Health Homes: What Are They and What Might They Look Like

Harvey Rosenthal NYAPRS Annual Conference September 14, 2011

Goals of Our Presentation

• • To raise awareness and get your feedback about: – what a health home is and why they have been developed – how they will change how some Medicaid beneficiaries get their health and mental health care – how they will effect service providers To discuss examples of what health homes might look

Health Homes are about Medicaid

• • • • Medicaid pays for health services for Americans with low incomes and resources. It is funded by the state and federal governments and is managed by the states. People with disabilities represent a large number of Medicaid beneficiaries.

Medicaid is the largest source of funding for medical and mental health and substance use health-related services for New Yorkers.

Why are Changes Coming to Your Medicaid Healthcare?

• • • US and New York state budgets can no longer keep up with Medicaid’s rising costs At the same time, too many Medicaid beneficiaries don’t get or participate in enough of the right kind of healthcare As a result, too many spend too much time in expensive visits to emergency rooms and hospitals

Health Homes 101

• • Health homes are a new way to structure how Medicaid health, mental health and substance use services will work together to deliver coordinated services to beneficiaries with ongoing (‘chronic’) conditions Their goals are to help improve the health of beneficiaries while saving money for the state and federal governments

Health Homes 101

• • These homes are not residences or buildings….they are a network of care providers led by one lead group that will take primary responsibility to make sure your healthcare needs are understood and met.

That lead provider and that network is supposed to provide you a safe and responsive ‘home’ for your healthcare needs

How are Your Mental Health Needs Addressed Now?

PH Emergency Services (diversion) Inpatient Services (diversion) CDT Clinic IPRT

PROS

Clubs Employment Peer Services Recovery Ctr ACT Case Management

Housing

What About Your Other Healthcare Needs?

Emergency Services/Urgent Care Hospital Services Primary doctor/nurse practitioner Specialists for teeth, heart, lung, feet, diabetes and so forth…..

Substance use treatment/detox

Uncoordinated Services Result In…

• • • • Many different treatment plans with no one knowing what the other is doing Missed opportunities to make the right diagnoses and provide the right treatment Wrongful and/or too many medications Huge costs

Uncoordinated Services Result In…

• • • • • Confusion and fear Loss of hope for improvement and wellness Discouragement for self care Over/under treatment No one person to help explain it all (health literacy) to you, bring the treatment providers together and explain you to them

The U.S. has a Sick Care System

not a Health Care System

• Half of Americans have one or more chronic health conditions (155+ million) • Over half of these people receive their care from 3 or more physicians • In total, treating chronic health conditions consumes 75%+ of the $2.5 trillion we spend on healthcare each year in the U.S.

• In large part due to the fact that money doesn’t start flowing in the US healthcare system until after you become sick

America’s Healthcare System at the Brink

“The American healthcare system is a dysfunctional mess.”

(Ezekiel Emanuel, MD, Chair of the Department of Bioethics at the Clinical Center of the National Institutes of Health) 110 100 90 80 70

Preventable Deaths* per 100,000 Population in 2002-2003 (19 Industrialized Nations, Commonwealth Fund ) (* by conditions such as diabetes, epilepsy, stroke, influenza, ulcers, pneumonia, infant mortality and appendicitis)

110 90 93 96 101 103 103 104 71 71 74 74 77 80 82 82 84 84 65 60 $2.3 - $5.2 Trillion “As much as 30% of health care costs (over $700 billion per year) could be eliminated without reducing quality”: Big focus for Nat./State Budget Cutters 12

Big Stakes for Our Community

• • We’re among the sickest disability groups, dying 25 years earlier than the general public.

Compared to non-Hispanic whites with SMI, African Americans and Latinos with major MH diagnoses face serious health inequities due to:  Higher rates of obesity, diabetes, metabolic syndrome, and cardiovascular disease  Poorer access and quality of medical care

NYS Backdrop: High Cost of Medicaid Care for New Yorkers w/ Multiple ‘Chronic’ Conditions

• • • New York’s Medicaid program serves almost 5 million beneficiaries at a cost of over $50 billion annually. 20% of Medicaid beneficiaries (1,029,621 )

account for 75% of the program’s

expenditures: $31.1 million Average cost per year: $30,195 which is 15 times higher than the average beneficiary

NYS Backdrop: High Cost of Medicaid Care for New Yorkers w/ Multiple ‘Chronic’ Conditions

• These beneficiaries have “multiple co morbidities, are medically complicated and require services across multiple provider agencies. Due to their multiple and intensive needs, their care can often be fragmented, uncoordinated and at times duplicative. “ •

Over 40% of these beneficiaries are diagnosed

with mental illness and chemical dependency.

• • • •

NYS Ranks 50

th

in Avoidable Hospital Readmissions

NYS Department of Health estimated that $800 million was spent last year on ‘avoidable Medicaid hospital readmissions.’

70% of these involved beneficiaries with mental health, substance use and major medical conditions.

65% of admissions for this group were for medical reasons.

Latest estimates rise to $1.4 billion

Health Homes

• • NY health homes are multidisciplinary teams comprised of medical, mental health, and chemical dependency treatment providers, social workers, nurses and other care providers. The team will be led by a dedicated care manager who will assure that enrollees receive all needed medical, behavioral, and social services in accordance with a single care management plan.

Heath Homes Goal

• The health home provider will be accountable for reducing avoidable health care costs, specifically preventable hospital admissions/readmissions, skilled nursing facility admissions and emergency room visits and meeting quality measures.

Core Health Home Services

• Care Management • Coordination And Health Promotion; • Transitional Care; • Patient and Family Support; • Referrals • Use of Information Technology (IT)

Health Home Network Leader

• • • Health home providers can either directly provide, or subcontract for the provision of, health home care coordination services. The health home provider remains responsible for all health home program requirements, including services performed by the subcontractor.

Health homes coordinate services to network

partners who continue to bill Medicaid

Health Home Network Requirements

• Preferred health home applications will include an integrated health care and community provider network that includes  managed care plans  hospitals  community based organizations,  targeted case management providers  mental health and substance abuse services providers.

Health Home Provider Network

• Medical care providers: primary care, ambulatory care, preventive and wellness care, FQHCs, clinics, specialists including HIV/AIDS providers, hospitals, rehabilitation/skilled nursing facilities, pharmacies/medication management services, home health services, chronic disease self-management and patient education services, etc.

Health Home Provider Network

• • Behavioral health care providers: acute and outpatient mental health, substance abuse services and rehabilitation providers, etc.); and

Community based organizations and social

services providers: TCMs, public assistance support services, housing services, etc.

HH Program Requirements

• • • Coordination of care and services post critical events, such as emergency department use, hospital inpatient admission and discharge; Language access/ translation capability;

24 hour 7 days a week telephone access to a

care manager;

HH Program Requirements

• • • • Crisis intervention;

Links to acute and outpatient medical,

mental health and substance abuse services;

Links to community based social support

services-including housing; Beneficiary consent for program enrollment and for sharing of patient information and treatment.

Electronic Healthcare Records

• Health homes will be using health information technology to link services, facilitate communication among team members and between the health team and individual and family caregivers

Health Home Priority Groups

• • The State will provide health home providers a roster of assigned enrollees and current demographic information to facilitate outreach and engagement. The roster will include people – from clinical risk groups (CRG), – who are predicted to be re-hospitalized based on state algorithms – with major behavioral health conditions (100k with SPMI only, most with co-occurring conditions)

Health Home Priority Groups

• HH priority groups at program roll out will be groups who are “least engaged” in case management, medical, mental health and substance use treatment services and those who have high acuity scores.”

Auto-Assignment, Opt-out

• Medicaid enrollees will receive letters, assigning them to a health home provider based, “to the extent possible, on existing relationships with health care providers or health care system relationships, geography, and/or qualifying condition.”

Auto-Assignment, Opt-out

• • • Once assigned, enrollees will be given the option to choose another provider when available, or opt out of health home enrollment. Health Homes will be urged to engage/retain enrollees. They expect good engagements to lead to high retention rates. Pending federal approval, enrollment in the Health Home will be mandatory with opt out provisions.

860,000+ high cost/high need Medicaid enrollees

Draft

(1) Chronic conditions at risk for a 2 nd chronic condition

Patient Flow

(2) Chronic conditions Yes Patient Meets Health Home Criteria Assigned a Health Home Patient Assessment* (1) Serious & Persistent Mental Health Condition

*Medically and Behaviorally Complex Non-Compliant with Treatment Health Literacy Issues ADL Status Inability to Navigate Health Care System Social Barriers to Care Homelessness Temporary Housing Lack of Family or Support System Food , Income Need assistance applying for Entitlement Programs

Level I Health Home Services –

Moderate Need

Level II Health Home Services –

Multiple Complex Needs

Periodic Reassessment * for continuation of Health Home Services Level III Health Home Services –

Intensive Complex Needs

Health Home Services Not Required

Primary Care Practitioner Manages

31

Key Roles for TCM, Housing, Supports

• • Inclusion of TCM programs (including OMH and HIV/AIDS COBRA TCMs, and Managed Addiction Treatment Services Providers (MATS)), housing and other community based organizations is “strongly encouraged.” Beneficiary assignment to health homes will partially be based on an organization’s network capacity.

Tiered Case Management Plan

•

A strong plan to deploy tiered care

management plan for: – Low need- stable individuals in ambulatory care with episodic crisis or inpatient need – Intermediate need individuals- not as connected to ambulatory care, more frequent emergency room and inpatient use – High need individuals- such as those serviced by OMH and HIV/AIDS COBRA TCMs and the MATS program.

From Case Management to Care Management

• • • Care managers will have more responsibility and authority to coordinate a broader array of healthcare (e.g MH, SU, medical conditions) They will be able to do more than ‘assess, link and monitor’, e.g. transportation, individualized support More slots will be needed beyond existing case management/MATS to serve 900,000 health home eligible beneficiaries.

Big Potential Role for Peer Services

• Health Homes are encouraged to utilize peers as part of their multidisciplinary team, especially with activities relating to patient

and family support and utilization of

community and social support services.

Expected Impact on Beneficiaries

• • • Most people will likely be auto assigned into health homes that include their case management program and provider More attention, help needed to protect beneficiary rights and choices You will likely be asked to participate in fresh new health/BH assessments and to help shape new goal and treatment plans

Expected Impact on Beneficiaries

• • • Health home coordinators will have and share with provider systems up to date information about beneficiaries’ past and current health issues, their providers and their response and follow up with medications and treatments Unmet needs will be identified and referrals will be made and coordinated to new or ‘better’ health care providers Everyone will be focused on averting avoidable ER and hospital visits.

Financial Pressures, Healthcare Reform Can Speed the Pace of Wellness and Recovery Promotion…

• • If we do more than simply save dollars by diverting people from ERS and hospitals and are successful… at truly helping people meet their health and personal goals via a more responsive and person directed health care and supports

Or Are We Back to the Medical Model?

• • We have helped advance mental health systems by infusing recovery, rehabilitation, rights and peer support approaches and values. In integrating with the healthcare system and its illness, medication and patient based emphases, we must be strong and persistent in infusing these values into those systems by demonstrating that they need us and them to succeed.

Changing Timelines, Trends

• • • •

Health Homes Letters of Intent now due September 7 due to Hurricane Irene.

Health Homes Application due October 5 Health Home start up: November 1 – 8 quarters of federal 90% Medicaid share begins – Payment to health homes begin Children will not be included in first round

NYAPRS Regional Forums

• • • • • • • • • Syracuse September 27th: 10:00am - 1:00pm Hutchings Psychiatric Center Westchester - White Plains October 4th: 10:00am - 1:00pm Long Island – Amityville October 9th: 10:00am - 1:00 Pm Buffalo October 12th: 11:00am - 2:00pm Rochester October 13th: 10:00am - 1:00pm Poughkeepsie October 20th: 10:00am – New York City – October 21

Capital District - Albany: October 26

North Country - Date And Location Tbd