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MISSOURI PARTNERSHIP Children’s Division/DSS MO HealthNet/DSS Office of Clinical Officer/DMH.

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Presentation on theme: "MISSOURI PARTNERSHIP Children’s Division/DSS MO HealthNet/DSS Office of Clinical Officer/DMH."— Presentation transcript:

1 MISSOURI PARTNERSHIP Children’s Division/DSS MO HealthNet/DSS Office of Clinical Officer/DMH

2 “Policy” Webster's Dictionary 1966 “Prudence or wisdom in the management of public affairs” “A definite course or method of action and selected from among alternatives and in the light of given conditions to guide and determine present and future decisions”

3 “Policy” Thomas Fuller 1608-1661 “Policy consists in serving God in such a manner as not to offend the devil”

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5 5 Be Soft on People Hard on the Problem Fisher & Vry “Getting to Yes” 1981

6 What Made it Possible? - Relationships Values – Stability- Transparency – Trust- Common Agenda Partners – The State Medicaid Authority – MO HealthNet – DMH – State Budget Office – Missouri Coalition of CMHCs – The Missouri Primary Care Association – Vendors: Xerox, CMT, WIPRO, MIMH Data - Use of Health Information Technology to identify and monitor problems, and assess performance

7 S.M.R. Covey, The Speed of Trust Behaviors that Promote Trust Character – Talk Straight – Demonstrate Respect – Create Transparency – Right Wrongs – Show Loyalty Competence – Deliver Results – Get Better – Confront Reality – Clarify Expectations – Practice Accountability Character & Competence Listen First Keep Commitments Extend Trust

8 8 Strategy for Success – The “Win / Win” Opportunity Solve someone else’s problem and they will solve yours – Physicians – become more data and cost conscious – Medicaid – pursue clinical quality – Dept of Mental Health – help Medicaid manage utilization and preserve access – Advocates – work together to identify acceptable limits and interventions – Vendors – combat inappropriate use

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10 10 Pharmacy Management “Guiding Principles” Manage through data, not intuition or anecdote. Monitor for both planned and unplanned consequences. Focus management interventions on good evidence, quality treatment guidelines and compliance with medication plans. Don’t establish the primary goal as “cost savings”. Allow cost savings to be the natural result of evidence based care, quality and adherence to treatment guidelines; Don’t discriminate between physical and behavioral drugs, i.e. don’t limit behavioral drugs more than you would physical drugs. Don’t punish the many, for the sins of the few. Target your Interventions to outliers who need it, not to compliers who don’t.

11 Missouri’s Behavioral Pharmacy Management Helps improve prescribing practices Identifies clinicians whose prescribing patterns deviate from current clinical best-practices Quality Indicators are developed from – continuous review of medical literature – consensus guidelines – nationally recognized clinical panels

12 The Quality Indicators™ and analytic methods presented in this document are confidential and proprietary trade secrets of Care Management Technologies (CMT). This document and its contents may not be used, disclosed, or redisclosed except with the written agreement from CMT. Child BPM Program 1,367 Missouri children who triggered BPM QI’s in May 2011 and were eligible in October 2011 and April 2-12 were studied. From May 2011 to April 2012, behavioral pharmacy costs fell 11% for this group. During this time, total pharmacy costs fell 7.5%. Most children triggering polypharmacy QI’s in May 2011 were no longer triggering them in April 2012.

13 The Quality Indicators™ and analytic methods presented in this document are confidential and proprietary trade secrets of Care Management Technologies (CMT). This document and its contents may not be used, disclosed, or redisclosed except with the written agreement from CMT. Child BPM Program QI # May 2011 April 2012 % Change May 2011 to April 2012 101Use of Benzodiazepines for 60 or More Days (Under 18 Years)325135-58% 205 Use of 2 or More Antipsychotics for 45 or More Days (Under 18 Years) 19276-60% 510 Use of an Antipsychotic at a Higher Than Recommended Dose for 45 or More Days (Under 18 Years) 16541-75% 202Use of 3 or More Psychotropics for 90 or More Days (6-12 Years)10318-83% 505 Use of Clonidine at a Higher Than Recommended Dose for 45 or More Days (Under 18 Years) 9938-62% 311Use of an Atypical Antipsychotic in a child four years old or younger9619-80% 417 Multiple Prescribers of the Same Class of Psychotropic Drug for 45 or More Days (Under 18 Years) 9226-72%

14 The Quality Indicators™ and analytic methods presented in this document are confidential and proprietary trade secrets of Care Management Technologies (CMT). This document and its contents may not be used, disclosed, or redisclosed except with the written agreement from CMT. Child BPM Program QI # May 2011 April 2012 % Change May 2011 to April 2012 205Use of 2 or More Antipsychotics for 45 or More Days (Under 18 Years)19276-60% 202Use of 3 or More Psychotropics for 90 or More Days (6-12 Years)10318-83% 106 Use of 2 or More Atypicals and a Stimulant or ADHD Non-Stimulant for 30 or More Days (Under 18 Years) 7223-68% 201Use of 4 or More Psychotropics for 90 or More Days (13-17 Years)5010-80% 511 Use of an Antipsychotic at a Higher Than Recommended Dose and a Stimulant or ADHD Non-Stimulant for 45 or More Days (Under 18 Years) 268-69% 508 Use of a Stimulant or ADHD Non-Stimulant AND Use of a TCA at a Higher Than Recommended Dose and for 45 or More Days (Under 18 Years) 92-78% 504 Use of an ADHD Non-Stimulant at a Higher Than Recommended Dose for 45 or More Days (Under 18 Years) 63-50% 160 Use of 2 or More Benzodiazepines for 45 or More Days (Under 18 Years) 10-100% 167 Use of 2 or More Tricyclic Antidepressants for 60 or more days (Under 18 Years) 10-100% 169 Use of 2 or More Insomnia Agents for 60 or More Days (Under 18 Years) 110% Total (may include duplicate patients)461141-69%

15 Impact analysis shows $6.77 million in behavioral pharmacy cost avoidance for the 23,371 child patients continuously eligible since February 2010 who were subjects of a BPM mailing. This is an average of $124.42 per intervened patient per month. The patients were followed for an average of 17.5 months post- mailing. The Quality Indicators™ and analytic methods presented in this document are confidential and proprietary trade secrets of Care Management Technologies (CMT). This document and its contents may not be used, disclosed, or redisclosed except with the written agreement from CMT. Child BPM Program

16 Outlier Pattern 2006-2009 Kids Percentage of Patients 7/09-9/099/09-11/09 Total Antipsychotics25.7%22.5% 2 Antipsychotics2.5%2.7% Hi Dose Antipsychotic1.8%2.0% Antipsychotics < 4 y o1.3%1.4% 5 or more1.8%1.6%

17 Outlier Pattern 2006-2009 Adult Percentage of Patients 7/09-9/099/09-11/09 Total All Antipsychotics25.7%23.5% 2 Antipsychotics5.9% 3 Antipsychotics0.37%0.38% Hi Dose Antipsychotic2.0%2.6% 2 Benzodiazepines3.1%

18 Use of Antipsychotics in Medicaid Children- 16 States, 2004-2007 Highest rate of use in Kids under 18 yo Highest rate of use in Kids under 6 yo Above median use of multiple psychotropics Median rate of high dose antipsychotic use Median rate of multiple antipsychotic use Fewest Gaps in therapy for antipsychotics

19 The Quality Indicators™ and analytic methods presented in this document are confidential and proprietary trade secrets of Care Management Technologies (CMT). This document and its contents may not be used, disclosed, or redisclosed except with the written agreement from CMT. Child Antipsychotic Prevalence Program

20 Missouri Initiative for Children in Foster Care There are approximately 10,750 children in state custody at a given time Data pulled – Top diagnoses were Major Depression, Adjustment Disorder, Attention Deficit Hyperactivity Disorder, and Post Traumatic Stress Disorder 28% were on a psychotropic medication

21 Missouri Initiative Behavior Pharmacy Management Program 20% of children prescribed a medication triggered at least one quality indicator – 6.65% were prescribed 5 or more psychotropics – 3.03% were prescribed two or more antipsychotics – 6.05% had multiple prescribers for 45 or more days

22 Past and Current Initiatives 2009 - 2011 – Provided Integrated Summary of Care to Foster Care Case Managers with pharmacy recommendations – Foster Care Case Managers did not feel qualified to question prescribers regarding recommendations. Currently – For all children under 5 years old – PA all psychiatric meds – Case review by child psychiatrist

23 Next Missouri Initiative Current focus has been on the development of a second opinion review process – Initially addressing children on more than 5 psychotropics – Plans to address use of multiple antipsychotics as well – Identification of prescriber with outlier prescriptions

24 Missouri Initiative Review of records by Board Certified Child/Adolescent Psychiatrist Via teleconference Reviewer discusses best practices for prescribing of patients Prescriber continues to be monitored to assess for change in prescribing

25 Missouri Initiative Strategies Under Consideration – Data monitoring/system development – Clinical edits Medication Therapies – Access to Clinical Consultation – Functional Outcomes

26 c c WebNeuro Online Standardized Assessment 1) 45 Questions assessing anxiety, depression, and stress 2) 13 Standardized Cognitive Tests 3) Standardized scoring for risk, resilience, and social skills 4) Decision support for diagnosis and treatment 5) 40 minutes to complete, three minutes to receive report

27 Integrative Neuroscience Assessment [home computer] Questions [Feeling and Self Regulation] (<5 min) Objective Cognitive Tasks [Emotion and Thinking] (30 min) Motor Tapping Switching of Attention Digit Span Maze Memory Recognition Choice Reaction Time Continuous Performance Test Verbal Interference Emotion Recognition Go/No-Go Delayed Memory Recognition Emotion Identification “I Find it difficult to relax” “I respond best to positive feedback” English, Hebrew, Mandarin, Arabic, Spanish, Dutch, French, German

28 c c WebNeuro Report: Patient’s Sores Scores range from 0-10, with 10 being better Red shading = clinically significant problem (score of 1) Orange shading = problem of borderline significance (1.5 to 3) Gray shading = healthy average range (3.5 to 7.5) Green shading = above average/superior (8 to 10)

29 Example Reporting of Cognitive Capacities Reporting averages scores from tests commonly used to assess specific cognitive and emotional capacities into a psychological-level score. In example above, Negativity Bias in assessment of negative outlook on world and a validated marker for disorder risk.

30 Cognitive Reporting: Cognition & Thinking Objective assessment & reporting of emotional and cognitive processes

31 Supporting Treatment

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