ACHIEVEMENTS OF MISSOURI HEALTH HOMES How far we’ve come

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 June;49(6): 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 Apr 30;176(2-3):242-5

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, McEvoy JP et al. Schizophr Res. 2005;80:19-32.

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.

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

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

MH/SU costs in NY State’s Medicaid Program

Health Care Home Strategy  Case management coordination and facilitation of healthcare  Primary Care Nurse Care Managers  Disease management for persons with complex chronic medical conditions, SMI, or both  Behavioral Health management and behavior modification as related to chronic disease management for persons with Medical Illness  Preventive healthcare screening and monitoring by MH providers  Integrated Primary Care and Behavioral Healthcare

Health Home 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 Health Home provide system support.  Behavioral Health Consultants in each Primary Care Health Home  Statewide coordination and training support the network of Health Homes.

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

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

Anticipated Health Home Results  Improved patient outcomes and health status  Improved coordination of primary care and behavioral health  Reduced inappropriate ED utilization  Reduced avoidable inpatient utilization  Enhanced use of community resources and reduction in non- medically required residential stays  Reduction in health care costs

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  Diabetes (also as single condition)  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

Missouri’s Health Homes Providers – 18 FQHCs 67 Clinics – 6 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

 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

 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 patients to discuss health concerns and wellness and treatment goals  Consult with MH Community Support Specialists in CMHC’s about health of their clients  Coordinate care with external health care providers Healthcare Home Team Members Nurse Care Managers

 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 CMHC Healthcare Home Team Member Primary Care Physician Consultant

 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

 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 Planning for similar process in PCHH’s Healthcare Home Team Members Psychiatrists, QMHPs, PSR and CSWs

Principles  One Team  CMHC’s composed of pre-2012 CPRC staff plus NCM and PC Consultant  PCHH’s composed of new infrastructure and team members  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, mental health providers, community supports, etc

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

Comprehensive Care Management  Identification and targeting of high-risk individuals  Monitoring of health status and adherence  Identification and targeting care gaps  Individualized planning with the patient

Step 1 – Create Disease Registry  Get Historic Diagnosis from Admin Claims  Get Clinical Values from Metabolic Screening, clinical evaluation and management, care plans  Combine into EHR Disease Registry (Central Data Registry, PROACT)  Online Access available to all Providers

Step 2 – Identify Care Gaps and ACT!  Compare Combined Disease Registry Data to accepted Clinical Quality Indicators  Identify Care Gaps  Sort patients groups with care gaps into agency specific To-Do lists  Nurse care manager helps team decide who will act  Set up indicated visits and pass on info with request to treat

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

Chronic Disease and At Risk HCH Adults

Body Mass Index

PERFORMANCE PROGRESS A1c, LDL, and Blood Pressure

Good News Small Changes Make a Big Difference  Blood cholesterol  10%  = 30%  in CVD ( )  High blood pressure (> 140 SBP or 90 DBP)  ~ 6 mm Hg  = 16%  in CVD; 42%  in stroke  Diabetes (HbA1c > 7)  1% point  HbA1c = 21% dec in DM related deaths, 14% decrease in MI, 37% dec in microvascular complications Stratton, et al, BMJ 2000 Hennekens CH. Circulation 1998;97: Rich-Edwards JW, et al. N Engl J Med 1995;332: Bassuk SS, Manson JE. J Appl Physiol 2005;99:

Conclusions A1c Control  5222 individuals with two data points  About 7% had uncontrolled A1c levels  A 1 point reduction in A1c level has significant clinical benefits  All cohorts with elevated A1c levels showed at least a 1 point reduction  All cohorts with normal A1c levels increased by 0.1 point or less

Reduction in A1c Level

Diabetes ( 2232 Continuously Enrolled Adults)* * 30% of continuously enrolled adults

Conclusions LDL Control  8,282 individuals with two data points  About 45% had uncontrolled LDL levels  A 10% reduction in LDL levels has significant clinical benefits  All cohorts with elevated LDL levels showed more than a 10% reduction  All cohorts with normal LDL levels increased by 7 to 8 points but remained in the low 80’s

Reduction in LDL Level

Conclusions Blood Pressure Control  10,321 individuals with two data points  20%-24% had uncontrolled Blood Pressure levels  A 6 point drop in Systolic and Diastolic blood pressure has significant clinical benefits.  All cohorts with elevated Blood Pressure levels showed more than a 6 point drop in both systolic and diastolic pressure  In every cohort, on average, Systolic pressure dropped below 140, and Diastolic pressure dropped below 90  Systolic and Diastolic pressure increased by 1 to 5 points in cohorts with normal Blood Pressure levels, with Systolic pressure averaging in the low 120’s and Diastolic pressure averaging in the mid 70’s

Reduction in Blood Pressure

Hypertension and Cardiovascular Disease (Continuously Enrolled Adults) 269 Adults* as of June’ Adults* as of June ‘14 *38% of Adults *4% of Adults

BMI, Tobacco, and Complete Screens

Outcomes Medication Adherence CMHC Healthcare Homes

Outcomes Reducing Hospitalization Primary Care Health HomesCMHC Healthcare Homes

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

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 $ PMPM  Total Cost Reduction $22.3M

Hospitalizations based on Discharge Diagnosis 1.7% 14,504

ER Visits based on Discharge Diagnosis 42,854

Hospitalizations based on Discharge Diagnosis 1.7% 14,504

ER Visits based on Discharge Diagnosis 42,854

DM 3700 ENROLLED IN CMHC HEALTHCARE HOMES Progress Report

 old model  Client, family, or healthcare referral makes a call if the consumer seeks services, and they have to be evaluated for eligibility to receive services.  New Model  High cost, high risk outreach to selected consumers that the payer has selected for services. Analysis of Care Management Change in Business

old

NEW

Target Population  $20,000 minimum cost for previous 12 months or risk predicted to have high cost  A diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, or recurrent major depression  Not a consumer of public mental health system in previous 12 months  Excluded nursing home, developmental disability, hospice and renal failure over$50,000 per year  Average cost of group over $50,000 per year Analysis of Care Management

 Auto-enrolled January, 2012: 1,438  Continuous Enrollment  As of January, 2013: 1,101 (77%)  As of June, 2013: 941 (65%)  As of January, (51%)  Total enrolled as of January, 2014:1,975 DM 3700 Healthcare Home Enrollment

Chronic Disease

Diabetes Control

Asthma/COPD Control

Hypertension Control

Cardiovascular Disease Control

Obesity

Tobacco Use

 DM 3700 adults enrolled in HCH for at least 9 months: 2,237  Dual Eligibles  25%, or 552 DM 3700 HCH enrollees  Medicaid Savings: $10.1 million  Unable to determine cost to Medicare  Medicaid Only  75% or 1,685 DM 3700 HCH enrollees  Medicaid Savings: $ PMPM -$78.74 PMPM $ PMPM or $4.9 million  Medicaid Savings including non-DM 3700 HCH adults: $7.3 million Financial Impact

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 Note: States with stripes have both

What Makes it Possible?  A Relationship of Basic Trust between:  Department of Mental Health  Mo HealthNet  State Budget Office  MO Coalition of CMHCs  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  Lot’s of Training and Practice Coaching

WebSites   hcarehome.htm hcarehome.htm