DMH Net Missouri’s CMHC Health Care Home Project

Principles

• • Physical healthcare is a core service for persons with SMI MH systems have a primary responsibility to ensure:   Access to preventive healthcare Management and integration of medical care

Missouri Health Home Initiatives

Missouri Medicaid state plan amendment  CMHC healthcare home – CMHCs and CMHC affiliates  Primary care chronic conditions healthcare home – FQHCs, RHCs, Physician practices Missouri Foundation for Health Patient-Centered Home Multi-payer Learning Collaborative

4

DMH NET – Strategy

• • • • • Health technology is utilized to support the service system.

“Care Coordination” is best provided by a local community-based provider.

Community Support Workers who are most familiar with the consumer provide care coordination at the local level.

Nurse Liaisons working within each provider organization provide system support.

Statewide coordination and training support the network of providers.

CMHC as Health Care Home

• • • • • Case management coordination and facilitation of healthcare Medical disease management for persons with SMI Preventive healthcare screening and monitoring by MH providers Integrated/consolidated CMHC/CHC Services Primary Care Nurse Managers Care

Recommendation – Medical Needs Have Same Priority as MH Needs

• • • Obtaining a “medical home” – a primary care provider responsible for overall coordination Medication adherence – just as important for non-MH meds Assisting in scheduling and keeping medical care appointments

Care Coordination Integrates Healthcare Issues into CMHC Care Mechanisms

• • • • • • Include healthcare goals in treatment plan Include healthy lifestyle goals in treatment plan Identify client’s internal health care expert/champion Develop health and wellness services Provide nurse healthcare liaison – proven practice Verify healthcare services are occurring by utilizing data

Provide Information to Other Healthcare Providers

• • • HIPAA permits sharing information for coordination of care Nationally consent not necessary Exceptions:    HIV Substance abuse treatment – not abuse itself Stricter local laws

Clients Eligible for CMHC HH

A serious and persistent mental illness  Adults with SMI (Schizophrenia, Bipolar Disorder, Major Depression Recurrent)  Youth with Severe Emotional Disturbance

Clients Eligible for CMHC HH

• A mental health condition and one other chronic health condition (asthma, cardiovascular disease, diabetes, substance abuse disorder, developmental disability, chronic pain, or overweight BMI>25

Clients Eligible for CMHC HH

• A substance abuse condition and one other chronic health condition (asthma, cardiovascular disease, diabetes, mental illness, developmental disability, chronic pain, or overweight BMI>25

Provider Infrastructure

Reimbursed by HH funding    Physician led team Primary care nurse Health coaches     Clinical support staff Pharmacy consultant Primary care consultation Information technology

Provider Infrastructure

NOT reimbursed by funding but by existing fee-for- service systems, including DMH and Medicaid   Community support worker Physician services   Peer specialist Psychosocial rehabilitation    Medication Primary care medical services Labs

Comprehensive Care Management

• • • • Identification and targeting of high-risk individuals Monitoring of health status and adherence Development of treatment guidelines Individualized planning with the consumer

Recommendations

• • • • Screen for general health with priority for high risk conditions Offer prevention and intervention especially for modifiable risk factors (obesity, abnormal glucose and lipid levels, high blood pressure, smoking, alcohol and drug use, etc.) Prescribers will screen, monitor and intervene for medication risk factors related to treatment of SMI (e.g. risk of metabolic syndrome with use of second generation anti-psychotics) Treatment per practice guidelines: eg, heart disease, diabetes, smoking cessation, use of novel anti-psychotics

ADA/APA/AACE/NAASO Consensus on Antipsychotic Drugs and Obesity and Diabetes: Monitoring Protocol*

Start 4 wks 8 wks 12 wk qtrly 12 mos.

Personal/family Hx X X Weight (BMI) X X X X X Waist circumference Blood pressure Fasting glucose X X X X X Fasting lipid profile X X

*More frequent assessments may be warranted based on clinical status

X

X X X 5 yrs.

X

Diabetes Care.

2004;27:596-601

Metabolic Syndrome Disease Registry

• • • • Metabolic Syndrome    Blood pressure Cholesterol Triglycerides - weight - height - blood sugar Screening Required Annually since January 1 Disease registry with results maintained on cyber access Next step – utilize data to identify care gaps

DMHNET HEIDIS Indicators

• • • • • DM1: Use of inhaled corticosteroid medications by persons with a history of COPD (chronic obstructive pulmonary disease) or Asthma.

DM2: Use of ARB (angiotensin II receptor blockers) or ACEI (angiotensin converting enzyme inhibitors) medications by persons with a history of CHF (congestive heart failure).

DM3: Use of beta-blocker medications by persons with a history of CHF (congestive heart failure).

DM4: Use of statin medications by persons with a history of CAD (coronary artery disease).

DM5: Use of H2A (histamine 2-receptor antagonists) or PPI (proton pump inhibitors) medications for no more than 8 weeks by persons with a history of GERD (gastro-esophageal reflux disease).

DMHNET HEIDIS Indicators

• • • • • DM6: Presence of a fasting lipid profile within the past 12 months for patients with CAD (coronary artery disease). DM7: Presence of a DRE (dilated retinal exam) within the past 12 months for patients with diabetes mellitus.

DM8: Presence of a urinary microalbumin test within the past 12 months for patients with diabetes mellitus DM9: Presence of at least 2 hemoglobin A1C tests within the past 12 months for patients with diabetes mellitus. DM10: Presence of a fasting lipid profile within past 12 months for patients with diabetes mellitus.

Initial Results

• • • Provide specific lists of CMHC clients with care gaps as identified by HEIDIS indicators to CMHC primary care nurse liaisons quarterly Provide HEIDIS indicator/disease state training on standard of care to CMHC MH case managers First quarter focus on indicator one-asthma substantially reduced percentage with care gap   Range 22% - 62% reduction Median 45% reduction

Support Patient Wellness through Self Management using Peer Specialists • • • • • • Implement a physical health/wellness approach that is consistent with recovery principles, including supports for smoking cessation, good nutrition, physical activity and healthy weight.

Educate patient on implications of psychotropic drugs Teach/support wellness self-management skills Teach/support decision making skills using Direct Inform Use motivational interviewing techniques New psychosocial rehab focus    Smoking cessation Enhancing Activity Obesity Reduction/Prevention

Care Coordination

 Coordinating with the patients, caregivers and providers  Implementing plan of care with treatment team    Planning hospital discharge Scheduling Communicating with collaterals

Mapping & Data Integration

Pharmacy Claims Medical Claims Reference Data Diagnosis Membership

Integrated

Drug Office

Data Repository

Hospital Laboratory ER 4/27/2020 24

CyberAccess

TM

Current Features  Patient demographics  Electronic Health Record – Record of all participant prescriptions – All procedures codes – All diagnosis codes   E prescribing Preferred Drug List support – Access to preferred medication list – – – Precertification of medications via clinical algorithms Implementation of step therapy Prior authorization of medications)    Medication possession ratio DirectCare Pro Disease Registry for CMHCs 4/27/2020 25

Slide 26 CyberAccess - Log-In Screen

Slide 27 CyberAccess - EULA

Slide 28 CyberAccess - Home Page

Slide 29 CyberAccess - Demographics

Slide 30 CyberAccess – Paid Drug Claims

CyberAccess – Paid Drug Claims/MPR An MPR between 80-100% will display in green text. An MPR between 60-79% will display in yellow text. An MPR of less than 60% will display in red text. If an MPR does not exist for type of drug or the drug is not for maintenance the column will display a dash.

Slide 31

Slide 32 CyberAccess – Medical Procedures

Slide 33 CyberAccess – Diagnosis Codes

Health Promotion

• • • • • • Population-based (non-client, outpatient, and CPRC) Patient self-management Health education Smoking prevention Obesity reduction Reversal of social determinates of health

Comprehensive Transitional Care

• • • • Hospital admission follow-up Hospital discharge follow-up Development of intermediate care tools Data and patient registry supported

Individual & Family Support

• • • • Family education Peer support and/or NAMI/MHA Patient advisory and input processes Direct inform

Direct Inform

TM

• • • • Access to program provided benefits  Program integrity notification of services provides (EOB equivalent) Notification of wellness lapses Web portal participant health information MORx Compare (current) 4/27/2020 37

4/27/2020

DirectInform Screen Shot 1 MHD

38

Referral to Community and Social Support Services

• • • • CPRC teams will be well established for this Non-CPRC clients have not had as much support with housing benefits, medical assistance programs, legal services, employment, schools, etc.

Local SB 40 Boards NAMI/MHA

OUTCOMES

• • • • • • • Avoidable hospital readmissions Medication adherence HEDIS indicators Cost Quality of life Satisfaction Experience of care

HEALTH IT

• • • • • • Electronic health record Move toward HIT meaningful use Regional exchanges Cyber-Access Outcomes reporting CMT data tools

Population Based

  Payments for HH services will be paid PMPM, not unit by unit Service needs will be identified by patient health history and status  Outcomes will be measured by groups of clients (i.e., by organization, region, medication used, co-morbid conditions)

Practice Transformations

• • • • • • • Focus on overall health More medically oriented team members Open access scheduling No-show/cancellation policies Increased patient input processes Significant increase in data reporting and outcomes Treatment planning tools supported by treatment guidelines

Implementation Training

System change training  National consultants on health home, access to care, and patient-centered medical home, using learning collaborative approach Program training  State regulations and specific state program HH CORE TEAM training

Implementation Training

HH CORE TEAM training   Primary care nurse Health coaches (will include specific medical supplemental training)  Physicians

A Typical Participant in This Overview

• • • • • • A 47 year old male More than one major targeted disease Likely has a major cardiovascular diagnosis and diabetes Likely has experienced a major cardiac event A third have a major behavior health co morbidity A generally motivated cohort

Continuously Enrolled 7/1/2007 - 6/30/2008

24,700

Disease

Asthma CAD CHF COPD Diabetes GERD Sickle Cell Behavioral Disability

Number of Individuals

9,817 16,982 5,746 8,155 12,939 12,592 558 8,395

Percentage

39.7% 68.8% 23.3% 33.0% 52.4% 51.0% 2.3% 34.0% *Includes co-morbid conditions 4/27/2020 46

Missouri CCIP Diabetes Outcomes

Hemoglobin A1c Compliance

50% 40% 30% 20% 10% 0% 47% 25% 26% 12% HbA1c - one or more tests HbA1c - two or more tests

Clinical M easure

ENROLLED N=12,939 NON-ENROLLED N=33,631 HbA1c testing provides an estimation of average blood glucose values in people with diabetes. Enrollees in the CCIP program received substantially more HbA1c testing than those not enrolled.

4/27/2020 47

Missouri CCIP Coronary Artery Disease (CAD) Outcomes

Lipid Panel Compliance

50% 40% 30% 20% 10% 0% 40% 20% 14% 7% Lipid Panel - one or more tests Lipid Panel - two or more tests

Clinical Measure

Enrolled N=16,982 Non Enrolled N=29,088 CCIP enrollees with coronary artery disease (CAD) received lipid (cholesterol) testing at twice the rate of non-enrollees.

4/27/2020 48

Trend Analysis of Total Costs

MO HealthNet Average Total Monthly Costs for CCIP Disease Eligible Population

$1,600 $1,400 $1,200 $1,000 $800 $600 $400 $200 $ Ja n-0 6 Fe b-0 6 M ar 06 Ap r-0 6 M ay -0 6 Ju n-0 6 Ju l-0 6 Au g-0 6 Se p-0 6 O ct 06 N ov -06 D ec -06 Ja n-0 7 Fe b-0 7 M ar 07 Ap r-0 7 M ay -0 7 Ju n-0 7 Ju l-0 7 Au g-0 7 Se p-0 7 O ct 07 N ov -07 D ec -07 Ja n-0 8 Fe b-0 8 M ar 08

$1,283 PMPM $962 PMPM

Actual CCIP Enrolled Eligible-Not Enrolled Linear (Actual) Average Total Monthly Costs for CCIP-enrolled participants were below projection. March 2008 demonstrates a $321 PMPM savings.

4/27/2020 49

Trend Analysis of Emergency Room Utilization ER Usage Rate per 1000

300 250 Projection 200 150 100 50 Achieved ER reduction ~30% 0 Ja n-0 6 Fe b-0 6 M ar 06 Ap r-0 6 M ay -06 Ju n-0 6 Ju l-0 6 Au g-0 6 Se p-0 6 O ct-0 6 No v-0 6 De c-0 6 Ja n-0 7 Fe b-0 7 M ar 07 Ap r-0 7 M ay -07 Ju n-0 7 Ju l-0 7 Au g-0 7 Se p-0 7 O ct-0 7 No v-0 7 De c-0 7 Ja n-0 8 Fe b-0 8 M ar 08 Enrolled Identified, Not Enrolled Identified Linear (Identified) ER visits decreased more substantially than projected representing another key cost driver for savings 4/27/2020 50

Statewide Information

• • • • Community Mental Health Centers have approved 10% of the healthcare home plans of care in the State Medicaid program.

More than 35,000 patient histories have been reviewed in CyberAccess.

More than 70% of patients have had a primary care visit within a 12-month period, according to claims; sampled chart review indicates a higher percentage (3 agency sample over 90%).

Outcomes review of Missouri Psychiatric Rehabilitation programs indicates substantial off-trend cost savings for the overall healthcare cost after admission to the program.

Cost Savings achieved for clients in CMHCs

Base Period (CY2006) Expected Trend Expected Trend with no Intervention Actual PMPM in Performance Period (FY2007) Gross PMPM Cost Savings Lives Gross Program Savings Vendor Fees Net Program Savings NET PMPM Program Savings Net Program Savings/(Cost) as percentage of Expected PMPM $1,556 16.67% $1,815.81

$1,504.34

$311.47

6,757 $25,254,928 $0 $25,254,928 $311.47

17.15%

OFF TREND COST SAVINGS FOR CMHC-CM CLIENTS ELIGIBLE FOR CCIP Category Pharmacy General Hospital Psych Rehab Psychologist Independent Clinic Overall pre CMHC-CM post CMHC-CM $39,367,496 $30,154,143 Net Change ($9,213,352) Percent Change -23.4% $23,140,172 $35,378,951 $463,069 $3,549,715 $101,899,402 $21,546,466 $37,467,731 $144,434 $4,324,452 $93,637,226 ($1,593,706) $2,088,780 ($318,635) $774,738 ($8,262,176) -6.9% 5.9% -68.8% 21.8%

-17.2%

Total Healthcare Cost Trend Pre-/Post CMHC Enrollment

Selection Criteria – 636 persons identified  Newly enrolled in CMHC case management  At least nine months of Medicaid claims in each of the preceding two years and two years following CMHC enrollment Methodology  Calculate total monthly Medicaid costs PMPM 24 months pre and post-enrollment  month zero is 24 months prior to enrollment, month 24 is the month of enrollment, month 48 is 24 months after enrollment  Calculate linear regression trend lines

Total HealthCare Utilization Per User Per Month Pre and Post Community Mental Health Case Management

Months with case management initiated on month 24

CMHC DISEASE MANAGEMENT

• • • Clients were Medicaid enrolled with a CCIP eligible medical diagnosis and a serious mental illness enrolled in a CMHC, but may or may not have been enrolled in CCIP. Clients received Psychiatric Rehabilitation services if they were eligible for those services.

Average Medicaid annual medical cost for the clients was $18,672 per year.

WebSites

www.nasmhpd.org/medical_director.cfm

http://www.dmh.mo.gov/MHMPP/MHMPP.htm