Enhanced Community-Based, Integrated Care Strategies for Individuals with Complex Needs Matt Hurford, M.D., Chief Medical Officer Kelly Lauletta, NY Regional Director © 2016 Community Care Behavioral Health Organization

Agenda UPMC Health Plan and Community Care Health and wellness of members with complex medical and psychosocial factors Community Team: A brief overview of the model, early results, and case vignette NY outreach to members Lessons learned Questions © 2016 Community Care Behavioral Health Organization

UPMC Operational Structure University of Pittsburgh Medical Center (UPMC) UPMC Insurance Services Division UPMC Health Plan Askesis Development Group, Inc. Medicaid Community Care © 2016 Community Care Behavioral Health Organization

UPMC Health Plan Owned by UPMC, making us part of an integrated health care and finance delivery system with one of the nation’s top ranked health systems 2.5 million members Second largest provider-owned insurer 4 star HMO MA plan Integrated population health and productivity products Highest provider satisfaction © 2016 Community Care Behavioral Health Organization

Community Care Behavioral health managed care company founded in 1996; part of UPMC and headquartered in Pittsburgh, PA Federally tax exempt nonprofit 501(c)(3) Major focus is publicly funded behavioral health care services; currently doing business in PA and NY Licensed as a Risk-Assuming PPO in PA Serving approximately 1 million individuals in 39 counties through a statewide network of over 1,800 providers Behavioral health for Medicaid members in PA often managed by counties in a “Human Service carve-in” model with MCO partners © 2016 Community Care Behavioral Health Organization

Accreditation/Commendations NCQA Accredited Quality Program Full URAC Health Utilization Management Accreditation Moffic Award: American Association of Community Psychiatrists American Psychiatric Association’s Gold Achievement Award for Institutions Recipient of two PCORI awards related to physical/behavioral health integration and shared decision making © 2016 Community Care Behavioral Health Organization

PA Counties Served Community Care Office Pike Erie Crawford Mercer Venango Lawrence Butler Beaver Washington Armstrong Indiana Westmoreland Allegheny Greene Fayette Somerset Cambria Blair Delaware Clarion Forest Warren McKean Potter Cameron Elk Jefferson Clearfield Bedford Centre Clinton Fulton Franklin Adams Cumberland Perry Mifflin Snyder Union Lycoming Tioga Bradford Columbia Montour Northumberland Dauphin York Lancaster Chester Berks Lebanon Schuylkill Montgomery Philadelphia Juniata Sullivan Huntingdon Bucks Lehigh Northampton Carbon Monroe Luzerne Wyoming Lackawanna Susquehanna Wayne © 2016 Community Care Behavioral Health Organization

NY Counties Served © 2016 Community Care Behavioral Health Organization

Background and Rationale The health care system is facing increasing cost constraints A high percentage of health care expenditures are associated with a small proportion of the population The Institute for Healthcare Improvement (IHI) notes that over half of U.S. health care dollars are spent on 5% of the population A report by the Center for Studying Health System Change identified the health of elderly Medicare patients as the single biggest factor in driving costs, not market dynamics or the provider The report concluded that tailoring interventions to improve care and lower costs for specific types of complex and costly patients may hold the most promise for “bending the cost curve” © 2016 Community Care Behavioral Health Organization

The Need for Integrated Systems 68% of adults with mental health (MH) conditions also have medical conditions People with medical conditions: 58% of adult population People with MH conditions: 25% of adult population Social and modifiable lifestyle factors are key contributors to medical status Increased morbidity & mortality associated with SMI Largely due to preventable medical conditions: metabolic disorders, cardiovascular disease & high prevalence of modifiable risk factors (i.e., obesity, smoking) Traumatic stress exposure can lead to both mental & medical illness Co-morbid substance abuse can increase medical illness 68% of adults with mental health conditions have medical conditions 29% of adults with medical conditions have mental health conditions © 2016 Community Care Behavioral Health Organization

Community Team © 2016 Community Care Behavioral Health Organization

Community Team Background Health Plan members with high costs, multiple admissions, complex medical conditions related to behavioral and psychosocial conditions receive intensive case management in home/community settings Vision Goal is to reduce 30-day readmission rates, inpatient utilization rates, and total cost of care for members with a history of utilization of inpatient services Action Community-based program with SW/RN/CHW, which focus on member engagement while inpatient, provider communication, medication review, increase self-management skills, and linkage with community resources to increase level of wellness and quality of life Developed with consultation from The Camden Coalition and Health Quality Partners. Provides intensive care management in the members home following initial engagement during readmission (bedside engagement) and other community settings for those health plan members who have been identified as having high costs and high utilization (multiple hospital readmissions). Strong focus on impact of behavioral or other psychosocial conditions/social determinants of health. Aim to reduce 30 day re-admission rates, inpatient utilization rates, and total cost of care; improve health status (QLES to measure) © 2016 Community Care Behavioral Health Organization

What are the goals of the team? Identify members with complex needs and high medical spend Focus on individuals with multiple readmissions within a prior 12-month period (almost all have high spend over at least 24 months) Process goals: Engage individuals while hospitalized Medication reconciliation in home within 2 days of discharge Enhance connections with PCPs Outcome goals: Reduce readmissions Reduce medical spend compared to controls © 2016 Community Care Behavioral Health Organization

Integrated & Multidisciplinary Team Social Worker Nurse Community Health Worker © 2016 Community Care Behavioral Health Organization

Integrated & Multidisciplinary Team Social Worker Nurse Pharmacist Community Health Worker © 2016 Community Care Behavioral Health Organization

Team Roles & Responsibilities Integrated team approach: using the combined strengths and expertise of each team member to best serve the individual based on their unique needs Clinical care manager (registered nurse) Specialized skills: physical health conditions, medication reconciliation, and coordination of care Mobile social service care manager (social worker) Specialized skills: behavioral health (mental health and substance use) and the psychosocial components of health Community health worker Specialized skills: member engagement and activation in care Pharmacist Specialized skills: medication review and education © 2016 Community Care Behavioral Health Organization

Dimensions of Wellness © 2016 Community Care Behavioral Health Organization

Problems, Goals, and Interventions 804 cases were analyzed Top four identified problems Medication adherence (130)/medication management (549) Care coordination (329) Clinical issue (228) Transportation (290) © 2016 Community Care Behavioral Health Organization

Medication Adherence/Mgmt. Goals © 2016 Community Care Behavioral Health Organization

Med. Adherence/Mgmt. Interventions © 2016 Community Care Behavioral Health Organization

Care Coordination Goals © 2016 Community Care Behavioral Health Organization

Care Coordination Interventions © 2016 Community Care Behavioral Health Organization

Clinical Issue Goals © 2016 Community Care Behavioral Health Organization

Clinical Issue Interventions © 2016 Community Care Behavioral Health Organization

Transportation Goals © 2016 Community Care Behavioral Health Organization

Transportation Interventions © 2016 Community Care Behavioral Health Organization

Social Determinants Goals Food Housing Transportation © 2016 Community Care Behavioral Health Organization

Coordination and Collaboration Member Community Human Services UPMC Health Plan Primary Care Physician Specialists Family Community Care BH Providers Monthly program meetings Meetings with members and providers © 2016 Community Care Behavioral Health Organization

Case Management Interventions Link to PCP and specialists Link to mental health and drug & alcohol treatment Coordinate care Medication management Referral for in-home supports (AAA, TRCIL) Housing Transportation (MATP) Link to community resources (utility, food banks, Meals on Wheels) Address end-of-life issues (five wishes, hospice, palliative care) © 2016 Community Care Behavioral Health Organization

Progress: Case Vignette 50-year-old African American woman History of uncontrolled diabetes, epilepsy, reflux, HTN, hypothyroidism, metabolic encephalopathy, bipolar disorder, addiction, trauma Lacks natural supports, no family, and difficulty trusting others Staying in local women’s shelter due to serious interpersonal violence Interventions: RN and CHW gained member’s trust over period of time RN worked closely with PCP and accompanied member to appointments Assisted member in navigating overwhelming health care system Connected member with behavioral health service coordinator Member identified safe housing as priority so staff assisted member in obtaining her own apartment in safe housing development © 2016 Community Care Behavioral Health Organization

Progress: Case Vignette Outcomes 7 months without inpatient or ER visit Regular PCP visits Medication adherence Smoking cessation with 8 weeks non-smoking Substance use in remission Has been drug- and alcohol-free and attends 12-step meetings Active in drop-in centers and residential activities in apt. building Engages in mental health treatment and with service coordinator Participated in telehealth session with Vidyo with CHW and RN © 2016 Community Care Behavioral Health Organization

Community Health Workers Member and community engagement specialists Work closely with members, family members, and providers Patient, non-judgmental, active listeners Build positive relationships with all members Assist members in increasing their confidence and support and working on individual health care goals Help members explore meaningful and pleasurable activities © 2016 Community Care Behavioral Health Organization

CHWs Roles and Responsibilities Outreach & Engagement Locate and engage challenging or elusive members Work closely with members, family, and providers On the ground “eyes and ears” for the team Work closely with social workers and nurses on team Education Health literacy on chronic health conditions and equip members with tools/strategies to manage health conditions Wellness Coaching and assist members in developing healthy behaviors Assist members to recognize early warning signs of illness and obtain care © 2016 Community Care Behavioral Health Organization

CHWs Roles and Responsibilities Community Networking Liaison between health and social services and community Assist member in locating community services Help members access and connect with resources Collaborate with community agencies Connect members to recovery supports Link members and inform them of available community resources © 2016 Community Care Behavioral Health Organization

CHWs Roles and Responsibilities Social Support Non-judgmental Build relationships with members, including those reluctant to engage in health care Increase members’ confidence and support Shared life experiences Coordinate care Work with members on their individual health care goals Help members explore past activities that gave them meaning Assist with developing key skills Assist members in developing a plan towards independence with medication management © 2016 Community Care Behavioral Health Organization

CHWs Roles and Responsibilities Advocacy Assist members in developing self-advocacy and independent skills Assist members in following through with appointments Work with members on their identified SMART goals Ensure members get the care they need Help members navigate the medical and behavioral health systems Provide support to members in voicing concerns Support members in developing outline/plan prior to medical or behavioral health appointments © 2016 Community Care Behavioral Health Organization

Previous Success & Early Results Community Team launched in May 2015, but initial results promising: Expected 30-day inpatient/observation rate among the target population is 23%; have seen a reduction to 15% readmission rate Completion of in-home medication reconciliations (71%) PCP appointments within 5 days of hospital discharge (70%), increasing consistently each month Modest improvement on Quality of Life Enjoyment & Satisfaction Questionnaire (QLES) © 2016 Community Care Behavioral Health Organization

Early Results on Readmissions Current CNI criteria of 2.5-4.5 adopted in May © 2016 Community Care Behavioral Health Organization

Lessons Learned: Community Team © 2016 Community Care Behavioral Health Organization

Community Team: Lessons Learned Brief hospital stays (1-2 days) currently associated with low engagement rates Many commercial and Medicare members are not receptive to psychosocially focused model CHWs are helpful, but integrating into clinical team is very complex Longer term model (several months) seems more effective We are viewed as innovation leaders by non UPMC services [moved this bullet off slide and down here to the Notes out of concern that it sounded too self-congratulatory. © 2016 Community Care Behavioral Health Organization

Community Team: Lessons Learned Program evaluation and metrics for success Define primary outcome measures and measure often (readmission impact, total medical and pharmacy cost, improved health cost, ROI) Population health management in the context of complex needs Leverage data analytics and predictive modeling tools to determine target population Our approach included a thorough study of the population to determine inclusion and exclusion criteria to maximize impactability Ongoing review of data to inform interventions, barriers, resource, and training needs For example: engagement rates, medication reconciliation in home by nurse with pharmacist review within first week of discharge, pcp visit within 5 days of discharge, staff productivity, readmission reasons (as identified by team and by the member) There were 2,880 members across 10 counties who met the criteria. The criteria specifies at least two inpatient or observation admissions in prior year for Medicaid or SNP members and at least 3 or more inpatient or observation admissions in prior year for Commercial or Medicare members. We limited the potential population to this level of utilization per standards set by the Camden Coalition of Healthcare Providers, which applied risk levels to patients based on annual utilization. This was the general level set to distinguish normal range of utilization from potential high utilizers. Eligibility Criteria: Members with an acute inpatient and/or observation within the past 12 months: Adult age ≥ 18 years old Cave Care Needs Index (CNI) of 2.5-4.5 Counties include Allegheny, Armstrong, Beaver, Butler, Crawford, Erie, Fayette, Lawrence, Washington, and Westmoreland Exclude members with hospice or long term care Number of admits of at least 2 for Medicaid and SNP and at least 3 for all other lines of business Common Attributes: Risk levels assigned based on annual utilization Adults with at least 2 inpatient admissions, CAVE CNI index score 2.4 – 4.5, counties with high concentration of members Members with multiple chronic conditions, multiple providers, high rates of admission and readmission, frequent Emergency Department utilization, high medication costs, and limited self-management skills Needs of members are complex, variable and encompass issues with physical health conditions, behavioral health conditions, and/or severe psychosocial issues © 2016 Community Care Behavioral Health Organization

Community Team: Lessons Learned Collaborations and engagement with primary care Building relationships: approach involvement at the system, population, and individual levels System level: Community Advisory Board Population level: PCP practices Individual level: Member’s PCP Program design: implications for workflows and team composition Know and continue to study your population to develop assessments, clinical pathways, training and supervision model to meet each identified need Quarterly meetings with broad range of community stakeholders including health care leaders from partnering systems, physical and behavioral health and palliative care providers, social service and community agencies, and other representative stakeholders experts Identify and inform program leadership regarding opportunities for collaboration and program enhancements PCP stakeholder discussion regarding their preferences for communication (SBAR format) incorporated into program design Use data to identify largest PCP providers serving the target population for targeted outreach and engagement Member care coordination profile delivered by team to PCP Accompany member to first appointment post-discharge (if member agrees) and any other appointments per member request © 2016 Community Care Behavioral Health Organization

NY Engagement Strategies © 2016 Community Care Behavioral Health Organization

Community Care’s Work in NY Implemented a care monitoring initiative in New York City (2009) New York State Office of Mental Health (OMH) New York City Department of Health & Mental Hygiene (DOHMH) Awarded 16-county Hudson River Region in Behavioral Health Organization (BHO) Initiative (2012) New York Office of Mental Health (OMH) New York State Office of Alcoholism and Substance Abuse Services (OASAS) Partnered with CDPHP to serve HARP members beginning July 1, 2016 © 2016 Community Care Behavioral Health Organization

How do you stratify outreach? Who do you outreach first? Individuals who have been admitted to PH or BH units Critical time interventions represent opportunities for engagement Community Care works closely with medical and behavioral health departments to identify when members have been admitted Whenever possible, Community Care CMs coordinate visits while the member is inpatient to assess post-discharge needs © 2016 Community Care Behavioral Health Organization

How do you stratify outreach? Members triggering BH flags in PSYCKES Members identified as HARP enrolled are run through PSYCKES to identify those who may meet the criteria for one or more of the following flags: Medication-related Polypharmacy High dose Acute care utilization High utilization Readmission Health promotion and care coordination Behavioral health Medical © 2016 Community Care Behavioral Health Organization

How do you stratify outreach? Members meeting PH flags in PSYCKES When a HARP member triggers medical flags in PSYCKES, Community Care CMs work closely with CDPHP medical CMs to assess the member’s needs and determine which team will take the lead in coordinating the member’s care If a member is exhibiting significant needs, the member may be switched to a co-managed status © 2016 Community Care Behavioral Health Organization

How do you locate members? Once members are stratified using PSYCKES data, the outreach begins! CMs begin with the contact information contained in: The state data feed Other data platforms, including HIXNY and MAPP Providers on recent claims © 2016 Community Care Behavioral Health Organization

Barriers & Interventions © 2016 Community Care Behavioral Health Organization

Barriers and Interventions Barrier: Inability to communicate with CMAs Intervention: CDPHP is working to enter into BAAs through the health home to ensure ongoing coordination Barrier: Health home assessments and plans of care Intervention: CDPHP/CCBH are working closely with health homes and CMAs to assess readiness to perform assessments and complete POCs, as well as HCBS provider readiness to accept referrals Barrier: Health home assessments are deficit-based and engagement-averse - too may assessments asking the same questions Intervention: Use peer organizations to assist with moving questions to a strengths-based perspective; review and align existing assessments and share collected information across providers © 2016 Community Care Behavioral Health Organization

Subscribe to the PDSA PLAN – Work with the existing provider system to develop a plan that is sensitive to needs and resources DO – Give it a try! (Recognize that it won’t be pretty) STUDY – Review – are the processes in place meeting the overall need? ACT – Regroup – find out what is working and not working and make adjustments accordingly © 2016 Community Care Behavioral Health Organization

Questions ? © 2016 Community Care Behavioral Health Organization