Wellness Recovery Teams – An Innovative Approach to Integrated Health Homes

for Individuals with SMI

LeeAnn Moyer, Deputy Administrator of Behavioral HealthMontgomery County Department of Behavioral and Developmental

Disabilities

DBHIDS Health Care Integration in PhiladelphiaJune 25, 2013

Pennsylvania Serious Mental Illness (SMI) Innovation Project

• In 2008, the Center for Health Care Strategies (CHCS) launched a multi-state, national effort to improve quality and reduce expenditures for Medicaid beneficiaries with complex medical and behavioral health needs

• Pennsylvania was among the states selected to participate in the effort

• SE Project Name: HealthChoices HealthConnections (HCHC)

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Pennsylvania Serious Mental Illness (SMI) Innovation Project

SE Project Partners• Department of Public Welfare• Mathematical Policy Research and IPRO• Center for Health Care Strategies • Bucks, Montgomery and Delaware Counties• Magellan Behavioral Health of Pennsylvania, Inc.• Keystone Mercy Health Plan

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Partner Vision Group Meeting

Criteria for Inclusion• Ages 18+• Diagnosis of Schizophrenia (295.XX)• Diagnosis of a Mood Disorder (296.XX)• Diagnosis of Borderline Personality Disorder (301.83)• Program is voluntary and individuals may opt-out• Consent needed to release and share information

(includes MH, Substance Abuse (SA) and HIV-related information)

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Program Goals and Objectives

Improve Health for Members• Decrease gaps in care for behavioral and medical conditions• Improve the rate of medication adherence• Improve the rate of preventive services• Improve the rate of visits with providers• Reduce avoidable hospital admissions and emergency room

visits

Improve Member Satisfaction• Better access and services• Improved coordination of care

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Pennsylvania SMI Innovations Project Intervention Pillars

• Coordination of hospital discharge & appropriate follow-up• Pharmacy management• Co-location of resources• Focus on appropriate Emergency Department use for

Behavioral Health (BH) treatment• Focus on alcohol and substance abuse treatment/care

coordination• Consumer engagement• Data management and information exchange• Provider engagement/medical home

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Montgomery County Project Scope and Funding

• Total Consenting Member: 367

• Five Agencies and Two ACT Teams

• 2009-2010: Funded with Reinvestment

• 2010: OMHSAS approved service description; HealthChoices funding effective October 1, 2010

• Funding: Per member per month case rate

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Plan Level Interventions: Member Profile

Unique marriage of data between two independent health plans Magellan and Keystone Mercy Health Plan

• Demographics• Primary Care Provider (PCP) and BH provider contact

information• Physical Health (PH) and BH diagnoses• Service utilization of specialists• PH and BH levels of service and claims information• Hospitalizations; ER visits; BH Crisis Service• Pharmacy data• Gaps in routine physical health screenings/evaluations• Includes D/A and HIV information

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Plan Level Interventions• Easy access with plan-based case coordinators to

collaborate on the special needs of member

• Notify of BH & PH Hospitalization

• Recommend referrals as appropriate• Pharmaceutical Management • Access to BH & PH educational material • Joint Case Rounds (Includes plans’ case coordinators, plans’

physician advisors, Wellness Recovery Team and other healthcare participants, as needed)

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Provider Level Interventions: Wellness Recovery Team (WRT)

• Team of Navigators: RN, masters level MH or BH Professional, Administrative Navigator *Completed approved integrated PH/BH certification

• Phased approach to interventions with the goal of self-management

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Member with her WRT and Magellan HCHC Community Support Partner

Provider Level Interventions: Wellness Recovery Team (WRT)

• Outreach and Engagement• Therapeutic alliance with WRT• Utilize Member Profile as tool to coordinate care• Assist member in creating individual Wellness Plan• Identification of “virtual team” supports-relationship building• Community-based, mobile

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Member reviewing her Wellness Plan with RN Navigator and Therapist

Provider Level Interventions: Wellness Recovery Team (WRT)

• Notification of BH & PH hospitalization• Discharge planning and coordination• Linkage to community supports• Referrals as appropriate

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Triage and planning by WRT and RN

Provider Level Interventions: Wellness Recovery Team (WRT)

• Joint Case Rounds• Develop and maintain an ongoing relationship with a PCP and Psychiatrist• Pharmacy consultation and collaboration• Co-occurring substance use

screening and treatment interventions

• Trauma-informed and Motivational interventions

• Preventive care

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WRT consultation with Psychiatrist

Provider Level Interventions: Wellness Recovery Team (WRT)

• Continuity of relationships over time; immediate re-engagement if needed

• Wellness groups• BH and PH wellness checks• Provide educational material• Collaborative care management

activities are billable

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Member monitoring her wellness goal

Advantage of Multi-Level Approach to Coordination

• PH plan to BH plan to WRT• Coordination between WRT and PCP• Creating a “virtual team”• Specialist coordination• Achieving financial efficiencies

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HealthChoices HealthConnections Cost Impact Study

Selection of Population• Members Consented for Participation in HealthChoices

HealthConnections (HCHC)• Members Anchored in the Wellness Recovery Team (WRT)• 137 Members identified as having active participation in the

WRT program as of November 30, 2010

Measurement Periods• 6 Months prior to participation (anchor date) in WRT• 6 Months during participation (anchor date) in WRT

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The change found in individuals’ use of treatment in 24 hour settings and Emergency Rooms while participating in HCHC is substantially diminished compared with such need prior to HCHC involvement.

• The need for emergency care in a medical facility ER decreased by 11%• Admissions to medical facilities reduced by 56%• Admissions to psychiatric hospitals reduced by 43%• The need for an assisted residential environment declined by 14%

The support and proactive coordination of services and wellness activities found with the HCHC approach has resulted in a reduced need for these high level and often invasive interventions.

HealthChoices HealthConnections Cost Impact Study

Continuous Quality Management:Monthly Learning Collaborative

• Ongoing learning by sharing of collective experiences and challenges• Development and spread of promising practices and strategies• Network, relationship development and information/resource exchange• Identify and meet education and training needs

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Learning Collaborative

Continuous Quality Management: Onsite Meetings with Each Provider

• Provide Technical Assistance• Implementation of the Consumer Health Inventory (CHI) Tool• Conduct Quality Initiatives• Collaboratively Monitor Program

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Member completing a CHI

Continuous Quality Management:Administration of the Consumer Health Inventory (CHI)

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Domain% of HCHC Members Reporting

Progress

% of All Magellan PS Members

Reporting Progress

Behavioral Symptoms 29.03% 21.57%

Strength 38.71% 32.62%

Provider Relationship 80% 33.30%

Work-School Participation 22.58% 6.20%

Domain % of Members with Improvement% of All Magellan PS Members

with Improvement

Emotional Health 58.06% 38.05%

Physical Health 54.84% 35.16%

Continuous Quality Management: Consumer Satisfaction Surveys

• Active involvement with HCHC Consumer Advisory Board• Member Surveys conducted by Consumer Satisfaction Team• Peer Specialist involvement with Quality Improvement activities

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Consumer Advisory Board Members (Person in Recovery, Certified Peer Specialist, and Montgomery County QI Coordinator )

Continuous Quality Management: Consumer Satisfaction Surveys

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Definitely, 62.5%

Somewhat, 20.8%

Same as before, 12.5%

More confused, 2.1%

I don't know, 2.1%

I don't take medications,

0.0%

Do you have a better understanding of the medications you take as a result of using this service?

Continuous Quality Management: Consumer Satisfaction Surveys

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Highly effective

56.3%

Somewhat effective

37.5%

Not effective6.3%

Please rate the effectiveness of this service on your quality of life

Continuous Quality Management: Consumer Satisfaction Surveys

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Where Are We Today• Current census 380 adults• Working on Protocol to share PH/BH data with

DPW• Expansion of Health Homes by Adding RN

services in Outpatient• Magellan Behavioral Health enhanced their

website to promote Mobile Access to website by Navigators and Consumers; Introduced a new tool- Health & Wellness Questionnaire

• Montgomery County HealthConnections: Wellness Recovery Teams were selected as a promising innovative model by the Medicare-Medicaid Coordinating Office (MMCO) in 2012

• Montco recognized for the wide array of community based supportive services; housing initiatives and evidence based practices