Connected Care Program Connected Care Initiative to improve the connection and coordination of care for those with Serious Mental Illness among health plans, PCPs, and behavioral health providers in outpatient, inpatient and ED care settings. Based on Patient Centered Medical Home model with integrated care team and care plan to address all medical, behavioral, social needs. Partnership between: Center for Health Care Strategies (CHCS) Department of Public Welfare (DPW) UPMC for You Community Care Behavioral Health Allegheny County Department of Human Services 2 1
About Community Care Community Care Licensed 501 (c)3 (not-for-profit) behavioral managed care company. Approximately 1,000,000 members in Pennsylvania 600,000 Medicaid 400,000 Commercial and Medicare members through UPMC Health Plans 3 The Pennsylvania HealthChoices Program Pennsylvania Department of Public Welfare submitted a 1915b waiver to offer a mandated Medicaid program that included a behavioral health carve out. The physical health MCO s compete for members within a county but the behavioral health program is offered on a county-wide basis The MCO chosen by a specific county (or by the PA Department of Public Welfare) covers all of the Medicaid-eligible persons within that county; Community Care is a partner with the state and the counties in these BH Medicaid programs. 4 2
5 Counties Served by Community Care Erie Crawford Mercer Lawrence Butler Beaver Allegheny Washington Greene Venango Clarion Warren Armstrong Forest Westmoreland Fayette Jefferson Indiana Somerset McKean Elk Cambria Clearfield Cameron Blair Bedford Potter Clinton Centre Huntingdon Fulton Franklin Mifflin Tioga Lycoming Snyder Juniata Perry Union Cumberland Adams Bradford Sullivan Susquehanna Wayne Wyoming Lackawanna Pike Luzerne Columbia Monroe Montour Carbon Northumberland Schuylkill Northampton Lehigh Dauphin Lebanon York Lancaster Berks Bucks Montgomery Chester Delaware Philadelphia Community Care Contracted Counties Community Care Office 6 3
Rationale for Connected Care Historic gap between PH and BH providers Occurs regardless of financing mechanism Similar to gaps between other specialists and PCPs Coordination challenge posed by confidentiality provisions Shortened lifespan of consumers with serious mental illnesses, primarily due to physical health issues (complications of smoking and weight) 7 Key Areas of Concern of Consumers Access to good clinical healthcare, including physical health h care Identifying and developing supportive relationships. Determining meaningful activity, including work. Gaining personal control over life, including housing Overcoming stigma. Changing g how they are treated by health care and other social service systems Progress towards these goals has been episodic and slow 8 4
Target Population Members qualify for Connected Care if they are: A UPMC for You and a Community Care member Age 18 or older Live in Allegheny County Defined as having Serious Mental Illness (SMI)* * SMI has been defined as individuals who have been diagnosed with schizophrenic disorders, episodic mood disorders, or borderline personality disorder. 9 Program Goals and Objectives Improve Health: Decrease gaps in care for behavioral & medical conditions Improve the rate of medication adherence Improve the rate of preventive services Improve the rate of visits with providers Reduce avoidable readmissions & emergency room visits Improve Satisfaction: Better access and services Improved coordination of care 10 5
Extensive Planning Process Extensive analysis of federal and PA law related to privacy/confidentiality restrictions Feedback from a consumer advisory group Strong emphasis on member recovery goals Communication with PCPs and Behavioral Health Providers Data exchanges Staff work flow between care managers 11 Member Consent Member Consent requirements: Exchange of PHI between the Health Plans: The Health Plans may exchange information without consent, except for Drug/Alcohol and HIV Exchange of PHI from Health Plans to providers: No information shared with providers except ED visits/hospitalizations, w/o active member consent No release of drug and alcohol or HIV information to providers, even with member permission 12 6
Connected Care - Key Components Medical Home: All members linked to a medical home Identify providers seen by member Integrated care management team supporting providers through: Holistic PH/BH care plan Education and support for member selfmanagement ED and inpatient discharge coordination Facilitating and tracking PH/BH visits and recommended tests or treatments Data infrastructure / information exchange to support care coordination Coordination by a lead care manager 13 Connected Care - Key Components Integrated care plan: Care plan viewable by staff from both Health Plans. Integrated care team meetings which include input from: PCP Community Care Pharmacist PCP/BH providers Member and/or their care givers Staff from Health Plans: Medical Directors Nurses including those placed in high volume practices Social Workers Pharmacist Network staff BH Provider Patient UPMC for You 14 7
Connected Care - Key Components Consumer Engagement: Using providers to help inform members of the program Letters sent to members describing the program Members eligible for a $25 member incentive for seeing their PCP Navigator / Personal Wellness Advocate: Lead Care Manager Health Risk Assessment Tool: Designed to identify behavioral, medical, social, health education needs and lifestyle risks Coaching for lifestyle risks like smoking, diet, and exercise Encouraging substance abuse screening by PCPs 15 Connected Care - Key Components Information Exchange timely, coordinated, meaningful: Member flags in Health Plans IT systems Integrated, shared care plan viewable by care management staff from both Health Plans Patient registries that list gaps in care for chronic conditions or preventive services Notifying PCPs and Behavioral Health Providers of their patients who have been admitted (excluding HIV or drug and alcohol) or seen in an emergency room Notifying the PCP and prescribers of gaps in refilling antipsychotics and missing recommended lab tests 16 8
Connected Care - Key Components Coordination of care in provider offices: 11 sites have additional care coordination support in provider offices: 4 will have co-located physical and behavioral health services in the same office 7 have Practice Based Care Managers who are UPMC for You staff working with high volume PCP practices 17 Connected Care - Key Components Improved Discharge Planning: Essential to optimize outcomes and reduce avoidable readmissions Coordinated by the Integrated Care Team Ensure member clearly understands what to do and everything is in place for follow-thru with the care plan Key Components of discharge plan: Timely post-discharge follow-up appointments t Identify care giver support needs Symptom response plans to manage care post discharge Medication reconciliation 18 9
Member Stratification Members identified from Medical & Behavioral Health claims data and stratified into 3 Intervention levels based on services utilized Designed to ensure members receive the right level of health plan outreach, consistent with their behavioral and physical health needs Re-stratification performed monthly to identify new members and those who are at high-risk High BH/PH & High PH/Low BH High BH/ Low PH Low BH/Low PH Members will not be moved down to a lesser level of stratification during the project 19 Member Identification From July 1, 2009 to September 30, 2009 3,375375 121 73% 3% 1,101 24% Tier 1 - High PH/High BH and High PH/Low BH Tier 2 - High Behavioral / Low Physical Health Needs Tier 3 - Low Physical / Low Behavioral Health Needs Total Members Identified = 4,597 20 10
Timeline Initial Planning Phase Physician Communication Initial Member Letter Go Live Newly Identified Member Letter Telephonic Outreach Begins Integrated Care Plans In Development Oct 08 - May 09 Jun Jul Aug Sep Oct Nov Dec Weekly Integrated Care Team Meetings KEY: All members qualifying for Connected Care Tier 1 Members Tier 2 Members Tier 3 Members 21 Care Management Activities July 1, 2009 to September 30, 2009 Of the 4,597 members identified: Enrollment: 97 members have agreed to enroll and signed consents to share information 94 members have agreed to enroll but do not want to share their information 95 members have declined 208 were unable to be reached Staff are actively outreaching to an additional 1,032 members Care Plans: 1,526 integrated care plans have been started Inpatient and Emergency Room notices to providers (utilization tracking as of August 2009): 568 ED visits 176 inpatient admissions 22 11
Preliminary Observations Staff are seeing the value of not working in silos. Care coordination is being integrated. Integrated Care Team meetings identifying valuable information related to the medical and behavioral health services the member has received, gaps in care, and their medication profile. Medical and behavioral health providers are seeing the value of the work of the integrated team, particularly with their challenging patients. Daily inpatient reports providing an opportunity for staff to visit the members that we have not been able to find while in the hospital to improve engagement and care coordination. Locating members is still a challenge. 23 SMI Population with Diabetes (N=1366) % Members With Completed Test Medical Home (n=283) No Medical Home (n=1083) 83% 82% 75% 73% 86% 80% 37% 34% HbA1c Lipid Panel Nephropathy Retinal Eye Exam All testing completion is significantly higher with Medical Home at p<0.05, except Eye Exam 24 12
Next Steps Continue to foster the communication and improve work flows between UPMC for You and Community Care staff. Further development and management of the integrated care plans Use providers to help educate members on the program and engage them in the program. Do more provider education on the program and how it may support them in managing their members with SMI. Further develop the implementation plan for the Wellness Navigators 25 13