September 8, 2015

Presentation to the Ohio House Healthcare Efficiencies Study Committee

Shawnee Family Health A Journey Through Time

Shawnee Family Health Center Behavioral Health & Primary Care Clinic Locations

Adams County – West Union Lawrence County – Coal Grove Scioto County - Portsmouth

Rural Health Clinic Locations Adams County – West Union Scioto County - Portsmouth

Employment Services – 13 Counties Adams, Brown, Clermont, Lawrence, Clinton, Gallia,

Jackson, Pike, Highland, Ross, Scioto, Hamilton, Fayette 6700 people annually (kids and adults) 128 Staff

Our Journey

2006Mortality Rates - NASMHPD Reconnect the mind with the body

1988De-institutionalization Case management; community

nursing; team based care

1973Worried Well Talk Therapy

1973 – 1987 The Early Years

Population: People with problems managing daily stressors – sometimes referred to as the “worried well”

Treatment: Outpatient therapy and some group therapy

Most people with SMI still in hospital 1960 de-institutionalization not too effective

The Ceramic Age

March 28, 1988 Mental Health Act Commitment from the State to address needs of people

with severe mental illness: Community based services Transition from state hospital to community Community Nursing & Team Based Care We became part of the safety net for those with mental illness

Transportation Housing & Food Psychiatric medications SSI/SSDI Emotional Support & Counseling Handling crises Drug and alcohol addiction assistance

Community Support Services

An array of services that are provided to:– help a person succeed in the community;– identify and access needed services– help a person succeed in school, work and family

despite MI– help person integrate within the community– help manage their psychiatric illness– Help deal with the functional impairments related

to mental health diagnosis

Our Journey

2006Mortality Rates - NASMHPD Reconnect the mind with the body

1988De-institutionalization Case management/CPST; community

nursing; team based care

1973Worried Well Talk Therapy

The Problem Increased Morbidity and Mortality Associated with Serious Mental Illness

(SMI)

Increased Morbidity and Mortality Largely Due to Preventable Medical Conditions Metabolic Disorders, Cardiovascular Disease, Diabetes Mellitus High Prevalence of Modifiable Risk Factors (Obesity, Smoking) Epidemics within Epidemics (e.g., Diabetes, Obesity)

Some Psychiatric Medications Contribute to Risk

Established Monitoring and Treatment Guidelines to Lower Risk Are Underutilized in SMI Populations

The BODY was being ignored

Mortality Crisis

US Life Expectancy 2008 = 78 years Serious mental illness = 53 – 57 years

Comparable to Cameroon, Gabon, Democratic Republic of Congo

Mortality Crisis

Biggest lifespan disparity in U.S.

Widest other disparity = Black males (8.9 years)

Top Causes of Death in U.S.

Cardiovascular Disease 3.4 X

Cancer Maybe lower rates except lung

Stroke 2x in age < 50

Respiratory disease 5x

Accidents higher Diabetes 3.4x

SMI = High Rates of Chronic Illness

• 70% SMI have a chronic health condition----Mostly pulmonary disease

• 50% have two or more

• 42% severe enough to limit function

• 34% HTN

• Hep B rates increased 5x; Hep C 11x

Reduced Use/Inefficient Use of Medical Services

Poverty

Social Isolation

Systemic Barriers to Ideal Health CareHealthcare systems and financing

Psychotropic medications

Individual health habitsSmokingInactivityObesity/poor nutrition

Factors Associated with Premature Death

The Journey

Mental Health & Primary Care are inseparable; any attempts to separate

the two leads to inferior care

Institute of Medicine 1996

Support for Integration – 1600s Mind-body as a "problem" is generally traced to

Rene Descartes, who asked how the immaterial mind (or soul) could influence the material body.

Would not the interaction between the two have to partake somehow of the character of both?

Our Journey - Reconnecting the Mind to the Body 2007-2012

Responding to the Problem

The Problem What do we Need to Do?

People with MI are dying early

People with MI smoke more – related to early death

Deaths related to preventable Medical Conditions (Metabolic Disorders, Cardiovascular Disease, Diabetes Mellitus )

Psychiatric Medications Contribute to Risk

Providers are not using established Monitoring and Treatment Guidelines to Lower Risk

The BODY is ignored in BH

Educate staff

Address smoking

Screen people for HTN; Diabetes; Hyperlipdemia, etc)

Closely monitor medications that pose health risk

Modify medications if seeing signs of developing chronic illness

Develop wellness programming

Provide primary care to our clients

Vision To become a person-centered health home –

integrate BH & PC Provide behavioral health services Provide physical health services Coordinate care and non-medical needs for adults with

severe MI and for children with serious emotional disturbance

Challenges Funding Workforce readiness How do you integrate care?

Challenges - Funding BH Services:

No reimbursement for Care Coordination No reimbursement for health and wellness promotion No reimbursement for teaching a person with

schizophrenia how to monitor glucose No reimbursement for taking people to needed medical

appointments No reimbursement for getting people engaged in physical

activity.

Challenges - Funding

Grants:• Health Foundation of Greater Cincinnati

$300,000 ( 2007)

• SAMHSA - $2Million (2009)

• HRSA - $200,000 (2011) Health Information Technology

Challenges – Workforce Readiness

Does our workforce know how to deliver integrated care? Tobacco Cessation Prevention and interventions for high blood pressure Prevention and interventions for lipids How diabetes impacts depression

Challenges – What is Integrated Care

Facilitated Referrals

Partnerships

Solo

Shawnee in 2012 Primary care staff in all of our clinics

Nurse Practitioners LPNs Wellness coaches

PC & BH Same administrative structure – one corporation Staff occupy same building Share support & billing staff Integrated, shared electronic health record

Integration – The Missing LinkAbility for BH Professionals to Provide Care

Coordination & Focus on Whole Person

Health Home Service – October 2012

What is a health home – is it a building, or house or a hospital?

 A health home is not a building of any kind. It is a team of people working together to make sure that medical and

non-medical needs are met.

Medical – physical and mental health

Non-medical – housing, transportation, child care, employment, social/recreational, educational, etc.

Health Home Service Comprehensive care management Care Coordination Health Promotion Comprehensive transitional care & follow-up Individual & Family supports Referral to community & social supports

CPST vs. Health Home

CPST Goals Health Home Goals Enhance person’s ability to

live in community Help person identify &

access needed services Improve functioning in

school, work, family Dev. skills to effectively

manage the mental illness/or impact of mental illness

Improve integration of physical and mental health;

Lower rates of ER use; reduce hospital admissions/readmissions

Reduce health costs Decrease reliance on long term

care facilities Improve experience of care &

quality of life for client Improve health outcomes

Fee-for-service Per-member-per-month rate

2013 - Present

Future of Health Homes in Ohio BH Redesign will eliminate Health Homes as they

are now Disagregate Community Support & Health Home

Collection of services will be broken into separate, distinct services

Reimbursement structure unknown

BH Redesign - What do we need to do? Seek designation of people with SMI as both an at risk and

a health disparities population

Promote & Compensate BH provider systems to screen, assess and treat both mental health & general health issues

Establish coordinated mental health and general health care as a state health care priority – allow BH providers to provide and get paid for care coordination

Promote team based care- ALL licensed professionals to practice at the top of their license.

BH Redesign ExampleBH Service – Pharmacologic Management/Medication

Services

Current Providers: Physicians Nurse practitioners Physician Assistants R.Ns LPNs

50% of pharmacologic management services are provided by nurses (RNs & LPNs)

BH Redesign PlanBH Service – Pharmacologic Management/Medication

Services would be redefined to match CPT codes & Medicare regulations

Future Providers: Physicians Nurse practitioners & Physician Assistants

Nurses (RNs/LPNs) could provide limited, low-level service ($10.00)

Nurses could provide higher level of services IF a physician was in the suite/office – “incident to” service

BH Redesign Plan – Why this Would be a Problem Shortage of psychiatrists

Zero full-time on-site psychiatrists Tele-psychiatry

Contract Psychiatrist in Miami Part-time in Cincinnati

Redefining providers of this service will significantly decrease access to pharmacologic services – Can’t recruit psychiatrists Replacing nurses with psychiatrists too expensive

Tele-psychiatrists are not considered to be “in the suite/office” as defined by Medicare – our nurses could not provide incident to services – decrease in access

BH Redesign Promote team based care – ALL licensed

professionals practicing at top of their license

We’ve Come a Long Way…Whole Person Health

2015 Office & community care Screen for high risk health

conditions Prescribers screen for

medication related risk factors Person-centered care Medical providers available

under same roof - integrated Coordinate Care People with SMI living and

working in community

Age of Ceramics

1973 Office based care Relies on initiative of client No consideration of physical

health conditions No nursing presence in office No blood tests/screens The “doctor” knows best People with SMI in hospitals

Let’s Not Go Backwards

“Go back?" he thought. "No good at all! Go sideways? Impossible! Go forward? Only thing to do! On we go!" So up he got, and trotted along with his little sword held in front of him and one hand feeling the wall, and his heart all of a patter and a pitter.”

J.R.R. Tolkien, The Hobbit