SHOW-ME INNOVATION: Missouri s Health Care Homes Integrate Behavioral Health and Primary Care Jaron Asher, MD February 28, 2014

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1 SHOW-ME INNOVATION: Missouri s Health Care Homes Integrate Behavioral Health and Primary Care Jaron Asher, MD February 28, 2014

2 Jaron Asher, MD Medical Director at Places for People in St. Louis, MO Chief Behavioral Health Officer at Family Care Health Centers (FCHC) in St. Louis, MO Acknowledgments Joseph Parks, MD Director Missouri HealthNet (Medicaid) Former Medical Director for Missouri s Department of Mental Health (DMH) Behavioral Health Director at Family Health Center in Columbia, MO Sosunmolu Shoyinka, MD Assistant Professor of Clinical Psychiatry at UM - Columbia Caroline Day, MD Associate Medical Director at FCHC Physician Consultant at Places for People

3 Columbia St. Louis Jefferson City Branson Missouri The Show-Me State

4 Objectives 1) Identify the benefits of Health Care Homes to patients. 2) Understand the policy implications of the Health Care Home model at the state level 3) Recognize the benefits of implementing TEAMcare in collaborative practice. 4) Identify the essential components of a curriculum teaching integrated care to psychiatry residents. 5) Time for questions and answers

5 What is a Health Home? How does a Health Home promote recovery?

6 What is a Health Home? A designated provider of whole person services including: Comprehensive Care Management Care Coordination and Health Promotion Comprehensive Transitional Care Patient and Family Support Referral to Community and Social Support Services Use of Information Technology to Link Services With the goal of increasing quality of care, improving the patient s healthcare experience, while decreasing the cost of care.

7 SAMHSA Definition of Recovery From Substance Abuse and Mental Health Services Administration (SAMHSA) website A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.

8 SAMHSA Definition of Recovery 4 Dimensions Health : overcoming or managing one s disease(s) as well as living in a physically and emotionally healthy way; Home: a stable and safe place to live; Purpose: meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income and resources to participate in society; and Community : relationships and social networks that provide support, friendship, love, and hope.

9 Why and how did Missouri initiate Health Homes? What are the outcomes data thus far?

10 Missouri s Health Home Initiative Affordable Care Act March 2010 Section 2703 allows states to amend their Medicaid state plans to provide Healthcare Homes for enrollees with chronic conditions. Missouri Medicaid state plan amendment submission to CMS (Centers for Medicare and Medicaid) in 2011 Missouri went live January the first state to amend its Medicaid state plan

11 Missouri s Health Home Initiative FQHCs and CMHCs Currently over 900,000 Missourians are served by MO HealthNet (Missouri Medicaid) Missouri Population about 6,000, Patient Centered Medical Homes in 18 Missouri Federally Qualified Health Centers (FQHCs) - about 16,000 Medicaid recipients 2. Health Homes in 28 Missouri Community Mental Health Centers (CMHCs) - about 19,000 Medicaid Recipients This talk will focus on #2

12 Missouri s Health Home Initiative - Why CMHCs? Persons served by CMHCs die 25 years earlier than the general population. (Multiple state data, Dr. Joe Parks et al. Morbidity and Mortality in People with Serious Mental Illness.) Most of the premature deaths in persons with schizophrenia are due to cardiovascular, pulmonary and infectious diseases. Premature because the risk factors are often modifiable

13 Missouri s Health Home Initiative Health Homes are a way for CMHCs to address these early deaths and risk factors. Coordination and integration of care improves access to quality care Comprehensive Care Management Care Coordination and Health Promotion Comprehensive Transitional Care Patient and Family Support Referral to Community and Social Support Services Use of Information Technology to Link Services

14 Missouri s Health Home Initiative - Eligibility People selected for CMHC Health Home have Medicaid and: A serious and persistent mental illness, or A mental health condition and substance use disorder, or A mental health condition and/or substance use disorder and one other chronic health condition (Diabetes, Cardiovascular disease, Chronic obstructive pulmonary disease (COPD), Overweight (BMI >25), Tobacco use, Developmental disability) People selected are in unless they opt out CMHCs can add people who meet criteria

15 Health Home Eligibility Graphic Substance Use Disorders Chronic Disease Diabetes, Cardiovascular disease, Chronic obstructive pulmonary disease (COPD), Overweight (BMI >25), Tobacco use, Developmental disability SPMI Mental Illness

16 Missouri s Health Home Initiative - Staff on the Health Home Team Community Support Specialists Behavioral Health Clinicians New - Health Home Director New - Primary Care Physician Consultant New - Nurse Care Manager

17 Missouri s Health Home Initiative - Financing Supported by a Per Member Per Month (PMPM) payment from Medicaid to the CMHC, triggered by Health Home service HCH Director: $ Based on 500 enrollees Primary Care Physician Consultant: $ Based on 1 hr per enrollee Nurse Care Manager: $ Based on 1 NCM to 250 enrollees Administrative Support: $12.07 Total PMPM: $78.74

18 Missouri s Health Home Initiative - Financing 1.2 Health Home FTEs for 375 Clients 1 1 Full Time Equivalent Health Home Director PCP Consultant Nurse Care Manager one Nurse Care Manager two

19 Missouri s Health Home Initiative Vital Supports Structured Learning Physician Institute (DMH, MOCMHC) Learning Collaborative (MFH, CSI Solutions) Missouri Medicaid Health Home Health Information Technology CyberAccess ProACT BPM (Care Management Technologies)

20 Missouri s Health Home Initiative - What were the expectations? Reduce healthcare costs Lower rates of emergency room use Reduce in-hospital admissions and readmissions Decrease reliance on long-term care facilities Improve experience of care, quality of life and consumer satisfaction Improve health outcomes

21 Missouri s Health Home Initiative - What are outcomes so far? Data from Dr. Joe Parks % of CMHC Health Home patients with at least one hospitalization % reduction $13.5 million saved from reduced hosp ns and ER visits $9.3 million invested in the per member per month $4.2 million NET SAVINGS for Missouri

22 Missouri s Health Home Initiative - What are outcomes so far? Data from Dr. Joe Parks 4 Regions evaluated: St. Louis Central and South, Columbia, Kansas City From 2011 to 2012 all 4 regions showed improvement in HgbA1c, BP, LDL metrics. 2 regions showed improvement in Tobacco Cessation

23 How did one CMHC implement TEAMcare in their Health Home?

26 Original TEAMcare Study Design Wayne Katon, MD University of Washington, patients assigned to intervention 108 patients assigned to usual care Intervention: medically supervised nurse, working with each patient s primary care physician, provided guideline-based, collaborative care management, with the goal of controlling risk factors associated with multiple diseases, including depression.

28 Original TEAMcare Intervention Nurses received weekly supervision with a psychiatrist, primary care physician, and psychologist to review new cases and patient progress. Electronic registry was used to track PHQ-9 scores and glycated hemoglobin, LDL cholesterol, and bloodpressure levels. Supervising physicians recommended initial choices and changes in medications tailored to the patient s history and clinical response. Nurse communicated recommended medication changes to the primary care physician responsible for medication management.

29 Original TEAMcare Study Results As compared with controls, patients in the intervention group had greater overall 12- month improvement across: glycated hemoglobin levels LDL cholesterol levels systolic blood pressure SCL-20 depression scores

30 TEAMcare in Missouri Introduced at Physician Institute in Branson in June 2012 TEAMcare consultant from Washington State presented the model in a half-day presentation Missouri CMHCs had time to discuss how they would implement

33 Population Staff Health care system Metrics Original TEAMcare Primary care (SMI excluded) Nurses, psychiatrist, primary care physician, psychologist Patient s physician agreed to participate in the program HgbA1c, LDL, BP, PHQ-9 PfP Adaptation 100% Serious Mental Illness Nurses, community support specialists, primary care physician, psychiatric pharmacist, data specialist Most of the patients physicians are not aware of the program HgbA1c, BP, DLA subscores

34 Integrated Care at PfP Consultant PCP Psychiatrist or Psychiatric Pharmacist Nurse Care Manager Community Support Specialist PCP Patient

35 TEAMcare at PfP Weekly in two hour blocks. One hour per team. The HCH Program Assistant coordinates the schedule. In advance, team scheduled for that week submits up to 3-5 patients to be discussed. Also some patients who are not in HCH. HCH Program Assistant prepares and brings the data. Access database (the registry ) Behavioral Pharmacy Management (BPM) Disease Management Indicators

36 TEAMcare table at PfP Nurse Care Manager Community Support Specialist HH Program Assistant Consultant PCP Psychiatrist or Psychiatric Pharmacist

37 Daily Living Activities - 20 (DLA-20) Rating from 1 to 7 on 20 different subscales The average of the scores multiplied by 10 is a rating of the person s functioning and an estimation of the Global Assessment of Functioning (GAF.) DLA-20 was already being used at PfP as a guide for determining level of service needed

38 Daily Living Activities - 20 (DLA-20) 1. Health practices 5. Managing time 9. Family relationships 2. Housing stability 6. Managing $ 10. Alcohol/ drug use 3. Communication 4. Safety 7. Nutrition 8. Problem solving 11. Leisure 12. Community resources 13. Social network 14. Sexuality 15. Productivity 16. Coping skills 17. Behavior norms 18. Personal hygiene 19. Grooming 20. Dress

39 Daily Living Activities - 20 (DLA-20) (1) Health Practices - score of 3 = Limited self-care & compliance, serious impairments in moods, symptoms, mental status, maybe physical issues, prompting continuous help for health care (10) Alcohol/Drug Use - score 3 = Current abuse or dependence, acknowledges serious substance abuse problem but shows limited self-control, struggles with treatment plan. (16) Coping Skills - score of 3 = Ineffective use of few coping skills prompting regular interventions (e.g. extra contacts, frequent use of over-the-counter medications)

40 TEAMcare Example 3/5/13 Patient = Steve, 50 year old male Diagnoses: Schizophrenia on clozapine diabetes, well controlled hypertension hyperlipidemia former smoker regular alcohol consumption aortic regurgitation from congenital bicuspid valve ongoing weight gain Issues: Unexplained tachycardia Anemia with family history of colon cancer So groggy hard to engage DLA (1) Health Practices = 6 (10) Alcohol/Drug = 3 (16) Coping = 4

41 Implementation Number of clients discussed July 2012 to Oct 2013: 157 Number of clients discussed at length 2-4 times: 34 Number of teams from agency involved: 14 Rotation of turn : every 7 weeks Each iteration: Initial time review of previous action items; determine success vs. barriers Then 2-4 clients discussed each for at least 8 minutes (either HCH or not) Action items assigned to any of participants or other team members

Standardized TEAMCare FORM ID of client, team & meeting variables Metrics Identifying problems (mental & physical) Review of medications Psychiatrist,

42 Standardized TEAMCare FORM ID of client, team & meeting variables Metrics Identifying problems (mental & physical) Review of medications Psychiatrist, PCP, nurse care manager Health goals from Treatment Plan Review of quality reports: Behavioral Pharmacy Management CMT reports Action items & to whom assigned.

43 TEAMcare Client Statistics # of clients in PfP s Health Care Home (HCH) 375 # of clients discussed in TEAMcare to date 157 # of clients who were connected to a PCP 19 # of different psychiatrists who serve clients of PfP s HCH 55 # of PfP s HCH clients served by the 4 PfP psychiatrists 153 # different PCPs who serve clients of PfP s HCH 98 # of PfP s HCH clients served by PCPs with close connection* 98 *Through PfP s partnership with Family Care Health Centers (FQHC)

44 Typical Action Items Part 1 Prioritized list of action items to prevent overwhelmed clients and staff Community Support Specialist (CSS) and client discussion using website/handout. (e.g. about sleep apnea and sleep studies) Referral to nutritionist or other specialist CSS to join client at upcoming appointment to highlight change in metrics

45 Typical Action Items Part 2 Communicate with psychiatrist in-house (or via call/letter to outside psychiatrist) regarding medication change around weight gain or other metabolic concerns Letter to primary care provider, psychiatrist, or pain specialist regarding concern re: risky medications (e.g. opioids, benzodiazepines) Health Home nurse to provide education on diabetic diet or other problem solving

46 Typical Action Items Part 3 Assistance in getting resources for clients to take action on a medical goal (e.g. buy a scale) Recommendations on how to approach housing changes when there are physical health concerns (e.g. does client need more structured living like RCF or SNF.) Help change PCP or primary psychiatrist when not responsive to concerns Establish new PCP or psychiatrist when there is none

47 TEAMCare serves clients by strengthening TEAM approach

48 Survey says The information and coordination is helpful and fills a prior void. Still hard to take action and engage some clients. TEAMCare is a team but not necessarily the team that ends up doing the action items. 14/20 thought TEAMCare should continue. Talks given by primary care consultants to groups of clients and groups of CSS regarding health issues helps understand action items

49 TEAMcare Example Patient = Steve, 50 year old male Diagnoses: schizophrenia diabetes, well controlled hypertension hyperlipidemia former smoker regular alcohol consumption aortic regurgitation from congenital bicuspid valve ongoing weight gain Issues: Unexplained tachycardia Anemia with family history of colon cancer So groggy hard to engage ACTION ITEMS: Refer for sleep study had 6 pack of beer before study as typical night, used CPAP, woke up less groggy than usual. Tachycardia being on clozaril does cardiology think he has developed cardiomyopathy or arrhythmia concern on clozaril. Letter back from cardiologist no but I will continue to monitor for you.

50 TEAMcare Summary One Treatment Plan Health Homes and TEAMcare facilitate big picture team-based review with data and vital input from each vantage point, leading to the creation and prioritization of one treatment plan with action items from that comprehensive perspective.

51 What are the essential components of a curriculum teaching integrated care to psychiatry residents?

55 Teaching Integrated Care to Psychiatry Residents - Background 4 Psychiatry Residencies in Missouri: St. Louis University, Washington University, UM Columbia, UM Kansas City Instead of a CMHC in St. Louis, we are now talking about a CHC (FQHC) in Columbia, MO

58 Teaching Integrated Care to Psychiatry Residents - Goals Increase interest, recruitment and retention in Community Psychiatry by implementing current best practices in Community Psychiatry Training. Increase knowledge of integrated care models and skills in integrated care Tighten the mental health safety net in Columbia - i.e. fill the gaps in existing services with innovative projects and ideas Increased access in the safety net to substance abuse treatment.

59 Teaching Integrated Care to Psychiatry Residents - How Supplement the current mental health resources of Family Health Center in Columbia.1 FTE Psychiatrist.6 FTE Psychiatric Nurse Practitioner Behavioral Health Consultants from a local CMHC (Burrell) Integrated Care Elective 1 year elective by 3 rd and/or 4 th year psychiatry residents 4 hours per week Consultant role is emphasized Scheduled visits for consultation Curbside consultation Open access

60 Teaching Integrated Care to Psychiatry Residents - Details Patients seen by residents are not billed, insurance is not billed either Documentation consultation forms are scanned into the EMR No more than 3 follow up visits to maintain the focus on consultation Prescribing is always done by PCP, much direct contact between psych resident and PCP Supported by Department of Mental Health who pays UM Columbia $5000 for the attending to supervise

CMHC Healthcare Homes. The Natural Next Step

CMHC Healthcare Homes. The Natural Next Step CMHC Healthcare Homes The Natural Next Step Partners in Planning A collaborative effort involving Dept. of Social Services (Mo HealthNet) Dept. of Mental Health Primary Care Association (FQHCs) Coalition