Missouri’s
Primary Care and CMHC
Health Home Initiative
Samar Muzaffar, MD MPH
Missouri Department of Social Services
MO HealthNet Division
Medical Director
Overview
• Two Medicaid Health Home initiatives- primary care
and mental health
o Partnership between MO HealthNet and Department of
Mental Health
o Collaboration with Missouri Primary Care Association
(MPCA), Missouri Hospital Association (MHA), Missouri
Coalition of Community and Mental Health Centers
• Multipayer Initiative coordinated by Missouri
Foundation for Health (MFH)
• One Learning Collaborative for all participants
o Collaboration between MFH, Health Care Foundation of
Greater Kansas City, MPCA, and MHA
Overview
• Missouri is the first state to have both mental health and
primary care CMS approved State Plan Amendments
• A unique aspect of the program is the integration of
behavioral health with primary care and vice versa in its
structure.
o Literature speaks to the centrality of appropriately and effectively
managing behavioral health conditions in the management of physical
health conditions
• By implementing the health home program we hope to
demonstrate
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o
o
o
Reduced inappropriate ED utilization
Reduced avoidable in-patient utilization
Improved patient outcomes
Reduction in health care costs
Overview
• Key Health Home Services for MO:
o
o
o
o
o
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Comprehensive Care Management
Care Coordination
Health Promotion
Comprehensive Transitional Care
Individual and Family Support Services
Referral to Community and Social Support
Services
Missouri’s Health Homes
o Primary Care Health Homes (24)
• 19 Federally Qualified Health Centers
(FQHCs)
• 5 Public and Private Hospitals
oIncludes 14 Rural Health Clinics
• ~18,800 patients enrolled in October
o CMHC Healthcare Homes (29)
Primary Care
Target Population
• Clients are eligible for a Primary Care health home as a result
of having two chronic conditions; or having one chronic
condition and being at risk for a second chronic condition. To
be eligible patients must meet one of the following criteria
1.
Have Diabetes
• At risk for cardiovascular disease and a BMI>25
2. Have two of the following conditions
1. COPD/Asthma
2. Cardiovascular disease
3. BMI>25
4. Developmental Disability
5. Use Tobacco
o At risk for COPD/asthma and cardiovascular
disease
Primary Care Health Homes
• Provide primary care services, including screening for,
and “comprehensive management” of, behavioral
health issues
• Ensure access to, and coordinate care across,
prevention, primary care, and specialty medical care,
including specialty mental health services
• Promote healthy lifestyles and support individuals in
managing their chronic health conditions
• Monitor critical health indicators
• Divert inappropriate ER visits
• Coordinate hospitalizations, including psychiatric
hospitalizations, by participating in discharge planning
and follow up
Initial Provider
Qualifications
• Utilize interoperable registry
o
o
o
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Input annual metabolic screening results
Track/measure care
Automate care reminders
Produce exception reports
• MOU with regional hospital or system within 3
months health home service
implementation
Initial Provider
Qualifications
• Meet state’s minimum access requirement
including enhanced access requirement
• Have a formal and regular process for
patient input
• Have completed EMR implementation/use
EMR for at least 6 months prior to beginning
health home services
• Actively use MHD EHR for care coordination
& Rx monitoring
Initial Provider
Qualifications
• Substantial percentage of patients enrolled
in Medicaid (> 25%)
• Special consideration to those with
considerable volume of needy individuals
• Strong, engaged, committed leadership
• Meet state requirements for patient
empanelment
Primary Care Health Home
Basics
• Practice site physician or nurse practitionerled
• Health Team
o
o
o
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Primary care physician or nurse practitioner
Behavioral health consultant
Nurse care manager
Care Coordinator
Others per practice
Health Home Team Members
•
•
•
•
Health Home Director
Nurse Care Manager
Behavioral Health Consultant
Care Coordinator
1:2500
1:250
1:750
1:750
Health Home Team Members
• Staffing ratio development
• PMPM development
• Team member roles and training
CMHC Health Homes
• 29 CMHC Health Homes
• 17,882 individuals auto-enrolled
o 3203 children and youth (18%)
o CMHC consumers with at least $10,000 Medicaid
costs
• ~18,300 enrolled in October
CMHC Health Homes
Target Population
• Clients eligible for a CMHC health home
must meet one of the following three
conditions
1. A serious and persistent mental illness or
serious emotional disorder
2. A mental health condition and substance
use disorder
3. A mental health condition and/or
substance use disorder and one other
chronic health condition
CMHC Health Homes
Target Population
• Chronic health conditions include:
1. Diabetes
2. Cardiovascular disease
3. Chronic obstructive pulmonary disease
(COPD)
• Asthma
• Chronic bronchitis
• Emphysema
4. Overweight (BMI >25)
5. Tobacco use
6. Developmental disability
CMHC Health Homes
• Provide psychiatric rehabilitation, including
screening, evaluation, crisis intervention,
medication management, psycho-social
rehabilitation, and community support
services
• Embody a recovery philosophy that respects
and promotes independence and
responsibility
• Complete a comprehensive health
assessment
• Monitor critical health indicators
CMHC Health Home
• Assure access to, and coordinate care
across prevention, primary care
(including assuring consumers have a
PCP) and specialty medical services.
• Promote healthy lifestyles and support
individuals in the self-management of
chronic health conditions
• Coordinate/monitor ER visits and
hospitalizations, including participating
in discharge planning and follow up
CMHC Health Homes
o Health Home Director
o Nurse Care Manager
enrollees
1 per 500 enrollees
1 per 250
o Primary Care Physician Consultant
hr/enrollee
o Care Coordinator/Clerical
enrollees
1
1 per 500
CMHC Health Homes
HCH Team Members
• Health Care Home Director
• Primary Care Consulting Physician
• Nurse Care Managers (NCM)
• HCH Clerical Support Staff
• Community Support Specialists (CSS)
• Psychiatrist
• QMHP, PSR and other Clinical Staff
• Peer Specialists
• Family Support Specialists
Integration of Behavioral Health
and Primary Care
• The two health home programs coordinate behavioral
health and primary care health needs:
• PCHH’s coordinate primary care and behavioral
health needs through the embedded behavioral
health consultant
• CMHC HH’s coordinate primary care and behavioral
health through the embedded primary care
physician consultant and the nurse care manager
o Much of the effort, education, learning, and work,
including The Learning Collaborative, has been around
how to successfully integrate and coordinate the
primary care and behavioral health
Questions?
• Missouri Health Home Website information:
• http://dss.mo.gov/mhd/cs/health-homes/
• http://dmh.mo.gov/about/chiefclinicalofficer/healthcarehome.htm