Planning Effective. Workflows & Payment Models

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Planning Effective

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Collaborative Care

Workflows & Payment

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Models

Virna Little PsyD LCSW‐r SAP Virna Little, PsyD, LCSW‐r, SAP

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‘ ’ TWO PROCESSES TWO NEW ‘TEAM MEMBERS’ collaborate with PCPs Care Manager Consulting Psychiatrist Ca e a age Co su t g syc at st 1. Systematic diagnosis and outcomes tracking

e g PHQ 9 to facilitate diagnosis and

‐ Patient education / self‐ management support ‐ Close follow up to make sure ‐ Caseload consultation for care manager and PCP (population‐based) ‐ Diagnostic consultation on difficult e.g., PHQ‐9 to facilitate diagnosis and

track depression outcomes patients don’t ‘fall through _{the cracks’} cases

2. Stepped Care ‐ Support anti‐depressant Rx by PCP ‐ Consultation focused on patients not improving as expected a) Change treatment according to evidence‐based algorithm if patient is not improving ‐ Brief counseling (behavioral activation, PST‐PC, CBT, IPT) ‐ Facilitate treatment change /

referral to mental health

‐ Recommendations for additional treatment / referral according to evidence‐based guidelines b) Relapse prevention once patient is improved referral to mental health ‐ Relapse prevention

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Workflows

• Why workflowsWhy workflows

• Workflows after financing

il • _Detail • _Training

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Patient Presents for Medical Care  PHQ‐2 BPA Fires OR  Patient presents with Depressive Symptoms, including Sadness, feelings of Helplessness/Hopelessness, Fatigue, Chronic body or headaches PHQ‐2 Administered  Utilize PHQ‐2 SmartSet to document result  Who: Nursing Patient Scores Negatively (No “yes”) Administer GAD‐7 Who: Nursing Patient Scores Positively (one or more “yes”) Administer PHQ‐9 Who: Nursing

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Who are You ?

• FQHCFQHC • Article 28 primary care i l 3 l h l h ( G d G) • _{Article 31 mental health ( APG and non APG)} • _{Article 28 Hospital Outpatient}

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Article 28 Mental Health

• FQHC have behavioral health billingFQHC have behavioral health billing • Article 28 has limits in New York C i bill bl • _{Care management is not billable} • _{Case management is not billable} • _{CCI care management services are not billable} in article 28 non fqhc centers q

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What to do ?

• Integrated licensureIntegrated licensure

• Article 31 on premises or within organization

ddi id i i l i

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Review Payer Mix

• What payers does your organization or BHWhat payers does your organization or BH services get reimbursement from

• _{Review guidelines for each payer‐ are services} part of the contract or do they need to be added • _{Does the payer reimburse for all credentials, i.e.}

social workers vs. counselors social workers vs. counselors

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Make A Grid

• What payers are involvedWhat payers are involved

• _{List all of your payers Individually‐ remember} some have more then one plan

• List all of your billable staff • List all of your billable staff

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ORG NAME Individual Psychotherapy

payor mix LCSW LMSW LMHC LPC PCP Psycho Psychi RN NP/PA MA Ph.D

Medicare

Medicaid

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Contracts

• Can be second source if a provider or code is notCan be second source if a provider or code is not billable

C t t l b li f th ti bl

• _{Contrary to popular belief they are negotiable} • If you don’t ask (is this the best rate you are

offering in this state ?)

• Check with other CCI project membersCheck with other CCI project members

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Credentialing

• Not to be confused with professional appointmentsNot to be confused with professional appointments • Why should I bother if most of our patients are Medicaid? Medicaid? • What if my organization doesn’t credential behavioral h l h id ? health providers? • Subject to reviews by credentialing organizations Takes a long time‐ Delegated credentialing is a goal

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Abstract Dollars

• Can help support IMPACT workCan help support IMPACT work

• Will vary by organization/setting/payer mix • Time spent with PCP

N h t f PCP i lt

• No show rates for PCP, specialty care • Medication adherenceMedication adherence

• Emergency room visits/utilization • Productivity for behavioral health

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Quality Dollars

• _{Disease Management industry}_g _y – _{Potential to have care management paid for ( at} your site vs. by phone ) • Brings in additional dollars above wrap • _{Showcases your program/project} • _{Offer to be a “ pilot”} • _{Gain sharing agreements} • Health Home or ACO

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Optimize By

• Knowing what you should be paid for allKnowing what you should be paid for all services

• _{Reviewing work flows, opportunities to} maximize revenue

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Medicare Does Pay For

• Two Visits on the same dayTwo Visits on the same day • _{Incident too visits}

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Getting Paid What You’re Due

Getting Paid What You re Due

• Look closely at EOB’sLook closely at EOB s

– Not all payments are correct Review and Track your Denials – Review and Track your Denials

– May see PCP denials for depression dx

• _Review:

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Behavioral Health Billable

• _{Progress notes vs psychotherapy notes}

Documentation

g p y py

• _{Included in compliance}

• _{Many have not billed before or have not had}

oversight in article 28 settings

• _{Clear meaningful progression}

• _{Treatment plans}

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The Documentation Linkage

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Psychosocial Assessment

Treatment Plan

Progress Notes

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The Documentation Linkage

• DiagnosesDiagnoses • Strengths/Challenges • Assessed Needs/Personal Goals

Psychosocial

• Goals and Objectives • Should link to assessed needs and goals from

Treatment

Plan

initial assessment

Plan

P

• Interventions • Clinical progress

Progress

Notes

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Most Common Deficiencies*

Psychosocial Assessments:

Most Common Deficiencies

• Not enough symptom information in assessment to support diagnosis • Not capturing clinical baselines • No documentation that clients were given the opportunity to identify their own goals for treatment

*Based on NYSCRI regulatory review *Based on NYSCRI regulatory review

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Continued…

Treatment Plans

Continued…

• _{Not completed within required timeframes (90} days) days) • _{Goals are not clearly related to assessed needs} • _{Interventions not included} • _{Evidence Based Interventions} • _{Goals and Objectives‐Measurable}

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Contents of Behavioral Health Notes

• _{Reason for visit} • _{Review of symptoms} • _{Clinical Interventions} • _{Clinical Interventions} • Plan‐progress towards treatment plan goals

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Questions

j @i i 2000