Implementing innovative service changes with a focus on value-based care and reimbursement often involves identifying how to provide more effective service outcomes through coordination-of-care and integration of services – internally and with other community providers. A good model for this change in focus is the Certified Community Behavioral Health Clinic (CCBHC). The CCBHC service model was created and funded on a demonstration basis with the Excellence in Mental Health Act (EMHA). The EMHA created a new Medicaid provider type requiring participating organizations to provide, or contract for, essential services for individuals needing behavioral health and substance use disorder services to ensure accessibility, care coordination, and service integration. Eight states were selected for participation in the two year demonstration beginning in 2017 – Minnesota, Missouri, Nevada, New Jersey, New York, Oklahoma, Oregon and Pennsylvania. We recently had the opportunity to talk with Chad Van Houten, Chief Financial Officer of Zumbro Valley Health Center, one of six CCBHCs that were created in Minnesota. Chad shared with us the opportunities and challenges of creating a new value-based service line.
Implementing a new innovative service creates challenges impacting culture, communications, and infrastructure. For Zumbro Valley Health Center, the model encompassed 60% of the program and 80% of clients across multiple programs, and involved almost all staff. A key requirement when reviewing current workflows was having open communication with staff, and continually asking the question, “Will this help improve client access?” Training sessions were implemented initially so that staff understood the new focus and requirement. Key consumer workflows were then redesigned, starting with intake and insurance coverage to determine whether consumers were covered by CCBHC services and funding, or another source. This caused therapists to begin to think about the services available to consumers based on their payer, and created more streamlined and better communication to maximize those services. Another challenge was keeping the state, as funder, in the loop with open communication. Pilot programs don’t always go as planned and unforeseen issues come up such as administrative bottlenecks, or conflict with other state mandates. Addressing these challenges required frequent pre-implementation and post-implementation meetings to identify unanticipated issues and collaborative work to identify solutions.
To address the significant shift in culture required by the new service model, leadership staff had to continually ask the question, “How does this impact staff?” This focus provided both an opportunity to identify issues, and engage staff in solutions to address those issues. Therefore, establishing a process for clear, open, and ongoing communication was critical. Helping staff understand how the design of the CCBHC would improve client outcomes created a common point for creating cultural and operational change.
Chad also described the changes in technology and data reporting necessary to create a focus on outcomes. The CCBHC reimbursement rate in Minnesota is a bundled rate based on the prospective (anticipated) cost of services and an estimate of potential consumers. A daily charge is created when a consumer receives one, or any number, of services in a day. Their EHR was already configured to work with bundled rates, however they engaged assistance to set up the new service and billing codes, ensuring that only one bill would be created daily per consumer. Getting the data needed to drive and report outcomes was the bigger part of the challenge of measuring quality outcomes. This entailed creating agreements and accepting data from other providers, and implementing a process for consumers to self-report information.
An important aspect of tracking data was having the right staff skills available. Zumbro Valley Health Center increased their resources in this area, hiring an analyst to work the clinical and financial data. This was critical in achieving their operational target since the reimbursement rate was based on anticipated costs, and tracking actual results to estimates ensured alignment with the operational plans. Precise plan execution was important to ensure that the estimated rate remained accurate for the future, for example, making sure that staff were hired when planned. Having a data analyst was helpful because that person had the knowledge and skills to manipulate large amounts of data to meaningfully inform staff about services and create the cost reporting required by the state.
To drive and monitor performance against contracted outcomes, the organization developed key metrics for each director of the organization. This involved a process of identifying outcome targets, determining data sources, and capturing and reporting data. Teams met bi-weekly, or monthly, as needed, to identify outcomes that were off course and collaborate on corrective actions. Chad came from a manufacturing background prior to behavioral health, so he was familiar with this focus on data. This focus was fairly new to the organization as a whole, so time was spent creating a data-driven culture – emphasizing the role of data to ensure the best outcomes – and the skills needed to work with data. These skills included capturing and analyzing the right data and sharing the results in a meaningful, informative dashboard for staff comprehension.
When asked to identify the two top lessons learned in implementing the CCBHC, Chad said, “When you implement, you think that you have a good process. But you need to stop periodically, and look at things from the consumer perspective. If something is cumbersome, then identify a new process. It’s all about access and making integrated services available when they are most needed.”
Because of the focus on consumer access – the services needed, when they are needed – along with care coordination, integration, and a focus on outcomes, Minnesota has committed resources, continued funding of the six CCBHC and plans to expanse the service model to two additional providers. For more on innovative value-based services, see:
Building An Infrastructure For Data-Driven Performance: An Executive Guide For Success In A Value-Based Market – https://vbcforbh.com/building-an-infrastructure-for-data-driven-performance-an-executive-guide-for-success-in-a-value-based-market/
Rate Setting For Value-Based Reimbursement: A Guide To Developing Capitated Payment Models – https://vbcforbh.com/021519ratesetting/
Value-Based Reimbursement: 3 Steps To Go From Idea To Action – https://vbcforbh.com/value-based-reimbursement-3-steps-go-idea-action/
Health Homes, Specialty Health Plans, CCBHCs. Oh My! – https://www.openminds.com/market-intelligence/executive-briefings/health-homes-specialty-health-plans-ccbhcs-oh-my/
Successfully Managing Bundled Rates—The Voice Of Experience – https://www.openminds.com/market-intelligence/executive-briefings/successfully-managing-bundled-rates-the-voice-of-experience/