Clinical Management & Clinical Performance Archives - Providers’ Resource Center for Behavioral Health and Human Services

Woods Services Launches ‘Woods Healthcare’ Community Health Clinics For People With I/DD

On May 18, 2023, Woods System of Care announced the launch of Woods Healthcare, with three community outpatient centers located at its headquarters in Langhorne, Pennsylvania. The three centers are: The Center for Behavioral Health at Woods; The Medical Center at Woods; and Penn Dental Medicine at Woods. The three centers initially opened to serve consumers served by Woods and to serve Woods employees, but are now open to any individual in the community with intellectual/developmental disabilities (I/DD), autism, and emotional and behavioral challenges. The new outpatient centers are the realization of six years of effort to transform Woods into a population health management organization.

The Center for Behavioral Health at Woods opened in May 2023 to provide behavioral services for all ages. It also provides comprehensive autism evaluations for children aged 12 months through 18 years. The center’s convenient 6 day schedule is complemented by telehealth and telepsychiatry options. Private pay is available, and the center anticipates obtaining in-network status soon with Pennsylvania Medicaid HealthChoices and Behavioral HealthChoices managed care organizations (MCOs). It also participates in New Jersey Medicaid, Medicare, and private plans.

The Medical Center at Woods opened in June 2018. It provides outpatient primary care services for people ages six through adulthood diagnosed with I/DD, autism, or emotional and behavioral challenges. In April 2023, the Medical Center was awarded Recognition by the National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home Program and is the first to be recognized with a specialty in I/DD. The Center is accepting new patients and is in-network with private insurers and Pennsylvania Medicaid HealthChoices MCOs, and Medicare. It also participates in New Jersey Medicaid.

Penn Dental Medicine at Woods, Mikey Faulkner Dental Care Center opened in early 2023 to provide dental care for individuals of all ages. For this center, Woods partnered with the University of Pennsylvania School of Dental Medicine, which, through the vision of Dean Mark Wolff, DDS, specializes in oral health care for people with I/DD. The Dental Center program and clinic space provide extra comfort to those with a varying range of disabilities, with features such as specially-appointed operatories with advanced equipment as well as a quiet space for those needing a lower-stimulation environment. The Dental Center team is seeing new consumers daily and is in-network with most private dental insurers and Pennsylvania Medicaid HealthChoices MCOs. It also participates in New Jersey Medicaid.

In addition, a fourth service location is planned. Woods created a partnership with New Jersey-based RWJBarnabas Health and Rutgers University Behavioral Health Care to create a new integrated primary care and behavioral health clinic. The clinic is slated to open in spring of 2024 at Robert Wood Johnson University Hospital Hamilton in Hamilton, Mercer County, New Jersey.

Woods System of Care, a Pennsylvania- and New Jersey-based population health management organization and healthcare network that provides support services for individuals with intellectual/developmental disabilities (I/DD), autism and mental health conditions across their lifespan. With its nine affiliate organizations, Woods Services has formed the Woods System of Care which provides innovative, comprehensive, and integrated primary, behavioral and dental health care, plus specialty and allied health care. The system also provides education, housing, workforce, nursing and case management services. The Woods System of Care serves more than 22,000 children and adults with I/DD, and/or mental health disorders who also have complex and intensive medical and behavioral health care needs.

In 2016, Woods appointed Tine Hansen-Turton as President and CEO, leveraging her extensive health care experience to lead the organization’s transformation into a population health management organization and the system of care which it is today. Ms. Hansen-Turton said, “In order to reshape Woods into its current cutting-edge model, we put emphasis on expanding our extraordinary team of top health care thought leaders. This transformation has enabled us to fully realize an integrated care model which takes into account physical and behavioral health needs, and addresses all of the social determinants of health.”

The organization’s transformation to become a system of care is documented in Thriving Through Transformation: A Practical Guide to Creating Organizational Change in the Social Sector, which was released in January 2023. It can be downloaded at https://www.woods.org/wp-content/uploads/2023/01/Thriving-Through-Transformation-FINAL-for-website.pdf.

For more information, contact: Tine Hansen-Turton, President and Chief Executive Officer, Woods System of Care, Post Office Box 36, Langhorne, Pennsylvania 19047-0036; 215-801-3272; Email: tine@woods.org; Website: https://www.woods.org/woods-services/wsoc/

Countdown To Launching Your CCBHC

During this webinar, Qualifacts shares their proprietary approach to launching a Certified Community Behavioral Health Clinic (CCBHC). In this presentation, Qualifacts’ resident CCBHC expert and program manager, Mary Givens, MRA, and OPEN MINDS‘ Senior Associate, Deanne Cornette, MHA, GPC, walk through the five stages of the CCBHC Experience. In looking at each stage, they share some of the tasks and deliverables each CCBHC must complete to launch, and how the right technology partner can help you be successful.

With Qualifacts supporting 33% of the CCBHCs across the country, they are a great knowledge source. Whether you’ve applied for funding, have received funding, or are curious about the process, viewers of this webinar will walk away with actionable information.

A special congratulations to all those who received CCBHC funding this year!

Some of the objectives covered in this webinar are:

Understanding what it takes to launch the CCBHC Treatment Model
Tools to assist in launching your CCBHC
Selecting the right EHR technology partner for your CCBHC

Download Presentation Here

Whole Person Care – Challenges & Opportunities For Behavioral Health Provider Organizations In Integrated Systems Of Care

Whole person care has become a larger focus in behavioral health. This focus creates challenges and opportunities for the provider organizations serving this population. There is evidence that integrated care and whole person care, especially those care models which include social determinants of health, improves patient experience, clinical outcomes, and can lead to reduction in cost of total medical expense. Therefore, provider organizations that embrace this approach, along with alternative payment models, have the potential to improve their own financial position/performance. Learn more about how integrated care models can service vulnerable populations in this presentation by Monica Oss, Chief Executive Officer of OPEN MINDS.

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Navigating Complex Care Models – 5 Stages of Complex Care and Reimbursement Model Experience

As provider organizations evaluate and adopt complex care and reimbursement models, there are five consistent stages of experience. Whether taking on Value-Based Care contracts, becoming or working with a CCBHC program provider, the path to success travels a similar progression.

On August 24, 2022, Qualifacts’ CCBHC Program Manager Mary Givens shared insights and best practices from organizations around the country in different stages of their complex care experience. She also discussed how to evaluate progress across the stages and how to build a cycle of continuous quality improvement.

Presentation Slides

6 Steps To Improving CCBHC Outcomes The Berks Counseling Center Case Study

On May 25, 2022, Qualifacts’ CCBHC Program Manager Mary Givens and John Heim, Technology Specialist, EHR Systems for Berks Counseling Center discussed a 6-step process for improving performance on behavioral health led CCBHC outcomes. They provided insight into the greatest challenges of high performance on the CCBHC behavioral health led measures along with the successes and lessons learned from a mature CCBHC.

Presentation Slides

Who Should Do What? Scope of Practice; Treatment Tech Shift Clinical Best Practices

By Monica E. Oss, Chief Executive Officer

There has been a long debate about the scope of health care practices. What type of licensed clinical professionals can perform particular functions? Should psychologists and/or pharmacists prescribe psychotropic medications? What supervision do nurse practitioners and physician assistants need? (Should ‘physician assistants’ be renamed ‘physician associates’?)

Psychologists can prescribe in five states: Louisiana, New Mexico, Illinois, Iowa, and Idaho (see Can Psychologists Prescribe Medications?). The scope of pharmacists’ practices is state-dependent and varies widely from state-to-state (see Mapping U.S. Statewide Protocols For Pharmacist Prescriptive Authority). Pharmacists may or may not give injections and immunizations and prescribe everything from naloxone, tobacco cession aids, travel medications, and more. Physician Assistants are licensed to practice in all 50 states, the District of Columbia, all US territories, and the uniformed services. Physician Assistants are authorized to prescribe medications in all jurisdictions where they are licensed, except Puerto Rico (see PA Prescribing and Assessing Scope of Practice in Health Care Delivery: Critical Questions in Assuring Public Access and Safety).

Executives of health and human service organizations need to plan to leverage the ‘value’ of their clinical team members by developing systems where they can work at the ‘top of their practice’—with most of their time going to the services that require their specific level of training. But that is easy to say and much harder to accomplish in practice. This type of service specialization is an essential part of the specialization needed to achieve maximum operational efficiency—and the highest value.

But there are two factors that complicate plans for specialization to increase value. The first is that in systems that are increasingly rewarded for a ‘whole person’ approach to care—which runs contrary to specialization. The second is that health care treatment technologies are reaching a level of sophistication that they can be a replacement for some of the work of licensed clinical professionals. The key for executive teams is using technology to address both of these issues. The first is ‘virtual integration’—creating a singular consumer data set that is available to all health care professionals. The second is to use data—both small data and big data—to develop algorithms that curate the recommendation of treatment services for specific consumers—both treatment technology and the most appropriate clinical professional. These are essentials to sustainability—building organizational efficiencies that result in competitive advantage.

For more on our coverage of efficiency and effectiveness in staffing models—and in emerging treatment technology, check out these resources in the OPEN MINDS Industry Library.

Scope of Practice Issues

Digital Treatment Trends & Strategy

Digital Treatment Developments

For more on managing and practicing at the top of your team’s skillsets, join me for The 2022 OPEN MIND Management Best Practices Institute in Newport Beach, California from August 30 to September 1, 2022.

Tech For Success: How To Assess Current Tech Functionality Readiness For Future Growth

By Joe Naughton-Travers, Ed.M.

With my work at OPEN MINDS, I’m often asked by my specialty health care provider organization clients which type of technology is the most important. My answer is always the same: it’s not about the individual technology itself, it’s about how all of the technology platforms come together and “play nice” to manage and optimize overall clinical and financial performance. Without the integration across all platforms, each are merely working in silos without the ability to use each platform’s data as decision-making guides for the organization.

In response, I’ve worked with our team of senior advisors to develop a technology platform framework for specialty provider organizations to aid in planning technology needed for the future. This framework has six domains:

#1 Electronic Health Record & Billing System — The functionality of a comprehensive electronic health record (EHR) software application.

#2 Human Resource Information System & Financial/General Ledger System — These are the two other key software applications for administrative operations. The Human Resource Information System (HRIS) is the software that maintains, manages, and processes detailed employee information and human resources-related policies and procedures. The Financial/General Ledger System is the software that tracks all financial transactions and is used to generate a company’s financial statements.

#3 Hybrid & Community Based Service Delivery Platform — Technology tools that support virtual and community-based service delivery.

#4 Consumer Experience & Engagement Platform — Technologies for enhancing consumer engagement in the health care experience and optimizing consumers’ experience with the system of care.

#5 Value-Based / Risk-Based Reimbursement Platform — Technology capabilities that support measuring value in terms of customer experience and engagement and of the cost and quality of services.

#6 Integrated Analytics & Service Performance Optimization — Software applications for aggregating and analyzing the data from all the other software systems and databases to manage and optimize clinical and financial performance.

Domain #1: A Whole Person Care Record: Comprehensive EHR Software

The first requirement is a comprehensive EHR software application for all the consumers your organization serves, and all the service lines delivered. The EHR must record the demographic and clinical data for consumers, the services they receive, and the corresponding clinical documentation. Additionally, the EHR must:

Document all referrals and referral dispositions
Support tracking performance and clinical quality metrics
Include standard functionality for medical services (e.g., e-prescribing, laboratory orders, and electronic medication administration records)
Provide support for the delivery of routine primary care services

Mobile access to the EHR (both on- and off-line) is a must, and clinical decision support for medical necessity, clinical appropriateness for care, evidence-based practices, and payer-mandated clinical pathways is highly desirable. The EHR should be interoperable with the EHRs of other provider organizations to facilitate care coordination. Lastly, the software must handle all of your organization’s billing and accounts receivable operations (including fee-for-service, bundled, case rate, and VBR payment models) and have tools for maximizing revenue collection.

That covers the technical details—the functionality of a good electronic health record. The essential questions to ask about any EHR system are:

Does the EHR help you manage whole person care for the consumers you serve?
Does it have functionality to monitor physical and behavioral health as well as social determinants of health (SDoH)?
Does it aid in care coordination with other provider organizations to achieve the best health outcomes?

If your EHR software application is not addressing these key service management functions, it is time to consider a change.

Domain #2: Managing Administrative Functions: Human Resource & Financial Management Software

The second domain helps provider organizations ensure that key administrative operations—human resources and finance—have the right software applications to meet your organization’s needs. The HRIS (human resource information system) must do more than track employees, salaries, and benefits. The HRIS also should include functionality for job applicant tracking and position control, time and attendance tracking, employee self-service capabilities, and a learning management system. A final requirement is comprehensive support for employee appraisals and development plans.

The financial management software (sometimes called the general ledger or accounting system) should have all the basic capabilities: budgeting, financial reporting, payroll, accounts payable, and fixed asset management. To support VBR contracts, the financial management software also needs to have the capability to aid in the management of the cost-of-service delivery—overall—and for individual health plan contracts. (It will need access to the service delivery data in the EHR to do this.) Lastly, this software application should have functionality for monitoring and managing health plan contracts and other payer contracts.

Domain #3: Delivering Care Conveniently: Hybrid & Community-Based Service Delivery Capabilities

This domain is more than just the telehealth services that your organization has become proficient at delivering during the COVID-19 pandemic. It includes other technologies that support and enhance your community- and home-based care delivery. Telehealth capabilities must be integrated into the EHR itself and should also be available on mobile devices so that community-based staff can bring in additional staff virtually when needed. Electronic visit verification (EVV) is needed to report that staff were physically present at consumer service delivery sites during community-based care. Smart home and remote health monitoring technologies can be used to ensure the health and safety of consumers. Secure communication between staff and consumers should be available in multiple formats (text, email, telephone, and video). Ideally, you would also have technologies that aid in route optimization for staff travel in the community as well as tools for managing these field and remote-based staff.

Domain #4: A Focus On Customer Service: Consumer Experience & Engagement Tools

Technology in this fourth domain is new to many specialty provider organizations. Consumer experience is the subjective response consumers have with any contact with your organization. Questions you might consider when evaluating for consumer experience include:

Are your services convenient and easy to access?
Are communication and other interactions smooth and painless?
Is there a personal touch to service delivery and an impression of quality?

Consumer engagement is when individuals take action to become more informed and more proactively involved in his or her health and the health care services received. There are numerous technology tools to help with both consumer experience and engagement, including:

24/7 centralized access to care
An easy to navigate website with the ability to access care and schedule appointments
A consumer portal for communication, bill payment, and health record access
Web- and app-based self-directed consumer health and well-being technologies
Enhanced social media presence
Net promoter scoring integrated into all aspects of care delivery
Appointment and health check-in reminders via telephone, text, and email

As provider organizations expand their focus on consumer experience and engagement, a key focus is to determine which technology tools they may already have to support these efforts and which they will need to acquire and implement.

Domain #5: Managing Care & Costs: A Value-Based Reimbursement Platform

The fifth domain of the technology platform framework is technology tools for managing service performance and cost. Provider organizations should assume that most, if not all, of their health plan contracts in the future will be value-based, with both upsides and downsides in terms of payment models. You’ll need technologies that monitor clinical quality metrics in comparison to contract requirements. Will these be in your EHR? In other software applications? In analytic dashboards?

You’ll also need to monitor other contract performance metrics. Examples include metrics to monitor access to care, treatment engagement, telephone and referral response time, and other industry standard metrics such as Healthcare Effectiveness Data and Information Set (HEDIS) and Certified Community Behavioral Health Clinic (CCHBC) requirements. You may also be required to track and monitor SDOH and adherence to evidence-based practices.

Other key questions you’ll want to consider about managing care and cost include:

What other technologies can better facilitate your ability to manage care and cost?
Can you accomplish this with your EHR and financial management software alone?
Do you need to invest in a better telephone system and website?
Should you implement separate technology tools for quality and performance tracking that your EHR cannot handle?

This leads to Domain #6—does your organization need business intelligence and data analytic technologies to aggregate, analyze, and present the data in a meaningful way to your staff?

Putting It All Together With Domain #6: Analytics & Optimization

The last domain uses technology for aggregating your data in a meaningful way to proactively manage your organization. This is accomplished by utilizing business intelligence (BI) or other data analytic software applications that aggregate data for analysis and performance optimization. This is the ‘holy grail’ of performance measurement and optimization, having meaningful data to report your organization’s financial strength and operational performance and to monitor progress towards strategic objectives.

Most commonly, provider organizations begin with using these technology tools to manage and optimize clinical quality and performance metrics through reporting. The next step is to implement the use of dashboards for the board of directors, the executive team, department managers and individual staff. The most sophisticated use of BI software applications for specialty provider health care organizations is for population-health management. Here, BI software applications are used to provide the analytics to improve the health of the overall population of consumers served, to enhance consumer experience, and to reduce costs through consumer segmentation and analytics.

Where To Start In Building A “Next Generation” Technology Platform

The question is how to proceed with planning for and implementing the technology functionality needed to support future growth plans. There is a two-step process—addressing both immediate functionality needs for success in the current market and assessing the technology needed to support your strategic plan.

For the first, addressing immediate functionality needs, we have created a short assessment of ‘must have’ current tech functionality—The OPEN MINDS’ Technology Requirements Checklist – Eighteen Must-Have Capabilities For Specialty Provider Organization Success. To see how your organization stacks up in this preliminary list, go through the checklist.

*OPEN MINDS’* Technology Requirements Checklist – Eighteen Must-Have Capabilities For Specialty Provider Organization Success	Yes	No	Working On It
#1 Electronic Health Record & Billing System
Does your EHR handle all your health record documentation and billing requirements?
Does your EHR have the capability to share data with other provider organizations (interoperability)?
Does your EHR have mobile access (both on-line and off-line)?
#2 Human Resource Information System & Financial/General Ledger System
Does your HRIS include functionality for job applicant tracking, position control, and employee self-service?
Is your Financial/General Ledger System chart of accounts set-up so that you can report the unit cost and case costs of all the services you deliver?
Does your Financial/General Ledger System include contract management functionality?
#3 Hybrid & Community Based Service Delivery Platform
Do you have secure telehealth technologies in operation?
Do you have electronic visit verification (EVV) in operation?
Do you have technologies in place to monitor or report consumers’ health status (e.g. blood pressure, body mass index, lab levels, etc.)?
#4 Consumer Experience & Engagement Platform
Do you have centralized scheduling or other tools that make it easy for consumers, their families, and referral sources to access care at your organization?
Can consumers communicate securely with their care providers through a web portal, text, or other technologies?
Have you implemented net promoter scores, or a similar measure, to routinely measure consumer experience?
#5 Value-Based / Risk-Based Reimbursement Platform
Does your team have a system for reporting payer-centric and consumer-centric performance metrics?
Do you have technologies in place to report timely access to care and hospitalization readmission performance metrics?
Do you have a system to report other value-based and risk-based reimbursement contract performance measures such as follow-up after hospitalization, emergency room utilization, and use of evidence-based care protocols?
#6 Integrated Analytics & Service Performance Optimization
Do you have software technologies in place that can aggregate data from your EHR, HRIS, and Financial/General Ledger System to report on key strategy metrics?
Do executives and managers have access to real-time dashboards for key performance and operational metrics?
Does your staff know how to interpret and use the data that is available to them for performance management (data literacy)?

This checklist provides an assessment of basic technology-enabled management capabilities. Where there are gaps in these management capabilities, management teams should develop a plan to meet these functionality basics. If there are functionality deficiencies in Domain #1 and #2 (the EHR, HRIS, and GL systems) these should be an area of immediate focus.

Beyond these basic areas of tech-enabled management capabilities, executive teams need to also crosswalk their strategic plans with the tech requirements to support those strategic initiatives. For more on that process, see From Strategic Plan To Tech Strategy: Building Your Crosswalk.

Looking ahead, every executive team member—and not just the CIO or CTO—need to focus on the coming digital transformation of the health and human service field—and the strategy and technology needed to succeed.

Metrics-Based Management: Using Analytics For Strategy Implementation & Business Optimization

By Joe Naughton-Travers, Ed.M.

If you have great staff and great infrastructure, your organization still needs a strong management team—and management practices—to make sure that organizational plans to deliver great performance becomes reality. To do this, management teams need well-designed, real-time performance metrics. In successful organizations, metrics-based management happens in two contexts: managing strategy implementation and optimizing business operations. The key is to ensure you have the right data and the right analytical tools to report these performance metrics.

Managing Strategy Implementation

The use of metrics in implementing a strategic plan is considered a core element of strategic management built around key performance indicators (KPIs). Simply put, KPI’s are the ‘metrics’ that measures progress towards your strategic objectives, as well as whether your organization has achieved them. Some metrics are a direct measures of success. For example, if a strategic objective is to operate at a 10% positive financial margin, then the KPI for this objective is the margin, which is reported at least monthly. In other instances, you may choose process or proxy metrics that measure progress made in various initiatives to accomplish a particular strategic objective.

There are four important steps to selecting these KPIs and managing strategy implementation:

Step #1: Start with your strategic plan. It should have a short list of quantifiable strategic objectives, initiatives for accomplishing them, timelines, assignments, and budgets.

Step #2: Select metrics for success. These are your key performance indicators (KPIs) calculated from obtainable data that indicate organizational performance in progressing toward and accomplishing strategic objectives. An effective KPI is specific, measurable, and actionable. Use a ‘balanced scorecard’ framework that includes metrics that report financial performance, customer performance, organizational innovation, and effective internal operations.

Step #3: Create a KPI reporting system. Ideally, this is from a business intelligence (BI) or data analytics software application that includes management dashboards to report the metrics, showing a comparison to the performance trend from past to present. Minimally, the KPIs are reported monthly with the trend data as well as against performance targets. This reporting system and its use communicates the importance of the organization’s strategic objectives and the executive team’s focus on them. As Peter Drucker said, “You can’t improve what you don’t measure.”

Step #4: Coach your staff to use the KPIs. Engage in ongoing monitoring and proactive management using the KPIs with your executive team and staff. Modify the KPI metrics if needed to ensure progress in implementing your organizational strategy.

Much has been written about the development of KPIs and models for selecting both leading and lagging financial and non-financial indicators of performance. The challenge, beyond selecting the measures, is two-fold: developing the ability to routinely report the measures using data from existing software systems or databases (or expanding current information systems to collect the data) and analyzing the KPIs monthly to develop or update organizational strategies to improve performance.

Optimizing Business Operations

Metrics-based management also plays a key role in optimizing business operations for specialty provider organizations. What exactly is business process optimization? It is the management discipline that promotes efficiency and effectiveness of organizational process—employing methods, policies, management practices, software tools, and metrics to optimize an organization’s activities across the business process life cycle.

Optimizing business operations is critical for provider organizations. All aspects of service delivery (referral, admission, routine services, and discharge or transfer) and administrative operations need to run smoothly. Processes should be standardized to be effective and consumer and staff friendly. Data and analytics are critical tools for doing this.

Organizations that have superior process management performance share a few key competencies—corporate strategy that is connected to performance indicators as described above, process and project management expertise, deliberately designed process models that promote service quality, access to information, support of management for process improvement initiatives, and incentive-focused employee compensation.

It sounds simple. But if business process management is so simple, why do so many organizations have bad performance from bad processes? Author Janne Ohtonen, in an article titled, “Enabling strategic growth and improved performance through Business Process Management,” offered some interesting insights. His list of the ten key capabilities needed to be successful with business process management and optimization include:

Co-workers have confidence and trust in each other
There is open communication between employees and managers
Managers share vision and information with employees
The organization is able to respond to changes in markets quickly
Senior management has confidence and trust in managers
There are efficient communication channels for transferring information
The organization has appointed people responsible for processes
The organization extensively uses information systems
No one has to worry about losing his or her job because of process changes
Managers support changes in processes

How does your organization stack up in terms of using data and analytics to drive strategy and to optimize operations? Your team can’t perform or manage without the metrics to support both of these. In fact, I would argue that, beyond strategy, metrics and metrics-based management competency are the most fundamental ingredients for organizational success for providers in today’s market. Why?

I’ve seen executive teams of organizations with all sorts of other competencies—but with no access to timely performance metrics or the ability to use them—fail to optimize performance. Without real-time performance metrics for your management team:

Identification of performance issues is often delayed
Organizational performance relative to competitors is more a matter of opinion than a measured achievement
The identification of performance problems requires constant observation—and is often anecdotal
The “causes” of poor performance are harder to identify (and often the subject of disputes between team members)
It is difficult to sort out persistent performance problems and separate “trends” from short-term issues
It is challenging to prioritize operational improvement initiatives and investments

I could go on…

If current performance data is not the focus of your management team meetings, it will be more difficult for your team to respond to evolving consumer and payer demands, a rapidly changing health care market, or emerging competitive threats. I liken it to flying blind; the airline pilot without the dashboard.

Key elements of an organization with metric-based, performance-driven culture:

Visible metrics—both customer-centric and organizational—and the data and analytical tools for reporting them routinely
Actionable insights based on rich data and identification of the actions needed to improve performance
Clear team member accountability for specific performance metrics
Real-time performance feedback at all levels of the organization
Targeted coaching based on performance data with individualized goals to improve team member performance
Recognition of great performance
An interactive strategy and budgeting process
Nimble and data-driven service line reengineering and development

So, collect the data and teach staff how to use metrics and analytics to improve your business operations and achieve your strategic objectives. Metrics-based management is one of those “must develop” competencies for health and human service organizations. Organizational performance—including financial, service, quality, compliance, etc.—matters more to the sustainability and success of organizations every passing year.

How To Manage The 5% With Multiple Chronic Conditions & Complex Support Needs

By Monica E. Oss
There is a lot of investment money going into the mental health field—in fact, $14.7 billion in the first half of this year (see Why Are Digital First Mental Health Companies So Popular?). Much of that investment is focused on digital behavioral health systems and tools for both professional and self-care.

However, these new platforms and tools are not the perfect fit for every consumer with a mental illness. In fact, 25% of consumers with any mental illness have a serious mental illness (SMI). In all, 13.1 million consumers, or 5% of the total United States population, have an SMI (see Key Substance Use & Mental Health Indicators In The United States: Results From The 2019 National Survey On Drug Use & Health). Of consumers with SMI, 27% have co-occurring substance use disorders. We also know that SMI consumers on average tend to die 10 to 25 years earlier than the general population—and have a mortality rate that is twice as high as that of the general population because of chronic physical medical conditions such as cardiovascular, respiratory, and infectious diseases; diabetes; and hypertension (see Premature Death Among People With Severe Mental Disorders). 20% of the SMI population lives in poverty Approximately 20% of jail inmates and 15% of state prison inmates have an SMI (see Mental Health & Criminal Justice). 33% of the homeless population has an SMI (see 250,000 Mentally Ill Are Homeless. 140,000 Seriously Mentally Ill Are Homeless).

For the approximately 5% of the population—those with multiple chronic conditions and complex support needs—that use a majority of the health care resources, a different approach is needed to assure good consumer outcomes and prevent inappropriate use of resources. That population was the focus of our recent discussion with Carole Matyas, Vice President, Operations at Sunshine Health, and the keynote speaker at the upcoming 2021 OPEN MINDS Executive Leadership Retreat.

On September 22, Ms. Matyas will deliver the keynote address, The Future Of Managing Care For Consumers With An SMI—What Works. The cornerstone of progressive interventions for the high-risk/high-needs population with a serious mental illness is based on a “whole person” treatment strategy that encompasses medical, behavioral, pharmacy, social needs, and caregiver collaboration and coordination. Ms. Matyas will review Sunshine Health programs that are showing promising positive outcomes such as reduced use of acute/crisis care, better engagement with primary care that improves medical health outcomes and addresses high comorbidity issues, stabilized community-based living environment by addressing social needs for the enrolled Medicaid and Medicare members served. She will provide an overview of their Long Acting Injectable (LAI) program with data that demonstrates reductions in emergency department and inpatient services, and increase in community-based and medical services for members.

My takeaway from our pre-Institute discussion with Ms. Matyas? The Sunshine Health approach to optimizing the management of consumers with an SMI has four key components—intensive case management to assure care coordination, leveraging long-acting medications, a focus on primary care, and addressing social support needs.

Intensive case management to assure care coordination. One approach that has improved outcomes for SMI consumers is intensive case management. Sunshine Health took its top 400 high-needs, high-risk consumers (who have 30+ hospital admissions a year, go to the emergency room every other week, and reject any type of community-based treatment) and had its staff provide proactive and intensive case management services in collaboration with a host of community provider organizations and stakeholders. For example, case managers work closely with a telehealth provider organization that Sunshine Health contracts with to ensure that consumers discharged from hospital have their seven-day follow up appointment virtually and then connect them with an outpatient provider organization for ongoing care.

Leveraging long medications. Sunshine Health has been encouraging provider organizations to use long-acting injectables (LAIs) for antipsychotic medication administration. Ms. Matyas shared that SMI consumers receiving monthly LAIs have shown significant stabilization in their mental health and also do better at getting care for their comorbid medical conditions, engage with peers socially, and are even able to have part-time employment. She said, “We are promoting use of LAIs and really going a long way in working with hospital systems, primary care physicians, and mental health providers to make it easy to obtain those medications, administer them, monitor, and do outreach so members continue treatment. While the medications can be expensive, the results definitely show reductions in hospitalizations, readmissions, and emergency room visits as well as better outcomes from community-based treatment.”

Sunshine Health has a number of strategies to increase the use of LAIs. They do not require provider organizations to obtain prior authorizations to administer LAIs. In addition, if clinical professionals start an LAI when a consumer is in the hospital, case managers make sure to follow up with the consumer to make sure they get to the outpatient provider organization for their next dose when it’s due. They also have a “concierge program” within their pharmacy network and customer service representatives call members to schedule an appointment for their next LAI dose. Some pharmacies are also authorized to administer the LAIs. Sunshine’s provider relations team is charged with providing information about LAIs to community mental health and primary care provider organizations.

Ms. Matyas said, “We have a goal of increasing long acting injectables 25% year over year. During the pandemic, we had interruptions with folks getting their long acting injectables, but we are working towards getting back to normal state, which is encouraging.” And now there are two barriers to overcome to extend the use of LAIs, she added. The first is adherence which becomes challenging when consumers are say, cycling in and out of homelessness and are not stable in their environment or engaged in their treatment. The other issue is that there’s a history of long acting injectables not getting authorized by managed care. So provider organizations need to be educated and learn that “they don’t have to jump through a lot of hoops” to be able to prescribe LAIs if appropriate for the consumers.

Focus on primary care. Sunshine Health is encouraging provider organizations to go the integrated care route by participating in health home models and value-based reimbursement (VBR) models. They are also leveraging data to encourage collaborations and equipping primary care provider organizations to better address the needs of SMI consumers. Recently, they launched a behavioral health home program and seven community mental health centers have signed up to date. These centers have co-located primary care and behavioral health services and are delivering whole-person care under value-based contracts.

VBR is the cornerstone for integrated care. Sunshine Health offers incentives for provider organizations to address “gaps in medical and behavioral care.” In the behavioral health homes program, the incentive program is contingent on preventive health screenings being conducted for all consumers and on addressing the comorbidities that SMI consumers have. All provider organizations in Sunshine’s network—whether they are primary care practices or community mental health centers—are expected to address comorbidities and to report on the array of HEDIS measures related to both medical and behavioral care. Ultimately, Ms. Matyas explained, “The goal is to move more to value-based care, where we can impact members by having them in a health care environment so that they don’t have to go eight different places to get the care they need. They should be able to be more easily referred and seen, for whatever service it is they need. Value-based care incentivizes providers to work together without dictating a one-size-fits-all model.”

Sunshine Health embeds behavioral health services in primary care and offers psychiatrists who can consult on prescribing patterns and other issues in the care of SMI consumers. Ms. Matyas explained, “Every member covered by us is assigned a primary care provider regardless of whether they have an SMI diagnosis or not. So every one of the 5% of our 2.6 million members with SMI has a primary care physician. We take the data to our primary care practices and say, ‘Here are the demographics of the population assigned to you and here are the care gaps.’ The primary care practices will tell us whether they can handle the whole-health needs of these SMI members or want us to move them to a different provider. Or the practices may say they are equipped to handle some things but not others. So then we bring in behavioral health quality practice advisors to work with them, or we move the SMI members to a primary care practice that is better suited to work with this population.”

Addressing social support needs. Sunshine Health addresses social determinants of health (SDOH) in a variety of ways. Many of their behavioral health provider organizations have robust case management programs and the case managers connect consumers to social supports as needed. The health plan maintains a database of community resources that these case managers can access on request. They also offer micro grants to small community projects that support social needs. Some of their Medicaid programs, like the SMI specialty plan, have expanded benefits such as housing rental deposit or one month’s advance rent to help consumers get into housing. They’ve distributed cell phones and tablets for consumer use. SMI consumers get $35 a month in over-the-counter benefits from CVS to buy non-prescription items.

The fact that health plans are looking at primary care as the hub for SMI treatment should be a wake-up call for specialty provider organization executives who believe that their niche in serving this population assures a steady stream of business. Assuming responsibility for the whole-person care (medical, behavioral, and social) of the SMI populations served and participating in value-based arrangements are becoming the basics for sustainability planning.

Addressing Social Determinants As A Path To Revenue Growth

By Monica E. Oss

Over the last 15 years, there have been many pilot projects by payers, health plans, and public and private entities to address social determinants of health (SDOH). In the past couple years, we’ve heard from several health plan executives about their SDOH initiatives (see Mind, Body, Community: Kaiser Permanente’s Unique Approach, Innovation: Tag, You’re It, ‘Leaning In’ To Medicare: Social Needs Opportunities, Will Investing In Social Determinants Pay Off, Housing = Health: The Five Levers, and Medicaid Wants More Than Health: Be Prepared For Contract Changes). We’ve seen many new SDOH program launches by health plans—UnitedHealthcare’s recent Empowering Health grants, Humana’s Bold Goals program, Horizon Blue Cross Blue Shields of New Jersey’s Neighbors in Health program, and North Carolina Medicaid’s Healthy Opportunities Pilots, to name just a few. And there are the requirements to address SDOH under new Medicaid managed care contracts in a number of states (see Medicaid Authorities & Options To Address Social Determinants Of Health).

For specialty provider organizations, the question is how to address SDOH—and find a funding stream to do just that. Previously, we outlined the two paths to adding social service supports and supports coordination to traditional service lines. One way is to add a social supports coordination element that will get more referrals or improve reimbursement under value-based reimbursement arrangements—and pay for itself as an enhanced service feature with more total revenue for existing services. The other way is to build social supports programs that health plans or government payers will reimburse—and build a new revenue stream. Whatever option an executive team chooses, return-on-investment analysis is key. I wrote recently about our six-step model for assessing the effectiveness (both proactively and in practice) of enhanced social service programming in Building An ROI For Social Service Referrals.

We heard two great case studies of provider organizations that are taking the second path— building service lines for social services with payer/health plan revenue—during the session, Incorporating Social Determinants Of Health Into Your Practice To Improve Patient Outcomes & Increase Reimbursement at last week’s 2021 OPEN MINDS Management Best Practices Institute (session recordings and decks are available at https://openminds.com/live-mbpi/sessions/ until September 27). June Simmons, President and Chief Executive Officer of Partners in Care Foundation and Karin Annerhed-Harris, Vice President, Business Development at Resources for Human Development (RHD), shared how they are working with health plans on unique initiatives to address SDOH for complex consumers.

*June Simmons, President & CEO, Partners In Care Foundation*

Partners in Care Foundation builds community networks to provide a single point of access for consumers. Partners in Care contracts with health plans—and sometimes with health systems—to provide care management and home and community-based social services. Their goal is to integrate all community health resources and supports into a seamless delivery system for easy access and management. Ms. Simmons said, “If you’re just referring Ms. Smith to go down the street where they provide meals, it’s one thing. But if you’re paying for something, it’s a whole new paradigm. And sometimes you’re going to have to pay for care coordination and concrete services on a targeted basis.”

Partners contracted with Blue Shield of California (BSC) in 2014 to provide SDOH services to BSC consumers through primary care practices. BSC pays Partners for specialized staff—community health advocates (CHAs)—who are trained and supervised by PIC, and embedded in medical practices. To date, Partners has trained and placed 70 CHAs in three years. CHAs assess and analyze consumer needs, work with consumers on care planning, connect them to services, follow up, and track outcomes. The relationship with BSC has grown since over time, with Partners providing a variety of SDOH-related services.

Partners also operates specialized Outreach and Engagement Centers for Anthem in California, Georgia, Colorado, and Virginia. Through these centers, they develop care plans, engage with consumers, and make sure they get the needed social services. “You can take a horse to the water but you can’t make it drink. So engagement is crucial to ensure that consumers actually use the services they are connected to and that’s why the health plans partner with experts like us.”

For health plans, the benefit is in contracting with a single entity that manages the comprehensive network of social care. Access to supports becomes easier for consumers. Data sharing between the health plan and community-based organizations is also streamlined and simplified. Ms. Simmons said, “So if you’re a health plan and want to address a certain population—maybe it’s young moms and kids, maybe it’s frail elders and keeping them out of the nursing home—are you going to go out and identify all the agencies involved, organize them, and contract with them? Or would you like a lead entity that’s going to do that for you—curate the services, qualify the agencies, be the central intake, the oversee the quality, and do the billing?” Working with a trusted local entity is a far more practical and efficient route for health plans in Ms. Simmons’ opinion. She said, “A more mature community entity can bring their neighboring health and human service provider organizations into an organized delivery system, so consumers don’t have to be referred to multiple entities.”

*Karin Annerhed-Harris, VP, Business Development, Resources for Human Development*

Resources for Human Development addresses food and housing needs. RHD provides outpatient and residential services for consumers with mental illness, substance use disorders, and intellectual and developmental disabilities. RHD partnered with Temple University Hospital and two managed care organizations (MCOs)—Health Partners Plans and Keystone First—to pilot the Housing Smart program. The program was intended to reduce avoidable emergency room utilization and hospital readmissions among homeless individuals through peer outreach, supportive services, and subsidized housing resources.

The MCOs agreed to criteria for eligibility and generated a list of member referrals for RHD. RHD provided the high-users experiencing homelessness with access to housing vouchers that are good for two years. The consumers were housed in apartments across Philadelphia and local food banks provided three meals a day for three months, followed by cooking classes. The pilot resulted in a 74% drop in emergency room use, 48% reduction in hospitalizations, and a 76% increase in outpatient hospital visits. And with stable housing, 12 consumers in the program are actively engaged in behavioral health outpatient services.

At the outset of the program, Temple generated a list of eligible people using target population criteria and shared that with the MCOs. They enrolled 25 high utilizers prioritizing consumers with opioid use disorder, persistent mental illness, and co-occurring physical health conditions. RHD used an MCO-funded team comprising a peer support specialist, care coordinator, and tenant services coordinator to engage consumers in services. While the MCOs reimburse for services, 36% of the program is grant funded and goes toward housing, Ms. Harris said. RHD is exploring expanded health plan funding, now that Pennsylvania allows health systems and MCOs that can save money through a value-based agreement to use the profits to fund housing.

Lessons learned—partnership, evidence-based interventions, data sharing, and more. Ms. Simmons shared the four key elements for successful integration of SDOH—strong partnerships to form a comprehensive community network of care, the capacity to deliver home-based services, the use of good screening tools to assess consumer needs and preferences, and the delivery of evidence-based interventions for SDOH.

At RHD, Ms. Harris attributes the success of their pilot to robust partnerships and collaborations (between provider organizations, a health system, health plans, and other community organizations); cross-sector tools and training; and data sharing to enable a holistic view of consumer needs, goals, and care gaps.

The takeaway for provider organization executives? As my colleague and OPEN MINDS Senior Associate Cathy Gilbert, who moderated the session, said, “Entrepreneurial provider organizations have the opportunity to package many consumer support services that were previously not reimbursable and turn them into new revenue streams in partnership with plans. Providing these services drives better outcomes for consumers and ultimately reduces overall costs.”

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