Presentation on theme: "Central Florida Behavioral Health Network “Achieving the dream envisioned in single management strategies.”"— Presentation transcript:
Central Florida Behavioral Health Network “Achieving the dream envisioned in single management strategies.”
2 Why is the network initiative important? Networks will be the lead entities for: Innovation Collaboration and care integration Contracting Purchasing of mental health and substance abuse services.
3 CSAT Technical Assistance Report to Florida January, 2000 Comprehensive continuation of accessible quality services in the most appropriate environment Regulatory oversight of treatment system that ensures appropriate clinical care provided consistently and with prevailing standards Training for personnel Treatment system includes clinical assessment, individualized service planning, referral, progress review and follow-up How it started…
4 Characteristics and Features of a Well-Organized System of Care (From CSAT Technical Assistance Report to Florida – January, 2000) Services are organized into a simple network of care Network services are available through multiple single entry points Formal linkages exist between mental health, substance abuse and primary care Local networks are responsible for coordination of client services Case managers are identified to coordinate care Services are community-based Prevention and intervention strategies are clearly defined Stakeholders have direct input
5 Characteristics and Features of a Well-Organized System of Care (From CSAT Technical Assistance Report to Florida – January, 2000) Treatment available upon demand for special populations (pregnant women, IV drug users, individuals in family protection, dually-diagnosed, SPMI, etc.) Individualized, client-centered and flexible programs Flexible funding strategies, including fee for service and prospective payment mechanisms Network-wide utilization management
6 Florida Legislature passed SB1258 to meet the service delivery needs for: Control Costs Admission/Discharge with State Hospitals Disseminate Data for Planning Purposes Special ALF Services Reduction of Kids in Residential Care Services to Kids under Court Orders Accountability Continuity of Care Early Diagnosis & TX Assess Local Needs Quality/Best Practices Cross – System Integration Creative Financing Florida’s response…
7 Service Delivery Goals 1258 Coordination, Integration & Management DCF/MH/SA and AHCA/Medicaid Unit Cost Contracting & Fee-For-Service Risk-Sharing Arrangements Managing Entities – Public/Private Promote Flexibility & Responsiveness Expand Waivers, Maximize Federal $$$, New Procedure Codes or Certified Match
8 Florida Legislature expanded the goals of SB1258 with the passage of SB2404 in 2003 which: Creates the Substance Abuse and Mental Health Corporation Responsible for oversight of publicly funded substance abuse and mental health systems, including marking policy and resource recommendations. Requires DCF and AHCA to ensure Medicaid and Department funded services are delivered in a coordinated manner, using common service definitions, standards and accountability mechanisms. Requires corporation to conduct annual evaluation and report the status of publicly funded mental health and substance abuse systems to Legislature.
9 Amendment to Chapter Provides direction for FMHI to continue the evaluation of strategies in SB1258 and SB2404 pilot projects Requires report by December 31, 2006 that includes target dates for state-wide implementation
10 Amendment to Chapter (Relating to Mandatory Medicaid Managed Care Enrollment) Directs AHCA to work with DCF to ensure children and families in child protection system have access to mental health and substance abuse services. Directs AHCA to seek Federal approval to contract with single management entities for all behavioral health services for Medicaid recipients in an AHCA area. Directs AHCA and DCF to collaborate to jointly develop all policy, budgets, procurement procedures, contracts and monitoring plans for behavioral health and targeted case management programs. Requires AHCA and DCF to contract with managed care entities or arrange to utilize capitated pre-paid arrangement for all inpatient and outpatient behavioral health services to all Medicaid recipients by 07/01/06.
11 Amendment to Chapter (Relating to Mandatory Medicaid Managed Care Enrollment) Specifies that in AHCA areas with less than 150,000 Medicaid eligible clients, AHCA must contract with a single managed care plan; in areas over 150,000 Medicaid eligible clients, AHCA may contract with more than one plan. – Contracts must be competitively procured. – Both for-profit and not-for-profit entities are eligible to compete Requires AHCA to submit a plan by October 1, 2003 providing full implementation of capitated behavioral health throughout the State. – Plan must include provisions ensuring service accessibility for children and families in the child welfare and/or foster care system. – Plan must include participation of community-based care lead agencies, community alliances, Sheriff’s Department and providers serving dependent children. Requires implementation to begin in 2003 in areas of the State that are able to establish sufficient capitation rates.
12 Amendment to Chapter (Relating to Mandatory Medicaid Managed Care Enrollment) Allows AHCA to adjust capitation rates in any one area as necessary. Directs AHCA to develop policies and procedures to allow for certification of local and state funds. Excludes children residing in inpatient and DCF residential programs (BHOS) from enrollment into pre-paid plans. Requires existing child welfare providers under contract with DCF be offered the opportunity to participate in any provider network for pre-paid behavioral health services. Requires AHCA and DCF to develop a plan for new procedure codes for emergency and crisis care, supportive residential services and other services designed to maximize use of Medicaid funds for recipients needs.
13 Network Administration What is a Network? – Two or more agencies with a formal agreement to manage or deliver behavioral health services. What is the purpose of a Network? – Improve access to care – Improve quality – Improve efficiency and effectiveness – Assist providers/members
14 Unique Features of Community-Based Networks Strengths Community governance and oversight Shared risk with providers Comprehensive service delivery and ability to provide integrated services Consumer involvement Community re-investment Coordination with collateral systems Opportunity for gradual transition
15 Unique Features of Community-Based Networks Vulnerabilities Historical preservationists - May be slow to change practice standards - May be difficult to move from program-focused planning to person-focused planning Lack of capacity for utilization management, $$ required for IS development and capitation risk pools, RFP grant response/marketing, provider accreditation, administrative capabilities
16 Not-for-Profit Provider-Sponsored Networks Services are based on needs of persons served and stakeholders Demonstrated opportunity for consumer choice Timely services Services are culturally sensitive Mission is communicated and embraced by all members
17 Not-for-Profit Provider-Sponsored Networks A common set of indicators is applied – Access- Efficiency – Effectiveness- Consumer satisfaction Indicators are used for quality improvement, performance assessment and corrective actions
18 Not-for-Profit Provider-Sponsored Networks Individual provider and aggregate performance outcomes Review of service patterns Utilization of data to improve efficiency, effectiveness and customer satisfaction
19 Not-for-Profit Provider-Sponsored Networks Coordination of a system of care for a person receiving services from more than one provider or levels/types of care includes: Planning of individual services Delivery of services Evaluation of services Service review and revision as needed Formal information sharing process
20 Not-for-Profit Provider-Sponsored Networks A prerequisite for membership in the Network is a demonstrated commitment to and the history of client advocacy and collaborative practice. Non-profit providers Contracts with the State SAMH Program Office Medicaid provider
21 Not-for-Profit Provider-Sponsored Networks Accreditation, licensing, certification Fiscal stability and responsibility Commitment to community-based care principles – Commitment to consumer choice – Rehabilitative principles of care Ability to provide access to treatment Ability to deliver service
22 Network Benefits Examples of benefits the Network strives to offer include: Enhancement of core competencies Ability to share administrative functions and associated costs Improved continuity of care Improved linkages with non-ADM services Development of best practices Maximization of revenues Joint marketing efforts Stronger advocacy efforts Ability to shift contract funds between providers Shared knowledge _____
24 Core Administrative Functions Provider Network Management Planning and identifying network components – Defining continuum of care- Community planning – Determination of type, number and provider qualifications Selection of providers/networks – Open or competitive bidding- Selection criteria – Evaluation- Approval process Credentialing – Documentation of licensure- Accreditation – Professional credentialing Management of provider network – Communication- Community input – Assessment of continuum of care – Training and technical assistance
25 Core Administrative Functions Strategic Planning Annual review of: – Services – Utilization data – Access standard – Outcomes Gap analysis Needs assessment Member satisfaction Provider input
26 Core Administrative Functions Customer Services Customer relations – Board members- Providers – Consumers- Funding sources – Advocacy groups- Community stakeholders – State/local agencies Members – Benefits and services- Member advocacy – Rights and responsibilities - Grievances and appeals Coordination with other systems – Child welfare- Education – Juvenile justice- Corrections – Health c are
27 Core Administrative Functions Leadership commitment – Accreditation – Board structure and management Quality management goals – Focus on persons served Enhance access and quality of behavioral health services – Improve coordination of care within geographic areas – Promote effective, efficient and economical use of resources Quality Assurance, Continuous Quality Improvement, Performance Improvement
28 Core Administrative Functions Quality Improvement Committee – Comprised of QI personnel from all providers Performance improvement reviews – Case file review – Medical record review – Customer survey – Data/outcomes review – Service validation review Performance measures – State mandated outcomes – High risk – High volume – Problem prone
29 Core Administrative Functions Quality assurance – Continuous quality improvement – Performance improvement – Utilization review – Risk management Data driven – What, how, when to measure – How to use what is measured – Is system in management tool for improving quality Treatment – Screening/assessment – Placement criteria – Continuing care criteria – Services individualized to client’s need/client driven – Continuums of care – Alignment of resources and utilization
30 Core Administrative Functions Prior authorization – Define covered services requiring prior authorization – Medical necessity – Lead restrictive level of care Concurrent review – Continued medical necessity – Level of care appropriate – Continued stay criteria Retrospective review – Emergency admissions – Sample of cases to establish provider profile Reviews decrease with provider readiness
31 Core Administrative Functions Financial Management Regulatory compliance – Legal – Contract – Grants management Accounting – Safeguard assets – Monthly, quarterly and annual financial statements – Surplus/deficit and provider utilization reports – Annual budgets and forecasts Integration of clinical and financial data – Cost analysis – Clinical analysis – Rate setting
32 Members tracking Utilization management Claims Quality - Enrollment/eligibility - Admission/authorization - Continued stay - “Seamless” care across levels of care and providers - Integration of assessments and treatment planning - Aggregate reporting - Utilization - Billing, processing, reconciliation - Provider performance - Reporting - Outcomes analyses - Utilization analyses Core Administrative Functions Information Management
33 Core Administrative Functions Revenue Maximization Develop and define services to be covered Reimbursement consistent with level of service and cost to provide service Payment methodologies – FFS, capitation, rates, unit cost, case rates, etc. Use of multiple revenue streams to support treatment – TANF – Medicaid – Private insurance – Corrections – General revenue
34 Transition Planning for Networks Planning Process Significant changes to the management and financing of systems of care require careful planning Changes should be implemented in stages over time Transition planning team is focal point for identifying issues and developing detailed implementation strategies
35 Current System Performance Based/Unit Cost/Cost Center-based ADM Contracts TANF system with cumbersome and expensive administrative requirements. CFBHN subcontracts with providers on same basis. Complicated and expensive billing and data systems. Delays in receipt of funds. Interim System Contracts based on OCA categories for identified number of persons to be served (similar to District 1 Prepaid Aggregate Fixed Sum Contract) Payment on 1 st day of month, actual advance funding. Reconciliation based simply on number of persons served. Utilize PIDS Manual and DCF Guide to SB1258 Contracting for ADM Services Ideal System Risk or shared risk-based or other types of contracts based on valid actuarial data and models. Permit subcontracts to be on risk or shared-risk basis, case rate or other strategies to be developed. If indicated, utilize profit and loss risk corridors. Current System Program Monitoring by ADM and CFBHN Administrative and contract monitoring by CPU, ADM and CFBHN Licensure monitoring by ADM and AHCA Medicaid compliance by AHCA CPA Audits Accreditation for most providers Interim System Use accreditation in lieu of monitoring as described in SB1258 (Ch394) CFBHN performs interim monitoring as described in SB1258 (Ch394) ADM and CPU review CFBHN’s monitoring reports Utilize CPA audits to replace certain items in the monitoring instruments Develop process to redefine/reduce items to be monitored Ideal System Accreditation for all providers and networks Move from system that focuses on monitoring to one that focuses on leadership & management development, development of organizational competencies, refinement of quality and performance improvement strategies and practices, best practices, improvements to system integration, and staff training and development Development of legislative budget requests jointly by CFBHN and ADM/DCF based upon identified needs of Suncoast Region. Current System IDS, HomeSafeNet, etc. Data validity problems, some of which are based on matching services to enrollments Lack of timely mechanisms to correct inefficiencies and problems Limited utility of database by providers Interim System Suncoast and CFBHN become additional demonstration project for PIDS, currently be developed and implemented in District 1 Would include participation in Unity One system and ability to access other state data systems Ideal System The ideal integrated database (s) has yet to be defined, but at a minimum it should eliminate all double or triple entries. It (they) should be efficient to use and effective for the state, CFBHN and subcontractors Transition Planning for Networks Contract Financing Management, Monitoring and Oversight Data Collection and Reporting
36 Transition Planning Team Consists of Three Separate Teams Regional Transition Planning Team Contract Development Team MIS & Data Team System of Care Team
37 Transition Planning Team At a minimum, team consists of representatives of the following parties and other appointed by team. DCF SAMH Program Office DCF Contract Manager ASO Provider Network representative/Board member Representative from AHCA and any prepaid plan, if established Representative from community-based care agency Consumer representative Ad hoc representation from identified stakeholders as required
38 Transition Planning Team MIS & Data Team Responsible for analyzing all data and management information issues Provides data need by Contract Development Team for preparation of the contract Includes representatives from State MIS, ASO, providers, Regional SAMH Program Office, system consultant
39 Transition Planning Team Contract Development Team Addresses the changes to the contract between the Department and the Network’s ASO Development of prepaid, fixed sum or risk-based contract Development of provider contract requirements – Incorporates provider application process – Incorporates provider credentialing process – Incorporates recommendations from MIS and System of Care Teams
40 Transition Planning Team System of Care Team Addresses the array of services to be provided Addresses access to care requirements Addresses clinical protocols, clinical pathways, etc.
41 Central Florida Behavioral Health Network CFBHN is a not-for-profit network of community providers incorporated to ensure and enhance an array of behavioral health and other human service needs for the citizens of our community.
42 Current Organizational Capacity The mission, values and principles ensure highly-effective, family-focused services are provided in a fiscally sound manner A provider-sponsored network that has demonstrated commitment to and treatment of client advocacy and collaborative practice Encourages network membership and provider development in a manner that is representative of both geographic and specific service needs of clients and their families Currently provides the following services for five major funders: – Administrative services – Systems and network development – Quality oversight – Training, education and clinical development Serves over 6000 clients annually, has 19 member agencies and 28 service providers under contract
43 Network Goals Provide identified regions in the state with a well-managed and integrated behavioral health delivery system to: Increase access to care Improve continuity of care to vulnerable populations Prevent duplication of effort Reward efficiencies Encourage exemplary practices
44 Organizational Structure In May, 2002 Bylaws revised to reflect significant changes in the organizational leadership and Board structure Changes implemented to meet the Network’s need for the Board to be more representative of the expanded geographic area
45 Organizational Structure Board President represents substance abuse agencies President Elect represents mental health agencies The two offices rotate annually between substance abuse and mental health systems to ensure both areas are adequately represented
46 Executive Committee Executive Committee is comprised of the President, President Elect and one representative selected by each of the four designated Network regional councils The four regional councils include: – Hillsborough County – Pinellas/Pasco Counties – South Region (Manatee, Sarasota and DeSoto Counties) – District 14 (Highlands, Hardee and Polk Counties)
47 Regional Council Responsibilities Nominate Executive Committee regional representative Design and coordinate a localized system of care for each business activity identified for that region Establish and maintain local planning forums of members, vendors, stakeholders and partners to formulate and articulate services delivery strategies and plans for inclusion in the Corporate Business Plan Develop and implement regional business plans Facilitate the implementation of behavioral health services that are responsive to the needs and institutions of their respective communities Develop vendor recommendations PINE
48 Inclusiveness & Provider Relations Communities, funders, persons served and providers are integral partners in the design, evaluation and support of the Network’s services and service delivery structure CFBHN is a provider-sponsored network striving to meet the needs of its members by providing outstanding services and value-added benefits that clearly demonstrate the advantages of membership
49 Network Membership ACTS Boley Center for Behavioral Health Care Centre for Women Coastal Recovery Center Directions for Mental Health DACCO First Step of Sarasota Gulf Coast Community Care The Harbor Behavioral Healthcare Institute Human Services Associates Manatee Glens Mental Health Care Northside Mental Health Center Operation PAR Peace River Center PEMHS Suncoast Center for Community Mental Health Tri-County Human Services Winter Haven Hospital
50 TANF Provide management and oversight for all ADM TANF-funded services throughout the Region and District 14 Co-location of outreach at One-Stop centers in some child welfare community-based care lead agencies Partner with Family Safety/diversion clients Partner to provide Dependency Court services Service provider for Welfare-to-Work/Hillsborough County Workforce Board Contract with Workforce Development Lead Agencies to provide support and outreach Enhance supportive employment opportunities throughout Network area Collaborate with the Spring for domestic violence outreach Manage funds throughout the Suncoast Region and District 14 17 agencies provide services Allow full utilization of benefits for TANF-eligible persons
51 Co-Occurring 2001Project to develop capacity of mental health and substance abuse agencies to treat persons with co-occurring disorders Federal SAMHSA Grant – Center for Mental Health Services (CMHS) Community Action Grant on co-occurring disorders 2002New GP Wood funding to Network to implement community action plan for integration of services for persons with co-occurring disorders Agency action plans Goals for additional resources Systems integration and development Research capability and agreement to share information with Florida Health Partners
52 Co-Occurring Systems Coordinator works with providers to “move” action plans -Funding to agencies to enhance co-occurring services -Co-occurring capability for all Family Intervention services -Expansion of model throughout Network
53 Family Safety Mental health dollars targeted to community-based care needs Additional resources for intervention with caretakers and reunification with clinical support to co-locate staff Additional resources for adoption stabilization needs, clinical support and co-location of staff Specialty services for abused children Family Intervention services co-located throughout Suncoast Region and District 14 Dependency Court services in District 14
54 Family Safety Assist in level of care decisions Specialty network developed for HKI for: – Psychological evaluations – Domestic violence evaluations – Parenting classes 8 agencies participating with HKI 6 agencies participating with the Partnership for Safe Children Pilot diversionary program developed for Sarasota Family YMCA
55 Bibliography Network Development, Thomas E. Lucking, Ed.S.,Lucking Consulting, Brave New World of Managed Care, National Council for Community Behavioral Health Care, Troy Baily, Neal Cash, Colette Croze, Jeff Jorde Administration & Policy in Mental Health, Volume 29, Number 1, September, 2001 CSAT Technical Assistance Report, January, 2000 OPPAGA Report, 2001