1. Wellness Recovery Teams – An Innovative Approach to Integrated Health Homes for Individuals with SMI Collaborative Family Healthcare Association 13 th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A. Session #G3b October 28, 2011 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 Montgomery County Department of Behavioral and Developmental Disabilities Sandra Zebrowski, MD, Newtown Care Management Center Medical Director Magellan Behavioral Health of Pennsylvania, Inc.

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months. 2

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. 3

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. 4

5. Expected Outcome Participants will learn promising practice strategies for: training information exchange member engagement clinical intervention integrated treatment planning outcomes monitoring 5

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) 6

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 7 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) 8

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 9

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 10

11. Montgomery County Project Scope and Funding Total Consenting Member: 367 Five Agencies and Two ACT Teams 2009-2010: Funded with Reinvestment 2010: OMHSAS approved service description; HealthChoices funding effective October 1, 2010 Funding: Per member per month case rate 11

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 12

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) 13

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 14 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 15 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 16 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 17 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 18 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 19

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 20

21. 21 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. HealthChoices HealthConnections Cost Impact Study

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 22 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 23 Member completing a CHI

24. Continuous Quality Management: Administration of the Consumer Health Inventory (CHI) 24 Domain % of HCHC Members Reporting Progress % of All Magellan PS Members Reporting Progress Behavioral Symptoms29.03%21.57% Strength38.71%32.62% Provider Relationship80%33.30% Work-School Participation22.58%6.20% Domain% of Members with Improvement % of All Magellan PS Members with Improvement Emotional Health58.06%38.05% Physical Health54.84%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 25 Consumer Advisory Board Members (Person in Recovery, Certified Peer Specialist, and Montgomery County QI Coordinator )

26. Continuous Quality Management: Consumer Satisfaction Surveys

29. Learning Assessment Questions and Answers 29

30. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you! 30