2014 HCE Annual Conference
Moving Forward:
Embracing Change and
Innovation
California Endowment  November 20, 2014
Cutting High-Dollar Medical Spending for the
Mentally Ill by 35%
“Cutting the High-Dollar Medical Spend
for the Mentally Ill by 35%”
Panel Presentation:
Ginny Romig, MBA, Regional Vice President Operations
Richard Louis, III, Executive Director Strategic Development and Planning
Michael Varadian, MBA, JD
3
SESSION OVERVIEW
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•
•
•
•
•
•
About Providence Human Services
The Cost of Relapse and Chronic Mental Illness
National and Local Trends
Care Coordination and Collaborative care
The Providence Experience: Collaborative Care Outcomes
Behavioral Health Homes
Q&A
4
Panelist Presentation
Richard Louis, III
Executive Director Strategic Development and Planning
Providence Human Services – Pacific Division
5
About
Providence Human Services
6
National
• Headquartered in Tucson, Arizona, Providence Service Corporation is
a national leader in home- and community-based human services,
collaborative care services, and nonemergency transportation (NET)
services. We pride ourselves in delivering cost savings and improved
efficiencies with solutions that avoid traditional institutionalized
care and focus on creating healthy communities.
• Providence has more than 11,000 employees that provide services
in 41 states, the District of Columbia and 10 countries across the
world. We proudly serve more than 53,100 unique clients and nearly
17 million individuals who qualify for services through more than
580 active contracts.
• Providence is unique because it provides or manages human
services primarily in the client's own home and community based
settings rather than in hospitals or other treatment facilities.
7
Providence National Service Lines
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•
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•
•
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Mental Health and Substance Abuse
Care Coordination/Care Management
Assessments and Evaluations
IDD/Autism Services
Home-Based Services
Community-Based Services
Corrections and Juvenile Justice
Therapeutic Foster Care
Virtual Residential Program
8
California Service Lines
“Proudly Serving Adults, Youth and Families Since 1996”
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•
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•
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Outpatient Mental Health Treatment and Assessment
Assessment and Evaluation
Medication Assessment and Management
Community Support Services
Care Coordination / Care Management
Substance Abuse Treatment and Education
Supported Housing and Employment
24-7 Call Center Mental Health Support
Evidence Based Practices
9
California
In California, Providence operates in over 40 locations in 7
counties and is a Medicaid (Medi-Cal) and Medicare certified
provider.
• Serving Children (0-18), Transition Age Youth (16-25), Adults
(18+) and Older Adults (60+)
• Comprehensive Continuum of Care – service levels for clients
with mild, moderate and severe conditions
10
The Cost of Relapse And
Chronic Mental Illness
11
Schizoprenia
12
Broad Impact of Schizophrenia
• American taxpayer
• Estimated cost at $62.7B health care cost 1
• 20.4% of consumers with serious mental illness are uninsured 2
• Criminal justice system
• 46% of patients with schizophrenia have one or more encounters
with the criminal justice system 3
• Consumers and families
• 51% of caregivers have felt taken advantage of by loved ones
living with schizophrenia 4
1. Wu EQ, et al. The Economic Burden of Schizophrenia in the United States in 2002. J Clin Psychiatry 2005
Sep;66(9):1122-1129. http://www.ncbi.nlm.nih.gov/pubmed/16187769. Accessed March 1, 2011
2. Hyde, P. Increasing prevention & wellness to decrease risk for rates of suicide [powerpoint]. Presented
at: American foundation for suicide prevention & SPAN USA legislative luncheon; March 8, 2010; Orlando,
FL. Available at http://www.spanusa.org/?fuseaction=home.download&folder_file_id=76DB3B4B-F93F-0671
D9A9FA66DBB9B1B9. Accessed March 8, 2011
3.Ascher-Svanum et al.Involvement in the US criminal justice system and cost implications for persons
treated for schizophrenia. BMC Psychiatry 2010;10:11.
http://www.biomedcentral.com/1471-244X/10/11. Accessed March 9, 2011
4. Schizophrenia: Public attitudes, personal needs. Views from people living with schizophrenia,
caregivers, and the general public. National Alliance on Mental Illness, June 2008. Available at
http://www.nami.org/SchizophreniaSurvey/SchizeExecSummary.pdf. Accessed March 8, 2011
13
Wide Impact of Schizophrenia and/or Relapse
Victimization
Hospitalization
Trauma During
Hospitalization
Comorbidity
Substance Abuse
Homelessness
Incarceration
Mortality
14
Victimization
• Patients with schizophrenia or
schizoaffective disorder are
14 times more likely to be victims
of a violent crime than be arrested
for one.
• Severity of clinical symptoms and
substance abuse at baseline are
associated with a higher
probability of victimization.
Brekke J, Prindle C, Bae S, Long J. Risks for individuals with schizophrenia who are living in
the community. Psychiatric Services. October 2001; 52:1358-1366.
http://psychservices.psychiatryonline.org/cgi/content/full/52/10/1358. Accessed March 7,
2011
15
Hospitalization
• About one in five patients with
schizophrenia are hospitalized
in a year 1
• In 2004, there were over 800,000
stays for patients with mental
health or other psychotic disorders.
2
• Almost one in four community
hospital stays are mental health or
substance abuse disorders. 2
1. One in Five Admissions Are for Patients with Mental Disorders. AHRQ News and
Numbers, October 30, 2008. Agency for Healthcare Research and Quality, Rockville, MD.
http://www.ahrq.gov/news/nn/nn103008.htm. Accessed March 21, 2011
2. Owens P, Myers M, Elixhauser A, Branch, C. Care of adults with mental health and
substance abuse disorders in U.S. community hospitals, 2004. Agency for health and
research quality – U.S. Department of Health and Human Services. Available at
http://www.ahrq.gov/data/hcup/factbk10. Accessed March 7, 2011
16
Trauma During Hospitalization
• Data revealed high rates of patient
reported lifetime trauma that occurred
within psychiatric settings:
• Over 60% witnesses traumatic events
• Over 30% have been physically
assaulted
• 8% have been sexually assaulted
• Patients are often subjected to
institutional measures:
• Approximately 60% have been
secluded
• Approximately 2/3 were handcuffed
during transport
• Over 1/3 have been physically
restrained
Frueh B. et al. Patients Reports of Traumatic or Harmful Experiences Within the Psychiatric
Setting, 2005, Vol. 56, No. 9. Psychiatric Services. Available at
http://psychservices.psychiatryonline.org/cgi/reprint/56/9/1123. Accessed March 23, 2011
17
Substance/Alcohol Abuse
• Drugs and alcohol are often
used to ‘escape’ from symptoms
of schizophrenia. However,
these substances can 2:
Nearly one-half (50%) of patients
with schizophrenia have a comorbid
substance use disorder 1
• Worsen symptoms
• Reduce treatment effectiveness
• Make it difficult for HCPs to discern
between symptoms of
schizophrenia and symptoms of
substance/alcohol use
1. Lehman A. et_al. Practice Guidelines for the treatment of patients with Schizophrenia. American
Psychiatric Association 2004. Available at
http://www.psychiatryonline.com/pracGuide/PracticePDFs/Schizophrenia2e_Inactivated_04-1609.pdf. Accessed March 2, 2011
2. Swofford C, Scheller-Gilkey G, Miller AH, Woolwine B, Mance R. Double jeopardy: schizophrenia
and substance abuse. AM J Drug Alcohol Abuse, 2000 Aug;26(3):343-53. Available at
http://www.ncbi.nlm.nih.gov/pubmed/10976661. Accessed Feburary 24, 2011
18
Comorbidity in Patients with
Schizophrenia
• Patients with schizophrenia
have a high rate of co-existing
health problems compared to
the general population.
• Three times more likely to be
smokers and suffer from
hypothyroidism
• Eight times higher rate of
infectious disease, i.e.
hepatitis C
• Two times as vulnerable to
asthma, stroke, COPD and
diabetes
Carney C, et al. “Medical Comorbidity in Women and Men with Schizophrenia: A Population
Based Controlled Study,” Journal of General Internal Medicine (November 2006). Vol. 21, No.
11, pp.1133-37. Available at http://www.ncbi.nih.gov/pubmed/17026726. Accessed March 21,
2011
19
Homelessness
Uncontrolled Symptoms
Relapse
Unemployment
Economic Distress
On average 24% of homeless adults are
severely mentally ill 1
Poverty
Homelessness
1. Lehman A. et_al. Practice Guidelines for the treatment of patients with Schizophrenia.
American Psychiatric Association 2004. Available at
http://www.psychiatryonline.com/pracGuide/PracticePDFs/Schizophrenia2e_Inactivated_04-1609.pdf. Accessed March 2, 2011
20
Incarceration
• According to a report from the
US Department of Justice, more
than half of all prison and jail
inmates had a mental health
illness in 2005. 1
• Persons with severe mental
illness are approximately three
times more likely to be in jail
than in a hospital. 2
1. James D, Glaze L, Mental Health Problems of Prison and Jail Inmates. U.S. Department of
Justice, Office of Justice Programs, Bureau of Justice statistics Special Report. 2006, NCJ
213600. Available at http://bjs.ojp.usdoj.gov/content/pub/pdf/mhppji.pdf Accessed March
27,2011
2. Moran M, Jail More Likely Than Hospital for Severely Mentally Ill. 2010, Psychiatric News.
Volume 45 Number 11 Page 1. Available at
http://pn.psychiatryonline.org/content/45/11/1.1.full. Accessed March 9, 2011
21
Mortality
• People with severe mental illness
die, on average, 25 years earlier
than the general population. 1
• 60% of premature deaths among
people with Schizophrenia are due
to cardiovascular, pulmonary, and
infectious diseases. 1
• Suicide is the number one cause of
death for patients with
schizophrenia. 2
1. Morbidity and Mortality in People with Serious Mental Illness. National Association of State
Mental Health Program Directors. 2006
http://www.nasmhpd.org/general_files/publications/med_directors_pubs/technical%20report%20
on%20morbidity%20and%20mortaility%20-%20final%2011-06.pdf. Accessed March 27, 2011
2. Restoring Reason to Treating Mental Illness, Schizophrenia Facts. Treatment and Advocacy
Center. 2009
http://www.treatmentadvocacycenter.org/index.php?option=com_content&task=view&id=464&It
emid=102. Accessed March 27, 2001
22
Recovering From Schizophrenia
The Course of Schizophrenia
40%
35%
30%
25%
20%
15%
10%
5%
0%
35%
25% 25%
25%
25%
15%
15%
15%
10%
Patients have recovered
Show significant
Show definite
Require hospitalization
completely
improvement and can improvement but still
live independently
need an active support
network
10 years after onset of the disease
10%
Deceased, often the
victims of suicide
30 years after onset of the disease
Schizophrenia Facts and Statistics. Schizophrenia.com 2010. Available at:
http://www.schizophrenia.com/szfacts.htm. Accessed March 27, 2011
23
National and Local Trends
24
A Nationwide Concern
People with a Behavioral Health Diagnosis
Require Significant Care
Source: Hamblin, A., Verdier, J., & Au, M. (Oct 2011). Technical Assistance Brief: State options for integrating physical and behavioral health care. Integrated Care Resource Center.
25
Soaring Cost of Emergency
Room Visits
• Healthcare spending continues to climb, reaching approximately
17.6% of the US GDP in 2009.1 It is estimated that 5% of the
population accounts for almost 50% of all healthcare spending.
• Nationally, there were more than 6.4 million visits to emergency
rooms in 2010, or about five percent of total visits, involved patients
whose primary diagnosis was a mental health condition or
substance abuse.
• That is up 28 percent from just four years earlier, according to the
latest figures available from the Agency for Healthcare Research and
Quality.
• By one federal estimate, spending by general hospitals to care for
these patients is expected to nearly double to $38.5 billion in 2014,
from $20.3 billion in 2003.
26
High ER Utilization Rates
ER Use Rates Among Patient with Mental Illness and Substance Abuse
Vs. Patients Without these Diagnoses
7x
higher
3.8x
higher
2.6x
higher
No MH/SA
patients
All ER Visits
1.7x
higher
MH or SA
patients
Medical Visits Only
MH and SA
patients
Source: Freeman, E, Yoe, J. Analysis of Emergency Department Use for People with Mental Health and Substance Abuse Disorders, Presentation
to the Maine DHHS/APS Data Forum, May 2006.
27
The Cost of Untreated Mental Illness
in Colorado
• Among Colorado Medicaid enrollees, patients with mental health problems
spend eight times more than patients without mental health problems.
• In Colorado Medicaid, 33% of “superutilizers” of resources have behavioral
health claims – and the Medicaid medical expenses associated with mental
illness reached an estimated $2 billion in 2013.
• Workers with mental disorders earn $16,000 less per person – costing Colorado
an estimated $2.9 billion per year.
• According to the Social Security Administration, disability pay in Colorado in
2012 was $425 million.
• There was $62 million in state education spending for children with emotional
disorders.
• The cost of holding inmates with mental illnesses in the seven county jails
around Denver cost $44.7 million per year.
• Colorado is spending $28 million per year treating the mental illnesses of state
prison inmates.
• The grand total: $5.4 billion per year, or $1,000 for every Colorado citizen
28
SMI Population Distribution By
Payer: National vs. State
National
Medicaid including Dual Eligibles 25%
Medicare 37%
Commercial 11%
25%
25%
37%
11%
California
Medicaid including Dual Eligibles 30%
Medicare 27%
Commercial 11%
30%
27%
30%
2%
11%
2%
*Based on 2011-2012 data
Top 10 Major Diagnostic Categories By Share Readmitted For
Any Cause Within 30 Days, 2011 (All Payers)
Mental Diseases & Disorders
16.7%
Circulatory System
17.0%
Respiratory System
17.5%
Alcohol/Drug Use
17.6%
Hepatobiliary System & Pancreas
18.1%
Kidney & Urinary Tract
18.3%
Infectious & Parasite
Blood, Blood Forming Organs, Immunological
Human Immunodeficiency Virus Infections
Myeloproliferative & Poorly Diff. Neoplasm
19.4%
24.5%
25.3%
49.3%
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0%
Source: Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID),
2011, Agency for Healthcare Research and Quality (AHRQ).
30
Top Ten Conditions Resulting in Readmissions
By Payer: Principal Diagnoses, 2011
Medicare
•
•
•
•
•
•
•
•
•
•
Congestive heart
failure
Septicemia
Pneumonia
COPD
Cardiac dysrhythmias
Urinary tract
infections
Renal failure
Acute myocardial
infarction
Complication of
device implants
Acute
cerebrovascular
disease
Medicaid
•
•
•
•
•
•
•
•
•
•
Mood disorders
Schizophrenia
Diabetes
Other complications of
Pregnancy
Alcohol-related
disorders
Early labor
Congestive heart failure
Septicemia
COPD
Substance related
disorders
Private Insurance
• Maintenance
Chemotherapy
• Mood disorders
• Complications of
surgical or medical care
• Complications of device
implants
• Septicemia
• Diabetes
• Secondary
malignancies
• Early labor
• Pancreatic disorders
• Heart disease
Uninsured
•
•
•
•
•
•
•
•
•
Mood disorders
Alcohol related disorders
Diabetes
Pancreatic Disorders
Skin infections
Nonspecific chest pain
Schizophrenia
Congestive heart failure
Substance related
disorders
• Acute myocardial
infarction
Source: AHRQ, Conditions With the Largest Number of Adult Hospital Readmissions by Payer, 2011
31
Largest CA Health Plans By
Estimated SMI Enrollment
Plan Name
Basic
Plan Type
Starter
Enrollment*
Standard
Estimated SMI
Enrollment*
Premium
Medicare Fee-For-Service
Medicare
2,800,674
243,659
Medicaid Fee-For-Service
Kaiser Foundation Health Plan
California
Medicaid
2,689,651
134,483
Medicare
956,865
83,247
Local Initiative Health for LA City
Medicaid
1,193,086
59,654
837,912
41,896
5,788,883
40,522
5,423,775
37,966
Medicaid
Blue Cross of California
Kaiser Foundation Health Plan of
Commercial
California
Anthem Blue Cross Life and Health
Commercial
Insurance Co.
Inland Empire Health Plan
Medicaid
628,917
31,446
PacifiCare of California
Medicare
330,237
28,731
Orange County Health Authority
Medicaid
475,369
23,768
*Based on enrollment as of fourth quarter 2013
Consequences of Medication Non-Adherence All
Health Conditions
•
Increased
Utilization
Increased
Morbidity
& Mortality
Increased
Spending
•
•
50%: Estimated rate of
people with Rx who are
non-adherent
$105B: Estimated annual
avoidable health care costs
due to medication nonadherence
125,000: Estimated number
of preventable deaths
annually, due to nonadherence
Source: National Council
on Patient Information
and Education, 2013
Medication Adherence Lowers Health Care Costs &
Utilization for Complex SMI
• When consumers were adherent to both medications
(antipsychotic and cardiometabolic)
• ER and IP expenses were 34% less for adherent group
vs. non-adherent group
• IP visits and ER visits were 50% lower for adherent
group
• Outpatient visits increased for adherent group
Study Design
• Study group: Adult Medicaid beneficiaries with (1) history of
complex SMI, and (2) received at least one antipsychotic Rx
• Goals: Compare utilization rates and expenses for non-adherent
beneficiaries vs. adherent beneficiaries
Source: Boden R, et al (2011)
© 2014 OPEN MINDS. All rights reserved.
Common Factors Influencing
Non-Adherence
Poor insight into
their condition
History of nonadherence, other
medications
(AMA)
People with
Mental
Disorders
Forgot to take
anti-psych
medications as
prescribed
Source: Kane JM (2007)
© 2014 OPEN MINDS. All rights reserved.
Traditional Approaches To Improving Medication
Adherence For Mental Disorders
Psychoeducational
Approaches
Cognitive Behavioral
Therapy
Motivational
Interviewing
Source: Ehret MJ, et al. (2013)
© 2014 OPEN MINDS. All rights reserved.
Panelist Presentation
Ginny Romig, MBA, Regional Vice President
Providence Human Services – Pacific Division
37
Care Coordination and
Collaborative Care
38
Flipping the Resource Triangle
Increasing prevention reduces expensive inpatient & specialty care
Inpatient & Specialty
Care
Primary Care
Prevention &
Early
Intervention
Inpatient &
Specialty
Care
Primary Care
Prevention & Early
Intervention
39
Care Coordination Background
• Health care spending in the Unites States is highly disproportionate, with half of US health
care dollars spent on five percent of the population.
• Individuals with chronic conditions consume a high proportion of health care services, and
these conditions are expensive to treat.
• Many people with chronic medical conditions struggle with multiple illness combined with
social complexities (ex. Mental health and substance abuse needs).
• Only about 40% of persons in the U.S. who are in need of treatment for depression actually
received any sort of treatment at all, and less than half of those received care that was
thought to be “minimally adequate”.
• Our health care system is too fragmented and complex for these individuals to access and
navigate.
• Most of care providers recognize the need for better coordinated care that leverage all
community resources (ex. Housing, healthy food, safe environment, etc.) to assist these
individuals, but they don’t have the means to do so.
• Care coordination delivers health benefits to those with multiple needs, while improving
their experience of the care system and driving down overall health care and societal cost.
Craig, C., Eby, D., & Whittington, J. (2011). Care Coordination Model:
Better Care at Lower Cost for People with Multiple Health and Social Needs.
What is care coordination?
Care Coordination is “the deliberate organization of patient
care activities between two or more participants (including
the patient) involved in a patient's care to facilitate the
appropriate delivery of health care services. Organizing care
involves the marshalling of personnel and other resources
needed to carry out all required patient care activities, and is
often managed by the exchange of information among
participants responsible for different aspects of care”.
Mc Donald et al.(2007) Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies
Goal of Care Coordination
The goal of care coordination is to ensure that
clients, especially those with complex needs,
receive the most appropriate care at the right time
to ensure that their health and life goals are met
and their overall health is improved.
The Role of the Care Coordinator
in Providing Integrated Care
•
•
•
•
•
•
•
•
•
•
•
Outreach and engagement
Ensures client Support and (health) education
Ensuring communication between providers
Screening and tracking outcomes
Facilitating referrals
Entering data and maintaining care registry
Conducting systematic caseload review
Medication reconciliation
Supporting client self-management
Shared care planning
Please remember that the role of the care coordinator may change based on the
needs of the clients and the population served.
Avery, M. (2014) The Role of the Care Coordinator in Providing Integrated Care for Safety-Net Populations
Care Coordinator vs. Case Manager
Care Coordinator
Case Manager
(Serves in an overarching role and coordinating all of
the services that a person receives)
 Screening
 Manage transitions
 Facilitate and Track referrals
 Share Care Plans
 Single point of contact
 Sharing information
 Engagement
 Identification of Care Team
 Medication reconciliation
 Support self-management
 Population-based
 Track Outcomes
(Typically identified as part of the mental health or
social service teams)









Outreach
Linkage
Intake
Referrals
Care Planning
Applications/Benefits
Money Management
Advocacy
Crisis Intervention
Avery, M. (2014) The Role of the Care Coordinator in Providing Integrated
Care for Safety-Net Populations
The Five Principles of Effective
Integrated Models of Care
1.
2.
3.
4.
5.
Person-Centered and Coordinated: All care should be aimed toward accomplishing the patient’s
stated health goals.
Population-based Care: Population-based care means keeping track of all the patients in a
population to assure that everyone is achieving expected health outcomes.
Treatment is targeted to meet expected outcomes: This is achieved via the use of structured
screening and tracking tools. The first step is to implement screening tools to identify who is in need
of service and who isn’t.
Treatment is evidence based: Evidence based care plays a pivotal role in the services provided to
persons in an integrated care setting. “Try something to see if it works, if it doesn’t, try something
else!”
Accountable: All stages of care – providers, regulators, payers, and patient alike should all be able to
answer the question, “ Is the care being provided working and if not, why not?”
http://aims.uw.edu/sites/default/files/Five_Principles.pdf
Six Levels of
Collaboration and Integration
Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated
Healthcare. Washington, D.C.SAMHSA-HRSA Center for Integrated Health Solutions. March 2013
Care Coordination Collaborative Changes by CiBHs
DEVELOP EFFECTIVE COLLABORATIVE CARE RELATIONSHIPS
1.
2.
3.
4.
5.
6.
7.
8.
Convene agencies that have a
shared aim of improving the
health status of individuals
Define the client/patient
population
Engage and strengthen
relationships between the
provider organizations
convened
Increase knowledge of the
roles peer and family member
providers
Develop the role of the
Convener Organization
Establish the Care
Coordination Team and
individual agency roles and
responsibilities
Develop the role of the Care
Coordinator
Build the Business Case for
ongoing support of the care
coordination effort
ENGAGE CLIENTS IN THEIR WHOLE HEALTH NEEDS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Do outreach
Actively engage each
client/patient in his/her Care
Coordination
Screen clients/patients’ whole
health
Follow up with more in-depth
assessments
Actively engage client/patient
in Care Planning
Actively engage client/patient
in Self Mgmt.
Develop the roles of peers
Collaborate with the
client/patient/family to
develop a whole health service
plan
Promote health literacy
Match level/intensity of care
coordination
DELIVER COORDINATED SERVICES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Assign Care Coordinator to identified
clients/patients
Make Clinical Care Managers available
Use a universal release of information (ROI)
Develop and use standard referral
processes and protocol
Create processes and workflows to achieve
coordinated care
Conduct regular multi-disciplinary
meetings,
Require multidisciplinary team meetings
Perform monthly medication reconciliation
Care Coordinator insures clients/patients
have a single medication list
Design a single page Care Coordination
Service Plan
CARE COORDINATION INFRASTRUCTURE
Address mental health and substance use stigma
Integrate Peer Providers into all agencies that are part of the Partnership Team
Integrate Family Member Providers into all agencies that are part of the Partnership Team
Use clinical information systems to coordinate and monitor services for individuals and
populations
Measure coordination of care and outcomes
Seamless
experience
of care that
is personcentered,
cost
effective,
and
improves
health and
wellness for
individuals
and
populations
The Providence Experience:
Collaborative Care Outcomes
48
Top Psychiatric Diagnoses in PCS Programs
Adults (18+), Medicaid Eligible, With Complicated Mental Illness
% of Clients With Diagnosis
25
23.2
23
22.4
20
15
Over 80% of our clients have either Major
Depression, Schizoaffective Disorder, Bipolar I
Disorder or Schizophrenia.
13.8
10
5
4
3.1
2.8
2.4
2
1.6
1.6
0
N=1725
Primary Diagnoses - OASIS Older Adult Program
% of Members With Diagnosis
Older Adults (60+), Medicaid Eligible, With Complicated Mental Illness
50
45
40
35
30
25
20
15
10
5
0
43
Major Depression, Bipolar I Disorder and
Schizophrenia account for 80% of mental health
diagnoses in our older adult program.
21
16
11
5
1
0.6
0.6
0.6
0.6
0.6
0.6
Multiple Medical Diagnoses in Adult Programs
Adults (18+), Medicaid Eligible, With Complicated Mental Illness
Nearly 40% of our adult clients have 2 or more medical diagnoses.
15% have three or more diagnoses.
% of Clients with
1 Medical Diagnosis (32%)
2 Medical Diagnoses (24%)
3 Medical Diagnoses (8%)
4+ Medical Diagnoses (7%)
No Condition Reported (29%)
Top 5 Medical Diagnoses:
1.
2.
3.
4.
5.
Diabetes
High Blood Pressure
Obesity
Asthma
High Cholesterol
N=1725
51
Multiple Medical Diagnoses – OASIS Older Adult Program
Older Adults (60+), Medicaid Eligible, With Complicated Mental Illness
% of Members
1 Medical Diagnosis (17%)
2 Medical Diagnoses (17%)
3 Medical Diagnoses (22%)
4 Medical Diagnoses (20%)
5 Medical Diagnoses (15%)
No Medical Condition (5%)
Not Reported (4%)
Nearly 75% of our members have 2 or more medical diagnoses.
35% have four or more diagnoses.
52
Medical Hospitalizations - OASIS Older Adult Program
Medicaid Eligible, With Mental Illness
29
1 Year Prior to Enrollment
93%
Decrease
2
After Enrollment
0
5
10
15
20
25
Clients Hospitalized
30
 Clients enrolled as of June 30, 2012
53
Psychiatric Hospitalizations – OASIS Older Adult Program
Days
Older Adults (60+), Medicaid Eligible, With Mental Illness
700
600
500
400
300
200
100
0
602
91% Decrease
52
Psych Hospital Days 1 Year Prior to
Enrollment
Psych Hospital Days Since Enrollment
54
Psychiatric Hospitalization Rates
Adults (18+), Medicaid Eligible, With Mental Illness
30.4%
National Average
62%
Lower
11.7%
Providence Programs
N=1725
0
5
10
15
20
25
% of clients
30
35
55
• Providence demonstrates clinical and fiscal improvements in
all areas of treatment. Our full-service partnerships in
Southern California have documented the following results:
 83% DECREASE in days hospitalized (medical)
 72% DECREASE in hospital admissions (psychiatric)
 90% DECREASE in incarcerations
 85% DECREASE in homelessness
 79% INCREASE in education engagement
 314% INCREASE in employment engagement
56
Providence Collaborative Care
Mission Statement
Our Mission:
To integrate care and support wellness and recovery
through a menu of strength-based, cost effective
treatment services that focus on self-identified goals
that instill empowerment and self-responsibility.
Our Goal:
To ensure clients’ needs are fully integrated
into one individualized service experience.
57
Providence Philosophy
Our Philosophy – “Human Services Without Walls”
• “Whatever and Whenever”
• Whatever it takes and wherever they are
• Focus on accessible, integrated, community-based care
• Recovery and Wellness Focused
• Hope, Self-Responsibility, Empowerment & Meaningful Roles
• Collaborative, multidisciplinary, client-driven care
• Flexibility
• Customized services to fit the health plan’s needs.
• Customized services to fit each member’s needs.
• Commitment to Evidence Based Practices & Outcomes Driven Services
• To date, our outcomes are demonstrating decreased morbidity, reduced hospitalizations
(psychiatric and medical), improved quality of life and experience of care, among others.
• Innovation
• Cost effective approaches
• Technology focused
• Electronic health records, telepsychiatry, online access, etc.
58
Providence Approach
Our Approach
• Client-Centered Treatment and Service Planning
• vs. Illness Centered, Symptom Reduction Approach (Strengths vs. Deficits, Functionality
vs. Symptomatology)
• Comprehensive, Multidisciplinary Teams
• Therapists, service coordinators, nurses, psychiatrist substance abuse specialists,
housing specialists, education/employment specialists, benefits specialists and peer
mentors
• Integrated, Coordinated Care
• Collaborative Partnerships with a wide array of providers
 Healthcare and Behavioral Health
 Inpatient and outpatient
 Facility based and community based
• “Flexible Funding”
• for removing barriers to preventative care and supporting Recovery services
• Peer Support
59
Best Practices
Evidence Based Practices
Best Practices
• Assertive Community Treatment (ACT) • Community-Based Care
• Motivational Interviewing
• Flexible, Individualized Service Delivery
• Wellness Recovery Action Planning
• Member-centered and Member-driven
(WRAP)
Care
• Cognitive Behavioral Therapy (CBT)
• Multidisciplinary Teams
/Trauma-Focused CBT
• Peer Mentoring, Education and
• Dialectical Behavioral Therapy (DBT)
Advocacy
• Psycho-Educational Multifamily Group • Supported Employment/Supported
Therapy
Housing
• Seeking Safety
• Culturally Competent Services
• PEARLS Program for Depression
• Collaborative Documentation
• IMPACT Coordinated Depression Care
• Milestones of Recovery Scale (MORS)
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Continuum of Integrated Care
Severity
Mild
Behavioral Health Issues
Moderate
Behavioral Health Issues
Severe and Persistent
Behavioral Health Issues
Acuity
Low
Moderate
High
Functioning
High
Moderate
Low
Medical Health Home
Coordinated Care with Medical &
Mental Health Equally Integrated
Behavioral Health Homes
All care, including behavioral health
care, is directed and coordinated by the
PCP.
Collaboration between PCP Health
Provider, with both providing treatment
direction. Care coordinate by 3rd party
integration specialist.
Fully integrated behavioral & primary
care in a community behavioral health
setting, with the behavioral health
provider acting as integration specialist.
Low Intensity
Moderate Intensity
High Intensity
with Community Support Services
Model
Behavioral Health
Treatment Level
Behavioral
Health
Services
Outpatient Therapy,
Possible medications through PCP or
psychiatrist
Therapy
Case Management
Psychiatry
Case Management
Psychiatry
Community Support Services
Wellness & Recovery Services
Therapy w/ some diagnoses
61
Menu of Coordinated Care
Services
•
•
•
•
•
•
•
•
•
•
•
•
•
24/7 Call Center Access
Health Risk Assessments
Behavioral Health Assessments
Network of Treatment Providers for Medication and Therapy Services
Telepsychiatry
Medication Reconciliation
Care Management and Coordination
Motivational Coaching and Support
Coordination of Community Services
Discharge Planning & Transition Coordination
Full Service Wraparound, Tiers 1 & 2
Field-based Services
Housing / Employment Support
62
Menu of Support Services
• EHR - field based
•
•
•
•
•
•
•
•
•
Electronic Billing
Quality Assurance & Improvement
Outcomes Tracking & Reporting
Payer Reporting & Partnership
Centralized Credentialing
Eligibility Verification
Provider Network
Centralized Call Center
MCO Account Management
63
Public Sector Experience: County
Orange County Healthcare Agency
o Oasis Older Adult Program
o Opportunity Knocks Adult Criminal Justice
o Stay Transition Age Youth Program, ages 16-25
o Anaheim Adult Recovery Center
o Camino Nuevo Recovery Center
San Diego County Health and Human Services
o Catalyst Assertive Community Treatment for Transition Age Youth, ages 16-25
o Kickstart Early Intervention for the Prevention of Psychosis Program
Kern County Department of Mental Health
o Adult Intensive Outpatient Program - Assertive Community Treatment
64
Private Sector Experience:
Health Plan and MCO
Beacon Health Strategies / Anthem Blue Cross PPO
o Community Health Partnership CA
Kaiser Permanente
o Tier I Intensive Care Management Program
o Tier II Moderate Care Management Program
o Post Hospital Discharge Care Coordination Program
65
Panelist Presentation
Michael Varadian, MBA, JD
66
Behavioral Health Homes
Rhode Island
67
ACA/CMS Health Home Initiative
• An innovative initiative to provide services to
individuals to address both Behavioral Health
and Primary Care conditions
• Aligns with RI’s effort to implement a
recovery oriented system of care
• Offers states the opportunity to provide
Medicaid coverage, at an enhanced Federal
Medicaid Participation Rate of 90-10 (FMAP)
• Win-Win results for patients, providers and
payers
68
Define the Population
• CMS Requires that the Health Home
Populations meet one of the following
criteria:
• Have two chronic conditions
• Have one chronic condition and be at risk
for a second
• Have one Serious Mental Illness (SMI)
• RI has 5,200 Eligible Participants
69
Core CMS Health Home Services
• Comprehensive Care Management
• Care Coordination
• Health Promotion
• Comprehensive Transitional Care
• Individual and Family Support Services
• Referral to Community and Social Support
Services
70
Health Homes Service Development Principles
•
•
•
•
•
•
•
•
Person/Family Centered Care Coordination
Comprehensive Whole Person Care
Evidenced-Based (Self Management Goal)
Accountable (HH fixed point of responsibility)
Continuity and Transition Management
Proactive Outreach/Engagement
Data-Driven Outcome-based Approach (to
customize ongoing treatment plans)
Community Provider Engagement/Collaboration
Strategy
71
The CMHO Health Home Team (200 clients)
•
•
•
•
•
•
•
•
A Master’s Level Team Coordinator (1 FTE)
A Psychiatrist (0.5 FTE)
A Registered Nurse (2.5 FTE)
A Licensed and Master’s prepared mental health professional (1 FTE)
A Community Support Professional – Hospital Liaison (1 FTE)
Community Support Professionals (5.5 FTE) (caseload<30)
A Peer Specialist (0.25 FTE)
Other Team Members/Consultants Could Include:
• Primary Care Physicians
• Pharmacists
• Substance Abuse Specialists
• Vocational/Employment Specialists
• Community Integration Specialists
• Housing Coordinators
72
Quality Measures
• Goal Based Quality Measures:
• Improve Care Coordination
• Reduce Preventable Emergency Department (ED) Visits
• Increase Use of Preventive Services
• Improve Management of Chronic Conditions
• Improve Transitions to CMHO Services
• Reduce Hospital Readmissions
• Within each domain, measures are included for:
• Clinical care
• Experience of Care
• Quality of Care
73
RI Health Home Program Audit Findings
• Focus on key areas of medical discharge and urgent care follow-up
• Caseload size (<30) and turnover key factors of effectiveness
• Health Home client medical hospital admission notification to
agencies is still a challenge because of privacy, HIPAA rules, hospital
regulations and medical clinical territorial issues
• Plans of care need improvement related to consumer and family
preferences, education, support for self-management, coping skills
and resources to understand health risks and implement health
action goals
• Variable effectiveness in focus on self-management and addressing
risk factors of heart disease, obesity, diabetes, hypertension, and
circulatory conditions (training, consumer desire)
• The barrier of information sharing will be the major factor limiting
the effectiveness of care coordination
74
Health Homes Implementation Financial Challenges
• Financial Challenges
• Transition from blended fee for service and per diem rate to case rates were
both favorable to some and unfavorable to other agencies
• Changes in rules and reporting (minimums) negatively affected revenue
streams in most agencies
• New payment methodology provided reimbursement for care coordination
activities that were not funded or provided uniformly (thus new encounter
reporting)
• Enrollees were going in and out of Medicaid eligibility which created vacuums
in reimbursement and coverage
• Staff report that there should be a group home facility for more intensive
SPMI clients that don’t do well in a nursing home care as a more cost and
clinically effective setting
• Some admissions increase with coordinated access to needed care and better
educated consumer
75
Health Homes Client Feedback
• What Are the Clients Saying, so far..?
• I never had these clinicians, specialists, coordinators and
transportation services
• More attentive to interventions
• Better grasp of treatment compliance issues
• Higher self esteem in primary care settings
• Less medication errors and omissions (unintentional and
intentional!)- Prescription Monitoring Program
• Hospital liaisons and peer specialists very helpful
• Positive response from their PCPs (welcoming help with
difficult patient population)
• Major life improvement- physical ailments have inhibited
behavioral health recovery, and vice versa
76
Questions and Answers
77