Care Coordination & Integrated
Health Care
Texas Enhanced Care Program and
Mental Health Services Coordination
Esteban R. López, M.D., M.B.A, McKesson Health Solutions
Dena Stoner, Sr. Policy Advisor, Department of State Health Services
Anna Sicher, RN, M.P.A, Health and Human Services Commission
Texas Medicaid Enhanced Care Program
Whole person management: Addressing barriers
Self-Management
Coaching
Symptom
Assessments
Medication
Adherence
Motivation and
Confidence
Facilitate access
to community
services
Coordinate and
Arrange Care
Incentives
Ensure
appropriate
Medical Home
Self-Empowered
Member
Connection with
Providers
05/23/10
Facilitate access
to behavioral
health services
Lifestyle
behavioral
change
Texas Medicaid Enhanced Care Program
Overview
 Program launched November 2004
 Serving Primary Care Case Management (PCCM) and fee-for –service (FFS)
beneficiaries statewide in Texas
 Currently, more than 60,000 clients in the program
 Program provides disease management (DM) services to those clients with at
least one of the covered diseases:





Congestive Heart Failure (CHF)
Chronic Obstructive Pulmonary Disorder (COPD)
Asthma (AST)
Coronary Artery Disease (CAD)
Diabetes Mellitus (DIA)
 Telephonic and Community Based Nursing Model
 Both clinical and financial outcomes reviewed by
independent 3rd party actuarial firm
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Texas Medicaid Enhanced Care Program
Delivery Model
 Predicts/stratifies members who will:


Benefit most from DM services,
education, & improved self-management This is the
population
techniques
where
 Provide best opportunity to reduce
DM has the
costs & achieve savings
greatest
Intervention levels:
savings
impact
 Low risk – mailings, telephonic RN

interventions & 24/7 nurse advice line
Moderate & high risk – mailings, high
touch field based & telephonic RN
interventions, & 24/7 nurse advice line
 Moderate & high risk clients supported
by care coordination staff



Medicaid Resource Coordinators
Texas Based Registered Nurses
Bilingual Community Health Workers
 Provider outreach & support directed
by Texas Based Medical Director &
Provider Outreach Coordinators
05/23/10
Population
Distribution
Claims Cost
Distribution
Highest
Risk
~20%
Moderate
Risk
~20%
Lower Risk
~60%
50-80% of
Claims
10%-30%
of Claims
10-20% of
Claims
Texas Medicaid Enhanced Care Program
Key components: Care Coordination
Care coordination services aid member success by reducing or eliminating barriers
to care and assisting members & providers achieve member access & success
Coordinator
Medicaid
Resource
Coordinator
Types of Referrals









05/23/10
Utilization (hospital, emergency department/urgent care visits)
Durable Medical Equipment (DME) Issues
Mental Health Issues
Transportation Issues
Home Issues
Education/Information Issues
Medication Issues
Provider Issues
Benefits/Eligibility Issues
YTD 2009









3,728 = 18%
4,720 = 23%
1,703 = 8%
765 = 4%
2,223 = 11%
1,617 = 8%
3,895 = 19%
1,713 = 8%
322 = 1%
Texas Medicaid Enhanced Care Program
Key components: Evidence Based Guidelines
 Enhanced Care Program uses national guidelines as the basis for all DM
programs. Each condition-specific program is reviewed, updated, and
modified as national guidelines are updated and other relevant information is
made available from recognized resources.
 Use of disease-specific standardized clinical guidelines ensures consistency
of the assessment and monitoring processes delivered to the member by the
care management professional.
 Tools are used to evaluate staff performance and knowledge of the program
during all aspects of the program intervention, such as the enrollment,
assessment, and monitoring/coaching processes.
 Providers are informed of client status and “gaps in care” via
post-assessment letters or through faxed alerts.
05/23/10
Texas Medicaid Enhanced Care Program
Asthma Action Plan and Post Assessment Letter
05/23/10
Texas Medicaid Enhanced Care Program
Key components: Connection with Providers
 Over 7,000 provider visits by Provider Outreach
Coordinators and Medical Director since Nov 2004.
 Quarterly Advisory Board with participation by providers from
across the State.
 Close relationship with statewide organizations including Texas
Medical Association, Texas Pediatric Society, Asthma Coalition
of Texas, Texas Diabetes Council, and Texas Council for
Cardiovascular Disease and Stroke.
 New Stakeholders include, School Nurse Organization,
National Association of Social Workers, Texas Dietetic
Association, and Behavioral Health Organizations.
05/23/10
Texas Medicaid Enhanced Care Program
Outcomes for Clinical Metrics
 The Texas Medicaid Enhanced Care Program evaluates clinical
outcomes for the Medicaid clients served by the program during
each year.
 The contract-based goals were developed collaboratively by
McKesson Health Solutions and the Medicaid staff of the Texas
Health & Human Services Commission.
Average Clinical Metrics Improvement Each Year (Claims-Based and Self Reported Combined) Year over Year Improvement
Program Period 1 11-01-04 through
10-31-05
Program Period 2 11-01-05 through
10-31-06
Program Period 3 11-01-06 through
10-31-07
Program Period 4 11-01-07 through
10-31-08
17.40%
15.60%
16.10%
19.40%
05/23/10
Texas Medicaid Enhanced Care Program
Outcomes for Clinical Metrics
Percentage of Self-Reported Clinical Metrics Meeting the Contract-Based Goal for Each Condition*
Program Period 1
11-01-04 through 10-31-05
Program Period 2
11-01-05 through 10-31-06
Program Period 3
11-01-06 through 10-31-07
Program Period 4
11-01-07 through 10-31-08
Asthma
100.0%
50.0%
100.0%
100.0%
CAD
100.0%
100.0%
80.0%
100.0%
CHF
100.0%
75.0%
100.0%
75.0%
COPD
100.0%
100.0%
33.3%
100.0%
Diabetes
100.0%
100.0%
100.0%
80.0%
Aggregate Total:
100%
86%
86%
90%
Condition
*Self-reported data calculated from actively managed clients in program
05/23/10
Texas Medicaid Enhanced Care Program
Outcomes for Clinical Metrics
Aggregate Clinical Metrics Outcomes (Self-Reported and Claims-Based)
Condition
Asthma
CAD
CHF
COPD
Diabetes
Aggregate Total:
Program Period 1
11-01-04 through 10-31-05
Program Period 2
11-01-05 through 10-31-06
Program Period 3
11-01-06 through 10-31-07
Program Period 4
11-01-07 through 10-31-08
60.0%
30.0%
80.0%
70.0%
60.0%
70.0%
50.0%
70.0%
62.5%
50.0%
75.0%
50.0%
57.1%
71.4%
28.6%
57.1%
69.2%
75.0%
54.5%
54.5%
63%
60%
59%
61%
*Claims based measures calculated from all identified clients using reconciliation data
05/23/10
Texas Medicaid Enhanced Care Program
Outcomes for Financial Metrics
05/23/10
Texas Medicaid Enhanced Care Program
Innovative Pilot Projects
 Targeted interventions for frequent ED users.
 Bilingual Social Worker to identify members with high
ED usage .
 Connect
those members to their medical home and
reduce barriers in access to care, provide education and
follow-up.
 Promote
use of Nurse Advice Line when appropriate.
 Increase collaboration with Large Practice Providers.
 Office Health Worker to assist with increased enrollment
into program and improved clinical metrics.
 Office
Health Worker to provide real time referrals to
ECP care coordination team and assist with continuity of
care.
05/23/10
Texas Medicaid Enhanced Care Program
Innovative Pilot Projects
 Partnership with Diabetech for enhanced Diabetes
Management.
 Members mailed glucose monitoring device, and A1c
testing kit.
 Follow-up
electronic monitoring, and coaching provided
for education and testing.
 Behavioral Health Co-Morbid Management.
 Intensified the identification and management of comorbid conditions involving behavioral health,
specifically depression and schizophrenia.
 Dedicated
staff to ensure appropriate interventions and
care coordination.
05/23/10
Texas Medicaid Enhanced Care Program
Summary
 5 years and over 168,000 TX lives touched, with 61,949 clients
currently enrolled in program.
 On average, an 18% engagement rate among all risk levels;
 24% engagement rate for those high cost/high risk client.
 Strong cost saving results.
 $20.6 million net savings (after program fees) through Program
Year 4. This includes $2.6M in payback to the State.
 New integration with Behavioral Health Programs.
 Management of clients with depression and
schizophrenia.
 Closer relationship with state mental health authorities.
 Coordination between behavioral health and physical
health providers through case management.
05/23/10
Building Bridges
The Role of Public Mental Health
Dena Stoner, Senior Policy Advisor, Mental Health and Substance Abuse Services
Texas Department of State Health Services
[email protected]
05/23/10
The Cost of Mental Illness
People with severe mental illness live 25 yrs less, on average,
than other Americans.1
46% of Texas Medicaid emergency room visits are related to
mental health or substance abuse.2
People with mental illness are among the least employed
groups. Over 80% of Texas adult working age mental health
clients are unemployed. 3
In 2007, over 7,000 Texas nursing facility residents were former
clients of the public mental health system.4
1. Lutterman T, Ganju V, Schacht L, Shaw R, Monihan K, et.al. Sixteen State Study on Mental Health Performance Measures. DHHS Publication No. (SMA) 03-3835. Rockville, MD: Center for Mental Health Services, Substance Abuse
& Mental Health Services Administration, 2003
2. Senate Health & Human Services Committee Presentation by Dr. David Lakey, DSHS Commissioner, October 13, 20083.
3. DSHS MHSA CARE database, 2010
4. Texas Department of State Health Services and Texas Department of Aging and Disability Services (2007). Data match showing prevalence of former DSHS clients in DADS licensed nursing facilities
05/23/10
TEXAS Department of State Health Services
Why Integrate?
Texas has lower per capita mental health funding
than most states.
72 Texas counties are designated mental health
manpower shortage areas.
Better outcomes are possible using a “whole person”
approach to services.
05/23/10
TEXAS Department of State Health Services
Role of Public Mental Health
Research and development of integrated services and
supports. Examples include:
Working Well Demonstration
Money Follows the Person BH Pilot
 SUPPORT Pilot
Coordination with other efforts. Examples include:
HHSC Enhanced Care Program project
05/23/10
TEXAS Department of State Health Services
Integration Principles
Evidence-based, scientifically validated
Person-centered (builds on the person’s strengths,
needs and motivations)
Provide flexibility to address complex issues
affecting the person’s health
Collaboration with other systems is key
05/23/10
TEXAS Department of State Health Services
Current Reality
Large numbers of nursing facility residents have a
primary diagnosis of mental illness, with a
disproportionate number under age 65. 1
Nursing facilities are not optimal environments for
treatment of and recovery from mental illness.
For example, administration of antipsychotic
medication often violates quality guidelines. 2
1. . Bagchi, A.D., Simon, S.E. & Verdier, J.M. (2009). How many nursing home residents live with a mental illness? Psychiatric Services,
60(7), 958-964.
2 Blank, Jeffrey (2009). Persons with Mental Illness in Nursing Homes: Placement and Quality of Treatment. SAMHSA Presentation to
National Home and Community-based Services Conference.
05/23/10
TEXAS Department of State Health Services
Money Follows the Person
Behavioral Health Pilot
Transitions adults with severe mental illness or
substance abuse disorders from nursing facilities and
support them in the community.
Integrates evidence-based mental health and
substance abuse services with long-term services and
supports.
If successful, long-term services and supports waiver
programs will be amended to include evidence-based
BH services. (pilot ends 2016)
05/23/10
TEXAS Department of State Health Services
Cognitive Adaptation Training (CAT)
Helps people master independent skills living.
Uses a motivational strengths perspective to facilitate
person’s initiative and independence.
Provides assistance and simple, inexpensive
environmental modifications (calendars, clocks, signs,
organizers…) to help people establish daily routines,
organize their environment and function independently.
Adapts the physical environment to help improve
person’s functioning.
05/23/10
TEXAS Department of State Health Services
CAT Interventions: Dressing
Apathy
05/23/10
Disinhibition
Mixed
TEXAS Department of State Health Services
MFP Findings
88% of individuals have maintained independence.
Examples include getting a paid job at competitive wages,
driving to work, volunteering, getting a GED, attending
computer classes and working toward a college degree.
Participants demonstrate statistically significant
improvement on components of standardized scales which
measure adjustment to living (independence in daily life).
Preliminary analysis indicates that average Medicaid costs
are lower under the pilot than prior to discharge.
05/23/10
TEXAS Department of State Health Services
Mike
Schizoaffective disorder
Insulin dependent diabetes
Street drug and alcohol addiction
Emaciated and physically debilitated
Lacked social, living skills and family supports
Considered a “behavior problem”
In and out of nursing facilities for most of his adult life
05/23/10
TEXAS Department of State Health Services
Mike
Mike’s dream was to have a job and a place of his own. With the help
of CAT, Mike set employment goals, learned to interview and got some
vocational training. He began working 20 hours a week.
Through CAT, he learned the social skills needed to get along in the
community. He now handles daily activities like catching the bus, taking
medication, doing laundry and caring for himself. CAT also helped him
learn to manage his blood sugar level and eat healthy. His
STAR+PLUS service coordinator helps him get the health services he
needs.
Through substance abuse counseling, Mike was able to understand
issues in his past and is reconnecting with his natural family.
05/23/10
TEXAS Department of State Health Services
The Cost of Disability
Workers are the fastest growing category of federal
disability payments ($65 billion of $77 billion in 2003).
Significant numbers of people with mental illness are
on long term disability.
250,000 working-age Texans with disabilities received
SSI and 380,000 received SSDI in 2005, Medicaid
expenses = $3.5 billion.
05/23/10
TEXAS Department of State Health Services
Working Well
(Demonstration to Maintain Independence and Employment)
Rigorous scientific design (randomized controlled trial).
1600+ working people with potentially disabling
conditions in Harris County.
Integrated health, mental health, dental, vision,
substance abuse, and vocational services.
Provided person-centered planning, management, and
navigation of health and employment systems.
05/23/10
TEXAS Department of State Health Services
Disability Applications Reduced
Texas
Minnesota
Hawaii
12 month national evaluation findings
05/23/10
TEXAS Department of State Health Services
Other Outcomes
Majority of the intervention group is receiving SSI/SSDI at a
significantly lower rate.
Navigation via case management related to better health
and employment outcomes..
Intervention group has significantly increased access to
health care (outpatient services, prescription drugs, mental,
dental, optical care).
Intervention group participants report satisfaction with case
management, reduced costs and improved access.
05/23/10
TEXAS Department of State Health Services
Mary
Middle-aged, divorced with total care-giving responsibility
for her disabled son. Her health issues included
depression, bipolar disorder, adrenal adenoma, back pain,
dental, and vision problems. She had a job, but the income
was not predictable. She was not taking her medications or
going to the doctor on a regular basis. She could not use
her right hand due to an old industrial accident which
resulted in nerve damage.
She was feeling increasingly hopeless, isolated, and
overwhelmed. She slept most of the day. She had
previously applied for disability benefits because of her
physical limitations and planned to apply again, due to the
disabling nature of her severe mental illnesses.
05/23/10
TEXAS Department of State Health Services
Mary
With her case manager’s help, Mary began to understand the
importance of seeing her doctor regularly; asking friends and family for
assistance; taking medications as prescribed; attending behavioral
therapy sessions; and improving her health through exercise, diet and
stress management. Through Working Well, Mary was able to get
needed medical, mental health, dentures, and vision care.
Her Working Well Case Manager provided Mary with vocational
counseling and referred her to a community organization that helps
older workers find employment. Mary entered a job training program
and was prepared for an occupation that better accommodated her
physical limitations. She regained her self esteem, began working 30
hours per week. She currently is studying for her GED and plans to
obtain an associate's degree.
05/23/10
TEXAS Department of State Health Services
SUPPORT Pilot (HHSC)
Includes master’s level behavioral health specialists in
pediatric offices.
Evaluates and treats children who have, or are at risk for
developing, a mental health disorder.
Scheduled to be completed in September 2010.
Concept was developed by DSHS and implemented by
HHSC (state Medicaid agency).
05/23/10
TEXAS Department of State Health Services
Collaboration: Enhanced Care Program
DSHS and HHSC have enabled Exchanging information with HHSC disease
management provider to improve care coordination
Information can include:
General and specific health information
Claims and assessment data
Care plans
Alerts and updates
Coordination of treatment to improve services
05/23/10
TEXAS Department of State Health Services
Future Possibilities…
New federal Medicaid option (in 2011) for individuals with
serious mental illness to designate a health home
Medicaid and insurance expansions
05/23/10
TEXAS Department of State Health Services
Texas Medicaid Enhanced Care Program
Transition to the Future
“Texas Health Management Program”
Anna Sicher RN, MPA
Clinical Program Specialist
Medicaid/CHIP Division
05/23/10
Texas Health Management Program
New Contract Model
 RFP Release - August 2009

New Contract Operational Start - Nov. 1, 2010 (3 year contract)
 New model for Chronic Disease Management based on E.H.
Wagner’s Chronic Care Model
1. Client self-management
2. Provider/practice delivery system design; and
3. Technological support
2
3
05/23/10
1
Texas Health Management Program
Contract Requirements
 Whole person based on high-cost/high risk (HC/HR) – not
disease specific.
 Vendor must develop a coordinated care plan.
 Vendor must offer a minimum of:
1. Self-management education to all Texas Health
Management (THM) Program clients
2. A health & wellness program for all HC/HR clients.
3. Behavioral & mental health management when needed.
4. Pharmacy management when needed.
 Identification using Predictive Modeling
 Diabetes Self-management Training Component
 Initial year - must offer 10 hours of training + 3 hours
nutritional counseling to all diabetics.
 Diabetes training by a Cert. Diabetes Educator.
05/23/10
Texas Health Management Program
Contract Requirements (con’t)
 Provider equally important as client – vendor must:
1.
Offer tools and educational resources to providers.
2.
Provide practice facilitation (PF) to providers who may not be using
evidence-based guidelines and who request PF.
3.
Must educate providers about Medicaid resources & programs.
 20% or 50% of the vendor’s per-member per-month
(PMPM) payment will be at risk depending on:
1.
Financial - 5% Total Annual Claims cost savings for the program (40% of
overall at-risk fee).
2.
Clinical Quality Indicators - with targets ( 50% of overall at-risk fee).
3.
Humanistic Measures – client/caregiver and provider surveys (10% of
overall at-risk fee).
05/23/10
QUESTIONS?
05/23/10
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Care Coordination - Texas Department of State Health Services