Fallon Total Care Presentation to Implementation Council November 21, 2014 Dan Rome, MD Medical...
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Fallon Total Care Presentation to Implementation Council November 21, 2014 Dan Rome, MD Medical Director [email protected]
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Transcript of Fallon Total Care Presentation to Implementation Council November 21, 2014 Dan Rome, MD Medical...
Fallon Total CarePresentation to Implementation
CouncilNovember 21, 2014
Dan Rome, MDMedical Director
Day Treatment
Screening & Assessment
24/7 Coverage
Judicial Service
Quality Programs
Long TermCare
Skilled Home Care
Transportation
DME
Credentialing
Disease Mgmt
CERIndividual Care PlanSocial
Services
Case Review
PCA & other HCBS
Vocational Services
Eligibility/Benefits
Home based Services
MemberServices
TCM/RehabServices
Crisis Services
Wellness
Family & Supports
Pharmacist Other Agencies
IL-LTSS Coordinator
Navigator
Case Manager
Social Workers
Peer support specialist
Behavioral Health
Provider
Specialists
PCP Member
Fallon Total CareModel of Care
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Access to Behavioral Health Services
Inpatient BH services (MH and SA)Available 24/7Broad network, reaching well outside FTC service areaDedicated clinician 24/7
Works with ESP’s (community crisis teams) and hospital ED’s to assist in appropriate placementMonitors bed-finding activities and timelinessAlerts FTC medical director to ED “stuck cases”
Significant delays in inpatient placement: < 5%
General psychiatryEating disordersMedical psychiatryLevel 4 medically managed detoxification
Access to Behavioral Health Services
Diversionary levels of careMobile crisis teamsCrisis stabilization bedsRespite bedsPartial hospitalIntensive outpatientCommunity detoxification programs (Level 3, medically monitored)
Community stabilization services
DDART (dual diagnosis residential treatment)
Access to Behavioral Health Services
Additional BH-related servicesCommunity Mental Health CentersPrivate mental health clinics/practicesCommunity Support ProgramsPACT (Program for Assertive Community Treatment)Peer Outreach ProgramPeer support servicesRecovery Learning CommunitiesIndependent Living CentersClubhousesDMH case workers and case managers
Transitions of CareCase manager responsibilities:
Engagement and AssessmentGoal-settingCare planningTransitions management
Every member with active BH is served by a BH case manager (as well as a Navigator and nurse case manager)Core activities:
Working with member to understand member’s goals and needsWorking to arrange needed clinical servicesWorking with members, providers and IL-LTSS C’s at times of care transition
Bridging function: integration of BH and primary careBH case managers attend primary care clinic rounds
IL-LTSS coordinatorsre-assessment following hospital or SNF discharges
Transitions of Care
Broad range of transitions management activities, including:
Anticipation of the transition by active following of members in acute care settingsDialogue with member, as well as referring and receiving providersAssistance with access to, and coordination of, needed aftercare services
MedicalBehavioralSocial services
Medication reconciliation oversight
“Best Practices”Collaboration with regional Emergency Services Providers
Development and communication of crisis and diversion plansUse of “alerts” in ESP providers’ information systemsNotification to BH case manager of BH ED presentations
Visiting members during BH hospitalizationsEspecially valuable for previously “unfound” membersFosters member engagement and successful transition planning
ED utilization/diversion programUses pharmacy claims to identify emergency room visits of all typesResults in follow up call to member to understand needs and to educate
“Reverse Integration”Supporting co-location of primary care within mental health clinics
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“Best Practices”
Peer Outreach ProgramUses peers to assist in finding, engaging and supporting members
Working with community sheltersTo locate membersTo identify needsTo support stability/acceptability during shelter stay
“It’s who you know”Use of our staff’s prior professional relationships to improve access and to advocate on behalf of our members
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Member Engagement
Navigator Introduction and Outreach callIn-home Assessment and Goal-setting visitProvision of new services and supports
Housing assistanceTransportationPersonal Care Attendants
Periodic check-in calls and home visits, as appropriateAdvisory Board participation
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Remaining ChallengesStable housing
Demand greatly exceeds supply“Personae non-grata”
Reliable transportation servicesTimely access to Outpatient BH services
Initial intakesTherapy servicesMedication/prescribing services
Limited supply of non-english speaking therapistsMember transience
Many members still hard to locateSome located and seen during initial assessments and planning now unreachable
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Remaining Challenges
Providing meaningful services and supports for chronically addicted individualsDemanding and/or abusive individuals“Throw-away” and time-limited phones
Reached become unreachableMembers conserve their “minutes”
Managing the boundary between case management/care coordination and service provision
Case managers and Navigators become some members’ “hot line” and all-purpose problem solverExpectations management, for both members and staff
Scope/scale of needs and staff morale
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Opportunities
Many…Continue to address the challenges noted aboveContinue to educate, collaborate with and support providers and caregivers of all types to improve
AccessQualityEffectiveness…of services offered
Continue to collaborate with MassHealth and CMS, with the other One Care plans and with FIDA programs underway in other states
Much has been done and much has been learned. Our commitment to One Care remains as strong as ever.
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