state innovation model community and clinical integration ... · of health with a goal toward...
TRANSCRIPT
February 28, 2018
State Innovation ModelCommunity and Clinical Integration ProgramComprehensive Care Management and Behavioral Health Learning Collaborative
Hannah’s story…
Celiac/refractory sprueCeliac/refractory sprue
Gall bladder surgeryGall bladder surgery
Dehydration/ED/hospital (repeat)Dehydration/ED/hospital (repeat)
Community & Clinical Integration Program
Individuals with Complex Health Needs
High risk
Medium Risk
Low Risk
Population Health Pyramid
• Multiple chronic conditions with high acuity
• Psycho‐social and socio‐economic barriers
• Frequent hospitalizations and ER visits
• High‐costs and poor outcomes
• Intensive care management
• Community resources navigation
• Address non‐clinical needs• Effective care coordination
and care transition planning
Conditions & Priorities
• Limited chronic conditions in a more stable state
• Potential prevalence of socio‐economic and psycho‐social barriers
• Occasional bursts of utilization due to poor management
• Incorporate team‐based coordinated care
• Address foreseeable clinical and socio‐economic complications
Conditions & Priorities
Helping care teams succeed…
Understanding the whole person
Using data to guide
improvement
Linking to community supports
Expanding the care team
Connecting with the care
team
Patient as part of the medical home team
Attitudes, values, beliefsChallenging life events Behavioral health and physical health needsPersonal goals for care
Health CoachPatient Navigator
Behavioral Health CounselorNutritionistand more…
Issues and Barriers: Socioeconomic factors
http://content.healthaffairs.org/content/33/5/778.full.pdf+html
For example,People living in high poverty were 24% more likely to be re‐admitted
Socioeconomic factors at the patient and community levels are shown to be related to the probability of readmission
Poverty, illiteracy, housing, food insecurity, social
isolation, transportation
7
Issues and Barriers: Socioeconomic factors
http://www.ncbi.nlm.nih.gov/pubmed/23929401
Another study found that...
1 out of every 2 hospitalizations in the homeless population resulted in a 30‐day hospital inpatient readmission
54% of readmissions occurred within 1 week And 75% within 2 weeks
Community and Clinical Integration Program
…coordination and communicationwith key clinical and community partners
Hospital
Home health
Specialty care
Skilled nursing
Behavioral health Social services
Housing
Homemaker & companion
Cultural health organizations
Employment services
Advanced Network
Community Health Worker
• Emerging workforce on the national stage
• Connecticut definition established in PA 17‐74
• https://www.cga.ct.gov/2017/ACT/pa/2017PA‐00074‐R00SB‐00126‐PA.htm
• …"community health worker" means a public health outreach professional with an in‐depth understanding of the experience, language, culture and socioeconomic needs of the community who (1) serves as a liaison between individuals within the community and health care and social services providers to facilitate access to such services and health‐related resources, improve the quality and cultural competence of the delivery of such services and address social determinants of health with a goal toward reducing racial, ethnic, gender and socioeconomic health disparities, and (2) increases health knowledge and self‐sufficiency through a range of services including outreach, engagement, education, coaching, informal counseling, social support, advocacy, care coordination, research related to social determinants of health and basic screenings and assessments of any risks associated with social determinants of health.
Key Elements of Comprehensive Care Management
Identify Individual with complex
health care needs
Conduct Person‐Centered
Assessment
Develop Individualized Care Plan
Establish Comprehensive Care Team
Execute and monitor individualized care plan
Identify patient readiness to transitionto self‐directed care maintenance and
primary care team support
Monitor individuals to reconnect to comprehensive care team when
needed
Evaluate and improve intervention
Identify and Assess Plan and Execute Monitor and Evaluate
Community & Clinical Integration Program
Behavioral Health in America
60% of adults with a mental illness didn’t receive mental health services in the previous year
1 in 5 adults in America experience mental illness in the
previous year
60%
Source: https://www.nami.org/NAMI/media/NAMI‐Media/Infographics/GeneralMHFacts.pdf
57% of adults will experience mental
illness at some point in their lifetime
Behavioral Health Services “Issues & Barriers”
Combined Physical & Behavioral Health Needs
Across the top 9 chronic conditions, including Arthritis, Asthma, and Diabetes, depression goes undiagnosed 85% of the time**
Under‐diagnosis
Source: *Druss, B.G., and Walker, E.R. (February 2011). Mental Disorders and Medical Comorbidity. Research Synthesis Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation**http://www.ncbi.nlm.nih.gov/
*
Behavioral Health Services “Issues & Barriers”
Cost of Care
…spending on medical services for patients that also have mental health or substance abuse problems is two to three times higher than those without such problems***
Sources: *http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1494870/ **Cartesian Solutions, Consolidated Health Claims Data***http://www.commonwealthfund.org/publications/newsletters/quality‐matters/2014/august‐september/in‐focus
Behavioral Health Services “Issues & Barriers”
Medical readmissions have been found to be 32% higher among individuals with a psychiatric condition*
Lack of Care Management
*http://www.psychcongress.com/article/depression‐and‐anxiety‐linked‐higher‐hospital‐readmission‐rates‐21918http://www.carecoordination.org/documents/whatwecandotoaddressunnecessaryreadmissions‐dr.elisabethhager.pdf
No psychiatric condition With psychiatric condition
Medical Readmissions
Behavioral Health Access
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Behavioral health Other specialists
Referring for Treatment “Very Challenging”
PCMH CAHPS 3.0+
Ease of BH access
http://www.healthreform.ct.gov/ohri/lib/ohri/sim/steering_committee/2015‐04‐09/report_physician_survey_feb_2015.pdf
Key Elements of Behavioral Health Integration
Identify individuals with behavioral health needs
Behavioral health referral and treatment
Behavioral health coordination with primary care source of referral
Track behavioral health outcomes/improvement for
identified individuals
Identify Serve Evaluate
Integrated (on‐site) brief assessment and treatment
or
End