Coordinating Care for Individuals with Serious Mental Illness
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1 Coordinating Care for Individuals with Serious Mental Illness Kishor Malavade, MD Chief Medical Officer for Behavioral Health, Department of Population Health Maimonides Medical Center
2 Who we are Maimonides Medical Center is a tertiary care/safety net hospital in Southwest Brooklyn Maimonides has strategically focused some of its efforts on population health Maimonides is the lead agency for two collaborative entities: The Brooklyn Health Home Community Care of Brooklyn
3 Prevention Opportunity that led to the Innovation Highly fragmented health care in Brooklyn Disproportionate effects on individuals with Serious Mental Illness (SMI) Increased morbidity and mortality with SMI pop Higher cost and utilization associated with SMI population attributable to physical health issues Develop care management model for chronic, complex disorders, using SMI as test case
4 Key elements of the Innovation Reduced utilization in SMI population Improved coordination of care and management of transitions of care Model of care successful in closed systems. Brooklyn is not a closed system SMI patients with highly complex needs that require collaboration across systems Multi-stakeholders partnership
5 Description of the Innovation Use the Health Home model in NYS as a vehicle for coordinating care for SMI pop Key components: The Virtual Care Team Implementation through multi-stakeholder engagement, with executive and clinical committee structures to develop shared standards of care CMMI HCIA: July 2012 June 2015
6 BHH Goals Identify and address full range of behavioral, medical and social problems affecting chronically ill patients Foster collaboration and timely exchange of patient information among involved providers Drive measurable improvements in patient outcomes, including reduced hospital use, improved engagement and satisfaction
7 Overview of the BHH Clinical Model Key Feature: Virtual co-location of providers and services enabled by health IT and coordination of services Member 7
8 BHH Providers Care Management Providers Baltic Street Brooklyn Community Services (BCS) CAMBA CASES Catholic Charities EAC Family Services Network of New York Jewish Board of Family and Children Services (JBFCS) Health Care Choices ihealth: - APICHA - Brightpoint - Diaspora Community Services - Gay Men s Health Crisis, Inc. - Heartshare Human Services of NY - Housing Works Institute for Community Living Interborough Developmental and Consultation Services Lutheran Medical Center Maimonides Medical Center NADAP Ohel Children s Home and Family Services Promoting Specialized Care and Health (PSCH) The Puerto Rican Family Institute, Inc. Services for the Underserved Village Care VNSNY Network Providers Beth Israel Medical Center Black Veterans for Social Justice Realization Center Bridge Back to Life Brookdale Hospital Brooklyn AIDS Task Force Brooklyn Hospital Brooklyn Plaza Medical Center Center for Behavioral Health Services Center for Urban Community Services (CUCS) Kingsboro Psychiatric Center Liberty Behavioral Management Medisys Health Network Providers National Alliance on Mental Illness (NAMI) Phoenix House Public Health Solutions (PHS) St. John s Riverside Hospital South Beach Psychiatric Center SUNY Downstate Medical Center White Glove Community Care Wyckoff
9 BHH Goal: Transition to Integrated Care Physical Health Services Physical Health Services Payer Behavioral Health Services Payer Behavioral Health Services Health Home Siloed Model of Care Integrated Model of Care
10 Milestones and Results to date CMMI HCIA completed June individuals with SMI enrolled in BHH and CBC HH Reduced hospitalization (~30%) Reduced ER use (~50%) Reduced costs of care (~$50 million) Improved transitions of care
11 Lessons Learned Little was easy Multi-stakeholder committees highly effective Much was challenging Provider engagement Patient engagement Early emphasis on enrollment, rather than developing effective care teams
12 Implication / Next Steps If this can be done with SMI, then it is very doable for other chronic, complex conditions Collaboration across systems essential to health care success Co-location is not necessary HARP Pilot: Healthfirst Next step: DSRIP
13 Social Service Provider OASAS/Addiction Services Case Management Public Health Authorites Home Care SPOA Speciality Physcians Care Coordination Platform GSI Health Therapist Specialists Care Manager Patient Care Coordination Platform Intensive Care Management Providers Psychiatrist Specialists Family Payer Homeless Shelters Peer Advocacy Correctional Services Supporting Housing Organizations Foundation for Success Long-standing multi-organizational partnerships Health Home/Care Management expertise Information Technology Workforce SHIN-NY/BHIX SHIN-NY/BHIX SHIN-NY/BHIX Care Coordination Platform Social Services Primary Care Physician SHIN-NY/BHIX Care Coordination Platform Social Services Care Navigator SHIN-NY/BHIX SHIN-NY/BHIX Launched Mental Health Home with HEAL 10/17 to improve care for SMI Expand mental health model, training, HIT with CMMI award : Co-location of primary care & behavioral health services at South Beach Psychiatric Center Launch HARP Pilot
14 Community Care of Brooklyn Network 448,000 attributed lives 3,700+ practitioners, including 1,600+ PCPs 350 partner entities, including: 6 Hospitals 8 FQHCs Behavioral health providers Social service providers Community-based organizations Health Homes Substance Abuse Providers Advocacy Organizations Home Care Long-Term Care Correctional Health Housing Providers and Advocates Payers/ MCOs RHIO Unions Job Training Providers SNFs
15 CCB Practice Characteristics 7% (>10) 16% (2-10) 77% (Single Provider) Physicians and other practitioners overwhelmingly organized in small practices
16 CCB Centralized Services Web-Based Care Coordination Platform (Dashboard) Workforce Development Analytics & Reporting Network Development & Management PCMH Support Centralized clinical resources to provide collaborative care back up for: Behavioral Health Palliative Care Pharmacy VBP Support
17 Summary Coordinating care for SMI pop is challenging, but doable Requires collaboration across systems Requires IT infrastructure and platform Virtual care teams are possible Innovation builds on innovation CMMI HCIA was prep work for DSRIP
18 Contact information Kishor Malavade, MD Chief Medical Officer for Behavioral Health, Department of Population Health Maimonides Medical Center
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