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Presentation on theme: "ACHIEVEMENTS OF MISSOURI CMHC HEALTH HOMES How far we’ve come."— Presentation transcript:


2 My Background Medicaid Director Previously DMH Medical Director – 20 years Practicing Psychiatrist CMHCs – 10 years FQHC – 18 years Distinguished Professor, Missouri Institute of Mental Health, University of Missouri St. Louis

3 Life Expectancy Bar 1 & 2: Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Med Care. 2011 June;49(6):599-604 Bar 3; Daumit GL, Anthony CB, Ford DE, Fahey M, Skinner EA, Lehman AF, Hwang W, Steinwachs DM. Pattern of mortality in a sample of Maryland residents with severe mental illness. Psychiatry Res. 2010 Apr 30;176(2-3):242-5

4 Change in US General Population Age- Adjusted Mortality (1979-1995) Morbidity and Mortality Weekly Report. 1999; 48(30):649-656.

5 Mortality Risk From All Causes and From Cardiovascular Disease Increased Among Patients With Schizophrenia Between 1970- 2003

6 Comparison of Metabolic Syndrome Prevalence in Fasting CATIE Subjects and Matched NHANES III Subjects Meyer et al., Presented at APA annual meeting, May 21-26, 2005. McEvoy JP et al. Schizophr Res. 2005;80:19-32.

7 The CATIE Study At baseline investigators found that:  88.0% of subjects who had dyslipidemia  62.4% of subjects who had hypertension  30.2% of subjects who had diabetes were NOT receiving treatment.

8 Causes of Excess Mortality  Smoking  Obesity  Inactivity  Polypharmacy  Under Diagnosis of Medical Conditions  Inadequate Treatment of Medical Conditions

9 Maine Study Results: Comparison of Health Disorders Between SMI & Non-SMI Groups

10 Per Member Per Month Costs Melek et al Milliman Inc, 2013

11 MH/SA costs in NY State’s Medicaid Program

12 Why CMHC Healthcare Homes? Because addressing behavioral health needs requires addressing other healthcare issues  Individuals with SMI, on average, die 25 years earlier than the general population.  60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases.  Second generation anti-psychotic medications are highly associated with weight gain, diabetes, dyslipidemia (abnormal cholesterol) and metabolic syndrome.

13 Our Mission Recovery for Persons with SMI

14 Our Problem Early Death from Physical Illness Prevents Recovery from SMI


16 CMHC as Health Care Home  Case management coordination and facilitation of healthcare  Primary Care Nurse Care Managers  Medical disease management for persons with SMI  Preventive healthcare screening and monitoring by MH providers  Integrated/consolidated CMHC/CHC Services

17 CMHC-HH Strategy  Health technology is utilized to support the service system.  “Care Coordination” is best provided by a local community- based provider.  MH Community Support Workers who are most familiar with the consumer provide care coordination at the local level.  Primary Care Nurse Care Managers working within each CMHC provide system support.  Statewide coordination and training support the network of CMHC Health Homes.

18 Medical Needs Have Same Priority as MH Needs  Obtaining a “medical home” – a primary care provider responsible for overall coordination  Medication adherence – just as important for non-MH meds  Assisting in scheduling and keeping medical care appointments

19 What is a CMHC Healthcare Home?  Not just a Medicaid Benefit  Not just a Program or a Team  A System and Organizational Transformation

20 Treatment as UsualHealth Homes What is Different about Health Homes? Individual Practitioner Episodic Care Focus on Presenting Problem Referral to meet other Needs Managed Care – Manages access to care – Does not change clinical practice Integrated Primary/Behavioral Health Care Team Continuous Care Comprehensive Care Management – Coordinates care across the healthcare system – Data driven population management – Transforms clinical practice – Emphasizes healthy lifestyles and self- management of chronic health problems

21 Practice Transformation  Planned Care  Data Driven Care  Team Care  Integration of Behavioral and Primary Care  Addressing Social Determinates of Health

22 Principles  One Team composed of pre-2012 CPRC staff plus NCM and PC Consultant  One Treatment Plan for the Whole Person  Rehab Goals  Medical Goals  Healthy Lifestyle Goals  Some Goals and Outcomes reference Health Home Performance Measures  Wrap –Around approach to outside treating PCP

23 Health Home Target Populations  Patients with Diabetes  At risk for cardiovascular disease and a BMI > 25  Patients who have two of the following  COPD/Asthma  Cardiovascular Disease  BMI>25  Developmental Disabilities  Use Tobacco  Individuals with a serious mental illness; or with other behavioral health problems who also have  Diabetes  COPD/Asthma  Cardiovascular Disease  BMI>25  Developmental Disabilities  Use Tobacco Primary Care Health HomesCMHC Healthcare Homes

24 Missouri’s Health Homes Providers – 18 FQHCs 67 Clinics – 5 Hospitals 22 Clinics 14 Rural Health Clinics Enrollment – 15,526 adults – 428 children – 15,954 total Providers – 28 CMHCs 120 Clinics/Outreach Offices Enrollment – 16,611 adults – 2,387 children – 18,998 total Primary Care Health HomesCMHC Healthcare Homes

25  Champion healthy lifestyles and preventive care  Provide Population Based Care Management  Provide Individual Care Management  Initially review client records and patient history  Participate in annual treatment planning including Reviewing and signing off on health assessments Conducting face-to-face interviews with consumers to discuss health concerns and wellness and treatment goals  Consult with CSS’s about health of their clients  Coordinate care with external health care providers Healthcare Home Team Members Nurse Care Managers

26  Champions Healthcare Home practice transformation  Oversees the daily operation of the HCH  Tracks enrollment, declines, discharges, and transfers  May serve as a NCM on a part-time basis  HCHs must have at least a half-time HCH Director  Coordinates management of HIT tools  Develops MOUs with hospitals and coordinates hospital admissions and discharges with NCMs Healthcare Home Team Members Healthcare Home Director

27  Assures that HCH enrollees receive care consistent with appropriate medical standards  Consults with HCH enrollees’ psychiatrists regarding health and wellness  Consults with NCM and CPR team regarding specific health concerns of individual HCH enrollees  Assists with coordination of care with community and hospital medical provider  Consults regarding selection of patients and conditions to target for current attention Healthcare Home Team Members Primary Care Physician Consultant

28  Assures that HCH enrollees receive care for MH, Substance Abuse and Behavioral problems related to chronic Medical conditions  Assists with behavior modification to achieve improved patient participation, adherence, and compliance with management of complex chronic conditions  Consults with HCH enrollees’ PCP, NCM, and HH team regarding specific behavioral health concerns of individual HCH enrollees  Assists with coordination of care with outside behavioral health providers  Consults regarding selection of patients and conditions to target for current attention Primary Care Healthcare Home Team Member Behavioral Health Consultant

29  Continue to fulfill current responsibilities  Collaborate with Nurse Care Managers in providing individualized services and supports  CSWs are trained as health coaches who Champion healthy lifestyle changes and preventive care efforts, including helping consumers develop wellness related treatment plan goals Support consumers in managing chronic health conditions Assist consumers in accessing primary care Healthcare Home Team Members Psychiatrists, QMHPs, PSR and CSWs

30 Six CMS Required Health Home Functions  Care Management  Care Coordination  Managing Transitions of Care  Health Promotion  Individual and Family Support  Referral to Community Services

31 Comprehensive Care Management  Identification and targeting of high-risk individuals  Monitoring of health status and adherence  Development of treatment guidelines  Individualized planning with the consumer

32 Step 1 – Create Disease Registry  Get Historic Diagnosis from Admin Claims  Get Clinical Values from Metabolic Screening  Combine into EHR Disease Registry  Online Access available to all Providers

33 Step 2 – Identify Care Gaps and ACT!  Compare Combined Disease Registry Data to accepted Clinical Quality Indicators  Identify Care Gaps  Sort patients with care gaps into agency specific To-Do lists  Send to CMHC nurse care manager  Set up PCP visit and pass on info with request to treat


35 Disease Management Report: Patient Data

36 Disease Management Report: Agency Stats

37 Medication Adherence Reports 7 Drug Classes: o Antidepressants o Antipsychotics o Mood Stabilizers o Antihypertensives o Asthma/COPD Medications o Cardiovascular Medications o Diabetes Medications

38 Medication Possession Ratios (MPRs) MPR is a measure of medication adherence. Based on pharmacy claims and delays in getting refills. Refers to the percentage of time that a patient has a prescribed medication in their possession. o In a 3 month period, if a patient fills the medication for the first 30 days, then skips the next 30 days, then fills it for the last 30 days, they have the medication in their possession for 60 out of the 90 days (60/90), or 67% of the time – an MPR of 0.67. An MPR of 1.0 is perfect adherence (100% possession). An MPR of 0.8 or higher (possession 80% of the time) is considered adherent, per the scientific literature.

39 Adherence: Lapsed Refill Alerts

40 Care Coordination  Coordinating with the patients, caregivers and providers  Implementing plan of care with treatment team  Planning hospital discharge  Scheduling  Communicating with collaterals

41 Provide Information to Other Healthcare Providers  HIPAA permits sharing information for coordination of care  Nationally consent not necessary  Exceptions:  HIV  Substance abuse treatment – not abuse itself  Stricter local laws

42 Provide Payer Information to Providers at Transition of Care Medicaid requires hospitals to notify MHN within 24 hours of a new admission of any Medicaid enrollee and provide information about diagnosis, condition and treatment for authorization of an inpatient stay using a web based tool. A daily data transfer listing all new hospital admissions discharges is transferred to the HH data analytic staff New admits are matched to the list of all persons assigned and/or enrolled in a healthcare home. An Automated email notifies the healthcare home provider of the admission.

43 Support Patient Wellness through Self Management using Peer Specialists  Implement a physical health/wellness approach that is consistent with recovery principles, including supports for smoking cessation, good nutrition, physical activity and healthy weight.  Educate patient on implications of psychotropic drugs  Teach/support wellness self-management skills  Teach/support decision making skills using Direct Inform  Use motivational interviewing techniques  New psychosocial rehab focus  Smoking cessation  Enhancing Activity  Obesity Reduction/Prevention

44 44

45 Body Mass Index

46 Chronic Disease and At Risk HCH Adults

47 Disease Management Continuously Enrolled Adults with Data

48 Disease Management BMI, Tobacco, and Complete Screens

49 Disease Management Diabetes ( 2434 Continuously Enrolled Adults)* * 29% of continuously enrolled adults

50 Hypertension and Cardiovascular Disease 3023176

51 Hennekens CH. Circulation. 1998;97:1095-1102. Goals: Lower Risk for CVD  Blood cholesterol  10%  = 30%  in CHD (200-180)  High blood pressure (> 140 SBP or 90 DBP)  4-6 mm Hg  = 16%  in CHD; 42%  in stroke  Cigarette smoking cessation  50%-70%  in CHD  Maintenance of ideal body weight (BMI = 25)  35%-55%  in CHD  Maintenance of active lifestyle (20-min walk daily)  35%-55%  in CHD

52 Improving Diabetes (HbA1c)  7.2% Uncontrolled (too high)  For 51% there are 2 results so we can find the trend  The uncontrolled group average HbA1c decreased from 9.50% to 8.95% (-0.55%)  1% point decrease in HbA1c yields: 21% decrease in Diabetes related deaths 14% decrease in Heart Attacks 37% decrease in micro-vascular complications

53 Improving Cholesterol (LDL)  46.3% Uncontrolled (too high, greater than 100)  For 58% there are 2 results so we can find the trend  The uncontrolled group average LDL decreased from 122 to 115 (-7)  A 10% Cholesterol Reduction yields a 30% reduction in Coronary Heart Disease

54 Improving Hypertension (BP)  23% Uncontrolled (too high, greater than 140/90)  For 61% there are 2 results so we can find the trend  The uncontrolled group average BP decreased from 142/90 to 137/86 (-5/4)  A 6 point reduction yields:  16% reduction in Coronary Heart Disease  42% reduction in Stroke

55 Disease Management Asthma 2427 Adults Continuously Enrolled 42 Children and Youth Continuously Enrolled

56 Outcomes Medication Adherence CMHC Healthcare Homes


58 Percent of Follow Up Compared to # of Hospital Discharges


60 ER Events for PCHH Members with at Least 8 Months of Service and Who Were Initially Enrolled during First Quarter 2012

61 Outcomes Reducing Hospitalization Primary Care Health HomesCMHC Healthcare Homes

62 Intial Estimated Cost Savings after 18 Months  Health Homes  43,385 persons total served (includes Dual Eligibles)  Cost Decreased by $51.75 PMPM  Total Cost Reduction $23.1M  DM3700  3560 persons total served (includes Dual Eligibles)  Cost Decreased by $614.80 PMPM  Total Cost Reduction $22.3M

63 Intial Estimated Cost Savings after 18 Months  CMHC Health Homes  20,031 persons total served (includes Dual Eligibles)  Cost Decreased by $76.33 PMPM  Total Cost Reduction $15.7 M  PC Health Homes  23,354 persons total served (includes Dual Eligibles)  Cost Decreased by $30.79 PMPM  Total Cost Reduction $7.4 M

64 Agency Leadership Buy-In Implementation was led by DMH & Coalition  Helped standardize implementation  Paving the Way  Accreditation (CARF) Assist other programs to include HCH Time for in-house trainings  Assist other programs to include HCH

65 Agency Leadership Buy-In Setting up the right team  HH Director Experience in Primary & Behavioral health  HH Nurse Care Manager Promote from within  Primary Care Consultant  Care Coordinator  Having a MH clinician available for cold calls/assmts. Equipment  LDX machine, B/P cuffs

66 Organizational Changes Policies and Procedures Job descriptions Additional trainings  Standardize duties across staff  Discuss success stories  Community trainings  Identify transformational change

67 Training Medical training for Community Support Specialist  NCM highlight what the CSS needs to target  CSS needs to bill to staff clients with NCM  NCM make health care meaningful to CSS CSS recognition of how health care helps each client Medication and side effects Preventative care

68 Treatment Team Meetings NCM is a must Provide medical perspective NCM brings primary consultation opinion Solidify primary & behavioral health interventions

69 EMR Electronic Medical Records  Allows communication among treatment team  All treatment team members add information  Progress notes Psychiatric Nurse (vitals) NCM (Cyber Access) CSS (Direct care) QMHP (Treatment Planning) Primary consult (Medication interactions)

70 Common Challenges Write a good treatment plan  Core Competency QA Treatment Plans Health Screenings Metabolic Screenings Progress notes Buy-in  Taking blood pressures  Training clients to care for their health care More work than staff

71 Training and Technical Assistance  Introduction and Orientation  Healthcare Home Implementation  Access to Care  Healthcare Home Administration  Data and Care Management Reports  Physicians Institute  Disease Management and Clinical Training  Introduction to Disease Management  Motivational Interviewing  TEAMcare  Wellness Coaching

72 Outcomes Pro Act  Flags  Medication adherence Core Competencies  Global and individual targets Technology  Stay on top of what is needed to complete work

73 Surprises Health education for clients, transfers  Good results for clients  Good results for family  Good results for staff

74 Success Stories Billie lost 19 pounds and reduced her BMI from 55.6 to 51.34 in 12 months and in the last 3 weeks has lost another 4 pounds. Susan was working on smoking cessation. During this time she had a stroke. With the help of her nurse care manager and CSS she was able to go to a nursing home with her handicapped daughter, whom she cares for, to recover. The nurse care manager and CSS then helped her and her daughter transition back to her home. Through all this Susan achieved her goal and quit smoking.

75 Tips Have the correct staff on the team Total buy-in  Leadership  Middle management  Front line staff  Support staff

76 WA OR TX CO NC LA PA NY IA VA NE OK AL MD MT ID KS MN NH ME AZ VT MO CA WY NM IL WI MI WV SC GA FL UT NV ND SD AR IN OH KY TN MS DE RI NJ CT MA HI Approved State Plan Amendment(s) (12) Planning Grant (17) ACA Section 2703 Health Home Activity AK ★ ★ As of June 2013 Note: States with stripes have both


78 What Makes it Possible?  A Relationship of Basic Trust between:  Department of Mental Health  MO Coalition of CMHCs  State Medicaid Authority  State Budget Office  MO Primary Care Association  Transparent use of Health Information Technology to identify and monitor problems, and assess performance  Willingness of all partners to tolerate risk  Funding Primary Care Nurse Care Managers

79 WebSites   hcarehome.htm hcarehome.htm


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