PARTNERING TO MITIGATE SOCIAL DETERMINANTS &

REDUCE HIGH UTILIZATION• Amy Gallagher, Psy.D.- Vice President, Whole Health, LLC• Randall Reitz, Ph.D.- Director of Behavioral Medicine, St. Mary’s Family Residency• Alex Hulst, Ph.D.- Integrated Behavioral Health Advisor, Rocky Mountain Health Plans

Session # B2

CFHA 20th Annual ConferenceOctober 18-20, 2018 • Rochester, New York

Faculty DisclosureThe presenters of this session have NOT had any relevant financial relationships during the past 12 months.

Conference ResourcesSlides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2018

Slides and handouts are also available on the mobile app.

Learning ObjectivesAt the conclusion of this session, the participant will be able to:

• Identify a multi-agency, interdisciplinary pilot program and its outcomes.

• Understand lessons learned from program implementation and evaluation.

• Conceptualize the program through case studies.

Bibliography / Reference1-Reference Thompson, M.P., Podila, P. S. B., Clay, C., Sharp, J., Bailey-DeLeeuw, S., Berlkley, A. J., Baker, B. C., &

Waters, T. M. (2018). Community navigators reduce hospital utilization in super-utilizers. The American Journal of Managed Care, 24, 70-76.

2-Reference Johnson, T. L., Rinehart, D. J., Durfee, J., Brewer, D., Batal, H., Blum, J., Oronce, C. I., Melinkovich, P., Gabow, P. (2015). For many patients who use large amounts of health care services, the need is intense yet temporary. Health Affairs, 34, 1312-1319.

3-Reference Greene, J., Hibbard, J. H., Sacks, V., Overton, V., & Parrotta, C. D. (2015). When patient activation levels change, health outcomes and costs change, too. Health Affairs, 34, 431-437.

4-Reference Findley, S., Matos, S., Hicks, A., Chang, J., & Reich, D. (2014). Community health worker integration into the health care team accomplishes the triple aim in a patient-centered medical home: A Bronx tale. Journal of Ambulatory Care Management, 37, 82-91.

5-Reference Miller, B. F., Ross, K. M., Davis, M. M., Melek, S. P., Kathol, R., & Gordon, P. (2017). Payment reform in the patient-centered medical home: Enabling and sustaining integrated behavioral health care. American Psychologist, 72, 55-68.

Learning AssessmentA learning assessment is required for CE credit.

A question and answer period will be conducted at the end of this presentation.

IN THE BEGINNING

Presenter

Presentation Notes

As far as health plans go, we’re a pretty small fish (local, regional). But we are known for our innovation. RMHP holds the state Medicaid contract for providing services on the Western Slope of Colorado. In managing Medicaid RCCO funds, the health plan chose to invest in a different approach to managing people at risk due to social / behavioral challenges that impact utilization of health care rather than solely relying on a fee-for-service program.

DEVELOPING A PROGRAM

KEY STARTING POINTS

Behaviors Health outcomes

KEY STARTING POINTS

KEY STARTING POINTS• Logic Model

•Global Budget

•Workforce development

•30% shared risk agreement

IMPLEMENTATIONResearched CHW work in other states

Created training program

Hired initial workforce ◦ 5 CHWs across 4 counties; 6 medical practices

Currently11 CHWs; 10 medical practices & unattributed members

Focused upon systems integration◦ Continuous program evaluation and evolution

CREATION OF WHOLE HEALTH, LLC

Strategized use of LLC in order to assist with communication & coordination◦ Decreased CMHC limitations of HIPAA and 42-CFR

Broke down barriers◦ Increased communication/relationships with medical practices

CREATING BFFs…Community collaboration◦ Health Engagement Team (HET) Steering Committee

◦ RMHP, WH, medical practices, IPA, ER representation ◦ Started with monthly meetings, currently quarterly

HET Joint Ops◦ RMHP & WH◦ Monthly meetings

WH meetings with medical practices

BUDGETARY CONSIDERATIONSRMHP pays for program with the expectation that MSH takes 30% financial risk on the entire PMPM cost of care

◦ Salaries & benefits◦ IT equipment (e.g. laptops, EMR license, cell phones)◦ Leased vehicles/travel expenses◦ Training◦ Program materials/supplies◦ Overhead/CMHC infrastructure

TRAINING PROGRAMWeek-long classroom training program

Mental Health First Aid

Crisis Prevention and Intervention (CPI)

Shadowing of Mind Springs Health programs

Shadowing of CHW team

Ongoing training & supervision

THE ROLE OF THE CHWFocus on health behaviors in patient’s home or community◦ ED reduction

Engage patient in health behavior change

Link the patient with medical, behavioral,& social services needed to improve & maintain quality health & wellness

Facilitate access to a wide range of services through outreach, community education, informal mentoring, and social support

Provide transportation

MEASURING OUTCOMES

OUTCOME MEASURES

Initial Added Over Time

ER use Patient Activation Measure (PAM)

Needs addressed Western CO Needs Assessment

Service utilization Generalized Self Efficacy Scale

Medical practice narratives

RECENT COHORT DATA

67%

33%

WCNA Measure

Patients Met Measure

Patients Did Not MeetMeasure

50%50%

GSE Measure

Patients MetMeasure

Patients Did NotMeet Measure

“Our CHW was able to help implement transitional housing & address his alcoholism at a facility in AZ. He connected with our practice through the CHW program & we were able to treat several physical issues that he would have gone to the ED for.”

“The patient benefitted from the kind, caring, and wise relationship with the CHW. She became informed of resources & the process to access them.”

“The patient & family are aware of many resources, but the patient isn’t willing to use them until they are desperately desired. This has educated several family members. The program might not have influenced the patient directly, but possibly, the entire family benefitted.”

“The main recoverable success was decreased ER utilization & increased PCP visits.”

“The patient had virtually no ER visits and completed 90 days in a recovery center. At discharge, patient had 120 days clean and better relationship with the PCP.”

PATIENT STORIES

LESSONS LEARNED

Presenter

Presentation Notes

It’s all about the relationships Buy-in Ongoing communication Contributions from all involved Openness of leadership is also essential for innovation

Presenter

Presentation Notes

It continues to be about payer’s pain points but attempts to align with practice’s pain points

Presenter

Presentation Notes

Goodness of fit when hiring

Presenter

Presentation Notes

Rapid cycle change mentality – PDSA cycles Role of PT Team

Presenter

Presentation Notes

Absolute importance of transportation

Presenter

Presentation Notes

Generalization of program Urban vs. rural Negotiation of nuances with medical practices while remaining standardized

COMMUNITY HEALTH WORKERS REPORT…

Coordination-of-care with pharmacy◦ One fill date/month, less anxiety about transportation, increased

Transportation conversations are amazing◦ Transport to CMHC for treatment

Being able to model appropriate behavior for pts is helpful

ER communicated with CHW about pt concerns◦ Coordinate care, find assisted living, figure how pt will get psychotropic

inoculations during transition-of-care, arranged out-of-county transportation, and pt reports he is “happy and loves it here”

$50,000 savings in one through coordination-of-care efforts (saved helicopter ride and unnecessary hospitalization)

Session Evaluation

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Thank you!