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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