Presenters:

1. The Next Frontier of Integrated Healthcare: Using Data and Txt4Health Technology to Improve Clients' Physical and Behavioral Health Presenters: Diana McIntosh, Ph.D, APRN, BC, Hamilton County  Mental Health and Recovery Services Board Roni Christopher, M.Ed., OTR/L, LNHA The Health Collaborative Shana Trent, MSW, LSW, The HealthCare Connection Collaborative Family Healthcare Association 14th Annual Conference October 4-6, 2012 Austin, Texas U.S.A. Session # G3b October 5, 2012

2. Faculty Disclosure • We have not had any relevant financial relationships during the past 12 months.

3. Objectives • Describe effective partnerships that promote integrated medical and behavioral health models • Discuss Txt4Health as a viable technological intervention to improve healthcare • List quality improvement strategies and consumer outcomes • Identify consumer and provider responses to Txt4Health

4. Learning Assessment • A learning assessment is required for CE credit.

5. Demonstration Project Partnership for Integrated Care • Partners include: • Hamilton County Mental Health and Recovery Services Board • HealthCare Connection • CCHB • GCB • Talbert House/Centerpoint • Greater Cincinnati Beacon Community • Health Collaborative • HealthBridge • The Health Foundation of Greater Cincinnati • Target population is adults with diabetes and a severe mental illness • Partnership will use data and technology for improvement of behavioral and physical health care

6. The Partners • The HealthCare Connection • Federally Qualified Health Center (FQHC) • National Committee for Quality Assurance , Patient Centered Medical Home recognition • Seven locations serving 18,000 patients annually • Mission: Provide quality, culturally sensitive and accessible primary care focusing on the medically underserved, underinsured and uninsured in northern Hamilton County Ohio and surrounding areas • Oldest FQHC in Ohio. Founded in 1967 www.healthcare-connection.org

7. The Partners • Greater Cincinnati Behavioral Health Services • A comprehensive mental health agency serving adults with severe mental illness in the Cincinnati area. • 300 care professionals serve over 4,000 adults annually • Rehabilitation services at 10 locations • Provides psychiatric, nursing, counseling, care management, residential, vocational, day programs and others • SMI clients include the homeless, incarcerated, and those with many dual disorders. www.gcbhs.com

8. The Partners • Central Community Health Board of Hamilton County • A Private, non-profit corporation founded in 1970. • Provides comprehensive mental health and drug treatment, alcoholism referral services and HIV prevention services to Hamilton County residents. • Mission: Provide the best possible mental illness, substance abuse and HIV prevention and treatment services • Services: Case management, psychotherapy, partial intervention, emergency and long-term residential, psychiatric , addictions and methadone treatment. www.cchbinc.com

9. The Partners • Talbert house/Centerpoint Health • Comprehensive Behavioral Health Care Provider in Hamilton County (Cincinnati) with five locations • Mission: Strengthen communities served by providing the best quality mental health care to children, adults and families • Care provided includes outpatient treatment, counseling, case management, support services, crisis and prevention services www.talberthouse.org

10. The Partners • The Health Foundation of Greater Cincinnati • Awards grants to non-profit and governmental organizations for programs and activities that improve health in Cincinnati and 20 surrounding counties in Kentucky, Indiana and Ohio • A leader in promoting integrated healthcare www.healthfoundation.org

11. The Partners • The Health Collaborative and Greater Cincinnati Beacon Community • The Health Collaborative is a multi-stake holder organization who was sub contracted on the Beacon grant for Cincinnati • It is the home of the largest Adult Diabetes public report in the United States • It’s role in Beacon: to use HIT (provided by HealthBridge) married with QI to improve diabetes outcomes

12. Greater Cincinnati Beacon Community • One of 17 communities funded by the Office of the National Coordinator • One of 3 communities afforded the opportunity to test Txt4Health technology • Cincinnati medical systems have begun to form and build their own integrated networks including the purchasing of primary care • Cincinnati is largely an “EPIC” HIT town

13. Adult Diabetes Goals for Cincinnati Beacon • Reduce the “D5” by 5% points for a community of publicly reporting physicians (450+) • Reduce each “D5” component measure by 5% for the same group of publicly reporting physicians • LDL>100 • BP 140/90 • A1c >8 • Tobacco cessation self report • Aspirin regimen as appropriate

14. Integrating Mental Health • Beacon project did not define a mental health intervention • Cincinnati is a collaborative and innovative city… • We found an opportunity to work together with Mental Health

15. Need/Practice Gap & Supporting Resources • People in Ohio with Severe Mental Illness (SMI) die 32.2 years earlier than the rest of the population (Miller, Paschall, Svendsen, 2006) • Studies show that 60% of patients with SMI die of preventable health conditions • Access to primary care is limited/a problem for SMI clients • By report a large percentage of SMI clients have poorly controlled chronic health problems, e.g., Diabetes, Hypertension • Care for SMI clients is fragmented–not coordinated.

16. Our Partnership Co-Location Model Independent, Parallel Clinical Processes Behavioral Health Clinic Site Psychiatrist MH intake Case Manager Client Partnership’s Client Flow Supervising PC Physician Referral MD & APN PC intake Support Staff: LPN & MA

17. New Partner: Hamilton County Mental Health and Recovery Services Board • Authority under Ohio Revised Code 340 to lead public behavioral health in Hamilton County through: • Planning • Funding • Managing • Evaluating

18. Goals for Integrated Project • Improve mutually agreed upon client outcomes. • Increase integration between physical and behavioral health focusing on adults with diabetes and a severe mental illness • Facilitate NCQA certification for the community mental health centers. • Foster collaboration among Beacon, behavioral health system and FQHC • Examine the use of technology, such as Txt4Health, in improving patient care.

19. The Model • Loose adaptation of the Breakthrough Series framework from IHI • Rapid Cycle Change and Improvement Science methods (Plan Do Study Act) • Enhance Health Information Technology capabilities • What we wanted to know: • Could the mental health providers utilize social media with their patients? • Could we impact the ability for mental and physical health providers to work as an interdisciplinary team? • Would these patients improve outcomes? • How would these patients respond to this technology?

20. The Mental-Physical Health Measures • Blood pressure less than 140/90; • LDL levels less than 100mg; • Hemoglobin A1C below 8%; • Decrease in symptom distress; • Increase in quality of life.

21. Use of Texting To Improve Outcomes • Use of mobile phone text messaging can be effective in improving health behaviors and health outcomes (Cole-Lewis and Kershaw, 2010; Fjeldsoe, et al., 2009; Krishna, et al., 2009; Wei, et al., 2011; Whittaker et al., 2009;) • Among a sample of low income households on Medicaid, 80% of patients report texting regularly (pricewaterhousecoopers, 2011) Cole-Lewis H, Kershaw T. Text messaging as a tool for behavior change in disease prevention and management. Epidemiol Rev. 2010;32:56–69. doi: 10.1093/epirev/mxq004 Fjeldsoe BS, Marshall AL, Miller YD. Behavior change interventions delivered by mobile telephone short-message service. Am J Prev Med. 2009;36:165–73. doi: 10.1016/j.amepre.2008.09.040. Krishna S, Boren SA, Balas EA. Healthcare via cell phones: a systematic review. Telemed J E Health 2009. 15231–40.40. doi: 10.1093/epirev/mxq004. Wei J, Hollin I, Kachnowski S. A review of the use of mobile phone text messaging in clinical and healthy behaviour interventions. J TelemedTelecare. 2011;17:41–8. doi: 10.1258/jtt.2010.100322. Whittaker R, Borland R, Bullen C, Lin RB, McRobbie H, Rodgers A. Mobile phone-based interventions for smoking cessation. Cochrane Database Syst Rev 2009(4):CD006611. Pricewaterhousecoopers Health Research Institute, Healthcare Unwired, 2010.

22. Technology – Txt 4 Health • A mobile health information service designed to help people: • Understand their risk for type 2 diabetes • Become more informed about the steps they can take to lead healthy lives • In a 14-week text-based program engage with and manage their own health. • a private public partnership with American Diabetes Association, Center for Disease Control, Office of National Coordination for Health Information, Voxiva, and Beacon • The Health Foundation of Greater Cincinnati agreed to fund cell phones for 4 months for 100 clients as part of the Txt4Health demonstration project.

23. The Mental-Physical Health Chronic Disease/Diabetes Results (5-6 Month Intervention)

24. Ohio Consumer OutcomesClients Exhibiting Improvement (N=60) Information regarding the Ohio Consumer Outcomes system can be found at: http://www.mh.state.oh.us/what-we-do/protect-and-monitor/consumer-outcomes/index.shtml

25. Ohio Consumer OutcomesChange in Client Health, Medication and Physical Health (N=60) Information regarding the Ohio Consumer Outcomes system can be found at: http://www.mh.state.oh.us/what-we-do/protect-and-monitor/consumer-outcomes/index.shtml

26. Pre(N=100) and Post (N=47) Surveyof Clients Using Txt4Health

27. Client Anecdotal Data: Txt4Health messages were helpful • Remind me to do things • Remind me to eat right and take my medicine • Good reminder to check blood sugars and take insulin • Encouragement and support • Informational

28. Client Anecdotal Data: Txt4Health messages not helpful • Could not read the text • Lost phone in one month • Low service at house, one bar and had trouble with getting messages • Rather have someone to talk to me

29. Client Anecdotal Data: Report Changing Behaviors to improve their health • Better diet and more exercise • Make appts and taking meds as prescribed • Started going to gym and eating healthy • Walk more and started yoga • Drink less soda and eat less fast food

30. Post Case Manager Surveys (N = 32) • 91% reported no problems in assisting clients to register for Txt4Health • Only 1% used text for appointments • Only 34% thought text messaging was an important tool to use with clients

31. Mental Health Case Manager Anecdotal Data: Changing Their Interventions • Report doing the following differently: • more communication with home health nurse, healthcare provider or PCP • discussing health issues more in-depth • asking about blood sugar levels • encouraging healthy food choices and exercise • Reminding client about physical health appt.

32. What We See in the Data • No significant improvement in the short timeframe, but showing promise • Patients tolerated the phone and idea of text messages • Patients wanted to receive health messages more often • Providers were not as comfortable using text messaging

33. Conclusions • No significant change in outcomes at this time in the project • Conclusion: • While the intervention did not show a change in numbers as expected, it did not show a significant decrease either. • There are anecdotal stories to support that this intervention may have be worth continued pursuit. • The introduction of technology for mental health patients and providers should be explored further to determine what factors might contribute to improved outcomes. • The Mental-Physical health collaboration is essential for improved patient outcomes and improved professional development.

34. Acknowledgements • Consumers who participated in the project • Staff from all partner agencies who participated and provided data • Dr. Erik Stewart, Hamilton County Mental Health and Recovery Services Board • Janice Bogner, The Health Foundation of Greater Cincinnati • Hamilton County Public Health Department • Sprint

35. Acknowledgements Cont.Beacon Community • The Beacon Community Program is funded by the Office of the National Coordinator (ONC) for Health Information Technology, part of the U.S. Department of Health and Human Services. Greater Cincinnati is one of the 17 ONC-funded Beacon Communities that are building and strengthening local health IT infrastructure and testing innovative approaches to make measurable improvements in quality, cost and population health. Greater Cincinnati Beacon Collaboration partners supporting this program include HealthBridge, Cincinnati Children's Hospital Medical Center, the Greater Cincinnati Health Council, the Health Collaborative, GE, Hamilton County Public Health, the University of Cincinnati and dozens of area hospitals and physician practices. • Support is provided under cooperative agreement #90BC0016/01 from the Office of the National Coordinator for Health Information Technology of the U.S. Department of Health and Human Services.

36. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!