Regional Partnership Meeting

Transcription

1 RHP 1 Regional Partnership Meeting September 15, 2015 NORTHEAST TEXAS REGIONAL HEALTHCARE PARTNERSHIP

2 RHP 1 Welcome & RHP 1 Updates Daniel Deslatte NORTHEAST TEXAS REGIONAL HEALTHCARE PARTNERSHIP

3 RHP 1 RHP 1 Learning Collaboratives Brittney Nichols NORTHEAST TEXAS REGIONAL HEALTHCARE PARTNERSHIP

4 RHP 1 Primary Care and Behavioral Health Integration Andrews Center Community Healthcore Texoma Community Center Trinity Mother Frances NORTHEAST TEXAS REGIONAL HEALTHCARE PARTNERSHIP

5 Andrews Center Medical Services Jana Campbell, RN Integrated Healthcare Program Director

6 Andrews Center is an outpatient community mental health/idd center with integrated physical health. Our Medical Services Department opened in September

7 Learning Collaborative What did AC change during this collaborative? Andrews Center chose to become a Tobacco Free facility during this collaborative time. Why? Andrews Center is committed to the preservation of the health and wellness of all of our clients and employees. We strive to promote a healing environment for our clients, guests, associates, volunteers and the community.

8 CPRIT Prevention Grant The University of Texas MD Anderson Cancer Center, The University of Houston, and the Austin Travis County Integral Care received an Evidence-Based Cancer Prevention Services Grant from the Cancer Prevention Institute of Texas to help disseminate a multi-pronged Tobacco-Free Workplace Program to selected Texas Local Mental Health Authorities. AC applied for and was awarded this grant. The grant provided training/education, consultation, policy assistance, treatment resources, and practical guidance, as needed, to both implement and sustain the changes that will result in the long-term prevention of tobacco related cancers among consumers, employees, and the larger communities in which they live.

9 CPRIT Grant Sent 2 of our providers to a Prescribers Training in Houston, Texas. Sent 1 counselor to Rutgers University in New Jersey for a 5 day training to become a Certified Tobacco Treatment Specialist. Provided training for Executive Management, Mid Level Managers, and direct/non-direct care staff for the changes that would need to take place. Funding: AC received approximately $1,200 for signage and approximately $8,000 in /Nicotine Replacement Therapy. This included Nicorette gum and Nicotine patches. We provided this to both clients and employees, who enrolled in the Smoking Cessation Program, at no cost to them.

10 Smoking Cessation Program First step: Assign a Program Leader and then form a committee. Our committee consisted of employee s from HR, Executive Management, case management, and nurses and providers from both our Medical Services and our Mental Health departments. This committee worked on policy and procedures, signage, dates for implementing changes, forms to be used, questions that came up during the process, etc. Our team chose a quit date of August 1, 2015 Andrews Center kicked off our Smoking Cessation Program May 1, 2015

11 Smoking Cessation Program Case managers perform the Tobacco Assessment Tool when they had client appointments. If the client was interested in joining the program, they brought them to our Medical Services department. Medical Services staff would go over the assessment with them, determine NRT needed (depending on their tobacco use), have them sign the NRT Therapies Acknowledgment, give them educational materials, and answer any questions they may have. Employees could come by Medical Services at their convenience and fill out the Tobacco Assessment Tool and then go through the same steps listed above. Seems pretty simple and what could go wrong, right?!?!?! Well

12 Problems we encountered: We were not prepared for the amount of people who wanted to participate in the program. Although this was a great thing, since all of these people were seen on a walk in basis, it was overwhelming for the Medical Services staff. It was quite disruptive to the daily schedule and there was a lot of extra paperwork. We were also trying to keep a detailed database tracking all of this information and making follow up phone calls to those in the program. All of these things were quite time consuming. But, we found a solution!!! INTERNS!!! Approximately a month into the program we were able to bring an intern onto our team. We set up an office for our intern in one of our exam rooms and he/she was able to handle all of these things, except times when he felt the client needed more provider input or counseling. By the time the program ended on August 1, 2015, we had the help from 3 different interns.

13 Results: 257 assessments performed 144 clients/employees joined the program (14 employees, 130 clients) 46 were successful in reducing OR quitting the use of tobacco products Andrews Center became a Tobacco Free Campus on August 1, 2015

14 RHP 1 Regional Partnership Meeting September 15, 2015 NORTHEAST TEXAS REGIONAL HEALTHCARE PARTNERSHIP

15 RHP 1 MCO and 1115 Waiver Collaboration Daniel Crowe, M.D., C.D.E. Senior Medical Director Superior Health Plan Angie Parks, R.N., B.S.N. Senior Quality Director UnitedHealthcare Community & State, Texas NORTHEAST TEXAS REGIONAL HEALTHCARE PARTNERSHIP

16 MCO and 1115 Waiver Collaboration RHP 1 Fall Conference September 15, 2015 Angie Parks, RN, BSN Senior Quality Director UnitedHealthcare Community & State, Texas Daniel Crowe, MD, CDE Senior Medical Director Superior Health Plan

17 MCO Quality Programs All MCOs in Texas are required to have a Quality Assessment and Performance Improvement (QAPI) program with the following components: QAPI Program Description QAPI Work Plan Annual Evaluation of QAPI Program Effectiveness Adoption of Clinical Practice Guidelines Access and Availability Monitoring Participation in the HHSC Pay-for-Quality Program for MCOs Performance Improvement Projects (PIPs)

18 MCO Quality Programs Two primary opportunities for collaboration with MCOs and 1115 Waiver DSRIP projects: HHSC Pay-for-Quality Program for MCOs o Potentially Preventable Events (PPEs) o HEDIS Measures Performance Improvement Projects (PIPs)

19 State MCO Pay-for-Quality Program: CY 2015 Measures

20 Performance Improvement Projects (PIPs) May target improvement in relevant clinical and non-clinical areas Should have a potentially significant impact on members health, functional status, or satisfaction for high-volume or high-risk conditions of the population served Minimum 2 years to conduct in order to allow time for interventions to have impact

21 Performance Improvement Projects (PIPs) Related to MRSA NE MCOs HHSC Assigned

22 DSRIP Collaboration Opportunities Projects that support performance improvement in the following areas are of interest to MCOs: Reduction of preventable admissions, readmissions, ER visits and complications Closure of gaps in care (diabetes, prenatal care, postpartum care, well child visits, medication management) Increasing medication adherence Providing care in the home or alternate settings Integration of medical, behavioral and social supports

23 MCO Collaboration Considerations How many potential members will a project touch for the MCO? o If low number of members, not as desirable due to low impact Does the project address a key area of impact needing improvement for the MCO s members? o For example, schizophrenia is a major driver of preventable admissions and readmissions programs addressing this would be more desirable than those affecting a less significant driver

24 MCO Collaboration Considerations Does the facility (hospital, clinic) participate in the MCO s network? o If not, there may be contracting and HIPAA barriers to overcome Does the project target MCO membership? o Not all MCOs participate in all products in all service delivery areas Can the collaborating partner show program effectiveness either actual or potential related to the MCO s membership? o Is there data to show a return on the investment? If not, what is the plan for measuring effectiveness?

25 Angie Parks, RN, BSN Senior Quality Director UnitedHealthcare Community & State, Texas Daniel Crowe, MD, CDE Senior Medical Director Superior Health Plan

26 Cognitive Adaptation Training in Transitional Care for SMI Dawn I. Velligan, Ph.D. Professor, Department of Psychiatry Director: Division of Community Recovery, Research and Training University of Texas Health Science Center, San Antonio Funded in part by grants awarded from the National Alliance for Research on Schizophrenia and Depression, and the National Institute of Mental Health R01 MH61775; R01 MH62850; R011 MH074047; R01 MH082793

27 Cognitive Adaptation Training in Transitional Care Transitional Care Clinic Rationale for the use of environmental supports Cognitive Adaptation Training Outcome Studies Use in transitional care

28 TCC Program Overview Individuals discharged from psychiatric hospital, ER or consult services in need of transitional psychiatric care Treatment for 90 days or until psychiatric care can be established in the community Services are comprehensive include group intake to streamline access, diagnostic assessment, medication management, counseling, in home Cognitive Adaptation Training (CAT), care coordination and social work services Funding from MHM and DISRIP Goal: Keep people out of hospital and ER who can successfully be treated in a outpatient setting

29 Neuropsychological Profile for Patients with Schizophrenia z Score ABS Profile Mean control subjects Profile Mean VBL SPT SME VME LRN LNG VSM AUD MOT ABS Abstraction VBL Verbal Cognitive SPT Spatial Organization SME Semantic Memory VME Visual Memory LRN Verbal Learning LNG Language VSM Visual-Motor Processing and Attention AUD Auditory Processing and Attention MOT Motor Speed and Sequencing From Saykin et al. Arch Gen Psychiatry 1991;48:

30 MATRICS Taxonomy of Cognition Attention/Vigilance Speed of Processing Working Memory Executive Functioning / Reasoning and Problem Solving Verbal Learning and Memory Visual Learning and Memory Social Cognition Green et al., Biol. Psychiatr 2004;56:

31 Continuous Performance Test Identical Pairs Version Misses False Alarms

32 California Verbal Learning Test Let s suppose you were going shopping. I m going to read a list of items for you to buy. Listen and when I m through, I want you to say back as many of the items as you can. drill plums vest parsley grapes paprika sweater wrench etc. Assesses-verbal memory the ability to recall, to recognize previously learned information and to use contextual cues. Delis DC, Kramer JH, Kaplan E and Ober BA (1987) San Antonio, TX: The Psychological Corporation

33 Executive Functions Initiation and inhibition Cognitive flexibility Planning Problem solving Judgment

34 Wisconsin Card Sort Heaton R.K 1981 Wisconsin Card Sorting Test. Manual Odessa, FL: Psychological Assessment Resources Tests cognitive flexibility and problem-solving

35 End Trails B I 10 B 4 D 3 7 Begin 1 12 H C G A L 2 6 K Lezak, MD Neuropsychological Assessment, Oxford University Press,1995 E 5 J

36 Verbal Fluency Please tell me all the words you can that begin with the letter C Perseveration Cat Cow Cat Carrot Car Cat Can Cow Apathy Car Cat Cow Coin Disinhibition Cat Dog Cow Coin Penny Cake Can Car Truck Benton AL Hamsher K des (1989) Multilingual Aphasia Examination Iowa City, Iowa: AJA Associates.

37 Leading Causes of Disability in Developed Regions Ages Both Genders 1. Major Depression 2. Alcohol Use 3. Road Traffic Accidents 4. Schizophrenia 5. Self-Inflicted Injuries 6. Bipolar Disorder 7. Drug Use

38 Compensatory strategies can reduce the functional consequences of cognitive Executive Function Attention Memory Psychomotor Speed deficits CAT Compensatory strategies Environmental supports Performance of ADL s Social Function Occupational Function

39 Glasses reduce problems in functioning associated with poor vision Poor Vision Glasses Difficulties in: Reading Driving Interpreting Facial Expression Playing Sports

40 Executive Functions formulate plans for goal directed behavior sequence behavior and thought maintain goal-directed-action in the face of distraction inhibit irrelevant or inappropriate behavior

41 Behaviors Associated with Impaired Executive Function Apathy Deficits in Executive Function Disinhibition Frith, 1993; Hart & Jacobs, 1993 Mixed

42 Dressing Behavior--Apathetic Profile Stays in day clothes to sleep Does not complete dressing steps adequately (e.g. shoes untied, shirt incorrectly buttoned, fly unzipped) Stays in pajamas all day Maples & Velligan Am J Psychiatric Rehab 2008 Apr;11(2):

43 Dressing Behavior -- Disinhibited Profile wears multiple layers of clothing wears clothing that is too small, torn or soiled because it is in the closet wears clothing inappropriate for weather or scheduled activity wears clothing or accessories in an inappropriate manner skips important steps in dressing due to distraction from irrelevant stimuli Maples & Velligan Am J Psychiatric Rehab 2008 Apr;11(2):

44 Taking the bus Apathy May ride the bus to the end of the line and not get off at their stop. May miss the bus because they couldn t get going. Disinhibition Mixed May be late for the bus because they have misplaced necessary objects (e.g. keys). May get off the bus at the wrong stop following someone else. May get distracted by store windows or people on the way to the bus. May show behaviors listed under both apathy and disinhibition. Once going on the way to the bus, they may get distracted on the way.

45 General Intervention Strategies for CAT Based upon level of executive functioning and overt behavior Apathy--Prompting and cueing to complete each step in a sequenced task Disinhibition--Removal of distracting stimuli and cues for inappropriate behavior Mixed--Both prompting of steps and removal of distracting stimuli Poor Executive function--cues must be larger, more proximal, more numerous Fair Executive function--more subtle cues, less proximal General interventions are then adapted for strengths or weaknesses in specific areas of cognitive functioning (e.g. attention, memory)

46 Cognitive Adaptation Training Assessments Cognitive Function--Attention, Memory, Executive Functions, Fine Motor Overt Behavior--Frontal Systems Behavior Scale Environmental and Functional Assessment Velligan et al., 2000 Am J Psychiatry; Velligan et al., 2002 Schiz Bul

47 Prior to intervention--dresser and Drawers

48 CAT Intervention for Dressing Apathy Disinhibition Mixed

49 Problems with Orientation Velligan et al., Schizophrenia Bulletin 2009;35(1S):

50 Disinhibition-Fair Executive Function Did I take my medication today? For problems with attention--signs or checklists are printed in florescent colors and the colors of the signs are changed weekly.

51 Making it easy to take medication Decreasing the number of steps needed to take medication increases the likelihood that it will be taken.

52 Checklists for everyday Date 1. Take shower 2. Brush teeth 3. Use deodorant 4. Put on clean clothes 5. Take medication 6. Talk to a friend 7. Do a fun activity behaviors Apathetic-- Poor Executive Function Sunday Monday Tuesday Wednesday Thursday Friday Saturday Velligan et al., Schizophrenia Bulletin 2009;35(1S): ; Maples & Velligan Am J Psychiatric Rehab 2008 Apr;11(2):

53 Daily Schedule Apathetic-- Fair Executive Function Mon Tues Wed Thurs Fri Sat Sun Velligan et al., Schizophrenia Bulletin 2009;35(1S): ; Maples & Velligan Am J Psychiatric Rehab 2008 Apr;11(2):

54 Dental Hygiene --Apathy, poorer executive function Brush Teeth Everyday

55

56 Taking the bus Disinhibition--Fair Executive Function

57 CAT Interventions for complex skills locating key rings all belongings have a clearly marked place where they are used/removed (pouch attached to the bed for glasses, laundry baskets placed where clothing is removed) menu-driven electronic instructions for cooking written instructions attached to cleaning supplies

58 Prior to Intervention

59 CAT Intervention

60 CAT Intervention for Work Fair Executive Function Apathy Disinhibition Mixed

61 Study Design 240 approached 156 consented 99 inpatients 3 mos post DC 57 outpatients TAU (n=29) 105 Randomized 95 with baseline and 1 follow-up CAT (N=32) PharmCAT (N=34) R01 MH62850 Velligan et al.,. Schizophrenia Bulletin 2008 May;34(3):

62 Medication Adherence Over Time 100 by Treatment Treatment Period Follow-up Velligan et al.,. Schizophrenia Bulletin 2008 May;34(3): Percent Adherence Velligan et al., 2007 Group- F(2,138)=23.51; p<.0001 Interaction with time quadratic F(2,251)=3.46p p<.033). 3 months 6 months 9 months 12 months 15 months Comprehensive Supports for Standard Supports Medication Care Adherence by Unannounced, in-home pill Counts/ Blood levels were not used due to problems in interpretation. Pharmacy records produce Similar findings to those illustrated here.

63 Social and Occupational Functioning Scale Social and Occupational Functioning Over Time by Treatment Velligan et al.,. Schizophrenia Bulletin 2008 May;34(3): Treatment Period Follow-up Main effect of Group-F(2,147)=113.38; p<.0001; visits by group (linear)-f(2,202)=4.85; p<.009; visits by visits by group (quadratic) F(2,290)=3.51; p<.032. CAT>Standard and PharmCAT at all time points except 6 mo follow-up. PharmCAT >Standard at 3 and 6 mos. 3 months 6 months 9 months 12 months 15 months Comprehensive Supports Supports for Medication Standard Care

64 Time to Relapse by Treatment Group Survival Distribution Function PharmCAT CAT Standard * Time in Months Velligan et al.,. Schizophrenia Bulletin; 2008 May;34(3):

65 Conclusions Environmental supports can improve target behaviors and broad outcomes There needs to be a focus on implementation in community settings and alterations of reimbursement structures

66 CAT at the TCC Milestones: Decrease 30-day readmission rates Improve Positive and Negative symptom rating scores Engaging patients in care

67 Referral to CAT Referred out of group intake process when cognitive impairment, disorganization, low motivation are identified Referrals are also made by other providers who identify these issues later in treatment or these individuals reinforce a recommendation that was made earlier but not accepted

68 CAT caseloads patients for a full time CAT therapist/trainer Depends upon the system of care long hours spent at our CMHC to get patients an intake and to get patient to first doctor s appointment CAT therapists also provide assistance in SDM and care-coordination

69 Key: Interdisciplinary Communication Regular contact with prescribers at TCC Team effort to reschedule, note medication side effects Communication about the home environment

70 Successes Clinical Over 2400 patients served-approximately 1/3 receiving CAT TCC Provides more than $2,400,000 in care annually Estimated $3,000,000 in savings from ER diversion High patient satisfaction 1.5% reduction in 30-day readmission rates Teaching 45 psychiatry residents, 4 APN students, 6 PA students, 16 counseling students, 13 social work students, 5 psychology interns, and 60 third-year medical students Research PCORI grant Applications in process for PCORI and NIDA UTHSCSA Kick start grant

71 Medicine you can t put in a bottle. September 15, 2015 Eduardo Sanchez, MD,MPH,FAAFP Chief Medical Officer for Prevention American Heart Association

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73 2013 Leading Causes (and Numbers) of o Death in the Texas 1. Heart disease: Stroke (cerebrovascular diseases): Lung disease: Lung Cancers: Alzheimer's disease: Breast Cancer: Hypertension: Diabetes Mellitus: Blood Poisoning: Kidney Disease: Influenza and Pneumonia: Colon-Rectum Cancers: 1572 worldlifeexpectancy.comm; accessed 9/4/15

74 Multiple Chronic Conditions (MCC) One in four (25%) Americans has multiple chronic conditions(mcc), including one in 15 children Among Americans aged 65 years and older, as many as three out of four persons (75%) have MCC. People with MCC are at increased risk for mortality and poorer day-to-day functioning. Approximately 66 percent (66%) of total health care spending in the U.S. is associated with care for Americans with MCC. HHS Initiative on Multiple Chronic Conditions, hhs.gov

75 AHA 2020 Impact Goal 2020 By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%.

76 Ideal Cardiovascular Health: Life s Simple 7 Smoking Status Physical Activity Healthy Diet Healthy Weight Blood Pressure Cholesterol Blood Glucose

77 Cardiovascular Health Health Definitions Status Levels LIFE S SIMPLE 7 POOR INTERMEDIATE IDEAL Smoking Status Adults >20 years of age Children (12 19) Current Smoker Tried prior 30 days Former 12 mos Never /quit 12 mos Physical Activity Adults > 20 years of age Children years of age None None min/wk mod or 1-74 min/wk vig or min/wk mod + vig >0 and <60 min of mod or vig every day 150+ min/wk mod or 75+ min/wk vig or 150+ min/wk mod + vig 60+ min of mod or vig every day Healthy Diet Adults >20 years of age Children 5-19 years of age 0-1 components 0-1 components 2-3 components 2-3 components 4-5 components 4-5 components Healthy Weight Adults > 20 years of age Children 2-19 years of age 30 kg/m 2 >95 th percentile kg/m2 85th-95th percentile <25 kg/m 2 <85 th percentile Blood Glucose Adults >20 years of age Children years of age 126 mg/dl or more 126 mg/dl or more mg/dl or treated to goal mg/dl Less than 100 mg/dl Less than 100 mg/dl Cholesterol Adults >20 years of age Children 6-19 years of age 240 mg/dl 200 mg/dl mg/dl or treated to goal mg/dl <170 mg/dl Blood Pressure Adults >20 years of age SBP 140 or DBP 90 mm Hg SBP or DBP mm Hg or treated to goal <120/<80 mm Hg Children 8-19 years of age >95th percentile 90th-95th percentile or SBP 120 or DBP 80 mm Hg <90th percentile

78 Why focus on Simple 7? Number of Ideal Heart Health Behaviors or Factors and Mortality Deaths per 1000 person-years Yang, et al, JAMA, Vol 307, No.12, March 28, 2012

79 Age-standardized prevalence estimates of US adults aged 20 years meeting different numbers of criteria for ideal cardiovascular health, overall and in selected race subgroups from National Health and Nutrition Examination Survey 2009 to Go A S et al. Circulation. 2014;129:e28-e292 Copyright American Heart Association, Inc. All rights reserved.

80 Simple 7 Prevalence in Adults: Dallas, TX 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Percent Adults Smoking Cigarettes 13.6% Percent Adults with BMI > 30.0 (Obese) 28.9% Percent of Adults with <150 min of MVPA / Week 51.2% Percent of Adults with Inadequate Fruit / Veggie Consumption 76.8% Percent Adults with High Cholesterol 42.3% Percent Adults told to have High Blood Pressure 29.6% Percent Adults with Diagnosed Diabetes 9.4% BRFSS MVPA moderate to vigorous physical activity

81 Texas Public Health Challenges (2005) Exploding costs Highest rate of uninsured Rapid population growth Low immunization rates Threat of bioterrorism An epidemic of obesity Challenges of border region Sharp health disparities Mental health challenges Substance abuse challenges

82 It s like déjà vu all over again. -Yogi Berra

83 Texas Public Health Challenges (2015) Exploding costs Highest rate of uninsured Rapid population growth Better Low immunization rates Threat of bioterrorism emerging infectious diseases and other public health challenges An epidemic of obesity Challenges of border region Persistent health disparities Mental health challenges Substance abuse challenges

84 National Healthcare Quality and Disparities Report 2014 Texas is a weak performer in its balance of below average, average, and above average measures compared to all states. (continuum very weak, weak, average, strong, very strong) Texas is 3 rd from last. Healthy living weak Diabetes very week Prevention weak Chronic at intersection of very weak and weak Ahrq.gov

85 National Healthcare Quality and Disparities Report 2014 Texas Strongest measures 3 of 5 related to vaccinations in 13 to 17 year olds Weakest measures ESRD due to diabetes per 1,000,000 Lower extremity amputations due to diabetes per 1000 Admissions for uncontrolled diabetes without complications per 100,000 Avoidable admissions for high blood pressure per 100,000 New AIDS cases per 100,000 Ahrq.gov

86 Underinvestment in Public Health 3% Of real national health care expenditures since 1980s Prevention requires tools that are often unfamiliar because educational, behavioral, and social interventions, not usually considered to be part of medicine, may be most effective for many diseases. Moses et. al. (JAMA, 2013) Moses et al. The anatomy of health care in the United States. JAMA. 2013

87 Public Health Spending Linked to Declines in Preventable Deaths Mortality rate % decrease per 10% spending increase Infant deaths per 1000 live births 6.85 Heart disease deaths per 100, Diabetes deaths per 100, Cancer deaths per 100, Influenza deaths per 100, Mays and Smith, Health Affairs. Aug 2011;30(8).

88 1115 Waiver in Texas Social Security grants HHS Secretary the authority to approve projects aimed at furthering the objectives of Medicaid. Texas five-year Waiver extends through September Deadline for extension request September 30, 2015 Report by Texas Academy of Family Physicians and Texas Association of Community Health Centers concludes that Texas leaders must adopt and execute a plan for the 115 waiver renewal that includes drawing down all available federal funds to expand health coverage for low-income Texans. Texas Family Physician, Vol. 66 No

89 1115 Waiver in Texas Two funding pools Uncompensated care to hospitals - $17.6 billion Delivery System Reform Incentive Program regional health system reform to achieve the triple aim $11.4 billion $12 billion local dollars that serves as leverage to draw down $17 billion federal dollars Texas Family Physician, Vol. 66 No

90 Delivery System Reform Incentive Program (DSRIP) 25% behavioral health 20% access to primary care 18% chronic care management and health system navigation Texas Family Physician, Vol. 66 No

91 Prevalence of psychiatric disorders in low-income primary care patients Psychiatric *35% disorder of patients with a psychiatric General Primary diagnosis care population patients saw their PCP in the past 3 months. Low-income At least one psychiatric disorder 28% 51% Mood disorder 16% 33% Anxiety disorder 11% 36% Alcohol abuse 7% 17% Eating disorder 7% 10% *35% of patients with a psychiatric diagnosis saw their PCP in the past 3 months. Mauksch, L. B., et al. (2001). Mental illness, functional impairment, and patient preferences for collaborative care in an uninsured, primary care population. Journal of Family Practice, 50(1),

92 A quick reflection cms.gov 27,000,000 (27 million) Texans Using a 20% uninsured rate 5,400,000 (5.4 million) uninsured Texans Then the waiver represents a spend of $ per uninsured Texan per year over 5 years U.S. health care spending reached $9,255 per person in 2013.

93 A quick reflection $ 3.3 billion annual budget for DSHS 27,000,000 (27 million) Texans Then the state spends $ per Texan per year through DSHS 8% of DSHS funding identified as spending for public health = $9.78 per Texan per year dshs.state.tx.us

94 Code Red 2015 Recommendations Obtain a greater share of federal tax funding to expand health insurance coverage so more Texans have access to primary care Create an appropriate state health plan, such as Texas Prescription TxRx Extend/renew the current Medicaid 1115 Waiver. Develop robust local and regional health care delivery systems with increasing emphasis on wellness and prevention programs. Continue to expand behavioral health care and integrate with primary care. Expand the health care workforce in response to community need. Support continued federal funding of FQHCs. Code Red Task Force on Access to Health Care in Texas;

95 A Different Approach

96 Building a Culture of Health in My Community Tobacco Increase percentage of Americans who live in environments that support smoke-free air and smoking cessation Nutrition Improve environments that support healthy eating and improve quality of foods available Physical Activity Increase percentage of Americans who live in environments that support active lifestyles Health Factors Improve environments that support healthy weight, blood pressure, glucose and cholesterol CPR/Chain of Survival Increase percentage of Americans who live in environments that support emergency response for cardiac arrest Acute Care & Emergency Response Increase percentage of Americans who live in environments that support decreased cardiovascular disease mortality and improved quality of life Post-Event Care Increase percentage of Americans who receive the support and education needed after acute events Social Determinants Ensure safe places to work, play, and get care are available for all Americans

97 Relationship Between Social Determinants and Mortality (2000) Galea et al, Estimated Deaths Attributable to Social Factors in the United States, AJPH, August 2011, Vol 101, No. 8.

98 88

99 Example: Tobacco Reduce Tobacco Outcome Good Intermediate Poor 100% of 100% of community community covered by clean covered by clean indoor air indoor air legislation in all legislation in all restaurants/bars restaurants/ bars/ workplaces Increase percentage of Americans who live in environments that support smoke-free air and smoking cessation. Excise tax=$1.85 or > per pack Access to smoking cessation and prevention campaign Excise tax=$1 or > per pack Access to smoking cessation and prevention campaign Community covered by clean indoor air legislation below intermediate level Excise tax= <$1 per pack Access to smoking cessation and prevention campaign

100

101 Global, Federal Legislative/ Regulatory and Industry Environments State Legislative/ Regulatory and Industry Environments Community (Work, School, Religious, Neighborhood) Family, Friends, Social Networks Individual Creating a culture of Health

102 Bridging Community and Clinical Care

103 IOM: Public Health and Medical Care Primary Care and Public Health: Exploring Integration to Improve Population Health Recommendations whose implementation would assist the CDC, HRSA, and HHS in creating an environment that would foster broader integration of primary care and public health. HHS should work with its agencies to develop a national strategy and investment plan for creating a primary care and public health infrastructure robust enough and appropriately integrated to enable the agencies to play their appropriate roles in furthering the nation s population health goals. Annual Report, IOM, March 28, 2012

104 The Practical Playbook Public Health. Primary Care. Together. Enhancing the capacity to improve health and health outcomes by bringing together primary care and public health Stages of integrated population health improvement Success stories (by size of community) Practical Playbook website, 2014

105 Example #1. US Smoking Trends High School Seniors and Adults ( ) DSHS

106 Example #2. Diabetes Prevention Program (DPP) Incidence of diabetes Placebo Metformin Lifestyle (percent per year) 11.0% 7.8% 4.8% Reduction in incidence compared with placebo 31% 58% Number needed to treat to prevent 1 case in 3 years The DPP Research Group, NEJM 346: ,

107 AHA: Tackling High Blood Pressure Improve blood pressure control in traditional and non-traditional settings. Increase HBP control in clinical settings through the adoption of HBP treatment algorithm and other systems changes. Increase HBP control in non-traditional settings through community-based programs that are evidence-based. Linking Clinical and Community Settings

108 Improving Hypertension Control (in Blacks and African Americans) Community to Clinic, Clinic to Community (C2C2) COMBINING UNIQUE ASSETS Bringing together strategic AHA assets directed toward a key national and local issue. Science (evidence-based guidelines) Life s Simple 7 (evidence-based health measures) Check.Change.Control. (community HBP program) Heart360 (online personal health tracking tool) Empowered To Serve (faith-based mega community) The Guideline Advantage (HCP quality improvement) Communications (infrastructure & media partnerships) INTEGRATED APPROACH Leadership, shared tools, protocols, resources and training to deliver improved care, resulting in new, reciprocal connectivity and targeted support between the patient, the clinic, and the community. Community TRUSTED PARTNERS SELF TRACKING HEALTH MENTORS SELF MONITOR ALGORITH M SHARED METRICS TEACH LIFESTYLE SKILLS AD COUNCIL MEDICAL ASSISTANT REGISTRY MEDS CONSULT SERVICES Clinical INNOVATION Transformative care delivery mechanism Lean management principles to iterate the model Surround-sound communication campaign Registry to connect the community and clinical settings Learning Collaborative 2 CITIES 3 YEARS 1 ATLANTA 2 SAN DIEGO The AHA and Kaiser Permanente have a unique opportunity to co-create a scalable, groundbreaking model which establishes and maximizes clinical care and community stakeholder assets, competencies, and partnerships.

109 COMBINING UNIQUE ASSETS Bringing together strategic AHA assets directed toward a key national and local issue. Science (evidence-based guidelines) Life s Simple 7 (evidence-based health measures) Check.Change.Control. (community HBP program) Heart360 (online personal health tracking tool) Empowered To Serve (faith-based mega community) The Guideline Advantage (primary care quality improvement) Communications (infrastructure & media partnerships)

110 INTEGRATED APPROACH Leadership, shared tools, protocols, resources and training to deliver improved care, resulting in new, reciprocal connectivity and targeted support between the patient, the clinic, and the community. Clinic TRUSTED PARTNERS ALGORITHM MEDICAL ASSISTANT SELF TRACKING SHARED METRICS REGISTRY Clinical Community HEALTH MENTORS TEACH LIFESTYLE SKILLS MEDS SELF MONITOR AD COUNCIL CONSULT SERVICES

111 INNOVATION Transformative care delivery mechanism Lean management principles to iterate the model Surround-sound communication campaign Registry to connect the community and clinical settings Learning Collaborative

112 Accountable Care as a Strategy for Achieving Population Health Goals To meet the responsibility to improve health outcomes for those under their care and society at large, health systems will need to: 1. Take responsibility for the health of their patient populations 2. Create and expand partnerships with other entities with the potential to influence health 3. Respond to social demands for equity and value Eggleston & Finkelstein. JAMA 2014;311(8); 2/26/14

113 Challenges Associated with Establishing and Maintaining Population Health Initiatives Public health benefits are dispersed and delayed, and success is when nothing happens Public health practitioners are not celebrities not since C Everett Koop Public health programs are taken for granted (think indoor plumbing, water quality, food safety) Approaches that may involve regulation or fees or taxes can generate fierce opposition Public health sometimes clashes with moral values (think HPV, needle exchange, family planning) Population health improvement requires actions and resources outside of public health [and medical care] Mayes and Oliver, Journal of Health Politics, Policy and Law, Vol. 37, No. 2, April 2012

114 The Role of Health Care in Population Health Barriers that must be overcome for health system-based efforts to contribute to optimized population health 1. Misaligned stakeholder interests and population health investments 2. Inadequate information transfer 3. Inadequate service integration between health care and other sectors 4. Designing and functioning within a sustainable budget 5. Difficulties addressing health disparities Eggleston & Finkelstein. JAMA 2014;311(8); 2/26/14

115 The American Health Care Paradox: Why Spending More is Getting Us Less In translating the triple aim into the regulatory sphere, population health was largely lost ACO payment system should be based on performance indicators that measures health and progress on social determinants of health such as per cent (%) of population at healthy weight, not depressed, housed, employed, and on track to graduate high school or college Public Affairs, 2013

116 Accountable Health Organizations (AHOs) Manages the health investment portfolio for a community Health in All Policies to produce health All services - retail, government, other private (the business sector), social, health (including public health, medical, dental, mental health care) services associated with a defined population that should be held accountable for the health status and outcomes for that population. Attribution methodologies for accountability (credit for contribution to health for allocation of resources and charges to fund and sustain the system). A system whose performance is measured by progress towards achieving highest health status (= economic competitiveness)

117 Accountable Community for Health (ACH) 1) improve community-wide health outcomes and reduce disparities with regard to particular chronic diseases; a collaborative of the major health care systems, providers, and health plans, along with public health, key community and social services organizations, schools and other partners serving a particular geographic that is responsible for improving the health of the entire community, with particular attention to reducing health disparities. The goals of an ACH are to: 2) reduce costs; and, 3) through a Wellness Fund, develop financing mechanisms to sustain the ACH and provide ongoing investments in prevention and other system-wide efforts to improve population health. 20Communities%20for%20Health%20Webinar%20slides.pdf3/6/14

118 Accountable Community for Health (ACH) Portfolio of interventions Policy and systems Environments Community resource and social services Community-Clinical Linkages Clinical Services 20Communities%20for%20Health%20Webinar%20slides.pdf3/6/14

119 The Healthcare Imperative: Lowering Costs and Improving Outcomes Annual US health care waste costs $765 billion $210 billion Unnecessary services (services used too frequently) $190 billion Insurance/bureaucratic costs (unproductive documentation) $130 billion Inefficient services (uncoordinated care, errors) $105 billion Prices that are too high $75 billion Fraud $55 billion Missed prevention opportunities Workshop Summary, IOM, Feb 24, 2011

120 Hospital Community Benefit Programs Increasing Benefits to Communities Principles to guide the development of a strategy for leveraging community benefit 1. Defining mutually agreed-on regional geographic boundaries to align both community benefit and AHC initiatives, 2. Ensuring evidence-based community benefit funded interventions 3. Increasing the scale and effectiveness of community benefit investments by pooling resources 4. Establishing shared measurement and accountability for regional population health improvement Corrigan, Fisher, and Heiser. JAMA 2015;313(12); March 24/31, 2015

121 The New Triple Aim New designs can and must be developed whose prime directive is to produce health by: Addressing and improving social and environmental conditions as well as public health and medical care delivery Basing funding and expenditures on evidence (what works most effectively) and tracking clinical, health, and social metrics Optimizing the health of the population NRC and IOM, January, 2013

122 Real Health Reform to Achieve Health Equity Healthy, safe, and affordable housing Quality education (preschool to high school) 100% graduation rates Employment/Income Comprehensive indoor smoking laws/policies including housing units Affordable food and physical activity Access to health - equitably funded public health and population health Access to medical care health insurance and quality primary care

123 An Integrated Health System Medical Care Public Health Community Services Workplace Schools

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125 Memorial Hermann Behavioral Health Services RHP 1 Learning Collaborative: Expanding Continuum of Behavioral Health Services Region 3 M a r k W i l

126 Promoting Community Collaborations 116

127 DSRIP Psych Response Case Management Intensive field-based case management services for individuals with behavioral health diagnosis and multiple hospitalizations Services aimed at individuals with high rates of inappropriate ED utilization and with preventable hospital admissions and readmissions Link clients to outpatient treatment and community resources Supports and assist clients in navigating barriers to these services 117

128 Psych Response Case Management: Customized Approach Integrated with Memorial Hermann Behavioral Health Services expanding continuum of care Post discharge goals with focus on long term recovery Client is active participant in the service plan development and recovery goals Crisis planning provides immediate intervention to decrease unnecessary hospital admissions Improve outpatient engagement 118

129 DSRIP Mental Health Crisis Clinics Immediate access to psychiatric services Non-traditional access Services Diagnose mental health disorders Administer crisis medications Prescribe psychiatric medications (no narcotics) Brief solution focused intervention Social work services to link patients to integrated medical home Multi-disciplinary Team Psychiatrist Psychiatric Mental Health Nurse Practitioner Clinical Social Worker 119

130 Mental Health Crisis Clinics Clinic #1 Location: Memorial Hermann Northeast Hospital Campus 9813 Memorial Blvd, Suite A Humble, TX (April 2014) Clinic #2 Location: Spring Branch Area Westview Dr. Suite C Houston, Texas (Nov 2014) Clinic #3 Location: Construction underway in Meyer Land Area (October 2015) 120

131 DSRIP Psych Home Health: Community Needs Assessments continue to identify Psychiatric Services as lacking in our community Patients who have dual diagnosis of a medical condition and a psychiatric issue have few options for treatment The goal of the project is to provide support to those patients with mental health issues, to better manage their care in the home and community, and reduce the number of visits to emergency departments for psychiatric care that could be managed in the home and community environment. 121

132 Psych Home Health: Services to Patients and System Reduction of hospitalizations and ED visits Early recognition and intervention to signs and symptoms of exacerbation Education on diagnosis Optimize independence by maximizing strengths and abilities Medication education and compliance adherence Developing and coaching coping skills Motivation strategies Connection to local resources Psychiatric trained nurses for patients confined to home due to medically complex skilled needs 122

133 Psych Response Team Evaluate patients at 10 Memorial Hermann acute care facilities Providing behavioral health evaluations and dispositions in consultation with attending physician: service provisions Determination of voluntary/involuntary status Psychiatric hospitalization transfers Medical admit with on-going psychiatric stabilization Discharge with referrals to lower levels of care 123

134 Psych Response Team Volumes Response Team (RT) Volumes: FY15 Evaluations > 8000 Total transfers out of Memorial Hermann to public and private psychiatric hospitals were 1977 of which 645 patients were nonresourced Public/Private 33% transfer rate System full-time psychiatrist annual volume ~600 patient encounters per year 124

135 Psych Response Team Challenges Increasing volumes with no way to predict pattern Increasingly complicated co-occurring medical and psychiatric disorders Few inpatient psychiatric beds available Even fewer inpatient options to treat complex co-occurring disorders Limited out-patient services to meet patient needs 125

136 Memorial Hermann Behavioral Health Services Continuum of Care and Collaboration

137 Case Scenario 51 y/o female, history of Depression and CHF; brought to ER after altercation with daughter (patient lives with adult daughter and son-in-law). Per daughter, Mom has been making strange comments about Jesus and my husband. She believes she is the Blessed Mother. Memorial Hermann EMR indicates patient has a history of non-compliance with psychiatric medications and has been to the ER six times within the past 2 months for similar complaints. Patient evaluated by Psych Response Team in the ER. Upon medical clearance: discharge plan is for daughter to take patient directly to the Mental Health Crisis Clinic for evaluation by Psychiatrist or PMHNP. patient referred to Psych Home Health due to patient s current skilled nursing need (related to CHF) and history of noncompliance with psychiatric medications patient referred to Psych Response Case Management due to repeated visits to ER and lack of medical home for both her physical and behavioral health needs. 127

138 Crisis Intervention Response Team (CIRT) DSRIP Project

139 CIRT and Memorial Hermann in Partnership Courtesy transport to consumers who do not need hospitalization under an Emergency Detention Order (EDO) Consumers will be referred to Memorial Hermann Crisis Clinics for emergency psychiatric treatment 129

140 Promoting Community Collaborations: MHMRA, HPD, Harris County Sheriff s Office and Memorial Hermann Mental Health Crisis Clinic At 3pm on Saturday, a 911 call was dispatched to the Crisis Intervention Response Team (CIRT): 52 y/o male, with complaints of hearing voices and had become slightly agitated in his personal care home. He was able to be calmed upon CIRT s arrival to the scene and it was determined that he was in need of further psychiatric intervention, but not currently a danger to himself or others. He reported missing his last psychiatric appointment and was out of his anti-psychotic medication Risperdal. CIRT transported the patient to the Memorial Hermann Mental Health Crisis Clinic. Patient was evaluated by a psychiatrist and crisis medications were administered. His immediate symptoms subsided. The team was not able to reach his outpatient psychiatrist but the PCH confirmed patient s most recent medication list and inventory. A prescription was provided to the patient and he was then referred back to his outpatient provider for further ongoing outpatient treatment. PCH Staff agreed to pick up patient and transport back to PCH. 130

141 Questions 131

142 Thank You!

143 RHP 1 Statewide Topics & 1115 Waiver Renewal Updates Daniel Deslatte & Stephanie Fenter NORTHEAST TEXAS REGIONAL HEALTHCARE PARTNERSHIP

144 RHP 1 Regional Partnership Meeting Thank you for attending. NORTHEAST TEXAS REGIONAL HEALTHCARE PARTNERSHIP