Transcript ASAP

Health Homes Care Coordination:
A Key to Integrated Care
&
Positive Outcomes
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Presented by
Joanna Larson,
Senior Director of Health
and Business Services
Empowering Individuals to Strengthen Communities
Part I: What is Health Homes?
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HEALTH HOMES
The Health Home program resulted from of the
Affordable Care Act and the Medicaid Redesign Team for
NY State
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The Medicaid Redesign Team was charged with
reducing cost while increasing quality and efficiency in
NY’s Medicaid program
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The chronically ill represents 25% of Medicaid
recipients yet, they drive 80% of the cost (6.9B)
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It is estimated that at least 975,000 Medicaid
individuals meet the criteria for the Health Homes
program
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Health Homes will improve the health care provided to
both Fee-For-Service( FFS) and Managed Care Plan
(MCP) members of the Medicaid program
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TRIPLE AIM – 3 DIMENSIONS OF VALUE
Population Health
Experience
of Care
Per Capita
Cost
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HEALTH HOMES GOALS
Improve the experience of care
 Improve health outcomes for chronically ill
clients
 Reduce Medicaid expenditures
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Intended outcomes:
The Health Homes Program will save money by
reducing preventable hospitalizations, emergency
room visits, and unnecessary care via the provision
of a higher level of coordination among the
patients’ various care providers
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ELIGIBILITY CRITERIA
Two Chronic Conditions, or a Severe
Mental Illness, or HIV/AIDS.
Chronic conditions include, but are not limited to:
mental health disorder
 substance use disorder
 asthma
 diabetes
 heart disease
 obesity (BMI over 25)
 HIV/AIDS
 Hypertension
 certain types of cancer
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CLIENT ATTRIBUTION TO HEALTH HOMES
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The State uses a combination of the following to assign
Medicaid enrollees to Health Homes:
o clinical risk groups (CRG),
o an algorithm that predicts hospitalizations, and
o behavioral health indicators
Medicaid enrollees are assigned to a health home, to the extent
possible, based on existing relationships with ambulatory,
medical and behavioral health care providers or health care
system relationships, geography, and/or qualifying condition.
Initial assignments are for members who qualify for Health
Home services but are not currently linked with primary care
or case management providers.
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HOW DOES A HEALTH HOME WORK?
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Clients are either found in the community and meet
eligibility criteria, or are assigned to us directly by the
Health Home
The client is outreached, located, engaged and enrolled
Once enrolled, the Care Coordinator identifies areas of
need and current providers in the client’s care team, and
referrals are given to fill gaps in service
The Care Coordinator and client collaboratively build a
care plan that outlines goals, barriers and strengths
The Care Coordinator collaborates with the various
treatment providers in the care team to ensure client
compliance and continuity of care
If the client is hospitalized or otherwise involved in a
critical event the Care Coordinator takes the lead on
transitional care planning and stabilization
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WHAT ARE HEALTH HOME SERVICES?
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Health Home services in accordance with federal
and State requirements:
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Comprehensive Care Management
Care Coordination and Health Promotion
Comprehensive Transitional Care
Patient and Family Support
Referral to Community and Social Support Services
Use of Health Information Technology (HIT) when feasible
Quality Measure Reporting to NYS
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EXAMPLES OF SERVICE PROVISION
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Client X’s qualifying diagnosis’ are Schizophrenia and
Diabetes. The client is linked with a Therapist and
Psychiatrist at an outpatient clinic, but does not have
a PCP.
Care Coordinator (CC) will refer Client X to a PCP so
that their Diabetes can be monitored and treated
appropriately.
CC will coordinate with the Client X’s existing
providers to create a comprehensive client centered
care plan that is collaboratively arrived at with the
input of the client and his/her care team.
Client X’s housing is suddenly compromised – CC
works with the client’s care team and community
providers to ensure housing is reinstated, or client is
relocated.
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Part II: Health Homes Results
&
Best Practices
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NADAP & HEALTH HOME CARE
COORDINATION
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Since 1971, NADAP has been working with clients
diagnosed with Substance Use Disorders (SUD); in the
early years our primary focus was on employment
support services for recovering addicts
We have been engaged with multiple Health Homes
since 2012
We contract with 7 Health Homes in New York City and
partner with 30+ community based treatment providers
and 2 hospitals to engage clients in Health Homes Care
Coordination
We currently serve approximately1,600 clients in
outreach and serve 1,000 enrolled members.
Approximately 50% of our enrolled members are
diagnosed with a SUD
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Health Home Members with
Substance Use Disorders
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ASSESSMENT SCORES
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The total Average for this sample is 71.55
from a range of 0 – 112
Physical well-being:17
Social well-being:10.36
Emotional well-being:10.53
Functional well-being: 12.71
Health Home Functional Questionnaire: 20.95
Clients in Staten Island have lower overall average social
well-being scores, followed closely by clients in the Bronx
This sample shows low social/emotional/functional wellbeing scores on average
Clients who are homeless or who have unstable housing
have lower overall emotional well-being assessment scores.
Clients who are linked with SUD services have higher
overall assessment scores.
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Diagnosis: 100% of clients have a SUD and there is
an overlap among the co-occurring disorders
Mental Health
Disorders
69%
Medical
Diagnosis
58.3%
HIV/AIDS
1.2%
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WHAT WAS IT LIKE PRIOR TO HEALTH HOMES?
In the years from 2000 through 2012, Medicaid
enrollment grew by more than 80 percent
statewide to cover about 5 million New Yorkers
 With high rates of chronic illness and
homelessness the inpatient hospital and ED
expenditures skyrocketed
 $54 billion in Medicaid expenditures in 2012 in
NY alone, which is double or triple the majority
of other states in the US
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OUTCOMES
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CASE EXAMPLE – CLIENT X
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Age – 55
Gender – Male
Race/Ethnicity – African American
Location – Brooklyn, NY
Diagnosis – Major Depressive Disorder with Psychotic
Features, Drug Induced Mood Disorder, Diabetes
Barrier to achieving wellness – chronic illnesses, history of
non-adherence to treatment, history of chronic
homelessness, history of frequent hospitalization
Strengths – Openness to a new service model, engaged with
his Care Coordinator, close relationship with his Brother
Average number of monthly contacts/attempts to serve this
client – 12 per month; sometimes as many as 20
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CASE EXAMPLE CONT’D
Length of enrollment – 2.5 years
 Number of months without hospitalization
since enrollment – 29, no hospitalization
since enrollment, for the past 2.5 years
 Linkages achieved – PCP, Therapist,
Psychiatrist, SUD clinic counselor and outpatient
program, completed 2010E housing application
and was placed in permanent housing
 Next Steps – Care Coordinator has recently
linked this client with a GED prep program so
that he can pursue a degree and employment
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RESULTS OVERALL
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Clients with SUD’s have higher rates of
hospitalization than other client populations; even
when linked with SUD services
Hospitalization rates are highest among the homeless
or clients with unstable housing
Clients who are linked with mental heath services
have lower rates of hospitalization
The most common discharge reasons for the SUD HH
population: “Inability to Contact/Locate” and
“Enrolled HH Patient Lost to Services”
The average number of attempted
contacts/interventions required per client per month
in the sample is 5, but in some cases as many as 20 in
one month are required
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SUMMARY
What does this tell us about the role that linkage to
Substance Use and Mental Health services
play in the success of the triple aim?
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Outcomes are more successful
Detox and ED admissions are less frequent
Long-term recovery is being supported
Care Coordination efforts are more successful
Interdisciplinary team approaches are fostered
Continuity of care increases
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LOOKING TO THE FUTURE
Client satisfaction scores –
Inquiry
Average
Answers (1—5)
I have an understanding of what Health
Homes are.
4.2
My urgent needs are being met.
4.5
I have been linked to community based
treatment for my Substance Use Disorder.
3.9
I feel that my addiction issues have improved
since my enrollment in Care Coordination.
3.9
I would recommend Health Homes services to
a friend or family member in need.
4.5
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NEXT STEPS
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Build and sustain more co-location projects with Health
Homes staff imbedded in emergency departments,
outpatient psych units, detoxes, and rehabs
Ensure that clients are linked with SUD and MH
services in the community in order to promote better
outcomes
Accurately identify acuity levels amongst clients from a
care coordination perspective through use of a risk
stratification tool
Inform key stakeholders that more resources are needed
to appropriately compensate staff for the intensive work
that is required to achieve successful outcomes
Effectively partner with the MCO’s to bridge the gap
between health plans and service providers
Increase awareness about Health Homes throughout the
larger health care community
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Empowering Individuals to Strengthen Communities
Joanna Larson
Senior Director of
Health and Business Services
NADAP
[email protected]
(212)986-1170 ext. 111
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RESOURCES
http://www.health.ny.gov/health_care/medicaid/p
rogram/medicaid_health_homes/
 http://kff.org/medicaid/state-indicator/totalmedicaid-spending/
 http://www.ibo.nyc.ny.us/iboreports/2013medicai
d.html
 https://www.health.ny.gov/health_care/docs/201011_medicaid_admin_report.pdf
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