Transcript Children`s Medicaid Redesign and Value Based Payments

Children’s Medicaid Redesign and
Value Based Payments (VBP)
New York State Coalition for Children’s Behavioral
Health
Presentation by Lana I. Earle
Deputy Director, Office of Health Insurance Programs
November 29, 2016
November 2016
Key Concepts on the Road to Value Based
Payments – Bringing it all Together
• Medicaid Redesign Team (MRT) – Children’s Medicaid Redesign Plan /
Behavioral Health and Health Transition to Managed Care
• Delivery System Reform Incentive Payment Program (DSRIP)
• Value Based Payments (VBP)
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November 2016
Creation of Medicaid Redesign Team
• In 2011, Governor Cuomo created the Medicaid Redesign Team (MRT)
• Made up of 27 stakeholders representing every sector of healthcare delivery system
• Developed a series of recommendations to lower immediate spending and propose reforms
• Closely tied to implementation of ACA in NYS
• The MRT developed a multi-year action plan – that Plan includes:
 The Children’s Medicaid Redesign Plan
 1115 Waiver that includes:
 Delivery System Reform Incentive Payment Program (DSRIP)
 Value Based Payments
 The Goals of MRT: Transform the State’s Health Care System, Bend the Medicaid Cost
Curve, Assure access to quality care for all Medicaid members, Create a financially
sustainable safety net infrastructure
November 2016
Children’s Medicaid Redesign Plan – MRT Vision
for Children’s Transformation
 Keep children on their developmental trajectory
 Identify needs early and intervene
 Focus on recovery and building resilience
 Prevent escalation and longer term need for higher end services
 Maintain child at home with support and services
 Maintain the child in the community in least restrictive settings
 Maintain accountability for improved outcomes and delivery of quality care
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November 2016
Transforming System from Today to the Vision
Today
 Care Coordination is limited to six 1915c Waiver Programs and OMH TCM Program (12,000 kids) – no
Health Home (Coming Soon! – December 8, 2016)
 Current state plan services
 Limited array of Home and Community Based Services (HCBS) available only to 1915c Waiver children services depend on and vary by waiver
 Behavioral health and physical health services are not integrated
 Care planning is not integrated
 Transitional care across children’s system is lacking
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November 2016
Transforming System from Today to the Vision
Tomorrow Full Implementation of Children’s Design
 December 8, 2016 Health Home care management for children with two or more chronic conditions, serious
emotional disturbance (SED), complex trauma, HIV
 Other care management for non-HH eligibles (e.g., Managed Care Plans, PCMH)
 Current state plan services
 Six new state plan services
 Integrate and transition behavioral health benefits to managed care
 Transition foster care per diem population to managed care
 Expanded array of 12 HCBS based on target, risk, and functional criteria
 Foster transitional care and continuity of care across children serving systems (education, child welfare, juvenile
justice)
 Shift focus to quality, monitoring, and tracking and reward quality outcomes (value based payments)
 New investments in new and expanded services
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November 2016
Timeline for Children’s MRT Health and Behavioral Health Transition
Revised Timeline
SPA Other Licensed Practitioners (OLP) - FFS
(1 of 6 new SPA Services)
•
•
SPA Rehabilitation Services under Managed Care and FFS
(Crisis Intervention, CPST, Family and Peer Supports, PSR – remaining 5 of 6 new SPA
Services)
SPA Other Licensed Practitioners under Managed Care and FFS
3/1/17
10/1/17 Downstate
1/1/18 Upstate
NYC, Nassau, Suffolk, Westchester
• HCBS benefit array
• 1915(c)Waiver Care Management to Health Home
• BH Benefits Transition to Managed Care
10/1/17
Rest of State
• HCBS benefit array
• 1915(c)Waiver Care Management to Health Home
• BH Benefits Transition to Managed Care
1/1/18
LON Community Eligible – begin to receive HCBS benefits
7/1/18
LON Family of One – expansion group begins eligibility & access
1/1/19
Foster Care Population Transition to Managed Care
1/1/19
(Accommodates Legislation and Licensing
VFCA Required for MC Transition Under
Corporate Practice of Medicine)
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November 2016
DSRIP Objectives are Aligned with the Objectives of
Health Home and Children’s MRT Transformation and
Redesign
Develop
Integrated
Delivery
Systems
Remove
Silos
 DSRIP was built on the CMS and State
goals in the Triple Aim:
 Better care
 Better health
 Lower costs
Enhance
Primary
Care and
Communitybased
Services
Goal:
Reduce avoidable
hospital use –
Emergency
Department and
Inpatient – by 25%
over 5+ years of
DSRIP
Integrate
Behavioral
Health and
Primary
Care
 DSRIP has projects that seek to
promote healthy women, infants, and
children, but does not have an exclusive
pediatric or child-focused project
 However, its holistic and integrated
approach to healthcare transformation is
set to have a positive effect on children’s
health
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November 2016
Performing Provider Systems (PPSs) are networks of
providers that collaborate to implement DSRIP projects
 PPSs were required to include providers from the entire care
continuum
 Hospitals
 Health Homes (for Children too!)
 Social Service Departments and Local Government Units
 Skilled Nursing Facilities
 Clinics & Federally Qualified Health Centers
 Behavioral Health Providers
Assessing community
healthcare needs based on
multi-stakeholder input and
objective data
Implementing a DSRIP
Project Plan based upon the
needs assessment in
alignment with DSRIP
strategies
 Home Care Agencies
 Physicians/Practitioners
 Other Key Stakeholders
Meeting and reporting on DSRIP
Project Plan process and
outcome milestones
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November 2016
PPS DSRIP Projects that Impact Children’s Healthcare
DSRIP Project Organization
Domain 1:
Organizational Components
Domain 2:
System Transformation
3.a.i: Integration of
primary care
services and
behavioral health
Domain 3:
Clinical Improvement
Domain 4:
Population Health
3.a.ii: Behavioral
health community
crisis stabilization
services
3.d.ii: Expansion of
asthma homebased selfmanagement
programs
3.d.iii: Evidence
based medicine
guidelines for
asthma treatment
4.a.i: Promote
mental, emotional,
and behavioral wellbeing in
communities
4.a.iii: Strengthen
mental health and
substance use
infrastructure across
systems
4.d.i: Reduce
premature births
Source: New York State DSRIP Project Toolkit. NYSDOH DSRIP Website.
3.f.i: Increase
support programs
for maternal & child
health
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November 2016
DSRIP Will Have a Positive Impact on Children’s Health
Outcomes
Today
Child in
Medicaid with a
chronic health
condition
After DSRIP
Engagement
Delivery
Outcome
Intermittent
care provided
by separate
providers, as
necessary
Unnecessary
ER visits &
hospitalizations
in childhood
Unnecessary
ER visits &
hospitalizations
throughout
adulthood
Care managed
by a
coordinated set
of integrated
providers
Preventive
healthcare
provides the
resources the
child requires
Integrated care
follows through
adolescence
into adulthood
=
Unnecessary strain on
the child, the family,
and the healthcare
system
=
Value to the child, the
family, and the
healthcare system
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November 2016
Sustaining the Objectives of DSRIP with Value Based Payment Reform:
Delivery Reform and Payment Reform are Two Sides of the Same Coin
• A thorough transformation of the delivery system
can only become and remain successful when the
payment system is transformed as well
• Many of NYS system’s problems (fragmentation,
high re-admission rates) are rooted in how the
State pays for services
• Fee-for-Service (FFS) pays for inputs rather
than outcome; an avoidable readmission is
rewarded more than a successful transition to
integrated home care
• Current payment systems do not adequately
incentivize prevention, coordination, or
integration
Financial and regulatory
incentives drive…
a delivery system which
realizes…
cost efficiency and quality
outcomes: value
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November 2016
Mental Health Facilities
Facilities for the disabled
Nursing home care
Physiotherapy
Home Care
Inpatient services
Hospital / Clinic outpatient
services
Specialty docs
Home care
Imaging Services
Laboratory
Services
Medical Equipment and
Appliances
Behavioral Health
Professionals
Rx
PCPs
The Old World: Fee for Service; Each in its Own
Silo
• There is no incentive for coordination or integration across the continuum of care
• Much Value is destroyed along the way:
• Quality of patient care & patient experience
• Avoidable costs due to lack of coordination, rework, including avoidable hospital use
• Avoidable complications, also leading to avoidable hospital use
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November 2016
Reforming the Payment System and Moving from
Volume to Value
Value Based Payments (VBP)
An approach to
Medicaid
reimbursement that
rewards value over
volume
An approach to
incentivize providers
through shared
savings and financial
risk
A method to directly
tie payment to
providers with quality
of care and health
outcomes
A component of
DSRIP that is key to
the sustainability of
the program
• VBP arrangements are not intended primarily to save money for the State, but to allow
providers to increase their margins by realizing value.
VOLUME
VALUE
Current State
VOLUME
VALUE
Future State
Source: New York State Department of Health Medicaid Redesign Team. A Path Towards Value Based Payment, New York State Roadmap
for Medicaid Payment Reform. NYSDOH DSRIP Website. Published March 2016.
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November 2016
Different Types of VBP Arrangements
Types
Total Care for General
Population (TCGP)
Integrated Primary Care
(IPC)
Care Bundles
Special Need
Populations
Definition
Party(ies) contracted
with the MCO assumes
responsibility for the
total care of its
attributed population
Patient Centered Medical
Home or Advanced
Primary Care, includes:
• Care management
• Practice transformation
• Savings from
downstream costs
• Chronic Bundle
(includes 14 chronic
conditions related to
physical and behavioral
health related)
Episodes in which all
costs related to the
episode across the
care continuum are
measured
• Maternity Bundle
Total Care for the Total
Sub-pop
• HIV/AIDS
• MLTC
• HARP
Contracting
Parties
IPA/ACO, Large Health
Systems, FQHCs, and
Physician Groups
IPA/ACO, Large Health
Systems, FQHCs, and
Physician Groups
IPA/ACO, FQHCs,
Physician Groups
and Hospitals
IPA/ACO, FQHCs and
Physician Groups
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November 2016
Reminder: MCOs and Contractors can Choose
Different Risk Levels of VBP Arrangements
There are different levels of risk that the providers and MCOs may choose to take on in their
contracts:
Level 0 VBP*
Level 1 VBP
Level 2 VBP
Level 3 VBP
(feasible after experience with Level
2; requires mature contractors)
FFS with bonus and/or
withhold based on
quality scores
FFS with upside-only shared
savings available when outcome
scores are sufficient
(For PCMH/IPC, FFS may be
complemented with PMPM subsidy)
FFS with risk sharing (upside
available when outcome scores
are sufficient)
Prospective capitation PMPM or
Bundle (with outcome-based
component)
FFS Payments
No Risk Sharing
FFS Payments
FFS Payments
Prospective total budget payments
 Upside Risk Only
 Upside & Downside Risk
 Upside & Downside Risk
*Level 0 is not considered to be a sufficient move away from traditional fee-for-service incentives to be counted as value based
payment in the terms of the NYS VBP Roadmap.
November 2016
Contracting Entities / VBP Contractors
1. Independent Practice Associations (IPA)
2. Accountable Care Organizations (ACO)
3. Individual Providers
• Hospital Systems
• FQHCs and large medical groups
• Smaller providers including community based organizations (CBOs)
1. Individual provider could either assume all responsibility and upside/downside risk or make
arrangements with other providers; or
2. MCOs may want to create a VBP arrangement through individual contracts with these providers
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November 2016
VBP Contractors: Independent Practice
Association (IPA)
• An Independent Practice Association is a corporation (nonprofit or for-profit)
and/or LLC that contracts directly with providers of medical or medically related
services, or another IPA in order to contract with one or more MCOs to make the
services of such providers available to the enrollees of an MCO.
• Who negotiates the IPA contract?
• What is the governance of the IPA?
• Who should the individual provider look to if there are questions and/or
concerns?
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November 2016
VBP Contractors: Independent Practice
Association (IPA)
• IPAs facilitate network development and access
• Single signature authority
• Typically for a category of services amongst competing providers
(could be with providers across the care continuum)
• Allows providers to maintain independence regarding governance and
clinical decision-making
• IPAs are not unions or guilds
• Antitrust concerns related to collective negotiation
• To avoid antitrust concerns, IPAs are usually entities that share risk or are
clinically integrated
• IPAs can provide administrative services to providers who participate in
the IPA and/or management services to MCOs
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November 2016
VBP Contractors: Accountable Care Organization
(ACO)
• An Accountable Care Organization (ACO) is an organization of clinically
integrated health care providers that work together to provide, manage, and
coordinate health care (including primary care) for a defined population; with a
mechanism for shared governance; the ability to negotiate, receive, and distribute
payments; and accountability for the quality, cost, and delivery of health care to
the ACO’s patients
• Medicare-only ACO (approved by CMS) for Medicare population
• Medicare ACO does not make you a Medicaid ACO and vice versa*
• IPAs may be certified by DOH as an ACO
*There is an expedited approval process for Medicare ACOs to become Medicaid ACOs.
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November 2016
Where Do You Fit in the Structure of a VBP
Arrangement: Total Care for General Population (TCGP
Flow of Funds
DOH
MCO
IPA/ACO
Hospitals
Physicians
FQHCs
BH
Providers
Pharmacies
CBOs
Ancillary
Providers
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November 2016
TCGP: Flow of Funds
IPA/ACO to
IPA/ACO Contract
DOH
MCO
IPA/ACO
Hospitals
Physicians
FQHCs
IPA/ACO
Provider
Provider
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November 2016
Where Do You Fit in the Structure of a VBP Arrangement:
Total Care for a Subpopulation
Flow of Funds
DOH
MCO
BH Provider
FQHC
IPA/ACO
Physician
Group
Physicians
Hospitals
HCBS
Provider
CBOs
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November 2016
Where Do You Fit in the Structure of a VBP Arrangement:
Integrated Primary Care (IPC)
Flow of Funds
DOH
DOH
DOH
MCO
MCO
MCO
Physician
Groups
FQHCs
Hospital
November 2016
The Work of the Children’s VBP
Subcommittee / Clinical Advisory Group
(CAG)
November 2016
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Where Children Currently Factor in New York’s
Systemic Approach to VBP
TCGP
Large-Scale Population Health Focused Providers
• About 2.1 million kids, ages 0-18, eligible to be included in these arrangements
• Measures from Advanced Primary Care (APC) preventive care set included, some with relevance for
pediatric care, as well as chronic condition measures selected by CAGs & NYS
IPC
Professional Practices Focused on Primary Care
• Covers preventive care, routine sick care, and chronic condition management for 14 conditions (e.g. diabetes
and asthma) for designated age ranges depending on episode parameters
• Measures include APC preventive care set as well as measures specific to chronic conditions, some with
pediatric relevance
Subpopulation
Total Cost of Care for Designated Specialty Populations
• Covers all eligible services, care coordination is deemed a central value, and all general population as well
as specialty measures (CAG & NYS selected) apply
• Example - HIV/AIDS includes about 1,600 children
November 2016
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Children’s Health VBP Subcommittee / Clinical
Advisory Group (CAG) Composition: A Dual Approach
Subcommittee
Focus: to create
recommendations to the
State on VBP design
Clinical
Experts
A geographically diverse
group of leading experts
and key stakeholders
throughout NYS healthcare
delivery system.
Providers Universities
Health
Plans
State
Agencies
Comprehensive Stakeholder Engagement
CAG
Focus: to develop quality
measures for VBP
Arrangements
Medical
Societies
Medical
Centers
November 2016
Children’s Health VBP Subcommittee / Clinical
Advisory Group: Objectives
• Understand the State’s vision for the Roadmap to Value Based Payment
• Review VBP arrangements for children’s services
• Develop a plain language value statement for the health and well-being of New
York’s child and adolescent Medicaid beneficiaries
• Make recommendations to the State that reflect the value statement on:
• Overall design for children’s VBP, including populations / subpopulations
• Pertinent quality measures for children’s VBP arrangements
• Data and other support required for providers to be successful
• Implementation details related to VBP
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November 2016
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Children’s Health Subcommittee / CAG Meeting Schedule
Meeting #1
October 20 - Albany
•
•
•
•
Introductions and Explanation
of Roles
Overview of VBP and
Children's MRT
Review of Children’s Medicaid
Data and population
distinctions
Identification and Prioritization
of Key Principles for Children’s
VBP
Meeting #2
November 18 - NYC
Meeting #3
December 12 - Albany
•
Recap of Meeting #1
•
Recap of Meetings #1 & 2
•
Children’s VBP Design
•
Quality Measures Overview
•
Model Options for Children’s
VBP
•
•
Group to discuss Model
Recommendations
Detailed Measure Review and
Discussion
• Pediatric Health
• Pediatric BH
• Other (e.g. life outcomes;
school readiness
•
Group to discuss Key
Implementation Considerations
•
Quality Measure Selection and
Recap
•
Preview of Quality Measures
•
Connection to Principles of
Children’s VBP
By the end of 2016, the recommendations put forth by the Subcommittee / CAG will be
submitted and written into the recommendation report. The group will potentially reconvene in
2017 to ensure any outstanding items have been addressed.
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November 2016
Opening Platform to Inform Our Work
 Children Are Not Just Mini Adults!
Early childhood development, social
determinants of health, parental
health, and clinical care all play a
part in children’s wellbeing
Ensuring that all children have
access to high quality primary
health care is important
Early Interventions can have
profound, long-term positive effects
on children’s lifetime outcomes
Value from improving child
outcomes will accrue over a longer
time frame and to society at large
Cross-system collaboration is
important as children follow their
developmental trajectory
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November 2016
Starting Points for Selection of Quality Measures
Alignment with DSRIP (avoidable hospital use)
Reduce ‘drowning’ in measures phenomenon: outcome measures have priority
Measuring the quality of the total cycle of care of the VBP arrangement
Relevance for patients and providers
Alignment with Medicare: linking to point of care registration (EHR)
Alignment with State Heath Innovation Plan’s Advanced Primary Care measure set
Transparency of process, of measures, of outcomes
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November 2016
Selecting and Refining Quality Measures is an Ongoing
Process
Start
During the process:
CAG selects
measures
End of year:
evaluation
results
reported
back to CAG
• Lists gets refined and reduced to those
measures that really matter (specific to
VBP arrangement)
OQPS
reviews
measures
• Key outcome measures
• Measures that are key to DSRIP success
• Nationally standardized key process
measures
• Focus on outcomes will increase as
outcome measures mature
Start of
measurement
VBP
Workgroup
sets
measures
• Pilots are essential to test feasibility and
relevance of measures
November 2016
Health Homes Serving Children: Update
on Readiness and Implementation
Activities
November 2016
Health Home for Children Begins
• On December 8th we will begin to enroll children in Health Home – A Major Step
Forward in Medicaid Redesign
• Thank you for your patience and support during the design phase
• December 8th is just the beginning - we look forward to continuing to work with
Health Homes, care managers, Plans and stakeholders to implement Health
Homes for children and complete readiness activities
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November 2016
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Status of Health Home Designations for Children
•
Designated Health Homes will begin to serve children December 8, 2016
•
16 Contingently Designated Health Homes have been working on readiness activities
 HIT Compliance – Care Management/EHR and Billing Readiness
 Network Adequacy
 ASAs with Managed Care Plans
 Policies and Procedures In Place
 Results of Health Home Serving Adults Re-designation Surveys
•
Site Visits for Three Health Homes Serving Children Only
 Identified Contingencies
 Regular readiness calls regarding the Health Home Readiness Tool that highlights the areas of
capacity, training, policies and procedures, etc. for Health Homes and network partners
 Review progress on concrete Health Home deliverables of MMIS ID #, BAAs, ASAs and Network
Adequacy
•
On November 4, 2016, the State issues letters to each of the 16 Health Homes regarding an assessment of
their readiness to begin to enroll children on December 5, 2016
November 2016
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Status of Health Home Designations for Children
•
Of the 16 Health Homes Serving Children, 9 have been designated to begin enrollment effective
December 8th. The county service area of one of those 9 was reduced pending completion of
readiness activities
•
The remaining 7 have not been designated to begin enrollment as of December 8 – readiness
activities will continue.
 3 are not Health Home Infrastructure Ready (2 did not meet HIT care planning
requirements, 1 is not billing ready)
 4 postponed – Received an adult re-designation performance level of 3, Performance
Improvement Plan (PIP) must be submitted and demonstration PIP has been implemented
•
State is committed to working with these Health Homes to move to readiness as quickly as
possible
•
Since the release of the November 4th designation letter, the State has met with each of the
7 Health Homes and is involved in ongoing discussions to move to readiness
November 2016
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Health Homes Designated to Serve Children for December 8, 2016
Health Home
Adirondack Health Institute, Inc.
Catholic Charities of Broome
County
Encompass Catholic Charities
Children’s Health Home
Central New York Health Home
Network (CNYHHN Inc.)
Counties Designated to Serve Children
Clinton, Essex, Franklin, Hamilton, St.
Lawrence, Warren, Washington
Albany, Allegany, Broome, Cattaraugus,
Chautauqua, Cayuga, Chemung, Chenango,
Clinton, Columbia, Cortland, Delaware, Erie,
Essex, Franklin, Genesee, Greene, Hamilton,
Herkimer, Jefferson, Lewis, Livingston,
Madison, Monroe, Niagara, Oneida,
Onondaga, Ontario, Orleans, Otsego,
Rensselaer, Saratoga, St. Lawrence,
Steuben, Wayne, Wyoming, Yates
Albany, Rensselaer, Schenectady, Cayuga,
Herkimer, Jefferson, Lewis, Madison, Oneida,
St. Lawrence
Designation Status to Serve Children
Designated to Serve Children as of
December 5, 2016
Designated to Serve Children as of
December 5, 2016
(Readiness Activities Continuing,
Not Authorized to Operate in the following counties:
Fulton, Montgomery, Oswego, Schenectady,
Schoharie, Schuyler, Seneca, Tioga, Tompkins,
Warren, and Washington)
Readiness Activities Continuing,
Not Authorized to Operate as of December 5, 2016
November 2016
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Health Homes Designated to Serve Children for December 8, 2016
Health Home
Children’s Health Homes of Upstate New
York, LLC (CHHUNY)
Counties Designated to Serve Children
Designation Status to Serve Children
Albany, Allegany, Broome, Cattaraugus, Cayuga,
Chautauqua, Chemung, Chenango, Clinton, Columbia,
Cortland, Delaware, Dutchess, Erie, Essex, Franklin,
Fulton, Genesee, Greene, Hamilton, Herkimer,
Jefferson, Lewis, Livingston, Madison, Monroe,
Montgomery, Niagara, Oneida, Onondaga, Ontario,
Orange, Orleans, Oswego, Otsego, Putnam,
Rensselaer, Rockland, Saratoga, Schenectady,
Schoharie, Schuyler, Seneca, St. Lawrence, Steuben,
Sullivan, Tioga, Tompkins, Ulster, Warren, Washington,
Wayne, Wyoming, Yates
Designated to Serve Children as of
December 5, 2016
Collaborative for Children and Families
Bronx, Brooklyn, Manhattan, Nassau, Queens, Staten
Island, Suffolk, Westchester
Coordinated Behavioral Care, Inc. dba
Pathways to Wellness Health Home
Bronx, Brooklyn, Manhattan, Queens, Staten Island
Greater Rochester Health Home Network
LLC
Cayuga, Chemung, Livingston, Monroe, Ontario,
Seneca, Steuben, Wayne, Yates, Allegany, Genesee,
Orleans, Wyoming
Hudson River HealthCare, Inc. dba
Community Health Care Collaborative
Columbia, Dutchess, Greene, Orange, Putnam,
Rockland, Sullivan, Westchester, Nassau, Suffolk
Designated to Serve Children as of
December 5, 2016
Designated to Serve Children as of
December 5, 2016
Readiness Activities Continuing, Not Authorized to Operate as
of December 5, 2016
Designated to Serve Children as of
December 5, 2016
November 2016
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Health Homes Designated to Serve Children for December 8, 2016
Health Home
Counties Designated to Serve Children
Designation Status to Serve Children
Institute for Family Health
Ulster
Kaleida Health-Women and Children’s
Hospital of Buffalo
Allegany, Cattaraugus, Chautauqua, Erie,
Genesee, Niagara, Orleans, Wyoming
Montefiore Medical Center dba Bronx
Accountable Healthcare Network Health
Home
Bronx
Niagara Falls Memorial Medical Center
Niagara
North Shore LIJ Health Home
Queens, Nassau, Suffolk
Readiness Activities Continuing, Not Authorized to
Operate as of December 5, 2016
Mount Sinai Health Home Serving
Children
Bronx, Brooklyn, Manhattan, Queens, Staten Island
Readiness Activities Continuing, Not Authorized to
Operate as of December 5, 2016
St. Mary’s Healthcare
Fulton, Montgomery
VNS – Community Care Management
Partners, LLC (CCMP)
Bronx, Brooklyn, Manhattan, Queens, Staten Island
Readiness Activities Continuing, Not Authorized to
Operate as of December 5, 2016
Readiness Activities Continuing, Not Authorized to
Operate as of December 5, 2016
Designated to Serve Children as of
December 5, 2016
Designated to Serve Children as of
December 5, 2016
Designated to Serve Children as of
December 5, 2016
Readiness Activities Continuing, Not Authorized to
Operate as of December 5, 2016
November 2016
Prioritizing the Enrollment of Eligible Children in Health
Homes: December 2016 Begin Date for Enrollment
• To manage initial capacity (and provide time to build up capacity) Health Homes, LDSS, LGU, Care Managers and
Plans, should prioritize the enrollment of children that meet Health Home chronic condition eligibility and
appropriateness criteria and have the highest needs, including the following:
 Children enrolled in OMH TCM care management programs that will convert to Health Home
 Children on OMH Waiver waiting list (already Medicaid eligible), within 30 days of discharge from
inpatient/residential/day treatment settings to participate in discharge planning
 Children on TCM waitlist; [SPOA who refers to HH]
 Children who are on the Bridges to Health (B2H) Wait list,
 Children in licensed congregate care,
 Children that are within 3 months of foster care discharge,
 Children enrolled in LDSS prevention services where foster care placement is imminent,
 Children prescribed 3 or more psychotropic medications
 Children who are within 30 days of discharge from inpatient, residential or detox setting
 Medically Fragile Children with multiple chronic conditions that have had recent (past 30 days) inpatient stay
 Children who have an ER referral but are not admitted for inpatient services; or are discharged with a
recommendation for community follow up;
 Children with multiple system involvement (child welfare, criminal justice)
 Children in Early Intervention (EI) target date to be enrolled March 2017 (when procedures for integrating EI and HH
requirements have been established, with stakeholder feedback, and trainings provided).
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November 2016
Leveraging the Expertise of OMH TCM Providers
that will Transition to Health Home
• To more fully leverage the expertise of OMH TCM providers and the Single Points of
Access (SPOAs) to preserve the delivery of high quality care management to children
with Serious Emotional Disturbance (SED) under the Health Home program, the OMH
and DOH are working together to integrate processes which will incorporate SPOA
referrals to OMH TCM providers and other requirements for OMH TCM providers that
transition to Health Home
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November 2016
New Process for Serving SED Children in Health Homes:
Role of the SPOA and Health Home Care Manager Assignments
•
Current Health Home Requirements:
 Health Homes and Care Management Agencies are required to ensure that CMAs
providing Health Home care management are qualified to meet the needs of the child and
family (e.g., be able to meet the care management needs of a child with SED, that has HIV,
or has multiple chronic conditions)
•
New Process: Beginning in December, Children that are identified to be eligible for Health
Home because they have or potentially have an SED through the SPOA process will be
referred by the SPOA to a “Designated Health Home Care Management Agency (CMA) for
SED”
• Designated HH CMAs for SED will be existing OMH TCM Programs that are transitioning to
Health Home
• SPOA will assign SED children to Designated HH CMA for SED
• SPOA assignments must reflect alignment between Health Home, Designated HH CMAs for
SED, and Managed Care Plans for children enrolled in Plans
• Health Home has BAA with Designated HH CMA for SED, Plan the child is enrolled in
has ASA in place with that same Health Home
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November 2016
New Process for Serving SED Children in Health Homes:
Role of the SPOA and Health Home Care Manager
Assignments
•
SPOA assignments are limited, on a Designated HH CMA for SED basis, to the current capacity
for Medicaid children served by the existing TCM, (i.e., 3,000 children statewide) - “SPOA
Assignment”
•
Designated HH CMA for SED will “assign” children with a CANS-NY acuity of High or Medium to a
SPOA Assignment
• Children with CANS-NY acuity of low or that step down from High or Medium to Low will
continue to be served by HH CMA for SED but does not count towards SPOA Assignment
•
SPOA will track and report the number of assignments made to each Designated HH CMA for SED
to OMH and DOH and each Lead Health Home – this will be a manual process that will occur
outside of the MAPP HHTS
•
SPOAs will use only use the MAPP HHTS to make a referral for assignment through the MAPP
HHTS Children’s Referral Portal if the Designated HH CMA for SED does not have capacity to
serve that child (i.e., their SPOA Assignments are filled) or for other non-SED referrals
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November 2016
New Process for Serving SED Children in Health Homes:
Role of the SPOA and Health Home Care Manager
Assignments
• SPOA recommendation is subject to family / child choice, family may
choose and be informed of other Health Homes CMAs non-designated for
SED
• Health Homes may also make assignments to Designated HH CMAs for
SED
• HH CMAs non-designated for SED that may be working with children and
families with SED Children may continue to directly enroll such children
through the MAPP HHTS Children’s Referral Portal
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November 2016
45
New Requirements for Serving SED Children in Health
Homes: Case Load Sizes for Designated HH CMAs for
SED
•
Current Health Home Requirements:
 Health Homes are required to provide a level of service, (e.g., number of contacts and methods of
contact), that support the needs of the child and the family and meet the Health Home core
requirements
 Health Homes and care managers serving children with high acuity per the CANS-NY are required to
keep their case loads mix predominantly to children of the High acuity level
 Children with High and Medium acuity per the CANS-NY are required to receive two Health Home
services per month, one of which must be a face-to-face encounter with the child
 Case load sizes have been built into the development and calculation of the Health Home rates for
children – presumption is CMAs will manage case loads around these assumptions
 The rates assume underlying case load ratios of 1:12 for “High”, 1:20 for “Medium” and 1:40 for
“Low”
•
New Requirements: Designated HH CMAs for SED will be required to maintain the case load ratios built
into the rates for children that are referred by the SPOA
•
1:12 for High
•
1:20 for Medium
•
1:40 for Low
November 2016
46
New Requirements for Serving SED Children in
Health Homes: Care Manager Qualifications
• Current Health Home Requirements:
 Care Managers that serve children with an acuity level of “high” as determined by
the CANS-NY are required to have:
•
•
•
•
A Bachelors of Arts or Science with two years of relevant experience, or
A License as a Registered Nurse with two years of relevant experience, or
A Masters with one year of relevant experience.
Providers may seek a waiver qualifications waiver from the State
• New Requirements:
 Designated HH CMAs for SED serving children with medium acuity that do not
have CMA qualifications of at least an associates degree with one year of relevant
experience must notify the State and seek a waiver from such qualifications
November 2016
Next Steps
Week of December 5th – Posted on the Health Home Webpage
 DOH/OMH will provide SPOAs and Designated HH CMA for Children w/SED of the
number of SPOA assignments by County and Agency
 DOH/OMH will provide, to SPOAs, the MMIS of Health Homes and Designated HH
CMA for SED for their County
 DOH/OMH will provide, to SPOAs, HH, Plan and CMA Alignment for their County
 DOH/OMH will provide the initial roster data collection tool
Week of December 12th – Webinar and Web Posting
 DOH/OMH will provide the SPOAs with the SPOA tracking form
 SPOA training Webinar on Data Collection and use of tracking form
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November 2016
Subscribe to the HH Listserv
• Stay up-to-date by signing up to receive Health Home e-mail updates
• Subscribe
http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/listserv
.htm
• Health Home Bureau Mail Log (BML)
https://apps.health.ny.gov/pubdoh/health_care/medicaid/program/medicaid_health_hom
es/emailHealthHome.action
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• Please send any questions, comments or feedback
on Health Homes Serving Children to:
[email protected] or contact the Health Home
Program at the Department of Health at
518.473.5569
• Stay current by visiting our website:
http://www.health.ny.gov/health_care/medicaid//pro
gram/medicaid_health_homes/health_homes_and
_children.htm