Brenda Reiss-Brennan, PhD, APRN Mental Health Integration Director 2018 Montana Integrated Behavioral Health Summit Achieving Population Health through Mental Health Integration & Team Based Care Impact on Quality, Healthcare Use, Cost & Patient Experience
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Brenda Reiss-Brennan, PhD, APRNMental Health Integration Director
2018 Montana Integrated Behavioral Health Summit
Achieving Population Health through Mental Health
Integration & Team Based Care Impact on Quality, Healthcare Use, Cost & Patient Experience
Objectives
• To present the value of integrated care delivery science in helping to solve critical global health issues
• To advance the evidence-based results of integrated team based care –Mental Health Integration
• To engage participants in critical thinking in addressing economic and cultural barriers to building value for integrated delivery models
• To generate open discussion on the value of population health & redesigning care to meet patients and their families ‘where they are’
3
The costliest medical
conditions ($B, 2013)
Global Health Priority
$$$
Supporting mental health is a growing global priority
52
54
62
67
91
95
122
143
147
Mental disorders
Heart conditions
Trauma
201
Cancer
Pulmonary conditions
Osteoarthritis
Kidney disease
Normal birth
Diabetes
Hypertension
43MAmericans suffer a
form of mental illness
300MPeople worldwide live with
depression
68% of adultswith mental disorders have
other medical conditions
Significant cost
$200 billionannually, exceeding all medical conditions
Rising death toll
~64,000drug overdose deaths
annually in 2016
1suicide death every
40 seconds (2014)
20MAmericans suffer from
substance mental illness of
substance abuse
1
Mental Health & Healthcare Market
Market Analysis18.6% 19.6%21.2%
15.8% 14.9%
22.0%
18 or
Younger
18 to 25 26 to 49 50 or Older Male Female
Prevalence of Adult Mental Illness and ACA
41.0%
62.9%
45.9%
29.0%
8.5%
Any Mental
Illness (AMI)
Series Mental
Illness (SMI)
Moderate Mental
Illness (MMI)
Low (Mid)
Mental Illness
No Mental Illness
Substantial Unmet Need & Across Adult Population
Source: Harris Williams and Co, Behavioral Health Industry Overview 2014
Source: Harris Williams and Co, Behavioral Health Industry Overview 2014
Over 1/3 of SMI Patients and
over 1/2 of MMI Patients do
not received treatment
Tre
atm
en
t in
Dia
gn
ose
d P
op
ula
tio
nP
erc
en
t w
ith
an
y M
en
tal I
llne
ss
(AM
I) in
th
e P
ast
Ye
ar
45.7%
28.2%
22.8%
14.3%
10.2%
9.6%
9.5%
9.5%
8.2%
8.1%
7.9%
7.3%
5.5%
0.0% 10.0% 20.0% 30.0% 40.0% 50.0%
Could Not Afford Cost
Could Handle the Problem
without Treatment
Did Not Know Where to Go for
Services
Did Not Have Time
Did Not Feel Need for Treatment
Concerned About Confidentiality
Might Cause Neighbors /
Community to Have Negative…
Fear of Being Committed / Having
to Take Medicine
Did Not Want Others to Find Out
Might Have Negative Impact on
Job
Health Insurance Did Not Cover
Enough Treatment
Treatment Would Not Help
Health Insurance Did Not Cover
Any Treatment
Reasons For Not Delivering Mental Health Care
Source: Harris Williams and Co, Behavioral Health Industry Overview 2014
May be Mitigated by ACA
American Healthcare
Amazing Successes and Tragic Failures
Rescue Care
vs.Prevention and Effective
Management of
Chronic Conditions
5
Intermountain Healthcare
Intermountain Healthcare
1975
SelectHealth
1983
Medical Group
1994
An Integrated Health System
We are on a Measured Journey –“Helping people live the healthiest lives possible®”
1975
• System-wide standards
(quality, management)
• First clinical & financial
information systems
• Added new hospitals
• Continuum of care
• Health plans
• Vertical integration strategy
• Continuous Quality Improvement
• Medical Group
• Clinical Programs
• Clinical Board goals
• Population Health
• iCentra
• New Mission Statement
• National brand
• Zero Harm
• New business development
• Reorganization
• Partnering for Success
• Supply Chain Organization
• Revenue Cycle Organization
• Patient Flow
• Efficiency improvements
• New care process models
to Present1980s 1990s 2000s 2010s
Intermountain Foundation
A Rich History of Innovation, Improvement, and Excellence
Culture of Learning Builds ValuesCommon Vision | Clinical Work Processes | Data and Evaluation Transparency
2000 – First Surgeon General Meeting Washington DC
What is Mental Health?
“A state of successful performance of mental and physical functioning resulting in productive activities, fulfilling relationships with others and the ability to adapt to change and cope with adversity”
US Surgeon General Report on Mental Health, 1999
Integration To form, coordinate, or blend into
a functioning or organized whole: Unite
Integration Defined
Team Co-Production Functioning in a group with standard clinical line of thought (CPM)
and contributing assets to holistic results
What Is Mental Health Integration? (MHI)
Patients &
Families
3
Information
Systems
4
Financing
& Operations
1
Leadership
& Culture
5
Community
Resources
2
Clinical
Workflow
Leadership and culture – champions establishing
a core value of accountable and cooperative
relationships
Clinical Workflow – engaging patients and
families on the team and matching their
complexity and need to the right level of support
Information systems – EMR, EDW, registries,
dashboard to support team communication and
outcome tracking
Financing and operations – projecting, budgeting
and sustaining team FTE to measure the ROI
Community resources – who are our community
partners to help us engage our population in
sustaining wellness
1
2
3
4
5
Essential Integrated ElementsMental Health Integration
(CPM) provides evidence
based team approach and
tools for caring for patients/
persons and families.
A standardized clinical and operational team relational
process that incorporates mental health as a
complementary component of wellness & healing.
15
Emma63 year old who has hip and knee pain, questions about 2 of her 18 meds,
“no energy”, has a ten minute appointment at 3:30 pm
•Diabetes, Hypertension, MCI, Arthritis, CHF
•Exam is unremarkable except for slight low blood sugar
•You talk about management of diabetes for a few minutes, answer the med questions wish them well, stand to leave, and with one hand on the door the husband says
•“Um, before you go, we need to ask you about one other thing we are really worried about…”
•Explore treatment options, insurance, access to care, will the family even follow up…(5 to 25 minutes if you include all staff time)
•Staff gives patient drug samples, referral names, husband given number for the ER ,Emma is on her own
•Your 3:50 yelled at staff and left very upset
•Your receptionist has tried to reassure three other patients (4:00, 4:20, 4:30) that the doctor will be in soon (5 to 10 minutes and lots of energy used up)
How does MHI –TBC Work to Prevent and Manage Chronic Disease?
26
What is Team-based Care (TBC)?
How- Tools - Standardized screening and assessment Packet- Organized workflow- Team function scorecard - Registry & Dashboard
Who - Team Roles - What is role of leaders ? -What is the role of the PCP in TBC?-What is the role of patient & family? -What are the roles of other clinicians & staff?- What is role of the community?
Research Impact — Pediatric study shows that integrating mental and physical health through primary care teams results in better clinical outcomes and lower costs.
ACOs are maturing, but mental health integration has remained difficult
Initial CMS ACO definition offered little
room for behavioral health participation
• ACO providers were largely limited
to physicians (MD/DO)
• Entities authorized to form ACOs
were limited to acute care hospitals
• Assignment of enrollees to
participating ACOs based on PCP
ACO model continues to grow, but
savings have been elusive
• Only ~1/2 of Pioneer ACO participants
earned meaningful savings
• Pioneer ACOs had lower spending on
mental health admissions in the first
year, but not in subsequent years
• Early ACOs had no changes in inpatient
mental health admissions
ACO participants identify challenges to
addressing behavioral health issues
• Scarcity of behavioral health
workforces
• Challenges in developing a
sustainable funding model
• Limitations with sharing mental and
substance abuse disorder data
• Continued resistance to discussing
mental health issues
CMS Integrated Care Models may
strengthen behavior health in ACOs
• Integrated Care Models move from FFS
to value-based reimbursement
• Establishes an architecture for reimbursing
on improvements in healthcare quality
• Behavioral health integration may be
hampered by attribution methodologies
connecting interventions with a provider
Source: Integrating Behavioral Health into Accountable Care Organizations: Challenges, successes, and failures at the federal and state levels; Sept 2016. National Association of State Mental Health Program Directors.
Intermountain's outcomes with MHI-TBC align strongly to the goals of the ACO model
MHI is a model that delivers what ACOs need –high quality, cost-effective care for patients1...
...however, ACOs have historically struggled to
implement team-based mental health care2
Alluceo provides a potential solution to historical limitations that
often prevent effective integration of mental health within ACOs
26%Increased
Adherence to diabetes protocol
23%Reduced
10.6%Reduced
7%Reduced
Emergency room visits
Hospital admissions
Primary care encounters
Resistance to discussing mental health issues,
including hesitation to provide screening
Challenges related to using the EMR and IT to
share data and coordinate care
Scarcity of psychiatrists and other behavioral
health professionals
1. Reiss-Brennan et al. JAMA 20162. National Association of State Mental Health Program Directors, 2016
Scaling MHI within Intermountain’s ACO
ACO Advances Value-based Practice at Intermountain Healthcare
• Launched new Medicare Accountable Care Organization (ACO) on January 1, 2018
• Called Intermountain Accountable Care
• Includes approx. 53,000 Medicare members
• Involves employed physicians and advanced-practice clinicians from Intermountain
Medical Group and Intermountain hospitals
• Also contracted with open-staff physicians and APCs
“Having a Medicare ACO advances our mission, supports our vision to be a model health system, and is another step toward value-based care,” Mikelle Moore, Intermountain’s Senior Vice President of Community Health and the President of Intermountain
Accountable Care, LLC.
Reimaging Primary Care – Enhancing TBC
Reimaging Primary Care Focuses on Aligning PCPs towards Better Patient
Management
• Premise is to keep people well and keep them out of the hospital
• Launched in summer of 2018
• 6 primary care clinics
• Salaried physicians
• Approximately 700 to 800 patients in a panel
“What's been unique in this setting is thinking about a team and teaming. It's a different mindset. It requires a growth mindset to be part of the team. I think this is a shift for
physicians, in being able to really trust each member on the team is doing their work.
We're all working together with a common purpose.” Dr. Anne Pendo, Medical Director – Population Health, Intermountain Healthcare
What Is the Real Cost?
“ Providing integrated mental health and primary care is the right thing to do for the sake of the patient, but the resultant financial benefits of reduced resource utilization accrue to someone else — the employer who pays for health insurance, the insurance company itself, or a large health system — and not to the practice that bears the expense and reduced reimbursement.”
55
JAMA Editorial: Integrated Behavioral and Primary Care, “What Is the Real Cost?”Thomas L. Schwenk, MD
Population Health & Well Being
Time to Move towards Providing Prevention
& Effective Management through Holistic Care Teams
10 years of Intermountain experience shows $115 PMPY savings1
PMPY savings at $22 program cost$115
PMPY savings for commercial payer patients $260
PMPY savings for patients with other chronic conditions2$1,400
Saved during implementation, which covered 7-8% of patients $5M
$
$
• $2B+ in savings if scaled across a national payer such as United Health4
• $800M+ in savings if adopted broadly at 10 large hospital systems5
• $200M in savings if 10 largest US employers adopted the system6
Representing a meaningful opportunity for other health systems and payers
1. Association of Integrated Team-Based Care With Health Care Quality, Utilization, and Costhttps://jamanetwork.com/journals/jama/fullarticle/2545685?resultClick=1
2. Chronic Patients: patients with multiple comorbidity 3. Over a 4 year study period: jamanetwork.com/journals/jama/fullarticle/2545685?resultClick=14. Assuming 50% penetration of plan members (excluding Medicare Supp, Medicaid etc.) 5. Assuming 50% penetration at the hospital of similar size as IM 6. Assuming 50% penetration
2
The digital app for patients is intuitive and engaging …
Engaging self care
materials and tools
In-app communication
with care team
Engaging Patient
screening
Care plan
Patient centered
care team
60
3
61
… and seamless
tools for providers
61
EMR
integration2
Care plan and
care team formation1
Patient Outcome
tracking
Secure team
communication
… with seamless desktop tools for providers
1. Covers the practice management 2. Not in scope for MVP, but on the roadmap
3
$4Billion Potential U.S.
healthcare
Annual Savings
43Million
Approx.
Adults in the
U.S suffer with
mental Illness
18% of total
population
seconds from
suicide by
2020
1 deathevery 20
JAMA: Association of Integrated Team-Based Care with Health Care Quality,
Utilization, and Cost, 2016;316(8):826-834. doi:10.1001/jama.2016.11232