A Medical Home for a Complex Medicaid Population Thomas L. Schwenk, M.D. Department of Family Medicine University of Michigan

A Medical Home for a Complex Medicaid Population Medicaid Special Needs Plan. Medicaid Special Needs Plan. High-risk patient population with serious mental illness and disability. High-risk patient population with serious mental illness and disability. Strong interest in expanding plan to include other high-risk, complex groups (i.e. chronic disease disability, psychiatric co-morbidity). Strong interest in expanding plan to include other high-risk, complex groups (i.e. chronic disease disability, psychiatric co-morbidity). Approached by Health System to lead development of new care model. Approached by Health System to lead development of new care model. “Perfect storm” of need for institutional leadership, community citizenship, and academic expertise. “Perfect storm” of need for institutional leadership, community citizenship, and academic expertise.

The Issue Leadership and guidance of Washtenaw Community Health Organization (WCHO, a Medicaid intermediary). Leadership and guidance of Washtenaw Community Health Organization (WCHO, a Medicaid intermediary) patients with serious mental illness and developmental disorders patients with serious mental illness and developmental disorders. Fragmented, poor quality, expensive care ($23,000/enrollee). Fragmented, poor quality, expensive care ($23,000/enrollee). Opportunity for waivers to explore novel, innovative approaches to integration. Opportunity for waivers to explore novel, innovative approaches to integration.

Background Political advantages to UMHS. Political advantages to UMHS. Inevitable responsibility of UMHS as primary source of care. Inevitable responsibility of UMHS as primary source of care. Previous approaches non- institutional, organized through Department of Psychiatry, predominant focus on mental illness. Previous approaches non- institutional, organized through Department of Psychiatry, predominant focus on mental illness. Needs new champion and new institutional home. Needs new champion and new institutional home.

Why Family Medicine? Not the first Department approached (and not the second). Not the first Department approached (and not the second). Clinical credibility, IT expertise, academic reputation in mental illness care, visibility and performance in chronic disease management. Clinical credibility, IT expertise, academic reputation in mental illness care, visibility and performance in chronic disease management. Building on recent events demonstrating institutional leadership. Building on recent events demonstrating institutional leadership. Department’s financial stability, quality, reputation. Department’s financial stability, quality, reputation. Why not? Why not?

Clinical and Academic Opportunities 2500 current enrollees, high level of complexity and case mix severity current enrollees, high level of complexity and case mix severity. Potential opportunities for improved quality and decreased cost. Potential opportunities for improved quality and decreased cost. Unknown how low “fruit” is hanging. Unknown how low “fruit” is hanging. Serendipitous availability of Medicaid expertise. Serendipitous availability of Medicaid expertise. (Purported) availability of waivers. (Purported) availability of waivers. (Purported) opportunities for grants and contracts. (Purported) opportunities for grants and contracts.

Benefits to Institution Community and state citizenship. Community and state citizenship. Political capital, university-state partnerships. Political capital, university-state partnerships. Improved financial performance and clinical quality of care that frequently reverts to UMHS anyway. Improved financial performance and clinical quality of care that frequently reverts to UMHS anyway. Academic reputation and leadership. Academic reputation and leadership.

Benefits to Department of Family Medicine Community and state citizenship. Community and state citizenship. Political capital, university-state partnership. Political capital, university-state partnership. Improved financial performance and clinical quality of care that frequently reverts to UMHS anyway. Improved financial performance and clinical quality of care that frequently reverts to UMHS anyway. Academic reputation and leadership. Academic reputation and leadership. Laboratory for Medical Home development. Laboratory for Medical Home development. Opportunity to evaluate wide range of pilot programs Opportunity to evaluate wide range of pilot programs Geographic accessibility, local knowledge. Geographic accessibility, local knowledge. Access to grant support for something we want to do anyway. Access to grant support for something we want to do anyway.

Potential Threats and Risks High-risk, expensive, complex patient population (the ultimate test of the Medical Home!). High-risk, expensive, complex patient population (the ultimate test of the Medical Home!). Poor psychosocial and logistical support may not be addressed by the Medical Home concept. Poor psychosocial and logistical support may not be addressed by the Medical Home concept. Lack of grant support and access to waivers may sabotage otherwise effective approach. Lack of grant support and access to waivers may sabotage otherwise effective approach. Department ambition may exceed that of the University or State. Department ambition may exceed that of the University or State.

Operational Issues Leadership team including expertise in clinical operations, finance, IT, chronic disease management, community relations, institutional relations. Leadership team including expertise in clinical operations, finance, IT, chronic disease management, community relations, institutional relations. Community advisory board. Community advisory board. Medical Home pilot programs, development models and expertise. Medical Home pilot programs, development models and expertise. Staff support. Staff support.

Summary Creating a Medical Home for a complex, high-risk Medicaid Special Needs population should be done by Family Medicine because ….. It is the right thing to do. It is the right thing to do. We know how to do it right. We know how to do it right. We are the right department to do it. We are the right department to do it. It is good for the institution and good for the department because it is good for the patient. It is good for the institution and good for the department because it is good for the patient.