Team-Based Care, a New Paradigm

UPMC Insurance Services Division 3.0 million members 2nd largest provider-owned insurer $7.0B annual revenues Integrated population health & productivity products 10% average annual growth YOY 10,000+ employer group #1 ranked commercial HMO in WPA (2016 U.S. News & World Report) Fastest growing Medicaid & CHIP plans in PA One of 3 companies awarded PA MLTSS contract Highest provider satisfaction J.D. Power certified call center National Business Group on Health Platinum Winner (x5) ICMI Global Call Center Award Best Customer Experience Program

UPMC Insurance Services Division

Community Care Behavioral Health Incorporated in 1996 primarily to support Pennsylvania Part of the UPMC Insurance Services Division 501(c)(3) nonprofit behavioral health managed care organization Licensed as risk-bearing PPO Currently managing behavioral health HealthChoices in 39 counties in Pennsylvania Experience with full-risk, shared-risk, and Administrative Services Only (ASO) contracts Variety of contracts in New York State since 2009

Community Care’s Behavioral Health Home Plus Community Care’s commitment to overall health & recovery-based programs Behavioral & physical health systems have historically failed to systematically address and support prevention and wellness, especially the most vulnerable populations such as adults with SMI Belief that BH providers are uniquely positioned to assist adults with SMI in addressing whole health and wellness

Community Care’s BHH Plus Successful early collaboration with Community Care & BH providers in North Central region of PA to address wellness through BHH model in 2010 with a focus on: Enhancing capacity of behavioral health providers to serve as health homes Comprehensive care management Care coordination and health promotion Linkage of service users to community resources

Study Overview: Optimal Health Main partners include: Community Care UPMC Center for High-Value Health Care University of Pittsburgh Stakeholder Advisory Board BHARP, NC and Chester Counties and Providers Principal investigators: James Schuster, MD, MBA, Community Care Charles (Chip) Reynolds III, MD, University of Pittsburgh Tracy Carney, CPRP, CSP, Community Care Supported by the Patient-Centered Outcomes Research Institute (PCORI) A multi-stakeholder collaboration to study the key components of the BHHP model

Optimal Health Providers Pike Warren McKean Elk Jefferson Centre Mifflin Chester Juniata Huntingdon Clarion Provider Offices

Study Duration: May 1, 2013 to January 31, 2017 PCORI: Optimizing Behavioral Health Homes by Focusing on Outcomes that Matter Most for Adults with Serious Mental Illness Study Duration: May 1, 2013 to January 31, 2017 Funding Amount: 1.8 Million Main partners include: Community Care UPMC Center for High-Value Health Care University of Pittsburgh Stakeholder Advisory Board BHARP, NC and Chester Counties and Providers Principal investigators: James Schuster, MD, MBA, Community Care Charles (Chip) Reynolds III, MD, University of Pittsburgh Tracy Carney, CPRP, CSP, Community Care Collaboration built on: UPMC/Community Care commitment to overall health & recovery-based programs Successful early collaboration with Community Care & BH providers in North Central region of PA to address wellness Belief that BH providers are uniquely positioned to assist adults with SMI in addressing whole health and wellness

Key Interventions to Help Individuals with Serious Mental Illness Train case managers and peer specialists as wellness coaches/health navigators Support of a nurse focused on PH in MH settings Create a high-risk disease registry with key indicators of PH and BH needs Develop self-management toolkits to support common challenges such as obesity, smoking, exercise, and medication adherence Both strategies promote a culture of wellness and utilize case managers and certified peer specialists as health navigators Wellness coaching supports the development of a behavioral health home model and a foundation for a culture of wellness and recovery. Training program developed by national wellness expert, Dr. Peggy Swarbrick, a consultant to the project Wellness coaching is a new role that can help people in their pursuit of individually-chosen health and wellness goals. Activating consumers to be more informed and effective managers of their health and health care lies at the heart of patient-centered care

Study & Interventions Comparative effectiveness study of two behavioral health home model approaches to improve the health status of individuals with serious mental illness, increase patient activation in care, and improve engagement with primary/specialty physical health care. Both approaches train BH staff as wellness coaches and utilize high risk registries. Provider-Supported Care Wellness nurses focused on PH & wellness (5 providers) Self-Directed Care Self-management toolkits & resources (6 providers) Enhancing patient & BH provider capacity to address PH & wellness Both strategies promote a culture of wellness and utilize case managers and certified peer specialists as health navigators Wellness coaching supports the development of a behavioral health home model and a foundation for a culture of wellness and recovery. Training program developed by national wellness expert, Dr. Peggy Swarbrick, a consultant to the project Wellness coaching is a new role that can help people in their pursuit of individually-chosen health and wellness goals. Activating consumers to be more informed and effective managers of their health and health care lies at the heart of patient-centered care

Learning Collaborative Structured approach for change Adopt best practices in multiple settings Uses adult learning principles & techniques Time-limited learning process Shared learning and collaboration A learning collaborative supports implementation Learning Sessions Training Manuals Action Periods Apply Skills Test Changes Collaborative Meetings Ongoing TA & Support Measure Outcomes Share Progress Please note that the quality improvement teams from each agency were made up of an agency administrator, clinical staff, quality improvement staff, and a person in recovery.

Study Data & Data Sources PCORI Optimal Health Participants HealthChoices Eligibility Data (Medicaid eligibility) Self-Report Measures (Patient activation,** health status,** hope, quality of life, functional status, satisfaction with care, social support) Learning Collaborative (LC) Data (Implementation information) Qualitative Data (Service user & provider interviews) **Primary outcome Administrative Data (Demographic info) Behavioral Health Claims (BH diagnosis, utilization) Physical Health Claims (Engagement in primary/specialty care**) Primary Data Sources Secondary Data Sources Pharmacy Claims (Medication utilization) 1229 participants Mean age = 42.7 37.4% Male 62.6% Female Primary Outcomes Health status Activation in care Engagement in primary / specialty care Secondary / Exploratory Outcomes Mental health symptoms, hope, quality of life, medication use, functional status, emergent care, lab monitoring, individual and family satisfaction with care Covariates Engagement in interventions, social support, severity of mental illness, medical stability, patient demographic and clinical characteristics

Findings: Executive Summary Learning Collaborative/Implementation Findings: Performance on all process/outcome goals improved over time Provider-supported arm reported higher degree of achievement on all process goals after one year of implementation Qualitative Interview Findings: Little difference in findings between intervention arms Overall positive experiences participating in (service users) or implementing (providers) interventions

Findings: Executive Summary Quantitative Findings: Intervention type (Provider-Supported vs. Self-Directed) has a differential impact on some patient-centered outcomes (treatment X time interaction effect) Both interventions positively impact several of our outcomes over time (change over time) Financial Findings: Indicative of long-term cost reductions in Provider-Supported (Wellness Nurse) sites, with some evidence of long-term decreases in Self-Directed (Self-management Navigator) sites. Suggestive of increased short-term PH use at both sites, but more ambulatory and lower inpatient.

Post-Trial Comparison Group: Results Total Year 2: PMPM 15% lower Years 1 and 2: PH use (40-50%) higher Year 2: BH PMPM 20-30% lower IP Year 2: Use 30-40% lower and cost 20-25% lower Year 2: PH Use 30-35% lower Rx Years 1 and 2: Use 25-30% lower; Year 1: PMPM 15-20% higher TCM Year 2: PMPM 17% lower ER Matched cohort not comparable for ER analysis Nurse + Nav vs.  Statistically significant (<0.05)  Suggestive; not quite statistically significant (<0.2) Comparison PH Use: Change from Y0-Y1 is significantly higher than Y0-Y1 change in Comparison group; Change from Y1-Y2 is actually significantly lower than in Comparison group but of a smaller magnitude than the Y0-Y1 difference RX: Showing decrease in RX penetration with a short-term spike in costs followed by suggestion of long-term cost decreases TCM: Higher use in baseline with slight increase in Y0-Y1 change relative to Comparison but large significant decreases in use and cost from Y1-Y2 relative to Comparison group IP: Results should be interpreted with some caution due to geographic differences but suggestive of long-term decrease in PH IP use

Behavioral Health Home Expansion Erie Allegheny Clarion Forest Warren McKean Potter Cameron Elk Jefferson Clearfield Blair Centre Clinton Adams Snyder Union Lycoming Tioga Bradford Columbia Montour York Chester Berks Schuylkill Luzerne Wyoming Susquehanna Lackawanna Wayne Pike Monroe Carbon Juniata Sullivan Mifflin Huntingdon Northumberland Additional populations served: adolescents, opioid treatment programs Population Health LC for mature providers focused on hypertension & smoking cessation: 19 BHHs participating in first cohort, second cohort started this past spring Behavioral Health Home Plus model scaled to 52 sites Population expansion to adolescents, opioid treatment programs Population Health Learning Collaborative for mature BHH providers focused on hypertension and smoking cessation

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