Transcript Integrated Health Care Initiative (cont.)

Texas and Integration
Emilie A. Becker, M.D.,
Mental Health Medical Director
Medicaid CHIP Division
Winter 2016
Health Behavior Assessment and
Intervention
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April 1, 2014
Less than 20 years old
Medical diagnosis
Biopsychosocial factors
Colocation of Licensed Practitioner Healing Arts (LPHA) and
Primary Care Provider
96150-96155
Texas Medicaid Healthcare Partnership website
LPHA to have own National Provider Identification (NPI),
can use pediatrician’s office address/ billing service
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Same Day Billing
• May vary by plan
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plans have been told to cover both medical and BH
providers
• FQHCs included
• May be a problem if same procedure code is used
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Texas Health Steps
• February 28, 2014
• THSteps Advisory Panel recommended specific mental and
behavioral health screening as part of the checkup for
clients 12 years of age (older if not completed at 12 yr.
checkup)
• Four approved tools
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Pediatric Symptom Checklist (PSC-35)
Pediatric Symptom Checklist-Youth (PSC-Y)
Personal health Questionaire-9 (PHQ-9)
CRAFFT
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2014
Hedis Quality of Care
Measures
• Antidepressant Medication Management
• Follow up Care for Children Prescribed
ADHD medication
• Follow Up After Hospitalization for Mental
Illness
• Diabetes Screening for People with
Schizophrenia or Bipolar Disorder Who
are Using Antipsychotic Medications
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2014
Hedis Quality of Care
Measures
• Diabetes Screening for People with
Schizophrenia or Bipolar Disorder Who
Are Using Antipsychotic Medications
• Diabetes Monitoring for People with
Diabetes and Schizophrenia
• Cardiovascular Monitoring for People with
Cardiovascular Disease and
Schizophrenia
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2014
Hedis Quality of Care
Measures
• Adherence to Antipsychotic Medications
for Individuals with Schizophrenia
• Use of Multiple Concurrent Antipsychotics
in Children and Adolescents
• Metabolic Monitoring for Children and
Adolescents on Antipsychotics
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Mental Health Care in the
Hidalgo Catchment Area
Unique mental health delivery system
• Most Medicaid patients do not receive their care at Tropical
Texas Behavioral Health (community MHMR)
• Most receive care from private psychiatrists, therapists, and
facilities
• This “private practice” approach lacks multidisciplinary
coordination the patients require
HealthSpring STAR+PLUS identified this lack of care
coordination by the private providers and sought solutions to
assist its most mentally ill members
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The Psych Nurse, Inc
The Psych Nurse, Inc (TPN) is a mental health community
treatment outreach program that provides empathetic and
compassionate mental illness disease management and
education
• TPN helps reduce health care costs by serving and supporting
patients, families, and the community
• TPN specializes in hands-on personal management for all
mental disorders
• Under the supervision of a psychiatrist, the RNs perform
evaluations of home safety, medication management and
education, life skills assessments, crisis intervention, behavior
management, and anxiety/stress reduction
• Services include psychiatric nurse consultation and home visits
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HealthSpring STAR+PLUS
partnership with
The Psych Nurse, Inc
Started in August 2012
Member referrals: Behavioral health STAR+PLUS members with the
highest acuity, most hospital admissions, highest degrees of
noncompliance and recidivism, highest abuse of alcohol and illicit
substances
Number of member referrals in 2012:
• August: 15
• September: 2
• October: 12
• November: 3
• December: 13
Total members referred to TPN in 2012: 45
HeathSpring STAR+PLUS Medical Director coordinates referrals and
leads weekly clinical rounds between HealthSpring STAR+PLUS
staff and TPN nurses.
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Impact
•ALL paid claims associated
with initial 15 referred
patients, 2012 data (MarchDecember)
$120,000
$110,951
Initial TPN
referrals
$100,000
$82,471
$77,461
$80,000
$70,524
$58,779
$60,000
$50,548
•Cost of program is included
•Cost of program is not
administrative, it is medical
as it is billed by the
psychiatrist
$43,635
$40,367
$40,000
$29,481
$20,000
$7,010
$0
March
April
May
June
July
August
September
Data run on 1/18/2013
October
November
December
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Impact
•ALL paid claims associated with all 45 referred patients, 2012 data
(March-December)
•Cost of program is included
•Cost of program is not administrative, it is medical as it is billed by
the psychiatrist
$250,000
Initial TPN
referrals
$200,000
$190,890
$182,340
$170,490
$169,975
$151,380
$146,474
$150,000
$140,402
$108,708
$100,000
$89,639
$50,000
$33,969
$0
March
April
May
June
July
August
September
Data run on 1/18/2013
October
November
December
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Testimonials
11/1/2012
HealthSpring STAR+PLUS Behavioral Health Social
Worker received call from Rosie, a member's mother
and personal rep, who stated she wanted to call and
thank the Social Worker for the referral to TPN and for
listening to her. Rosie stated TPN has made “such a
difference” and she connected Rosie with a
counselor in order to increase her own coping skills
and she is now taking an anti-depressant herself. She
explained her daughter is responding very well to the
nurse's interventions, "this has been a God-send, she
knows what she's doing and how to talk to my
daughter.” She added, "God bless you all.”
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Testimonials
12/11/2012 Portions of a letter sent from a member’s daughter:
I like to take the time to thank everyone involved in helping my mother, JR return to a life of normalcy.
For several years I have grieved the loss of my loving mother, whom I thought was lost forever to
a mental illness. I no longer received loving phone calls, words of encouragement, and even a
simple hug for several years. My father and I have longed for the day to enjoy life again with her. I
had to come to terms that she may never be the mother I once knew, the mother that taught me
love is kind, God is real, and most of all faith conquers all……
….My mother was recommended take part of a pilot program through Health Spring for in home
treatment. “Wow! Finally, they get it,” I said to myself. I spoke to Karen the initial social worker for
Health Spring; she was nice and genuinely interested to know my mother’s medical history. “
Although apprehensive because everything else had seemed to fail, this was our last hope, our last
attempt, and even our last chance to restore our family. For the last couple of months I began to
notice a slow change, but significant for our family. “It’s like broken pieces of glass slowly and
poetically coming together restoring lives of three people becoming a family once again.” For
once my mother is being treated as a human being, an actual person, a mother, sister,
daughter, and a wife.
Ultimately, I would like to say to Health Spring insurance, staff, nurses, doctors you have
humanized the treatment and experience for my mother. She looks forward to the visits by the
nurses and doctors. This program is unique and different from anything else out there. …I can’t
thank you enough for all the help, passion, and commitment towards my mother’s recovery. …
….There is no doubt this exceptional program should continue so other lives can be restored
by the specialized treatment.
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The Center for Children and
Women
The Center for Children and Women is a patient and family-centered
medical home developed as an innovative, comprehensive, and
coordinated primary care practice exclusively for TCHP members
(Children and Pregnant Women).
With the joint principles of a patient-centered primary medical home
serving as the underpinning for The Center, there is the opportunity to:
•Keep members healthy
•Focus on coordinated care
•Leverage the EMR
•Eliminate financial disincentives
•Decrease avoidable ER visits
Access: Hours
Pediatric Hours:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
9 AM – 7 PM
7 AM – 11PM
7 AM – 11PM
7 AM – 11PM
7 AM – 11PM
7 AM – 11PM
9 AM – 7 PM
Obstetric Hours:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Closed
7 AM – 7 PM
7 AM – 7 PM
7 AM – 7 PM
7 AM – 7 PM
7 AM – 7 PM
9 AM – 3 PM
Engagement: ER Visits &
Inpatient Days
Texas Children's Health Plan - The Center
Utilization Effect on ER Visits & Patient Days
(For the period ended April 30, 2015)
The Center Panel
ER Visits per 1000 Members - Greenspoint
The Center Panel
Patient Days per 1000 Members - Greenspoint
2,500
1,500
Visits
Visits
2,000
1,000
500
0
New Borns
Children
At least 1 Visit to The Center
Pregnant Women
New Borns
No Visits to The Center
Visits
Visits
1,500
500
0
Children
At least 1 Visit to The Center
Pregnant Women
No Visits to The Center
Pregnant Women
No Visits to The Center
The Center Panel
Patient Days per 1000 Members - Southwest
2,000
1,000
Children
At least 1 Visit to The Center
The Center Panel
ER Visits per 1000 Members - Southwest
New Borns
6,000
5,000
4,000
3,000
2,000
1,000
-
6,000
5,000
4,000
3,000
2,000
1,000
New Borns
Children
At least 1 Visit to The Center
Pregnant Women
No Visits to The Center
Calendar Year 2014 HEDIS
(Final)
• *Weight Assessment Documentation: Total BMI Percentile
73.72%
80.00%
• Follow-up Care for Children Prescribed ADHD Medication: Initiation
46.99%
72.09%
• Appropriate Testing for Children with Pharyngitis
77.96%
76.55%
• Appropriate Treatment for Children with Upper Respiratory Infection
91.21%
93.78%
• Use of Appropriate Medications for People with Asthma
87.26%
89.29%
• Post-Partum Care
69.47%
57.65%
• Prenatal Care
89.62%
74.32%
• Adolescent Well-Care Visits: Total
59.21%
68.29%
• Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life
77.26%
80.21%
• *Childhood Immunizations Status: Combination 4
72.51%
85.70%
Green = Goal Met or Yellow = Within 10%
Exceeded
of Goal
* Hybrid Measure
Pharmacy
(August 2015)
Key Performance Metrics
Average Plan
Paid
The Center - GP
The Center - SW
TCHP
$42.75
$30.41
$78.63
Average Days Supplied
16.42
13.77
18.46
Generic Rate
81.2%
87.5%
71.1%
719 (Rank 3)
25,582
Over the Counter Prescriptions
1,091 (Rank 1)
Obstetrics Cesarean Delivery Rates
40%
35%
35%
33%
31%
30%
27%
25%
Center -- Primary
Center -- All
TCHP
Texas
US
20%
15%
14%
10%
5%
0%
C/S Rate
Notable Accomplishments
Behavioral Health Integration
• 49% of patients reached for telephonic motivational interviewing
intervention for weight management
• 98.4% of the OB patients receive postpartum depression
screening
ACOG Annual District Meeting
• Oral Abstract Presentation “Utilization of 17-αHydroxyprogesterone Caproate in a Texas Medicaid Population”
Pregnancy Medical Home
• On-going partnership with HHSC to evaluate the effectiveness of
our model
Integrated Behavioral
Healthcare in DSRIP
90 DSRIP projects focus on integration of behavioral healthcare (BH) with
primary care (PC)
• Most focus on individuals with complex BH needs
Over 80 projects on individuals with co-occurring mental health and
substance abuse
Outcomes baseline data submission began in October 2014
Most common outcomes selected for integrated BH/PC projects
• Screening and treatment plan for clinical depression
• Controlling high blood pressure
• Depression remission at twelve months
• Also outcomes related to quality of life, patient satisfaction, diabetes
HbA1c control, and reducing emergency department visits for
BH/substance abuse
Prospects Courtyard
Integrated Clinic
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Center for Health Care Services, San Antonio (RHP 6)
A comprehensive, integrated care management center offering
primary and behavioral health care to homeless adults living at
Prospects Courtyard (PCY) within the Haven for Hope campus.
The great majority have co-occurring mental health and/or
substance use and chronic physical disorders.
In 2011, there were 600 transports to area hospital emergency
departments from the Haven for Hope, most after hours
Services: walk-in triage, preliminary diagnostics, initial
treatment, referral and follow up for medical care, psychiatric
care, urgent care, medication management, medication
assistance, immunizations, and chronic disease prevention
strategies
Prospects Courtyard
Integrated Clinic (cont.)
60 individuals served, with goals of 125 and 175 individuals served
in demonstration years 4 and 5
Outcome measures
• Assessment for Psychosocial Issues of Psychiatric
Patients and Client Satisfaction Questionnaire 8 (CSQ-8)
Sustainability planning
• Increase 3rd party billing by strengthening of the benefits
enrollment process and utilization of SOAR (a national
program designed to increase access to the disability
income benefit programs)
• Analysis of cost savings to negotiate sustainable funding
with community partners, such as local hospitals
• Partner with universities to use clinic as a training site for
residents
• Integration of peer support services
Integrated Health Care
Initiative
MHMR Tarrant County (MHMRTC), Fort Worth (RHP 10)
Partnership with JPS Health Network to co-locate primary care and
behavioral health services at MHMRTC’s homeless/crisis
services center for individuals with severe mental, developmental,
and addictions disorders who may also be homeless, and who
are not otherwise able to access primary care services.
Services
• Wellness checkup exams, well woman checks, smoking
cessation, specialty referrals, medication reconciliation,
community-based case management services, substance
abuse treatment, counseling, peer support and group classes,
community/field-based case management and rehabilitation
services, RN care coordination
• Community outreach teams to refer individuals living in
campsites or on the street into the integrated care initiative
Integrated Health
Care Initiative (cont.)
325 individuals served, with goals of 332 and 553 in demonstration
years 4 and 5
Outcome measures
• Controlling High Blood Pressure (HEDIS) and SF-36 Quality of
Life instrument
• As of April 31, 2015 119 (45%) of 263 integrated care patients
had a diagnosis of hypertension in EPIC. Of those individuals
87 (73%) had more than one blood pressure reading. Of the
87 integrated care patients, 56 (64%) were recorded to have
controlled blood pressure (<140/90) at the second reading.
Sustainability planning
• Collaboration with managed care plans to develop innovative
contractual ventures
• Integration of primary care services into clinical locations
systemwide
Screening, Brief Intervention
and Referral to Treatment
Fort Bend County Clinical Services, Fort Bend County (RHP 3)
Add a Screening, Brief Intervention and Referral to Treatment
model (SBIRT) at intake for at-risk persons and persons with
substance use who are patients in the AccessHealth Federally
Qualified Health Center (FQHC) clinic in Richmond, Texas. This
is an enhancement to the IMPACT model AccessHealth currently
uses to integrate depression care into primary care.
Project Services
• SBIRT model
• Patient education and referrals to more extensive services
• Coordination of wrap-around services in the community and
within the FQHC
• Improvements to the electronic health records system
Screening, Brief Intervention
and Referral to Treatment
(cont.)
94 individuals served, with goals of 225 and 300 in demonstration
years 4 and 5
• Outcome measure
– Initiation and Engagement of Alcohol and Other Drug
Dependence Treatment
Other performance indicators
• Diversions from the emergency department, emergency
medical services (EMS), and criminal justice system
Sustainability planning
• Collaboration with local partners and stakeholders to identify
additional funding sources.
• Exploration of opportunities for reimbursement through Texas
Medicaid managed care plans
Integrated Care Clinic
in Rural Texas
Burke Center (RHP 2)
Partner with Angelina County/Cities Health District to create an
integrated health home for Burke Center clients with one or more
comorbid chronic conditions and expand access to behavioral
health services for clients of the Health District Clinic. Targets
Medicaid and low-income uninsured clients with serious mental
illness.
Project services
• Integration of co-located behavioral and primary care services
within both behavioral health and primary care settings to
meet patients needs.
• Enhancement of the electronic medical records to include all
primary-care related diagnoses
• Training for primary care workforce in co-managing chronic
behavioral health conditions
Integrated Care Clinic in
Rural Texas (cont.)
280 individuals served, with goals of 600 and 990 in demonstration
years 4 & 5
• Outcome measures
• Depression Management: Screening and Treatment Plan for
Clinical Depression
• Comprehensive Diabetes Care: LDL Screening
• Adult Body Mass Index (BMI) Assessment
Sustainability planning
• Coordination with County and City Health Districts to support
data sharing between primary care and behavioral health
care providers
• Engagement of all Texas managed care plans to improve
billing and reimbursement processes for co-located services
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Questions
Emilie Attwell Becker, M.D.
Mental Health Medical Director
Medicaid and CHIP Division
Texas Health and Human Services Commission
Email: [email protected]
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