REACH Health Services Health Home. Collaborative Care Summit April 16, 2015

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1 REACH Health Services Health Home Collaborative Care Summit April 16, 2015

2 Health Homes Health Homes are behavioral health organizations that assist participants in improving overall wellness through a wholeperson approach to addressing their behavioral, somatic, and social needs. The Health Home allows OTPs to expand upon their existing services, building upon and adding to their staff and activities to better serve participants. Health Homes connect participants to various supports and services, offer health promotion activities, and monitor somatic and behavioral health needs.

3 The Health Home Team Nurse Care Manager External care providers & other supports MD/NP Consultant Patient Admin staff Health Home Director Counselor

4 Health Home Team Member Roles Counselors Work with patients to develop HH goals for treatment plan Review/update treatment plan every 6 months Provide monthly HH services to HH patients on caseload Provide HH services consistent with patients treatment goals Coordinate care with Nurse Care Manager for patients who are medically complex Nurse Care Manager (NCM) Maintain caseload of up to 250 patients Work with patients and counselors to develop and implement treatment plans Care coordination for most complex patients 24-hour follow-up with patients who have been to the ER or hospitalized Provide health promotion and education to patients

5 Health Home Team Member Roles Health Home Director Trains care team on health issues, resources, etc. Identifies quality improvement opportunities Population-level care management Provides HH services Partnership building with clinics, hospitals, other organization Assures all HH regulatory and accreditation requirements are met General administrative oversight MD/NP Consultant Signs off on and/or performs initial intake assessment and treatment plans Consults on medical issues as necessary Coordinates with external medical providers Participates in case reviews and quality improvement efforts Provides training to staff

6 The Challenge for Our Patients Those with substance use disorders face unique barriers in addressing physical health needs, resulting in poorer health outcomes, lower engagement in preventive health efforts, and high rates of avoidable hospital and emergency room visits. The complexity of managing the substance use disorder often increases the challenge of treating and preventing chronic health issues, both behavioral and somatic.

7 Challenges for our Patients Stigma in the community Community providers not receptive to the population Patient experience of care Few family/supportive other resources Burned a lot of bridges Health literacy Capacity to obtain and process

8 The Challenges for our Clinic Integrating the Health Home into the daily fabric of the treatment program Traditional medical care does not use the same approach as the HH The model is very much aligned with Social Work and Nursing models of care Missed appointments High users take up a lot of time

9 Health Home Team Member Roles Admin support staff Data management and reporting Schedules HH staff and participants Assists with chart audits Reminds participants regarding keeping appointments, filling prescriptions, etc. Requests and sends medical records for care coordination Intake Coordinator Coordinates HH enrollment for new OTP intakes Billing staff Seeks reimbursement for HH services Management team Provides leadership and supports HH integration

10 HH Intake Process New OTP Admissions HH intake process is completed at OTP intake HH Director coordinates with counselor to develop Health Home goals for patient MD/NP signs off on intake assessment and patient is enrolled in emedicaid system Current OTP Patients Current patients are referred ( , phone call; no special referral forms)to Nurse Care Manager, who completes Health Home intake NCM coordinates with counselor to develop Health Home goals for patient MD/NP signs off on intake assessment and patient is enrolled in emedicaid system

11 Health Home Services How we fund the HH! We must perform 2 HH services for each patient each month to be reimbursed The 2 services can be performed at the same time Counselors, nurses, MD, NP, and administrative staff can perform HH services if it is appropriate (i.e., as long as they are trained or licensed to provide a specific service). For example, administrative staff can remind patient of an upcoming appointment but cannot provide health education Counselors can provide HH services during their regular counseling session, but they must document the service(s) with a HH case note Beware double dipping! Any services that are specific to substance use treatment cannot be documented as HH services For example, referral for residential treatment.

12 The billable HH services: Treatment Plan updated (health goals) Treatment Plan progress reviewed with patient (health goals) Communication with other providers and supports, specify type of provider: Medical scheduling assistance, specify type of provider: Health education regarding a chronic condition Sexuality education and family planning Smoking prevention or cessation Nutritional counseling Physical activity counseling, planning

13 The Billable Health Home Services Counselors Helping patients schedule medical appointments Creating or updating health goals on the treatment plan Counseling on behavior change (quitting smoking, nutrition, exercise, safe sex, taking medications, keeping medical appointments) Health education Help patients obtain or maintain housing, transportation, legal services, disability benefits, etc.

14 These are not billable HH services Referring a patient to the Health Home program Internal communication with IBR staff about a patient health issue Giving a patient a pamphlet on a health topic to read (e.g., smoking cessation pamphlet) but not discussing it Health education provided in OTP groups

15 Outcomes Reporting We are required to report on patient clinical and social indicator outcomes every 6 months We can gather the outcomes data from medical records, collecting it ourselves (blood pressure, weight), or asking the patient The HH Director and NCM are responsible for managing outcomes reporting, but will ask counselors to assist with collecting outcomes data from patients.

16 Outcomes Asthma severity Supplemental oxygen dependency HbA1C LDL-c Blood Pressure Weight Height BMI Medication Compliance-mental health prescription Tobacco Intake Physical Activity Substance Abuse Relapse Appointment Compliance Employment Education Attainment Residential Status Recent Legal Incidents

17 Questions? Vickie Walters, LCSW-C Executive Director Institutes for Behavior Resources, Inc. REACH Health Services , ext. 115

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