Social Determinants of Health: Creating a Multi-Agency Coordinated Care Hub for Homeless Adults

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1 Social Determinants of Health: Creating a Multi-Agency Coordinated Care for Homeless Adults Boston Health Care for the Homeless Program Green River

2 BHCHP Mission Since 1985, our mission has remained the same: To provide or assure access to the highest quality health care for all homeless individuals and families in the greater Boston area.

3 Massachusetts 27,337 sq.km (44/50) 6.7 million people (14/50) #1 Healthiest state (2017) #1 State with highest rate of health care coverage (97.5%) #2 State with highest per capita health care costs ($11k/person)

4 BHCHP Population Our patients are complex: 68% mental illness 60% substance use disorders (SUD) 48% co-occurring mental illness & SUD High prevalence of medical illnesses, e.g. HCV (23%) & HIV (6%) High prevalence of chronic illnesses, e.g., 37% hypertension, 26% COPD or asthma, & 18% diabetes mellitus Disease burden = DxCG score of 3.8 (average = 1.0) Our patients are costly: $2,036 PMPM vs. $568 for all MassHealth members >1/3 had 6 or more ED visits/year; 1/5 had 3 or more hospitalizations 10% population accounted for ~50% total expenditures Bharel, M., Lin, W.C., Zhang, J., O Connell, E., Taube, R. and Clark, R.E., Health care utilization patterns of homeless individuals in Boston: preparing for Medicaid expansion under the Affordable Care Act. American journal of public health, 103(S2), pp.s311-s317.

5 SDH Consortium A history of collaboration Shared space Public health emergencies State Infrastructure & Capacity Building Grants Legal agreement to share data across health, mental health, substance use, housing, social service sectors Linkage to City of Boston Continuum of Care data platform A shared need to stay relevant in changing delivery system Massachusetts is significantly restructuring public insurance (Medicaid) delivery into Accountable Care Organizations (ACOs) ACOs mandated to buy not build and contract with Community Partner (CP) entities Massachusetts Health Policy Commission grant to build pilot for 60 patients June 2018 model will be scaled to 1000+

6 Initial Health Policy Commission Grant Objective: Coordinate care across 10 agencies to better serve people experiencing homelessness, improve access to services that address SDH, and reduce avoidable ED and hospital utilization by 20%. Timeline: 2-year, $750k grant from December Target population: ~60 homeless individuals with high costs/high health care utilization

7 Coordinated Care ❶ DEDICATED RESOURCES 15:1 client-to-staff ratio Recognizes challenge of engaging highestrisk clients Delegated case management based on existing relationships At least weekly encounters Support from BHCHP RN ❷ SHARED INFORMATION TECHNOLOGY Shared care management platform Consent required from client ❹ CONNECTION TO PRIMARY CARE Regular communication with doctor/nurses Joint training and case conferencing Accompaniment to appointments ❺ DATA TO HELP UNDERSTAND CLIENT S NEEDS & SERVICE USE Information from Medicaid claims, EHR, and other social service agencies Data to improve client s connection to care Data about recent hospitalizations/ed visits Data about care management & housing ❸ SHARED CARE PLANS Client s goals are created by him or her and supported by team ❻ SUPPORT FROM LEADERSHIP TEAM Meets regularly to troubleshoot and strategize about progress and pain points Monthly dashboard May be able to prioritize housing, services, or leverage other resources

8 Case Study: Medical Record Adam is in his early 60s and has a complex medical history including COPD, HIV/AIDS, and polysubstance use disorder. He was most recently hospitalized for neck swelling likely due to an abscess, for which he required intubation to keep his airway open. He left this hospitalization against medical advice and before completing a course of antibiotics. He has previously been hospitalized in the ICU for alcohol withdrawal. He has had dangerous cardiac arrhythmias while withdrawing from alcohol as well as delirium. His hepatitis is reportedly stable with an undetectable viral load and he reportedly continues to regularly take his medications for HIV. He has been admitted to the ICU for COPD exacerbations (he continues to smoke despite using oxygen although he is trying smoking cessation medications). He has been repeatedly prescribed prednisone (steroid) for his COPD flares but he reports that it makes him feel jittery and he doesn t like to take it.

9 SDH: Beyond the Medical Record Adam was formerly incarcerated for over 20 years. Having been institutionalized for a long time, he feels extremely anxious in public spaces, particularly when surrounded by many people. Yet, due to this institutionalization, he is also afraid of living alone. His main barrier is struggling to interact with other people. In prison, he learned he needed to distrust others, and the survival mechanisms he used while in prison no longer serve him outside of it. He does not know how to interact with others. He also went through a period of homelessness, but has been recently housed by a local community organization. He currently lacks social support, while the little support he has tends to socialize over drinking. He is facing eviction because of smoking while using oxygen inside his apartment.

10 Coordinated Care HMIS HMIS HMIS HMIS EHR EHR Medicaid Claims Records Data Management Application Agency Provider Portal Care Provider Portal Warehouse Database Open source platform on HIPAA-compliant AWS Coordinated Access to Housing

11 Coordinated Care Individual client dashboard and service history screenshots shows data collected from multiple agencies HMIS.

12 Coordinated Care Housing status and assessment results over time.

13 Coordinated Care Problems, medications, appointments

14 Coordinated Care Managing team members, notes, and goals

15 Coordinated Care Performance assessment

16 Community Partner Funding Streams Care coordination payments = $180 PMPM. Infrastructure support payments decline over 5 years. Infrastructure payments are also held at risk tied to Accountability Score.

17 Community Partner Accountability Slate Source: Massachusetts EOHHS Updates to BH and LTSS CP Accountability Slates, Februa

18 Lessons Learned Data sharing is powerful. Nearly all patients have consented to participate; high levels of ongoing engagement with case managers. Face-to-face case management enabled by decentralized case managers; phone case management doesn t work well. Logjam for addiction services treatment beds/affordable housing Bridge to nowhere Some costs we cannot control. Pharmaceutical is huge cost center. Many patients have advanced disease 4 patients have died to date. Integration is hard work: cultures collide. But universal agreement that this is the right path.

19 Thank you... Senior Health Policy Advisor Boston Health Care for the Homeless Program Director of Strategic Development Green River