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Advancing Behavioral Health Care Management: How Intelligent Integration Improves Clinical Case and Health Plan Performance

What is Intelligent Integration?

Best Practices White Paper | Medical Affairs Team, ODH, Inc. | April, 2017

• Learn the five best practice steps of successful population health management

• Uncover strategies to improve health plan performance through optimized behavioral health care delivery

• Explore intelligent integration and its critical role in managing high-risk behavioral health populations

• Find out how population segmentation contributes to improvedhealth outcomes and reduced overall health care costs for high-risk, high-need members

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TableOfContents:

I. ExecutiveSummary

II. TheImpactOfBehavioralHealthConditionsOnHealthStatus&HealthCareResourceUse

III. TheRoleOfBehavioralHealthOptimizationInPopulationHealthManagement

IV. BehavioralHealthRiskAssessmentForPopulationSegmentation:TheFirstStepInBehavioralHealthOptimizationInPopulationHealthManagement

V. CaseExampleOfBehavioralHealthRiskAssessmentInPopulationSegmentationInitiatives

VI. References

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I. ExecutiveSummary

Thehealthcaresystemhaslongrecognizedthehumanandfinancialimpactofcomorbidbehavioralhealthandphysicalhealthconditions.Behavioralhealthconditionshaveapronouncedimpactonhealthstatus,healthoutcomes,andresourceutilization.Individualswithphysicalhealthconditionscompoundedbybehavioralhealthissuesaremorelikelytobe“super-utilizers”ofhealthcareresources.1Thosewithundiagnosedand/oruntreateddisordersaremorelikelytobehospitalizedandtousetheemergencydepartment.2Inaddition,lackofintelligentintegrationandcarecoordinationincreasescomplicationsandpoorhealthoutcomes.

Healthplans,providers,policymakers,andadvocateshaveidentifiedandsoughtintegratedbehavioralhealthandphysicalhealthcareasapriorityfordecades.Fortunately,theadventofinnovativemodels,useofdataanalytics,andenablingtechnologyisputtingthisheretoforeelusivegoalwithinreach.

Today,healthplanmanagersareadoptinginnovativestrategiesfocusedonidentifyingandengagingtargetedpopulationsofundiagnosedandhigh-risk/highneedindividuals;expandingaccesstoandsupportingadherencetoappropriatetreatment;coordinatingcareforpopulationswithcomorbidconditions;anddevelopingquality-basedproviderpartnershipstooptimizedeliveryofvalue-basedcare.Examplesofthesestrategiesincludeinnovativeandspecializedintegratedcarecoordinationinitiatives,personalhealthnavigatorprograms,enhancedaccesstotech-enabledservices,psychotropicmedicationreviewinitiatives,specializedemergencydepartmentdiversionprograms,andprovidergainsharingwithincentivesfocusedoninnovativetreatmentmodelsandoutcomes.

Thesestrategiesrequiretheabilitytoidentifyandsegmentpopulations,definepopulationspecifictherapeuticapproachesandvenues,enablecarecoordination,monitortreatmentadherence,andidentifyindividualsforspecifictargetedinterventions.Thispracticeofintelligentintegration–incorporatingpopulationsegmentationbasedonbehavioralhealthriskassessment–isafoundationaltoolinabestpracticesapproachtopopulationhealthmanagement.

Whencombined,clinicalinnovationandtechnologybecomeapowerfultoolforaggregating,analyzingandunderstandinghealthdata,whichmayleadtoimprovedpopulationhealth.

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OneBehavioralHealthDisorder

1Addi`onalCondi`on

2Addi`onalCondi`ons

3Addi`onalCondi`ons

4Addi`onalCondi`ons

IndividualsWithBehavioralDisorders&ComorbidMedicalCondi?onsHaveHigherAverageCosts

2010-2013AverageAnnualPerCapitaHealthCareSpendingFor

IndividualsWithBehavioralHealthDisordersByAddi?onalComorbidCondi?ons

II. TheImpactOfBehavioralHealthConditionsOnHealthStatus&HealthCareResourceUse3,4

IndividualsWithBehavioralHealthDisorders&ComorbidMedicalConditionsHaveHigherAverageCosts&OftenExperienceGapsInCareManagement5

AboutathirdofUnitedStates(U.S.)adultswithmedicalconditionshavebehavioralhealthconditions.Additionally,68%ofadultswithbehavioralhealthconditionsalsohavemedicalconditions.6Behavioralhealthdisorderswithcomorbidmedicalconditionsincreaseaveragehealthcarecostsbyover200%,with4ormorecomorbidconditionsincreasingcostsfrom$12billiontoover$540billionannually.7Behavioralhealthconditionsrankinthetopfivediagnosticcategoriesforhealthcarespending.8,9

Individualswithbehavioraldisordershavehigheroverallhealthcarespending.Theseindividualsmorefrequentlyvisitemergencydepartments,anduse35%morepaidhomehealthcaredaysthantheirpeers.Adultswithabehavioralhealthconditionarealsomorelikelytoremaininthetop10%ofspendingovertwoyears,whencomparedtopeerswithoutabehavioralhealthcondition(34%versus23%,respectively).10

Historicalpopulationhealthmanagementmodelshavefocusedonspecificconditionsinsteadofaholistic,person-centeredapproach.Assuch,individualswithcomorbiditiesoftenexperiencefragmentationorgapsincare,whichcanleadtountreatedhealthproblemsandutilizationofexpensivesettings,includingapotentialrelianceonemergencydepartmentandinpatienthospitalstays.11

Behavioralhealthconditionshaveapronouncedimpactonhealthstatus,healthoutcomes,andresourceutilization.Consumerswithphysicalhealthconditionscompoundedbybehavioralhealthissuesaremorelikelytobe“super-utilizers”ofhealthcareresources.iiiThosewithundiagnosedand/oruntreateddisordersaremorelikelytobehospitalizedandtousetheemergencydepartment.ivInaddition,lackofintelligentintegrationandcarecoordinationincreasescomplicationsandpoorhealthoutcomes.

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IndividualsWithBehavioralDisordersOftenHavePoorOutcomesDespiteBeing“Super-Utilizers”OfHealthCareResources12,13

Individualswithabehavioralhealthconditionaremorelikelytobelabeled“super-utilizers”duetotheprevalenceofmultipleillnesses,uncoordinatedandfragmentedcare,andrelatedhighresourceuse.14

Super-utilizersarethe5%ofthepopulationwhoconsumeadisproportionateamountofhealthcareresources.15Thereisauniqueopportunitytousetechnologytoidentifyfactorstopredictwhoislikelytobeclassifiedasasuper-utilizer.Inmanypopulations,the5%grouputilizesasmuchas50%oftheresources,16furtherunderscoringtheimportanceofknowingwhichmembersareinthe5%.Morethan80%ofMedicaidsuper-utilizershaveacomorbidmentalillness.17Inaddition,mentalhealthandsubstanceabusedisordersareamongthetenmostfrequentdiagnosesforsuper-utilizers,regardlessofpayersource.18

Despitehigherutilizationofhealthcareresources,theimpactofuncoordinatedandfragmentedcareultimatelyincreasesthelikelihoodofpoorhealthoutcomesfortheseindividuals.19Foranypopulationhealthprogramtobesuccessful,identificationandmanagementofthissuper-utilizergrouparekey.Riskstratificationandpopulationsegmentationarecriticaltoidentifyingwhotheyare,whatservicestheyuse,andeffectivestrategiesfordiseasemanagementandrecovery.

UntreatedBehavioralHealthConditionsHinderTreatment&LeadToIncreasedUseOfHighCostServices20

Theimpactofbehavioralhealthconditionsonhealthcareuseandspendingislikelyunderestimatedsincebehavioralhealthconditionsoftengoundiagnosedoruntreated.21Individualswithuntreatedbehavioralhealthconditionssufferfromdiminishedhealthstatus,andaremorelikelytousehigh-costservices.22,23

Untreatedbehavioralhealthconditionsresultinrecurrenceofacutecrises,includingadversesocialoutcomessuchaslosthousingandpotentialincarceration,whichrequireimmediateintervention.24Recurringacutecrisesalsoresultinapatternofindividualsseekingcareinhospitalemergencydepartmentsandinpatientunits,twohigh-costlocations.In2013,themostrecentyearforwhichthereisfederaldata,emergencydepartmentshadanestimated640,000visitsforsymptomsofschizophreniaorotherpsychosis.25

Almost60%ofindividualssufferingfromdepression,oneofthemostcommonbehavioralhealthdiagnoses,havenotreceivedtreatmentwithinthelastyear—andtwo-thirdsofdepressioncasesgoundiagnosedinprimarycaresettings.26,27Mooddisorderslikedepressionarethethirdmostcommoncauseofhospitalizationamongnon-elderlyadults.28

Substanceusedisordersalsopresentapopulationhealthmanagementchallenge.Only11%ofthosewithasubstanceusedisorderreceivetreatment.29Individualswithuntreatedsubstanceusedisorderswere46%morelikelytoreportanemergencydepartmentvisitinthepastyear,and81%morelikelytobeadmittedtothehospitalduringanemergencyroomvisit.30,31

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LackOfIntelligentIntegration&CareCoordinationResultsInPoorerOutcomes&HigherCosts

Traditionally,healthcaresystemshavefocusedonmanagementofspecificdiseasestatesinsteadofusingintelligentintegrationandcarecoordination.Agrowingbodyofknowledgeabouttheeffectsofcomorbidconditionshascreatedgrowinginterestincoordinatedcaremanagement.Therearemultipleopportunitiesforimprovedcarecoordinationforindividualswithcomorbidities.

Thefirstistoaddressthemedical,behavioral,andsocialneedsofbehavioralhealthindividuals.Theabsenceofcoordinated,person-centeredcaremanagementforindividualswithcomorbidbehavioralhealthconditionsleadstomisseddiagnoses,poorfollow-up,andgapsincare.32Forexample,whenschizophreniaisleftuntreated,complications–suchassuicideandalcoholabuse–aresignificantlyincreased.Currently,thesuiciderateforschizophreniaisbetween5%and10%,whichissignificantlyhigherthanthegeneralpopulation.33Estimatesputtherateofexcessiveuseofdrugsoralcoholat50%ofthatpopulation,andnicotineuseatamuchhigherrate(60%to65%)thanthegeneralpopulation(15%).34,35,36Socialproblems,suchaslong-termunemployment,poverty,incarceration,andhomelessness,aremorecommonforindividualswithseriousmentalillness(SMI),whichincludesschizophreniaandmajordepressivedisorder.37Forindividualswithapoorlymanageddiagnosis,allofthesefactorscontributetoanaveragelifeexpectancythatis13to30yearsshorterthanforthosewithoutthediagnosis.38

Appropriatebehavioralhealthdiagnosis,treatment,andcarecoordinationarealsoessentialforthosewithphysicalhealthconditionscompoundedbybehavioralhealthissues.Thisisespeciallycriticalforchronicconditionswheremedicationadherenceandotherbehavioralfactorsdirectlyimpactoutcomes.

Forexample,thereisa200%highermortalityforindividualswithdiabetesanddepressioncomparedtothosewhoonlyhavediabetes.Thispopulationalsohasa2-3foldincreasedriskoffuturecardiaceventsforindividualswithcoronaryarterydisease(CAD)anddepressioncomparedtothosewithout.39Recentstudieshavealsoshownthatindividualswithmajordepressionwhoarerecoveringfromstrokesorheartattackshaveamoredifficulttimemanagingtheirillness,andhaveahigherriskofdeathinthefirstfewmonthsafteraheartattack.40

Onecurrentmeasureofsystemperformanceforcarecoordinationispromptcommunity-basedfollow-upafterdischargefromhospitalizationforabehavioralhealthdiagnosis.CurrentHealthcareEffectivenessDataandInformationSet(HEDIS)scoresshowthatmorethan47%ofcommercially-insuredindividuals,55%ofMedicaidenrollees,and64%ofMedicareenrolleesdidnotreceivefollow-upcarewithin7days.41Thislackoffollow-upcausesagapinthecarecontinuum,andcanpotentiallyleadtorelapse,crisis,orreturningtotheemergencydepartmentandhospitalforcare.42

Summary

Behavioralhealthconditionshaveapronouncedimpactonhealthstatus,healthoutcomes,andresourceutilization.Individualswithphysicalhealthconditionscompoundedbybehavioralhealthissuesaremorelikelytobesuper-utilizersofhealthcareresources.43Thosewithundiagnosedand/oruntreateddisordersaremorelikelytobehospitalizedandtousetheemergencydepartment.44Inaddition,lackofintelligentintegrationandcarecoordinationincreasesthelikelihoodofcomplicationsandpoorhealthoutcomesforindividualswithchronicconditions.Withgrowingevidenceaboutthese

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effects,payersandhealthplansneedenhancedtoolstooptimizetheirbehavioralhealthdeliverysystem.45

III. TheRoleOfBehavioralHealthOptimizationInPopulationHealthManagement

Withthegrowingunderstandingoftherelationshipbetweenindividualbehavioralhealthconditionsandhealthcareresourceuse,healthplansandpayersareadoptingawiderangeofstrategiestooptimizetheperformanceofthebehavioralhealthsystemtoimproveindividualoutcomes.46Thiswiderangeofstrategiesisfocusedonaccess,engagement,qualityimprovement,andcarecoordination.Toolswhichprovideenhancedanalyticcapabilities,suchasthosewhichallowforaccuratepopulationsegmentation,arecriticaltothesuccessoftacticsfocusedonoptimizingthebehavioralhealthservicesystem.

Healthplansareadoptinginnovativestrategiesfocusedonimprovingtheeffectivenessofbehavioralhealthservices.Includedinthesestrategiesarethosewhichincreaseengagement,improveaccess,andensurequality.Strategiesforimprovingcoordinationofcareforpopulationswithcomorbidconditionshavebeenofaparticularinterest. Moreandmoreresearchisshowingalinkbetweencarecoordinationandvalue.

Effectivestrategiesrequiretheabilitytoidentifyandsegmentpopulations,definepopulation-specifictherapeuticapproachesandvenues,enablecarecoordinationandmonitortreatmentadherence,aswellasidentifyindividualsforspecifictargetedinterventions.Thispracticeofintelligentintegrationincorporatingpopulationsegmentationbasedonbehavioralhealthriskassessmentisafoundationaltoolinthebestpracticesapproachtopopulationhealthmanagement.

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Examplesofthesestrategiesincludeinnovativeandspecializedintegratedcarecoordinationinitiatives,personalhealthnavigatorprograms,enhancedaccesstotech-enabledservices,medicationreviewinitiatives,specializedemergencydepartmentdiversionprograms,andprovidergainsharingwithincentivesfocusedoninnovativetreatmentmodelsandoutcomes.

Summary47

Toimprovethehealthoutcomesandreduceunnecessaryuseofhealthcareresourcesforindividualswithcomorbidbehavioralandphysicalhealthconditions,healthplansareimplementingawidearrayoftargetedpopulationhealthmanagementstrategies.Withtheincreaseininnovations,pinpointingtheindividualsforwhichagivenstrategyisbestiscriticaltooptimizingthatindividual’sbehavioralhealthstatusandtheiroverallhealthstatus.Assuch,thesestrategiesdependonanalytictoolsforsuccess,suchasthosewhichallowaccuratepopulationsegmentation.

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IV. BehavioralHealthRiskAssessmentForPopulationSegmentation:TheFirstStepInBehavioralHealthOptimizationInPopulationHealthManagement

Proactivelysupportingtheneedsofhigh-riskindividualsiskeytoimprovingpopulationhealthandreducingunnecessaryhealthcarespending.Foramaximumreturnonstrategiestosupporttheseindividuals,accurateandtimelymatchingofspecificindividualstospecificinterventionsisessential.Forsuccessfulpopulationhealthmanagement,findingtheappropriatestrategy-individualmatchisthegoalofpopulationsegmentationusingbehavioralhealthriskassessment.

ThePopulationHealthManagementFramework

Populationhealthsegmentationhappenswithintheoverallcontextofbestpracticepopulationhealthmanagement.Broadly,thepopulationhealthmanagementframeworkincorporates:50,51

• Definingthepopulationandproblemfirst.Forexample,apopulationmaybedefinedasindividualswithchronicmedicalconditionswhohavecomorbidSMI.Theproblemisdisease-based,fragmented,uncoordinatedcareresultinginsub-optimaloutcomesfortheindividualandsubstantiallyhighercosts.

• Leveragingthepowerofclinicalandfinancialdatafrommultiplesystems.Thisdatahelpsidentifywhichspecificindividualsfallintothedefinedpopulation;gaugetheprevalenceofthedefinedproblemamongthispopulation;observeadditionalbarriers,gaps,unmetneeds,andrisksexperiencedbythedefinedpopulation;andinformtheadoptionofcaremanagementstrategiestomeetthegaps,needs,andrisksobserved.

• Transformingdataintoactionableinformation.Informaticsanddataanalytictoolsorganizeaggregateddatasetsintoactionableinformationtodrivepopulationhealthstrategyandempowerthecaremanagementprocess.Informationiseffectivewhenitistransparentandaccessibleacrossthecareteam;timely,allowingaswiftreactiontochangingrisks;andrelevanttospecificquestionsthatinformclinicaldecision-making.Inthisbestpracticeapproach,greaterinformationtransparencycreatesaccountability.

• Makinginformation-drivenclinicaldecisions.Atitsfoundation,populationhealthmanagementrequirestheuseofinformationtopredictfuturerisks,andthenrequiresthedevelopmentofcaremanagementapproachesthatmitigatethoserisks.Information-drivendecision-makingenhancescomprehensivecaremanagement,improvesthequalityofcare,improvesindividualhealthoutcomes,reducesavoidableandpreventableutilization,andhelpspredictfuturecosts.

• Continuouslyseekingimprovement.Populationhealthsegmentationstrategiesarepartofstandardpractice,andshouldbecontinuouslymeasuredforperformanceandsuccess.Thisincludesevaluatingriskassessmentmethodologyandriskidentification;timelinessofinformation;relevance

Toaddresstheneedsofhigh-riskconsumersinhealthplans,particularlythosewithcomorbidbehavioralhealthandphysicalhealthconditions,anumberofinnovativeapproachesareemerging.Formaximumeffectiveness,thesestrategiesdependontheabilitytoidentifytheappropriateindividualsforspecific,targetedinterventions.Thisabilitytodointelligentintegration,incorporatingpopulationsegmentationbasedonbehavioralhealthriskassessment,isafoundationaltoolinpopulationhealthmanagement.

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ofinformationtospecificcaremanagementdecisions;andeffectivenessofcaremanagementstrategiesatboththeaggregateandindividuallevels.

PopulationSegmentationUsingBehavioralHealthRiskAssessment:TheFirstStepInPopulationHealthManagementStrategy

Populationsegmentationusingbehavioralhealthriskassessmentisanimportantstepinidentifyingpopulationhealthmanagementimprovementopportunities–andmatchingthepopulationtotheappropriateintervention.52Thisprocessusesavailabledatatoidentifyspecifichealthrisksforindividualsthatarelinkedtofuturespending.53

Simplemodelsforpopulationsegmentationinpopulationhealthmanagementprogramshavemostoftenuseddemographicsandself-reportedhealthstatusinformation.Moreadvancedmodelsincorporatediagnosesandmedicalconditions,treatmentandprescriptionutilization,and/orprevioushealthspendingpatterns–oftenfocusedexclusivelyonmedicalcare.54

Themanagementissueisthattheseriskstratificationmodelstypicallyunderestimatecostsofcareforindividualswithbehavioralhealthconditions,whileoverestimatingcostsofcareforindividualswithoutbehavioralhealthconditions.55Thisisasignificantbecausebehavioralhealthissuesarehighlyprevalent,complex,andcostly-andahighproportionofsuper-utilizerindividualshaveoneormorebehavioralhealthconditions.56Theseissuescanbeaddressedbymodifyingtraditionalriskstratificationmodelstoincludemorebehavioralhealthfactorstosupportimprovementsincostpredictions.57

Enhancedanalytictoolswhicharedesignedtoassessbehavioralhealthriskcanbeusedtoaddresstheeffectsofbehavioralhealthconditionsonindividualhealthoutcomesandspending.Intheseadvancedapproaches,additionalcharacteristicsofindividuals–suchasprimaryandsecondarydiagnoses,mentalillnessseverity,medicalconditions,ethnicity/minoritystatus,language,andsocio-economicstatus(loweducation,lowerincome,homelessness,unemployment,etc.)–canbeincorporated.58,59

Summary

Forpopulationhealthmanagementstrategiestobemosteffective,populationsegmentationiscriticaltomatchingindividualstohealthmanagementsupports.Whileahighproportionofsuper-utilizershavebehavioralhealthdisorders,thepopulationhealthmodelsdevelopedformedicalcaredonotsufficientlyexplainthevarianceintotalhealthcarecostsforpopulationswithbehavioralhealthconditionssincemedicalmodelsdonotincorporatesufficientbehavioralhealthdata.Asaresult,traditionalmedicalmodelsunderestimatetotalhealthcarecostsforindividualswithbehavioralhealthconditions,andoverestimatecostsforthosewithoutthem.60Thiscanberesolvedbysupplementingtraditionalapproacheswithbehavioralhealthdatatoaccuratelyestimatetotalhealthcostsandidentifyindividualsmostat-riskforhighresourceutilizationandcosts.

Tomakepopulationhealthmanagementstrategiesforindividualswithbehavioralhealthdisordersmoreeffective,enhancedanalytictoolsfocusedonassessingbehavioralhealthriskmustbeusedtoaddresstheeffectsofbehavioralhealthconditionsonindividualhealthoutcomesandspending.

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V. CaseExampleOfBehavioralHealthRiskAssessmentInPopulationSegmentationInitiatives61

ThiscasestudydescribestheMissouriCommunityMentalHealthCenter(CMHC)HealthcareHomeModelexperience.

DefinitionofHealthHomes

InMarch2010,Section2703oftheAffordableCareAct(ACA)allowedstatestoamendtheirMedicaidstateplanstoprovideHealthHomesforenrolleeswithchronicconditions,creatingtheopportunityfortheMissouriCMHCmodel.TheHealthHomemodelprovideshealthservices,preventiveandhealthpromotionservices,andmentalhealthandsubstanceabuseservicestoindividualswithchronicconditionsusingawholepersonapproach.Ideally,thehealthhomeachievespopulationmanagementthroughcomprehensivecaremanagement,empowermentoftheindividual,team-basedcare,andpromotionofwellnessandhealthylifestyles.

MissouriHealthcareHomePurpose,PhilosophyandApproach

MissourichosetoestablishCMHCHealthcareHomesafterrecognizingthatindividualswithmentalhealthconditionstendtohavehigherhealthcarecostsduetocomorbidphysicalhealthconditions.Theyconcludedthat,inadditiontobehavioralhealthneeds,otherhealthcareissuesmustbeaddressedinordertoimproveoverallwholepersonhealthwhilereducinghealthcarecosts.Afteridentifyingthatleadingcontributorstopoorhealthoutcomesandhighercostswerepreventablecauses,MissourichosetocreatetheCMHCHealthcareHomestoaddressgeneralhealthissues,wellness,andpreventionalongwithbehavioralhealthissues.Thegoalwastoimprovenotonlyhealthoutcomes,butthequalityofcare.

StateofMissouriHealthHomeInitiatives

In2011,MissouriwasthefirststateinthenationtoreceiveapprovalofaMedicaidStatePlanAmendment(SPA)establishingHealthHomesunderSection2703oftheAffordableCareAct.MissourihastwotypesofHealthcareHomes:PrimaryCareHealthHomesandCMHCHealthcareHomes.EffectiveJanuary2012,Missouriauto-enrolled17,882individualsinto28CMHCHealthcareHomes(thesubjectofthiscasestudy).Thesehealthhomesreceivedan$80.31permemberpermonthreimbursement(PMPM).

TargetPopulations,CharacteristicsAndCostsOfIndividualsEnrolledInMissouriHealthcareHomes

Missouri’sCMHCHealthcareHomestargetedindividualswithmentalillness,substanceusedisorders,andchronichealthconditionsincludingdiabetes,cardiovasculardisease,COPD/asthma,overweight(BMI>25),tobaccouse,anddevelopmentaldisability.Thefollowingshowstargetpopulationbycondition:

TheMissouriteamobservedtheleadingcontributorstopoorhealthoutcomesandhighercostswerepreventablecauses

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• 89%haveaseriousmentalillnesso 36%withMajorDepressiono 30%withSchizophreniao 28%withBipolarDisordero 16%withPostTraumaticStressDisorder

• ~25%withCOPD/Asthma• >than25%withDiabetes• 35%withHypertension• 81%withaBMI>25• Atleast50%reportsmoking• ~50%ofadultshaveahistoryofsubstanceabuse

TheImportanceOfPopulationHealthManagementInTheCMHCHealthcareHomeSetting

PriortotheACA,Missourihadidentifiedpopulationhealthmanagement,expandedservicesforindividualslivingwithbehavioralconditions,andtheintegrationofbehavioralandphysicalhealthcareasimportanttoimprovinghealthcareoutcomesandcosts.Theyinitiatedkeystepstobettersegmentandservehigh-riskpopulationsthroughtheuseoftechnology,aswellasastructuredapproachtocareintegrationandcoordination,whichbecamethefoundationforwhattheyidentifiedasthenextlogicalstep–theMissouriCMHCHealthcareHome.

SuccessFactors,Technology,Metrics,andReports

Byincorporatingtechnologythatallowedcareteamstotakea360-degreeapproachtomembercareanddecisionmaking,consideringsocialservicesandsupportsinadditiontomedicalandbehavioralhealthneeds,careteamsareabletoidentifythehigh-riskindividuals.Monthlyreportsallowcaremanagersto“flag”individualsandprioritizeappropriateinterventions.Onanindividuallevel,someinterventionsmayberequiredtoaddressimminentlyharmfulneeds.Onanaggregatelevel,selectinterventionsmayimpactthecareofalargerpopulation.TechnologythroughouttheCMHCHealthcareHomesenabledprovidersandcareteamstoaccessaweb-basedMedicaiddatasystemwhichincluded:

• patienthistoriesbasedonMedicaidclaims;• ametabolicscreeningdatabase;• caremanagementreportsbasedonpaidMedicaidclaimsdata;• medicationadherencereports;and,• behavioralhealthpharmacymanagementreports.

Withoutintegration,careteamswouldnothavehadaccesstocompletecarerecords.Thedisparatedatafrommultiplesourceswouldhavepreventedtheteam’sabilitytoaccuratelyidentifytheindividualsandpopulationsconsideredhigh-risk.

ImpactofCMHCHealthHomes

ThecombinationofinnovativeprogramswithenablingtechnologyresultedinatotalMedicaidcostsavingsof$2.4million.Morethanjustcostsavings,theintegratedapproachresultedinbettercare:62

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• Overallimprovementinhospitalfollow-upafterdischarge(upfrom33%to66%ofallhospitaldischarges)

• Overallimprovementinmedicationreconciliationonhospitaldischarge(upfromapproximately25%to60%ofallhospitaldischarges)

• Reductionof12.8%inhospitaladmissions/1000• Reductionof8.2%inemergencydepartmentvisits/1000• ImprovementinmedicationsbeingfilledbyindividualsintheCMHChealthhomes,when

comparedtothestateoverall(asdeterminedbyamedicationpossessionratioofatleast80%inthequartersbeingevaluated).Between80-84%ofindividualsintheCMHChealthhomesareadherentbasedonthiscriterion.

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VI. References

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