Population Health & Integrated Care Skye Pletcher, Director of Utilization & Care Management Amanda Horgan, deputy director

Scope of Plan Mid-State Health Network (MSHN) is committed to increasing its understanding of the health needs of individuals within its 21-county service region and finding innovative ways to achieve the goals of better health, better care and better value by utilizing informed population health and integrated care strategies. The purpose of the MSHN population health and integrated care plan is to establish regional guidance and best practices in these areas as well as describe specific population health and integrated care initiatives currently underway in the MSHN region. The plan will: Identify the population served by MSHN and explore key population health needs Identify chronic co-morbid physical health conditions that contribute to poor health and drive health costs for individuals with behavioral health disorders Describe population health and explore social determinants of health Examine key foundational areas necessary to support population health programs and evaluate MSHN’s stage of readiness for each area Describe current population health and integrated care initiatives underway by MSHN and its CMHSP organizations Amanda

Population Served& Key Health Needs Figure 1: Displays the top 5 Behavioral Health Chronic Conditions by the percentage of Medicaid individuals served by CMHSPs within the MSHN region in the past 12 months. (MA Population: 39656) Figure 2: Displays the top 5 Behavioral Health Chronic Conditions by the percentage of Medicaid individuals served by SUD providers within the MSHN region in the past 12 months. (MA Population: 7918) Based on Medicaid claims data; diagnosis listed on claim is capturing the reason for that specific encounter and is not necessarily reflective of a primary diagnosis or condition for the individual  

Population Served & Key Health Needs Figure 1: Displays the top 5 Behavioral Health Chronic Conditions by the percentage of Medicaid individuals served by CMHSPs within the MSHN region in the past 12 months. (MA Population: 39656) Figure 2: Displays the top 5 Behavioral Health Chronic Conditions by the percentage of Medicaid individuals served by SUD providers within the MSHN region in the past 12 months. (MA Population: 7918) Based on Medicaid claims data; diagnosis listed on claim is capturing the reason for that specific encounter and is not necessarily reflective of a primary diagnosis or condition for the individual  

Population Served & Key Health Needs Amanda

Measurement Portfolio Measure Name FY 17 Achieved FY 18 Achieved Cardiovascular Screening 30.16% 61.0% Diabetes Screening 84.50% 87.8% Diabetes Monitoring 58.28% 56.3% FU Children ADHD Med C&M Phase 99.01% 96.9% FU Children ADHD Med Initiation Phase 74.70% 82.5% Adults Access to Care 92.80% 95.0% Children Access to Care 95.28% 96.0% FU Hospitalization Mental Illness Adult 66.97% 79.1% FU Hospitalization Mental Illness Children 72.14% 84.0% Plan All-Cause Readmissions 11.74% 11.5% Cardiovascular Screening for Antipsychotics Amanda – Measures align with HEDIS CMHSPs have access to and can view their CMHSP-specific data. Metrics are reviewed quarterly, if not more frequently, by regional MSHN councils and committees for ongoing input into performance improvement strategies. Expanded descriptions for each performance measure, rationale for selection, and accompanying clinical protocols are contained in Attachment C of this document.

FY19 Shared Metrics with MHPs Implementation of Joint Care Management Processes: MSHN continues to meet monthly with the MHPs to develop care plans for those identified in the joint risk stratification. Follow-Up After Hospitalization for Mental Illness within 30 Days: MSHN has been monitoring this measure for a few years and continues to demonstrate high performance. Plan All-Cause Readmission (PRC): MSHN identified this measure as a priority in 2016 and began initiatives for performance improvement. In FY19, MDHHS is including this measure only as a review and validation of data. MSHN will work with MDHHS to identify any discrepancies. Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence: This measure is also informational for FY19. Validation of this measure will continue throughout FY19. In addition, MSHN is developing an action plan to collaborate with the hospitals for identification and to assure reporting of encounters occurring as part of the follow-up. Amanda Review metrics; Note- all CMHSPs performed at/above the required FUH metric, not just the region as a whole. Excellent effort at local level to achieve this high level of performance

Care Coordination Plans - Measures Care Coordination Plans, Monitoring and Indicators Reduction in number of visits to ER Reduction in hospital admissions for psychiatric/physical health reasons Number of chronic conditions Percent of consumers who have had a PCP visit in the last twelve months Reason for closure of care coordination case Amount of time (in days) spent in a care coordination plan arrangement Amount of time (in days) open to care coordination where there has been no consumer engagement Skye- brief overview of meetings every month with all 8 MHPs, members selected based on established risk criteria, partner with CMHs to perform the “on the ground” coordination with the individual and healthcare providers

Initial Outcomes of Care Coordination Efforts ER Visit Reduction for individuals with Care Coordination Plan: After 3 Months: 70% (57/81) After 6 Months: 68% (41/60) After 9 Months: 72% (23/32) After 12 Months: 53% (8/15) (Each of the above is all individual plans when they have reached that level) Overall; each individual at current month in Care Coordination Plan (3, 6, 9, 12) status: 79% (64/81) IP Admission Reduction for individuals with Care Coordination Plan: After 3 Months: 75% (61/81) After 6 Months: 67% (40/60) 69% (56/81) Total overall reduction in ED utilization of 79% Skye Baseline data gathered for each consumer (number of ED visits and I/P stays during the 12 months prior to care coordination plan being opened). At 3 months, 6 months, 9 months, and 12 months, data is compared against baseline data to determine if there was reduction or increase since beginning care coordination plan.

Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence Report Ending: 12/31/2017 Report Ending: 3/31/2018 Report Ending: 6/30/2018 Rate Statewide Medicaid Total 22.75% 23.6% 24.52% MSHN 12.77% 17.34% 21.18% Amanda – They tweaked the measure and went away from the true HEDIS and included some Michigan specific SUD service codes that seem to be prevalent in our region’s treatment model.  Without them, those services were being dropped in that 30 days. REMI and the rate at which we can process and submit encounters with accuracy to MDHHS

Value Based Purchasing Pilot Program Overview Mid-State Health Network (MSHN) proposed a pilot project to improve the quality and efficiency of substance abuse treatment through the development of a value based purchasing model for Substance Use Disorder (SUD) services. MSHN intended to partner with 1-2 SUD providers and 1-2 Medicaid Health Plans to collaboratively develop a payment model that focuses on: Improved clinical outcomes for at-risk populations Expanded care coordination between providers at all levels Consistent engagement in an SUD treatment and recovery relationship Engagement with primary care Reduction in unnecessary emergency department use Reduction in inpatient psychiatric care amanda

This report is a comparison analysis between the target SUD population of individuals served by three specific SUD providers and by two specific Health Plans and the Medicaid population as a whole served by the two Health Plans. Amanda Used this report to discuss with MHPs, while there was interest, there wasn’t enough population for the MHP to be involved. – Pilot only working with 3 SUD providers Then broke it down by other items, employment, homelessness, living arrangement, primary drug, type of chronic conditions, etc.

Skye to discuss here the work with SUD pilots Interventions to address high ED use, lack of engagement with primary care: set up care alerts in CC360 so provider knows when clients use ED, scheduling all clients with PCP when they enter tx, staff competency training in area of trauma-informed care, etc Data drilling in the PCP and ER use.. By MHP by SUD provider – As we met with the SUD Providers

Skye

Regional Opioid Strategies Scope of Opioid Epidemic in Michigan 17X Increase in Overdose Deaths in MI from 1999-2016 In 2017 more deaths from overdoses (2729) than from auto accidents in MI Ranked 11th in Nation for overdose deaths per capita (NIH, 2018) MSHN regional response strategies Prevention Strategies Project ASSERT Expansion of MAT (Increased from 10 to 15 providers in FY18) Naloxone-Narcan Regional Availability (To date over 1000 kits distributed by CMHs) Developed MAT-inclusive treatment statement which was also adopted by MDHHS and all PIHPs Skye: PS:County Prevention Coalitions sponsoring “town hall” educational meetings in their local communities Media Campaigns to promote awareness and reduce stigma Ensuring adequate number of medication drop boxes in each community and providing education regarding safe medication disposal Physician trainings on pain management Promoting the use of MAPS (Michigan Automated Prescription System) with health providers in local communities

CMHSP Integrated Health Initiatives Verify consumer self-reported health conditions either through ICDP, CC360 or direct contact with primary care Inform every consumer that the CMHSP is required to coordinate care with their primary care physician. Meet the measurements identified through Meaningful Use for patient portals. Each CMHSP will identify its high-risk utilizers and develop a plan for stratification as locally determined and defined. MSHN monitors and defines its risk stratification as defined in this plan as high-risk. (Consumers identified as having 1 or more emergency department visits, no primary care visit within the previous 12 months, 2 or more chronic conditions, psychiatric or physical hospitalization within the previous 12 months) Care Coordination occurs with primary care and behavioral health care At least once annually (typically during the pre-planning for person centered planning), staff will utilize electronic data feeds to determine the last time the individual had contact with their primary care physician. Each CMHSP will work with its medical directors to review and discuss MSHN priority measures that we will measure and track as a region. Each CMHSPs Information Technology Directors and EMR vendors will work together to embed ICDP/CC360 into the electronic medical record to facilitate easier access to integrated health data for practitioners. Skye

Summary & Recommendations Care Alerts – Electronic Health Record Interface Predictive Modeling - ICDP Great Lakes Health Connect – Virtual Integrated Patient Record (VIPR) Expand Dashboard product availability: CMHSP & SUD Provider Network Expand cc360 Access: CMHSP Providers & SUD Provider Network FY19 Shared Metrics with MHPs Increase care coordination & collaboration – Primary Care & Behavioral Health, including SUD SUD ER: Coordination with Hospitals Physician Letters Amanda: Develop & Monitoring Workplan Includes monitoring of progress with identified measures in this plan. Balanced Scorecard – Quarterly Performance Incentive Bonus & MDHHS report submission – Annually, & Quarterly Semi-Annual Reports on SUB VBP  

Amanda – EXAMPLE of new DASHBOARD – Speak briefly to measures..

Questions Contact information: Amanda.Horgan@midstatehealthnetwork.org 517.253.7551 Skye.Pletcher@midstatehealthnetwork.org 517.657.3010