1. C are O f M ental, P hysical A nd S ubstance-use S yndromes Claire Neely, MD Medical Director, ICSI August 23, 2013

2. 2 C are O f M ental, P hysical A nd S ubstance-use S yndromes Claire Neely, MD Medical Director,ICSI

3. 3 Year CMS Innovation Challenge Grant Awardee Objectives : Lower cost of care for people enrolled in government programs Leverage existing models to improve patient care quickly Engage broad set of partners to test new delivery models Identify workforce development opportunities to create jobs 3

4. Scope of COMPASS work To implement a collaborative care management model for patients with depression and diabetes/CVD, and optional risky substance use, in primary care that accomplishes the Triple Aim 4 Supported by Cooperative Agreement Number 1C1CMS331048-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services

5. Triple Aim Measures of Success Population health –Increase remission/response rates for patients with depression –Improve control rates for diabetes and cardiovascular disease and their risk factors –Reduce risky substance use Experience of care –Improve quality for patient and provider satisfaction Affordability –Decrease readmissions, admissions and ED visits to reduce health care costs

6. COMPASS Consortium: Overarching Scope Intervention – Develop an evidence-based model, train and facilitate implementation and quality improvement Evaluation/Study – Develop multiple data collection and analysis approaches for QI and for demonstrating triple aim success Communications – Marketing & messaging to multi-stakeholder audiences Payment methodology – Develop new financial models Spread and sustaining model – Systems approach to link with and embed in ongoing work 6

7. COMPASS Consortium Partners

8. COMPASS Intervention Partners Community Health Plan of Washington Institute for Clinical System Improvement (ICSI) Kaiser Colorado Kaiser Southern California Mayo Health System Michigan Center for Clinical Systems Improvement Mount Auburn Cambridge Independent Practice Association Pittsburgh Regional Health Initiative

9. COMPASS Partners ICSI Principal investigator for oversight of the award Design, train, implement and support this work across all intervention partners Advancing Integrated Mental Health Solutions Center Care Management Tracking System Advisor/trainer on development of COMPASS intervention Ongoing resources post-implementation for identified gaps with individual practices HealthPartners Institute for Education & Research Evaluation Quality improvement reporting

10. Work informing COMPASS IMPACT & DIAMOND Depression TEAMCare Depression + CVD/Diabetes SBIRT Substance Use Partners in Integrated Care Depression + Substance Use MI Primary Care Transformation Multiple chronic conditions RARE, Project BOOST Care Transitions

11. Tracking Enrollment & Data Transparency Transformation Leadership, Culture, Readiness Treatment Intensification Triple Aim Team New Roles & Relationships COMPASS 4 Ts to Leverage 11

12. Enrollment Population Management & Care Plan Development Outcome-Oriented Care Management Monitoring /Transition to Routine Care 12

13. Enrollment Proactive patient identification and outreach Adult Medicaid or Medicare patients With sub-optimally managed depression (PHQ-9 >9) AND treatable medical comorbidities defined by one or more of the following: – Diagnosis of diabetes with A1c >8.0% OR BP >145 mm Hg OR LDL >100 mg/dl – Existing cardiovascular disease (e.g. history of ischemic heart disease diagnosis, coronary procedure, CHF or stroke) with BP >145 OR LDL >100 mg/d – Uncontrolled HTN (>160) in those over 65 years of age – Recent hospitalization related to diabetes or cardiovascular disease 13

14. Enrollment Study enrollment Notify of study using script Agree to be contacted by study team Study team calls patients Further explain study Get consent into study 14

15. PRIMARY CARE TEAM SYSTEMATIC CASE REVIEW TEAM with Psychiatric/Physician Consultants PATIENT CARE MANAGER Team - Collaborative Care 15

16. Ambulatory: Hospital Partnerships Partnering with hospital transition staff – Med Rec – Rehab units Visiting patients in hospital – Engage & Enroll – Follow-up Creating contingency plans – Use of alternative healthcare resources – Self-care

17. Challenges Program not for all patients Targeted diseases (mostly) Socio-economic EHR and other systemic disconnections Patients disconnected from the healthcare system

18. Ongoing support for sustainability Weekly enrollment reports Care manager networking calls Partner project manager calls Weekly newsletters Google site & other on-line resources Webinars & learning collaboratives Data feedback for quality improvement Practice coaching Building training capacity at the sites

20. Questions ?

21. Upcoming RARE Events…. Stay tuned for the next RARE Webinar September 27, 2013! Topic: Implementation of the Care Transitions Innovation (C-Train) in Oregon RARE Action Learning Day – November 11, 2013

22. Future webinars… To suggest future topics for this series, Reducing Avoidable Readmissions Effectively RARE Networking Webinars, contact Kathy Cummings, kcummings@icsi.org kcummings@icsi.org