Using CC360 Data to Inform Care Bridge Community Support & Treatment Services and the University of Michigan Health System Complex Care Program Brandie Hagaman Michael Harding Heather Rye
Objectives of Presentation Identify necessary components of a Care Bridge Understand the data used in order to provide clinical care planning Understand the elements of both organizations
Background Community Support and Treatment Services (CSTS) Washtenaw County CMH Over 4,000 individuals served University of Michigan Hospital and Health System Complex Care Management Program (CCMP) Scope of Practice Serve High Risk, High Need and High Utilizing Patients Provide Longitudinal Care
What is a Care Bridge? Care Bridge Components Two mutual partners Shared consumer Ability to share information Collaboration to achieve holistic health outcomes
What is a Care Bridge? Care Bridge Activity: Collaboration between CSTS and CCMP Determine lead on care coordination Quarterly case reviews Co-attended consumer appointments (Medical, Behavioral, Home Visit, etc.)
Care Bridge Model Joint Leadership Team Team Make Up Both Medical Directors (U of M &CSTS) Director of CSTS Both Program Directors (U of M & CSTS) Team Leader of Complex Care (U of M) Chief Information Officer of CSTS Administrative Support
Administrative Functions Develop project goals Monitor outcomes Data development analysis Discuss successes & barriers Care Bridge Model Joint Leadership Team
Care Bridge Model Clinical Team Make Up 5 Nurse Care Managers (CSTS) 7 Complex Care Managers (U of M) Medical Director Program Directors Care Bridge Co-Manager Communication Regular contacts via phone, email, or appointments Quarterly meetings
Care Bridge Process Data Driven: Subset of Mental Health Population Health home enrolled Disease management U of M adds costs to their patients of subset CSTS joins subset to CC360 Data Top 50 reviewed High utilizers New to health home enrolled Clients that need team consultation
CCMP/CSTS Utilization Review (patient costs)
CCMP CSTS Utilization Review (CC360)
Overall ER Visits Every 3 Months Overall Inpatient Stays Every 3 Months BH Inpatient Stays Last 6 Months Personal Health Review Conditions
CCMP Care Managers and CSTS HWP Care Managers Case Presentation Format 1. Overview of Patient (<3 Minutes presentation) o Basic Info Demographics o Medical Diagnosis Medications Providers on Care Team o Mental Health Diagnosis Medications Providers on Care Team o Utilization in past quarter and previous quarter ED Inpatient Appointment Compliance % PCP visits Specialty Visits Upcoming Appointments 2. Problems identified for discussion: o What has been done o Treatment Options o What needs to be done o Assign tasks CSTS CCMP PRESENTATION FORMAT
Case Example Caucasian Male age 37 with 24/7 care Mental Health Mood and Anxiety Disorder Personality Disorder Somatization Disorder Physical Health Cerebral Palsy Quadriplegic, neurogenic bowel and bladder Chronic UTI Supra pubic catheter
Treatment Team CSTS Supports Coordinator Team Nurse Health & Wellness Nurse * Community Living Supports Occupational Therapist Nutritionist U of M Nurse Care Navigator * Complex Care Manager * Primary Care Physician Specialty Care
Case Example Presenting Problem: Frequent visits to the ER for UTI s. (Rarely Admitted) Improper catheter care Limited understanding of dietary needs Inability to manage symptoms Lack of understanding of resources other than ER MH impact on physical health
Care Coordination CLS Provider Education Home Visits Health Education Medical Tx Plan CSTS Case Conferencing U of M Bridging the Gap
Case Example Outcomes Developed care plan Utilization decreased Comprehensive care team Improved physical symptoms CLS providers implemented the care plan Improved catheter care
Data Development Release of Information CC360 Medicaid data for the quarterly list
Washtenaw s Consent Model Consent is the key for physical health providers to receive behavioral health information Partnering agencies within Washtenaw are utilizing the standard behavioral health consent Consents are stored centrally within the PIX HIE Consent is all or nothing Consumer controls who has access to the behavioral health information through the unified consent
! CONSENT'TO'SHARE'YOUR'HEALTH'INFORMATION' ' THIS FORM CANNOT BE USED FOR A RELEASE OF INFORMATION FROM ANY PERSON OR AGENCY THAT HAS PROVIDED SERVICES FOR DOMESTIC VIOLENCE, SEXUAL ASSAULT OR STALKING. A SEPARATE CONSENT MUST BE COMPLETED WITH THE PERSON OR AGENCY THAT PROVIDED THOSE SERVICES. (See FAQ at www.michigan.gov/bhconsent to determine if this restriction applies to you or your agency) Individual s'name:' Date'of'Birth: Individual s'id'number'(medicaid'id,'ssn,'other):' at www.michigan.gov/bhconsent I.' I'consent'to'share'my'information'among:'' ' II.' I'consent'to'share:'' ' ' ' ' III.' By'signing'this'form'I'understand:'' ' '!
Behavioral Health View of Physical Health Real-Time
Example of Physical Health Clinical Note Real-Time
Real-Time Physical Health Provider View of Behavioral Health Info
Example of Behavioral Health Clinical Note Real-Time
Retrospective Using CC360 Data Use Agreements CSTS utilizes the data extract from CC360 CSTS then cleans the data CSTS matches the data to the behavioral health EMR data Personal Health Review Wellness Note
Data Source CC360 CC360 CC360 EMR EMR
Case Example Caucasian female, age 63, ACT Consumer Mental Health Schizoaffective disorder Bipolar disorder Physical Health Type 2 diabetes Obesity DVT on Coumadin Psoriasis Irritable bowel syndrome
Case Example Presenting Problem: ACT consumer at CSTS Discharged from ED at midnight with paper scripts (Lovenox and Coumadin) Can not self administer injections Has DVT ER Doc concerned that she didn t know medications and had poor hygiene
Community Assessment What would happen in your community in this example? Is there a community resource to help with this consumers needs? What health system would you partner with? Who is the mental health lead? Who is the physical health lead? Does your community have the ability to share information and the necessary data to inform decisions? What opportunities exist? What steps could you do in your community to develop a care bridge?
Take Homes Bridge the silo s between physical, behavioral and social service systems Take advantage of what your community/partner has to offer Don t let technology get in the way of innovation Small steps go a long way This will not happen overnight!
Questions?
Contact Information Brandie Hagaman 734-790-5435 hagamanb@ewashtenaw.org Mike Harding- 734-260-4644 hardingm@ewashtenaw.org Heather Rye- 734-936-0381 hrye@med.umich.edu