11/4/2014

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How Can Population Based Care Models

Be Applied to Improve Health Outcomes

for Persons with Serious Mental IllnessOctober, 15, 2014

Marc Avery, MDClinical Associate Professor of Psychiatry

Associate Director for Clinical Services,

Department of Psychiatry and Behavioral Sciences

University of Washington School of Medicine,

Jennifer Clancy, MSWAssociate Director, California Institute for Behavioral Health Solutions

Director, CIBHS Coordinated Care Collaborative

Outline

Population-Based Care and SMI

Marc Avery

1. Definition

2. Importance

3. Supporting evidence

Jennifer Clancy

1. Organizational Considerations

2. The Convening Organization

3. Barriers

4. Examples

© University of Washington

Building on 25 years of Research and Practice in

Integrated Mental Health Care

Marc Avery, MD

DISCLOSURES

Employment:

Associate Director for Clinical Services, Division of Integrated Care and

Public Health and AIMS Center (Advancing Integrated Mental Health

Solutions)

Clinical Associate Professor of Psychiatry, School of Medicine; Dept. of

Psychiatry and Behavioral Sciences, University of Washington School of

Medicine

Contracts (current & recent)

California Institute of Behavioral Health Solutions

Wyoming Health Care Authority

Telehealth Corporation

Psychiatric Advisor Magazine

NO FINANCIAL RELATIONSHIPS THAT PRESENT A CONFLICT OF

INTEREST FOR TODAY’s PRESENTATION

I WILL NOT DISCUSS OFF LABEL OR INVESTIGATIONAL USE OF

MEDICATIONS OR OTHER TREATMENTS

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Definition 1:

Population based care means

Ensuring outcomes for all patients in a

group with a targeted condition

Definition 2:

Population Based Care Means –

Not allowing our patients to fall between

the cracks.

1. Tufts Managed Care Institute Newsletter, November 2000

http://www.tmci.org/downloads/topic11_00.PDF

2. Jurgen Unutzer, AIMS Center, University of Washington

© University of Washington

Where does population based care “fit in”?

Patient Centered / Team Based Care

Population-Based

Measurement-Based Treatment to Target

Evidence-Based

Accountable

Mental Disorders

• Are common, disabling, expensive,

and with high mortalities.

• Are mostly chronic conditions that

require deliberate / persistent follow up.

• A small percentage of persons in need of

mental health get any services.

*Multiple investigators, references available by request.

• System and Payment Reform

-Expanded Coverage

-Accountable Care Organizations

-Health Home

• Control of Escalating Costs

• Clinical Effectiveness

Why Population Based Care for SMI

Persons?

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Why are Persons with Severe Mental Illness

more Vulnerable to “Falling Through the

Cracks”?

Systems Issues

1. Payment system that discourages recovery

2. Episodic treatment authorizations

3. Services that often favor crisis intervention over

disease management.

4. Fragmented service network

Patient and Provider Issues

1. Stigma

2. Patient Health Behaviors

3. Clinical InertiaWashington State Senate Ways and Means January 31, 2011 10

DDD

Effects are Bidirectional

© University of Washington

Chronic disease score

Annual

Cost ($)

Unutzer J, et al. JAMA. 1997;277:1618-1623.

Mental Illness Results in Increased MEDICAL

COSTS50% higher Annual Health Care

Costs regardless of # medical

illnesses

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Sometimes the patients who need us most

are the ones we forget..

Group 1 Group 2

Punctual

Articulate

Polite

Engaging

Compliant / Adherent

Responsive

Has transportation

Good support system

Clinically straightforward

Culturally Similar

Misses Appointments

Disorganized

Angry, agitated

Reserved

Isolative, Avoidant

Rejecting

Lacks transportation

Lacks social supports

Complex and Confusing

Culturally Dissimilar From: O’Conner, Patrick, et. Al, Clinical Inertia and Outpatient Medical

Errors, 2005 AHRQ, Advances in Patient Safety

“At baseline”?

“Stable”?

Good News! We have evidence and

increasing experience with models of care

that work better!

Primary Care Locus

• IMPACT / Collaborative Care

• TEAMcare

• Behavioral Health Consultant /

Cherokee Model

Community Behavioral Health Locus

• P-Care

• Health Promotion Activities

• SAMSHA-PBHCI

IMPACT Team Care Model(Patient Centered Healthcare Home for Behavioral Health)

Primary Care Practice with Mental Health Care Manager

Outcome

MeasuresTreatment

Protocols

Population

Registry

Psychiatric

Consultation

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An Integrated Team-Based Approach

– with a new Twist

PCP

Patient BH Care

Manager

Psychiatric

Consultant

Core

Program

New Roles

IMPACT doubles effectiveness of

care for depression

0

10

20

30

40

50

60

70

1 2 3 4 5 6 7 8

Usual Care IMPACT%

Participating Organizations

50 % or greater improvement in depression at 12 months

Unützer et al., JAMA 2002; Psych Clin NA 2004

© University of Washington

MHIP: P4P-based quality improvement cuts median time to depression treatment response in half.

0.00

0.25

0.50

0.75

1.00

Est

imat

ed C

umul

ativ

e P

roba

blili

ty

0 8 16 24 32 40 48 56 64 72 80 88 96 104 112 120 128 136

Weeks

Before P4P After P4P

Unutzer et al, AJPH, 2012.

IMPACT reduces health care costsROI: $ 6.5 saved / $ 1 invested

Cost Category

4-year

costs

in $

Intervention

group cost

in $

Usual care

group cost in

$

Difference in

$

IMPACT program cost 522 0 522

Outpatient mental health costs 661 558 767 -210

Pharmacy costs 7,284 6,942 7,636 -694

Other outpatient costs 14,306 14,160 14,456 -296

Inpatient medical costs 8,452 7,179 9,757 -2578

Inpatient mental health /

substance abuse costs

114 61 169 -108

Total health care cost 31,082 29,422 32,785 -$3363

Unützer et al., Am J Managed Care 2008.

Savings

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What about SMI patients who:

1.Get the majority of their services in a CMHC?

2.Have much more complicated service teams?

VS.Integrated Primary Care

Team

Integrated Community BH

Care Team

Primary Care Access, Referral and

Evaluation PCARE

• Increased Preventive Care (58% versus 21%)

• Treatment for CV illness (34% versus 28)

• Primary Care Linkage (71% versus 52%)

• Increase in self-rated health

(Druss, et. Al 2010)

Community Mental

Health (n = 142)

RN Care

ManagerPrimary Care /

Medical

Health Promotion: Improving Fitness and Reducing

Obesity: What Works

Stephen J. Bartels, M.D., M.S. & John A. Naslund, M.P.H. HEALTH PROMOTION RESOURCE GUIDE:

Choosing Evidence-Based Practices for Reducing Obesity and Improving Fitness for People with Serious

Mental Illness. 2014 SAMSHA Publication. www.integration.samsha.gov

From: World Psychiatry. 2011 June; 10(2): 138–151.

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Create a Table to follow…

Topic Tool Frequency Target Goal

Blood Pressure SBP/DBP Monthly SBP<140 and

DBP<90

45%, 50%

Tobacco/Nicotine Smoking status Monthly 0 5%

Depression PHQ Monthly 5 point

reduction or

score <10

10%

Anxiety GAD Monthly 5 point

reduction or

score <10

10%

Obesity BMI Quarterly >25 45%

Diabetes HBA1c Annually <7.5 25%

Cholesterol / Lipids LDL-C Annually HDL-C>40

LCL-C<130

50%

Alcohol AUDIT (modified) Quarterly

Drug Use DAST (modified) Quarterly

SAMSHA-HSA Primary and Behavioral Health

Care Integration (PBHCI) Program

Deborah M. Scharf, Nicole K. Eberhart, et. Al., December 2013. EVALUATION OF THE SAMHSA PRIMARY AND

BEHAVIORAL HEALTH CARE INTEGRATION (PBHCI) GRANT PROGRAM: FINAL REPORT, U.S. Department of

Health and Human Services Assistant Secretary for Planning and Evaluation Office of Disability, Aging and Long-Term

Care Policy.

SAMSHA

Grantees

I II III IV V VI

13 9 34 8 30 9

Training and T.A.

National Council

Evaluation

RAND

SAMSHA Primary and Behavioral Health Care Integration (PBHCI)

Program

Study Questions:1.Is PCBHCI Possible?2.Does it improve outcomes?3.What components work best?

SAMSHA Primary and Behavioral Health Care Integration (PBHCI)

Program

Core Elements:Required:• Screening and Referral for Primary Care Prevention• Use of Clinical Registry or Tracking System• Person-Centered Care Management• Prevention and Wellness Support Services

Optional:• Co-Location• Population Consultation• Embedded RN care managers• Preventive EBPs

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SAMSHA-HAS Primary and Behavioral Health Care Integration (PBHCI)

Program

Deborah M. Scharf, Nicole K. Eberhart, et. Al., December 2013. EVALUATION OF THE SAMHSA PRIMARY AND

BEHAVIORAL HEALTH CARE INTEGRATION (PBHCI) GRANT PROGRAM: FINAL REPORT, U.S. Department of

Health and Human Services Assistant Secretary for Planning and Evaluation Office of Disability, Aging and Long-Term

Care Policy.

Models:1.Coordinated Care2.Co-located Care3.Integrated Care

• Partner with primary care organization• Hire primary care team

© University of Washington

Marc Avery, MDmavery@uw.edu http://uwaims.org/index.html

THANK YOU!

Practical Experience with Facilitating Population Based Care

Jennifer Clancy, MSW

Associate Director

CA Institute for Behavioral Health Solutions

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DISCLOSURES

Employment: Associate Director, California Behavioral Health Solutions

Grant funding (current & recent)None

Contracts (current & recent) CA Department of Health Care Services

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NO FINANCIAL RELATIONSHIPS THAT PRESENT A CONFLICT OF INTEREST FOR TODAY’s PRESENTATION

I WILL NOT DISCUSS OFF LABEL OR INVESTIGATIONAL USE OF

MEDICATIONS OR OTHER TREATMENTS.

Jennifer Clancy, MSW Topics

1. Overview Of The Organizations That Are Vital for the SMI Population

1. The Role of Convening Organizations in SMI Population Health

2. Historical Barriers to Creating Coordinated Care Systems for SMI Population

3. Solutions: Examples of Convening Organizations Coordinated Care to Address Population Health Needs

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The Organizations Shaping the SMI Population Health- As Is

CMS SAMHSATax Payers

(Millionaires)HRSAFoundationsFUNDERS

RECIPIENT/ INTERMEDIARY DHCS CBO:

SUDFQHC

County BH

HEALTHCBO: MH

CBO: Social Service, Peers…. Etc., etc.

PAYORS/ CONTRACTORS FQHC

County Behavioral

Health

Managed Care Plan

PROVIDER NETWORK

CBOs(MH, SUD, SS,

Peers)

County Behavioral

Health

FQHCs/Health Clinics

UNCOORDINATED SYSTEM

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Where Are We Going? Coordinated System Offering Integrated Care

Convening Organization/Integrator

Accountable for Population Health

Social Service

Agencies, i.e. Housing

Behavioral Health

Provider: SUD and MH

Primary Care Provider

Peer Providers

Wellness Agencies: i.e. Gym

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Various Funding Sources Organized

by Population Health and Triple

Aim Principles

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Convening Organizations1. What Can The “Convening Organization” Do?

Assumes accountability for a population

Convenes all provider organizations necessary to support the whole health of the population

Builds a vision and shared understanding of the potential benefits of a coordinated system

Supports the development of the organizational relationships and agreements/MOUs

2. Which Organizations Can Serve as “Convening Organizations” for SMI population?

Medi-Cal Managed Care Plans

County Mental Health Plan

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Convening Organizations

1. What Are The Barriers each Faces in serving as the “Convening Organization” for SMI population?

Medi-Cal Managed Care Plans (MCPs):

Historically not responsible for mental health care-

Subcontracts to Managed Behavioral Health Organizations

MCPs need to develop knowledge- build a provider network and a delivery system SMI population

County Mental Health Plans (MHPs):

Historically isolated from agencies they must partner with

Organizational isolation consequence of : stigma; carved out funding; traditional split of mind/body care

Limited experience using health information technology

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Solutions for Coordinated Care Partnerships for Population Health

Fresno County Care Coordination Partnership:

(County Mental Health Plan as Convener)

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Fresno County Dept. of Behavioral Health

County MHP, convening organization and

client care coordinator

Ambulatory Care Center

High-fidelity IMPACT model of integrating mental health services into primary care clinic. Serves clients with mild/moderate mental

illness

Clinica Sierra Vista: FQHC, integrated mental

health & primary care clinic serving Medi-Cal, Medi-Care

& uninsured individuals

A local Public Health Plan created by the Regional Health Authority to

serve Medi-Cal members in the counties of Fresno, Kings & Madera.

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AmbulatoryCare Center

(PCP)

Clinica Sierra

Vista (FQHC)

CalViva Health(MCP)

Fresno County Dept. of Behavioral

Health(MHP)

*18%

*38%

*12%

1%4%

*Percentages may include duplicated

clients

Ambulatory Care Ctr

12% Clinica Sierra Vista

21%

PCP Unknown

31%

Other PCP36%

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The Fresno County Care Coordination Partnership Team will make changes to improve the whole health status of adult individuals by coordinating services for the clients with the most serious mental illness and substance use disorders.

Behavioral Health and physical health care’s coordination has, thus far, been driven by individual providers rather than system change. Long-term change must be driven by the systems rather than pushed forward by a few practitioners.

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Overall Theme Across All Agency Partners

• Recognize the importance of physical and mental health care to overall well-being of an individual

• Shared goal and all agency partners benefit!

Agency Catalysts for Care Coordination/Population Health:

– Mental Health (Medical Director)

– CalViva Heath Plan

– Primary Care

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Key changes the Team has been working on

• Multidisciplinary Clinical Care Conferences (routine & ad hoc)

• Develop routine SUD screening

• Support of client self-management

• Ensuring and monitoring routine medication reconciliation

• Ensuring and monitoring authorizations for sharing client PHI

• Referral process between MHP and PCP

• Sharing of patient physical exams, test & lab results

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CC measures data collection process

• Excel spreadsheet (tracks key health indicators, ROIs, etc.)

• MHP’s EHR system (Avatar) - Data reports created specifically for CCC & embedded into EHR for ease of generating data

Who is responsible for collection?

• PCPs and MCPs collect data for their respective measures.

• MHP data analyst responsible for MH data collection, synthesis of data from MCP & PCPs, and reporting out to CiBHS

ACC(PCP)EPIC

CSV (FQHC)NextGen

CalViva(MCP)

DBH(MHP)Avatar

CiBHSCCC

Agency-Specific CCC Data Measures & Client List

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Maintain key personnel from partner agencies

Buy-in from executive leadership

Right People at the Table with the Right Personalities:

• Client centered and dedicated providers

• Providers who follow through and are accountable

• Providers who are real learners. “Care coordination and population health is so different from what has been done before- given the learning curve, the team members must be learners”.

• Providers who are honest, transparent, and “leave their egos at the door”

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Solutions for Coordinated Care Partnerships for Autism Population Health

Autism Assessment Center of Excellence

(Medi-Cal Managed Care Health Plan as Convener)

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Age diagnosis

can be reliable &

valid

The Problem:

Late Diagnosis = Late Intervention =

Diminished Quality of Life & Higher

Life-Long Care Cost

National

Ave Age of

diagnosis

Average

age of ASD

diagnosis in

the

Inland

Empire

Average age

of ASD

diagnosis of

Latino

Childrenin the

Inland

Empire

48

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Delay in diagnosis =

Lost early intervention =

Diminished life-long

functioning

Quality of Life

Lack of clinical criteria

Lack of essential

medical personnel

Kids with

Autism

Deserve an

Answer!

Fragmented System

Treatment is not well

understood or coordinated

Decisions based on cost

rather than clinical criteria

Scarce Resources

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Autism Society

Inland Empire

Concept Desert

Mountain

Special

Education

LPA

Children’s

Network

First 5

Riverside &

First 5 San

Bernardino

Counties

Inland Empire

Health Plan

(IEHP)

The Solution:Formation of the Inland Empire ASD Collaborative

Inland

Regional

Center

Riverside

County Mental

Health

Department

Riverside

County Office

of Education

San Bernardino

Department of

Behavioral

Health

Dept of

Pediatrics

Loma

Linda

University

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Inland Empire (IE) ASD Collaborative

Vision:

“Every child in the Inland Empire will have access to a collaborative, organized, integrated and Trans-Disciplinary Assessment/treatment resource for Autism.”

Mission:

“To meet the autism community’s needs through shared responsibility for a comprehensive and Trans-Disciplinary assessment, Treatment Recommendations, Referrals and Resources in order to maximize the quality of life for children in the Inland Empire with Autism and their families.”

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Early Intervention

Access to treatment

at an earlier age

leads to a higher

Quality of Life &

functioning

AACE Center:

Integrated & Child-Centric

Inter-agency

collaboration

Improves

referrals and

aligns providers

and educators

Comprehensive

assessment

Eliminates

wasted time &

duplicative

assessments

“One Stop Shop”

Reduces parent’s

burden of having to

advocate and

coordinate across

multiple agencies

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The AACE Center Opens 2014

and Promises to:

Be recognized by medical treatment providers,

school districts and social service programs as a

trusted and credible assessment provider

Provide families and providers with useful,

appropriate and actionable treatment

recommendations, referrals and resources

Be financially self-sustaining 2 years after start-up

Create a model that can be replicated in other

communities.

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Creating Population Health

When a Solution Depends on Shared Responsibility, there Must Still Be a “Convening Organization”

Collaboration takes Longer to Implement

Bringing Everyone Along takes Shared Vision and Mission which must be centered on the Target Population - not any single Agency

When Commitment and Perseverance Prevail a Collaborative Strategy often yields The Best Result for Population Health as it is a:

“Community Solution”

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