1. Using Healthcare Data Sets to Improve the Coordination of Medical and Behavioral Health - The Potential Role For Health Homes Richard Surles, Ph.D. May 2013 YAI International Conference New York Hilton, New York, NY

2.  Understanding & Aligning Data Sets to Optimize Care and Control Costs  Potential Use of Data Sets to Identify Members and Needs  Leveraging Data Sets to Drive Workflow in Support of Effective Medical Homes Agenda 2

3.  ~50% of People Who Have a Severe Mental Illness (SMI) Have Medical Co- morbidities –Higher rates of utilization and costs –Problems achieving desired treatment outcomes –Lack of access to integrated services  Major Issues in SMI Overall Care are Medication Management and Suboptimal Care Delivery combined with the Need for Non-medical Support Services  Proven Interventions –Communication between mental health and physical health providers to provide integrated care –Use of information systems (tracking RX refills, clinical visits) to promote patient adherence and improved outcomes –Targeted interventions for both patient self care and provider engagement are critical –Care Management program engagement goals: decrease isolation, promote access –Relapse prevention programs contribute to medication maintenance, increased patient self-monitoring of symptoms Complex Conditions Require New Ideas for Coordination Beyond Traditional Medical Management 3

4. SMI Participants Account for 58% of Total Costs 39% of Population Has a SMI Top 5% of SMI Population Account for ~25% of All Costs 118,681$1.34 B $778 M $321 M *Aged, Blind & Disabled SMI and Medical Comorbidities in ABD* Population 4

5. Category Differences by Acuity  PMPM –Low: $679.94 –Mod:$3,471.14 –High: $8,262.26  Average Number of Conditions –Low: 1.8 –Mod:4.9 –High: 7.1  Average Risk Score (CDPS)* –Low: 1.9 –Mod:5.2 –High: 10.7  Average MDs –Low: 3.3 –Mod:6.6 –High: 10.9 Levels of Complexity for Aged, Blind & Disabled ABD Medicaid Spend (10/10-9/11) 36,408$582M * Chronic Illness & Disability Payment System; Index risk score is 1.0 5

6. ABD Population – Prevalent BH + Chronic Medical 6

7. Dimensions of Care - Supporting the Whole Perso n Where Treatment is Done What is Treated How Treatment is Delivered Intensive/Procedural Medical Treatment Rehabilitative Treatment Combined Treatment Patient Education & Counseling Self-Help & Natural Supports Biomedical Intrapsychic Social/Legal Vocational/Financial Marital/Familial Office Partial Care Hospital Community Home 7

8. Inpatient Hospital Outpatient Hospital Critical Access Hospital FQHC Skilled Nursing Home Health Rural Health Clinic Other Medical Ambulance Office Visits Specialists Lab Tests Comprehensive Medication Service Minor Procedures Anesthesia Major Procedures ER Visits Other Tests Medical Services Community Services Residential Facility Intermediate Care Habilitation Other Supports Alcohol/Drug Treatment Community Wrap-Around services Community Support Services Case Management Personal Care Non-emergency Transportation BH Day Treatment Attendant care Psychosocial Rehabilitation Crisis Intervention Assertive Community Treatment Other DME Supported Employment Clinical 8 Supports

9.  Affordable Care Act Encourages the Use of Health Homes for Chronically Ill and People with SMI via Financial Incentives  SMI Health Homes Addresses Behavioral Health Needs While Responding to Other Healthcare Issues –Individuals with SMI, on average, die 25 years earlier than the general population –60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases –Second generation anti-psychotic medications are highly associated with weight gain, diabetes, dyslipidemia (abnormal cholesterol) and metabolic syndrome Are Integrated SMI Health Homes a possibility? 9

10. Key Features of the Health Home: All Data Driven FeaturePurpose Comprehensive care management Predictive Modeling and Disease Stratification to identify clients with chronic disease and pinpoint risk Technology that integrates settings of care and data sources Secure messaging for information sharing and coordination Monitoring Enhances clinical care by alerting team to client events and changes in client status Addresses both clients and providers Supports innovative payment systems Reporting & Quality Easily accessible performance reports on key measures at multiple levels – client, provider, region, and state Quality improvement program for structured initiatives Outcome Measurement Stabilization of acuity and reduction of symptoms Clinical performance – engagement, medication adherence, reduction of ER, Inpatient, Readmissions Return on Investment analysis 10

11. A Vision of Provider Data Support Systems  Medical Home Has Current and Complete Information Via the Integrated Technology Platform –Data Driven Plan of Care –Aggregate view of all services/billing/interactions  Provider Tools –Real time access to data via secure Provider Portal –Reports highlighting alignment to best practice, gaps in care, services received outside of Medical Home Patient Specific Information Provider panel aggregate information  Service Vendor Requirements –Integrated technology platform –Technical assistance and training –Community and telephonic member engagement –Engage providers for care coordination –Appointment tracking and follow up 11

12. James R: A Member Case Study of Integration  47 Year Old Male with CAD, Diabetes, HTN, Asthma, Hyperlipidemia, GERD, Bipolar Disorder –New enrollee at program “go live” –Gaps in care analysis triggered (IP, multiple ER), General Assessment identified positive PHQ-2 and housing issues  Issue –Ineffective medical home –Unstable diabetes and behavioral health conditions –Unstable housing  Model Intervention –Secured stable housing –Secured effective medical home –Transitioned from Telephonic Health Coach to Field Health Coach intervention 12

13. James R: Member Case Study Assessments Provide Additional Information 13

14. James R: Member Case Study 14

15. Changing the Dialogue: Data Driven Systems of Care > Data Driven, Predictive Modeling >Data analysis >Assessments >Facilitate access to care & service supports >Improve self- management skills Measure goal progress >Feedback on results Engaged, educated member >Informed HCH >Alert system for HR/HC potential “Provider – Clinical, Service & Community - Support and Tools” INTERVENE IDENTIFYEVALUATEMONITOR “Health Care Home” HCH 15

16.  Access and Quality of Data  Privacy and Consumer Consent  Coordination of Medical and Behavioral Care with Pharmaceuticals  Full integration of traditional Medical Managed Care with Non-traditional Community Support Services Including: –Psychosocial Rehabilitation –Habilitation –Personal Care –Other Home and Community Care Services The Finish: Issues for a Data Driven Health System 16