Identify Best Practices of Behavioral Health Home Organizations to Prevent Admissions and Readmissions

Transcription

1 Orlando, Florida No Disclosures DE2: MaineCare Behavioral Health Homes: An Innovative and Integrated Approach to Care Liz Miller, MPH, Project Manager, Maine Quality Counts Mary Beyer, MS, Quality Improvement Specialist, Maine Quality Counts IHI Summit March 20 22, 2016 Session Objectives Identify Best Practices of Behavioral Health Home Organizations to Prevent Admissions and Readmissions Explore Primary Care and Behavioral Health Opportunities for Partnership Utilize Key Changes to Guide Safe and Effective Care Transitions 1

2 Where did it all begin? Section Maine State Innovation Model (SIM) Initiative Primary Innovations Strengthen Primary Care Integrate Physical & Behavioral Health Care Develop New Workforce Models Develop New Payment Models Centralize Data & Analysis Engage People & Communities SIM Goals by 2017 The total cost of care per member per month in Maine will fall to the national average Maine will improve the health of its population in at least four categories of disease prevalence (i.e. diabetes, mental health, obesity, etc.) Maine will improve targeted practice patient experience scores by 2% from baseline for practices that participated in the 2012 survey Maine will increase from 50% to 66% the number of practices reporting on patient experience of care 4 2

3 Improve Health Reduce Cost Provide Quality Care SDOH: Social Determinants of Health Develop a Resilient Workforce 5 Maine s Health Home Movement ~ 500 Maine Primary Care Practices ~220+ NCQA PCMH recognized practices Payers: Medicare Medicaid (Health Homes) Commercial plans Self-funded employers 175+ MaineCare Health Home Practices 70 PCMH Pilot Practices 14 FQHCs CMS APC Demo Payer: Medicaid 6 29 MaineCare Behavioral Health Home Organizations Payer: Medicare 3

4 Role of Behavioral Health Homes in Promoting Safe and Effective Care Transitions Primary Care (PCMH MaineCare Health Homes) MaineCare Behavioral Health Homes Integrated Behavioral Health 7 MaineCare Behavioral Health Homes What is it? A Medicaid Integrated Mental Health Case Management Service Who can receive this service? Adults living with a diagnosis serious mental illness and Children living with a diagnosis of serious emotional disturbance Who Provides the Service? Licensed Community Mental Health Agency Primary Care Practices Behavioral Health Home Organizations 8 4

5 MaineCare Behavioral Health Homes 28 Behavioral Health Homes Orgs 70 locations across the state 29 locations serving Adults 11 locations serving Children 30 locations serving Both 9 10 Core Expectations 1. Demonstrated provider leadership 2. Team-based approach 3. Population risk-stratification and management 4. Enhanced access to care 5. Comprehensive consumer/family directed care planning 6. Behavioral-physical health integration 7. Inclusion of members & families 8. Connection to community 9. Commitment to improve efficient use of health care 10. Integrated HIT 10 5

6 Core Services Care Management Care Coordination Health promotion Individual and family Support Transitions of care Resulting In Improved physical and behavioral health outcomes Reduced hospital admissions and emergency room use Better transitional care Improved communication between health care providers Increased use of preventive services and self-management tools 11 Certified Peer Support Specialist (CIPSS) Family or Youth Support Specialist Psychiatric Consultant Health Home Coordinator for Adults Nurse Care Manager Person Centered Team Health Home Coordinator for Children and Families Medical Consultant Clinical Team Leader Admin Team Leader 12 6

7 Care Management People living with multiple complex conditions Complex Care Transitions People living with chronic conditions Disease Management Self-Management All People Preventive Care & Wellness Programs 13 Year 1 Behavioral Health Homes In 2014, there were over 200 Emergency Department Visits for non-emergent reasons 12% of hospital admissions resulted in readmission to the hospital 14 7

8 Roadmap for Safe & Effective Transitions of Care Prevent Avoidable Readmissions Outreach and Follow Up Connect to Community Resources Build the Medical Neighborhood Develop Systems for Communication Facilitate Access to Services Plan Ahead 15 BHH Client Population 100% BHH QI SUCCESSES 75% 50% 25% Decrease in Risk Factors for Emergency Department Utilization 54% Reduction in Medications 25% Reduction in Emergency Department Visits AIM 9 Months Results 16 8

9 BHH QI SUCCESSES Emergency Department Utilization 10% 6 Month AIM 42% 6 Month Result Increase trend in Enhanced Access from 135 BHH Clients utilizing the service to BHH QI SUCCESSES Emergency Department Utilization for Non Emergent Reasons 23% 14% 9 months Awareness of Alternative Health Care AIM 70% 9 months Actual 82% 18 9

10 Your Turn! - Roadmap Worksheet Strategies Identify the activities needed in this area Who is the Lead Organization (BHH, PCP, Other?) Description ofthe Role Lead Organization Has in this Domain 1 Preventing Avoidable Readmissions 2 Develop Systems for Communication 3 Outreach and Follow Up 4 5 Facilitate Access to Services Connection to Community Resources 6 Planning Ahead 7 Build the Medical Neighborhood 19 10