health home evaluation overview

CASAColumbia in Partnership with the

New York State Department of Health

2013

HEALTH HOME

EVALUATION OVERVIEW

JON MORGENSTERN PH.D. PROFESSOR AND DIRECTOR, SUBSTANCE ABUSE

SERVICES DEPARTMENT OF PSYCHIATRY

© CASAColumbia 2013

HH Evaluation Committee

• NYS Department of Health

• NYS Office of Mental Health

• NYS Office of Alcoholism and Substance Abuse Services

• Columbia University

• New York University

2 Partial support provided by the National Institute

on Drug Abuse


Presentation Overview

• Critical features of NYS health homes (HH)

• Evaluation goals

• Methods

Quantitative study (well-defined)

Qualitative study (in progress)

• Bidirectional provider-evaluator feedback loops

Inform evaluation

Improve HH implementation

• Conclusions

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Overview of Section

2703 if ACA: What Federal Statute Attempts to Accomplish?

• Medicaid recipients with multiple chronic conditions

• Fragmented, inefficient, crisis-driven care leads to high costs to govt.

and poor health outcomes

• Expansion of medical home “whole person” approach

Care management and service integration

Flexibility for states to design programs

90% FMAP rate for 8 quarters

• Better health care outcomes (quality measures) and reduced costs

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NYS HH: Overview of

Distinctive Features • Medically complex, costly chronic behavioral health conditions

Priority based on clinical acuity & care disconnection

• “Whole person” care enabled via diverse network partners

(new/merged entities)

Patient centered care includes robust outreach & engagement efforts

Novel payment arrangements to incentivize system-redesign

Flexible approach to defining HH standards coupled with quality

measurement

• Engagement, access, and receipt of appropriate care can reduce

crisis care (ED, inpat. readmissions), improve health outcomes, and

reduce costs

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Health Home Evaluation Goals

I. Did HHs increase “appropriate” care, improve health outcomes & reduce costs? (Impact)

Across diagnostic and “priority” subgroups

Across regions

Consistency across success metrics

II. Were HHs implemented as planned? (Implementation)

Needed context to interpret patient-level outcomes

Critical to inform NYS healthcare system redesign

III. Can evaluation feedback to providers improve HH performance?

DOH led efforts

Develop bidirectional-evaluator information sharing loops

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Impact Analysis Methods:

Administrative Data • Medicaid Claims & Encounters

Basic demographics (e.g., gender)

Diagnostic groups & health status

Geography, managed care status, prior case mgmt. enrollment

Service utilization

Quality indicators

Pharmacy

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Administrative Data • CMART

Care management activity

Functional assessment

• OASAS Client Data System

SUD tx outside Medicaid

Richer individual description

• OMH utilization and program status

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Outcome Domains

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Outcome Domain Data Source Example Question

Assignment/Enrollment Eligibility/HH

Enrollment

What are characteristics of

enrollees?

Avoidable Utilization Medicaid

Claims/Encounters

Do HH reduce ED visits and re-

hospitalizations?

Quality of Care Medicaid

Claims/Encounters,

CMART

Are quality of care indicators (e.g.,

HEDIS HbA1c for diabetes)

improving? Is care management

activity associated with improvement

in quality of care?

Patient Functioning &

Experience CMART

Is patient functional status

improving? Are patients satisfied

with care?

Cost Reductions Medicaid

Claims/Encounters Are HH reducing costs?



Quality Indicators

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Quality Domain Example

Care Management Engagement rate; Contact rate

Guideline Concurrent Care

HEDIS & Behavioral Health

indicators (e.g., appropriate

medication utilization)

Continuity of Care Post-discharge admissions to next

level of care

Prevention Chlamydia screening in women

Patient Functioning Improved capacity to perform basic

tasks

Patient Experience of Care Patient satisfaction



Analytic Plan

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Descriptive

• Patient characteristics

Overall and by HH

• Quality of care

Overall, by patient sub-population (e.g., MH, SUD HIV/AIDS), and by HH



Analytic Plan

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Multivariable

• Times series

Longitudinal trends (2006-2017)

Control for individual (demographic, clinical) and regional characteristics

“risk-adjusted” by HH

• Statistically matched comparison group

Propensity score methods

Longitudinal design



Analytic Plan

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Mechanism analysis

Association between patient characteristics and outcomes

Association between care management activity outcomes


Implementation Analysis:

Areas For Inquiry • Assignment, enrollment, and engagement process

• HH structure, organization, staffing, roles & training

• Implementation of HH core services (e.g. integrated care plans)

• Health Information Technology (HIT)

• Payment methods (e.g., acuity-based CM rates) & quality measure

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Implementation Analysis:

Methods • Survey of all HHs

• Site visits to representative sample of HHs for more intensive

assessment

Key stakeholder interview across partners

Chart reviews

Focus groups with staff & possibly HH enrollees

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Feedback Efforts to Improve

HH Implementation DOH led efforts

Quality indicator feedback

CMART training and feedback

Potential to develop process improvement collaborations across

evaluators and HHs

Select high priority areas HHs (e.g., HIT)

Limited number of HHs interested in specific issues

Create low threshold process improvement feedback cycles

Strong evaluator support and access to expert technical assistance

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Summary Federal HH legislation encourages state to experiment

Strategies to improve care to vulnerable populations

Foster healthcare system redesign

NYS HH project is among the most novel and ambitious state program

Size, scope, complexity

Goals for system redesign

Evaluation is designed to support HH goals

Multiple methods

Multiple perspectives

Attempt to provide timely feedback

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Ending Addiction

Changes Everything

www.casacolumbia.org


Speaker Notes Slide 3: • From November 2012 Medicaid Update

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health home evaluation overview

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