Western New York Care Coordination Program

1
Western New York Care Coordination Program

• Meeting with New York State
• Office of Mental Health
• November 19, 2004

2
Stakeholders

• A collaborative effort of
• New York State Office of Mental Health
• Chautauqua, Erie, Genesee, Monroe, Onondaga, and
  Wyoming Counties
• Peers and Family Members
• Care Coordination Organizations (CCO)
• Licensed Outpatient Providers (LOP)
• Community Service Providers (CSP)

3
Implementation Structure

• Steering Committee
• Eleven voting members, plus two non-voting
  representatives from OMH
• Representatives from counties, service recipients
  and families, and provider organizations
• Peer and Family Advisory Group
• County advisory/implementation groups
• Subcommittees, workgroups, trainings
• Project management staff

4
Enrollment
5
Goals

• To improve outcomes for persons diagnosed with a
  serious mental illness
• To transform community service systems for
  persons diagnosed with serious mental illness,
  creating systems that
• Are based on a person-centered approach
• Promote rehabilitation and recovery, based on a
  single, comprehensive plan
• Ensure access to high quality services
• To develop a financial model that supports
  flexible resources in support of rehabilitation
  and recovery
• To improve physical health outcomes for persons
  diagnosed with a serious mental illness

6
Accomplishments 2004

• Person-centered planning
• Performance management
• Review of Individual Service Plans for indicators
  of person-centered planning
• Enrollee Satisfaction Survey
• CAIRS data on client outcomes based on Periodic
  Reporting Form
• Medicaid claims data on cost effectiveness
• Peer and Family
• Family Education and Support Initiative
• Collaborative planning for PROS Plus
• Physical/mental health integration model

7
Creating a Culture Change 2004

• Person-centered approaches and planning
• Training begun 2003
• Continued in 2004
• Over 300 provider staff members, 97 training days
  at 3 sites
• Care Coordination Organizations, service
  providers who will be converting to PROS,
  community support providers, peer organizations,
  clinicians and others
• 21 organizations developed strategic plans for
  transitioning to a person-centered approach
• 46 individuals trained as trainers will present
  the training in 2005
• Curriculum developed by The Blessing/Meissner
  Group

8
WNYCCP Video

• Video produced to introduce the concept of
  person-centered planning to a wide variety of
  constituencies

9
Have Person-Centered Planning and the Care
Coordination Program had an impact?

• Care Coordinators report
• Redefining relationships with enrollees as
  partnerships
• Listening differently
• Focusing on goals, not just disabilities
• Pro-actively supporting individuals in achieving
  their goals in the face of obstacles and systems
• They attribute it to
• Training in Person-Centered Planning
• Processes and documentation that require a new
  way of listening and setting priorities
• Flexible funds to be able to go beyond life
  necessities and be creative around community
  integration and wellness

10
Care Coordination Quality Process Improvement

• Step 1 Care Coordination identified as the
  evidence-based practice to bring about the
  desired system.
• Step 2 Review of the Individual Service Plans
  developed in the early months of the project
  shows no evidence of transition from Case
  Management to Care Coordination
• Step 3 Person-Centered Planning identified as a
  philosophy and technology to drive the change to
  Care Coordination
• Step 4 Tool designed to review Individual
  Service Plans for indicators of person-centered
  planning
• Step 5 Training in Person-Centered Planning
  begun Spring 2003, and continued in 2004
• Step 6 Care Coordinators identify need to
  revise Individual Service Plan to more directly
  support Person-Centered Planning for Enrollees.
  Full transition to new form by 12/31/04
• Step 7 Survey of 10 of Individual Service
  Plans conducted September 2003 (n102) and
  September 2004 (n161) significant progress

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Survey of Individual Service Plans for Indicators
of Person-Centered Planning6 Questions, 4-Point
Scale

• Q1 The person's (enrollee's) dreams, interests,
  preferences, strengths and capacities are
  explicitly acknowledged and drive activities,
  services and supports (QOLSA and ISP).
• Q2 Services and supports are individualized and
  don't rely solely on pre-existing models (ISP).
• Q3 The person has a presence in a variety of
  typical community places. Segregated services
  and locations are minimized (ISP).
• Q4 Planning activities occur periodically and
  routinely. Lifestyle decisions are revisited
  (QOLSA, ISP).
• Q5 A group of people who know, value and are
  committed to the person remains involved (ISP).
• Q6 There are steps towards tangible changes in
  areas where the person is dissatisfied (QOLSA,
  ISP).

12
Review of Individual Service Plans for Indicators
of Person-Centered Planning
13
Sallys Story

• Person-centered planning as a powerful force for
  change for individuals and systems
• Sally is 36 and has been in the mental health
  system for her entire adult life.
• Multiple admissions to RPC, other hospitals, and
  emergency departments.
• She is in case management, a residential setting
  and has a reputation as being difficult.
• Service plan goals read maintaining mental
  health and compliance.
• Enrollment in WNYCCP.
• Sallys Care Coordinator is trained in
  Person-Centered Planning.
• Using the new Care Coordination forms, the
  Quality of Life Self Assessment and the
  Individual Service Plan, Sally and her Care
  Coordinator partner in developing a plan in a new
  way.
• The Care Coordinator listens differently,
  focusing on goals and not just disabilities.
• Sally articulates a goal of having her own
  apartment.
• Sallys clinical provider suggests her move is
  clinically inappropriate and will result in her
  case being closed. Residential staff work to
  convince Sally to stay.
• Outcome
• Sally has been in her own apartment for 10
  months.
• Working in partnership with her Care Coordinator,
  Sally found a new therapist.
• The residential staff who have loved Sally now
  support her in non-traditional ways and celebrate
  her success!

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Enrollee Satisfaction SurveyProcess

• Enrollee Satisfaction Survey redesigned for 2004
  in response to feedback from 2003 and new
  clinical initiatives. Added dimensions
• Measure transition to a person-centered,
  recovery-oriented approach
• Provide ability to distinguish between
  satisfaction with Care Coordinators and with
  Primary Service Providers
• Measure satisfaction with Care Coordination tools
  and processes
• Redesign included input from all WNYCCP
  stakeholders
• Survey conducted October, 2004
• Findings will drive planning at the Project and
  County levels

15
Enrollee Satisfaction Survey2004 Results New
Elements

• Transition to a recovery-orientation
• The staff (primary service provider) believe
  that I can grow, change and recover.
• 95 of respondents agreed or strongly agreed
• My Care Coordinator believes that I can grow,
  change and recover.
• 91 of respondents agreed or strongly agreed
• n122

16
Enrollee Satisfaction Survey2004 Results New
Elements

• Individual Service Planning Process
• Agree or Strongly Agree
• ISP reflects my plans for recovery 86
• Satisfied with range of services available 86
• Like using the ISP 84
• ISP reflects strengths as well as needs 84
• Feel free to choose or reject services 83
• Availability of Self-help and Peer Support Groups
  76
• Have a Crisis Prevention Plan that is helpful
  75
• Like using the Quality of Life Self Assessment
  form 72
• QOLSA was helpful in developing my ISP 71

17
Outcome Data

• Data Source CAIRS PRF data for Erie and Wyoming
  Counties for the 3 months preceding report
  (6-12, 13-18, gt18 mos).
• Preliminary data needs further analysis and
  integration with Monroe, Onondaga, Chautauqua and
  Genesee data
• 1153 individuals, 291 (25) in sample cohort (at
  least 2 reports, at least 6 months apart).

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Preliminary Results

• ER Visits Average of 0.7 visits to average of
  0.2 visits (77 decrease)
• Days in Hospital Average of 6.6 days to an
  average of 2.7 days (59 decrease)
• Self Harm 24 enrollees to 7 (71 decrease)
• Suicide Attempts 21 enrollees to 6 (71 decrease)

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Preliminary Results

• Competitive Employment 7 of enrollees to 10
  (50 increase)
• Physical Harm to Others 15 enrollees to 7 (53
  decrease)
• Arrests 30 enrollees to 16 (47 decrease)
• Self Help 30 enrollees to 33 (9 increase)
• Substance Abuse 121 enrollees to 110 enrollees
  (9 decrease).

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Karen, Ruth and WilmaA story of community
inclusion

• Peers enrolled in the WNYCCP are encouraged and
  supported in attending community events.
• Six enrollees decide to attend a dinner at the
  local Grange.
• Karen, Ruth and Wilma like the experience so much
  that they join the Grange.
• Over the course of six months, all three are
  asked to take positions in the organization.
• Obstacle
• Older members of the Grange speak up at a
  meeting. These people cant do these things,
  they are mentally ill.
• Outcome
• The President of the organization lets the
  members know that they are doing it and they
  will be helping to run the organization in the
  future.
• The Grange becomes a natural support for those
  involved and will support and encourage them to
  do more.

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Measuring performance based on Medicaid claims
data

• Current enrollment is 1800
• Projected enrollment 2005 - 2800
• Analysis of claims data for 601 individuals
  enrolled in the CCP for the full year 2003
• 587 used services in 2002
• 513 used services in 2001
• 453 used services in 2000

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First full year of enrollment
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Initial Medicaid Claims Data 2004
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Simulated Case Payment Dollars

• Supporting a person-centered, recovery oriented
  system
• Current use examples
• Non-Medicaid paid medications and treatment
  guarantees for Medicaid pending individuals same
  day medications
• For Thomas, payment for a Christian chiropractor.
  (Hes now willing to explore other alternative
  techniques.)
• Community inclusion Y memberships,
  socialization outside of the mental health system
• Achieving goals cost of materials to teach an
  Italian class at a community center, art classes,
  writing classes
• Peer coaches peer transportation
• For Theresa, bi-monthly appointments at a salon
  to treat a scalp condition and assure the
  self-esteem needed for her goal of working as a
  nurses assistant. (She graduated)
• Future uses
• Physical health

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Beverlys Story

• Simulated Case Payment Dollars helping Enrollees
  to achieve previously unattainable goals
• Beverly has a case manager and is forced to live
  in unsafe neighborhoods because of financial
  necessity.
• Beverly is constantly moving in search of a safe
  place.
• For 35 years, she has kept a scrapbook of her
  dream home no one took her seriously.
• Enrollment in WNYCCP.
• Care Coordinator listens differently to Beverly.
• Beverly sets a goal of home ownership in her ISP.
  
• Update
• Beverly has found a house she likes.
• Her Care Coordinator has introduced her to the
  Home of Your Own Program
• Simulated Case Payment dollars have been used to
  enable completion of all the program
  requirements. And their availability made it
  possible to issue a guarantee against the cash
  requirement.
• Beverly is now waiting for the closing on her new
  home, a 30,000 bungalow in a safe neighborhood.
• The house payment before taxes will be 143 an
  month.

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Continuing the Culture Change in 2005

• Core Curriculum
• Offer twice at 5 sites, run by 2004
  Train-the-Trainers
• Care Coordinators, PROS staff, housing staff, and
  others engaged in planning
• Recovery Module
• Add a recovery module to the Core Curriculum
• Develop in collaboration with NYAPRS
• Trainers
• Support individuals trained in 2004 through a
  learning community with local and project-wide
  activities
• Add additional trainers

30
Continuing the Culture Change in 2005

• Methods specialists
• Advanced training for individuals to provide
  community wide resource as specialists in
  particular Person-Centered Planning Methods
• Organizational change
• On-going consultation on implementation of the
  PATH plans for creating person-centered agencies
  and programs
• Expand PATH planning to additional agencies
• Training for other groups
• Tailor core curriculum for specific audiences
• Offer specialized programs other groups
  including
• Clinic staff, housing staff, inpatient staff
• Community groups such as NAMI, Community Service
  Boards, Neighborhood Associations

31
Peer and Family Advisory Group

• Expansion of Enrollee involvement in project
  planning
• More enrollees participating in County level peer
  and family advisory groups
• A once enrolled individual heading group in
  Wyoming County
• Real time feedback
• Two enrollees now serving on project level Peer
  and Family Advisory Group
• Peer and Family involvement in all project
  initiatives
• Video
• Physical/Mental Health Integration Initiative
• Updating survey instrument and administering
  Enrollee Satisfaction Survey
• Peer leaders in training to be trainers in
  Person-Centered Planning
• Designing PROS Plus processes and documentation

32
Peer and Family Perspectives

• Peer trainer for Person-Centered Planning
• Family member
• Peer staff

33
Family Education and Support Initiative

• Alternate implementation model
• Cost efficient dissemination to 17 providers in 6
  counties same resources as 4 providers in the
  traditional implementation model
• WNYCCP operating and training structures
• Institute for Healthcare Improvement model
• Learning collaborative vs. consultation
• Agency level project teams
• Training-site level collaborative
• Family Institute and OMH expert resources
• Multiple Family Groups with participants from
  multiple agencies and programs

34
Family Education and Support Initiative (cont.)

• Implementation status
• Orientation, agency recruitment and 2-day
  intensive training completed at all sites
• Of the 15 agencies reporting implementation
  status as of 10/04
• 16 have identified clients and families
• 10 have begun outreach
• 8 have held Joining Session 1
• 10 have planned the Family Education Workshop
• 2 have held the Family Education Workshop

35
PROS Plus

• Goal
• WNYCCP and OMH agreement Fall 2003 to develop
  PROS Plus as a means to achieve common goals
  for a more fully integrated, cost effective and
  responsive system of publicly funded mental
  health services for persons diagnosed with mental
  illness.
• Objectives
• Implement PROS within the context of WNYCCP
• Use PROS license to achieve regulatory
  flexibility goals of WNYCCP
• Integrated, single system for Care Coordinators
  and PROS providers
• Same benefits for PROS enrollees as are being
  pursued in WNYCCP

36
PROS Plus

• Principles
• Person centered philosophy
• PROS services structure
• PROS organizational culture
• Integration of Care Coordination with PROS
• Evidence-based practices
• Performance and outcomes management

37
PROS Plus Implementation

• Planning for person-centered approaches in PROS
  agencies
• Community level planning
• 8 facilitated community planning days for
  implementation of Pros Plus
• Agency level planning
• 22 facilitated, 1-day strategic planning sessions
  for organizational implementation of
  person-centered PROS programs (PATH methodology)

38
PROS Plus Implementation

• Training in person-centered planning for PROS
  staff
• Core Curriculum developed by Blessing/Meissner
  Group
• Person-centered planning philosophy and
  methodology
• Developing person-centered PROS Individual
  Recovery Plans
• Module on orienting PROS participants to their
  role in person-centered planning
• 8-12 session training, offered 2 times at each of
  3 training sites
• 300 slots in 2004 for PROS and other provider
  staff
• 47 participating in train-the-trainer in 2004

39
PROS Plus Implementation

• Documentation to support person-centered planning
  and integration of Care Coordination with PROS
  planning
• Quality of Life Self-Assessment, same for both
• PROS Plus Assessment, integrated with QOLSA
• Participants Crisis Prevention Plan, same for
  both
• Individual Recovery Plan, designed to stand alone
  or flow from the ISP prepared with a Care
  Coordinator
• Review for compliance with OMH, Medicaid and
  Medicare regulations

40
PROS Plus Implementation

• County-Provider Agreement Appendices
• Consensus on selected PROS Plus elements to be
  included in all counties agreements
• Data and reporting requirements
• Operational requirements
• Performance and outcome indicators
• Review of IRPs for indicators of person-centered
  planning

41
PROS Plus

• Flexible funding for PROS Plus
• Proposal developed to use Simulated Case Payment
  Dollars to support appropriate expenditures for
  PROS Plus participants who are not in the
  current CCP cohort
• Demonstration project regarding benefits of
  flexible funding for PROS participants

42
PROS Plus

• Agreement on preferred process for WNYCCP
  conversion to PROS
• Phase One
• Simultaneous

43
Physical/Mental Health Integration Initiative

• New initiative 2004
• Goal
• To improve health outcomes for persons diagnosed
  with a serious mental illness by reducing
  complications of common co-occurring physical
  illnesses through improved access to and
  integration of behavioral health and primary care
  services

44
Person centered, recovery-oriented care

• Presidents New Freedom Commission on Mental
  Health
• Called for a recovery-oriented mental health
  system with a single, comprehensive plan that
  includes all of an individuals service needs.
• Institute for Medicine
• Called for coordination of care across patient
  conditions, services and settings over time.

45
Work group formed April 2004 to plan this
initiative includes

• County Directors
• OMH Staff
• Peers and Family Members
• Health Care Providers
• Behavioral Health Care Providers
• Pharmacist
• Medical Directors for Managed Care Plan and
  Psychiatric Center
• Public Health Director
• Project Legal Consultant
• Project Management Staff

46
WNYCCP Initiative Focus

• Disease management model
• Useful organizing principle, affecting
  individuals and systems of care
• Potential focus on diabetes/obesity, tobacco use
• Interventions to be County specific, building on
  existing resources

47
WNYCCP InitiativeMedicaid Claims Data Review

• Analysis of Medicaid claims data for Erie County,
  top quartile of mental health service users as
  proxy for WNYCCP and broader high needs
  population
• Service utilization and cost information confirms
  diabetes as top non-mental health related
  diagnosis for individuals in top quartile of
  mental health and top quartile of physical health

48
Medicaid Claims Data
49
Approaches to Care Integration

• Bazelon Center for Mental Health Law report
• In a recovery-oriented mental health system,
  physical health care is as central to an
  individuals service plan as housing, job
  training or education.
• Get it Together How to Integrate Physical and
  Mental
• Health Care for People with Serious Mental
  Disorders

50
WNYCCP Initiative 3 Models for Integrating Care

• Collaboration between providers
• UB Family Medicine program
• UR Community Nursing Center program
• Unity Mental Health satellites in PCP offices
• PCPs embedded in mental health programs
• Strong Ties Medicine in Psychiatry
• Unified programs
• Federally Qualified Community Health Center and
  Community Mental Health Center

51
WNYCCP InitiativeModels for Managing
Co-Morbidities

• UIC College of Nursing project Diabetes
  Management in the Context of Serious Mental
  Illness
• Evidence-based practice guidelines for integrated
  care
• Web-based instructional module for the clinical
  education of nurses and other health
  professionals, as well as clients
• Technical competencies in diabetes care
• Nursing case management/outreach

52
WNYCCP InitiativeEnrollee Data

• Physical Health Services Questionnaire
• Data on WNYCCP enrollees current physical health
  service utilization, needs, experience, barriers,
  successes and concerns
• Purpose
• Tool for discussion between Care Coordinator and
  Enrollee about physical health services/possible
  goals to be included in the Individual Service
  Plan
• Program design
• Baseline information

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Questionnaire Preliminary Findings15 of
Monroe County Enrollees

• BMI
• 53 Obese (lt30)
• 23 Overweight (lt25)
• Queried health conditions
• 38 high blood pressure
• 35 diabetes
• 14 heart problems
• 8 emphysema
• n91

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Questionnaire Preliminary Findings(Continued)

• 53 rated their physical health as fair or poor
• 27 reported physical problems interfering with
• normal social activities all or most of
  the
• time 20 some of the time
• 39 used the Emergency Room for medical care
• 29 were hospitalized 1 or more times in the
• past year for medical issues
• 70 regularly take 4 or more medications
• 59 smoke
• 41 would like to work on smoking
• 52 would like to work on exercise, nutrition
• and weight

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Work Plan Fall 2004 through 2005

• Analyze Medicaid claims data and Health Services
  Questionnaires for all counties
• Finalize outcome indicators and critical elements
  that are project-wide
• Develop training materials for
• Care Coordinators, Mental Health Providers, PCPs,
  Enrollees
• Design and implement county-specific
  interventions
• Counties to select model based on local needs,
  resources

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Example- Monroe County Pilot

• Implementation date January, 2005
• P/T Coordinator/trainer to oversee project
  development and look for grant opportunities
• Target- 200 enrollees having diabetes
• Goal- Cost savings through reduced inpatient and
  ER visits
• Collaboration model using UR CNC
• Risk adjusted populations-intervention intensity
  to match risk
• Nursing case management- monitor health
  parameters and service utilization
• SCP dollars for nonbillable services

57
Phase 3 Financing

• Principles
• Flexibility
• More effective use of available resources
• Maximize Federal financial participation
• Fewer silos
• Administrative simplification
• Provider support
• Evolution Build on previous work
• Services Planning Payment Authorization
• Based on Person Centered Planning ISP
• Quality and appropriateness review

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Phase 3 Single Payment System 2005

• Plan level issues
• Covered Persons Covered Services
• Administration Enrollment Claims Appeals
• Rates Administrative budget
• Risk allocation money management
• Legal/Regulatory
• Organized health care arrangement?
• Prepaid Ambulatory Health Plan?
• Contractual obligations
• Should we consider a physical health or pharmacy
  management demonstration?

59
Work Plan 2005

• Person-centered planning
• Recovery Module
• Core curriculum delivered twice at 4 sites
• Specialized curricula for various groups
• Supporting the trainers
• Supporting organizations
• Implement PROS Plus
• Physical health initiative
• Financial model development