Show Me Outcomes Progress Update Netsmart Pilot/ SPQM & - - PowerPoint PPT Presentation

Progress Update

Show Me Outcomes

BPM Mailings Email Notifications Disease Registry ProAct

Netsmart Pilot/ SPQM & Costing/ Data Warehouse/ DLA-20

MO + CMT Nurse Liaisons DM3700 Outreach Healthcare Home CMHL/ERE Excellence 2005 2008 2010 2012 2013 2015

FQHC Partnership Training Contracts

26 Missouri CMHC Health Homes 24,063 Current Enrollment (as of January 1, 2016)

• 1,236 elderly
• 19,652 adults
• 3,175 children

Missouri county map with CMHC Health Home locations

Children (<18)

13.2%

Adult (18-64)

81.7%

Elderly (>64)

5.1%

CMHC Health Home Enrollment by Age Group

N = 24,063 total health home enrollment as of January 1, 2016

Missouri’s Health Homes have saved an estimated

$36.3 million

($60 PMPM Cost Savings) Community Mental Health Center Healthcare Homes have saved Missouri $31 million ($98 PMPM Cost Savings)

Current per member per month (PMPM) rate for CMHC Health Homes is $85.23 (Jan. 2016) Disease Management 3700 cohort enrolled in CMHC Health Homes saved $22.8 million ($395 PMPM Cost Savings)

DM3700 N =4,800 lives

37% 30% 28% 23%

0% 5% 10% 15% 20% 25% 30% 35% 40% Baseline Year 1 Year 2 Year 3

 14%

CMHC Health Homes January 1, 2012

50 100 150 200 250 300 2009 2010 Baseline Year 1 Year 2 Year 3

ER Visits Hospital Days

ER Visits Per 1000 Hospital Days Per 1000

 34%  38%

CMHC Health Homes January 1, 2012

0.85 0.68 0.62 0.58 2.5 2.27 2.09 2.06

0.5 1 1.5 2 2.5 3 Baseline Year 1 Year 2 Year 3

Avg # Hospitalizations Per Enrollee Per Year Avg # ER Visits Per Enrollee Per Year

Total CMHC Health Home participants:

(2011) = 17,084 (2012) = 18,776 (2013) = 19,103 (2014) = 20,345

year end 2011 year end 2012 year end 2013 year end 2014

CMHC Health Homes January 1, 2012

7% 9% 29% 11% 1% 15% 9% 36% 29% 62% 45% 9% 8% 53%

18% 3% 4% 7% 0% 9% 6%

0% 10% 20% 30% 40% 50% 60% 70%

General Nat. Pop. HCH Adults HCH Youth

HYPERTENSION CARDIOVASCULAR DISEASE SUBSTANCE USE DISORDER ASTHMA

General population stats from 2015 Centers for Disease Control and Prevention (CDC) and Substance Abuse and Mental Health Services Administration (SAMHSA)

Total CMHC Health Home participants (2012-2014): HCH Adults N = 22,801 HCH Youth N = 3,944

27% 29% 19% 9% 44% 48% 23% 2% 0% 0% 0% 3%

0% 10% 20% 30% 40% 50% 1 Chronic Disease 2 Chronic Disease 3 Chronic Disease ≥4 Chronic Disease SUD+2 or more

• ther CD

MH+2 or more other CD

HCH Adults HCH Youth

Total CMHC Health Home participants (2012-2014): HCH Adults N = 22,801 HCH Youth N = 3,944

Total CMHC Health Home participants (2014): HCH Adults N = 20,590 DM3700 Adults N = 2,407

2% 31% 35% 25% 7% 1% 18% 24% 37% 19% 1% 19% 23% 37% 20%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Underweight BMI <18.5 Normal BMI 18.5-24.9 Overweight BMI 25-29.9 Obese BMI 30-39.9 Extremely Obese BMI ≥40

General MO Adult Pop. HCH Adults DM3700 Adults

0.4% 7% 37% 45% 12% 2% 0% 0%

0% 10% 20% 30% 40% 50% 60% 70% 1-20 mGAF 21-30 mGAF 31-40 mGAF 41-50 mGAF 51-60 mGAF 61-70 mGAF 71-80 mGAF 81-90 mGAF

Score 31-40 Major impairment in several areas of functioning Score 41-50 Some serious symptoms

• r impairment in

functioning

Total CMHC Health Home participants (CY 2014): N = 13,550 with DLA-20 in last 18 months

Performance Measures & Outcomes

22% 27% 18% 38% 46% 42% 47% 59% 53% 57% 73% 61% 54% 72% 61%

0% 10% 20% 30% 40% 50% 60% 70% 80% Good Cholesterol (<100 mg/dL) Normal Blood Pressure (<140/90 mmHg) Normal Blood Sugar (A1c <8.0%) Feb'12 Baseline Feb'13 12 Months June'13 18 Months June'15 3.5 Years Dec'15 current enrolled pop

Adults continuously enrolled at each point in time and adults enrolled as

• f December 2015

N = 1,889 (3.5 yr. enrollment) N = 4,526 (Dec 2015)

21% 24% 37% 41% 49% 55% 60% 70% 56% 67%

0% 10% 20% 30% 40% 50% 60% 70% 80% Good Cholesterol for Clients w/ CVD (<100 mg/dL) Normal Blood Pressure for Clients w/ HTN (<140/90 mmHg) Feb'12 Baseline Feb'13 12 Months June'13 18 Months June'15 3.5 Years Dec'15 current enrolled pop

Adults continuously enrolled at each point in time and adults enrolled as

• f December 2015

CVD N = 232 (3.5 yr. enrollment) CVD N = 564 (Dec 2015) HTN N = 2,401 (3.5 yr. enrollment) HTN N = 6,111 (Dec 2015)

12% 46% 61% 80% 89% 88%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Metabolic Syndrome Screening Feb'12 Baseline Feb'13 12 Months June'13 18 Months June'14 2.5 Years June'15 3.5 Years Dec'15 current enrolled pop

All CMHC Health Homes have attained a completion rate above 80%!

N = 6,553 (3.5 yr. enrollment) N = 20,648 (Dec 2015)

reduction in cholesterol 10%  in cardiovascular

disease

reduction in HgbA1c 21%  in diabetes related

deaths

14%  in heart attacks 37%  in microvascular

complications

reduction in blood pressure 16%  in cardiovascular

disease

42%  in stroke

Baseline to Year 1: Reduced the mean LDL 131 to 115 = 12% decrease Baseline to Year 3: Reduced the mean LDL 131 to 106 = 19% decrease

For individuals with LDL >100 at Baseline

131.5 115 111.64 106

100 105 110 115 120 125 130 135 140 145 Baseline Year 1 Year 2 Year 3

19%

Baseline to Year 1: Reduced the mean BP

Systolic: 152 to 134= 18 mm/Hg Diastolic: 98 to 86= 12 mm/Hg

Baseline to Year 3: Reduced the mean BP

Systolic: 152 to 133= 19 mm/Hg Diastolic: 97 to 83= 14 mm/Hg For individuals with Systolic BP >140 and Diastolic BP >90 at Baseline

152.9 134.9 134.4 133.1 97.9 86 84.9 83.3

30 50 70 90 110 130 150 170 Baseline Year 1 Year 2 Year 3

14mm/Hg Systolic 19mm/Hg Diastolic

10.08 9.2 8.9 8.6

7.5 8 8.5 9 9.5 10 10.5 Baseline Year 1 Year 2 Year 3

Baseline to Year 1: Reduced the mean HgbA1c 10.1 to 9.2 = .88 points Baseline to Year 3: Reduced the mean HgbA1c 10.1 to 8.6 = 1.48 points

For individuals with HbA1c >9.0 at Baseline



NASCA leaders discuss health homes.

• State/Provider Collaboration Key
• CEO Presentation Mandate
• Kids Model Wrong – More

Wellness/Family

• MCO Challenges (Kansas Example)
• Data! Data! Data!
• Engage the Nurses
• Hospital MOU
• Agency Integration

MO Health Home Resources

MO Department of Mental Health

dmh.mo.gov/mentalillness/mohealthhomes.html

MO Coalition for Community Behavioral Healthcare

mocoalition.org/#!health-homes/c14fu

MO Department of Social Services | MO Primary Care Health Homes

dss.mo.gov/mhd/cs/health-homes/

CMS Health Home Information Resource Center

www.medicaid.gov/state-resource- center/medicaid-state-technical-assistance/health- homes-technical-assistance/health-home- information-resource-center.html

Articles and Recognitions

“The Promise of Convergence: Transforming Health Care Delivery in Missouri” (Harvard Case Study for 2015 NASCA Institute on Management and Leadership)

www.naspo.org/dnn/Portals/16/2015%20NASCA%2 0Case%20Study%20- %20The%20Promise%20of%20Convergence%20FIN AL%20for%20article.pdf

Gold Award: Community-Based Program: A health Care Home for the “Whole Person” in Missouri’s Community Mental Health Centers (APA Achievement Awards 2015)

ps.psychiatryonline.org/doi/full/10.1176/appi.ps.66 1013can Psychiatric Association |