Health Integration Project: Emergency Department Navigation Presented by Robin Henderson, PsyD Interim Executive Director, Central Oregon Health Council St Charles Health System September 24, 2012 Presented at WSHA Safe Table – ER is for Emergencies 1

Why Transform? Unsustainable: Health care costs are increasingly unaffordable to individuals, businesses, the state and local governments Inefficient healthcare systems bring unnecessary costs to taxpayers When budgets are cut, services are slashed Dollars from education, children’s services, public safety 2014: as many as 200,000 Oregonians will be added to OHP 2 2 Presented at WSHA Safe Table – ER is for Emergencies

Game is rigged We haven’t been doing anything to solve the problem of rising costs because we were dealing with 10% of the pie 3 3 Presented at WSHA Safe Table – ER is for Emergencies

Oregon’s Health Care Reform During 2011 and 2012 legislative session Governor Kitzhaber and bi-partisan lawmakers passed landmark legislation for healthcare reform 200 people met in Governor appointed work groups to help create the framework for CCOs More than 1,200 Oregonians provided input through eight community meetings that were held around the state 4 Presented at WSHA Safe Table – ER is for Emergencies

The road to health care reform SB 1580 became law in 2012, laying the foundation for CCO development with aggressive timelines $1.9 billion in Federal funds over 5 years to support healthcare transformation efforts Agreement with federal government to reduce projected state and federal Medicaid spending by $11 billion over 10 years Oregon will lower the cost curve by two percent over the next two years Presented at WSHA Safe Table – ER is for Emergencies 5

CCO Definition 6 Presented at WSHA Safe Table – ER is for Emergencies

Vision of Coordinated Care Local accountability for health and resource allocation Standards for safe and effective care Global budget indexed to sustainable growth Integration and coordination of benefits and services Improved outcomes Reduced costs Healthier population Redesigned delivery system 7 Presented at WSHA Safe Table – ER is for Emergencies

Oregon Health Plan 50% of babies born in Oregon 16% of Oregonians 85% of providers 11% percent of total state budget Fastest growing portion of state budget 8 Presented at WSHA Safe Table – ER is for Emergencies

Who is Impacted in Central Oregon ? 35,000 Medicaid (Oregon Health Plan) beneficiaries in Deschutes, Jefferson, Crook, and part of Northern Klamath and Lake counties, predicted to grow to 52,000 by miles north to south 200,000 residents, expected to grow to 250,000 by 2019 Approximately $120m coming into the community Oregon Health Plan (Medicaid) beneficiaries only, in 2012 Inclusion of additional State sponsored health benefits programs in the future (Public employees) Potential implications on non-Medicaid lines of business in Central Oregon 9 Presented at WSHA Safe Table – ER is for Emergencies

Improved Population Health Improved Consumer Satisfaction Shared Savings$ Resource Integration & Conservation Care Coordination Regional Health Policy &Planning Transforming Health in Central Oregon Transforming Health in Central Oregon 10 Presented at WSHA Safe Table – ER is for Emergencies

Central Oregon Health Council 11 Presented at WSHA Safe Table – ER is for Emergencies

VISION STRATEGY Resources INITIATIVES Care Coordination PCMH ED Diversion BHC’s PEDAL/NICU PCMH ED Diversion BHC’s PEDAL/NICU Regional Health Fiscal Integration Regional Health Improvement Plan Shared Savings $ Fiscal Integration Regional Health Improvement Plan Shared Savings $ Triple Aim CO Health Council CO Health Board Advisory Committee Coordinated Care Organization CO Health Council CO Health Board Advisory Committee Coordinated Care Organization Presented at WSHA Safe Table – ER is for Emergencies 12

Search for the low hanging fruit… …and make a pie Presented at WSHA Safe Table – ER is for Emergencies 13

Distribution of Non-MH Claims Paid Presented at WSHA Safe Table – ER is for Emergencies 14

Claims Distribution by Member 15 Presented at WSHA Safe Table ER is for Emergencies 15

Project focused on reducing non-emergent use of the Emergency Department in regional Emergency Department’s using Health Engagement Teams, Behavioral Health Consultants and Community Health Workers 274 Patients in the first cohort; over 600 identified participants to date 144 of these are actively identified needing intervention Patients removed from study due to Death Relocation (moved, jail, etc.) Data issues from the original pull Reduction of Non-Emergent ED Usage Presented at WSHA Safe Table – ER is for Emergencies 16

Thirteen or more emergency department visits/year Diagnostic cluster one or more of the following: Mental Health Diagnosis Chronic Pain Addiction Initial assumptions: Primarily Indigent: WRONG Lack of Primary Care Home: WRONG Primarily Chronic Mental Health: WRONG Who is This Population? Presented at WSHA Safe Table – ER is for Emergencies 17

Primarily Medicaid recipients Always enrolled in Primary Care Home Did not know who PCP was Kicked out of Primary Care Home due to missed appointments or other behavioral issues Rarely engaged with mental health services Complex social health issues Often clusters of familial or socially related individuals Eager to engage in care Who They Really Were? Presented at WSHA Safe Table – ER is for Emergencies 18

“Ashley” is a 34 year-old divorced mother of two enrolled in Medicaid and prescribed medication for an anxiety disorder and chronic pain due to a previous on the job injury. Meet Ashley. Presented at WSHA Safe Table – ER is for Emergencies 19

Ashley Attempts to Negotiate the Barriers of Her Primary Care Community. Ashley’s immediate needs are met: short-term pain and anxiety medication prescriptions She’s referred to Community Mental Health for her anxiety disorder but she’s not acute enough to qualify for county services Ashley doesn't have access to a primary care provider so she goes to the ER when she has health needs. Presented at WSHA Safe Table – ER is for Emergencies 20

Health Engagement Team Person HETPlanCHWPCPBHC Health Engagement Team includes ED physician, RN Care Manager, Social Worker, BHC and CHW Individualized community wide treatment plans are developed by the HET in consultation with the person, the provider and any specialty services Community Health Workers are usually the first contact with the person and meet with them to present the plan Contact is made with the primary care provider. If none exists, Pathway established to connect to a Person-Centered Primary Care Home. Behavioral Health Consultants are psychologists integrated in primary care clinics who specialize in brief interventional treatment. Presented at WSHA Safe Table – ER is for Emergencies 21

Primary Focus: the 90% Social Disparities of Health Poverty Food insufficiency Transportation Healthcare Navigators Walk alongside the patient Based in ER and in PCPCH Voluntary program Under Supervision of RN Care Coordinator or Behavioral Health Consultant Community Health Workers Presented at WSHA Safe Table – ER is for Emergencies 22

Psychologists work with medical providers in shared system Focus on behavioral interventions for medical conditions Always available for consultation and interventions with patients Primarily unscheduled Some targeted appointments One integrated treatment plan covers full spectrum of patient’s needs Shared medical record Behavioral Health Consultants Presented at WSHA Safe Table – ER is for Emergencies 23

Medically Unexplained Physical Symptoms Cyclical Vomiting Plan of Care Attached to ED Record Interventions Plan for Discharge Behavioral Health Plan Plan for care from Community Mental Health Children Elders Increased Provider satisfaction Primary Care Practitioners Presented at WSHA Safe Table – ER is for Emergencies 24

Medication Seeking Behaviors Regional Pain Contract Pain School to obtain medication Chronic Mental Health Conditions Alternative plan with Community Mental Health Illegal Behavior Seeking drugs for others Generational ED as Primary Care Urgent Care intervention Decline to Participate Presented at WSHA Safe Table – ER is for Emergencies 25

541 visits 541 visits Presented at WSHA Safe Table – ER is for Emergencies 26

Average Cost/Patient Medicaid and Medi/Medi Q1 Q vs 2011 Presented at WSHA Safe Table ER is for Emergencies 27

Emergency Department Visits Per Quarter Presented at WSHA Safe Table – ER is for Emergencies 28

Reduction in Emergency Department Costs (excluding ancillaries) Presented at WSHA Safe Table – ER is for Emergencies 29

Shared Savings 100 people $200,000 investment $325,000 RETURN Presented at WSHA Safe Table – ER is for Emergencies 30

ED Diversion: Cohort #2 Visits (205 patients) Presented at WSHA Safe Table – ER is for Emergencies 31

Cohort #1 (144 patients): Behavior is cyclical Outliers are normal and need different interventions Savings are difficult to quantify What constitutes a cohort? Cohort #2 (205 patients): Better initial intervention Cohort #3 (195 patients): Strategies for other hospitals within the region ED Diversion: Lessons Learned Presented at WSHA Safe Table – ER is for Emergencies 32

Complex Persons across the Lifespan Birth/Early Childhood Early Childhood/ Nurse Family Partnership NICU Clinic/ CaCoon RN PEDAL Clinic Early Childhood/ Nurse Family Partnership NICU Clinic/ CaCoon RN PEDAL Clinic Complex Care Strategies ED Navigation PCPCH Focus Complex Care Center Severely and Persistently Mentally Ill ED Navigation PCPCH Focus Complex Care Center Severely and Persistently Mentally Ill Aging and End of Life Long Term Care/Care Transitions Advanced Illness Management Long Term Care/Care Transitions Advanced Illness Management Community Wide Plan of Care HIT--Clara Health Engagement Team 33 Presented at WSHA Safe Table – ER is for Emergencies 33

Complex Care: the 12% of patients who are 72% of cost  Complex Care Center Development  Continuation of the Emergency Department Navigation Project  Develop and Implement Comprehensive Hospital Discharge Follow-up Program  Develop and Implement a Comprehensive Chronic Pain Program  Expansion/Integration of Integrated Care Management & Health Engagement Teams  Expand RN Care Coordination with High Utilizers and Physician Directed/At-Risk Patients Year One Strategic Initiatives* * Initiatives in dark teal are existing projects. Light blue are new/expanding. 34

Integration of Behavioral Health and Physical Health:  Psychopharmacology Utilization Initiative  Modification of OAR requirements to increase access to care  Expansion of Integrated Behavioral Health Consultants in Primary Care including Pediatrics Pediatrics: Largest Service Population  Program for the Evaluation of Development and Learning  Neonatal Intensive Care Unit Follow Up clinic  Expansion of Title V $$ to all Children with Special Healthcare Needs (enabling increased care coordination and support services) Year One Strategic Initiatives, Cont. Presented at WSHA Safe Table – ER is for Emergencies 35

Synergy and Systems: Global Strategies for the Community  Maintain Policy and Planning Objectives  One four-year Regional Health Improvement Plan  One ongoing Regional Community Health Needs Assessment  Healthy Communities Institute website  Timely information for care coordination, patient care and outcomes measurement with a pilot project goal  Expansion of Health Information Exchange  Database/Communication Solution for Social Health needs  Aligned Payment Reform  Global Budget Initiatives Year One Strategic Initiatives, Cont. Presented at WSHA Safe Table – ER is for Emergencies 36

Never doubt that a small group of thoughtful people can change the world. Indeed, it's the only thing that ever has.— Margaret Mead Presented at WSHA Safe Table – ER is for Emergencies 37

Central Oregon Health Council Presented at WSHA Safe Table – ER is for Emergencies 38