PARTNERING TO MITIGATE SOCIAL DETERMINANTS & REDUCE HIGH UTILIZATION • Amy Gallagher, Psy.D.- Vice President, Whole Health, LLC • Randall Reitz, Ph.D.- Director of Behavioral Medicine, St. Mary’s Family Residency • Alex Hulst, Ph.D.- Integrated Behavioral Health Advisor, Rocky Mountain Health Plans Session # B2 CFHA 20 th Annual Conference October 18-20, 2018 • Rochester, New York
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PARTNERING TO MITIGATE SOCIAL DETERMINANTS ...PARTNERING TO MITIGATE SOCIAL DETERMINANTS & REDUCE HIGH UTILIZATION • Amy Gallagher, Psy.D.- Vice President, Whole Health, LLC •
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PARTNERING TO MITIGATE SOCIAL DETERMINANTS &
REDUCE HIGH UTILIZATION• Amy Gallagher, Psy.D.- Vice President, Whole Health, LLC• Randall Reitz, Ph.D.- Director of Behavioral Medicine, St. Mary’s Family Residency• Alex Hulst, Ph.D.- Integrated Behavioral Health Advisor, Rocky Mountain Health Plans
Session # B2
CFHA 20th Annual ConferenceOctober 18-20, 2018 • Rochester, New York
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Please insert the assigned session number (track letter, period number), i.e., A2a Please insert the TITLE of your presentation. List EACH PRESENTER who will ATTEND the CFHA Conference to make this presentation. You may acknowledge other authors who are not attending the Conference in subsequent slides.
Faculty DisclosureThe presenters of this session have NOT had any relevant financial relationships during the past 12 months.
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You must include ONE of the statements above for this session. CFHA requires that your presentation be FREE FROM COMMERCIAL BIAS. Educational materials that are a part of a continuing education activity such as slides, abstracts and handouts CANNOT contain any advertising or product‐group message. The content or format of a continuing education activity or its related materials must promote improvements or quality in health care and not a specific propriety business interest of a commercial interest. Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If the educational material or content includes trade names, where available trade names for products of multiple commercial entities should be used, not just trade names from a single commercial entity. Faculty must be responsible for the scientific integrity of their presentations. Any information regarding commercial products/services must be based on scientific (evidence‐based) methods generally accepted by the medical community.
Conference ResourcesSlides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2018
Slides and handouts are also available on the mobile app.
Learning ObjectivesAt the conclusion of this session, the participant will be able to:
• Identify a multi-agency, interdisciplinary pilot program and its outcomes.
• Understand lessons learned from program implementation and evaluation.
• Conceptualize the program through case studies.
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Include the behavioral learning objectives you identified for this session
Bibliography / Reference1-Reference Thompson, M.P., Podila, P. S. B., Clay, C., Sharp, J., Bailey-DeLeeuw, S., Berlkley, A. J., Baker, B. C., &
Waters, T. M. (2018). Community navigators reduce hospital utilization in super-utilizers. The American Journal of Managed Care, 24, 70-76.
2-Reference Johnson, T. L., Rinehart, D. J., Durfee, J., Brewer, D., Batal, H., Blum, J., Oronce, C. I., Melinkovich, P., Gabow, P. (2015). For many patients who use large amounts of health care services, the need is intense yet temporary. Health Affairs, 34, 1312-1319.
3-Reference Greene, J., Hibbard, J. H., Sacks, V., Overton, V., & Parrotta, C. D. (2015). When patient activation levels change, health outcomes and costs change, too. Health Affairs, 34, 431-437.
4-Reference Findley, S., Matos, S., Hicks, A., Chang, J., & Reich, D. (2014). Community health worker integration into the health care team accomplishes the triple aim in a patient-centered medical home: A Bronx tale. Journal of Ambulatory Care Management, 37, 82-91.
5-Reference Miller, B. F., Ross, K. M., Davis, M. M., Melek, S. P., Kathol, R., & Gordon, P. (2017). Payment reform in the patient-centered medical home: Enabling and sustaining integrated behavioral health care. American Psychologist, 72, 55-68.
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Continuing education approval now requires that each presentation include five references within the last 5 years. Please list at least FIVE (5) references for this presentation that are no older than 5 years. Without these references, your session may NOT be approved for CE credit.
Learning AssessmentA learning assessment is required for CE credit.
A question and answer period will be conducted at the end of this presentation.
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Please incorporate audience interaction through a brief Question & Answer period during or at the conclusion of your presentation. This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy accreditation requirements.
IN THE BEGINNING
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As far as health plans go, we’re a pretty small fish (local, regional). But we are known for our innovation. RMHP holds the state Medicaid contract for providing services on the Western Slope of Colorado. In managing Medicaid RCCO funds, the health plan chose to invest in a different approach to managing people at risk due to social / behavioral challenges that impact utilization of health care rather than solely relying on a fee-for-service program.
DEVELOPING A PROGRAM
KEY STARTING POINTS
Behaviors Health outcomes
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Shared assumption between community partners that behaviors influence health outcomes
KEY STARTING POINTS
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Started with funding source…payer….asking what their pain points were (ER utilization, high cost, strain on system).
KEY STARTING POINTS• Logic Model
•Global Budget
•Workforce development
•30% shared risk agreement
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Use of global budget & logic model Mind Springs Health (Community Mental Health Center) Rocky Mountain Health Plans (insurer) The Center for Mental Health (Community Mental Health Center) Agreed upon shared risk model (30%)
IMPLEMENTATIONResearched CHW work in other states
Created training program
Hired initial workforce ◦ 5 CHWs across 4 counties; 6 medical practices
Currently11 CHWs; 10 medical practices & unattributed members
Focused upon systems integration◦ Continuous program evaluation and evolution
CREATION OF WHOLE HEALTH, LLC
Strategized use of LLC in order to assist with communication & coordination◦ Decreased CMHC limitations of HIPAA and 42-CFR
Broke down barriers◦ Increased communication/relationships with medical practices
CREATING BFFs…Community collaboration◦ Health Engagement Team (HET) Steering Committee
◦ RMHP, WH, medical practices, IPA, ER representation ◦ Started with monthly meetings, currently quarterly
HET Joint Ops◦ RMHP & WH◦ Monthly meetings
WH meetings with medical practices
BUDGETARY CONSIDERATIONSRMHP pays for program with the expectation that MSH takes 30% financial risk on the entire PMPM cost of care
◦ Salaries & benefits◦ IT equipment (e.g. laptops, EMR license, cell phones)◦ Leased vehicles/travel expenses◦ Training◦ Program materials/supplies◦ Overhead/CMHC infrastructure
TRAINING PROGRAMWeek-long classroom training program
Mental Health First Aid
Crisis Prevention and Intervention (CPI)
Shadowing of Mind Springs Health programs
Shadowing of CHW team
Ongoing training & supervision
THE ROLE OF THE CHWFocus on health behaviors in patient’s home or community◦ ED reduction
Engage patient in health behavior change
Link the patient with medical, behavioral,& social services needed to improve & maintain quality health & wellness
Facilitate access to a wide range of services through outreach, community education, informal mentoring, and social support
Provide transportation
MEASURING OUTCOMES
OUTCOME MEASURES
Initial Added Over Time
ER use Patient Activation Measure (PAM)
Needs addressed Western CO Needs Assessment
Service utilization Generalized Self Efficacy Scale
Medical practice narratives
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Evolving process to align with program aims and objectives Baseline and follow-up assessments
RECENT COHORT DATA
67%
33%
WCNA Measure
Patients Met Measure
Patients Did Not MeetMeasure
50%50%
GSE Measure
Patients MetMeasure
Patients Did NotMeet Measure
“Our CHW was able to help implement transitional housing & address his alcoholism at a facility in AZ. He connected with our practice through the CHW program & we were able to treat several physical issues that he would have gone to the ED for.”
“The patient benefitted from the kind, caring, and wise relationship with the CHW. She became informed of resources & the process to access them.”
“The patient & family are aware of many resources, but the patient isn’t willing to use them until they are desperately desired. This has educated several family members. The program might not have influenced the patient directly, but possibly, the entire family benefitted.”
“The main recoverable success was decreased ER utilization & increased PCP visits.”
“The patient had virtually no ER visits and completed 90 days in a recovery center. At discharge, patient had 120 days clean and better relationship with the PCP.”
PATIENT STORIES
LESSONS LEARNED
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It’s all about the relationships Buy-in Ongoing communication Contributions from all involved Openness of leadership is also essential for innovation
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It continues to be about payer’s pain points but attempts to align with practice’s pain points
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Goodness of fit when hiring
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Rapid cycle change mentality – PDSA cycles Role of PT Team
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Absolute importance of transportation
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Generalization of program Urban vs. rural Negotiation of nuances with medical practices while remaining standardized
COMMUNITY HEALTH WORKERS REPORT…
Coordination-of-care with pharmacy◦ One fill date/month, less anxiety about transportation, increased
Transportation conversations are amazing◦ Transport to CMHC for treatment
Being able to model appropriate behavior for pts is helpful
ER communicated with CHW about pt concerns◦ Coordinate care, find assisted living, figure how pt will get psychotropic
inoculations during transition-of-care, arranged out-of-county transportation, and pt reports he is “happy and loves it here”
$50,000 savings in one through coordination-of-care efforts (saved helicopter ride and unnecessary hospitalization)
Session Evaluation
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