in emergency room visits per enrollee*
• 53% reduction in days spent in a hospital*
• 78% of enrollees report “dealing more effectively with problems” (2009 Enrollee Survey)
Better outcomes
• 31% increase in gainful activity*
• 54% decrease in self harm among enrollees*
• 53% reduction in harm to others*
Lower costs
10
• 2008 Medicaid mental health costs for Care Coordination populations in NYCCP vs.
comparison counties: (OMH August 2010)
• 92% lower for inpatient services
• 42% lower for outpatient services
• 13% lower for community support physical health savings would be additional.
• $5,541 lower average cost person
* 2009 Periodic Reporting Form Analysis
DATA DRIVEN: Medicaid claims analysis shows need to refocus
community care coordination on the right MH consumers
Of Erie and Monroe mental health users, the
“top 10% in total cost” represent 63% of
Medicaid hospital and residential spending…
100%
22,836
80%
60%
$69.1M
…yet only a quarter of the “top 10%” were
enrolled in available Care Coordination
programs
100%
100%
80%
Other Erie
and Monroe
County MH
Consumers
60%
40%
40%
20%
20%
Not Enrolled
Enrolled
Top 10%
0%
• ACT
• ICM
• SCM
0%
Note: Analysis of all 2007 claims for Medicaid recipients 18 or over, with any mental health claim,
11
excluding
individuals with any OMRDD or nursing home claim.
11
ACT 2: NYCCP in Partnership with Beacon Health
Strategies, LLC for Managed Fee for Service
 Complex Care Management
 Intensive, short-term service for individuals with highest needs -serious mental illness, complex medical needs, top 10% in total costs.
Average length of stay of 6 months.
 Melds Person-Centered Practice as an underpinning for the initiative
AND a managed care focus on an episode of care and movement to
recovery.
 Teams provider-based Complex Care Coordinators (ICM) with
MBHO based Complex Care Managers.
 Identified care coordinators are trained for delivery of care coordination in a
short term model with a focus on physical as well as behavioral health care
 Identified MBHO care management staff required to be trained in PersonCentered Practices
 On the ground, in the community Care Coordinators plus office based
CMSA-lead, office based Care Managers with significant physical health and
behavioral health experience
12
Complex Care Management (cont.)
 Grounded in supporting individuals to attain recovery goals
related to life objectives – living, working, socializing.
 Empowers individuals through development of skills for selfmanagement of physical and behavioral health symptoms
 Supports individuals in building an integrated, coordinated
team of providers of choice
 Enhances the use of Peer Support services and other natural
supports in the community. As generally available in the
community, but also purchased using wrap around dollars if
necessary for program enrollees. (e.g. Compeer Peer Wellness
Coaches for the Well Balanced Program)
13
Learning through Collaboration
 Managed care learned about person-centered practice
 NYCCP providers, peers and counties learned that the
managed care tools and skills are helpful in promoting
recovery
 Focusing efforts on high cost/high need individuals can
produce dramatic outcomes
14
ACT 3:
Managed Care and Health Homes
 NYCCP wants to build on what we have learned about the
effectiveness of:
 Collaborative processes
 Person-centered, recovery-focused approaches
 Complex Care Management in collaboration with Beacon Health
Strategies
 Can be an effective core for Specialty Behavioral Health Homes
Focuses HR/HN populations and episodes of care
Can be expanded through “repurposing” of care coordinators/targeted
case managers and added MBHO capacity
 Maximizes resources through shorter lengths of stay in care coordination
and effective linkage with providers of choice
 Effective linkage to a provider of choice for a “health home” can lead to
enhanced self management skills, timely health promotion and prevention
services, early intervention, and mind-body health


15
NYCCP RBHO/Health Home Vision
HH1
Provider A
HH4
RBHO
HH2
Provider B
Provider
C
HH3
16
Functions of RBHO as ‘superstructure”
 Develop/coordinate health homes throughout the designated




17
region.
Coordinate care and manage utilization for Medicaid
behavioral health services delivered throughout the region.
Approve, coordinate & facilitate continuity and integration of
behavioral health/physical health services within Health
Homes and between Health Homes in the region.
Provide “back office” functions (e.g. data analysis) for the
network of affiliated health homes.
Functional overlap comparison:
Functional Overlap Comparison
REGIONAL BEHAVIORAL HEALTH
ORGANIZATION OPERATIONS
18
SPECIALTY BEHAVIORAL HEALTH
HOME SUPPORT FUNCTIONS
Provider network development,
contracting and credentialing
Same, for subset that are Health
Home Providers
N/A
Training for provider based Health
Home Care Coordinators
Preauthorization of services and
utilization review
N/A
Complex Care Management
Same, for Health Home enrollees
Medical Oversight of utilization review
and case management
Same, for case management only
Claims payment (preferred)
Same
Comparison of Functions (cont.)
19
REGIONAL BEHAVIORAL HEALTH
ORGANIZATION OPERATIONS
Data submission to New York State,
including to the EMedNY system, as
required by New York State
Client Outcomes and Quality
monitoring
SPECIALTY BEHAVIORAL HEALTH
HOME SUPPORT FUNCTIONS
Same, as per for Health Home
Claims data analysis for case finding
purposes
Same, as per for Health Home
Reporting
Provider and Recipient Dispute
Resolution
Same, as per for Health Home
Same, as per for Health Home
Coordination of care with Health
Maintenance Organizations in which
individuals are enrolled
Same, as per for Health Home
Same, as per for Health Home
Comparison of Functions (cont.)
REGIONAL BEHAVIORAL HEALTH
ORGANIZATION OPERATIONS
20
SPECIALTY BEHAVIORAL HEALTH
HOME SUPPORT FUNCTIONS
Coordination of care with HMO’s in
which individuals are enrolled
Same
Coordination of care with Health Homes
Coordination of care with RBHO
Use of the FlexCare information system
to manage RBHO program operations;
Same, for Health Home program
operations
Use of the FlexCare System for Care
Management
Use of the FlexCare System for
Care Management and Care
Coordination (enable provider care
coordinators, individual recipients,
NYCCP, and local governmental
units to view case management
records of individuals in the RBHO.)
Target Populations for Specialty
Behavioral Health Homes
 Adults with Serious Mental Illness
 Children with Serious Emotional Disturbance
 Adults and Children with Serious Chemical Dependency +
Co-Occurring Chronic Physical Illness
21
Model for Direct Services to Specialty
Behavioral Health Home Enrollees
 Health Home Services:
 Care Coordination will be provider-based and include
working with individuals to develop a comprehensive personcentered service plan. As necessary, it will include coordinating
comprehensive transitional care from inpatient to other
settings, including appropriate follow-up; arranging individual
and family support; and arranging referral to community and
social support services. The RBHO based Comprehensive Care
Manager will provide consultation as appropriate.
22
Model for Direct Services to Specialty
Behavioral Health Home Enrollees
 Levels for designated Health Home services
 Basic Level Care Coordination Services - all individuals
identified as meeting the criteria for SMI/SED or Serious Chemical
Dependency established by NYS OMH, OASAS, and DOH. Likely
provided within Clinic Regulations, not requiring discrete care
coordinators. Facilitates flow.
 Intensive Care Coordination Services
 Intensive Care Coordinators will provide time limited services, for the sub-
set of individuals needing more intense service at a point in time.
 Criteria for this level will take into account multiple factors including service
utilization and costs.
 Additional to care coordination provided as part of the Basic Level Care
Coordination Services specified above.
 Data analysis suggests an ability to meet the need for Intensive Care
Coordination Service through repurposing existing TCM dollars.
23
Model for Direct Care Services: Treatment,
Health Promotion, Community Support
 The Behavioral Health Home Provider provides behavioral
health services, and a basic level of Physical Health services on
site, in close collaboration with the individual’s Primary Care
Physician.
 Specialty Behavioral Health Home Core Team
 Mental Health or Chemical Dependency Primary Therapist (PT)
 Nurse Practitioner or Primary Care Physician onsite at Specialty
Behavioral Health Home
 Care Coordinator (CC) - with appropriate qualifications and
training for integrated, person-centered work and a team
reflecting the need for peer experience and cultural and linguistic
competency
24
Model for Direct Care Services: Treatment,
Health Promotion, Community Support
 Behavioral Health Treatment Providers will contract with Primary
Care Providers, particularly FQHC’s with NCQA Level 3
Certification as Person-Centered Medical Homes. They will also
collaborate with independent Primary Care Physician practices
serving individuals in the Health Home.
 Health Promotion, Inpatient, Pharmacy, Specialist, Rehabilitation as
referred and per the Person-Centered Service Plan
 Communication will be supported by Beacon IT and RHIO’s and
facilitated by the Care Coordinator
 Community Supports
 Peer support services
 Housing, social services and community supports will be
provided as specified in the Person-Centered Treatment Plan
25
For more information
 Adele Gregory Gorges
 Executive Director, New York Care Coordination Program
 C/O Coordinated Care Services, Inc.
 1099 Jay Street, Building J, Rochester, NY 14611
 585-613-7656
 agorges@ccsi.org
 www.carecoordination.org
26