Region 1 IDN - Constant Contactfiles.constantcontact.com/1f19db8e001/d2e68877-39c... · Region 1...

Region 1 IDN

Integrated Delivery Network Region 1: Partnership for Integrated Care

Region 1 IDN Request For Proposal Process • The Region 1 IDN following a community driven process has elected

to open all DSRIP projects (B1, C1, D3, E5) to IDN partners through an RFP process for first round funding through the month of May, 2017.

• Deadlines for proposals are Monday, June 5th

• Following proposal submission there will be a review within the Region 1 IDN Admin Lead Team, 5 days of review by a 9 person Independent Review Panel and finally a no contest approval by the Region 1 Executive Committee.

• Given this process and the timing of this presentation all of the components shared are driven from the C1 Project Team and Scope of Work developed to guide the RFP- No concrete details are yet known

Regional Target Populations/Institutions IDN-1 Providers Support 27,574 Medicaid Members in 61 Towns

• Target Population: Adults with serious mental illness.

• Target Participating Organizations: Hospitals (including New Hampshire Hospital), primary care providers, behavioral health providers, community-based social services organizations. • Currently Involved on C1 Project Team:

• West Central Behavioral Health (CMHC) • Monadnock Family Services (CMHC) • Sullivan County • Cheshire Medical Center • Dartmouth Hitchcock Medical Center • Servicelink – Monadnock, Sulllivan • Keene Housing Authority • Alice Peck Day Hospital • Crotched Mountain Services • Home Healthcare Hospice and Community Services

Targeting/Screening & Enrollment Processes/Tools

• Likely the Region 1 C1 Project will start as a pilot based out of Cheshire Medical Center. The ED has been working with other organizations on co-located case management over the past 2 years. From that system the C1 project may build out to formalize screening, enrollment, and the support available to the CTI case manager • Details of the screening tools and process steps for enrollment will be

dependent on the organizations collaborating to apply for C1 funding

• Additionally all tools, screenings, and processes selected will be likely used as a foundation for the other replicated CTI implementation in other sub-regions of the IDN

Workforce Recruiting, Management & Development Plan

• Per the C1 scope of work developed: The intervention team encompasses • A Bachelor’s Degree level or Master’s Level caseworker trained in CTI

• A licensed Master’s Degree level clinical supervisor

• A lay professional or Bachelor’s Degree level fieldwork coordinator

• Some organizations may choose to combine the clinical supervisor and fieldwork coordinator roles.

• More will be known on the institutional home, team structure, and supervision once the proposals are received

Project Implementation Timeline RFA Timeline Milestones Date

RFP & Application Forms Released to Region 1 IDN Partners Thursday, May 4th

Region 1 Admin. Leads hold “Office Hours” and Q&A Webinars for RFP & Application Support

Weeks of May 8th and 15th

Application Deadline for Submission Monday, June 5th at 5:00 p.m.

Application Review Period by Admin. Leads Project Teams Independent Review Panel

Weeks of June 5th, 12th and 19th

Final Approval by Executive Committee Week of June 26th

• As of July 1st the CTI team needs will be identified within the awarded organization • Details on recruitment and implementation will be included with the

RFP • Through July, August continued coordination for statewide training on CTI • July, August – Development of process, case management and

implementation framework for CY17 and CY18

Current Tracking, Monitoring & Evaluation Plan

• Per the RFP process proposals there will be submissions from organizations that will include their internal tracking, monitoring and evaluation frameworks

Gaps, Challenges, Unanswered Questions

1. How best can you integrate the CTI case manager into other system processes, team support etc.? • Role of co-location

• Team Meetings

• Community Based Forums

2. How best can the system be structured for caseload support and the transition of clients through phases I-III?

3. General questions on feasible evaluation and tailoring if necessary

IDN 3:

Nashua Region

Regional Target Populations/Institutions

• Target Population: Adults with a primary serious mental illness (SMI) or serious and persistent mental illness (SPMI) • Not already connected to community-based care that currently meets their

clinical needs

• Transition: Hospital Emergency Department and NH Hospital to the community


• Screening tools under consideration: • Patient Health Questionnaire (PHQ) 2 & 9 or Mental Health Screening Form III

(MHSF-III) • Screens to identified functional impairments (screening tool(s) TBD)

• Referrals • From ERs: through Transitional Care Coordinators • From NH Hospital: through Discharge Planner and Social Workers • To: CTI Clinical Supervisor or one of CTI Case Managers

• Conducts CTI Brief Assessment determining appropriateness to CTI • Referrals to primary care physician (if lacking one)


• Master’s Level Licensed Clinical Supervisor (1 FTE) • Caseload of up to 10 patients, depending upon CTI phase • Weekly supervision of CTI staff

• Bachelor’s Level Case Manager (2 FTEs) • Caseload of maximum 20 patients each, depending upon CTI phase

• Fieldwork Coordinator (1 FTE) • Could be Community Health Worker, Peer Support Worker, Navigator level • Links patient to community resources and provides community education

Project Implementation Timeline • July-August 2017:

• CTI team recruitment • Agreements signed with NH Hospital, Southern NH Medical Center, St. Joseph

Hospital • Training/education for patient referrals and work flow protocols • Set-up of HIT:

• Shared Care Plan (SCP), Electronic Notification Service (ENS), Data Aggregator

• September – October 2017 • CTI Supervisor/Program Fidelity and CTI Team Trainings • CTI Community of Practice Kick-off

• October/November 2017 • Full implementation of CTI

• Early 2018 • CTI Train-the-Trainer to build in sustainability


• Use of Collective Medical Technology (CMT) Shared Care Plan • Through Electronic Medical Records (EMR) and cloud-based platform

• Case management meetings: CTI team and other care team members • Patient engagement and education about IDN’s coordinated care model

• Evaluation: • Reduction in repeat ER visits • Yearly screening and referral protocols monitored for physical, mental and

substance use, as well as for social determinants of health


• Workflow for referral – via EHRs? Via other means?

• Creating resource base/referral process with non-IDN social service entities (e.g., Southern NH Services, DHHS, etc)

Region 4 IDN

Co-lead: Susan Stearns

Co-lead: Vic Topo

Region Director: Peter Janelle

Project Manager: Jennifer Turransky

CTI Kickoff Event June 1, 2017


17 CTI Kickoff Event June 1, 2017

• Transitions from Hospital to the Community • Clients with either an ED visit or inpatient stay where either a primary or

secondary diagnosis or comorbidity includes a behavioral health condition

• Transitions from Corrections to the Community • Clients released from correctional facilities, including Sununu Youth Services

Center, with an identified behavioral health condition

• Transitions from Youth Behavioral Health programming to Adult Services

Screening & Enrollment Processes


• Referrals accepted from any N4H partnering organization

• Individual will be navigating 1 of the 3 critical transitions identified

• Eligibility criteria established

• Participate in N4H approved Core Standardized Assessment

Workforce Management & Development Plan

• N4H Care Transitions Director/Clinical Supervisor • Education

• Masters level experienced clinician

• Governance • Reports to N4H Executive Director

• Care Transition Coach (5-6 FTEs) • Education

• Bachelors level or lived experience

• Governance • Reports to N4H Care Transitions Director


Project Implementation Timeline

• May-June 2017 • Kickoff event (Phase 1) • Refine workforce needs (FTEs needed, job descriptions, salaries, hosting

organizations)

• July-September 2017 • Recruitment of staff • Organization and DSRIP orientation

• September-October 2017 • CTI Training to begin (Phase 2)

• October- December 2017 • Monthly coaching for CTI staff (Phase 3) • Identify staff for train-the-trainer training • Begin accepting referrals

• January- February 2018 • Train-the-Trainer training to begin (Phase 4)


Monitoring & Evaluation Plan

• N4H Core Standardized Assessment performed upon referral

• Baseline assessment on admission and reassessment at 30, 60 and 90 days to identify: • Hospital admissions

• Emergency room visits

• Utilization of crisis services

• Criminal justice system involvement and incarcerations


Challenges

• Workforce • Identifying organizational home • Turnover • Recruitment

• Capacity • Unknown demand

• Education of referral sources

• High fidelity implementation


Discussion


Questions?

Comments

Follow-up

Thank you

Region 6


• Target Population • >18yo Individuals/Head of Household • Primary or co-occurring disorders SMI/SPMI; SUD; TBI

• Risk Factors (2-3): • At risk of homelessness or homeless • Lack of positive social support/natural supports network • Inability to perform activities of daily living adequately • Lack of basic subsistence needs (food stamps, benefits, medical care, transportation) • Inability to manage money • Unemployment/underemployed/lack of employment skills • Probation/Parole

• Institutions • Hospital (Frisbie Memorial) • Crossroads Homeless Shelter • Eventually Corrections and Residential Treatment


• Screening and Comprehensive Assessment TBD

• Combination of tools (10th Decile Approach) • Diagnoses • Housing Stability • Crisis Service Utilization • Social Supports • ADLs

• Assessment of Needs/Strengths across categories • Arizona Self Sufficiency Matrix

• Service Order/Authorization

• CTI Phase Planning


• Contemplating one Full CTI Team comprised of: • Masters level Team Leader • 3 FTE CTI Workers (Bachelors Level-competencies composite)

• Team Leader located at Strafford County Complex • One CTI Worker at Crossroads House • Other two CTI Workers at partner organizations

• Weekly Case Conference/Supervision at County (with IDN Ops)

• Integration with Community Care Teams

• Continuous QI and Supplemental Trainings (offered across IDN)


• June 30 • Plan/Budget Finalized • MOUs/Contracts finalized

• September 1 • CTI Staff Hired; On-boarding (services orientation)

• October 15 • Initial CTI Training complete (Team Leader; CTI Staff) • Enrollment begins

• January 2018 • Train-the-Trainer

Current Tracking, Monitoring & Evaluation Plan < Institutional Nights (Hospital, Corrections) < ED Utilization < Ambulance > Psychiatric – stability, med management > Housing Stability (Days Housed) > Self Sufficiency

> Linkage to Services/Benefits > Daily Life skills > Social Support Network > Community Involvement > Food Security > Mobility


• All the usual challenges related to recruiting and retention

• Are any Regions contemplating in-reach to State Hospital?

• Process for making distinctions with existing services/resources • i.e. ACT, Community Paramedicine, etc. (exclusion criteria, or supplemental?) Work Group: Frisbie Memorial Hospital Goodwin Community Health Cornerstone VNA Community Partners CMHC Tri-City Co-op Crossroads House

Region # Coos, Carroll and Northern Grafton Counties


Medicaid recipients transitioning from hospitals, long term care, or incarceration

Individuals with a primary diagnosis of SPMI/SMI Those not actively connected with ACT or ongoing programs that meet

clinical needs Risk factors that include: homeless or risk of homelessness; lack of social

or natural supports; daily living skills are compromised; lack connections to basic needs (medical, food, benefits); possible substance use; lack employment skills; challenged by daily functioning; inability to manage money.

Navigating critical transitions without skills or clinical support


Referral organizations

Outreach and education (brochure)

Understanding/ agreement

CTI Referral Form

Client is identified

Meets eligibility criteria

Screening and Assessment

Initial Risk Assessment

Enrollment Process

Signed Service Order

Transition Plan created Individualized

Phase Plan

Crisis P&I

Phase 1

Phase 1 Begins

CTI Progress Notes

Phase-Date Form

CTI Team Supervision

Caseload Review

Worker Self Assessment


Workforce Development

Outreach to Educational providers

Educate Providers High schools Professional Development

Create Regional Hubs

Minimum of 4 staff Define maximum caseload Define regions Inclusive of Peer Specialists

Provider Organizations/Staffing

Serve population Have complimentary

positions Job Descriptions Clinical supervisor


CTI Kick Off- June 1, 2017

Program essentials are shared and will be incorporated into program components and processes

Finalizing Program Components-June 2017

Design and Development of clinical services infrastructure

Progress and Phase Reporting

Discharge Process

Evaluation, Tracking and Fidelity

Project Budget-June 2017

Budget Projections reviewed and final budget determined.

Timeline

Participating Providers Confirmed June 2017

CTI participating provider organizations complete agreements with referring organizations

CTI Training- Fall 2017

CTI Training provided by CACTI

5 CTI Professionals Trained including a Clinical Supervisor, Case Managers and Peer Specialists.

Implementation- Fall 2017

Participating providers identify eligible participants/referrals are made

On-going additional trainings such as Person Centered Thinking; Motivational Interviewing

Timeline

Technical Assistance and Mentoring Fall 2018 and ongoing

CTI Trainer to provide TA and mentoring.

Regional CTI Workgroup to share best practices and provide updates to current processes.

CTI Trainer candidates are recruited.

CTI Train the Trainer – Jan/Feb 2018

CTI regional Trainer is trained.

Regional Review- July 2018

Regional participating providers to meet for a review of the first 9 months of the program. Recommendations for improvements.


Phase or PCP

Plan

Phase Plan

Progress Notes

Tracking tool

Staff self assessment

Fidelity Assessment

Closing Plan

Adherence Follow up


• Has the program been started within a Jail setting?

• Recommended program exclusions- is the program ever used with a SUD primary diagnosis?

• Is eligibility criteria determined by region or does the CTI program define that?

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