Driving Outcomes and Quality

Commitment to Quality: Our commitment to quality performance manifests through our values, our service culture, the courteous and knowledgeable daily interactions of our staff with members and providers, and the outcomes achieved. We believe that company performance can be measured through various metrics examining access, service, satisfaction, outcomes, and process. We continually monitor the performance of our duties to members, providers and our corporate clients and strive for continual improvement. We are proud to report the following metrics:

MBHN statistical analysis of behavioral health utilization data indicates that major depression is the leading behavioral health condition for health plan populations for which New Avenues administer benefits. This accounts for a fourth of outpatient visits and is the most common diagnosis for inpatient treatment and ECT. In order to improve outcomes for persons suffering from major depressive disorders, New Avenues adopted a disease management outreach program to intervene and support the recovery process for those persons who are at moderate to high levels of risk.

The Depression Disease Management Program goals are to provide tools and support to help individuals reach recovery, encourage self-empowerment in managing one’s illness, increase adherence to treatment, reduce the incidence of relapse, treatment failure, ER visits,  andre-hospitalizations, and avert the tragic losses related to lost work time, family breakdowns, and suicide.   New Avenues delivers a Depression Disease Management program designed and based on the Lilly USA Depression Disease Management model.

The program delivers targeted outreach to enrolled members with moderate to high levels of risk as demonstrated by prior hospitalizations, extended treatment, suicide attempts or risk, multiple episodes of care, the presence of serious co-morbid conditions, referrals by primary care provders or utilization review.

The Depression Disease Management Program Features:

• Telephonic outreach by licensed clinical social workers
• Personalized service at no cost to the member
• 4 mailings to the member
  • Tools to adhere to treatment
  • Understanding one’s condition
  • Dealing with stress
  • Health lifestyle choices
• Coordination of care with the member’s treating providers and primary care physician.
• Communication with medical utilization review for addressing co-morbid cardiac, pulmonary, diabetes, obesity, or chronic pain conditions if applicable.
• Consents for Case management and involvement of providers and family members.

Results:

• 73% of members discharged from a hospital setting for a mental health condition had an appointment within 7 days of their discharge; 90% of members had an appointment within 30 days. This results from our persistent follow-up efforts to assist members with post hospital care.

What have members told us?

Feedback from a member discharged from the hospital and grateful for the help and guidance that she received from her Care Manager…

The premier solution.

Health plans can achieve cost effective solutions for addressing behavioral health issues by positioning a New Avenues EAP as the entry point for early intervention. Then by using New Avenues to administer behavioral health benefits, the health plan will realize maximum savings.

With this delivery model, the organization will reduce behavioral health claims against the health plan. How does this work?

• Gives employees easy access to professional resources for addressing common personal and family daily living and adjustment issues and keeps these claims outside of the health plan;
• Short term counseling costs at the EAP level are absorbed by New Avenues; only longer term, significant behavioral health claims pass through the health plan;
• Longer term professional services, psychiatric services, inpatient and specialized behavioral healthcare costs that do pass through the health plan are managed for risk, quality, and effectiveness by the Care Management staff.
• Obtain the lowest provider negotiated rates with the New Avenues – MBHN provider network selected as an approved PPO for the health plan; New Avenues has demonstrated consistently that health plan in-network claims are reduced by 35-50% off retail charges.
• New Avenues provides employees with continuity of care from EAP to health plan with minimal disruption
• The EAP delivery model facilitates members using in-network providers which reduces employees’ out of pocket expenses and supports cost savings for the health plan.
• Care management staff focuses on reaching out to members with serious mental health and substance abuse conditions to improve resilience and probability of recovery, as well as treatment adherence in order to avoid relapses, inpatient hospitalizations, ER visits, lost work time, suicide, and health complications.
• Risk management strategies include coordinating care with member’s primary care physicians, specialized protocols for ADHD testing, and case management services for persons with workplace performance issues, depression/mood disorders, autism spectrum disorders, serious mental illness or chronic substance abuse conditions. 

Specialists in Building Behavioral Health Provider Networks and Preferred Provider Network Management

• New Avenues specializes in credentialing and contracting Behavioral Health Providers including private and public practitioners and facilities at all levels of care
• Timely contracting within 90 days of completed application
• Experienced in building behavioral health networks within 90-120 days for large health plans or to meet needs of an employer with multiple locations
• New Avenues, Inc., d/b/a/ Midwest Behavioral Health Network, is registered in Indiana as a Preferred Provider organization
• To achieve maximum savings, fee schedules are based upon proprietary fixed rates for outpatient professionals and facility per diems
• Providers enjoy working with New Avenues due to ease of telephonic access, minimal paperwork, respectful communications, fair and reasonable utilization review practices, provider input into credentialing and utilization review policies and procedures.

New Avenues and the Midwest Behavioral Health Network

Full Spectrum of Behavioral Health Providers:

• Psychiatrists  
• Psychologists
• Therapists
• Marriage and Family Therapists
• Mental Health Counselors
• Advanced Nurse Practitioners
• Addiction Specialists
• Board Certified Behavior Analysts
• Intensive Outpatient Programs
• Inpatient & Partial Hospitalization programs
• ABA Programs

MBHN Provides Health Plans With:

• Rigorous credentialing program based on the National Committee for Quality Assurance standards
• Access to providers nationwide and in 200 countries
• Maximum savings to the health plan
  • 35-50% savings from billed charges
  • Aggressive negotiated fixed rates for outpatient practitioners
  • Use of per diems for inpatient, partial, and IOP programs
  • Reduced out of pocket expenses for members
• Capacity to build networks quickly for Commercial andMedicare contracting
• Choice, convenience and access to all levels of care
• Quality assurance oversight of network
• NCQA compliant programs
• Private practice offices, multi-specialty groups, hospitals, private hospitals, community mental health centers and private agencies
• Autism Specialty Networks including credentialing of BCBA and ABA facility providers fortreating autism spectrum disorders
• Member satisfaction – our surveys indicate employees have over 90% satisfaction with their Provider access and experience

Contract Options:

• MBHN Network – Stand Alone PPO Access Fee
• Administrative Services Arrangement: features MBHN Network bundled with a utilization review and case management program
• Claim re-pricing or full claim adjudication/processing services available
• Integrated EAP and Behavioral Health program management

MBHN Member Services

The Facts:

• About 1 Million employees miss work each day due to stress
• Mental Health conditions are the 2nd leading cause of workplace absenteeism
• Each year, in an office of 20 people, 4 will suffer from a mental health problem
• One in 150 children is now diagnosed with Autism Spectrum Disorder
• Workers who abuse drugs cost their employers 2 times as much in medical and workers compensation claims than workers who do not abuse drugs
• Depression is the 2nd leading cause of disability in the United States
• People who receive treatment for depression are 2/3 less likely to miss work days due to illness
• Stress is linked to the six leading causes of death: heart disease, cancer, lung ailments, accident, cirrhosis of the liver and suicide
• Suicide is one of the top 15 causes of death in America

The good news is that there is highly effective and cost efficient treatment available. Mental health problems actually have better treatment outcome rates than the vast majority of common medical conditions, including heart disease.

New Avenues Care Managers work diligently each day to help people access proper treatment. We realize it is difficult to make the call for behavioral health concerns. Our staff is selected and trained to provide courteous, respectful and compassionate care. This is the hallmark of New Avenues.

Member Services highlights:

• When a member calls, he or she speak to an experienced behavioral health Care Manager who is a licensed psychiatric nurse or masters level social worker knowledgeable in behavioral health, and the levels of care indicated
• Care Managers provide members with referral assistance based upon personal or family needs, practice setting preferences, and geographic considerations
• Standard appointments are available within 10 days of a request for services; care managers will arrange for urgent and emergent care.
• Providers are available within a variety of settings including private practice offices, multispecialty groups, community agencies, and hospital settings.  New Avenues MBHN network is extensive and offers members choice and convenience. In a 2011 geoaccess study, over 95% of HMO members in Indiana had access to outpatient care within 30 minutes and 30 miles of home or work.
• 85-90% of members with point-of-service policies use in-network options finding local providers with solid reputations and proximity to their homes or workplaces
• Care managers are on call during all non-business hours to assist members with emergencies and to perform inpatient utilization reviews
• New Avenues has designed diagnostic protocols for ADHD psychological testing to assist families and pediatricians with assessment needs for children with suspected attention deficit problems
• New Avenues is experienced in administering a wide variety of health plan policies including HMO, point-of-service, union trusts etc. Each health plan policy has its unique features; New Avenues has the flexibility and information technology resources to quickly assist members in understanding their benefits and network options

Member Satisfaction:

What members say about their New Avenues/MBHN experience…

Delivering Results:

• About 6% of enrollment use behavioral health benefits – the vast majority of members utilize outpatient care. Average number of session for outpatient care is 6.5 visits; over 90% of members complete care within 20 visits. New Avenues performs utilization management based upon data driven algorithms for medical necessity review points to ensure that members are receiving effective care based upon industry best practices
• Less than 1% of the enrollment incur 35-45% of behavioral health costs. Charges for an average inpatient stay for a behavioral health disorder are in the range of $11,300 as opposed to average charges for an outpatient case at under $900 per episode of care. Aggressive case management efforts are made to engage members with serious behavioral health conditions to participate in treatment and case management
• 2011: robust case management efforts to ensure post hospital follow-up for patients with serious mental health conditions resulted in69% of patients being seen within 7 days of a hospital discharge; 88% were seen within 30 days
• Readmissions were reduced by 50% in 2011 over 2010 as a result of case management interventions. MBHN readmission rates within 30 days were less than 6%, far below national averages
• New Avenues has specialized case management programs designed for members with depressive mood disorders, high risk serious behavioral health conditions, autism spectrum disorders, and workplace performance issues

New Avenues delivers comprehensive behavioral health clinical management programs that use dynamic strategies to ensure quality, use of evidenced based practices, and cost effective treatment. Health plans looking to manage costs, risk and quality, achieve results through New Avenues' dynamic approach to behavioral health benefit administration that features:

• Risk management by tracking utilization, costs trends, and outlier situations
• Specialty-designed case management programs for members with severe depressive disorders, autism spectrum disorders, chronic behavioral health conditions, and high risk cases; members are engaged in treatment and psycho-educational support programs to build recovery and resilience
• Use of industry best clinical practices and efficient care by monitoring provider treatment through proprietary medical necessity review protocols
• A service culture that emphasizes our commitment to helping people manage personal and family problems with the utmost respect, compassion, sensitivity and confidentiality
• Performance metrics:  We continually monitor quantitative measures of quality of care indicators that include access, service, satisfaction, and utilization

Managing Behavioral Health Benefits under Parity Environment:

On July 1, 2010, the federal government’s Mental Health Parity and Addiction Equity Act Interim Final Rules went into effect for employer health plans with over 50 employees.  The parity and health care reform expanded responsibilities for employers in providing coverage for mental health and substance abuse benefits. Under these regulations, visit and day limits were prohibited and utilization review processes such as pre-certification practices became much more limited. The current environment intensifies the need for health plans to take dynamic approaches to managing behavioral health benefits. New Avenues has responded with unique, proprietary evidenced based approaches to providing comprehensive behavioral health clinical management programs that help individuals and meet pragmatic cost containment strategies.

The Utilization Review Program is the foundation of the delivery system and is characterized by:

• Diligent, knowledgeable in-patient pre-authorization reviews by experienced psychiatric nurses supported by a board certified psychiatrist available for daily reviews and peer-to-peer consultations
• Proprietary evidenced based outpatient medical necessity review program designed from 5 years of data on utilization patterns for outpatient care
• Utilization Review utilizing NCQA recognized Medical Necessity Guidelines developed by The Mihalik Group
• Dynamic case management outreach approaches to helping persons with serious behavioral health conditions
• Strong expectations of providers to coordinate and communicate behavioral health treatment with primary care physicians
• Integration approaches to coordinating case management of behavioral health needs with case managers handling members’ chronic medical conditions.

MBHN Care Management Services Provide:

• Referral Assistance for employees and their families to identify an appropriate in-network provider with the subspecialty to treat each person’s unique behavioral health needs.
• 24 hour availability for emergencies.
• Telephonic assessment, referral assistance, emergency assistance, and utilization review performed by experienced care managers who are psychiatric nurses or licensed masters level social workers with oversight by aboard certified psychiatrist as Medical Director.
• Depression Disease Management program for members with moderate to severe major Depressive disorders– the #1 most prevalent behavioral health condition.
• Case Management Protocols for Autism Spectrum Disorders.
• Case Management for high risk cases with severe or chronic conditions
• Commitment to quality and evidence-based care.
• Credentialing and Utilization Review programs operated according to National Committee for Quality Assurance (NCQA) standards.
• Integration with medical plan at several interface points including eligibility, case management, and primary care communication.
• Reports on utilization benchmarked with national metrics.
• An integrated EAP/Work-Life program that can be designed to enhance any health plan.

The Purpose of Case Management:

• Encourage adherence to treatment,
• Coordinate and help individuals navigate care with all providers and the individual’s primary care physician,
• Provide information and tools to empower individuals to understand their condition and find solutions,
• Encourage healthy lifestyle,
• Engage family support systems, and most importantly
• To intervene early so that each individual has the utmost opportunity to recover.

Over half of our professional care management resources are directed to delivering case management outreach to persons with serious behavioral health conditions affecting their work performance, social or family functionality, and well-being.

Children with ASD

We recognize that parents with children with autism spectrum disorders face a host of unique challenges in identifying resources and providers experienced in assessment and treatment of pervasive developmental disorders. We further recognize the importance and effort it takes to obtain a diagnosis and to coordinate treatment with many specialty professionals including speech therapy, occupational therapy, physical therapy, behavioral training programs, outpatient therapy, and psychiatric services. That is why we have dedicated a care manager who works in this specialty area to help parents navigate local and statewide resources. Each child is unique in their developmental needs, medical conditions, and educational/school programming.

MBHN can assist in meeting the needs of families with a child with an autism spectrum disorder. Information and benefit coverage is subject to each member’s health plan Certificate of Coverage. MBHN offers the following range of services:

• Designated specialized Care Management services to assist families in arranging treatment and coordinating care. The Care Manager is a licensed clinical social worker who works telephonically with the family and providers in coordinating care.
• The MBHN provider network includes traditional behavioral health providers such as psychiatrists, psychologists, and therapist. MBHN also has providers that specialize in behavioral training such as Board Certified Behavior Analysts known as BCBA’s, agencies and facilities that specialize in treatment of PDD including applied behavior analysis programsreferred to as ABA programs; these provide in-home services or facility based programs, LOVAAS, and CARF accredited autism treatment programs.
• Guidance to families in hiring direct care workers in geographic areas where agency-employed direct care staff are not available.
• Protocols for assessment, evaluation, diagnosis, and treatment of PDD.
• Coordination of care with primary care providers.
• Understanding and compliance with state mandate regulatory provisions.

For more information contact New Avenues, Care Management Department, at 800-232-6246. Ask for the Autism Program Care Manager.