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

2. 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

3. 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

4. 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

5. Population Served & Key Health Needs
Amanda

6. 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.

7. 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 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

8. 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

9. 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.

10. 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

11. 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

12. 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.

13. 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

14. Skye

15. Regional Opioid Strategies
Scope of Opioid Epidemic in Michigan
17X Increase in Overdose Deaths in MI from
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

16. 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

17. 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

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

19. Questions
Contact information: