MISSOURI’S BEHAVIORAL
HEALTH CARE HOME MODEL
Presented at the Roadmap to Integrated Care Conference
Chateau on the Lake, Branson, MO
June 4, 2015
Paul Thomlinson, PhD
Jeff Ziegler, RN
Teresa Condor, RN, FNP
INTRODUCTIONS
1. Paul Thomlinson, Ph.D.,Vice President-
Research & QA
2. Jeff Ziegler, RN
3. Teresa Condor, RN, FNP
WHAT IS SO?
We have behaved and organized our care
delivery and reimbursement systems as if
the head were detached from the body.
SO WHAT?
This proverbial detachment of head from
body results in:
 Increased costs of both health and behavioral health care
 Decreased effectiveness of both
 Failed or less than effective interventions
 Misdiagnosis and missed diagnoses
 Interventions that aggravate rather than improve conditions
being treated (ADHD and sleep apnea?)
 Health disparities for those with mental illness
SO?
Health care should direct its energies toward treating the whole
person, with head firmly attached to body, using:
 A philosophy that respects and promotes independence and
responsibility
 Integrated approaches that achieve coordinated care and
mutually experienced relevant value (MERV)
 Methods and interventions that have scientific evidence of
effectiveness, including stages of change models
PRECURSOR TO THE FLOOD: THE NOAH
PROJECT
 New Opportunities to Advance Health
 Funded by Burrell Foundation as a collaborative with a healthcare
partner, CoxHealth
 Premise is that there are many health promotion strategies,
including screening, education, psycho-education and selfmanagement with strong evidence base for effectiveness.
 As such, it should be as easy for a provider to order these
services as it is to order lab tests, or medications, or other
services.
NOAH PROJECT
Asthma Education Group
SF-36 Results
60
53
53
50
44
45
40
Mean
37
PCS
34
30
MCS
Pretest
Posttest
6 Months
Won Missouri Healthcare Quality
Award for this project, integrated into
ER as feeder system; Results show
significant improvement in physical
functioning.
Uses Lorig’s Evidence-based Chronic
Disease Self-Mgt Program (6 weeks);
shows significant reduction in mental
health and health care visits in 6 months
following program.
Program participants also show significant
reductions in depression and health distress six
months after program.
THE EVOLUTION OF HEALTHCARE
 The healthcare delivery system has not evolved to keep pace
with our understanding of what really drives healthcare
utilization.
 The increasing prevalence of chronic illness has driven much of
the increase in healthcare spending.
 The search for a fix has generated a new vocabulary, including
collaborative care, integrated care, ACO’s, patient-centered
medical homes, quality driven care, population health, and on
and on.
LOOKING FOR THE FIX
 Why has behavioral health moved to the forefront of the
discussion? Cost!
 The top five health problems based on economic cost are drug
abuse, mental illness, heart disease, alcohol use disorders, and
tobacco use—at least four are squarely in the domain of the
mental health provider.
 The “fix” is to rework our healthcare system to achieve what
CMS calls the triple aim: better care, better health, and lower
costs.
LOOKING FOR THE FIX
 We know that people with mental illness have significant
reduction in lifespan (about 25 years!) and that their co-morbid
medical conditions frequently go undiagnosed and untreated.
 Integrated care is a concept whose time has come, brought to
the fore by expectations of quality and the need for cost
containment.
TEST THESE HYPOTHESES BACK HOME…
 A high percentage of un- and under-insured patients have
chronic medical and mental health conditions
 A small number of chronic, treatment- resistant patients
account for a disproportionately high percentage of poorly
reimbursed inpatient and outpatient services, emergency room
use, and unreimbursed early readmissions
TEST THESE HYPOTHESES BACK HOME…
 Mental health specialists are unavailable or their services are
substantially delayed in inpatient and outpatient medical settings
 Medical services for chronic mental health patients are difficult
to access
 The few mental health services available in the medical setting
are poorly organized and of limited value
TEST THESE HYPOTHESES BACK HOME…
 Hospital stays are twice as long for medical patients with
mental condition co-morbidity
 Unreimbursed constant observation for behavioral issues in the
inpatient medical setting is escalating
 High service use and costs persist in the same chronic comorbid physical and mental condition patients year after year.
DIS-INTEGRATION
 Many barriers: different facilities, payment streams and an
almost complete lack of communication or integration.
 Our dis-integration creates the delusion that we better serve
patients if behavioral health remains autonomous from the rest
of health care.
 About 80% of patients with behavioral health co-morbidities
are seen in the general health sector.
THE HIDDEN HORDE
 There are more people with serious mental illnesses in general
medical populations than in the specialty behavioral health
sector.
 And, 30% to 45% of them get little or no care for their
behavioral health problems when hospitalized for a medical
problem: These are the people—the 30% of patients—who cost so
much more to treat.
AVERAGE COSTS?
 Studies of annual treatment costs for insured populations show
that the average annual medical cost for a treated individual was
about $2,700.
 But if that person has a chronic medical condition, costs double
or triple (up to $8100).
 Add on a mental health condition, and you double that figure
again (up to $16,200).
 This is where we have an opportunity to impact the total cost
of care. This is where we can make the return-on-investment
(ROI) much better.
AGAIN, SO WHAT?
Without significant change, billions of dollars in annual
unnecessary physical health service use costs associated with
ineffectively treated mental conditions in medical patients are
projected:
 Up to $241 billion for commercial payors
 Up to $110 billion for Medicare B
 Up to $351 billion total
Melek & Norris (2008) Chronic conditions and comorbid psychological disorders, Milliman Research
Report.
WHY INTEGRATE PRIMARY AND
BEHAVIORAL HEALTHCARE?
ANSWER: Because treating illness
is not enough.
Wellness and prevention are as important as
treatment and rehabilitation.
Addressing general health issues is necessary in
order to improve outcomes and quality of care.
Because behavioral health
consumers can live longer, as
opposed to dying younger than
necessary
The increased morbidity and mortality of behavioral
health clients is caused by largely preventable medical
conditions, AKA “modifiable risk factors.”
The New England Journal of Medicine, 357, 1221-8,
ranked five factors that impact premature death:
Environmental exposure – 5%
Healthcare – 10%
Social circumstances – 15%
Genetic predisposition – 30%
Lifestyle patterns – 40%
COMPONENTS OF PRESENTATION
GOING FORWARD…
1. Introduce key components of HCH
2. Review the challenges of integrating HCH
with primary care
3. Describe successful care management
strategies
4. Discuss data on performance of HCH
I. KEY COMPONENTS OF HCH
FIRST IN THE NATION
On October 20, 2011, Missouri became the first
state in the nation to receive approval of a
Medicaid State Plan Amendment (SPA) establishing
Health Homes under Section 2703 of the
Affordable Care Act.
Effective Jan. 1, 2012, the first approved SPA
established behavioral health homes: Missouri’s
CMHC Healthcare Homes.
NEW HEALTHCARE DELIVERY SYSTEM
 HCHs created a healthcare delivery approach that focuses
on the whole person from head to toe (not just from the
neck up), and
 Provides integrated healthcare coordination of primary and
behavioral healthcare.
 HCHs implement recovery-based models of care in the
area of chronic health conditions, rather than just getting
clients from one crisis to the next crisis.
 HCHs enable clients to live longer and live better.
CLIENT STORIES
 We will pause now and then to relate client stories that
illustrate concepts as we discuss them.
 As you would expect, some stories relate successes, and
others describe challenges that come with our population.
 This first example shows what “recovery” can look like
when Burrell staff members collaborate with a client to
promote wellness.
REACHING TOWARD RECOVERY
60-year-old male with depression, hypertension and
obesity was in the hospital every other week and
living in a hotel. He used a walker, had difficulty
doing personal hygiene, and lived on Ramen
noodles. His Burrell team helped him gain RCF
placement, where he’s eating healthy, gaining
strength, compliant with his meds, and has not been
hospitalized for 13 months. His latest goal is to
move into his own apartment and care for himself.
GAPS IN HEALTHCARE DELIVERY
The next two client stories illustrate existing
gaps in the typical healthcare system, which
sometimes can be bridged through the
HCH’s ability to focus on individuals and
look at the big, overall picture of their
health.
IMPROVED OUTCOMES
 44-year old male with PTSD, social phobia, major depressive
disorder, schizophrenia and diabetes met with his NCM, and
later said, “She made me realize my (health) problems are
real.” In less than 2 years, he has become responsible for
taking his own medications, has advanced from being an
insulin-dependent diabetic to only taking half the dose of
one oral anti-diabetic med, has lost 20 pounds, and has gone
from never leaving his apartment to being able to ride the
city bus to destinations. “I feel healthier,” he says. “I feel
good about myself.”
Challenges of behavioral health
 53-year old female with depression, paranoid schizophrenia,
diabetes, chronic pain and obesity met with her NCM for a health
assessment. Regarding her abnormal blood sugars and other
unresolved health issues, the client made excuses about forgetting
to take her meds. After discussing the importance of medications
and how meds relate to her diseases, the client confessed that she
had “Googled” some of her meds, and when she tried to discuss her
concerns with her PCP he ignored her concerns, so she had been
filling her meds at the pharmacy, then flushing them down the toilet
each day. Despite efforts to improve trust toward her prescriber,
the client has been hospitalized multiple times, and now resides in a
SNF.
WELLNESS
Wellness is a deliberate, conscious
process of creating and adapting patterns
of behavior that lead to improved health.
Why are wellness and prevention just as
important as treatment and rehabilitation?
LIFESTYLE PATTERNS
The next client story illustrates how
small changes in lifestyle patterns can
have a major impact on wellness and
the overall quality of life for our clients.
WELLNESS GOALS ACHIEVED
47-year-old female with obesity,
hyperlipidemia, arthritis and schizophrenia,
has reached her weight-loss goal of 25
pounds. She told her NCM that she’s more
active than ever, has started working a job
that requires a lot of activity and standing,
and reports that her knee pain has
improved.
HCH TEAM MEMBERS
 Primary Care Consulting – Physician/Nurse Practitioner
 HCH Director and Assistant Directors (1 per 500 clients)
 Nurse Care Managers (1 per 250 clients)
 Care Coordinators (1 per 500 clients)
 Community Support Specialists (partner with NCMs to
affect wellness)
 Psychiatrists (willingness to advocate metabolic syndrome
screening)
HCH FUNCTIONS
 Provide health and wellness education
 Meet with each client to complete a health assessment, and to set
an annual health goal, then create a treatment plan involving the
CSS and NCM to work toward that goal
 Assure that clients receive the preventative and primary care they
need
 Assist clients in self-managing their chronic illnesses (behavioral
and medical)
 Follow up with clients after hospital discharge to reconcile
medications, provide education, and assist with discharge
instructions
TARGETED MEASURES
 CMT Analytics “ProAct” is a state DMH database that
tracks HCH and CMHC clients’ data to document health
improvement, as well as flag problem areas.
 ProAct tracks data such as blood pressure, weight, fasting
blood sugar and HbA1c, and lipid panels.
 ProAct also tracks such things as ER visits, hospitalizations,
recommended health screenings, and prescribing practices
that fall outside normal parameters.
PAYMENT SYSTEM
 CMHC Healthcare Homes are reimbursed by Missouri
PMPM – Per Member Per Month.
 Monthly attestation report by each HCH attests which
consumers received services the previous month.
 DMH verifies that the consumers attested to were eligible
for HCH services, and sends a monthly payment.
 Retro payments are issued for consumers whose Medicaid
is reactivated.
II. CHALLENGES OF
INTEGRATING HCH
WITH PRIMARY CARE
MOVEMENT TOWARDS
INTEGRATED CARE
Organizational Transformation Inside the
Community Mental Health Center
MOUs with the Hospitals
Communication with the Primary Care Providers
Communication with Clients/Guardians
Adults vs. Youth population
ORGANIZATIONAL TRANSFORMATION
How did we make it happen?
 Integrated care is our new enhanced service delivery model
 Initial training for all staff in the agency on the ways
Healthcare Homes will enhance our service delivery.
 Redefined the clinical roles of the staff
 Healthcare Homes principles were integrated into the
interview and hiring process.
 Ongoing training for staff
MEMORANDUMS OF UNDERSTANDING
Established with local hospitals to ensure
Formalized structure for transitional care
planning
Communication of inpatient admissions and
discharges
Emergency Department usage
Follow up care with Primary Care Providers
COMMUNICATION WITH PRIMARY CARE
PROVIDER (PCP)
What is the best way for communication
What does the PCP really want support with
How do we keep open communication with the
PCP
How do we keep from having the PCP think we are
telling them what to do
COMMUNICATION WITH CLIENTS AND
GUARDIANS
Why do I need HCH if I already have a PCP?
 Care is individualized
 A Nurse Care Manager is available to help you identify and
achieve your healthcare and wellness goals
 Assist in helping you manage your health conditions
 Help you access a family doctor and other medical providers
 Provide you with access to health education opportunities
addressing smoking cessation, nutrition and physical activity
 We are partners with your PCP to help meet your healthcare
needs
YOUTH CPRC CHALLENGES &
OPPORTUNITIES
Requires family engagement and participation
Home visits require more NCM time
During business hours, parents are often at work
and the children are at school
Important data, such as BMI, are different for youth
than for adults
Prevention is a key focus
III. SUCCESSFUL CARE
MANAGEMENT
STRATEGIES
HEALTH TECHNOLOGY
 Cyber Access is a web-based HIPAA compliant portal that allows
healthcare professionals to see the medical and drug claim history
of clients who have Medicaid. Services and meds covered by
Medicare do not appear in Cyber Access.
 Nurses, doctors and caseworkers can review prescriptions,
procedures, diagnoses and services received in the past 2-3 years.
 The med-possession ratio helps track whether medications are
being filled as prescribed.
 Prescribers and pharmacies are listed, identifying possible abuses
of the system.
INITIAL & ANNUAL HEALTH ASSESSMENT
WITH PHYSICAL HEALTH GOAL
Complete Health Assessment
 Physical health
 Assessment of services needed by client
 Primary Care Provider Determined
 Person-Centered Physical Health Goal
Who is at this meeting:
 Client
 Nurse Care Manager
 Community Support Specialist
 Family Members or Guardians
CLIENT CENTERED CONFERENCES
Who participates?
Primary Care Consultant
Nurse Care Manager
Community Support Specialist Supervisor
Community Support Specialist
CLIENT CENTERED CONFERENCES
What is discovered during conferences?
 Gaps in medical care
 Poor medication compliance
 Poly-pharmacy and drug-drug interaction
 Physical Health Goals that are not being met
 Preventive care that is not being completed
 Determination of need for specialists based on review of
health records and concerns brought up by client when
meeting with NCM and CSS
TWO TYPES OF CLIENT CENTERED
CONFERENCES: POST HOSPITALIZATION
Clients after a Hospitalization
Discuss the reason for hospitalization
Were there things that could have been done to
prevent the hospitalization
What can be done to prevent a rehospitalization
Follow-up care that is needed
TWO TYPES OF CLIENT CENTERED
CONFERENCES: GENERAL
 All Clients – Discuss:
 Concerns the client has mentioned to CSS or CSS has been
noticed
 Client’s medical diagnoses
 Current medication
 Use of PCP and compliance with PCP directions
 Preventive care
 Metabolic Screening
 Health and Wellness goal
 How is the client doing with the goal, challenges they
may be having, ways we can support the client to help
meet the goal, should the goal be changed
NEED FOR MEDICATION
RECONCILIATION
 One in five patients experience an adverse event in
transition from hospital to home, and 62% were considered
preventable. (Annals of Internal Medicine, 2003; 138:161-7)
 About 48% of client readmissions to hospitals within the
first month after discharge happen because they:
 Didn’t know how to take their medications properly
 Didn’t get medications filled after discharge
 Didn’t follow discharge instructions because they didn’t
understand them
NCM ROLE IN MED RECONCILIATION
 NCM attempts to obtain copy of discharge orders, including
instructions and medications.
 NCM contacts client within 72 hours of discharge.
 NCM reviews list of post-hospitalization meds with prehospitalization list, making sure the clients have the
medications in their possession and are taking them as
prescribed, and helping the clients problem solve as needed.
 NCM reviews discharge instructions to verify that the
clients understand them.
HEALTH EDUCATION
 Monthly presentations at CPRC team meetings about
topics relevant to caseworkers and their clients
 Individual education on health topics of concern or
interest to clients
 Available as health information resource to staff
members and clients
 Special programs such as Tobacco Treatment Specialist
for tobacco cessation, and My Way to Health for weight
management
HEALTHCARE HOMES MAKE A
DIFFERENCE
Two quick stories about clients who are
living better and are likely to live longer
because they partnered with the Burrell
Healthcare Home CSS and NCM to set
physical health goals:
HCH: MAKING A DIFFERENCE
 44-year-old female with obesity, chronic pain, COPD,
depression and PTSD met with her NCM for education and
has since increased her physical activity, stopped smoking,
and no longer requires a walker.
 34-year-old male with cerebral palsy, and bipolar and anxiety
disorders, had uncontrolled diabetes, to the point he was
dependent on insulin injections. After two years in HCH, he
has modified his diet, exercises regularly, has lost 60 pounds,
and is off all his diabetes medications and is able to control
his diabetes by diet alone.
IV. PERFORMANCE DATA
AND OUTCOMES
CAUSES FOR CELEBRATION &
OPPORTUNITIES FOR IMPROVEMENT
BURRELL SW HCH
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
83%
82%
75%
64% 61%
54%
41%
10%
Lipid Levels
Not in Control
BP Not in
Control
Report
Tobacco Use
Metabolic
Screening
Adherence
Baseline
Current
HCH: MAKING A DIFFERENCE IN COST OF
CARE STATEWIDE
 COST SAVINGS (IN 18 MONTHS)
Missouri Health Homes have saved an estimated $23.1
million.
 For the 3,560 lives served, Missouri’s Disease Management
3700 has saved an additional $22.3 million.
 Reductions in hospitalizations in first year 9.1%.
HCH: MAKING A DIFFERENCE IN HEALTH
OUTCOMES STATEWIDE
 IMPROVING HEALTH OUTCOMES (24 MONTHS)
 CLIENTS WITH DIABETES 2-YEAR OUTCOMES
•
Good Cholesterol improved by 28%
•
Normal Blood Pressure improved by 30%
•
Normal Blood Sugar improved by 39%
HCH: MAKING A DIFFERENCE IN HEALTH
OUTCOMES STATEWIDE
 IMPROVING HEALTH OUTCOMES (24 MONTHS)
 CLIENTS WITH HYPERTENSION AND CARDIOVASCULAR
DISEASE 2-YEAR OUTCOMES
 Good Cholesterol (Clients with Cardiovascular disease) improved by 34%
 Normal Blood Pressure (Clients with Hypertension) improved by 38%
CONCLUSIONS AND Q&A