Presentation on theme: "Positioning Providers for a Managed Care Environment"— Presentation transcript:
1 Positioning Providers for a Managed Care Environment Adele Gregory GorgesExecutive DirectorNew York Care Coordination Program, Inc.June 3, 2014.NYSACRA .NYSRA
2 Who we are New York Care Coordination Program, Inc. Creating a person-centered, recovery-focused system of care for individuals with serious behavioral health issuesWestern Region Behavioral Health Organization“Glide Path” to Medicaid Managed Care for the 19 county Western Region for BHO’s in New York StateHealth Homes of Upstate New YorkHealth Home Care Management in 22 counties
3 AgendaReview of competencies, knowledge and skills that support success in the world of Managed CareInfrastructureUnderstanding MCO business practicesDemonstrating outcomes/valueActions providers should be taking to support readiness
4 Getting Ready…. Competencies, Practices and Skills that will Support Success in Managed Care To make sure you are meeting MCO expectationsThree main categories:Build organizational infrastructure to effectively work with MCOsUnderstand MCO business practices and imbed these practices in the work of your organizationDemonstrate desired outcomes /value
5 Organizational Infrastructure Build the infrastructure to support the changes necessary to succeed in the new managed care environmentData analytic capacity:Collecting, housing and analyzing process and clinical data with CQI follow upInnovation and change management capacityIdentify and empower “Change Champions.”Develop leaders (not managers)Share the “power” tied to establishing a strategic direction. Use those with a variety of experience and perspectives.Fiscal capacity beyond FFSLearn more about what MCOs currently require and possible future payment modelsTraining and workforce developmentDevelop a flexible and forward thinking workforce that responds positively to quantified performance feedback
6 Organizational Infrastructure Develop channels for effective communication…Within your organizationShare changes with Board and engage them in the change processMake certain the Leadership Team is clear on expectations that will support a successful transitionEncourage the sharing of information about Medicaid Redesign and the next phase of Managed Care with staff across the organizationEncourage cross- department conversations about the role each will play in the organization achieving identified outcomes.Support cross-discipline effortsRegardless of discipline, leaders must believe in and be champions of transformation and communicate this expectation across the array of disciplinesRedesign care to optimize each professional disciplines expertise and knowledge.Members of multidisciplinary teams must be collaborative, share a mutual respect for one another and rotate leadership based on the initiative and the skill set the project requiresAcross the system of careDevelop process to promote inter- organization communication in support of shared outcomes and opportunities for Continuous Quality Improvement.
7 Organizational Infrastructure Build capacity to support continuous clinical improvement…Invest in clinical staff to review data reflective of key service delivery process and clinical outcome measures that are collected internally – and externally ( e.g., reports prepared by State Agencies, PSYCKES, MCOs, etc).Develop processes to review outcome measures w/clinical team members (including MDs when appropriate) on a routine basis. Team makes recommendations for improvement. Changes in practice are monitored.Reports on the work of the Clinical Team are routinely distributed to leadership team members (including Board)Organization consistently articulates its full support for ongoing quality improvement activities.
8 Understand MCO Business Practices – Build a successful business relationship w/MCOs MCO prioritiesContractingCommunication/Reporting: data exchange in required formats, requests for clinical information, services authorization, member verificationIT systems requirementsCredentialing processesLevel of Care Criteria/Utilization Management PracticesMember Services/Grievance ProceduresMedical ManagementNetwork ManagementQuality Management/ Quality Studies/ Incentive OpportunitiesBilling/Payment PracticesAuditing practices
9 Deliver and Demonstrate Impact/Value Determine the outcomes and related measures that define success for the MCOs with which you workInventory data sources that reflect impactWork with or develop Quality Team to review available data and assess organization’s positionDevelop new data collection protocols as neededObtain information on Cost Per Unit/Episode of ServiceBegin to build your value proposition (continuously improve)
10 Deliver and Demonstrate Impact/Value How to Define Value…
12 Deliver and Demonstrate Impact/Value Value = health outcomes that matter to patients relative to the cost of achieving those outcomesFailure to improve value = failure
13 Where to begin:A Managed Care Readiness Assessment/ Work Plan for your agency is key. Areas of detailed focus include:Organizational Infrastructure AuditInventory of documents pertaining to MCO practices and staff that understand these documentsInventory of quality and financial data/ reports that demonstrate impact of your organization’s work and how the information is being usedReview history of collaboration with other providers and potential future collaborative opportunitiesResources currently available throughNew York Care Coordination Program and CCSI
14 Where to begin:Develop new relationships and structures to support your work in a managed care environmentBuild relationships with the MCOs in your areaBe part of integrated systemsConsider joining or forming an IPAANDTHINK DSRIP
15 Contact information: Adele Gregory Gorges Executive Director New York Care Coordination Program, Inc