integrated behavioral health for complex patients roadmap, … · 2019-09-25 · shoulders by naomi...

National Center Conference: Putting Care at the CenterLos Angeles, California

Integrated Behavioral Health for Complex Patients: Roadmap, Tools and Technology

Jeffrey M. Ring, Ph.D.Elise Pomerance, M.D., M.P.H.

Kru Vyas, Ph.D., M.B.A.November, 2017

Faculty Disclosure

Dr. Ring is a Speaker for Merck Pharmaceuticals on doctor-patient communication and culturally responsive care.

Shoulders by Naomi Shihab Nye A man crosses the street in the rain,Stepping gently, looking two times north and south,Because his son is asleep on his shoulder.No car must splash him.No car drive too near to his shadow.This man carries the world’s most sensitive cargo but he’s not marked.Nowhere does his jacket say FRAGILE, HANDLE WITH CARE.His ear fills up with breathing. He hears the hum of a boy’s dream deep inside him.We’re not going to be able to live in this world if were not willing to do what he’s doing with one another.

The road will only be wide. The rain will never stop falling.

Objectives - Participants will:• Articulate core competencies for BH

integration for complex patients• Receive overview of initial project outcomes• Understand the successes and challenges of

the BHICCI

How does one build an integrated complex care initiative?• Who do you want on your team?• What skills do you want them to

possess?• How will you manage data to know if

patients are improving?

Bibliography / Reference

www.bhintegration.com

Inland Empire Challenges• 55% Minorities• Limited Education• Unemployment more than doubled

since 2007 > 14.7% (12% US, 10% CA)

• Poverty 12.7%

IE Health Inequities - Mortality1 Heart Disease2 Cancer3 Lung Disease4 Stroke5 Unintentional Injuries7 Diabetes (5x for Latinos/as)

Our Health Care System• Few providers• Isolated Partners• Disconnected BH• Fragmented Care• Poor Health Outcomes• Lack of IT Infrastructure• Very High Costs

Project Goals are consistent with National Goals: Address social factors in payment and performance through incentives and support for health equity efforts• Office of the Assistant Secretary for Planning

and Evaluation in DHHS• National Academy of Medicine• National Quality Forum

How many of these people with behavioral health concerns will see a mental health provider?

12

No Treatment Primary Care Provider

Wang P, et al., Twelve-Month Use of Mental Health Servicesin the United States, Arch Gen Psychiatry, 62, June 2005SlideCourtesyofAIMSCenter,UniversityofWashington

Mental Health Provider:psychiatric provider or therapist)

CourtesyofAIMSCenter,UniversityofWashington

A$30,000,000Investment

BHICCI Key Commitments• Improve patient and team experience• Improve care coordination and integration of

primary, specialty, addiction, and mental health care across and between healthcare/treatment settings

• Improve complex care management of individuals with chronic conditions

BHICCI Key Commitments• Improve population health

management by using data analytics• Improve access• Reduce overall health care costs in the

Inland Empire safety net

BHICCI Core Elements• 24 month pilot• 30 safety net sites: Primary

Care, BH, Hosp. Ambulatory Clinics

• Health Homes• Whole Person Care

Target Population• 2+ chronic conditions (PH/BH)• Benefit from care management• High cost• IEHP members

BHICCI Roadmap

Engage LeadersEngage TeamsPartner with PatientsData and MeasurementAdopt a QI MethodDefine/Identify PopulationBuild Multidisciplinary, Complex Care Teams/SCRIntegrate Behavioral Health Services with Complex CareSustain Change

TRIAD TEAMS and Coaches

Relationship-Centered Care

“I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”

-Maya Angelou

22

Registries to Track Progress

Courtesy of AIMS Center, University of Washingtonhttp://aims.uw.edu

Note:ThecurrentaveragelengthofenrollmentforMembersinBHICCIis3-4months

BHICCIClinicSiteTypesBHICCIClinicSiteTypes #ofSites #ofMembersEnrolled(9/1/17)

MedicalClinics 19 2,859Behavioral HealthClinics 3 431Coordination-FocusedClinics 3 228PediatricClinics 2 234SpecialtyPainClinics 3 624BHIClinic(nocomplexcare) 1 148

Total 31 4,524

Workforce Education Sessions

Core Competencies• Outreach/engagement• Health Literacy• Medication Adherence• Supporting Self-Management• Shared Care Planning• Registry Management• Transitions of Care• Cross-System Leadership

Team and Patient Experience

PATIENT Participation & Sites Active

265

621

515

578

734

15

21

21

26

31

March

April

May

June

July

Completes SitesActive

Patient ExperienceMean & Net Promoter Score

29

Mean(avg ofthesequestions)– 5pts

1. Careteamlistenstomeandunderstand

2. Itrustmycareteam

3. Careteamalwaysinvolvesmeinthedecisions

4. Myoverallhealthisbetter

NetPromoterScore(NPS)– 10pts

1. Howlikelyisitthatyouwouldrecommendthiscarecenter

4.27 4.41 4.3 4.44 4.38

8.84 9.038.52 8.62 8.55

0

1

2

3

4

5

6

7

8

9

10

Marn=265 Apriln=621 Mayn=515 Junen=578 Julyn=734

Mean NPS

PatientExperience– Mean&NetPromoterScore

Team ExperienceMean & Net Promoter Score

30

3.87 3.9 3.94 3.85 3.78 3.89

0 0

8.01

0

7.81

00

1

2

3

4

5

6

7

8

9

Febn=79 Marn=123 Apriln=163 Mayn=167 Junen=179 Julyn=184

Mean NPS

Mean(avg ofthesequestions)– 5pts

1. Ifeelvaluedatwork2. IhaveeverythingIneedto providethebest

care3. Itrustmyteamtosupportme4. Mylifeisbetter5. Iplantobeherethreeyears(quarterly)

NetPromoterScore(NPS)– 10pts*

1. Howlikelyisitthatyouwouldrecommend

TeamExperience– Mean&NetPromoterScore

*NPSperformedquarterlyforTeamMembers

What are some early learnings from the data?

On average, patients with elevated Behavioral Health scores at Baseline had lower scores, on average, at their last follow-up assessment.

Patients with elevated HbA1c and blood pressure scores at Baseline experienced some improvements in scores, on average.

These results represent a small percentage of all BHICCI patients.

The majority of BHICCI patients are enrolled at Med HCOs and are fairly new to BHICCI (less than 6 months).

More recent data review: what can we say now?

Datathrough8-2-17

35Note:*indicatesstatisticalsignificance

nrepresentsBHICCIpatientsenrolledforaminimumof1month

ChangeinAveragePHQ-9Scores(BaselineScore>=10)

BehavioralHealthOutcomes– PHQ-9

Datathrough8-2-17

Datathrough8-2-17

MeMeBeBe

SpSpBHBH

moderatedepression10

5mild

15

milddepression

average scoresat first assessment

average scoresat last assessment

MedHCO (n=281) * 9.6 8.9CCHCO (n=9) 8.1 7.9SpecPainC (n=15) 10.1 9.6BHI (n=22) 9.2 9.6Overall (n=315) * 9.5 8.9

3

4

5

6

7

8

9

10

11

12

13Change in HbA1c Average Scores (Baseline Score >= 7.0%)

diabetes

normal

prediabetes 5.7%

6.4%

38Note:*indicatesstatisticalsignificance

nrepresentsBHICCIpatientsenrolledforaminimumof1month

ChangeinAverageSBPScores(BaselineScore>=140)

PhysicalHealthOutcomes– SystolicBloodPressure

39

PreliminaryCostData(UCSD)

Preliminary Cost Data are Trending in the Right Direction

40

PreliminaryCostData(UCSD)

Preliminary Cost Data are Trending in the Right Direction

BHICCICaseRates

• ProjectGoal– DevelopCaseRatesfortheBHICCITeamsthatwillkickinafterthepilotendsinJuly2018.

41

BHICCI RoadmapHealthHomesProgram(HHP)– BHICCIisfootprintforCalifornia1115waiverHHP--startsJanuary2019

BHICCIAwardedDepartmentofCaliforniaHealthCareServicesManagedCareQualityAward– October,2017

Questions | Discussionjring@healthmanagement.com

elise.pomerance@iehp.orgdrvyas@desertclinics.com

©2017.LEADthedifferenceLLCforJCC.Allrightsreserved.

PhysicalHealthOutcomesHbA1c

44*Note:ThecurrentaveragelengthofenrollmentforMembersinBHICCIis3-4months

PhysicalHealthOutcomes– Diabetes

9.5 8.9

3456789

10111213

OverallAverageScoreatFirstAssessment OverallAverageScoreatLastAssessment

ChangeinAverageHbA1cScores(BaselineScore>=7.0%)(n=132)*

PhysicalHealthOutcomesSystolicBloodPressurePhysicalHealthOutcomes– Diabetes(HbA1c)

PoorlyControlledDiabetes

PhysicalHealthOutcomesSystolicBloodPressure

45*Note:ThecurrentaveragelengthofenrollmentforMembersinBHICCIis3-4months

151.9

135.3

80

100

120

140

160

180

200

AverageScoreatFirstAssessment AverageScoreofLastAssessment

PhysicalHealthOutcomes– Hypertension(SBP)ChangeinAverageSystolicBloodPressure(SBP)Scores(BaselineScore>=140)

(n=364)*

Stage1Hypertension

BehavioralHealthOutcomesPHQ-9

46*PatientHealthQuestionnaire(PHQ-9)– DepressionScreening**Note:ThecurrentaveragelengthofenrollmentforMembersinBHICCIis3-4months

17.1

12.4

0

5

10

15

20

25

30

AverageScoreatFirstAssessment AverageScoreofLastAssessment

ChangeinAveragePHQ-9Scores(BaselineScore>=10)(n=828)**

BehavioralHealthOutcomes– Depression(PHQ-9*)

ModerateDepression

ModeratelySevereDepression