1. How California Learning Collaboratives are Building New Health Neighborhoods Jennifer Clancy, MSW CA Institute for Behavioral Health Solutions November 18, 2014

2. Overview CA Solution- Creating Accountable and Coordinated Care Methodology Intervention A County Experience Key Learning 2

3. The Problem…. FUNDERS RECIPIENT/ INTERMEDIARY PAYORS/ CONTRACTORS PROVIDER NETWORK CMSHRSASAMHSATax Payers (Millionaires)Foundations DHCS FQHC County BH Health CBO: Housing CBO: SUD CBO: MH CBO: Social Service, Peer, Etc FQHC Managed Care Plan County Behavioral Health CBOs (MH, SUD, SS, Peers) CBOs (MH, SUD, SS, Peers) County Behavioral Health County Behavioral Health FQHCs / Health Clinics FQHCs / Health Clinics Result of Uncoordinated Systems is that Serious Mental Illness is: 1.Common 2.Disabling 3.Expensive 4.Deadly UNCOORDINATED SYSTEM Jennifer Clancy, CIBHS 3

4. 4 California Building Blocks for the System Solution Social Service Agencies, i.e. Housing Behavioral Health Providers: SUD and MH Primary Care Providers Peer Providers Wellness Agencies Community Supports Various Funding Sources Organized by Triple Aim Principles Single Accountable Entity

5. California/ACA Building Blocks for the Practice Solution Practice Transformation: Integrated and Coordinated Care 1. Comprehensive Care Plans 2. Quality Driven 3. Comprehensive Services 4. Care management, care coordination, and transitional care 5. Use of HIT 5

6. Collaborative Team Model Primary Care Patient Care Coordinator Psychiatrist Substance Use Counselor Case Manager Peer Counselor Primary Care Psychiatrist Population Consultants Care Coordination Team Direct Service Providers Care Plan

7. 7 How Do We Get There?

8. CIBHS: IHI Breakthrough Series Learning Collaboratives History: 5 years, 40 counties Funder: Department of Health Care Services Focus Areas: Recovery, Care Coordination and Integration Organizational Partners: Mental health, Substance Use, Primary Care and Peer Providers & Managed Care Plans County Aims: Make fundamental systems and practice changes to improve the health status of individuals with chronic, complex and co-occurring behavioral health and physical health disorders 8

9. Methodology- Quality Improvement Framework 9

10. Convening, Developing a Shared Vision for Care Coordination & Key Processes to Get Started Supporting Clients Whole Health and Self Management Improving Day to Day Care Coordination to Deliver Coordinated Services Formalizing the Shared Work Flows and Expanding Capacity Spreading Effective Changes that Demonstrate Improvement The Intervention THEME #1THEME #2THEME #3 THEME #4 THEME # 5 Care Coordination Infrastructure 10

11. Small Tests of Fundamental Care Coordination Processes Some CC processes done by the care coordinator… 1. Outreach and engagement 2. Release of Info 3. Patient-Centered Care Coordination Plan 4. Screening 5. Referrals 6. Use Registry 7. Medication Reconciliation While some CC processes monitored by the care coordinator… 8. Shared Care Goals 9. Multidisciplinary Clinical Care Teams 10. Promote Self Management 11. Ad Hoc Clinical Case Consultation 12. Ensuring Urgent Access 13. Manage Transitions 8. Shared Care Goals 9. Multidisciplinary Clinical Care Teams 10. Promote Self Management 11. Ad Hoc Clinical Case Consultation 12. Ensuring Urgent Access 13. Manage Transitions

12. Results- Example Measures FOR ALL PARTNER ORGANIZATIONS BMI & BP Shared Care Goals Medication Reconciliation Client Experience of Care and Confidence MENTAL HEALTH Clients Who Smoke Who Have Been Advised to Quit Substance Use Disorder Screening 2 nd Gen Antipsychotic with A1c in last year SUBSTANCE USE Substance Use Disorder TX Mental Health Screening PCP Designation and Documentation PRIMARY CARE CVD with LDL less than 100 Mental Health and SUD Screening DM Appropriate Lab Testing HEALTH PLANS Cost Per Member Per Month Emergency Room Use

13. FRESNO COUNTY One County’s Story… 13

14. Fresno County Dept. of Behavioral Health County MHP, convening organization and client care coordinator Ambulatory Care Center High-fidelity IMPACT model of integrating mental health services into primary care clinic. Serves clients with mild/moderate mental illness Ambulatory Care Center High-fidelity IMPACT model of integrating mental health services into primary care clinic. Serves clients with mild/moderate mental illness Clinica Sierra Vista: FQHC, integrated mental health & primary care clinic serving Medi-Cal, Medi-Care & uninsured individuals A local Public Health Plan created by the Regional Health Authority to serve Medi-Cal members in the counties of Fresno, Kings & Madera. 14

15. The Fresno County Care Coordination Partnership Team will make changes to improve the whole health status of adult individuals by coordinating services for the clients with the most serious mental illness and substance use disorders. Behavioral Health and physical health care’s coordination has, thus far, been driven by individual providers rather than system change. Long- term change must be driven by the systems rather than pushed forward by a few practitioners. 15

16. Overall Theme Across All Agency Partners Recognize the importance of physical and mental health care to overall well-being of an individual Shared goal and all agency partners benefit! Agency Catalysts for Care Coordination/Population Health: – Mental Health (Medical Director) – CalViva Heath Plan – Primary Care 16

17. Key changes the Team has been working on Multidisciplinary Clinical Care Conferences (routine & ad hoc) Develop routine SUD screening Support of client self-management Ensuring and monitoring routine medication reconciliation Ensuring and monitoring authorizations for sharing client PHI Referral process between MHP and PCP Sharing of patient physical exams, test & lab results 17

18. CC measures data collection process Excel spreadsheet (tracks key health indicators, ROIs, etc.) MHP’s EHR system (Avatar) - Data reports created specifically for CCC & embedded into EHR for ease of generating data Who is responsible for collection? PCPs and MCPs collect data for their respective measures. MHP data analyst responsible for MH data collection, synthesis of data from MCP & PCPs, and reporting out to CiBHS CSV (FQHC) NextGen CSV (FQHC) NextGen CalViva (MCP) CalViva (MCP) DBH (MHP) Avatar DBH (MHP) Avatar CiBHS CCC CiBHS CCC Agency-Specific CCC Data Measures & Client List 18

19. Maintain key personnel from partner agencies Buy-in from executive leadership Right People at the Table with the Right Personalities: Client centered and dedicated providers Providers who follow through and are accountable Providers who are real learners. “Care coordination and population health is so different from what has been done before- given the learning curve, the team members must be learners”. Providers who are honest, transparent, and “leave their egos at the door” 19

20. Key Learning and So What Commit to Building Org. Relationships/Partnerships Collective Responsibility but Accountable Convening Entity Invest in Data Infrastructure Use QI Methodology and Data Routinely Sustain Engaged Leadership Test Fundamental Changes- Don’t Tinker