how california learning collaboratives are building new health neighborhoods jennifer clancy, msw ca...
TRANSCRIPT
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How California Learning Collaboratives are Building New
Health Neighborhoods
Jennifer Clancy, MSWCA Institute for Behavioral Health Solutions
November 18, 2014
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Overview
• CA Solution- Creating Accountable and Coordinated Care
MethodologyInterventionA County ExperienceKey Learning
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The Problem….
FUNDERSFUNDERS
RECIPIENT/ RECIPIENT/ INTERMEDIARYINTERMEDIARY
PAYORS/ PAYORS/ CONTRACTORSCONTRACTORS
PROVIDER PROVIDER NETWORKNETWORK
CMS HRSA SAMHSA Tax Payers (Millionaires) Foundations
DHCS FQHC County BH Health
CBO:Housing
CBO:SUD
CBO:MH
CBO:Social Service,
Peer, Etc
FQHC Managed Care Plan County Behavioral Health
CBOs (MH, SUD, SS,
Peers)
CBOs (MH, SUD, SS,
Peers)
County Behavioral
Health
County Behavioral
Health
FQHCs / Health Clinics
FQHCs / Health Clinics
Result of Uncoordinated Systems is that Serious Mental Illness is:
1. Common2. Disabling3. Expensive4. Deadly
UNCOORDINATED SYSTEM
Jennifer Clancy, CIBHS
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California Building Blocks for the System Solution
Various Funding Sources Organized by Triple Aim
Principles
Single Accountabl
e Entity
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California/ACA Building Blocks for the Practice Solution
• Practice Transformation: Integrated and Coordinated Care1. Comprehensive Care Plans2. Quality Driven3. Comprehensive Services4. Care management, care coordination, and
transitional care5. Use of HIT
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Collaborative Team Model
Primary CarePrimary Care
PatientPatient Care Coordinator
Care Coordinator
PsychiatristPsychiatrist
Substance Use
Counselor
Substance Use
CounselorCase ManagerCase Manager Peer
CounselorPeer
Counselor
Primary CarePrimary Care
PsychiatristPsychiatrist
Population Consultants
Care Coordination Team
Direct Service Providers
Care Plan
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How Do We Get There?
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CIBHS: IHI Breakthrough Series Learning Collaboratives
• History: 5 years, 40 counties• Funder: Department of Health Care Services• Focus Areas: Recovery, Care Coordination and
Integration• Organizational Partners: Mental health, Substance
Use, Primary Care and Peer Providers & Managed Care Plans
• County Aims: Make fundamental systems and practice changes to improve the health status of individuals with chronic, complex and co-occurring behavioral health and physical health disorders
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Methodology- Quality Improvement Methodology- Quality Improvement FrameworkFramework
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The Intervention
Care Coordination InfrastructureCare Coordination Infrastructure10
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Small Tests of Fundamental Care Coordination Processes
Some CC processes done by the care coordinator…
1. Outreach and engagement2. Release of Info3. Patient-Centered Care
Coordination Plan4. Screening5. Referrals6. Use Registry7. Medication Reconciliation
While some CC processes monitored by the care coordinator…
8. Shared Care Goals9. Multidisciplinary Clinical
Care Teams10. Promote Self Management11. Ad Hoc Clinical Case
Consultation12. Ensuring Urgent Access13. Manage Transitions
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Results- Example Measures
FOR ALL PARTNER ORGANIZATIONSBMI & BP
Shared Care Goals
Medication Reconciliation
Client Experience of Care and Confidence
MENTAL HEALTHClients Who Smoke Who Have Been Advised to Quit
Substance Use Disorder Screening
2nd Gen Antipsychotic with A1c in last year
SUBSTANCE USESubstance Use Disorder TX
Mental Health Screening
PCP Designation and Documentation
PRIMARY CARECVD with LDL less than 100
Mental Health and SUD Screening
DM Appropriate Lab Testing
HEALTH PLANSCost Per Member Per Month
Emergency Room Use
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Fresno CountyOne County’s Story…
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Fresno County Dept. of Behavioral Health
County MHP, convening organization and
client care coordinator
Ambulatory Care Center
High-fidelity IMPACT model of integrating mental health services into primary care clinic. Serves clients with mild/moderate mental
illness
Ambulatory Care Center
High-fidelity IMPACT model of integrating mental health services into primary care clinic. Serves clients with mild/moderate mental
illness
Clinica Sierra Vista: FQHC, integrated mental
health & primary care clinic serving Medi-Cal, Medi-Care
& uninsured individuals
A local Public Health Plan created by the Regional Health Authority to
serve Medi-Cal members in the counties of Fresno, Kings & Madera.
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The Fresno County Care Coordination Partnership Team will make changes to improve the whole health status of adult individuals by coordinating services for the clients with the most serious mental illness and substance use disorders.
Behavioral Health and physical health care’s coordination has, thus far, been driven by individual providers rather than system change. Long-term change must be driven by the systems rather than pushed forward by a few practitioners.
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Overall Theme Across All Agency Partners• Recognize the importance of physical and mental health care
to overall well-being of an individual• Shared goal and all agency partners benefit!
Agency Catalysts for Care Coordination/Population Health:
– Mental Health (Medical Director)– CalViva Heath Plan– Primary Care
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Key changes the Team has been working on• Multidisciplinary Clinical Care Conferences (routine & ad
hoc) • Develop routine SUD screening• Support of client self-management • Ensuring and monitoring routine medication reconciliation• Ensuring and monitoring authorizations for sharing client PHI• Referral process between MHP and PCP• Sharing of patient physical exams, test & lab results
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CC measures data collection process • Excel spreadsheet (tracks key health
indicators, ROIs, etc.)• MHP’s EHR system (Avatar) - Data
reports created specifically for CCC & embedded into EHR for ease of generating data
Who is responsible for collection?• PCPs and MCPs collect data for their
respective measures.• MHP data analyst responsible for MH
data collection, synthesis of data from MCP & PCPs, and reporting out to CiBHS
CSV (FQHC)NextGen
CSV (FQHC)NextGen
CalViva(MCP)
CalViva(MCP)
DBH(MHP)Avatar
DBH(MHP)Avatar
CiBHSCCC
CiBHSCCC
Agency-Specific CCC Data Measures & Client List
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Maintain key personnel from partner agenciesBuy-in from executive leadership Right People at the Table with the Right
Personalities:• Client centered and dedicated providers• Providers who follow through and are accountable • Providers who are real learners. “Care coordination and
population health is so different from what has been done before- given the learning curve, the team members must be learners”.
• Providers who are honest, transparent, and “leave their egos at the door”
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Key Learning and So What
• Commit to Building Org. Relationships/Partnerships
• Collective Responsibility but Accountable Convening Entity
• Invest in Data Infrastructure• Use QI Methodology and Data Routinely• Sustain Engaged Leadership• Test Fundamental Changes- Don’t Tinker