Adult Care Home Sub Group
November 18, 2011Notes
Medical/Health Homes and Population Management Work Group
Dual Eligibles Planning Grant
Participants: Kenny Burrows, Janet Schanzenbach, Tim Daaleman, Kim Sturkey, Jennifer
Wehe, Lynne Perrin, Cindy Oakes, Nidu Menon, Pat Gerney, Elise Bolda
There were no corrections suggested for the last meeting minutes.
How to integrate behavioral health with medical home model? Are there any examples of
how it is done across the country?
 Locally (Chapel Hill) physicians are making house calls. Independent group
that contracts with homes —fee for service, but they are not linked with any
larger health system
 Most visiting physician programs elsewhere are affiliated with larger
institutions (ex: Washington DC’s national hospital, Mt. Sinai). Location
within these larger structures provide fiscal support which is important to
this business model
 Geography is very important
 Some adult care homes (ACH) facilities have house physician who may come
to the facility, along with capability to take residents to their offices between
visits, as needed.
Critical Access Behavioral Health Agencies (CABHAs) are not necessarily assigned to an
ACH
 Can have 1 ACH with 2 residents needing support, and 2 different CABHAs
serving them, or facility with 40 residents and services provided by 1 or 2
CABHAs.
 PCP & MH care – interesting dilemma with multiple CABHAs a challenges
when home & CABHA are in different counties – busing residents across
county lines
Summary of work in Buncombe County – Jennifer Wehe
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Collaboration with Law Enforcement & DSS & LME to address homes that are
prosing challenges for county, hospital and MH system. Beginning to look at moving
from medical homes to medical communities approach. Providing medical care on
sight but not equipped to provide other services.
Currently looking at a comprehensive package of wrap–around care for the frequent
readmissions population, to include education, PCP, bringing in multiple resources,
mobile crisis team. Interested in achieving an integrated system One group is
residence-based, medical management group all do some version of house physician
model.
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Adventist – Parkview practice
Henderson County house physician model & office model set up for SNF &
ACH residents focuses more on geriatric patient
A large FQHC is assigned provider for a couple ACH – they see patients in the
FQHC setting
Most recent effort - starting with 10 homes with high cost MH and high number of
residents with mental health conditions
o Doing gap analysis with LME as partner – that can bring resources to bear at
the CABHA level – medical communities cooperative
o Have 1 group who provide house physician model – they provide the medical
care onsite – The rest do not have the resources to address – it is going to
take a collaborative to bring in the resources.
o In Buncombe folks all on same page about sharing information, informatics
and sharing real time information are critical. Some roadblocks will be
removed in January when 122C law changes. CABHA’s mandated to seek
information for Medicaid pts they are managing – to get snapshot, who’s
involved, what are meds Group needs to get someone with that expertise
involved.
Transitions are important - Transitions Workgroup notes absence of information about
behavioral health considerations surrounding transitions
Buncombe County group has great interest among hospitalist to develop highly function
interdisciplinary teams to address people with multiple hospitalizations/ED visits
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ACH have a high percentage of these folks – there’s motivation at hospital level to
develop better plans of care for these folks
Must be an integrated, structured handoff. Rural and metropolitan hospitals are
focusing on readmission rate.
Proposal in the works for MH supports - contract with Sandhills, Orange, Person,
Chatham to provide hospital transition teams for MH population
o When high utilizers are going back in the hospital - it is ACH responsibility
(LME makes us aware) – providing intense supervision – pick up at hospital,
take to follow-up appointment, follow for 30 – 45 days helping him get to his
PCP – housing, be sure living place (not homeless) get them into an
appropriate setting to break cycle
Need Ways to look at facility level- experience; for sites with higher utilizers – how to we
involve facility or administrator in this process
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Geriatric adult specialty teams could help spread the message
February there is a continuing education conference & will start to have district
meetings again – had over 240 people in past
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Need to begin testing models Just recently began enroll ACH residents – having
monthly meetings with facilities & to get 1-1 issues inviting LME
Buncombe County hosts monthly educational meetings with facilities. Objective is
to improve access to mental health care and provide general information on what to
expect from a medical home.
Buncombe do what can to help with placement selection in these homes – educating
PCP & hospital so they understand options in terms of level of care & provide staff at
facility information on patient care needs (to make an appropriate placement within
their home); opportunities to better screen and place based on levels of care – can
have better outcome
Jennifer & Lynne will recruit DSS input (Susan McCracken or others); Elise will seek
behavioral health information sharing resources person
Next meeting/call: December 9, 2011, 8:00 a.m. to 9:00 a.m.