1. Managing DCF SAMH Services to Create Systems of Care Goals, Requirements, Timetable, Alternative Structure, Provider Choice

2. Lucia Maxwell, FADAA, 10-20092 DCF Has Pursued the Goal of Managed Systems of Care for a Decade Commission on Mental Health and Substance Abuse recommended services integration/ pre-paid reimbursement in 2001. SB 1258 (2001) DCF & AHCA contract with same ME pilots in 2 areas of the state SB 2404 (2003) DCF to contract with MEs statewide by 2006; prepaid capitation HB 1843 (2004) Shift Medicaid MH to HMOs Provider Networks bill proposed (2007) SB 2626 (2008) Managing entity law SB 2612 (2009) Definition of a DCF client

3. Lucia Maxwell, FADAA, 10-20093 DCF Managed Care Initiatives Case rate pilots, children’s demonstration networks, DCF enrollment form to help define client eligibility Integration of DCF and Medicaid funds first proposed, but Medicaid policy surpassed this initiative. DCF leadership proposed at one time a provider network in partnership with an MCO. There have been Managing entity pilots in Districts # 1, 4, 8, 11, 12 and the Suncoast, some more than 10 years old. DCF statewide work groups in 2005-2006 recommended basic elements for provider networks and managing entities.

4. Lucia Maxwell, FADAA, 10-20094 Managing Entity Contracts Statewide 2009 43% of $537,180,002 DCF funds contracted for SAMH community services are expected to be contracted to a Managing Entity or similar model by the end of 2009.

5. Lucia Maxwell, FADAA, 10-20095 Schedule for Implementation in remaining areas of the state Select model by January 1, 2010. Complete Regional implementation plan by January 31, 2010. Report progress quarterly beginning July 1, 2010 on 6 stages of implementation, and how baseline functions will be addressed. Full implementation by July 1, 2011.

6. Lucia Maxwell, FADAA, 10-20096 Provider choice Contracting with a Managing Entity is optional, providers participate voluntarily. State law requires providers be represented on ME Boards. Participating in planning allows you to influence the decision, unless you choose to oppose any and all change. Consensus of providers and stakeholders to select a model does not require universal agreement.

7. Lucia Maxwell, FADAA, 10-20097 DCF Expressed Goals for Systems Management Move from numerous contracts to one accountable entity, allows the department to take on broader planning, training and systems development role. More flexible, innovative management (private contractor outside state government.) Unify funding streams (DCF, Medicaid, JJ, DOC, Healthy Kids.) Improve access to care and service continuity. More efficient and effective delivery of services, fiscally effective use of resources.

8. Lucia Maxwell, FADAA, 10-20098 DCF Goal Statements “Statewide initiatives such as... co-occurring can more effectively be woven into the fabric of the statewide system as a rule, not the exception” “... will enable the Department to more effectively focus its resources on the development of good public policy, setting systemic quality and performance goals, community development..., interagency coordination...”

9. Lucia Maxwell, FADAA, 10-20099 DCF Goal Statements There has been “inadequate state leadership to... unify traditionally funded programs and Medicaid” (implies long term goal) “The approach emphasizes UM, CQI, and training and t/a... activities that currently cannot be accomplished on a systemic basis across the state.. “Managed care principles, strong collaborations and stakeholder involvement will help remove fragmented systems of care.”

10. Lucia Maxwell, FADAA, 10-200910 The role of “Stakeholders” is critical Definition: Individuals served, family members, community agencies such as child welfare, the courts, law enforcement, health agencies, local government and “others with demonstrated interest. “ Stakeholders participate in planning and administration, comprise the agency Board of Directors, participate in councils and committees to provide strategic direction and oversight. DCF “strong preference” for majority stakeholders on ME Board. Stakeholder oversight of finances, quality of care and interagency collaboration is emphasized.

11. Lucia Maxwell, FADAA, 10-200911 System of care Services coordinated and developed into a network accessible and responsive to individuals in need, families and community stakeholders. Vision includes interagency collaboration and unification of funding streams (DCF, Medicaid, JJ, DOC) at the point of client service. Critical administrative functions are centralized and coordinated among partners and stakeholders to optimize resources and service delivery.

12. Lucia Maxwell, FADAA, 10-200912 What is not a system of care? Silo-ed agencies making independent decisions about services development (no joint planning). Data systems not interoperable, no integrated information about persons served in the community. Treatment decisions not based on data. No person centered focus on navigating the community service system (identifying issues, barriers, “pathways” for clients). No community standards of care, recognized and enforced (best practices, QI). No single point of access for community stakeholders. Competitive, not collaborative. No will to enforce system change.

13. Lucia Maxwell, FADAA, 10-200913 National trends in health care require systems of care Era of the corporation: favor large organizations, favor technology, favor organized systems Financing and delivery through provider networks Health information exchange among providers serving the same person - physical and behavioral health, allied and social services Data driven medicine: comparative effectiveness research, data based treatment decisions, provider profiling, benchmarking Consumer focused management approach, medical home, case management Provider joint contracting (blending public and private financing, insurance requirements for parity) The decline of “fee for service” – move to lump sum financing, cost containment, pay for performance.

14. Lucia Maxwell, FADAA, 10-200914 National trends in BH reinforce systems of care - NIATx 2009 national conference agenda Integration with primary care, e.g. Screening Brief Intervention Referral and Treatment SA/MH integration National Outcome Measures, concurrent documentation, benchmarking Aligning incentives in payment and accountability with Quality Improvement Process improvement, learning communities Asset based community development

15. Lucia Maxwell, FADAA, 10-200915 ME 10 Basic Functions Required no matter what model is chosen 1.System of Care Development and Management 2.Utilization Management 3.Network/ Subcontract Management 4.Quality Improvement 5.Technical Assistance and Training

16. Lucia Maxwell, FADAA, 10-200916 10 Basic Functions Required no matter what model is chosen 6.Data collection, Reporting and Analysis 7.Financial Management 8.Planning 9.Board Development and Governance 10. Disaster Planning & Responsiveness

17. Lucia Maxwell, FADAA, 10-200917 What are the components of an ME? 1.Tax exempt, non profit corporation to contract with DCF for all funds, single contract, for the area. 2.Representative Community Board, a governance structure and decision-making protocols. (sub area councils?) 3.Executive Director (reports to the Board) 4.Management staff and an operational infrastructure to perform contracting, financial accountability, UM, CQI, clinical monitoring, training, and planning. 5.Central data system w/ significantly expanded capacity. claiming and payment processing systems. 6.Contracts with a providers representing a continuum of services, and responsive to the needs of special populations.

18. Lucia Maxwell, FADAA, 10-200918 Provider network definition Direct service organizations that are under contract with a managing entity. Together constitute a comprehensive array of behavioral health services. To include emergency, acute care, residential, outpatient, recovery support, and consumer support services.

19. Lucia Maxwell, FADAA, 10-200919 DCF Contracts with Managing Entities DCF region ME staff employed by BOD Provider AProvider BProvider CProvider D Managing Entity Corp Board of Directors (providers, consumers, community stakeholders)

20. Lucia Maxwell, FADAA, 10-200920 Alternatives for a tax exempt corporation NOTE: The corp will have a Board of Directors representing community SA/MH stakeholders, with authority for this contract. New corporation formed by providers and stakeholders A lead agency (works best in smaller or rural areas where one provider clearly has superior capacity for management) Another community agency (difficult to ensure focus, priority, comprehensive knowledge of the service system, control, absence of conflict of interest, the invested people at the table.) Health plan or hospital system (unlikely that behavioral health will be emphasized, more difficult for community goals to be realized or what stakeholders believe is best for the system of care.)

21. Lucia Maxwell, FADAA, 10-200921 Alternatives for operational infrastructure Recruit Executive Director, who selects management staff Use lead agency’s staff, recruit to fill gaps in expertise Contract with a community agency which has the expertise ( in board development, strategic planning, quality improvement, utilization management, planning, training, evidenced based practices for publicly purchased, safety net behavioral health services) Contract with Managed Care Organization (most only have experience with insurance plans, capitation, corporate for profit culture.) A combination of the above

22. Lucia Maxwell, FADAA, 10-200922 Information System Requirements Comply with DCF and community health system standards for interoperability Financial and clinical monitoring and performance review Associate services, costs, and outcomes at individual and aggregate client levels Interactive system to inform clinical decisions Electronic Health Records capability Claiming and payment process system, (Medicaid billing in future?)

23. Lucia Maxwell, FADAA, 10-200923 Alternatives for Information System Build your own data systems over time. Buy services from an established Managing Entity with capacity. Use one network provider’s data system, expand as necessary. Purchase services or capacity from a Managed Care Organization or a hospital system.

24. Lucia Maxwell, FADAA, 10-200924 Considerations in model selection Most important: sustainability, long term benefit to the community, since the community will make a substantial investment, including service dollars. “Is this entity the best custodian of the community’s investment, now and into the future? ……Does the organization share the community’s goals for our BH system, by its vision, mission, and core values?” Accessibility/ responsiveness to stakeholders Capability to mobilize the community to participate in e.g. planning, performance review, advocacy Responsive and workable administrative services organization for providers, to achieve required admin. efficiencies?

25. Lucia Maxwell, FADAA, 10-200925 Other considerations An infrastructure to enable community BH providers to jointly contract with other payers? Does this choice enable us, now or in the future, to integrate funding streams to match clients to a payer at the point of service? Knowledge, linkages, capability to change services and service models, adopt a new commitment to quality and EBPs, and to create a coordinated system of care, Compatibility with health care reform

26. Lucia Maxwell, FADAA, 10-200926 What are the advantages to providers of becoming part of a system of care? Spread the costs of new IT. Access to expert resources and training. Transfers commonsense admin systems to become shared, centralized functions (group purchasing of insurance & vehicles, standard policy development, preparation for accreditation reviews, some HR, data reporting, peer review, training). Can enhance diversity by providing services to smaller agencies w/out funds to invest in IT or other systems. Organizes and enhances stakeholder collaborations (to approach hospitals, insurers, community agencies), brings a network of credentialed services to the table, a continuum of care.

27. Lucia Maxwell, FADAA, 10-200927 System of Care Advantages Enables providers to jointly contract w/ payers who require more sophisticated data systems, service protocols, and a Single Signature Contract. More players, more clout for advocacy, better bargaining position for contract negotiations Communities can use reliable, consistent statewide data and advocacy to increase rates and funding. Stronger, more responsive, more sustainable system of care.

28. Lucia Maxwell, FADAA, 10-200928 Financing of Managing Entities - Initially “there may be reduction in service dollars” - DCF expects eventual costs savings from:  Transfer of functions, $ from regional/ circuit offices  “Other changes” in state administration  Network management of tx capacity (utilization management) e.g. review deep end services for less costly alternatives  “Streamlining” the provider network  Reduce DCF dollars for provider indirect/ admin costs (those functions which duplicate ME capacity) Current ME administrative rates vary between 4.5% and 6.85% “The Regional Director and SAMH Program Director should be able to identify resources allocated for ME administration.”

29. Lucia Maxwell, FADAA, 10-200929 Geographic (service) area may be: a county, circuit, region or multi-regional area Considerations in selecting service area: Traditional consumer service patterns. Longstanding relationships between business entities. If area is too small, insufficient administrative and service dollars to develop infrastructure without impacting services. If the area is too large, difficult to be responsive and need multiple management sites. Must have adequate provider network for continuum. ME central office must be accessible to public and stakeholders, in proximity to local governments, courts, and community agencies.

30. Lucia Maxwell, FADAA, 10-200930 Community education and planning to select a management model Regional offices have the responsibility to organize meetings of stakeholders. Goal: learn about and discuss models Formal and informal meetings with the public, specific groups, government reps, contracted providers, stakeholders Consensus means not that all agree but all understand the model, the rationale for selection, how the community will move forward to implement the management system. Core group of stakeholders may partner with DCF in development of Regional Implementation Plan.

31. Lucia Maxwell, FADAA, 10-200931 DCF guidance to regions: affirm the mandate “With resistance and insufficient dialogue, the community remains trapped in the current service delivery system. Change has been mandated by the Florida Legislature and the Department believes a managing entity or similar model must be implemented to optimize resources and service delivery.”

32. Lucia Maxwell, FADAA, 10-200932 FADAA’s position has been….. If you have no choice but to be on the train, why not position yourself to be one of the drivers? The most successful systems of care will grow from community providers who take responsibility: they have the knowledge and the relationships to make this work. Providers may organize a network and come up with a plan to develop the Managing Entity capacities and functions required. FADAA is available to provide support in any way we can.

33. Lucia Maxwell, FADAA, 10-200933 Providers in networks say….. Strong agencies have much to gain….tend to expand and prosper if willing to embrace change, and to LEAD Average capacity agencies can use this environment to grow, to prove themselves Weak agencies will have the tools to improve, need not spend dollars on admin. Infrastructure.

34. Lucia Maxwell, FADAA, 10-200934 DCF’s managed care solution is provider friendly An alternative to contracting with traditional for profit Managed Care Organizations, who use restrictive approvals to enforce changes in the service system The DCF model emphasizes communities and stakeholders …..BUT providers can sabotage collaborations by 1) working only to preserve historical services and market position, and 2) refusing to support more efficient centralized administrative systems that create cost savings. Providers have the knowledge and the long standing relationships which enable them to develop real systems of care in their communities…..