The Systematic Approach To Integrated Health Care: The Data … · 2018-10-24 · The Systematic Approach To Integrated Health Care: The Data You Need To Make Primary/Behavioral

www.openminds.com n 15 Lincoln Square, Gettysburg, Pennsylvania 17325 n 717-334-1329 n [email protected]

The Systematic Approach To Integrated Health Care: The Data You

Need To Make Primary/Behavioral Health Integration A Success

Th e 2 0 1 8 O P E N MI NDS Te c h no lo gy & I n f o rm a t i c s I n s t i t u t e

O c t ob e r 2 3 , 2 0 1 8 | 1 0 : 1 5a m – 11 : 3 0 am

J o s ep h P. N a u g h t on -Trave rs , E d M , S e n i o r A s s o c i a t e , O P E N MI N D S

© 2018 OPEN MINDS

AgendaI. Integration In A Value-Based Market

II. Data Integration Case Study: Partners In Recovery

Christy Dye, Chief Executive Officer & President, Partners in Recovery

III. Data Integration Case Study: Resources for Human Development

Emily Nichols, MPH, Director of Operations, Resources for Human Development

(RHD)/Family Practice Counseling Network

Bill Maroon, Organizational Development Specialist, Business Development

Team, Resources for Human Development (RHD)

IV. Questions & Discussion

2

© 2018 OPEN MINDS© 2018 OPEN MINDS

Integration In A Value-Based Market

3

© 2018 OPEN MINDS

The Big Picture

Payer preference for integration driving use of value-based reimbursement

Value-based reimbursement increasing in all types of health and human service financing

Value-based reimbursement changing the fundamental business model of provider organizations

Success in this environment requires evolution –governance, management culture, and operating infrastructure

© 2018 OPEN MINDS

Shifting Payer Focus On “Superutilizer” Impact On Health Resource Use – Driving Interest

• $43,212 average expenditure per person per year

5% of U.S. population account for half (49%) of health care spending

• $253 average expenditure per person per year

50% of U.S. population account for only 3% of health care spending

“Superutilizers”

Term for people with complex

physical health, behavioral

health, and social issues who

have high rates of utilization for

ER and hospital services

More than 80% of Medicaid

superutilizers have a comorbid

mental illness

An estimated 44% of

“superutilizers” have a serious

mental illness


© 2018 OPEN MINDS

Behavioral Health Conditions PredictIncreased Health Care Spending

People diagnosed with a comorbid behavioral

health and chronic health condition

Cost 300% more

than those with only a chronic

health condition

Behavioral health problems cost

$200 billion

per year, more than heart

conditions, trauma, or cancer

People with one or more behavioral health conditions

spend

$672 billion

annually on overall health

care


© 2018 OPEN MINDS

Lack Of Integrated Care Coordination Results In Poorer Outcomes & Higher Cost Per Consumer

Drives adoption of coordinated care models across medical, behavioral, and social

systems...

Social

Behavioral

Medical

New service model:

behavioral health

services “imbedded” in

primary care for

mild/moderate

conditions

New service model:

single “vertical” care

coordination program

for each consumer

Social

Behavioral

Medical


© 2018 OPEN MINDS

Emerging Framework For Integrated Care Coordination

Behavioral health system optimization is central to success – and value-based

reimbursement is key to that optimization

Managed Care Programs & Health

Plans

Accountable Care Organizations

Medical Homes & Specialty Medical

Homes

Specialized Disease Management Program

‘At Risk’ For

Population

Health

Management

‘At Risk’ For

Individual

Health

Management


© 2018 OPEN MINDS

What Are The Value-Based Reimbursement Options?

Case

rates and

bundled rates

Medical homes and specialty medical homes

Capitation and/or population health gainsharing arrangements

With P

ay-F

or-

Perf

orm

ance C

om

ponents

Specialist

positioning

Comprehensivist

positioning

Value-based reimbursement increasing


Partners In Recovery Case Study

Christy Dye, Chief Executive Officer & President, Partners in

Recovery

10

Christy Dye

Chief Executive Officer

Partners In Recovery

OPEN MINDS

Technology & Informatics Institute

October 2018

Began as Outpatient Behavioral Health provider serving 3,800

adults with SMI in 2009

An alternative to traditional mental health services for adults

with SMI emphasizing:

Choice

Whole person wellness

Voice & involvement

Integration of best clinical practices and compassionate

professionals with the wisdom of individuals receiving services

and their family members

Began experimenting with different models of delivering primary care in 2011

Co-located physician group practice – 2011

Co-location by a local FQHC - 2012

First PIR Integrated Health Home - 2014

Medical ACT Team – 2015

Serving 8,000 adults with SMI at 7 clinics across Maricopa County

5 Integrated Health Homes

1 Medical ACT Team (stand-alone clinic)

1 rural FQHC partnership

CMS Transforming Clinical Practice Initiative (TCPI) participating agency

34% (1,588 Members)

Arrowhead -Aug 2016

MACT Team- Oct 2016

Gateway -September

2017

Metro -December

2017

West Valley- April 2018

797

100

748

1243974

50%

100%

55%

39%

20%

High rates of premature mortality among SMI

Disease burden magnified by manageable health conditions (smoking, obesity, sedentary, SUDs)

Focus on high cost/high need

Who are the 10% most at risk?

Integrating PCP within BH clinic supports a learning model unique to populations with cognitive impairments

Direct access to healthcare on site

Small doses over long periods of time

Existing relationships with psychiatry

Meeting people where they are on their road to health

Condition 2016 AZ

General Pop.

(6,392,017)

PIR

Arrowhead

(n=1,020)

PIR

Gateway

(n=976)

Hypertension 30.8% 34% 43%

Respiratory/

Asthma

15.7% 54.3% 35.8%

Diabetes 10.1% 14% 20.8%

Heart Disease 3.8% 32.6% 35.8%

Obesity/BMI 28.4% 58.7% 56.8%

Tobacco Use 14% 55.3%

# of ED Visits % of Total

Visits

# of Patients Total Visits

10+ 31.6% 181 2,837

5-9 25.2% 388 2,266

3-4 20.4% 580 1,771

2 11.8% 565 1,059

1 11.5% 1,116 1,030

Total 100% 2,797 8,963

Data Source: Mercy Care

Clinical Structures that support integration, not co-location

Facility design

Clinical team roles, including care coordination & care

management

What services are offered

Technology that supports integrated workflow & member

outcomes

Population health management

High risk interventions

SMI Integrated Health Home

Behavioral Health, Primary Care, Pharmacy

& Robust Wellness Services

Engaging People on their Journey to Health

PIR’s “teaching kitchen” develops skills in

food safety, selection and preparation.

Supervised by a master’s level nutritionist

Certified fitness trainers provide classes in

equipment safety, yoga, weights, step and

chair activities

Drop in or PCP referral

Wellness Strategies Targeting: Through:

Obesity Nutritional Counseling

Sedentary Lifestyle Fitness, Stress & Exercise

Management

Poor Nutrition Teaching Kitchen

Life Stress Peer Health Coaching

Smoking & Other Substance Use Life Skills/Health Promotion

Services

Sources of Data

Single EMR & Integrated Care Plan

Social Determinants of Health Screening

Health Information Exchange ADT Alerts

Care Management

Population Health Platform & Claims

Using data to target population-wide and person-specific

clinical interventions

High risk – utilization

Care gaps – prevention

Improving BH/PH outcomes – care management

Managing/negotiating value-based contracts

Change to Policy –

Follow up appointment after psych inpatient discharge in 4 days,

rather than 7

Change to Staffing –

Hire Discharge Coordinators

Staff Training –

Driving Suicide to Zero Screening

Initiative Focused on Specific Care Gap –

On-Site Retinal Eye Exam

Environmental –

Home Visit to Check on A/C Unit

OctoberNovember

December

January FebruaryMarch

April

May

June July August

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Hosp

ital A

dm

issi

ons

Per

1,0

000

SMI Psychiatric Admissions per 1,000

October 2017-August 2018(SMI Medicaid Population =5,500*)

50%

Reduction

High Risk Registry for familiar faces

Establish clinic-based teams to focus specifically on these

individuals

Functional Risk Analysis

Record review

Member outreach, natural supports

Individualized assessment & strategy

Medications, Dx, baseline

Health literacy

Reason for visit (stomach ache, headache)

Goal is to provide alternatives to high cost settings

0

5

10

15

20

25

30

35

ED Visits

Hospital Visits

MAT

Risk

Analysis

JT’s Story

Pre-Intervention – 96 ED Visits in 12 mos

Functional Risk Analysis determined that visits were

driven by opiate use

Team accessed Az Pharmacy Board CSMDP and identified

multiple prescribers of opiate medications

High Risk Assessment Group implemented a clinical

intervention involving:

Medication Assisted Treatment

Pharmacy Lock

Better coordination with staff in his housing program

0

5

10

15

20

25

30

35

January Febuary March April May

64%

ReductionIntervention

Functional Risk

Analysis &

Intervention

Baseline

ED High Risk ACT Teams 2018

Pre-Intervention - 18 patients @ 4 Visits pmpm

Present utilization reports for past 6 months to ACT Teams

Monthly update

ACT Morning Meeting focus on top utilizers on each team

ACT on-call proactive in reaching out after-hours and on

weekends

Connecting ACT members with PIR’s PCP

January

February

March

April

May

June

July

August

0

100

200

300

400

500

600

Tota

l ER

Vis

its

per

1,0

00 m

em

bers

$218,000

$99,000

PIR ED Visits per 1,000(SMI Medicaid Population)

Total Savings YTD 2018

$119,000

Measure Goal Omega Varsity West

Valley

MACT

Psych

Hospital

-20% -38% -14% -36% -29%

Acute

Hospital

-20% -13% -42% -55% -25%

ED Visits -20% -25% -20% -4% -42%

Employed +5% 128% 49% 13% 100%

PCP Visits +10% 26% 23% 57% 24%

Jail -10% 22% -40% 10% 2%

A1c

Test

57% of

pop

50%

Eye Exam 49% of

pop

75%

Questions?

[email protected]

mailto:[email protected]


Resources For Human Development Case Study

Emily Nichols, MPH, Director of Operations, Resources for

Human Development (RHD)/Family Practice Counseling Network

35

Emily Nichols, MPHFamily Practice & Counseling Network

Director of Operations

Integrated Care In A Behavioral Health Setting

Outline History of FPCN

Using tablets to screen for trauma history, depression and

drug/alcohol use

Data

Workflow

Outcomes

Lessons learned

What’s next?

37

Family Practice & Counseling Network (FPCN)

A network of 5 federally qualified health centers in Philadelphia

• 4 patient-centered medical homes

• 1 “expanded” convenient care in a grocery store

23,288 patients and 104,485 visits in 2017

38

Primary care

Dental

Outpatient BH

Integrated BH

Prenatal

MAT

Mind/Body

Nutrition

Social Services

Transportation

Outreach & Enrollment

Community Health Workers

Using Tablets to Screen for SDOH Trauma history using ACEs

• ACEs-2 screener

• Research project by Roy Wade, MD identified:

– 2 questions as a significant predictor of ≥4 ACEs

» Were you sworn at, insulted, or put down by a parent or adults in your home more than once during your childhood?

» During your childhood, did you live with anyone who was a problem drinker or alcoholic?

– Reliable/Valid method of screening patients

Depression using the PHQ

Alcohol and Drug Use using SBIRT

39

Workflow Patients are given tablets at registration

• All registration info at every visit

• ACEs

• 14 – 17 years of age – screened every 6 months

• ≥18 years of age – screened once

• PHQ: ≥14 years of age – screened every 6 months

• SBIRT: ≥12 years of age – screened every 6 months

Medical Assistant: during triage, data will flow into the patient’s chart via a

button on the intake form

Warm hand-offs to BHCs or other support staff by Provider, MA, if +

screening

40

Trauma History

41

Depression

42

Drug & Alcohol Use

43

Data: ACEs Screening

44

0 2

832

647

7 5

457

351

0

100

200

300

400

500

600

700

800

900

9/17 - 11/17 2/17 - 2/18 3/18 - 5/18 6/18 - 8/18

ACE-2 + ACES Score >=4

Tablets Implemented

Data: PHQ Screening

45

Tablets Implemented

108133

653

506

1345

448

349

0

100

200

300

400

500

600

700

9/17 - 11/17 2/17 - 2/18 3/18 - 5/18 6/18 - 8/18

PHQ2 + PHQ9 score >=10

Data: Drug & Alcohol Screening

46

Tablets Implemented

10 11

184

163

2820

182

162

0

20

40

60

80

100

120

140

160

180

200

9/17 - 11/17 2/17 - 2/18 3/18 - 5/18 6/18 - 8/18

SBIRT - Alcohol +

SBIRT - Drug +

Current Outcomes Identifying more patients than ever before with significant trauma

history, depression and/or current drug/alcohol issues

• 55% of patients with a +ACEs-2 has an ACEs score ≥4

• 68% of patients with a +PHQ-2 has a PHQ-9 ≥10

Linking to Resources

• 43% of patients with an ACEs score ≥4 have a BHC visit

• 69% of patients with a PHQ-9 score ≥10 have a BHC visit

• 33% of patients with a +SBIRT screen for drug or alcohol have a

BHC visit

47

Lessons Learned Communicate, communicate, communicate

• Involve ALL members of the care team in the development and

workflow of the tablets

If you ask a patient a question, you need to be ready to respond

Staff Capacity & Training

• Are ALL of your staff ready to discuss a patient’s trauma history?

Depression? Drug/Alcohol use?

• Are ALL of your staff prepared to give patients needed resources?

• Do you have ENOUGH staff to address all of the positive responses in

the moment of the visit?

48

What’s Next? Add PRAPARE questions to on the tablets

Add food insecurity questions to the tablets

Add additional languages to the tablets

Strengthen the workflow to connect our MAT team with patients

with +SBIRT screens

Continue to build staff capacity on addressing patients’

responses

Assess staffing levels

49


Resources For Human Development Case Study

Bill Maroon, Organizational Development Specialist, Business

Development Team, Resources for Human Development (RHD)

50

Bill MaroonDirector of Business Development and Innovation

Integrated Care In a Behavioral Health Setting

Established 1970

14 States

160 programs

CCBHC grantee

LMCMS – Lower Merion Counseling and Mobile Services

The very first RHD program in 1970, started with a $50,000 grant

from Montgomery County

Community-based outpatient mental health treatment center

• D&A and MH Services to individuals, groups and families

• Mobile Recovery Support Teams and Peer Specialists

53

CCBHC – Certified Community Behavioral Health Clinic

CCBHC pilot grants were only given eight states (currently up to 67 clinics nationwide)

Goals of the demonstration program:

• To better integrate behavioral health with physical health care

• To increase consistent use of evidence-based practices

• To improve access to high quality care for people with mental and substance use disorders

54

Alternative Payment Method – Bundled Payment

One payment for each day versus one rate per service

Goal is to get multiple services completed in one day

Rate per day will eventually be tied to Outcomes/Performance

• Currently, capturing data on 21 different quality measures such

as program records, Medicaid claims, managed care encounter

data, clinic cost and integration of services.

55

Integration efforts

Collateral Contacts and Doc to Doc consultations are paid at our same daily

rate.

D+A evaluations completed for local hospital for persons who on their Kidney

and Liver transplant list… Hospital pays for 4 D&A sessions.

Recovery Coaches perform ‘Strengths Assessment” every six months which

includes a set of physical healthcare questions that may trigger a referral to

primary care or doc to doc consultation

56

Integration efforts

Traumatic Brain Injury education and referral by local rehab

Development of Wellness Team and adding Nursing component to current

Recovery Teams

WRAP plans include physical health question

Local Emergency Room – Friendly Faces triggers a contact to our Mobile

Teams

57

Integration – Where we want to go…

Health Care Exchanges – regional and/or national

• HSX

• Carequality

Direct Interoperability with certain local providers

Nursing on-staff

EHR interoperability with Mobile Wellness Applications

58

Lessons Learned

Data, Data, Data

What you put in is what you get out…

• better data, better service = healthier people

Let your legal team figure it out... ROI

It goes slower than you anticipate

59


Questions & Discssion

60

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Documents

The Systematic Approach To Integrated Health Care: The Data … · 2018-10-24 · The Systematic Approach To Integrated Health Care: The Data You Need To Make Primary/Behavioral