3/23/2017

1

Integrating Healthcare

Through Population

Health Management

Joseph Parks, M.D.

National Council Behavioral Health Medical Director

Today’s Moderators

Madhana Pandian

Associate

Deann Jepson, M.S.

Co-facilitator

Slides for today’s webinar will be

available on the CIHS website:

www.integration.samhsa.gov

In the About Us/Innovation Communities 2017 tab

To participate

Use the chat box to communicate with other attendees

Use the question box to send a question directly to Dr. Parks.

Disclaimer: The views, opinions, and content

expressed in this presentation do not

necessarily reflect the views, opinions, or

policies of the Center for Mental Health

Services (CMHS), the Substance Abuse and

Mental Health Services Administration

(SAMHSA), the Health Resources and

Services Administration (HRSA), or the U.S.

Department of Health and Human Services

(HHS).

Setting the Stage

Dr. Joe Parks

National Council Behavioral Health Medical Director

3/23/2017

2

IC Learning Objectives- Screening and treatment of depression and diabetes

- Impact of comorbid depression and diabetes on treatment

outcomes for both

- Development of screening protocols, treatment pathways, and

disease registry to improve co-management of diabetes and

depression

- Use of data to improve clinical workflows and outcomes -

Population Health Management

- Develop work plan to achieve 2-3 goals related to one or more areas

of sustainability:

Staff core competencies

Quality metrics/Key Performance Indicator Development/Analysis

Billing/Cost Analysis

Overview of Today’s Webinar

What is population health?

What is population health management?

– Why do we need it?

– Good outcomes are dependent on patient behaviors.

– People with a serious mental illness (SMI) are more ill.

There is a psychiatry shortage.

Let’s look at a health home example.

How will the information presented in today’s webinar help you

with your Innovation Community workplan goals?

Population Health Definitions

The health of the population as measured by health status

indicators and as influenced by social, economic and physical

environments, personal health practices, individual capacity

and coping skills, human biology, early childhood

development, and health services (Dunn and Hayes, 1999).

A conceptual framework for thinking about why some

populations are healthier than others as well as the policy

development, research agenda, and resource allocation that

flow from it (Young, 2005).

Health Rankings

75

76

77

78

79

80

81

82

Japan

France

Australia

Canada

Germany

New Z

ealand

United K

ingdom

United S

tate

s

The IHI Triple Aim How do you deliver PHM in any care setting?

Assess Stratify

Implement Solutions

Measure & Report

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Population Management Principles

Population-based care

Data-driven care

Evidence-based care

Patient-centered care

Social determinants of health

Team care

Integration of behavioral and primary care

Population-based Care

Don't rely solely on patients to know when they need

care and what care to ask for and from whom - use

data analytics for outreach to high need/utilizer

patients.

Don't focus on fixing all care gaps one patient at a

time - choose selected high prevalence and highly

actionable individual care gaps for intervention across

the whole population.

The population-based health care provider is the

public health agency for their clinic population.

Data-driven Care

Patient registries

Risk stratification

Predictive analytics

Performance benchmarking

Data sharing

Population Management

Selects those from whole population:

– Most immediate risk

– Most actionable improvement opportunities

Aids in planning:

– Care for whole populations

– New interventions and programs

– Early identification and prevention

– Choosing and targeting health education

Data Uses

Aggregate reporting ― performance benchmarking

Individual drill down ― care coordination

Disease registry ― care management

– Identify care gaps

– Generate to-do lists for action

Enrollment registry ― deploying data and payments

Understanding ― planning and operations

Telling your story ― presentation like this

Principles Use data you have before collecting more.

Show as much data as you can to as many partners as you

can as often as you can.

– Sunshine improves data quality.

– They may use it to make better decisions.

– It’s better to debate data than speculative anecdotes.

When showing data, ask partners what they think it means.

Treat all criticisms that results are inaccurate or misleading

as testable hypotheses.

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More Principles

Tell your data people that you want the quick, easy data runs

first. Getting 80 percent of your request in 1 week is better than

100 percent in 6 weeks.

Treat all data runs as initial rough results.

Important questions should use more than one analytic

approach.

Several medium data analytic vendors/sources are better than

one big one.

Transparent benchmarking improves attention and increases

involvement.

Most Important Principle

Perfect is the enemy of good.

Use an incremental strategy.

If you try to figure out a comprehensive plan first,

you will never get started.

Apologizing for a failed prompt attempt is better than

apologizing for a missed opportunity.

Six Population Health Management Services

1. Care management

2. Care coordination

3. Transitions of care management

4. Health promotion

5. Individual and family support

6. Referral to community services

Comprehensive Care Management

Identifying and targeting of high-risk individuals

Monitoring of health status and adherence

Identifying and targeting care gaps

Individualized planning with patient

Step 1 – Create Disease Registry

Get historic diagnosis from administrative claims

Get clinical values from metabolic screening, clinical

evaluation and management, and care plans

Combine into EHR Disease Registry (Central Data

Registry, PROACT)

Have online access available to all providers

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Step 2 – Identify Care Gaps and ACT!

Compare combined disease registry data to

accepted clinical quality indicators

Identify care gaps

Sort patient groups with care gaps into agency

specific to-do- lists

Nurse care manager helps team decide who will act

Set up indicated visits and pass on information with

request to treat

Care Coordination

Coordinating with the patients, caregivers, and providers

Implementing plan of care with treatment team

Planning hospital discharge

Scheduling

Communicating with collaterals

Why Behavioral Health Needs

Population Management

Legislation requires it

People with SMI more ill

Population management needs behavioral health

Psychiatry shortage

Population Health Management

Community health needs assessment requirements

Expansion of prevention and wellness services

Hospital readmissions reduction program

Community-based care transitions program

Accountable Care Organizations

Patient-centered medical homes

Health homes for chronic conditions

Increased funding for health centers

Care Coordination

Clinical Integration

Care Management

Important Provider Competencies

Characteristics:

• Outcomes-oriented

• Enabled by

technology

• Patient-centered

• Use of data and

analytics

• Performance

transparency

• Ability to partner

across

organizations

Life Expectancy

40

45

50

55

60

65

70

75

80

No Mental Disorder Any Mental DisorderGeneral Population

Any Mental DisorderPublic 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. 2011 June;49(6):599-604

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. 2010 Apr 30;176(2-3):242-5

3/23/2017

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Causes of Excess Mortality

Smoking

Obesity

Inactivity

Polypharmacy

Under diagnosis of medical conditions

Inadequate treatment of medical conditions

Per Member Per Month Costs

$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

$1,600

PrivateSector

Medicare Medicaid

No Mental Disorder

Any MentalDisorder

MH/SUD costs in NY State’s Medicaid Program

$10,000

$12,000

$14,000

$16,000

$18,000

$20,000

$22,000

$24,000

$26,000

$28,000

$30,000

MH Disorder SU Disorder No MH/SUDisorder

Behavioral Health costs

Physical Helath costs

So, what to do...

NO one magic bullet

Integration of behavioral health

and primary care

Team care with everyone

working at the top of their training

Population health management

Healthcare delivery based on

deep partnerships

What is a Health Home?

Not just a Medicaid benefit

Not just a program or a team

A system and an organizational

transformation

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Health Care Home Strategy

Case management coordination and facilitation of healthcare

Primary care nurse care managers

Disease management for persons with complex chronic medical

conditions, SMI, or both

Behavioral health management and behavior modification as

related to chronic disease management for persons with medical

illness

Preventive healthcare screening and monitoring by mental health

providers

Integrated primary care and behavioral healthcare

Health Home Strategy

Health technology used to support service system

“Care coordination” best provided by a local community-based

provider

Mental health community support workers who are most familiar

with the consumer provide care coordination at the local level.

Primary care nurse care managers working within each health

home provide system support

Behavioral health consultants in each primary care health home

Statewide coordination and training support the network of health

homes

What is Different about Health Homes?

Treatment as Usual 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 healthcare system

- Uses data driven population management

- Transforms clinical practice

- Emphasizes health lifestyles and

self-management of chronic health problems

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

Primary Care Health Homes CMHC Healthcare Homes

Individuals with SMI or with

other behavioral health

problems who also have:

- Diabetes

- COPD/Asthma

- Cardiovascular disease

- BMI > 25

- Developmental disabilities

- Use tobacco

Missouri’s Health Homes

Providers

- 23 FQHCs

- 61 clinics

9 Hospitals- 36 clinics

3 Independent practices

- 3 clinics

Enrollment- 17,823 adults

- 1,168 children

- 18,991 total

Providers

- 26 CMHCs

- 120 clinics/outreach offices

Enrollment- 20,877 adults

- 3,359 children

- 24,236 total

Primary Care Health Homes CMHC Healthcare Homes

Health Home Team

Nurse care managers (1FTE/250pts)

Care coordinators (1FTE/500pts)

Home health director

Behavioral health consultants

(primary care)

Primary care physician consultant

(behavioral health)

Learning collaborative training

Next day notification of hospital

admissions

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Six CMS Required Health Home Functions

1. Care management

2. Care coordination

3. Managing transitions of care

4. Health promotion

5. Individual and family support

6. Referral to community services

HCH Responsibilities

Hospital Admissions

The importance of following up on hospital discharges

A joint letter prepared by the Missouri Hospital

Association and Missouri HealthNet was distributed to

all hospitals describing the health home initiative and

encouraged hospital cooperation.

A draft Memorandum of Understanding (MOU) has

been distributed to your CMHC administration to use as

a guide in developing a MOU with hospitals serving

your area.

HCH Responsibilities

Hospital Admissions

Hospitals are required by most payers, including Missouri

Medicaid, to contact the payer at the time of admission to

receive an Initial Authorization of Stay.

All-new authorizations for inpatient care are sent in an

overnight flat file data transfer from the inpatient

authorization unit to the health home analytics unit.

An access database is used to automatically sort the

patients by health home and generate an automated email

listing those patients with new authorizations to each health

home director.

HCHs receive daily emails regarding hospital admissions.

HCH Responsibilities

Hospital Admissions

HCH members discharged from the hospital must have a contact

within 72 hours of discharge

- This contact may be made by the individual's CSS, case manager, or NCM

Nurse care managers must complete a medication reconciliation

on HCH members discharged from the hospital

- Information regarding the enrollees’ medications may be collected by the

individual’s CSS or case manager for review by the NCM

Emergency Room Visits

In response to the anthrax scare following 9/11 all emergency

rooms were required to send a notification of every emergency

room visit to the state health department.

All new emergency room (ER) visit notifications are sent in an

overnight flat file data transfer from the state health department to

the health home analytics unit.

An access database is used to automatically sort the patients by

health home and generate an automated email listing those

patients with new ER visits to each health home director.

HCHs receive daily e-mails regarding ER visits.

CMHC Health Home Performance Progress

LDL, A1C, and Blood Pressure

3/23/2017

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Metabolic Syndrome Screening

All CMHC

Health

Homes have

attained a

completion

rate above

80%!

N= 6,553

(at 3.5 years)

N= 20,648

(Dec 2015)

A1C Levels Over Time

About 7% had uncontrolled A1c levels

10.1

9.2

8.9

8.6

7.5

8

8.5

9

9.5

10

10.5

Baseline Year 1 Year 2 Year 3

CMHC-HH

10.0

9.29.1

9.1

7.5

8

8.5

9

9.5

10

10.5

Baseline Year 1 Year 2 Year 3

PCHH

1 POINT DROP

IN A1C

21% ↓ in diabetes

related deaths

14% ↓ in heart

attack

31% ↓ in

microvascular

complications

132

115

112

106

100

110

120

130

140

150

160

Baseline Year 1 Year 2 Year 3

CMHC-HHs

LDL Levels Over TimeAbout 45% had uncontrolled LDL levels

132

121119

116

100

110

120

130

140

150

160

Baseline Year 1 Year 2 Year 3

PCHHs

10% DROP

IN LDL

LEVEL

30% ↓ in

cardiovascular

disease

Blood Pressure Changes

Over Time

6 POINT DROP

IN BLOOD

PRESSURE

• 16% ↓ in CD

• 42% ↓ in stroke

152.9144.1 143.3 141.4

96.989.7 89.1 87.4

30

50

70

90

110

130

150

170

Baseline Year 1 Year 2 Year 3

PCHHs

SystolicDiastolic

152.9

134.9 134.4 133.1

97.9

86 84.9 83.3

30

50

70

90

110

130

150

170

Baseline Year 1 Year 2 Year 3

CMHC-HHs

Systolic

Diastolic

20-24% had uncontrolled BP levels

Hospital Follow-up Jan. 2012 – July 2014

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

20

12-1

20

12-2

20

12-3

20

12-4

20

12-5

20

12-6

20

12-7

20

12-8

20

12-9

20

12-1

0

20

12-1

1

20

12-1

2

20

13-1

20

13-2

20

13-3

20

13-4

20

13-5

20

13-6

20

13-7

20

13-8

20

13-9

20

13-1

0

20

13-1

1

20

13-1

2

20

14-1

20

14-2

20

14-3

20

14-4

20

14-5

20

14-6

20

14-7

%Follow-Up

Diabetes

Adults continuously enrolled

N= 1,889 (at 3.5 years)

N= 4,526 (Dec 2015)

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Hypertension & Cardiovascular Disease

Adults

continuously

enrolled

CVD N= 232

(at 3.5 years)

CVD N= 564

(Dec 2015)

HTN N= 2,401

(at 3.5 years)

HTN N= 6,111

(Dec 2015)

Percent of Clients with 1+ Hospitalization

10%

15%

20%

25%

30%

35%

40%

2008 2009 2010 2011 2012

First Year

9.1%

CMHC HCH Implementation January 1, 2012

ER and Hospital Days per 1,000 Hospital Encounters

N= 17,084 (2011)

N= 18,776 (2012)

N= 19,103 (2013)

N= 20,345 (2014)

ER Encounters

N= 17,084 (2011)

N= 18,776 (2012)

N= 19,103 (2013)

N= 20,345 (2014)

6534 5792 5498 5694

36320 36924 34540 36336

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

Pre 12011

Year 12012

Year 22013

Year 32014

PsychiatricER Visit

General MedicalER Visit

15% 14% 14% 14%

85% 86% 86% 86%

Average # of ER & Hospital Encounters

N= 17,084 (2011)

N= 18,776 (2012)

N= 19,103 (2013)

N= 20,345 (2014)

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Initial Estimated Cost Savings After 18 Months

CMHC Health Homes

20,031 persons total served (includes dual eligibles)

Cost decreased by $98.22 PMPM

Total cost reduction $31.0 M

PC Health Homes

23,354 persons total served (includes dual eligibles)

Cost decreased by $18.22 PMPM

Total cost reduction $5.3 M

What Makes it Possible? A relationship of basic trust between:

Department of Mental Health

Missouri HealthNet (Medicaid)

State Budget Office

Missouri Coalition of CMHCs

Missouri Primary Care Association

Transparent use of data instead of anecdotes to explore and

discuss issues

Willingness of all partners to tolerate and share risk

Principled negotiation and Motivational Interviewing

Partnership Principles

DO

Ask about their needs first

Give something

Assist wherever you can

Make it about the next 10

Pursue common interest

Reveal anything helpful

Take one for the team

DON’T

Talk about your need first

Expect to get something

Limit assistance to a project

Make it about this deal

Push a specific position

Withhold information

Let them take their lumps

SMR. Covey, The Speed of Trust

Behaviors that Promote Trust

Character

― Talk straight

― Demonstrate respect

― Create transparency

― Right Wrongs

― Show Loyalty

Competence

― Deliver results

― Get better

― Confront reality

― Clarify expectations

― Practice Accountability

Character & Competence

― Listen first

― Keep commitments― Extend trust

3/23/2017

12

Questions?

Thank you for joining us today.

Please take a moment to provide

your feedback by completing the

survey at the end of today’s

webinar.

If you have additional questions/comments, please send them to:

Joe Parks – joep@thenationalcouncil.org

Deann Jepson – djepson@ahpnet.com

Madhana Pandian – madhanap@thenationalcouncil.org