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Executive Summary: Utilization Management for HUSKY Youth Members

Quarter 1, 2014

General Overview

On at least a quarterly basis, the reports mutually agreed upon in Exhibit E of the CT BHP contract are submitted to the state for review. This Executive Summary focuses on the utilization management portion of these reports, evidenced in the 4A and 10B series which review utilization statistics such as average length of stay (ALOS) and admissions per 1,000 members (Admits/1,000) and Discharge Delay. NOTE: A detailed description of the measures can be found at the end of this document. The review on the following pages provides information regarding the Child/Adolescent Medicaid

population’s utilization of behavioral health services in various levels of care. This summary focuses on

trends in utilization during Q1 ’14 and particularly on those levels of care (LOC) with significant findings.

Additionally, this summary provides possible explanations for the findings and descriptions of any

utilization management strategies identified to address them. When appropriate, recommendations are

made regarding remaining challenges with utilization patterns.

This Q1 ’14 UM analysis focuses on the following areas:

4A_2: Total Unique Membership Youth (0-17)

4A_1: Membership Youth (0-17) DCF Members

4A_1: Membership Youth (0-17) Non-DCF Members

4A_1/4A_2 Inpatient Admits/1,000; All Youth (0-17) ; DCF vs. Non-DCF Members

4A_1/4A_2: Inpatient Days/1,000; DCF vs. Non-DCF Members

4A_1/4A_2: Inpatient Average Length of Stay, DCF vs. Non-DCF Members

PAR: Inpatient Average Length of Stay (ALOS) and Discharges for In-State Pediatric Hospitals;

All Youth (0-17)

PAR: Inpatient Average Length of Stay (ALOS) for In-State Pediatric Hospitals; Child (3-12) and

Adolescent (13-17), DCF vs. Non-DCF

10B_7: Inpatient Number of Days Delayed , DCF vs. Non-DCF Members

CTBH12087: Inpatient Average Days in Delay by Reason code(s)

CTBH12087: Inpatient Solnit Center ALOS; All Youth, Court Ordered and Non Court Ordered

data

4A_2: Community PRTF Admissions; Youth (5-13), Community PRTF Days/1,000 and PRTF

Average Length of Stay, All Youth

10B7: Community PRTF Number of Days Delayed; Youth ( 5- 13),

4A_2: IICAPS Admits/1,000; All Youth (0-17)

Beginning in 2012, and as agreed upon in the CORE meetings, the Executive Summary now focuses on

only those levels of care in which the data reveals findings or trends that warrant discussion. Those

findings that have remained flat or consistent over time are removed from the body of the analysis

document and placed in an Appendix at the end of the analysis document. For this quarter the following

graphs can be found in the Appendix at the end of the main report.

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4A_2: Inpatient Solnit Center Admissions by Quarters; All Youth (0-17)

4A_2: Inpatient Solnit Center Days/1,000 by Quarters; All Youth (0-17)

10B7: Inpatient Solnit Center Number of Days Delayed

CTBH12212: Quarterly Inpatient Solnit Center Average Days in Delay by Reason Code

4A_2: Solnit Center PRTF Admission by Quarters; All Youth (13-17)

4A_2: Solnit Center PRTF Days/1,000 by Quarters; All Youth (13-17)

PAR: Quarterly Solnit Center PRTF Average Length of Stay ; All Youth (13-17)

10B7: Solnit Center PRTF Number of Days Delayed; All Youth ( 13-17)

4A_2;EDT Admits/1,000 by Quarters; All Youth (0-17)

4A_2:Home Based Services (MDFT, MST,FFT) Admits/1,000 by Quarters; All Youth (0-17)

4A_2: Outpatient (OTP/TST) Admits/1,000 by Quarters; All Youth (0-17)

4A_2: PHP Admits/1,000 by Quarters; All Youth (0-17)

4A_2: IOP Admits/1,000 by Quarters; All Youth (0-17)

18A: Volume of Outpatient Registrations; Youth (0-17)

18A;Location of Outpatient Treatment; Youth (0-17)

18A OTP- Provider Obtained Consent to Contact Other Providers; Percent of Cases; Youth (0-17)

18A OTP Provider Indicated Need for Medication Eval/Management Visit: Percent of Cases; Youth( 0-17)

18A OTP-Provider Indicated Family/Significant Other is Involved Members Treatment/Recovery Plan” Percent of Cases; Youth (0-17)

In addition, the following sets of graphs will be found in the appendix each quarter:

The 10B: Discharge Delay Series

10B4A: Inpatient discharge Delay Reason Codes

10B4A: Inpatient Discharge Delay Reason Awaiting Placement

10B4B: PRTF Discharge Delay Reason Codes

10B4B: PRTF Discharge Delay Reason Awaiting Placement

10B4B PRTF Discharge Delay Reason Awaiting Placement

10BD: Group Home Delay Reason Codes

10BD: Group Home Awaiting Placement

10B4A: Inpatient Solnit Center Discharge Delay Reason codes

10BA: Inpatient Solnit Center Discharge Delay Reason Awaiting Placement

10B4B: Solnit PRTF Discharge Delay Reason Codes

10B4B: PRTF Solnit Center Discharge Delay Awaiting Placement

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Methodological Factors The utilization data in the 4A and 10B series reports are exclusively based on authorizations entered into

the ValueOptions Connect system. In some cases, additional data, primarily drawn from the Provider

Analysis and Reporting program (PAR), are included to enhance the understanding of the drivers of the

utilization trends. An example of this is the inclusion of the Inpatient Child PAR data that helps to further

explain how changes in the average length of stay (ALOS) for child inpatient hospitalization during Q1’ 14

are impacted by individual hospital performance.

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The data for the utilization reports are refreshed in each subsequent set of Quarterly Reports. As a result

of retrospective authorizations and changes in eligibility, the results for each quarter often differ from the

previously-reported values. In most cases, the refreshed data does not result in significant differences in

the previously reported conclusions. However, on some occasions there is sufficient variation that the

previous analysis is no longer relevant. This phenomenon has been much more common for analyses of

adult utilization, as retrospective membership variations have been significantly larger for adults than for

youth. For any analysis affected by these variations, we identify it in the narrative and describe the

implications.

Membership

Total youth membership has continued to increase on an annual basis. Over the past three years, there

has been a 10.5% increase (274,903 to 303,773) in total membership from Q1’ 11 to Q1 ’14. From Q4

’13 to Q1 ’14, membership for all youth (0-17) decreased by 0.39%. This change is contrary to previous

results that showed continuous growth in the youth membership. A similar phenomenon has been found

for adult members due to delays in the eligibility process, and it is possible that a similar result has

occurred this quarter for the youth. If so, then analyses of population-based indicators would be

misleading because not all members would be included in the process. We will monitor the changes

during the coming quarters to determine whether our methodology must change to reflect such factors.

Assuming the membership information is correct, the total unique youth membership (0-17) for Q4 ’13

was 303,773, with DCF youth accounting for approximately 2.70% (8,207) of all youth members and Non-

DCF youth accounting for the remaining 97.8% (297,114). Despite a slight 3.1% increase (7,964 to 8,207)

from Q4 ’13 to Q1 ’14, overall, DCF membership has been declining since Q2’ 11. There has been a

3.5% decline in DCF membership from Q1 ’13 to Q1 ’14. Conversely, Non-DCF membership has

increased over the past two years, with a 1% increase over the last year. There have been consistent

annual increases in Non-DCF membership.

Please note: Membership numbers for DCF and Non-DCF youth will not add up to the total number of

youth members. The total membership number for youth is an unduplicated count of all youth who were

eligible for services at any time during the quarter. Since youth members can and do fall into both the

DCF and non-DCF category during a quarter, there are members who are included in both the DCF and

Non-DCF count during a quarter. Thus, the total unduplicated membership count will always be less than

the sum of DCF and non-DCF youth during the quarter.

INPATIENT LEVEL OF CARE

HUSKY Inpatient Admits/1,000- All Youth (0-17)

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Quarterly:

The Total Admits/1,000 decreased 6.3% (0.79 to 0.74) from Q4’13 to Q1’14. Both the Non-DCF and the

DCF admits/1,000 decreased from last quarter to this quarter. Non-DCF decreased by 1.6% and the DCF

decreased 25%. The Q1 ‘14 DCF Admits/1,000 (0.15) was the lowest reported in the past thirteen

measured quarters. For the past two years, we have seen an increase in Total Admits/1,000 from Q4 to

Q1, the decrease in Total Admits/1,000 noted this year indicates a change in this trending.

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HUSKY Inpatient Days/1,000 Youth (0-17)

Quarterly:

The Total Inpatient Days/1,000 have decreased 10% (9.80 to 8.82) from Q4’13 to Q1’14.

The DCF Inpatient Days/1,000 accounted for most of the change, decreasing 14.8% (2.83 to 2.41) from

last quarter, while the Non-DCF Inpatient Days/1,000 also decreased 8% (6.97 to 6.41) this quarter.

During Q1 ’14, Non-DCF (N=593) comprised 78.7% of the total cases (721) and DCF comprised the

remaining 21.2% (N=153). There is similar quarterly trending noted between the Non-DCF Inpatient

Days/1,000 and the Total Inpatient Days/1,000. This is likely related to the higher volume of the Non-DCF

population admissions. Overall, the Non-DCF population has utilized more Inpatient days/1,000 than the

DCF population.

HUSKY Inpatient Average Length of Stay (ALOS) Youth (0-17)

Quarterly:

The Inpatient ALOS for all youth has remained consistent (12.14 to 12.13) from Q4 ’13 to Q1 ’14 and from

Q1 ’13 to Q1 ’14 (12.29 to 12.13). The DCF ALOS increased by 22.8% (14.06 to 17.27) while the Non-

DCF ALOS decreased 7.0% (11.51 to 10.71). The DCF involved population is staying inpatient longer, on

average, with fewer discharges. Overall, the DCF population has continued to have a longer ALOS than

the Non-DCF populations across all quarters.

Provider Analysis and Reporting (PAR) Quarterly Data:

The average length of stay (ALOS) for In-State Pediatric hospitals decreased 3.4% (11.8 to 11.4) from Q4

’13 to Q1 ’14. This is the lowest ALOS for In-State Pediatric hospitals over the past two years.

Despite the overall decrease, the ALOS continues to vary, based on DCF status and age. The DCF ALOS (in-state pediatric hospitals) for the younger children (ages 3-12) increased 16.2% (14.8 to 17.2) this quarter, while the Non-DCF ALOS for this age group decreased 15% (14.0 to 11.9). The DCF ALOS for the younger children continues to remain higher than the Non-DCF involved children across all time periods.

There was also an increase in the DCF ALOS (in-state pediatric hospitals) rate for adolescents (ages 13 -

17) by 22.2% (12.6 to 15.4) this quarter, while the Non-DCF rate decreased by 4.9% (10.2 to 9.7). The

DCF younger children ages 3-12 continue to have the longest length of stay, followed by the DCF

adolescents 13 -17, Non-DCF children 0-12, and last, the Non-DCF adolescents 13-17 who have the

shortest ALOS of the four groups. Across all time periods, the DCF involved youth have longer lengths of

stay than Non-DCF involved youth.

We will continue to monitor closely the ALOS for the DCF youth. We believe this finding reflects DCF’s

policy regarding limiting the use of congregate care with younger children and promoting community and

family based intervention.

The ALOS of the seven (7) in-state hospitals is displayed below.

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In-State Pediatric hospitals’ ALOS decreased by 3.4% this quarter. Three of the seven providers’

average length of stay decreased; Waterbury, Yale and Manchester hospital. Manchester hospital’s

ALOS decreased the most from last quarter, falling 23.5% (10.2 to 7.8). St. Vincent’s, St. Francis,

Natchaug and IOL’s average length of stay increased this quarter. IOL’s ALOS increased the most from

Q4 to Q1 (26.4 %, from 12.9 to 16.3).

Conclusion:

The Admits/1,000 and Inpatient Days/1,000 decreased from last quarter to this most recent quarter. The

ALOS has also decreased during this time. This indicates increased movement through the inpatient level

of care. These results signify that there are fewer youth being admitted to hospitals, with shorter lengths

of stay, which allows for increased flow within the service delivery system.

There was a decrease in Admits/1,000 this quarter for both the DCF, and Non-DCF

population. The decrease in Admits/1,000 was largely due to the DCF population decrease of

25% from last quarter to this quarter. As stated above, we will monitor population information

across coming quarters to confirm this change.

There was a decrease in Inpatient Days/1,000 for all youth for both the DCF and Non-DCF

population. This decrease was largely driven by the DCF population. The DCF Inpatient

Days/1,000, which comprised 21.2% of the total cases, decreased almost 15% this quarter.

The ALOS for all youth this quarter decreased slightly. This was largely due to the Non-DCF

population. The Non-DCF ALOS decreased in both the younger children and adolescents

from Q4 ’13 to Q1’ 14. The ALOS for DCF youth increased in both age groups from last

quarter.

The DCF population continues to have longer lengths of stay than the Non-DCF youth. This

was evident in both the younger children and the adolescents this quarter. The DCF youth

ages 3-12 continue to have the longest ALOS, as options for other levels of care are limited.

Q1 '12 Q2 '12 Q3 '12 Q4 '12 Q1 '13 Q2 '13 Q3 '13 Q4 '13 Q1 '14

ALL In-State Pediatric Hospitals 12.7 12.8 13.4 11.8 12.0 12.0 12.7 11.8 11.4

Waterbury Hospital 5.9 6.8 8.8 10.0 5.9 8.3 9.5 9.1 9.0

Manchester Hospital 7.6 8.1 6.9 6.2 6.5 6.2 7.0 10.2 7.8

St. Vincents 14.1 15.4 11.3 11.7 9.9 11.5 13.1 8.8 9.5

St. Francis 12.9 13.2 14.9 11.7 10.2 11.9 13.7 11.6 11.8

Yale New Haven Hospital 12.3 12.8 12.9 12.1 12.5 12.1 12.1 13.0 11.2

Natchaug Hospital 14.3 12.7 13.2 12.4 14.7 13.4 13.6 11.6 11.8

Institute of Living 13.9 14.2 16.0 13.4 15.6 15.2 14.4 12.9 16.3

Average Length of Stay (ALOS)

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Discharge Delay (DD) ~ Inpatient Discharge delay occurs when a youth no longer meets inpatient medical necessity criteria and is awaiting placement to an alternative program or level of care. Inpatient Number of Days Delayed

Quarterly:

The number of inpatient days delayed decreased by 31.9% (783 to 533) from Q4 ’13 to Q1’14. The number of cases in discharge delay has also decreased by 14.0% this quarter (43 to 37) and by 23.4% (696 to 533) over the past year from Q1 ’13 to Q1’ 14.

Inpatient Percent of Days Delayed

Quarterly

The inpatient percent of days delayed decreased 22.5% (8.0% to 6.2%) from Q4 ’13 to Q1 ’14. The DCF

inpatient percent of days delayed increased by 19.4% (12.4% to 14.8%) while the Non-DCF decreased by

56.4% (6.2% to 2.7%), indicating Non-DCF is the primary driver of this quarter’s decrease in total

inpatient percent of days delayed. We have seen consistent decreases in the Non-DCF percent of days

delayed for the past three quarters. There were a total of 37 cases in delayed status this quarter. DCF

comprised 56.8% (N=21) of the total volume, and Non-DCF 43.2% (N=16). The Non-DCF population

continues to have a lower percent of days delayed than the DCF population over all quarters.

Inpatient Average Days in Delay by Reason Code The reasons and percentages identified for Inpatient discharge delay in Q1 ’14 are shown in the table below:

Awaiting Placement ~ State Hospital State Hospital In Q1 ‘14, 18.9% of youth who were delayed during their inpatient stay were awaiting placement for the State Hospital. Of the 37 cases, there were 7 cases in discharge delay awaiting Solnit South – State Hospital. The average Inpatient Days in Delay awaiting the State Hospital was 12.3 days for those 7 cases. From Q4 ‘13 to Q1 ‘14, there was a decrease in the number of cases (11 to 7) on discharge delay awaiting Solnit inpatient, and a 39.4% decrease (20.3 to 12.3) in the average days awaiting placement.

Number of

Cases

Average Days in

Discharge Delay

% of Cases

Awaiting LOC

Number

of Cases

Average Days in

Discharge Delay

% of Cases

Awaiting LOC

Awaiting State Hospital 11 20.3 26.2% 7 12.3 18.9%

Awaiting PRTF 20 26.3 47.6% 18 13.4 48.6%

Awaiting RTC 4 23.3 9.5% 3 43.7 8.1%

Awaiting GH 1 20.0 2.4% 2 22.5 5.4%

Awaiting Foster Care 2 8.0 4.8% 2 11.0 5.4%

Awaiting Other 4 11.5 9.5% 5 36.4 13.5%

Q1 '14Q4 '13

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Awaiting Placement ~ PRTF The inpatient average days in delay awaiting PRTF decreased by 49% (26.3 to 13.4) from Q4 ‘13 to Q1 ’14. There are 10% (20 to 18) fewer cases on delay this quarter as compared to last quarter. However, over the past year, the greatest percentages of youth in discharge delay have been awaiting PRTF. In Q1 ’14, 48.6% of youth who were in delayed status during their inpatient stay, were awaiting a PRTF placement. There were 18 of 37 members delayed awaiting PRTF, with the largest total days in delay (N=169). Awaiting Placement ~ Residential and Group Home In Q1 ’14, 8.1% of youth in discharge delay during an inpatient stay were awaiting Residential level of care. The average number of days in delay for those members nearly doubled (23.3 to 43.7) from Q4 ‘13 to Q1 ’14, and the number of cases for that time period decreased by 25% (4 to 3). Over the past year, there has been 62.5% fewer youth (8 to 3) on delay waiting for this level of care. There were only two cases (5.4%) of children in delay awaiting a Group home placement. The time awaiting placement increased slightly from last quarter by 12.5%. Awaiting Foster Care/Other: There were 2 cases awaiting Foster Care during the quarter. This number represents no change from last quarter. These children spent an average of 11 days in discharge delay on an inpatient unit awaiting placement. There were 5 cases awaiting placement for “other services”. Other services most often are educational, or a level of care which is not part of Medicaid services, such as flex funded services through DCF. These children spent an average of 36.4 days in delay. Conclusion: The number of inpatient days, and the inpatient percent of days delayed decreased this quarter. This was

largely due to the Non-DCF population. The Non-DCF inpatient percent of days delayed decreased by

56% from last quarter, while the DCF increased. The number of children in discharge delay has also

decreased this quarter by 14% (43 to 37). The DCF population comprised 56% (N=21) of the cases

delayed, and Non-DCF the remaining 44% (16). The Non-DCF population continues to have a lower

percent of days delayed than the DCF population over all quarters

Over the past year, the greatest percentages of children in discharge delay on an inpatient unit were awaiting community based PRTF. This trending has continued into the first quarter of 2014. In Q1 ‘14, 48.6% of the youth who were in delayed status were awaiting PRTF placement. The children awaiting PRTF placements have utilized the most total inpatient days in delay overall, which has been a trend since Q2 ’13. Due to State mandates, DCF and hospitals are no longer requesting residential or Solnit placement, but instead are more frequently seeking PRTF. The discharge delay days and volume of children awaiting the State hospital has decreased this quarter and overall, the number of children awaiting Residential placement has decreased. ValueOptions continues to work collaboratively with inpatient units, State agencies, community providers and families to build community resources and address the barriers in the system of care which contribute to discharge delay.

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Solnit Center Inpatient ALOS Quarterly: The Average length of stay for all youth placed at Solnit Center decreased by 7.1% (126.1 to 117.1) from Q4’13 to Q1 ’14. The ALOS for Non-Court ordered youth decreased by 1.7% (136.8 to 134.48), while the ALOS for Court ordered youth increased by 100% (40.3 to 80.9). There were 37 total discharges during Q1 14. The Non-Court ordered comprised 68% (N=25) and the Court ordered comprised 32% (N=12). The ALOS and number of discharges for Non-Court Ordered youth and Court Ordered youth are found in the table below for each corresponding quarter:

. Conclusion: The average length of stay for all youth at Solnit Center inpatient has decreased by 7.1 %( 126.1 to 117.1) from Q4 ’13 to Q1’14. This overall decline in ALOS can be attributed to a much higher percentage of Court Ordered youth being discharged during this quarter. That group has a much shorter ALOS, so their increase in relative numbers (from 11% of the total discharges in Q4 ’13 to 32.4% of the total in Q1 ’14) produces the reduction in the overall average. VO has continued to support triage and coordination efforts with the State agencies and Solnit Center and continue to meet weekly with all Solnit units. These efforts continue with Solnit inpatient, and both Solnit PRTF units. VO has collaborated with Solnit North to support Emergency department diversion efforts for those members who meet PRTF level of care.

Quarter

Number of

Discharges ALOS

Number of

Discharges ALOS

Q1 '12 25 150.5 12 64.1

Q2 '12 18 212.2 25 70.1

Q3 '12 15 191.5 18 43.1

Q4 '12 17 149.4 17 82.7

Q1 '13 29 133.3 9 72.4

Q2 '13 37 123.1 11 87.0

Q3 '13 30 84.6 5 90.0

Q4 '13 24 136.8 3 40.3

Q1 '14 25 134.5 12 80.9

Court OrderedNon- Court Ordered

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Community Psychiatric Residential Treatment Facility; PRTF PRTF Admissions; All Youth Admissions to PRTF increased by 9.5% ( 21 to 23) from Q4 ‘13 to Q1 ’14. We have seen a 21.1% (19 to 23) increase in PRTF admissions from Q1’13 to Q1’14.

Days/1,000 There was a 5.4% ( 4.47 to 4.23) decrease in Community PRTF Days/1,000 from Q4’ 13 to Q1’ 14. Over the past year, however, from Q1’13 to Q1 ’14, there was a 6% (4.50 to 4.23) decrease in Community PRTF Days/1,000. Average Length of Stay; ALOS The PRTF ALOS has increased by 42.1% ( 117.7 to 167.3) from Q4 ’13 to Q1 ’14.. Over the past year, there has been a 17.3% ( 142.6 to 167.3) increase in ALOS from Q1’ 13 to Q1 ’14.

The increase in PRTF ALOS seems related to limited service capacity for this age group. DCF has imposed limitations on residential and Solnit inpatient levels of care for the 12 and under age group. All of the children who were, and currently are, in delayed status in PRTF are awaiting Foster Care Placement.

Discharge Delay PRTF Number of Days Delayed The PRTF number of days delayed has increased by 41.8% (595 to 844) from Q4 ’13 to Q1 ’14. The number of cases has also increased over that same time by 18.18% (11 to 13). Conclusion: There have been increased Admissions to PRTF level of care, fewer Days/1,000 and an increased ALOS and Discharge Delay. This continues to indicate a decreased throughput from this level of care. The majority of children in delay are awaiting a Foster Care placement. With DCF limitations on Congregate care and Solnit placement for the under 12 age group, it continues to be necessary to increase community resources and services that can meet the complex needs of this acute population. ValueOptions has continued to collaborate with PRTF providers, State agencies and community services to coordinate timely and clinically effective disposition plans. ValueOptions will continue to monitor this level of care.

Intensive In-Home Child and Adolescent Psychiatric Services (IICAPS) There was a 6.7% (0.60 to 0.64) increase in IICAPS Admits/1,000 from Q4 ’13 to Q1 ’14. Over the past year from Q1 ’13 to Q1 ’14, however, the number of IICAPS Admits/1,000 remained the same. The increased utilization of these services indicates a need to increase In-home clinical services that can meet the needs of clinically complex children. Currently, IICAPS is the only community based service that is able to manage the high acuity needs of children who, prior to DCF limitations, would have received clinical treatment within a congregate care setting or Solnit.

OVERALL CONCLUSIONS: The current analyses indicate Admits/1,000 and Inpatient Days/1,000 have decreased over the past quarter, in addition to a decreased ALOS and Discharge Delay. This indicates increased movement though the inpatient level of care.

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The majority of children in delayed status on inpatient units continue to be those children awaiting PRTF (52.9%) and Solnit (20.3%) levels of care. There continues to be an increase in the volume of PRTF referrals from the inpatient providers and longer periods of time awaiting placement at a PRTF level of care. Children experience longer lengths of stay in PRTF, which also can include discharge delay while awaiting their next placement. The majority of these children are awaiting Foster Care Placement. Additionally, with minimum community services to meet the complex clinical needs of these children, we have seen a consistent increase in IICAPS utilization and admissions. The recent trends and mandates suggest a need to build a community behavioral health care delivery system which is able to meet the needs of a more complex child/adolescent population. Collaboration between inpatient hospitals, community providers and State agencies is imperative if we are to build community infrastructure that is timely and effective in addressing not only the clinical, but the psychosocial aspects of children with complex behavioral health needs. These needs are addressed in our recommendations below.

CHILD/ADOLESCENT RECOMMENDATIONS

UPDATES TO RECOMMENDATONS FROM PREVIOUS QUARTER – This section documents activity since the previous quarterly report

1. Establish a preventive model of behavioral health care and crisis intervention: Over the past

three months, ValueOptions has continued to collaborate with State agencies, providers and the

community on strategies to identify youth who are in need of behavioral health services, and to

provide more effective crisis prevention services.

Establish and/or expand existing ISS/MSS meetings within each of the DCF Regional

areas: Participation from local area community providers, including, inpatient

providers, PRTF providers, school, outpatient providers, congregate care, and foster

care providers to discuss high risk youth within the region: During this quarter,

ValueOptions has continued to participate in local area meetings such as Regional

DCF meetings, Collaborative meetings, PRTF provider meetings, and emergency

department meetings to support the establishment and/or expansion of existing

meetings to discuss high risk youth. Those areas with established meetings; Region 1

(Bridgeport), Region 3 (Willimantic), Region 4 (Hartford), and Region 6 (New

Britain/Meriden) continue to include standing agenda items to discuss local area

Emergency Department activity, including ED stuck children, ED volume, best practices

for crisis prevention, and coordination of care. Regional Emergency Mobile Psychiatric

Service (EMPS) providers and CTBHP Intensive Care Managers continue to participate

within these meetings providing clinical updates and relevant data to support an action

plan for those youth identified as high risk. The most recent focus of these meetings

has been youth awaiting foster care placement, with less focus on the youth who are

utilizing crisis and inpatient services. While most youth inpatient units (6 of the 8) host

weekly clinical rounds which include the VO ICM and representation from the DCF

Regional area office, most inpatient units no longer have representatives attend the

Regional area DCF ISS/MSS meeting. This quarter, there have been continued efforts

to engage local youth inpatient units and emergency departments within the meetings.

An example of this has been the increased collaboration and meetings between Region

3 (Willimantic) DCF and Natchaug hospital. There are opportunities to establish an

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ISS/MSS model in Region 2 (New Haven) and Region 5 (Waterbury), in addition to

expanding existing forums to include consistent statewide parameters/measures to

identify high risk youth, and subsequent child specific action plans.

Continued State Agency collaboration with ValueOptions: Intensive Care Managers

continue on site at DCF, inpatient units, PRTF units and Emergency Departments to

identify high risk youth and those who have a high utilization of services. The ICMs

have continued to utilize a wraparound philosophy to coordinate care and discharge

plan which focus on crisis prevention and protective factors. During this quarter,

ValueOptions has implemented a weekly Complex Case report document which alerts

DCF, DSS and VO management to current HUSKY youth within all levels of care, who

require additional State agency collaboration, intervention, and escalation. This is

reviewed with DCF management weekly.

.

Family Peer Specialists: The Family Peer Specialists have continued to inform and

engage family members/caregivers, and local school personal about preventative

programs and interventions which focus on strengthening parenting, building child

resilience and crisis intervention. In addition to member-specific case management

activities, Family Peer Specialists have participated this quarter within various

community presentations and information fairs where this type of preventative

information was shared.

2. Increase collaboration with CHN to establish preventative integrated care: All of the collaborative

activities identified last quarter have continued in the most recent three months. Some of the

recommended strategies to expand collaborative efforts last quarter included: CHN participation

within ISS/MSS and System of Care meetings, CHN participation within Regional Connect to

Care meetings, and CT BHP ICM collaboration with CHN on-site at pediatric inpatient units.

Those recommendations have been carried out during this quarter. CHN has participated in

several System of Care Collaborative meetings, and regularly within the Hartford System of Care,

and ISS/MSS monthly meeting. VO ICMs have increased collaboration on site at the DCF area

offices with the DCF Registered Nurses who act as the liaison with CHN if there is a co-occurring

medical concern/diagnosis. However, other opportunities remain to further develop collaborative

efforts with CHN. Those efforts could include participation within other Regional area ISS/MSS,

System of Care, and Connect to Care meetings, in addition to expanding collaboration with CHN

while on-site at pediatric inpatient units when a medical diagnosis is present.

3. Continue to work collaboratively with EMPS agencies: Last quarter, ValueOptions recommended

continued expansion of EMPS services, which included allocation of an EMPS clinician on site in

each of the high volume Emergency Departments. During this quarter, there has been an

expansion of EMPS services, which included allocation of EMPS clinicians on site to a few high

volume Emergency Departments. The Connecticut Children’s Medical Center (CCMC), one of the

highest pediatric volume Emergency departments, currently has EMPS clinicians on site during

high volume hours. Wheeler EMPS continues to expand its collaboration with CCMC outreaching

to multiple police departments, schools and parent oriented community forums to educate

families and the community on crisis prevention. Yale New Haven hospital is another high

volume emergency department who is in the process of collaborating with DCF and Clifford Beers

EMPS agency to allocate an EMPS clinician to the ED during hours of peak volume. In a different

model, Saint Mary hospital utilizes Wellmore EMPS agency under a contract agreement to

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complete all crisis evaluations within their ED. Opportunities still exist to expand EMPS services

and staffing throughout the State by allocating clinicians to the emergency departments with

moderate to high pediatric behavioral health volume. An essential part of this role would include

continued engagement; assessment and intervention post-ED discharge to implement

wraparound plans. As part of the wraparound plans, EMPS clinicians would provide education to

the parents/caregivers regarding; crisis prevention, identification of symptoms/triggers and de-

escalation techniques.

4. Continue to expand implementation and development of Rapid Response model: The goal of the

Rapid Response model is to promote timely connection to care for children and adolescents.

During this quarter, this Rapid Response model has continued with CCMC’s Emergency

Department. Participants continue to include ValueOptions, DCF, EMPS and CCMC. A VO

Intensive Care Manager has fully participated within this model, and, at times, has been deployed

on site to CCMC to coordinate care and provide case management. Multiple opportunities

remain to implement the Rapid Response model in other Emergency Departments with high

pediatric behavioral health volume.

5. Establish Behavioral Health Urgent Care Centers for Youth: This activity continues to be an area

of opportunity to meet the behavioral health care needs of the State’s youth. The development of

these centers will require collaborative efforts by hospitals, state departments, and providers.

While there has been discussion of such facilities in some cities, it is likely that serious movement

will be some time in coming.

6. Expand PRTF capacity and develop alternatives for the children 12 years and under to include

crisis stabilization: During this quarter, there has been some dialogue between State agencies

and community providers regarding moving forward with the development of additional PRTF

capacity. However, the community provider’s business interest in this proposal has been less

than anticipated. This circumstance potentially was due to the higher acuity of the children

entering the PRTF level of care, and the financial implications secondary to the DSS rate of

reimbursement to provide these services. There continues to be dialogue at the State level

regarding potential expansion of PRTF capacity, and the associated variables effecting the

implementation of this recommendation.

7. Collaborate with DMHAS and DCF to support coordination of care for youth in transition: It was

recommended VO expand efforts to partner with DMHAS and DCF to support care coordination

for youth in transition. ValueOptions ICMs have not had the opportunity to participate in Youth

transition meetings while on site at the regional DCF area offices. They do continue to case

manage these youth, and have participated within member-specific case conferences to provide

needed information such as clinical history, prior services, clinical recommendations and

authorizations. A centralized process with VO ICM participation may support the identification of

effective clinical services to meet the needs of the youth in transition. There are continued

opportunities to expand on the implementation of this recommendation in the upcoming quarter.

8. Continue Connect to Care meetings: During this quarter, there were no further Connect to Care

meetings scheduled, and CHN has not participated. However, ValueOptions has continued to

support members in connecting to care upon discharge from an inpatient hospitalization through

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the Connect to Care Process. Clinical Liaisons, Peer Specialists and Care Managers

telephonically support members discharging from an inpatient level of care by assisting them to

connect with services. During the Connect to Care process, the identification of medical co-

occurring diagnosis or need is identified, and a referral and/or communication with CHN has been

implemented. There are opportunities to continue to seek collaborative efforts to improve

coordination between providers in the upcoming quarters.

9. Participation within Youth Behavioral Health Forums: In a collaborative effort with State

agencies, DCF held three forums this quarter across the State to gather input about the need for

mental health services for youth from families, communities and providers. Three additional

forums are planned for Q2 of 2014, as well. ValueOptions has participated in several of the

Regional Youth Behavioral health forums, in addition to the Child Behavioral Advisory Council

meeting. These meetings discussed the multiple factors affecting access to services, early

identification of behavioral health issues, and crisis response and management. Family Peer

Specialists have also attended regional system of care meetings where the content of the

Behavioral Youth forums have been discussed and presented.

New Recommendations The most recent quarterly and annual data indicate an increase in youth utilizing Emergency Departments, an increased volume of youth in inpatient discharge delay awaiting PRTF level of care, and in PRTF awaiting foster care placement. With increased DCF limitations on utilization of congregate care, out of state placements, and Solnit center admissions, there are fewer youth utilizing these services. In response to this situation, the need to build community-based infrastructure which provides a high level of clinical treatment, and crisis stabilization is greater. In response to this trending, we continue to recommend the development of a preventative model of integrated care which provides early identification of children in need of services with timely connection to crisis and behavioral health care. The following are opportunities which will promote this type of community based delivery system. 1. Establish a preventive model of behavioral health care and crisis intervention: This recommendation

continues from the past two quarters, given that the pressures on the service system have not been

relieved.

Establish in each of the Regional areas a centralized forum which meets regularly to

discuss at-risk youth with high utilization of crisis and behavioral health services: This

model would have elements similar to the Milwaukee Youth Wrap around planning

model, and the Community Care Team (CCT) model already established in some areas

in Connecticut to manage Adults with similar utilization. We recommend participation by

local area DCF personnel, community providers, inpatient providers, Emergency Mobile

Psychiatric Services, PRTF providers, schools, Solnit, congregate care staff, and foster

care providers. The focus would be on high risk youth within the region. An essential

part of this meeting would include consistent statewide parameters/measures which

identify high risk youth, and the development of collaborative, child-specific wraparound

action plans. It is recommended that the action plan be developed with the family’s

input and participation.

Develop community-based behavioral health services which meet the higher acuity

behavioral health needs of child/adolescents, including crisis and wraparound teams

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which follow children throughout the level of care continuum: With increased

limitations on Congregate Care and Solnit inpatient placement, an increased number of

children and adolescents with very complex behavioral health needs are now receiving

clinical services within the community. The most recent data indicates a higher volume

of referrals, and longer lengths of stay at PRTF levels of care, and a steady increase in

the volume of pediatric behavioral health utilization of emergency department services.

There is a clear need to develop a clinically sophisticated infrastructure that can meet

the needs of those children who, prior to DCF limitations, would have been placed in

congregate care, out of state, or Solnit settings. In addition to the lack of community

infrastructure to meet these needs, families/caregivers whom children are returning to,

or placed with, often feel unprepared to manage the fluctuations of symptomatology

and intermittent crisis situations which often are common with a mental health

diagnosis. It is our recommendation to expand services to existing EMPS agencies

which would include crisis teams allocated to emergency departments with higher

volume of pediatric behavioral health utilization. In addition to meeting families in the

ED, an essential part of this role would include continued engagement, assessment

and intervention post-ED discharge into the community to provide education to the

parents/caregivers on crisis prevention, identification and de-escalation, and

development of a wrap plan based on the Wraparound Milwaukee model.

Continued State Agency collaboration with ValueOptions: This recommendation is

continued from last quarter. ValueOptions will continue to implement a weekly

Complex Case report to alert DCF, DSS and VO management to current HUSKY youth

who require additional collaboration, intervention, and escalation

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Family Peer Specialists: This recommendation is continued from last quarter, as well.

2. Increase collaboration with CHN to establish preventative integrated care: Collaborative efforts

with CHN have improved connect to care and quality of service for members with both medical

and behavioral health-related issues. We recommend continuing these efforts and determining if

there are additional ways to collaborate.

3. Continue to expand implementation and development of Rapid Response model: VO continues

to recommend the continued development and implementation of the Rapid Response model

within high volume Emergency Departments. The Rapid Response model has been implemented

with the Connecticut Children’s Medical Center (CCMC), and has proven to be effective. The

most recent ED data suggests despite a higher volume of children in the ED, the average length

of time stuck has been equal to, or lower than, past stuck time. Participants of the model include

representatives from VO, DCF, EMPS, and the ED. Multiple opportunities remain to implement

Rapid Response model in other Emergency Departments with high pediatric behavioral health

volume.

4. Expand community behavioral health resources and infrastructure to include the capacity to

manage youth with highly complex behavioral health needs, including specializations such as

Developmental disabilities and behaviors associated with autism; With continued restrictions and

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mandates from State Agencies limiting out of state placement, Solnit inpatient hospitalization,

and placement in RTC/GH/congregate care settings for all youth, there is a need to build

additional in-state programming for youth with highly acute, complex mental health and

psychosocial needs. It is recommended community providers expand in-home clinical service

teams to include specialized Autism/developmental disability teams and integrated, medical and

psychiatric teams. These youth tend to be highly volatile, with multiple needs that in-state

providers lack the resources to effectively manage. Therefore, these are the individuals who tend

to become stuck in Emergency departments, seek out of state inpatient hospitalization, or out of

state specialized RCT programs. It is also recommended Community providers build additional

inpatient and PRTF bed capacity for these populations.

5. Establish Behavioral Health Urgent Care Centers for Youth: This recommendation remains

unchanged from the past two quarters.

6. Expand PRTF capacity and develop alternatives for the children 12 years and under to include

crisis stabilization: This recommendation also remains unchanged from the previous quarter.

7. Collaborate with DMHAS and DCF to support coordination of care for youth in transition: VO

continues to recommend collaboration with DMHAs and DCF in efforts to support care

coordination for youth in transition. VO ICMs continue to provide case management and

coordination support to HUSKY members while on site at DCF. This is an opportunity to identify

youth at an earlier juncture, and to recommend interventions and referral to DHMAS at that time.

There are continued opportunities to expand on the implementation of this recommendation in the

upcoming quarter.

8. Continue Connect to Care meetings: With more emphasis on building the infrastructure of

community-based behavioral health programming, the connection to care process is critical to the

success a member/youth has within the community. VO recommends the Connect to Care

meetings continue. It is also recommended to expand the participants to include schools and

CHN, to promote an integrated service delivery system. ValueOptions will continue to support

members through telephonic outreach in connecting to care upon discharge from an inpatient

hospitalization through the Connect to Care Process.

9. Participation within Youth Behavioral Health Forums: VO will participate in the three remaining

forums to support the statewide efforts to enhance the service system, and to hear any additional

feedback which can inform CT BHP clinical practice and process.