Transcript Document

DMH Net
Missouri’s CMHC Health Care
Home Project
Principles
• Physical healthcare is a core service for persons with
SMI
• MH systems have a primary responsibility to ensure:
 Access to preventive healthcare
 Management and integration of medical care
Missouri Health Home Initiatives
Missouri Medicaid state plan amendment
 CMHC healthcare home
– CMHCs and CMHC affiliates
 Primary care chronic conditions healthcare home
– FQHCs, RHCs, Physician practices
Missouri Foundation for Health Patient-Centered
Home Multi-payer Learning Collaborative
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DMH NET – Strategy
• Health technology is utilized to support the service
system.
• “Care Coordination” is best provided by a local
community-based provider.
• Community Support Workers who are most familiar with
the consumer provide care coordination at the local level.
• Nurse Liaisons working within each provider organization
provide system support.
• Statewide coordination and training support the network
of providers.
CMHC as Health Care Home
• Case management coordination and facilitation of
healthcare
• Medical disease management for persons with SMI
• Preventive healthcare screening and monitoring by MH
providers
• Integrated/consolidated CMHC/CHC Services
• Primary Care Nurse Managers Care
Recommendation – Medical Needs Have
Same Priority as MH Needs
• Obtaining a “medical home” – a primary care provider
responsible for overall coordination
• Medication adherence – just as important for non-MH
meds
• Assisting in scheduling and keeping medical care
appointments
Care Coordination
Integrates Healthcare Issues into CMHC
Care Mechanisms
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Include healthcare goals in treatment plan
Include healthy lifestyle goals in treatment plan
Identify client’s internal health care expert/champion
Develop health and wellness services
Provide nurse healthcare liaison – proven practice
Verify healthcare services are occurring by utilizing data
Provide Information to Other Healthcare
Providers
• HIPAA permits sharing information for coordination of
care
• Nationally consent not necessary
• Exceptions:
 HIV
 Substance abuse treatment – not abuse itself
 Stricter local laws
Clients Eligible for CMHC HH
A serious and persistent mental illness
 Adults with SMI (Schizophrenia, Bipolar Disorder, Major
Depression Recurrent)
 Youth with Severe Emotional Disturbance
Clients Eligible for CMHC HH
• A mental health condition and one other chronic health
condition (asthma, cardiovascular disease, diabetes,
substance abuse disorder, developmental disability,
chronic pain, or overweight BMI>25
Clients Eligible for CMHC HH
• A substance abuse condition and one other chronic
health condition (asthma, cardiovascular disease,
diabetes, mental illness, developmental disability,
chronic pain, or overweight BMI>25
Provider Infrastructure
Reimbursed by HH funding
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Physician led team
Primary care nurse
Health coaches
Clinical support staff
Pharmacy consultant
Primary care consultation
Information technology
Provider Infrastructure
NOT reimbursed by funding but by existing fee-for- service systems,
including DMH and Medicaid
 Community support worker
 Physician services
 Peer specialist
 Psychosocial rehabilitation
 Medication
 Primary care medical services
 Labs
Comprehensive Care
Management
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Identification and targeting of high-risk individuals
Monitoring of health status and adherence
Development of treatment guidelines
Individualized planning with the consumer
Recommendations
• Screen for general health with priority for high risk
conditions
• Offer prevention and intervention especially for
modifiable risk factors (obesity, abnormal glucose and
lipid levels, high blood pressure, smoking, alcohol and
drug use, etc.)
• Prescribers will screen, monitor and intervene for
medication risk factors related to treatment of SMI (e.g.
risk of metabolic syndrome with use of second generation
anti-psychotics)
• Treatment per practice guidelines: eg, heart disease,
diabetes, smoking cessation, use of novel anti-psychotics
ADA/APA/AACE/NAASO
Consensus on Antipsychotic Drugs and Obesity and
Diabetes: Monitoring Protocol*
Start
4 wks
8 wks
12 wk
qtrly
12 mos.
Personal/family Hx
X
Weight (BMI)
X
Waist circumference
X
Blood pressure
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Fasting glucose
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Fasting lipid profile
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*More frequent assessments may be warranted based on clinical status
Diabetes Care. 2004;27:596-601
5 yrs.
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Metabolic Syndrome Disease Registry
• Metabolic Syndrome
 Blood pressure
 Cholesterol
 Triglycerides
- weight
- height
- blood sugar
• Screening Required Annually since January 1
• Disease registry with results maintained on cyber
access
• Next step – utilize data to identify care gaps
DMHNET HEIDIS Indicators
• DM1: Use of inhaled corticosteroid medications by persons with a
history of COPD (chronic obstructive pulmonary disease) or Asthma.
• DM2: Use of ARB (angiotensin II receptor blockers) or ACEI
(angiotensin converting enzyme inhibitors) medications by persons
with a history of CHF (congestive heart failure).
• DM3: Use of beta-blocker medications by persons with a history of
CHF (congestive heart failure).
• DM4: Use of statin medications by persons with a history of CAD
(coronary artery disease).
• DM5: Use of H2A (histamine 2-receptor antagonists) or PPI (proton
pump inhibitors) medications for no more than 8 weeks by persons
with a history of GERD (gastro-esophageal reflux disease).
DMHNET HEIDIS Indicators
• DM6: Presence of a fasting lipid profile within the past 12
months for patients with CAD (coronary artery disease).
• DM7: Presence of a DRE (dilated retinal exam) within the
past 12 months for patients with diabetes mellitus.
• DM8: Presence of a urinary microalbumin test within the
past 12 months for patients with diabetes mellitus
• DM9: Presence of at least 2 hemoglobin A1C tests within
the past 12 months for patients with diabetes mellitus.
• DM10: Presence of a fasting lipid profile within past 12
months for patients with diabetes mellitus.
Initial Results
• Provide specific lists of CMHC clients with care gaps
as identified by HEIDIS indicators to CMHC primary
care nurse liaisons quarterly
• Provide HEIDIS indicator/disease state training on
standard of care to CMHC MH case managers
• First quarter focus on indicator one-asthma
substantially reduced percentage with care gap
 Range 22% - 62% reduction
 Median 45% reduction
Support Patient Wellness through Self
Management using Peer Specialists
• Implement a physical health/wellness approach that is consistent with
recovery principles, including supports for smoking cessation, good
nutrition, physical activity and healthy weight.
• Educate patient on implications of psychotropic drugs
• Teach/support wellness self-management skills
• Teach/support decision making skills using Direct Inform
• Use motivational interviewing techniques
• New psychosocial rehab focus
 Smoking cessation
 Enhancing Activity
 Obesity Reduction/Prevention
Care Coordination
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Coordinating with the patients, caregivers
and providers
Implementing plan of care with treatment
team
 Planning hospital discharge
 Scheduling
 Communicating with collaterals
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Mapping & Data Integration
Diagnosis
Membership
Integrated
Pharmacy
Claims
Medical
Claims
Reference
Data
7/7/2015
Drug
Data Repository
Office
Hospital
Laboratory
ER
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CyberAccessTM
Current Features
 Patient demographics
 Electronic Health Record
– Record of all participant prescriptions
– All procedures codes
– All diagnosis codes
 E prescribing
 Preferred Drug List support
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Access to preferred medication list
Precertification of medications via clinical algorithms
Implementation of step therapy
Prior authorization of medications)
 Medication possession ratio
 DirectCare Pro
 Disease Registry for CMHCs
7/7/2015
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CyberAccess - Log-In Screen
CyberAccess - EULA
CyberAccess - Home Page
CyberAccess - Demographics
CyberAccess – Paid Drug Claims
CyberAccess – Paid Drug Claims/MPR
An MPR between 80-100% will display in green text. An MPR between 60-79% will display in yellow text. An MPR of
less than 60% will display in red text. If an MPR does not exist for type of drug or the drug is not for
maintenance the column will display a dash.
CyberAccess – Medical Procedures
CyberAccess – Diagnosis Codes
Health Promotion
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Population-based (non-client, outpatient, and CPRC)
Patient self-management
Health education
Smoking prevention
Obesity reduction
Reversal of social determinates of health
Comprehensive Transitional Care
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Hospital admission follow-up
Hospital discharge follow-up
Development of intermediate care tools
Data and patient registry supported
Individual & Family Support
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Family education
Peer support and/or NAMI/MHA
Patient advisory and input processes
Direct inform
Direct InformTM
• Access to program provided benefits
 Program integrity notification of services provides (EOB
equivalent)
• Notification of wellness lapses
• Web portal participant health information
• MORx Compare (current)
7/7/2015
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DirectInform Screen Shot 1 MHD
7/7/2015
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Referral to Community and Social
Support Services
• CPRC teams will be well established for this
• Non-CPRC clients have not had as much support with
housing benefits, medical assistance programs, legal
services, employment, schools, etc.
• Local SB 40 Boards
• NAMI/MHA
OUTCOMES
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Avoidable hospital readmissions
Medication adherence
HEDIS indicators
Cost
Quality of life
Satisfaction
Experience of care
HEALTH IT
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Electronic health record
Move toward HIT meaningful use
Regional exchanges
Cyber-Access
Outcomes reporting
CMT data tools
Population Based
Payments for HH services will be paid
PMPM, not unit by unit
 Service needs will be identified by patient
health history and status
 Outcomes will be measured by groups of
clients (i.e., by organization, region,
medication used, co-morbid conditions)
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Practice Transformations
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Focus on overall health
More medically oriented team members
Open access scheduling
No-show/cancellation policies
Increased patient input processes
Significant increase in data reporting and outcomes
Treatment planning tools supported by treatment
guidelines
Implementation Training
System change training
 National consultants on health home, access to care,
and patient-centered medical home, using learning
collaborative approach
Program training
 State regulations and specific
state program
HH CORE TEAM training
Implementation Training
HH CORE TEAM training
 Primary care nurse
 Health coaches (will include specific medical supplemental
training)
 Physicians
A Typical Participant in This Overview
• A 47 year old male
• More than one major
targeted disease
• Likely has a major
cardiovascular diagnosis
and diabetes
• Likely has experienced a
major cardiac event
• A third have a major
behavior health comorbidity
• A generally motivated
cohort
7/7/2015
Continuously Enrolled 7/1/2007 - 6/30/2008
24,700
Disease
Number of
Individuals
Percentage
Asthma
CAD
CHF
COPD
Diabetes
GERD
Sickle Cell
Behavioral Disability
9,817
16,982
5,746
8,155
12,939
12,592
558
8,395
39.7%
68.8%
23.3%
33.0%
52.4%
51.0%
2.3%
34.0%
*Includes co-morbid conditions
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Missouri CCIP Diabetes Outcomes
Hemoglobin A1c Compliance
Percent Compliant
50%
47%
40%
30%
25%
26%
ENROLLED N=12,939
20%
12%
NON-ENROLLED N=33,631
10%
0%
HbA1c - one or more tests HbA1c - two or more tests
Clinical Measure
HbA1c testing provides an estimation of average blood glucose values in people with diabetes.
Enrollees in the CCIP program received substantially more HbA1c testing than those not enrolled.
7/7/2015
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Missouri CCIP Coronary Artery Disease
(CAD) Outcomes
Lipid Panel Compliance
Percent Compliant
50%
40%
40%
30%
Enrolled N=16,982
20%
20%
14%
10%
Non Enrolled N=29,088
7%
0%
Lipid Panel - one or more tests Lipid Panel - two or more tests
Clinical Measure
CCIP enrollees with coronary artery disease (CAD) received lipid (cholesterol) testing
at twice the rate of non-enrollees.
7/7/2015
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Trend Analysis of Total Costs
MO HealthNet Average Total Monthly Costs for CCIP Disease
Eligible Population
$1,600
$1,283 PMPM
$1,400
$1,200
$962 PMPM
$ PMPM
$1,000
$800
Actual
$600
CCIP Enrolled
$400
Eligible-Not Enrolled
Linear (Actual)
$200
$-
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Average Total Monthly Costs for CCIP-enrolled participants were below projection.
March 2008 demonstrates a $321 PMPM savings.
7/7/2015
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Trend Analysis of Emergency Room Utilization
ER Usage Rate per 1000
300
Projection
250
Achieved ER
reduction ~30%
Rate per 1000
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Identified, Not Enrolled
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ER visits decreased more substantially than projected representing another key cost driver for savings
7/7/2015
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Statewide Information
• Community Mental Health Centers have approved 10% of the
healthcare home plans of care in the State Medicaid program.
• More than 35,000 patient histories have been reviewed in
CyberAccess.
• More than 70% of patients have had a primary care visit
within a 12-month period, according to claims; sampled chart
review indicates a higher percentage (3 agency sample over
90%).
• Outcomes review of Missouri Psychiatric Rehabilitation
programs indicates substantial off-trend cost savings for the
overall healthcare cost after admission to the program.
Cost Savings achieved for clients in
CMHCs
Base Period (CY2006)
Expected Trend
$1,556
16.67%
Expected Trend with no Intervention
$1,815.81
Actual PMPM in Performance Period (FY2007)
$1,504.34
Gross PMPM Cost Savings
Lives
Gross Program Savings
Vendor Fees
Net Program Savings
$311.47
6,757
$25,254,928
$0
$25,254,928
NET PMPM Program Savings
$311.47
Net Program Savings/(Cost) as percentage of Expected PMPM
17.15%
OFF TREND COST SAVINGS FOR CMHC-CM
CLIENTS ELIGIBLE FOR CCIP
Category
pre CMHC-CM post CMHC-CM
Net Change
Percent Change
Pharmacy
$39,367,496
$30,154,143
($9,213,352)
-23.4%
General Hospital
$23,140,172
$21,546,466
($1,593,706)
-6.9%
Psych Rehab
$35,378,951
$37,467,731
$2,088,780
5.9%
$463,069
$144,434
($318,635)
-68.8%
$3,549,715
$4,324,452
$774,738
21.8%
$101,899,402
$93,637,226
($8,262,176)
-17.2%
Psychologist
Independent
Clinic
Overall
Total Healthcare Cost Trend
Pre-/Post CMHC Enrollment
Selection Criteria – 636 persons identified
 Newly enrolled in CMHC case management
 At least nine months of Medicaid claims in each of the
preceding two years and two years following CMHC enrollment
Methodology
 Calculate total monthly Medicaid costs PMPM 24 months pre
and post-enrollment
 month zero is 24 months prior to enrollment, month 24 is the
month of enrollment, month 48 is 24 months after enrollment
 Calculate linear regression trend lines
per month
Average Medicaid expenditures
Total HealthCare Utilization Per User Per Month Pre and
Post Community Mental Health Case Management
Months with case management initiated on month 24
CMHC DISEASE MANAGEMENT
• Clients were Medicaid enrolled with a CCIP
eligible medical diagnosis and a serious mental
illness enrolled in a CMHC, but may or may not
have been enrolled in CCIP.
• Clients received Psychiatric Rehabilitation
services if they were eligible for those services.
• Average Medicaid annual medical cost for the
clients was $18,672 per year.
WebSites
www.nasmhpd.org/medical_director.cfm
http://www.dmh.mo.gov/MHMPP/MHMPP.htm