Behavioral Health Partnership Oversight Council
Quality Management & Access Subcommittee
Legislative Office Building Room 3000, Hartford CT 06106
(860) 240-0321 Info Line (860) 240-8329 FAX (860) 240-5306
www.cga.ct.gov/ph/medicaid
Meeting Summary: November 17, 2006
Chair: Dr. Davis Gammon Vice-Chairs – Paula Armbruster
Next meeting: Friday December 15, 2006 at 11:30 AM at CTBHP/VOI, Rocky Hill.
Husky A Behavioral Health ED Utilization
Virginia Mulkern (Human Service Research Institute (HSRI) and Judith Meyers, (Child Health & Development Institute of CT – CHDI) reviewed a draft summary of HUSKY A children's ED use with primary psychiatric diagnoses. (Click on icon below to view draft report).
This report is part one of a three-part study that looked at:
• ED visits by HUSKY A children/youth for primary psychiatric diagnoses between 2002 and 2005 under the managed care system.
• ED visits by ALL children to CT EDs between 2001 and 2005, using the CT Hospital CHIME database.
• A qualitative study based on interviews with a sample of parents whose children used the ED for mental health problems and theED staff who provided care to these children.
Highlights of the Report #1 included:
ü Psychiatric ED volume for HUSKY A children increased by 38% between 2002 and 2005. Half the increase was related to HUSKY enrollment increases and half due to increases in actual ED use for primary psychiatric diagnoses. Youth ages 13-15 accounted for more of the visits than children ages 9 and younger.
ü Sixty-four percent (64%) of children were connected to BH services 6 months prior to an ED visit.
o Older children were less apt to have BH services (52%) 6 months prior to the ED visit.
o More than half the ED visits (52%) were children who had received 13 or more days of BH services during the 6 months prior to the ED visit.
o Forty-seven (47%) of ED visits that were preceded by psychiatric hospitalization showed a 2-6 month inpatient stay with no intervening service prior to the ED visit.
ü 76-78% of children had at least one BH service during the 6 months following the ED visit, with nearly one-half receiving a BH service within one week of the ED visit. Younger HUSKY children were more apt to have a follow-up visit (85%) after an ED visit compared to 65% of those 16 and older. There was an increase, from 59% in 2002 to 63% in 2005, of the proportion of ED visits that were followed by more intensive follow-up care of 13 or more days during the 6 months post ED visit. Younger children were more apt to be engaged in treatment post ED visit (73%) than older youth (48%).
ü The percentage of children with a repeat ED visit during the subsequent 6 months declined from 22% in 2002 to 19% in 2005; however children under 12 years were more likely to have a repeat visit (25%) compared to older youth (16%).
Subcommittee Discussion highlights:
• The CHIME data report has statewide ED use/volume; the second report will shed light on the scope and nature of pediatric psychiatric ED use throughout the state for public/private insured.
• HSRI is just beginning the qualitative study that will help answer questions about why families chose/needed ED services for their children's mental health problems and perhaps issues about connecting to or remaining engaged in BH services.
• The HUSKY ED data does not show a seasonality utilization pattern. What is apparent from the HUSKY data is that a majority of children using the ED have received MH services during the 6 months prior to an ED visit and that a significant percentage of inpatient clients do not receive follow-up BH services after discharge (the data is claims based, therefore appointment “no-shows” could not be quantified). The data identifies the need for 1) intensive follow up care management for children/youth discharged from inpatient settings and 2) assessing if/how providers and families develop crisis plans that may divert some ED crisis visits.
• Dr. Schaefer (DSS) conjectured about policy implications arising from this study. While MH access has improved among those seen in the ED, questions remain:
o What is the nature of care provided to HUSKY A children, who sends the child/youth to the ED and why, are crisis plans developed and used by providers and families?
o ED use patterns do not seem to be dominated by DCF-involved children, who have higher intensive service use. Should increasing ED use of “healthier” enrolled non-DCF children raise alarms or does it reflect the pent-up demand for MH services?
o The hypothesis is that improving access to community-based services will reduce institutional discharge delays, but could there be an associated paradoxical increase in ED visits? Crisis management planning is a critical component of the system delivery changes.
o Emergency Mobile Crisis Intervention Services (EMPS) impact on ED use is not known. It may be that EMPS increases ED use through new case findings.
• Going forward, the BHP and Council want to look at data that identifies best practices by practice type (i.e. independent practices, clinics, etc) to promote care outside the ED. The CTBHP 10B_7 census analysis report (See below) on discharge delays by service class will be able to identify trends in local areas for institutional discharge delays and look at the overall impact of the Enhanced Care Clinics policy of timely access to services.
The Subcommittee recommended that the HUSKY A report #1 be reviewed at the full BHP Oversight Council in December.
Outpatient Registration and Re-authorization Process Content
ü The Outpatient Registration process reportedly takes 11 minutes to complete IF there are no web-based delays (i.e. the screen freezes; the completed screens are saved if this happens). Providers will know if a registration is successful/unsuccessful immediately on the screen or in 48 hours via mail. Issues discussed:
o The Quality SC will continue to look at the design/content of screens and the Operations SC will continue to address system issues.
o The primary reasons for lengthy new outpatient registration times remain unclear. The BHP plans to assess provider burden by first evaluating where the technical delays occur- at a provider web-based system or at the CTBHP/VOI system, with implementation of technical solutions. At that point the registration items can be assessed, referencing the VOI performance requirements.
o The BHP expects a level-of-effort report from VOI in the 1st week of December on implementation costs of provider electronic submission of data to VOI that would meet the registration requirements.
ü Dr. Gammon asked the subcommittee participants present, including the CCPA representative, to request providers to directly contact the Chair about their experiences the registration screen time burdens, identifying technical versus content issues.
ü Wheeler Clinic requested the BHP to consider the phone authorization for IICAPS include the outpatient registration information as most IICAPS clients also need medication management services. While the information required for IICAPS and outpatient services authorization share some similarities, one form currently does not meet both levels of care authorization requirements. Linda Russo was asked to summarize the problem/potential solutions and send this to Dr. Gammon.
ü Dr Gammon summarized the issues that require actions:
o Identify the registration technical problems and improve server efficiency.
o BHP is determining the feasibility of provider electronic “batch” submission of registration data.
o BHP & CTBHP/VOI identify improved efficiencies in IICAPS/outpatient authorization processes.
o BHP establishment of an interagency task force with time specific goals to reduce redundancy of provider reports to various granting agencies (i.e. DCF, DMHAS).
o The Subcommittee will review the re-authorization content at the December Subcommittee meeting prior to this process being finalizing.
HSRI Program Indicator report Update: DSS reviewed the indicators and the system specs and have sent these back to HSRI. Dr. Gammon requested DSS send him the final indicators and specs.
ASO Performance Targets: DSS distributed ASO performance target proposals under consideration for CY 2007 associated with CTBHP/VOI performance withholds/incentives. (Click on icon below). The Subcommittee will review and make recommendations regarding the proposal at the December meeting.
Enhanced Care Clinics: 42 applications have been reviewed and are being scored. The decisions on the designated ECCs should be completed in mid-December. DSS stated the timelines haven't changed in that reimbursement will be retroactive to Oct. 2006. The intent all along has been to apply the ECC criteria to the successful applicants 6 months from the date the applicant is informed of being chosen as an ECC.