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HomeMy WebLinkAbout072318_ra02 Regular Agenda JEFFERSON COUNTY BOARD OF COUNTY COMMISSIONERS AGENDA REQUEST TO: Board of County Commissioners Philip Morley, County Administrator FROM: Vicki Kirkpatrick, Director Jefferson County Public Health DATE: July 23, 2018 SUBJECT: DISCUSSION and POTENTIAL ACTION re: RESOLUTION for Salish Behavioral Health Organization (BHO) Request to Create an Integration Pilot to the Washington State Legislature STATEMENT OF ISSUE: The Board of County Commissioners will consider a proposed Resolution that has been submitted by the Salish Behavioral Health Organization (Salish BHO) in support of creating a pilot for the clinical integration of Medicaid-funded behavioral health and physical health. Clallam and Kitsap Counties have already adopted the Resolution. At the July 9, 2018 Board of County Commissioners heard a presentation by the Administrator of the Salish BHO and comments from the Jefferson County Public Health Director, the CEO of Jefferson Health Care, and a representative from Discovery Behavioral Health. At the conclusion of the presentation and comments, the Board of County Commissioners decided to postpone acting on the Resolution requesting more information and further opportunity to discuss the potential impacts of the proposed pilot. Vicki Kirkpatrick, Director, Jefferson County Public Health will make a presentation. Dr. Locke, Jefferson County Health Officer will provide comments. Anders Edgerton, SBHO Administrator will be there to respond to questions. Additionally, a representative from a Managed Care Organization will also be available to comment or respond to questions from the Board ANALYSIS: Each of the three counties covered by the Salish BHO have been invited to join the Salish BHO Board of Directors in requesting the Washington State Legislature to create a legislatively q 9 9 9 9 Y approved pilot region in a geographically isolated area that provides for the clinical integration of Medicaid behavioral and physical health care services without full financial integration; and, that the pilot project shall, (1) measure the effect of maintaining separate funding streams for Regular Agenda Behavioral Health Organizations and Managed Care Organizations on the overall clinical integration of care (basically maintains the status quo within the Salish BHO region); (2) use standards for measuring clinical integration that shall be negotiated between the HCA, the existing BHO, and partnering MCOs and that are comparable to fully integrated regions; (3) provide annual detailed analysis of its ongoing integration efforts; and (4) be terminated at the end of 2024, should the region be comparatively unsuccessful in its service delivery and outcome levels. The decision that the Board of County Commissioners will be making will determine the direction of the provision of mental health and substance use disorder services in Jefferson County. Attached to this Agenda Request is the proposed Resolution for Board consideration. FISCAL IMPACT: There is no fiscal impact from the Resolution itself, but a pilot may have impacts on the amount and use of Medicaid funding in all three counties in future years. RECOMMENDATION: Continue the discussion and consideration of whether or not to approve Resolution No. regarding the Salish Behavioral Health Organization (SBHO) Request to Create an Integration Pilot to the Washington State Legislature. REVIEWED :Y: Mark McCauley, £1ng County AdminisiOar Date C J<l.lilk vt'1.-j IL _irefir RESOLUTION NO. -2018 Salish Behavioral Health Organization—Integration Pilot Whereas the State of Washington's vision for full financial integration of health care is within Managed Care Organization by January of 2020, therefore eliminating county behavioral health organizations and ceasing the accountability and oversight of local authorities in the planning and management of behavioral health care in the region; Whereas it has been a long-held value of Kitsap, Jefferson and Clallam Counties that, if possible, behavioral and physical health care should be delivered locally; Whereas the unique geographic areas within the Salish BHO region have distinct community based nonprofit behavioral health providers, hospitals, and health clinics working with the vast majority of the region's Medicaid clients; Whereas the geographically isolated Salish BHO region is connected by more ferries than roads to the rest of the state, the provider community has long standing linkages and relationships that facilitate strong community collaborations and the coordination of care central to improving consumer focused, whole person care; Whereas there are significant benefits to having local oversight and accountability of behavioral health care services and outcomes; Whereas the Salish BHO region has been a leader in the planning necessary to bring on new innovative programs, including integrated care, to address behavioral health needs; Whereas the Salish BHO maintains strong relationships between health and behavioral health providers throughout the Region; and WHEREAS: The Salish BHO supports continuing its long-standing practice of full clinical integration of behavioral health services; now, therefore, be it Resolved, that the Clallam County Board of Commissioners, Jefferson County Board of Commissioners, and the Kitsap County Board of Commissioners join the Salish BHO Board of Directors requesting the Washington State Legislature to create a legislatively approved pilot region in a geographically isolated area that provides for the clinical integration of Medicaid behavioral and physical health care services without full financial integration; and, be it, further Resolved, that the pilot project shall, (1) measure the effect of maintaining separate funding streams for Behavioral Health Organizations and Managed Care Organizations on the overall clinical integration of care; (2) use standards for measuring clinical integration that shall be negotiated between the HCA, the existing BHO, and partnering MCOs and that are comparable to fully integrated regions; (3) provide annual detailed analysis of its ongoing integration efforts; and (4) be terminated at the end of 2024, should the region be comparatively unsuccessful in its service delivery and outcome levels. PASSED AND APPROVED on this day of , 2018 BOARD OF COUNTY COMMISSIONERS JEFFERSON COUNTY, WASHINGTON KATE DEAN, Commissioner, Dist. 1 KATHLEEN KLER, Commissioner, Dist. 2 DAVID SULLIVAN, Commissioner, Dist. 3 ATTEST: Carolyn Gallaway, Deputy Clerk of the Board PASSED AND APPROVED on this day of , 2018 BOARD OF COUNTY COMMISSIONERS CLALLAM COUNTY, WASHINGTON RANDY JOHNSON Commissioner MARK OZIAS, Commissioner BILL PEACH, Commissioner ATTEST: , Clerk of the Board PASSED AND APPROVED on this day of , 2018 BOARD OF COUNTY COMMISSIONERS KITSAP COUNTY, WASHINGTON ROBERT GELDER, Chair EDWARD E. WOLFE, Commissioner CHARLOTTE GARRIDO, Commissioner ATTEST: Dana Daniels, Clerk of the Board Proposal for Salish BHO Integrated Care Proviso Purpose: To create a legislatively approved Pilot Project in a geographically isolated area that provides for the clinical integration of Medicaid behavioral and physical health care services without full financial integration. What is Being Proposed: • Create a Pilot Project to implement full clinical integration of behavioral health with physical healthcare without modifying or moving funding streams. Rationale: • Local oversight of care is imperative to ensure care to a very vulnerable population • Coordination of the SYSTEM is lost with full financial integration • Rates for provider organizations,some of which are very small,will be adversely effected under full financial integration • Continued program development, including capital projects, is important in order to improve services, and it is difficult to understand how this occurs under full financial integration • The existing BHO pays all outpatient providers with Value Based payments(capitation or Case rate),which is unlikely to occur under the revised system • Clinical integration efforts are already well underway in the Salish BHO • The continuing disruption of the healthcare system, including continued changes in the 1115 project and consolidation among providers and carriers, provides no benefit to the individuals receiving Behavioral Health care,and the pilot would lend some stability to the system that supports them Sample Proviso Language: The Legislature finds that to further the goals of fully integrated health for individuals with severe and chronic mental illness and/or substance use disorders, a pilot project will be established in one Regional Service Area to measure the effect of maintaining separate funding streams for Behavioral Health Organizations and Managed Care Organizations on the overall clinical integration of care. Proposal for Salish BHO Integrated Care Proviso Purpose: To create a legislatively approved Pilot Project in a geographically isolated area that provides for the clinical integration of Medicaid behavioral and physical health care services without full financial integration. Background: The Washington Health Care Authority and Governor's Office have interpreted SSB 6312, passed in 2014, as requiring full financial integration of health care within Managed Care Organization contracts by January of 2020. The involvement of local authorities in the planning and management of behavioral health care (Mental health and/or substance use) would cease under this scenario and locally based Behavioral Health Organizations would be eliminated. It has been a long held value of Kitsap,Jefferson and Clallam Counties that health care should be delivered locally if at all possible and that there are significant benefits to having local oversight of behavioral health care. This region has been a leader in the planning necessary to bring on new innovative programs, including integrated care,to address behavioral health needs, and there are strong affiliations between health and behavioral health providers throughout the Region. Request: That the Commissioners of Kitsap,Jefferson and Clallam Counties seek legislative authorization for a pilot project to be implemented under the auspices of the Satish Behavioral Health Organization requiring full clinical integration of care for the Medicaid population in our counties while continuing the current funding mechanism. Sample language is attached. Salish BHO Related Strengths: The Salish BHO brings to bear many existing strengths which position it and the provider community for full integration, such as: Administrative Strengths: • Established Value Based Payment Structures—sub capitated payments for Mental Health Services contractors and case rates for Substance Use Disorder Services contractors. • Long standing, local collaborative provider networks already include behavioral health providers, hospitals and physical health care clinics. All of these and the SBHO, have demonstrated commitment to the well-being of the individuals we serve. • In the majority of our region, most physical health care is under the oversight of locally elected Hospital boards, with Kitsap County being the only exception. In Kitsap County the vast majority of Medicaid clients are served by one hospital and one not for profit health center already providing integrated care. • Distinct geographic areas within the BHO have distinct community based non profit behavioral health providers, hospitals, and health clinics working with the vast majority of the region's Medicaid clients. • As a geographically isolated region connected by more ferries than roads to the rest of the state,the provider community has long standing linkages and relationships that facilitate strong community collaborations and the coordination of care central to improving consumer focused, whole person care. Clinical Strengths and Impact: • Long history of innovations in behavioral health, having established the first independent Evaluation and Treatment facility in the state, as well as the first Adolescent Inpatient facility at a Community Behavioral Health Agency(CBHA). • Implementation of integration efforts throughout the region for an extended period of time, including: o Primary Care Providers on site in largest Community Behavioral Health Agency o Behavioral Health clinicians from CBHAs on site in many primary care clinics o Dental clinic located at CBHA for children and adults o CBHAs share staff with hospitals o Screening, Brief Intervention, Referral and Treatment for Substance Use widely applied across primary care, hospital/emergency room settings o Collaborative care meetings for targeted clients include behavioral health service providers, physical health providers, hospitals, emergency services and others. o Standing protocols for cross agency referrals and health information/data sharing as needed for continuity and coordination of care o Cross-training and bi-directional consultations among behavioral and physical health providers becoming normative o Collaborations to improve health information exchange, including sharing of information between Primary Care practices, hospitals, CBHAs where feasible, including Emergency Department Information Exchange, Consent2Share, or similar o Population based health initiatives under way for Federally Qualified Health Centers and other primary care providers, CBHAs, hospitals; shared new EHR (4/18) for CBHAs supports shift to population based health approach/registries • Kitsap Mental Health Services (KMHS), our largest contractor,was awarded and successfully implemented a 3 year Centers for Medicare and Medicaid Services Health Care Innovation Award, Race to Health!(RTH) RTH demonstrated enhanced care coordination with primary care providers, improved physical health monitoring with shared records,joined evidence based wellness and chronic disease interventions with mental health and substance use disorder treatment services, and provided behavioral health consultation and services to primary care providers. An independent evaluation conducted for CMMS found reduced ED visits, hospitalization rates, and decreased total expenditures for clients with Medicare coverage as a result of these interventions. Deliverables: Integration standards, means of measurement, and outcome standards would be negotiated with the Health Care Authority. There are existing nationally recognized outcome measures related to health care integration which include Emergency Department utilization, hospitalization rates, psychiatric readmission rates,jail admissions for served population, mental health and substance use disorder service penetration rates, physical health and metabolic screenings, and improvements in health status. Proposal for Salish BHO Integrated Care Proviso Pilot Project This pilot project recognizes the clinical integration of care already established in the Salish BHO region while achieving excellence in local, whole person integrated, coordinated care under the current funding mechanism for Medicaid eligible beneficiaries. Mental Health/Behavioral Substance Use Provider Primary Care Provider Health(CBHA) Target Population Adults with Serious Mental Children or adults with Patient Centered Medical Illnesses or Children with substance use disorder Home for general child and Serious Emotional requiring outpatient/ adult population, behavioral Disturbance inpatient care health needs not at level requiring specialty BH care Financing Capitation Case rates MCO Risk-holder Provider at risk BHO at risk MCO at risk Services Crisis, Inpatient,Outpatient, Acute, Inpatient, Acute, Outpatient, BH Residential Outpatient, Residential Specialty referral Bi-Directional Co-located primary care or Care coordination with Co-located behavioral health care owned primary care primary care via SBHO or owned behavioral health Multidisciplinary team based care Yes in some practices Yes in some practices Population based health In process In process In process May be MCO coordinator, Care MH assigned team member SUD assigned team practice appointed Coordination as primary coordinator member as primary coordinator;or other coordinator external coordinator Wellness& Specialty programs for Specialty programs for Patient self-management Chronic Disease illnesses with high incidence illnesses with high programs in PCP, hospital, Self-Management among population incidence among pop community setting Electronic Health Athena (FQHCs) EPIC(many) Record Valent for all CBHAs Vary and other Data sharing Consent2Share, Vary EDIE/Premanage Vary EDIE/Premanage Other in process Other in process Core measures (meet and report) Yes Yes Yes Payment Accountability BHO BHO MCO Sample Proviso Language: The Legislature finds that to further the goals of fully integrated health for individuals with severe and chronic mental illness and/or substance use disorders, a pilot project will be established in one Regional Service Area to measure the effect of maintaining separate funding streams for Behavioral Health Organizations and Managed Care Organizations on the overall clinical integration of care. • The pilot shall be established in a geographically isolated RSA. • Current Access to Care (Mental Health) Standards will be eliminated (date); all Mental Health services would be managed by the pilot BHO. • Agency Affiliated Licensed Therapists will be allowed to practice in primary care settings to provide a mechanism for bi-directional care between mental health and substance use treatment providers and primary care practices. • Standards for measuring clinical integration shall be negotiated between the HCA, the existing BHO, and partnering MCOs. These measures shall be utilized in the pilot RSA as well as in fully financially integrated RSAs. o If measures determine that integration efforts in the pilot RSA are comparatively unsuccessful at the end of 2024, the pilot shall end, and the pilot RSA shall become FIMC.