Safe Harbor Behavioral Health Jonathan Evans, MA; President & CEO Mandy Fauble, PhD, LCSW; Vice President of Clinical Operations Lee Penman, RN; Clinic Coordinator

 Founded in 1993 in response to initial CHIPP.  Intensive outpatient & implementation of comprehensive crisis services.  Significant growth with outpatient census approaching 7,000.  Average of 200 new consumers each month with 80% in need of psychiatric care.

 Implementation of HealthChoices  Downsizing and closure of state hospitals.  Affordable Care Act.  Overall increased recognition of the importance of behavioral healthcare.  Increasing demand for outpatient services.

 Systematic response to increase in demand for services  MTM Services ◦ Concurrent Documentation. ◦ Open Access. ◦ “What level of service would we want for our family members?” ◦ Results= average of 200 new clients per month with an active census of 7,000.

 MTM ◦ Open Access Presentations  Intake  Psychiatry  Collaborative Documentation ◦ Good outcomes with No Show work group  The Waiting Game & The Telephone Tag Game ◦ Inability to schedule because we can’t talk! ◦ Waiting for appointments/blocking schedules

 Reorganization of ‘intake’ ◦ Reduction in phone triage and up front clinical triage  Prep for the unexpected ◦ Increase in staff for financial intake  Increased focus on payment info during intake ◦ Clear telephone message/info ◦ Those scheduled?  Preparing for the WAVE of people who had called and/or scheduled prior to Open Access starting  Therapy and Flexibility ◦ All hands on deck ◦ Referral out ◦ Scheduling

 Collaborative documentation ◦ 3 hour webinar training ◦ Therapy ◦ Peer ◦ BCM ◦ Advantages and Disadvantages ◦ Challenges with new E&M codes  Conceptualization of Nurse Liaison ◦ Eventual hire of Nurse Liaison in 2013  Availability of New Client Blocks for therapy

Care Level OneServicesAmountAdd-ons Recommended Length of Episode of Care prior to d/c to semi-annual visit: 30 to 120 days Indicators of Level 1:  No prior history of hospitalization within past five years  No imminent risk  Good structure and supports  Daily functioning is normative  Has demonstrated strong engagement with providers  Person describes feeling stable  No significant crisis involvement  Stable housing  Consistently employed, volunteering, etc. 1.Diagnosis and Assessment 2.Individual Therapy 3.Psychoeducation Group Therapy 4.Medication Services 5.Crisis Services as needed 1.Maximum of 2 per episode (psychosocial and psych eval) 2.Up to 6 sessions 3.Up to 12 sessions 4.1 psych evaluation, 3 follow up medication checks  Crisis hotline  Warm Line  Education & Referral  Pharmacy Service  Medication Assistance (prior authorization; medication education)  Engagement Services (Phone call prior to psychiatric evaluation; calls for clients who do not connect)

Care Level Two Recommended Length of Episode of Care prior to d/c to semi-annual visit: 3 to 12 months Indicators of Level 2:  Hospitalization within past five years  No imminent risk  Good supports  Some difficulty with everyday functioning  Demonstrates healthy potential for engagement with providers  Describes feeling less stable than desired  Crisis management involvement or indication for involvement  Situational stressors, such as housing, employment or relationship strains 1.Diagnosis and Assessment 2.Individual Therapy 3.Psychoeducation Group Therapy 4.Support Group Therapy 5.Medication Services 6.Peer Services 7.Care Management 8.Crisis Services as needed 1.Maximum of 2 per episode (psychosocial and psych eval) 2.Up to 15 sessions 3.Up to 18 sessions 4.Up to psych evaluation, 6 follow up medication checks 6.As needed, up to 2 hours (individual and group) a week for up to 120 days 7.Follow up contact after psychiatric evaluation 8.As needed  Crisis hotline  Warm Line  Education & Referral  Pharmacy Service  Medication Assistance (prior authorization; medication education)  Engagement Services (Phone call prior to psychiatric evaluation; follow up after psychiatric evaluation, calls for clients who do not connect)

Care Level Three Recommended Length of Episode of Care prior to d/c to semi-annual visit (where possible): 2 or more years. Indicators of Level 3:  Hospitalization within past two years  No imminent risk, but potential for risk has been identified  Moderate supports  Moderate difficulty with everyday functioning  Has demonstrated difficulty engaging with providers  Describes feeling less stable than desired  Crisis management involvement  Situational stressors, such as housing, employment or relationship strains  Co-morbid medical or substance abuse concerns  Current medication regimen requires more frequent engagement (e.g. lab work, Clozaril support services, injection medications, etc.)  Serious Mental Illness Diagnosis 1.Diagnosis and Assessment 2.Individual Therapy 3.Psychoeducation Group Therapy 4.Support Group Therapy 5.Medication Services 6.Peer Services 7.Care Management 8.Crisis Services as needed (including Crisis Residential) 9.CSANDS 10.Specialized nursing and medication services 1.Maximum of 2 per episode (psychosocial and psych eval) 2.Up to 25 sessions, per year 3.Up to 12 sessions, per year 4.Up to 25 sessions, per year 5.1 psych evaluation, 8 follow up medication checks, per year (psych eval update may be utilized) 6.As needed, up to 2 hours (individual and group) a week 7.Follow up contact after psychiatric evaluation, monthly contact by telephone, and by appointment as indicated 8.As needed 9.1 psych eval, 3 med checks, 1 psychosocial, 8 therapy visits, within 30 days 10.As indicated nursing support, based on medication regimen  Crisis hotline  Warm Line  Education & Referral  Pharmacy Service  Medication Assistance (referrals; prior authorization; medication education; coordination with PCP, case managers, housing supports, etc.; medication administration coordination; Clozaril support services; calls for clients who need additional medication or health related support; coordination with Crisis Services and with inpatient staff, as indicated)  Engagement Services (Phone call prior to psychiatric evaluation; follow up after psychiatric evaluation, calls for clients who do not connect; reminder calls as needed)

Care Level Four Recommended Length of Episode of Care prior to d/c to semi-annual visit (where possible): 5 or more years. Indicators of Level 4:  Hospitalization within the last year  Potential for risk without strong supports  Potential for self harm without strong supports  Serious co-occurring medical or substance abuse which could be life threatening  Frequent crisis management  Difficulty with engagement (e.g. missed appointments, frequent ER visits, difficulty taking medications)  Severe symptoms  Limited or poor supports  Requires referral to more intensive service  Serious Mental Illness Diagnosis 1.Diagnosis and Assessment 2.Individual Therapy 3.Psychoeducation Group Therapy 4.Support Group Therapy 5.Medication Services 6.Peer Services 7.Care Management 8.Crisis Services as needed (including Crisis Residential) 9.CSANDS 10.Specialized nursing and medication services 1.Maximum of 2 per episode (psychosocial and psych eval) 2.Up to weekly sessions, per year 3.Up to 12 sessions, per year 4.Up to 25 sessions, per year 5.1 psych evaluation, 12 follow up medication checks, per year (psych eval update may be utilized) 6.As needed, up to 2 hours (individual and group) a week 7.Follow up contact after psychiatric evaluation, biweekly contact by telephone, and by appointment as indicated 8.As needed 9.1 psych eval, 3 med checks, 1 psychosocial, 8 therapy visits, within 30 days 10.As indicated nursing support, based on medication regimen  Crisis hotline  Warm Line  Education & Referral  Pharmacy Service  Medication Services (referral; prior authorization; medication education; coordination with PCP, case managers, housing supports, etc.; medication administration coordination; Clozaril support services; coordination with Crisis Services and with inpatient staff, as indicated)  Engagement Services (Phone call prior to psychiatric evaluation; follow up after psychiatric evaluation, calls for clients who do not connect; calls for clients who need additional medication or health related support; reminder calls as needed; engagement with families)

 Prepping people to refer out ◦ Who walks in the door? How do they walk out?  People interpret the care levels differently ◦ Hx vs. Current orientation ◦ Medical factors ◦ Awareness of meds/systems  There is no rhyme or reason ◦ Very hard to predict timing of entry  Payer mix is a huge issue ◦ Credentialing and scheduling

 Since February of 2013, 88% wait less than an hour from the financial to the start of assessment ◦ Average is 30 minutes ◦ Average total from sign in to end of intake1:35 ◦ Represents 3,109 walk in intakes  72% are done by intake staff  This year about 19% of adults have Medicare  664 intakes were scheduled ◦ Largely satellites and interpreter/major medical, dc  Age of Intakes

 9/1/13 > 3/23/14  Level 1 ◦ 48  Level 2 ◦ 202  Level 3 ◦ 512  Level 4 ◦ 151  Total 913

 Psych Evaluations/Diagnostics 2014: 715 as of 8/20/14  Payer Mix/Scheduling  Adjustment of times for intake  Need for additional financial intake staff  Staffing the intake line as needed  Overwhelmed nurse liaison with referrals  Alternatives ◦ CSANDS and CRU ◦ BCM ◦ PCPs

 New client blocks  Payer  Improved productivity for no shows

 Nurse Liaison acuity changes ◦ Nursing Assessments  Evaluation of therapy acuity and frequency  ID of potential referrals out  Better ID of potential high risk clients  Better ability to quantify desired time slots  Evaluation of therapy caseloads vs. prescriber

 Resource Management  Team Integration  DEMAND and volume  Attention to payer and scheduling

 Referral to PCP?  Templates based on triage?  Revisions based on standardized measures?  Evaluating past versus current risk factors