CMS/CMMI Cooperative Agreement to Advance Integrated Care: Essential to Payment for Quality and Outcome

• W. Douglass Tynan, PhD, ABPP; Director of Integrated Care, American Psychological Association

• Elena J. Eisman, EdD, ABPP; Director – Center for Psychology & Health, American Psychological Association

• Christopher D. Nettles, PhD, Project Director – Integrated Health Care Alliance, American Psychological Association

Session # D4

CFHA 19th Annual ConferenceOctober 19-21, 2017 • Houston, Texas

Faculty Disclosure

The presenters of this session have NOT had any

relevant financial relationships during the past 12

months.

Conference Resources

Slides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2017

Slides and handouts are also available on the mobile app.

Learning Objectives

At the conclusion of this session, the participant will be able to:

Describe the essential common elements of effective primary care behavioral health models.

Define the role of integrated behavioral health within the context payment for value and outcome.

Describe development of integrated teams compared to coordinating existing services.

Discuss the workforce issues associated with transition to integrated care models

Identify the goals and change processes associated with the Transforming Clinical Practice Initiative.

1. Tice, J.A., Ollendorf, D.A., Reed, S.J., Shore, K.K., Weissberg,J., & Pearson, S.D. (2015). Integrating Behavioral Health into Primary Care: A Technology Assessment. Retrieved from Institute for Clinical and Economic Review website: https://icer-review.org/wp-content/uploads/2016/01/BHI_Final_Report_0602151.pdf

2. McDaniel, S. H., & deGruy, F. V., III. (2014). An introduction to primary care and psychology. American Psychologist, 69, 325–331. http://dx.doi.org/10.1037/a0036222

3. Bachrach, D., Anthony, S., & Manatt, A D. (2014). State Strategies for Integrating Physical and Behavioral Health Services in a Changing Medicaid Environment. Retrieved from The Commonwealth Fund website: http://www.commonwealthfund.org/~/media/files/publications/fund-report/2014/aug/1767_bachrach_state_strategies_integrating_phys_behavioral_hlt_827.pdf

4. American Psychological Association. (2016). 2015 survey of psychologist health providers. Retrieved from http://www.apa.org/workforce/publicaitons/15-health-service-providers/index.aspx

5. Kearney, L. K., Post, E. P., Pomerantz, A. S., & Zeiss, A. (2014). Applying the interprofessional aligned care team in the Department of Veterans Affairs: Transforming primary care. American Psychologist, 69(4), 399-408.

6. McDaniel, S. /H., Grus, C. L., Cubic, B. A., Hunter, C. L., Kearney, L. K., Schuman, C. C., . . . Johnson, S. B. (2014). Competencies for psychology practice in primary care. American Psychologist, 69(4), 409-429. http://dx.doi.org/10.1037/a0036072

7. Robinson, P. J. & Reiter, J. T. (2007). Behavioral Consultation and Primary Care: A guide to Integrating Services. Springer Science+ Business Media, LLC

8. William N. Robiner, PhD, & John A. Yozwiak, PhD (2013). The Psychology Workforce: Trials, Trends, and Tending the Common. The National Register Report. Retrieved from https://www.nationalregister.org/pub/the-national-register-report-pub/spring-2013-issue/the-psychology-workforce-trials-trends-and-tending-the-commons

Bibliography / Reference

Learning Assessment

A learning assessment is required for CE credit.

A question and answer period will be conducted

at the end of this presentation.

Integrated Care: Increasing Value

W. DOUGLAS TYNAN, PHD, ABPP

DIRECTOR, OFFICE OF INTEGRATED HEALTHCARE

AMERICAN PSYCHOLOGICAL ASSOCIATION

Get off the Fee for Services

treadmill!! Look at the full picture

for revenue.

Healthcare reform: Changes in PaymentEmphasis on quality

- Payment for Services

- Patient Improvement

- Patient and Family Satisfaction

Emphasis on outcome

-Utilization

-Reduced hospitalizations

-Medication adherence

De-Emphasis on services provided

- Fee-for-Service

Typical Insurer or

State Scorecard:

Meeting Quality Goals for Depression

Meeting Depression Screening example:

Choose screener – PHQ 9, Other screen.

Imbed within Electronic Health Record

Build into workflow –by office staff.

Emotional / Behavioral screener - 96127

Establish disposition for patients

Meeting Quality Goals in Screening: Example

Four Offices, 20000 patients:

1. 70% goal, 14,000 screened

2. 8.0% screen positive, 1100 – disposition plans.

3. $70,000 collected for screening.

For the patient: Early Screen, services to address needs

Meeting Efficiency Goals in Primary Care: Gouge N, Polaha J, Rogers R, Harden A. (2016)

• On days when an integrated behavioral health consultant (BHC)◦ was present, medical providers spent 2 fewer minutes on average

◦ for every patient seen in comparison to days when the consultant

◦ was not available.

On days when an integrated BHC was available, medical◦ providers saw 42% more patients than they did on days when

◦ no consultant was available.

• The practice generated $1142 more in revenue on days with BHC◦ integration as compared with non-BHC days.

Reviewing Revenue

Help meet goals for Quality Payment.

Develop a system for billing of behavioral screens◦ Can use a similar system for developmental behavioral screens, screens.

◦ This generates additional revenue.

Makes Primary care provider more efficient – see more patients.◦ Likely reduces stress on PCP.

You have increased revenue, improved efficiency, in addition, factor in your fee for service billing.

Moving the WorkforceELENA J. EISMAN, ED.D., ABPP

DIRECTOR, CENTER FOR PSYCHOLOGY AND HEALTH

The Workforce to move-demographics106,000 licensed psychologists in the US

Approximately 16% of behavioral and social science workforce were psychologists

Added health to mission statement

Competencies for work in integrated primary care

http://www.apa.org/Images/15-hsp-figure-2a_tcm7-207971.png

http://www.apa.org/workforce/publications/15-health-service-providers/index.aspx

Employment Characteristics of Psychologists: setting, Arrangement, Status

Goal of TransitioningPsychologists move up the ramp from independent practice through coordination, colocation to integration

Develop skills in addressing/treating:

health related behaviors

team practice

brief interventions

brief assessments

system based record keeping

system based approach to outcome measurement

healthcare economics

management and leadership skills

Six levels of integrated primary care

Minimal collaboration Communicate rarely

Collaboration at a distanceCommunicate periodically about shared patients

Collaboration onsiteCommunicate regularly about patients; share referrals

Close collaboration onsiteCollaborate on treatment plans for some patients, communicate regularly

Approaching an integrated practiceCollaborate on overall care and coordinate treatment for some patients

Full collaborationCommunicate at all levels, provider roles blended, business systems integrated

Source: Derived from A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C. SAMHSA-HRSA Center for Integrated Health Solutions. March 2013

Stepping stones in transitionIndependent practice

Coordinated practice

Co-location

Integration

Areas of transition

Practice

Financial

Record keeping

Outcomes and QI

Barriers to TransitioningIndependent practice system-historically separate from medical community

MH carve-outs

Health condition knowledge and credentialing

HiTech exclusion

PQRS, MIPS and MACRA non-participation

Confidentiality principles

Stigma

Lack of integration in medical neighborhood

Confusion about scope

Few appropriate billing codes

Confusing political climate

Lack of access to physical health metrics

Strategies for TransitionCMMI ◦ Online and face to face training

◦ Referral for continued training and skill development

◦ stages of practice transformation

◦ Strategic alignment networks

Focus on QI

Outcomes measurement

Connections with medical community◦ State Psychological Association joint meeting

◦ Joint training opportunities

◦ On-line “matching service”

Advocacy opportunity

Taking The Transformation Journey

CHRISTOPHER D. NETTLES, PHD

PROJECT DIRECTOR - INTEGRATED HEALTH CARE ALLIANCE

AMERICAN PSYCHOLOGICAL ASSOCIATION

CMMI’s Transforming Clinical Practice Initiative

Support more than 140,000 clinicians in their practice transformation work

Improve health outcomes for millions of Medicare, Medicaid and CHIP beneficiaries and other patients

Reduce unnecessary hospitalizations for 5 million patients

Generate $1 to $4 billion in savings to the federal government and commercial payers

Sustain efficient care delivery by reducing unnecessary testing and procedures

Transition 75% of practices completing the program to participate in AlternativePayment Models

Build the evidence base on practice transformation so that effective solutions can be scaled

1

2

3

4

5

6

7

Transforming Psychology Clinical Practice

The Integrated Health Care Alliance (IHCA) is funded by CMMI/CMS as part of their Transforming Clinical Practice Initiative.

Project goals include developing, sharing, and adapting comprehensive quality improvement strategies in conjunction with other healthcare and professional organizations

Plan to engage more than 6k providers

For psychologists we will provide training, tools, and technical assistance in:

The basics of integrated care from both the practice and business perspectives

Value-based Payment Models

Measuring Quality and Outcome

Participating in a broad network of thought-leader clinicians dedicated to integrated care.

TCPI Five Phases of Transformation

Practice

TransformationPhase 2:

Use Data

to Drive

Care

Phase 3:

Achieve Progress on

Aims

Phase 4:

Achieve

Benchmark

Status

TCPI Ch. Pkg.

Driver 2:

Continuous, Data-Driven

Quality Improvement

1

3

4

5

2

Phase 1. Setting aims

Practice has developed and shared a vision and detailed plan that addresses goals of transformation with specific clinical outcomes and utilization aims along with the detail on how each of the aims will be addressed.

Phase 2. Use Data to Drive Care

18. Using sound business practices

16. Produces reports …follow up system

10. Account-ability for care management

15. Building QI capability …

14. Regular Improvement method …

8. Referral to community resources

Implementation Activities

Service Delivery System

Practice Aims TCPI Aims

TCPI Enrolled PracticeDeveloping Implementing Performing

7. ID high risk patients …

1. Monitor metrics on TCPI aims …

4. Training in patient shared decision making …

19. Improve experience …joy in work

Administrative Staff

Clinical Staff

New Capabilities:Use of data to

drive care

Phase 3. Achieve Progress on Aims1. Practice has shown improvement in metrics related to TCPI aims but has not reached its targets or improvement is not yet sustained.

2. Practice has a formal system for obtaining patient and family feedback but does not consistently incorporate the information received into the QI and overall management systems of the practice.

3. The practice has documented each team member’s role and accountability lanes and each team member works to the maximum of his skill set and credentials in order to optimize efficiency and outcomes.

4. Practice has collaborated with the primary care practices in its medical neighborhood and has jointly developed criteria for referrals for episodic care, co-management, and transfer of care but processes have not yet been implemented.

Phase 3. Achieve Progress on Aims (cont)5. Practice has a reliable system in place to identify the primary care provider of each patient and to communicate with the primary care team about each visit or encounter.

6. Practice has developed or identified evidence -based protocols or care maps to use but these have not yet been implemented consistently within the practice.

7. Practice has a clinician available from the practice or on contract who can speak to patients after hours while being able to access the patient’s record.

8. Practice has developed QI capability within the practice and empowers staff/ providers to participate in QI activities by allocating time for QI activities, including QI within defined job duties, recognizing and rewarding innovation and improvement.

9. Practice is developing its internal capability to success in an alternative payment system and a date has been set for this migration has been set within the TCPI timeframe.

10. Practice has worked to streamline a number of its work flows by reviewing the steps and eliminating waste and rework, but the concept of value is not consistently considered during these efforts.

Phase 4. Achieve Benchmark status • Practice has met at least 75% of its targets and sustained improvements in practice-identified metrics for at

least one year.

• Practice has demonstrated improvement in reducing unnecessary tests.

• Practice has implemented and documented a tested process and has demonstrated a reduction in unnecessary

hospitalizations from its baseline.

• Practice can demonstrate that patients and families are collaborating in goal setting, decision making and self-

management (e.g. shared care plans, documentation of self- management goals, compacts, etc.).

• Practice has a formal system for obtaining patient and family feedback and can document operational or

strategic decisions made in response to this feedback.

• Practice has successfully implemented and documented a tested process that identifies patient risk level and

includes follow up with care appropriate to the risk level identified, including ensuring that those at highest risk

receive care management services or have a care plan in place that the practice is following.

• Practice has completed its resources inventory and consistently links patients with appropriate community

resources and follows up on referrals made.

Phase 4. Achieve Benchmark status (cont)

• Practice has collaborated with the primary care practices in its medical neighborhood and has jointly

developed and implemented criteria for referrals for episodic care, co-management, and transfer of care/

return to primary care, processes for care transition, including communication with patients and family.

• Practice consistently uses evidence -based protocols or care maps where appropriate to improve patient care

and safety.

• The practice fully incorporates regular improvement methodology to execute change ideas in the practice

setting.

• Practice offers multiple forms of alternative visit types (e.g. email, Skype, or tele-visits) or communication

media (e.g. portal, texting) and has integrated these alternatives into regular practice.

• Practice has implemented strategies to support joy in work and can demonstrate the results through metrics

such as staff survey results, high retention rates, or low turnover rates.

• Practice uses an organized approach (e.g. lean, process mapping) to reviewing its processes, eliminating or

reducing waste in the process, and understanding the value of each process step to the patient and other

customers.

Phase 5. Thrive as a pay-for-value business

• Practice is providing education and practice data on business metrics to staff at all levels across the organization.

• Specialized training is being provided to those at the practice level that may be involved in analysis of alternative payment arrangements and in contracting for services.

• Practice is confident of its readiness for migrating into alternative payment approaches.

Benefits of Enrollment

Free subscription to Clinical Quality Outcome Reporting Registry

Use current expertise in new ways while developing new & in-demand skills

Advocate for psychology by providing data and feedback specific to psychologists to health care leaders

Earn up to 8 hours of CE credit** at no cost to you

**Continuing Education credits are sponsored by the APA Office of Continuing Education in Psychology (CEP). The APA CEP Office has reviewed and approved the programs to offer CE credits for psychologists. The APA CEP Office maintains responsibility for the content of the programs.

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