Reducing Fragmentation Through Coordinated Care
Behavioral and Physical Health Co-Management Series Webinar #1
National Council for Behavioral Health
Montefiore Medical Center
Northwell Health
New York State Office of Mental Health
Netsmart Technologies
Today’s Presenter
Mindy Klowden, MNMDirector, Training and Technical AssistanceNational Council for Behavioral Health
Learning Objectives for the Co-Management Series• Understand the continuum of integrated care, the benefits
of coordinated care and how it ties in with triple/quadruple
aim objectives.
• Establish clear lines of communication with medical
providers to more effectively coordinate care.
• Understand key components of developing referral criteria
with medical providers.
• Identify approaches to forming personal and electronic
relationships with medical neighborhood providers to
support co-management.
CMS Change Package: Roadmap for Transformation
Patient and Family-Centered Care Design
1.1 Patient & family engagement 1.2 Team-based relationships 1.3 Population management 1.4 Practice as a community partner
1.5 Coordinated care delivery 1.6 Organized, evidence-based care1.7 Enhanced access
Continuous, Data-DrivenQuality Improvement
2.1 Engaged and committed leadership 2.2 QI strategy supporting a culture of quality & safety 2.3 Transparent measurement and monitoring2.4 Optimal use of HIT
Sustainable Business Operations
3.1 Strategic use of practice revenue 3.2 Staff vitality and joy in work 3.3 Capability to analyze and document value 3.4 Efficiency of operation
Milestone 9: Practice works with the
primary care practices in its medical neighborhood to develop criteria for referrals for episodic care, co-management, and transfer of care/return to primary care, processes for care transition, including communication with patients and family.
Milestone 10: Practice identified the
primary care provider (PCP) or care team of each patient seen and communicates to the team about each visit/encounter.
Key Definitions: Integrated Care
The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population.
Integrated care models occur along a continuum from coordinated to co-located to fully integrated care.
Source: Agency for Healthcare Research and Quality
Key Definitions: Care Coordination Coordination
Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care. This means that the patient's needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.
Source: Agency for Healthcare Research and Quality
Key Definitions: Co-managementCona
Co-management is the shared responsibility, authority and accountability for the care of a patient.
Co-management involves enhanced communication and sharing of care and knowledge between health care providers.
Co-Morbidity of Mental Health Disorders and Other Chronic Conditions
Source: Druss, BG & Walker, ER (2011) RWJF. Adapted from the National Comorbidity Survey Replication 2001-2003.
People with mental illness disorders: 25% of adult population
People with medical conditions: 58% of adult population
68% of adults with mental disorders have medical conditions
29% of adults with medical conditions have mental disorders
Morbidity and Mortality in People with Serious Mental Illness
✓Persons with serious mental illness (SMI) are dying 25 years earlierthan the general population.
✓While suicide and injury account for about 30-40% of excess mortality, 60% of premature deaths in persons with schizophrenia are due to preventable medical conditions with modifiable risk factors, such as cardiovascular, pulmonary and infectious diseases.
Source: National Association of State Mental Health Program Directors
Co-Morbidity Risk Factors
Tobacco UseAlcohol
ConsumptionPoor
Nutrition/Obesity
Lack of ExerciseUnsafe Sexual
BehaviorSubstance Use and
Misuse
Inadequate Primary/Preventive
Care
Adverse Childhood Experiences (ACES)✓“Relationship of Childhood Abuse and
Household Dysfunction to Many of the Leading Causes of Death in Adults,” published in the American Journal of Preventive Medicine in 1998
✓Over 17,000 adults studied from 1995-1997
✓Almost 2/3 of participants reported at least one ACE, and over 1/5 reported three or more ACEs, including abuse, neglect, and other childhood trauma
✓Major links identified between early childhood trauma and long term health outcomes, including increased risk of many chronic illnesses and early death.
Source: Centers for Disease Control ACES Major Findings https://www.cdc.gov/violenceprevention/acestudy/about.html
As the number of ACEs increases, so does risk for the following*:• Alcoholism and alcohol abuse
• Chronic obstructive pulmonary disease
• Depression
• Fetal death
• Health-related quality of life
• Illicit drug use
• Ischemic heart disease
• Liver disease
• Poor work performance
• Financial stress
• Risk for intimate partner violence
• Multiple sexual partners
• Sexually transmitted diseases
• Smoking
• Suicide attempts
• Unintended pregnancies
• Early initiation of smoking
• Early initiation of sexual activity
• Adolescent pregnancy
• Risk for sexual violence
• Poor academic achievement
*This list is not exhaustive. For more outcomes see selected journal publications.
Hospitals
Hospitals
Specialty
Clinics
Specialty
Clinics
Primary
Care Clinics
Primary
Care Clinics
Social Service Agencies
Dental Clinics Housing Providers
Providers Working in Silos
Graphic courtesy of Dale Jarvis & Associates
The “Quadruple Aim”
Population Health
Experience of Care
Per Capita Cost Provider Satisfaction
Impact of Integrated Care:
a Sampling of the Evidence
✓“Collaborative Care Model improves symptoms from mood disorders and mental health-related quality of life.” (Millbank Fund, May 2016)
✓“Reduced depression severity and enhanced patients' experience of care.” (Journal of the American Board of Family Medicine, March 2017)
✓“Resulted in dramatic increases in workflow productivity of the primary care team.” (South Central Foundation, Alaska)
✓“ The whole health model reduced Medicare expenditures, ED visits, and hospitalization rates. Medicare expenditures decreased by $266 per month on average” (Psychiatry Online, Aug, 2018)
✓ “Resulted in statistically and potentially clinically significant improvements in cholesterol” among patients with serious mental illness (Rand Corporation, Nov. 2016)
Economic Impact of Integrated Care✓ Patients with chronic medical and comorbid mental health/substance use
disorder (MH/SUD) conditions cost 2-3 times more as those without.
✓ Projected costs for those with comorbid conditions in 2017 was estimated at
$406 billion across commercially-insured, Medicaid, and Medicare
beneficiaries in the United States.
✓ Most of the increased cost is attributed to medical services (not behavioral).
✓ “An estimated $38-$68 billion could be saved annually through effective
integration of medical and behavioral healthcare”, with most of the projected
reduced spending associated with facility and emergency room expenditures
in hospitals.
Source: Milliman, Jan 2018
Goals of Improved Care Coordination and Co-Management
To reduce costs.
• Eliminate redundant tests, blood work, etc.
• Improve management of chronic conditions within primary care settings, thus reducing ER utilization, hospitalization and readmissions
To benefit the patient.
• Better health outcomes
• Improved experience of care
• Improved patient safety (e.g. medication interactions)
To benefit the providers.
• More joy in the work (Milestone #19)
• Improved provider satisfaction
• Reduced stress/chaos/burden
Challenges to Care Coordination
• Accountability for the process is shared, which contributes to ambiguity as to who is responsible for making it work well.
• Many PCPs and BH providers have been siloed and do not have strong relationships in place in their healthcare neighborhood.
• PCPs and BH Providers are on separate electronic health records.
• The added time and effort required to achieve an effective referral/consultation, transition of care, or co-management relationship is generally not reimbursed.
Key Elements of Successful Care Coordination
✓Organizational commitment and accountability
✓Streamlined referral processes (access to care)
✓Signed agreements in place
✓Strong communication mechanisms in place (may or may not include connectivity)
✓A focus on the total health care needs of the patient and appropriate patient support in place
✓Clear and simple information that patients can understand
Where do Your Patients go for Primary Care?
Do you have a signed release of information?
Is this captured in your EHR?
Have they been seen in the last year?
Do they have a PCP?
A Targeted Approach
• Focus on high risk patients or patients with specific diagnoses/co-morbidities
• Use your financial utilization and cost reports
• Develop partnerships
Building the Relationship
Have you developed an MOU, care compact, coordination of care or co-management agreement?
Do you understand one another’s goals around coordination of care?
Do you understand one another’s referral process?
Have you and the PCP met?
Define critical elements of the referral
request
Establish the referral
response
Establish protocol for scheduling
appointments
Close the loop: referral
tracking protocol
Streamlining Referral Processes
What Information is Important to Share?• Allergies
• Problem list/diagnoses
• Procedures
• Relevant family/social history
• Advance directives
• Medication list and history
• Immunizations
• Medical equipment
• Vital signs
• Lab results
• Treatment Plan/goals
• Significant changes in status
• Hospitalizations
Does the Care Coordination Agreement:
Describe and establish the parties’ mutual expectations and responsibilities?
Describe the process by which the parties will share patient health information/medical records?
Include assurances that both parties will adhere to all relevant privacy laws (HIPAA, 42 CFR Part 2, any state regulations)?
Engaging Patients and Families
• Patient is a partner in care
• Provide pre-visit education
• Use warm hand-offs whenever possible
• Use targeted outreach to patients who are disengaged, e.g., who do not show for appointments, struggle to adhere to medication
• Share with patient their health measures and wellness goal trends, if available
Defining Protocols and Staffing Roles
• Leadership engaged in defining protocols around care coordination/co-management, and defining staff roles
• Define protocol of how practice will coordinate with primary care providers and clear roles for clinical staff
• Determine who on your staff will have primary responsibility for engaging patients in a conversation around primary care
• Within your practices protocol, clearly define the documentation requirements and where information should be documented related to care coordination/co-management
Discussion
What’s Next
• Reducing Fragmentation Through Coordinated Care Series
• Part 2: February 21st from 12-1pm
• Part 3: March 2019
• Individual consultations with Mindy Klowden
• Care Pathways Workshop – March 2019
• Other Upcoming Webinars:
• Financial Utilization Reports: Using Data to Inform Value-Based Decision Making in Behavioral Health Populations – January 23rd from 1-2pm
• Substance and Psychosis – January 29th from 12-1pm
Resources
National Council's Integrated Health Solutions
Agency for Health Research and Quality (AHRQ): Care Coordination
Safety Net Medical Home Initiative: Care Coordination
National Center for Medical Home Implementation: Co-management Between Primary and Specialty Care
Care Transitions Network Transitions of Care Planning Guide
Don’t forget to enter “NATCON200” to get $200 off your registration!
Thank you!Contact: Mindy Klowden, MNM, Director, Technical Assistance and Training
www.CareTransitionsNetwork.orgCareTransitions@TheNationalCouncil.org
The project described was supported by Funding Opportunity Number CMS-1L1-15-003 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services.
Disclaimer: The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
