6 Steps To Improving CCBHC Outcomes The Berks Counseling Center Case Study

On May 25, 2022, Qualifacts’ CCBHC Program Manager Mary Givens and John Heim, Technology Specialist, EHR Systems for Berks Counseling Center discussed a 6-step process for improving performance on behavioral health led CCBHC outcomes. They provided insight into the greatest challenges of high performance on the CCBHC behavioral health led measures along with the successes and lessons learned from a mature CCBHC.

Presentation Slides

Who Should Do What? Scope of Practice; Treatment Tech Shift Clinical Best Practices

By Monica E. Oss, Chief Executive Officer

There has been a long debate about the scope of health care practices. What type of licensed clinical professionals can perform particular functions? Should psychologists and/or pharmacists prescribe psychotropic medications? What supervision do nurse practitioners and physician assistants need? (Should ‘physician assistants’ be renamed ‘physician associates’?)

Psychologists can prescribe in five states: Louisiana, New Mexico, Illinois, Iowa, and Idaho (see Can Psychologists Prescribe Medications?). The scope of pharmacists’ practices is state-dependent and varies widely from state-to-state (see Mapping U.S. Statewide Protocols For Pharmacist Prescriptive Authority). Pharmacists may or may not give injections and immunizations and prescribe everything from naloxone, tobacco cession aids, travel medications, and more. Physician Assistants are licensed to practice in all 50 states, the District of Columbia, all US territories, and the uniformed services. Physician Assistants are authorized to prescribe medications in all jurisdictions where they are licensed, except Puerto Rico (see PA Prescribing and Assessing Scope of Practice in Health Care Delivery: Critical Questions in Assuring Public Access and Safety).

Executives of health and human service organizations need to plan to leverage the ‘value’ of their clinical team members by developing systems where they can work at the ‘top of their practice’—with most of their time going to the services that require their specific level of training. But that is easy to say and much harder to accomplish in practice. This type of service specialization is an essential part of the specialization needed to achieve maximum operational efficiency—and the highest value.

But there are two factors that complicate plans for specialization to increase value. The first is that in systems that are increasingly rewarded for a ‘whole person’ approach to care—which runs contrary to specialization. The second is that health care treatment technologies are reaching a level of sophistication that they can be a replacement for some of the work of licensed clinical professionals. The key for executive teams is using technology to address both of these issues. The first is ‘virtual integration’—creating a singular consumer data set that is available to all health care professionals. The second is to use data—both small data and big data—to develop algorithms that curate the recommendation of treatment services for specific consumers—both treatment technology and the most appropriate clinical professional. These are essentials to sustainability—building organizational efficiencies that result in competitive advantage.

For more on our coverage of efficiency and effectiveness in staffing models—and in emerging treatment technology, check out these resources in the OPEN MINDS Industry Library.

Scope of Practice Issues

Digital Treatment Trends & Strategy

Digital Treatment Developments

For more on managing and practicing at the top of your team’s skillsets, join me for The 2022 OPEN MIND Management Best Practices Institute in Newport Beach, California from August 30 to September 1, 2022.

Tech For Success: How To Assess Current Tech Functionality Readiness For Future Growth

By Joe Naughton-Travers, Ed.M.

With my work at OPEN MINDS, I’m often asked by my specialty health care provider organization clients which type of technology is the most important. My answer is always the same: it’s not about the individual technology itself, it’s about how all of the technology platforms come together and “play nice” to manage and optimize overall clinical and financial performance. Without the integration across all platforms, each are merely working in silos without the ability to use each platform’s data as decision-making guides for the organization.

In response, I’ve worked with our team of senior advisors to develop a technology platform framework for specialty provider organizations to aid in planning technology needed for the future. This framework has six domains:

#1 Electronic Health Record & Billing System — The functionality of a comprehensive electronic health record (EHR) software application.

#2 Human Resource Information System & Financial/General Ledger System — These are the two other key software applications for administrative operations. The Human Resource Information System (HRIS) is the software that maintains, manages, and processes detailed employee information and human resources-related policies and procedures. The Financial/General Ledger System is the software that tracks all financial transactions and is used to generate a company’s financial statements.

#3 Hybrid & Community Based Service Delivery Platform — Technology tools that support virtual and community-based service delivery.

#4 Consumer Experience & Engagement Platform — Technologies for enhancing consumer engagement in the health care experience and optimizing consumers’ experience with the system of care.

#5 Value-Based / Risk-Based Reimbursement Platform — Technology capabilities that support measuring value in terms of customer experience and engagement and of the cost and quality of services.

#6 Integrated Analytics & Service Performance Optimization — Software applications for aggregating and analyzing the data from all the other software systems and databases to manage and optimize clinical and financial performance.

Domain #1: A Whole Person Care Record: Comprehensive EHR Software

The first requirement is a comprehensive EHR software application for all the consumers your organization serves, and all the service lines delivered. The EHR must record the demographic and clinical data for consumers, the services they receive, and the corresponding clinical documentation. Additionally, the EHR must:

  • Document all referrals and referral dispositions
  • Support tracking performance and clinical quality metrics
  • Include standard functionality for medical services (e.g., e-prescribing, laboratory orders, and electronic medication administration records)
  • Provide support for the delivery of routine primary care services

Mobile access to the EHR (both on- and off-line) is a must, and clinical decision support for medical necessity, clinical appropriateness for care, evidence-based practices, and payer-mandated clinical pathways is highly desirable. The EHR should be interoperable with the EHRs of other provider organizations to facilitate care coordination. Lastly, the software must handle all of your organization’s billing and accounts receivable operations (including fee-for-service, bundled, case rate, and VBR payment models) and have tools for maximizing revenue collection.

That covers the technical details—the functionality of a good electronic health record. The essential questions to ask about any EHR system are:

  • Does the EHR help you manage whole person care for the consumers you serve?
  • Does it have functionality to monitor physical and behavioral health as well as social determinants of health (SDoH)?
  • Does it aid in care coordination with other provider organizations to achieve the best health outcomes?

If your EHR software application is not addressing these key service management functions, it is time to consider a change.

Domain #2: Managing Administrative Functions: Human Resource & Financial Management Software

The second domain helps provider organizations ensure that key administrative operations—human resources and finance—have the right software applications to meet your organization’s needs. The HRIS (human resource information system) must do more than track employees, salaries, and benefits. The HRIS also should include functionality for job applicant tracking and position control, time and attendance tracking, employee self-service capabilities, and a learning management system. A final requirement is comprehensive support for employee appraisals and development plans.

The financial management software (sometimes called the general ledger or accounting system) should have all the basic capabilities: budgeting, financial reporting, payroll, accounts payable, and fixed asset management. To support VBR contracts, the financial management software also needs to have the capability to aid in the management of the cost-of-service delivery—overall—and for individual health plan contracts. (It will need access to the service delivery data in the EHR to do this.) Lastly, this software application should have functionality for monitoring and managing health plan contracts and other payer contracts.

Domain #3: Delivering Care Conveniently: Hybrid & Community-Based Service Delivery Capabilities

This domain is more than just the telehealth services that your organization has become proficient at delivering during the COVID-19 pandemic. It includes other technologies that support and enhance your community- and home-based care delivery. Telehealth capabilities must be integrated into the EHR itself and should also be available on mobile devices so that community-based staff can bring in additional staff virtually when needed. Electronic visit verification (EVV) is needed to report that staff were physically present at consumer service delivery sites during community-based care. Smart home and remote health monitoring technologies can be used to ensure the health and safety of consumers. Secure communication between staff and consumers should be available in multiple formats (text, email, telephone, and video). Ideally, you would also have technologies that aid in route optimization for staff travel in the community as well as tools for managing these field and remote-based staff.

Domain #4: A Focus On Customer Service: Consumer Experience & Engagement Tools

Technology in this fourth domain is new to many specialty provider organizations. Consumer experience is the subjective response consumers have with any contact with your organization. Questions you might consider when evaluating for consumer experience include:

  • Are your services convenient and easy to access?
  • Are communication and other interactions smooth and painless?
  • Is there a personal touch to service delivery and an impression of quality?

Consumer engagement is when individuals take action to become more informed and more proactively involved in his or her health and the health care services received. There are numerous technology tools to help with both consumer experience and engagement, including:

  • 24/7 centralized access to care
  • An easy to navigate website with the ability to access care and schedule appointments
  • A consumer portal for communication, bill payment, and health record access
  • Web- and app-based self-directed consumer health and well-being technologies
  • Enhanced social media presence
  • Net promoter scoring integrated into all aspects of care delivery
  • Appointment and health check-in reminders via telephone, text, and email

As provider organizations expand their focus on consumer experience and engagement, a key focus is to determine which technology tools they may already have to support these efforts and which they will need to acquire and implement.

Domain #5: Managing Care & Costs:  A Value-Based Reimbursement Platform

The fifth domain of the technology platform framework is technology tools for managing service performance and cost. Provider organizations should assume that most, if not all, of their health plan contracts in the future will be value-based, with both upsides and downsides in terms of payment models. You’ll need technologies that monitor clinical quality metrics in comparison to contract requirements. Will these be in your EHR? In other software applications? In analytic dashboards?

You’ll also need to monitor other contract performance metrics. Examples include metrics to monitor access to care, treatment engagement, telephone and referral response time, and other industry standard metrics such as Healthcare Effectiveness Data and Information Set (HEDIS) and Certified Community Behavioral Health Clinic (CCHBC) requirements. You may also be required to track and monitor SDOH and adherence to evidence-based practices.

Other key questions you’ll want to consider about managing care and cost include:

  • What other technologies can better facilitate your ability to manage care and cost?
  • Can you accomplish this with your EHR and financial management software alone?
  • Do you need to invest in a better telephone system and website?
  • Should you implement separate technology tools for quality and performance tracking that your EHR cannot handle?

This leads to Domain #6—does your organization need business intelligence and data analytic technologies to aggregate, analyze, and present the data in a meaningful way to your staff?

Putting It All Together With Domain #6:  Analytics & Optimization

The last domain uses technology for aggregating your data in a meaningful way to proactively manage your organization. This is accomplished by utilizing business intelligence (BI) or other data analytic software applications that aggregate data for analysis and performance optimization. This is the ‘holy grail’ of performance measurement and optimization, having meaningful data to report your organization’s financial strength and operational performance and to monitor progress towards strategic objectives.

Most commonly, provider organizations begin with using these technology tools to manage and optimize clinical quality and performance metrics through reporting. The next step is to implement the use of dashboards for the board of directors, the executive team, department managers and individual staff. The most sophisticated use of BI software applications for specialty provider health care organizations is for population-health management. Here, BI software applications are used to provide the analytics to improve the health of the overall population of consumers served, to enhance consumer experience, and to reduce costs through consumer segmentation and analytics.

Where To Start In Building A “Next Generation” Technology Platform

The question is how to proceed with planning for and implementing the technology functionality needed to support future growth plans. There is a two-step process—addressing both immediate functionality needs for success in the current market and assessing the technology needed to support your strategic plan.

For the first, addressing immediate functionality needs, we have created a short assessment of ‘must have’ current tech functionality—The OPEN MINDS’ Technology Requirements Checklist – Eighteen Must-Have Capabilities For Specialty Provider Organization Success. To see how your organization stacks up in this preliminary list, go through the checklist.

OPEN MINDS’ Technology Requirements Checklist – Eighteen Must-Have Capabilities For Specialty Provider Organization Success   Yes   No   Working
    On It
#1 Electronic Health Record & Billing System
Does your EHR handle all your health record documentation and billing requirements?
Does your EHR have the capability to share data with other provider organizations (interoperability)?
Does your EHR have mobile access (both on-line and off-line)?
#2 Human Resource Information System & Financial/General Ledger System
Does your HRIS include functionality for job applicant tracking, position control, and employee self-service?
Is your Financial/General Ledger System chart of accounts set-up so that you can report the unit cost and case costs of all the services you deliver?
Does your Financial/General Ledger System include contract management functionality?
#3 Hybrid & Community Based Service Delivery Platform
Do you have secure telehealth technologies in operation?
Do you have electronic visit verification (EVV) in operation?
Do you have technologies in place to monitor or report consumers’ health status (e.g. blood pressure, body mass index, lab levels, etc.)?
#4 Consumer Experience & Engagement Platform
Do you have centralized scheduling or other tools that make it easy for consumers, their families, and referral sources to access care at your organization?
Can consumers communicate securely with their care providers through a web portal, text, or other technologies?
Have you implemented net promoter scores, or a similar measure, to routinely measure consumer experience?
#5 Value-Based / Risk-Based Reimbursement Platform
Does your team have a system for reporting payer-centric and consumer-centric performance metrics?
Do you have technologies in place to report timely access to care and hospitalization readmission performance metrics?
Do you have a system to report other value-based and risk-based reimbursement contract performance measures such as follow-up after hospitalization, emergency room utilization, and use of evidence-based care protocols?
#6 Integrated Analytics & Service Performance Optimization
Do you have software technologies in place that can aggregate data from your EHR, HRIS, and Financial/General Ledger System to report on key strategy metrics?
Do executives and managers have access to real-time dashboards for key performance and operational metrics?
Does your staff know how to interpret and use the data that is available to them for performance management (data literacy)?

This checklist provides an assessment of basic technology-enabled management capabilities. Where there are gaps in these management capabilities, management teams should develop a plan to meet these functionality basics. If there are functionality deficiencies in Domain #1 and #2 (the EHR, HRIS, and GL systems) these should be an area of immediate focus.

Beyond these basic areas of tech-enabled management capabilities, executive teams need to also crosswalk their strategic plans with the tech requirements to support those strategic initiatives. For more on that process, see From Strategic Plan To Tech Strategy: Building Your Crosswalk.

Looking ahead, every executive team member—and not just the CIO or CTO—need to focus on the coming digital transformation of the health and human service field—and the strategy and technology needed to succeed.

Metrics-Based Management: Using Analytics For Strategy Implementation & Business Optimization

By Joe Naughton-Travers, Ed.M.

If you have great staff and great infrastructure, your organization still needs a strong management team—and management practices—to make sure that organizational plans to deliver great performance becomes reality. To do this, management teams need well-designed, real-time performance metrics. In successful organizations, metrics-based management happens in two contexts: managing strategy implementation and optimizing business operations. The key is to ensure you have the right data and the right analytical tools to report these performance metrics.

Managing Strategy Implementation

The use of metrics in implementing a strategic plan is considered a core element of strategic management built around key performance indicators (KPIs). Simply put, KPI’s are the ‘metrics’ that measures progress towards your strategic objectives, as well as whether your organization has achieved them. Some metrics are a direct measures of success. For example, if a strategic objective is to operate at a 10% positive financial margin, then the KPI for this objective is the margin, which is reported at least monthly. In other instances, you may choose process or proxy metrics that measure progress made in various initiatives to accomplish a particular strategic objective.

There are four important steps to selecting these KPIs and managing strategy implementation:

Step #1: Start with your strategic plan.  It should have a short list of quantifiable strategic objectives, initiatives for accomplishing them, timelines, assignments, and budgets.

Step #2: Select metrics for success. These are your key performance indicators (KPIs) calculated from obtainable data that indicate organizational performance in progressing toward and accomplishing strategic objectives. An effective KPI is specific, measurable, and actionable. Use a ‘balanced scorecard’ framework that includes metrics that report financial performance, customer performance, organizational innovation, and effective internal operations.

Step #3: Create a KPI reporting system. Ideally, this is from a business intelligence (BI) or data analytics software application that includes management dashboards to report the metrics, showing a comparison to the performance trend from past to present. Minimally, the KPIs are reported monthly with the trend data as well as against performance targets. This reporting system and its use communicates the importance of the organization’s strategic objectives and the executive team’s focus on them. As Peter Drucker said, “You can’t improve what you don’t measure.”

Step #4:  Coach your staff to use the KPIs. Engage in ongoing monitoring and proactive management using the KPIs with your executive team and staff. Modify the KPI metrics if needed to ensure progress in implementing your organizational strategy.

Much has been written about the development of KPIs and models for selecting both leading and lagging financial and non-financial indicators of performance. The challenge, beyond selecting the measures, is two-fold: developing the ability to routinely report the measures using data from existing software systems or databases (or expanding current information systems to collect the data) and analyzing the KPIs monthly to develop or update organizational strategies to improve performance.

Optimizing Business Operations

Metrics-based management also plays a key role in optimizing business operations for specialty provider organizations. What exactly is business process optimization? It is the management discipline that promotes efficiency and effectiveness of organizational process—employing methods, policies, management practices, software tools, and metrics to optimize an organization’s activities across the business process life cycle.

Optimizing business operations is critical for provider organizations. All aspects of service delivery (referral, admission, routine services, and discharge or transfer) and administrative operations need to run smoothly. Processes should be standardized to be effective and consumer and staff friendly. Data and analytics are critical tools for doing this.

Organizations that have superior process management performance share a few key competencies—corporate strategy that is connected to performance indicators as described above, process and project management expertise, deliberately designed process models that promote service quality, access to information, support of management for process improvement initiatives, and incentive-focused employee compensation.

It sounds simple. But if business process management is so simple, why do so many organizations have bad performance from bad processes? Author Janne Ohtonen, in an article titled, “Enabling strategic growth and improved performance through Business Process Management,” offered some interesting insights. His list of the ten key capabilities needed to be successful with business process management and optimization include:

  1. Co-workers have confidence and trust in each other
  2. There is open communication between employees and managers
  3. Managers share vision and information with employees
  4. The organization is able to respond to changes in markets quickly
  5. Senior management has confidence and trust in managers
  6. There are efficient communication channels for transferring information
  7. The organization has appointed people responsible for processes
  8. The organization extensively uses information systems
  9. No one has to worry about losing his or her job because of process changes
  10. Managers support changes in processes

How does your organization stack up in terms of using data and analytics to drive strategy and to optimize operations? Your team can’t perform or manage without the metrics to support both of these. In fact, I would argue that, beyond strategy, metrics and metrics-based management competency are the most fundamental ingredients for organizational success for providers in today’s market. Why?

I’ve seen executive teams of organizations with all sorts of other competencies—but with no access to timely performance metrics or the ability to use them—fail to optimize performance. Without real-time performance metrics for your management team:

  • Identification of performance issues is often delayed
  • Organizational performance relative to competitors is more a matter of opinion than a measured achievement
  • The identification of performance problems requires constant observation—and is often anecdotal
  • The “causes” of poor performance are harder to identify (and often the subject of disputes between team members)
  • It is difficult to sort out persistent performance problems and separate “trends” from short-term issues
  • It is challenging to prioritize operational improvement initiatives and investments

I could go on…

If current performance data is not the focus of your management team meetings, it will be more difficult for your team to respond to evolving consumer and payer demands, a rapidly changing health care market, or emerging competitive threats. I liken it to flying blind; the airline pilot without the dashboard.

Key elements of an organization with metric-based, performance-driven culture:

  1. Visible metrics—both customer-centric and organizational—and the data and analytical tools for reporting them routinely
  2. Actionable insights based on rich data and identification of the actions needed to improve performance
  3. Clear team member accountability for specific performance metrics
  4. Real-time performance feedback at all levels of the organization
  5. Targeted coaching based on performance data with individualized goals to improve team member performance
  6. Recognition of great performance
  7. An interactive strategy and budgeting process
  8. Nimble and data-driven service line reengineering and development

So, collect the data and teach staff how to use metrics and analytics to improve your business operations and achieve your strategic objectives. Metrics-based management is one of those “must develop” competencies for health and human service organizations. Organizational performance—including financial, service, quality, compliance, etc.—matters more to the sustainability and success of organizations every passing year.

How To Manage The 5% With Multiple Chronic Conditions & Complex Support Needs

By Monica E. Oss
There is a lot of investment money going into the mental health field—in fact, $14.7 billion in the first half of this year (see Why Are Digital First Mental Health Companies So Popular?). Much of that investment is focused on digital behavioral health systems and tools for both professional and self-care.

However, these new platforms and tools are not the perfect fit for every consumer with a mental illness. In fact, 25% of consumers with any mental illness have a serious mental illness (SMI). In all, 13.1 million consumers, or 5% of the total United States population, have an SMI (see Key Substance Use & Mental Health Indicators In The United States: Results From The 2019 National Survey On Drug Use & Health). Of consumers with SMI, 27% have co-occurring substance use disorders. We also know that SMI consumers on average tend to die 10 to 25 years earlier than the general population—and have a mortality rate that is twice as high as that of the general population because of chronic physical medical conditions such as cardiovascular, respiratory, and infectious diseases; diabetes; and hypertension (see Premature Death Among People With Severe Mental Disorders). 20% of the SMI population lives in poverty Approximately 20% of jail inmates and 15% of state prison inmates have an SMI (see Mental Health & Criminal Justice). 33% of the homeless population has an SMI (see 250,000 Mentally Ill Are Homeless. 140,000 Seriously Mentally Ill Are Homeless).

For the approximately 5% of the population—those with multiple chronic conditions and complex support needs—that use a majority of the health care resources, a different approach is needed to assure good consumer outcomes and prevent inappropriate use of resources. That population was the focus of our recent discussion with Carole Matyas, Vice President, Operations at Sunshine Health, and the keynote speaker at the upcoming 2021 OPEN MINDS Executive Leadership Retreat.

On September 22, Ms. Matyas will deliver the keynote address, The Future Of Managing Care For Consumers With An SMI—What Works. The cornerstone of progressive interventions for the high-risk/high-needs population with a serious mental illness is based on a “whole person” treatment strategy that encompasses medical, behavioral, pharmacy, social needs, and caregiver collaboration and coordination. Ms. Matyas will review Sunshine Health programs that are showing promising positive outcomes such as reduced use of acute/crisis care, better engagement with primary care that improves medical health outcomes and addresses high comorbidity issues, stabilized community-based living environment by addressing social needs for the enrolled Medicaid and Medicare members served. She will provide an overview of their Long Acting Injectable (LAI) program with data that demonstrates reductions in emergency department and inpatient services, and increase in community-based and medical services for members.

My takeaway from our pre-Institute discussion with Ms. Matyas? The Sunshine Health approach to optimizing the management of consumers with an SMI has four key components—intensive case management to assure care coordination, leveraging long-acting medications, a focus on primary care, and addressing social support needs.

Intensive case management to assure care coordination. One approach that has improved outcomes for SMI consumers is intensive case management. Sunshine Health took its top 400 high-needs, high-risk consumers (who have 30+ hospital admissions a year, go to the emergency room every other week, and reject any type of community-based treatment) and had its staff provide proactive and intensive case management services in collaboration with a host of community provider organizations and stakeholders. For example, case managers work closely with a telehealth provider organization that Sunshine Health contracts with to ensure that consumers discharged from hospital have their seven-day follow up appointment virtually and then connect them with an outpatient provider organization for ongoing care.

Leveraging long medications. Sunshine Health has been encouraging provider organizations to use long-acting injectables (LAIs) for antipsychotic medication administration. Ms. Matyas shared that SMI consumers receiving monthly LAIs have shown significant stabilization in their mental health and also do better at getting care for their comorbid medical conditions, engage with peers socially, and are even able to have part-time employment. She said, “We are promoting use of LAIs and really going a long way in working with hospital systems, primary care physicians, and mental health providers to make it easy to obtain those medications, administer them, monitor, and do outreach so members continue treatment. While the medications can be expensive, the results definitely show reductions in hospitalizations, readmissions, and emergency room visits as well as better outcomes from community-based treatment.”

Sunshine Health has a number of strategies to increase the use of LAIs. They do not require provider organizations to obtain prior authorizations to administer LAIs. In addition, if clinical professionals start an LAI when a consumer is in the hospital, case managers make sure to follow up with the consumer to make sure they get to the outpatient provider organization for their next dose when it’s due. They also have a “concierge program” within their pharmacy network and customer service representatives call members to schedule an appointment for their next LAI dose. Some pharmacies are also authorized to administer the LAIs. Sunshine’s provider relations team is charged with providing information about LAIs to community mental health and primary care provider organizations.

Ms. Matyas said, “We have a goal of increasing long acting injectables 25% year over year. During the pandemic, we had interruptions with folks getting their long acting injectables, but we are working towards getting back to normal state, which is encouraging.” And now there are two barriers to overcome to extend the use of LAIs, she added. The first is adherence which becomes challenging when consumers are say, cycling in and out of homelessness and are not stable in their environment or engaged in their treatment. The other issue is that there’s a history of long acting injectables not getting authorized by managed care. So provider organizations need to be educated and learn that “they don’t have to jump through a lot of hoops” to be able to prescribe LAIs if appropriate for the consumers.

Focus on primary care. Sunshine Health is encouraging provider organizations to go the integrated care route by participating in health home models and value-based reimbursement (VBR) models. They are also leveraging data to encourage collaborations and equipping primary care provider organizations to better address the needs of SMI consumers. Recently, they launched a behavioral health home program and seven community mental health centers have signed up to date. These centers have co-located primary care and behavioral health services and are delivering whole-person care under value-based contracts.

VBR is the cornerstone for integrated care. Sunshine Health offers incentives for provider organizations to address “gaps in medical and behavioral care.” In the behavioral health homes program, the incentive program is contingent on preventive health screenings being conducted for all consumers and on addressing the comorbidities that SMI consumers have. All provider organizations in Sunshine’s network—whether they are primary care practices or community mental health centers—are expected to address comorbidities and to report on the array of HEDIS measures related to both medical and behavioral care. Ultimately, Ms. Matyas explained, “The goal is to move more to value-based care, where we can impact members by having them in a health care environment so that they don’t have to go eight different places to get the care they need. They should be able to be more easily referred and seen, for whatever service it is they need. Value-based care incentivizes providers to work together without dictating a one-size-fits-all model.”

Sunshine Health embeds behavioral health services in primary care and offers psychiatrists who can consult on prescribing patterns and other issues in the care of SMI consumers. Ms. Matyas explained, “Every member covered by us is assigned a primary care provider regardless of whether they have an SMI diagnosis or not. So every one of the 5% of our 2.6 million members with SMI has a primary care physician. We take the data to our primary care practices and say, ‘Here are the demographics of the population assigned to you and here are the care gaps.’ The primary care practices will tell us whether they can handle the whole-health needs of these SMI members or want us to move them to a different provider. Or the practices may say they are equipped to handle some things but not others. So then we bring in behavioral health quality practice advisors to work with them, or we move the SMI members to a primary care practice that is better suited to work with this population.”

Addressing social support needs. Sunshine Health addresses social determinants of health (SDOH) in a variety of ways. Many of their behavioral health provider organizations have robust case management programs and the case managers connect consumers to social supports as needed. The health plan maintains a database of community resources that these case managers can access on request. They also offer micro grants to small community projects that support social needs. Some of their Medicaid programs, like the SMI specialty plan, have expanded benefits such as housing rental deposit or one month’s advance rent to help consumers get into housing. They’ve distributed cell phones and tablets for consumer use. SMI consumers get $35 a month in over-the-counter benefits from CVS to buy non-prescription items.

The fact that health plans are looking at primary care as the hub for SMI treatment should be a wake-up call for specialty provider organization executives who believe that their niche in serving this population assures a steady stream of business. Assuming responsibility for the whole-person care (medical, behavioral, and social) of the SMI populations served and participating in value-based arrangements are becoming the basics for sustainability planning.

Addressing Social Determinants As A Path To Revenue Growth

By Monica E. Oss

Over the last 15 years, there have been many pilot projects by payers, health plans, and public and private entities to address social determinants of health (SDOH). In the past couple years, we’ve heard from several health plan executives about their SDOH initiatives (see Mind, Body, Community: Kaiser Permanente’s Unique ApproachInnovation: Tag, You’re It‘Leaning In’ To Medicare: Social Needs OpportunitiesWill Investing In Social Determinants Pay OffHousing = Health: The Five Levers, and Medicaid Wants More Than Health: Be Prepared For Contract Changes). We’ve seen many new SDOH program launches by health plans—UnitedHealthcare’s recent Empowering Health grants, Humana’s Bold Goals program, Horizon Blue Cross Blue Shields of New Jersey’s Neighbors in Health program, and North Carolina Medicaid’s Healthy Opportunities Pilots, to name just a few. And there are the requirements to address SDOH under new Medicaid managed care contracts in a number of states (see Medicaid Authorities & Options To Address Social Determinants Of Health).

For specialty provider organizations, the question is how to address SDOH—and find a funding stream to do just that. Previously, we outlined the two paths to adding social service supports and supports coordination to traditional service lines. One way is to add a social supports coordination element that will get more referrals or improve reimbursement under value-based reimbursement arrangements—and pay for itself as an enhanced service feature with more total revenue for existing services. The other way is to build social supports programs that health plans or government payers will reimburse—and build a new revenue stream. Whatever option an executive team chooses, return-on-investment analysis is key. I wrote recently about our six-step model for assessing the effectiveness (both proactively and in practice) of enhanced social service programming in Building An ROI For Social Service Referrals.

We heard two great case studies of provider organizations that are taking the second path— building service lines for social services with payer/health plan revenue—during the session, Incorporating Social Determinants Of Health Into Your Practice To Improve Patient Outcomes & Increase Reimbursement at last week’s 2021 OPEN MINDS Management Best Practices Institute (session recordings and decks are available at https://openminds.com/live-mbpi/sessions/ until September 27). June Simmons, President and Chief Executive Officer of Partners in Care Foundation and Karin Annerhed-Harris, Vice President, Business Development at Resources for Human Development (RHD), shared how they are working with health plans on unique initiatives to address SDOH for complex consumers.

June Simmons, President & CEO, Partners In Care Foundation

Partners in Care Foundation builds community networks to provide a single point of access for consumers. Partners in Care contracts with health plans—and sometimes with health systems—to provide care management and home and community-based social services. Their goal is to integrate all community health resources and supports into a seamless delivery system for easy access and management. Ms. Simmons said, “If you’re just referring Ms. Smith to go down the street where they provide meals, it’s one thing. But if you’re paying for something, it’s a whole new paradigm. And sometimes you’re going to have to pay for care coordination and concrete services on a targeted basis.”

Partners contracted with Blue Shield of California (BSC) in 2014 to provide SDOH services to BSC consumers through primary care practices. BSC pays Partners for specialized staff—community health advocates (CHAs)—who are trained and supervised by PIC, and embedded in medical practices. To date, Partners has trained and placed 70 CHAs in three years. CHAs assess and analyze consumer needs, work with consumers on care planning, connect them to services, follow up, and track outcomes. The relationship with BSC has grown since over time, with Partners providing a variety of SDOH-related services.

Partners also operates specialized Outreach and Engagement Centers for Anthem in California, Georgia, Colorado, and Virginia. Through these centers, they develop care plans, engage with consumers, and make sure they get the needed social services. “You can take a horse to the water but you can’t make it drink. So engagement is crucial to ensure that consumers actually use the services they are connected to and that’s why the health plans partner with experts like us.”

For health plans, the benefit is in contracting with a single entity that manages the comprehensive network of social care. Access to supports becomes easier for consumers. Data sharing between the health plan and community-based organizations is also streamlined and simplified. Ms. Simmons said, “So if you’re a health plan and want to address a certain population—maybe it’s young moms and kids, maybe it’s frail elders and keeping them out of the nursing home—are you going to go out and identify all the agencies involved, organize them, and contract with them? Or would you like a lead entity that’s going to do that for you—curate the services, qualify the agencies, be the central intake, the oversee the quality, and do the billing?” Working with a trusted local entity is a far more practical and efficient route for health plans in Ms. Simmons’ opinion. She said, “A more mature community entity can bring their neighboring health and human service provider organizations into an organized delivery system, so consumers don’t have to be referred to multiple entities.”

Karin Annerhed-Harris, VP, Business Development, Resources for Human Development

Resources for Human Development addresses food and housing needs. RHD provides outpatient and residential services for consumers with mental illness, substance use disorders, and intellectual and developmental disabilities. RHD partnered with Temple University Hospital and two managed care organizations (MCOs)—Health Partners Plans and Keystone First—to pilot the Housing Smart program. The program was intended to reduce avoidable emergency room utilization and hospital readmissions among homeless individuals through peer outreach, supportive services, and subsidized housing resources.

The MCOs agreed to criteria for eligibility and generated a list of member referrals for RHD. RHD provided the high-users experiencing homelessness with access to housing vouchers that are good for two years. The consumers were housed in apartments across Philadelphia and local food banks provided three meals a day for three months, followed by cooking classes. The pilot resulted in a 74% drop in emergency room use, 48% reduction in hospitalizations, and a 76% increase in outpatient hospital visits. And with stable housing, 12 consumers in the program are actively engaged in behavioral health outpatient services.

At the outset of the program, Temple generated a list of eligible people using target population criteria and shared that with the MCOs. They enrolled 25 high utilizers prioritizing consumers with opioid use disorder, persistent mental illness, and co-occurring physical health conditions. RHD used an MCO-funded team comprising a peer support specialist, care coordinator, and tenant services coordinator to engage consumers in services. While the MCOs reimburse for services, 36% of the program is grant funded and goes toward housing, Ms. Harris said. RHD is exploring expanded health plan funding, now that Pennsylvania allows health systems and MCOs that can save money through a value-based agreement to use the profits to fund housing.

Lessons learned—partnership, evidence-based interventions, data sharing, and more. Ms. Simmons shared the four key elements for successful integration of SDOH—strong partnerships to form a comprehensive community network of care, the capacity to deliver home-based services, the use of good screening tools to assess consumer needs and preferences, and the delivery of evidence-based interventions for SDOH.

At RHD, Ms. Harris attributes the success of their pilot to robust partnerships and collaborations (between provider organizations, a health system, health plans, and other community organizations); cross-sector tools and training; and data sharing to enable a holistic view of consumer needs, goals, and care gaps.

The takeaway for provider organization executives? As my colleague and OPEN MINDS Senior Associate Cathy Gilbert, who moderated the session, said, “Entrepreneurial provider organizations have the opportunity to package many consumer support services that were previously not reimbursable and turn them into new revenue streams in partnership with plans. Providing these services drives better outcomes for consumers and ultimately reduces overall costs.”

Four ‘Must Have’ Competencies For Post-Pandemic Competitive Advantage

By Monica E. Oss

We’ve covered the “triple whammy” of the pandemic on next normal health care—shifting competition based on changing consumer expectations, payer expectations, and price points (see Post-Pandemic, Strategy Needs Technology). I got a better sense of the market factors driving these changes—and the new competencies required for success—in a recent article, How Digital Is Changing The Pharma & Healthcare Industry, by Nikki Gilliland at Econsultancy. My takeaway is that there are four new competencies that executive teams should be thinking about to stay in the game as the effects of the pandemic digital shift become standard market factors.

To start with, the “must have” hybrid service model requires digital first consumer intake processes. For care coordination programs to be successful—and cost-effective—remote monitoring capabilities will likely be a “must have.” Another takeaway—to improve consumer engagement, social communities need to be built on and integrated into existing commercial internet platforms. And finally, without a robust web presence and expertise in search engine optimization, competing for referrals will be increasingly difficult. These are the next frontiers in organizational infrastructure for competitive advantage—and I’m adding them to my specialty provider organization competency map (see From Crisis To Growth: A New Leadership Mindset).

Digital first consumer intake/interface is critical to success with hybrid models. The pandemic has moved much of care delivery to virtual. But as we move to the post-pandemic landscape, the preferred service delivery modality is a combination of virtual and in-person care in clinics and in consumers’ homes. Recent research confirms this preference—in a national survey, more than 40% of consumers said that when it comes to mental health and routine care, they’d rather access services virtually or through a combination of virtual and in-person visits (see Post-Pandemic, Majority Of Patients Say They Prefer In-Person Care, Survey Finds). And a Healthgrades study found that when given a choice between health care providers with similar experience, proximity, availability, and patient satisfaction ratings, the vast majority of consumers—81% for primary care and 77% for specialists—choose the provider who offers online scheduling (see Specialty Care Strategy For A Tech-Enabled Future).

To make hybrid services an operational reality at scale, provider organization executive teams should develop a digital first consumer intake process with a well-designed “digital front door.” This intake process should include real-time appointment scheduling that is linked to both benefits eligibility information and the schedules of clinical team members. Many components of the digital front door, including online scheduling, can likely be built into existing EHR systems but standalone technology platforms are also available and can be integrated with current technology platforms.

Best practice care coordination will require leveraging personalized remote monitoring. Care coordination and case management services are slowly moving to risk-based and value-based reimbursement models—with reimbursement tied to outcomes. To be competitive in this market space, provider organization managers will likely need to deploy a coordinated suite of tech-enabled functionality. What does that look like? Decision support tools for care coordinators, driven by consumer data. Smartphone-based outreach to consumers for active monitoring, self-care supports, and engagement. Passive remote monitoring tools for staying on top of consumer health status over time. Market advantage will go to the organizations that can reduce costs by leveraging their clinical workforce with technology, while managing and optimizing performance and consumer outcomes.

Consumer engagement success will depend on strategies to build specialized social communities on existing platforms. Consumer engagement and participation in managing their health is key to making value-based reimbursement work. The question for clinical management teams is how to connect with those consumers. There are many standalone consumer web portals, discussion boards, blogs, and more. But getting traction with those standalone initiatives is difficult. Rather, consumers are likely to discuss issues and seek health care information, opinions, and suggestions from channels they are already active on. Provider organizations should consider facilitating social networks on existing platforms for their consumers and encouraging staff to weigh in on these online communities to share expertise when appropriate.

Social media platforms like Facebook, Twitter, Instagram, and YouTube (and to a lesser extent, LinkedIn), as well as messaging apps like What’s App and WeChat (in China) host consumer and caregiver groups with interest in specific conditions and treatments. Some of the newer apps for behavior-based chronic disease management also include a social component to let consumers engage with peers. But most consumer and professional engagement communities are web-based—they can be found through simple online searches and accessed with a web browser, while they also maintain a presence on all the major social media platforms. A Pew Research survey indicated that 26% of adult internet users had read or watched someone else’s health experience about health or medical issues in the past 12 months. And 16% of adult internet users in the U.S. go online to find others who share the same health concerns (see The Social Life Of Health Information).

There are a number of existing online communities. For example, MedHelp has communities for mental health, general health, diabetes, heart disease, pregnancy, and coronavirus. PsychU offers information, resources, and collaboration and discussion platforms on challenges and treatment approaches for mental health professionals. Verywell Mind offers consumer-friendly information, generated by clinical professionals, on a range of mental health topics. And, HealthUnlocked offers technology to build health communities and is available free to nonprofits, health advocates, and consumer organizations to start new communities.

Web presence and SEO expertise are needed to compete for customer eyeballs. As care becomes increasingly virtual, referrals will become increasingly virtual. Today, 13% to 17% of visits across all of health care are conducted via telehealth—which is 38 times higher than pre-pandemic use of virtual care (see Telehealth: A Quarter-Trillion-Dollar Post-COVID-19 Reality?). Prior to the pandemic, 67% of consumers searched for health care information online and 60% searched for provider reviews online (see Digital Health Consumer Adoption Report 2020). The pandemic has likely increased this consumer behavior and will also likely change the nature of professional referrals.

As executive teams consider whether their current website and web presence is an impediment to success or an asset, there are some basic questions to ask. Is the website content, user experience, search engine performance, and online reputation strategy meeting current consumer and referral source expectations? (For more, see our on-demand OPEN MINDS Circle Executive Roundtable Session, Designing Best In Class Websites: The OPEN MINDS Website Evaluation & Improvement Process.) The answers will drive strategies for enhancing the online brand presence, upgrading web site design and content, evaluating paid web advertising options to be “found” in web searches, and linking content to social platforms in order to increase reach to consumers and health plan partners.

The bottom line? To meet the preferences of consumers  and health plans—and succeed with new reimbursement rates and models—executive teams need to make a few additions to their “core competencies.” This will involve broader planning of infrastructure, both technology and human. The key question is not “What technology should we invest in?” but rather to define how technology can help to drive strategic objectives.

For more on the organizational competencies needed for strategic success, check out these resources:

Value-Based Reimbursement Models Help SPARC Get A Leg Up In Medicaid Managed Care Contracting

By Meena Dayak

SPARC Services & Programs (SPARC) is a behavioral health provider organization in North Carolina that has been providing home and community-based services since 2015. They serve 425 consumers monthly and employ 70 full-time staff. They focus on complex consumers—children and adults with severe and persistent mental illnesses (SPMI) who have not been successful with residential and other traditional treatment services—and work to keep them out of institutional care. Currently, most of their consumers are covered by Medicaid, although they have just started to expand into the commercial insurance space. SPARC’s service array includes outpatient services, home and community-based therapy services, rehabilitation services to help consumers transition from residential treatment to community living, support for daily living activities to help consumers live independently in the community, case management, and enhanced crisis response.

Since its inception, SPARC has operated predominantly through value-based reimbursement (VBR) arrangements with managed care organizations. SPARC’s Co-Founder and Chief Executive Officer, Teri Herrmann, MA, talked to OPEN MINDS about their VBR models and how they have helped to advance the mission of SPARC.

Reimbursement Models

SPARC currently has two VBR contracts with two managed care organizations (MCOs), Cardinal Innovations and Partners Behavioral Health Management. 26% of their consumers receive services under these VBR models, which constitute nearly 48% of SPARC’s total revenue.

Both of SPARC’s VBR contracts are based on per member per month (PMPM) case rates. When a consumer is referred to them, they do an assessment and seek initial authorization for treatment from the health plan. Typically they get a 6-month authorization and bill one unit per month. The case rates range from $2,800 to $3,000 per month.

SPARC’s very first health plan contract with Cardinal Innovations in 2015—for children’s services—was a value-based contract with downside risk. If a child receiving Family Centered Treatment® (FCT) services from SPARC entered into residential care either during the course of treatment or up to a year post-treatment, then SPARC had to give money back to the payer. “It was pretty unheard of in that landscape,” said Ms. Herrmann. After a year, SPARC re-evaluated the contract with the payer and decided that the goal was “too aggressive.” They re-negotiated the contract to make payback contingent on no readmissions within six months of treatment. The health plan was flexible with value-based contracting as it was new territory for them, too, said Ms. Herrmann. So now, if during treatment, or up to six months post-treatment, the consumer enters into residential care or stays in an inpatient setting longer than 10 days, then SPARC is charged back up to 30% of the amount that they have billed. Ms. Herrmann noted that they’ve had to pay monies back to their health plan, especially because the consumers they serve are so complex but SPARC remains committed to value-based contracting because of the longer term potential for revenue growth and the flexibility offered by the model to improve the quality of care.

In a second value-based contract with Partners Behavioral Health, SPARC has an incentive-based payment with upside risk only for children in FCT. If the children—who receive home and community based services from SPARC—are able to remain at home three months and six months after discharge from a residential facility, then SPARC receives incentives.

For one year, SPARC also had a value-based contract with Cardinal Innovations (operating under a North Carolina Department of Justice mandate) to help adults with SPMI—who had been “inappropriately placed” in adult care homes—transition to independent living in the community. This was a value-based contract with upside risk only, where SPARC was rewarded if they could help consumers transition successfully from the adult care homes and keep them in community housing through continuous interventions.

Success Factors For Value-Based Reimbursement

Ms. Herrmann attributes the success of value-based reimbursement to four factors—a strong referral network, the use of evidence-based practices in treatment, robust data integration and reporting capabilities, and a mindset of innovation and risk tolerance.

Value-based reimbursement—and the “willingness to take on consumers that no one else wants”—has strengthened SPARC’s status as a “preferred provider” with health plans and other state entities. They receive referrals from their MCOs, local hospital systems, state social services and juvenile justice departments, residential treatment facilities, and community-based provider organizations. Ms. Herrmann said, “We’ve got a pretty sophisticated referral process that tracks all our referral sources, and then aligns them with the payers. We can see what’s working and see where the holes are so we can put a referral marketing plan in place to address the gaps.” In addition, 85% of referral sources reported that SPARC kept them informed of the status of their referral. This “closed loop” referral approach strengthens SPARC’s appeal in helping to maintain continuity of care.

SPARC was built on the foundation of the family-centered treatment (FCT) model, an evidence-based practice (EBP) with a trauma treatment model of home-based family therapy that Ms. Hermann was involved in developing in the early 2000s. She underscored that using FCT helped to achieve the improved outcomes that value-based models demand. The use of EBPs is accompanied by relevant training and certification for staff using the model, which replaces some of the prior mandated state training that was not always relevant to the services staff delivered.

Ms. Herrmann describes herself as a “data nerd” focused on assimilating and continuously monitoring outcomes data to examine the potential to improve services. She said, “We don’t just want to measure if the person showed up. We want to objectively look at each person and if they are getting better.” They have built their electronic health record system to produce the key data and desired reports and are continuously working with their developers to manipulate and learn from the data. SPARC applies this data-informed approach across their value-based as well as fee-for-service programs so they can improve performance all around. Ms. Herrmann noted that the health plans are primarily looking for data on avoidance of emergency department utilization and avoidance of inpatient services or residential care for the consumers that SPARC serves. She said, “We’ve had a pretty long placement culture here in North Carolina that we’re slowly changing the tide on. If someone really needs those more acute levels of care, there is a place in the continuum for them. But we don’t want those services to be overutilized for the wrong reasons. And so that’s where we’re really focused for outcomes measurement right now.”

SPARC was proactive from the outset and proposed value-based contracting to their health plans. Ms. Herrmann elaborated, “As we were brainstorming and envisioning the concept for this company, we wanted to serve those niche individuals whose needs weren’t being met. And we were hearing from stakeholders and payers that they were really struggling to figure out what services to get to them. So we saw that we had to be innovative. We knew that starting a company and immediately jumping into value-based contracts was a little risky. But we also knew it would say a lot about us. As a new provider organization, we said to the health plans, ‘Let’s take this walk in value-based work together and learn.’ And this pitch for risk-based contracting opened doors that may not otherwise have been opened.”

Services & Outcomes

For 2019, SPARC reported the following outcomes from its range of services covered by value-based contracts (see SPARC Services & Programs: 2019 NC Outcome Data).

Family-Centered Treatment: Family-centered treatment (FCT) is an evidence-based practice with four phases of treatment—joining and assessment, restructuring, valuing changes, and generalization. FCT is targeted toward consumers at risk for higher levels of residential service—those with extensive histories of using acute services without successful outcomes; those who’ve been hospitalized with little prior treatment and are being recommended for residential services; and those currently in residential treatment where discharge is delayed because of lack of family systems.

Services are intensive with a minimum of 10 hours per month provided to the family. FCT incorporates trauma treatment and coordination with other systems, such as the school, justice, primary care, and social service systems as well as 24/7/365 crisis intervention services. FCT seeks to confirm and capitalize on internal changes within the family so that the family is not dependent on the therapist once services terminate. Families also have the opportunity to give back to their communities and share what they have learned with other families.

While starting FCT at SPARC, 57% of referrals were in some form of an out-of-home placement and 43% were at home with their family. After treatment, 81% of consumers receiving FCT were able to remain with or be reunified in the community with their family or another caregiver. 100% of families were engaged in treatment, participating in five or more sessions in 30 days. And 96% of families reported that treatment improved their family life.

In-Home Therapy Services: In-home therapy services (IHTS) is a combination of motivational interviewing and care coordination provided in the home and community to children and their families where there are complex clinical needs that traditional outpatient therapy cannot adequately address. IHTS is a time limited service, approximately 6 months, in which a therapist and the case manager work with the child and their family to meet the therapeutic needs as well as provide linkage to professional and natural supports. The case manager works with the various systems involved with the child and family, such as the school, primary care, social services, and justice systems. Upon discharge from IHTS, children and their families can continue to receive outpatient therapy to ensure continuity of care.

85% of families successfully completed treatment and 97% of consumers were either at home with family, or in other family placements, at the time of discharge from treatment.

Transition management services: Transition management services (TMS) is a rehabilitative service intended to increase and restore a consumer’s ability to live successfully in the community by maintaining tenancy in community housing. TMS increases the consumer’s ability to live as independently as possible, managing their illness, and reestablishing their community roles related to emotional, social safety, housing, medical and health, educational, vocational, and legal services. TMS provides structured rehabilitative interventions and works in partnership with the individual’s behavioral health service provider.

90% of members participating in services were able to both obtain and maintain their housing in 2019. Only 5% were discharged from the program because they needed a higher level of care. And the program is working with 98% of consumers are on four or more social determinants of health in addition to their housing needs.

Enhanced crisis response: The enhanced crisis response (ECR) service is intended to put supports in place as quickly as possible for youth with behavioral health needs that are at risk for abandonment, crisis episodes, or being placed in restrictive levels of care. With timely assessments and supports, ECR is intended to keep youth in their environment—such as non-therapeutic foster homes, kinship placements—or minimize needs for long stays in residential treatment. Services last 60 to 90 days on average. SPARC staff work with consumers and families to diffuse the imminent crisis and get the family linked to appropriate community-based services that allow the consumer to thrive and meet their goals.

71% of youth who were discharged from the program in 2019 were able to be discharged into the community with community-based services.

Overall, SPARC’s services received an average customer satisfaction rating of 4.6 stars on a 5-point scale. The net promoter score (based on consumers and families sharing the likelihood that they would refer others to SPARC services) was 4.3 stars.

Benefits Of Value-Based Reimbursement

Ms. Hermann explained that value-based treatment has incentivized service quality and built more staff buy-in for outcomes-driven treatment, afforded flexibility, and proved to be good for business development. She said, “We knew that the landscape of health care is shifting to value-based care, we want to jump in with both feet and have skin in the game. It forced us to say doing ‘A-level’ work isn’t good enough, we need to do ‘A-plus’ work. We committed to a pretty aggressive value-based contract because without that, we knew this would not be a sustainable model.”

The value-based model drives performance-based compensation incentives for staff, which increases their buy-in for achieving better outcomes. Ms. Hermann elaborated, “If a client is in crisis, the therapist response at eight o’clock at night is not just ‘Well go to the emergency room.’ Sometimes that’s a needed intervention but often it’s not. They know that once somebody goes to the emergency room, the whole treatment plan can get derailed. And so our clinicians want to go the extra mile, not only because it’s the right thing to do but also because we have some skin in the game. It creates just a little shift for them at the frontline level, so that they’re committed to providing unique services and really engage in creative problem solving.”

The services SPARC delivers under value-based contracts are labeled “in lieu of services” and have been designated by MCOs to meet an unmet need in their communities. Therefore service definitions afford more freedom and flexibility and avoid the need to fit the treatment model into a state plan amendment service definition which sometimes can be like “fitting a square peg in a round hole.” The VBR model is also designed to reduce administrative burden on provider organizations and payers. For example, given that FCT as an EBP is known to typically discharge families with successful outcomes after six months of treatment, six months of services are authorized at the outset. So instead of wrangling submissions for authorization, clinical professionals can focus on delivering needed services. And the intensity of treatment can be increased or decreased depending on current needs. “If a crisis happens and we need to increase the intensity and frequency of services, we don’t have to go back to that payer and request more time and risk potential denial. That is a huge difference between some of our fee-for-service vs. value based contracts,” said Ms. Herrmann.

Value-based contracting has created opportunity for SPARC to expand its mission to keep consumers out of institutional care. And it has allowed stakeholders to see their innovation and that creativity and to come to them when there are new needs. “It has allowed us to have opportunities that I’m not sure we would’ve had if we’d come in as a provider saying we want to do regular fee-for-service contracting,” Ms. Hermann said.

What’s next? As SPARC moves into providing more services for mild and moderate mental illnesses and pursues contracts with commercial insurance, value-based contracting will continue to define their business development efforts. They plan to work with their MCOs to move from an individual consumer focus to applying a population health lens in their VBR models. They are also looking to focus more on whole-person value-based care and to and certify and train staff to become a “care management agency” as part of North Carolina’s Medicaid transformation (see North Carolina Extends Deadline For Tailored Plan Care Management Applications To June 1, 2021). In addition to Cardinal Innovations Healthcare and Partners Behavioral Health Management, SPARC has entered into contracts with five more managed care organizations appointed by North Carolina Medicaid—WellCare of NC, AmeriHealth Caritas of NC, Blue Cross and Blue Shield of NC, United Healthcare of NC, and Carolina Complete Health, Inc. As these new MCOs get ready for value-based care—once they understand their new consumers and the needs—SPARC is well-poised to leverage their experience and hit the ground running. “We’re really committed to continuing to learn more and doing more in the value based space,” summarized Ms. Herrmann.

VBR: Are You Walking In Your Customer’s Shoes?

Despite the significant upset to the health and human service system caused by the pandemic crisis, the move to value-based reimbursement (VBR) seems to be moving along. On June 3, The Centers for Medicare and Medicaid Services (CMS) announced adjustments to 16 value-based care (VBC) models, with goals of accounting for COVID-19-related changes in health care delivery (and the uptick in costs), as well as allowing more time for participating provider organizations to transition to VBC (see CMS Makes COVID-19-Related Changes To Value-Based Care Models). And, on June 19, CMS issued a proposed rule to grant state Medicaid programs and other payers flexibility to enter value-based payment (VBP) arrangements with drug manufacturers (see CMS Proposes Regulatory Changes To Promote Medicaid Value-Based Drug Purchasing).

At the health plan level, most recent was the launch of Blue Cross and Blue Shield of North Carolina’s “Accelerate to Value” program to help primary care practices deal with COVID-19-related financial challenges (see Blue Cross Of North Carolina Launches Program To Pay Primary Care Practices To Switch To Value-Based Model). The program, which requires primary care practices to commit to transitioning to VBC by the end of 2020, provides financial stabilization payments based on the practice’s 2019 revenue.

Over the past few months, we’ve seen similar initiatives emerge from BlueCross BlueShield of Western New York (BCBSWNY) (see BlueCross BlueShield & Value Network Partner To Start Behavioral Health Value-Based Payment In Western New York), the Pennsylvania Clinical Network with Geisinger Health Plan (see PA Clinical Network & Geisinger Health Plan Announce Value-Based Contract Agreement), and Aetna (see Pennsylvania Clinical Network Signs Value-Based Contract With Aetna Medicare Advantage Plan).

What this means for provider organization recovery strategy depends on the organization’s current market positioning. The likely impact of the impending payer budget crunch (both government and employer) is more managed care and more value-based reimbursement arrangements. But that will vary by specialty, by consumer type, and by geography. Many provider organization executive teams are not waiting to see what comes their way. They are using changing reimbursement as a market positioning advantage for their post-recovery strategy.

For example, Heal announced the launch of a new “health assurance” offering called “Heal Pass”—a monthly subscription of $49 dollars where enrollees receive eight physician house calls, annual physicals, and next-day shipping on medications prescribed by a Heal clinical professional (see Heal Launches New ‘Health Assurance’ Offering). And, Talkspace has a number of subscription options that consist of unlimited texting, live sessions, or therapy options geared toward specific populations including couples and adolescents—ranging from a rate of $260 per month to $396 per month (see How Much Does Talkspace Cost?).

The question for executive teams is to evaluate whether a proposed non-fee-for-service reimbursement model would be better for market positioning—with more revenue and/or greater profitability. To evaluate that question, executive teams need an external perspective—good customer perspectives on what they need and how they prefer to pay for those services. But equally as important, executive teams need to understand the costs of their services, not only by unit of service but by type of consumer over time.

Ken Carr, Senior Associate, OPEN MINDS

And my colleague and OPEN MINDS Senior Associate Ken Carr believes that our traditional view of VBR—reduced costs, focus on value, and consumer outcomes—needs to take on an additional dimension with the advent of models like Heal and Talkspace. Their approach to value is to identify what is important to the consumer—immediate access, price transparency, and consistent payment, with good service and outcomes implied. For provider organization managers, fee-for-service reimbursement has driven business models—filling the schedules of clinical professionals, ensuring required levels of productivity, and shaping consumer access around available office hours. And consumers have no idea how much the service costs until they receive a statement in the mail a month later. In contrast, as Mr. Carr explained, “The new approach to value must focus on ease of access—house calls, phone calls, and virtual services.” The consumer (or the health plan) doesn’t need to worry about the cost—the subscription can be worked into a monthly spending budget like a gym fee or even a Netflix subscription.

Moving to using VBR as a proactive market strategy requires setting aside past structures, and creating entirely new approaches. But how do provider organization managers begin to deal with the costs of a consumer-driven access model and set prices for these new models? Identifying the unit cost of a service and the related utilization is a starting point. But building a sustainable model will also require data on how consumers access the service, how often they use the service, and the intensity of their needs. “Provider organizations must create a structure to manage a new payment method that will lower their financial risks while better meeting consumer needs. For that, having timely data, and adjusting resource capacity is critical,” said Mr. Carr.

Mr. Carr had some more pointers for provider organizations gearing up for the shift to value in his seminar, Succeeding With Value-Based Reimbursement: An OPEN MINDS Executive Seminar On Organizational Competencies & Management Best Practices For Value-Based Contracting, at The 2020 OPEN MINDS Strategy & Innovation Institute:

At the end of the day, VBR is here to stay. As Mr. Carr explained, “Now is the time to start the transition. VBR isn’t going to be set aside or delayed as a result of the pandemic. If anything, it’s going to be adopted as a strategy to keep costs down during a time where budgets are increasingly strained.”

For more on value-based care, check out these resources in The OPEN MINDS Industry Library:

And for even more, join us at The 2020 OPEN MINDS Management Best Practices Institute for the session, Navigating Health Plans: Keys To Developing Long Term Relationships, with OPEN MINDS Senior Associate Paul Duck and OPEN MINDS Vice President Richard Louis, III.

Making Your Clinical Programs VBR-Ready

The adoption of value-based reimbursement (VBR) has been inconsistent over the past few years (see VBR – Where’s The Beef? And Where Are We On The Road To Value? The 2020 OPEN MINDS Performance Management Survey). But the consensus is that the recession that is upon us and the likely reduced federal/state budgets will drive more VBR and more financial risk transfers from managed care organizations to provider organizations (see Show Me The Value, Show Me The Money).

Dominick DiSalvo, MA, LPC, Corporate Director of Clinical Services, KidsPeace
Dominick DiSalvo, MA, LPC, Corporate Director of Clinical Services, KidsPeace

Our team does a lot of organizational assessments of ‘readiness’ for VBR—and we’ve developed a self-assessment tool to do just that. The tool (see The OPEN MINDS Value-Based Reimbursement Readiness Assessment) has several key domains including provider network management; consumer access and service engagement; financial management; leadership and governance; technology and reporting; and clinical management and performance optimization. But, readiness assessments tend to focus on the organizational management infrastructure. A big question for executive teams is whether clinical programs are ready for VBR. That was the focus of the session Creating & Managing The Clinical Models You Need For Value-Based Reimbursement, led by Dominick DiSalvo, MA, LPC, corporate director of clinical services at KidsPeace at The 2020 OPEN MINDS Strategy & Innovation Institute.

KidsPeace offers a full continuum of behavioral health care services for children and families, from serving youth in the foster care and child welfare system to providing residential treatment, accredited educational services, and a free standing psychiatric hospital. Headquartered in Pennsylvania, its services span 10 states and the District of Columbia. Between 2016 and 2017, the organization followed the state of Pennsylvania in its initial journey to VBR. Since then, KidsPeace has participated in performance-based contracting, including pay-for-performance, with payments linked to a specific set of benchmarked outcomes.

But success with VBR doesn’t come without its challenges—it requires a significant shift in both leadership mindset and organizational infrastructure. As Mr. DiSalvo discussed, “The most difficult task we have is to limit risk by finding the balance between person/family-centered care and structured programs that reduce variability in services and outcomes.” His advice? Focus on trauma-informed care; synthesize evidence-based clinical models; use data to drive clinical decisionmaking; and engage clinical professionals to engage consumers.

Focus on trauma-informed care—KidsPeace began the move to VBR by using the Trauma History Questionnaire (THQ), a 24-item self-report measure that examines an individual’s experience with possible traumatic events including crime, physical or sexual assault, and neglect. Mr. DiSalvo described this as a necessary first step in moving toward a value-based framework for care, because when trauma wasn’t factored in, the desired treatment outcomes were not being achieved. After it started to implement trauma-informed care, KidsPeace found that youth self-reported experiencing an average of 10 traumatic categories before entering the program. The new focus on trauma as an underlying cause required a considerable shift in how clinical professionals were supporting consumers—and how senior leaders were supporting clinical professionals. “This data really convinced our leadership team that we needed to have a complete change in focus—we needed to be family and youth driven, trauma-informed, and have data drive what is going on in our programs,” said Mr. DiSalvo. (For more on becoming trauma-informed, see Making Trauma-Informed Care A Scalable Reality and How ‘Trauma-Informed’ Is Your Organization?).

Synthesize evidence-based clinical models—After understanding the “value” of becoming trauma-informed to provide more effective treatment—and ultimately—more meaningful and measurable outcomes, KidsPeace completely restructured their clinical programming by synthesizing a core set of evidence-based practices within each program. The restructure allowed each individualized treatment plan to be guided by both the youth and their family—and driven by objective and relevant data—an essential part in defining “value” for each consumer. The organization adopted four clinical practice models—including trauma focused-cognitive behavioral therapy (with all clinical leadership becoming or in the process of becoming Nationally Certified Trauma Therapists); motivational interviewing (to increase motivation and engagement among youth); community living (to prepare adolescents for young adulthood and community inclusion); and individualized treatment planning. By using these four clinical models, the organization has the flexibility to provide individualized care as well as the consistency and structure to meet the needs of all youth and families that are served. (For more on evidence-based practices, see Care Delivery In A Value-Based Era – Evidence-Based, Practice-Based, Standardized & Measurement-Based and Behavioral Health Evidence-Based Practices As Population Health Management Tools).

Use data to drive clinical decisionmaking—Before they restructured clinical program models to focus on value, Mr. DiSalvo noted that KidsPeace had challenges with using data to drive treatment and decisionmaking processes. “When I had conversations with our foster care program in Indiana versus conversations with our residential program in Georgia, the way they captured data and assessed youth were very different.” To ensure consistency across all programs, no matter the location or service line, the organization moved to a corporate wide electronic health record and adopted the use of a data dashboard to visually track key metrics over time. Those metrics included discharge disposition and post-discharge follow up surveys, high risk behaviors (e.g. suicidal ideation), clinical treatment benchmarks, length of stay, and individualized score cards in graph format. The data is then broken down further by day, time of day, over time, and total score. “We’ve even gotten as granular as examining if there is a particular staff member that youth are struggling more with and if we need to provide more training.” The key quality indicators (in a simple, color-coded format) are reviewed quarterly with the senior leadership team to quickly identify any pain points and make changes to maximize program efficiency. Mr. DiSalvo explained, “Not only can we track youth individually but we are also able to track specific program progress from an aggregate level—and then make changes and help continuously improve that program.” (For more on using data to drive decisionmaking, see Don’t Underestimate The Culture Change In Becoming Data Drive and Proving Your Unique Value To Payers: Data Speaks Louder Than Words).

Engage clinical professionals to engage consumers—To truly drive optimal outcomes in value-based clinical programming, Mr. DiSalvo highlighted a final key component—engaging clinical professionals. “It’s impossible to succeed with risk-based payment models if staff aren’t engaged. If a child feels like a staff member is there simply to get a paycheck, they are not going to respond well.” Rather, a significant shift in mindset was necessary for many professionals to continuously find ways to improve the overall experience for youth, families, and staff. “Once we started to have the data inform practice, our clinicians started seeing clear, quantitative results. Once that happened, it was a ripple effect—our youth found more enjoyment in their experience. Ultimately, it’s the clinicians who then become the champions for change.” (For more on engagement, see Health Plans Invest In Consumer Engagement and Navigating The Performance Loop – Customer Service, Consumer Experience & Consumer Engagement).

Any significant transformation isn’t sustainable without embedding those changes within the organizational culture (see How Culture Makes Organizational Change Less Painful). Mr. DiSalvo discussed the importance of cultivating a cohesive culture to act as the foundation of any clinical program focused on providing value, “Our initiative at KidsPeace is to integrate all of our resources to improve safety, engagement, connection, clinical practice and outcomes for all staff, youth, and families but it doesn’t come naturally. It requires robust training and a strong understanding about what engagement actually looks like. Clinical professionals must move away from the mindset that ‘we are the ones who know best’ and understand that the family and youth are the experts. We are simply here to join them in their journey.”

My takeaway from the session is that it’s not enough to have your administrative and financial infrastructure “ready” for VBR. Making clinical programs VBR-ready is a critical aspect of strategy development for sustainability.

For more on finding and demonstrating your value, check out these resources in the OPEN MINDS Industry Library:

And for even more on best practices in establishing service standards and key performance measures, join us on October 8 at 1:00 pm EDT for the web briefing, Measuring & Improving Consumer Experience, Consumer Engagement & Consumer Performance – A Best Practice Approach, led by OPEN MINDS Executive Vice President Kimberly Bond. The web briefing is offered as part of The OPEN MINDS Executive Blueprint For Crisis Management: Building Organizational Sustainability & Success In A Disrupted Health & Human Service Market, a program designed to help executive teams prepare, respond, and navigate the disruption caused by a market in turbulence.