Session # C8a Multivariate approaches to assessing clinical outcomes and changes in healthcare costs associated with bi-directional integrated care Lauren Woodward Tolle, Ph.D., Director of Integrated Care, Aurora Mental Health Center Adam Soberay, Ph.D., Research Associate, Aurora Research Institute Margie Kaems, LCSW, Program Manager, Chambers Hope Health and Wellness Clinic Please insert the assigned session number (track letter, period number), i.e., A2a Please insert the TITLE of your presentation. List EACH PRESENTER who will ATTEND the CFHA Conference to make this presentation. You may acknowledge other authors who are not attending the Conference in subsequent slides. CFHA 18th Annual Conference October 13-15, 2016  Charlotte, NC U.S.A. Collaborative Family Healthcare Association 12th Annual Conference

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: List strategies for gathering data to assess program outcomes Identify statistical and data management strategies for assessing outcomes Discuss strategies for reporting outcomes to stakeholders and clients Include the behavioral learning objectives you identified for this session Collaborative Family Healthcare Association 12th Annual Conference

Bibliography / Reference Colton, C.W. and Manderscheid, R.W. (2006) Congruencies in Increased Mortality Rates, Years of Potential Life Lost, and Causes of Death among Public Mental Health Clients in Eight States. Prevention of chronic Disease, 3, A42. Karow, A., Reimer, J., König, H. H., Heider, D., Bock, T., Huber, C., ... & Ohm, G. (2012). Cost-effectiveness of 12-month therapeutic assertive community treatment as part of integrated care versus standard care in patients with schizophrenia treated with quetiapine immediate release (ACCESS trial). The Journal of clinical psychiatry, 73(3), 402-408. Hert, M., Correll, C. U., Bobes, J., Cetkovich-Bakmas, M., Cohen, D., Asai, I., ... & Newcomer, J. W. (2011). Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World psychiatry, 10(1), 52-77.  Drummond, M. F., Sculpher, M. J., Claxton, K., Stoddart, G. L., & Torrance, G. W. (2015). Methods for the economic evaluation of health care programmes (4th ed.). Oxford university press.  Woltmann, E., Grogan-Kaylor, A., Perron, B., Georges, H., Kilbourne, A. M., & Bauer, M. S. (2012). Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: systematic review and meta-analysis. American Journal of Psychiatry, 169(8), 790-804.  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

Overview Aurora, Colorado: 3rd most diverse city per capita in the nation Aurora Mental Health Center (AuMHC) – 1975 – pres. Over 19,000 served annually, over 60% publicly insured, life span in 13 locations and partner sites Integrated Care at AuMHC: 5 community primary care partners – FQHC, 2 non-profit pediatric practices, 2 hospitals, and 3 bidirectional integrated care clinics, 1 high- utilizer program Chambers Hope Health and Wellness Clinic: Funded through SAMHSA’s PBHCI initiative, 4th year of operation You can begin your own slides here. Feel free to use your own background on this and subsequent slides. Collaborative Family Healthcare Association 12th Annual Conference

Need for Bidirectional Care Adults with Serious Mental Illness (SMI) have approximately a 25 year shorter life expectancy than the general population – the largest health disparity in the United States1. Substantially higher rates of chronic disease and modifiable risk factors (3-5x RR in SMI2) Systems, provider and patient level barriers

Chambers Hope Health and Wellness Clinic Highly integrated multidisciplinary team: Medical Provider and Medical Assistant Behavioral Health Provider Care Coordinator Health Navigator Peer Specialist Wellness groups: chronic pain, meditation, insomnia, weight loss, onsite personal trainer and fitness center Person-centered treatment planning, close coordination with primary mental health providers Population-based monitoring of health status and outcomes

Data Collection At baseline and every 3 months thereafter, basic physical health indicators are gathered E.g. blood pressure At baseline and every 6 months thereafter, the National Outcomes Measures (NOMs) is administered. Contains numerous subscales (e.g. psychological distress, substance use, stable housing) At baseline and every 12 months thereafter, bloodwork is drawn E.g. Cholesterol Challenges: Missing Data Attrition

Are People Getting Better? Primary Outcomes Analysis Multi-level Mixed Effects Regression Models NOMs, PHI outcomes Advantages can handle missing data (ML) can handle varying observations per client interpret similar to OLS regression output Disadvantages large sample size required complex modeling strategies

What Factors Impact Retention? Survival Analyses Cox Regression Advantages combines duration/ attrition differential attrition Disadvantages Coding for censored cases sufficient number of terminated clients

How Long Until People Start Getting Better? Duration until treatment effect Repeated Measures ANOVA Advantages more powerful analysis Disadvantages requires complete cases looks at specific timeframe

Are Certain People Benefiting More? Differential Treatment Effect For NOMs/PHI Outcomes: Interaction terms within mixed effects models

Cost Analysis Claims Data Primary Outcomes: from the State back through 2010 comparison group claims Primary Outcomes: Total costs (multiple metrics) ER admissions Hospital utilization Preventable hospital readmissions

Cost Analysis Interrupted Time Series Analysis Are spending trends changing after enrollment? Focus on program clients establish baseline costs over time compare to costs after enrolling in program linear and non-linear trends

Quantifying Changes in Cost Propensity Score Matching create matches across a combination of covariates reduces dimensionality problem of traditional/stratified matching Propensity scores can also be used within regression models Descriptive Approaches to comparing pre-/post- enrollment costs 6- and 12-month time frames, average cost per person per month Multiple metrics of cost

Who is Saving Money? Identifying factors related to cost savings? Are there individual demographic or clinical factors predictive of cost savings? Regressing cost on client variables Are there certain “types” of clients associated with cost savings? Are there certain profiles, composed of clinical or demographic variables, associated with cost savings? Latent class/profile analysis

Data & the Clinical Workflow Collecting Data Point person tracking when to collect data Everyone is trained to collect data and help out Huddles Individual collecting data from each client discussed Wellness goals from registry discussed Registry Wellness Reports—engaging patients in their health data Involving patients in their goals and progress

Huddles

Wellness Report Card Reviewed every 3 months with patient: Wellness goals Steps toward goal History of health indicators Color coded risk Graphs

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