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Turning High-Utilizers into Partners: Pay for Success & Behavioral Health
- 1. Turning High-Utilizers into Partners Pay for Success (PFS) & Behavioral Health
- 2. About Telecare Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 2
- 3. PFS Model: Why Now? More PFS Models to Come Increased Attention & Funding Likely Growing Opportunity for Innovation and Impact • $100M in federal funding • 1115 & Specialty MH Waivers – renewal in 2020 • More focus: value based purchasing Resources: Urban Institute Social Impact Partnerships to Pay for Results Act (SIPPRA) Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 3
- 4. Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 4 What are the most difficult system of care challenges you face with county MH clients?
- 5. PFS Model: Potential How Does PFS Relate to These Larger System of Care Challenges? • Effective across systems • Reduces barriers within the system • Creates new strategies for collaboration • Shared effort to address shared system challenges Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 5
- 6. PFS Model: Goals Connect private sector Jump-start innovation Increase social service rigor Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 6
- 7. PFS Model: Highlights Investors Partnering with Government Incentives for Outcomes Impact Measured over Time Data-Driven, Rigorously EvaluatedResources: payforsuccess.org/learn/basics/ Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 7
- 8. Tell us about the complex individuals not well served in your system of care What 4 Words Come to Mind? Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 8
- 9. Our PFS: Typical Partner Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 9 Accept all Referrals • We See It All – Complex Needs Mental Health (psychosis, mania, depression, anxiety…) Active Substance Use Physical Health (diabetes, hypertension, hyperlipidemia…) Complex Life Needs (unhoused, not working, isolated, history of violence) Meet Enrollment Criteria High Utilization SMI (severe MH diagnosis) Life Needs can be met Randomized In/Out Partners in Wellness Control Group
- 10. Cristiano Age 41 Schizoaffective Disorder, Bipolar Type Before Graduated high school 6 years as plumber Age 25, first break For 14 years In PES 2-3 times a year (assault, drunk & disorderly) In outpatient case management, including forensic Meth & Alcohol Unhoused First 6 months of 2016 in PES, Jail, IMD Dec 2016 randomized into our program Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 10 0 0.5 1 1.5 2 2.5 3 3.5 4 CrisisResidential UrgentCare(episodes)PES(episodes)IM D (m onths) AcuteHospital(m onths) Year Prior Year Prior
- 11. Cristiano Age 41 Schizoaffective Disorder, Bipolar Type Before Graduated high school 6 years as plumber Age 25, first break For 14 years In PES 2-3 times a year (assault, drunk & disorderly) In outpatient case management, including forensic Meth & Alcohol Unhoused First 6 months of 2016 in PES, Jail, IMD Dec 2016 randomized into our program Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 11 His Goals: obtain independent living get off probation reduce alcohol & meth get off conservatorship volunteer in community
- 12. Our PFS: Clinical Services Partnerships Whole Health Data- and Performance- Driven Treatment Flexible Array of Clinical Services Self Management Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 12
- 13. Our PFS: How It’s Different Pay for Success • Responsible in & out of program • Highest risk population, can’t say no to referrals • Accountability (even after graduation) • Outcome measures • At risk – financial/clinical Typical Outpatient Mental Health • Responsible within clinic • Discretion on referrals • Accessibility ends with episode • Process measures (typically measure access) • Fee for Service Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 13
- 14. What would you most like to hear about next? Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 14 o CLARIFY: Goals of PFS o CLARIFY: PFS Model o NEW: Key Criteria for a PFS Project o NEW: Flow of PFS Data, Services, and Funds o NEW: Steps in Building a PFS Project
- 15. Key Criteria for a PFS Project 15 Source: Santa Clara County Pay for Success Case Study provided for RFP Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com
- 16. Social Impact Bond Overview: Flow of Funds and Services Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 16
- 17. Project Selection Release RFP on Acute Mental Health PFS Project Selection Project Launch Begin Budget Negotiations Service Delivery; Begin evaluation of outcomes Select Lead Agency Formal Announcement Determine success metric definition Launch Ramp-Up MAY 2015 DEC 2014 JULY 2015 AUG 2015 JUNE 2016 JAN 2017 • Finalize project design, programmatic details, operational plan, evaluation design and economic model • Determine target outcomes and intervention impact • Contract negotiations between stakeholders • Board of Supervisors approval, MOU, Press Releases • Determine target outcomes/measures tied to payment • Begin ramp-up period prior to full project launch • Pilot service delivery Project Construction Timeline Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 17
- 18. Our PFS: Lessons Learned Data matters (historical data analysis & modeling, real-time data dashboards, leadership comfort & skill) Reduce novelty (new customer, new program- type, new payment model) Organizational size & culture matter (entrepreneurial, bench strength, investment) Relationships & candor are vital (internal, customer, system of care) Share the risk (reputation and financial) Triple check high-risk costs (housing) 18Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com
- 19. Our PFS: Clinical Impact Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 19
- 20. Our PFS: Financial Impact (1st year, preliminary) Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 20
- 21. What have you heard that excites you or seems to offer promise to your system of care? Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 21
- 22. For Hospitals: Practical Benefits Challenging Partners Served More Quickly & Effectively Conserving resources for other community needs Moving People Out of ERs to Appropriate Levels of Care Reducing Disruption in Waiting Rooms, ER, Etc. Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 22 Resources: Telecarecorp.com/pfs
- 23. Cristiano Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 23 Schizoaffective Disorder, Bipolar Type Progress on His Goals Obtain independent living Get off probation Reduce alcohol & meth use Get off conservatorship Volunteer in community
- 24. Cristiano Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 24 His Outcomes: Whole Health 0 0.5 1 1.5 2 2.5 Hope (HHI) Alcohol(AUDIT) Drugs(DAST) Depression (PGQ-9) Anxiety(GAD-7) Blood Pressure LDL("Bad"Cholesterol) BM I Sm oking (CO) Admission Current
- 25. Cristiano Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 25 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 Crisis Residential (months) Urgent Care (episodes) PES (episodes) IMD (months) Acute Hospital (months) Year Prior First 12 months Next 10 months His Outcomes: Utilization
- 26. Telecare Corporation www.telecarecorp.com Faith Richie, SVP of Development, frichie@telecarecorp.com Shannon Mong, Director of Innovation, smong@telecarecorp.com In 2015, Telecare celebrated 50 years of providing support to people with co-occurring conditions and complex needs. Founded in 1965, we're a family- and employee-owned organization delivering a wide range of services. Learn more about Telecare at www.telecarecorp.com. Telecare Corporation | Respect. Recovery. Results. | www.telecarecorp.com 26
Editor's Notes
- (8 min) 4:00 – 4:08 pm INTRODUCTIONS SPEAKER: NA, being introduced ACTIONS: Connect PPT, ensure video plays and audio works TALKING POINTS: NA LINKS TO REFERENCE:
- (1 min) 4:08 – 4:09pm WHO WE ARE SPEAKER: Faith & Shannon ACTIONS: TALKING POINTS: Speakers each self-identify (Hi, I’m ___) FAITH Not a tele-health provider MH provider Full spectrum of services 50+ years in operation Specialize in SMI, complex needs More info at booth Forgive us in advance – we often use words like patient, partner, member, client interchangeably LINKS TO REFERENCE: 0
- (2 min) 4:09 – 4:11 pm CONTEXT SPEAKER: Faith ACTIONS: TALKING POINTS: Change is in the air lots of chatter about value-based purchasing 1115 Waiver, will expire 12/31/2020 Specialty MH waiver will expire 6/30/20 As these waivers are renewed – creates opening for new design elements/reimbursement $100M federally (out of THIS administration!) [there are 2 links here] Implications for the system: Other PFS models exist – started out as Justice initiative – trying to reduce jail/prison recidivism This is what we imagine, envision for the future $100M federally LINKS TO REFERENCE: Urban Institute and SIPPRA Legislation https://pfs.urban.org/get-started/issue-areas/content/social-impact-partnership-pay-results-act-sippra http://socialinnovationcenter.org/wp-content/uploads/2018/02/PFS-2018.pdf
- (10 min) 4:11 – 4:21pm ENGAGEMENT: Hospital sx challenges SPEAKER: Shannon ACTIONS: Activate Word Cloud poll TALKING POINTS: Present activity Please provide a single word or very short phrase in response to this question: “As your hospital works with county mental health patients, what are the most difficult system of care challenges you face?” Review results (these will show up as single words, some larger than others). Our interest is in the challenges they are experiencing within their hospitals, as well as within the larger system of care. Possible system of care pain points Relationships between county BH systems and local hospitals Unmet needs Funding siloes Funding rules (annual contracts; fee for service or cost reimbursed; not necessarily related to performance) Regulatory restrictions Licensing and certifications (medical necessity criteria) Potential hospital pain points Inadequate psych beds for adults and for kids Complex relationships with county MH, managed care plans, insurers, conservators, poverty, homelessness) Discharge options Homeless needs ER needs ER backup and overcrowding Conserved client needs Extremely complex needs clients LINKS TO REFERENCE: 0 PREP TASKS: CHA to check the activity and give us “okay” (or provide updated PPT) by 12/5 Shannon to test the activity by 12/6 – identify if Word Cloud is okay or if we will use a different interaction Shannon – write sample poll responses for our test presentation Shannon – make scraps by 12/6 with sample responses for test audience to select/enter in internal test presentation
- (2 min) 4:21 – 4:23pm CONNECT Pain points to PFS model SPEAKER: Shannon & Faith ACTIONS: TALKING POINTS: Link pain points people expressed to PFS – how it can help address these broader systems challenges. These bullet points are intentionally broad Effective across systems Reduces barriers within the system Creates new strategies for collaboration Shared effort to address shared system challenges LINKS TO REFERENCE: 0
- (2 min) 4:23 – 4:25pm PFS Model (Typical Goals) SPEAKER: Shannon ACTIONS: TALKING POINTS: Engaging outside investors is a way to connect private & public sectors. This approach gets different players invested in becoming champions of social change. Jump-start change Social services have traditionally not used data to identify their target population or to measure outcomes. By paying for performance the PFS model forces increased rigor in social science arena. LINKS TO REFERENCE: 0 PREP TASKS: Shannon – add to talking points by 12/5
- (4 min) 4:25 – 4:29pm PFS Model (Highlights) SPEAKER: Faith ACTIONS: TALKING POINTS: PFS model New model of funding – Investors provide upfront capital – repaid by Government if outcomes achieved. At risk on behalf of service provider – they have skin in the game too Incentives for outcomes – there is risk AND reward – projects are designed to put money on the line – with penalties and bonuses – one form of Value based Purchasing Performance-based Data driven – there is a Randomized Control Trial study associated with the project. Clients in the regular System of Care will be compared to our members. RCT’s typically part of the design. More topics: Pay for innovation: testing new interventions, tools, processes, etc. Pay for evidence: implementation of existing, bundling in new ways, etc. Longer-Term Contracts: Recognizes long arch of mental health recovery while also acknowledging need for shorter-term impact Encourages flexibility and innovation Creates stable, enduring relationships Short-Term Incentives: Incentivizes us to partner in creative ways Supports immediate progress Reinforces diligent effort Underlines productive effort, relationships Varieties of the model: MH is only one Also used related to homelessness, jails/recidivism LINKS TO REFERENCE: https://payforsuccess.org/
- (5 min) 4:29 – 4:34pm ENGAGEMENT: Complex Person Served SPEAKER: Faith ACTIONS: Activate Word Cloud poll TALKING POINTS: Present activity “Tell us about a complex client that might be in your Hospital (or ER) that you think is not well-served in your system (facility).” “What are four words/attributes that come to mind?” Review results (these will show up as single words, some larger than others). Unhoused Uninsured SMI Substance use LINKS TO REFERENCE: 0 PREP TASKS: CHA to check the activity and give us “okay” (or provide updated PPT) by 12/5 Shannon to test the activity by 12/6 – identify if Word Cloud is okay or if we will use a different interaction
- (1 min) 4:34 – 4:35pm Our PFS (Typical Partner) SPEAKER: Shannon ACTIONS: TALKING POINTS: Who we typically see Our criteria – we accept ALL referrals, except…. Issues -- clinical, medical, etc Life needs Utilization of services LINKS TO REFERENCE: 0
- (3 min) 4:35– 4:38pm Our PFS (“Cristiano”) SPEAKER: Shannon ACTIONS: TALKING POINTS: Cristiano (BR) 41-year old Male Latino Schizoaffective disorder, bipolar type BEFORE THE PROGRAM Graduated from high school and worked as a plumber for about 6 years. At about the age of 25 he began interacting with Santa Clara county mental health. For 14 years he was being taken to emergency psychiatric services at least twice a year (often related to being under the influence of alcohol and/or meth in public and assaults). During this time he received outpatient case management and housing services (including forensic specialized services), however he was unable to maintain housing, and was homeless. In mid-2016 after resisting arrest and assaulting a police officer and a fire fighter he was placed in jail. While incarcerated he collected feces and placed them underneath his bed and on his food. He was then placed in an IMD where he threw feces on the wall and out into the unit, believing he had parasites. He was then referred to and randomized into our program. His Initial Goals obtain independent living get off probation reduce alcohol & meth get off conservatorship volunteer in community LINKS TO REFERENCE: 0 PREP TASKS: Perhaps replace image with a “before” image?
- (3 min) 4:35– 4:38pm Our PFS (“Cristiano”) SPEAKER: Shannon ACTIONS: TALKING POINTS: Cristiano (BR) 41-year old Male Latino Schizoaffective disorder, bipolar type BEFORE THE PROGRAM Graduated from high school and worked as a plumber for about 6 years. At about the age of 25 he began interacting with Santa Clara county mental health. For 14 years he was being taken to emergency psychiatric services at least twice a year (often related to being under the influence of alcohol and/or meth in public and assaults). During this time he received outpatient case management and housing services (including forensic specialized services), however he was unable to maintain housing, and was homeless. In mid-2016 after resisting arrest and assaulting a police officer and a fire fighter he was placed in jail. While incarcerated he collected feces and placed them underneath his bed and on his food. He was then placed in an IMD where he threw feces on the wall and out into the unit, believing he had parasites. He was then referred to and randomized into our program. His Initial Goals obtain independent living get off probation reduce alcohol & meth get off conservatorship volunteer in community LINKS TO REFERENCE: 0 PREP TASKS: Perhaps replace image with a “before” image?
- (3 min) 4:38 – 4:41pm Our PFS (Clinical Services) SPEAKER: Shannon ACTIONS: TALKING POINTS: First MH PFS program General clinical goal = self management illness self-management system self-management (empowering people to be better users of services when they go into services) Partnerships Shared decision-making Primary partnerships with BAPS (Santa Clara inpatient psych emergency services) Secondary partnership with contract hospitals as backup; quick response time to client hospitalizations, referrals Whole Health Data- and Performance-driven Treatment Screenings used in treatment planning Data used in morning huddle to prioritize team actions Performance-driven management (outcomes focus) Flexible array of clinical services: Multidisiplinary team to serve complex needs Provide high-intensity supports Teaching skills Co-occurring services Long-term relationships – stay connected after they graduate/leave to prevent rehospitalization Get people out of contract hospitals faster and more effectively) LINKS TO REFERENCE: 0
- (2 min) 4:41 – 4:43pm Our PFS (How it’s Different) SPEAKER: Faith ACTIONS: TALKING POINTS: PFS Risk – we’re at risk; there is long-term longitudinal risk even after graduate. Penalties for other bad outcomes (jail, suicide.) Referrals – can’t say no, we don’t get to decline partners who meet criteria Outcome measures – how we measure success in a PFS, not just process measures, but also outcomes (total costs, client level of functioning, housing status) Payment (all in costs.) Typical Outpatient Mental Health Episodic care Most focused on access Discretion on accepting referrals No-shows mean less work Fee for service
- (3 min + 4 min for clarification) 4:43 – 4:46pm POLL, 4:46-4:50 clarification ENGAGEMENT: Clarification SPEAKER: Shannon ACTIONS: Activate Single Choice poll For CHA: Use these as responses participants can select from in poll: CLARIFY: Goals of PFS CLARIFY: PFS Model NEW: Key Criteria for a PFS Project NEW: Flow of PFS Data, Services, and Funds NEW: Steps in Building a PFS Project TALKING POINTS: Present activity We’ve covered a lot of information. Before we move on we’d like to know what you want to hear about next. We’ve put up a couple of topics we could go over again to provide clarification if needed as well as 3 new topics we could cover. There’s only time to go over one of these choices, so let us know “What would you most like to hear about next?” Here is a list of the topic areas we covered, pick the items that you want us to provide some clarification or more information on Review poll results. Pick items to clarify (slides 6-7) or add new content (slides 14-16) LINKS TO REFERENCE: 0 PREP TASKS: CHA to check the activity and give us “okay” (or provide updated PPT) by 12/5 Shannon to test the activity by 12/6 – identify if Word Cloud is okay or if we will use a different interaction
- SLIDE 1 FOR POTENTIAL ELABORATION FOLLOWING POLL * NOTE TO CHA: DO NOT INCLUDE IN PDF THAT IS SENT OUT TO AUDIENCE IN ADVANCE
- SLIDE 2 FOR POTENTIAL ELABORATION FOLLOWING POLL * NOTE TO CHA: DO NOT INCLUDE IN PDF THAT IS SENT OUT TO AUDIENCE IN ADVANCE
- SLIDE 3 FOR POTENTIAL ELABORATION FOLLOWING POLL * NOTE TO CHA: DO NOT INCLUDE IN PDF THAT IS SENT OUT TO AUDIENCE IN ADVANCE
- (3 min) 4:50 – 4:53pm Lessons Learned SPEAKER: Shannon first 3 bullets, Faith last 3 bullets ACTIONS: TALKING POINTS: The historical data analysis and modeling future years was labor intensive. Even with technical advisor’s (Third Sector) modeling data, and Telecare investing hundreds of hours, we still ended up pulling dozens of paper charts and doing a clinical scan. The county invested a significant amount in a software provider (Palantir) to create dashboards to provide real time feedback – still a work in progress New customer or new provider presents unique challenges (hard to fully understand a new system of care) Candor is vital – critical to voice the challenges within the county system (e.g. relationship with Conservator, other Provider’ attitudes) Reputation and financial risk for both parties Housing – we underbid the costs/supportive housing. Telecare is completely at risk for this six-year liability Leadership of program needs to be different – high use of data Size matters (to manage financial risk) and be able to commit staff time for development Requires entrepreneurial culture – both county and provider LINKS TO REFERENCE: 0 PREP TASKS: Faith & Shannon – decide who will tackle each talking point by 12/5
- (2 min) 4:53 – 4:55pm Clinical Impact SPEAKER: Shannon ACTIONS: TALKING POINTS: TBD LINKS TO REFERENCE: 0 PREP TASKS: Carol – finalize data and graphs by 11/30 Shannon – clarify and work with Carol on data Shannon – talking points by 12/5
- (2 min) 4:55 – 4:57pm Financial Impact SPEAKER: Faith ACTIONS: TALKING POINTS: Program designed to save $19.6 million over the 6 year life – measuring total cost of client’s utilization compared to baseline. Entirely pay for program and relieve capacity constraints in system Initial year of results – beating targets by over half a million. Measuring all mental health utilization. Specifically beat PES target by over 80% - biggest area of success. Telecare offered to go at riks for medical ER usage – since we knew we coul dimpact that from our other experiences – but county had data/system measurement challenges.
- (3 min) OPTIONAL TO INSERT ONLY IF AHEAD OF TIME ENGAGEMENT: What Excites You SPEAKER: Shannon ACTIONS: Activate Multiple Choice poll TALKING POINTS: Present activity We’ve covered a lot of information. We’d like to hear what you are finding promising about PFS for your system of care. what was confusing that you may want us to clarify. “What have you heard that excites you or seems to offer promise to your system of care?” Review poll results. LINKS TO REFERENCE: 0 PREP TASKS: CHA to check the activity and give us “okay” (or provide updated PPT) by 12/5 Shannon to test the activity by 12/6 – identify if Word Cloud is okay or if we will use a different interaction
- (1 min) 4:57 – 4:58pm CONNECT PFS to benefits for Hospitals SPEAKER: Faith ACTIONS: TALKING POINTS: Practical Benefits of PFS for hospitals: what we’ve noticed! Challenging partners served more effectively and quickly Moving people out of ER and/or other hospital resources more quickly Preventing/reducing disruption in waiting rooms, ER, etc. Conserving resources for other community needs LINKS TO REFERENCE: https://nff.org/learn/pay-for-success https://www.thirdsectorcap.org/what-is-pay-for-success/https://pfs.urban.org/pfs-101/content/what-pay-success-pfs https://pfs.urban.org/pfs-101/content/what-pay-success-pfs PREP TASKS: Faith – identify whether to include urban institute Shea – replace the 3 links with single link to Telecare site with document with 3rd party project manager links
- (4 min) 4:58 – 5:02pm FOR ALL 3 SLIDES Our PFS (“Cristiano” – AFTER) and Client Testimonials SPEAKER: Shannon ACTIONS: TALKING POINTS: His Initial Goals obtain independent living – YES from crisis residential the team transitioned him into a licensed board and care psychiatrist adjusted medication and he is taking it regularly consistent contact with team members (at least twice a week) housing specialist Has been in unlicensed board and care for last 3 months get off probation – YES participation in Seeking Safety group (to address trauma and manage symptoms and behaviors) 0 altercations in community, 0 with peers, 0 with staff reduce use of alcohol & meth – YES not using meth or alcohol (is using marijuana) frequent visits with substance use specialist on team – harm reduction participated in Co-occurring Education Group at program attends AA/NA meetings team addressed transportation needs & introduced him to meetings get off conservatorship – YES conservatorship lifted 2 months ago volunteer in community PREP TASKS:
- (4min) 4:58 – 5:02pm Our PFS (“Cristiano” – AFTER) and Client Testimonials SPEAKER: Shannon ACTIONS: TALKING POINTS: Anxiety reduced We see depression increasing, which was associated with an increase in insight that was possible when psychotic symptoms abated High risk behaviors with alcohol & drugs reduced Losing weight
- (4min) 4:58 – 5:02pm for 3 slides Our PFS (“Cristiano” – AFTER) and Client Testimonials SPEAKER: Shannon ACTIONS: TALKING POINTS: Service Utilization: In the year prior to enrollment had: 3 emergency psychiatric episodes a stay in jail 4 months in an IMD. In the almost 2 years since his enrollment he initially spent 2.5 months in crisis residential setting after which he’s had no other use of high intensity services (no PES, IMD, etc) 0 altercations in community, with peers, with staff
- (1 min) 5:02– 5:03pm WRAP UP SPEAKER: Faith ACTIONS: TALKING POINTS: Thank You How to reach us LINKS TO REFERENCE: Telecare website