Coordina(ng Care to Improve Outcomes & Reduce Costs

Coordina(ng Care to Improve Outcomes & Reduce Costs Steven Ronik, Ed.D. Chief Execu6ve Officer Henderson Behavioral Health sronik@hendersonbh.org @DrStevenRonik

Who is Henderson Behavioral Health Oldest and Largest non- profit behavioral health system in South Florida Over 650 staff, over 20 loca6ons in several South Florida Coun6es. Helped over 30,000 last year, over 1/3 are children Culture of Being an Early Adopter SAMHSA Science to Service Award Winner Connect4MH featured organiza6on Early Interven6on First ACT teams in Florida First MH Court in Na6on First First- Episode Team in Florida First High- Fidelity Wraparound Provider in Florida First CARF- accredited Student Counseling Provider, world- wide Heavy emphasis on teaching and learning- - Research Department and ini6a6ves, CATIE trials, MHTS, RAISE, ICRC.

An Introduc(on to the Benefits Realized for the Value of Health IT S: Increases coordina6on of pa6ent care across mul6ple se]ngs, making the transi6on process smoother and more organized for clients. Therefore they will feel be^er about their experience with both organiza6ons. T: Improved the overall health of individuals with a physical health diagnosis who are co- morbid with a mental illness. E: The informa6on exchange is done securely and enables a Con6nuity of Care Document to be sent electronically from Memorial to Henderson and vice versa. P: Coordina6on will focus more on the needs of the pa6ents and make clinicians be^er poised to manage chronic disease and mental illness. S: The implementa6on results in so_ and hard ROI. 3

Organiza(on Introduc(on Oldest/largest not-for-profit behavioral health care system in South Florida Over 20 locations 650 staff Serves more than 30,000 clients per year $40 million annual budget Public Healthcare System in South Broward County, Florida 6 hospitals with 2,020 licensed beds 4

Overview Uni6ng the dis6nct needs and technology solu6ons of the physical health and human health services communi6es is a cri6cal challenge for health and human execu6ves today. Defining strategies and solu6ons for success for evolving to a coordinated service delivery model is a top priority in both arenas. A new integra6on between Henderson Behavioral Health and Memorial Health System - - the first of its kind in the country - - will help bridge the gap between pa6ents with co- occurring physical and behavioral illnesses and allow for seamless and secure integra6on between the behavioral health and acute care facili6es, ensuring total data accuracy and visibility. 5

Trends Care management a major core competency Care and services will be fully integrated Coordina6on will be essen6al with hospital networks and provider networks Increased emphasis on popula6on data analy6cs Sharing of health informa6on through Health Informa6on Exchanges (HIEs) Capitated payments 6

Behavioral Healthcare Nearly 70 percent of adults with behavioral health condi6ons also have a medical condi6on Affects all aspects of their life increased emergency room visits hospitaliza6ons substance abuse homelessness unemployment legal involvement Adults w/ Behavioral Health Conditions Adults w/ Medical Conditions Henderson was recognized in Phase I of Connect 4 Mental Health 7

Call To Action Health Concern People with serious mental illness treated in the public behavioral health system in the U.S. die on average 25 years earlier than those without a mental illness, according to a study by the Na6onal Associa6on of State Mental Health Program Directors. These early deaths are a^ributable not directly to mental illness, but more o_en to untreated co- occurring physical health issues such as metabolic syndrome and tobacco use. 8

Call To Action Cost Concern Studies show the top 20 percent of consumers with a physical health diagnosis who are co- morbid with a mental illness account for more than 80 percent of Medicaid costs. Average length of stay for a mental health pa6ent in the emergency department is 21 hours. As a result, the overall cost savings inherent with care integra6on are enormous. 9

Care Coordination Required Focus to alleviate some of the persistent challenges associated with undiagnosed, untreated, or undertreated mental illness Ø early interven6on Ø par6cipa6on in cu]ng- edge research Ø evaluate best prac6ces Ø promote recovery Ø stop cycle of relapse 10

Leadership Drives Care Coordination What is leadership s role? 11

Integration HIE Direct Connection Memorial Hospital West South Broward Community Health Services Memorial Hospital Pembroke Memorial Hospital Miramar Memorial Regional Hospital Memorial Center for Behavioral Health & SHARE (Outpa(ent Services) Memorial Regional Hospital South Joe DiMaggio Children's Hospital Continuity of Care Document (CCD) Referrals CSU Treasure Coast South Branch Wilson Gardens West Broward Lake Worth Summit West Prospect (NV) Administra(on SCS Chalet Freedom Project Central Branch Community Support Services Henderson Village Charlee House Henderson House Crisis Walk In Centers Rainbow Village 12

Considerations Technical Opera6onal Memorial Healthcare System Epic EHR Atlan6c Coast HIE Protect pa6ent privacy (adhering to 42 CFR guidelines) Henderson Behavioral Health Netsmart EHR Clinical workflows 13

Technical Standards EHR Interoperability Standards Pa6ent Demographics Query (PDQ) and Cross- Enterprise Document Sharing- b (XDS.b) Cross- Community Pa6ent Discovery (XCPD) and Cross- Community Access (XCA) Cross- Enterprise Document Reliable Interchange (XDR) 14

Technical Scope Health Level 7 (HL7) v3 Consolidated- Clinical Document Architecture (C- CDA) includes key data needed for the treatment team to provide comprehensive care as soon as the person arrives Ø labs or studies that have been completed Ø demographic informa6on Ø medical summary Ø medica6on list Ø vital signs Con6nue to properly document pa6ent authoriza6on EHR security profiles to provide clinicians with appropriate access to cri6cally- needed informa6on 15

Implementation Methodology Outlined the scope of the project in phases Mul6- disciplinary support and par6cipa6on Execu6ve level Technical leads Clinicians Trainers Itemized the deliverables for each team member Met collec6vely and regularly as a group to review the project Regularly communicated 16

EHR Integration Itera6ve tes6ng process Common troubleshoo6ng Ø security cer6ficates Ø Configura6ons Ø IDs 17

Industry Challenges and Opportunities Challenges Gaps in interoperability specifications Expense Implementation time Demands of other project priorities New clinical workflow Opportunities Conquered by the testing efforts that Epic and Netsmart EHRs had completed prior to engaging Memorial and Henderson EHR vendors ensured this was not a barrier Conquered with a dedicated and experienced project team that was responsive and results-driven Each team member held each other accountable and provided prompt assistance Conquered by: 1) Identify the current paper-based process, then ensure all activities continue to be followed and are improved upon in the electronic workflow 2) Provide visual concepts to clinicians prior to software configuration and formal training. Visuals enabled clinicians to better contribute to the project workflow 18

The Problem Why Connect to Acute Care Hospitals? Current healthcare systems are o_en disjointed, and processes vary among and between behavioral health and physical health sites Specialists do not consistently receive clear reasons for the referral or adequate informa6on on completed tests Primary care physicians do not o_en receive informa6on about what happened in a referral visit Referral staff deals with many different processes and lost informa6on, which means care is less efficient

The Goal Improve pa6ent safety by reducing medica6on and medical errors Increase efficiency by elimina6ng unnecessary paperwork and handling Provide caregivers with clinical decision support tools for more effec6ve care and treatment Eliminate redundant or unnecessary tes6ng Improve public health repor6ng and monitoring Engage healthcare consumers regarding their own personal health informa6on Improve healthcare quality and outcomes Reduce health related costs

Henderson Behavioral Health Strategy for Integration with Primary Care The HILL Project (Helping Individuals Live longer) provides primary medical care and wellness services to persons who receive behavioral health service at HBH Strategy involves on-site medical exams, lab tests, coordination of follow-up services, and onsite wellness activities Adheres to principles of informed choice, recoveryfocused and person-centered care and incorporation of evidence based practices in routine care.

HBH Current Primary Care Goals and Objectives Increase delivery of a coordinated array of medical, self- help, social, suppor6ve, and rehabilita6ve services designed around the needs and desires of the individual. To improve the physical health of individuals with serious mental illness who are at- risk for co- occurring behavioral health and primary care condi6ons. To assist persons in taking an ac6ve role in their health and well- being. To assist in the coordina6on of primary, specialty, and behavioral health services. To increase individual and family input thereby enhancing their experience of care. To reduce/control the per capita cost of care.

HILL Project Outcomes Year-to-date 2015 604 Individuals have been enrolled in the program to date. 36% of individuals served demonstrated an improvement in combined blood pressure from baseline to reassessment. Of those par6cipants most ac6ve in program elements (Care Management, Peer Groups), 95% showed improvement in blood pressure readings. 35% of individuals served demonstrated an improvement in BMI (Body Mass Index) from baseline to reassessment. 37% of individuals served demonstrated an improvement in Breath CO Measurements from baseline to reassessment. (Breath Carbon Monoxide measurements are used to assess, mo6vate, and educate individuals for smoking cessa6on.) 37% of individuals served demonstrated an improvement in plasma glucose readings from baseline to reassessment. Of those par6cipants most ac6ve in program elements (Care Management, Peer Groups), 80% showed improvement in glucose readings. 17% of individuals served demonstrated an improvement in triglycerides from ini6al assessment to reassessment. Of those par6cipants most ac6ve in program elements (Care Management, Peer Groups), 89% showed improvement in cholesterol readings. The program has hired an addi6onal medical provider (an ARNP) for 20 hours. The program has over 200 ac6ve par6cipants. The majority of people who are discharged from the program do so because they have been linked with a primary care doctor in the community and are receiving specialty care either through insurance or through the county health programs.

HBH Integration with Memorial Health System Ini6al project focused on improving consumer sa6sfac6on and coordina6on of care between Memorial Health System & Henderson: Ø Reduce average 18 hour stay in MHS ED Ø Move consumer to more appropriate site of care for BH issues Ø Open ED bed for more appropriate use Ø Reduce cost to county and state Why a direct connect? Simple two- way informa6on exchange that eliminates major roadblocks encountered due to 42CFR. Releases are obtained between just two systems. Memorial Healthcare System and Henderson Behavioral Health are the largest Healthcare and Behavioral Healthcare Systems in the Greater Fort Lauderdale region. Strong leadership and staff rela6onships between the two systems that support the ini6a6ve.

Integration Use Case MHS ED determines that the pa6ent would be appropriate for Henderson CSU Inpa6ent facility based on the Florida Baker Act MHS determines that appropriate consents have been obtained If applicable, a copy of legal paperwork faxed to Henderson Staff at MHS send the referral C- CDA CCD (elements listed below) from the Epic system to Henderson Avatar system: ü Labs or studies that have been completed for the medical diagnosis while in the emergency room/hospital to support medical clearance ü Demographic Informa6on ü Medical Summary ü Medica6on List ü Vital Signs Henderson CSU receives the C- CDA CCD When the C- CDA CCD is received at the Henderson server a no6fica6on is generated to staff on duty that a referral from MHS has been sent Henderson staff review the informa6on received to determine accuracy and appropriateness for Nurse review If accurate, a MHS Nurse to Henderson Nurse exchange is performed for ques6ons and acceptance or denial

HBH Expected Clinical and Financial ROI Much more accurate informa6on Much less 6me involved Data entry reduced in Avatar by impor6ng the CCD directly into MyAvatar Huge 6me savings over faxing Increased client sa6sfac6on scores and process will feel smoother and more organized for clients focus on the client experience When shi_s change referral process will create an easier process from one clinician to another if the referral is s6ll in a pending status, it will save 6me transi6oning these referrals

Conclusion Go- live is completed So_ and hard ROI Ø data entry 6me Ø paper and prin6ng expenses Ø save Memorial staff from collec6ng all the appropriate referral informa6on Ø save 6me sending electronically versus staff faxing Ø standardize the referral package for both organiza6ons Achieve CMS Meaningful Use Stage 2 objec6ves, Summary of Care 27

Successes and Lessons Learned Set achievable milestones Divide and conquer opera6onal and technical topics Engaged EHR vendors and partners Dedicated and experienced project team Proac6ve approach by everyone kept everything on task Helps when everyone buys into their vested interest and truly understands the value it will provide to all par6es. Technology + Compassion unites the needs of acute care and behavioral health 28

Recommendations Define your outcomes and iden6fy their baselines to focus your efforts Break your implementa6on into phases; it s easy to get stalled if you try to do everything at once Everyone on the project team agrees on scope Evaluate your pa6ent consent process and iden6fy how it needs to be updated for health informa6on exchange Iden6fy peers who have already done health informa6on exchange projects that you can reach out to for their iden6fied lessons learned 29

Questions? Steven Ronik, Ed. D. Chief Execu6ve Officer Henderson Behavioral Health, Inc. Phone: (954) 486-4005 Email: sronik@hendersonbh.org @DrStevenRonik 30