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Progress Update
Show Me Outcomes
BPM Mailings
Email Notifications
Disease Registry ProAct
NetsmartPilot/ SPQM & Costing/ Data Warehouse/
DLA-20
MO + CMT NurseLiaisons
DM3700Outreach
HealthcareHome
CMHL/ERE Excellence
2005 2008 2010 2012 2013 2015
FQHC Partnership
Training Contracts
26Missouri CMHC Health Homes
24,063 Current Enrollment (as of January 1, 2016)
• 1,236 elderly
• 19,652 adults
• 3,175 children
Missouri county map with
CMHC Health Home locations
Children (<18)
13.2%
Adult (18-64)
81.7%
Elderly (>64)
5.1%
CMHC Health Home
Enrollment by Age Group
N = 24,063 total health home enrollment as of January 1, 2016
Missouri’s Health Homes have saved an estimated
$36.3 million($60 PMPM Cost Savings)
Community Mental Health Center Healthcare Homes
have saved Missouri $31 million
($98 PMPM Cost Savings)
Current per member per
month (PMPM) rate for
CMHC Health Homes is
$85.23 (Jan. 2016)
Disease Management 3700 cohort
enrolled in CMHC Health Homes
saved $22.8 million
($395 PMPM Cost Savings)DM3700 N =4,800 lives
37%
30%28%
23%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Baseline Year 1 Year 2 Year 3
14%
CMHC Health HomesJanuary 1, 2012
0
50
100
150
200
250
300
2009 2010 Baseline Year 1 Year 2 Year 3
ER Visits Hospital Days
ER Visits Per 1000
Hospital Days Per 1000
34%
38%
CMHC Health HomesJanuary 1, 2012
0.850.68 0.62 0.58
2.5
2.272.09 2.06
0
0.5
1
1.5
2
2.5
3
Baseline Year 1 Year 2 Year 3
Avg # HospitalizationsPer Enrollee Per Year
Avg # ER VisitsPer Enrollee Per Year
Total CMHC Health Home
participants:
(2011) = 17,084
(2012) = 18,776
(2013) = 19,103
(2014) = 20,345
year end 2011 year end 2012 year end 2013 year end 2014
CMHC Health HomesJanuary 1, 2012
7%9%
29%
11%
1%
15%
9%
36%
29%
62%
45%
9% 8%
53%
18%
3% 4%7%
0%
9%6%
0%
10%
20%
30%
40%
50%
60%
70% General Nat. Pop.
HCH Adults
HCH Youth
HY
PE
RT
EN
SIO
N
CA
RD
IOV
AS
CU
LAR
DIS
EA
SE
SU
BS
TA
NC
E U
SE
DIS
OR
DE
R
AS
TH
MA
General population stats from 2015 Centers for Disease Control and Prevention (CDC) and Substance Abuse and Mental Health Services Administration (SAMHSA)
Total CMHC Health Home
participants (2012-2014):
HCH Adults N = 22,801
HCH Youth N = 3,944
27%29%
19%
9%
44%48%
23%
2%0% 0% 0%
3%
0%
10%
20%
30%
40%
50%
1ChronicDisease
2ChronicDisease
3ChronicDisease
≥4Chronic Disease
SUD+2 ormore
other CD
MH+2 ormore other
CD
HCH Adults HCH Youth
Total CMHC Health Home
participants (2012-2014):
HCH Adults N = 22,801
HCH Youth N = 3,944
Total CMHC Health Home
participants (2014):
HCH Adults N = 20,590
DM3700 Adults N = 2,407
2%
31%
35%
25%
7%
1%
18%
24%
37%
19%
1%
19%
23%
37%
20%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
UnderweightBMI <18.5
NormalBMI 18.5-24.9
OverweightBMI 25-29.9
ObeseBMI 30-39.9
Extremely ObeseBMI ≥40
General MO Adult Pop.
HCH Adults
DM3700 Adults
0.4%
7%
37%
45%
12%
2%0% 0%
0%
10%
20%
30%
40%
50%
60%
70%
1-20mGAF
21-30mGAF
31-40mGAF
41-50mGAF
51-60mGAF
61-70mGAF
71-80mGAF
81-90mGAF
Score 31-40Major impairment in several areas of functioning
Score 41-50Some serious symptoms or impairment in functioning
Total CMHC Health Home
participants (CY 2014):
N = 13,550 with DLA-20
in last 18 months
Performance Measures & Outcomes
22%27%
18%
38%
46%42%
47%
59%53%
57%
73%
61%
54%
72%
61%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Good Cholesterol(<100 mg/dL)
Normal Blood Pressure(<140/90 mmHg)
Normal Blood Sugar(A1c <8.0%)
Feb'12Baseline
Feb'1312 Months
June'1318 Months
June'153.5 Years
Dec'15current enrolled pop
Adults continuously
enrolled at each point in
time and adults enrolled as
of December 2015
N = 1,889 (3.5 yr. enrollment)
N = 4,526 (Dec 2015)
21%24%
37%41%
49%55%
60%
70%
56%
67%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Good Cholesterol for Clients w/ CVD(<100 mg/dL)
Normal Blood Pressure for Clients w/ HTN(<140/90 mmHg)
Feb'12Baseline
Feb'1312 Months
June'1318 Months
June'153.5 Years
Dec'15current enrolled pop
Adults continuously
enrolled at each point in
time and adults enrolled as
of December 2015
CVD N = 232 (3.5 yr.
enrollment)
CVD N = 564 (Dec 2015)
HTN N = 2,401 (3.5 yr.
enrollment)
HTN N = 6,111 (Dec 2015)
12%
46%
61%
80%
89% 88%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Metabolic Syndrome Screening
Feb'12Baseline
Feb'1312 Months
June'1318 Months
June'142.5 Years
June'153.5 Years
Dec'15current enrolled pop
All CMHC Health Homes
have attained a completion
rate above 80%!
N = 6,553 (3.5 yr. enrollment)
N = 20,648 (Dec 2015)
reduction in cholesterol
10% in cardiovascular disease
reduction in HgbA1c
21% in diabetes related deaths
14% in heart attacks
37% in microvascular complications
reduction in blood pressure
16% in cardiovascular disease
42% in stroke
Baseline to Year 1:
Reduced the mean LDL131 to 115 = 12% decrease
Baseline to Year 3:
Reduced the mean LDL131 to 106 = 19% decrease
For individuals with LDL >100 at Baseline
131.5
115
111.64
106
100
105
110
115
120
125
130
135
140
145
Baseline Year 1 Year 2 Year 3
19%
Baseline to Year 1:
Reduced the mean BPSystolic: 152 to 134= 18 mm/HgDiastolic: 98 to 86= 12 mm/Hg
Baseline to Year 3:
Reduced the mean BPSystolic: 152 to 133= 19 mm/HgDiastolic: 97 to 83= 14 mm/Hg
For individuals with Systolic BP >140 and Diastolic BP >90 at Baseline
152.9
134.9 134.4133.1
97.9
86 84.983.3
30
50
70
90
110
130
150
170
Baseline Year 1 Year 2 Year 3
14mm/Hg Systolic
19mm/Hg Diastolic
10.08
9.2
8.9
8.6
7.5
8
8.5
9
9.5
10
10.5
Baseline Year 1 Year 2 Year 3
Baseline to Year 1:
Reduced the mean HgbA1c10.1 to 9.2 = .88 points
Baseline to Year 3:
Reduced the mean HgbA1c10.1 to 8.6 = 1.48 points
For individuals with HbA1c >9.0 at Baseline
NASCA leaders discuss health homes.
• State/Provider Collaboration Key• CEO Presentation Mandate• Kids Model Wrong – More
Wellness/Family• MCO Challenges (Kansas Example)• Data! Data! Data!• Engage the Nurses• Hospital MOU• Agency Integration
MO Health Home Resources
MO Department of Mental Healthdmh.mo.gov/mentalillness/mohealthhomes.html
MO Coalition for Community Behavioral Healthcaremocoalition.org/#!health-homes/c14fu
MO Department of Social Services | MO Primary Care Health Homesdss.mo.gov/mhd/cs/health-homes/
CMS Health Home Information Resource Centerwww.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/health-homes-technical-assistance/health-home-information-resource-center.html
Articles and Recognitions
“The Promise of Convergence: Transforming Health Care Delivery in Missouri” (Harvard Case Study for 2015 NASCA Institute on Management and Leadership)www.naspo.org/dnn/Portals/16/2015%20NASCA%20Case%20Study%20-%20The%20Promise%20of%20Convergence%20FINAL%20for%20article.pdf
Gold Award: Community-Based Program: A health Care Home for the “Whole Person” in Missouri’s Community Mental Health Centers (APA Achievement Awards 2015)ps.psychiatryonline.org/doi/full/10.1176/appi.ps.661013can Psychiatric Association |