1. Adult Asthma Working with Adult Medicaid Clients

2. Medicaid Overview  Miles City is one of 14 centers for the Medicaid Health Improvement Program  Miles City covers 9 counties and serves nearly 4000 Medicaid members Eastern Montana area in purple

4. Medicaid Overview  As claims are generated, risk scores are calculated for each member using predictive modeling software. Hospitalizations, surgical procedures, ER visits, outpatient services, and certain medications increase risk scores  On average, over 200 clients in this area have risk scores above 4.9  High scores are around 30

5. Medicaid Overview  Of the 200 members with higher risk scores, 13.8% have a pulmonary diagnosis including asthma, COPD, or other pulmonary disease.  These members are contacted and offered health education and assistance with medical or social needs.

6. Medicaid Overview  Out of the 200 high risk members, 29 have elected to be contacted on a regular basis and are “active”.  92% of the 29 adult Medicaid members actively served in the Eastern Montana region have a mental health diagnosis (primary or secondary)  66% of pediatric members actively served in the Eastern Montana region ages 12-17 have a mental health diagnosis  Mental Health is a complicating factor serving the Medicaid population

7. Medicaid Overview  Reaching this population can be difficult:  Reaching a member by phone for the first time is a mere 14%  Teaching methods require multiple exposures to retain information  Many members do not have a high school education  Family support is often not available for adult members

8. Medicaid Overview  Adult Education Facts  Family support is limited o Transportation and geographic isolation  Many under educated  Resources and access to care is limited  Non-Compliance with health care not uncommon  Pediatric Education Facts  Family support may include extended family  Mental health issues (parents or child) compromise understanding  School often used to achieve compliance  Family compliance can compromise health

9. Medicaid Overview What does this mean to you working with Medicaid clients?

10. Medicaid Overview Facts to Consider :  Medicaid is the single largest payer for mental health services in the United States.  Available mental health services are limited for many and hospitalizations cannot address underlying issues.  This particular section of population are some of the most vulnerable:  Income, education, transportation issues, geographic isolation, culture and compliance issues are factors in care.

11. Facts from MentalHealthAmerica.net  Depression is the most common mental health issue  Nearly 74 percent of Americans who seek help for depression or symptoms of depression will go to a primary care physician rather than a mental health professional.  The more severe the medical condition, the more likely that patient will experience clinical depression.

12. Facts from MentalHealthAmerica.net  People with depression experience greater distress, an increase in impaired functioning and less ability to follow medical regimens, thus hindering the treatment of any other medical conditions  Unfortunately, the diagnosis of depression is missed 50 percent of the time in primary care settings

13. Facts from MentalHealthAmerica.net Why Depression and Medical Illnesses Often Occur Together o Medical disorders may contribute biologically to depression. o Medically ill people may become clinically depressed as a psychological reaction to the prognosis, the pain and/or incapacity caused by the illness or its treatment. o Though occurring together, depression and a general medical disorder may be unrelated.

14. Adult Asthma Education Results

15. Adult Asthma Education  Education given to 6 adult clients and 1 pediatric client  2 adults are currently in the program with the others receiving secondary education due to occasional pulmonary issues.  Pediatric client currently enrolled in the MAP program as well as the Health Improvement Program receiving additional health, social, and family education.

16. Adult Asthma Client Information Adult Client #1  Female, age 56  Disabled due to Mental Health disorder  Asthma is a secondary diagnosis  Non compliant with medical care Adult Client #2  Female, age 18  Asthma is a secondary diagnosis  Non compliant with medical care due to age, income, no family support due to caregiver deaths

17. Adult #1 Pre Asthma education # ER/Unscheduled visits in past year: # Night awakenings (monthly) # Days albuterol use in the past month #Routine check ups for asthma in past year Post Asthma educatio n 20 20 3010 01 (early in education) Change Adult #1 Education after 3 months

18. Adult #1 Self-Management Education and Control Pre- Program End of Program Do you currently use a spacer or holding chamber with your asthma inhaler (yes/no) No Yes Do you have a complete asthma action plan? (yes/no) No Yes Can you demonstrate proper inhaler technique? No Yes Adult #1

19. Entrance Survey Adult #1 Pre Program  Rate the severity of your asthma (1-5)  How much do you know about asthma (1-5)  How much would you say that you know about asthma medication?  Do you know the relationship between environment and asthma?  How confident are you to handle an asthma attack at home? Post Program 42 24 24 25 35

20. Adult #1 Contributing Factors  Positive changes were made and demonstrated increased knowledge  Member could not progress due to inability to manage home environment, associated with mental illness factors.  Member cancelled multiple appointments to address asthma medication review after feeling better.  Member informed she had progressed as far as possible with the program and without environmental changes, her asthma would not get better.  Continued telephone encounters have been made.

21. Adult #2 Entrance Survey  Rate the severity of your asthma (1-5)  How much do you know about asthma (1- 5)  How much would you say that you know about asthma medication?  Do you know the relationship between environment and asthma?  How confident are you to handle an asthma attack at home? 44 24 24 24 33 Pre Program 1Brief visit results

22. Adult #2 Report Card # ER/Unscheduled visits in past year: # Night awakenings (monthly) # Days albuterol use in the past month #Routine check ups for asthma in past year 2Goal is 0 1 1 2Goal is scheduled Pre Asthma education Post Asthma educatio n Change

23. Self-Management Education and Control Pre- Program Goal for End of Program Do you currently use a spacer or holding chamber with your asthma inhaler (yes/no) No Provided Do you have a complete asthma action plan? (yes/no) No Yes Can you demonstrate proper inhaler technique? No Yes

24. Adult #2 Contributing Factors  Age is a factor in compliance  No adult supervision for over a year due to death of mother, and then her grandmother  Working, alternative school schedule, learning disability and juvenile rheumatoid arthritis contributing factors to her compliance

25. Summary  The numbers for patient success are low due to multiple contributing factors  Mental Health is a contributing factor for over 90% of the population that receive health and wellness coaching  These patients are extremely grateful for reaching out to them and that cannot be recreated in data.