Physical & Behavioral Health Integration: Health Home Models BEST Meetings March, 2014

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1 Physical & Behavioral Health Integration: Health Home Models BEST Meetings March, 2014

2 Community Care Quick Facts A nonprofit recovery-oriented behavioral health managed care company Provider-owned (UPMC) Incorporated in 1996 and headquartered in Pittsburgh, PA Federally tax exempt nonprofit 501(c)(3) Major focus is publicly-funded behavioral health care 2

3 Mission and Vision Improve the health and well-being of the community through the delivery of effective and accessible behavioral health services Improve the quality of services through a stakeholder partnership focused on outcomes Support high-quality service delivery through a nonprofit partnership with public agencies, experienced local providers, and involved members and families 3

4 Organizational Structure Key levels: executive management team, senior management team, and dedicated front-line staff Workforce includes individuals with a lived experience of mental illness, persons in recovery, and individuals from Welfare-to-Work programs Qualified, professional clinical staff experienced with the populations they serve Hire local people Member and family input 4

5 Major Strengths Responsive to partners, providers, community, and member needs Proven success: improved outcomes and well-being Fiscally accountable: good stewards of public resources Innovative and recovery-oriented programs and services State-of-the-art technology to support program goals Experienced and dedicated leadership and staff 5

6 HealthChoices Regions Served Erie Crawford Mercer Lawrence Butler Beaver Allegheny Washington Greene Venango Armstrong Westmoreland Fayette Clarion Warren Forest Jefferson Indiana Somerset Cambria McKean Elk Clearfield Cameron Bedford Fulton Potter Clinton Centre Franklin Tioga Mifflin Lycoming Cumberland Adams Bradford Luzerne Columbia Montour York Sullivan Juniata Blair Perry Dauphin Lebanon Huntingdon Lancaster Susquehanna Wyoming Lackawanna Union Carbon Northumberland Snyder Schuylkill Berks Chester Wayne Monroe Pike Northampton Lehigh Bucks Montgomery Delaware Philadelphia Southwest Region Southeast Region North Central Region: County Lehigh-Capital Region North Central Region: County North Central Region: County Northeast Region North Central Region: County North Central Region: State Community Care Office 6

7 Focus on Recovery Peer & Family Involvement Recovery Transformation Physical & Behavioral Health Integration Person with Lived Experience Focused Care Management Model Respecting Individual Differences Systems Integration (Children & Youth) 7

8 Supporting Best Practices Work to improve access and address disparities Communicate expectations and support providers Provide training and oversight Preserve community-based services Promote effective dialogue among government and community stakeholders 8

9 BH/PH Quick Facts People with behavioral health (BH) conditions are at higher risk for physical illness and disability The cost of medical care for them is, on average, much higher than the cost of medical care for people without BH conditions (United Hospital Fund in New York City report) Medicaid recipients with mental health conditions are 30-60% more likely to have hypertension, heart disease, pulmonary disorders, diabetes, and dementia People with substance use disorders are % more likely to have heart disease, pulmonary disorders, and HIV/AIDs 9

10 System Failure BH and physical health (PH) systems have failed to systematically address and support prevention and wellness across all populations, especially the most vulnerable such as adults with SMI Recovery must include a focus on wellness and physical health Improving the life expectancy of individuals with behavioral health conditions requires improved wellness and prevention Many recovery goals are not possible with physical health challenges 10

11 Why System Needs to Improve Better integration of PH and BH can lead to positive outcomes for patients Various research shows that the use of nurse and health navigators who provide comprehensive care management, care coordination, and health promotion can: Help to engage underserved populations Help patients set health-related goals and access medical- and community-based services Improve preventive care, cardiac care, mental health quality of life measures Reduce costs 11

12 Collaborating Framework Integration of health, wellness, prevention activities, and PH/BH interventions are best achieved through local collaborations The existing BH system can be enhanced to support good health outcomes for persons with SMI and/or substance use disorders, and concurrent serious physical conditions Community Care s commitment to overall health- and recovery-based programs for its membership 12

13 BH/PH Integration Implemented use of Medicaid PH pharmacy data in the development of disease management programs for mental illness; identification of best practices Supporting protocols to expand access to BH services in primary care settings (especially IMPACT model) Developed implementation strategies for chronic care model of integrated BH/PH, including two-way data sharing with PH-MCOs Participation in SMI Innovations Project with OMHSAS and Center for Healthcare Strategies (Connected Care in southwest) 13

14 Health Home Eligibility Health Homes The Affordable Care Act of 2010, Section 2703, created an optional Medicaid State Plan benefit for states to establish Health Homes to coordinate care for people with Medicaid who have chronic conditions by adding Section 1945 of the Social Security Act. CMS expects states health home providers to operate under a "wholeperson" philosophy. Health Homes providers will integrate and coordinate all primary, acute, behavioral health, and long-term services and supports to treat the whole person. 14

15 Health Home Eligibility Health Homes are for people with Medicaid who: Have 2 or more chronic conditions Have one chronic condition and are at risk for a second Have one serious and persistent mental health condition Chronic conditions listed in the statute include mental health, substance abuse, asthma, diabetes, heart disease and being overweight. Additional chronic conditions, such as HIV/AIDS, may be considered by CMS for approval. States can target health home services geographically States can not exclude people with both Medicaid and Medicare from health home services 15

16 Health Home Services Comprehensive care management Care coordination Health promotion Comprehensive transitional care/follow-up Patient & family support Referral to community & social support services 16

17 New York State Health Home Model A Health Home is a care management service model whereby all of an individual's caregivers communicate with one another so that all of a patient's needs are addressed in a comprehensive manner. This is done primarily through a "care manager" who oversees and provides access to all of the services an individual needs to assure that they receive everything necessary to stay healthy, out of the emergency room and out of the hospital. Health records are shared (either electronically or paper) among providers so that services are not duplicated or neglected. The health home services are provided through a network of organizations providers, health plans and community-based organizations. When all the services are considered collectively they become a virtual"health Home. *NY DOH Website 17

18 Targeted Case Management and HH Targeted Case Management (TCM), specifically the COBRA HIV/AIDS TCM and the OMH TCM, plays a significant role in assisting eligible Medicaid individuals gain access to needed medical, behavioral, and social services. With implementation of Health Homes, the Department of Health's Medicaid program, AIDS Institute, and the Office of Mental Health developed the following draft guiding principles and scenarios to help understand the role of TCMs relative to Health Homes. These documents discuss TCMs and "converted" TCMs. Converted TCMs are Medicaid enrolled targeted case management programs that, once approved by the State, are designated Health Homes, or participate in a State approved Health Home network. *NY DOH Website 18

19 Managed Care Roles and Responsibilities in HH Management 1.MCOs contracting for Health Home services must utilize NYSDOH designated Health Homes and have a signed contract (Administrative Health Home Services Agreement) with the Health Home 2.MCOs assign patients to NYSDOH designated Health Homes based on Health Home eligibility lists received from NYSDOH utilizing loyalty and attribution data as augmented by MCO data 3.MCOs will bill Health Home services through emedny using a Managed Care Plans MMIS identification number and Health Home rates 4.MCOs can retain up to three percent (not to exceed amount established in the Administrative Health Home Services Agreement) of the Health Home fee and pass the rest through to the Health Home unless additional services have been negotiated 5.MCOs will continue to manage all in-plan services for Health Home members but will contract with Health Home care managers to coordinate services *NY DOH Website 19

20 Managed Care Roles and Responsibilities in HH Management 6.MCOs and Health Homes share responsibility for outcomes for patients that are assigned to Health Homes 7.MCOs will share member PHI with the Health Home that provides services. Guidance for sharing information prior to member consent can be found here. 8.MCOs with members currently in OMH and AIDS/HIV COBRA, MATS and CIDP targeted case management (TCM)converting programs will follow special guidance for these individuals. MCOs do not assign existing TCM patients to Health Homes, converting TCM programs assign their members to the Health Home that will best meet the member's needs and preserve the care management relationship. MCOs will work with TCM programs through Health Homes on behalf of members in existing TCM slots to coordinate care and share data. 9.Health Homes must utilize the MCOs contracted network of providers for services that are included in the benefit package when arranging for care for Health Home members. MCOs may opt to expand provider networks based on Health Home member need. *NY DOH Website 20

21 Health Home Agreements with MCO s There are three options available for Health Homes to enter into Administrative Health Home Services Agreements with Managed Care Organizations (MCOs): 1) MCOs may develop plan-specific agreements for Health Home services. Plan specific agreements must include the Key Contract Provisions that were developed collaboratively between the MCOs, the Health Homes and NYS. The MCO must submit the plan specific agreement to the NYSDOH Division of Health Plan Contracting and Oversight, Bureau of Managed Care Certification and Surveillance for review and approval. Once the MCO has an Approved Agreement for Health Home services on file with the Bureau of Managed Care Certification and Surveillance, the MCO and Health Home can use that as a template to negotiate mutually acceptable agreements/contracts. Changes may be made to the Approved Agreement, but the amended agreement must be submitted once again by the MCO to the Bureau of Managed Care Certification and Surveillance for final approval. 21

22 HH Agreements with MCO s 2) If the MCO does not have a plan specific Approved Agreement on file with the Bureau of Managed Care Certification and Surveillance, or if the Health Home and MCO are unable to negotiate a mutually acceptable agreement/contract using the Approved Agreement, the Standard Agreement can be used. The signed agreement must be submitted by the MCO to the Bureau of Managed Care Certification and Surveillance for review and approval. 3) If the MCO and Health Home modify the Standard Agreement, the modified Standard Agreement must be submitted by the MCO to the Bureau of Managed Care Certification and Surveillance for review and approval. When approved it becomes a plan specific Approved Agreement on file for that MCO. 22

23 NCQA Guidelines NCQA has recently published guidance related to accreditation for health plans that are participating with state Medicaid agencies in the implementation of Health Home programs. This information supplements the Technical Assistance Tool, "Implications of Health Homes for NCQA Health Plan Accreditation", published on line at the Integrated Care Resource Center. This information is important for plans in New York State who are participating in the Health Home implementation that are NCQA accredited. In the Health Home project, the health plan is delegating an NCQA standard activity to a, generally, non-ncqa recognized provider. Delegation under the NCQA standards has very specific requirements which include pre-delegation evaluations, delegation agreements and monitoring activities. NCQA is allowing certain short term modifications to requirements for managed care plans implementing a Health Home. The application of these modifications will vary by plan structure and time in the accreditation cycle. It is important for plans to have their accreditation specialist review these documents and communicate directly with NCQA to determine the applicability of these modifications to the particular plan. The New York State Department of Health will provide to requesting plans documentation that the Health Homes working with their plans are approved by the state for this purpose and the nature of the funding 23 structure for Home activities.

24 CMS Core Quality Measures for HH 1.Adult Body Mass Index (BMI) Assessment, 2. Ambulatory Care - Sensitive Condition Admission, 3. Care Transition Transition Record Transmitted to Health care Professional, 4. Follow-up After Hospitalization for Mental Illness, 5. Plan- All Cause Readmission, 6. Screening for Clinical Depression and Follow-up Plan, 7. Initiation and Engagement of Alcohol and Other Drug Dependence Treatment, 8. Controlling High Blood Pressure. 24

25 Other Models 25

26 Connected Care Program Initiative to improve the connection and coordination of care for those with SMI among health plans, PCPs, and BH providers in outpatient, inpatient, and emergency department settings Based on Patient-Centered Medical Home model with integrated care team and care plan to address all medical, behavioral, and social needs Partnership between: Center for Health Care Strategies (CHCS) Department of Public Welfare (DPW) UPMC for You and UPMC for Life Specialty Plan Community Care Allegheny County Department of Human Services 26

27 Connected Care Outcomes Decreased mental health admissions Decreased readmissions Increased number of days in the community between admissions 27

28 Expanding Connected Care Designed to demonstrate the efficacy of care coordination of PH/BH services for individuals with SMI and co-occurring medical conditions in a Medicaid and dual-eligible BH carve-out Combines technological infrastructure, data management, and clinical expertise of a BH-MCO and a BH provider-based care coordination model Expands on Community Care s Allegheny County Connected Care program Embeds nurses in case management, peer, and psych rehab programs Provides wellness coach training to case managers, peers, and other staff Includes a patient-driven personal health record Web portal Development of structured strategies for specific wellness challenges for individuals with BH conditions underway 28

29 Behavioral Health Home Plus (BHHP) Successful collaboration with Community Care and BH providers in North Central state option region of PA over the past two years: Creating a health home in behavioral health agencies Development of a wellness culture through wellness coaching training Case managers, certified peer specialists, and nurses as health navigators Web-portal wellness tools and resources 29

30 BHHP Follow the evidence Community Care and North Central provider implementation experience to date is positive and encouraging Improve the competence of BH providers to engage and support individuals in treatment with wellness coaching and health navigator roles Evaluate all efforts Outcome measures Develop financial models to sustain successful project 30

31 PCORI Grant Recipient Optimizing Behavioral Health Homes by Focusing On Outcomes That Matter Most for Adults with Serious Mental Illness $1.7 million dollar three-year grant from the Patient-Centered Outcomes Research Institute (PCORI) Focus on patient- and provider-directed interventions to address wellness and PH concerns Builds on prior work in North Central state option region of Pennsylvania 31

32 A Multi-Stakeholder Collaboration Strong emphasis on patient and stakeholder involvement in all stages of the study, from proposal development through implementation, and dissemination of results Implemented under the guidance of a Stakeholder Advisory Board with implementation support from the UPMC Center for High-Value Health Care, BHARP, and Community Care Main partners include: Community Care UPMC Center for High-Value Health Care University of Pittsburgh Individuals with SMI (2,200) Providers (11) 32

33 A Unique Opportunity Unique opportunity to study the effectiveness of wellness interventions for individuals with SMI across 11 Community Mental Health Centers (CMHC) in the North Central and Chester regions Clustered randomized design using mixed methods to examine impact of strategies/interventions on patient-centered outcomes Will compare two promising strategies for promoting the health, wellness, and recovery of adults with SMI 33

34 Promising Strategies Provider-Supported Integrated Care Uses registered nurses on staff at participating facilities to work with patients on coordinating their care, enhance communication between providers, and provide patient wellness support and education Self-Directed Care Service delivery at self-directed facilities to focus on providing tools, education, and resources that activate patients to be more informed and effective managers of their health and health care 34

35 Promoting a Culture of Wellness Both strategies promote a culture of wellness and utilize case managers and certified peer specialists as health navigators Wellness coaching supports the development of a behavioral health home model and a foundation for a culture of wellness and recovery Training program developed by national wellness expert, Dr. Peggy Swarbrick 35

36 Multiple Evaluation Strategies Comparative effectiveness study to examine impact of wellness interventions on patientcentered outcomes Applying research methods in real-world settings Interviews Patients Providers Secondary data Use of existing claims and administrative data Self report Survey measures 36

37 Outcomes That Matter Primary outcomes Health status Activation in care Engagement in primary/specialty care Secondary/exploratory outcomes Mental health symptoms, hope, quality of life, medication use, functional status, emergent care, lab monitoring, individual and family satisfaction with care Covariates Engagement in interventions, cognitive status, social support, severity of mental illness, medical stability, patient demographic, and clinical characteristics 37

38 Research Questions Given my mental and physical conditions, what should I expect will happen to my overall health, wellness, and recovery when I engage in the new services offered by my CMHC? If I choose to participate in these services, what are the potential advantages or disadvantages to me? In what ways can I become more active in managing my own health and health care? Which of the services that my CMHC could make available to me will impact outcomes that I care about and help me make the best decisions about my health and care? 38

39 C-SNP Chronic Condition Special Needs Plan (UPMC Community Care) Medicare Special Need Plan (SNP) for persons with serious mental illness (SMI) led by behavioral health MCO and based in behavioral health provider settings SMI is defined as having one of the following: Bipolar Disorder Major Depressive Disorder Paranoid Disorder Schizophrenia Schizoaffective Disorder Plan may serve persons who are dual eligible (Medicare and Medicaid) and non-dual (Medicare only) 39

40 C-SNP Goals Improve member experience through communicative, convenient, accountable and customer service oriented health care plan Better coordination of benefits through Medicaid and Medicare Build a model in primary and behavioral health care coordination 40

41 C-SNP Model The C-SNP Model includes: Behavioral Health Home Improved access to care Additional focus by the physician and interdisciplinary team Better coordination of members needs Facilitate access to preventive services Prevent unplanned care and uncoordinated transitions Information sharing, data, and reporting Enhanced Medicare benefits 41

42 Contact Information James Schuster, MD, MBA Chief Medical Officer Carole Taylor, MSN, RN Chief Clinical Officer Kelly Lauletta, LCSW, Regional Director HRR Community Care Behavioral Health Organization One Chatham Center, Suite Washington Place, Pittsburgh, PA

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