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Central FloridaBehavioral Health Network
“Achieving the dream
envisioned in
single management strategies.”
2
Why is the network initiative important?
Networks will be the lead entities for: Innovation Collaboration and care integration Contracting Purchasing of mental health and substance abuse
services.
3
CSAT Technical Assistance Report to FloridaJanuary, 2000
Comprehensive continuation of accessible quality services in the most appropriate environment
Regulatory oversight of treatment system that ensures appropriate clinical care provided consistently and with prevailing standards
Training for personnel
Treatment system includes clinical assessment, individualized service planning, referral, progress review and follow-up
How it started…
4
Characteristics and Featuresof a Well-Organized System of Care
(From CSAT Technical Assistance Report to Florida – January, 2000)
Services are organized into a simple network of careNetwork services are available through multiple single entry pointsFormal linkages exist between mental health, substance abuse and primary careLocal networks are responsible for coordination of client servicesCase managers are identified to coordinate careServices are community-basedPrevention and intervention strategies are clearly definedStakeholders have direct input
5
Characteristics and Featuresof a Well-Organized System of Care
(From CSAT Technical Assistance Report to Florida – January, 2000)
Treatment available upon demand for special populations (pregnant women, IV drug users, individuals in family protection, dually-diagnosed, SPMI, etc.)
Individualized, client-centered and flexible programs
Flexible funding strategies, including fee for service and prospective payment mechanisms
Network-wide utilization management
6
Florida Legislature passed SB1258 to meetthe service delivery needs for:
Control Costs Admission/Discharge with State
Hospitals Disseminate Data for Planning
Purposes Special ALF Services Reduction of Kids in Residential
Care Services to Kids under Court
Orders
Accountability
Continuity of Care
Early Diagnosis & TX
Assess Local Needs
Quality/Best Practices
Cross – System Integration
Creative Financing
Florida’s response…
7
Service Delivery Goals 1258
Coordination, Integration & Management
DCF/MH/SA and AHCA/Medicaid
Unit Cost Contracting & Fee-For-Service
Risk-Sharing Arrangements
Managing Entities – Public/Private
Promote Flexibility & Responsiveness
Expand Waivers, Maximize Federal $$$, New Procedure Codes or Certified Match
8
Florida Legislature expanded the goals ofSB1258 with the passage of SB2404 in 2003which:
Creates the Substance Abuse and Mental Health Corporation Responsible for oversight of publicly funded substance abuse and
mental health systems, including marking policy and resource recommendations.
Requires DCF and AHCA to ensure Medicaid and Department funded services are delivered in a coordinated manner, using common service definitions, standards and accountability mechanisms.
Requires corporation to conduct annual evaluation and report the status of publicly funded mental health and substance abuse systems to Legislature.
9
Amendment toChapter 394.9082
Provides direction for FMHI to continue the evaluation of strategies in SB1258 and SB2404 pilot projects
Requires report by December 31, 2006 that includes target dates for state-wide implementation
10
Amendment to Chapter 409.912(Relating to Mandatory Medicaid Managed Care Enrollment)
Directs AHCA to work with DCF to ensure children and families in child protection system have access to mental health and substance abuse services.
Directs AHCA to seek Federal approval to contract with single management entities for all behavioral health services for Medicaid recipients in an AHCA area.
Directs AHCA and DCF to collaborate to jointly develop all policy, budgets, procurement procedures, contracts and monitoring plans for behavioral health and targeted case management programs.
Requires AHCA and DCF to contract with managed care entities or arrange to utilize capitated pre-paid arrangement for all inpatient and outpatient behavioral health services to all Medicaid recipients by 07/01/06.
11
Amendment to Chapter 409.912(Relating to Mandatory Medicaid Managed Care Enrollment)
Specifies that in AHCA areas with less than 150,000 Medicaid eligible clients, AHCA must contract with a single managed care plan; in areas over 150,000 Medicaid eligible clients, AHCA may contract with more than one plan.
– Contracts must be competitively procured.– Both for-profit and not-for-profit entities are eligible to compete
Requires AHCA to submit a plan by October 1, 2003 providing full implementation of capitated behavioral health throughout the State.
– Plan must include provisions ensuring service accessibility for children and families in the child welfare and/or foster care system.
– Plan must include participation of community-based care lead agencies, community alliances, Sheriff’s Department and providers serving dependent children.
Requires implementation to begin in 2003 in areas of the State that are able to establish sufficient capitation rates.
12
Amendment to Chapter 409.912(Relating to Mandatory Medicaid Managed Care Enrollment)
Allows AHCA to adjust capitation rates in any one area as necessary.
Directs AHCA to develop policies and procedures to allow for certification of local and state funds.
Excludes children residing in inpatient and DCF residential programs (BHOS) from enrollment into pre-paid plans.
Requires existing child welfare providers under contract with DCF be offered the opportunity to participate in any provider network for pre-paid behavioral health services.
Requires AHCA and DCF to develop a plan for new procedure codes for emergency and crisis care, supportive residential services and other services designed to maximize use of Medicaid funds for recipients needs.
13
Network Administration
What is a Network?– Two or more agencies with a formal agreement to
manage or deliver behavioral health services.
What is the purpose of a Network?– Improve access to care– Improve quality– Improve efficiency and effectiveness– Assist providers/members
14
Unique Features ofCommunity-Based Networks
Strengths Community governance and oversight Shared risk with providers Comprehensive service delivery and ability to
provide integrated services Consumer involvement Community re-investment Coordination with collateral systems Opportunity for gradual transition
15
Unique Features ofCommunity-Based Networks
Vulnerabilities Historical preservationists
- May be slow to change practice standards- May be difficult to move from program-focused planning to
person-focused planning
Lack of capacity for utilization management, $$ required for IS development and capitation risk pools, RFP grant response/marketing, provider accreditation, administrative capabilities
16
Not-for-Profit Provider-Sponsored Networks
Services are based on needs of persons served and stakeholders
Demonstrated opportunity for consumer choice
Timely services
Services are culturally sensitive
Mission is communicated and embraced by all members
17
Not-for-Profit Provider-Sponsored Networks
A common set of indicators is applied– Access - Efficiency– Effectiveness - Consumer satisfaction
Indicators are used for quality improvement, performance assessment and corrective actions
18
Not-for-Profit Provider-Sponsored Networks
Individual provider and aggregate performance outcomes
Review of service patterns
Utilization of data to improve efficiency, effectiveness and customer satisfaction
19
Not-for-Profit Provider-Sponsored Networks
Coordination of a system of care for a person receiving services from more than one provider or levels/types of care includes:
Planning of individual services
Delivery of services
Evaluation of services
Service review and revision as needed
Formal information sharing process
20
Not-for-Profit Provider-Sponsored Networks
A prerequisite for membership in the Network is a demonstrated commitment to and the history of client advocacy and collaborative practice.
Non-profit providers
Contracts with the State SAMH Program Office
Medicaid provider
21
Not-for-Profit Provider-Sponsored Networks
Accreditation, licensing, certification
Fiscal stability and responsibility
Commitment to community-based care principles– Commitment to consumer choice– Rehabilitative principles of care
Ability to provide access to treatment
Ability to deliver service
22
Network Benefits
Examples of benefits the Network strives to offer include:
Enhancement of core competencies Ability to share administrative functions and associated costs Improved continuity of care Improved linkages with non-ADM services Development of best practices Maximization of revenues Joint marketing efforts Stronger advocacy efforts Ability to shift contract funds between providers Shared knowledge
_____
_____
_____
23
Core Administrative Functions
Provider network management Strategic planning Customer services Quality management Utilization management Financial management Information management
24
Core Administrative Functions
Provider Network Management
Planning and identifying network components– Defining continuum of care - Community planning– Determination of type, number and provider qualifications
Selection of providers/networks– Open or competitive bidding - Selection criteria– Evaluation - Approval process
Credentialing– Documentation of licensure - Accreditation– Professional credentialing
Management of provider network– Communication - Community input– Assessment of continuum of care– Training and technical assistance
25
Core Administrative Functions
Strategic Planning
Annual review of:– Services– Utilization data– Access standard– Outcomes
Gap analysis Needs assessment Member satisfaction Provider input
26
Core Administrative Functions
Customer Services
Customer relations– Board members - Providers– Consumers - Funding sources– Advocacy groups - Community stakeholders– State/local agencies
Members– Benefits and services - Member advocacy– Rights and responsibilities - Grievances and appeals
Coordination with other systems– Child welfare - Education– Juvenile justice - Corrections– Health c are
27
Core Administrative Functions
Leadership commitment– Accreditation– Board structure and management
Quality management goals– Focus on persons served
Enhance access and quality of behavioral health services
– Improve coordination of care within geographic areas– Promote effective, efficient and economical use of resources
Quality Assurance, Continuous Quality Improvement, Performance Improvement
28
Core Administrative Functions
Quality Improvement Committee– Comprised of QI personnel from all providers
Performance improvement reviews– Case file review– Medical record review– Customer survey– Data/outcomes review– Service validation review
Performance measures– State mandated outcomes– High risk– High volume– Problem prone
29
Core Administrative Functions
Quality assurance– Continuous quality improvement– Performance improvement– Utilization review– Risk management
Data driven– What, how, when to measure– How to use what is measured– Is system in management tool for improving quality
Treatment– Screening/assessment– Placement criteria– Continuing care criteria– Services individualized to client’s need/client driven– Continuums of care– Alignment of resources and utilization
30
Core Administrative Functions
Prior authorization– Define covered services requiring prior authorization– Medical necessity– Lead restrictive level of care
Concurrent review– Continued medical necessity– Level of care appropriate– Continued stay criteria
Retrospective review– Emergency admissions– Sample of cases to establish provider profile
Reviews decrease with provider readiness
31
Core Administrative Functions
Financial Management
Regulatory compliance– Legal– Contract– Grants management
Accounting– Safeguard assets– Monthly, quarterly and annual financial statements– Surplus/deficit and provider utilization reports– Annual budgets and forecasts
Integration of clinical and financial data– Cost analysis– Clinical analysis– Rate setting
32
Members tracking
Utilization management
Claims
Quality
- Enrollment/eligibility- Admission/authorization- Continued stay- “Seamless” care across levels of care and
providers- Integration of assessments and
treatment planning
- Aggregate reporting- Utilization
- Billing, processing, reconciliation
- Provider performance- Reporting- Outcomes analyses- Utilization analyses
Core Administrative Functions
Information Management
33
Core Administrative Functions
Revenue Maximization
Develop and define services to be covered Reimbursement consistent with level of service and cost to
provide service Payment methodologies
– FFS, capitation, rates, unit cost, case rates, etc. Use of multiple revenue streams to support treatment
– TANF– Medicaid– Private insurance– Corrections– General revenue
34
Transition Planning for Networks
Planning Process
Significant changes to the management and financing of systems of care require careful planning
Changes should be implemented in stages over time
Transition planning team is focal point for identifying issues and developing detailed implementation strategies
35
Current System
Performance Based/Unit Cost/Cost Center-based ADM Contracts
TANF system with cumbersome and expensive administrative requirements.
CFBHN subcontracts with providers on same basis.
Complicated and expensive billing and data systems.
Delays in receipt of funds.
Interim System
Contracts based on OCA categories for identified number of persons to be served (similar to District 1 Prepaid Aggregate Fixed Sum Contract)
Payment on 1st day of month, actual advance funding.
Reconciliation based simply on number of persons
served.
Utilize PIDS Manual and DCF Guide to SB1258 Contracting for ADM Services
Ideal System
Risk or shared risk-based or other types of contracts based on valid actuarial data and models.
Permit subcontracts to be on risk or shared-risk basis, case rate or other strategies to be developed.
If indicated, utilize profit and loss risk corridors.
Current System
Program Monitoring by ADM and CFBHN
Administrative and contract monitoring by CPU, ADM and CFBHN
Licensure monitoring by ADM and AHCA
Medicaid compliance by AHCA
CPA Audits
Accreditation for most providers
Interim System
Use accreditation in lieu of monitoring as described in SB1258 (Ch394)
CFBHN performs interim monitoring as described in SB1258 (Ch394)
ADM and CPU review CFBHN’s monitoring reports
Utilize CPA audits to replace certain items in the monitoring instruments
Develop process to redefine/reduce items to be monitored
Ideal System
Accreditation for all providers and networks
Move from system that focuses on monitoring to one that focuses on leadership & management development, development of organizational competencies, refinement of quality and performance improvement strategies and practices, best practices, improvements to system integration, and staff training and development
Development of legislative budget requests jointly by CFBHN and ADM/DCF based upon identified needs of Suncoast Region.
Current System
IDS, HomeSafeNet, etc.
Data validity problems, some of which are based on matching services to enrollments
Lack of timely mechanisms to correct inefficiencies and problems
Limited utility of database by providers
Interim System
Suncoast and CFBHN become additional demonstration project for PIDS, currently be developed and implemented in District 1
Would include participation in Unity One system and ability to access other state data systems
Ideal System
The ideal integrated database (s) has yet to be defined, but at a minimum it should eliminate all double or triple entries. It (they) should be efficient to use and effective for the state, CFBHN and subcontractors
Transition Planning for NetworksContract Financing
Management, Monitoring and Oversight
Data Collection and Reporting
36
Transition Planning Team Consistsof Three Separate Teams
Regional TransitionPlanning Team
ContractDevelopment
Team
MIS & DataTeam
System ofCare Team
37
Transition Planning TeamAt a minimum, team consists of representatives of the following parties and other appointed by team.
DCF SAMH Program Office DCF Contract Manager ASO Provider Network representative/Board member Representative from AHCA and any prepaid plan, if
established Representative from community-based care agency Consumer representative Ad hoc representation from identified stakeholders as
required
38
Transition Planning TeamMIS & Data Team
Responsible for analyzing all data and management information issues
Provides data need by Contract Development Team for preparation of the contract
Includes representatives from State MIS, ASO, providers, Regional SAMH Program Office, system consultant
39
Transition Planning TeamContract Development Team
Addresses the changes to the contract between the Department and the Network’s ASO
Development of prepaid, fixed sum or risk-based contract
Development of provider contract requirements– Incorporates provider application process– Incorporates provider credentialing process– Incorporates recommendations from MIS and System of Care
Teams
40
Transition Planning TeamSystem of Care Team
Addresses the array of services to be provided
Addresses access to care requirements
Addresses clinical protocols, clinical pathways, etc.
41
Central FloridaBehavioral Health Network
CFBHN is a not-for-profit network of community
providers incorporated to ensure and enhance an
array of behavioral health and other human
service needs for the citizens of our community.
42
CurrentOrganizational Capacity
The mission, values and principles ensure highly-effective, family-focused services are provided in a fiscally sound manner
A provider-sponsored network that has demonstrated commitment to and treatment of client advocacy and collaborative practice
Encourages network membership and provider development in a manner that is representative of both geographic and specific service needs of clients and their families
Currently provides the following services for five major funders:
– Administrative services
– Systems and network development
– Quality oversight
– Training, education and clinical development
Serves over 6000 clients annually, has 19 member agencies and 28 service providers under contract
43
Network Goals
Provide identified regions in the state with a well-managed and
integrated behavioral health delivery system to:
Increase access to care
Improve continuity of care to vulnerable populations
Prevent duplication of effort
Reward efficiencies
Encourage exemplary practices
44
Organizational Structure
In May, 2002 Bylaws revised to reflect significant changes in the organizational leadership and Board structure
Changes implemented to meet the Network’s need for the Board to be more representative of the expanded geographic area
45
Organizational Structure
Board President represents substance abuse agencies
President Elect represents mental health agencies
The two offices rotate annually between substance abuse and mental health systems to ensure both areas are adequately represented
46
Executive Committee
Executive Committee is comprised of the President, President Elect and one representative selected by each of the four designated Network regional councils
The four regional councils include:– Hillsborough County– Pinellas/Pasco Counties– South Region (Manatee, Sarasota and DeSoto
Counties)– District 14 (Highlands, Hardee and Polk Counties)
47
Regional CouncilResponsibilities
Nominate Executive Committee regional representative
Design and coordinate a localized system of care for each business activity identified for that region
Establish and maintain local planning forums of members, vendors, stakeholders and partners to formulate and articulate services delivery strategies and plans for inclusion in the Corporate Business Plan
Develop and implement regional business plans
Facilitate the implementation of behavioral health services that are responsive to the needs and institutions of their respective communities
Develop vendor recommendations
PINE
48
Inclusiveness & Provider Relations
Communities, funders, persons served and providers are integral partners in the design, evaluation and support of the Network’s services and service delivery structure
CFBHN is a provider-sponsored network striving to meet the needs of its members by providing outstanding services and value-added benefits that clearly demonstrate the advantages of membership
49
Network Membership
ACTS Boley Center for Behavioral
Health Care Centre for Women Coastal Recovery Center Directions for Mental Health DACCO First Step of Sarasota Gulf Coast Community Care The Harbor Behavioral
Healthcare Institute Human Services Associates
Manatee Glens Mental Health Care Northside Mental Health
Center Operation PAR Peace River Center PEMHS Suncoast Center for
Community Mental Health Tri-County Human Services Winter Haven Hospital
50
TANF
Provide management and oversight for all ADM TANF-funded services throughout the Region and District 14 Co-location of outreach at One-Stop centers in some child welfare community-
based care lead agencies Partner with Family Safety/diversion clients Partner to provide Dependency Court services Service provider for Welfare-to-Work/Hillsborough County Workforce Board Contract with Workforce Development Lead Agencies to provide support and
outreach Enhance supportive employment opportunities throughout Network area Collaborate with the Spring for domestic violence outreach Manage funds throughout the Suncoast Region and District 14 17 agencies provide services Allow full utilization of benefits for TANF-eligible persons
51
Co-Occurring
2001 Project to develop capacity of mental health and substance abuse agencies to treat persons with co-occurring disorders
Federal SAMHSA Grant – Center for Mental Health Services (CMHS) Community Action Grant on co-occurring disorders
2002 New GP Wood funding to Network to implement community action plan for integration of services for persons with co-occurring disorders
Agency action plans Goals for additional resources Systems integration and development Research capability and agreement to share information with
Florida Health Partners
52
Co-Occurring
2003 - Systems Coordinator works with providers to “move”
action plans
- Funding to agencies to enhance co-occurring services
- Co-occurring capability for all Family Intervention
services
- Expansion of model throughout Network
53
Family Safety
Mental health dollars targeted to community-based care needs
Additional resources for intervention with caretakers and reunification with clinical support to co-locate staff
Additional resources for adoption stabilization needs, clinical support and co-location of staff
Specialty services for abused children
Family Intervention services co-located throughout Suncoast Region and District 14
Dependency Court services in District 14
54
Family Safety
Assist in level of care decisions Specialty network developed for HKI for:
– Psychological evaluations– Domestic violence evaluations– Parenting classes
8 agencies participating with HKI
6 agencies participating with the Partnership for Safe Children
Pilot diversionary program developed for Sarasota Family YMCA
55
Bibliography
Network Development, Thomas E. Lucking, Ed.S.,Lucking Consulting, [email protected]
Brave New World of Managed Care, National Council for Community Behavioral Health Care, Troy Baily, Neal Cash, Colette Croze, Jeff Jorde
Administration & Policy in Mental Health, Volume 29, Number 1, September, 2001
CSAT Technical Assistance Report, January, 2000
OPPAGA Report, 2001