1. Missouri’s CMHC Healthcare Homes

2. Agenda Why CMHC Health Homes? Missouri’s Health Homes Preliminary Outcomes and Cost Savings Lessons Learned and Changes Considered

3. Cardiovascular Disease Is Primary Cause of Death in Persons with Mental Illness *Average data from 1996-2000. Colton CW, Manderscheid RW. Prev Chronic Dis [serial online] 2006 Apr [date cited]. Lori Raney, M.D., Physician Institute, 6/12 Percentage of deaths

4. Disorder ↑ Odds of Obesity Depression1.2 - 1.8x 1,2 Bipolar Disorder1.5 – 2.3x 1,2 Schizophrenia3.5x 3 1. Simon GE et al Arch Gen Psychiatry. 2006 Jul;63(7):824-30. 2. Petry et al Psychosom Med. 2008 Apr;70(3):288-97 3. Coodin et al Can J Psychiatry 2001;46:549–55 Risk of Obesity Among Patients with SMI Joseph Parks, M.D., National Council, 4/14/12

5. Psychotropic Medications and Weight Gain Most antidepressants 1 Most mood stabilizers 2 Most antipsychotic medications 3 However there are alternative drugs within each class that are potentially weight-neutral Joseph Parks, M.D., National Council, 4/14/12 1. Rader et al J Clin Psychiatry. 2006 Dec;67(12):1974-82. 2. Kerry et al Acta Psychiatr Scand 1970: 46: 238-43. 3.Newcomer J Clin Psychiatry. 2007;68 Suppl 4:8-13.

6. 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. Joseph Parks, M.D., National Council, 4/14/12

7. Fatal or nonfatal MI (%) 3.5% 18.6% 20.2% 45.0% Equivalent MI Risk Levels No Prior MI Prior MI Non-diabetic SubjectsType 2 Diabetic Subjects (n = 1373)(n = 1059) Haffner SM et al. N Engl J Med. 1998;339:229-234. Diabetes is a CVD Risk Equivalent to Previous Myocardial Infarction Joseph Parks, M.D., National Council, 4/14/12

8. Mental Disorders and Smoking > Higher prevalence of cigarette smoking (56-88%) for SMI patients (overall US prevalence 25%). > More toxic exposure for patients who smoke (more cigarettes, larger portion consumed). > Smoking is associated with increased insulin resistance. > 44% of all cigarettes in US are smoked by persons with mental illness. Joseph Parks, M.D., National Council, 4/14/12 George TP et al. Nicotine and tobacco use in schizophrenia. In: Meyer JM, Nasrallah HA, eds. Medical Illness and Schizophrenia. American Psychiatric Publishing, Inc. 2003; Ziedonis D, Williams JM, Smelson D. Am J Med Sci. 2003(Oct);326(4):223-330

9. . Good News Small Changes Make a Big Difference Blood cholesterol o 10%  = 30%  in CVD High blood pressure o ~ 6 mm Hg  = 16%  in heart attack; o ~ 6 mm Hg  = 42%  in stroke Maintaining Normal Body Weight o 35%-55%  in CVD Stratton, et al, BMJ 2000;Hennekens CH. Circulation 1998;97:1095-1102.;Rich-Edwards JW, et al. N Engl J Med 1995;332:1758-1766;Bassuk SS, Manson JE. J Appl Physiol 2005;99:1193- 1204

10. Good News Small Changes Make a Big Difference Cigarette smoking cessation o ~ 50%  in CVD Maintaining an active lifestyle (30-min walk daily) o 35%-55%  in CVD Diabetes (HbA1c > 7) o 1% point  HbA1c = 21% decrease in Diabetes related death 14% decrease in heart attack, Stratton, et al, BMJ 2000;Hennekens CH. Circulation 1998;97:1095-1102.;Rich-Edwards JW, et al. N Engl J Med 1995;332:1758-1766;Bassuk SS, Manson JE. J Appl Physiol 2005;99:1193-1204

11. Missouri’s Health Homes

12. Partners in Planning o Medicaid and Mental Health o FQHC and CMHC Associations o Hospital Association o Health Foundations Two Types of Health Homes o Primary Care Health Homes o CMHC Healthcare Homes

13. A CMHCs and FQHCs effort to integrate primary and behavioral health care convinced us that o Collaboration, not integration, is critical to meeting the primary care needs of CMHC consumers o Embedding behavioral health consultants into primary care teams enhances primary care efficiency and effectiveness Because that is where people already “reside” Why Two Types of Health Home?

14. Missouri’s Health Homes Primary Care Health Homes CMHC Healthcare Homes Providers 18 FQHCs/5 Hospitals Enrollment: 15,954 Adults: 15,226 Children: 428 Providers 28 CMHCs Enrollment: 18,998 Adults: 16,611 Children: 2,387

15. Target Populations Primary Care Health HomesCMHC Healthcare Homes Patients with Diabetes o At risk for cardiovascular disease and a BMI > 25 Patients who have two of the following o COPD/Asthma o Cardiovascular Disease o Developmental Disabilities o Use Tobacco o BMI>25 Individuals with a serious mental illness Individuals with other behavioral health problems who also have o Diabetes o COPD/Asthma o Cardiovascular Disease o Developmental Disabilities o Use Tobacco o BMI>25

16. Chronic Conditions Primary Care HHCMHCs HCH

17. CMHC Healthcare Homes Context Missouri Population 5.98 million 25 Service Areas Medicaid Rehabilitation Option o 29 Providers o 34,000 consumers CMHCs serve as “Administrative Agents” for the Department of Mental Health

18. Medicaid Rehab Option Community Psychiatric Rehab (CPR) Teams o Team Caseloads: 125 o Master’s Level BH Clinician: 1 o BA Level Community Support Specialists (CSSs): 5 o Psychiatrist (serves multiple teams) o Psycho-social rehabilitation staff (serve multiple teams)

19. The CPR program fulfills many Health Home functions, though focused on psychiatric disorders: o Identifies and targets high-risk individuals o Monitors health status and adherence o Individualizes planning, and services and supports o A recovery model based on respect o Coordinates with the patients, caregivers and providers o Implements plan of care using a team approach o Promotes consumer self-management of the psychiatric disorder o Links consumers to community and social supports o Arranges psychiatric hospital admission and follows up on discharge Medicaid Rehab Option

20. “whole person” Because healthcare homes take a “whole person” approach, we’ll continue and expand our emphasis on: o Providing health and wellness education and opportunities o Assuring consumers receive the preventive and primary care they need o Assuring consumers with chronic physical health conditions receive the medical care they need and assisting them in managing their chronic illnesses and accessing needed community and social supports HH Functions: Added Emphasis

21. “whole person” Because healthcare homes take a “whole person” approach, we’ll continue and expand our emphasis on: o Facilitating general hospital admissions and discharges related to general medical conditions in addition to mental health issues o Using health technology to assist in managing health care o Providing or arranging appropriate education and supports for families related to consumers’ general medical and chronic physical health conditions HH Functions: Added Emphasis

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

23. Health Home Reimbursement: PMPM PMPM: $80.31 ( Year 1 = $78.74) o Health Home Director o Primary Care Physician Consultant o Nurse Care Manager (1:250) o Care Coordinator/Clerical Support o Data monitoring and reporting o Training

24. HCH Team Members Primary Care Physician Consultant Establishes priorities for disease management and improving health status. Participates in case consultation with psychiatrist, QMHP, nurse care managers, and community support specialists Helps educate community support specialists, case managers, and clinical staff on the nature, course, and treatment of chronic diseases Develops collaborative relationships with treating PCPs and Psychiatrists, as well as other healthcare professionals and facilities

25. HCH Team Members Nurse Care Managers Champion healthy lifestyles, preventive care and managing chronic diseases Assigned to two CPR Teams Provide individual care for consumers on their caseload o Review client records and patient history o Participate in annual treatment planning including Reviewing and signing off on health assessments Conducting face-to-face interviews with consumers to discuss health concerns and wellness and treatment goals o Consult with CSS’s about identified health conditions of their clients o Coordinate care with external health care providers o Document individual client care and coordination in client records o Average caseload: 233

26. CMHC Healthcare Homes Comprehensive Care Management Health Screening Accessing Primary Care Hospital Admission & Discharge Continuous Team-based Care Wellness and Healthy Lifestyles Population Management – Statewide Registry

27. CMHC Healthcare Homes Care Management Tools Metabolic Screening Disease Management Reports Medication Adherence Reports Behavioral Pharmacy Management Reports Hospital Admission E-mails

28. Preliminary Outcomes and Cost Savings

29. Preliminary Health Home Outcomes Reduction in Hospitalization Individuals enrolled in health home at least 2 months

30. Lessons Learned and Changes Considered

31. Commitment to Training Organizational Commitment: Why is this important? Team Training: What is a “health home”? Chronic Diseases and Risk Factors Accessing and Using Data Acquiring New Skills o Motivational Interviewing o Health Coaching

33. Data Complexities and Problems Medicaid Claims Data o Includes erroneous diagnoses o Only Medicaid paid claims Metabolic Screening o Excel, Access, and ProAct™ o From Tests to Values o A “Complete” Screen Reports o Quarterly to Monthly o Positive, Negative and Unknown

34. Evaluation Complexity and Problems Delays: Paid Claims Run Out Complexity of Systems o Multiple Provider Codes o Multiple Service Codes o Multiple Beneficiary Codes o Required vs. Optional Input Complexity of Assumptions o Cohorts o Periods and Times One Year Is Not Enough!

35. Changes? NCM Caseload Size Administration Levels of Care Practice Coaches PMPM Adjustments

36. What About Children and Youth? Unique Characteristics o Less often at the CMHC o Families vs. Individuals o Multiple Case Managers o Prevention and Risk Factors vs. Chronic Disease Changes? o Nurse Care Managers o Family Engagement and Focus o Case Load Size o Trauma Informed Care

37. Questions?