1. Taking Care Of The Whole Person Bradley P. Gilbert, MD, MPP Chief Executive Officer, IEHP

2. Introduction Inland Empire Health Plan (IEHP) is a Joint Powers Agency formed by Riverside and San Bernardino County IEHP has been serving Members since September 1996 We currently serve over 1.13 million Members We are a not for profit entity with a public benefit mission: 2 Mission Statement To organize and improve the delivery of quality, accessible and wellness based healthcare service for our community.

3. Nomenclature Whole Person Care – Why would we do “partial” person care? Integrated Delivery Systems – Is disintegrated better somehow? Population Health – Are we not supposed to take care of the population we serve? 3 ??

4. Potential Factors Impacting Well being and Health Status Both important, not always linked Genetics – 30% – Depends on condition Depression 40% Hypertension 30% Diabetes Type 2 – 8-14% Early / Mid Childhood Influences – Parents… or not – Home environment – School – Trauma! Growing evidence of impact on well being and health status 4

5. Potential Factors... Cont. Social determinants – 15% contribution – Socio-economic status – race, ethnicity, culture – Education – Income – Employment – work hazards, stress – Housing – Food Lifestyle Behaviors – 40% contribution – Diet – Exercise – Smoking – Alcohol – Drugs – Risky other – Sex, hang gliding… 5

6. Healthcare Access is not the Primary Determinant of Health 6 Schroeder, NEJM 357; 1221-1228

7. What can “We” Impact? Genetics – new targeted therapies Early / Mid Childhood Influences – Behavioral Health Social Determinants – SES – cannot change race or ethnicity, but can be aware and address – Education – community resources – Employment – community resources, behavioral health – Housing – community resources – Food – community resources 7

8. What can “We” Impact? Cont. Lifestyle – Information – Behavioral Health – Substance Use Treatment – Medications – Coaching – Support Access to Healthcare – Coverage – ACA, SB75 (undocumented children) – Availability – tough one, IEHP NEF – Alternative Access – online MD, apps, tele-health, texting Ability to self manage – See above! 8

9. Then What Do We Do? Current delivery system fragmented Social Services / Community Resources limited in some areas Physical health “separated” from Behavioral Health and Substance Abuse Treatment – Different providers – Different payers – Data sharing difficult 9

10. Do Our Best To Integrate and Coordinate Start with Physical and Behavioral Health – Addresses many potential factors – Clear data on impact of BH on health status – early death, poor outcomes, increased utilization and cost – Seems like “low hanging fruit” Medi-Cal data demonstrates costs up to 40% higher – Cost for a given medical diagnosis if a behavioral health diagnosis is present 10

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12. How? Multidisciplinary Care Teams co-located and collaborating at point of care – MD/NP/PA – Psychiatrist / Psychologist / LCSW / LMFT – RN / LCSW care management – Care coordinators / Navigators / Peer Coaches – Medical Assistants Assessments – Health Risk Assessment – ADLs, health status, conditions, etc. – PHQ-9 (depression) – GAD-7 (anxiety) – Substance Use Assessment 12

13. How? Stratification – High Risk Care Plan – Multi-disciplinary – Focused – Monitored – Evaluated on a regular basis – Daily huddles with team Care Coordination – Across all domains – Navigation – Referrals to community resources with follow up Self Management – Education – Coaching – Support – Referral 13

14. 14 Progress toward Fully Integrated care system: 6 levels of collaboration and coordination* Coordinated care (off-site) Level 1: Minimal collaboration Patients are referred to a provider at another practice site, and providers have minimal communication. Level 2: Basic collaboration Providers at separate sites periodically communicate about shared patients. Co-located care (on-site) Level 3: Basic collaboration on-site Providers share the same facility but maintain separate cultures and develop separate treatment plans for patients. Level 4: Close collaboration on-site Providers share records and some system integration. Integrated care Level 5: Close collaboration approaching an integrated practice Providers develop and implement collaborative treatment planning for shared patients but not for other patients. Level 6: Full collaboration in a merged integrated practice for all patients Providers develop and implement collaborative treatment planning for all patients. * Source: Heath B., Wise Romero P., Reynolds K. (2013). A Standard Framework for Levels of Integrated Healthcare. Washington, D.C.: SAMHSA-HRSA Center for Integrated Health Solutions. http://www.integration.samhsa.gov/resource/ standard-framework-for- levels-of-integrated-healthcare.)

15. Can It Be Done Really? Yes! IEHP - $20 million investment over two years – Behavioral Health Integration Initiative – Really… Complex Care Management 34 Sites – Primary care clinics – county, FQHC’s – Specialty Care Clinics – Behavioral Health Clinics – Community Based Adult Services (old ADHC) – Assisted Living Sites – Pain Medicine Clinics 15

16. Can It Be Done Really? Cont. Jennifer Clancy Consulting – Multi-disciplinary Team – psychiatrists, LLSWs, Clinic manager, PCP (one double boarded) – Program Development – Coaching – Data / Metrics Structure IEHP – Internal infrastructure – Data analysis – dbMotion population health tool Sites – Staffing paid for by IEHP NP, LCSW, Care Managers, Data Staff – MOU’s – commitment to process and metrics UCSD – Formal evaluation 16

17. Outcomes Depression Scale Anxiety Scale Comprehensive Diabetes Care Blood Pressure Control BMI Pain Scale Member Satisfaction Provider Satisfaction ED Utilization Inpatient Utilization 17

18. Challenges Significant process and workflow changes needed for physician / clinic offices – Assessments – Care Plans – Accessing outside resources – Use of a team – Not just a medical/clinical issue! Thinking Population Health – Cannot just be focused / pay attention to the patient and their chief complaint that day – Use of data – Find the “non-users” of primary care – Address preventative needs, other clinical issues at visits Coordination across disparate and non-communicating systems – Use Health Plan resources – On site Care Management 18

19. Challenges cont. Data sharing issues – Legal interpretation challenges – Systems don’t talk to each other Resources limited – Housing – Other No organized ‘referral’ process 19

20. Conclusion Why is there even a debate about Whole Person Care or Integrating Care? Health Care delivery has the least overall impact on health status Obviously critical for secondary and tertiary care once an individual has chronic illness Mental health and substance use a significant contribution to outcomes and cost of individuals with chronic illness 20

21. Key Changes In System Assessment! If you don’t know about it you cannot address it – Care Plans / Care Coordination Comprehensive approach – all factors – May have to prioritize – eg. Integrating BH / SA first Sharing of data! – Privacy versus care Episodic Care vs Population Health – Systematic approach to group Investment – IEHP!! 21