Community providers presentation__june_16,_2010 non profit


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Mental Health care Opportunites

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  • New expensive meds. SNFs lose money on every patient. Unfunded Trauma patients.
  • Community providers presentation__june_16,_2010 non profit

    1. 1. American Innovative Healthcare Solutions Psychiatric Care Service Expansion Proposal For long Term Care
    2. 2. Presentation Overview <ul><li>Who is American Innovative Solutions? 3-5 </li></ul><ul><li>Continuum of Care. 6 </li></ul><ul><li>Advantages for Members. 10 </li></ul><ul><li>Advantages to Community Provider. 11 </li></ul><ul><li>Levels of Care 12-13 </li></ul><ul><li>Professional Disciplines. 14 </li></ul><ul><li>Licensed Clinician Functions. 15 </li></ul><ul><li>Medicare Specifics 16-20 </li></ul><ul><li>Shared Casework Functions. 21 </li></ul><ul><li>Next Steps. 22 </li></ul><ul><li>Contact Information. 23 </li></ul>
    3. 3. Values <ul><li>Compassion </li></ul><ul><li>Excellence </li></ul><ul><li>Partnership </li></ul><ul><li>Innovation </li></ul>
    4. 4. Principles of our Philosophy <ul><li>Social responsibility to help underserved. </li></ul><ul><li>Respect and dignity. </li></ul><ul><li>Collaboration. </li></ul><ul><li>Concern for the whole person. </li></ul><ul><li>Address clinical, business, corporate and social-ethical issues. </li></ul>
    5. 5. Cost Effectiveness comes from: <ul><li>Removing obstacles to help patients. </li></ul><ul><li>Rapid Innovation/anticipation of regulatory changes. </li></ul><ul><li>Innovative integration of clinical and billing services. </li></ul><ul><li>Optimizing full time equivalent staff. </li></ul><ul><li>Using Contractors to expand services. </li></ul><ul><li>Matching skill levels of staff to case mix. </li></ul><ul><li>Continuous Quality Improvement. </li></ul><ul><li>Using “ Experts ” for training. Optimizes resources of talent and time toward measurable training goals. </li></ul>
    6. 6. Developing a Continuum of Care
    7. 7. Targeted Populations Adults <ul><li>Inpatient Readmissions <30 days </li></ul><ul><li>Medicare Funded </li></ul><ul><li>Chronically Mentally Ill. </li></ul><ul><li>Mentally ill people living in extended care facilities. </li></ul><ul><li>Mentally ill living in group homes, shared apartments. </li></ul><ul><li>Newly Diagnosed conditions. </li></ul><ul><li>Mental status changes. </li></ul><ul><li>General functioning between 35-70 on the Global Assessment of Functioning scale. </li></ul>
    8. 8. Who We Are and Are Not Adults <ul><li>We Are: </li></ul><ul><li>Innovative medical management company. </li></ul><ul><li>Serving Mentally ill patients living in nursing homes. </li></ul><ul><li>Serving patients from the Subpart S group requiring a higher level of psychiatric care. </li></ul><ul><li>Serving Mentally ill patients living in group homes, shared apartments. </li></ul><ul><li>Serving Newly Diagnosed conditions. </li></ul><ul><ul><li>Due to mental status changes </li></ul></ul><ul><ul><li>Changes in Placement </li></ul></ul><ul><li>We Are Developing: </li></ul><ul><li>Partnership on Illinois Subpart S services. </li></ul><ul><li>Linkage to Inpatient Care providers. </li></ul><ul><li>A Partial Hospital Provider. </li></ul><ul><li>Linkage with Psychosocial Rehabilitation Providers. </li></ul>
    9. 9. What We Learned/Where We Are Going <ul><li>What We have Learned </li></ul><ul><li>There are many underserved Mentally Ill people. </li></ul><ul><li>Day Programs are not sustainable. </li></ul><ul><li>IL HFS and Medicaid are too unstable to build a service delivery continuum. </li></ul><ul><li>Medicare provides stable income through 2014 through Mental Health Parity. </li></ul><ul><li>We are Developing </li></ul><ul><li>A continuum of sustainable services. </li></ul><ul><li>Partnerships with Nursing Home owners. </li></ul><ul><li>Replication of Services in Wisconsin. </li></ul><ul><li>Developing linkage to Inpatient Care providers. </li></ul><ul><li>Linkages to Partial Hospital Programs. </li></ul><ul><li>Linkages to Intensive Outpatient Programs. </li></ul>
    10. 10. Advantages for Members <ul><li>Members receive excellent patient care. </li></ul><ul><li>No out of pocket cost. </li></ul><ul><li>We process and store patient charts. </li></ul><ul><li>We document their ongoing needs or disability. </li></ul><ul><li>We assist in audit or accreditation preparation. </li></ul><ul><li>We provide treatment with IL. Licensed Clinicians. </li></ul><ul><li>We are able to use some existing employees. </li></ul><ul><li>PROFESSIONAL MANAGEMENT OF: </li></ul><ul><li>Treatment Planning. </li></ul><ul><li>Integration of care. </li></ul><ul><li>Billing and revenue collection. </li></ul><ul><li>CMS Psychiatric care changes. </li></ul>
    11. 11. Advantages for Community Provider <ul><li>We assess and/or treat more challenging behaviors. </li></ul><ul><li>We treat patients on site or where members live. </li></ul><ul><li>We provide assessments and treatment under Medicare standards. </li></ul><ul><li>We bring an additional revenue stream to fund care. </li></ul><ul><li>We assist in audit or accreditation preparation. </li></ul><ul><li>Patient documentation may qualify patients for additional reimbursement. </li></ul><ul><li>We recruit, hire, train and supervise, Illinois Clinically Licensed professionals. </li></ul>
    12. 12. Psychiatric Levels of Care Problems and Services Problems GAF Appropriate Services Inpatient Severe uncontrolled delusions, hallucinations, suicidal plans or attempts. 1 0-30 Medication management, crisis stabilization, referral to outpatient resources, including housing and 24 X 7 supervision. Partial Hospitalization Moderate-Severe delusions, hallucinations, suicidal thoughts without plans. 25-40 Medication optimization, group Therapy, Psychological education, Med. Ed., Individual therapy and referrals to outpatient resources made. Intensive Outpatient Mild-moderate, Delusions, hallucinations, decreasing suicidal thoughts without plans. 41-60 Group Therapy, psychological education, Individual therapy has begun with an individual therapist and psychiatrist. Linkage to outpatient resources completed. Outpatient Medically Necessary Care Reasonable Probability to Benefit. Mild-moderate, Delusions, hallucinations, decreasing suicidal thoughts without plans. 35-70 Group Therapy. Individual therapy has begun with an individual therapist and psychiatrist. Evaluation and Management. Medication management. Psychosocial Rehabilitation No medical necessity for group or individual therapy. Moderate-Severe delusions, hallucinations, without suicidal plans. 10-50 Assistance with most activities of daily living, group social, recreational activity. Medication compliance, teaching social interaction skills, Med. Ed.,
    13. 13. Psychiatric and Addictions Levels of Care Levels of Care Behaviors Global Assessment of Functioning (GAF) Axis V Hours per week What is Medically Necessary & Reasonable? Appropriate Services Inpatient Hallucinations, delusions, suicidal GAF 10-30 24 X 7 care Emergency management, Stabilization. Medication changes Individual, family, group tx, medication Ed., OT Partial Hospitalization Impairment in reality testing and communication GAF 25-40 16-20 hours per week Increase family support, teach coping skills, optimize meds. Individual, family, group tx, psychological education, medication Ed., OT Intensive Outpatient (Not recognized by Medicare) Moderate symptoms, and difficulty in working and social functioning GAF 50-70 10-20 hours per week Expand support system, demonstrate effective coping skills, return to work or school. Psych Assessment, psychological education, Group, individual and family therapy. Outpatient Mild-severe symptoms. 35-70 1-10 hours per week Talk therapy, medical management, reassessment every 30-90 days. Psych Assessment, Group, individual and family therapy Psychosocial Rehabilitation Low probability to improve Reached their baseline of functioning Activities Daily Living, recreation, social activity, med. compliance Support, counseling, employment to maintain baseline.
    14. 14. LCPC LCSW Behavioral Health Assistants M.D. Senior Leadership Professional Disciplines Psychiatrists
    15. 15. Licensed Clinicians Functions <ul><li>Complete Assessments (Differential Diagnosis) </li></ul><ul><li>Appropriate level of care determination with medical necessity. </li></ul><ul><li>Authorize Treatment Plans. </li></ul><ul><li>Collaborate with primary care physicians. </li></ul><ul><li>Provide individual therapy. </li></ul><ul><li>Use critical thinking to: </li></ul><ul><ul><li>Compare treatment plan to efficacy based practices. </li></ul></ul><ul><li>Function in a collaborative and supportive role with: </li></ul><ul><ul><li>the case worker. </li></ul></ul><ul><ul><li>Other Clinically Licensed staff. </li></ul></ul><ul><ul><li>Behavioral Health Assistants. </li></ul></ul>
    16. 16. Psychological Services under the Incident-to Provision WPS PSYCH-013-014 ~ ~
    17. 17. List of “Qualified Individuals” Illinois <ul><li>Only the following types of individuals, … are qualified to perform the indicated diagnostic and/or therapeutic psychological services under the &quot;incident to&quot; provision: </li></ul><ul><ul><li>Psychiatrist, LCSW Licensed Clinical Social Worker, MSN psychiatrically trained, master’s level LCPC Licensed Clinical Professional Counselors, doctoral level Licensed clinical psychologist, CP . </li></ul></ul><ul><ul><li>Qualified providers must meet both the educational and licensing criteria listed in PSYCH-002. This includes Illinois requirement for independent practice. </li></ul></ul>~ ~
    18. 18. Professional Credentialing <ul><li>Billing provider can only hire and supervise a professional whose scope of practice is within their own scope of practice </li></ul><ul><ul><li>Example: Certified nurse midwife may not hire a CP and bill for that CP’s services under the incident-to provision </li></ul></ul>~ ~
    19. 19. Professional Credentialing <ul><li>Psychological services may be delegated only to employees who qualify to perform the service. </li></ul>~ ~
    20. 20. Coding Guidelines for Incident-to <ul><li>Any ICD-9 code submitted must have medical justification in the medical record for establishing that diagnosis </li></ul><ul><ul><li>If medical record is lacking such justification, a retroactive denial and recoupement may be made. </li></ul></ul>~ ~
    21. 21. Shared Case Work Functions <ul><li>Implementation of treatment plan. </li></ul><ul><li>Daily record review and assessment of patient ’ s progress. </li></ul><ul><li>Validate that medical record accurately reflects patient ’ s current condition. </li></ul><ul><li>Coordinate/facilitate communication among team members, and other providers. </li></ul><ul><li>Use critical thinking to: </li></ul><ul><ul><li>Remove obstacles. </li></ul></ul><ul><ul><li>Compare treatment plan to services received. </li></ul></ul><ul><li>Function in a collaborative and supportive role with: </li></ul><ul><ul><li>Primary Care Physician. </li></ul></ul><ul><ul><li>Facility social service staff. </li></ul></ul><ul><ul><li>Psychiatrists. </li></ul></ul>
    22. 22. Next Steps <ul><li>Completion of AIHS Management Services Agreement. </li></ul><ul><li>Start Up Plan Development. </li></ul><ul><li>Interactive Orientation to policies, procedures and documentation. </li></ul><ul><li>Physician Referral for Services. </li></ul><ul><li>Individualized Patient Care is Matched to Patient Choice and Availability. </li></ul>
    23. 23. Contact Information <ul><li>American Innovative Healthcare Solutions </li></ul><ul><li>10 W. 35th Street, 11th Floor </li></ul><ul><li>Chicago, IL 60616 </li></ul><ul><li>Independents such as; Independent Consultant Relationships, Opportunites per State (Relationships and Time) (Convert Contacts to opportunites in Healthcare) </li></ul><ul><li>DRUGTESTINGONE.COM DNATESTINGONE.COM LABTESTINGONE.COM KRYPTOPRROLE.COM PYLORIATESTING.COM </li></ul><ul><li>Contact Information: </li></ul><ul><li>Robert J. Sommerfeld </li></ul><ul><li>[email_address] </li></ul><ul><li>[email_address] </li></ul>