MICHIGAN PATHWAYS TO BETTER HEALTH THE 2016 DIRECT SERVICE PROGRAMS ANNUAL MEETING April 26, 2016
ACKNOWLEDGEMENT The project described was supported by Grant Number C1CMS331025 from the Department of Health and Human Services, Centers for Medicare and Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.
OVERVIEW MPHI, in partnership with MDCH and multiple agencies and organizations in Saginaw, Muskegon, and Ingham Counties, received a Health Care Innovations Award from CMS over $14 million to implement the Pathways Community HUB model in three Michigan counties Michigan Pathways to Better Health (MPBH) is a 3 year grant beginning July 1, 2012 and ending June 30, 2015
PROJECT GOALS & TARGET POPULATION CMS Health Care Innovation Award: Better care for patients Better health for communities Lower costs through health care system improvement MPBH focuses on Social determinants of health Integration of health care and social services Targets at risk population Adults with two or more chronic conditions Enrolled in or eligible for Medicaid and/or Medicare
PATHWAYS COMMUNITY HUB MODEL The Pathways Community HUB Model A centralized community resource that utilizes care coordinators (CHWs) to link individuals to health and social services Model based upon 3 principles: 1) Find those at greatest risk 2) Serve to ensure individuals receive evidencebased health and social services 3) Measure and evaluate benchmarks and final outcomes
TOP 10 CHRONIC CONDITIONS: PERCENT OF CLIENTS REPORTING 0% 10% 20% 30% 40% 50% 60% Hypertension Depression Tobacco Abuse Arthritis Anxiety Diabetes Type 2 Hyperlipidemia Asthma Vision Loss Obesity 18.2% 16.2% 15.1% 48.3% 46.6% 41.1% 34.8% 31.3% 29.8% 25.3% Results as of 2/5/15
PATHWAYS AND TOOLS Social Services Medical Referral Tobacco Cessation Medication Assessment Medication Management Medical Home Health Insurance Chronic Disease Education Healthy Changes Plan Healthy Homes Checklist PHQ 9 Screening Fall Prevention CAGE AID Pregnancy, Postpartum, Family Lower Planning Costs
TOP 10 NEEDS IDENTIFIED: PERCENT OF CLIENTS REPORTING NEED 0% 10% 20% 30% 40% 50% 60% Housing Dental Care Transportation Food Clothing Utilities Primary Care Health Insurance Employment Education 22.6% 21.6% 20.0% 18.6% 18.2% 18.0% 39.6% 39.3% 38.4% 31.0% Results as of 2/5/15
ADDRESSING SOCIAL DETERMINANTS: NUMBER OF CLIENTSLINKED TOSOCIAL SERVICES 1,400 1,200 1,000 1,329 1,270 800 600 400 200 741 669 542 0 Food/WIC Transportation Housing Clothing Utilities Results as of 2/5/15
CONNECTION TO CARE: NUMBER OF CLIENTSLINKED TOHEALTHCARE 2,000 1,800 1,600 1,400 1,200 1,000 800 600 400 200 0 1,890 1,197 653 531 340 Primary Care Specialty Care Dental Care Mental Health Vision Results as of 2/5/15
ADDRESSING OTHER NEEDS: NUMBER OF CLIENTS RECEIVING ADDITIONAL SERVICES 2,500 2,000 1,500 1,981 1,690 1,000 625 500 0 Medication Reconciliation Chronic Disease Education Health Insurance 56 Tobacco Cessation Results as of 2/5/15
EMERGENCY DEPARTMENT UTILIZATION: NUMBER OF VISITS PER 1,000 MEMBER MONTHS Full Benefit Medicaid Participants No. of Visits per 1,000 Member 700 600 500 400 300 200 100 Cohort 1 (n=405) Cohort 2 (n=446) Cohort 3 (n=544) Cohort 4 (n=744) 2013 County Level Full Medicaid Beneficiaries 0 Participants with Medicare FFS Claims No. of Visits per 1,000 Member 600 500 400 300 200 100 0 21 to <24 18 to <21 15 to <18 12 to <15 9 to <12 Pre enrollment 6 to <9 Disclaimer: The described results need to be confirmed by independent CMS evaluators. 3 to <6 <3 <3 3 to <6 6 to <9 Post enrollment Cohort 1 (n=376) Cohort 2 (n=467) Cohort 3 (n=621) Cohort 4 (n=435) 9 to <12 12 to <15
INPATIENT UTILIZATION: NUMBER OF ADMISSIONS PER 1,000 MEMBER MONTHS Full Benefit Medicaid Participants No. of Admissions per 1,000 Member 180 160 140 120 100 80 60 40 20 0 Participants with Medicare FFS Claims No. of Admissions per 1,000 Member 100 80 60 40 20 0 21 to <24 18 to <21 15 to <18 12 to <15 9 to <12 Pre enrollment 6 to <9 3 to <6 Cohort 1 (n=405) Cohort 2 (n=446) Cohort 3 (n=544) Cohort 4 (n=744) <3 <3 3 to <6 2013 County Level Full Medicaid Beneficiaries Disclaimer: The described results need to be confirmed by independent CMS evaluators. 6 to <9 Post enrollment Cohort 1 (n=376) Cohort 2 (n=467) Cohort 3 (n=621) Cohort 4 (n=435) 9 to <12 12 to <15
30 DAY HOSPITAL READMISSIONS: NUMBER OF HOSP. READMISSIONS WITHIN 30 DAYS OF A HOSP. ADMISSION Full Benefit Medicaid Participants No. of Hospital Readmissions 50 45 40 35 30 25 20 15 10 5 0 Participants with Medicare FFS Claims 35 Cohort 1 (n=405) Cohort 2 (n=446) Cohort 3 (n=544) Cohort 4 (n=744) Disclaimer: The described results need to be confirmed by independent CMS evaluators. No. of Hospital Readmissions 30 25 20 15 10 5 Cohort 1 (n=376) Cohort 2 (n=467) Cohort 3 (n=621) Cohort 4 (n=435) 21 to <24 18 to <21 15 to <18 12 to <15 9 to <12 6 to <9 3 to <6 <3 <3 3 to <6 6 to <9 9 to <12 12 to <15 Pre enrollment Post enrollment
CLIENT SATISFACTION Client Satisfaction Surveys are mailed to those in the program for 3 months; in last quarter (n=222): 93% were happy or very happy with the CHW services 87% would recommend the service to family or friends Of those needing specific services, over 90% indicated their CHW was helpful or very helpful with: Connecting to people who can help (93%) Providing information on managing their health (93%) Making a medication list (93%)
SUMMARY MPBH Pathways Community HUB model Valuable community resource for improving health Aim to incorporate Pathways services into primary care Outcomes Data and Cost Savings Analysis Targeting social determinants of health while identifying gaps in community resources Cost trends are promising Additional data needed Community Impact Fosters development of new partnerships to advance community health
CONTACTS Michigan Public Health Institute Clare Tanner ctanner@mphi.org Elaine Beane ebeane@mphi.org Ingham Debbie Edokpolo Sarah Bryant Lori Noyer Muskegon Judy Kell Tracy Host Saginaw Barb Glassheim Sandy Lindsey DEdokpolo@ingham.org SBryant@ingham.org LNoyer@ingham.org Judith.Kell@mercyhealth.com Hostt@mercyhealth.com barbglassheim@comcast.net slindsey@sccmha.org