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.

NCQA Adjusts HEDIS Quality Measures Due To COVID-19 Pandemic-Driven Telehealth Surge

On June 5, 2020, the National Committee for Quality Assurance (NCQA) announced adjustments to 40 Healthcare Effectiveness Data and Information Set (HEDIS) measures to support the use of telehealth during the coronavirus disease 2019 (COVID-19) pandemic and after. NCQA will apply the adjustment for measurement of health care quality starting in 2020. The adjustments align with guidance from the Centers for Medicare & Medicaid Services and other federal and state regulators.

NCQA is updating the measures in “HEDIS Volume 2 Technical Specifications,” which will be published on July 1, 2020. Telehealth revisions will be outlined in each measure specification . . .

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Presentation: Health Plan Innovation For VBID, Part D Payment Modernization & Part D Senior Savings Models – Overview

The webinar took place on April 2, 2020. The Centers for Medicare & Medicaid Services (CMS) presented Medicare Advantage and Part D health plan innovation models for calendar year 2021. The models include Value-Based Insurance Design, the Part D Senior Savings Model, and the Part D Payment Modernization Model.

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The Current Service & Financing Trends Affecting Children, Families & Provider Organizations

This presentation was delivered by Sean Klutinoty, MBA, Senior Associate, OPEN MINDS, on June 5, 2020 at The 2020 OPEN MINDS Strategy & Innovation Institute. In the presentation, Mr. Klutinoty discussed key data elements in the current service trends for children and families, health homes and value-based integrated models, as well as questions for the future of service delivery in our current landscape.

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Creating & Managing The Clinical Models You Need For Value-Based Reimbursement

This presentation was delivered on June 2, 2020 at The 2020 OPEN MINDS Strategy & Innovation Institute. In the presentation, the speakers discussed the development process for clinical models for value-based reimbursement (VBR); evidence-based treatment plans for consumers with complex needs to ensure measurable outcomes; and case studies of organizations that have built effective clinical models for VBR.

The presentation speakers included:

  • Drew Di Giovanni, Senior Associate, OPEN MINDS
  • Dominick DiSalvo, MA, LPC, Corporate Director of Clinical Services, KidsPeace



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