EHRs/HIT for Integrated Behavioral Health in Primary Care Settings: Special Features to Support Care Coordination Within the Team April 16, 2015

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1 CiMH 15 th Annual Information Management Conference EHRs/HIT for Integrated Behavioral Health in Primary Care Settings: Special Features to Support Care Coordination Within the Team April 16, 2015 Michael R. Lardieri, LCSW AVP Strategic Program Development North Shore LIJ Health System

2 Behavioral Health Service Line Inpatient Programs 870 inpatient behavioral health beds in 12 hospital locations 688 psychiatry and 182 substance abuse Approx 17,000 inpatient discharges General Hospital Psychiatric Inpatient Unit Private Psychiatric Hospital State Psychiatric Hospital Residential Treatment Facility North Shore-LIJ Facility Lenox Hill 27 Psych Beds NSUH 26 Psych Beds Glen Cove 18 Psych Beds* Huntington 21 Psych Beds Syosset 20 Psych Beds SIUH-North 29 Psych Beds ZHH 221 Psych Beds Franklin 21 Psych Beds NUMC (affiliate) 133 Psych Beds 50 Sub Abuse Beds South Oaks 117 Psych Beds 52 Sub Abuse Beds Southside 20 Psych Beds SIUH-South 35 Psych Beds 80 Sub Abuse Beds Affiliated hospital

3 North Shore-LIJ Behavioral Health Clinic Sites 9/4/14

4 Healthcare Reform Goals: To increase access and reduce costs while providing better care, better health and increased patient satisfaction. This will be done by fostering innovation in the use of technology, better training of staff, enhanced application of evidenced based and personalized medicine and, very importantly, creating the right incentives.

5 Faces of Medicaid White Paper Mental illness is nearly universal among the highest cost, most frequently hospitalized Medicaid beneficiaries Center for Healthcare Strategies (2010)

6 % of Population with Behavioral Health Disorders One or More Past Year Disorders (Including Substance Use Disorders and Adjustment Disorder) 8 One or More Disorders 22.5% 1 Disorder 14.9% 2 Disorders 4.1% 3+ Disorders 2.2% Past Year Mental Disorders among Adults in the United States: Results from the Mental Health Surveillance Study SAMHSA CBHSQ Data Review October 2014 Authors Rhonda S. Karg, Jonaki Bose, Kathryn R. Batts, Valerie L. Forman-Hoffman, Dan Liao, Erica Hirsch, Michael R. Pemberton, Lisa J. Colpe, and Sarra L. Hedden

7 Life Expectancy from Presentation by Dr. Joseph Parks for NS-LIJ Health System July, No Mental Disorder Any Mental Disorder General Population Any Mental Disorder Public Sector Bar 1 & 2: Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Med Care June;49(6): Bar 3; Daumit GL, Anthony CB, Ford DE, Fahey M, Skinner EA, Lehman AF, Hwang W, Steinwachs DM. Pattern of mortality in a sample of Maryland residents with severe mental illness. Psychiatry Res Apr 30;176(2-3):242-5

8 Per Member Per Month Costs from Presentation by Dr. Joseph Parks for NS-LIJ Health System July, 2014 $1,600 $1,400 $1,200 $1,000 $800 $600 No Mental Disorder Any Mental Disorder $400 $200 $0 Private Sector Medicare Medicaid Melek et al Milliman Inc, 2013

9 MH/SU costs in NY State s Medicaid Program from Presentation by Dr. Joseph Parks for NS-LIJ Health System July, 2014 $30,000 $28,000 $26,000 $24,000 $22,000 $20,000 $18,000 $16,000 $14,000 $12,000 $10,000 MH Disorder SU Disorder No MH/SU Disorder Behavioral Health costs Physical Helath costs

10 Health Home Like Functionality as a Framework

11 What is Different about Health Homes? Individual Practitioner Episodic Care Focus on Presenting Problem Referral to meet other Needs Managed Care Manages access to care Does not change clinical practice Integrated Primary/Behavioral Health Care Team Continuous Care Comprehensive Care Management Coordinates care across the healthcare system Data driven population management Transforms clinical practice Emphasizes healthy lifestyles and self-management of chronic health problems Treatment as Usual Health Homes

12 Anticipated Health Home Results Improved patient outcomes and health status Improved coordination of primary care and behavioral health Reduced inappropriate ED utilization Reduced avoidable inpatient utilization Enhanced use of community resources and reduction in nonmedically required residential stays Reduction in health care costs

13 Health Home Target Populations Patients with Diabetes At risk for cardiovascular disease and a BMI > 25 Patients who have two of the following COPD/Asthma Diabetes (also as single condition) Cardiovascular Disease BMI>25 Developmental Disabilities Use Tobacco Individuals with a serious mental illness; or with other behavioral health problems who also have Diabetes COPD/Asthma Cardiovascular Disease BMI>25 Developmental Disabilities Use Tobacco Primary Care Health Homes CMHC Healthcare Homes

14 Missouri s Health Homes Providers 18 FQHCs 67 Clinics 6 Hospitals 22 Clinics 14 Rural Health Clinics Enrollment 15,526 adults 428 children 15,954 total Primary Care Health Homes Providers 28 CMHCs 120 Clinics/Outreach Offices Enrollment 16,611 adults 2,387 children 18,998 total CMHC Healthcare Homes

15 Principles One Team CMHC s composed of pre-2012 CPRC staff plus NCM and PC Consultant PCHH s composed of new infrastructure and team members One Treatment Plan for the Whole Person Rehab Goals Medical Goals Healthy Lifestyle Goals Some Goals and Outcomes reference Health Home Performance Measures Wrap Around approach to outside treating PCP, mental health providers, community supports, etc

16 It Does Work!!!

17 LDL Changes in PCHH Patients with Initially High Levels HA1c Changes in PCHH Patients with Initially High Levels p< p< Pre Post Pre Post Systolic Blood Pressure Changes in PCHH Patients with Initially High Values p< Diastolic Blood Pressure Changes in PCHH Patients with Initially High Values p< Pre Post Pre Post

18 Outcomes Medication Adherence % Continuously enrolled CMHC Health Home Clients with an MPR >.80 by Medication Type 85% 84% 83% 82% 81% 2/1/2012 1/1/ % 79% 78% 77% 76% Pscyhiatric Cardiovascular Asthma/COPD CMHC Healthcare Homes

19 Outcomes Reducing Hospitalization Primary Care Health Homes CMHC Healthcare Homes

20 % Enrollees with ER Events for PCHH Members with at Least 8 Months of Service and Who Were Initially Enrolled during First Quarter % 50% 0% 34% Chronic Health Conditions 81% 69% 56% 37% 3% Number of ER Events By Month Since Enrollment PCHH ER Events Linear (PCHH ER Events) Months in Health Home (0=Admission Month)

21 Intial Estimated Cost Savings after 18 Months Health Homes 43,385 persons total served (includes Dual Eligibles) Cost Decreased by $51.75 PMPM Total Cost Reduction $23.1M DM persons total served (includes Dual Eligibles) Cost Decreased by $ PMPM Total Cost Reduction $22.3M

22 What Makes it Possible? A Relationship of Basic Trust between: Department of Mental Health Mo HealthNet State Budget Office MO Coalition of CMHCs MO Primary Care Association Transparent use of Health Information Technology to identify and monitor problems, and assess performance Willingness of all partners to tolerate risk Funding Primary Care Nurse Care Managers Lot s of Training and Practice Coaching

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24 EHRs Not Built for Integration There are few if any EHRs that are built for Physical and Behavioral Health Integration for a licensed Mental Health or licensed Substance Use agency perspective Medical EHRs are moving to integrate Behavioral Health Behavioral Health EHRs are moving to integrate some medical information Both do an inadequate job at this point in time

25 Misunderstanding of HIPAA and 42 CFR Part 2 Regulations Providers in the same organization can view behavioral health and medical information without any HIPAA or Part 2 violations Some behavioral health providers still want all information sequestered and unavailable to medical staff This does not support integrated care efforts and is unwarranted Difficulties understanding legal arrangements for partnering In the FQHC world there are specific requirements FTCA coverage can be an issue These are not insurmountable Issues

26 What HIT Functionalities are Necessary to Tie this all Together?

27 Focus on High Utilizers 20% of the Population uses 80% of Resources or 15% of Population uses 50% of Resources

28 Define your population Assess your population who is a high utilizer or a potential high utilizer Predictive modeling (a more advanced application) Stratify the population Not all high utilizers need high touch. They may be stable with supports and using services appropriately for their condition at the time Engage the identified patients Manage the identified patients

29 Assessment Tools to Identify At-Risk Populations What do you have available? Practice Management System only? EHR + PMS only? More sophisticated and integrated systems including claims data?

30 Integrated Treatment or Care Planning Tools Fully Integrated Tools Plans based on Patient Acuity Episodic Care Planning Might be redundant but still useful

31 Ability to Assign Roles and Responsibilities Automated Referrals Referrals generated via a network Manual Referrals Role Based Access to the Care Plan Non Role Based Access is still Workable but cannot Audit

32 Data Sharing & Access to Information Centralized, single view by all providers Providing Consolidated and aggregated data HIPAA compliant Multiple systems need to be viewed Not ideal but still workable

33 Analytics Sophisticated Informatics Platform including Unstructured Data Ability to Query Individual Care Plans Sophisticated Population Health Management Tools Only Provides ad hoc reporting

34 Monitoring Evaluation tools to measure individual care plan progress Universal access for all caregivers Basic patient data without measurement tools Access limited to only some individuals i.e. care managers only

35 Communication Alerts and notifications to all providers depending on roles Use of many different forms of communication including text, , voice, remote monitoring data Access limited to only some individuals i.e. care managers only who then communicate with others

36 Patient Friendly/Centered Patient communicates with one key person throughout the continuum of their care Patient communicates with various providers who then coordinate among each other Patient has access to the tool via a secure portal

37 It is a Continuum You may not have the most sophisticated tools when you begin We are starting with a mix of EHR and PMS data

38 Healthcare Analytics Adoption Model Level 8 Level 7 Level 6 Personalized Medicine & Prescriptive Analytics Clinical Risk Intervention & Predictive Analytics Population Health Management & Suggestive Analytics Tailoring patient care based on population outcomes and genetic data. Fee-for-quality rewards health maintenance. Organizational processes for intervention are supported with predictive risk models. Fee-for-quality includes fixed per capita payment. Tailoring patient care based upon population metrics. Feefor-quality includes bundled per case payment. Level 5 Waste & Care Variability Reduction Reducing variability in care processes. Focusing on internal optimization and waste reduction. Level 4 Automated External Reporting Efficient, consistent production of reports & adaptability to changing requirements. Level 3 Automated Internal Reporting Efficient, consistent production of reports & widespread availability in the organization. Level 2 Standardized Vocabulary & Patient Registries Relating and organizing the core data content. Level 1 Enterprise Data Warehouse Collecting and integrating the core data content. Level 0 Fragmented Point Solutions Inefficient, inconsistent versions of the truth. Cumbersome internal and external reporting. Dale Sanders Copyright 2013 Health Catalyst.

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40 Contact Info Michael R. Lardieri, LCSW AVP Strategic Program Development Behavioral Health Service Line North Shore LIJ Health System Website: