RP OAK HILL DEVELOPMENT

LOYOLA RECOVERY FOUNDATION, INC.Health System Innovation: Supporting Recovery in a post ACA Environment

Long Island Recovery ConferenceNovember 15, 2013

August 2013AGENDABrief Review of Loyola ModelKey Current Business ComponentsState and Federal VA and Non-VA Healthcare EnvironmentmPOWERProtecting Veterans at Risk

August2013The ChallengeCan inpatient and outpatient medical/surgical, specialty, mental health, primary care and substance treatment service arrays be altered or augmented with evidence based tools embedded in technology?Can those products be developed, tested and approved with consumer input or control?Can behavioral health business models understand and generate products that consumers, health systems and public health systems will value?Can those products be monetized in durable ways?What is The Local Imperative ?Traditional BH Systems Largely Outside Robust Consumer Control (Peer Systems an Exception), Health Systems Planning and Significant Public Health InvestmentRapid Decline of State Discretionary Funding given Big State Employment Legacy, Health and Education Costs60 Months of Medicaid Rate Erosion and the Prolific 2014 Risk Bearing Care Management ProliferationMetrics, Outcomes and Cost Models Not Widely DevelopedImperative, cont.Business Planning, Administration and Development Expertise Largely Drawn from Itinerant Board Members.Welcome to Parity and the ACAThe Doctor and Everyone else is Not In; Staffing ProblemsBH Passed By in initial pre-ACA Health Infomatics InvestmentsAnecdotal Observation: Most FQHCs and Medical Homes are collaborating for Housing and building ACO or Medical Home BH services within.Imperative, cont.The Emerging Complex ProblemsOpiate Dependent Surgical PatientsOpiate Dependent Moms/NewbornsCollege Binge DrinkingVeteransSuicide, IOM FindingsWorkplace Health (Including Health Systems)DWITraffic FatalitiesLoyola Model ReviewProvide an Aspirin for VA Healthcare Headaches for Veterans with Complex Care, Addiction, Housing, Employment and Behavioral Health Needs.Loyola Rubric: Better Care as Evidenced by Clinical Outcomes and Patient Satisfaction; Lower Price; Expanded Service; Proof of Concept that Evidence Based Medicine, Innovation and Integration are possible.August2013Loyola Model Review ContinuedMaintain Rubric in Accordance with a Recovery Vision Veterans Support:Recovery = Health, Job, Home, Relationships (A Life in the Community For EveryoneCharles Curie)Care Questions Normalized to the Voice of the Veteran with Veteran Governance.Services Build Mutual Reinforcement by providing Veteran Employment.August 2013Loyola Model Service Components50 Crisis Detoxification Beds (Bath, Albany VAMCs 25 Each).Eaglestar Housing 15 Transitional Beds in East Pembroke, 15 in Spencerport and SPARC.mPOWER Outpatient Model for At Risk Veterans.VITAL Intervention Project with Rochester General Hospital.Operation Economic Freedom Call Center

August 2013Loyola Service MatrixAugust2013VA and Non-VA Healthcare EnvironmentAffordable Care Act seeks to bend the cost curve through effective management of high risk/high need patients.September, 2012 Presidential Executive Order directs VA to Contract with Community Healthcare Providers for Service needs not met by VA.IOM Report (September 2012) indicating high opioid/alcohol prevalence among veterans and low infrastructureAugust 2013VA and Non-VA Healthcare EnvironmentIntegrated Specialty Care Components based on evidence based models with Pay for Performance approaches Sought by Healthcare entities (build or buy) to capture savings or enhanced Medicaid.Adoption of Meaningful Use EHRs, Predictive Analytics and Mobile Technologies Essential (Loyola has all three).Track Record, Accreditation, Quality Assurance.August 2013mPOWERIn 2010, Loyola identified 43 Veterans with 3 or more Detoxification Hospitalizations in 18 months or less.Similar profiles of chronic alcohol dependence, trauma, mental health condition and physical illnessEvery detox episode offered the same thing for a recovery support strategyHealth kept deteriorating and Risk Factors were risingAugust 2013mPOWERLoyola designed a bundled evidence based care and integration strategy combining cutting edge technology in, smartphone recovery support (ACHESS), pharmacological recovery support (Vivitrol), trauma support (Najavits, et.al.) and peer support (White, et.al.).Strategy defined as mPOWER Program (Mobile Patient Opportunities for Wellness, Empowerment and Recovery)August 2013mPOWERSAMHSA funded project for 3 years (2011-2014)Service Partners: University of Wisconsin ACHESS Project, Westat (Evaluation) and myStrength (online mental health support)Key metric for the program is to reduce inpatient hospitalization rate to 1 or less every 18 months.Data Collected: GPRA, SF-36, PHQ-6, Brief Alcoholism MonitorBAM (weekly analytic)August 2013mPOWERProject integration strategy is that mPOWER medical providers are credentialed by VA Health System and project works as collaborative care model with VA Mental Health and PACT primary care teams.All services delivered at Bath VAMC and supported by Loyola Transportation NetworkLoyola staff paid for by grant. Medication prescribed out of and procured by VA pharmacy and labs paid for by VA. August 2013mPOWERLoyola staff enters notes in VA CPRS system capturing encounters for VA utilization data and Vivitrol ordered out of VA pharmacyLoyola staff attends Behavioral Health and Primary Care team meetings.Patients weekly survey mapping risk and protective factors are done on the smartphone (BAM) and staff responds to high risk situationsSmartphone ACHESS application utilization tracked by UW.August2013mPOWERKey Results (Updated Sept. 1, 2013)44 Active Patients (0 to 18 Months, 26 for 12 Months or more)Pre-Enrollment Total Hospitalizations in Patient Cadre = 153Post-Enrollment Total Hospitalizations in Patient Cadre = 5663% Reduction in Hospitalizations. Multiple relapses localized to 6 patients

October 2013mPOWERRaises Questions about evolution of managing typical chronic co-morbidities and complex patient medical homes; use of Big DataProgram Admission Demand, driven by veteran patient word of mouth is double current capacityVISN recognizing need for more capacity; ACHESS and Dashboard purchased for 1000 Veterans, contracting underway for service expansion Rest of Care Continuum must be developed (Housing, Employment)October 2013Three Essential Ingredients of Change(CHESS Foundation)August 2013CopingCompetence SocialRelatedness AutonomousMotivation

Qualityof Life

ACHESSAugust 2013ACHESSMonitoring and alertsRemindersAutonomous motivationAssertive outreachCare coordinationMedication remindersPeer & family supportRelaxationLocations trackingContact with professionalsInformation

August 2013

ACHESS has better 30 day abstinenceDifferences significant at p = .03August 2013N = 349ACHESS had fewer heavy drinking days Differences significant at p = .003August 2013N = 349Chronic Disease Costs

Top Chronic Conditions22 May 2013Total Expenses & % Distribution of Top 10 Most Expensive Conditions, United States, 2012Chonic ConditionTotal (billions) All PayersShare of Total: Medicare (%)Share of Total: Medicaid (%)Heart Conditions$107.244.26.8Trauma Related Disorders$82.324.39.2Cancer$81.748.74.4Mental Disorders$73.119.623.5COPD, Asthma$63.833.311.8Osteoarthritis$62.427.410.8Diabetes$51.332.610.2Hypertension$42.929.79.6Back Problems$39.314.814.5Hyperlipidemia$37.226.48.3Business Model DisconnectSubstance Use DisordersCo-MobiditiesClinical Intervention

Social Determinants

SpiritualityChronic DependencePhysicalCognitive Modalities(Ind./Family)

Housing

TranscendentMental HealthPharmacology

Jobs

ReligiousPeer Support

Non-PeerRelationshipsMysticalAbuseCare Management

22 May 2013Creative Destruction of Medicine22 May 2013Technology Functions (M. Oss)Diagnostics Consumer Education/Decision Support Clinical Treatment Cognitive Function Restoration Change In Disease State Detection Relapse Prevention Remote Monitoring Of Consumer Health

22 May 2013Technology Types (M. Oss)Smarthome TechnologiesWearable Remote Vital Sign SensorsSmartphone ApplicationsText Messaging AlertsCompanion Robots (NZ-Rural Gerontological Medication Adherence)Remote Therapy, Consultation and Recovery SupportNeurotechnology (Neuroplasticity, Neurofeedback)Active vs. Passive (Monitoring v. Self Entry)22 May 2013Big Questions About TechWhich of these perform a non-clinical service producing an outcome that equals or exceeds a clinical intervention?Which of these can be characterized as non-clinical in nature and thus outside the social, legal, regulatory requirements of the clinical milieu?Which of these best reflects the voice and preference of the end user or (even better) was developed by end users?Which of these will be captured before commercialization?22 May 2013Key Questions About PatientsWhat Do Patients Need to Have the Highest Probability of Attaining a Positive Health OutcomeWhat Does the Public Health Case Mandate?What Do You Know How To Do?Can You Operationalize It and Prove It Over the Long Haul?Are You the Least Expensive, Most Effective, Most Valuable Thing They Have Ever Seen?What Will You Become When You Have Become #5?22 May 2013Thoughts, Next Steps, Discussion22 May 2013Contact DetailsChristopher R. Wilkins, Sr., PresidentLoyola Recovery Foundation, Inc. 1159 Pittsford Victor Road, Suite 240 Pittsford, New York 14534PH: +1 585.203.1250FAX: +1 585.203.1013cwilkins@loyolarecovery.comAugust 2013