Transcript Person Centered Care Management Practice

Person-Centered
Care Management Practice
NYS Case Management Coalition Conference
May 1, 2012
Presented by:
Valerie Way, LCSW-R
New York Care Coordination Program
Converging Forces Bring
Us Here Today…
National
and State
Health Care
Reform
Rapid Paced Change
and Instant
Communication
Emerging Knowledge
About Recovery
A Focus on
the
PERSON as
Central to
our Work
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Health Care Reform Goals
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Improve Quality of Care
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Improve Outcomes
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Decrease Cost
The emerging health care
environment is focused on…
The “Whole”
Person
Recovery and
Person-Centered Practices
Greater
Accountability
for Outcomes
Engaged
Partnerships
with
Consumers
Integrated
Physical/
Behavioral
Health Care
Phase I
Timeline for Transformation
• 2002 - Laying the foundation for transformation
• Collaborative processes, care coordination, person-centered
practices, recovery focus, promotion of peer services & supports,
physical health awareness, data driven
Phase II
• 2009 - Partnership with Beacon Health Strategies, LLC
• Managed care readiness
• Complex Care Management Program
Phase III
• 2011 - RBHO’s and Health Homes
• Award of the Western Region Behavioral Health Organization
• Health Home Application
What have we learned that supports
person-centered care management?
#1: Listen to
the
Customer
#2: Person
Centered,
Recovery
Oriented
Services
produce
better
outcomes
#3: Getting
those
outcomes
requires new
knowledge,
new skills, a
new culture
#4:Targeted Case
Managers are well
positioned to make
a successful
transition to
Health Home Care
Management
#1 Listen to the Customer
Guiding Principles for Person-Centered,
Recovery-Focused Services
Developed by the WNYCCP Peer and Family Advisory Group, 2007
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The goal is recovery, not just stabilization and maintenance.
Hope is necessary and recovery is possible for everyone.
Every individual is unique; every recovery different.
People have prompt access to compassionate care and
services.
The system is flexible, wherever possible, to support the
person’s recovery.
Every plan for recovery is centered on the person’s goals,
strengths, and preferences -- not the availability of a particular
program or service.
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Guiding Principles for Person-Centered,
Recovery-Focused Services (continued)
• Natural supports, outside the mental health system,
are explored and encouraged.
• Family support is valued and included when
appropriate.
• There is a partnership between individuals and their
treatment team, care coordinators, service providers,
and their peers and family members, when appropriate.
• Individuals are educated to make informed choices
about their health care and recovery.
• Peers (people in recovery) are included and involved
at all levels in the organization.
• Everyone is treated with dignity and respect;
differences in culture, belief, or language are valued.
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#2 Person-centered, recovery-focused care coordination
produces better outcomes for individuals and lowers costs
Better quality
• 46% decrease in emergency room visits per enrollee*
• 53% reduction in days spent in a hospital*
• 78% of enrollees report “dealing more effectively with problems” (2009 Enrollee Survey)
Better outcomes
• 31% increase in gainful activity*
• 54% decrease in self harm among enrollees*
• 53% reduction in harm to others*
Lower costs
• 2008 Medicaid mental health costs for Care Coordination
populations in NYCCP vs. comparison counties: (OMH August
2010)
• 92% lower for inpatient services
• 42% lower for outpatient services
• 13% lower for community support, physical health savings would
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be additional
• $5,541 lower average cost per person * 2009 Periodic Reporting Form Analysis
Outcomes:
Westchester County Care Coordination Program
N=31
Medicaid (other
than hospital)
Incarceration
State Hospital
Total
2007- 2008
Pre-Enrollment
$ 822,119
$ 870,260
$ 592,150
$ 2,284,529
2008-2009
1 year after
$ 535,634
$ 410,860
$ 129,850
$ 1,076,344
Savings $
$ 286,485
$ 459,400
$ 462,300
$ 1,208,185
Savings %
35%
53%
78%
53%
In addition, there was a significant decrease in days of homelessness and an increase in
attendance at chemical dependency treatment programs.
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#3 Getting those outcomes requires new knowledge,
new skills and new culture- and that is hard work!
Understand
Health Homes
Use Recovery-Focused and
Person -Centered Practices
Focus on the Whole Person
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New Knowledge, New Skills,
New Culture…
Understand
Health
Homes
• What is a health home?
• How are individuals
determined eligible and
assigned to health
homes?
• What are my roles
responsibilities?
• Where do I fit on a
larger health care team?
• How will I manage my
new caseload?
• How do I bill/get
reimbursed for services?
• How do I use HIT to
improve outcomes?
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What are Health Homes?
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Not a residence……..
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Section 2703 of the Patient Protection and Affordable Care Act of 2010
(P.L. 111-148) adds a new section 1945 to the Social Security Act. This
section allows States to amend their State Medicaid Plans to provide
“Health Homes” to enrollees with chronic conditions, including mental
health conditions, substance abuse disorders, asthma, diabetes, heart
disease and being overweight( BMT > 25).
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A Health Home is a care management service model whereby all of an
individual’s caregivers communicate with one another so that all of a
patient’s needs are addressed in a comprehensive manner. This is done
primarily through a “care manager” who oversees and provides access
to all of the services an individual needs to assure that they receive
everything necessary to stay healthy, out of the emergency room and
out of the hospital. Health records are shared (either electronically or
paper) among providers so that services are not duplicated or
neglected. The health home services are provided through a network of
organizations- providers, health plans and community-based
organizations. When all the services are considered collectively they
become a virtual “Health Home”.
http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_ho
mes/
© 2009 Coordinated Care Services, Inc.
NYS Health Home Care Management
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The health home model of service delivery expands on the traditional
medical home model to build linkages to other community and social
supports, and to enhance coordination of medical and behavioral health
care, with the main focus on the needs of persons with multiple chronic
illnesses.
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Health home services include:
◦ comprehensive care management
◦ care coordination
◦ health promotion
◦ comprehensive transitional care, including appropriate follow-up from
inpatient to other settings
◦ patient and family support
◦ referral to community and social support services, and
◦ use of health information technology to link services
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Expect that use of the health home service delivery model will result in
lower rates of emergency room use, reduction in hospital admissions and
re-admissions, reduction in health care costs, less reliance on long-term
care facilities, and improved experience of care and quality of care
outcomes for the individual.
Roles/Responsibilities of Health Home Care Managers
-Margy Meath
COORDINATOR
FACILITATOR
???
PHYSICAL
PSYCHOLOGICAL
ENVIRONMENTAL
PERSON with
HOPES and
DREAMS
BROKER
CULTURAL
SOCIAL
TEAM BUILDER
SPIRITUAL
QUALITY
ASSURANCE
INVESTIGATOR
[email protected]
Core TCM Skills Necessary in
Health Home Care Management
Targeted Case
Management
Services
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Assessment &
Re-Assessment
Planning &
Coordination
Health Home Care
Management Services
*see HH qualification standards
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Comprehensive care
management
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Care coordination and health
promotion
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Comprehensive transitional
care from inpatient to other
settings, including appropriate
follow-up;
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Individual and family support;
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Referral to community and
social support services, if
relevant; and
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Meaningful use of health
information technology to
integrate service provision
Implementation of
Plan/Linking
Monitoring &
Follow-Up
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New Knowledge, New Skills,
New Culture…
Use
RecoveryFocused
and
Person Centered
Practices
• What does
recovery mean?
• How do people
recover?
• What does it
mean to be
person-centered?
• What will help
guide my work so
that I can be
recovery focused
and person
centered?
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SAHMSA’s Recovery Definition
“A process of change through
which individuals improve their
health and wellness, live a selfdirected life, and strive to reach
their full potential.”
http://www.samhsa.gov/
What Supports Recovery?
HEALTH
HOME
RECOVERY
PURPOSE
COMMUNITY
WWW.SAMHSA.GOV
Guiding Principles of Recovery…
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Emerges from hope
Is person-driven
Occurs via many pathways
Is holistic
Is supported by peers and allies
Is supported through relationships and social
networks
Is culturally based and influenced
Is supported by addressing trauma
Involves individual, family and community
strengths and responsibility
Is based on respect
WWW.SAMHSA.GOV
Core Values of Person Centeredness
-Adapted from Michael Kendrick
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A commitment to know and deeply seek to
understand an individual.
A conscious resolve to be of genuine service.
Openness to being guided by the person.
Willingness to struggle for difficult goals.
Willingness to stand by values that enhance the
humanity and dignity of the person.
Flexibility, creativity, and openness to trying what
might be possible; including innovation,
experimentation, and unconventional solutions.
To look for the good in people and help to bring it
out.
Tool: Important To/Important For
Important “To”
the person
Things that resonate
with the person
regarding:
◦ Values and ideals
◦ Personal
preferences
◦ Interests
◦ Talents
◦ Dreams and
aspirations
Important “For”
the person
Things that must be
kept in mind
regarding issues of:
◦ Health and safety
◦ What is needed to
be a valued member
of his or her
community of choice
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Important To:
All Choice, No Responsibility
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Important For:
Health and Safety Dictate Lifestyle
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Person-Centered Practices…
Gives equal priority to what is important to
and what is important for the individual
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New Knowledge, New Skills,
New Culture…
Focus on
the Whole
Person
• What do I need to
address in my care
management needs
assessment?
• How do I build an
integrated and
coordinated care plan?
• What is my role with
other formal and
informal supports?
• Will other providers be
on board with the plan?
• What is my role in
facilitating health
behavior change and
promoting health?
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Care Management Needs Assessment
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What are Individual’s Hopes and Dreams?
What are their Strengths, Supports,
Resources?
What Barriers are Impacting Individual?
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Mental Health
Substance Use
Physical Health
Social Service Needs
Other
What are their preferences, priorities, etc.
that need to be taken into consideration?
Physical Health Questions
1. What is the individual’s idea of health? Is the individual’s quality of life
impacted by their health? What are the individual’s health habits/typical
patterns? Have they tried to make changes in any of the following areas? Do
they want to focus on any of these areas? (follow up would be with MH, CD and PH providers)
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Diet and nutrition
Exercise
Dental care
Sexual health
Sleep
Use of alcohol, drugs, tobacco
2. What are known risk factors/ existing disease states?
3. When you have a health care need, where do you go? Do you have health
insurance?
4. Are you in contact with health care providers? Who are your providers?
◦ When was your last physical exam? By whom? Are you comfortable with your providers?
◦ Do your health care providers communicate with each other?
◦ Who is your dentist? When was you last dental exam?
5. Have your health care providers offered any health recommendations? What is your understanding of these recommendations?
How interested are you with following these recommendations?
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Medications?
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Are you taking any prescribed, over the counter, herbal remedies, diet supplements, etc.? How many?
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Are your health providers aware of all the medications you are taking?
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What pharmacy (pharmacies) do you fill your medication?
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Do you have extra medication at home you are not currently using?
Medical equipment?
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Do you use eyes glasses, hearing aides, etc?
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Does your provider recommend regular blood work? How often? For what reason?
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When was the last time you had your weight / BMI measured? Your blood pressure? Do you know what these are?
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Does your health care provider ask you about your interest in quitting smoking?
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Are you interested in maintaining a personal health record and/or communication log that you could take to all of your
appointments?
6. Are you interested in alternative or non-traditional treatment methods?
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(e.g.: Yoga, acupuncture, meditation, massage therapy, Reiki, etc.)
7. Do you participate in any community wellness activities? What resources do you have to improve your health?
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Exercise group/gym
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Illness management group (e.g.: diabetes education)
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Nutrition/cooking group
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Other: ___________________
8. Are there barriers, assumptions, fears that need to be overcome in any of the above
Questions?