Medicaid Inpatient Psychiatric and Detoxification Utilization

Appropriation ID - 15000 Global Commitment

The DVHA strives towards the Institute for Healthcare Improvement’s “Triple AIM":

• Improving the patient experience of care (including quality and satisfaction)
• Improving the health of populations
• Reducing the per capita cost of healthcare

One of the strategies the DVHA has adopted to move towards the “Triple AIM” is utilization management of our most intensive and high-cost services, which include inpatient psychiatric hospitalization. Inpatient psychiatric services, which include detoxification, are paid on a per day basis, unlike hospitalization on traditional medical inpatient units. This per day payment methodology has the potential to create a dis-incentive for providers to make efficient use of this high cost, most restrictive level of care. While CRT members’ hospital costs are included in their case rate payment to the Designated Agencies (DAs), which creates an incentive for the DAs to work efficiently with the inpatient units to transition their members back to their existing community services and supports, no such incentives exists for children or non-CRT enrolled adults.

• Department of Mental Health Adult and Children and Families Units,
• Department of Disabilities, Aging and Independent Living,
• Department for Children and Families,
• Integrated Family Services,
• Designated Hospitals,
• Designated Agencies,
• Special Service Agencies,
• Vermont Chronic Care Initiative

Historically, as a part of an acute care management program that was developed in response to the 1115b Waiver, children’s inpatient admissions at the Brattleboro Retreat were managed through a concurrent review process, however this oversight ended in late 2006 and during this “unmanaged” period the average length of stay and inpatient costs grew substantially. In 2010 the Department of Vermont Health Access began a utilization management (UM) system for children and adolescents, adults ages 18-22 admitted to the Brattleboro Retreat, and all adults admitted to out of state facilities. In 2011, the DVHA added inpatient detoxification admissions and adult psychiatric admissions (excluding CRT and Involuntary) to the UM program. In 2012 the Department of Mental Health (DMH) and the Department of Vermont Health Access (DVHA) collaborated to create a unified utilization management system for all Medicaid funded inpatient psychiatric and detoxification services. The goals for the utilization management system are as follows:

- Clinical care is provided only as long as necessary for safety and/or other acute needs.

- There are standardized criteria for admission, continued stay and discharge throughout the system of care.

- Care is continuous between the ongoing community treatment teams and episodes of inpatient or residential care. Ideally the hospital or residential facility and community teams develop and share a common treatment plan developed in partnership with the individual and their family, beginning within 24 hours of admission.

- Resources of the public system are effectively and efficiently used.

- The system of care will ensure access to effective, appropriate, recovery-based services that promote an individual’s health, wellness and resiliency and will support successful integration into the community.

Collaboration between VCCI and DVHA utilization review staff helps ensure timely communication with inpatient facilities and supports beneficiaries being able to successfully re-integrate with outpatient supports and services.Collaboration between DVHA and DMH UR staff and DCF, DAIL and DMH adult Care Managers and DMH CAFU Care Managers helps to ensure that active and appropriate aftercare planning is facilitated between the Designated Hospitals and the outpatient providers, this allows for aftercare services to be in place and ready to receive beneficiaries as soon as they are ready to be discharged and return to their communities. Our Agency partners are also invaluable in holding their preferred providers accountable to the tenets of the “Triple AIM”.

Together the following performance measures focus on whether Vermonters are better off as a result of this program. They do so by looking at the quality and efficiency of these programs and services.