C are O f M ental, P hysical A nd S ubstance-use S yndromes

1. Care Of Mental, Physical And Substance-use Syndromes Claire Neely, MD Medical Director, ICSI August 23, 2013

2. Claire Neely, MD Medical Director,ICSI Care Of Mental, Physical And Substance-use Syndromes

3. 3 Year CMS Innovation Challenge Grant Awardee Objectives : • Lower cost of care for people enrolled in government programs • Leverage existing models to improve patient care quickly • Engage broad set of partners to test new delivery models • Identify workforce development opportunities to create jobs

4. Scope of COMPASS work Supported by Cooperative Agreement Number 1C1CMS331048-01-00from the Department of Health and Human Services, Centers for Medicare & Medicaid Services To implement a collaborative care management model for patients with depression and diabetes/CVD, and optional risky substance use, in primary care that accomplishes the Triple Aim

5. Triple Aim Measures of Success • Population health • Increase remission/response rates for patients with depression • Improve control rates for diabetes and cardiovascular disease and their risk factors • Reduce risky substance use • Experience of care • Improve quality for patient and provider satisfaction • Affordability • Decrease readmissions, admissions and ED visits to reduce health care costs

6. COMPASS Consortium: Overarching Scope • Intervention • Develop an evidence-based model, train and facilitate implementation and quality improvement • Evaluation/Study • Develop multiple data collection and analysis approaches for QI and for demonstrating triple aim success • Communications • Marketing & messaging to multi-stakeholder audiences • Payment methodology • Develop new financial models • Spread and sustaining model • Systems approach to link with and embed in ongoing work

7. COMPASS Consortium Partners

8. COMPASS Intervention Partners • Community Health Plan of Washington • Institute for Clinical System Improvement (ICSI) • Kaiser Colorado • Kaiser Southern California • Mayo Health System • Michigan Center for Clinical Systems Improvement • Mount Auburn Cambridge Independent Practice Association • Pittsburgh Regional Health Initiative

9. COMPASS Partners ICSI • Principal investigator for oversight of the award • Design, train, implement and support this work across all intervention partners Advancing Integrated Mental Health Solutions Center • Care Management Tracking System • Advisor/trainer on development of COMPASS intervention • Ongoing resources post-implementation for identified gaps with individual practices HealthPartners Institute for Education & Research • Evaluation • Quality improvement reporting

10. Work informing COMPASS IMPACT & DIAMOND Depression TEAMCare Depression + CVD/Diabetes SBIRT Substance Use Partners in Integrated Care Depression + Substance Use MI Primary Care Transformation Multiple chronic conditions RARE, Project BOOST Care Transitions 

11. COMPASS 4 T’s to Leverage Triple Aim Team New Roles & Relationships Tracking Enrollment & Data Transparency Treatment Intensification Transformation Leadership, Culture, Readiness

13. Enrollment Proactive patient identification and outreach • Adult Medicaid or Medicare patients • With sub-optimally managed depression (PHQ-9 >9) • AND treatable medical comorbidities defined by one or more of the following: • Diagnosis of diabetes with A1c >8.0% OR BP >145 mm Hg OR LDL >100 mg/dl • Existing cardiovascular disease (e.g. history of ischemic heart disease diagnosis, coronary procedure, CHF or stroke) with BP >145 OR LDL >100 mg/d • Uncontrolled HTN (>160) in those over 65 years of age • Recent hospitalization related to diabetes or cardiovascular disease

14. Enrollment Study enrollment • Notify of study using script • Agree to be contacted by study team • Study team calls patients • Further explain study • Get consent into study

15. Team - Collaborative Care SYSTEMATIC CASE REVIEW TEAM with Psychiatric/Physician Consultants PRIMARY CARE TEAM PATIENT CARE MANAGER

16. Ambulatory: Hospital Partnerships • Partnering with hospital transition staff • Med Rec • Rehab units • Visiting patients in hospital • Engage & Enroll • Follow-up • Creating contingency plans • Use of alternative healthcare resources • Self-care

17. Challenges • Program not for all patients • Targeted diseases (mostly) • Socio-economic • EHR and other systemic disconnections • Patients disconnected from the healthcare system

18. Ongoing support for sustainability Weekly enrollment reports Care manager networking calls Partner project manager calls Weekly newsletters Google site & other on-line resources Webinars & learning collaboratives Data feedback for quality improvement Practice coaching Building training capacity at the sites

20. Questions ?

21. Upcoming RARE Events…. • Stay tuned for the next RARE Webinar September 27, 2013! • Topic: Implementation of the Care Transitions Innovation (C-Train) in Oregon • RARE Action Learning Day – November 11, 2013

22. Future webinars… • To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Networking Webinars, contact Kathy Cummings, kcummings@icsi.org