Download Healthcare Provider Network Management and Participation Solutions

Healthcare Provider Network
Management and Participation
Solutions - December 6, 2012
Presented by:
David Lloyd,
Founder
M.T.M. Services
P. O. Box 1027, Holly Springs, NC 27540
Phone: 919-434-3709
Fax: 919-773-8141
E-mail: [email protected]
Web Site: mtmservices.org
Presented By:
David Lloyd, Founder
1
Two Focus Areas Today:
1.
2.
LME/MCO Operations/Provider
Network Management and KPIs
Network
et o Providers
o de s – “Value”
a ue
Indicators Needed
Presented By:
David Lloyd, Founder
2
Three Overarching Themes:
1.
Access to Service MCO/Provider Network
Focus in an “at risk” 1915(b)/(c) Waiver
funding environment
2.
Definition of Treatment to support
engagement indicators and positive
clinical outcomes in a Treat to Target
environment
3.
CQI instead of QI Change Management
Model
Presented By:
David Lloyd, Founder
3
1
Distributive Justice Ethical Focus
of “At Risk” LME/MCO and
Network Providers

Distributive Justice Ethical Dilemma:
1.
2.
3.
How does the LME/MCO/Providers in the Network ensure
that it is providing the greatest good to the greatest
number of people based on the limited resources
available
How do the LME/MCO/Providers shift the primary service
delivery focus from its current caseloads to an equal
focus between current caseloads and persons presenting
to access services?
The LME/MCOs Provider Network Management (PNM) will
need to establish key performance standards to ensure
that the needs of ALL of the people in the catchment area
are responded to timely and effectively
Presented By:
David Lloyd, Founder
4
Key Qualitative Based Utilization
Management Focus Area to Secondary
Service Capacity
•
Are we treating the needs we have
professionally diagnosed that each
consumer has?
OR
•
Are we carrying inactive active
caseload members while consumers
seeking services are waiting?… (i.e.,
Clinical Protocols that require Therapist to
Carry Chart for Physicians)
Presented By:
David Lloyd, Founder
5
Sample Definition of Treatment

Define a definition of “treatment” and
therefore what is not treatment:
Sample Definition:
“Behavioral health therapeutic
p
interventions
provided by licensed or trained/certified staff
either face to face or by payer recognized
telephonic/ Telepsychiatry processes that
address assessed needs in the areas of
symptoms, behaviors, functional deficits, and
other deficits/ barriers directly related to or
resulting from the diagnosed behavioral health
disorder.”
Presented By:
David Lloyd, Founder
6
2
MCO and Provider Change Requires A
Shift from “Perfect Solution” to Rapid
Cycle CQI Process of Improvement


7
Quality Improvement Process Focus
(QI) – Typically Supports Process/Lack of
Forward Movement/ Attainment
Vs.
Continuous Quality Improvement
Solution Focus (CQI) – Implies
Movement Forward/Action Has Happened
to Provide Continuous Improvement
Presented By:
David Lloyd, Founder
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Sample MCO Development Focus Areas
Presented By:
David Lloyd, Founder
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Sample MCO Timeline and Scope of Work
Presented By:
David Lloyd, Founder
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3
Presented By:
David Lloyd, Founder
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Presented By:
David Lloyd, Founder
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Presented By:
David Lloyd, Founder
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4
Presented By:
David Lloyd, Founder
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Provider Re-Credentialing Policy
Sample
1.
2.
It is the policy of the MCO that all individually contracted clinical providers
will be re-credentialed and have clinical privileges reviewed every year.
Clinical privilege will be based upon specific license, education, training,
experience, competence, and judgment as specified in the attachments to
this policy. Providers’ level of competence and professional ethics must be
of the highest order, and must continuously meet or exceed the
qualifications standards,
qualifications,
standards and requirements set forth by MCO.
MCO
Every year, the providers must submit a fully completed re-credentialing
application. Re-credentialing shall include the primary verification of
pertinent information described in the procedure section of this policy.
Providers have the right to review information submitted in support of their
application and the right to correct erroneous information submitted by
another party. Once all information related to each re-credentialing and
privileging element has been obtained, the provider’s file with complete
information, is forwarded to the Credentialing Committee for review and
recommendation for ongoing participation. Final approval is granted by the
Board of Directors
Presented By:
David Lloyd, Founder
14
Network Provider “Values” Needed
1.
2.
3.
4.
5.
Under a MCO model the Value of Network
Providers will depend upon our ability to:
Be Accessible (Fast Access to all Needed
Services)
Be Efficient (Provide high Quality Services at
L
Lowest
t Possible
P
ibl C
Cost)
t)
Electronic Health Record capacity to connect
with other providers
Focus on Episodic Care Needs/Treat to Target
Produce Outcomes!
•
•
•
Engaged Clients and Natural Support Network
Help Clients Self Manage Their Wellness and Recovery
Greatly Reduce Need for Disruptive/ High Cost Services
Presented By:
David Lloyd, Founder
15
5
Quality Vs. Quantity Discussion: Quality for
Current Caseloads and/or Quality for Persons
Waiting For Services? A Scope of Quality
Definition Challenge
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Accessible Services
Consumer-Centered Services
Cost-Effective Services
Outcome Based Services
Full integration of Utilization Management
CMS Corporate Compliance
HIPAA Compliance
State/Federal Standards
JCAHO/CARF/COA Accreditation Standards
Clinical Best Practice Performance Standards
Community Support Best Practice Performance
Standards
Non-Clinical Best Practice Performance Standards
Presented By:
David Lloyd, Founder
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Poll Results based on over 600 Registrants for
the NC LIVE Webinar on Enhanced Revenue
Presented by David Lloyd, MTM Services on
December 15, 2009 and January 12, 2010
From the clinicians’ perspective, are the caseloads in your organization “full” at
this time?
Yes = 74% No = 26%
Do you know the cost and days of wait for your organization’s first call to
treatment plan completion process?
Yes = 41% No = 59%
Indicate the no show/cancellation percentage last quarter in your organization
for the intake/assessment appointments:
A. 0 to 19% = 20%
B. 20 to 39% = 42%
C. 40 to 59% = 15%
D. Not aware of percentage = 23%
Indicate the no show/cancellation percentage last quarter in your organization
for Individual Therapy appointments:
A. 0 to 19% = 24%
B. 20% to 39% = 50%
C. Not aware of percentage = 26%
1.
2.
3.
4.
Presented By:
David Lloyd, Founder
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Change Initiatives to Enhance CBHOs
“Value” as a Partner in Healthcare
Reform
1.
2.
3.
4.
5.
6.
7.
8.
Reduce access to treatment processes and costs through a reduction in
redundant collection of information and process variances
Develop Centralized Schedule Management with clinic/program wide and
individual clinician “Back Fill” management using the “Will Call”
procedure
Develop scheduling templates and standing appointment protocols for all
di
direct
care staff
ff li
linked
k d to bill
billable
bl h
hour standards
d d and
d no
show/cancellation percentages
Design and implement No Show/Cancellation management principles and
practices using an Engagement Specialist to provide qualitative support
Design and implement internal levels of care/benefit package designs to
support appropriate utilization levels for all consumers
Design and Implement re-engagement/transition procedures for current
cases not actively in treatment.
Develop and implement key performance indicators for all staff including
cost-based direct service standards
Collaborative Concurrent Documentation training and implementation
Presented By:
David Lloyd, Founder
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6
Change Initiatives to Enhance CBHOs
“Value” as a Partner in Healthcare
Reform
9.
Design and implement internal utilization management functions
including:
Pre-Certs, authorizations and re-authorizations

Referrals to clinicians credentialed on the appropriate third
party/ACO panels

Co-Pay Collections

Ti
Timely/accurate
l /
t claim
l i submission
b i i
tto supportt paymentt ffor services
i
provided
Develop and implement Supervision/Coaching Plan with coaching/action
plans
Develop objective and measurable job descriptions including key
performance indicators for all staff and develop an objective coaching
based Evaluation Process
Provide Leadership/Management Training that changes the focus from
supervision to a coaching/leadership model
Develop public information and collaboration with medical providers in
the community through an Image Building and Customer Service plan

10.
11.
12.
13.
Presented By:
David Lloyd, Founder
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Sample MCO Network Providers
KPI Categories
1.
2.
3
3.
4.
5.
6.
7.
Access to treatment indicators
Utilization Management Indicators
Clinical Outcome Indicators
Consumer Satisfaction Indicators
Clinical Performance Indicators
Non-Clinical Performance Indicators
Physical Facility Indicators
Presented By:
David Lloyd, Founder
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Recommended Network Provider KPI Format
Presented By:
David Lloyd, Founder
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7
Network Providers Access to
Treatment Indicators
Presented By:
David Lloyd, Founder
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Access to Treatment Challenge
Areas:
1.
2.
3.
The primary challenge facing almost every healthcare
provider is having adequate service delivery capacity to
support timely and effective access to treatment.
In an era of integrated healthcare reform, access to
treatment is even more critical.
critical
The historical three levels of access to care challenge
have been:
a.
b.
c.
23
Primary Access – Time to provide client face to face initial
intake/assessment after call for help
Secondary Access – Time to provide client face to face service
with his/her treating clinician following intake/assessment date
Tertiary Access – Time to first face to face service with
Psychiatrist/APRN following the intake/assessment data Address
a historical
Presented By:
David Lloyd, Founder
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Measurement
Tools/ Processes
First Contact to
Treatment Plan
Completion Process Flows
Created To Identify
Redundancy and Wait
Times
Presented By:
David Lloyd, Founder
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8
Access to Care Process Cost Model
Presented By:
David Lloyd, Founder
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Access Flow Design Outcomes for
National IHP Learning Collaborative
1.
2.
3.
4.
5.
Measurement of current processes from first call for
routine help to treatment plan completion
Measurement processes provided indicate that the
cohort of 15 centers have 191 different flow
p
processes
Number of staff hours needed range from .5 hours
to 11.7 hours – Cohort average is 5 hours of staff
time
Cost of processes range from $11 to $855 – Cohort
average cost is $369
Total days wait to treatment range from less than
one day to 150 calendar days – Cohort average
wait time is 31.30 calendar days for all
divisions/programs
Presented By:
David Lloyd, Founder
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Access Process - Staff vs. Client time by Division
Access to Treatment Process Flows – Measurement Process Summary
Information based upon 177 individualized GAP Analysis Charts
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Presented By:
David Lloyd, Founder
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9
Access Process - Wait time by Division
Access to Treatment Process Flows – Measurement Process Summary
Information based upon 177 individualized GAP Analysis Charts
Presented By:
David Lloyd, Founder
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Access Process – Average Cost by Division
Information based upon 177 individualized GAP Analysis Charts
Access to Treatment Process Flows –
Measurement Process Summary
29
Presented By:
David Lloyd, Founder
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29
Access to Treatment National Best Practice
Target Averages
1.
Access to Treatment processes within each center:


2.

3.
4.
Gold Standard – Standardized Process for the center
Silver Standard – No more than one per division
Number of staff hours needed from first call for
routine help
p to treatment p
plan completion
p
range from 2 hours to 2.5 hours which will require
staff to use collaborative documentation process
Assessment process target is one hour using CSR
support
Cost of processes range from $150 to $200
Total days wait to treatment for
therapist/case manager is 8 calendar days or
less and to MD/APRN is 10 total calendar days
or less from Intake/Assessment date
Presented By:
David Lloyd, Founder
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10
Measurement Tools/Processes
Presented By:
David Lloyd, Founder
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Assessment Data Point Collection/Mapping
Presented By:
David Lloyd, Founder
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Data Mapping to Reduce Access Time

Case Study of Exhaustive Data Collection Model: M.T.M.
Services provides project management and consultation
services for the Access and Retention Grant. In their work with
CBHOs they provide data mapping of the number of data
elements each center collects from the first call for services
through the completion of the diagnostic assessment/intake. A
recent data mapping effort for a community provider produced
th ffollowing
the
ll i
outcomes:
t
1.
Total number of data elements collected in the process =
1,854
2.
Total number of redundant data elements collected in the
process = 564
3.
Total number of data elements really required for access
to treatment planning processes = 957
4.
Total staff time required to administer the original flow
process =
Four hours ten minutes
5.
Total staff time required to administer the revised flow
process =
One hours twenty minutes
Presented By:
David Lloyd, Founder
33
33
11
CBHO Consortium EMR Case
Study

GAIT Consortium Case Study:
1.
2.
3.
4.
5.
6.
Six Georgia Community Service Boards (now up to 9
members)
Reduced 29 separate process flows to one
standardized service flow process
Red ced over
Reduced
o e 2,700
2 700 data elements being
recorded to 975 data elements through data
mapping process to reduce staff costs and wait
times by over 50%
Standardized documentation data elements for all
clinical forms processes
Co-Location of one IT – electronic record solution
Consortium based cost savings over $1,000,000
over the next first four years
Presented By:
David Lloyd, Founder
34
Standard
Access to
Treatment for
the Consortium
Presented By:
David Lloyd, Founder
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Presented By:
David Lloyd, Founder
36
12
National Access and Engagement Grant Outcomes
Total Annual Savings:
• Produced an average annual savings of $231,764 per CBHO – 39%
Reduction in costs
• 29% reduction in staff time
• 17% reduction in the client time
• 60% reduction in wait time
• 26% increase in Intake Volume Provided
• Based on eight first year A&E Centers from seven states - total annual
savings equals $1,854,119.
Presented By:
David Lloyd, Founder
37
Access and Engagement and Access Redesign Initiatives First
Call to Assessment Kept vs. No Show/Cancelled Trend by
Days Wait from First Call to Appointment
Presented By:
David Lloyd, Founder
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Access to Care Timeliness Case Study

Same Day access center produced data that demonstrate
the following about the relationship between initial contact
for help, Open access, second appointments and noshows. Sample size is 561 new clients who received an
intake between January 1, 2009 and May 31, 2009. The
summary of outcomes identified are outlined below:



a. Approximately 95 percent showed for the customers who
have their second appointment scheduled within 12.2 days of
their Intake show for that appointment. Therefore the 10 day
access standard that is recommended is valid for the second
counseling service and medical appointment.
b. Approximately 70 percent of customers did not show
who had their second appointment scheduled 22 days or more
after their intake
c. 100 percent of the customers whose second appointment
was canceled by the Center – never came back.
Presented By:
David Lloyd, Founder
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13
NCQA Accreditation Standards for PatientCentered Medical Homes (PCMH)


NCQA has published accreditation
standards for PCMHs
Primary Care Development Corporation
has developed a standard version of the
Baseline PCMH Self-Assessment Tool
that will guide PCMHs in their need to
obtain accreditation
Presented By:
David Lloyd, Founder
40
Source: Primary Care
Corporation – PCMH SelfAssessment Tool
Presented By:
David Lloyd, Founder
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What is Same Day Access?
What Does it Mean?
Open Access is a shift in definition
of “treatment” from “scheduling a
client” as a solution today to a
practice management process
that expects the practice to
respond to the client’s needs by
seeing the client the day services
are requested and then engage
the client in an Episode of Care.
Presented By:
David Lloyd, Founder
42
14
Four Step Process Change To
Move To Same Day Access
1.
2.
3.
4.
5.
Identify when clients are calling or walking in
seeking help (two hour segments per day of week)
Identify the current first call for routine help to
treatment plan completion processes, costs and
time delays
Develop
l
standardized
d d d process that
h is more time and
d
cost effective (i.e., one hour assessment
appointment face to face and write up total time)
Use new standardized access process as the basis
for the Same Day Access model and include JUST IN
TIME protocols for assessment capacity beyond on
call staff
Develop service capacity within center to access
new referrals more timely
Presented By:
David Lloyd, Founder
43
Same Day Access Models
1.
2.
Centralized Intake Model
De-centralized at different locations



Measure when clients call for help and
how many – not when we scheduled
them historically
Identify two hour on call status for
clinical staff to provide intakes
Four step protocol to support on call
staff
Presented By:
David Lloyd, Founder
44
Open Scheduling Same Day Access Model –
Consumer Engagement Standards
1.
2
2.
3.
4.
Open Scheduling Same Day Access - Master’s Level
assessment provided the same day of call or walk in
for help (If the consumer calls after 3:00 p.m. they
will be asked to come in the next morning unless in
crisis or urgent need)
Initial diagnosis determined
Level of Care and Benefit Design Identified with
consumer
Initial treatment plan Developed based on Benefit
Design Package


2nd clinical appointment for TREATMENT within 8 days
of Initial Intake
1st medical appointment within 10 days of Initial Intake
Presented By:
David Lloyd, Founder
45
15
Same Day Access and Open Meds
Models of Care
Encourage staff to view the “Same
Day Access and Open Meds”
Webinar provided on August 9th,
2012
 The National Council for Community
Behavioral Healthcare Site:
http://www.thenationalcouncil.org/cs/
recordings_presentations

Presented By:
David Lloyd, Founder
•
•
•
46
Kim Beauregard, CEO
Dr. Ann Price, CMO
Tyler Booth, COO
• Phone 860-291-1313
• Email: [email protected]
InterCommunity, Inc.
Presented By:
David Lloyd, Founder
47
Identifying The Problem at
InterCommunity BH
Recognizing that what we were doing wasn’t working, and that although
it seemed to be the norm for most agencies it wasn’t really good care,
we began looking at data and meeting in Project Change Teams to
identify where we were working harder rather than smarter.
Perhaps the most significant issue we discovered was how No-Shows:
 Prevented clients in need from getting in to see their “booked”
provider
 Caused providers to manage case loads rather than provide services
 Financially
Fi
i ll were ruining
i i
th
the agency as staff
t ff were paid
id tto b
be b
busy b
butt
were not generating revenue.
No Show Percentage by Service – Sept. – Nov. 2011 Trend
Presented By:
David Lloyd, Founder
48
16
InterCommunity - Outcomes Achieved with
Immediate Access Model
49
Presented By:
David Lloyd, Founder
49
InterCommunity - Immediate Access Appointment
Type Outcomes Achieved:
485 No Shows and Canceled by Clients Vs. 13
1. Average of 54 No Show and Client Canceled
Appointments per Month in 2011
2. Compared with an Average of 2 per month in
2012
50
Presented By:
David Lloyd, Founder
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Case Study: InterCommunity, E. Hartford, CT
Medication Management Services
51
Presented By:
David Lloyd, Founder
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17
Rosecrance Berry Campus
Open Access
Richard Jaconette M.D.
Charity Shaw-Moyado, LCSW, Administrator
Rosecrance Berry Campus
Presented By:
David Lloyd, Founder
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Dr. Jaconette: Aggregate of Med Monitoring and Evaluation
Events Trend
Presented By:
David Lloyd, Founder
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Open Access Model
53
Benefits



54
EXCELLENT CLIENT CARE
Increased Capacity to see clients:
Decrease in System Noise Level
through reduction in Canceled and
No Show events
Presented By:
David Lloyd, Founder
54
18
Network Providers Clinical
Outcome Indicators
Presented By:
David Lloyd, Founder
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National Healthcare Homes New
Medicaid Services Under Section
2703 of the Affordable Care Act
1.
Comprehensive Care Management
2. Care
3.
Coordination and Health Promotion
Patient and Family Support
4. Comprehensive
C
h
i
5.
Transitional
T
iti
l Care
C
Referral to Community and Social Support
Services
Presented By:
David Lloyd, Founder
56
“Mental Health Community Case Management
and Its Effect on Healthcare Expenditures”
By: Joseph J. Parks, MD; Tim Swinfard, MS; and Paul Stuve, PhD
Missouri Department of Mental Health
Source: PSYCHIATRIC ANNALS 40:8 | AUGUST 2010




People with severe mental illness served by public mental health systems
have rates of co-occurring chronic medical illnesses that of two to three
times higher than the general population, with a corresponding life
expectancy of 25 years less.
Treatment of these chronic medical conditions ……. comes from costly ER
visits and inpatient
p
stays,
y , rather than routine screenings
g and preventive
p
medicine.
In 2003, in Missouri, for example, more than 19,000 participants
in Missouri Medicaid had a diagnosis of schizophrenia. The top
2,000 of these had a combined cost of $100 million in Missouri
Medicaid claims, with about 80% of these costs being related not
to pharmacy, but to numerous urgent care, emergency room, and
inpatient episodes.
The $100 million spent on these 2,000 patients represented 2.4% of all
Missouri Medicaid expenditures for the state’s 1 million eligible recipients
in 2003.
Presented By:
David Lloyd, Founder
57
19

Total healthcare utilization per user per month, pre- and post-community mental
health case management. The graph shows rising total costs for the sample during
the 2 years before enrolling in CMHCM, with the average per user per month
(PUPM), with total Medicaid costs increasing by over $750 during that time. This
trend was reversed by the implementation of CMHCM. Following a brief spike in
costs during the CMHCM enrollment month, the graph shows a steady decline over
the next year of $500 PUPM, even with the overall costs now including CMHCM
services.
Source: PSYCHIATRIC ANNALS 40:8 | AUGUST 2010
Presented By:
58
David Lloyd, Founder
Advancing Standards of Care for
People with Schizophrenia
Final Project Summary and Outcomes
October 17, 2011
A National Council for Community Behavioral Healthcare Initiative
Sponsored by Sunovion Pharmaceuticals Inc.
Inc
Presented By:
David Lloyd, Founder
59
Participating Behavioral Health
Organizations
Organization
City and State
AltaPointe Health Systems Inc.
Mobile, Alabama
AtlantiCare Behavioral Health
Egg Harbor Township, New Jersey
Cobb/Douglas Counties Community Services Board
Smyrna, Georgia
Family Guidance Center for Behavioral Healthcare
Saint Joseph Missouri
Gallahue Mental Health Services
Indianapolis, Indiana
Hill Country Mental Health Services
Kerrville, Texas
Mental Health Centers of Central Illinois
Springfield, Illinois
Recovery Resources
Cleveland, Ohio
Seminole Behavioral Healthcare
Fern Park, Florida
Spokane Mental Health
Spokane, Washington
Presented By:
David Lloyd, Founder
60
20
Project Background
The National Council in conjunction with the MTM consultants
and an expert panel of clinicians, administrators, and
researchers in the schizophrenia and mental health arena
selected:
 523 consumer cohort members who has a primary diagnosis
of Schizophrenia or Schizoaffective Disorder
 Average age of consumer cohort 46.7 years old
 The Wellness Self Management Program (New York State
Office of Mental Health in conjunction with the Center for
Practice Innovations at Columbia Psychiatry) as the evidence
based practice for implementation at pilot sites.
 The DLA-20 (Willa Presmanes M.Ed., M.A. and R.L. Scott
Ph.D.) as the evidence based functional assessment tool to be
used by pilot sites.
Presented By:
David Lloyd, Founder
61
Wellness Self Management
Program

Each client in the WSM Program
received an individual workbook.

57 Lessons
L
organized
i d into
i
19 Topic
T i
Areas
Each Lesson includes:
• Important Information
• Discussion Points
• Personalized Worksheets
• Action Steps
Presented By:
David Lloyd, Founder
62
Wellness Self Management
Program

Sample Lessons:
Presented By:
David Lloyd, Founder
63
21
Wellness Self Management
Program
For more information and access to
WSM workbooks and other materials
go to the Center for Practice
Innovations Website at:
http://practiceinnovations.org/WellnessSelfManage
mentWSM/tabid/118/Default.aspx
Presented By:
David Lloyd, Founder
64
DLA-20 Functioning
Assessment







The Daily Living Activities (DLA) Functional Assessment is a functional assessment, proven
to be reliable and valid, designed to assess what daily living areas are impacted by mental
and/or substance use disorders or disability. The assessment tool quickly identifies how
signs and symptoms of the client’s DSMIV disorder(s) have impacted their wellness as
measured by their ability to function in twenty daily living domains. Several of the twenty
indicator areas provide the direct care staff the ability to assess an expanded look at the
total wellness needs of the client as outlined below:
Health Practices: Assessment of client’s ability to take care of health issues, infections;
takes medication as prescribed; follows up on medical appointments.
Nutrition: Assessment of whether client’s eats at least 2 basically nutritious meals daily.
Alcohol/Drug Use: Assessment of the client’s ability to avoid abuse or abstains from
alcohol/drugs, cigarettes; understands signs and symptoms of abuse or dependency;
avoids misuse or combining alcohol, drugs, medication.
Sexuality: Assessment of the client’s level of appropriate behavior toward others;
comfortable with gender, respects privacy and rights of others, practices safe sex or
abstains.
Personal Hygiene: Assessment of the client’s ability to care for personal cleanliness,
such as bathing, brushing teeth.
NOTE: A recommended protocol to increase the level of internal MH/SU staff referrals to
primary care would be if any client MH/SU staff assess has a finding of “1, 2, 3 or 4” in
any of the above indicators, the outcome would be a referral to the primary care
physician.
Presented By:
David Lloyd, Founder
65
Presented By:
David Lloyd, Founder
66
22
Presented By:
David Lloyd, Founder
67
Presented By:
David Lloyd, Founder
68
Functioning Level Improvement Outcomes
Presented By:
David Lloyd, Founder
69
23
Functioning Level Improvement Outcomes for
All Providers in Network
Presented By:
David Lloyd, Founder
70
Person Centered Engagement
Strategies Implemented At Subset A
Teams:
Collaborative Documentation
Person Centered Linkage Between
Personal-Life Goals, Identified BH Needs,
T Pl
Tx
Plan G
Goals
l and
d Obj
Objectives,
ti
and
d
Client/Clinician Interactions
Addressing Specific Engagement Barriers
Relapse Prevention/ WRAP Plans
A.
B.
C.
D.
Presented By:
David Lloyd, Founder
71
Medication Adherence:
Client Report
Medication Adherence
Client Report
100
95
Percent
90
Subset B %
Subset A %
Linear (Subset B %)
Linear (Subset A %)
85
80
75
70
2
3
4
5
6
7
8
9
10
Presented By:
David Lloyd, Founder
11
72
24
Medication Adherence:
Clinician Report
Medication Adherence
Clinician Report
100
95
Percent
90
Subset B %
Subset A %
85
Linear (Subset B %)
Linear (Subset A %)
80
75
70
2
3
4
5
6
7
8
9
10
11
Presented By:
David Lloyd, Founder
73
Network Providers Utilization
Management Indicators
Presented By:
David Lloyd, Founder
74
Utilization Review Vs. Utilization
Management
•
•
Utilization Review is primarily
focused on retrospective review of
what has or has not happened in
services
Utilization Management is focused
on retrospective, concurrent and
prospective management of service
delivery capacity from intake to
discharge and every thing in between
Presented By:
David Lloyd, Founder
75
25
Focus Areas for UM Plan
•
•
•
•
Front End (i.e., Screening/Triage,
Eligibility, Emergency Services, Referrals,
etc.)
Concurrent (i.e., Urgent/Routine
/
g Criteria/Planning,
/
g,
Transfer/Discharge
Services for high risk consumers,
qualitative review of clinical documentation
and treatment planning, etc.)
Prospective (i.e., what are the next steps
with the consumer following current LOC)
Retrospective (i.e., Qualitative/
Quantitative Review of Charts and
Outcomes/Satisfaction Measures, etc.)
Presented By:
David Lloyd, Founder
76
Services Appropriate for Diagnostic/Function Level Profile
Presented By:
David Lloyd, Founder
77
Hi Service Utilizers Profile
Presented By:
David Lloyd, Founder
78
26
Sample UM Plan Table Of Contents
Presented By:
David Lloyd, Founder
79
Internal Benefit Design to Support
Engagement and Create A Capacity for
New Clients to Receive Treatment




Purpose is to establish Group Practice Clinical
Guidelines to Facilitate Integration of all services into
one service plan
Provide an awareness to consumers at entry to
services the types of services and duration of
services the practice has found most helpful to meet
their treatment needs so that the consumer will know
and the staff will know what services are needed to
complete that level of care
Moves consumers to a more recovery/ resiliency
based service planning and service delivery approach
Facilitates being able to use centralized scheduling
using the actual service plan of each consumer
Presented By:
David Lloyd, Founder
80
Internal Benefit Design/Levels of Care
Provide the Required Framework for UM Plans
and to Create Capacity for New Clients to
Receive Treatment
1.
2.
Development of internal levels of care/benefit
package designs to support appropriate utilization
levels for all consumers
Core Elements of Benefit Design/LOC
g
Model:
1.
Admission Criteria (as objective as possible using
Diagnostic Profiles, DLA-20/LOCUS scores, etc.)
2.
Continue Stay Criteria
3.
Transition/Discharge Criteria
4.
Service Array and Frequency to be Provided
5.
Projected Service Duration within each level
Presented By:
David Lloyd, Founder
81
27
Episodes of Continuous Care Model
Intensity of
Need
Episodes of Care Need
Low
Moderate
High
Lifetime of Client/Consumer
Presented By:
David Lloyd, Founder
82
Engagement Based Same Day Access/Treatment Plan
Model Using Benefit Design/Level of Care Criteria
Presented By:
David Lloyd, Founder
83
Adult Mental Health Benefit Design Level Two
Presented By:
David Lloyd, Founder
84
28
Child/Adolescent Mental Health Benefit Design
Level Three
Presented By:
David Lloyd, Founder
85
Child/Adolescent Mental Health Benefit Design
Level Two
Presented By:
David Lloyd, Founder
86
ASAM
Criteria for
Persons with
Substance
Use
Disorders
Presented By:
David Lloyd, Founder
87
29
Provider Specific Cost of Services Based on Claims and
Clinical Correlation Factors (i.e., LOC, Service Mix, etc.)
Presented By:
David Lloyd, Founder
88
Provider Specific Utilization Rates/Penetration Rates
Geo Mapping
Presented By:
David Lloyd, Founder
89
Third Party/Managed Care Utilization
Management Plan Components:
1.
Internal utilization management
processes and support staff to help
ensure:
a.
b.
c.
d.
Pre-Certification, authorizations and reauthorizations are obtained
Referrals are made to only clinicians credentialed
on the appropriate third party panels
Appropriate front desk co-pay collections
Timely/Accurate claim submission to support
payment for services provided
Presented By:
David Lloyd, Founder
90
30
UM Plan Tools Needed
Entry Into Care
What are the Access to Care standards for consumers per level
of acuity that are required by the third party payers
(Emergent = within one hour, Urgent = within 24 hours
and Routine = within 7 to 10 days)?
Who will:

1.
2
2.
Determine the type of Third Party Insurance a client has
Obtain initial authorization prior to service delivery and
Refer the client to a clinician that is credentialed on the right insurance company
panel?
Confirm if an additional authorization is needed to continue services after the
initial intake/assessment




What clinical tool(s)/Reports will they use to make the
assignment (i.e., Access data base of all third party payers and
the clinicians credentialed on each panel, etc.)?
3.
Presented By:
David Lloyd, Founder
91
UM Plan Tools Needed
Re-Authorizations During Service

Who will:
1.
Confirm the number of sessions that have been delivered
against the current authorization from payer

Obtain
Ob
i re-authorization
h i
i
prior
i to the
h end
d off the
h current
authorization if additional services are clinically needed, and

Engage in appeals process with payer if re-authorization is
denied?

What reports will they need/use to monitor current
authorization levels and confirm need for re-authorizations
(i.e., Number of remaining session in current authorization are
recorded in centralized scheduler, etc.)?
2.
Presented By:
David Lloyd, Founder
92
Roles of Support Staff In External
Authorized Services
1.
Centralized Scheduling is needed to ensure
referral is made to clinician on the appropriate
insurance panel

2.
Ability to know at all times the availability of clinical
staff that are credential on third party panels will be
critical to timely acceptance of new referrals
Re-think Front Desk functions/needs



Collection of Co-Pays prior to Service
Confirmation of Insurance via copy of Insurance
cards prior to service
Confirmation of the number of authorized services
remaining for client
Presented By:
David Lloyd, Founder
93
31
Roles of Clinical and Financial Staff In
Third Party Billing
3.
4.
5.
Completion and submission of all required clinical
documentation by direct care staff will be needed
to support authorizations after Intake (if
required) and re-authorizations – (i.e., Case
study from DuPage County MHS
MHS, IL - 99.9%
99 9%
contained within day of service)
Filing timely and accurate claims will be critical
Monitoring level of unreimbursed third party care
– determine reasons for non payment and correct
issues
Presented By:
David Lloyd, Founder
94
Network Provider Consumer
Satisfaction Indicators
Presented By:
David Lloyd, Founder
95
Consumer Service = Engagement
Presented By:
David Lloyd, Founder
96
32
Consumer Service Indicators – Action Plan
Presented By:
David Lloyd, Founder
97
Presented By:
David Lloyd, Founder
98
Presented By:
David Lloyd, Founder
99
33
Network Provider Clinical
Performance Indicators
Presented By:
David Lloyd, Founder
100
Sample Network Provider KPIs
1.
2.
3.
4.
5.
6.
Provider attainment of a 95% compliance rating on
Qualitative and Quantitative Chart Reviews
Percent of services that are adequately linked to
assessed needs and goals/objectives in the treatment
p
plan
Provider attainment of 95% documentation submission
on the day services provided
Provider attainment of 97% data accuracy of documented
services vs. billed services
Provider will have 90% of outcome ratings showing
maintenance or improvement in the last survey period.
Provider will have 90% positive Consumer Satisfaction
Ratings regarding their opinions about services provided.
Presented By:
David Lloyd, Founder
101
Presented By:
David Lloyd, Founder
102
34
Presented By:
David Lloyd, Founder
103
Presented By:
David Lloyd, Founder
104
Practice Variance for Case Management by
Provider – Qualitative Review of Charts
Presented By:
David Lloyd, Founder
105
35
Practice Variance for Medication Check by
Provider – Access Capacity Indicator
Presented By:
David Lloyd, Founder
106
Treat to Target Attainment
Levels:
1.
2.
3.
Most of our clinicians use a “treat to target”
approach to planning, service delivery, and
adjusting the care plan if it’s not working.
The majority of clinicians and supervisors have
studied the treat to target literature and develop
care plans that include measureable targets (e
(e.g.
g
enhanced functioning in DLAs within 12 weeks),
measure progress at least monthly, and work with
consumers to adjust the care plan if targets are not
being met.
Part of this process includes the use of clinical tools
that measure improvement in symptomology,
functional status, and recovery and resiliencebuilding for the children, families and adults we
serve.
Presented By:
David Lloyd, Founder
107
National Engagement
Indicators:
National Standard for Appointment
Types:
 Appointment
Kept
 No Show (less than 36 to 24 hrs
notice)
 Appointment Canceled by Client
(36 to 24 hrs or more notice)
 Appointment Canceled by Staff
Presented By:
David Lloyd, Founder
108
36
No Show Definition Clarification:
1.
2.
No Show definition is not based solely on
clients behavior as much as the impact of this
behavior on service capacity of each direct
care staff that day
y (i.e.,
(
, Late cancellation
results in a potential no show to schedule)
Cancellations count as No Shows IF the team
is not backfilling 90% of pre-cancelled
appointments – Therefore, no shows and
cancellations carry the same weight of
reduced service capacity if the backfilling
process is not happening
Presented By:
David Lloyd, Founder
109
National Engagement Key
Performance Indicators
1.
2.
3.
4.
Initial Intake/Diagnostic Assessment Services =
0% No Show/Cancel rate based on Same Day
access models
Ongoing Therapy Services = 8% - 12% No
Show/Late Cancelled
Initial Psychiatric Evaluations = 12% to 15% No
Show/Late Cancelled
Ongoing Medication Follow Up Services – 5% - 8%
No Show/Late Cancelled - NOTE: Medications
provided by phone to clients that missed their
appointments will have to be addressed to
positively impact ongoing no show rates.
Presented By:
David Lloyd, Founder
110
Engagement Level Data Report Sample
Presented By:
David Lloyd, Founder
111
37
Non-Clinical Performance
Indicators
Presented By:
David Lloyd, Founder
112
Network Provider Non-Clinical
Performance Indicators
1.
2.
3.
4.
5.
Percent of clean claims submitted
Percent of timely claim submission
Percent of services provided that did
not have
h
appropriate
i
authorization
h i
i
or
re-authorization from MCO
Fiscal Indicators such as Days of Cash
on Hand, Current Assets to Current
Liability Ratio, etc.
IT Capacity to transmit to MCO
Presented By:
David Lloyd, Founder
113
Presented By:
David Lloyd, Founder
114
38
Physical Facility Indicators
Presented By:
David Lloyd, Founder
115
Presented By:
David Lloyd, Founder
116
Presented By:
David Lloyd, Founder
117
39
Presented By:
David Lloyd, Founder
118
Questions and Feedback

Questions?

Feedback?

Next Steps?
Presented By:
David Lloyd, Founder
119
40