1. Decreasing Emergency Room Visits: A New Collaboration Primary Care and Care Management
Mary DeVivo, LCSW
Cristina Victoria, BSW
Human Development Services of Westchester, Inc.

2. Who is CBHS? Coordinated Behavioral Health Services Coalition of Non-Profit Community Behavioral Health Providers serving nine counties in the Hudson Valley region.

3. Who Are the Partners? Which Counties Do they Serve?
Access: Supports for Living- Dutchess, Orange, Ulster
Hudson Valley Mental Health- Dutchess, Ulster
Human Development Services of Westchester (HDSW) – Westchester
Mental Health America of Dutchess- Dutchess
Mental Health Association of Rockland- Rockland
Mental Health Association of Westchester – Westchester
Putnam Family & Community Services – Putnam
Rehabilitation Support Services (RSS) – Westchester, Orange, Sullivan, Dutchess, Ulster (In addition to other Counties in NYS)
Westchester Jewish Community Services (WJCS) - Westchester

4. HRHCARE
HRHCare provides the highest quality of comprehensive primary, preventative, and behavioral and oral health care and care coordination services to all who seek it, regardless of insurance status or ability to pay.
AFFORDABLE services for all patients
ACCESSIBLE services designed to be available where and when the patient is
PROFESSIONAL and caring treatment of all patients
HIGHEST QUALITY and COMPASSIONATE care based on the HRHCare Multidisciplinary Planned Care Model
26 Health Centers
Over 350 Practitioners

5. CBHCARE
CBHS and HRHCare formed a partnership to better meet the needs of clients and patients
CBHCare is an Independent Practice Association (IPA)
Contracting vehicle for value-based payment
Integrating physical health and behavioral health services
Developing cutting edge programs utilizing the individual and collective strength

6. Establishment of CBHCare IPA
Collaborative of 9 (grown from 7) behavioral health providers
Primary care
Spent a little over 1 year establishing the legal and governance structure

7. MVP HEALTH CARE
Nationally- recognized, regional, not for profit health plan committed to having a positive impact on the health and wellness of all members
Over 700,000 members in the NY/Vermont area
Educate clients to improve care and outcomes

8. Taking First Steps toward Value-Based Contracting
First arrangement focused on reduction of ER visits
Care Managers were deployed at HRHC facilities to meet with clients to discuss ER visits and to link them to services in the community and to Health Home Care Managers if already assigned.

9. HRHCare Site Locations
Park Care, Yonkers- Westchester County
Valentine Lane, Yonkers- Westchester County
Peekskill – Westchester County
Haverstraw- Rockland County
Spring Valley- Rockland County
Walden- Orange County
Monticello- Sullivan County
Beacon- Dutchess County
Poughkeepsie- Dutchess County
Amenia- Dutchess County
Dover- Dutchess County
Pine Plains- Dutchess County

10. Who we are reaching out to
Individuals who are using the Emergency Room as the source for primary care.
Not necessarily individuals with a behavioral health diagnosis.
Individuals living with issues related to the social determinants of health.
Some are using the Emergency Room due to substance abuse issues.

11. MVP CONTRACT CBHCare and MVP are contracting for:
July 1-December 31, 2016:
PMPM Care Management Fee
Quality- Bonus for improvement on a set of 8 quality measures
Utilization- Incentive for reduction in rate of unnecessary ED utilization
For 2017/2018:
Move to a Total Cost of Care Model
Quality measures will be revised (still in progress)

12. Training Motivational Interviewing Trauma Informed Care eCW GSI
Development of Person Centered Care Plan

13. Outcomes Decrease in Emergency Room visits
Individuals had better access to primary care
Primary Care physicians had the support of a behavioral health Care Manager
Individuals had better coordination of care through on-site Care Management

14. Barriers Difficulty locating clients using data from 2015
Part-time status in primary care setting
Integration as full team member
Care Manager leaving host facility
Limited caseloads

15. Moving Forward in 2017
Care Manager will be full-time in primary care setting
Rosters will increase to 50 clients per Care Manager including other MCO’s besides MVP.
Team huddles each morning
Enrollment of clients into HRHCare Health Home
Clinical supervision provided by a Licensed professional at the host agency
Administrative supervision provided by the nurse manager
Ongoing meetings with all of CBHS providers in the project

16. Strategies for 2017
HRHCare and MVP will determine HEDIS measures that need to be attained
Value based payments will be determined based on the HEDIS measures decided upon
Savings for both CBHS and HRHCare for achieving goals above the set rates

17. Director of Care Management
Mary DeVivo, LCSW
Director of Care Management
Human Development Services of Westchester, Inc.
(914) Ext 1030
Cristina Victoria, BSW
Care Manager
(914) Ext 1044