FOLLOW UP STUDY OF HEALTHFIRST SENIOR MEMBERS WITH DIAGNOSES OF DIABETES AND DEPRESSION Deborah Brotman, MD, FACP Chief Medical Officer FEGS Health & Human Services Monday, November 4, 2013 Inspiring Success HEALTH DISABILITIES HOME CARE HOUSING EMPLOYMENT WORKFORCE EDUCATION YOUTH FAMILIES
OVERVIEW FEGS HEALTH & HUMAN SERVICES Education Employment Workforce Development CORE OPERATING Health Established in 1934 Serving 120,000 Individuals from the Metropolitan New York Area Annually $275 Million Operating Budget Workforce of 4,000 Staff and >4,000 Volunteers and Student Interns 350 Locations 16 Subsidiaries Youth & Families AREAS Disabilities Home Care Housing INNOVATIONS IN THE INTEGRATION OF PRIMARY & BEHAVIORAL HEALTHCARE 2 2
HEALTHCARE PORTFOLIO HEALTH HOMES NEW YORK CITY COMMUNITY HEALTH CLINIC SERVICES (ARTICLE 16, 28, 31) LONG ISLAND LONG ISLAND BEHAVIORAL ALLIANCE (LIBA) (BEHAVIORAL HEALTH) JOINT VENTURES OUTPATIENT SINGLEPOINT BEHAVIORAL HEALTH Service Delivery Network CARE NETWORK (MLTC MARKET) RESIDENTIAL & HOUSING SERVICES ADVANCE CARE ALLIANCE (ACA) (SPECIAL NEEDS MARKET) COMMUNITY & EMPLOYMENT SUPPORTS NURSING HOME TRANSITION & DIVERSION SERVICES HOME CARE INNOVATIONS IN THE INTEGRATION OF PRIMARY & BEHAVIORAL HEALTHCARE 3
BEHAVIORAL HEALTH OPERATIONS CONSUMER PEER SELF-HELP DIVERSE SERVICE OPTIONS FOR PERSONS WITH MENTAL ILLNESS CLINIC SERVICES ASSERTIVE CONTINUING TREATMENT (ACT) CASE MANAGEMENT & CARE COORDINATION SERVICES EMPLOYMENT SERVICES PSYCHIATRIC REHABILITATION PERSONALIZED RECOVERY ORIENTED SERVICE (PROS) Serving about 25,000 clients Approximately $80 million RESIDENTIAL/HOUSING SERVICES (Community Residences, SRO, Intensive & Supportive Apartments) INNOVATIONS IN THE INTEGRATION OF PRIMARY & BEHAVIORAL HEALTHCARE 4
CARE GAP Clients with co-occurring behavioral and physical health disorders often do not have a connection to health care and if they do, do not have integrated care. It is well documented that this is associated with increased mortality, increased health care costs and decreased work productivity. NYSDOH: SPECIAL PLANS FOR HIGH-NEED MEDICAID POPULATIONS Total Complex N=976,356 $2,338 PMPM 32% Dual 51% MMC Developmental Disabilities 52,118 Recipients $10,429 PMPM Mental Health and/or Substance Abuse 408,529 Recipients $1,370 PMPM. $6.5 Billion 50% Dual 10% MMC $6.3 Billion 16% Dual 61% MMC $25.9 Billion $10.7 Billion 77% Dual 18% MMC $2.4 Billion 20% Dual 69% MMC Long Term Care 209,622 Recipients $4509 PMPM All Other Chronic Conditions 306,087 Recipients $698 PMPM Need for follow up data on complex cases with co-occurring morbidities. Complex psychiatric and health issues average $16,440/yr. - selected depression and diabetes. INNOVATIONS IN THE INTEGRATION OF PRIMARY & BEHAVIORAL HEALTHCARE 5
ELEMENTS OF INNOVATION ATTEMPTING TO ACHIEVE: INFORMATION ON: a) Accuracy of Assessment b) Continuity of Care c) Integration of Care d) Care Coordination Background: FEGS was awarded a grant from NYSDOH on the Chronic Illness Demonstration Project as a precursor to Health Homes. Demonstrated Need for Care Coordination. Anecdotal Evidence Of Improved Client Health Outcomes. Many MCOs telephonically try to assess this information. INNOVATIONS IN THE INTEGRATION OF PRIMARY & BEHAVIORAL HEALTHCARE 6
PROJECT PILOT Healthfirst identified 192 Members in the Bronx with co-occurring diabetes and depression where compliance with treatment or connectivity to care was unknown. Members needed to be assessed for the accuracy of the diagnoses, engagement in care, adherence to treatment and for potential barriers to care. FEGS designed a bio-psychosocial assessment for primary health care associated with diabetes including medications, lab work, benchmarks, referral appointments, hospitalizations, ER visits and lifestyle. The assessment tools used were the PHQ-9 for depression and the Modified Simple Screening Instrument for Substance Abuse (MSSI-SA). Nurses were hired to outreach by phone and make appointments to visit with the clients. January 2013 April 2013, nursing staff visited clients with the objectives: 1. Assess understanding of diagnoses and compliance to treatment. 2. Identify need for health care (physical and behavioral) referrals. INNOVATIONS IN THE INTEGRATION OF PRIMARY & BEHAVIORAL HEALTHCARE 7
FINDINGS 76 members (40%) were seen for a completed assessment. 70% reported Spanish as their primary language; the average age was 68 years. Of the remaining 116, most were not completed due to phones out of service or no response to messages. Four clients had died and 3 refused participation. PRIMARY CARE 100% of members reported being connected to primary care. 7% saw multiple physicians and could not remember the physician s name. 4% went to someone other than their primary care doctor for diabetic care. 91% reported additional physical health conditions other than DM. MENTAL HEALTH CARE 55% of members reported being connected to mental health care. No members reported having substance abuse issues ER visits: 16% reported going to the ER for DM in past year. 47% for other medical needs; most more than once. Hospitalizations: 17% hospitalized for DM in past year. 46% hospitalized for other medical needs. 24% hospitalized for psychiatric illness. INNOVATIONS IN THE INTEGRATION OF PRIMARY & BEHAVIORAL HEALTHCARE 8
FINDINGS CONT D DIABETES STATUS Clients had a difficult time responding to questions asked about what lab work/exams they usually have or when last done (i.e., A1C, LDL, podiatry, eye, renal). 35% reported checking their glucose daily but most could not report A1C numbers. 51% reported being on a diabetic diet. 29% reported regular exercise. Half the clients take their medication on their own and half use pill boxes as a reminder. DEPRESSION STATUS 70% (n=53) had at least a moderate form of depression, evidenced by the PHQ-9. 42% of those with moderate depression reported not being connected to mental health care. On average, Members with moderate to severe depression had almost twice the # of hospitalizations and ER visits than those with minimal to mild depressive symptoms. INNOVATIONS IN THE INTEGRATION OF PRIMARY & BEHAVIORAL HEALTHCARE 9
LESSONS LEARNED (OR CONFIRMED) Implications for Integrated Care: Although clients state that they are connected to care in some way, they often are not engaged. Clients often do not understand their illness. Fragmentation of care leads to ER visits, hospitalizations and poorer client health outcomes. Simple screening can identify many behavioral and primary care disorders. Clients seem to readily accept case assessment and, as an extrapolation, care management. Co-occurring behavioral and medical conditions need special attention. Healthcare dollars can be saved. INNOVATIONS IN THE INTEGRATION OF PRIMARY & BEHAVIORAL HEALTHCARE 10
NEXT STEPS/NEXT PHASES Go beyond a self-selected population that agrees to the intervention. Claims analyses can further identify other populations to examine. Expand From Assessment to Intervention Integrated care plans. Identify behavioral issues impacting health. Look at polypharmacy issues. Provide more psycho-education Objectives of Expanded Study Improve client health outcomes. Target risk and stratify interventions accordingly. Decrease health care costs by preventing overuse of medical services. Decrease stigma of accessing behavioral health services. INNOVATIONS IN THE INTEGRATION OF PRIMARY & BEHAVIORAL HEALTHCARE 11
Many thanks to the FEGS staff who contributed to the pilot study and presentation. INNOVATIONS IN THE INTEGRATION OF PRIMARY & BEHAVIORAL HEALTHCARE 12
CONTACT INFORMATION For more information, contact: Deborah Brotman, MD Chief Medical Officer FEGS Health & Human Services 212.366.8004 dbrotman@fegs.org INNOVATIONS IN THE INTEGRATION OF PRIMARY & BEHAVIORAL HEALTHCARE 13