Disease Management 3700

Disease Management 3700 MOPRA Annual Conference - September 23, 2011 Missouri’s Innovations in Care Management for Persons with Mental Illness Tim Swinfard & Rachelle Glavin Missouri Coalition of Community Mental Health Centers

Agenda • Analysis of Care Management • Disease Management 3700 Initiative • Project Implementation • Outreach and Engagement • Barriers and Strategies • Client Reponses • Stories from the Field • DM 3700 Progress Report

Analysis of Care Management Role of Community Mental Health Centers

Problem for Persons with Mental Illness Analysis of Care Management

Missouri Medicaid Reviewed by Lewin Group Analysis of Care Management • In 2010, Medicaid had a comprehensive review of the program by the Lewin Group • Reports available on the MO HealthNet Oversight Committee website • Of particular interest was the High Cost Beneficiary Report SOURCE: http://www.dss.mo.gov/mhd/oversight/reports.htm

Lewin Findings Analysis of Care Management • 58,000 consumers reached $25,000 cost level in CY2008. • This cohort represented 5.4% of the Medicaid population, butthey incurred 52.5% of all Medicaid costs. • 60% of these had $25,000 in cost in 2007 • LESSON: If they were high cost one year, then they are likely to be high cost the next.

Lewin Findings Analysis of Care Management • 90% of the consumers DID NOT reach $10,000 in cost • 6,182 people reached over $100,000 in cost • Adjusting for nursing homes, 35,000 people had $25,000 or more in cost

Lewin Findings Analysis of Care Management • 10,000 clients had signals needing more intervention • Persons with high pharmacy utilization • Persons with 3 or more inpatient medical/surgical/psychiatric • Persons with 10+ ER visits

Lewin Findings Analysis of Care Management • After adjusting for dual eligibles (Medicare), 23,823 clients reached $25,000 in claims cost level. Of those: • 85% had at least one claims for a mental health diagnosis. Of those: • 30% had a mental health prescription but NO office visit • 80% of the high volume med/surg users had evidence of at least one behavioral health condition

ROCKET SCIENCE Analysis of Care Management DO WE NEED AN INTERVENTION FOR HIGH-COST MEDICAID CONSUMERS?

Total Healthcare Utilization Per User Per Month Pre and Post Community Mental Health Case Management Analysis of Care Management Average Medicaid expenditures per month Months with case management initiated on month 24

Project Goals Analysis of Care Management • Target cost savings of over $3 million off trend in Medicaid cost in 2012, $15 million off trend in 2013 • Obtaining a “healthcare home” – a primary care or behavioral health provider responsible for overall coordination • Assisting in scheduling and keeping medical care appointments • Prevention and wellness core of community-based care • Facilitate adherence to medications

Change in Business Analysis of Care Management • old model • Client, family, or healthcare referral makes a call if the consumer seeks services, and they have to be evaluated for eligibility to receive services. • New Model • High cost, high risk outreach to selected consumers that the payer has selected for services.

old

NEW

Disease Management 3700 Initiative Analysis of Care Management • DM 3700 is a collaborative, two-year project between the DMH and MO HealthNet, beginning November 1, 2010. • Targets high cost Medicaid consumers who have a chronic physical health condition and an identified mental health condition.

Target Population Analysis of Care Management • $25,000 minimum cost for previous 12 months or risk predicted to have high cost • A diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, or recurrent major depression • Not a consumer of public mental health system in previous 12 months • Excluded nursing home, developmental disability, hospice and renal failure • Average cost of group over$50,000 per year

Physical Health Demographic Analysis of Care Management 35%COPD 34% Asthma 32% Diabetes 11% Congestive Heart Failure (CHF)

Baseline Costs of DM 3700 Analysis of Care Management

Disease Management 3700 Project Implementation

Project Implementation Disease Management 3700 Initiative • Established line of communication • Identified project coordinators • Bi-monthly TA calls • Identified and assigned client cohort = 3700 • Service areas • Past history with CMHC

Project Implementation Disease Management 3700 Initiative • DMH sent the 1st client cohort to CMHCs Nov. 1, 2010 • 2nd cohort Mar. 2011 • 3rd cohort July. 2011 • CMHCs may first target clients on their list with prior history with CMHC, higher costs or risk factors. • Report monthly client status update

Project Implementation Disease Management 3700 Initiative • CMHC outreach teams • Led by project coordinator(s) • Team of community support staff, QMHPs, peer specialists and/or nurse liaisons • New outreach team or integrated with current homeless/crisis teams • Clients notified of their eligibility • Co-signed letter from MO HealthNet and DMH

Outreach Strategies Disease Management 3700 Initiative • Mail letters on CMHC letterhead • Many letters were undeliverable • Received minimal responses • Follow-up phone call – if available • 16% had a phone number listed • Even less were accurate and working numbers

Outreach Strategies Disease Management 3700 Initiative • Home/Office visits • Most successful form of contact • One or two outreach staff sent on cold calls • Welcome packets made for clients • Referrals • ADA providers • Hospitals

Barriers Disease Management 3700 Initiative • Locating clients was the #1 barrier for outreach teams • Incorrect addresses and phone numbers • Abandoned buildings and vacant lots • Homelessness

Barriers Disease Management 3700 Initiative • Tracking mechanisms: • CyberAccess (pharmacy, ER, hospital stays) • Local primary care providers • Local Family Support Division office • and other Internet search engines • Online social networks (Facebook or MySpace) • Post office • Dept. of Corrections Registry • CaseNet website

Toolkits Disease Management 3700 Initiative • DM 3700 Outreach Toolkit (DMH website) • Effective Involvement in Mental Health Services: The Role of Assertive Outreach and the Voluntary Sector, by Rosie Davie, et. al. • Engaging People who are Homeless with a Mental Illness, Illinois Dept. of Human Services • Mental Health Outreach: Promising Practices in Rural Areas, by David Lambert • Strategies for Finding and Engaging Medicaid Beneficiaries for Complex Care Management, The Center of Health Care Strategies, Inc. • Community-Based Services Safety Manual, Ray of Light Homes

Barriers Disease Management 3700 Initiative • Need for education on chronic physical health conditions • Chronic disease training provided to outreach teams on diabetes, COPD/asthma, heart disease • Communication with community providers, pharmacies, FSD offices, ADA providers, and residential care facilities to educate about the program • MO HealthNet provider letters available • Memos to FSD, ADA and RCFs

Barriers Disease Management 3700 Initiative • Safety of the CMHC outreach staff is of great concern when going on cold calls • Safety is a priority when outreaching in the community • Outreach staff are encouraged to go in pairs on unknown home visits

Engagement Disease Management 3700 Initiative • Identify healthcare concerns using health information technology tools • CyberAccess • Disease Management Report • Medication Adherence Report • Presumptively eligible for CPR services • Assess client needs and develop a treatment plan within 30 days of admission • Metabolic screening within 180 days of admission

Engagement Disease Management 3700 Initiative What the Community Mental Health Center can do for you: • Help you find a family doctor if you don’t already have one • Help you obtain mental health and/or substance abuse treatment or any type of special medical care that you might need • Help you schedule and keep doctor appointments

Engagement Disease Management 3700 Initiative • Help you keep track of your medicine and other medical treatments • Help you work with all of the healthcare providers who take care of you • Offer you health education opportunities addressing smoking, obesity and physical activity • Help you get access to and stay in housing • Help you get access to and keep other social service benefits in your community

Client Response Disease Management 3700 Initiative

Client Response Disease Management 3700 Initiative • “Yes! Sign me up!” “Thank you!” • “I’m not sure. I think I have plenty of support.” • “Why are you here? I don’t need mental health services.” • “How did you get my address and/or phone number?” • “Why was I selected to receive benefits from a mental health center?” • Knock, knock…

Client Response Disease Management 3700 Initiative • Hard refusals include:

Stories from the Field Disease Management 3700 Initiative This one was a tough one. We enrolled her and she disengaged. We were trying to get her in to do a treatment plan, but had been unsuccessful. She was one that we could see on cyber had a lot of issues that we could help her with, but we couldn’t get her in. Her father found her in her bed and she was gone. He called our CSS, very upset, obviously, when he found her card in his daughter’s purse. It was like she slipped through our fingers. I think she was a year older than I and had a son as well. Terrible… St. Joseph, MO

Stories from the Field Disease Management 3700 Initiative Lisa, I just wanted to thank you for including me in the 3700 program. I feel that the opportunities that Burrell has to offer will benefit me. I especially one to shoot you an e-mail to tell you about my caseworker “Jamee” I have a lot of issues with health, doctors appointments and medications, the list seemes to go on and on. However, I do not realize that the more stress that was under until Jamee took over and started managing my appointments, help me go to the doctor and medications. I feel such a relief, and not so much stress now. Jamee is so one top of things and she really, genuinely seems to care and treats me like a person instead of a number or just a client.(and that means a lot) Lisa, I just felt compelled to tell you how much I appreciate Jamee’s effort and this program you all are a blessing. Again, thank you , John Doe Springfield, MO

FACT 3 out of 5(60%) individuals with mental illness die from a preventable disease due to deficiencies in the current management of chronic illnesses such as diabetes, heart disease and asthma.

DM 3700 Progress Six Month Project Outcomes

6-9 Month Update DM 3700 Progress • 1,658 clients enrolled in DM 3700 • 524 enrolled for more than 6 months • Very substantial cohort in SE Missouri

Consumer Profiles DM 3700 Progress • Healthcare Status • 89.8 % with physical health needs • 74.8% with dental health needs • 75.4% with vision needs • 55.9% with emergency needs

Level of Functioning DM 3700 Progress

Cost Savings Including Cost of Intervention DM 3700 Progress VERY PRELIMINARY DRAFT RESULTS • $180 PMPMactual cost savings for clients enrolled for over 6 months • $270 PMPMcost savings excluding one client with a substantial pharmacy issue • If adjusted for projected trend, that savings exceeds over $400 PMPM!

Where are Savings from? DM 3700 Progress

OUTREACH Continued Challenges DM 3700 Progress • Current cost per client of intervention is just under $300 PMPM, but that is increasing. • Need to track and manage • New expensive medications • Continued challenges with engagement of new consumers

Disease Management 3700