Show Me Outcomes - BHECON...BPM Mailings Email Notifications Disease Registry ProAct Netsmart Pilot/ SPQM & Costing/ Data Warehouse/ DLA-20 MO + CMT Nurse Liaisons DM3700 Outreach

Progress Update

Show Me Outcomes

BPM Mailings

Email Notifications

Disease Registry ProAct

NetsmartPilot/ SPQM & Costing/ Data Warehouse/

DLA-20

MO + CMT NurseLiaisons

DM3700Outreach

HealthcareHome

CMHL/ERE Excellence

2005 2008 2010 2012 2013 2015

FQHC Partnership

Training Contracts

26Missouri CMHC Health Homes

24,063 Current Enrollment (as of January 1, 2016)

• 1,236 elderly

• 19,652 adults

• 3,175 children

Missouri county map with

CMHC Health Home locations

Children (<18)

13.2%

Adult (18-64)

81.7%

Elderly (>64)

5.1%

CMHC Health Home

Enrollment by Age Group

N = 24,063 total health home enrollment as of January 1, 2016

Missouri’s Health Homes have saved an estimated

$36.3 million($60 PMPM Cost Savings)

Community Mental Health Center Healthcare Homes

have saved Missouri $31 million

($98 PMPM Cost Savings)

Current per member per

month (PMPM) rate for

CMHC Health Homes is

$85.23 (Jan. 2016)

Disease Management 3700 cohort

enrolled in CMHC Health Homes

saved $22.8 million

($395 PMPM Cost Savings)DM3700 N =4,800 lives

37%

30%28%

23%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Baseline Year 1 Year 2 Year 3

14%

CMHC Health HomesJanuary 1, 2012

0

50

100

150

200

250

300

2009 2010 Baseline Year 1 Year 2 Year 3

ER Visits Hospital Days

ER Visits Per 1000

Hospital Days Per 1000

34%

38%


0.850.68 0.62 0.58

2.5

2.272.09 2.06

0

0.5

1

1.5

2

2.5

3


Avg # HospitalizationsPer Enrollee Per Year

Avg # ER VisitsPer Enrollee Per Year

Total CMHC Health Home

participants:

(2011) = 17,084

(2012) = 18,776

(2013) = 19,103

(2014) = 20,345

year end 2011 year end 2012 year end 2013 year end 2014


7%9%

29%

11%

1%

15%

9%

36%

29%

62%

45%

9% 8%

53%

18%

3% 4%7%

0%

9%6%

0%

10%

20%

30%

40%

50%

60%

70% General Nat. Pop.

HCH Adults

HCH Youth

HY

PE

RT

EN

SIO

N

CA

RD

IOV

AS

CU

LAR

DIS

EA

SE

SU

BS

TA

NC

E U

SE

DIS

OR

DE

R

AS

TH

MA

General population stats from 2015 Centers for Disease Control and Prevention (CDC) and Substance Abuse and Mental Health Services Administration (SAMHSA)


participants (2012-2014):

HCH Adults N = 22,801

HCH Youth N = 3,944

27%29%

19%

9%

44%48%

23%

2%0% 0% 0%

3%

0%

10%

20%

30%

40%

50%

1ChronicDisease

2ChronicDisease

3ChronicDisease

≥4Chronic Disease

SUD+2 ormore

other CD

MH+2 ormore other

CD

HCH Adults HCH Youth


participants (2012-2014):


HCH Youth N = 3,944


participants (2014):


DM3700 Adults N = 2,407

2%

31%

35%

25%

7%

1%

18%

24%

37%

19%

1%

19%

23%

37%

20%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

UnderweightBMI <18.5

NormalBMI 18.5-24.9

OverweightBMI 25-29.9

ObeseBMI 30-39.9

Extremely ObeseBMI ≥40

General MO Adult Pop.

HCH Adults

DM3700 Adults

0.4%

7%

37%

45%

12%

2%0% 0%

0%

10%

20%

30%

40%

50%

60%

70%

1-20mGAF

21-30mGAF

31-40mGAF

41-50mGAF

51-60mGAF

61-70mGAF

71-80mGAF

81-90mGAF

Score 31-40Major impairment in several areas of functioning

Score 41-50Some serious symptoms or impairment in functioning


participants (CY 2014):

N = 13,550 with DLA-20

in last 18 months

Performance Measures & Outcomes

22%27%

18%

38%

46%42%

47%

59%53%

57%

73%

61%

54%

72%

61%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Good Cholesterol(<100 mg/dL)

Normal Blood Pressure(<140/90 mmHg)

Normal Blood Sugar(A1c <8.0%)

Feb'12Baseline

Feb'1312 Months

June'1318 Months

June'153.5 Years

Dec'15current enrolled pop

Adults continuously

enrolled at each point in

time and adults enrolled as

of December 2015

N = 1,889 (3.5 yr. enrollment)

N = 4,526 (Dec 2015)

21%24%

37%41%

49%55%

60%

70%

56%

67%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Good Cholesterol for Clients w/ CVD(<100 mg/dL)

Normal Blood Pressure for Clients w/ HTN(<140/90 mmHg)

Feb'12Baseline

Feb'1312 Months

June'1318 Months

June'153.5 Years


Adults continuously

enrolled at each point in

time and adults enrolled as

of December 2015

CVD N = 232 (3.5 yr.

enrollment)

CVD N = 564 (Dec 2015)

HTN N = 2,401 (3.5 yr.

enrollment)

HTN N = 6,111 (Dec 2015)

12%

46%

61%

80%

89% 88%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Metabolic Syndrome Screening

Feb'12Baseline

Feb'1312 Months

June'1318 Months

June'142.5 Years

June'153.5 Years


All CMHC Health Homes

have attained a completion

rate above 80%!

N = 6,553 (3.5 yr. enrollment)

N = 20,648 (Dec 2015)

reduction in cholesterol

10% in cardiovascular disease

reduction in HgbA1c

21% in diabetes related deaths

14% in heart attacks

37% in microvascular complications

reduction in blood pressure

16% in cardiovascular disease

42% in stroke

Baseline to Year 1:

Reduced the mean LDL131 to 115 = 12% decrease

Baseline to Year 3:

Reduced the mean LDL131 to 106 = 19% decrease

For individuals with LDL >100 at Baseline

131.5

115

111.64

106

100

105

110

115

120

125

130

135

140

145


19%

Baseline to Year 1:

Reduced the mean BPSystolic: 152 to 134= 18 mm/HgDiastolic: 98 to 86= 12 mm/Hg

Baseline to Year 3:

Reduced the mean BPSystolic: 152 to 133= 19 mm/HgDiastolic: 97 to 83= 14 mm/Hg

For individuals with Systolic BP >140 and Diastolic BP >90 at Baseline

152.9

134.9 134.4133.1

97.9

86 84.983.3

30

50

70

90

110

130

150

170


14mm/Hg Systolic

19mm/Hg Diastolic

10.08

9.2

8.9

8.6

7.5

8

8.5

9

9.5

10

10.5


Baseline to Year 1:

Reduced the mean HgbA1c10.1 to 9.2 = .88 points

Baseline to Year 3:

Reduced the mean HgbA1c10.1 to 8.6 = 1.48 points

For individuals with HbA1c >9.0 at Baseline

NASCA leaders discuss health homes.

• State/Provider Collaboration Key• CEO Presentation Mandate• Kids Model Wrong – More

Wellness/Family• MCO Challenges (Kansas Example)• Data! Data! Data!• Engage the Nurses• Hospital MOU• Agency Integration

MO Health Home Resources

MO Department of Mental Healthdmh.mo.gov/mentalillness/mohealthhomes.html

MO Coalition for Community Behavioral Healthcaremocoalition.org/#!health-homes/c14fu

MO Department of Social Services | MO Primary Care Health Homesdss.mo.gov/mhd/cs/health-homes/

CMS Health Home Information Resource Centerwww.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/health-homes-technical-assistance/health-home-information-resource-center.html

Articles and Recognitions

“The Promise of Convergence: Transforming Health Care Delivery in Missouri” (Harvard Case Study for 2015 NASCA Institute on Management and Leadership)www.naspo.org/dnn/Portals/16/2015%20NASCA%20Case%20Study%20-%20The%20Promise%20of%20Convergence%20FINAL%20for%20article.pdf

Gold Award: Community-Based Program: A health Care Home for the “Whole Person” in Missouri’s Community Mental Health Centers (APA Achievement Awards 2015)ps.psychiatryonline.org/doi/full/10.1176/appi.ps.661013can Psychiatric Association |

Documents

Show Me Outcomes - BHECON...BPM Mailings Email Notifications Disease Registry ProAct Netsmart Pilot/ SPQM & Costing/ Data Warehouse/ DLA-20 MO + CMT Nurse Liaisons DM3700 Outreach