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Missouri’s Multi modal Approach to Integrating Behavioral Health and Primary Care

Missouri’s Multi modal Approach to Integrating Behavioral Health and Primary Care. Spring Training Institute Tan-Tar-A Missouri Department of Mental Health May 20, 2010. Mortality Associated with Mental Disorders: Mean Years of Potential Life Lost.

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Missouri’s Multi modal Approach to Integrating Behavioral Health and Primary Care

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  1. Missouri’s Multi modal Approach to Integrating Behavioral Health and Primary Care Spring Training Institute Tan-Tar-A Missouri Department of Mental Health May 20, 2010

  2. Mortality Associated with Mental Disorders: Mean Years of Potential Life Lost Compared with the general population, persons with major mental illness lose 25-30 years of normal life span Lutterman, T; Ganju, V; Schacht, L; Monihan, K; et.al. Sixteen State Study on Mental Health Performance Measures. DHHS Publication No. (SMA) 03-3835. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2003. Colton CW, Manderscheid RW. Prev Chronic Dis. Available at: ttp://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm.

  3. Total YPLL by Primary Cause for Public Mental Health Patients with Mental Illness Combined data for schizophrenia and schizoaffective disorder from 5 US states (MO, OK, RI, TX and UT) from 1997 to 2001 *Note: Includes deaths from causes not listed; YPLL = years of potential life lost Unpublished results courtesy of CW Colton

  4. Noncardiovascular Disease Coronary Heart Disease (CHD) Decline (%) Stroke Change in US General Population Age-Adjusted Mortality (1979-1995) Year Morbidity and Mortality Weekly Report. 1999; 48(30):649-656.

  5. Mortality Risk From All Causes and From Cardiovascular Disease Increased Among Patients With Schizophrenia Between 1970-2003 Men Women Relative Risk for Standardized Mortality Ratio Relative Risk for Standardized Mortality Ratio Test for time trends of excess relative risks for SMRs were statistically significant (P<0.001) for all cause mortality and mortality due to cardiovascular disease. Ösby U et al. BMJ. 2000;321:483-484, andunpublished data courtesy of Urban Osby.

  6. Meyer et al., Presented at APA annual meeting, May 21-26, 2005. McEvoy JP et al. Schizophr Res. 2005;(August 29).

  7. The CATIE Study Nasrallah HA, et al. Schizophr Res. 2006;86:15-22. 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!

  8. Principles • Physical healthcare is a core service for persons with SMI • MH systems have a primary responsibility to ensure: • Access to preventive healthcare • Management and integration of medical care

  9. Four Strategies • Coordination of care • Electronic health records • Case management • Medical disease management for persons with SMI • Co-Location/Integration of primary care and behavioral healthcare • BH Interventions for Medical Risks • Obesity/Activity • Smoking • Screening for Prevention and Treatment

  10. Care CoordinationProvide Information to Healthcare Providers • HIPAA permits sharing information for coordination of care • Nationally consent not necessary • Exceptions: • HIV • Substance abuse treatment – not abuse itself • Stricter local laws

  11. CyberAccess • Current Features • Patient demographics • Electronic Health Record • Record of all participant prescriptions • All procedures codes • All diagnosis codes • E prescribing • Preferred Drug List support • Access to preferred medication list • Precertification of medications via clinical algorithms • Implementation of step therapy • Prior authorization of medications) • Medication possession ratio • DirectCare Pro

  12. HIT, How it Fits Together

  13. Intervention Method Outcome CMT Role in DMH-Net ID patient with deviations from best practice standards Aggregate Claims Data Best Practice Communication And Actionable Information Data OptimizerSM (CMT-proprietary data analytics system) Treatment Adherence Program-ID patients at risk of non-compliance Failure to Refill Alerts Increased Quality Decreased Costs Integrated Health Profiles Generate Clinically Actionable Recommendations Medical Risk Management-complex med/beh. conditions

  14. CNS/Missouri Partnership • Behavioral Pharmacy Management (BPM) • Adult & Child Statewide Medicaid • Adult & Child CMHC/CPRC • Adult HAB Centers • Health Care Optimization (HCO) • Adult • Children in Residential Care • Treatment Adherence Program (TAP) • Diabetes Initiative • CMHC as Medical Home • Ad Hoc Data Analytics

  15. Care coordination Medical Needs Have Same Priority as MH Needs • Obtaining a “medical home” – a primary care provider responsible for overall coordination • Medication adherence – just as important for non-MH meds • Assisting in scheduling and keeping medical care appointments

  16. Care CoordinationIntegrate Healthcare Issues Into CMHC Care Mechanisms • Include healthcare goals on Treatment Plan • Include healthy life style goals on Treatment Plan • Identify your internal health care expert/champion • Proven practice – nurse healthcare case manager

  17. Diabetes • Goals • Identify individuals with diabetes and pre-diabetes, and comorbid psychiatric illness • Provide management and educational tools to improve quality of life • Methods • Examine claims data to identify target individuals • Provide patient lists to CMHCs and FQHCs • Assist in care coordination by providing caregiver training, educational materials, and other services to target agencies

  18. Diabetes – Updates and Challenges • Partnered with the MO Primary Care Association to insure the MO diabetes management project complements and supports existing diabetes related initiatives occurring in the state. • Partnered with Diabetes Advisory Board and distributed over a 1000 copies of the diabetes consensus guidelines and screening algorithm to CMHC case managers across the state as part of the DMH Net program. • 14 target agencies (7 CMHCs, 7 FQHCs)

  19. Diabetes – Updates and Challenges • Services • Training for FQHC staff regarding the unique characteristics and problems encountered by patients with diabetes and co-occurring serious mental illnesses (SMI). • Training for CMHC staff to enable them to conduct consumer education self-management skills according to ADA guidelines. • Provide referral resources to Diabetes Self Management Education classes. • Training for DSME staff on how to enhance the educational experience through effective teaching styles and activities for individuals with co-occurring SMI. • Training for CMHC case managers to the unique characteristics and problems encountered by SMI patients who also suffer from diabetes.

  20. Diabetes – Updates and Challenges • Services • Distribution of educational materials to FQHC staff on mental health conditions such as schizophrenia and training and education materials to CMHC case managers to promote their understanding of diabetes, early stage diabetes and patient self-management behaviors (medication adherence, diet, exercise). • Distribution of consumer training and educational materials designed for persons with diabetes and co-occurring serious mental illness. • Equipment – on site handheld web screening • Next steps – creating a disease Registry

  21. Pre-Diabetes – Updates and Challenges • ~45,000 patients at risk for diabetes were identified • Difficulty assuring proper screenings were completed • Missing Medicare Claims • Time and cost to screen 45,000 patients • Method for reporting screening data

  22. Missouri’s Care Coordination for People with Schizophrenia • 2003 Missouri Medicaid Sample of the 19,700+ Recipients with a diagnosis of Schizophrenia: • The average cost of the bottom 10,000 in the 2003 Missouri sample was less than $4,500 per person or a combined total of $45 million, less than half the amount of the Top 2000. • The top 2,000 persons averaged over $50,000 in combined pharmacy, behavioral and medical costs per person, or $100 million in total. • It will be necessary to identify those characteristics of the population that have reliable predictive capability for high health care costs over a multi-year period (2-3 years)

  23. Characteristics of High Risk Medicaid Recipients with Schizophrenia • Medication adherence problems with complex medication regimen; • Chronic health disorders such as: • Obesity or Rapid Weight Gain, • Diabetes, • Chronic Heart Condition, • Hypertension, • HIV; • No stable medical home; • No stable psychiatric home; • Co-occurring alcohol and drug abuse problems; and • High risk for prescription drug side effects and drug-drug interactions.

  24. MRM for Schizophrenia • Services • Medical Profile Updates – sent to psychiatrist, PCP’s (or clinic) and case managers • Health Care Liaison – direct assistance to community agencies in locating medical home and support services • Community Support – targets MH case managers to overall health issues

  25. Medical Profile • Medications prescribed for past 90 days • Hospital and ER stays for past year • Health Care visits for past 3 months • Identifies lead primary care physician, psychiatrist and Mental Health Case Manager

  26. Care coordination by mental health case manager • Provide MRM profiles to other treaters • Facilitate adherents to non-mental health medications • Facilitate adherence to physical health care visits • Assist clients in obtaining a medical home • Assist clients in communicating with physical care providers

  27. JS is a 48 year old male with a diagnosis of Schizophrenia and history of self-mutilation, asthma and hypertension • In 2004 he spent 8 months in a state hospital • In 2005 he was released to group home and started on the MRM project

  28. At base line • he had been seen by 18 different providers in 3 months • was taking 10 medications • experiencing multiple medication side effects (some requiring visits to the ER)

  29. He has • become connected to a CMHC, • has been assigned a CM, • has a PCP • a primary psychiatric provider and • his physical problems have been integrated into his psychiatric care plan

  30. During the MRM reporting quarter JS was seen by 8 providers, is currently taking 1 medication and is in the process of transitioning from the group home to independent living with his girlfriend

  31. Changes in Service Utilization

  32. Results -- MRM Program in Missouri – Integration of Physical and Behavioral Health Inpatient Days per 1000 Cost change - $6.15 million Prior to Program Post Program Implementation Implementation

  33. Benefits of Co-Location • Patients prefer it • % of f/u raises from 15-20% to 40-60% • Builds personal relationships – the foundation of any enduring arrangement • Allows more accurate understanding of each others incentives, methods and constraints • Opportunities for informal consultation • Single clinical record reduces errors

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