Transitioning to The Health Home Model in PSH. Presented by Eric Morse, LISW-S, Chief Operating Officer

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1 Transitioning to The Health Home Model in PSH Presented by Eric Morse, LISW-S, Chief Operating Officer

2 Our Mission Reaching out to adults and children in Northeast Ohio to end homelessness, prevent suicide, resolve behavioral health crises and overcome trauma

3 MHS is a not-for-profit, 501(c)(3) corporation founded in 1988, providing mental heath and supportive services in Cuyahoga County for more than 14,000 adults and children each year. It operates the most comprehensive singe-agency continuum of care services for homeless people in Ohio. 16 homeless assistance programs provide assertive outreach, emergency shelter, residential services, case management, and psychiatric services. The services assist clients to achieve and maintain permanent housing and recovery from their mental disorder. The MHS Mobile Crisis Team operates the County s 24 hour suicide hotline and is the sole County provider of 24 hour mobile crisis intervention services for children and adults.

4 Cuyahoga County Housing First Community wide partnership led by Enterprise Community Partners, Cuyahoga County Office of Homeless Services and the City of Cleveland Targeted Permanent Supportive Housing to meet the needs of residents experiencing chronic homelessness The goal is to create 1,000 units to end chronic homelessness in Cuyahoga County Criteria includes those experiencing severe mental illness, chronic substance use or co-occurring disorders Many experience chronic physical health issues as well

5 Housing First Client Profile Severe and Persistent Mental Illness 65% Severe Alcohol or other Drug Dependency 75% Serious Physical Health Issues 50% Past Criminal Justice Involvement 70% Average Days Homeless Prior to moving in 700 days Employment Rate at Entrance 1% Average Income at Entrance - $370 Male 61% African-American - 69% Veterans 17% Average Age 45 years old

6 Outline Current Medicaid support for our PSH Current Level of Integration Why Change to Health Home Model? Overview of Ohio Model Lessons Learned and Challenges

7 Current Medicaid Funding Current Service Funding 60% HUD SHP 30% Medicaid 10% Local grant support Fee for Service system Community Psychiatric Supportive Treatment Medically Necessary Interventions Disincentives Integration Reimbursement rate has been flat for 15 years Rewards Volume over Quality

8 Current Level of Integration Clients meet Quadrant IV criteria but we provide a Quadrant II level of Integration Established informal relationships with two FQHC s (uses a lot of paper communication) One nurse funded by United Way of Greater Cleveland to serve 400 clients in Housing First Focus of service is on Housing and Behavioral Health Issues Funding reasons Agency culture and competencies

9 Why Health Home Model in PSH? Even with good outcomes, health outcomes remain worse than general population Last year the mortality rate in PSH was 3% Better care Emerging Best-Practice Changing funding environment

10 Ohio Health Homes Plan still being finalized with CMS Target population: Serious and Persistent Mental Illness & Serious Emotional Disturbance Eligible Providers: Current Community Mental Health Centers Services begin in Four Counties Starting in October more Counties will begin in April 2013 including Cuyahoga County Information from June 22 nd webinar, for more info:

11 Goals of Health Home Improve care coordination for clients with SPMI Improve Integration of Physical and Behavioral Health Care Improve health outcomes Lower rates of hospital emergency department use Reduce hospital admissions and readmissions Decrease reliance on LTC facilities Improve the experience of care and quality of life for the consumer Reduce healthcare costs

12 Must have the capacity to provide ALL health home service components: Comprehensive Care Management Care Coordination Health Promotion Comprehensive Transitional Care & Follow-up Individual and Family Supports Referral to Community and Social Support Services Use of health information technology to link services

13 Ohio Health Homes, cont. Team Leader Care Coordinator Proposed interdisciplinary team Embedded Primary Care Provider Mental health SA treatment Social work Nursing Single integrated plan of care Including health promotion

14 Ohio Health Homes, cont. Must achieve full HIT capability interoperable electronic health records Must offer access to all qualified Medicaid enrollees in service area Reimbursement is moving to a Fee for Service Case Rate Model (get paid for each client seen at least once in a month)

15 Lessons Learned/ Recommended Steps Develop a model Identify Partners Locations and Settings Team make-up Identify protocols and interventions distinct from current practices Write it down Find capacity building funding opportunities Address Electronic Medical Record Needs Pilot or start small: SAMHSA CABHI: Bridges to Housing (capacity building and experience)

16 Health Home Model (Still Under Construction) MHS would have two to three of the following teams MHS will contract with Health Care for the Homeless Provider (Care Alliance) for Embedded Primary Care Health Home Team Leader LISW, LPCC or MSN Care Manager Minimum 3 year RN Care Manager Minimum 3 year RN 125 Clients 125 Clients

17 SAMHSA CABHI Grant Goal to end chronic homelessness (Highly Targeted) Use Critical Time Intervention Integrates primary health care on team Expedited benefits Capacity Building Community Consortium

18 Challenges The Health Home Model in Ohio can only serve SPMI which only makes up 65% of PSH residents (what about chronic substance abusers?) How to integrate with HUD funding Devil is in the details (will the State reimburse at the level needed to implement) Relationships are hard work Funding for EMR (BH left out of stimulus funding) Workforce development in Health Related Services Recruiting new employees

19 Contact Information Eric Morse, COO Mental Health Services for the Homeless 1744 Payne Ave Cleveland, Ohio

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