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Behavioral Health Homes Plus
Matthew Hurford, M.D. | Melissa Michael, R.N. October 15, 2015 © 2015 Community Care Behavioral Health Organization
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Objectives Community Care overview
Describe the national landscape of physical and behavioral integration Share lessons learned from Behavioral Health Homes Plus initiative Quality improvement approaches from a nonprofit managed care organization © 2015 Community Care Behavioral Health Organization
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Community Care Behavioral health managed care company founded in 1996; part of UPMC and headquartered in Pittsburgh Federally tax exempt nonprofit 501(c)(3) Major focus is publicly-funded behavioral health care services; currently doing business in PA Licensed as a Risk-Assuming PPO in PA; NCQA- Accredited Quality Management Program Serving over 1.6 million individuals in 39 counties through a statewide network of over 1,800 providers © 2015 Community Care Behavioral Health Organization
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PA HealthChoices Regions Served
Pike Erie Crawford Mercer Venango Butler Armstrong Indiana Westmoreland Allegheny Greene Fayette Somerset Cambria Blair Delaware Clarion Forest Warren McKean Potter Cameron Elk Jefferson Clearfield Bedford Centre Clinton Fulton Franklin Adams Cumberland Perry Mifflin Snyder Union Lycoming Tioga Bradford Columbia Montour Northumberland Dauphin York Lancaster Chester Berks Lebanon Schuylkill Montgomery Philadelphia Juniata Sullivan Huntingdon Bucks Lehigh Northampton Carbon Monroe Luzerne Wyoming Lackawanna Susquehanna Wayne Lawrence Beaver Washington Southwest Region Southeast Region North Central Region: County Lehigh-Capital Region North Central Region: County North Central Region: County Northeast Region North Central Region: County North Central Region: State Community Care Office © 2014 Community Care Behavioral Health Organization
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Mission and Vision Improve the health and well-being of the community through the delivery of effective and accessible behavioral health services Improve the quality of services through a stakeholder partnership focused on outcomes Support high-quality service delivery through a nonprofit partnership with public agencies, experienced local providers, and involved members and families © 2015 Community Care Behavioral Health Organization
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Integrate Quality Improvement into Health Initiatives
© 2015 Community Care Behavioral Health Organization
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New Models of Care Delivery
New models of care delivery are important for behavioral health: World Health Organization ranks depression, alcohol, and tobacco use among the top causes of disability Individuals may be at higher risk for health conditions due to the psychiatric medications or other medications they are prescribed Individuals who have a serious mental illness (SMI) have a mortality rate that is higher than comparison groups – mostly due to medical conditions, such as cardiovascular disease or diabetes © 2015 Community Care Behavioral Health Organization
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The Need for Integrated Systems
68% of adults with mental health (MH) conditions also have medical conditions People with medical conditions: 58% of adult population People with MH conditions: 25% of adult population 68% of adults with mental health conditions have medical conditions 29% of adults with medical conditions have mental health conditions © 2015 Community Care Behavioral Health Organization
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Higher Medical Co-Morbidities
Medical Condition Risk Among Persons with SMI Diabetes 2-3x higher Cardiovascular disease HIV Higher, but varies Hepatitis 5-11x higher Chronic obstructive pulmonary disease (COPD) Higher © 2015 Community Care Behavioral Health Organization
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Key Points Increased morbidity & mortality associated with SMI
Largely due to preventable medical conditions: metabolic disorders, cardiovascular disease & high prevalence of modifiable risk factors (e.g., obesity, smoking) Some psychiatric medications contribute to risk Traumatic stress exposure can lead to both mental & medical illness Established monitoring & treatment guidelines to lower risk are underutilized in SMI populations Co-morbid substance abuse can increase burden of medical illness Social factors are key contributors to medical status © 2015 Community Care Behavioral Health Organization
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Behavioral Health Home Model
© 2015 Community Care Behavioral Health Organization
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Behavioral Health Home Plus
Designed to demonstrate the efficacy of care coordination of PH/BH services for individuals with SMI & co-occurring medical conditions Successful collaboration with Community Care and BH providers in PA over the past six years: Creating health homes in BH agencies Development of a wellness culture through wellness coaching training Case managers, certified peer specialists, and nurses as health navigators Web portal with wellness tools and resources © 2015 Community Care Behavioral Health Organization
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Community Care’s Approach
Enhance PH competencies in BH delivery system Use a collaborative model Ensure financial feasibility Outcomes oriented, data-informed Guided by mission and values Recovery Resilience Empowerment © 2015 Community Care Behavioral Health Organization
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Financing Strategy for BHH
Fee-for-service Pay for Participation (P4P) Provide an incentive for providers to report data and to participate in a collaborative quality improvement initiative (e.g., attendance at training) Initial payment, once letter of commitment is signed by provider (50% of total amount), then the remaining 50% once providers have completed the following implementation steps © 2015 Community Care Behavioral Health Organization
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Pay for Participation (P4P)
Agency develops leadership team who will participate in BHH planning and implementation Agency will hire/appoint a wellness nurse to serve as the Lead Health Navigator as the agency’s internal leader for Behavioral Health Home implementation Agency staff participating in BHH activities will have Web access to: Access patient level health info, wellness self-management tools Gather outcomes information about participants in BHHP Agency will support integration of wellness coaching into usual clinical activities Agency will establish collaborative relationships with PCP/medical specialty offices © 2015 Community Care Behavioral Health Organization
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Behavioral Health Home Model
Melissa Michael, RN Behavioral Health Home Model © 2015 Community Care Behavioral Health Organization
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Community Care BHHP Behavioral Health Home Plus (BHHP)
Initially developed by Community Care in 2009 with teams in the North Central region of PA Designed to integrate PH/BH services for individuals with SMI & co-occurring medical conditions © 2015 Community Care Behavioral Health Organization
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The BHHP Model Provide a person-centered system of care
Develop “virtual team” for each individual to coordinate physical, behavioral, and supportive services Use wellness coaching Develop person-centered plan with individual Enhanced PH competencies in BH team Promote health, wellness, recovery, use of personal medicine, and self-management © 2015 Community Care Behavioral Health Organization
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BH Home Key Components Wellness nurse Health navigators
Member registry and a Web portal Comprehensive care team Program tools for members and providers Placement of nurses in case management and other BH settings who focus on assessment and engagement of members with substantial health needs © 2015 Community Care Behavioral Health Organization
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Member Registry Information provided by Community Care to identify members who have both physical health and mental health needs Population identification Stratification Pharmacy and BH data Tier System (including: Medical Admissions, Emergency Department admissions, Behavioral admissions, Use of other high intensity BH services, Number of medications used in the prior six months, Number of physicians seen in the prior six months, Prescriptions in the past 90 days of medications for specific medical conditions ie: Diabetes, COPD, hypertension © 2015 Community Care Behavioral Health Organization
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Health Home Team Members
Member and their family Wellness nurse Health navigator Primary care provider Psychiatrists and mental health clinicians Community Care specialized care manager Health Plan special needs resource specialist © 2015 Community Care Behavioral Health Organization
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Health Home Team Members
Wellness coaching/health navigators Certified peer specialist Assists with engaging member and securing informed consent; if requested, accompanies member to appointments and coaches member to support his/her own advocacy within health care system Case manager Provides enhanced case management services accessing and coordinating both physical and behavioral health services © 2015 Community Care Behavioral Health Organization
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Health Home Team Members
Trained in wellness coaching in order to: Apply wellness principles and coaching techniques Assist individuals to identify strengths to achieve wellness goals Model wellness and recovery Advocate for unmet needs Accompany individual to community appointments if asked Provide peer support through stages of change Create environments that promote wellness and recovery practices © 2015 Community Care Behavioral Health Organization
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Health Home Team Members
Wellness nurse Provides clinical consultation/interface with PH and BH clinicians and member Identifies high-risk people in care Assures completion of wellness physical assessment Uses disease registry to monitor progress for each person participating Coordinates and collaborates with PCP and specialty medical providers Supervises wellness coach process by HN Wellness education for people in care, families and staff © 2015 Community Care Behavioral Health Organization
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WOOT (Used Every 6 Months)
© 2015 Community Care Behavioral Health Organization
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Health Home Team Members
Primary physical health provider (virtual team member) Provides physical health clinical services; has access to behavioral health team services and supports Ongoing reciprocal communications with all team members Primary behavioral health provider Provides accountability and lead responsibility for managing the health home team, ensuring access to both physical and behavioral health services, collecting data, and tracking outcomes Support of BHHP Understanding and learning about wellness coach approach Engagement and support of the person in care with wellness goals Support of collaboration and coordination with primary care provider including direct communication with PCP as needed © 2015 Community Care Behavioral Health Organization
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Health Home Team Members
Community Care specialized care manager A high risk care manager from community care that provides assistance to the health home regarding members strengths, care history and treatment plans. © 2015 Community Care Behavioral Health Organization
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Health Home Team Members
Health Plan special needs resource specialist High risk care manager from the physical health plan who assists with coordination for physical health needs Can provide members strengths, physical needs, past physical treatments, and medication lists. © 2015 Community Care Behavioral Health Organization
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Health Home Team Members
Member and their family Choose an area for self-management Develop new self-management strategies Set a SMART goal and create action plan Implement plan with intention of meeting goal Monitor how plan is working Adjust plan as needed © 2015 Community Care Behavioral Health Organization
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Tools for Members and Providers
Self-management toolkits: Diet and nutrition Physical activity Sleep Stress management Medical and behavioral care and recommended screenings (“know your numbers”) Smoking cessation Taking medications effectively © 2015 Community Care Behavioral Health Organization
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Other Components of BHHP
BHHPE learning collaborative Psychiatric provider physical health webinars DM,HTN,CVD,COPD, HIV/HEPATITIS C, preventative health, tobacco cessation, metabolic syndrome, stress & physical health Outcomes monitoring Case conferences to support best practice © 2015 Community Care Behavioral Health Organization
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Implementing the BHHP Engaging stakeholders Pay for Performance
Training: IHI learning collaborative implementation model Wellness coaching training Secure member portal training Self-management toolkits Physician(psychiatrist) training Quality Improvement Processes Sites are identified through a request for information (RFI) process. Sites are asked to clarify their history of focus on wellness and physical health and their level of proposed leadership and resources they are prepared to commit to the process. Pay for Participation (P4P) Provide an incentive for providers to report data or to participate in a collaborative quality improvement initiative (e.g., attendance at training) Paid for completing the following steps toward implementation Proposed initial payment, once letter of commitment is signed by provider (50% of total amount), then the remaining 50% once providers have completed the required implementation steps © 2015 Community Care Behavioral Health Organization
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Community Care’s Role Analyze and stratify the population
Standardize the model across behavioral health providers, including training and technical assistance Utilization and outcomes reporting Facilitate information exchange and provide notice of key events Provide specialized high-risk care management, including pharmacy management, with: Oversight/consultation of person centered planning Facilitation of data and information sharing with the health home team Agency develops leadership team who will participate in BHH planning and implementation Agency will hire/appoint a wellness nurse to serve as the Lead Health Navigator as the agency’s internal leader for BHH implementation Agency nurse and others participating in BHH activities will have web access Will use secure web portal to access patient level health info, wellness self-management tools, and other resources May also include use of web-based data entry to gather outcomes information about participants in BHHP Agency will support integration of wellness coaching into usual clinical activities Agency will establish collaborative relationships with PCP/medical specialty offices © 2015 Community Care Behavioral Health Organization
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The Learning Collaborative
Structured approach for change Adopt best practices in multiple settings Uses adult learning principles & techniques Time-limited learning process Shared learning and collaboration Developed by the Institute for Health Care Improvement (IHI) A Learning Collaborative is a group of organizations working together using a structured process to implement change and sustain it over time Each organization will establish a Quality Improvement Team (QIT) who will evaluate their progress by tracking process measures and outcomes © 2015 Community Care Behavioral Health Organization
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BHHPE LC Mission The mission of the LC is the primary purpose or focus of the quality improvement effort To implement behavioral health homes to improve the whole health and wellness of members with complex health conditions To increase engagement and activation of the person in their care To improve collaboration between PH/BH providers © 2015 Community Care Behavioral Health Organization
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Apply Skills Test Changes
Components of Our LC Training Manuals Learning Sessions Apply Skills Test Changes Action Periods Ongoing TA & Support Collaborative Meetings Share Progress Measure Outcomes Pre-Work phase: Includes orientation and organizing the structure and staffing in the provider to prepare for the start of the LC Learning sessions: Knowledge and practices are shared among provider teams Plan-Do-Study-Act (PDSA) cycles : Small tests of change implanted during Action Periods, or the time between Learning Sessions Measuring Progress: Provider teams collect data about their PDSAs and process and outcome aims, share that with the LC and faculty during monthly conference calls when collaborative learning and support occurs, and use that data to continue making improvements Providers tracked monthly process measures Number of individuals who developed a wellness goal/plan Strengths-based assessment targeted individuals’ values related to the goal and utilizes motivational engagement strategies/change talk Barriers and accountability plan are identified Key outcome of the wellness plan is the development of a SMART goal. A great deal of time was spent on training the development of the SMART goal to build success and momentum Number of individuals who used a self-management toolkit or other resource each month to assist in addressing their wellness goal The web portal has member tracking tools that they can use to measure progress with smoking cessation, sleep, and weight management © 2015 Community Care Behavioral Health Organization
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Quality Improvement Processes
Measure coordination of care with primary care providers Engagement of members in physical health and wellness programs who had not previously attended to those issues Documentation of decreased emergency department and acute medical service utilization Enhance medication adherence to specific medications for chronic medical illnesses © 2015 Community Care Behavioral Health Organization
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Initial Results: Positive Engagement
Strong engagement by members PH and wellness concerns become routine part of recovery plan Nurses and case managers partner to address PH concerns © 2015 Community Care Behavioral Health Organization
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Learning Collaborative Aims
Process Aim 1: Wellness By September 2015, 80% of all individuals presenting with complex needs will have completed the wellness planning tool Process Aim 2: Assessment By September 2015, 80% of all individuals presenting with complex needs will have completed a health assessment Outcome Aim: Involvement By September 2015, 80% of individuals engaged in BHHPE will report being highly involved (rated a 9 or 10) in working with their behavioral health service provider on physical health and wellness as measured by a 10-point involvement question © 2015 Community Care Behavioral Health Organization
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Wellness Process Aim Progress toward goal of 80% of individuals with complex needs completing the wellness planning tool © 2015 Community Care Behavioral Health Organization
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Assessment Process Aim
Progress toward goal of 80% of individuals with complex needs completing a health assessment © 2015 Community Care Behavioral Health Organization
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Involvement Outcome Aim
Progress toward goal of 80% of individuals reporting being highly involved in working with their behavioral health service provider on physical health and wellness © 2015 Community Care Behavioral Health Organization
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Lessons Learned: What Worked
BHHPE learning collaborative Psychiatric provider physical health webinars DM,HTN,CVD,COPD, HIV/HEPATITIS C, preventative health, tobacco cessation, metabolic syndrome, stress & physical health Use of disease registry Outcomes monitoring Case conferences to support best practice © 2015 Community Care Behavioral Health Organization
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Lessons Learned: Challenges
Implementing population management Ongoing psychiatrist/prescriber involvement Need for EMR (electronic medical records) Some provider not having computer access Staff turnover: need for additional wellness coach training Provider and member commitment to a new wellness culture © 2015 Community Care Behavioral Health Organization
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