11/4/2014
How Can Population Based Care Models
Be Applied to Improve Health Outcomes
for Persons with Serious Mental Illness
October, 15, 2014
Marc Avery, MD
Clinical Associate Professor of Psychiatry
Associate Director for Clinical Services,
Department of Psychiatry and Behavioral Sciences
University of Washington School of Medicine,
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
Jennifer Clancy, MSW
Associate Director, California Institute for Behavioral Health Solutions
Director, CIBHS Coordinated Care Collaborative
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
Building on 25 years of Research and Practice in
Integrated Mental Health Care
© University of Washington
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11/4/2014
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.
2.
Tufts Managed Care Institute Newsletter, November 2000
http://www.tmci.org/downloads/topic11_00.PDF
Jurgen Unutzer, AIMS Center, 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
© University of Washington
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.
Why Population Based Care for SMI
Persons?
• System and Payment Reform
-Expanded Coverage
-Accountable Care Organizations
-Health Home
• Control of Escalating Costs
• Clinical Effectiveness
*Multiple investigators, references available by request.
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11/4/2014
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 Inertia
Washington State Senate Ways and Means January 31, 2011
Effects are Bidirectional
10
Mental Illness Results in
Increased MEDICAL
COSTS
50% higher Annual Health Care
Costs regardless of # medical
illnesses
Annual
Cost ($)
Chronic disease score
DDD
Unutzer J, et al. JAMA. 1997;277:1618-1623.
© University of Washington
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11/4/2014
Sometimes the patients who need us most
are the ones we forget..
Group 1
Punctual
Articulate
Polite
Engaging
Compliant / Adherent
Responsive
Has transportation
Good support system
Clinically straightforward
Culturally Similar
Group 2
Misses Appointments
Disorganized
Angry, agitated
Reserved
Isolative, Avoidant
Rejecting
Lacks transportation
Lacks social supports
Complex and Confusing
Culturally Dissimilar
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
“At baseline”?
“Stable”?
From: O’Conner, Patrick, et. Al, Clinical Inertia and Outpatient Medical
Errors, 2005 AHRQ, Advances in Patient Safety
IMPACT Team Care Model
(Patient Centered Healthcare Home for Behavioral Health)
Primary Care Practice with Mental Health Care Manager
Outcome
Measures
Treatment
Protocols
Population
Registry
Psychiatric
Consultation
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11/4/2014
An Integrated Team-Based Approach
– with a new Twist
IMPACT doubles effectiveness of
care for depression
50 % or greater improvement in depression at 12 months
%
Usual Care
70
IMPACT
60
PCP
Core
Program
40
New Roles
Psychiatric
Consultant
BH Care
Manager
Patient
50
30
20
10
0
1
2
3
4
5
6
7
Participating Organizations
8
Unützer et al., JAMA 2002; Psych Clin NA 2004
IMPACT reduces health care costs
MHIP: P4P-based quality improvement
ROI: $ 6.5 saved / $ 1 invested
cuts median time to depression treatment response in half.
1.00
Cost Category
4-year
costs
in $
0
522
558
767
-210
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
31,082
29,422
32,785
-$3363
0.75
0.00
0.25
0.50
Pharmacy costs
16
24
32
40
48
56
64
72
80
88
96 104 112 120 128 136
Difference in
$
522
Outpatient mental health costs
8
Usual care
group cost in
$
661
IMPACT program cost
0
Intervention
group cost
in $
Total health care cost
Savings
Weeks
Before P4P
Unutzer et al, AJPH, 2012.
After P4P
Unützer et al., Am J Managed Care 2008.
© University of Washington
5
11/4/2014
Primary Care Access, Referral and
Evaluation PCARE (Druss, et. Al 2010)
What about SMI patients who:
1. Get the majority of their services in a CMHC?
2. Have much more complicated service teams?
Integrated Primary Care
Team
VS.
RN Care
Manager
Community Mental
Health (n = 142)
Integrated Community BH
Care Team
•
•
•
•
Primary Care /
Medical
Increased Preventive Care (58% versus 21%)
Treatment for CV illness (34% versus 28)
Primary Care Linkage (71% versus 52%)
Increase in self-rated health
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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11/4/2014
Create a Table to follow…
Topic
Tool
Frequency
Target
Goal
Blood Pressure
SBP/DBP
Monthly
SBP<140 and 45%, 50%
DBP<90
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 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-HSA Primary and Behavioral Health
Care Integration (PBHCI) Program
SAMSHA
Training and T.A.
Grantees
I
II
III
IV
V
VI
13
9
34
8
30
9
National Council
Evaluation
RAND
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 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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11/4/2014
SAMSHA-HAS Primary and Behavioral Health Care Integration (PBHCI)
Program
Models:
1.Coordinated Care
2.Co-located Care
3.Integrated Care
• Partner with primary care organization
• Hire primary care team
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.
THANK YOU!
Practical Experience with
Facilitating Population Based Care
Jennifer Clancy, MSW
Associate Director
CA Institute for Behavioral Health Solutions
Marc Avery, MD
mavery@uw.edu
http://uwaims.org/index.html
© University of Washington
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11/4/2014
Jennifer Clancy, MSW
Topics
1. Overview Of The Organizations That Are Vital for the SMI
Population
DISCLOSURES
Employment:
Associate Director, California Behavioral Health Solutions
1. The Role of Convening Organizations in SMI Population
Health
Grant funding (current & recent)
None
Contracts (current & recent)
CA Department of Health Care Services
2. Historical Barriers to Creating Coordinated Care Systems for
SMI Population
NO FINANCIAL RELATIONSHIPS THAT PRESENT A CONFLICT OF
INTEREST FOR TODAY’s PRESENTATION
I WILL NOT DISCUSS OFF LABEL OR INVESTIGATIONAL USE OF
3. Solutions: Examples of Convening Organizations Coordinated
Care to Address Population Health Needs
MEDICATIONS OR OTHER TREATMENTS.
33
The Organizations Shaping the SMI Population Health- As Is
FUNDERS
RECIPIENT/
INTERMEDIARY
PAYORS/
CONTRACTORS
PROVIDER
NETWORK
CMS
HRSA
DHCS
FQHC
FQHC
CBOs
(MH, SUD, SS,
Peers)
SAMHSA
County
BH
HEALTH
Managed
Care Plan
County
Behavioral
Health
Tax Payers
(Millionaires)
CBO:
SUD
34
Where Are We Going?
Coordinated System Offering Integrated Care
Foundations
CBO:
MH
CBO:
Social
Service,
Peers….
Etc., etc.
County
Behavioral
Health
FQHCs/Health
Clinics
UNCOORDINATED
SYSTEM
35
Various Funding
Sources Organized
by Population
Health and Triple
Aim Principles
Social
Service
Agencies, i.e.
Housing
Wellness
Agencies:
i.e. Gym
Convening
Organization/Integrator
Accountable for
Population Health
Peer
Providers
Behavioral
Health
Provider:
SUD and MH
Primary Care
Provider
36
9
11/4/2014
Convening Organizations
1.
Convening Organizations
What Can The “Convening Organization” Do?
1.
 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.
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):
Which Organizations Can Serve as “Convening Organizations” for
SMI population?
 Medi-Cal Managed Care Plans
 County Mental Health Plan
 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
37
38
Solutions for Coordinated Care
Partnerships for Population Health
Fresno County Care Coordination Partnership:
Fresno County
Dept. of Behavioral Health
Clinica Sierra Vista:
(County Mental Health Plan as Convener)
FQHC, integrated mental
health & primary care clinic
serving Medi-Cal, Medi-Care
& uninsured individuals
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
A local Public Health Plan created
by the Regional Health Authority to
serve Medi-Cal members in the
counties of Fresno, Kings & Madera.
39
40
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11/4/2014
Clinica Sierra
Vista (FQHC)
Fresno County
Dept. of Behavioral
Health
(MHP)
*12%
*18%
4%
Ambulatory
Care Center
(PCP)
Behavioral Health and physical health care’s coordination has, thus far,
been driven by individual providers rather than system change. Longterm change must be driven by the systems rather than pushed
forward by a few practitioners.
1%
*38%
CalViva Health
(MCP)
*Percentages may
include duplicated
clients
Ambulatory
Care Ctr
12%
Clinica
Other PCP
36%
Sierra Vista
21%
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.
PCP
Unknown
31%
41
42
Key changes the Team has been working on
Overall Theme Across All Agency Partners
• 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
• 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
43
44
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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
CSV
(FQHC)
CalViva
(MCP)
NextGen
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
 Maintain key personnel from partner agencies
 Buy-in from executive leadership
 Right People at the Table with the Right
Personalities:
ACC
(PCP)
EPIC
Agency-Specific CCC Data
Measures & Client List
• 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”
DBH
(MHP)
Avatar
CiBHS
CCC
45
Solutions for Coordinated Care
Partnerships for Autism Population Health
46
48
The Problem:
Late Diagnosis = Late Intervention =
Diminished Quality of Life & Higher
Life-Long Care Cost
Autism Assessment Center of Excellence
(Medi-Cal Managed Care Health Plan as
Convener)
National
Ave Age of
diagnosis
Average age
of ASD
diagnosis of
Latino
Children
Average
age of ASD
diagnosis in
the
Inland
Empire
in the
Inland
Empire
Age diagnosis
can be reliable &
valid
47
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11/4/2014
Kids with
Autism
Deserve an
Answer!
49
The Solution:
Formation of the Inland Empire ASD Collaborative
50
Autism Society
Inland Empire
Scarce Resources
Concept
Dept
Children’s
Network
Lack of clinical criteria
Lack of essential
medical personnel
Fragmented System
First 5
Riverside &
First 5 San
Bernardino
Counties
Desert
Mountain
Special
Education
LPA
Inland Empire
Health Plan
(IEHP)
Quality of Life
Treatment is not well
understood or coordinated
Delay in diagnosis =
Decisions based on cost
rather than clinical criteria
Diminished life-long
functioning
Inland
Regional
Center
Lost early intervention =
Vision:
Riverside
County Mental
Health
Department
Riverside
County Office
of Education
San Bernardino
Department of
Behavioral
Health
AACE Center:
Integrated & Child-Centric
Inland Empire (IE) ASD Collaborative
51
of
Pediatrics
Loma
Linda
University
52
“Every child in the Inland Empire will have access to a
collaborative, organized, integrated and TransDisciplinary Assessment/treatment resource for Autism.”
Mission:
“To meet the autism community’s needs through shared
responsibility for a comprehensive and TransDisciplinary 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.”
Inter-agency
collaboration
Comprehensive
assessment
Improves
referrals and
aligns providers
and educators
Eliminates
wasted time &
duplicative
assessments
“One Stop Shop”
Early Intervention
Reduces parent’s
burden of having to
advocate and
coordinate across
multiple agencies
Access to treatment
at an earlier age
leads to a higher
Quality of Life &
functioning
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11/4/2014
53
The AACE Center Opens 2014
and Promises to:
Creating Population Health
54





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.



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”
14