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Missouri’s CMHC Healthcare Homes

Missouri’s CMHC Healthcare Homes. Agenda. Why CMHC Health Homes? Missouri’s Health Homes Preliminary Outcomes and Cost Savings Lessons Learned and Changes Considered. Cardiovascular Disease Is Primary Cause of Death in Persons with Mental Illness. Percentage of deaths.

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Missouri’s CMHC Healthcare Homes

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  1. Missouri’s CMHC Healthcare Homes

  2. Agenda • Why CMHC Health Homes? • Missouri’s Health Homes • Preliminary Outcomes and Cost Savings • Lessons Learned and Changes Considered

  3. Cardiovascular Disease Is Primary Cause of Death in Persons with Mental Illness Percentage of deaths *Average data from 1996-2000. Colton CW, Manderscheid RW. Prev Chronic Dis [serial online] 2006 Apr [date cited]. Lori Raney, M.D., Physician Institute, 6/12

  4. Risk of Obesity Among Patients with SMIJoseph Parks, M.D., National Council, 4/14/12 1. Simon GE et al Arch Gen Psychiatry. 2006 Jul;63(7):824-30. 2. Petry et al Psychosom Med. 2008 Apr;70(3):288-97 3. Coodin et al Can J Psychiatry 2001;46:549–55

  5. Psychotropic Medications and Weight Gain • Most antidepressants1 • Most mood stabilizers2 • Most antipsychotic medications3 • However there are alternative drugs within each class that are potentially weight-neutral Joseph Parks, M.D., National Council, 4/14/12 1. Rader et al J Clin Psychiatry. 2006 Dec;67(12):1974-82. 2. Kerry et al Acta Psychiatr Scand 1970: 46: 238-43. 3.Newcomer J Clin Psychiatry. 2007;68 Suppl 4:8-13.

  6. The CATIE Study At baseline investigators found that: • 88.0% of subjects who had dyslipidemia • 62.4% of subjects who had hypertension • 30.2% of subjects who had diabetes were NOT receiving treatment. Joseph Parks, M.D., National Council, 4/14/12

  7. Diabetes is a CVD Risk Equivalent to Previous Myocardial Infarction Joseph Parks, M.D., National Council, 4/14/12 45.0% Equivalent MI Risk Levels Fatal or nonfatal MI (%) 20.2% 18.6% 3.5% No Prior MIPrior MI No Prior MI Prior MI Non-diabetic Subjects Type 2 Diabetic Subjects (n = 1373) (n = 1059) Haffner SM et al. N Engl J Med. 1998;339:229-234.

  8. Mental Disorders and Smoking • Higher prevalence of cigarette smoking (56-88%) for SMI patients (overall US prevalence 25%). • More toxic exposure for patients who smoke (more cigarettes, larger portion consumed). • Smoking is associated with increased insulin resistance. • 44% of all cigarettes in US are smoked by persons with mental illness. Joseph Parks, M.D., National Council, 4/14/12 George TP et al. Nicotine and tobacco use in schizophrenia. In: Meyer JM, Nasrallah HA, eds. Medical Illness and Schizophrenia. American Psychiatric Publishing, Inc. 2003; Ziedonis D, Williams JM, Smelson D. Am J Med Sci. 2003(Oct);326(4):223-330

  9. Good NewsSmall Changes Make a Big Difference • Blood cholesterol • 10%  = 30%  in CVD • High blood pressure • ~ 6 mm Hg  = 16%  in heart attack; • ~ 6 mm Hg  = 42%  in stroke • Maintaining Normal Body Weight • 35%-55%  in CVD Stratton, et al, BMJ 2000;Hennekens CH. Circulation1998;97:1095-1102.;Rich-Edwards JW, et al. N Engl J Med 1995;332:1758-1766;Bassuk SS, Manson JE. J ApplPhysiol2005;99:1193-1204 .

  10. Good NewsSmall Changes Make a Big Difference Stratton, et al, BMJ 2000;Hennekens CH. Circulation 1998;97:1095-1102.;Rich-Edwards JW, et al. N Engl J Med 1995;332:1758-1766;Bassuk SS, Manson JE. J ApplPhysiol2005;99:1193-1204 • Cigarette smoking cessation • ~ 50%  in CVD • Maintaining an active lifestyle (30-min walk daily) • 35%-55%  in CVD • Diabetes (HbA1c > 7) • 1% point  HbA1c = • 21% decrease in Diabetes related death • 14% decrease in heart attack,

  11. Missouri’s Health Homes

  12. Missouri’s Health Homes • Partners in Planning • Medicaid and Mental Health • FQHC and CMHC Associations • Hospital Association • Health Foundations • Two Types of Health Homes • Primary Care Health Homes • CMHC Healthcare Homes

  13. Why Two Types of Health Home? • A CMHCs and FQHCs effort to integrate primary and behavioral health care convinced us that • Collaboration, not integration, is critical to meeting the primary care needs of CMHC consumers • Embedding behavioral health consultants into primary care teams enhances primary care efficiency and effectiveness • Because that is where people already “reside”

  14. Missouri’s Health Homes Primary Care Health Homes CMHC Healthcare Homes Providers 18 FQHCs/5 Hospitals Enrollment: 15,954 Adults: 15,226 Children: 428 Providers 28 CMHCs Enrollment: 18,998 Adults: 16,611 Children: 2,387

  15. Target Populations Primary Care Health Homes CMHC Healthcare Homes Patients with Diabetes At risk for cardiovascular disease and a BMI > 25 Patients who have two of the following COPD/Asthma Cardiovascular Disease Developmental Disabilities Use Tobacco BMI>25 Individuals with a serious mental illness Individuals with other behavioral health problems who also have Diabetes COPD/Asthma Cardiovascular Disease Developmental Disabilities Use Tobacco BMI>25

  16. Chronic Conditions Primary Care HH CMHCs HCH

  17. CMHC Healthcare HomesContext • Missouri Population 5.98 million • 25 Service Areas • Medicaid Rehabilitation Option • 29 Providers • 34,000 consumers • CMHCs serve as “Administrative Agents” for the Department of Mental Health

  18. Medicaid Rehab Option • Community Psychiatric Rehab (CPR) Teams • Team Caseloads: 125 • Master’s Level BH Clinician: 1 • BA Level Community Support Specialists (CSSs): 5 • Psychiatrist (serves multiple teams) • Psycho-social rehabilitation staff (serve multiple teams)

  19. Medicaid Rehab Option • The CPR program fulfills many Health Home functions, though focused on psychiatric disorders: • Identifies and targets high-risk individuals • Monitors health status and adherence • Individualizes planning, and services and supports • A recovery model based on respect • Coordinates with the patients, caregivers and providers • Implements plan of care using a team approach • Promotes consumer self-management of the psychiatric disorder • Links consumers to community and social supports • Arranges psychiatric hospital admission and follows up on discharge

  20. HH Functions: Added Emphasis • Because healthcare homes take a “whole person” approach, we’ll continue and expand our emphasis on: • Providing health and wellness education and opportunities • Assuring consumers receive thepreventive and primary care they need • Assuring consumers with chronic physical health conditions receive the medical care they need and assisting them in managing their chronic illnesses and accessing needed community and social supports

  21. HH Functions: Added Emphasis • Because healthcare homes take a “whole person” approach, we’ll continue and expand our emphasis on: • Facilitating general hospital admissions and discharges related to general medical conditions in addition to mental health issues • Using health technology to assist in managing health care • Providing or arranging appropriate education and supports for families related to consumers’ general medical and chronic physical health conditions

  22. HCH Team Members Community Support Specialists (CSS) Psychiatrist QMHP, PSR and other Clinical Staff Peer Specialists Family Support Specialists Nurse Care Managers (NCM) Primary Care Consulting Physician Health Care Home Director HCH Clerical Support Staff

  23. Health Home Reimbursement: PMPM • PMPM: $80.31 ( Year 1 = $78.74) • Health Home Director • Primary Care Physician Consultant • Nurse Care Manager (1:250) • Care Coordinator/Clerical Support • Data monitoring and reporting • Training

  24. HCH Team MembersPrimary Care Physician Consultant • Establishes priorities for disease management and improving health status. • Participates in case consultation with psychiatrist, QMHP, nurse care managers, and community support specialists • Helps educate community support specialists, case managers, and clinical staff on the nature, course, and treatment of chronic diseases • Develops collaborative relationships with treating PCPs and Psychiatrists, as well as other healthcare professionals and facilities

  25. HCH Team MembersNurse Care Managers • Championhealthy lifestyles, preventive care and managing chronic diseases • Assigned to two CPR Teams • Provide individual care for consumers on their caseload • Review client records and patient history • Participate in annual treatment planning including • Reviewing and signing off on health assessments • Conducting face-to-face interviews with consumers to discuss health concerns and wellness and treatment goals • Consult with CSS’s about identified health conditions of their clients • Coordinate care with external health care providers • Document individual client care and coordination in client records • Average caseload: 233

  26. CMHC Healthcare HomesComprehensive Care Management • Health Screening • Accessing Primary Care • Hospital Admission & Discharge • Continuous Team-based Care • Wellness and Healthy Lifestyles • Population Management – Statewide Registry

  27. CMHC Healthcare HomesCare Management Tools • Metabolic Screening • Disease Management Reports • Medication Adherence Reports • Behavioral Pharmacy Management Reports • Hospital Admission E-mails

  28. Preliminary Outcomes and Cost Savings

  29. Preliminary Health Home OutcomesReduction in Hospitalization Draft Individuals enrolled in health home at least 2 months

  30. Lessons Learned andChanges Considered

  31. Commitment to Training • Organizational Commitment: Why is this important? • Team Training: What is a “health home”? • Chronic Diseases and Risk Factors • Accessing and Using Data • Acquiring New Skills • Motivational Interviewing • Health Coaching

  32. DataComplexities and Problems • Medicaid Claims Data • Includes erroneous diagnoses • Only Medicaid paid claims • Metabolic Screening • Excel, Access, and ProAct™ • From Tests to Values • A “Complete” Screen • Reports • Quarterly to Monthly • Positive, Negative and Unknown

  33. EvaluationComplexity and Problems • Delays: Paid Claims Run Out • Complexity of Systems • Multiple Provider Codes • Multiple Service Codes • Multiple Beneficiary Codes • Required vs. Optional Input • Complexity of Assumptions • Cohorts • Periods and Times • One Year Is Not Enough!

  34. Changes? • NCM Caseload Size • Administration • Levels of Care • Practice Coaches • PMPM Adjustments

  35. What About Children and Youth? • Unique Characteristics • Less often at the CMHC • Families vs. Individuals • Multiple Case Managers • Prevention and Risk Factors vs. Chronic Disease • Changes? • Nurse Care Managers • Family Engagement and Focus • Case Load Size • Trauma Informed Care

  36. Questions?

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