ACTION Campaign WebinarSurviving in a Health Reformed World

Victor Capoccia, PhDMarch 17,2011

Creating the Behavioral Health Future: What To Do?

“Get ready for health reform…”

The ‘get ready’ message

– Coverage 32 million • 18 Million Medicaid

• Parity

– Integration Primary Care and Mental Health

– Evidence• Comparative effectiveness

– Accountability

A Modern Day Story

Once upon a recent time…. There were 6 community based treatment organizations…. In Massachusetts….

…… That together provided 27+ % of all

the treatment in the state….

Massachusetts Context– Chpt 58 Universal coverage, 2006

– Full SUD Medicaid and SSA-BG benefit

– 570,000 require tx, 82,000 receive tx 117,000 seek tx, leaving 370,000 who qualify but, are not seeking treatment1

1. Brolin M, Horgan C, Doonan M. Substance Abuse Treatment in the Commonwealth of Massachusetts: Gaps, Consequences and Solutions. Boston (MA): Massachusetts Health Policy Forum; 2006.

What happened?

– Shift in revenue source

– Flat admissions

– Growth via service change

– One exception

…And the ‘moral of the story‘ is…

"Every system is perfectly designed to get the results it gets.“ Paul Batalden, MD

So what should I do???

Positive Deviance– The PD approach is a strength-based, problem-solving

approach that enables the community to discover existing solutions to complex problems.

– The PD approach differs from "needs based” approaches in that it does not focus primarily on identification of the external inputs necessary to meet those needs or solve problems. It invites the community to identify and optimize existing, sustainable solutions, which speeds up innovation.

Four D’s of Positive Deviance Approach

– Define the Problem

– Determine the Presence of PD

– Discover the Uncommon Qualities

– Design Activities and Systems

Uncommon Qualities:

– can schedule and assess all patients that are referred, or that call within ‘opportunity window’

– can offer appropriate level of specialty or medical service and live referral to any patient and family

– can bill any insurance… but especially Medicaid– can maintain patient engagement, and follow up patient status over time– can coordinate support or wrap around services with care plan– can report patient outcomes and process measures to patients and

payers– can engage in community level health system development and

population based health promotion activity

Achieving Uncommon Qualities

As Advocate:– Exchange that includes strong SUD and MH benefit– Coordination of benefit between BG and public insurance

including exchange– Purchasing standards that use evidence, and promote

continuous care– Eligibility process that is simple, timely, presumptive– Resources for infrastructure development, especially IT and

workforce – Payments that are fair, and that promote integration and results

Achieving Uncommon Qualities

As Manager:– Scheduling and assessments are timely – Connections to MH and PC are seamless, and transparent for

patient and family– Care is continuous, and includes active follow up– Care is based on patient needs and best available evidence– Workforce appropriately selected, supervised, supported,

provided with tools– Technology engaged, including tele-medicine, PDA, computer

assisted engagement

Achieving Uncommon QualitiesAs leader:

– Establish vision for future, that is understood and held by board and staff

– Continuous communication with staff, patients, community– Expand service, and location per need and resource– Establish cooperative, explicit connections with MH and PC

providers– Actively pursue participation in ‘system of health care’,

including Accountable Care Organizations– Determine need for collaborative or aligned ventures with

other health providers that include ASO, Medical Home, Affiliation, and ‘M’ word…( merger)

– Establish and reinforce presence in community health system

CONDITIONS FOR REFORM WHAT EXISTS WHAT'S NEEDED     

Patient Identification Primarily through criminal justice referral Referrals from all health care systems & non-    traditional health systems & populations centers

Accountability for patient care & Specialty care focus Integrated health services, seamless handoffsoutcomes   & follow up

Treatment practices Mix of personal experience, evidence- National Quality Forum  based practices & self help Evidence Based Practices    Data driven treatment planning

Patient & Family Role Dependent on clinician for treatment & Goal of self-care that is technology enabled  care management Family & peer support or knowledge exchange  Family has no formal role Family supports self-care

Workforce Sparse MD, sparse RN; up to 50% licensed More MDs, more RNs; 70% licensed & trained peers

Technology Limited to billing systems Need for follow up & track across the continuum;    EMR, patient self management

Infrastructure (Business system) Separate registration, appointment & Integrated patient and business management  follow up systems systems  Difficult to accept new payers Easy to accept new payment sources    A data repository for evaluation or ongoing     assessment of business operations

Assessing Your Qualitieshttp://www.niatx.net/hrri/Instructions.aspx

The future looks like…..

victor.capoccia@chess.wisc.edu