Integrated Healthcare: Striving for Better Care APP0040 ( 09/10)
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Transcript of Integrated Healthcare: Striving for Better Care APP0040 ( 09/10)
Integrated Healthcare: Striving for Better Care
APP0040 (09/10)
A combined presentation from the MCO’s
Presented by Lynn Bradford, Ph. D., HSPPDirector of Behavioral HealthMDwise, Inc.
Purpose of today’s presentation
Philosophy Administration Integration MDwise Managed Health Services Anthem
Philosophy Integrated Care is one way to open up access to
behavioral health services of which the 7 day follow up is one.
Local management of behavioral health services. Improved coordination and collaboration between
medical and behavioral health providers (work in progress)
Utilization management and case management services are integrated, medical and behavioral health managers work together to manage members’ needs.
Building a “right sized” network of skilled providers, statewide.
Administration
MDwise medical and behavioral health case managers and utilization mangers work together to mange our members as a unified team at the Delivery Systems.
At the delivery system level of MDwise there is integrated staffing of member’s cases.
Integration Grant Project
MDwise is piloting metrics with our grant recipients who are implementing integrated care so that each recipient can present their projects to other providers in the State to further implement integrated care throughout the State.
The pilot participants will include:St. Vincent Primary CareMidtown CMHCGallahue CMHCSt. Francis Medical Group
Integration Grant Project A seminar is planned for November for primary
care and behavioral health providers; continuing education credit will be offered
A historical overview of integrated care will be presented
Grantees will present their projects and outcome metrics
National best practice will be discussed Next steps for Indiana so that integrated care can
move forward
Discharge PlanningTransition Planning
History of fragmentation in systems of care Not part of treatment planning Little communication between service
providers Interruption of care is among the most
significant obstacles to a stable recovery
Discharge Planning
In response, MDwise is moving towards transition planning AACP (2001,2009) developed “Best Practices for Managing Transitions
Between Levels of Care”. (www.communitypsychiatry.org) http://www.communitypsychiatry.org/publications/clinical_and_administrative_tools_guidelines/COG.doc
Guidelines developed through clinical experience and existing information Committee consensus determined each element Each element has an outcome indicator to measure adherence to the
principles 14 elements identified as best practices for transition planning Guidelines not yet considered evidence based
Bridge Appointments MDwise uses codes 99401 and 99402 billed on a CMS-
1500 claim form. Revenue Code 513 is paid on a UB form Code 99401 pays a flat fee of $25 (15 minutes) Code 99402 pays a flat fee of $50 (30 minutes) Rev. Code 513 pays a flat fee of $50
A prior authorization through the member’s Delivery System must be obtained prior to discharge. This can be done during the initial call for an inpatient authorization.
The progress report, after the Bridge Appointment is completed, is faxed to the MDwise Delivery System, the outpatient therapist, and the member’s case manager at MDwise.
Provider Education Network Improvement Program Team and
Provider Relations provide outreach and education to the Behavioral Health provider network.
Provide education on claims, PA, and billing guidelines.
Provide education on HEDIS and the quality measures.
Provide education on Case Management. Provide educational materials and reports. Provide materials to assist in meeting the 7-day
follow up standard.
Hoosier Alliance & Select Health – Case Management Case Study Kept Hoosier Alliance and Select Health have
increased case management efforts and tracking of inpatient discharges.
The following information is tracked: Inpatient facility, date of discharge, bridge appointment provided, outpatient appointment schedule and date, reminder call, bridge and/or outpatient appointment kept.
The case manager does not allow a discharge without the 7 day follow up appointment scheduled.
The case manager contacts the member to remind them of the appointment and follows up after the appointment to ensure the appointment was.
Administration MHS Case Managers, Cenpatico
Intensive Case Managers (ICM) and Utilization Managers work together as integrated teams to ensure a seamless delivery of services. Cases are staffed jointly to identify service gaps and develop an integrated plan to improve member outcomes.
Intensive Case Management Cenpatico Intensive Case Managers (ICMs)
start intervening as soon as we are notified of and inpatient event.
Outreach to the Hospital Social Worker, Discharge planner and family prior to discharge to coordinate community appointments.
Once discharged from an in-patient stay, each member is followed by an ICM for 6 months to help ensure that there are no barriers to follow up care.
Intensive Case Management Once discharged, ICMs contact the
member/parent to confirm appointment. If appointment falls outside the 7 day window assistance is provided to obtain an appointment with seven days.
Summary of discharge information is faxed to member’s PMP and outpatient behavioral health providers.
Perinatal Depression MHS/Cenpatico have worked to increase the
identification and treatment of pregnant or postpartum women with depression.
In an effort to better coordinate medical and behavioral health care, Intensive Case Managers notify the member’s medical provider when a member returns a depression screening tool that scored positive for signs of depression.
The Intensive Case Manager informs the medical provider that education will be provided to the member regarding depression, the available benefits to her under MHS and how to access these services.
Post Hospitalization Safety Incentive
An Incentive targeted at ensuring the 7 day follow up appointment for members discharged from Inpatient Hospitalization.
Target members: Ages 4 – 18 years of age. Members are informed during an Inpatient Hospitalization
and/or immediately following that if they complete their 7 day follow up appointment they will receive an incentive.
The incentive consists of a Build A Bear, a book on feelings and a $10.00 gift card to Wal-Mart.
January – September 2010 226 incentive packages have been mailed.
Caring Voices Intensive Case Managers identify high-risk members
who otherwise have little or no access to telephone service and provide free cell phones.
All Cenpatico Intensive Case Managers currently have a Caring Voices phone available to deliver to inpatient providers prior to discharge to aid in bridging the gap between member and provider, increasing member compliance and improving healthy outcomes.
Caring Voices phones allow outgoing calls only to preprogrammed numbers: Community Mental Health Centers, MHS/Cenpatico, Primary Medical Provider, transportation, pharmacy. Incoming calls are always open.
Provider Education EffortsThe Bridge Appointment
A detailed explanation of the HEDIS measure is provided to the provider
Discussions take place to ensure that the provider understands the value of ensuring that the member is assisted in making the transition back to their home, family and community
Informed that this is a “last resort” and not to take the place of a valid OP appointment
Primarily used when getting an appointment within 90 days is very difficult
Explanation of how to bill for the Bridge Appointment for IP Providers and list of other services that OP Providers can perform that count toward the HEDIS measure
Bridge Appointments Cenpatico has identified several High volume Hospitals to
provide Bridge appointments. The Bridge Appointment takes place on the day of
discharge. Demographic information, Community Provider information,
including date of next appointment is reviewed. Completed Bridge Appointment document is faxed to ICM
staff within 24 hours. ICM staff follow up with member/ parent to ensure 7 day
appointment is made and to assist with barriers in completing the appointment.
Bridge Appointment Cont..
If there is an appointment listed on the Bridge Appointment document outside of the 7 day expectation the ICM staff assist with rescheduling a more appropriate appointment.
No Prior Authorization is needed Bridge Provider will contact Cenpatico ICM’s via fax with
Bridge Appointment Documentation Bridge Provider will create a report with the names and
dates of those members that participated Revenue Code 513 will be used to process all Bridge
Appointment claims and will be billed on a separate claim
Bridge Appointments Cenpatico uses Revenue Code 513 to assist with
ensuring that members that are being discharged from an in-patient stay have an opportunity to meet with a behavioral health provider after discharge to the discharge plan and any post discharge information.
Revenue Code 513 should be billed on a UB Form. A prior authorization through the member’s Delivery
System must be obtained prior to discharge. This can be done during the initial call for an inpatient authorization.
The progress report, after the Bridge Appointment is completed, is faxed to the MDwise Delivery System, the outpatient therapist, and the member’s case manager at MDwise.
Managed Health Services
What is Cenpatico is doing to make integration easier?
No need to bill Cenpatico when billing 96150-96155 and billing under a PMP for health providers
PMP is allowed to supervise mid-level behavioral health providers
School-Based Health Care Services
MHS and Cenpatico also facilitates the planning, development, implementation, and evaluation of comprehensive integrated School-Based Health Centers (SBHCs).
What is a School-Based Health Center -- SBHC?
A SBHC is a “health center located in a school or on school grounds that provides school-aged children on-site comprehensive preventive and primary health services, including behavioral health, oral health, ancillary, and enabling services.”
Services provided in a SBHC:
General health assessments EPSDT screenings Laboratory and Diagnostic screenings Immunizations First Aid Family Planning and counseling Prenatal and postpartum care
Services Provided in a SBHC:
Dental Services Behavioral Health Services
o Billing codes: 96150-96155 Drug & Alcohol Abuse Services Prescription Drug Distribution &
management Patient Education & other services based
on student need
Anthem Blue Cross and Blue Shield Values and Beliefs Development of strong collaborative relationships with
our providers / partners in care Integration, coordination, and collaboration between
medical and behavioral health delivery systems / providers
Innovation- Advanced programs to provide proactive interventions geared to promote and improve better health
Timely follow up after hospitalization promotes sustained progress and longer community tenure
Anthem Blue Cross and Blue Shield Strategy One Team caring for the Whole Person
Collocated Behavioral Health and Medical Case Managers Shared medical information system Coordinated Care Conferences
• Case Managers work closely with the “clinical team” involving behavioral health / medical management case managers as well as the Primary Medical Provider and Behavioral Health Service Provider
Mutual referral processes State of the Art Disease Management Programs
Co-Existing Depression and Anxiety Program (CODA) Maternity Depression Program (MDP) Bipolar Disease Management Program Attention Deficit Hyperactivity Disorder
(ADHD) Program Autism Program
Anthem Blue Cross and Blue Shield Strategy Tiered Case Management Program
Members move between a three tier program based upon need and progress
Community Partnerships Maintenance and development of collaborative community
relationships, i.e. ASK (About Special Kids) Provider Collaboration and Education
Case Managers work with providers as team members and not “vendors”
Comprehensive educational seminars and opportunities geared toward integration of care and best practices
Anthem Blue Cross and Blue Shield Discharge Planning Comprehensive Discharge Planning is crucial to the
overall success of the member’s treatment Engages the member and his/her family in the ongoing
treatment plan Encourages member and PMP interaction and assists the
member in choosing a medical home if one has not been selected
Establishes a follow up appointment with an outpatient provider within 7 days of discharge
Transitions the member to a longer term provider along the continuum of care Alignment of the right care in the right setting
for the right amount of time
Anthem Blue Cross and Blue Shield Discharge Planning
Educates the member about their medications and the importance of compliance
Supports integrated and non-disrupted ongoing care Members who attend an outpatient appointment within
seven days of discharge have:
• Longer community tenure
• Increased commitment to treatment with fewer failed appointments
Anthem Blue Cross and Blue Shield
Transition Program Provides a seamless transition from inpatient to
outpatient care Facilitates integration of care through expedited
communication with the outpatient provider regarding the member’s history and treatment plan
Addresses barriers to continued treatment / medication compliance
Supports member engagement with their community provider
Demonstrated Results Increased follow up rate with community provider Decreased hospital readmissions
Anthem Blue Cross and Blue Shield Provider Outreach Provides educational opportunities and materials around
HEDIS, quality improvements, and billing tips Provides feedback on performance and opportunities for
improvement through Facility Report Cards Provides tips and tools to assist in improving ambulatory
care follow up Provides education on member outreach and Anthem’s
Case Management Programs Provides numerous webinars, seminars, and materials
for increased knowledge
Anthem Blue Cross and Blue Shield Transition Program Providers should bill Revenue Code 0513 along with the
accompanying CPT code of xxxxx Revenue Code 0513 is reimbursed at $70
Authorization is required at the time of the appointment and is obtained by sending the summary report via facsimile to Anthem’s case management staff
The summary report is sent to the outpatient provider via facsimile
Questions?????