Using Lean to Integrate DSRIP, Managed Careand Community Based Services (HCBS) Into aStrategic Planning at NYC Health Hospitals/Kings CountyKristen Baumann, PhD

Disclosures No potential conflicts of interest to disclose

Kings County Behavioral Health ServicesThe Behavioral Health Service at Kings County snapshot: 235 Certified Beds (Adult 160; Pediatrics 45; Chemical Dependency 30)Philosophy of Care is Patient Centered and Recovery OrientedAdult Inpatient Admissions 2,481; Discharges 2,617Adolescent & Child Inpatient Admissions 662; Discharges 690Comprehensive Psychiatric Emergency Program (CPEP):Treat & Release visits 7,479Extended Observation Beds (6) Admissions 566; Discharges 443Detox Admissions 756; Discharges 748Outpatient Visits 158,807Total BH visits (CPEP & OPD) 166,286

Box 1: Reason For ActionBH has done a great deal of pre-work to ready itself for the restructuring of both itsfinancial operations and care delivery yet there remain significant gaps that willnegatively impact our ability to realize our goals: Numerous initiatives from HHC corporate in response to new healthcarelandscape. The heart of ambulatory care (AOPD) is unable to meet the current demandflowing from CPEP and Inpatient into AOPD and the anticipated futuredemand from our medical ambulatory services. AOPD remains largely a private practice model. Financial and business operations supporting clinicians and clinics is fracturedand inadequate for new managed care landscape. Connections between CPEP, INPT & Ambulatory services are not tight.We are unsure given the changing landscape if we have 1) the right disciplines, in theright roles, at the right times; 2) to deliver safe and evidenced based care; 3) when andwhere are patients and managed care companies need them; 4) for us to build afinancially stable system; 5) that can grow with our community needs.

Box 1: Reason For Action (scope)Scope: Behavioral Health has 3 major challenges for the next 12 months:1) Sustain gains made through DOJ process for CPEP & Inpatientservices (child/adult).2) Build financial & operations infrastructure around CPEP, INPT &Ambulatory care.3) Restructure how we deliver care in our adult ambulatory careservices.The focus of this VSA/VVSM is to develop a plan of action for integratingtraditional mental health, medical health and chemical dependency servicesusing the corporate initiatives for Managed Care, Access & DSRIP as ourguide in redesigning BH ambulatory care – AOPD, CIU, PCC, PHP, CHEM DEPwith our customers and suppliers.Aim: Create a care delivery model that is evidence-based & financiallysustainable throughout the continuum of care.Trigger: CPEP, AIP or CIU identify adult ambulatory need.Done: Patient seen by appropriate service within 5 days.

Box 2: Current State (pre-work) Not all initiatives aligned and prioritized with strategic goals in an effective manner.CPEP not used appropriately. There are patients that could be assessed elsewhere in our system.AIP must move from current 19 day stay to 12 days over the next 2 years.33 days to next available AOPD appointment.Financially, when revenue, non-revenue & grants reviewed finds that BHS expenses exceed revenueby 1/3.TrueNorthHDQ/SAFGMetricBaseline & SampleDatesAnalyzing dataData Source &methodologyHR files Turnover & Retention ratesCertifications by service (beyond what must do for licensure) HBIPS: 1) Psych Continued Care Plan created 2)Plantransmitted to next provider (INPT-OPD)94.6% /78.8%Average of Q32014Q22015 HBIPS 62.5%/79%Quality report Q2 AOPD: Quality Indicators 1) Is there a PE in last year for offsite? 2) Positive SBIRT reflected in Tx plan?Reportable cases ratio (soc met/not met)CIU: % seenCPEP: BriefsAIP: LOS 1) 15 days 2) 15 daysAOPD: Next available apt (TNAA)57/1075.5%23.7%8.5/3426.87SIRC report 1-6/152-8/20159/14-8/159/14-8/15Soarian 6-8/15 avg OPDS Productivity by dayCost/Revenue: AdultMH/PA/PHPDenials: AIPOvertime: AIP, CPEP & AOPDTemp usage: AIP, CPEP & AOPDOver 11 days AIPManaged Care members (out of network)272 384,79717 monthly avg3,5881,697 268,0301147FY15 Finance reportFY15 Finance report

Box 2: Current State (pre-work)

Box 3: Target State (pre-work) All initiatives funneled through Breakthrough.Data driving behavior and unit/team based decisionsCPEP work flows and staff patterns adjusted to meet projected demand.AIP workflows made nimble so that they can adjust to managed care changes.5 day appointment availability in all ambulatory services.Financial acumen of staff and leaders improved and infrastructure built to deliver on and monitorfinancial success monthly to radically reduce current and projected deficits.TrueNorthHDMetricQ/S Turnover & Retention ratesCertifications by service (beyond what must do forlicensure)HBIPS: 1) Psych Continued Care Plan created 2)Plantransmitted to next provider (INPT-OPD)AOPD: Quality Indicators 1) Is there a PE in last yearfor off site? 2) Positive SBIRT reflected in Tx plan?Reportable cases ratio (soc met/not met) CIU: % seenCPEP: BriefsAIP: LOS 1) 15 days 2) 15 daysAOPD: Next available apt (TNAA)OPDS Productivity by dayCost/Revenue: AdultMH/PA/PHPDenials: AIPOvertime: AIP, CPEP & AOPDTemp usage: AIP, CPEP & AOPDOver 11 days AIPManaged Care members (out of network) AFGBaseline & SampleDatesTBDTarget94.6% /78.8% 99% / 95%62.5%/79% 90% / 95%57/10Trends analyzed monthly and soc not met reduced.75.5%23.7%8.5/3426.87272 384,79717 monthly avg3,5881,697 268,0301147 95% 10% 5/12 14 good, 9 very good, 5 excellent 20% good, 30% very good, 40% excellent 20% good, 30% very good, 40% excellentLess than 34 monthly (allow due to payment) 20% good, 30% very good, 40% excellent 20% good, 30% very good, 40% excellent 161,700Reduction by month of 10%TBD

Box 3: Target State (pre-work)

Box 3: Target State (pre-work) Process map of demand flowing from CPEP-WIC-AIP-AOPD. Utilized to revise Workgroup activity and develop RIE & Rapid Experimentation plans.

Box 4: Gap Analysis SWOT (pre-work)Gaps: Managed Care/AccessStrength Learned a lot in pre-work &demonstration phase pilots Range of services Peer program in place MRL’s Interdisciplinary teams onAIP and AOPD IP and Recovery Center(early stages) BH has a financialdepartmentWeakness Inpatient focused 24% CPEP volume arebriefs Staff and management inearly stages ofunderstanding changes(Access, DSRIP, ManagedCare) No clearly identified“implementation team” Pre-work is limited inscope and in early stages Peer role needs to change Unknown takt, resourceallocation, infrastructure,and work flow needed formanaged careOpportunity IOT/IOPWIC/Recovery CenterExpand hours in PCC,WIC & AOPDLearn about and expandcommunity relationships(DSRIP partners)Group workHCBS – capitalizeInitiative integrationFinancial and clinicalpartnerships within KCHCBHCoordination of HH carecoordinator withprovidersThreat Integration challengesAligned challengesFinancial risk/viabilityLoss of market shareRecreating work and doingtoo much at KCHC BHEvidenced based practiceexpansion while changingHealth Home capacityPatient concerns regardingHealth Home enrollmentOPD infrastructureOPD flow between levelsof careSoarian functioning(system shifts after EPIC)Addressing Managed Care,Access, DSRIP & AOPDstructure whilemaintaining DOJcompliance in AIP andCPEP

Boxes: 1-7 Event Structure

Four Pillars of Operational Infrastructure

Box 3: Target State (event) usingFour Pillars of Operational InfrastructureStrategy:1. Deliver consistent/ standardized, individual continuum of care2. Deliver patient centered care through integrated services, staffed effectively and linked through strongcommunication that provides services when, where and how a patient desires.3. Provide financially sound care that utilizes all types of Behavioral Health services to develop a treatment plan that iscarried throughout the patients journeyFlow:1. Patient driven integrated health managementDaily Management:1. Data used to drive decisions and changes2. Clinical understanding of patient mix and resources to provide tailored patient careInfrastructure:1. Care allocated by population health2. Clear linkages and partnership with all internal and external partners3. Cross clinical flexing of resourcesCritical Elements:1. Integrated systems that deliver whole person care2. Coordinated care and transitions3. Value-based payment within a strong sustainable network4. Activated patients, consumers and clients who are equipped to fully participate in managing their health5. Optimal access to appropriate services6. Standardized performance measurement with accountability for improved outcomes

Box 4: Gap Analysis 7 Flows (event)7 FlowsGaps Patient education & buy-in: how do we truly put the patient in the center of carePatients required to interact with many providers to get TxPatients are not consulted on needs/desires prior to TxWhat do our patients want? Deliver services they wantDo we understand community needLow census: Access, Hours, LanguageResources Staff resistant to changeClinical staff at high burn out if tasked with pre-auth – attrition riskIncreased staff stress/dissatisfaction poor patient experienceLack flexibilityNo system for staff accountability within many departments or processesDo Union contracts all enough flexibility in staffing?Training/Communication Clinical staff not familiar with billing codes and vice versaStaff training not complex care capableClinicians not well suited/trained for changes in type of care neededProviders not trained in IDDTLack clarity about insurance and impact on service Treatment trajectory tends to be long-term and not recovery orientedAcute services over utilizedHave not built all needed levels of careMedical/ psychiatric/ substance abuse not integrated in the same floor or clinicAccess to care is a challengeAmbulatory services are not offering alternatives to acute careRemove license barriers: patient should access service no matter whereState agencies have different regulations for different servicesMultiple regulations: OMH, OASAS, DOHPatientStaffSystems

Box 4: Gap Analysis 7 Flows (event)7 ormation Resource intensive UM demands # of staff assigned for pre-auth may be outnumber by needs Not prepared for ICD-10 Lack of clarity around billing and managed care Who will get prior authorization?No/few clinical outcome measures that can be quickly acted uponConcrete barriers: housing, transportation, child careAre care plans truly patient centeredNo best practice guidelines for the patient common/prevalent diagnosisSeems to be a low threshold for our AOPD and outside OPDS to close casesdue to risk Community’s unmet needs (Geri, TBI) are rule-out for our AOPD High level regulations/processes not yet operationalized Prevention model & clinical programming not or underdeveloped Lack of clear outcomes data in OPDAbsence of actionable real-time dataEMR across services desperately neededNo clear way of tracking patient/ patient information across/betweenservices

Box 5: Solution Approach7 FlowsNeeds Better first patient contact Better initial assessment process that addresses wants, needs regulations, family andcommunity involvement HARP plan of temsFinanceResourceProcessProcessClinical Needs effective structure for supervision and monitoring functionsStaffing on demand (match hours/locations with patient need)Address case load/staffing ratioStaff engagement strategySupport staff development and trainingUse DSRIP to advocate scope of licensesUnion workforce contracts Plan for effective licensing and ID regulatory barrierSystem for monitoring and moving patients through the continuum (PCOMS?)Services designed to match need and provide continuum of careUnderstanding/ incorporate community servicesDesign effective billing systemIntegration of care between services/clinics Implementation of new billing system (appropriate staffing and process)Align existing services with managed care initiativeCOCUS system to ID patient level of carePackage services based on needs/ presentationHCBS: Community Psych support team, peer services, family training/ support, mobile crisisDSRIP compliance through evidence based practiceSystem for monitoring Tx effectivenessRevising current services and incorporating HCBS/ community/ family involvement

Box 5: Solution Approach (cont.)TreatmentPlanning NeedsPhase 1 (Infrastructure Building)- Design integrated continuum ofcare- Devise new care model deliveryFinancialNeedsProgramDevelopmentVertical Value Stream Map:Treatment Planning WGNeedsProgram Development WGQualityManagement &Getting Paid WGData NeedsAccess WGWorkforceDevelopmentHCBS WGNeedsAccess Needs- Incorporate evidence-basedpractices- Identify required resources- Integrate AccessCompletion Date: 1/1/2016Phase 2 (Implementation)- One-day VVSM (Part 2)- Operationalize Phase 1throughRIEs & projectsCompletion Date: 6/1/2016

Box 6: Rapid Experiment (VVSM)

Box 7: Completion PlanWGWHATWHENXCreate work standard for VSST and for workgroups: DMS coaching (M. McKenzie) & Workgroup coaching (Jenna & Jason)10/7/15XVerify dates and roles defined on VVSM map10/9/15XLaunch each workgroup: Team selected; Meeting schedule set & Boxes 1-3 & 7 ready for VSST.10/27/15XReach out to workgroup teams and schedule first meeting: Getting Paid Workgroup Program Development Treatment Planning10/13/15XAlign BHS table of organization to workgroup governance from VSA/VVSM11/18/15XFinalize AOPD leadership structure11/18/15XCommunicate clear plan to staff via Town Hall meetings, BH newsletter & updatedand simplified Mission Control Board: Finalized VSA/VVSM A3 Finalized EXCEL visual of VVSM project map Finalized Target State map Town Hall & Mission Control Board A3’s POSTEDXSchedule one-day VVSM session for Phase 2 (1/15/16)XStreamline data/analysis across DOJ, QC, SIRC, and Breakthrough: Investigation training SIRC & QUALITY sub-committee coaching support10/30/15TH scheduled 12/9/1511/15/153/1/16

Box 7: Completion Plan (cont.)WGRIE/WSxWHAT Update workgroup completion plan to reflect VVSM specificsWHEN1/20/16x Double book pilot1/19/16x New encounter form pilot1/19/16x Update Access completion plan to reflect VVSM specifics1/20/16x2/17/16x OPD appointment scheduling process clarification – integrationof finance, clinical, and schedulers OPD encounter form and Activity Guide roll out1/26/16x Soarian clean up and maintenance system2/5/16 Centralized Scheduling Workshop: Double booking intake slots on centralized Soarian intaketemplate Guide for how to find existing providers/last visit in QMed AIP intakes booked directly from AIP Can CPEP book directly into OPD (clear referral criteria)2/24/16 Update workgroup completion plan to reflect VVSM specifics1/20/16xx

Box 7: Completion Plan (cont.)WGRIE/WSWHATWHEN1/20/16xInform Dr. E that Recovery Center transition plan (from RIE) will be rolled into PC Integrationworkgroup and reported on monthly at VSSTUpdate workgroup completion plan to reflect VVSM specifics -regarding IOT development3/31/16xProvide regular updates in AOPD staff meetings1/20/16xFinance meetings and scorecard roll out3/31/16xxSupervisory and leadership structure to support: Clinical, Finance Soarian (template availability,intakes)3/28/16CPEP RIE:x Restructure WIC workflow, Briefs, CPEP team approach to careRestructuring AOPD work flow RIE:x Staffing pattern/afterhours calls for patients Teams & Case management SOW training for all staff Training of Best Practices template & sequencedRestructuring WIC work flow RIE: Changes based on needs post prior RIE’s listed above.Child VSA: OUT OF SCOPE FOR THIS VSA – Notes here to be used for future VSA’s. Soarian/Workflows for end to end care in child services Next Steps: need to set date & establish team for March 2017 VSA due to managed carerollout for child moved to July /1/17

Box 7: Completion Plan (cont.)WGRIE/WSWHATFind mechanism for how to imbed workgroup products into supervisory product/competencymodelsWHEN5/1/165/1/16: Drill down show gaps in SOW & use of PCB’sNext Steps: Build into 2 upcoming RIE’s and all VSA’a AND for areas that are not a focus of VSA –do in Monthly A3 mtg.Meeting to integrate workgroup products Getting Paid/Best Practices/Treatment Planning6/27/165/1/16Identify coaches w/ Lean experience to guide workshops and future RIE’s/Child VSA:5/1/165/1/16: Exploring Training with K Q, A P, R B & T R & development of internal Learn trainingprogram10/1/16Next Steps: Rethink how Quality & Training shops are structured to make room for this kind ofwork – new A3 for Quality started!Outpatient/Inpatient Best Practice Integration scheduled meeting6/27/20168/15/2016

BOX 7: BHS VALUE STREAM COMPLETION PLANGAPS & COUNTERMEASURES FOR REVIEW BEFORE CLOSING ADULT OPD VSAWHATClose out AOPD VSA with plans for gaps and next steps (VSA/A3’s)BOX 7:WORKGROUPS:GETTING PAID: Finance A3 1-2 day to address gaps in staffing plan of Getting Paid WG who/whenDATA TRACKING: Jordan Vanek will work on this with AOPD leadership whenHCBS: Pilot with H H Health home & Healthfirst who/whenTREATMENT PLANNING: Monitored in Quality Council – explore UR process. who/whenACCESS: A3 moved to monthly A3 meeting to address further spread and address no show rates and fill rates in AOPD.PCC & BEST PRACTICES: A3 driven Training plan developed to ensure all training initiatives planned (Partner for Safety, Co-Occur,PCC & Best Practices) happen. who/whenRIE’s:- AOPD: Training in Partner for Safety & Mock Codes then PCC/BEST PRACTICES when/who- WIC: Staffing schedule, huddle, flow. 90 days post- SOW INCOMPLETE: AOPD Resource Guide: SW intern to complete quick and final drafts Susan Cameron/Nov 1BOX 8:- First 5 metrics were out of scope of this VSA or RIE’s scheduled at end of year so lack of progress not of concern.- Final 7 metrics measured things we worked on and showed progress and gaps. Below are gaps ideas to work on through a varietyof mechanisms.FUTURE VSA’s:- Identify coaches with lean experience to assist A3, VSA and RIE needs.- AOPD: VSA or A3?- Substance Use: OCT?- Child OPD: March?Monthly A3 meeting & Quality Councils:- A3’s: First Wed 2-4 (monthly) all services present working A3’s to ensure continuous improvement & sustainment outside of VSST –status update after 9/7/16 meeting- Quality Council: SOW when metrics red or not improving-

Box 8: Confirmed StateAlignmentMetricQuality/SafetyCIU: % SeenAccessAOPD: 310365350,819385,901FinanceOPDS Productivity(by day)FinanceCost/Revenue(Adult MH, PA, PHP)FinanceAIP Denials(monthly average)1734FinanceOver 15 Days AIP( )268,030161,700Jan.2016Feb.2016314,812 342,5522214131,859 ,89922129161588,24964,092119,07093,63971,099323

Box 9: Insights Prep work (current & target state mapping, demand data, SWOT) extremelyhelpful allowed us to do deep and multiple gap analyses in event and create adetailed methodical action plan using the VVSM tool. Rapid Experiments from January 2015 Visioning & Managed Care TransformationPilots instrumental in shaping plan of action. Behavioral Health now has clear vision going forward, following DOJ achievements. Team representation across services (both within KCHC and outside) allowed for trueunderstanding of developing healthcare landscape. DSRIP, Health Home, & BHS Transformation representation on team allows for moreeffective collaboration going forward. Flexible use of Breakthrough models & tools allowed team to adapt and integratecomplex processes in a meaningful way.

Appendix: Event Recipe CardVSA/VVSM RECIPE CARDPREP PHASE1) Breakthrough Prep sheet: 90 DAYS PRIOR Clearly identify Scope, Aim, Reason for Action, Current and Target State narrative andassociated metrics with BT shop and BHS leadership. Suggest focusing on adult services first as BH Transformation initiative & Managed carefocus is adult this year and finances don’t change for child until 2017 as a way to helpscope activity. Reason for action should include need for integration of corporate initiatives aroundPrimary Care Access, BHS Transformation, DSRIP, Managed Care & Health homes. Pull all metrics required by various initiatives and regulatory agencies to inform yourhigh level metrics. Identify date & VSA/VVSM team members including BH senior leaders, site financialteam, DSRIP HUB ED, Health Home rep from CO, Primary Care & BH Transformation COcoaches and Managed Care reps to event 30-60 days out. Identify dates and teams to complete 3 maps: CPEP, INPT & AMBCARE services. Teamsshould be made up of Medical Director, Service area nursing and admin plus interdisciplinary staff members. Get VVSM paper.2) Current State Mapping: Schedule CPEP, INPT & AMBULATORY CARE services current state mapping sessionsindependent of one another as you would for a VSA (ie: flow map with data boxes,demand data for each service and hi utilizer data attached to maps). Review for completeness and amend VSA level metrics as demand data and data boxesinform the depth of your challenges.3) Matrix of Meeting structure, Table of Organization & list of all ongoing projects: All projects going on to date (Breakthrough and non-Breakthrough) so that this informationcan feed gap analysis and solution approach in event. Also gives a fuller picture of resources needed for Target State.4) Target State Mapping: High level map that shows full continuum of clinical services and financial infrastructurerequired from CPEP-INPT- AOPD that integrates the MCO, HH, HARP & DSRIPconnections. This is a tool that helps team see how these all interconnect and then the Target Statemaps then helps your team start with a series of gap analysis for your event.5) Gap Analysis part one: Complete a SWOT analysis using current and target state maps to give your team on dayone of event a high level understanding of gaps.

Appendix: Event Recipe CardEVENT ACTIVITY:Day One1) Review Boxes 1-3 of prep sheet; current and target state maps; SWOT.2) Use 4 pillars model (see A3) to do a current and target state view through an operationalinfrastructure.3) Finish day with a brainstorming session of all potential gaps using 5 categories (see A3).Day Two:1)2)3)4)5)Attach potential root causes and possible solutions to gaps.List out all milestone dates for DSRIP, Managed Care, & BH Transformation.Use 7 flows tool to filter solutions into a vertical and horizontal integration matrix.Further synthesize solutions into 4-6 main buckets of work.Identify project/workgroups based on 4-6 buckets of work.Day Three:1) Begin VVSM mapping for next 2 days.2) Start with identifying 1 or 2 major milestones and associated dates on your map and spell outthe outputs needed for both.3) Break team up into 4-6 groups (according to buckets of work) and have them identify tasks needto do to break this bucket of work into smaller steps; attach phases to this work and identifywho needs to be involved and then finally outputs for their phases.4) Review Matrix of Meeting structure, Table of Organization & list of all ongoing projects totable to inform buckets of work and governance structure for your integrated model goingforward (ie: how can current meetings be eliminated or added to ensure all work managedthrough a single structure like your VSST rather than having your initiatives and project workmanaged in silo’s; do some roles need to change to support your efforts’?)5) Label VVSM map as tool indicates (ie: dates down left side and core team, suppliers, customersacross top).6) Bring team together and use the work the 4-6 teams did to start VVSM map for rest of day 3 andmost of day 4.Day Four:1) Bring team together and use the work the 4-6 teams did to complete VVSM map for rest of day.2) Develop your box 7 tasks to drive this project (VVSM). VVSM project map is your box 6.

All initiatives funneled through Breakthrough. Data driving behavior and unit/team based decisions CPEP work flows and staff patterns adjusted to meet projected demand. AIP workflows made nimble so that they can adjust to managed care changes. 5 day appointment availability in all ambulatory services. Financial acumen of staff and leaders improved and infrastructure .