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

Show Me Outcomes Progress Update

Netsmart Pilot/ SPQM & Costing/ Data BPM Email Disease Warehouse/ Mailings Notifications Registry ProAct DLA-20 2005 2008 2010 2012 2013 2015 MO + CMT Nurse DM3700 Healthcare CMHL/ERE Excellence Liaisons Outreach Home Training Contracts FQHC Partnership

26 Missouri CMHC Health Homes 24,063 Current Enrollment (as of January 1, 2016) • 1,236 elderly • 19,652 adults Elderly (>64) 5.1% • 3,175 children Children (<18) 13.2% Adult (18-64) CMHC Health Home 81.7% Enrollment by Age Group N = 24,063 total health home Missouri county map with enrollment as of January 1, 2016 CMHC Health Home locations

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 Disease Management 3700 cohort CMHC Health Homes is enrolled in CMHC Health Homes $85.23 (Jan. 2016) saved $22.8 million ($395 PMPM Cost Savings) DM3700 N =4,800 lives

CMHC Health Homes January 1, 2012 40% 35% 37% 30% 30% 28% 25% 23% 20% 15%  14% 10% 5% 0% Baseline Year 1 Year 2 Year 3

ER Visits Hospital Days CMHC Health Homes January 1, 2012 300  38% 250 200 Hospital Days Per 1000 150  34% 100 50 ER Visits Per 1000 0 2009 2010 Baseline Year 1 Year 2 Year 3

Avg # Hospitalizations Avg # ER Visits CMHC Health Homes Per Enrollee Per Year Per Enrollee Per Year January 1, 2012 3 2.5 2.5 2.27 2.09 2.06 2 Total CMHC Health Home 1.5 participants: (2011) = 17,084 0.85 1 0.68 0.62 (2012) = 18,776 0.58 0.5 (2013) = 19,103 (2014) = 20,345 0 Baseline Year 1 Year 2 Year 3 year end 2011 year end 2012 year end 2013 year end 2014

70% General Nat. Pop. 62% HCH Adults 60% HCH Youth HYPERTENSION 53% 50% 45% SUBSTANCE USE DISORDER CARDIOVASCULAR DISEASE 36% 40% 29% 29% ASTHMA Total CMHC Health Home 30% participants (2012-2014): 18% 20% 15% HCH Adults N = 22,801 11% 9% 9% 9% 9% 8% HCH Youth N = 3,944 7% 7% 10% 6% 4% 3% 1% 0% 0% General population stats from 2015 Centers for Disease Control and Prevention (CDC) and Substance Abuse and Mental Health Services Administration (SAMHSA)

HCH Adults HCH Youth 48% 50% 44% 40% 29% 27% 30% 23% Total CMHC Health Home 19% participants (2012-2014): 20% HCH Adults N = 22,801 9% 10% HCH Youth N = 3,944 3% 2% 0% 0% 0% 0% 1 2 3 ≥4 SUD+2 or MH+2 or Chronic Chronic Chronic Chronic more more other Disease Disease Disease Disease other CD CD

50% General MO Adult Pop. HCH Adults 45% DM3700 Adults 40% 37% 37% 35% 35% 31% 30% 25% 24% 23% 25% Total CMHC Health Home 20% 19% 19% 18% 20% participants (2014): 15% HCH Adults N = 20,590 10% DM3700 Adults N = 2,407 7% 2% 5% 1% 1% 0% Underweight Normal Overweight Obese Extremely Obese BMI <18.5 BMI 18.5-24.9 BMI 25-29.9 BMI 30-39.9 BMI ≥40

70% Score 31-40 Score 41-50 60% Major impairment in Some serious symptoms several areas of or impairment in functioning functioning 50% 45% 37% 40% Total CMHC Health Home 30% participants (CY 2014): N = 13,550 with DLA-20 20% in last 18 months 12% 7% 10% 2% 0.4% 0% 0% 0% 1-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 mGAF mGAF mGAF mGAF mGAF mGAF mGAF mGAF

Performance Measures & Outcomes

80% 73% 72% 70% 61% 61% 59% 57% 60% Adults continuously 54% 53% 47% enrolled at each point in 46% 50% 42% time and adults enrolled as 38% 40% of December 2015 27% 30% 22% N = 1,889 (3.5 yr. enrollment) 18% 20% N = 4,526 (Dec 2015) 10% 0% Good Cholesterol Normal Blood Pressure Normal Blood Sugar (<100 mg/dL) (<140/90 mmHg) (A1c <8.0%) Feb'12 Feb'13 June'13 June'15 Dec'15 Baseline 12 Months 18 Months 3.5 Years current enrolled pop

80% 70% 67% 70% 60% 56% 60% 55% Adults continuously 49% enrolled at each point in 50% 41% time and adults enrolled as 37% 40% of December 2015 24% 30% 21% CVD N = 232 (3.5 yr. 20% enrollment) CVD N = 564 (Dec 2015) 10% HTN N = 2,401 (3.5 yr. 0% Good Cholesterol for Clients w/ CVD Normal Blood Pressure for Clients w/ HTN enrollment) (<100 mg/dL) (<140/90 mmHg) HTN N = 6,111 (Dec 2015) Feb'12 Feb'13 June'13 June'15 Dec'15 Baseline 12 Months 18 Months 3.5 Years current enrolled pop

100% 89% 88% 90% 80% 80% All CMHC Health Homes 70% have attained a completion 61% rate above 80%! 60% 46% 50% N = 6,553 (3.5 yr. enrollment) 40% N = 20,648 (Dec 2015) 30% 20% 12% 10% 0% Metabolic Syndrome Screening Feb'12 Feb'13 June'13 June'14 June'15 Dec'15 Baseline 12 Months 18 Months 2.5 Years 3.5 Years current enrolled pop

reduction in cholesterol reduction in blood reduction in HgbA1c pressure 10%  in cardiovascular 21%  in diabetes related 16%  in cardiovascular disease deaths disease 14%  in heart attacks 42%  in stroke 37%  in microvascular complications

145 140 135 131.5 130 Baseline to Year 1: Reduced the mean LDL 125 131 to 115 = 12% decrease  19% 120 Baseline to Year 3: 115 115 Reduced the mean LDL 111.64 131 to 106 = 19% decrease 110 For individuals with LDL >100 at 106 Baseline 105 100 Baseline Year 1 Year 2 Year 3

170  19 mm/Hg Diastolic 152.9 150 134.9 134.4 133.1 130  14 mm/Hg Systolic Baseline to Year 1: 110 Reduced the mean BP 97.9 Systolic: 152 to 134=  18 mm/Hg Diastolic: 98 to 86=  12 mm/Hg 86 84.9 90 83.3 Baseline to Year 3: Reduced the mean BP 70 Systolic: 152 to 133=  19 mm/Hg Diastolic: 97 to 83=  14 mm/Hg 50 For individuals with Systolic BP >140 and Diastolic BP >90 at Baseline 30 Baseline Year 1 Year 2 Year 3

10.5 10.08 10 9.5  Baseline to Year 1: 9.2 Reduced the mean HgbA1c 8.9 10.1 to 9.2 =  .88 points 9 Baseline to Year 3: 8.6 8.5 Reduced the mean HgbA1c 10.1 to 8.6 =  1.48 points For individuals with HbA1c >9.0 at 8 Baseline 7.5 Baseline Year 1 Year 2 Year 3

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 Articles and Recognitions MO Department of Mental Health “The Promise of Convergence: Transforming dmh.mo.gov/mentalillness/mohealthhomes.html Health Care Delivery in Missouri” (Harvard Case Study for 2015 NASCA Institute on MO Coalition for Community Behavioral Management and Leadership) Healthcare www.naspo.org/dnn/Portals/16/2015%20NASCA%2 mocoalition.org/#!health-homes/c14fu 0Case%20Study%20- MO Department of Social Services | MO %20The%20Promise%20of%20Convergence%20FIN Primary Care Health Homes AL%20for%20article.pdf dss.mo.gov/mhd/cs/health-homes/ Gold Award: Community-Based Program: A CMS Health Home Information Resource health Care Home for the “Whole Person” in Center Missouri’s Community Mental Health Centers www.medicaid.gov/state-resource- (APA Achievement Awards 2015) center/medicaid-state-technical-assistance/health- ps.psychiatryonline.org/doi/full/10.1176/appi.ps.66 homes-technical-assistance/health-home- 1013can Psychiatric Association | information-resource-center.html