How To Improve Health Care For Veterans
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1 Utilizing Bundled Technology to Prevent Re-Hospitalization Among Substance Dependent Patients At High Risk of Relapse New Zealand Presentations
2 AGENDA Brief Review of Loyola Model Key Current Business Components US and New York State Healthcare Environment mpower A Model Program Using the ACHESS Platform ACHESS Details Closing Thoughts on Health System Needs and the Need to Change Thinking on Addiction Treatment August2013
3 The Challenge Can outpatient mental health, primary care and substance treatment outpatient service arrays be altered or augmented with evidence based tools to minimize risk for chronically relapsing substance dependent patients?
4 Loyola Model Review Provide an Aspirin for US Veterans Administration Healthcare Headaches for Veterans with Complex Care, Addiction, Housing, Employment and Behavioral Health Needs. Loyola Rubric: Better Care as Evidenced by Clinical Outcomes and Patient Satisfaction; Lower Price; Expanded Service; Proof of Concept that Evidence Based Medicine, Innovation and Integration are possible. August2013
5 Loyola Model Review Continued Maintain Rubric in Accordance with a Recovery Vision Veterans Support: Recovery = Health, Job, Home, Relationships ( A Life in the Community For Everyone Charles Curie) Care Questions Normalized to the Voice of the Veteran with Veteran Governance. Services Build Mutual Reinforcement by providing Veteran Employment.
6 Loyola Service Matrix Evidence Based Addiction Medicine Housing Inpatient Crisis Services and Outpatient Specialty Support (mpower) Permanent and Transitional Housing, Employment and Peer Support Modeling Evidence Based Care and Integration Teaching the Loyola Method for Community VA Partnership Mutually Reinforcing Model of Loyola Job Creation Employment August2013
7 Loyola Model Service Components 50 Crisis Detoxification Beds (Bath, Albany VAMC s 25 Each). Eaglestar Housing 15 Transitional Beds in East Pembroke, 15 in Spencerport and SPARC. mpower Outpatient Model for At Risk Veterans. VITAL Intervention Project with Rochester General Hospital. Operation Economic Freedom Call Center
8 US and New York State Healthcare Environment Affordable Care Act seeks to bend the cost curve through effective management of high risk/high need patients. September, 2012 Presidential Executive Order directs VA to Contract with Community Healthcare Providers for Service needs not met by VA. IOM Report (September 2012) indicating high opioid/alcohol prevalence among veterans and low infrastructure
9 US and New York State Healthcare Environment Integrated Specialty Care Components based on evidence based models with Pay for Performance approaches Sought by Healthcare entities ( build or buy ) to capture savings. Adoption of Meaningful Use EHR s, Predictive Analytics and Mobile Technologies Essential (Loyola has all three). Track Record, Accreditation, Quality Assurance.
10 US and New York State Healthcare Environment All Services Being Shifted to Medicaid as enrollments begin in State Healthcare Exchanges; up to 30 Million New Enrollees Possible Most State Medicaid Plans have moved to or are moving to Care Management Technology is facilitating the development of Virtual Coordinated Care Management EHR s, Health Information Exchanges, Remote Monitoring, addressing Health related needs (broadly defined).
11 Key Assumptions in US Affordable Care Act Healthy, younger Americans will Enroll in Healthcare Exchanges to balance risk Existing US Primary Care, Hospital and Behavioral Health System can absorb 30 Million more users Existing High Utilizers of Healthcare will be managed into changing High Risk Behaviors Employers will maintain coverage for employees throughout the transition Physicians and Health Systems will engage incentives and build Accountable Care Organizations
12 mpower In 2010, Loyola identified 43 Veterans with 3 or more Detoxification Hospitalizations in 18 months or less. Similar profiles of chronic alcohol dependence, trauma, mental health condition and physical illness Every detox episode offered the same thing for a recovery support strategy Health kept deteriorating and Risk Factors were rising
13 mpower Loyola designed a bundled evidence based care and integration strategy combining cutting edge technology in, smartphone recovery support (ACHESS), pharmacological recovery support (Vivitrol), trauma support (Najavits, et.al.) and peer support (White, et.al.). Strategy defined as mpower Program (Mobile Patient Opportunities for Wellness, Empowerment and Recovery)
14 mpower SAMHSA funded project for 3 years ( ) Service Partners: University of Wisconsin ACHESS Project, Westat (Evaluation). Key metric for the program is to reduce inpatient hospitalization rate to 1 or less every 18 months. Data Collected: GPRA, SF-36, Brief Alcoholism Monitor BAM (weekly analytic)
15 mpower Project integration strategy is that mpower medical providers are credentialed by VA Health System and project works as collaborative care model with VA Mental Health and PACT primary care teams. All services delivered at Bath VAMC and supported by Loyola Transportation Network Loyola staff paid for by grant. Medication prescribed out of and procured by VA pharmacy and labs paid for by VA.
16 mpower Loyola staff enters notes in VA CPRS system capturing encounters for VA utilization data and Vivitrol ordered out of VA pharmacy Loyola staff attends Behavioral Health and Primary Care team meetings. Patients weekly survey mapping risk and protective factors are done on the smartphone (BAM) and staff responds to high risk situations Smartphone ACHESS application utilization tracked by UW. August2013
17 mpower Key Results 44 Active Patients for 11 months (110% of 1 st Projected Enrollment) Pre-Enrollment Total Hospitalizations in Patient Cadre = 147 Post-Enrollment Total Hospitalizations in Patient Cadre = 28 80% Reduction in Hospitalizations. Multiple relapses localized to 4 patients
18 mpower Emerging data on Health Status Improvement, Treatment Compliance and change in symptoms available in October, 2013 Program Admission Demand, driven by veteran patient word of mouth is double current capacity VAMC s recognizing need for more infrastructure; seeking model development (1000 Patient Expansion) Rest of Care Continuum must be developed (Housing, Employment)
19 Logic of the mpower Model Collaboration/Co-Location Service Integration Virtual Delivery of Care Management, Predictive Analytics and Recovery Support through Mobile Phone Platform (Self-Determination Theory) Risk Sharing Model of Cost, justified by Cost Offset Deliverables Mutual Accountability for Outcomes between Partners Activated Patients will display greater motivation to manage their own care. They will articulate a narrative of success
20 Three Essential Ingredients of Change Coping Competence Social Relatedness Autonomous Motivation (CHESS Foundation)
21 ACHESS
22 ACHESS Monitoring and alerts Reminders Autonomous motivation Assertive outreach Care coordination Medication reminders Peer & family support Relaxation Locations tracking Contact with professionals Information
23 ACHESS has better 30 day abstinence Differences significant at p = Month 4 Month 8 Month 12 ACHESS Control N = 349
24 ACHESS had fewer heavy drinking days Differences significant at p = ACHESS Control Month 4 Month 8 Month 12 N = 349
25 The Rest of the mpower Story What Health System Administrators Care About Patient Need/Community Public Health Profile Health Delivery System Health Outcomes/Efficacy/Data/Metrics Cost/Reimbursement/Cost Offsets Risk Management Safety/Compliance/Accreditation Staffing/Staff Retention Marketing/Brand/Market Share
26 mpower Story (cont.) What DON T Healthcare Administrators Care About? Everything They Can t Reconcile Against the Preceding List of Interests
27 Business Model Disconnect Substance Use Disorders Co- Mobidities Clinical Intervention Social Determinants Spirituality Chronic Dependence Physical Cognitive Modalities (Ind./Family) Housing Transcendent Mental Health Pharmacology Jobs Religious Peer Support Non-Peer Relationships Mystical Abuse Care Management
28 Creative Destruction of Medicine New Medicine -Wireless Sensors -Genomics -Imaging -Information Systems -Predictive Analytics Super Convergence -Mobile Connectivity -Internet -Social Networking -Computing Power Data Universe Old Medicine
29 Strategy Von Blucher and the Rear Guard Action
30 Von Blucher Had given his word to Wellington to meet him at Waterloo Army had been shaken on 16 and 17 June, 1815 by Napoleon Had to Save the Army by marching to Wavre, leaving a Rear Guard Force and moving the main Army to Waterloo The Action tipped the balance and Napoleon was defeated
31 Von Blucher A Rear Guard Action assumes the Rear Guard will fight to the last soldier to buy time. All of the Rear Guard is typically lost The main fighting force is maintained but forever altered-focusing on movement as well as impact A diminished army needs alliance to overcome a powerful force (military or market) Adaptation and Perseverance are Key Culture must rapidly eject all non-productive assumptions and practices
32 Closing 1. What Do Patients Need to Have the Highest Probability of Attaining a Positive Health Outcome 2. What Does the Public Health Case Mandate? 3. What Do You Know How To Do? 4. Can You Operationalize It and Prove It Over the Long Haul? 5. Are You the Least Expensive, Most Effective, Most Valuable Thing They Have Ever Seen? 6. What Will You Become When You Have Become #5?
33 Contact Details Christopher R. Wilkins, Sr., President Loyola Recovery Foundation, Inc Pittsford Victor Road, Suite 240 Pittsford, New York PH: FAX:
34
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