1. Session #G3b
October 28, 2011
Wellness Recovery Teams – An Innovative Approach to Integrated Health Homes for Individuals with SMI  
James Leonard, MBA, LCSW, Newtown Care Management Center Clinical Officer
Magellan Behavioral Health of Pennsylvania, Inc.
LeeAnn Moyer, Deputy Administrator of Behavioral Health
Montgomery County Department of Behavioral and Developmental Disabilities
Marylynn Windish, MS, LPC, CCDP-D, Adult Clinical Program Manager
Sandra Zebrowski, MD, Newtown Care Management Center Medical Director
Collaborative Family Healthcare Association 13th Annual Conference
October 27-29, Philadelphia, Pennsylvania U.S.A.
Collaborative Family Healthcare Association 12th Annual Conference

2. Faculty Disclosure
We have not had any relevant financial relationships during the past 12 months.
Collaborative Family Healthcare Association 12th Annual Conference

3. Need/Practice Gap & Supporting Resources
The needs of people with serious mental illness (SMI) present unique needs to collaborative models of care because of the multiple co-occurring issues they face.
Individuals with SMI have a shorter life expectancy by 25 years.
While persons may receive treatment and support from behavioral health providers, connections to physical health providers and communications among providers are often fragmented.
Health care costs are high, and still the mentally ill are dying younger.
Research supports the value of enhanced coordination between the physical and behavioral health systems as an opportunity to improve the quality of care provided to individuals, while achieving financial efficiencies.
Collaborative Family Healthcare Association 12th Annual Conference

4. Objectives
Participants will describe the characteristics of the Health Choices Health Connections program.
Participants will describe the characteristics of the integrated team approach.
Participants will list three strategies for supporting collaboration across multiple systems (i.e. physical health, behavioral health, residential, criminal justice, etc.)
Participants will describe the advantages of a multi-level approach to collaboration that includes:
Physical health plan to behavioral health plan
Agency internal function collaboration
Community stakeholders
Physical health & behavioral health providers
Participants will describe the strength of an integrated team approach in dealing with multiple co-occurring disorders.
Participants will list three promising practice strategies for integrated care planning and delivery.
Collaborative Family Healthcare Association 12th Annual Conference

5. Expected Outcome
Participants will learn promising practice strategies for:
training
information exchange
member engagement
clinical intervention
integrated treatment planning
outcomes monitoring
Collaborative Family Healthcare Association 12th Annual Conference

6. Pennsylvania Serious Mental Illness (SMI) Innovation Project
In 2008, the Center for Health Care Strategies (CHCS) launched a multi-state, national effort to improve quality and reduce expenditures for Medicaid beneficiaries with complex medical and behavioral health needs
Pennsylvania was among the states selected to participate in the effort
SE Project Name: HealthChoices HealthConnections (HCHC)

7. Pennsylvania Serious Mental Illness (SMI) Innovation Project
SE Project Partners
Department of Public Welfare
Mathematical Policy Research and IPRO
Center for Health Care Strategies
Bucks, Montgomery and Delaware Counties
Magellan Behavioral Health of Pennsylvania, Inc.
Keystone Mercy Health Plan
Partner Vision Group Meeting

8. Criteria for Inclusion
Ages 18+
Diagnosis of Schizophrenia (295.XX)
Diagnosis of a Mood Disorder (296.XX)
Diagnosis of Borderline Personality Disorder (301.83)
Program is voluntary and individuals may opt-out
Consent needed to release and share information (includes MH, Substance Abuse (SA) and HIV-related information)

9. Program Goals and Objectives
Improve Health for Members
Decrease gaps in care for behavioral and medical conditions
Improve the rate of medication adherence
Improve the rate of preventive services
Improve the rate of visits with providers
Reduce avoidable hospital admissions and emergency room visits
Improve Member Satisfaction
Better access and services
Improved coordination of care

10. Pennsylvania SMI Innovations Project Intervention Pillars
Coordination of hospital discharge & appropriate follow-up
Pharmacy management
Co-location of resources
Focus on appropriate Emergency Department use for Behavioral Health (BH) treatment
Focus on alcohol and substance abuse treatment/care coordination
Consumer engagement
Data management and information exchange
Provider engagement/medical home

11. Montgomery County Project Scope and Funding
Total Consenting Member: 367
Five Agencies and Two ACT Teams
: Funded with Reinvestment
2010: OMHSAS approved service description; HealthChoices funding effective October 1, 2010
Funding: Per member per month case rate

12. Plan Level Interventions: Member Profile
Unique marriage of data between two independent health plans Magellan and Keystone Mercy Health Plan
Demographics
Primary Care Provider (PCP) and BH provider contact information
Physical Health (PH) and BH diagnoses
Service utilization of specialists
PH and BH levels of service and claims information
Hospitalizations; ER visits; BH Crisis Service
Pharmacy data
Gaps in routine physical health screenings/evaluations
Includes D/A and HIV information

13. Plan Level Interventions
Easy access with plan-based case coordinators to collaborate on the special needs of member
Notify of BH & PH Hospitalization
Recommend referrals as appropriate
Pharmaceutical Management
Access to BH & PH educational material
Joint Case Rounds (Includes plans’ case coordinators, plans’ physician advisors, Wellness Recovery Team and other healthcare participants, as needed)

14. Provider Level Interventions: Wellness Recovery Team (WRT)
Team of Navigators: RN, masters level MH or BH Professional, Administrative Navigator
*Completed approved integrated PH/BH certification
Phased approach to interventions with the goal of self-management
Member with her WRT and Magellan HCHC Community Support Partner

15. Provider Level Interventions: Wellness Recovery Team (WRT)
Outreach and Engagement
Therapeutic alliance with WRT
Utilize Member Profile as tool to coordinate care
Assist member in creating individual Wellness Plan
Identification of “virtual team” supports-relationship building
Community-based, mobile
Member reviewing their Wellness Plan with RN Navigator and Therapist

16. Provider Level Interventions: Wellness Recovery Team (WRT)
Notification of BH & PH hospitalization
Discharge planning and coordination
Linkage to community supports
Referrals as appropriate
Triage and planning by WRT and RN

17. Provider Level Interventions: Wellness Recovery Team (WRT)
Joint Case Rounds
Develop and maintain an ongoing relationship with a PCP and Psychiatrist
Pharmacy consultation and collaboration
Co-occurring substance use
screening and treatment
interventions
Trauma-informed and
Motivational interventions
Preventive care
WRT consultation with Psychiatrist

18. Provider Level Interventions: Wellness Recovery Team (WRT)
Continuity of relationships over time; immediate re-engagement if needed
Wellness groups
BH and PH wellness checks
Provide educational material
Collaborative care management activities are billable
Member monitoring her wellness goal

19. Advantage of Multi-Level Approach to Coordination
PH plan to BH plan to WRT
Coordination between WRT and PCP
Creating a “virtual team”
Specialist coordination
Achieving financial efficiencies

20. HealthChoices HealthConnections Cost Impact Study
Selection of Population
Members Consented for Participation in HealthChoices HealthConnections (HCHC)
Members Anchored in the Wellness Recovery Team (WRT)
137 Members identified as having active participation in the WRT program as of November 30, 2010
Measurement Periods
6 Months prior to participation (anchor date) in WRT
6 Months during participation (anchor date) in WRT

21. HealthChoices HealthConnections Cost Impact Study
The change found in individuals’ use of treatment in 24 hour settings and Emergency Rooms while participating in HCHC is substantially diminished compared with such need prior to HCHC involvement.
The need for emergency care in a medical facility ER decreased by 11%
Admissions to medical facilities reduced by 56%
Admissions to psychiatric hospitals reduced by 43%
The need for an assisted residential environment declined by 14%
The support and proactive coordination of services and wellness activities found with the HCHC approach has resulted in a reduced need for these high level and often invasive interventions.

22. Continuous Quality Management: Monthly Learning Collaborative
Ongoing learning by sharing of collective experiences and challenges
Development and spread of promising practices and strategies
Network, relationship development and information/resource exchange
Identify and meet education and training needs
Learning Collaborative

23. Continuous Quality Management: Monthly Onsite Meetings with Each Provider
Provide Technical Assistance
Implementation of the Consumer Health Inventory (CHI) Tool
Conduct Quality Initiatives
Collaboratively Monitor Program
Member completing a CHI

24. Continuous Quality Management: Administration of the Consumer Health Inventory (CHI)
Domain
% of HCHC Members Reporting Progress
% of All Magellan PS Members
Reporting Progress
Behavioral Symptoms
29.03%
21.57%
Strength
38.71%
32.62%
Provider Relationship
80%
33.30%
Work-School Participation
22.58%
6.20%
% of Members with Improvement
% of All Magellan PS Members with Improvement
Emotional Health
58.06%
38.05%
Physical Health
54.84%
35.16%

25. Continuous Quality Management: Consumer Satisfaction Surveys
Active involvement with HCHC Consumer Advisory Board
Member Surveys conducted by Consumer Satisfaction Team
Peer Specialist involvement with Quality Improvement activities
Consumer Advisory Board Members (Person in Recovery, Certified Peer Specialist, and Montgomery County QI Coordinator )

26. Continuous Quality Management: Consumer Satisfaction Surveys

27. Continuous Quality Management: Consumer Satisfaction Surveys

28. Continuous Quality Management: Consumer Satisfaction Surveys

29. Learning Assessment Questions and Answers
Collaborative Family Healthcare Association 12th Annual Conference

30. Session Evaluation Thank you!
Please complete and return the evaluation form to the classroom monitor before leaving this session.
Thank you!
Collaborative Family Healthcare Association 12th Annual Conference