CFBHN Central FloridaBehavioral Health Network “Achieving the dream envisioned in single management strategies.”
Why is the network initiative important? • Networks will be the lead entities for: • Innovation • Collaboration and care integration • Contracting • Purchasing of mental health and substance abuse services.
How it started… CSAT Technical Assistance Report to FloridaJanuary, 2000 • Comprehensive continuation of accessible quality services in the most appropriate environment • Regulatory oversight of treatment system that ensures appropriate clinical care provided consistently and with prevailing standards • Training for personnel • Treatment system includes clinical assessment, individualized service planning, referral, progress review and follow-up
Characteristics and Featuresof a Well-Organized System of Care(From CSAT Technical Assistance Report to Florida – January, 2000) • Services are organized into a simple network of care • Network services are available through multiple single entry points • Formal linkages exist between mental health, substance abuse and primary care • Local networks are responsible for coordination of client services • Case managers are identified to coordinate care • Services are community-based • Prevention and intervention strategies are clearly defined • Stakeholders have direct input
Characteristics and Featuresof a Well-Organized System of Care(From CSAT Technical Assistance Report to Florida – January, 2000) • Treatment available upon demand for special populations (pregnant women, IV drug users, individuals in family protection, dually-diagnosed, SPMI, etc.) • Individualized, client-centered and flexible programs • Flexible funding strategies, including fee for service and prospective payment mechanisms • Network-wide utilization management
Florida’s response… Florida Legislature passed SB1258 to meetthe service delivery needs for: • Accountability • Continuity of Care • Early Diagnosis & TX • Assess Local Needs • Quality/Best Practices • Cross – System Integration • Creative Financing • Control Costs • Admission/Discharge with State Hospitals • Disseminate Data for Planning Purposes • Special ALF Services • Reduction of Kids in Residential Care • Services to Kids under Court Orders
Service Delivery Goals 1258 • Coordination, Integration & Management • DCF/MH/SA and AHCA/Medicaid • Unit Cost Contracting & Fee-For-Service • Risk-Sharing Arrangements • Managing Entities – Public/Private • Promote Flexibility & Responsiveness • Expand Waivers, Maximize Federal $$$, New Procedure Codes or Certified Match
Florida Legislature expanded the goals ofSB1258 with the passage of SB2404 in 2003which: • Creates the Substance Abuse and Mental Health Corporation • Responsible for oversight of publicly funded substance abuse and mental health systems, including marking policy and resource recommendations. • Requires DCF and AHCA to ensure Medicaid and Department funded services are delivered in a coordinated manner, using common service definitions, standards and accountability mechanisms. • Requires corporation to conduct annual evaluation and report the status of publicly funded mental health and substance abuse systems to Legislature.
Amendment toChapter 394.9082 • Provides direction for FMHI to continue the evaluation of strategies in SB1258 and SB2404 pilot projects • Requires report by December 31, 2006 that includes target dates for state-wide implementation
Amendment to Chapter 409.912(Relating to Mandatory Medicaid Managed Care Enrollment) • Directs AHCA to work with DCF to ensure children and families in child protection system have access to mental health and substance abuse services. • Directs AHCA to seek Federal approval to contract with single management entities for all behavioral health services for Medicaid recipients in an AHCA area. • Directs AHCA and DCF to collaborate to jointly develop all policy, budgets, procurement procedures, contracts and monitoring plans for behavioral health and targeted case management programs. • Requires AHCA and DCF to contract with managed care entities or arrange to utilize capitated pre-paid arrangement for all inpatient and outpatient behavioral health services to all Medicaid recipients by 07/01/06.
Amendment to Chapter 409.912(Relating to Mandatory Medicaid Managed Care Enrollment) • Specifies that in AHCA areas with less than 150,000 Medicaid eligible clients, AHCA must contract with a single managed care plan; in areas over 150,000 Medicaid eligible clients, AHCA may contract with more than one plan. • Contracts must be competitively procured. • Both for-profit and not-for-profit entities are eligible to compete • Requires AHCA to submit a plan by October 1, 2003 providing full implementation of capitated behavioral health throughout the State. • Plan must include provisions ensuring service accessibility for children and families in the child welfare and/or foster care system. • Plan must include participation of community-based care lead agencies, community alliances, Sheriff’s Department and providers serving dependent children. • Requires implementation to begin in 2003 in areas of the State that are able to establish sufficient capitation rates.
Amendment to Chapter 409.912(Relating to Mandatory Medicaid Managed Care Enrollment) • Allows AHCA to adjust capitation rates in any one area as necessary. • Directs AHCA to develop policies and procedures to allow for certification of local and state funds. • Excludes children residing in inpatient and DCF residential programs (BHOS) from enrollment into pre-paid plans. • Requires existing child welfare providers under contract with DCF be offered the opportunity to participate in any provider network for pre-paid behavioral health services. • Requires AHCA and DCF to develop a plan for new procedure codes for emergency and crisis care, supportive residential services and other services designed to maximize use of Medicaid funds for recipients needs.
Network Administration • What is a Network? • Two or more agencies with a formal agreement to manage or deliver behavioral health services. • What is the purpose of a Network? • Improve access to care • Improve quality • Improve efficiency and effectiveness • Assist providers/members
Unique Features ofCommunity-Based Networks • Strengths • Community governance and oversight • Shared risk with providers • Comprehensive service delivery and ability to provide integrated services • Consumer involvement • Community re-investment • Coordination with collateral systems • Opportunity for gradual transition
Unique Features ofCommunity-Based Networks • Vulnerabilities • Historical preservationists • May be slow to change practice standards • May be difficult to move from program-focused planning to person-focused planning • Lack of capacity for utilization management, $$ required for IS development and capitation risk pools, RFP grant response/marketing, provider accreditation, administrative capabilities
Not-for-Profit Provider-Sponsored Networks Philosophy & Mission • Services are based on needs of persons served and stakeholders • Demonstrated opportunity for consumer choice • Timely services • Services are culturally sensitive • Mission is communicated and embraced by all members
Not-for-Profit Provider-Sponsored Networks Quality Performance • A common set of indicators is applied • Access - Efficiency • Effectiveness - Consumer satisfaction • Indicators are used for quality improvement, performance assessment and corrective actions
Not-for-Profit Provider-Sponsored Networks Accountability • Individual provider and aggregate performance outcomes • Review of service patterns • Utilization of data to improve efficiency, effectiveness and customer satisfaction
Not-for-Profit Provider-Sponsored Networks Service Development Coordination of a system of care for a person receiving services from more than one provider or levels/types of care includes: • Planning of individual services • Delivery of services • Evaluation of services • Service review and revision as needed • Formal information sharing process
Not-for-Profit Provider-Sponsored Networks Membership Criteria A prerequisite for membership in the Network is a demonstrated commitment to and the history of client advocacy and collaborative practice. • Non-profit providers • Contracts with the State SAMH Program Office • Medicaid provider
Not-for-Profit Provider-Sponsored Networks Credentialing Criteria • Accreditation, licensing, certification • Fiscal stability and responsibility • Commitment to community-based care principles • Commitment to consumer choice • Rehabilitative principles of care • Ability to provide access to treatment • Ability to deliver service
_____ • _____ • _____ Network Benefits Examples of benefits the Network strives to offer include: • Enhancement of core competencies • Ability to share administrative functions and associated costs • Improved continuity of care • Improved linkages with non-ADM services • Development of best practices • Maximization of revenues • Joint marketing efforts • Stronger advocacy efforts • Ability to shift contract funds between providers • Shared knowledge
Core Administrative Functions • Provider network management • Strategic planning • Customer services • Quality management • Utilization management • Financial management • Information management
Core Administrative FunctionsProvider Network Management • Planning and identifying network components • Defining continuum of care - Community planning • Determination of type, number and provider qualifications • Selection of providers/networks • Open or competitive bidding - Selection criteria • Evaluation - Approval process • Credentialing • Documentation of licensure - Accreditation • Professional credentialing • Management of provider network • Communication - Community input • Assessment of continuum of care • Training and technical assistance
Core Administrative FunctionsStrategic Planning • Annual review of: • Services • Utilization data • Access standard • Outcomes • Gap analysis • Needs assessment • Member satisfaction • Provider input
Core Administrative FunctionsCustomer Services • Customer relations • Board members - Providers • Consumers - Funding sources • Advocacy groups - Community stakeholders • State/local agencies • Members • Benefits and services - Member advocacy • Rights and responsibilities - Grievances and appeals • Coordination with other systems • Child welfare - Education • Juvenile justice - Corrections • Health care
Core Administrative Functions Quality Management • Leadership commitment • Accreditation • Board structure and management • Quality management goals • Focus on persons served • Enhance access and quality of behavioral health services • Improve coordination of care within geographic areas • Promote effective, efficient and economical use of resources Quality Assurance, Continuous Quality Improvement, Performance Improvement
Core Administrative Functions Quality Management • Quality Improvement Committee • Comprised of QI personnel from all providers • Performance improvement reviews • Case file review • Medical record review • Customer survey • Data/outcomes review • Service validation review • Performance measures • State mandated outcomes • High risk • High volume • Problem prone
Core Administrative Functions Quality Management • Quality assurance • Continuous quality improvement • Performance improvement • Utilization review • Risk management • Data driven • What, how, when to measure • How to use what is measured • Is system in management tool for improving quality • Treatment • Screening/assessment • Placement criteria • Continuing care criteria • Services individualized to client’s need/client driven • Continuums of care • Alignment of resources and utilization
Core Administrative Functions Utilization Management • Prior authorization • Define covered services requiring prior authorization • Medical necessity • Lead restrictive level of care • Concurrent review • Continued medical necessity • Level of care appropriate • Continued stay criteria • Retrospective review • Emergency admissions • Sample of cases to establish provider profile • Reviews decrease with provider readiness
Core Administrative FunctionsFinancial Management • Regulatory compliance • Legal • Contract • Grants management • Accounting • Safeguard assets • Monthly, quarterly and annual financial statements • Surplus/deficit and provider utilization reports • Annual budgets and forecasts • Integration of clinical and financial data • Cost analysis • Clinical analysis • Rate setting
Members tracking Utilization management Claims Quality Enrollment/eligibility Admission/authorization Continued stay “Seamless” care across levels of care and providers Integration of assessments and treatment planning Aggregate reporting Utilization Billing, processing, reconciliation Provider performance Reporting Outcomes analyses Utilization analyses Core Administrative FunctionsInformation Management
Core Administrative FunctionsRevenue Maximization • Develop and define services to be covered • Reimbursement consistent with level of service and cost to provide service • Payment methodologies • FFS, capitation, rates, unit cost, case rates, etc. • Use of multiple revenue streams to support treatment • TANF • Medicaid • Private insurance • Corrections • General revenue
Transition Planning for NetworksPlanning Process • Significant changes to the management and financing of systems of care require careful planning • Changes should be implemented in stages over time • Transition planning team is focal point for identifying issues and developing detailed implementation strategies
Transition Planning for Networks Contract Financing Interim System Contracts based on OCA categories for identified number of persons to be served (similar to District 1 Prepaid Aggregate Fixed Sum Contract) Payment on 1st day of month, actual advance funding. Reconciliation based simply on number of persons served. Utilize PIDS Manual and DCF Guide to SB1258 Contracting for ADM Services Current System Performance Based/Unit Cost/Cost Center-based ADM Contracts TANF system with cumbersome and expensive administrative requirements. CFBHN subcontracts with providers on same basis. Complicated and expensive billing and data systems. Delays in receipt of funds. Ideal System Risk or shared risk-based or other types of contracts based on valid actuarial data and models. Permit subcontracts to be on risk or shared-risk basis, case rate or other strategies to be developed. If indicated, utilize profit and loss risk corridors. Management, Monitoring and Oversight Interim System Use accreditation in lieu of monitoring as described in SB1258 (Ch394) CFBHN performs interim monitoring as described in SB1258 (Ch394) ADM and CPU review CFBHN’s monitoring reports Utilize CPA audits to replace certain items in the monitoring instruments Develop process to redefine/reduce items to be monitored Current System Program Monitoring by ADM and CFBHN Administrative and contract monitoring by CPU, ADM and CFBHN Licensure monitoring by ADM and AHCA Medicaid compliance by AHCA CPA Audits Accreditation for most providers Ideal System Accreditation for all providers and networks Move from system that focuses on monitoring to one that focuses on leadership & management development, development of organizational competencies, refinement of quality and performance improvement strategies and practices, best practices, improvements to system integration, and staff training and development Development of legislative budget requests jointly by CFBHN and ADM/DCF based upon identified needs of Suncoast Region. Data Collection and Reporting Interim System Suncoast and CFBHN become additional demonstration project for PIDS, currently be developed and implemented in District 1 Would include participation in Unity One system and ability to access other state data systems Current System IDS, HomeSafeNet, etc. Data validity problems, some of which are based on matching services to enrollments Lack of timely mechanisms to correct inefficiencies and problems Limited utility of database by providers Ideal System The ideal integrated database (s) has yet to be defined, but at a minimum it should eliminate all double or triple entries. It (they) should be efficient to use and effective for the state, CFBHN and subcontractors
Transition Planning Team Consistsof Three Separate Teams Regional Transition Planning Team Contract Development Team MIS & Data Team System of Care Team
Transition Planning TeamAt a minimum, team consists of representatives of the following parties and other appointed by team. • DCF SAMH Program Office • DCF Contract Manager • ASO • Provider Network representative/Board member • Representative from AHCA and any prepaid plan, if established • Representative from community-based care agency • Consumer representative • Ad hoc representation from identified stakeholders as required
Transition Planning TeamMIS & Data Team • Responsible for analyzing all data and management information issues • Provides data need by Contract Development Team for preparation of the contract • Includes representatives from State MIS, ASO, providers, Regional SAMH Program Office, system consultant
Transition Planning TeamContract Development Team • Addresses the changes to the contract between the Department and the Network’s ASO • Development of prepaid, fixed sum or risk-based contract • Development of provider contract requirements • Incorporates provider application process • Incorporates provider credentialing process • Incorporates recommendations from MIS and System of Care Teams
Transition Planning TeamSystem of Care Team • Addresses the array of services to be provided • Addresses access to care requirements • Addresses clinical protocols, clinical pathways, etc.
CFBHN Central FloridaBehavioral Health Network CFBHN is a not-for-profit network of community providers incorporated to ensure and enhance an array of behavioral health and other human service needs for the citizens of our community.
CurrentOrganizational Capacity • The mission, values and principles ensure highly-effective, family-focused services are provided in a fiscally sound manner • A provider-sponsored network that has demonstrated commitment to and treatment of client advocacy and collaborative practice • Encourages network membership and provider development in a manner that is representative of both geographic and specific service needs of clients and their families • Currently provides the following services for five major funders: • Administrative services • Systems and network development • Quality oversight • Training, education and clinical development • Serves over 6000 clients annually, has 19 member agencies and 28 service providers under contract
Network Goals Provide identified regions in the state with a well-managed and integrated behavioral health delivery system to: • Increase access to care • Improve continuity of care to vulnerable populations • Prevent duplication of effort • Reward efficiencies • Encourage exemplary practices
Organizational Structure • In May, 2002 Bylaws revised to reflect significant changes in the organizational leadership and Board structure • Changes implemented to meet the Network’s need for the Board to be more representative of the expanded geographic area
Organizational Structure • Board President represents substance abuse agencies • President Elect represents mental health agencies • The two offices rotate annually between substance abuse and mental health systems to ensure both areas are adequately represented
Executive Committee • Executive Committee is comprised of the President, President Elect and one representative selected by each of the four designated Network regional councils • The four regional councils include: • Hillsborough County • Pinellas/Pasco Counties • South Region (Manatee, Sarasota and DeSoto Counties) • District 14 (Highlands, Hardee and Polk Counties)
PINE Regional CouncilResponsibilities • Nominate Executive Committee regional representative • Design and coordinate a localized system of care for each business activity identified for that region • Establish and maintain local planning forums of members, vendors, stakeholders and partners to formulate and articulate services delivery strategies and plans for inclusion in the Corporate Business Plan • Develop and implement regional business plans • Facilitate the implementation of behavioral health services that are responsive to the needs and institutions of their respective communities • Develop vendor recommendations
Inclusiveness & Provider Relations • Communities, funders, persons served and providers are integral partners in the design, evaluation and support of the Network’s services and service delivery structure • CFBHN is a provider-sponsored network striving to meet the needs of its members by providing outstanding services and value-added benefits that clearly demonstrate the advantages of membership
ACTS Boley Center for Behavioral Health Care Centre for Women Coastal Recovery Center Directions for Mental Health DACCO First Step of Sarasota Gulf Coast Community Care The Harbor Behavioral Healthcare Institute Human Services Associates Manatee Glens Mental Health Care Northside Mental Health Center Operation PAR Peace River Center PEMHS Suncoast Center for Community Mental Health Tri-County Human Services Winter Haven Hospital Network Membership
TANF Systems Development • Provide management and oversight for all ADM TANF-funded services throughout the Region and District 14 • Co-location of outreach at One-Stop centers in some child welfare community-based care lead agencies • Partner with Family Safety/diversion clients • Partner to provide Dependency Court services • Service provider for Welfare-to-Work/Hillsborough County Workforce Board • Contract with Workforce Development Lead Agencies to provide support and outreach • Enhance supportive employment opportunities throughout Network area • Collaborate with the Spring for domestic violence outreach • Manage funds throughout the Suncoast Region and District 14 • 17 agencies provide services • Allow full utilization of benefits for TANF-eligible persons