PowerPoint Presentation · Psychiatry and Behavioral Sciences, University of Washington School of...
Transcript of PowerPoint Presentation · Psychiatry and Behavioral Sciences, University of Washington School of...
11/4/2014
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How Can Population Based Care Models
Be Applied to Improve Health Outcomes
for Persons with Serious Mental IllnessOctober, 15, 2014
Marc Avery, MDClinical Associate Professor of Psychiatry
Associate Director for Clinical Services,
Department of Psychiatry and Behavioral Sciences
University of Washington School of Medicine,
Jennifer Clancy, MSWAssociate Director, California Institute for Behavioral Health Solutions
Director, CIBHS Coordinated Care Collaborative
Outline
Population-Based Care and SMI
Marc Avery
1. Definition
2. Importance
3. Supporting evidence
Jennifer Clancy
1. Organizational Considerations
2. The Convening Organization
3. Barriers
4. Examples
© University of Washington
Building on 25 years of Research and Practice in
Integrated Mental Health Care
Marc Avery, MD
DISCLOSURES
Employment:
Associate Director for Clinical Services, Division of Integrated Care and
Public Health and AIMS Center (Advancing Integrated Mental Health
Solutions)
Clinical Associate Professor of Psychiatry, School of Medicine; Dept. of
Psychiatry and Behavioral Sciences, University of Washington School of
Medicine
Contracts (current & recent)
California Institute of Behavioral Health Solutions
Wyoming Health Care Authority
Telehealth Corporation
Psychiatric Advisor Magazine
NO FINANCIAL RELATIONSHIPS THAT PRESENT A CONFLICT OF
INTEREST FOR TODAY’s PRESENTATION
I WILL NOT DISCUSS OFF LABEL OR INVESTIGATIONAL USE OF
MEDICATIONS OR OTHER TREATMENTS
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Definition 1:
Population based care means
Ensuring outcomes for all patients in a
group with a targeted condition
Definition 2:
Population Based Care Means –
Not allowing our patients to fall between
the cracks.
1. Tufts Managed Care Institute Newsletter, November 2000
http://www.tmci.org/downloads/topic11_00.PDF
2. Jurgen Unutzer, AIMS Center, University of Washington
© University of Washington
Where does population based care “fit in”?
Patient Centered / Team Based Care
Population-Based
Measurement-Based Treatment to Target
Evidence-Based
Accountable
Mental Disorders
• Are common, disabling, expensive,
and with high mortalities.
• Are mostly chronic conditions that
require deliberate / persistent follow up.
• A small percentage of persons in need of
mental health get any services.
*Multiple investigators, references available by request.
• System and Payment Reform
-Expanded Coverage
-Accountable Care Organizations
-Health Home
• Control of Escalating Costs
• Clinical Effectiveness
Why Population Based Care for SMI
Persons?
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Why are Persons with Severe Mental Illness
more Vulnerable to “Falling Through the
Cracks”?
Systems Issues
1. Payment system that discourages recovery
2. Episodic treatment authorizations
3. Services that often favor crisis intervention over
disease management.
4. Fragmented service network
Patient and Provider Issues
1. Stigma
2. Patient Health Behaviors
3. Clinical InertiaWashington State Senate Ways and Means January 31, 2011 10
DDD
Effects are Bidirectional
© University of Washington
Chronic disease score
Annual
Cost ($)
Unutzer J, et al. JAMA. 1997;277:1618-1623.
Mental Illness Results in Increased MEDICAL
COSTS50% higher Annual Health Care
Costs regardless of # medical
illnesses
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Sometimes the patients who need us most
are the ones we forget..
Group 1 Group 2
Punctual
Articulate
Polite
Engaging
Compliant / Adherent
Responsive
Has transportation
Good support system
Clinically straightforward
Culturally Similar
Misses Appointments
Disorganized
Angry, agitated
Reserved
Isolative, Avoidant
Rejecting
Lacks transportation
Lacks social supports
Complex and Confusing
Culturally Dissimilar From: O’Conner, Patrick, et. Al, Clinical Inertia and Outpatient Medical
Errors, 2005 AHRQ, Advances in Patient Safety
“At baseline”?
“Stable”?
Good News! We have evidence and
increasing experience with models of care
that work better!
Primary Care Locus
• IMPACT / Collaborative Care
• TEAMcare
• Behavioral Health Consultant /
Cherokee Model
Community Behavioral Health Locus
• P-Care
• Health Promotion Activities
• SAMSHA-PBHCI
IMPACT Team Care Model(Patient Centered Healthcare Home for Behavioral Health)
Primary Care Practice with Mental Health Care Manager
Outcome
MeasuresTreatment
Protocols
Population
Registry
Psychiatric
Consultation
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An Integrated Team-Based Approach
– with a new Twist
PCP
Patient BH Care
Manager
Psychiatric
Consultant
Core
Program
New Roles
IMPACT doubles effectiveness of
care for depression
0
10
20
30
40
50
60
70
1 2 3 4 5 6 7 8
Usual Care IMPACT%
Participating Organizations
50 % or greater improvement in depression at 12 months
Unützer et al., JAMA 2002; Psych Clin NA 2004
© University of Washington
MHIP: P4P-based quality improvement cuts median time to depression treatment response in half.
0.00
0.25
0.50
0.75
1.00
Est
imat
ed C
umul
ativ
e P
roba
blili
ty
0 8 16 24 32 40 48 56 64 72 80 88 96 104 112 120 128 136
Weeks
Before P4P After P4P
Unutzer et al, AJPH, 2012.
IMPACT reduces health care costsROI: $ 6.5 saved / $ 1 invested
Cost Category
4-year
costs
in $
Intervention
group cost
in $
Usual care
group cost in
$
Difference in
$
IMPACT program cost 522 0 522
Outpatient mental health costs 661 558 767 -210
Pharmacy costs 7,284 6,942 7,636 -694
Other outpatient costs 14,306 14,160 14,456 -296
Inpatient medical costs 8,452 7,179 9,757 -2578
Inpatient mental health /
substance abuse costs
114 61 169 -108
Total health care cost 31,082 29,422 32,785 -$3363
Unützer et al., Am J Managed Care 2008.
Savings
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What about SMI patients who:
1.Get the majority of their services in a CMHC?
2.Have much more complicated service teams?
VS.Integrated Primary Care
Team
Integrated Community BH
Care Team
Primary Care Access, Referral and
Evaluation PCARE
• Increased Preventive Care (58% versus 21%)
• Treatment for CV illness (34% versus 28)
• Primary Care Linkage (71% versus 52%)
• Increase in self-rated health
(Druss, et. Al 2010)
Community Mental
Health (n = 142)
RN Care
ManagerPrimary Care /
Medical
Health Promotion: Improving Fitness and Reducing
Obesity: What Works
Stephen J. Bartels, M.D., M.S. & John A. Naslund, M.P.H. HEALTH PROMOTION RESOURCE GUIDE:
Choosing Evidence-Based Practices for Reducing Obesity and Improving Fitness for People with Serious
Mental Illness. 2014 SAMSHA Publication. www.integration.samsha.gov
From: World Psychiatry. 2011 June; 10(2): 138–151.
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Create a Table to follow…
Topic Tool Frequency Target Goal
Blood Pressure SBP/DBP Monthly SBP<140 and
DBP<90
45%, 50%
Tobacco/Nicotine Smoking status Monthly 0 5%
Depression PHQ Monthly 5 point
reduction or
score <10
10%
Anxiety GAD Monthly 5 point
reduction or
score <10
10%
Obesity BMI Quarterly >25 45%
Diabetes HBA1c Annually <7.5 25%
Cholesterol / Lipids LDL-C Annually HDL-C>40
LCL-C<130
50%
Alcohol AUDIT (modified) Quarterly
Drug Use DAST (modified) Quarterly
SAMSHA-HSA Primary and Behavioral Health
Care Integration (PBHCI) Program
Deborah M. Scharf, Nicole K. Eberhart, et. Al., December 2013. EVALUATION OF THE SAMHSA PRIMARY AND
BEHAVIORAL HEALTH CARE INTEGRATION (PBHCI) GRANT PROGRAM: FINAL REPORT, U.S. Department of
Health and Human Services Assistant Secretary for Planning and Evaluation Office of Disability, Aging and Long-Term
Care Policy.
SAMSHA
Grantees
I II III IV V VI
13 9 34 8 30 9
Training and T.A.
National Council
Evaluation
RAND
SAMSHA Primary and Behavioral Health Care Integration (PBHCI)
Program
Study Questions:1.Is PCBHCI Possible?2.Does it improve outcomes?3.What components work best?
SAMSHA Primary and Behavioral Health Care Integration (PBHCI)
Program
Core Elements:Required:• Screening and Referral for Primary Care Prevention• Use of Clinical Registry or Tracking System• Person-Centered Care Management• Prevention and Wellness Support Services
Optional:• Co-Location• Population Consultation• Embedded RN care managers• Preventive EBPs
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SAMSHA-HAS Primary and Behavioral Health Care Integration (PBHCI)
Program
Deborah M. Scharf, Nicole K. Eberhart, et. Al., December 2013. EVALUATION OF THE SAMHSA PRIMARY AND
BEHAVIORAL HEALTH CARE INTEGRATION (PBHCI) GRANT PROGRAM: FINAL REPORT, U.S. Department of
Health and Human Services Assistant Secretary for Planning and Evaluation Office of Disability, Aging and Long-Term
Care Policy.
Models:1.Coordinated Care2.Co-located Care3.Integrated Care
• Partner with primary care organization• Hire primary care team
© University of Washington
Marc Avery, [email protected] http://uwaims.org/index.html
THANK YOU!
Practical Experience with Facilitating Population Based Care
Jennifer Clancy, MSW
Associate Director
CA Institute for Behavioral Health Solutions
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DISCLOSURES
Employment: Associate Director, California Behavioral Health Solutions
Grant funding (current & recent)None
Contracts (current & recent) CA Department of Health Care Services
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NO FINANCIAL RELATIONSHIPS THAT PRESENT A CONFLICT OF INTEREST FOR TODAY’s PRESENTATION
I WILL NOT DISCUSS OFF LABEL OR INVESTIGATIONAL USE OF
MEDICATIONS OR OTHER TREATMENTS.
Jennifer Clancy, MSW Topics
1. Overview Of The Organizations That Are Vital for the SMI Population
1. The Role of Convening Organizations in SMI Population Health
2. Historical Barriers to Creating Coordinated Care Systems for SMI Population
3. Solutions: Examples of Convening Organizations Coordinated Care to Address Population Health Needs
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The Organizations Shaping the SMI Population Health- As Is
CMS SAMHSATax Payers
(Millionaires)HRSAFoundationsFUNDERS
RECIPIENT/ INTERMEDIARY DHCS CBO:
SUDFQHC
County BH
HEALTHCBO: MH
CBO: Social Service, Peers…. Etc., etc.
PAYORS/ CONTRACTORS FQHC
County Behavioral
Health
Managed Care Plan
PROVIDER NETWORK
CBOs(MH, SUD, SS,
Peers)
County Behavioral
Health
FQHCs/Health Clinics
UNCOORDINATED SYSTEM
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Where Are We Going? Coordinated System Offering Integrated Care
Convening Organization/Integrator
Accountable for Population Health
Social Service
Agencies, i.e. Housing
Behavioral Health
Provider: SUD and MH
Primary Care Provider
Peer Providers
Wellness Agencies: i.e. Gym
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Various Funding Sources Organized
by Population Health and Triple
Aim Principles
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Convening Organizations1. What Can The “Convening Organization” Do?
Assumes accountability for a population
Convenes all provider organizations necessary to support the whole health of the population
Builds a vision and shared understanding of the potential benefits of a coordinated system
Supports the development of the organizational relationships and agreements/MOUs
2. Which Organizations Can Serve as “Convening Organizations” for SMI population?
Medi-Cal Managed Care Plans
County Mental Health Plan
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Convening Organizations
1. What Are The Barriers each Faces in serving as the “Convening Organization” for SMI population?
Medi-Cal Managed Care Plans (MCPs):
Historically not responsible for mental health care-
Subcontracts to Managed Behavioral Health Organizations
MCPs need to develop knowledge- build a provider network and a delivery system SMI population
County Mental Health Plans (MHPs):
Historically isolated from agencies they must partner with
Organizational isolation consequence of : stigma; carved out funding; traditional split of mind/body care
Limited experience using health information technology
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Solutions for Coordinated Care Partnerships for Population Health
Fresno County Care Coordination Partnership:
(County Mental Health Plan as Convener)
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Fresno County Dept. of Behavioral Health
County MHP, convening organization and
client care coordinator
Ambulatory Care Center
High-fidelity IMPACT model of integrating mental health services into primary care clinic. Serves clients with mild/moderate mental
illness
Clinica Sierra Vista: FQHC, integrated mental
health & primary care clinic serving Medi-Cal, Medi-Care
& uninsured individuals
A local Public Health Plan created by the Regional Health Authority to
serve Medi-Cal members in the counties of Fresno, Kings & Madera.
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AmbulatoryCare Center
(PCP)
Clinica Sierra
Vista (FQHC)
CalViva Health(MCP)
Fresno County Dept. of Behavioral
Health(MHP)
*18%
*38%
*12%
1%4%
*Percentages may include duplicated
clients
Ambulatory Care Ctr
12% Clinica Sierra Vista
21%
PCP Unknown
31%
Other PCP36%
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The Fresno County Care Coordination Partnership Team will make changes to improve the whole health status of adult individuals by coordinating services for the clients with the most serious mental illness and substance use disorders.
Behavioral Health and physical health care’s coordination has, thus far, been driven by individual providers rather than system change. Long-term change must be driven by the systems rather than pushed forward by a few practitioners.
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Overall Theme Across All Agency Partners
• Recognize the importance of physical and mental health care to overall well-being of an individual
• Shared goal and all agency partners benefit!
Agency Catalysts for Care Coordination/Population Health:
– Mental Health (Medical Director)
– CalViva Heath Plan
– Primary Care
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Key changes the Team has been working on
• Multidisciplinary Clinical Care Conferences (routine & ad hoc)
• Develop routine SUD screening
• Support of client self-management
• Ensuring and monitoring routine medication reconciliation
• Ensuring and monitoring authorizations for sharing client PHI
• Referral process between MHP and PCP
• Sharing of patient physical exams, test & lab results
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CC measures data collection process
• Excel spreadsheet (tracks key health indicators, ROIs, etc.)
• MHP’s EHR system (Avatar) - Data reports created specifically for CCC & embedded into EHR for ease of generating data
Who is responsible for collection?
• PCPs and MCPs collect data for their respective measures.
• MHP data analyst responsible for MH data collection, synthesis of data from MCP & PCPs, and reporting out to CiBHS
ACC(PCP)EPIC
CSV (FQHC)NextGen
CalViva(MCP)
DBH(MHP)Avatar
CiBHSCCC
Agency-Specific CCC Data Measures & Client List
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Maintain key personnel from partner agencies
Buy-in from executive leadership
Right People at the Table with the Right Personalities:
• Client centered and dedicated providers
• Providers who follow through and are accountable
• Providers who are real learners. “Care coordination and population health is so different from what has been done before- given the learning curve, the team members must be learners”.
• Providers who are honest, transparent, and “leave their egos at the door”
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Solutions for Coordinated Care Partnerships for Autism Population Health
Autism Assessment Center of Excellence
(Medi-Cal Managed Care Health Plan as Convener)
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Age diagnosis
can be reliable &
valid
The Problem:
Late Diagnosis = Late Intervention =
Diminished Quality of Life & Higher
Life-Long Care Cost
National
Ave Age of
diagnosis
Average
age of ASD
diagnosis in
the
Inland
Empire
Average age
of ASD
diagnosis of
Latino
Childrenin the
Inland
Empire
48
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Delay in diagnosis =
Lost early intervention =
Diminished life-long
functioning
Quality of Life
Lack of clinical criteria
Lack of essential
medical personnel
Kids with
Autism
Deserve an
Answer!
Fragmented System
Treatment is not well
understood or coordinated
Decisions based on cost
rather than clinical criteria
Scarce Resources
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Autism Society
Inland Empire
Concept Desert
Mountain
Special
Education
LPA
Children’s
Network
First 5
Riverside &
First 5 San
Bernardino
Counties
Inland Empire
Health Plan
(IEHP)
The Solution:Formation of the Inland Empire ASD Collaborative
Inland
Regional
Center
Riverside
County Mental
Health
Department
Riverside
County Office
of Education
San Bernardino
Department of
Behavioral
Health
Dept of
Pediatrics
Loma
Linda
University
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Inland Empire (IE) ASD Collaborative
Vision:
“Every child in the Inland Empire will have access to a collaborative, organized, integrated and Trans-Disciplinary Assessment/treatment resource for Autism.”
Mission:
“To meet the autism community’s needs through shared responsibility for a comprehensive and Trans-Disciplinary assessment, Treatment Recommendations, Referrals and Resources in order to maximize the quality of life for children in the Inland Empire with Autism and their families.”
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Early Intervention
Access to treatment
at an earlier age
leads to a higher
Quality of Life &
functioning
AACE Center:
Integrated & Child-Centric
Inter-agency
collaboration
Improves
referrals and
aligns providers
and educators
Comprehensive
assessment
Eliminates
wasted time &
duplicative
assessments
“One Stop Shop”
Reduces parent’s
burden of having to
advocate and
coordinate across
multiple agencies
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The AACE Center Opens 2014
and Promises to:
Be recognized by medical treatment providers,
school districts and social service programs as a
trusted and credible assessment provider
Provide families and providers with useful,
appropriate and actionable treatment
recommendations, referrals and resources
Be financially self-sustaining 2 years after start-up
Create a model that can be replicated in other
communities.
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Creating Population Health
When a Solution Depends on Shared Responsibility, there Must Still Be a “Convening Organization”
Collaboration takes Longer to Implement
Bringing Everyone Along takes Shared Vision and Mission which must be centered on the Target Population - not any single Agency
When Commitment and Perseverance Prevail a Collaborative Strategy often yields The Best Result for Population Health as it is a:
“Community Solution”
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