WNY Care Coordination Project.ppt

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					Physical and Mental Health
Integration in New York: Challenges
and Opportunities



         Stephen Snell, LCSW
     Wyoming County Department of
            Mental Health
                                    1
      Morbidity and Mortality in People
      with Serious Mental Illness
   Persons with serious mental illness (SMI) are
    dying 25 years earlier than the general
    population – highest mortality rate among ANY
    US population
   While suicide and injury account for about 30-
    40% of excess mortality, 60% of premature
    deaths in persons with schizophrenia are due to
    medical conditions such as cardiovascular,
    pulmonary and infectious diseases (NASMHPD,
    2006)
   Poor health negatively impacts mental illness
    and vice versa
                                                      2
                         Maine Study: Comparison of Health
                         Disorders Between SMI & Non-SMI
                         Groups
                  80
                                                                                                                        SMI (N=9224)
                  70                                                                                                    Non-SMI (N=7352)
                       59.4
Percent Members




                  60
                  50
                  40            33.9
                                            30        28.6       28.4
                  30                                                        22.8      21.7
                  20                                                                             16.5
                                                                                                            11.5       11.1
                  10                                                                                                              6.3        5.9

                   0
                          Sk           Ga          Ob          CO          Inf         Hy         De        Di                                   Liv
                               ele        st          es           PD          ec         pe         nt       ab Can         He
                                                                                                                               ar
                                                                                                                                       Pn
                                                                                                                                          eu         er
                                   tal       ro           ity                     tio        rte        al        ete   ce        tD          mo          Di
                                      -C        -In           /D                      us         ns        Di         s    r         ise                     se
                                                    tes          ys                                 ion      so                                  nia           as
                                         on                         lip                  Di                     rd                       as          /In          e
                                            ne          tin                                 se                     er                       e            flu          3
                                                cti         al          id                     as                    s                                       en
                                                    v                                             e
    CATIE Study


   At CATIE baseline:
      88% of subjects who had dyslipidemia

      62.4% of subjects who had hypertension

      30.2% of subjects who had diabetes




    WERE NOT RECEIVING TREATMENT FOR THESE
     CONDITIONS



                                                4
                          Washington State
                     General Assistance Population




DSHS | GA-U Clients: Challenges and Opportunities August 2006
                                                                5
  ERIE- MONROE - TOP 10% MENTAL HEALTH
                  USERS
TOTAL MEDICAID COSTS - 2007 (2,283 PERSONS)


        $5,248,614 ,
            5%


                                   PHYSICAL HEALTH
                                   TOTAL
                                   MENTAL HEALTH
$39,653,668 ,
                   $56,706,738 ,   TOTAL
    39%
                       56%         CHEMICAL
                                   DEPENDENCY TOTAL




                                                     6
       ERIE-MONROE TOP 10% MENTAL HEALTH USERS
      % OF PHYSICAL HEALTH MEDICAID COSTS BY TYPE -
                          2007
      EYE CARE
          DME
    CHILD CARE
TRANSPORTATION
   HOME HEALTH
   AMBULATORY
          HMO
   LABORATORY
        DENTAL
     INPATIENT
     PHARMACY
        CLINIC
  PRACTITIONER

                 0%   5%   10%   15%   20%   25%   30%   35%   40%
                                                                     7
    WNYCCP Enrollee Surveys,
    2004 - 2008
                WNY Enrollee Health Services Data           2004   2008
                                                                    N=
                                                           N = 613 1115
Have a medical provider                                      86%   83%
I have seen my medical provider in the last year                   84%
My medical provider talks w mh provider none of the time           36%
Have diabetes                                                20%   19%
Have BMI 25.0 - 29.9                                         25%   26%
Have BMI over 30.0                                           40%   38%
Smoke cigarettes                                             67%   62%
Take 7 - 9 medications                                       17%   14%
Take 10 or more medications                                   9%   11%
Rate current health as fair to poor                          41%   41%
Want medical care in my MH setting                           41%   36%    8
Key opportunity: focus community care coordination resources on
individuals who have the highest cost needs

  Of Erie and Monroe mental health users, the “top                   …yet only a quarter of the “top 10%” were
    10% in total cost” represent 63% of Medicaid                  enrolled in available Care Coordination programs
          hospital and residential spending…


                 22,836         $69.1M                                                100%
      100%                                                          100%



       80%                                                           80%



               Other Erie                                                          Not Enrolled
       60%                                                           60%
              and Monroe
              County MH
              Consumers

       40%                                                           40%



       20%                                                           20%                            • ACT
                                                                                     Enrolled
                                                                                                    • ICM
               Top 10%
        0%                                                            0%                            • SCM


Note: Analysis of all 2007 claims for Medicaid recipients 18 or over, with
any mental health claim, excluding individuals with any OMRDD or
nursing home claim. See Appendix A: Erie & Monroe County Data                                                 9      9
Analysis for further detail.
           Drilling down….

   Up to 30% of rural SMI individuals are not connected to
    primary care at all – many reasons
   Diabetes too often unsupervised or poorly managed
   Polypharmacy is rampant; Primary Care does not know all
    the meds in the medicine cabinet
   Primary care is often unaware of behavioral Dx, meds and
    treatment plan, or assumes BH provider is taking care of
    things
   Too often health care falls to the bottom of the list for case
    managers who may miss issues of medical importance
   Stopping smoking alone could add years to life expectancy
   Primary care has difficulty with “non-compliance”
                                                                     10
    The deeper you drill…
   Rural Counties:
        Primary care often doesn’t want to re-assume psych care for
         persons with MI
        Much of specialty care is often not available locally;
         transport to distant sites is difficult.
   Even with medical and behavioral health staff in the
    same organization and in the same locations, staff
    members tend not to communicate consistently.
   Deficit funding rules in NY prohibit the use of mental
    health surpluses to cover medical unit deficits even
    though the deficits resulted from the costs associated
    with providing treatment and follow-up to individuals
    with SPMI – Horizon Health 2007

                                                                  11
    More challenges: Wyoming
    County and others’ experience
   Encounter data across systems cannot be shared
    without special waivers
   Very difficult to bridge the two cultures
   Can’t use Medical CPT codes in Primary Care for BH
    yet
   Primary care does not have confidence in behavioral
    health services
   Funding does not reward either side for prevention,
    collaboration, positive outcomes




                                                          12
13
Overall Model for Improving Primary Care




                                           14
       Where Should Care Be Delivered?
       The National Council’s Four
       Quadrant Integration Model

   It is time to rethink where and how services
    might be delivered in each community. There
    is no one right answer.
   Nationally and in NYS, screening, early
    detection, and embedded behavioral health
    intervention models in healthcare settings,
    schools.
                                              15
    Structural responses gain
    momentum nationally

                    Co-location
                of Health Care and
              Behavioral Health Setting
                The Cherokee Model




Physical Health Care           Behavioral Health Care
 Embedded in BH                    Embedded in
       Setting                 Physical Health Setting
                                                         16
Green shoots of recovery




                           17
     Expanded services
     in Primary Care

   At least some behavioral health issues can be managed
    well within Primary Care
   DOH allows up to 30% BH services in Article 28 OPDs or
    D and TC’s.
   Primary care has not had the consultative care it needs
    from behavioral health
   Past results for embedded clinicians has been +/-
   New models seem to be working better
         (Chautauqua, Greene, others)



                                                              18
Medical practitioners
in CMHCs
   Druss study on integrated care in VA clinics
   Whole practices, NPs, nurses, many models
   All have shown significant benefit and are
    highly popular with clients
   Problem is who should pay for it and how
   Clinic restructuring and the “5% corridor” for
    Article 31 medical services – awaiting codes


                                                 19
    Improved linkages and
    coordination between
    existing services

   WNYCCP developing new curriculum for CM’s in
    person-centered cross-system work, including PH-BH
   Carve-in Managed Care brings information and
    services together
   “Curbside consultation” , telepsychiatry working in
    rural child psychiatry – reach out to primary care
   New regs for clinics provides opportunities to
    encourage better PH assessment and follow-up,
    encourage BH to reach out to PH and to assist
   Electronic records potentially facilitates
    communication                                         20
The Four Quadrant Model –
    Mauer/NCCBH 10

    QUADRANT II              QUADRANT IV
HIGH MENTAL ILLNESS       HIGH MENTAL ILLNESS
   LOW MEDICAL              HIGH MEDICAL CMH
CMH or primary care as   Co-managed care between
     medical home           CMH and primary care

    QUADRANT I               QUADRANT III
LOW MEDICAL AND LOW          HIGH MEDICAL
   MENTAL ILLNESS         LOW MENTAL ILLNESS
     Primary care             Primary care
   as medical home          as medical home

                                               21
          Washtenaw County, MI
        Collaborative Case Model 2
                           UNIFIED PLAN OF CARE
                            Medical, Mental Health &
                           Substance Abuse: Common
                                 Medication List
                            Clarity on treatment roles
                           Notes available to all to view
                             Releases to share info
                                 Outcomes Plan
                            Common Medical Record


 UNIFIED PLAN OF CARE                                             PRIMARY CARE
  Primary Care Practitioner                                       MEDICAL HOME
     embedded in CMH
                                                            MH professionals embedded to
Assess and primary treatment                                   provide consultation, brief
 with back up linkage to PC                                  treatment and med mgt; case
           Clinic;                                              management. Refer and
Close collaboration; Refer and                                consult for non routine care
 consult for non routine care                                     Quadrants I and III
     Quadrants II and IV                                                                     22
Western New York Care
Coordination Program (WNYCCP)
• A unique multi-stakeholder regional (three rural,
  three urban counties) consortium dedicated to
  transforming mental health services for adults with
  severe mental illness based on recovery and person-
  centered care.
• Access to cross-system claims data in some counties,
  can target high need/utilizers of services
• Piloting multiple approaches in physical and
  behavioral health services integration emphasizing
  better planning, collaboration/communication.
• Behavioral and physical health both will be covered
  (most likely carved in) under proposed Personal
  Health Advantage Plan
                                                     23
        WNYCCP: Sample
        Outcomes


Gainful activity                                    56%
Arrests                                             11%
Physical harm to others                             51%
Suicide attempts/self harm                          56%
Emergency room visits                               43%
Days spent in a hospital                            44%
Reports problems with SA                            2%

Samples are for 3914 individuals active for at least 6 months for
  whom we have at least two PRFs, 2003-2007

                                                                    24
      Wyoming County’s Well-Balanced
      Pilot Program Design:                                           8

   Designed with Center for Nursing Entrepreneurship at The
    University of Rochester’s School of Nursing
   Eligibility: Care coordination enrollees with moderate to high
    risk physical health problems, by referral
   “Embedded” nurse wellness coach (mh clinic employee) works
    in tandem with mental health clinicians and care coordinators
    on client-determined physical health issues
   Caseload: 20 slots, revolving enrollment, attends SPOA
   Not time limited; pace/frequency of contacts vary
   Program dovetails with Monroe’s Well Balanced Program, using
    same assessment, documentation and planning tools
   Not disease-specific: interventions customized to individual
    health problems, client wishes, capacities and readiness
   Maximize internet, disease-management protocols “best
    practices” for education

                                                                     25
Clinical Approaches: Wyoming’s Well-
Balanced Nurse Wellness Coach

   Client interview
   Comprehensive Health Risk Assessment
    (HRA) yields numerical score and
    suggested areas for intervention
        (Gordian: lcates@gordian-health.com)
   Home visit
   Laboratory

                                           26
     Consumer Health Status:
     Wyoming County N = 15
15
14
13
12
11                                     # Clients at High Risk
10
 9
 8                                     # Clients at Moderate
 7                                     Risk
 6
 5                                     # Clients at Lower
 4                                     Risk
 3
 2
 1
 0                                        Higher the score,
                                             lower the risk
       HRA Entering   HRA Completing


                                                                27
       Consumer Health Status: Wyoming
       County               N = 15

15
14
13
12
11
10
 9
 8
 7
 6
 5
 4
 3
 2
 1
 0
              Entering                  Completing

                    # Smoking   # Not Smoking


     Entering: 1.25 packs/20 years (average)
     Completing: 0.78 packs
     1 Quit 4 months, 4 reduced >1/2 ppd             28
    Wyoming Well-Balanced:
    Lessons Learned
   “Wellness coach” Person-centered approach reduces client
    wariness of nurse involvement/health goals

   Obtaining laboratory data is often difficult and time-consuming

   Health Risk Assessment is a useful tool for client, nurse and
    program; gives useful patient-friendly information key to
    starting change behaviors, tracks progress, encourages positive
    lifestyle shifts, provides aggregate data

   Interventions must be adjusted to client situation, considering
    current mental status, learning styles, literacy;

   Time, patience, relationship-building often required; changes
    often start slowly, build on earlier steps; individual readiness
    often surprises
                                                                       29
Wyoming Well Balanced Lessons:
contd
   Individual support usually most effective; formal disease
    management protocols, written materials of less use; many
    clients take well to charting progress (e.g. weight or exercise
    charts) especially if gains are being made

   Medical practitioners build confidence in nurse over time,
    welcome help from useful data (lab, etc.), better follow-up,
    enhanced client education and support; improves medical
    attention to health problems

   Results are comparable to Monroe County’s diabetes specific
    nurse wellness pilot project

   Attention to fears/concerns with medical care = better care

   Not reimbursable under 587-588. Possibly under clinic
    restructuring?
                                                                      30
    Enhanced Clinical Supports Services
    Project – Monroe County

   Population identified through claims data
   Basic bh care coordinator assigned
   Bh Coordinators work collaboratively with MCO Monroe
    Plan Case Managers. Weekly Meetings.
   Monroe Plan pharmacy expert and nurses review cases
    and support case managers
   High medical users – ID through claims data
   Monroe Plan’s Case Trakker: pharmacy bh & ph case
    status
   Metrics include quality of service, admissions, costs.
   Promising results – “lost to contact” people are found   31
   “The one thing that individuals with
    mental illness can do that will most
    improve their health and life expectancy
    is to quit smoking.”

                 Steven Schroeder, MD


                                           32
       Strategies that can help integration
       and improve health status

“If the tipping point has not yet been
    reached to support integrated ph/bh,
    it is certainly close” Reynolds et. al.

   Use evolving systems of care in behavioral health as an
    opportunity for system/collaborative care improvements

   Medical Home concept

   Select effective wellness/health promotion strategies readily
    available for behavioral health
      e.g. Wellness days, biggest loser, revised meals for
        nutritional benefit, exercise groups, disease management
        groups, smoke free settings, OMH wellness, LifeSpan
                                                                    33
No need to wait
Clinical interventions that work
   Use BH record forms/procedures to
    strengthen attention to physical health issues
    – e.g. as CQI project
   Early screening for diabetes, cardiac risk,
    hypertension, especially when prescribing
    drugs associated with these risks
   Full range of smoking cessation supports
   Specialists for diet, exercise



                                                 34
     Begin to address local larger
     healthcare system organization
   Public Health Approaches: Look at larger population
   Where are you in EHR?
   Obtain MA encounter data
   Start or step up dialogue with larger health care
    practices, county public health, hospitals
   Consider benefits of FQHC’s, include in planning
      Better rates, cheaper drugs, attract Docs, more

   SAMHSA Wellness Summit’s 10 X 10 Pledge to
    Reduce Early Mortality - 50 organizations signed on
   Local cross-system initiatives will improve PH-BH
    working relationships
   Public policy makers need reasons to make changes     35
    What we hear from the peer
    perspective…
   Peer involvement in delivery design
   Use Peers as influential and strong advocates
   Most welcome collaboration, but want to
    know what is being said, “Nothing about us
    without us” – transparency – access to
    records
   Choice and person-centered care always
   Being denied services based on BH Dx or
    coerced into treatment
   Include alternative therapies; concern re:
    impact of powerful drugs
                                                    36
Things to keep your eye on…
   Cannot ignore impact of substance abuse
   NYS DOH Initiatives – Carve In or Carve Out?
   White House Office of Health Reform
       Reform must include cost containment
       Incentivize outcomes, not services
       Need strong BH leadership in healthcare reform

   NCCBH leadership efforts
   $5.5 million SAMHSA Primary and Behavioral
    Health Integration grant – but only 11
   State of Maine reorganization – partnerships
                                                         37
     Opportunities: Final Advice from
     PH-BH Integration Leaders

   We cannot ignore this
    problem
   Address barriers at all levels
   Turning this around will take
    a long time
   County leadership can be a
    key: keep plugging, don’t
    take no for an answer; it is
    well worth it
   Many strategies work; build
    on your local situation
                                        38

				
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