Staffing for Success by Leveraging PPS

1. Staffing for Success by Leveraging PPS July 12, 2017 Xavior Robinson National Council for Behavioral Health Virna Little Institute for Family Health

3. Presenters Xavior Robinson – Senior Advisor, Practice Improvement • CCBHC Learning Initiative Project Lead • Public and Behavioral Health Financing Expert Virna Little, PsyD, LCSW-r, SAP, CCM – The Institute for Family Health • Integration specialist • Evidence Based Practices Advocate

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5. Learning Objectives • Examine the different opportunities and constraints for staffing and service delivery available to CCBHCs under PPS vs. fee-for-service • Explore strategies to innovate staffing models within the confines of your CCBHC’s current cost report and PPS rate. • Align CCBHC staffing model with client needs, outcome and quality measures, and your PPS rebasing strategy • Learn strategies to maximize recruitment and retention of clinical and non-clinical staff

6. FFS vs. PPS

7. Staffing Models: What does PPS Have to Do With It? • Staffing should be driven by patient need… • …and informed by new payment realities • Services with higher margins may no longer be billable – e.g. care coordination, case management • “Business as usual” can result in unrealized funding, failure of payments to cover total costs • Requires careful examination of staffing patterns and understanding of “threshold visit” • Strategic allocation of staff resources

8. What’s a threshold visit? A visit that triggers a payment! • Also known as “qualifying encounter” • Each state may define slightly differently • Know which services qualify under your state’s definition… and which do not • No matter how much of a service you provide, you don’t get paid if it’s not a threshold visit. • Remember that some nonbillable activities are required, core CCBHC services (e.g. crisis hotlines, care coordination)

9. Threshold visits & implications for staffing: Missouri example

10. The Threshold Visit Should be primary visit type A few exceptions but not the rule! Threshold visit provider types Its all about threshold visit! Efficiency counts more than ever……

11. Efficiency and Optimization Scheduling Optimization (future webinar Aug 9th) Staffing Optimization Billing and Coding Contracting

12. Changing Staffing Filling holes for services previously billable- Case Management/ Coordination Hiring practices- not hiring non- billable staff……. Example CM vs LMSW

13. The CCBHC Advantage In 3 Examples What flexibility do CCBHCs have within their existing rates to adjust staff mix and hire new staff?

14. Adding Psychologists Example: Two bachelor level unlicensed community support/case managers VS one licensed psychologist • PPS rate bundles all costs, creating flexibility for the components generating the cost to be swapped around. • Licensed Psychologist … • Offer a deeper and broader clinical skills • Can help organizations do more data-driven management and measurement based care • Caveat: examine scope of practice and unique skill set of each professional type – psychologists are just one example, and your clinic’s needs may vary!

15. Increase Access toEvidence Based Practices Example: Reduce the amount of supportive counseling & increase Dialectic Behavioral Therapy (DBT) • Assign an unlicensed master-level staff to do the psychoeducational classes, assign a supportive counselor to do the individual DBT therapy overseen by your new psychologist (from the prior example) who is running the group and overseeing the whole DBT program to assure fidelity to its EBP model.

16. Adding Psychiatrists • Option 1: As with the psychologist example previously, reduce some of the nonlicensed clinical staffing to cover increasing the amount of psychiatric staffing • Option 2: Increase your psychiatric staffing at the time of or prior to rebasing. In this case it is important to know the details of how the rebasing will be done (if at all).

17. Impact of staffing decisions on rebasing • PPS rates reflect your actual cost of providing services • CCBHCs that minimize psychiatrist (and other higher-level staff) utilization are likely to get a lower PPS when the rate is rebased, making it difficult to provide more of these services. • CCBHCs that increase psychiatrist utilization may see PPS rates rise or stay steady, supporting them in continuing to provide services by higher-level staff. • If there is a relatively short time period (e.g. six months) just prior to the rebasing occurring, then it may be feasible to increase psychiatric staffing and bear the six-month loss of providing service above cost of treatment to have higher psychiatric staffing going forward whose costs are completely covered.

18. Staffing decisions & quality measures • Number/Percent of New Clients with Initial Evaluation within 10 Business Days, & Mean Number of Days until Initial Evaluation for New Clients • Preventive Care & Screening: Adult Body Mass Index Screening & Follow-Up • Weight Assessment & Counseling for Nutrition & Physical Activity for Children/Adolescents • Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention • Preventive Care & Screening: Unhealthy Alcohol Use: Screening & Brief Counseling • Child & Adolescent Major Depressive Disorder: Suicide Risk Assessment • Adult Major Depressive Disorder: Suicide risk assessment • Screening for Clinical Depression & Follow-Up Plan • Depression Remission at 12 months Align staffing mix decisions with quality improvement efforts & outcomes monitoring! Quality measures drive bonus payments, and are being evaluated as part of the report to Congress

19. Recruitment Strategies • Focus on team-based staffing & hiring • Work as part of a team • Interview as part of a team • Re-examine your job descriptions/postings • Participate in virtual job fairs • Get certified as NHSC-eligible site

20. Poll: Are you a National Health Service Corps eligible site? Yes No Unsure

21. THE NATIONAL HEALTH SERVICE CORPS THE NATIONAL HEALTH SERVICE CORPS (NHSC) builds healthy communities by supporting qualified health care providers dedicated to working in areas of the United States with limited access to care. The NHSC is part of HRSA’s Bureau of Health Workforce (BHW). BHW improves the health of underserved populations by strengthening the health workforce and connecting skilled professionals to communities in need. 27% of BHW funding supports the NHSC and other programs that improve the distribution of health professionals to underserved areas.

22. NATIONAL HEALTH SERVICE CORPS: NOW* *As of September 30, 2015

23. IMPACT OF THE NHSC MORE THAN 9,600 NHSC members are currently providing care to more than… 10 MILLION PEOPLE IN THE UNITED STATES 87%of NHSC members continue to serve in areas of greatest need after completing their service obligation.

24. UP TO $50,000 FOR 2 YEARS SERVICE With continued service, providers may be able to pay off all their student loans. Offers fully trained primary care clinicians loan repayment in exchange for service in an area of greatest need, called a Health Profession Shortage Area (HPSA). Applicants working at NHSC-approved sites with higher HPSA scores are given priority.

25. PROVIDERS RECEIVE LOAN REPAYMENT IN ADDITION TO A COMPETITIVE SALARY FROM THEIR EMPLOYERS 1 Providers find a job at an NHSC-approved site THEN 2 Apply to the NHSC for loan repayment Watch the NHSC Site Video on the "HRSATube" YouTube channel. Find positions at NHSC-approved sites using the NHSC Jobs Center: http://nhscjobs.hrsa.gov

26. LOAN REPAYMENT AWARD The NHSC Loan Repayment Program offers priority funding to applicants who work at NHSC-approved sites in high-need areas, as defined by a Health Professional Shortage Area (HPSA) score. INITIAL AWARD AMOUNTS UP TO $50,000 FOR 2 YEARSFull-time UP TO $25,000 FOR 2 YEARS Half-time In FY15, awards were given to applicants working at sites with HPSA scores of 14 and above.

27. ELIGIBILITY U.S. citizen or national Currently work, or applying to work, at an NHSC-approved site Have unpaid government or commercial loans for school tuition, reasonable educational expenses, and reasonable living expenses, segregated from all other debts Licensed to practice in state where employer site is located Must be licensed in one of the following eligible disciplines: Physician (MD or DO) Nurse practitioner (primary care) Certified nurse-midwife Physician assistant Dentist (general or pediatric) Dental hygienist Psychiatrist Psychologist (health service) Licensed clinical social worker Psychiatric nurse specialist Marriage and family therapist Licensed professional counselor

28. - Lucia Lopez, Physician Assistant, Winston Salem, NC “I’m working, I’m getting my salary, I’m getting loan repayment, and I’m doing what I love.”

29. STUDENTS PURSUING CAREERS IN PRIMARY CARE CAN RECEIVEA SCHOLARSHIP NOW AND SERVE LATER THE SCHOLARSHIP* INCLUDES: Payment of tuition and required fees (tax-free) Some other tax-free educational costs (books, etc.) A monthly living stipend (taxable) *Available for up to 4 years

30. NHSC SITES Eligible sites include “comprehensive community-based primary behavioral and mental health setting or facility”  most CCBHCs should qualify

31. SCHOLARS: ELIGIBILITY U.S. citizen or national Full-time student at an accredited school, pursuing a degree in: Medicine (DO or MD) Dentistry (DMD or DDS) Nurse practitioner Certified nurse-midwife Physician assistant

32. STUDENTS TO SERVICE AWARD UP TO $120,000 FOR 3 YEARS Full-time Service UP TO $120,000 FOR 6 YEARS Part-time Service The NHSC offers up to $120,000 in tax-free loan repayment for 3 years of full-time service or 6 years of half-time service. Loan repayment begins during residency. With continued service, eligible providers may be able to pay off all their student loans.

33. 37 STATES ARE GRANTEES Provides cost-sharing grants to states to operate their own loan repayment programs for primary care providers in underserved areas. Eligible disciplines vary but may include physicians, nurse practitioners, physician assistants, dental professionals, registered nurses, mental health professionals, and pharmacists. 5 STATE LOAN REPAYMENT PROGRAM

34. SUPPORT FOR PROVIDERS SUPPORT FOR YOU IN YOUR REGION Dedicated BHW staff located in 10 regional offices provide dedicated contacts for your area. SUPPORT FOR YOU AT YOUR SITE NHSC Ambassadors help educate and inform current and prospective members.

35. RESOURCES FOR PROVIDERS NHSC JOBS CENTER http://www.nhscjobs.hrsa.gov • View job vacancies at thousands of NHSC-approved sites nationwide. • Google Maps technology allows users to view the surrounding community (e.g., schools, restaurants, parks, places of worship, shops) • Narrow your job search by: • Field of Practice • Specialty • HPSA Score • Site Name • Zip Code • Sites with Open Positions

36. FUTURE NHSC EFFORTS BETWEENFY 2017ANDFY 2020 NHSC will receive $2.8 billion in investments to address health professional shortages in underserved areas across the country. FY 2017 $380 MILLION In FY 2017, NHSC will receive $380 million in funding to expand access to mental health care and training to address drug abuse.

37. OTHER LOAN REPAYMENT &SCHOLARSHIP PROGRAMS BUREAU OF HEALTH WORKFORCE NURSE CORPS:Loan Repayment ProgramScholarship Program Native Hawaiian Health Scholarship Program Faculty Loan Repayment Program Scholarships for Disadvantaged Students

38. Additional Resources Workforce Connections newsletter: www.hrsa.gov/subscribe LinkedIn: www.linkedin.com/company/national‐health‐service‐corps www.linkedin.com/company/nurse‐corps Twitter: twitter.com/HRSAgov twitter.com/NHSCorps Facebook: www.facebook.com/HRSAgov/ www.facebook.com/nationalhealthservicecorps/ www.clinicians.org www.peacecorps.gov

39. Workforce Retention Be clear on expectations ( integrated setting) Quality indicators –shared accountability Visit /volume expectations Collaborative documentation Balancing Retention vs. Efficiency !

40. Medicaid Adult & Child QBP Bonus Measures

41. Why Quality Dollars ! In addition to PPS rate !! Start small or as a pilot ! Don’t let perfection block progress Paves readiness for VBP If you are not talking about quality dollars with payers……….

42. Coding is Key Helps with quality dollars Demonstrates complexity of population and services Additional dollars like testing, crisis and transitions of care

43. Don’t Forget Other Payers Medicare Third Party

44. Questions

45. Get Help! Peer Learning Network Participants • Listserv Inquiries • CCBHC Resource Page • https://www.nationalcouncildocs.net/ccbhc-learning-community

46. Get Help! Master Class Community of Practice Participants CCBHC Resource Page • https://www.nationalcouncildocs.net/ccbhc-learning-community Sign-Up for Faculty Office Hours Chat with Dr. Virna Little • Friday July 21 12:30p-2:00p EDT • Friday August 4 3:00p- 4:00p EST Attend an Affinity Group Call • Data/Quality – 7/17 at 2pm with David Swan • Clinical – 7/19 at 2pm with Dr. Joe Parks • Operational – 7/31 at 2pm with Kristin Woodlock • Financial – 7/31 at 2pm with Gil Bernhard Request Individualized Coaching • Sign up here

47. Webinars July 26 at 2pm EDT Living (and Thriving) Under PPS: What You Need to Know for the Year Ahead August 9 at 2pm EDT Enhanced Access August 23 at 2pm EDT Change Management

48. Resources Flannery Peterson Senior Project Manager FlanneryP@thenationalcouncil.org Chayla Lyon Project Manager ChaylaL@thenationalcouncil.org 202-629-5797