Suzanne Daub, LCSW | Jaspreet Brar, MD, PhD October 14, 2016 Optimizing the Health of Individuals with Serious Mental Illness: The Behavioral Health Home Plus Model Suzanne Daub, LCSW | Jaspreet Brar, MD, PhD October 14, 2016

You must include ONE of the statements above for this session. Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months. You must include ONE of the statements above for this session. CFHA requires that your presentation be FREE FROM COMMERCIAL BIAS. Educational materials that are a part of a continuing education activity such as slides, abstracts and handouts CANNOT contain any advertising or product‐group message. The content or format of a continuing education activity or its related materials must promote improvements or quality in health care and not a specific propriety business interest of a commercial interest. Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If the educational material or content includes trade names, where available trade names for products of multiple commercial entities should be used, not just trade names from a single commercial entity. Faculty must be responsible for the scientific integrity of their presentations. Any information regarding commercial products/services must be based on scientific (evidence‐based) methods generally accepted by the medical community. Collaborative Family Healthcare Association 12th Annual Conference

Learning Objectives At the conclusion of this session, the participant will be able to: Articulate the need for and describe the key components of an effective behavioral health home model such as Behavioral Health Home Plus. Describe wellness coaching as a strategy to effect clinical and health outcomes. Describe preliminary results of a learning collaborative approach used to spread the model across 50+ sites in PA. Include the behavioral learning objectives you identified for this session Collaborative Family Healthcare Association 12th Annual Conference

Bibliography / Reference Anderson, G. (2010). Chronic Care: Making the Case for Ongoing Care. Princeton, NJ: Robert Wood Johnson Foundation. Bartels, S. J. (2004). Caring for the whole person: integrated health care for older adults with severe mental illness and medical comorbidity. Journal of the American Geriatrics Society, 52(12 Suppl), S249–S257. Goff, D. C. (2007). Integrating general health care in private community psychiatry practice. The Journal of Clinical Psychiatry, 68 (Suppl 4), 49–54. Nasrallah, H. A., Meyer, J. M., Goff, D. C., et al., (2006). Low rates of treatment for hypertension, dyslipidemia and diabetes in schizophrenia: data from the CATIE schizophrenia trial sample at baseline. Schizophrenia Research, 86(1–3), 15–22. Surles, R. C., Blanch, A. K., Shern, D. L., Donahue, S. A. (1992). Case management as a strategy for systems change. Health Affairs, 11(1), 151–163. Continuing education approval now requires that each presentation include five references within the last 5 years. Please list at least FIVE (5) references for this presentation that are no older than 5 years. Without these references, your session may NOT be approved for CE credit. Collaborative Family Healthcare Association 12th Annual Conference

Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation. Please incorporate audience interaction through a brief Question & Answer period during or at the conclusion of your presentation. This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy accreditation requirements. Collaborative Family Healthcare Association 12th Annual Conference

Community Care Part of the UPMC Health System Covers approximately 950,000 HealthChoices members across 39 of Pennsylvania’s 67 counties Implement a wide variety of innovative programs in the area of integrated behavioral and physical health

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

Behavioral Health Home Plus Comprehensive model designed by Community Care Behavioral Health, county and consumer stakeholder groups. Model incorporates wellness nurse, wellness coach, stratified risk registry, self management tool kits, learning collaborative, fidelity tool. Model is spread using the IHI’s Break Through Learning Collaborative Model of Awarded 2016 Recognition of Excellence in Wellness in SAMHSA’s Program to Achieve Wellness. The core agency activities include: Managing the risk stratified registry provided by Community Care. Conducting a comprehensive health assessment with each person identified with “high needs” on the registry. Addressing lapses in clinical care, preventive screening, and history of significant traumatic stress exposure contributing to health concerns. Establishing a reciprocal and collaborative relationship with primary care and specialty medical providers. Engaging people in recovery in ongoing wellness coaching

Why have behavioral health homes? As a group, individuals with SMI have high rates of premature death, dying as much as 15 to 25 years younger than the general population largely due to modifiable lifestyle choices. Key contributors: Modifiable lifestyle choices and behaviors Negative metabolic effects of atypical antipsychotic medication higher rates of undiagnosed, untreated, or poorly treated medical illnesses Difficulties obtaining routine preventive and primary care. The existing behavioral health system can be enhanced to support good health outcomes for individuals with SMI/SUD

What’s the ultimate goal? Help individuals with SMI take a more active role in their own health and health care Build provider capacity to sustain and spread the Behavioral Health Home model with high quality

The Learning Collaborative Support for successful implementation of the Behavioral Health Home Model across the state Create an agency-wide culture of wellness Learning Collaborative process Build on Milestones (Detailed steps for successful implementation) PDSA Cycles (Process for quality improvement) Monitor outcome and process aims Learn from each other

Wellness Coaching Develop a Wellness Narrative highlighting strengths, struggles, accountability, turning points, accomplishments Assess The Eight Dimensions of Wellness Explore strengths, needs and desires to change in the physical dimension Health Education on common risk factors: weight, nutrition, smoking, physical inactivity, stress Wellness Planning Tool -- SMART Goal Self-management toolkit Track progress on member portal Create an agency-wide culture of wellness:

Learning Collaborative Aims Process Aim 1: Wellness. By September 2015, 80% of all individuals presenting with complex needs will have completed the wellness planning tool. Process Aim 2: Assessment: By September 2015, 80% of all individuals presenting with complex needs will have completed a health assessment. Outcome Aim: Involvement: By September 2015, 80% of individuals engaged in BHHPE will report being highly involved (rated a 9 or 10) in working with their behavioral health service provider on physical health and wellness as measured by a 10-point involvement question.

Provider-Reported Rating of Progress PRE Q1 Q2 Q3 Q4 1.0   1.5 50 2.0 40 2.5 20 3.0 10 60 3.5 4.0 30 4.5 100 5.0 Rating: Definition: 1.0 Charter and team established 3.0 Modest improvement 1.5 Planning for the project 3.5 Improvement 2.0 Activity, but no changes 4.0 Significant improvement 2.5 Changes tested, but no improvement 4.5 Sustainable improvement 5.0 Outstanding sustainable results

Collaborative Wellness Process Aim

Collaborative Assessment Process Aim

Collaborative Involvement Outcome Aim

The Wellness Outcome Online Tool! The Wellness Outcomes Online Tool (WOOT!) gathers information on individuals’ wellness goals as well as a self-assessment of overall physical and behavioral wellness Provider and individual complete together every 6 months This report is a summary of information gathered from the Secure Portal to August 9, 2015 The information pertains to each individual’s first survey completion 747 surveys received from 513 unique individuals across 10 contracted entities

Wellness Area: Importance Please complete for each area: How important is this area to you? (select one response for each area) Not at all A little Some Quite a bit A lot Diet and Nutrition 17 (3.4) 46 (9.3) 106 (21.5) 131 (26.5) 194 (39.3) Physical Activity 26 (5.3) 57 (11.7) 116 (23.8) 130 (26.6) 159 (32.6) Sleep/ Rest 25 (5.2) 44 (9.1) 92 (19.0) 145 (29.9) 179 (36.9) Relaxation/ Stress Management 19 (3.9) 40 (8.3) 114 (23.6) 141 (29.1) 170 (35.1) Medical Care/ Screening 27 (5.6) 33 (6.8) 86 (17.8) 123 (25.4) 215 (44.4) Smoking Cessation 196 (43.0) 58 (12.7) 65 (14.3) 52 (11.4) 85 (18.6) Taking Medications Effectively 36 (7.5) 26 (5.4) 66 (13.7) 124 (25.7) 231 (47.8) Habits and Routines 57 (12.5) 43 (9.4) 112 (24.6) 132 (28.9)

Wellness Area: Goals and Progress Please complete for each area: Do you have a current goal in this area? If this area is a goal for you, how would you rate your progress in the past month (select one response for areas specified as goals) Not at all A little Some Quite a bit A lot Diet and Nutrition No: 318 (64.9) Yes: 165 (33.7) 36 (22.2) 33 (20.4) 49 (30.2) 29 (17.9) 15 (9.3) Physical Activity No: 347 (70.5) Yes: 138 (28.0) 20 (14.6) 27 (19.7) 42 (30.7) 32 (23.4) 16 (11.7) Sleep/ Rest No: 400 (82.6) Yes: 81 (16.7) 21 (26.6) 19 (24.1) 12 (15.2) 8 (10.1) Relaxation/ Stress Management No: 380 (79.0) Yes: 99 (20.6) 15 (15.5) 19 (19.6) 36 (37.1) 20 (20.6) 7 (7.2) Medical Care/ Screening No: 359 (73.6) Yes: 120 (24.6) 11 (9.2) 12 (10.1) 38 (31.9) 27 (22.7) 31 (26.1) Smoking Cessation No: 413 (85.3) Yes: 61 (12.6) 19 (32.2) 13 (22.0) 7 (11.9) 10 (16.9) Taking Medications Effectively No: 392 (80.8) Yes: 82 (16.9) 4 (4.9) 8 (9.9) 19 (23.5) 22 (27.2) 28 (34.6) Habits and Routines No: 410 (86.1) Yes: 59 (12.4) 7(12.1) 12 (20.7) 18 (31.0) 9 (15.5)

PCP and Dentist Visits 0-6 months ago n (%) 7 months – 1 year ago   0-6 months ago n (%) 7 months – 1 year ago 1-5 years ago >5 years ago PCP 447 (88.9) 40 (8.0) 13 (2.6) 3 (0.6) Dentist 169 (34.1) 109 (22.0) 147 (29.7) 70 (14.1)

Challenges Staff felt overwhelmed at the start of the LC Understand the mission of the collaboration Define roles for members on the QIT Hard to collect and organize data and information over multiple sites Collaboration with physical health providers takes work Wellness is sometimes difficult to promote in a crisis driven community Fragmented efforts don’t work

Positive Feedback & Observations Learning the value of the process is the most important benefit of the LC The LC is good for moving teams from day to day activities to quality improvement visionaries The PDSA provides a helpful structure and helps to identify needs Staff appreciated the value of collaboration with physical health providers and communicating with physical health providers got easier over time. “We learned better ways to communicate with physical health providers” Routine meetings of the QIT are important (Drill large tasks down into small, actionable steps) LC resulted in a better understanding of the relationship between physical and behavioral health Hot button issues can be tied back to psychotropic medications and risk which link back to the PCP and why monitoring is important Get buy-in from staff by talking about the goals of the effort Share data and progress with staff Link to the PCP for diagnoses Attend the PCP visit; learn about inhalers, insulin injections, etc Collaboration between team members is important Collaboration with the local clinic is helpful If you need physical health information, it’s better to just show up rather than make an appointment Maintain the strategies that are working Ask the physical health provider for a little bit of information just to open the lines of communication, ex, date of last physical Having a team member on the QIT is helpful The ‘why’ is important when participating in a LC

Summary Engagement and participation in the Behavioral Health Homes is high Teams are completing Milestones at the same rate and most activities are completed successfully Most agencies have met goal on Process Aims Progress is being made toward meeting our Outcome Aims Melody

Questions ?

Session Evaluation Please complete and return the evaluation form before leaving this session. Thank you! This should be the last slide of your presentation Collaborative Family Healthcare Association 12th Annual Conference