Transcript Achievements of Missouri CMHC Health Homes

ACHIEVEMENTS OF
MISSOURI CMHC HEALTH
HOMES
How far we’ve come
My Background
•
•
Medicaid Director
Previously DMH Medical Director – 20 years
Practicing Psychiatrist
CMHCs – 10 years
FQHC – 18 years
•
Distinguished Professor, Missouri Institute of Mental
Health, University of Missouri St. Louis
Life Expectancy
80
75
70
65
60
55
50
45
40
No Mental Disorder
Any Mental Disorder General
Population
Any Mental Disorder Public
Sector
Bar 1 & 2: Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. Understanding excess mortality in persons with mental illness: 17-year
follow up of a nationally representative US survey. Med Care. 2011 June;49(6):599-604
Bar 3; Daumit GL, Anthony CB, Ford DE, Fahey M, Skinner EA, Lehman AF, Hwang W, Steinwachs DM. Pattern of mortality
in a sample of Maryland residents with severe mental illness. Psychiatry Res. 2010 Apr 30;176(2-3):242-5
Change in US General Population AgeAdjusted Mortality (1979-1995)
Morbidity and Mortality Weekly Report. 1999; 48(30):649-656.
Mortality Risk From All Causes and From Cardiovascular Disease
Increased Among Patients With Schizophrenia Between 19702003
Comparison of Metabolic Syndrome Prevalence in
Fasting CATIE Subjects and Matched NHANES III Subjects
Males
CATIE NHANES
N=509
N=509
p
Females
CATIE NHANES
N=180 N=180
p
Metabolic Syndrome
Prevalence
36.0%
19.7%
.0001
51.6%
25.1%
.0001
Waist Circumference Criterion
35.5%
24.8%
.0001
76.3%
57.0%
.0001
Triglyceride Criterion
50.7%
32.1%
.0001
42.3%
19.6%
.0001
HDL Criterion
48.9%
31.9%
.0001
63.3%
36.3%
.0001
BP Criterion
47.2%
31.1%
.0001
46.9%
26.8%
.0001
Glucose Criterion
14.1%
14.2%
.9635
21.7%
11.2%
.0075
Meyer et al., Presented at APA annual meeting, May 21-26, 2005.
McEvoy JP et al. Schizophr Res. 2005;80:19-32.
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.
Causes of Excess Mortality
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Smoking
Obesity
Inactivity
Polypharmacy
Under Diagnosis of Medical Conditions
Inadequate Treatment of Medical Conditions
Maine Study Results: Comparison of Health
Disorders Between SMI & Non-SMI Groups
Percent Members
80
60
40
20
0
SMI (N=9224)
Non-SMI (N=7352)
59.4
33.9
30 28.6 28.4
22.8 21.7
16.5
11.5 11.1
6.3
5.9
Per Member Per Month Costs
$1,600
$1,400
$1,200
$1,000
$800
No Mental Disorder
$600
Any Mental Disorder
$400
$200
$0
Private Sector
Medicare
Medicaid
Melek et al Milliman
Inc, 2013
MH/SA costs in NY State’s Medicaid Program
$30,000
$28,000
$26,000
$24,000
$22,000
$20,000
$18,000
$16,000
$14,000
$12,000
$10,000
Behavioral Health costs
Physical Helath costs
MH Disorder
SU Disorder
No MH/SU
Disorder
Why CMHC Healthcare Homes?
Because addressing behavioral health needs
requires addressing other healthcare issues
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Individuals with SMI, on average, die 25 years earlier than the
general population.
60% of premature deaths in persons with schizophrenia are
due to medical conditions such as cardiovascular, pulmonary
and infectious diseases.
Second generation anti-psychotic medications are highly
associated with weight gain, diabetes, dyslipidemia (abnormal
cholesterol) and metabolic syndrome.
Our Mission
Recovery for
Persons with SMI
Our Problem
Early Death from
Physical Illness
Prevents Recovery
from SMI
CMHC as Health Care Home
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Case management coordination and facilitation of healthcare

Primary Care Nurse Care Managers
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Medical disease management for persons with SMI
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Preventive healthcare screening and monitoring by MH
providers
Integrated/consolidated CMHC/CHC Services
CMHC-HH Strategy
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Health technology is utilized to support the service system.

“Care Coordination” is best provided by a local communitybased provider.

MH Community Support Workers who are most familiar with the
consumer provide care coordination at the local level.

Primary Care Nurse Care Managers working within each CMHC
provide system support.

Statewide coordination and training support the network of
CMHC Health Homes.
Medical Needs Have Same Priority as MH
Needs


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Obtaining a “medical home” – a primary care provider
responsible for overall coordination
Medication adherence – just as important for non-MH
Assisting in scheduling and keeping medical care
appointments
meds
What is a CMHC Healthcare Home?

Not just a Medicaid Benefit

Not just a Program or a Team

A System and Organizational
Transformation
What is Different about Health Homes?
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Individual Practitioner
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Episodic Care
•
Focus on Presenting Problem
•
Referral to meet other Needs
•
Managed Care
–
–
Manages access to care
Does not change clinical
practice
Treatment as Usual
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Integrated Primary/Behavioral Health
Care Team
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Continuous Care
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Comprehensive Care Management
–
–
–
–
Coordinates care across the healthcare
system
Data driven population management
Transforms clinical practice
Emphasizes healthy lifestyles and selfmanagement of chronic health
problems
Health Homes
Practice Transformation
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Planned Care
Data Driven Care
Team Care
Integration of Behavioral and Primary Care
Addressing Social Determinates of Health
Principles
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One Team composed of pre-2012 CPRC staff plus
NCM and PC Consultant
One Treatment Plan for the Whole Person
 Rehab
Goals
 Medical Goals
 Healthy Lifestyle Goals
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
Some Goals and Outcomes reference Health Home
Performance Measures
Wrap –Around approach to outside treating PCP
Health Home
Target Populations

Patients with Diabetes
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At risk for cardiovascular disease
and a BMI > 25
Patients who have two of
the following
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
COPD/Asthma
Cardiovascular Disease
BMI>25
Developmental Disabilities
Use Tobacco
Primary Care Health Homes
Individuals with a serious
mental illness; or with other
behavioral health problems
who also have

Diabetes
COPD/Asthma
Cardiovascular
Disease
BMI>25
Developmental
Use
Disabilities
Tobacco
CMHC Healthcare Homes
Missouri’s Health Homes
•
Providers
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18 FQHCs
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67 Clinics
•
–
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120 Clinics/Outreach
Offices
22 Clinics
14 Rural Health Clinics
Enrollment
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Providers
– 28 CMHCs
•
5 Hospitals
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•
•
15,526 adults
428 children
15,954 total
Primary Care Health Homes
•
Enrollment
– 16,611 adults
– 2,387 children
– 18,998 total
CMHC Healthcare Homes
Healthcare Home Team Members
Nurse Care Managers
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Champion healthy lifestyles and preventive care
Provide Population Based Care Management
Provide Individual Care Management
Initially review client records and patient history
 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
 Consult with CSS’s about health of their clients
 Coordinate care with external health care providers

Healthcare Home Team Members
Healthcare Home Director
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Champions Healthcare Home practice
transformation
Oversees the daily operation of the HCH
Tracks enrollment, declines, discharges, and
transfers
May serve as a NCM on a part-time basis



HCHs must have at least a half-time HCH Director
Coordinates management of HIT tools
Develops MOUs with hospitals and coordinates
hospital admissions and discharges with NCMs
Healthcare Home Team Members
Primary Care Physician Consultant

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Assures that HCH enrollees receive care consistent with
appropriate medical standards
Consults with HCH enrollees’ psychiatrists regarding health and
wellness

Consults with NCM and CPR team regarding specific health
concerns of individual HCH enrollees
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Assists with coordination of care with community and hospital
medical provider
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Consults regarding selection of patients and conditions to target for
current attention
Primary Care Healthcare Home Team Member
Behavioral Health Consultant
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Assures that HCH enrollees receive care for MH, Substance Abuse and
Behavioral problems related to chronic Medical conditions

Assists with behavior modification to achieve improved patient
participation, adherence, and compliance with management of complex
chronic conditions
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Consults with HCH enrollees’ PCP, NCM, and HH team regarding specific
behavioral health concerns of individual HCH enrollees

Assists with coordination of care with outside behavioral health providers

Consults regarding selection of patients and conditions to target for
current attention
Healthcare Home Team Members
Psychiatrists, QMHPs, PSR and CSWs
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
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Continue to fulfill current responsibilities
Collaborate with Nurse Care Managers in
providing individualized services and supports
CSWs are trained as health coaches who
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Champion healthy lifestyle changes and preventive care
efforts, including helping consumers develop wellness
related treatment plan goals
Support consumers in managing chronic health
conditions
Assist consumers in accessing primary care
Six CMS Required Health Home
Functions
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Care Management
Care Coordination
Managing Transitions of Care
Health Promotion
Individual and Family Support
Referral to Community Services
Comprehensive Care Management

Identification and targeting of high-risk individuals
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Monitoring of health status and adherence

Development of treatment guidelines
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Individualized planning with the consumer
Step 1 – Create Disease Registry
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Get Historic Diagnosis from Admin Claims
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Get Clinical Values from Metabolic Screening
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Combine into EHR Disease Registry
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Online Access available to all Providers
Step 2 – Identify Care Gaps and ACT!
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Compare Combined Disease Registry Data to accepted
Clinical Quality Indicators
Identify Care Gaps
Sort patients with care gaps into agency specific To-Do
lists
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Send to CMHC nurse care manager
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Set up PCP visit and pass on info with request to treat
Disease Management Report: Patient Data
Disease Management Report: Agency Stats
Medication Adherence Reports
•
7 Drug Classes:
o
o
o
o
o
o
o
Antidepressants
Antipsychotics
Mood Stabilizers
Antihypertensives
Asthma/COPD Medications
Cardiovascular Medications
Diabetes Medications
Medication Possession Ratios (MPRs)
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MPR is a measure of medication adherence.
Based on pharmacy claims and delays in getting refills.
Refers to the percentage of time that a patient has a prescribed
medication in their possession.
o
•
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In a 3 month period, if a patient fills the medication for the first 30 days,
then skips the next 30 days, then fills it for the last 30 days, they have the
medication in their possession for 60 out of the 90 days (60/90), or 67%
of the time – an MPR of 0.67.
An MPR of 1.0 is perfect adherence (100% possession).
An MPR of 0.8 or higher (possession 80% of the time) is considered
adherent, per the scientific literature.
Adherence: Lapsed Refill Alerts
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
Provide Information to Other Healthcare
Providers
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HIPAA permits sharing information for coordination of
care
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Nationally consent not necessary

Exceptions:
HIV
 Substance abuse treatment – not abuse itself
 Stricter local laws

Provide Payer Information to
Providers at Transition of Care
Medicaid requires hospitals to notify MHN within 24 hours of a
new admission of any Medicaid enrollee and provide
information about diagnosis, condition and treatment for
authorization of an inpatient stay using a web based tool.
A daily data transfer listing all new hospital admissions
discharges is transferred to the HH data analytic staff
New admits are matched to the list of all persons assigned
and/or enrolled in a healthcare home.
An Automated email notifies the healthcare home provider of
the admission.
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.
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Educate patient on implications of psychotropic drugs
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Teach/support wellness self-management skills
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Teach/support decision making skills using Direct Inform
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Use motivational interviewing techniques
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New psychosocial rehab focus
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Smoking cessation
Enhancing Activity
Obesity Reduction/Prevention
44
Body Mass Index
Chronic Disease and At Risk
HCH Adults
July, 2013
50%
44%
45%
40%
38%
35%
35%
33%
30%
30%
26%
25%
24%
20%
20%
15%
15%
13%
8%
10%
7%
3%
5%
2%
0%
Asthma/COPD
Diabetes
Hypertension
HCH Adults
Obese
Extremely Obese
Gen. Adult Pop.
Dev. Disability
Substance Abuse
Disease Management
Continuously Enrolled Adults with Data
120%
100%
15%
80%
11%
14%
17%
13%
10%
19%
14%
13%
16%
17%
11%
14%
14%
No Data
60%
Out of Date
Complete
40%
68%
74%
70%
HTN BP
DM LDL
76%
67%
71%
75%
DM A1c
BMI
Tobacco
20%
0%
Cardio LDL
DM BP
Disease Management
BMI, Tobacco, and Complete Screens
Disease Management
Diabetes
( 2434 Continuously Enrolled Adults)*
*29% of continuously enrolled adults
Hypertension and
Cardiovascular Disease
302
3176
Goals: Lower Risk for CVD





Blood cholesterol
 10%  = 30%  in CHD (200-180)
High blood pressure (> 140 SBP or 90 DBP)
 4-6 mm Hg  = 16%  in CHD; 42%  in stroke
Cigarette smoking cessation
 50%-70%  in CHD
Maintenance of ideal body weight (BMI = 25)
 35%-55%  in CHD
Maintenance of active lifestyle (20-min walk daily)
 35%-55%  in CHD
Hennekens CH. Circulation. 1998;97:1095-1102.
Improving Diabetes (HbA1c)

7.2% Uncontrolled (too high)

For 51% there are 2 results so we can find the trend


The uncontrolled group average HbA1c decreased from
9.50% to 8.95% (-0.55%)
1% point decrease in HbA1c yields:



21% decrease in Diabetes related deaths
14% decrease in Heart Attacks
37% decrease in micro-vascular complications
Improving Cholesterol (LDL)

46.3% Uncontrolled (too high, greater than 100)

For 58% there are 2 results so we can find the trend


The uncontrolled group average LDL decreased from 122 to
115 (-7)
A 10% Cholesterol Reduction yields a 30% reduction in
Coronary Heart Disease
Improving Hypertension (BP)

23% Uncontrolled (too high, greater than 140/90)

For 61% there are 2 results so we can find the trend


The uncontrolled group average BP decreased from 142/90
to 137/86 (-5/4)
A 6 point reduction yields:


16% reduction in Coronary Heart Disease
42% reduction in Stroke
Disease Management
Asthma
2427 Adults
Continuously Enrolled
42 Children and Youth
Continuously Enrolled
Outcomes
Medication Adherence
% Continuously enrolled CMHC Health Home Clients with an MPR >
.80 by Medication Type
85%
84%
83%
82%
2/1/2012
81%
1/1/2013
80%
79%
78%
77%
76%
Pscyhiatric
Cardiovascular
Asthma/COPD
CMHC Healthcare Homes
Hospital Follow Up
Jan. 2012 through May, 2013
80%
70%
60%
50%
40%
30%
20%
10%
0%
1
2
3
4
5
6 7 8 9 10 11 12 13 14 15 16 17
% Followed-up
% Med Rec.
Percent of Follow Up
Compared to # of Hospital Discharges
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
0
50
100
150
200
250
Jan-May, 2012
300
350
400
Jan-May, 2013
450
500
LDL Changes in PCHH
Patients with Initially High
Levels
132
HA1c Changes in PCHH
Patients with Initially High
Levels
131.19
10
130
9.89
9.8
128
9.6
126
9.4
124
121.12
122
p<.0001
p<.0001
9.17
9.2
120
9
118
8.8
116
Pre
Pre
Post
Diastolic Blood Pressure Changes
in PCHH Patients with Initially High
Values
Systolic Blood Pressure
Changes in PCHH Patients with
Initially High Values
89
152
150
88
149.75
Post
87.84
87
148
86
146
85
142.94
144
p<.0001
142
83
140
82
138
81
Pre
Post
83.85
84
Pre
Post
p<.0001
% Enrollees with
Chronic Health Conditions
ER Events for PCHH Members
with at Least 8 Months of Service
and Who Were Initially Enrolled
during First Quarter 2012
100%
69%
37%
34%
50%
56%
81%
3%
0%
1050
Number of ER Events By Month Since Enrollment
1000
950
900
850
800
750
700
PCHH ER Events
Linear (PCHH ER Events)
650
600
0
1
2
3
4
5
6
7
8
Months in Health Home (0=Admission Month)
9
10
11
12
Outcomes
Reducing Hospitalization
Primary Care Health Homes
CMHC Healthcare Homes
Intial Estimated Cost Savings after 18
Months

Health Homes
 43,385
persons total served (includes Dual Eligibles)
 Cost Decreased by $51.75 PMPM
 Total Cost Reduction $23.1M

DM3700
 3560
persons total served (includes Dual Eligibles)
 Cost Decreased by $614.80 PMPM
 Total Cost Reduction $22.3M
Intial Estimated Cost Savings after 18
Months

CMHC Health Homes
 20,031
persons total served (includes Dual Eligibles)
 Cost Decreased by $76.33 PMPM
 Total Cost Reduction $15.7 M

PC Health Homes
 23,354
persons total served (includes Dual Eligibles)
 Cost Decreased by $30.79 PMPM
 Total Cost Reduction $7.4 M
Agency Leadership Buy-In
•
Implementation was led by DMH & Coalition
Helped standardize implementation
 Paving the Way
 Accreditation (CARF)

•
•
Assist other programs to include HCH
Time for in-house trainings

Assist other programs to include HCH
Agency Leadership Buy-In
•
Setting up the right team

HH Director
•

Experience in Primary & Behavioral health
HH Nurse Care Manager
•
Promote from within
Primary Care Consultant
 Care Coordinator
 Having a MH clinician available for cold calls/assmts.

•
Equipment

LDX machine, B/P cuffs
Organizational Changes
•
•
•
Policies and Procedures
Job descriptions
Additional trainings
Standardize duties across staff
 Discuss success stories
 Community trainings
 Identify transformational change

Training
•
Medical training for Community Support Specialist
NCM highlight what the CSS needs to target
 CSS needs to bill to staff clients with NCM
 NCM make health care meaningful to CSS

•
•
•
CSS recognition of how health care helps each client
Medication and side effects
Preventative care
Treatment Team Meetings
•
•
•
•
NCM is a must
Provide medical perspective
NCM brings primary consultation opinion
Solidify primary & behavioral health interventions
EMR
•
Electronic Medical Records
Allows communication among treatment team
 All treatment team members add information
 Progress notes

•
•
•
•
•
Psychiatric Nurse (vitals)
NCM (Cyber Access)
CSS (Direct care)
QMHP (Treatment Planning)
Primary consult (Medication interactions)
Common Challenges
•
Write a good treatment plan

Core Competency QA
•
•
•
•
•
Treatment Plans
Health Screenings
Metabolic Screenings
Progress notes
Buy-in
Taking blood pressures
 Training clients to care for their health care

•
More work than staff
Training and Technical Assistance

Introduction and Orientation

Healthcare Home Implementation
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
Access to Care
Healthcare Home Administration
Data and Care Management Reports
Physicians Institute
Disease Management and Clinical Training




Introduction to Disease Management
Motivational Interviewing
TEAMcare
Wellness Coaching
Outcomes
•
Pro Act
Flags
 Medication adherence

•
Core Competencies

•
Global and individual targets
Technology

Stay on top of what is needed to complete work
Surprises
•
Health education for clients, transfers
Good results for clients
 Good results for family
 Good results for staff

Success Stories
•
•
Billie lost 19 pounds and reduced her BMI from 55.6 to
51.34 in 12 months and in the last 3 weeks has lost another
4 pounds.
Susan was working on smoking cessation. During this time
she had a stroke. With the help of her nurse care manager
and CSS she was able to go to a nursing home with her
handicapped daughter, whom she cares for, to recover.
The nurse care manager and CSS then helped her and her
daughter transition back to her home. Through all this
Susan achieved her goal and quit smoking.
Tips
•
•
Have the correct staff on the team
Total buy-in
Leadership
 Middle management
 Front line staff
 Support staff

ACA Section 2703 Health Home Activity
NH
VT
WA
AK
MT
MN
OR
ID
NY
WI
SD
MI
WY
IA
NE
NV
UT
CO
CA
AZ
IL
KS
OK
NM
MO
TX
OH
IN
WV VA
NC
TN
SC
AR
AL
GA
LA
FL
As of June 2013
Approved State Plan Amendment(s) (12)
Planning Grant (17)
PA
KY
MS
HI
Note: States with stripes have both
http://www.nashp.org/med-home-map
ME
★
ND
MA
RI ★
NJ CT
DE
MD
What Makes it Possible?

A Relationship of Basic Trust between:





Department of Mental Health
MO Coalition of CMHCs
State Medicaid Authority
State Budget Office
MO Primary Care Association

Transparent use of Health Information Technology to
identify and monitor problems, and assess performance

Willingness of all partners to tolerate risk

Funding Primary Care Nurse Care Managers
WebSites


www.nasmhpd.org/medicaldirector.cfm
www.dmh.mo.gov/about/chiefclinicalofficer/healt
hcarehome.htm