C are O f M ental, P hysical A nd S ubstance-use S yndromes Claire Neely, MD Medical Director, ICSI August 23, 2013.

Care Of Mental, Physical And Substance-use Syndromes

Claire Neely, MD Medical Director, ICSI

August 23, 2013

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Care Of Mental, Physical And Substance-use Syndromes

Claire Neely, MD Medical Director,ICSI

3 Year CMS Innovation Challenge GrantAwardee Objectives :

• Lower cost of care for people enrolled in government programs

• Leverage existing models to improve patient care quickly

• Engage broad set of partners to test new delivery models

• Identify workforce development opportunities to create jobs

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Scope of COMPASS workTo implement a collaborative care management

model for patients with depression and diabetes/CVD,

and optional risky substance use,

in primary care that accomplishes the Triple Aim

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Supported by Cooperative Agreement Number 1C1CMS331048-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services

Triple Aim Measures of Success

• Population health– Increase remission/response rates for

patients with depression– Improve control rates for diabetes and

cardiovascular disease and their risk factors

– Reduce risky substance use• Experience of care

– Improve quality for patient and provider satisfaction

• Affordability – Decrease readmissions, admissions and

ED visits to reduce health care costs

COMPASS Consortium: Overarching Scope

• Intervention– Develop an evidence-based model, train and facilitate

implementation and quality improvement

• Evaluation/Study– Develop multiple data collection and analysis approaches

for QI and for demonstrating triple aim success

• Communications – Marketing & messaging to multi-stakeholder audiences

• Payment methodology– Develop new financial models

• Spread and sustaining model– Systems approach to link with and embed in ongoing work

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COMPASS Consortium Partners

COMPASS Intervention Partners Community Health Plan of

Washington Institute for Clinical System

Improvement (ICSI) Kaiser Colorado Kaiser Southern California Mayo Health System Michigan Center for Clinical

Systems Improvement Mount Auburn Cambridge

Independent Practice Association Pittsburgh Regional Health Initiative

COMPASS Partners

ICSI Principal investigator for oversight of the award Design, train, implement and support this work across all

intervention partners

Advancing Integrated Mental Health Solutions Center Care Management Tracking System Advisor/trainer on development of COMPASS intervention Ongoing resources post-implementation for identified gaps with

individual practices

HealthPartners Institute for Education & Research Evaluation Quality improvement reporting

Work informing COMPASS

IMPACT & DIAMOND DepressionTEAMCare Depression + CVD/DiabetesSBIRT Substance UsePartners in Integrated Care

Depression + Substance UseMI Primary Care Transformation Multiple chronic conditions RARE, Project BOOST

Care Transitions

TrackingEnrollment

& Data Transparency

TransformationLeadership, Culture, Readiness

TreatmentIntensification

Triple Aim

TeamNew Roles & Relationships

COMPASS 4 T’s to Leverage

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EnrollmentProactive patient identification and outreach•Adult Medicaid or Medicare patients•With sub-optimally managed depression (PHQ-9 >9)•AND treatable medical comorbidities defined by one or more of the following:

– Diagnosis of diabetes with A1c >8.0% OR BP >145 mm Hg OR LDL >100 mg/dl

– Existing cardiovascular disease (e.g. history of ischemic heart disease diagnosis, coronary procedure, CHF or stroke) with BP >145 OR LDL >100 mg/d

– Uncontrolled HTN (>160) in those over 65 years of age– Recent hospitalization related to diabetes or cardiovascular disease

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EnrollmentStudy enrollment• Notify of study using script• Agree to be contacted by study team• Study team calls patients

• Further explain study • Get consent into study

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PRIMARY CARE TEAM

SYSTEMATICCASE REVIEW

TEAM withPsychiatric/Physician

Consultants

PATIENTPATIENT

CARE MANAGER

Team - Collaborative Care

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Ambulatory: Hospital Partnerships

• Partnering with hospital transition staff– Med Rec– Rehab units

• Visiting patients in hospital– Engage & Enroll– Follow-up

• Creating contingency plans– Use of alternative healthcare resources– Self-care

Challenges

• Program not for all patients• Targeted diseases (mostly)• Socio-economic • EHR and other systemic disconnections

• Patients disconnected from the healthcare system

Ongoing support for sustainability• Weekly enrollment reports

• Care manager networking calls

• Partner project manager calls

• Weekly newsletters

• Google site & other on-line resources

• Webinars & learning collaboratives

• Data feedback for quality improvement

• Practice coaching

• Building training capacity at the sites

Questions ?

Upcoming RARE Events….

• Stay tuned for the next RARE Webinar September 27, 2013!Topic: Implementation of the Care Transitions Innovation (C-Train) in Oregon

• RARE Action Learning Day – November 11, 2013

Future webinars…

•To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Networking Webinars, contact Kathy Cummings, kcummings@icsi.org