How California Learning Collaboratives are Building New

Health Neighborhoods

Jennifer Clancy, MSWCA Institute for Behavioral Health Solutions

November 18, 2014

Overview

• CA Solution- Creating Accountable and Coordinated Care

MethodologyInterventionA County ExperienceKey Learning

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The Problem….

FUNDERSFUNDERS

RECIPIENT/ RECIPIENT/ INTERMEDIARYINTERMEDIARY

PAYORS/ PAYORS/ CONTRACTORSCONTRACTORS

PROVIDER PROVIDER NETWORKNETWORK

CMS HRSA SAMHSA Tax Payers (Millionaires) Foundations

DHCS FQHC County BH Health

CBO:Housing

CBO:SUD

CBO:MH

CBO:Social Service,

Peer, Etc

FQHC Managed Care Plan County Behavioral Health

CBOs (MH, SUD, SS,

Peers)

CBOs (MH, SUD, SS,

Peers)

County Behavioral

Health

County Behavioral

Health

FQHCs / Health Clinics

FQHCs / Health Clinics

Result of Uncoordinated Systems is that Serious Mental Illness is:

1. Common2. Disabling3. Expensive4. Deadly

UNCOORDINATED SYSTEM

Jennifer Clancy, CIBHS

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California Building Blocks for the System Solution

Various Funding Sources Organized by Triple Aim

Principles

Single Accountabl

e Entity

California/ACA Building Blocks for the Practice Solution

• Practice Transformation: Integrated and Coordinated Care1. Comprehensive Care Plans2. Quality Driven3. Comprehensive Services4. Care management, care coordination, and

transitional care5. Use of HIT

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Collaborative Team Model

Primary CarePrimary Care

PatientPatient Care Coordinator

Care Coordinator

PsychiatristPsychiatrist

Substance Use

Counselor

Substance Use

CounselorCase ManagerCase Manager Peer

CounselorPeer

Counselor

Primary CarePrimary Care

PsychiatristPsychiatrist

Population Consultants

Care Coordination Team

Direct Service Providers

Care Plan

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How Do We Get There?

CIBHS: IHI Breakthrough Series Learning Collaboratives

• History: 5 years, 40 counties• Funder: Department of Health Care Services• Focus Areas: Recovery, Care Coordination and

Integration• Organizational Partners: Mental health, Substance

Use, Primary Care and Peer Providers & Managed Care Plans

• County Aims: Make fundamental systems and practice changes to improve the health status of individuals with chronic, complex and co-occurring behavioral health and physical health disorders

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Methodology- Quality Improvement Methodology- Quality Improvement FrameworkFramework

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The Intervention

Care Coordination InfrastructureCare Coordination Infrastructure10

Small Tests of Fundamental Care Coordination Processes

Some CC processes done by the care coordinator…

1. Outreach and engagement2. Release of Info3. Patient-Centered Care

Coordination Plan4. Screening5. Referrals6. Use Registry7. Medication Reconciliation

While some CC processes monitored by the care coordinator…

8. Shared Care Goals9. Multidisciplinary Clinical

Care Teams10. Promote Self Management11. Ad Hoc Clinical Case

Consultation12. Ensuring Urgent Access13. Manage Transitions

Results- Example Measures

FOR ALL PARTNER ORGANIZATIONSBMI & BP

Shared Care Goals

Medication Reconciliation

Client Experience of Care and Confidence

MENTAL HEALTHClients Who Smoke Who Have Been Advised to Quit

Substance Use Disorder Screening

2nd Gen Antipsychotic with A1c in last year

SUBSTANCE USESubstance Use Disorder TX

Mental Health Screening

PCP Designation and Documentation

PRIMARY CARECVD with LDL less than 100

Mental Health and SUD Screening

DM Appropriate Lab Testing

HEALTH PLANSCost Per Member Per Month

Emergency Room Use

Fresno CountyOne County’s Story…

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Fresno County Dept. of Behavioral Health

County MHP, convening organization and

client care coordinator

Ambulatory Care Center

High-fidelity IMPACT model of integrating mental health services into primary care clinic. Serves clients with mild/moderate mental

illness

Ambulatory Care Center

High-fidelity IMPACT model of integrating mental health services into primary care clinic. Serves clients with mild/moderate mental

illness

Clinica Sierra Vista: FQHC, integrated mental

health & primary care clinic serving Medi-Cal, Medi-Care

& uninsured individuals

A local Public Health Plan created by the Regional Health Authority to

serve Medi-Cal members in the counties of Fresno, Kings & Madera.

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The Fresno County Care Coordination Partnership Team will make changes to improve the whole health status of adult individuals by coordinating services for the clients with the most serious mental illness and substance use disorders.

Behavioral Health and physical health care’s coordination has, thus far, been driven by individual providers rather than system change. Long-term change must be driven by the systems rather than pushed forward by a few practitioners.

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Overall Theme Across All Agency Partners• Recognize the importance of physical and mental health care

to overall well-being of an individual• Shared goal and all agency partners benefit!

Agency Catalysts for Care Coordination/Population Health:

– Mental Health (Medical Director)– CalViva Heath Plan– Primary Care

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Key changes the Team has been working on• Multidisciplinary Clinical Care Conferences (routine & ad

hoc) • Develop routine SUD screening• Support of client self-management • Ensuring and monitoring routine medication reconciliation• Ensuring and monitoring authorizations for sharing client PHI• Referral process between MHP and PCP• Sharing of patient physical exams, test & lab results

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CC measures data collection process • Excel spreadsheet (tracks key health

indicators, ROIs, etc.)• MHP’s EHR system (Avatar) - Data

reports created specifically for CCC & embedded into EHR for ease of generating data

Who is responsible for collection?• PCPs and MCPs collect data for their

respective measures.• MHP data analyst responsible for MH

data collection, synthesis of data from MCP & PCPs, and reporting out to CiBHS

CSV (FQHC)NextGen

CSV (FQHC)NextGen

CalViva(MCP)

CalViva(MCP)

DBH(MHP)Avatar

DBH(MHP)Avatar

CiBHSCCC

CiBHSCCC

Agency-Specific CCC Data Measures & Client List

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Maintain key personnel from partner agenciesBuy-in from executive leadership Right People at the Table with the Right

Personalities:• Client centered and dedicated providers• Providers who follow through and are accountable • Providers who are real learners. “Care coordination and

population health is so different from what has been done before- given the learning curve, the team members must be learners”.

• Providers who are honest, transparent, and “leave their egos at the door”

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Key Learning and So What

• Commit to Building Org. Relationships/Partnerships

• Collective Responsibility but Accountable Convening Entity

• Invest in Data Infrastructure• Use QI Methodology and Data Routinely• Sustain Engaged Leadership• Test Fundamental Changes- Don’t Tinker