Transcript 1204POPULATIONMCCASLINX (Slide 1)

Models of Service Integration:
The Missouri Approach
National Governors Association
Planning for Expansion Populations in 2014
April 20, 2012
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Overview
MO HealthNet – Missouri’s Medicaid Program
Particular Focus on Better Quality of Life for Individuals with
Serious Mental Illness (SMI) and Other Chronic Conditions
Community Mental Health Centers (CMHC’s)
- Early Adopters
Health Home Models
- Missouri Community Mental Health Centers
- Missouri Primary Care Centers
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
OUR EMPHASIS is to increase the
health status of Missourians
through better:
Coverage for health care services
 Access to those services
 Quality of those services
 Accountability to taxpayers

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A Long History of Collaboration
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Many Challenges for Missourians
Overall Poor Health Status
Disturbing Rates of Smoking, Obesity, Chronic
Disease, Serious Behavioral Illness
Alarming Growth in Rate of Poverty
Striking Disparities in Access to Quality Care
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2011 Average Monthly MO HealthNet Participation
Per 1000 Population
(899,113* Enrollees)
WORTH
ATCHISON
SCHUYLER
PUTNAM
MERCER
SCOTLAND
NODAWAY
CLARK
HARRISON
GENTRY
SULLIVAN
HOLT
ADAIR
KNOX
GRUNDY
LEWIS
People Participating
Per 1,000 Population
ANDREW
DAVIESS
LINN
DEKALB
MACON
CALDWELL
BUCHANAN
MARION
SHELBY
LIVINGSTON
204.5-372.2 (29)
166.4-204.4 (29)
133.7-166.3 (28)
57.5-133.6 (29)
CLINTON
CHARITON
RALLS
MONROE
RANDOLPH
PLATTE
CARROLL
RAY
PIKE
CLAY
AUDRAIN
SALINE
HOWARD
BOONE
JACKSON
CALLAWAY
COOPER
JOHNSON
PETTIS
MONTGOMERY
LAFAYETTE
LINCOLN
ST. CHARLES
WARREN
CASS
ST. LOUIS CITY
150.1 people
participate
per 1,000
Missourians
COLE
OSAGE
MORGAN
HENRY
GASCONADE
MONITEAU
ST. LOUIS
FRANKLIN
BENTON
BATES
JEFFERSON
MILLER
MARIES
ST. CLAIR
CRAWFORD
CAMDEN
HICKORY
WASHINGTON
PHELPS
VERNON
STE.
GENEVIEVE
PULASKI
DALLAS
CEDAR
LACLEDE
POLK
IRON
DENT
BARTON
PERRY
ST. FRANCOIS
MADISON
CAPE
GIRARDEAU
REYNOLDS
DADE
GREENE
WEBSTER
WRIGHT
TEXAS
BOLLINGER
JASPER
SHANNON
LAWRENCE
WAYNE
SCOTT
CHRISTIAN
CARTER
DOUGLAS
NEWTON
HOWELL
MISSISSIPPI
STODDARD
STONE
BUTLER
BARRY
MCDONALD
TANEY
OZARK
OREGON
RIPLEY
NEW MADRID
Note: Based on average monthly number of people participating July 2010 through June 2011
and 2010 population from Census Bureau, Missouri Census Data Center
*Does not include Women’s Health Services participants.
PEMISCOT
DUNKLIN
DSS/September 2011
Missouri Medicaid: 895,479 Enrolled
• 542,408
children
• 28,528
pregnant women
• 80,538
low income parents
• 167,649
persons with disabilities
• 77,356
low income elderly
As of 02.28.12
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We Just Have To Do This. . . . . .
• Patient-centered Medical Homes
• Coordination of Behavioral and Physical Care
• Define, Measure, Improve Upon Quality of Care
• Better Understand High Need Populations
– Permanently and Totally Disabled
– Low Income Elderly
– Seriously Mentally Ill
Ian McCaslin - Fall 2007; slide for Oversight Committee
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Community Mental Health Center
Care Management Model
Principles
• Physical healthcare is a core service for persons
with Serious Mental Illness
• Mental Health systems have a primary
responsibility to ensure:
– Access to preventive healthcare
– Management and integration of medical care
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Comorbid Conditions,
typical CMHC SMI Cohort
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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.
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Medical Needs Have Same Priority
for CMHC Action as MH Needs
• Either directly embedding a primary care
provider responsible for physical health
coordination, or closely partnering with
community provider
• Medication adherence – just as important for
non-MH meds
• Assistance in scheduling and keeping medical
care appointments
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Care Coordination
Integrates Healthcare into CMHC
Care Mechanisms
• 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 Care Managers – proven practice
• Verify healthcare services are occurring by tracking
data from a number of sources
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Data Sources - Examples
• Cost - Claims
• Quality of Care – Claims and Metabolic Screen
Data
• Medication adherence
• MU/HEDIS indicators
• Clinical Outcomes - Claims
• Avoidable readmissions
• Experience of care - Survey
• MHSIP
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Comprehensive Care
Management
• Identification and targeting of high-risk individuals
• Monitoring of health status and adherence
• Development of treatment guidelines
• Individualized planning with the consumer
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Step 1 – Create Disease Registry
• Get Historic Diagnosis from Admin Claims
• Get Clinical Values from Metabolic Screening
• Combine into Electronic Disease Registry
• Online Access available to all Providers
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CyberAccess Electronic Web-based Tool
• Features
– Patient Demographics
– Partial Electronic Health Record
• Record of all participant prescriptions
• All procedures codes
• All diagnosis codes
– E prescribing
– Prior Authorization and Preferred Drug List support
– Medication possession ratio
– Consumer EHR Portal – Direct Inform
– Disease Registry for CMHCs
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Metabolic Syndrome Disease Registry
• Metabolic Syndrome
– Blood pressure
– Cholesterol
– Triglycerides
- Weight
- Height
- Blood sugar
• Screening Required Annually
• Disease registry with results maintained on
CyberAccess
• Billing Code under Rehab Option
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Step 2 – Identify & Address Care Gaps
• Compare Combined Disease Registry Data to
accepted Clinical Quality Indicators
• Identify Care Gaps
• Sort patients with care gaps into CMHC-specific
To-Do lists
• Send to CMHC nurse care manager
• Set up PCP visit with request to treat based upon
identified needs
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HEDIS Indicators
• Use of inhaled corticosteroid medications by persons with a
history of COPD (chronic obstructive pulmonary disease) or
Asthma
• Use of ARB (angiotensin II receptor blockers) or ACEI
(angiotensin converting enzyme inhibitors) medications by
persons with a history of CHF (congestive heart failure)
• Use of beta-blocker medications by persons with a history of
CHF (congestive heart failure)
• Use of statin medications by persons with a history of CAD
(coronary artery disease)
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Initial Results
• Provide specific lists of CMHC clients with care
gaps as identified by HEDIS indicators to CMHC
primary care nurse liaisons quarterly
• Provide HEDIS 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
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Care Coordination
 Coordinating
and providers
with the patients, caregivers
Implementing plan of care with treatment
team
 Planning hospital discharge
 Scheduling
 Communicating with collaterals

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Health Promotion
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Population-based
Patient self-management
Health education
Smoking prevention
Obesity reduction
Awareness of social determinates of health
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Support Patient Wellness through SelfManagement using Peer Specialists
• Implement a physical health/wellness approach
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
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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
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Individual & Family Support
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Family education
Peer support and/or NAMI/MHA
Patient advisory and input processes
Direct Inform
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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
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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
Increased data reporting and outcomes
Treatment planning tools supported by
treatment guidelines
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A Typical Participant
• 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 co- morbidity
• A generally motivated cohort
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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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.
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Cardiac Disease Outcomes
Percent Compliant
Beta Blocker Post MI Compliance
70%
60%
50%
40%
61%
33%
30%
20%
Enrolled N=16,982
Non Enrolled N=29,088
10%
0%
Beta Blocker Post-AMI
Clinical Measure
CCIP enrollees following a heart attack received recommended treatment with beta blocker
medications at nearly twice the rate of non-enrollees.
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Coronary Artery Disease (CAD) Outcomes
Statin Therapy Compliance
Percent Compliant
20%
17%
15%
11%
10%
Enrolled N=16,982
Non Enrolled N=29,088
5%
0%
Statin Therapy
Clinical Measure
CCIP enrollees with coronary artery disease (CAD) received recommended treatment with
statin medications at a greater rate than non-enrollees.
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CMHC Savings Off Trend
Category
pre CMHCCM
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%
Psychologist
$463,069
$144,434
($318,635)
-68.8%
Independent
Clinic
$3,549,715
$4,324,452
$774,738
21.8%
$101,899,402
$93,637,226
($8,262,176)
-16.%
Overall
Total Healthcare Cost Trend
Pre-/Post CMHC Enrollment, 2005-07
• Selection Criteria – 636 SMI 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
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Total HealthCare Costs Per User Per Month
Pre- and Post- CMHC Case Management
Running 48 months with case management beginning month 24,
636 continuously enrolled patients, 2005-07
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Missouri’s Health Home:
ACA Section 2703
Section 2703: Our Over-Arching Goals
• Support high quality, cost-effective primary
care for those with chronic conditions
• Financially support transformation of primary
care practices
• Build on principles of team-based care
• Help support partnerships among providers,
patients, and families
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Our Strategic Goals
• Maximize federal match from new funding
streams in order to support primary care.
• Develop basis for future multi-payer
collaborations driven by new payment models
• Develop experience in preparation for
development of ACO opportunities
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Keys to the Process
Many Friends, Old and New
Engaged Stakeholders
Early Support from Missouri Foundations
Preceding Health Centers’ Commitment
Strong Provider Base of EMR Adoption
Considerable Prior State HIT Investments
Supportive State Budget Director
Drive to Sustainability Beyond Eight Quarters
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Two State Plan Amendments Approved by CMS
last Quarter 2011
• Primary care chronic conditions healthcare home
– FQHC’s, RHCs, and certain other medical clinics
• Dept. of Mental Health state plan amendment
– CMHC healthcare home
Clients Eligible for CMHC Health Home
• A serious and persistent mental illness
– Adults with SMI (Schizophrenia, Bipolar
Disorder, Major Depression Recurrent)
– Youth with Severe Emotional Disturbance
Clients Eligible for CMHC Health Home
• A mental health condition, OR
• A substance abuse condition, AND
• One other chronic health condition
•
•
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•
•
•
asthma,
cardiovascular disease,
diabetes,
substance abuse disorder,
developmental disability
overweight BMI>25
Provider Infrastructure
• Reimbursed by HH funding
– 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 feefor- service systems, including DMH and
Medicaid
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–
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–
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–
–
Community support worker
Physician services
Peer specialist
Psychosocial rehabilitation
Medication
Primary care medical services
Labs
Links for more Information
• http://dss.mo.gov/mhd/cs/health-homes/
• http://dmh.mo.gov/about/chiefclinicalofficer
/healthcarehome.htm
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