Behavioral Health in the Managed Care Environment

1. Behavioral Health in the Managed Care Environment Caroline Carney Doebbeling, MD, MSc Chief Medical Officer, MDwise Cetan Health Consultants Lynn Bradford, PhD, HSPP Kelle Campbell Don Trainor

2. Horizon Scan • Integrated Care • Tools to Advance Integration • Changes in Delivery of Services • Quality Management • HEDIS and NCQA • CMS • Discussion

3. 4SE • Integrated internal medicine psychiatry unit • Locked unit • Acute Medically ill/Acutely mentally ill, or chronic, persistent SMI • Consult team and integrated clinics • What I learned: • Everything we used to do in the early 1990’s and called MedPsych is now in vogue today • Wished I had somehow patented the idea • That the social workers of yester year are the people we call complex care managers today • There is no substitute for the biopsychosocial model • There is no substitute for EMR • There is no substitute for the willing and able

4. Approaching Integration: Balance Cetan Health Consultants, LLC

5. Health Care Integration • Meaning and Context Very Important • Shape, deliver, manage, regulate, finance, evaluate health services • Does integration mean • Disease Management? • Medical Home? • Shared Care? • Collaborative Care? • Co-location, either physical or virtual? • Shared systems? Cetan Health Consultants, LLC

6. Integration Defined • “Bringing together of inputs, delivery, management and organization of services as a means of improving access, quality, user satisfaction, and efficiency” • Greater efficiency and effectiveness, less duplication & waste, more flexible service provision, better coordination and continuity • Holistic and personalized approaches to health care needs Grone, Garcia-Barbero, 2001; Brown, McCool, 1992; WHO Study Group Cetan Health Consultants, LLC

7. Critical Inputs • Rate of depression and anxiety disorders in primary care • Burden of medical illness in persons with SMI • Lack of training • Lack of qualified workforce Cetan Health Consultants, LLC

8. Why? Epidemiology • In any given year, about 5% to 7% of adults have a serious mental illness • A similar percentage of children — about 5% to 9% — have a serious emotional disturbance. • Millions of adults and children are disabled by mental illnesses every year 1. United States Public Health Service Office of the Surgeon General (2001). Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: 2. Department of Health and Human Services: Substance Abuse and Mental Health Services Administration (2002). National Household Survey on Drug Abuse: 3. Kessler, R. C et al. (2001). The prevalence and correlates of untreated serious mental illness. 4. Farmer, E. M. Z., et al (2003). The epidemiology of mental health programs and service use in youth: Results from the Great Smoky Mountains Study. In M.H. Epstein, K. Kutash, & A. Duchnowsk (Eds.), Outcomes for Children and Youth with Behavioral and Emotional Disorders and Their Families: Programs and Evaluation Best Practices 2nd ed., Cetan Health Consultants, LLC

9. % Persons 12 yrs and Older with Depression in U.S. 2005-2006 NCHS Data Brief Sept 2008 NHANES PHQ-9 Cetan Health Consultants, LLC

10. % of Persons with Depression by Poverty Status: 2005-2006 Cetan Health Consultants, LLC NCHS Data Brief Sept 2008

11. % Persons who had Contact with Mental Health Professional by Depression Severity Mental Health Professional defined as psychologist, psychiatrist, psychiatric nurse, or clinical social worker Cetan Health Consultants, LLC

12. Conversely, What About Medical Comorbidity with SMI? Carney, Jones: Psychosomatic Medicine & JGIM Cetan Health Consultants, LLC

13. Local EvidenceADHD Care and PMP Communication For continuity and coordination of care, evidence in the chart of: Communication to PMP Communication from PMP Evidence of periodic updates with PMP 7 day f/u if member was d/c’d from inpatient

14. Integrated Behavioral Health and Medical Care • Models of Delivery • Co-location—same bldg, clinic space, hospital • Virtual Relationships/agreements • Medical Home • Co-management/team • Traditional consultation-liaison • Midlevel professionals embedded in primary care setting • Full team embedded in setting • Source of funding • Information exchange Cetan Health Consultants, LLC

15. Practical Considerations or Clinic Setting Claims Systems and Coding Information Exchange Workforce Idea, planning, policy CMS Approval SPA Outcomes Patients Financing State Rule Cetan Health Consultants, LLC

16. Funding • Pooling of funds (at various levels) • Capitation (at various levels) • Coding parameters, including multiple same day services • 2009 Omnibus Appropriation included $7 million for demonstration grants (SAMHSA) • Medical Home demonstration projects Cetan Health Consultants, LLC

17. Organizational • Co-location of services • Discharge and transfer agreements • Inter-agency planning and/or budgeting • Service affiliation or contracting • Jointly managed programs or services • Strategic alliances or care networks • Consolidation, common ownership or merger Cetan Health Consultants, LLC

18. Service Delivery • Joint training • Centralized information, referral and intake • Case or care management • Multidisciplinary and/or interdisciplinary teamwork • Around-the-clock (on-call) coverage • Integrated information systems Cetan Health Consultants, LLC

19. Clinical • Standard diagnostic criteria (e.g. DSM IV) • Uniform, comprehensive assessment procedures • Joint care planning • Shared clinical record(s) • Continuous patient monitoring • Common decision support tools (i.e. practice guidelines and protocols • Regular patient family contact and ongoing support Cetan Health Consultants, LLC

20. Medical Care in Community Mental Health—the PCARE Study • Primary Care Access Referral & Evaluation • 407 subjects with SMI randomly assigned to medical care management or usual care • Two RN care managers provided manualized protocol • Motivational interviewing; provider communication; enrollment assistance; transportation and other social needs Cetan Health Consultants, LLC Druss, et al. Am J Psych, 2010

21. PCARE Measures • Primary Care Indicators—23 from 4 domains • Physical Examination: BP, ht, wt, oral, breast, mammo, pelvic exam • Screening Tests: cholesterol, fecal blood, HIV, sigmoid, TB • Vaccinations: influenza, hep B, MMR, pneumococcal, tetanus, varicella • Education: exercise, smoking, nutrition, wt • Framingham Cardiovascular Risk Index • Self-report presence of primary care provider other than ER doctor • MOS-36 using oblique method Cetan Health Consultants, LLC

22. Population Characteristics • 142/205 completed 12 month f/u • Median annual income $3,400 • 51% female • 76.5% African American • SCZ=37%; BPD=11%; MDD=46% • Baseline receipt of average proportion of preventive services received 21% Cetan Health Consultants, LLC

23. Quality of Preventive Services All differences p<0.001 or greater Cetan Health Consultants, LLC

24. Quality of Cardiovascular Care FI n=100, needs blood test results Cetan Health Consultants, LLC

25. PCARE Considerations • Economic outcomes not yet reported • Numbers of uninsured enrolled on Medicaid not yet reported • Single clinic site in urban Atlanta • Care Management possible in this setting • Similar to “guided care” models for elders • Relatively low cost and no need for PCP at CMHC • Must have link to PCPs in community Cetan Health Consultants, LLC

26. Extending Mental Health Services Beyond the Clinic • Medicaid Rehabilitation Option (MRO) • Wrap-around services • Complement usual medical model tx • Case management, Skills Training and Development, Adult Intensive Resiliency Services, Medication Management, ACT • Habilitation Services (1915i SPA) • Medical track???? Cetan Health Consultants, LLC

27. Opinion Only: Models • Care Management/PCP Embedded in Community Mental Health • Navigation Barriers • Expertise and trust with SMI • Focus on common conditions, preventive care • Behavioral Care Embedded or Closely Coordinated with Medical Setting or Medical Home • Performance measures around what matters Cetan Health Consultants, LLC

28. MEETING REQUIREMENTS, BEING PROACTIVE, COLLABORATING, SEEKING QUALITY What is mdWISE DOING?

29. Initiatives • CareSelect Program Redesign • Limited to persons with CAD, HTN, Asthma, DM, CKD, CHF, Depression, SMI, SED • Wards and Fosters with one of the above listed disease conditions • HRS, risk stratified, and enrolled in disease or complex care management • Integrated Care • Hiring strategies • Pod strategies • Care Gaps—outbound touches • Integrate RCP members into care management • Availability of care plans to behavioral and physical health providers • Call center assistance

30. Initiatives: HHW/HIP • Disease Management • Population, case, complex care • Same philosophy as Care Select—integrated care management • Evidence-based Disease Protocols • Same conditions, with addition of PDD, COPD, no HTN • Special emphasis on behavioral illness • Some functions done at MDwise, others at delivery system level

31. Program Management Tool • Program Management Tool (PMT) provides a full spectrum registry application that: • Dramatically updates disease associations • Identifies members with conditions of interest • Performs risk stratifications • Tracks care manager activities • Produces clinical exception lists • Provides outcomes reports • And more…

32. Program Management Tool

33. Program Management Tool PMT – Clinical Data Entry and Assessment Forms

34. Program Management Tool PMT – Population-level Reports

35. Integration Pilots • Funding earmarked in HHW contracts for integration projects • MDwise funded variety of pilots • Midtown • Gallahue/Community Family Practice Residency • St. Vincent Primary Care • St. Catherine (under discussion) • St. Francis Health Network South Family PHysicians • HealthNet, DMHA, OMPP pilot • Underway at two FQHC sites

36. Midtown • Collocated Care- Started January 2009 • 9 Sites-Wishard Community Health Centers • 26 Staff placed in the CHC’s • Provide real time consults to primary care patients • See patients for scheduled visits • See patients referred from our Access and other Midtown programs • Most frequent diagnoses seen: depression, anxiety and substance abuse • Work with primary care physicians on complex medical cases • Measurable outcomes

37. Other Projects • St. Vincent Primary Care Clinic • Services to Enhance Care for Children with Anxiety and OCD • St. Francis Health Network: South Family Physicians • Behavioral health disease manager and a navigator to coordinate between physical and behavioral health, and the family • Gallahue Mental Health Center and the Family Practice Residency Program at Community Health Network: • Behavioral health navigator in a family practice setting; navigator works with staff from Gallahue to manage cases • All projects have measurable outcomes

38. Details?? • Sponsored by MDwise and Community Health Network • Friday November 12, 8:15-noon at St. Francis South Campus • Free CME and CEU for attendees • Free parking and breakfast provided • Contact Dr. Lynn Bradford at 822-7307 if you did not receive a “save the date” notice via e-mail or fax

39. Reach Out for Quality roq

40. ROQ and MDwise P4P • MDwise only program—other MCEs may have similar programming • Measures linked to OMPP P4P • Delivery System earns $$ based on performance • Unearned $$ available in grant funds for quality initiatives • Network Improvement Team • Multi-disciplinary team to assist in analysis, programming, training, measuring • Key is to work with delivery system on meeting measures; working on quality improvement

41. MDwise and Behavioral Health Quality • Annually, MDwise audits for continuity and coordination of care between primary care and behavioral health, adherence to clinical practice guidelines and access to care • NCQA standards that MDwise is required to meet to maintain its accreditation • MDwise also monitors the quality of assessment information, treatment planning and progress of treatment

42. MDwise Behavioral Health Audits • Charts are selected randomly from MDwise high volume BH providers • In 2010, all but 3 were community mental health centers • 10 charts per center were audited by the MDwise director of behavioral health and behavioral health manager

43. Audit Methods • 0% in charts reflect centers that did not return surveys or reported data in narrative fashion • Providers were asked to provide for each call type: #who received that type of appointment who got the appointment / Total number of calls for that type of appointment

44. NCQA Quality Markers: Crisis Appt.MDwise Behavioral Health Audit NCQA definition: 24 hour access to crisis appointments

45. NCQA Quality Markers: Non-Life Threatening ApptMDwise Behavioral Health Audit NCQA definition: Non-life threatening emergency appointments within 6 hours

46. NCQA Quality Markers: Urgent AccessMDwise Behavioral Health Audit NCQA definition: Urgent situations, member seen within 48 hours

47. NCQA Quality Markers: Routine Appt.MDwise Behavioral Health Audit NCQA definition: Routine appointments within 10 business days

48. What Happens When We Work Together?

49. Seven Day Follow-Up • NCQA Theory: identify medication issues, social barriers, reduction in bounce-back admissions • Cougnard A, Parrot M, Grolleau S, Kalmi E, Desage A, Misdrahi D, Brun-Rousseau H, Verdoux H. Pattern of health service utilization and predictors of readmission after a first admission for psychosis: a 2-year follow-up study. Acta Psychiatr Scand 2006 Apr;113(4):340-9. PubMedDeFrances CJ, Lucas CA, Buie VC, Golosinskiy A. 2006 National Hospital Discharge Survey. Natl Health Stat Report 2008 Jul 30;(5):1-20. PubMedSubstance Abuse and Mental Health Services Administration (SAMHSA), Office of Applied Studies. Results from the 2007 National Survey on Drug Use and Health: national findings. NSDUH Series H-34, DHHS Publication No. SMA 08-4343]. Rockville (MD): Substance Abuse and Mental Health Services Administration (SAMHSA); 2008. 306 p.

50. Seven Day F/U Measure • Inpatient psychiatric facilities with high rates of 7-day outpatient follow-up differed from those with low rates: • Staff were more knowledgeable about follow-up standards • Distributed information about the measure • Assessed compliance • Arrange for patients' aftercare appointments • Distribute aftercare cards Schwartz, et al: Improving aftercare effectiveness, 2007