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www.openminds.com n 15 Lincoln Square, Gettysburg, Pennsylvania 17325 n 717-334-1329 n [email protected]
The Systematic Approach To Integrated Health Care: The Data You
Need To Make Primary/Behavioral Health Integration A Success
Th e 2 0 1 8 O P E N MI NDS Te c h no lo gy & I n f o rm a t i c s I n s t i t u t e
O c t ob e r 2 3 , 2 0 1 8 | 1 0 : 1 5a m – 11 : 3 0 am
J o s ep h P. N a u g h t on -Trave rs , E d M , S e n i o r A s s o c i a t e , O P E N MI N D S
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© 2018 OPEN MINDS
AgendaI. Integration In A Value-Based Market
II. Data Integration Case Study: Partners In Recovery
Christy Dye, Chief Executive Officer & President, Partners in Recovery
III. Data Integration Case Study: Resources for Human Development
Emily Nichols, MPH, Director of Operations, Resources for Human Development
(RHD)/Family Practice Counseling Network
Bill Maroon, Organizational Development Specialist, Business Development
Team, Resources for Human Development (RHD)
IV. Questions & Discussion
2
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© 2018 OPEN MINDS© 2018 OPEN MINDS
Integration In A Value-Based Market
3
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© 2018 OPEN MINDS
The Big Picture
Payer preference for integration driving use of value-based reimbursement
Value-based reimbursement increasing in all types of health and human service financing
Value-based reimbursement changing the fundamental business model of provider organizations
Success in this environment requires evolution –governance, management culture, and operating infrastructure
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© 2018 OPEN MINDS
Shifting Payer Focus On “Superutilizer” Impact On Health Resource Use – Driving Interest
• $43,212 average expenditure per person per year
5% of U.S. population account for half (49%) of health care spending
• $253 average expenditure per person per year
50% of U.S. population account for only 3% of health care spending
“Superutilizers”
Term for people with complex
physical health, behavioral
health, and social issues who
have high rates of utilization for
ER and hospital services
More than 80% of Medicaid
superutilizers have a comorbid
mental illness
An estimated 44% of
“superutilizers” have a serious
mental illness
Payer preference for integration driving use of value-based reimbursement
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© 2018 OPEN MINDS
Behavioral Health Conditions PredictIncreased Health Care Spending
People diagnosed with a comorbid behavioral
health and chronic health condition
Cost 300% more
than those with only a chronic
health condition
Behavioral health problems cost
$200 billion
per year, more than heart
conditions, trauma, or cancer
People with one or more behavioral health conditions
spend
$672 billion
annually on overall health
care
Payer preference for integration driving use of value-based reimbursement
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© 2018 OPEN MINDS
Lack Of Integrated Care Coordination Results In Poorer Outcomes & Higher Cost Per Consumer
Drives adoption of coordinated care models across medical, behavioral, and social
systems...
Social
Behavioral
Medical
New service model:
behavioral health
services “imbedded” in
primary care for
mild/moderate
conditions
New service model:
single “vertical” care
coordination program
for each consumer
Social
Behavioral
Medical
Payer preference for integration driving use of value-based reimbursement
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© 2018 OPEN MINDS
Emerging Framework For Integrated Care Coordination
Behavioral health system optimization is central to success – and value-based
reimbursement is key to that optimization
Managed Care Programs & Health
Plans
Accountable Care Organizations
Medical Homes & Specialty Medical
Homes
Specialized Disease Management Program
‘At Risk’ For
Population
Health
Management
‘At Risk’ For
Individual
Health
Management
Payer preference for integration driving use of value-based reimbursement
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© 2018 OPEN MINDS
What Are The Value-Based Reimbursement Options?
Case
rates and
bundled rates
Medical homes and specialty medical homes
Capitation and/or population health gainsharing arrangements
With P
ay-F
or-
Perf
orm
ance C
om
ponents
Specialist
positioning
Comprehensivist
positioning
Value-based reimbursement increasing
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© 2018 OPEN MINDS© 2018 OPEN MINDS
Partners In Recovery Case Study
Christy Dye, Chief Executive Officer & President, Partners in
Recovery
10
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Christy Dye
Chief Executive Officer
Partners In Recovery
OPEN MINDS
Technology & Informatics Institute
October 2018
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Began as Outpatient Behavioral Health provider serving 3,800
adults with SMI in 2009
An alternative to traditional mental health services for adults
with SMI emphasizing:
Choice
Whole person wellness
Voice & involvement
Integration of best clinical practices and compassionate
professionals with the wisdom of individuals receiving services
and their family members
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Began experimenting with different models of delivering primary care in 2011
Co-located physician group practice – 2011
Co-location by a local FQHC - 2012
First PIR Integrated Health Home - 2014
Medical ACT Team – 2015
Serving 8,000 adults with SMI at 7 clinics across Maricopa County
5 Integrated Health Homes
1 Medical ACT Team (stand-alone clinic)
1 rural FQHC partnership
CMS Transforming Clinical Practice Initiative (TCPI) participating agency
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34% (1,588 Members)
Arrowhead -Aug 2016
MACT Team- Oct 2016
Gateway -September
2017
Metro -December
2017
West Valley- April 2018
797
100
748
1243974
50%
100%
55%
39%
20%
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High rates of premature mortality among SMI
Disease burden magnified by manageable health conditions (smoking, obesity, sedentary, SUDs)
Focus on high cost/high need
Who are the 10% most at risk?
Integrating PCP within BH clinic supports a learning model unique to populations with cognitive impairments
Direct access to healthcare on site
Small doses over long periods of time
Existing relationships with psychiatry
Meeting people where they are on their road to health
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Condition 2016 AZ
General Pop.
(6,392,017)
PIR
Arrowhead
(n=1,020)
PIR
Gateway
(n=976)
Hypertension 30.8% 34% 43%
Respiratory/
Asthma
15.7% 54.3% 35.8%
Diabetes 10.1% 14% 20.8%
Heart Disease 3.8% 32.6% 35.8%
Obesity/BMI 28.4% 58.7% 56.8%
Tobacco Use 14% 55.3%
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# of ED Visits % of Total
Visits
# of Patients Total Visits
10+ 31.6% 181 2,837
5-9 25.2% 388 2,266
3-4 20.4% 580 1,771
2 11.8% 565 1,059
1 11.5% 1,116 1,030
Total 100% 2,797 8,963
Data Source: Mercy Care
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Clinical Structures that support integration, not co-location
Facility design
Clinical team roles, including care coordination & care
management
What services are offered
Technology that supports integrated workflow & member
outcomes
Population health management
High risk interventions
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SMI Integrated Health Home
Behavioral Health, Primary Care, Pharmacy
& Robust Wellness Services
Engaging People on their Journey to Health
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PIR’s “teaching kitchen” develops skills in
food safety, selection and preparation.
Supervised by a master’s level nutritionist
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Certified fitness trainers provide classes in
equipment safety, yoga, weights, step and
chair activities
Drop in or PCP referral
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Wellness Strategies Targeting: Through:
Obesity Nutritional Counseling
Sedentary Lifestyle Fitness, Stress & Exercise
Management
Poor Nutrition Teaching Kitchen
Life Stress Peer Health Coaching
Smoking & Other Substance Use Life Skills/Health Promotion
Services
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Sources of Data
Single EMR & Integrated Care Plan
Social Determinants of Health Screening
Health Information Exchange ADT Alerts
Care Management
Population Health Platform & Claims
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Using data to target population-wide and person-specific
clinical interventions
High risk – utilization
Care gaps – prevention
Improving BH/PH outcomes – care management
Managing/negotiating value-based contracts
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Change to Policy –
Follow up appointment after psych inpatient discharge in 4 days,
rather than 7
Change to Staffing –
Hire Discharge Coordinators
Staff Training –
Driving Suicide to Zero Screening
Initiative Focused on Specific Care Gap –
On-Site Retinal Eye Exam
Environmental –
Home Visit to Check on A/C Unit
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OctoberNovember
December
January FebruaryMarch
April
May
June July August
0.0
5.0
10.0
15.0
20.0
25.0
30.0
Hosp
ital A
dm
issi
ons
Per
1,0
000
SMI Psychiatric Admissions per 1,000
October 2017-August 2018(SMI Medicaid Population =5,500*)
50%
Reduction
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High Risk Registry for familiar faces
Establish clinic-based teams to focus specifically on these
individuals
Functional Risk Analysis
Record review
Member outreach, natural supports
Individualized assessment & strategy
Medications, Dx, baseline
Health literacy
Reason for visit (stomach ache, headache)
Goal is to provide alternatives to high cost settings
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0
5
10
15
20
25
30
35
ED Visits
Hospital Visits
MAT
Risk
Analysis
JT’s Story
Pre-Intervention – 96 ED Visits in 12 mos
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Functional Risk Analysis determined that visits were
driven by opiate use
Team accessed Az Pharmacy Board CSMDP and identified
multiple prescribers of opiate medications
High Risk Assessment Group implemented a clinical
intervention involving:
Medication Assisted Treatment
Pharmacy Lock
Better coordination with staff in his housing program
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0
5
10
15
20
25
30
35
January Febuary March April May
64%
ReductionIntervention
Functional Risk
Analysis &
Intervention
Baseline
ED High Risk ACT Teams 2018
Pre-Intervention - 18 patients @ 4 Visits pmpm
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Present utilization reports for past 6 months to ACT Teams
Monthly update
ACT Morning Meeting focus on top utilizers on each team
ACT on-call proactive in reaching out after-hours and on
weekends
Connecting ACT members with PIR’s PCP
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January
February
March
April
May
June
July
August
0
100
200
300
400
500
600
Tota
l ER
Vis
its
per
1,0
00 m
em
bers
$218,000
$99,000
PIR ED Visits per 1,000(SMI Medicaid Population)
Total Savings YTD 2018
$119,000
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Measure Goal Omega Varsity West
Valley
MACT
Psych
Hospital
-20% -38% -14% -36% -29%
Acute
Hospital
-20% -13% -42% -55% -25%
ED Visits -20% -25% -20% -4% -42%
Employed +5% 128% 49% 13% 100%
PCP Visits +10% 26% 23% 57% 24%
Jail -10% 22% -40% 10% 2%
A1c
Test
57% of
pop
50%
Eye Exam 49% of
pop
75%
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© 2018 OPEN MINDS© 2018 OPEN MINDS
Resources For Human Development Case Study
Emily Nichols, MPH, Director of Operations, Resources for
Human Development (RHD)/Family Practice Counseling Network
35
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Emily Nichols, MPHFamily Practice & Counseling Network
Director of Operations
Integrated Care In A Behavioral Health Setting
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Outline History of FPCN
Using tablets to screen for trauma history, depression and
drug/alcohol use
Data
Workflow
Outcomes
Lessons learned
What’s next?
37
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Family Practice & Counseling Network (FPCN)
A network of 5 federally qualified health centers in Philadelphia
• 4 patient-centered medical homes
• 1 “expanded” convenient care in a grocery store
23,288 patients and 104,485 visits in 2017
38
Primary care
Dental
Outpatient BH
Integrated BH
Prenatal
MAT
Mind/Body
Nutrition
Social Services
Transportation
Outreach & Enrollment
Community Health Workers
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Using Tablets to Screen for SDOH Trauma history using ACEs
• ACEs-2 screener
• Research project by Roy Wade, MD identified:
– 2 questions as a significant predictor of ≥4 ACEs
» Were you sworn at, insulted, or put down by a parent or adults in your home more than once during your childhood?
» During your childhood, did you live with anyone who was a problem drinker or alcoholic?
– Reliable/Valid method of screening patients
Depression using the PHQ
Alcohol and Drug Use using SBIRT
39
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Workflow Patients are given tablets at registration
• All registration info at every visit
• ACEs
• 14 – 17 years of age – screened every 6 months
• ≥18 years of age – screened once
• PHQ: ≥14 years of age – screened every 6 months
• SBIRT: ≥12 years of age – screened every 6 months
Medical Assistant: during triage, data will flow into the patient’s chart via a
button on the intake form
Warm hand-offs to BHCs or other support staff by Provider, MA, if +
screening
40
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Trauma History
41
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Depression
42
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Drug & Alcohol Use
43
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Data: ACEs Screening
44
0 2
832
647
7 5
457
351
0
100
200
300
400
500
600
700
800
900
9/17 - 11/17 2/17 - 2/18 3/18 - 5/18 6/18 - 8/18
ACE-2 + ACES Score >=4
Tablets Implemented
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Data: PHQ Screening
45
Tablets Implemented
108133
653
506
1345
448
349
0
100
200
300
400
500
600
700
9/17 - 11/17 2/17 - 2/18 3/18 - 5/18 6/18 - 8/18
PHQ2 + PHQ9 score >=10
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Data: Drug & Alcohol Screening
46
Tablets Implemented
10 11
184
163
2820
182
162
0
20
40
60
80
100
120
140
160
180
200
9/17 - 11/17 2/17 - 2/18 3/18 - 5/18 6/18 - 8/18
SBIRT - Alcohol +
SBIRT - Drug +
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Current Outcomes Identifying more patients than ever before with significant trauma
history, depression and/or current drug/alcohol issues
• 55% of patients with a +ACEs-2 has an ACEs score ≥4
• 68% of patients with a +PHQ-2 has a PHQ-9 ≥10
Linking to Resources
• 43% of patients with an ACEs score ≥4 have a BHC visit
• 69% of patients with a PHQ-9 score ≥10 have a BHC visit
• 33% of patients with a +SBIRT screen for drug or alcohol have a
BHC visit
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Lessons Learned Communicate, communicate, communicate
• Involve ALL members of the care team in the development and
workflow of the tablets
If you ask a patient a question, you need to be ready to respond
Staff Capacity & Training
• Are ALL of your staff ready to discuss a patient’s trauma history?
Depression? Drug/Alcohol use?
• Are ALL of your staff prepared to give patients needed resources?
• Do you have ENOUGH staff to address all of the positive responses in
the moment of the visit?
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What’s Next? Add PRAPARE questions to on the tablets
Add food insecurity questions to the tablets
Add additional languages to the tablets
Strengthen the workflow to connect our MAT team with patients
with +SBIRT screens
Continue to build staff capacity on addressing patients’
responses
Assess staffing levels
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© 2018 OPEN MINDS© 2018 OPEN MINDS
Resources For Human Development Case Study
Bill Maroon, Organizational Development Specialist, Business
Development Team, Resources for Human Development (RHD)
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Bill MaroonDirector of Business Development and Innovation
Integrated Care In a Behavioral Health Setting
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Established 1970
14 States
160 programs
CCBHC grantee
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LMCMS – Lower Merion Counseling and Mobile Services
The very first RHD program in 1970, started with a $50,000 grant
from Montgomery County
Community-based outpatient mental health treatment center
• D&A and MH Services to individuals, groups and families
• Mobile Recovery Support Teams and Peer Specialists
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CCBHC – Certified Community Behavioral Health Clinic
CCBHC pilot grants were only given eight states (currently up to 67 clinics nationwide)
Goals of the demonstration program:
• To better integrate behavioral health with physical health care
• To increase consistent use of evidence-based practices
• To improve access to high quality care for people with mental and substance use disorders
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Alternative Payment Method – Bundled Payment
One payment for each day versus one rate per service
Goal is to get multiple services completed in one day
Rate per day will eventually be tied to Outcomes/Performance
• Currently, capturing data on 21 different quality measures such
as program records, Medicaid claims, managed care encounter
data, clinic cost and integration of services.
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Integration efforts
Collateral Contacts and Doc to Doc consultations are paid at our same daily
rate.
D+A evaluations completed for local hospital for persons who on their Kidney
and Liver transplant list… Hospital pays for 4 D&A sessions.
Recovery Coaches perform ‘Strengths Assessment” every six months which
includes a set of physical healthcare questions that may trigger a referral to
primary care or doc to doc consultation
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Integration efforts
Traumatic Brain Injury education and referral by local rehab
Development of Wellness Team and adding Nursing component to current
Recovery Teams
WRAP plans include physical health question
Local Emergency Room – Friendly Faces triggers a contact to our Mobile
Teams
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Integration – Where we want to go…
Health Care Exchanges – regional and/or national
• HSX
• Carequality
Direct Interoperability with certain local providers
Nursing on-staff
EHR interoperability with Mobile Wellness Applications
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Lessons Learned
Data, Data, Data
What you put in is what you get out…
• better data, better service = healthier people
Let your legal team figure it out... ROI
It goes slower than you anticipate
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© 2018 OPEN MINDS© 2018 OPEN MINDS
Questions & Discssion
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