Missouri’s Primary Care and CMHC Health Home Initiative Samar Muzaffar, MD MPH Missouri Department of Social Services MO HealthNet Division Medical Director

Overview Two Medicaid Health Home initiatives- primary care and mental health Partnership between MO HealthNet and Department of Mental Health Collaboration with Missouri Primary Care Association (MPCA), Missouri Hospital Association (MHA), Missouri Coalition of Community and Mental Health Centers Multipayer Initiative coordinated by Missouri Foundation for Health (MFH) One Learning Collaborative for all participants Collaboration between MFH, Health Care Foundation of Greater Kansas City, MPCA, and MHA

Overview Missouri is the first state to have both mental health and primary care CMS approved State Plan Amendments A unique aspect of the program is the integration of behavioral health with primary care and vice versa in its structure. Literature speaks to the centrality of appropriately and effectively managing behavioral health conditions in the management of physical health conditions By implementing the health home program we hope to demonstrate Reduced inappropriate ED utilization Reduced avoidable in-patient utilization Improved patient outcomes Reduction in health care costs

Overview Key Health Home Services for MO: Comprehensive Care Management Care Coordination Health Promotion Comprehensive Transitional Care Individual and Family Support Services Referral to Community and Social Support Services

Missouri’s Health Homes Primary Care Health Homes (24) 19 Federally Qualified Health Centers (FQHCs) 5 Public and Private Hospitals Includes 14 Rural Health Clinics ~18,800 patients enrolled in October CMHC Healthcare Homes (29)

Primary Care Target Population Clients are eligible for a Primary Care health home as a result of having two chronic conditions; or having one chronic condition and being at risk for a second chronic condition. To be eligible patients must meet one of the following criteria Have Diabetes At risk for cardiovascular disease and a BMI>25 Have two of the following conditions COPD/Asthma Cardiovascular disease BMI>25 Developmental Disability Use Tobacco At risk for COPD/asthma and cardiovascular disease

Primary Care Health Homes Provide primary care services, including screening for, and “comprehensive management” of, behavioral health issues Ensure access to, and coordinate care across, prevention, primary care, and specialty medical care, including specialty mental health services Promote healthy lifestyles and support individuals in managing their chronic health conditions Monitor critical health indicators Divert inappropriate ER visits Coordinate hospitalizations, including psychiatric hospitalizations, by participating in discharge planning and follow up

Initial Provider Qualifications Utilize interoperable registry Input annual metabolic screening results Track/measure care Automate care reminders Produce exception reports MOU with regional hospital or system within 3 months health home service implementation

Initial Provider Qualifications Meet state’s minimum access requirement including enhanced access requirement Have a formal and regular process for patient input Have completed EMR implementation/use EMR for at least 6 months prior to beginning health home services Actively use MHD EHR for care coordination & Rx monitoring

Initial Provider Qualifications Substantial percentage of patients enrolled in Medicaid (> 25%) Special consideration to those with considerable volume of needy individuals Strong, engaged, committed leadership Meet state requirements for patient empanelment

Primary Care Health Home Basics Practice site physician or nurse practitioner-led Health Team Primary care physician or nurse practitioner Behavioral health consultant Nurse care manager Care Coordinator Others per practice

Health Home Team Members Health Home Director 1:2500 Nurse Care Manager 1:250 Behavioral Health Consultant 1:750 Care Coordinator 1:750

Health Home Team Members Staffing ratio development PMPM development Team member roles and training

CMHC Health Homes 29 CMHC Health Homes 17,882 individuals auto-enrolled 3203 children and youth (18%) CMHC consumers with at least $10,000 Medicaid costs ~18,300 enrolled in October

CMHC Health Homes Target Population Clients eligible for a CMHC health home must meet one of the following three conditions A serious and persistent mental illness or serious emotional disorder A mental health condition and substance use disorder A mental health condition and/or substance use disorder and one other chronic health condition

CMHC Health Homes Target Population Chronic health conditions include: Diabetes Cardiovascular disease Chronic obstructive pulmonary disease (COPD) Asthma Chronic bronchitis Emphysema Overweight (BMI >25) Tobacco use Developmental disability

CMHC Health Homes Provide psychiatric rehabilitation, including screening, evaluation, crisis intervention, medication management, psycho-social rehabilitation, and community support services Embody a recovery philosophy that respects and promotes independence and responsibility Complete a comprehensive health assessment Monitor critical health indicators

CMHC Health Home Assure access to, and coordinate care across prevention, primary care (including assuring consumers have a PCP) and specialty medical services. Promote healthy lifestyles and support individuals in the self-management of chronic health conditions Coordinate/monitor ER visits and hospitalizations, including participating in discharge planning and follow up

CMHC Health Homes Health Home Director 1 per 500 enrollees Nurse Care Manager 1 per 250 enrollees Primary Care Physician Consultant 1 hr/enrollee Care Coordinator/Clerical 1 per 500 enrollees

CMHC Health Homes HCH Team Members Health Care Home Director Primary Care Consulting Physician Nurse Care Managers (NCM) HCH Clerical Support Staff Community Support Specialists (CSS) Psychiatrist QMHP, PSR and other Clinical Staff Peer Specialists Family Support Specialists

Integration of Behavioral Health and Primary Care The two health home programs coordinate behavioral health and primary care health needs: PCHH’s coordinate primary care and behavioral health needs through the embedded behavioral health consultant CMHC HH’s coordinate primary care and behavioral health through the embedded primary care physician consultant and the nurse care manager Much of the effort, education, learning, and work, including The Learning Collaborative, has been around how to successfully integrate and coordinate the primary care and behavioral health

Questions? Missouri Health Home Website information: http://dss.mo.gov/mhd/cs/health-homes/ http://dmh.mo.gov/about/chiefclinicalofficer/healthcarehome.htm