esteban r. lópez, m.d., m.b.a, mckesson health solutions

Care Coordination & Integrated Health Care

Texas Enhanced Care Program and Mental Health Services Coordination

Esteban R. López, M.D., M.B.A, McKesson Health SolutionsDena Stoner, Sr. Policy Advisor, Department of State Health Services

Anna Sicher, RN, M.P.A, Health and Human Services Commission

05/23/10

Texas Medicaid Enhanced Care Program Whole person management: Addressing barriers

Self-EmpoweredMember

Self-Management Coaching

Self-Management Coaching

Motivation and Confidence

Motivation and Confidence

Coordinate and Arrange Care

Coordinate and Arrange Care

Connection with Providers

Connection with Providers

Facilitate access to community

services

Facilitate access to community

services

Symptom Assessments

Symptom Assessments

IncentivesIncentives

Facilitate access to behavioral

health services

Facilitate access to behavioral

health services

Lifestyle behavioral

change

Lifestyle behavioral

change

Medication AdherenceMedication Adherence

Ensure appropriate

Medical Home

Ensure appropriate

Medical Home

05/23/10

Texas Medicaid Enhanced Care Program Overview

Program launched November 2004 Serving Primary Care Case Management (PCCM) and fee-for –service (FFS)

beneficiaries statewide in Texas Currently, more than 60,000 clients in the program

Program provides disease management (DM) services to those clients with at least one of the covered diseases: Congestive Heart Failure (CHF) Chronic Obstructive Pulmonary Disorder (COPD) Asthma (AST) Coronary Artery Disease (CAD) Diabetes Mellitus (DIA)

Telephonic and Community Based Nursing Model Both clinical and financial outcomes reviewed by

independent 3rd party actuarial firm

05/23/10

Predicts/stratifies members who will: Benefit most from DM services,

education, & improved self-management techniques

Provide best opportunity to reduce costs & achieve savings

Intervention levels: Low risk – mailings, telephonic RN

interventions & 24/7 nurse advice line Moderate & high risk – mailings, high

touch field based & telephonic RN interventions, & 24/7 nurse advice line

Moderate & high risk clients supported by care coordination staff Medicaid Resource Coordinators Texas Based Registered Nurses Bilingual Community Health Workers

Provider outreach & support directed by Texas Based Medical Director & Provider Outreach Coordinators

Texas Medicaid Enhanced Care Program

Delivery Model

Highest Risk

~20%

Moderate Risk

~20%

Lower Risk

~60%

50-80% of Claims

10%-30% of Claims

10-20% of Claims

PopulationDistributio

n

Claims CostDistribution

This is thepopulation

whereDM has the

greatestsavingsimpact

This is thepopulation

whereDM has the

greatestsavingsimpact

05/23/10

Texas Medicaid Enhanced Care Program Key components: Care Coordination

Coordinator Types of Referrals YTD 2009

Medicaid Resource

Coordinator

Utilization (hospital, emergency department/urgent care visits) Durable Medical Equipment (DME) Issues Mental Health Issues Transportation Issues Home Issues Education/Information Issues Medication Issues Provider Issues Benefits/Eligibility Issues

3,728 = 18% 4,720 = 23% 1,703 = 8% 765 = 4% 2,223 = 11% 1,617 = 8% 3,895 = 19% 1,713 = 8% 322 = 1%

Care coordination services aid member success by reducing or eliminating barriers to care and assisting members & providers achieve member access & success

05/23/10

Texas Medicaid Enhanced Care Program Key components: Evidence Based Guidelines

Enhanced Care Program uses national guidelines as the basis for all DM programs. Each condition-specific program is reviewed, updated, and modified as national guidelines are updated and other relevant information is made available from recognized resources.

Use of disease-specific standardized clinical guidelines ensures consistency of the assessment and monitoring processes delivered to the member by the care management professional.

Tools are used to evaluate staff performance and knowledge of the program during all aspects of the program intervention, such as the enrollment, assessment, and monitoring/coaching processes.

Providers are informed of client status and “gaps in care” via post-assessment letters or through faxed alerts.

05/23/10

Texas Medicaid Enhanced Care Program Asthma Action Plan and Post Assessment Letter

05/23/10

Texas Medicaid Enhanced Care Program Key components: Connection with Providers

Over 7,000 provider visits by Provider Outreach

Coordinators and Medical Director since Nov 2004.

Quarterly Advisory Board with participation by providers from

across the State.

Close relationship with statewide organizations including Texas

Medical Association, Texas Pediatric Society, Asthma Coalition

of Texas, Texas Diabetes Council, and Texas Council for

Cardiovascular Disease and Stroke.

New Stakeholders include, School Nurse Organization,

National Association of Social Workers, Texas Dietetic

Association, and Behavioral Health Organizations.

05/23/10

Texas Medicaid Enhanced Care Program Outcomes for Clinical Metrics

The Texas Medicaid Enhanced Care Program evaluates clinical outcomes for the Medicaid clients served by the program during each year.

The contract-based goals were developed collaboratively by McKesson Health Solutions and the Medicaid staff of the Texas Health & Human Services Commission.

Average Clinical Metrics Improvement Each Year (Claims-Based and Self Reported Combined) Year over Year Improvement

Program Period 1 11-01-04 through 10-31-05




17.40% 15.60% 16.10% 19.40%

05/23/10


Percentage of Self-Reported Clinical Metrics Meeting the Contract-Based Goal for Each Condition*

Condition

Program Period 111-01-04 through 10-31-05




Asthma 100.0% 50.0% 100.0% 100.0%

CAD 100.0% 100.0% 80.0% 100.0%

CHF 100.0% 75.0% 100.0% 75.0%

COPD 100.0% 100.0% 33.3% 100.0%

Diabetes 100.0% 100.0% 100.0% 80.0%

Aggregate Total: 100% 86% 86% 90%

*Self-reported data calculated from actively managed clients in program

05/23/10


*Claims based measures calculated from all identified clients using reconciliation data

Aggregate Clinical Metrics Outcomes (Self-Reported and Claims-Based)

ConditionProgram Period 1

11-01-04 through 10-31-05Program Period 2



11-01-07 through 10-31-08

Asthma60.0% 30.0% 80.0% 70.0%

CAD60.0% 70.0% 50.0% 70.0%

CHF62.5% 50.0% 75.0% 50.0%

COPD57.1% 71.4% 28.6% 57.1%

Diabetes69.2% 75.0% 54.5% 54.5%

Aggregate Total:63% 60% 59% 61%

05/23/10

Texas Medicaid Enhanced Care Program Outcomes for Financial Metrics

05/23/10

Texas Medicaid Enhanced Care Program Innovative Pilot Projects

Targeted interventions for frequent ED users.Bilingual Social Worker to identify members with high ED

usage .Connect those members to their medical home and reduce

barriers in access to care, provide education and follow-up.Promote use of Nurse Advice Line when appropriate.

Increase collaboration with Large Practice Providers.Office Health Worker to assist with increased enrollment into

program and improved clinical metrics.Office Health Worker to provide real time referrals to ECP

care coordination team and assist with continuity of care.

05/23/10

Texas Medicaid Enhanced Care Program Innovative Pilot Projects

Partnership with Diabetech for enhanced Diabetes Management.Members mailed glucose monitoring device, and A1c

testing kit.Follow-up electronic monitoring, and coaching provided

for education and testing.

Behavioral Health Co-Morbid Management. Intensified the identification and management of co-

morbid conditions involving behavioral health, specifically depression and schizophrenia.

Dedicated staff to ensure appropriate interventions and care coordination.

05/23/10

Texas Medicaid Enhanced Care Program Summary

5 years and over 168,000 TX lives touched, with 61,949 clients currently enrolled in program.

On average, an 18% engagement rate among all risk levels; 24% engagement rate for those high cost/high risk client.

Strong cost saving results. $20.6 million net savings (after program fees) through Program

Year 4. This includes $2.6M in payback to the State. New integration with Behavioral Health Programs.

Management of clients with depression and

schizophrenia. Closer relationship with state mental health authorities. Coordination between behavioral health and physical

health providers through case management.

05/23/10

Building BridgesBuilding BridgesThe Role of Public Mental HealthThe Role of Public Mental Health

Dena Stoner, Senior Policy Advisor, Mental Health and Substance Abuse ServicesTexas Department of State Health Services

[email protected]

05/23/10

People with severe mental illness live 25 yrs less, on average, than other Americans.1

46% of Texas Medicaid emergency room visits are related to mental health or substance abuse.2

People with mental illness are among the least employed groups. Over 80% of Texas adult working age mental health clients are unemployed. 3

In 2007, over 7,000 Texas nursing facility residents were former clients of the public mental health system.4

1. Lutterman T, Ganju V, Schacht L, Shaw R, Monihan K, et.al. Sixteen State Study on Mental Health Performance Measures. DHHS Publication No. (SMA) 03-3835. Rockville, MD: Center for Mental Health Services, Substance Abuse & Mental Health Services Administration, 2003

2. Senate Health & Human Services Committee Presentation by Dr. David Lakey, DSHS Commissioner, October 13, 20083. 3. DSHS MHSA CARE database, 20104. Texas Department of State Health Services and Texas Department of Aging and Disability Services (2007). Data match showing prevalence of former DSHS clients in DADS licensed nursing facilities

The Cost of Mental Illness

TEXAS Department of State Health Services

05/23/10

Why Integrate?

Texas has lower per capita mental health funding than most states.

72 Texas counties are designated mental health manpower shortage areas.

Better outcomes are possible using a “whole person” approach to services.


05/23/10

Role of Public Mental Health

Research and development of integrated services and supports. Examples include: Working Well Demonstration Money Follows the Person BH Pilot SUPPORT Pilot

Coordination with other efforts. Examples include: HHSC Enhanced Care Program project


05/23/10

Integration Principles

Evidence-based, scientifically validated

Person-centered (builds on the person’s strengths, needs and motivations)

Provide flexibility to address complex issues affecting the person’s health

Collaboration with other systems is key


05/23/10

Current Reality

Large numbers of nursing facility residents have a primary diagnosis of mental illness, with a disproportionate number under age 65. 1

Nursing facilities are not optimal environments for treatment of and recovery from mental illness. For example, administration of antipsychotic medication often violates quality guidelines. 2

1. . Bagchi, A.D., Simon, S.E. & Verdier, J.M. (2009). How many nursing home residents live with a mental illness? Psychiatric Services, 60(7), 958-964.2 Blank, Jeffrey (2009). Persons with Mental Illness in Nursing Homes: Placement and Quality of Treatment. SAMHSA Presentation to National Home and Community-based Services Conference.


05/23/10

Money Follows the Person Behavioral Health Pilot

Transitions adults with severe mental illness or substance abuse disorders from nursing facilities and support them in the community.

Integrates evidence-based mental health and substance abuse services with long-term services and supports.

If successful, long-term services and supports waiver programs will be amended to include evidence-based BH services. (pilot ends 2016)


05/23/10

Cognitive Adaptation Training (CAT)

Helps people master independent skills living.

Uses a motivational strengths perspective to facilitate person’s initiative and independence.

Provides assistance and simple, inexpensive environmental modifications (calendars, clocks, signs, organizers…) to help people establish daily routines, organize their environment and function independently.

Adapts the physical environment to help improve person’s functioning.


05/23/10

CAT Interventions: Dressing

Apathy Disinhibition Mixed


05/23/10

MFP Findings

88% of individuals have maintained independence. Examples include getting a paid job at competitive wages, driving to work, volunteering, getting a GED, attending computer classes and working toward a college degree.

Participants demonstrate statistically significant improvement on components of standardized scales which measure adjustment to living (independence in daily life).

Preliminary analysis indicates that average Medicaid costs are lower under the pilot than prior to discharge.


05/23/10

Mike

Schizoaffective disorder

Insulin dependent diabetes

Street drug and alcohol addiction

Emaciated and physically debilitated

Lacked social, living skills and family supportsConsidered a “behavior problem”

In and out of nursing facilities for most of his adult life


05/23/10

Mike

Mike’s dream was to have a job and a place of his own. With the help of CAT, Mike set employment goals, learned to interview and got some vocational training. He began working 20 hours a week.

Through CAT, he learned the social skills needed to get along in the community. He now handles daily activities like catching the bus, taking medication, doing laundry and caring for himself. CAT also helped him learn to manage his blood sugar level and eat healthy. His STAR+PLUS service coordinator helps him get the health services he needs.

Through substance abuse counseling, Mike was able to understand issues in his past and is reconnecting with his natural family.


05/23/10

The Cost of Disability

Workers are the fastest growing category of federal disability payments ($65 billion of $77 billion in 2003).

Significant numbers of people with mental illness are on long term disability.

250,000 working-age Texans with disabilities received SSI and 380,000 received SSDI in 2005, Medicaid expenses = $3.5 billion.


05/23/10

Working Well (Demonstration to Maintain Independence and Employment)

Rigorous scientific design (randomized controlled trial).

1600+ working people with potentially disabling conditions in Harris County.

Integrated health, mental health, dental, vision, substance abuse, and vocational services.

Provided person-centered planning, management, and navigation of health and employment systems.


05/23/10

Disability Applications Reduced

Texas MinnesotaHawaii


12 month national evaluation findings

05/23/10

Other Outcomes

Majority of the intervention group is receiving SSI/SSDI at a significantly lower rate.

Navigation via case management related to better health and employment outcomes..

Intervention group has significantly increased access to health care (outpatient services, prescription drugs, mental, dental, optical care).

Intervention group participants report satisfaction with case management, reduced costs and improved access.


05/23/10

Mary

Middle-aged, divorced with total care-giving responsibility for her disabled son. Her health issues included depression, bipolar disorder, adrenal adenoma, back pain, dental, and vision problems. She had a job, but the income was not predictable. She was not taking her medications or going to the doctor on a regular basis. She could not use her right hand due to an old industrial accident which resulted in nerve damage.

She was feeling increasingly hopeless, isolated, and overwhelmed. She slept most of the day. She had previously applied for disability benefits because of her physical limitations and planned to apply again, due to the disabling nature of her severe mental illnesses.


05/23/10

Mary

With her case manager’s help, Mary began to understand the importance of seeing her doctor regularly; asking friends and family for assistance; taking medications as prescribed; attending behavioral therapy sessions; and improving her health through exercise, diet and stress management. Through Working Well, Mary was able to get needed medical, mental health, dentures, and vision care.

Her Working Well Case Manager provided Mary with vocational counseling and referred her to a community organization that helps older workers find employment. Mary entered a job training program and was prepared for an occupation that better accommodated her physical limitations. She regained her self esteem, began working 30 hours per week. She currently is studying for her GED and plans to obtain an associate's degree.


05/23/10

SUPPORT Pilot (HHSC)

Includes master’s level behavioral health specialists in pediatric offices.

Evaluates and treats children who have, or are at risk for developing, a mental health disorder.

Scheduled to be completed in September 2010.

Concept was developed by DSHS and implemented by HHSC (state Medicaid agency).


05/23/10

Collaboration: Enhanced Care Program

DSHS and HHSC have enabled -

Exchanging information with HHSC disease management provider to improve care coordination

Information can include: General and specific health information Claims and assessment data Care plans Alerts and updates

Coordination of treatment to improve services


05/23/10

Future Possibilities…

New federal Medicaid option (in 2011) for individuals with serious mental illness to designate a health home

Medicaid and insurance expansions


05/23/10

Texas Medicaid Enhanced Care Program

Transition to the Future“Texas Health Management Program”

Anna Sicher RN, MPA Clinical Program Specialist

Medicaid/CHIP Division

05/23/10

Texas Health Management ProgramNew Contract Model

RFP Release - August 2009

New Contract Operational Start - Nov. 1, 2010 (3 year contract)

New model for Chronic Disease Management based on E.H. Wagner’s Chronic Care Model

1. Client self-management

2. Provider/practice delivery system design; and

3. Technological support

2

3

1

05/23/10

Texas Health Management ProgramContract Requirements

Whole person based on high-cost/high risk (HC/HR) – not disease specific.

Vendor must develop a coordinated care plan. Vendor must offer a minimum of:

1. Self-management education to all Texas Health Management (THM) Program clients

2. A health & wellness program for all HC/HR clients.

3. Behavioral & mental health management when needed.

4. Pharmacy management when needed. Identification using Predictive Modeling Diabetes Self-management Training Component

Initial year - must offer 10 hours of training + 3 hours nutritional counseling to all diabetics.

Diabetes training by a Cert. Diabetes Educator.

05/23/10

Texas Health Management ProgramContract Requirements (con’t)

Provider equally important as client – vendor must:1. Offer tools and educational resources to providers.

2. Provide practice facilitation (PF) to providers who may not be using evidence-based guidelines and who request PF.

3. Must educate providers about Medicaid resources & programs.

20% or 50% of the vendor’s per-member per-month (PMPM) payment will be at risk depending on:

1. Financial - 5% Total Annual Claims cost savings for the program (40% of overall at-risk fee).

2. Clinical Quality Indicators - with targets ( 50% of overall at-risk fee).

3. Humanistic Measures – client/caregiver and provider surveys (10% of overall at-risk fee).

05/23/10

QUESTIONS?

esteban r. lópez, m.d., m.b.a, mckesson health solutions

Documents

program program

program intervention

care management professional

conditionspecific program

disease management

person management

management coachingmotivation

texas medical assoc