NH Citizens Health Initiative: Behavioral Health Integration Learning Collaborative Learning Series

NH Citizens Health Initiative: Behavioral Health Integration Learning Collaborative Learning Series Year 3 Opening Session Wednesday, November 8, 2017 UNH School of Law, Concord, NH WWW.CITIZENSHEALTHINITIATIVE.ORG 2 WHITE STREET CONCORD, NH 03301 TWITTER: @CITIZENSHEALTH 1

UNH Pathways to Behavioral Health Careers

Learning Objectives Understand HRSA/BHWET Grants Identify Shared Training Goals

PCBH WORKFORCE

(RE)TRAIN EXISTING WORKFORCE TRAIN FUTURE WORKFORCE SYSTEM REDESIGN AND SUPPORT

Behavioral Health Workforce and Education Training Grants (BHWET) 1.8 Million Dollars 4 Years 116 Students Social Work Occupational Therapy

Targeted Medically Underserved Areas Rural Areas

This Photo by Unknown Author is licensed under CC BY-SA

UNH Pathways to Behavioral Health Careers Training: Primary Care Behavioral Health Graduate Certification Program (SW/OT) Help Develop New PCBH Training Sites Provide Training/Supports for Supervisors Align with Stakeholders

Statewide Pathways to Behavioral Health Careers Antioch Doctoral UNH Master s Level Training Plymouth Bachelor s Level Training Manchester Community College Associates Level Training

How Can We Work Together? Students Supervisors Practice Transformation

Stakeholders (Partial List!!) Behavioral Health Learning Collaborative Institute on Disability Governor s Office Manchester Community College Plymouth State Antioch University Integrated Delivery Networks Practice Organizations

Contact Project Director: (SW) Will Lusenhop rwilliam.lusenhop@unh.edu Project Coordinator: Melissa Mandrell melissa.mandrell@unh.edu Project Evaluator: JoAnne Malloy joanne.malloy@unh.edu (OT): Alexa Trolley-Hanson alexa.trolly-hanson@unh.edu

Data in Action MARCY DOYLE, MS, MHS, RN, CNL, THE INITIATIVE HWASUN GARIN, THE INITIATIVE WWW.CITIZENSHEALTHINITIATIVE.ORG 2 WHITE STREET CONCORD, NH 03301 TWITTER: @CITIZENSHEALTH 15

Plan Do STUDY Act Alignment with State & National Initiatives Hypertension Accountable Care Learning Network (ACLN)/Behavioral Health Integration Learning Collaborative (BHI LC) Practice Transformation Network PULSE measure Rural Health Clinic Action Learning Collaborative (RHC ALC) Depression Screening ACLN/BHI PTN Integrated Delivery Network (IDN) Substance Use Disorder Screening ACLN/BHI IDN* WWW.CITIZENSHEALTHINITIATIVE.ORG 2 WHITE STREET CONCORD, NH 03301 TWITTER: @CITIZENSHEALTH 2017 UNIVERSITY OF NEW HAMPSHIRE ALL RIGHTS RESERVED 16

Study New Hampshire: OUR Population Accountable Care Learning Network (2017, Q1): More than 521,000* adult patients (age 18 or older) More than 225,000* patients with hypertension Profile of PTN in New Hampshire: * Based on practices that have submitted data from EHR to ACLN N = 1,326,813 2015 WWW.CITIZENSHEALTHINITIATIVE.ORG 2 WHITE STREET CONCORD, NH 03301 TWITTER: @CITIZENSHEALTH 2017 UNIVERSITY OF NEW HAMPSHIRE ALL RIGHTS RESERVED 18

PERCENT OF PATIENTS WITH HYPERTENSION IN CONTROL 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% National FQHC Average = 70.8% PTN: ADULT WITH HYPERTENSION AND BLOOD PRESSURE IN CONTROL 65.1% 80.9% 77.2% 2015-3 2015-4 2016-1 2016-2 2016-3 2016-4 2017-1 2017-2 YEAR-QUARTER 81.7% 64.4% AB AD AF AK AL AM AN AP AR AS D F H I J M Median O R S X WWW.CITIZENSHEALTHINITIATIVE.ORG 2 WHITE STREET CONCORD, NH 03301 TWITTER: @CITIZENSHEALTH 2017 UNIVERSITY OF NEW HAMPSHIRE ALL RIGHTS RESERVED 20

PERCENT OF PATIENTS WITH HYPERTENSION IN CONTROL 100% PTN: ADULT WITH HYPERTENSION AND BLOOD PRESSURE IN CONTROL Practice AB High Performer 90% 80% 70% 60% 50% 40% 30% National FQHC Average = 70.8% 64.4% AB Clinician champion 20.8% during 2-year period resulting in 227 additional patients with BP under control Spread increased by 19% overall to 351 additional patients with adequate BP control 20% Median Practice AB in multiple initiatives 10% 0% 2015-3 2015-4 2016-1 2016-2 2016-3 2016-4 2017-1 2017-2 YEAR-QUARTER WWW.CITIZENSHEALTHINITIATIVE.ORG 2 WHITE STREET CONCORD, NH 03301 TWITTER: @CITIZENSHEALTH 2017 UNIVERSITY OF NEW HAMPSHIRE ALL RIGHTS RESERVED 21

PERCENT OF PATIENTS WITH HYPERTENSION IN CONTROL 80% BHI: ADULT WITH HYPERTENSION AND BLOOD PRESSURE IN CONTROL AA 75% 70% National FQHC Average = 70.8% AJ B C K 65% 60% 55% 64.4% L Median U V W X 50% 2015-3 2015-4 2016-1 2016-2 2016-3 2016-4 2017-1 2017-2 YEAR-QUARTER WWW.CITIZENSHEALTHINITIATIVE.ORG 2 WHITE STREET CONCORD, NH 03301 TWITTER: @CITIZENSHEALTH 2017 UNIVERSITY OF NEW HAMPSHIRE ALL RIGHTS RESERVED 22

PERCENT OF PATIENTS SCREENED FOR SUBSTANCE USE 90% BHI: ADOLESCENT SUBSTANCE USE, SCREENING ONLY 80% B 70% 60% C 50% K 40% 30% Median 20% 19.9% U 10% 0% 2016-2 2016-3 2016-4 2017-1 2017-2 2017-3 YEAR-QUARTER V WWW.CITIZENSHEALTHINITIATIVE.ORG 2 WHITE STREET CONCORD, NH 03301 TWITTER: @CITIZENSHEALTH 2017 UNIVERSITY OF NEW HAMPSHIRE ALL RIGHTS RESERVED 24

PERCENT OF PATIENTS SCREENED FOR CLINICAL DEPRESSION 90% BHI: ADOLESCENT DEPRESSION, SCREENING ONLY AA 80% B 70% C * SSA = 156/180 60% 50% 55.6% K L 40% Median 30% U 20% V 10% 2015-3 2015-4 2016-1 2016-2 2016-3 2016-4 2017-1 2017-2 2017-3 YEAR-QUARTER W WWW.CITIZENSHEALTHINITIATIVE.ORG 2 WHITE STREET CONCORD, NH 03301 TWITTER: @CITIZENSHEALTH 2017 UNIVERSITY OF NEW HAMPSHIRE ALL RIGHTS RESERVED 25

PERCENT OF PATIENTS SCREENED FOR CLINICAL DEPRESSION 100% BHI: ADULT DEPRESSION, SCREENING ONLY AA 90% B 80% C * SSA = 156/180 70% 60% 50% 60.9% K L Median U 40% V 30% 2015-3 2015-4 2016-1 2016-2 2016-3 2016-4 2017-1 2017-2 YEAR-QUARTER W WWW.CITIZENSHEALTHINITIATIVE.ORG 2 WHITE STREET CONCORD, NH 03301 TWITTER: @CITIZENSHEALTH 2017 UNIVERSITY OF NEW HAMPSHIRE ALL RIGHTS RESERVED 27

PECENT OF PATIENTS WHO RECEIVED FOLLOW-UP IF POSITIVE FOR DEPRESSION 100% PTN: ADULT DEPRESSION SCREENING & FOLLOW-UP A 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% National FQHC 2015 Average 58.2% 2015-3 2015-4 2016-1 2016-2 2016-3 2016-4 2017-1 2017-2 YEAR-QUARTER 10.0% AE AF AK AM AR AS H I Median R S WWW.CITIZENSHEALTHINITIATIVE.ORG 2 WHITE STREET CONCORD, NH 03301 TWITTER: @CITIZENSHEALTH 2017 UNIVERSITY OF NEW HAMPSHIRE ALL RIGHTS RESERVED 28

PERCENT OF PATIENTS WHO DEMONSTRATE RESPONSE TO TREATMENT 12% BHI: ADULT DEPRESSION, RESPONSE TO TREATMENT 11% 10% 9% AA B 8% 7% C * SSA = 156/180 6% 5% 4% 3% 2% 1% 0% 2016-1 2016-2 2016-3 2016-4 2017-1 2017-2 YEAR-QUARTER K Median U V WWW.CITIZENSHEALTHINITIATIVE.ORG 2 WHITE STREET CONCORD, NH 03301 TWITTER: @CITIZENSHEALTH 2017 UNIVERSITY OF NEW HAMPSHIRE ALL RIGHTS RESERVED 29

PERCENT OF PATIENTS IN REMISSION 8% BHI: ADULT DEPRESSION, REMISSION 7% 6.7% B 6% C * SSA = 156/180 5% 4% Median 3% U 2% 1% V 0% 2015-3 2015-4 2016-1 2016-2 2016-3 2016-4 2017-1 2017-2 YEAR-QUARTER W WWW.CITIZENSHEALTHINITIATIVE.ORG 2 WHITE STREET CONCORD, NH 03301 TWITTER: @CITIZENSHEALTH 2017 UNIVERSITY OF NEW HAMPSHIRE ALL RIGHTS RESERVED 30

Data Summary Highlights More than 95% of participating practices are submitting data Active PDSA cycles utilizing measures Regional and National recognition of application of Quality Improvement (QI) science Knowledge and skills transfer of QI to other initiatives Opportunities Goal of 75 82% hypertension in control Depression screening follow-up and reduction/remission Increase rate of screening in adolescent population Peer learning based on data WWW.CITIZENSHEALTHINITIATIVE.ORG 2 WHITE STREET CONCORD, NH 03301 TWITTER: @CITIZENSHEALTH 2017 UNIVERSITY OF NEW HAMPSHIRE ALL RIGHTS RESERVED 31

Collaborative Care: Measurement-Based Treatment to Target Drives Improved Outcomes Anna Ratzliff, MD, PhD Associate Professor University of Washington TCPI National Faculty

Disclosures: Anna Ratzliff, MD, PhD Grant/Research Support: Supported from contracts and grants to the AIMS Center at the University of Washington including support from Washington State and CMMI. Allergan: Spouse employed in last 12 months Royalties: Wiley - Integrated Care: Integrated Care: Creating Effective Mental and Primary Health Care Teams (Paid to UW Department of Psychiatry and Behavioral Sciences)

Reflection of Polling Question Results What is challenging about moving beyond screening?

TCPI Drivers Support Tranformation Tremendous Opportunity!

Who gets treatment? Wang et al 2005

Who gets treatment? No Treatment Primary Care Provider Mental Health Provider Wang et al 2005

Why not just refer? Half of those referred do not follow through. Mean # of visits = 2 Grembowski, Martin et al. 2002 Simon, Ding et al. 2012

Why not just refer? Thomas KC et al, 2009 1 in 5: unmet need for non-prescribers 96%: unmet need for prescribers

Mental Health in Primary Care Settings Hospital CMHC Specialty Care Collaborative Care Brief Behavioral Interventions Primary Care Patient Self-Management

Collaborative Care Model (CoCM) Primary care patient-centered team-based care Systematic case review with psychiatric consultant (focus on patients not improved) Registry to track population Active treatment with evidence-based approaches Validated outcome measures tracked over time

Daniel s Story https://aims.uw.edu/daniels-story-introductioncollaborative-care

Percentage Doubles Effectiveness of Care for Depression 50% or greater improvement in depression at 12 months 70 60 Usual Care IMPACT 50 40 30 20 10 0 Unützer et al., 2002, 2004 1 2 3 4 5 6 7 8 Participating Organizations Unützer et al., JAMA 2002

IMPACT: Summary 1) Improved Outcomes: Less depression Less physical pain Better functioning Higher quality of life 2) Greater patient and provider satisfaction 3) More cost-effective THE TRIPLE AIM I got my life back

Collaborative Care: The Research Evidence Now over 80 Randomized Controlled Trials (RCTs) Meta analysis of collaborative care (CC) for depression in primary care (US and Europe) Consistently more effective than usual care Since 2006, several additional RCTs in new populations and for other common mental disorders Including anxiety disorders, PTSD Archer, J. et al., 2012

Collaborative Care Aligned with TCPI Goals Collaborative Care Patient satisfaction Leverage psychiatric prescriber Effective team collaboration Evidence based treatment Increased access to BH Measurement-based treatment to target Use of patient registry Improved patient outcomes Proven cost effective strategy Provider satisfaction New collaborative care payment

Principle 1: Patient Centered Team Care PCP Patient BHP/ Care Manager New Roles Psychiatric Consultant University of Washington

Principle 2: Population Based Treatment

Principle 3: Measurement Based Treatment To Target Regular use of behavioral health measures to track response to treatment Use of psychiatrists to help intensify treatment Stepped care makes efficient use of behavioral health resources

Principle 4: Evidence-Based Treatment

STAR-D Summary Level 1: Citalopram ~30% in remission Level 2: Switch or Augmentation ~50% in remission Level 3: Switch or Augmentation ~60% in remission Level 4: Stop meds and start new ~70% in remission Rush, 2007

Principle 5: Accountable Care Accountability to Patients and Population - Access - Outcomes Sustainability Continuous Quality Improvement

Medicare Collaborative Care (CoCM) Code - Started January 2017 CoCM codes bundle payment for the collective work of the collaborative care team Payment goes to the PCP who bills the service Billed on a per patient basis for those that have met the established time thresholds The psychiatrist does not bill separately. contract with the PCP practice The patient must provide general consent for the service and they will have a copay Interaction does not have to be face-to-face Care manager and psychiatrists can also bill additional codes for therapy etc.

Medicare CoCM Codes 2018 Code 2017 Code Description 2017 Rate 2018 Rate 99492 G0502 CoCM - first 70 min in first month $142.84 $161.28 99493 G0503 99494 G0504 CoCM - first 60 min in any subsequent months CoCM - each additional 30 min in any month (used in conjunction with 99492 or 99493) $126.33 $128.88 $66.04 $66.60 99484 G0507 Other BH services - 20 min per month $47.73 $48.60 For FQHC and RHC Only G0511 CCM General Care Management $61.37 G0512 CoCM: Psychiatric Collaborative Care Model $134.58

APA- SAN ADDITIONAL TOOLS/RESOURCES https://www.psychiatry.org/psychiatrists/practice/professionalinterests/integrated-care Psychiatrist and PCP training Office Hours monthly Making the Business Case: Financial Modeling tool Estimate visit volume and number of patient served Define and analyze how much time staff engage in key integrated care tasks Estimate fee for service and new COCM G Code revenues Webinar - how to bill the new G codes - 2018 CPT codes Advocacy materials for getting paid for Medicaid population 1115 waiver amendments Legislation CPC+ and other grants 55 2016 American Psychiatric Association. All rights reserved.

Behavioral Health Measures Support Continuous Quality Improvement University of Washington Care Manager 1 Care Manager 2

MHIP: Pay- for-performance cut median time to depression treatment response in half 0.00 0.25 0.50 0.75 1.00 AFTER P4P: ~ 26 week s to 50% of patients to improve 0 8 16 24 32 40 48 56 64 72 80 88 96 104 112 120 128 136 Weeks University of Washington BEFORE P4P: ~68 week s to 50% of patients to improve Before P4P After P4P Unützer et al., 2012

Tremendous Opportunity: Leaving in Action Increasing Depression Screening Are all the results captured? - Sometime this work is being done but not captured in a way that is captured by reporting function. Is there a prime population to start with? - Sometimes it helps to start with a patient population, team or practice then spread learning. Are you including all key team members to generate learning? - Many times the best ideas come from including the whole team, like front desk and medial assisting staff. Your ideas? - What ideas do you have? Increasing Depression Response Are all the results captured? - Sometime this work is being done but not captured in a way that is captured by reporting function. Is there a prime population to start with? - Sometimes it helps to start with a patient population, team or practice then spread learning. Consider implementation of CoCM or CoCM principles. - This is an evidence-based approach to delivering effective treatment AND support available. Your ideas? - What ideas do you have?

Questions? APA-SAN: https://www.psychiatry.org/psychiatrists/practice/profes sional-interests/integrated-care AIMS Center: http://aims.uw.edu/ Washington State Medicaid Transformation Demonstration Resources https://aims.uw.edu/washington-state-medicaidtransformation-demonstration Acknowledgments: Daniel and his family Annie McGuire Angel Mathis Rebecca Sladek Jürgen Unützer AIMS Center and ICTP Staff

What s Next? PTN Webinar Dec 7 th In Person February 1 st In Person April 12 th 2017 Nov Dec Jan Feb March April May June July Aug Sept 2018 Yr 3 BHI LC BHI Kick Off Nov 8 th In Person March 14 th In Person June 13 th Webinar January 10 th Webinar May 9th WWW.CITIZENSHEALTHINITIATIVE.ORG 2 WHITE STREET CONCORD, NH 03301 TWITTER: @CITIZENSHEALTH 2017 UNIVERSITY OF NEW HAMPSHIRE ALL RIGHTS RESERVED

Staff Contacts Jeanne Ryer Scott Trudo Stephanie Cameron Marcy Doyle Hwasun Garin Annie Averill Molly O Neil Janet Thomas Sally Minkow Kate Cox Holly Tutko jeanne.ryer@unh.edu scott.trudo@unh.edu stephanie.cameron@unh.edu marcy.doyle@unh.edu hwasun.garin@unh.edu annie.averill@unh.edu molly.oneil@unh.edu janet.thomas@unh.edu sally.minko@unh.edu katherine.cox@unh.edu holly.tutko@unh.edu WWW.CITIZENSHEALTHINITIATIVE.ORG 2 WHITE STREET CONCORD, NH 03301 TWITTER: @CITIZENSHEALTH 2017 UNIVERSITY OF NEW HAMPSHIRE ALL RIGHTS RESERVED 61