Behavioral Health Management Guide

Transcription

1 Population Health Advisor Behavioral Health Management Guide Your primer to developing a comprehensive behavioral health care delivery model RESEARCH REPORT Look inside for: Current landscape and future outlook for behavioral health care delivery Nine elements of a patient-centered, sustainable behavioral health strategy Case studies of best-in-class behavioral health programs research technology consulting

2 TOPIC READING TIME 30 min. Behavioral health BEST FOR Strategic planners and population health managers WHAT YOU LL LEARN Why behavioral health care innovation presents a challenge and opportunity How to provide patient-centered, sustainable behavioral health care What clinical, quality, and financial outcomes can be achieved with evidence-based behavioral health programs

3 Population Health Advisor Behavioral Health Management Guide Your primer to developing a comprehensive behavioral health care delivery model RESEARCH REPORT

4 LEGAL CAVEAT Population Health Advisor Project Director Petra Esseling Contributing Consultants Sean Donohue Darby Sullivan Clare Wirth Project Editor Tracy Walsh, MPH Program Leadership Tomi Ogundimu, MPH Megan Clark Design Consultant Nate Smith-Grasse Advisory Board is a division of The Advisory Board Company. Advisory Board has made efforts to verify the accuracy of the information it provides to members. This report relies on data obtained from many sources, however, and Advisory Board cannot guarantee the accuracy of the information provided or any analysis based thereon. In addition, Advisory Board is not in the business of giving legal, medical, accounting, or other professional advice, and its reports should not be construed as professional advice. In particular, members should not rely on any legal commentary in this report as a basis for action, or assume that any tactics described herein would be permitted by applicable law or appropriate for a given member s situation. Members are advised to consult with appropriate professionals concerning legal, medical, tax, or accounting issues, before implementing any of these tactics. Neither Advisory Board nor its officers, directors, trustees, employees, and agents shall be liable for any claims, liabilities, or expenses relating to (a) any errors or omissions in this report, whether caused by Advisory Board or any of its employees or agents, or sources or other third parties, (b) any recommendation or graded ranking by Advisory Board, or (c) failure of member and its employees and agents to abide by the terms set forth herein. The Advisory Board Company and the A logo are registered trademarks of The Advisory Board Company in the United States and other countries. Members are not permitted to use these trademarks, or any other trademark, product name, service name, trade name, and logo of Advisory Board without prior written consent of Advisory Board. All other trademarks, product names, service names, trade names, and logos used within these pages are the property of their respective holders. Use of other company trademarks, product names, service names, trade names, and logos or images of the same does not necessarily constitute (a) an endorsement by such company of Advisory Board and its products and services, or (b) an endorsement of the company or its products or services by Advisory Board. Advisory Board is not affiliated with any such company. IMPORTANT: Please read the following. Advisory Board has prepared this report for the exclusive use of its members. Each member acknowledges and agrees that this report and the information contained herein (collectively, the Report ) are confidential and proprietary to Advisory Board. By accepting delivery of this Report, each member agrees to abide by the terms as stated herein, including the following: 1. Advisory Board owns all right, title, and interest in and to this Report. Except as stated herein, no right, license, permission, or interest of any kind in this Report is intended to be given, transferred to, or acquired by a member. Each member is authorized to use this Report only to the extent expressly authorized herein. 2. Each member shall not sell, license, republish, or post online or otherwise this Report, in part or in whole. Each member shall not disseminate or permit the use of, and shall take reasonable precautions to prevent such dissemination or use of, this Report by (a) any of its employees and agents (except as stated below), or (b) any third party. 3. Each member may make this Report available solely to those of its employees and agents who (a) are registered for the workshop or membership program of which this Report is a part, (b) require access to this Report in order to learn from the information described herein, and (c) agree not to disclose this Report to other employees or agents or any third party. Each member shall use, and shall ensure that its employees and agents use, this Report for its internal use only. Each member may make a limited number of copies, solely as adequate for use by its employees and agents in accordance with the terms herein. 4. Each member shall not remove from this Report any confidential markings, copyright notices, and/or other similar indicia herein. 5. Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents. 6. If a member is unwilling to abide by any of the foregoing obligations, then such member shall promptly return this Report and all copies thereof to Advisory Board Advisory Board All Rights Reserved advisory.com

5 Table of Contents Executive Summary Making the Case for a Comprehensive Behavioral Health Management Strategy Prioritization Matrix of Behavioral Health Models Innovative Behavioral Health Care Delivery Models Also Available in Your Membership Integrated Behavioral Health Implementation Toolkit Compilation of surveys, checklists, and sample templates from leading health care organizations to support behavioral health integration in the primary care setting. Tools address six critical components of the integrated model: 1) Market demand 2) Organizational culture 3) Patient identification 4) Patient management 5) Care coordination 6) Sustainability planning Executive Research Briefing: Evaluating Reimbursement Models for Integrated Behavioral Health Profiles of six organizations to show spectrum of public and private reimbursement models to establish a sustainable integrated behavioral health program. Telebehavioral Health Primer Primer on telehealth market trends oriented around behavioral health care delivery including definition of key terms, discussion of investment considerations, and a sample case study from a leading health care organization with an established telebehavioral health program. Telepsychiatry in the ED: Market Overview and Service Self-Audit Report on trends in telebehavioral health in the emergency department (ED), including: Overview of national and state trends in telepsychiatry adoption, reimbursement and regulatory requirements Framework for setting strategic goals and evaluating investments in telepsychiatry platforms in the ED setting Selection of case studies representing best-in-class programs; includes operational details around staffing models, partnership dynamics, funding structures, and performance outcomes, when available 2017 Advisory Board All Rights Reserved advisory.com

6 Executive Summary Behavioral Health Management Guide Project Overview and Methodology The impact of behavioral health on health care delivery systems is staggering. Behavioral health conditions are highly prevalent (1 in 5 adults), often undiagnosed or untreated (only half of patients receive treatment), and deeply entangled with chronic disease management, making them one of the most costly co-morbidities ($293 billion in associated treatment cost each year). Despite high and growing demand, access to reliable behavioral health services continues to be a challenge. Provider shortages, stigma, and limited reimbursement create significant barriers to timely, cost-effective care. To address the needs of the greatest number of patients, providers design programs tailored to their patients specific acuity levels. This includes designing a scaled clinical model and identifying new ways to fund care delivery. Use this research report to prioritize and refine behavioral health interventions to address the needs of your specific patient populations. The three sections of this report (outlined below) provide the case for expanded investment, a tool for prioritizing your next steps, and nine case studies of successful behavioral health management models. Making the Case for a Comprehensive Behavioral Health Management Strategy Prioritization Matrix of Behavioral Health Models Innovative Behavioral Health Care Delivery Models Pages 8-14, review challenges facing behavioral health program leaders, including: Prevalence of behavioral health conditions Cost and quality implications of poor behavioral health outcomes Behavioral health patient population risk segmentation Pages 16-19, roadmap for prioritizing across behavioral health program models, based on: Patient demand Projected program impact Resource intensity Program scalability Pages 22-30, case profiles of innovative behavioral health care delivery models from the following organizations: Big White Wall Essentia Health Telehealth Network Intermountain Healthcare NYC Health + Hospital Passport Health Plan Program of Assertive Community Treatment University of California San Francisco Wake County Emergency Medical Services Yale New Haven Hospital and Connecticut Mental Health Center 2017 Advisory Board All Rights Reserved advisory.com

7 Developing a Comprehensive Behavioral Health Care Delivery Model Nine Critical Elements to Identify, Treat, and Offer Longitudinal Care Across Patient Segments Solutions for Behavioral Health Programs Mapped by Patient Acuity Level LOW MODERATE HIGH PROACTIVE IDENTIFICATION 1 Engage primary care teams in universal mental health screening 4 Establish coordinated, team-based care in primary care setting (e.g., integrated behavioral health) 7 Establish coordinated, team-based care in behavioral health setting (e.g., behavioral health homes) EPISODIC TREATMENT 2 Encourage provider collaboration through primary care co-location 5 Introduce telepsychiatry and remote consultation to increase reliable, timely access for at-risk patients 8 Proactively address acute needs with community partnerships (e.g., paramedics) LONGITUDINAL CARE 3 Leverage virtual platforms to expand patient social support networks 6 Develop transitional home care services for at-risk patients to prevent escalation 9 Connect patients with wraparound community and social services 5 Source: Population Health Advisor interviews and analysis Advisory Board All Rights Reserved advisory.com

8 2017 Advisory Board All Rights Reserved advisory.com

9 Making the Case for a Comprehensive Behavioral Health Management Strategy 2017 Advisory Board All Rights Reserved advisory.com

10 Nearly One in Five U.S. Adults Experience Mental Illness High Prevalence of Mental Illness in Chronically Ill Adults Complicates Patient Management Behavioral health conditions are highly prevalent with almost one in five adults experiencing a mental illness. Depression is the most common diagnosis followed by anxiety and/or panic disorder. Further complicating treatment, over half of patients with a diagnosed behavioral health need also have chronic conditions or other medical care needs. To design an effective behavioral health management strategy, programs must address common barriers and allocate resources based on acuity. Depression Most Common Mental Health Morbidity in U.S. Population Percent of U.S. Population with Specific Behavioral Health Conditions The Advisory Board Company Demographic Profiler Tool, % 7.0% 2.1% 1.4% Depression Anxiety/Panic Disorder ADD/ADHD Bipolar Disorder One in Five Adults Experience Mental Illness Percent of U.S. Adults with Any or Severe Mental Illness by Age National Survey on Drug Use and Health, 2015 Critical to Integrate with Chronic Care Management Percent of U.S. Adults with Comorbid Clinical and Behavioral Health Needs Medical Expenditure Panel Survey, Total Age Group % 5.0% 5.0% 17.9% 21.7% 20.9% High Need Adults Individuals with three or more chronic conditions and a functional limitation Comprises 5% of U.S. adults 56% High need adults with mental health conditions Patients with Medical and Behavioral Comorbidities Individuals diagnosed with a physical and mental health condition Comprises 68% of adults with mental health conditions % 14.0% Any mental illness Severe mental illness Source: American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5), (2013); Adams K, et al., Behavioral Health Trends in the United States: Results from the 2015 National Survey on Drug Use, SAMHSA Center for Behavioral Health Statistics and Quality, (2015), Agency for Healthcare Research and Quality (AHRQ), Medical Expenditure Panel Survey, (2012); Alegria M, et al., Collaborative Psychiatric Epidemiology Surveys (CPES), National Comorbidity Survey Replication, 3, no. 83 ( ): Population Health Advisor interviews and analysis Advisory Board All Rights Reserved advisory.com 8

11 Multiple Provider- and Patient-Related Barriers Restrict Access to Care Only half of patients with a mental health diagnoses actually receive treatment. The three largest barriers to address: Lack of Providers and Limited Program Availability 56% 1) Limited number of providers The lack of mental health professionals limits services available to meet demand. Shortage of mental health care professionals 1 in the U.S. as of January % Decrease in number of psychiatric beds ( ) 2) Patient concerns Even when services are available, patients are reluctant to use them. These include concerns about the cost of treatment, time, and limited knowledge about service access points. 3) Coverage challenges Patient Access Hindered by Financial, Social, and Logistical Factors Reported barriers to mental health treatment among adults with a perceived unmet need National Survey on Drug Use and Health, % 31% 27% 21% 13% Cost of care concerns persist even among those with health insurance. Many behavioral health providers do not accept insurance and when they do, denial rates are nearly twice as high than those for medical care. Could not afford cost Thought they could handle the issue without treatment Did not know where to go Low Insurance Acceptance and High Denial Rates 55% Did not have time Felt that treatment would not help Service denial rates of private insurance based on medical necessity criteria 29% 14% 18% Percent of psychiatrists who accept private insurance, which is 34% lower than other specialists Medical care Substance use care Mental health care 1) Mental health professionals include psychiatrists, clinical psychologists, clinical social workers, psychiatric nurse specialists, and marriage and family therapists. Source: Mental Health Care Health Professional Shortage Areas (HPSAs), Kaiser Family Foundation, Bastiampillai T, et al., Increase in US Suicide Rates and the Critical Decline in Psychiatric Beds, JAMA, 316, no. 24 (2016): ; Park-Lee E, et al., Receipt of Services for Substance Use and Mental Health Issues among Adults: Results from the 2015 National Survey on Drug Use and Health, SAMHSA, ServiceUseAdult-2015.htm; Cummings JR, Rates of Psychiatrists Participation in Health Insurance Networks, JAMA, 313, no. 2 (2015): ; Honberg R, et al., A Long Road Ahead: Achieving True Parity in Mental Health and Substance Use Care, NAMI, Reports/A-Long-Road-Ahead/2015-ALongRoadAhead.pdf; Population Health Advisor interviews and analysis Advisory Board All Rights Reserved advisory.com

12 Gaps in Treatment Escalate Care Needs and Costs The gap in behavioral health management negatively impacts clinical outcome, care utilization, and cost of care. Patients with a mental health diagnosis incur two to three times the health care cost of those without a mental health diagnosis. On a national scale, this translates to $293 billion in additional costs associated with treating patients with mental illness each year. Gaps in care delivery mean patients with behavioral health needs often experience worse outcomes across conditions. For example, in diabetic patients, depression is consistently associated with increased risk of poor self-management, poor glycemic control, complications, and care utilization. Lack of Coordination Across Care Continuum Limits Quality Improvements Clinical Quality Impact Patients with Mental Illness Experience Worse Clinical Outcomes 82% Diabetes Care, 2011 Utilization Impact Patients With Mental Illness Use Services Inappropriately 1 in 8 Higher risk of a heart attack in patients with comorbid depression and diabetes than those without Emergency department visits is associated with a behavioral health issue American Psychiatric Association, th Leading cause of death in the United States is suicide National Center for Injury Prevention and Control, % Average increase in length of stay for patients with mental and/or substance abuse disorders Journal of Rehabilitation Research & Development, 2010 Financial Impact Health Systems and U.S. Economy Carry the Economic Burden % Milliman Inc., 2014 Higher medical costs for treating patients with comorbid chronic and behavioral health conditions $293B Milliman Inc., 2014 National additional annual costs associated with treating patients with behavioral health conditions Source: Scherrer, JF, et al., Increased risk of myocardial infarction in depressed patients with type 2 diabetes, Diabetes Care, 34, no.8, (2011): Frayne SM, et al., Mental Illness-Related Disparities in Length of Stay, J Rehabil Res Dev, 47, no. 8 (2010): ; Melek SP, et al., Economic Impact of Integrated Medical-Behavioral Healthcare, Milliman, Inc., (2014); Topics/Integrated-Care/Milliman-Report-Economic-Impact-Integrated-Implications-Psychiatry.pdf; Insel TR, et al., Assessing the Economic Costs of Serious Mental Illness, Am. J. Psychiatry, 65, no. 6, (2008): ; National Alliance on Mental Illness, Arlington, VA; National Center for Injury Prevention and Control, Atlanta, GA; American Psychiatric Association; Population Health Advisor interviews and analysis Advisory Board All Rights Reserved advisory.com 10

13 Reimbursement Improving for Integrated Behavioral Health Policy makers, with bipartisan support, are starting to tackle reimbursement issues to make community services more accessible. Financial Support Reduces Challenges to Service Implementation New Behavioral Health Primary Care Billing Codes Enhance Fee-For-Service Reimbursement New primary care codes reward collaboration models and incentivize primary care providers to manage behavioral health conditions within and beyond patient office visits. Month one Initial patient encounter Subsequent months Subsequent patient encounters Ongoing patient management The 21st Century Cures Act allows for same-day clinical and behavioral health care billing and the ECHO Act promotes and funds the use of behavioral health tele-mentoring services. G0502: Initial collaborative care management G0503: Subsequent collaborative psychiatric care management G0507: Care management services for behavioral health conditions G0504: Each additional 30 minutes for initial or subsequent collaborative psychiatric care management These developments provide health systems with opportunities to devise new behavioral health strategies. Behavioral Health Largely a Bipartisan Issue 21st Century Cures Act (H.R. 34) The ECHO Act (H.R. 5395) Description Authorizes funding for several mental health initiatives, strengthens enforcement of mental health parity, and eliminates the Medicaid same-day exclusion. 1 Requires the study of tele-mentoring models and collaborative team-based care to improve the Department of Health and Human Services programs. Sponsors Latest Action Fred Upton (R-MI) Diana DeGette (D-CO) Passed in the House with a vote Passed in the Senate with a 94-5 vote Signed into law December 13, 2016 Orrin Hatch (R-UT) Brian Schatz (D-HI) Passed in the House by voice vote Passed in the Senate with a 97-0 vote Signed into law December 14, 2016 Source: CY 2017 Physician Fee Schedule Final Rule, CMS, Honberg R, et al., A Long Road Ahead: Achieving True Parity in Mental Health and Substance Use Care, NAMI, Policy-Reports/A-Long-Road-Ahead/2015-ALongRoadAhead.pdf; Press MJ, et al., Medicare Payment for Behavioral Health Integration, 1) The Medicaid same-day exclusion prohibited separate payment The New England Journal of Medicine, What You Need to Know About for mental health and primary care services provided to a the 2017 Medicare Physician Fee Schedule (MPFS) Final Rule, Physician Practice Roundtable, Advisory Board Company; Population 2017 Advisory Board All Rights Reserved Medicaid enrollee on the same day. Health Advisor interviews and analysis. advisory.com 11

14 Designing Behavioral Health Models to Match Patient Acuity Patient characteristics such as diagnosis, level of social and professional functioning, and duration of illness help to define acuity level and inform the development of tailored services. About one in five patients suffer from low-acuity behavioral health needs. While these patients are able to function socially and professionally and don t need ongoing support, they still benefit from early identification and prevention. Moderate-acuity patients have trouble functioning well in society and the workplace. They require low-intensity, ongoing support in order to improve functioning, facilitate self-management and prevent escalation. Patients with severe and persistent mental illness need constant support in order to allow for semi-independent functioning and reduce the cost of care. Tailoring services based on common barriers these patient groups face is the next step in developing an effective and sustainable system-wide strategy. Preview of Low, Moderate, and High Behavioral Health Acuity Acuity Level LOW MODERATE HIGH Patient Characteristics Low-acuity, rising-risk Diagnosis: Common, stable mental disorders including depression, anxiety disorders, ADHD, PTSD Disability: Full functionality Duration: Potential for self-management and/or symptom remission within 6-12 months Multiple comorbidities, rising or high-risk Diagnosis: Common mental disorders with unmanaged comorbid chronic disease Disability: Limited functionality Duration: Requires longitudinal care management support Severe and persistent mental illness Diagnosis: Major mental disorders, such as schizophrenia or severe bipolar disorder Disability: Significant functional impairment Duration: At least two years of disability Prevalence¹ 17.9% Of adults have at least one mental health condition 12.6% Of adults have comorbid mental health and chronic conditions 4.0% Of adults have severe and persistent mental illness 1) Estimated prevalence in U.S. population. Source: SAMHSA, Results from the 2015 National Survey on Drug Use and Health: Detailed Tables, Center for Behavioral Health Statistics and Quality, (2016); Population Health Advisor interviews and analysis Advisory Board All Rights Reserved advisory.com

15 Current Barriers No One-Size-Fits-All Intervention for Behavioral Health Current Barriers to Identification, Treatment, and Longitudinal Care Challenges for Behavioral Health Program Mapped by Patient Acuity Level LOW MODERATE HIGH PROACTIVE IDENTIFICATION Absence of standardized screening processes in the primary care setting Lack of outpatient coordination between physical and behavioral health services Lack of inpatient coordination between physical and behavioral health services EPISODIC TREATMENT Patient non-adherence to recommended treatment; inconsistent provider follow-up Avoidable utilization of emergency department services for unmanaged chronic conditions Avoidable utilization of emergency department services for psychiatric crisis treatment LONGITUDINAL CARE Insufficient community support to prevent relapse; perceived social stigma Disjointed care transitions between hospital and home; inability to maintain outpatient follow-up Inability to maintain stable living conditions (e.g., housing, nutrition) 13 Source: Population Health Advisor interviews and analysis Advisory Board All Rights Reserved advisory.com

16 Care Model Solutions Developing a Comprehensive Behavioral Health Care Delivery Model Nine Critical Elements to Identify, Treat, and Offer Longitudinal Care Across Patient Segments Solutions for Behavioral Health Programs Mapped by Patient Acuity Level LOW MODERATE HIGH PROACTIVE IDENTIFICATION 1 Engage primary care teams in universal mental health screening 4 Establish coordinated, team-based care in primary care setting (e.g., integrated behavioral health) 7 Establish coordinated, team-based care in behavioral health setting (e.g., behavioral health homes) EPISODIC TREATMENT 2 Encourage provider collaboration through primary care co-location 5 Introduce telepsychiatry and remote consultation to increase reliable, timely access for at-risk patients 8 Proactively address acute needs with community partnerships (e.g., paramedics) LONGITUDINAL CARE 3 Leverage virtual platforms to expand patient social support networks 6 Develop transitional home care services for at-risk patients to prevent escalation 9 Connect patients with wraparound community and social services 14 Source: Population Health Advisor interviews and analysis Advisory Board All Rights Reserved advisory.com

17 Prioritization Matrix of Behavioral Health Models 2017 Advisory Board All Rights Reserved advisory.com

18 Map Out Priorities Based on Program Impact and Ease of Implementation We analyzed the program impact and ease of implementation of successful behavioral health care delivery models to prioritize programs based on return on investment. Universal mental health screening in primary care and tele-psychiatry Two rows in of the text ED emerged as the strongest investment opportunities. Program Impact and Ease of Implementation Scorecard Behavioral Health Care Delivery Model 1 Universal Mental Health Screening Program Impact (0-4, 4=High) Implementation (0-4, 4=Easy) Total Score Screening and Tele-psychiatry Highest Priorities Models Ranked by Ease of Implementation and Program Impact Moderate Priority, Requires ROI Review High Priority, Near-Term Solution 2 Primary Care Co-location Virtual Patient Support Forums Integrated Behavioral Health Tele-psychiatry, Remote Consultation Transitional Home Care Services Ease of Implementation Behavioral Health Homes Community Paramedics Partnership Pilot to for Your Population Moderate Priority, Longer-Term Solution 9 Wraparound Community and Social Services Program Impact High Priority Moderate Priority Low Priority High Priority, Near-Term Solution See detailed analysis on pages Source: Population Health Advisor interviews and analysis Advisory Board All Rights Reserved advisory.com

19 LOW // MODERATE // HIGH Low-Acuity Programs Broadly Applicable, May Require Significant Investment Prioritization Matrix Methodology, Models 1-3 (Low-Acuity) Care Model Patient Demand Projected Impact Resources Required Economies of Scale Key Takeaways Patient demand: About 20% of U.S. adults experienced any mental health problem in Projected impact: The United States Preventive Services Task Force recommends administering the service to all patients due to its net benefits (B rating). Patients benefit when staff-assisted depression care support is in place to assure accurate diagnosis, effective treatment, and warm handoffs to follow-up care. Resources required: PHQ2/9 typically take less than 10 minutes to perform and can be administered by non-clinical staff (e.g., medical assistants). Economies of scale: Screenings are highly scalable, especially if PHQ and other screening tools are embedded in the EMR and/or patient portals. Model 1 Universal Mental Health Screening Patient demand: 56% of patients with any mental illness do not receive treatment and nearly a quarter of these patients report that they do not know where to go for services. Projected impact: Co-location typically improves patient adherence to follow-up and coordination between physical and mental health services. Resources required: For organizations partnering with community mental health agencies, required resources include physical space for the behavioral health consultant, dedicated time to develop referral protocols, and training of primary care team members on appropriate referral activity. Economies of scale: Reimbursement, patient, and provider eligibility standards may limit community partner activities, which require strong relationships with community mental health agencies. Model 2 Primary Care Co-location Patient demand: Approximately 10% of adults with a mental health condition report perceived stigma as a barrier to treatment. Projected impact: Virtual platforms connect activated patients to social support networks and community resources. Resources required: Leveraging existing forums reduces the start-up costs, leaving the organization to focus on patient and provider education and adoption. However, building a unique virtual platform in-house requires more significant investment. Economies of scale: Highly scalable, particularly for areas with consistent internet access and adoption. Model 3 Virtual Patient Support Forums z Composite score Favorable (2 points) Somewhat favorable (1 point) Unfavorable (0 points) Source: Mental Health Myths and Facts, HHS, USPSTF A and B Recommendations, U.S. Preventative Services Task Force, Results from the 2013 National Survey on Drug Use and Health, SAMHSA, Iskandar J, et al., Mental Health from the Perspective of Primary Care Residents: A Pilot Survey, Prim Care Companion CNS Disord, 16, no.4 (2014), Oyama O, et al., Mental Health Treatment by Family Physicians: Current Practices and Preferences, Family Medicine, 44, no. 10 (2012), Population Health Advisor interviews and analysis Advisory Board All Rights Reserved advisory.com

20 LOW // MODERATE // HIGH Moderate-Acuity Programs Represent Promising Mechanism to Improve Access Prioritization Matrix Methodology, Models 4-6 (Moderate-Acuity) Care Model Patient Demand Projected Impact Resources Required Economies of Scale Key Takeaways Model 4 Integrated Behavioral Health Patient demand: As many as 70% of primary care visits are driven by patients behavioral health problems or stress. However, provider surveys show limited knowledge or comfort around providing brief counseling for patients with a mental health need. Projected impact: The IMPACT Program used at the University of Washington documented an ROI of $6.50 per dollar over the course of four years resulting in an average savings of over $3,000 per participant. Resources required: Requires embedded behavioral health staffing and new care team workflows in primary care setting with an average time to adoption at 6-12 months. Economies of scale: Reimbursement, patient eligibility, and provider payment standards may limit integration. However, recent policy developments and new CMS reimbursement codes address some of the major hurdles impeding behavioral health integration. Patient demand: Nationally, there are over 4,600 designated Mental Health Professional Shortage Areas, and the existing workforce is unable to meet 48% of projected need. Projected impact: Evidence-based programs have demonstrated significant improvements to clinical and cost outcomes. South Carolina s statewide emergency tele-psychiatry program, for example, achieved $2,336 savings per 30-day inpatient cost, and 0.86 reduction in inpatient length of stay. Resources required: Tele-psychiatry networks require investment in technology infrastructure and support, as well as provider training and workflow development. Economies of scale: Highly scalable as Medicare/Medicaid reimbursement is more favorable in rural areas. Passing of the ECHO Act increases ability of organizations to use tele-mentoring in behavioral health. Model 5 Tele-psychiatry, Remote Consultation Patient demand: 22.6% of people with a perceived unmet need for mental health treatment and counseling cited that they did not know where to go for services. Projected impact: University of California San Francisco s Care Support program reduced median hospitalizations and median emergency department visits among complex patients who received in-home assessments and tailored care plan protocols. Resources required: Many of these services may be carried out by nurse practitioners and licensed clinical social workers. Generally these programs are limited to patients with high readmission risk due to high staffing requirements and time demands necessary for home visits. Economies of scale: Transitional home care services are built on existing home care services, and therefore require less upfront investment. Programs also benefit from dedicated time for training and collaboration between home health providers and inpatient discharge teams. Model 6 Transitional Home Care Services Composite score Favorable (2 points) Somewhat favorable (1 point) Unfavorable (0 points) Source: Kaiser Family Foundation, Mental Health Care Health Professional Shortage Areas (HPSAs), (2017): National Center for Health Statistics, National Ambulatory Medical Care Survey, (2010): Hager E, What Can We Do to Address Unnecessary Readmissions: A Review of the Literature, New York Care Coordination Program, (2013), Unützer J, et al., Collaborative Care Management of Late-life Depression in the Primary Care Setting: A Randomized Controlled Trial, JAMA, 2002, 288(22): ; Figeroa J, Targeting High Cost Patients and Their Needs, Alliance for Health Care Reform, (2015); Narasimhan M, et al., Quality, Utilization, and Economic Impact of a Statewide Emergency Department Telepsychiatry Program, Psychiatr Serv, 66, no. 11, (2015): ; Olsen D, Integrating Primary Care and Mental Health Key to Improving Patient Care, Lowering Costs, Medical Economics, May 08, 2014, Adams, K, et al., Behavioral Health Trends in the United States: Results from the 2015 National Survey on Drug Use, Center for Behavioral Health Statistics and Quality, (2015), /NSDUH-DetTabs-2015.pdfHunter CL, et al., Integrated Behavioral Health In Primary Care: Step-by-Step Guidance for Assessment and Intervention, Washington, DC: American Psychological Association, 2009; Population Health Advisor interviews and analysis Advisory Board All Rights Reserved advisory.com

21 High-Acuity Programs Require Trade-offs Between Cost Savings and Scalability Prioritization Matrix Methodology, Models 7-9 (High-Acuity) LOW // MODERATE // HIGH Care Model Patient Demand Projected Impact Resources Required Economies of Scale Key Takeaways Patient demand: Approximately 4% of adults experience a serious mental illness. These individuals face an increased risk of chronic medical comorbidities and die on average 25 years earlier than other Americans, largely due to treatable medical conditions. Projected impact: Screening patients for behavioral health symptoms at admission and then providing them with ongoing primary and psychiatric care in one setting improves care continuity and access to preventive services. The behavioral health primary care medical home cares for 600 patients annually. Resources required: Behavioral health homes are highly resource intensive, as patients may require longterm support from both primary care and behavioral health providers. Economies of scale: These programs are often unable to meet patient demand in the community, in part due to resource restraints in the form of provider shortages and unfavorable reimbursement. Model 7 Behavioral Health Homes Patient demand: In a recent study, one in eight ED visits in the United States were attributed to mental health and/or substance use problems in adults. The average behavioral health patient can take hours to treat in the ED. Projected impact: Community partnerships can greatly improve appropriate patient utilization of emergency departments for behavioral health needs. Wake County EMS reported a 34% decrease in total ED visits for patients assigned to advanced practice paramedics (APPs). Resources required: This type of community paramedicine partnership requires additional training for paramedics, including how to evaluate a patient s medical condition and direct them to a facility with the appropriate level of care. Economies of scale: Scalability for new partnerships is heavily dependent on APP capacity and requires broad stakeholder engagement from the surrounding community. Model 8 Community Paramedics Partnership Model 9 Wraparound Community and Social Services Patient demand: 4.2% of U.S. adults are diagnosed with a serious mental illness associated with disability. While the number of those with long-term effects is significantly lower, resources and cost associated with the treatment of this patient population are high. Projected impact: Wraparound community and social services can have a significant impact on cost savings for a health system. The Program of Assertive Community Treatment program at OU-Tulsa achieved $15,000 in savings per patient per year, after an intensified focus on multidisciplinary care. Resources required: The national estimate for PACT services is around $10,000 - $15,000 per patient per year. Economies of scale: This model is difficult to scale, due its high resource requirement with a provider-topatient ratio of 10:1 and difficulty in graduating patients from the program. Composite score Favorable (2 points) Somewhat favorable (1 point) Unfavorable (0 points) Source: Adams, K, et al., Behavioral Health Trends in the United States: Results from the 2015 National Survey on Drug Use, Center for Behavioral Health Statistics and Quality, (2015), Alakeson V, et al., A Plan to Reduce Emergency Room Boarding of Psychiatric Patients, Health Affairs, Increased Emergency Room Use by People with Mental Illnesses Contributes to Crowding and Delays, Judge David L. Bazelon Center for Mental Health Law, Serious Mental Illness (SMI) Among U.S. Adults, National Institute of Mental Health, Population Health Advisor interviews and analysis Advisory Board All Rights Reserved advisory.com

22 2017 Advisory Board All Rights Reserved advisory.com

23 Innovative Behavioral Health Care Delivery Models 2017 Advisory Board All Rights Reserved advisory.com

24 1. Engage primary care teams in universal mental health screening LOW // MODERATE // HIGH Routine, On-Site Training from Internal Experts Reinforces Care Standards Every population health leader should evaluate their current mental health screening efforts. Based on program impact and ease of implementation, universal mental health screening is a critical element of a comprehensive behavioral health management model. NYC Health + Hospital investigated the reasons for unexpectedly low depression prevalence rates within their catchment area. Leaders found under-diagnosis in primary care stemming from screening barriers and limited training of primary care teams. To improve screening rates, NYC Health + Hospital began assigning volunteer behavioral health experts to primary care practices to serve as coaches and trainers. These experts help primary care providers overcome screening implementation barriers, facilitate improved collaboration across settings, and lead training sessions in an effort to further screening and treatment efforts. In-person efforts are augmented by a virtual library of training resources available to participating primary care providers. NYC Health + Hospital s screening rates increased from 60% to 90% and diagnosis rates increased from 1% to 5% within two years. NYC Health + Hospital Clinical Coaches Promote Depression Screening Clinical Coaches Facilitate Screening in Primary Care Behavioral Health Training Topics for Primary Care Team Members Motivational Interviewing Implementation and Skills Coach Responsibilities Engages with leadership, helps troubleshoot implementation barriers, and supports the development of communication skills among collaborative care team members Works with a particular practice to reinforce relationship-building with care team members over time Leads individual and group sessions with collaborative care team members, offering direct observation, role-play opportunities, and constructive feedback Medication Management Brief Action Planning Shared Decision Making Case in Brief: New York City Health and Hospitals Corporation (NYC Health + Hospital) NYC Health + Hospital is the largest public hospital system in the U.S., with eleven acute care hospitals and six diagnostic and treatment centers. The organization launched its Depression Collaborative Care program in 2012 as part of an 1115 waiver for Medicaid program redesign to improve depression screening and treatment. The program has demonstrated significant increases in depression screening rates and screening yield over time. Self-Management Support Strategies 22 Source: Population Health Advisor interviews and analysis Advisory Board All Rights Reserved advisory.com

25 2. Encourage provider collaboration through primary care co-location LOW // MODERATE // HIGH Co-located Psychiatric Resident in Primary Care Clinic Provides Warm Handoffs However, once treatment is initiated, inconsistent provider follow-up can cause gaps in treatment. To address this problem, Passport Health Plan in Louisville, Kentucky, partnered with the University of Louisville and a rural pediatric primary care clinic. By co-locating psychiatric staff in primary care, teams prevent care gaps, improve service access, care team coordination, and outcomes. Multi-stakeholder Pilot Improves Rural Behavioral Health Access Health Plan Partners with Local University and Independent Primary Care Practice Faculty Psychiatrist and Psychiatric Resident Co-located in Primary Care Clinic A faculty psychiatrist and pediatric psychiatric resident support the clinic s primary care team by offering diagnosis and treatment services one day a week. Passport Health Plan covers some of the cost of the resident program and tracks outcomes, while the University of Louisville provides the faculty coverage. The clinic offers facility space and promotes warm handoffs to psychiatric providers whenever needed. Passport Health Plan Identifies and coordinates with primary care clinic Covers partial cost of psychiatric resident training program Tracks program outcomes and plans for future applications of integrated behavioral health model University of Louisville Employs and co-locates faculty psychiatrist and psychiatric resident within the primary care clinic Trains residents in the indepth foundation of pharmacologic and psychotherapeutic interventions Primary Care Clinic Provides practice space for psychiatrist and psychiatric resident one day per week Facilitates warm handoffs to psychiatric providers for patients with complex mental health needs Passport Health Plan has expanded their efforts and increased resource allocation due to the program s success. Case in Brief: Passport Health Plan Based in Louisville, Kentucky, Passport Health Plan is a nonprofit, provider-sponsored community-based health plan administering Kentucky Medicaid benefits. In 2014, Passport Health Plan launched a two-year pilot to support rural clinic s primary care clinics by offering colocated behavioral health diagnosis and treatment services one day a week. Since the program s launch, the pilot practice has increased staffing and reach. 23 Source: Population Health Advisor interviews and analysis Advisory Board All Rights Reserved advisory.com

26 3. Leverage virtual platforms to expand patient social support networks Online Social Support Complements Provision of In-Person Care LOW // MODERATE // HIGH While, most low-acuity patients will not require ongoing health system support, ensuring access to community or peer support can help manage reoccurring symptoms. Big White Wall provides anonymous online support to individuals with common behavioral health needs in partnership with health systems. A UK-based organization that expanded to the United States in 2015, Big White Wall has since partnered with health organizations like Kaiser Permanente s Northwest region and Catholic Health Initiatives. Big White Wall allows patients to access support services 24 hours a day, 7 days a week, with Wall Guides who ensure the full engagement, safety, and anonymity of all members. The organization provides a wide range of service offerings including diagnostic tools, care planning, a variety of virtual therapeutic interventions, and peer support groups. Big White Wall Facilitates Social Connectivity and Community Service Access Case in Brief: Big White Wall (BWW) Provides anonymous online support system for individuals with common behavioral health needs. Access is exclusively available through participating health organizations, including Kaiser Permanente s Northwest region. Big White Wall Connect, a one-onone talk therapy offering, became available to patients in the U.S. in late Multimodal Therapy BWW offers a number of therapeutic interventions, including one-on-one and group talk therapy and digital behavioral health courses. Outcomes with Big White Wall 95% 80% 73% Available Therapeutic Interventions Of patients reported improved wellbeing after active use of Big White Wall Of Big White Wall users reported enhanced self-care through regular access Of Big White Wall users reported an initial disclosure of a mental health issue on the website, many of whom would otherwise go untreated Anonymous Peer Guidance Patients can increase social connectivity through communication with other users through the website. Regular users report improved wellbeing (95%) and enhanced selfcare (80%). Safeguards from Self-Harm Along with an immediate alert system for words like suicide or abuse, trained Wall Guides have procedures for mitigating self-harm. Targeted Care Pathways Through a machine learning algorithm, services like art therapy and group therapy are customized for each patient s needs. Source: Sun, L.H., How Technology is Transforming Mental Healthcare, Especially After Midnight, Los Angeles Times, November 17, 2015; Population Health Advisor interviews and analysis Advisory Board All Rights Reserved advisory.com

27 4. Establish coordinated, team-based care in primary care setting (e.g., integrated behavioral health) Team-Based Care Improves Quality, Reduces Utilization and Cost LOW // MODERATE // HIGH For moderate-acuity patients, creating an integrated system for managing behavioral health care with other conditions is critical. In 1998, the Intermountain Healthcare system leadership began their Mental Health Integration (MHI) program in the primary care setting to improve access and care for patients with underlying depression. One of the keys to the program s success was standardized team-based care, including clearly defined roles and responsibilities for each stakeholder. Each primary care practice has a core behavioral health team (i.e., PCP, licensed mental health professional, care manager) that is supported by ancillary staff members who provide coordination, screening, and education to patients in need. In a 10-year study of the MHI program, participants had an 11% reduction in hospital admissions and the system observed $115 per member per year cost savings. Integrated Behavioral Health Requires a Standardized, Coordinated Approach Core Care Team Members Fulfill Distinct, Yet Complementary, Functions Primary Care Provider (PCP) Initiates Mental Health Team process and facilitates coordinated relationships with care manager and support staff Conducts ongoing patient care, including care planning and medication management Leads care team with the help of the clinic manager and staff Makes treatment decisions Patient and Family Act as major partners in treatment Participate in education opportunities, group-based support, and peer mentoring to help take active role in treatment and promote self-management. Case in Brief: Intermountain Healthcare Licensed Mental Health Professional Works with PCP to clarify patients diagnoses, determine complexity and care plan, consult on treatment and medication plan Provides therapy, diagnosis support, and medication management, if outside of PCP expertise Bridges care gap to stabilize patients in crisis while referrals to long-term care are in progress Care Manager Follows up with patients and family to provide education and ensure adherence to treatment protocols Tracks performance over time and communicates updates to team A nonprofit clinically integrated network of 22-hospitals, a medical group spanning 185 physician clinics, and a health insurance company. In 1998, the system leadership began their Mental Health Integration (MHI) program to improve care for patients with underlying depression in the primary care setting. 10-year controlled study reports a 40% increase in independent care plans, 5% increase in adherence to comorbid diabetes protocols, 7% reduction in primary care visits, 11% reduction in hospital admissions, and $115 per member per year cost savings compared to a control group, receiving care as usual. Source: Intermountain Healthcare, A Team-Based Approach to Mental Health Integration in Primary Care, Transforming Healthcare, July 16, 2014, Overview of Mental Health Integration, Intermountain Healthcare, Reiss-Brennan B, et al., Association of Integrated Team-Based Care With Health Care Quality, Utilization, and Cost, JAMA, 16, no.8 (2016): ; 2017 Advisory Board All Rights Reserved Population Health Advisor interviews and analysis. advisory.com 25

28 5. Introduce tele-psychiatry and remote consultation to increase reliable, timely access for at-risk patients Tele-psychiatry Extends Access to Areas with Provider Shortages LOW // MODERATE // HIGH Moderate-acuity patients often overutilize acute care services and receive unnecessary care in the ED due to a lack of access to behavioral health specialists. In 2011, Essentia Health Telehealth Network developed their Crisis Center to better serve patients with critical or acute mental health needs, who were inappropriately utilizing emergency care. The crisis center links the health system s critical access hospital and emergency room with mental health experts at their affiliated Mental Health Center. Essentia Health Virtually Connects Social Workers and Clinicians in ED On-Call Telebehavioral Health Center Mitigates Crises in the Emergency Department Patient presents in the emergency department in crisis and needs psychiatric care 6 Nurse calls crisis line with the patient s information and an explanation of the problem 5 During regular office hours, the crisis line front desk schedules an appointment After hours, MHP¹ contacts the nurse within 30 minutes to arrange a phone or video consult 4 Twenty-two credentialed behavioral health professionals, including clinical social workers, licensed marriage and family therapists, and master s prepared social workers, provide virtual support to patients with behavioral health problems in the ED. Support staff input the crisis note into Essentia Health s integrated EMR MHP informs the nurse of the treatment plan and reviews crisis note MHP finalizes crisis note, which includes name of referring physician and telehealth service code If a video consult is used, the ED nurse stays with the patient until the MHP conducts crisis assessment They help to mitigate behavioral health crises, assist with emergency department decisions, reduce avoidable admissions, and improve overall care. Case in Brief: Essentia Health Telehealth Network Essentia Health Telehealth Network includes 109 telehealth providers across 23 sites. Established in 2011, the crisis center links the health system s critical access hospital and emergency room in Fosston, Minnesota, with the Northwest Mental Health Center at Crookston, Minnesota. Hospital-based telehealth program offers a variety of services including behavioral health². 1) Mental Health Provider. Source: Ideker M, Partnerships to Meet Primary Care & ACO Challenges in Behavioral Health, Northwest Regional Telehealth Resource Center, 2) ED care, hospitalist access, stroke care, toxicology Population Health Advisor interviews and analysis Advisory Board All Rights Reserved services; clinic services include behavioral health, allergy, cardiac, pain management, and dermatology. 26 advisory.com

29 6. Develop transitional home care services for at-risk patients to prevent escalation LOW // MODERATE // HIGH Home Evaluation Identifies Complex Patient Needs and Personalizes Care Plan Problems managing behavioral health conditions often intensify once patients leave care settings. Nurse Practitioner Leads Home Assessment and Defines Patient Goals In-Home Assessment Informs Evidence-Based Mental and Physical Care Protocols The University of California San Francisco Health launched Care Support to improve transitional care for high-risk patients (e.g., 5 ED visits or 2 hospitalizations in the past 12 months) by conducting in-home assessments to inform care planning. 1 Nurse Practitioner Home Visit & Evaluation 2 Initiate Patient Assessment Determine Patient Goals A team of Care Support nurse practitioners and social workers then meet with appropriate specialists like geriatricians, mental health liaisons, and pharmacists to develop individualized care plans. This team also regularly consult with patients primary care team to ensure care plan goals are met. In a randomized controlled trial, participating patients showed decreased utilization and health care costs, as well as improved quality of care, patient satisfaction, and quality of life compared to those receiving care as usual. Difficulty Walking/Falls Case in Brief: University of California San Francisco Health Care Protocol Development Based on Assessment, Goals Cognitive Impairment Health Maintenance Advance Care Planning University of California San Francisco Health is an integrated health system of eight entities (hospitals, physician groups, foundations) serving Northern California. They adapted the Geriatric Resources for the Assessment and Care of Elders (GRACE) health care delivery model to improve care for their high-risk patients, by identifying and meeting patients spectrum of physical and mental health needs. A randomized-controlled trial suggests program effectiveness with a 5.5 decline in median emergency visits and hospitalizations, and a 33% increase in self-rated positive health reporting. 3 Source: Ritchie C, et al., Implementation of an Interdisciplinary, Team-Based Complex Care Support Health Care Model at an Academic Medical Center: Impact on Health Care Utilization and Quality of Life, PLoS One,11, no. 2 (2016): Population Health Advisor interviews and analysis Advisory Board All Rights Reserved advisory.com

30 7. Establish coordinated, team-based care in behavioral health setting LOW // MODERATE // HIGH Reverse Co-location Improves Care Continuity, Access to Preventive Services For high-acuity patients, traditional primary care and transitional services are typically insufficient. Yale New Haven Psychiatric Hospital formed the Behavioral Intervention Team (BIT) to screen patients for behavioral issues at admission and provide ongoing support if needed. Each BIT includes a psychiatrist, advanced practitioner, RNs, clinical nurse specialists and/or psychiatric social workers, peer wellness coaches, as well as the patient s primary care provider. The team evaluates and treats the patient s mental health needs, and follows up with the patient s primary care medical team to advocate for his or her care after discharge. If existing primary care services are deemed insufficient, the team refers patients to the Connecticut Mental Health Center for appropriate services. Connecticut Mental Health Center offers behavioral health primary care medical home services to 600 patients each year. Patients receive support from peer wellness coaches who serve as navigators to support the complex health needs of those in need of coordinated mental and physical care. High-Intensity Model Embeds Preventive Care in Behavioral Health Center Behavioral Health Home Integrates Primary Care and Psychiatric Rehabilitation Services 6 Patient receives continued coordination and preventive care 5 CMHC¹ Peer Wellness Coaches support and advocate for patients through the system Case in Brief: Yale New Haven Hospital and Connecticut Mental Health Center 1 Behavioral Intervention Team provides mental health screening at admission Psychiatric Rehabilitation Program Coordinates with Primary Care Team 4 Behavioral Intervention Team coordinates with primary care physician post-discharge Treats behavioral health needs 1,541 bed private, non-profit teaching hospital including the Yale New Haven Psychiatric Hospital, which formed the Behavioral Intervention Team to improve behavioral health care delivery. 2 3 May refer patient to primary care at CMHC¹. 1) Connecticut Mental Health Center. Source: Innovative Care, Yale New Haven Health, The Wellness Center: Integrating Health Care at CMHC, Yale School of Medicine, Behavioral Intervention Team Promotes Proactive Care, Staff Satisfaction on Medicine Units, Yale New Haven Health, Population Health Advisor research and analysis Advisory Board All Rights Reserved advisory.com

31 8. Proactively address acute needs with community partnerships (e.g., paramedics) LOW // MODERATE // HIGH Community Paramedicine Can Help Support Acute Behavioral Health Needs Community partners can help reduce avoidable acute utilization by acting as an extension of the care team. Paramedics allow health systems to divert high-acuity behavioral health patients from the ED to more appropriate services. Wake County EMS, in North Carolina, trained 16 advanced practice paramedics (APPs) to co-manage costly high-risk patients with the help of additional community providers. APPs provide in-home behavioral health counseling, education, and referrals. They transport patients with severe mental health or substance abuse problems to specialty facilities rather than to the ED. Wake County EMS calculated that in 2012, these diversions saved $350,000 in health care costs for the mental health/substance abuse population.¹ Duke Raleigh Hospital, one of Wake County EMS s partners, further observed a 34% reduction in ED visits, representing up to $325K in additional cost savings. Paramedics Trained to Assess, Treat, and Triage Patients to Right Site of Care APPs Receive In-House Training to Expand Responsibilities APPs receive 200 hours of didactic and clinical training prior to serving as an APP APPs divert patients from ED if they meet medical screening criteria; also provide informal counseling, health education, referrals for followup services, medication administration, and other homebased services Advanced Practice Paramedic (APP) Intervention Pathway Assessment and Treatment Disease Education Triage to Primary Care, Behavioral Health Facility or ED Case in Brief: Wake County Emergency Medical Services (EMS) An EMS organization in Wake County, North Carolina, with 16 advanced practice paramedics (APPs) partnered with Duke Raleigh Hospital, other providers, and Community Care of Wake and Johnson Counties, one of 14 networks within Community Care of North Carolina, ² to reduce inappropriate ED utilization by frequent utilizers. APPs can provide a range of home-based services including assessment of mental health, injury risk, and chronic condition management and also divert mental health patients away from medical EDs based on screening protocol. During monthly meetings with provider organizations, APPs also provide additional detail about patients home lives that can be used to adjust care plans. Of a sample of 25 APP-assigned patients, 72% experienced a decrease in ED visits, and their total ED visits dropped 34% from 641 to 424 between 2012 to 2014, representing a cost savings of approximately $325K. 1) In 2012, Wake County APPs placed 204 mental health/substance abuse patients in non-ed facilities. Because these patients continue on average 14 ED bed hours, while chest pain patients consume on average 3 ED bed hours, Wake County calculated they opened ED beds for 816 chest pain patients in a 12-month period by diverting mental health/substance abuse patients away from the ED. 2) Statewide nonprofit. Source: Population Health Advisor research and analysis Advisory Board All Rights Reserved advisory.com 29

32 9. Connect patients with wraparound community and social services Wraparound Resources Ensure Longitudinal Support to Acute Patients LOW // MODERATE // HIGH High-acuity patients often need ongoing support. Connecting these patients with wraparound community and social services can help reduce care team interactions and cost to the system. One model that has shown to effectively address the ongoing needs of high-acuity patients is the Program of Assertive Community Treatment (PACT). PACT provides intensive communitybased care support with the help of a multidisciplinary care team. The PACT team assesses patient progress, ensures proper medication compliance, helps to develop social, educational and professional skills, and discusses any other clinical and non-clinical concerns with patients on a daily basis during the first 6-12 months of enrollment. Within a few years, enrollees are generally able to maintain employment and a semi-independent living status. While patients rarely graduate from the program, PACT facilitates independence from clinical and social support services, resulting in improved quality outcomes and reduced hospitalizations. PACT Program Reduces Costs, Improves Care for High-Acuity Patients PACT Care Team Address Clinical and Non-clinical Concerns The PACT Care Team Social Workers Help patients navigate the complex mental health financing and delivery system. Psychiatrists Lead the care team. Pharmacists Work with psychiatrists to ensure patient safety and medication effectiveness. Nurses Manage treatment protocols between the illnesses of each patient, must have a strong background in psychiatric nursing. Occupational Therapists After an initial stabilization period, occupational therapists assist in the development of job-related skills and independence with activities of daily living. Case in Brief: Program of Assertive Community Treatment (PACT) Program Impact $15K Per patient per year 30% Decrease in symptom severity 30% Increase in independent living skills PACT is a community-based care delivery model for people with severe and chronic mental illnesses. PACT has been shown to improve quality outcomes and reduce hospitalizations. University of Oklahoma-Tulsa estimates that it saves the overall health care system $15,000 per patient, per year. Source: Program for Assertive Community Treatment, CPC Behavioral Healthcare, Program of Assertive Community Treatment (PACT), Oklahoma Department of Mental Health and Substance Abuse Services, unity_treatment_(pact)/; Population Health Advisor interviews and analysis Advisory Board All Rights Reserved advisory.com 30