Essential Tools for Patient Self-Management and Care Coordination: Knowledge, Skills and Abilities

for Health Care Reform

Dave Wanser, Ph.D.dave.wanser@intellicacorp.com

2

What you already (should) know

• There are tightening budgets and increasing demand• The Washington budget debate and subsequent cuts

will continue the trend• Healthcare Reform (ACA) is already increasing

competition and requiring the use of new and emerging technologies

• Many of the HHS agencies and their constituents are benefitting from the additional funding for technology (CDC, HRSA, CMS, ONC, WIC, ACF)

Patient Protection and Accountable Care Act

• Title I quality, affordable care for all Americans– Insurability reform; 2 problems people are uninsurable and people can’t

afford coverage. Addresses people who are not insurable and makes them so. This only works when everyone in in the pool otherwise adverse selection. Universal coverage is the logical accompaniment

• Title II Role of Public Programs - Affordability reform. Mainly about Medicaid but also expands public subsidies for those that can’t afford it.

• Title III Improving the Quality and efficiency of health through delivery system reforms

• Title IV Prevention of Chronic Disease and Improving Public Health -Health reforms

• Title V Health Care Workforce -Education reforms

Impact on Behavioral Health Providers

• 39% of individuals served by SMHAs have no insurance• 61% of individuals served by SSAs have no insurance• Many of these individuals could fall into either the

children covered by their parents policy or by Medicaid expansion

• 80% of specialty SA programs in the US are primarily government funded and private insurance pays for less than 12%.

• What are the impacts of parity?

Newly covered populations

• Ages– 40% under 29– 12% between 30-39– 29% between 40-54– 15% over 55

• 56% estimated to be living with parents• Don’t make assumptions about the expansion population -

use data to design services to match clinically distinct groups

Expectations for post health reform patient care

• Patient-centered care– • Patient engagement -• Interdisciplinary teams – • Evidence-based practice – • Quality and process improvement – These all demand a significant use of data to inform practice

Expectations for post health reform use of data

• Ability to use real time decision support tools• Ability to manage treatment adherence• Ability to exchange clinical data sets with other

entities• Ability to use structured data taxonomies which

will make data sharing meaningful and accurate• Health promotion and patient education materials

are generated through the electronic health record content and are individualized

Care coordination

• A number of mechanisms are needed to foster better care coordination and to improve outcomes– 25% of Medicare patients are re-admitted within 30

days of hospital discharge– More than 50% of these had not seen a physician

between discharge and readmission• Impacts to BH providers– MH/SUD in primary care settings– Primary care in MH/SUD settings– Much more bi-directionality

Clinical Decision Support to Improve Quality

• Incorporate all kinds of information– Traditional healthcare centered– Person-centered

• Health-related quality of life• Satisfaction with care• Lifestyle: knowledge, attitudes, behaviors, barriers• Adherence

– Community-centered• Apply clinic business rules to create action reports– Individual: Patient, providers– Aggregate: identified (registries) and de-indentified

• Is the process or outcome good enough?

10

What is the goal of Integration between primary care and BH?

• How do you define Integration?

EHR

LegacyDemographics

LabRadiology

MedsAllergies

Knowledge and Information Integration to improve patient outcomes

Self-reported Info

ClinicalGuidelines

Individualized Clinical Recommendation

Performance Improvement in clinical workflow processes

• Patient Summary “at a glance”• Clinical Decision Support at the point of care• Ability to monitor performance “on-the-fly” and identify

corrective action• Presenting information in the EHR the way the clinician

thinks: – bulleted recommendations– levels of alerts (critical, abnormal, normal)

2 way communication with the patient the 99% of the time they are not in your office

“Dynamic Feedback Loops” between patients and providers = much more focused care

coordination• Patient uses and provides information• Health care teams use and provide information• Is treatment progressing to goal?• How is adherence to treatment plan? What are the

barriers?• One patient will have several care team members at

different sites providing care many feedback loops• How to efficiently handle granular consent?

Patient –centered care• Patient-centered information delivered to the care team is

key to self-management, care coordination and quality improvement

• Patient-centered information can be – adherence to treatment, side-effects, symptom response– psycho-social stressors and other barriers– lifestyle assessments: healthy eating, physical activity– readiness to change and motivational interviewing feedback– screening: e.g., depression, problem drinking, PTSD– clinical preventive service history: cancer screening, vaccines

• medication reconciliation: over-the-counter, supplements

Service coverage issues• Decisions will be made at State and federal level concerning:

– Benchmark plans for Medicaid– Essential benefits for health insurance exchanges– Scope of services for parity– SAMHSA block grant funding utilization

• Providers will also need to be mindful of other coverage issues– Rehabilitation and habilitation services– Preventive and wellness services– Pharmacy coverage– Changes in payment strategies

Medical homes or Health homes?

• Health homes– Focus on those with, or at risk of, chronic conditions– Will be covered in Medicaid state plans– 90% federal match as incentives for states

• Several new services– Comprehensive care management– Care coordination and health promotion– Patient and family support– Comprehensive transitional care

Likely changes in health care provision• Accessibility: 24/7 access to medical practices

• Continuity: Incentives and penalties connected readmissions to hospitals and avoidable complications

• Quality: report cards on provider quality available to shoppers. Rewards for better care and increase in Accountable Care Organizations – sharing savings in integrated provider systems with prevention and wellness focus

• Choice: More providers, more innovation. Community Health Centers will become major providers of behavioral health services. $11 billion in new funding

What This Means ForSpecialty Behavioral Health Care

• Participating in any healthcare system will require that you can electronically transmit clinical and claims data in order to be paid.

• EHR systems will need be updated significantly over the next 5 years

• More behavioral health services will be provided in integrated settings, particularly community health centers

• Resources for specialty BH care will be harder to sustain outside of the rest of health care

How will we approach holistic health?

• Collaboration and co-location are old news• To succeed as medical homes and/or members of

accountable care organizations (ACOs), practices must be clinically integrated internally and with other providers.

• The current problem is that, even with electronic health records, practices find it difficult and costly to add new functionality and/or connect online with other providers.

• Within the next few years these linkages will be essential to achieve the requisite level of clinical integration.

Why Participation in integrated systems will be necessary

“Specialty Care” ≠ “Specialty Provider”

Federal resources are focused on development of FQHCs (where BH is already integrated with primary care)

Recall earlier discussion - Medicaid is changing, with more adults eligible and more services reimbursed (implications re: Parity)

Paul Keckley from Deloitte:

• Behavioral health still:– Remains a mystery to virtually all in the medical establishment—notably primary care

practitioners—our presumed future partners.

– Resists quality measurement using many traditional measures of outcome—the gold standard established for medicine and payment.

– Demands a more complex set of tools than traditional medicine, a combination of medical and social interventions whose impact and value are poorly understood outside of the field.

– Is rarely appreciated by individuals unless their lives, or the lives of others close to them, are adversely affected by a behavioral health problem that leads to loss of job, education, social relationships, or other aspects of what we consider to be a meaningful life.

Changes necessitated by working in integrated systems

• Do you think that other providers do not want to serve “your people”?

• Do you routinely use clinical guidelines?• Are you able to effectively address tobacco cessation in your

programs?• What about weight control, women’s health, recommended

screenings, immunizations• How comfortable are you with people looking over your clinical

work? • How much do you know about client’s adherence to treatment

recommendations?• How do you quantify it?

22

USPSTF and ACIP services covered under ACA• Primary prevention/Behavioral

– Tobacco Use screening for all adults and cessation interventions for tobacco users– Diet counseling for adults at higher risk for chronic disease– Obesity screening and counseling for all adults– Depression screening for adults– Alcohol Misuse screening and counseling– Breast Feeding interventions to support and promote breast feeding– Folic Acid supplements for women who may become pregnant– Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk

• Immunization vaccines for adults—– Hepatitis A– Hepatitis B– Herpes Zoster– Human Papillomavirus– Influenza– Measles, Mumps, Rubella– Meningococcal– Pneumococcal– Tetanus, Diphtheria, Pertussis– Varicella

USPSTF and ACIP services covered under ACA• Cardiometabolic disease screening

– Blood Pressure screening for all adults– Cholesterol screening for adults of certain ages or at higher risk– Type 2 Diabetes screening for adults with high blood pressure– Aspirin use for men and women of certain ages (Framingham Risk Score and contraindications to

aspirin)– Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked

• Cancer– Cervical Cancer screening for sexually active women– Colorectal Cancer screening for adults over 50– Breast Cancer screening over 40– BRCA counseling about genetic testing for women at higher risk– Breast Cancer Chemoprevention counseling for women at higher risk

• Sexually Transmitted Infection (STI) screening– HIV screening for all adults at higher risk– Gonorrhea screening for all women at higher risk– Chlamydia Infection screening for younger women and other women at higher risk– Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk– Syphilis screening for all adults at higher risk

• Osteoporosis screening for women over age 60 depending on risk factors

Accountable Care Organizations

• The goal of ACOs is to organize care around patients with care teams accountable to each other

• While the initial focus may be looking at reducing unnecessary procedures, waste and safety, there will soon be a focus on improving patient outcomes

• The focus of ACOs will have to be on preventative and primary care if they are to succeed

• ACOs will be able to share in savings

What is an ACO?

• A legally established provider organization that is directly responsible for many Medicare services and access to services they do not provide

• Medicare will be the initial focus but many States will use the same structure for Medicaid, and insurers will move quickly into this space. There also a provision for a pediatric ACO

• ACO regulations become effective January 1,2012

Are ACOs MCOs?

• ACOs are different from MCOs and HMOs in that they are explicitly provider organizations

• Participation of providers is voluntary, but participating providers will have to agree to accountability requirements

• There are different models for ACOs already in existence– Networks of individual providers– Group practices– Hospitals partnering with or employing providers

ACO reimbursement strategies• There is no requirement that ACOs include or contract with

all the providers that care for the patient• ACOs can elect for partial capitation and CMS has proposed

some options– PCMH reimbursement for care coordination, also being used by

BCBS MI, Community Care NC– Bundled case rates for a specified time interval, being used by

Geisinger Health Care and Health Care PA– Global fee structures for a time interval, being used by

Intermountain UT, Kaiser Permanente and BCBS MA– It is likely that CMS will create incentives for multi-payer ACO

arrangements

ACOs and you

• Do you see advantages to being in an ACO?• What would make you attractive to an ACO?• What data do you have to make a business case for

inclusion?• How can you address:– Staff competencies – Quality management– Clinical effectiveness– Efficiency– Responsiveness

ACOs and Community Health Centers

• Some FQHCs will form into ACOs• Predictable changes– More care will be provided in organized arrangements

to reduce fragmentation– Physicians will not have a major role in the primary care

workforce– Significant opportunities as well as threats regarding the

growth of FQHCs– FQHCs have better access to resources than you do!

Bottom Line: Implications of ACA

• More people have health insurance• Medicaid will play a bigger role in MH/SUD than ever

before• Focus on primary care and coordination across

providers• Major emphasis on home and community based

services• Prevention and wellness promotion is a major theme

– USPSTF recommended screenings, for example

The bottom line for providers

• Staff competencies in integrated health and responding to health risk behaviors

• Organizational focus on patient engagement and adherence to evidence-based treatments

• Extensive use of CDS• Fluid electronic interface with behavioral health,

primary care and ACOs• Redesigned clinical documentation requirements• Flexible, adaptable and modular EHRs

Current behavioral health treatment environment

• There are different assessment tools – if any• Documentation is done with extensive use of free text• Data systems do not assist in managing adherence to

treatment plans in a timely or data based fashion• We write a lot but have little actionable information• Almost all data is input by clinicians not patients• We struggle with sharing data across systems, both in

terms of interoperability and ability and willingness to partner

• We minimally address health issues – if at all

What This Means ForSpecialty Behavioral Health Care

• Participating in any healthcare system will require that you can electronically transmit clinical and claims data in order to be paid.

• EHR systems will need be updated significantly over the next 5 years

• More behavioral health services will be provided in integrated settings, particularly community health centers – and they will all be using EHRs

• Resources for specialty BH care will be harder to sustain outside of the rest of health care

HIT-Enabled Health ReformAchieving Meaningful Use

2009 2011 2013 2015

HIT-Enabled Health Reform

Mea

ning

ful U

se C

riter

ia HITECH Policies

2011 Meaningful Use Criteria

(Capture/share data)

2013 Meaningful Use Criteria

(Advanced care processes with

decision support)

2015 Meaningful Use Criteria (Improved Outcomes)

35

3 interrelated levels of Readiness Assessment

• Health Reform Readiness• HIT Readiness• Organizational Capacity

37

Planning is essential!

• The changes resulting from ACA and HITECH are fundamental and comprehensive. Incremental steps will have limited utility.

• Will your agency make this transition? • In 5 years?• How?

• 3 Questions to ask of your organization

38

1. What are the threats?

• Are leaders ready to lead? Are the right people at the table for policy and technical development activities?

• Is there a clear path forward?• Will lack of a coordinated effort between MH

and SA leaders and providers leave us behind?• Do we assume that we are indispensible?

39

2. Do you and your team understand EHR and HIE implementation needs in context?

• The requirements for EHRS, HIES and ACA are inextricably intertwined

• Health Information Technology and Quality are now linked • If your strategy is to maintain the ground you hold, you will

you will lose ground • It is essential for leaders to understand the policy implications

of these 3 issues in terms of HIT requirements– Purchasing and payment changes– Eligible populations – parity and Medicaid expansion

population– Cross system coordination

40

3. What do you bring to the table?

• What ensures your relevance?

Planning and Issue Identification

• What do you see as the most pressing issues for preparing your organization for post health reform success?

• What are the biggest unknowns?• What are the threats?• What will be the most difficult change?• How would you rate your comfort level with

your preparedness?

What should BH providers be doing now?

• Develop a work plan that mirrors ACA timeline• Develop uniform talking points for potential partners• Develop a financial mapping document of services across

agencies to know where the money is now• Develop ROI use cases to demonstrate benefits of MH/SUD

services in primary care and ACOs• Determine what insurers who will be participating in the

health insurance exchanges will need to know about your services

• Engage mainstream healthcare providers to identify and intervene with early detection and intervention

Organizational Assessment

• Have you begun?– As an organization– As an association– As a system

• Is there a formal planning process?• Absent a strategic plan for ACA and HIT how will

you prepare? • If you don’t like change, you will probably like

irrelevance even less

What are your organizational capabilities?

Compete in a fee-for-service or pay for performance environment

Submit claims and quality data through health information exchanges

Demonstrate use of clinical guidelines and client adherence to treatment

Partner with others in the healthcare systemDo eligibility determination and enrollmentMonitor outcomes and clinician performance

Issue 1: Where will capacity be needed and where will it exist?

• How will traditional BH providers assess capacity needs?• What other providers will be in the game?

– FQHCs– ACOs– Others?

• What potential opportunities can you take advantage of?– Money follows the person– Home visiting– P4P– School-based health clinics

• How familiar are with your current Medicaid system options?• What tools do you have to assess current capacity and efficiency?• What are the issues with becoming a provider in a health plan?• How will you address:

– New HIT requirements?– Provide for new consumer and family roles?– Create new business systems ?– Identify workforce and workflow issues?

Issue 2: Engagement

• Do you currently track issues associated with engagement as a routine dashboard performance measure?

• Do you have data to support needed workflow improvements

• How do you schedule intakes and post intake treatment?

• Are there expectations about effectiveness of engagement as staff performance measures?

Issue 3: How will you assure quality and efficiency?

• How will you incorporate CDS?• How will you support consumer directed care?• How will you actively manage care, engagement

and adherence to tretment?• How will you integrate evidence based practices

and clinical guidelines?• How will you capture and manage quality

measures?• How will you redesign workflows and processes?

Issue 4: Change management

• The hard stuff is the soft stuff– Leadership– Planning– Execution– Management– Information

Issue 5: Workforce issues

• Requires staff who are health and technology capable• Requires staff with experience in managing outsourcing projects,

managing service level agreements – monitoring performance• Who makes the decisions regarding technology and what are the

governance processes?• Is everyone in the organization working at the “top end” of their

license?• Key skills:– Faster decision making– Collaboration – Relationships

49

Issue 6: Patient engagement and patient centered care

• How accessible are you?• What information do you have about clients before they are in

your office?• How do you address physical health and wellness issues? • How do you know if patients are adhering to treatment

recommendations?• How do you know if they are improving?• What individualized patient education materials do you use?• How do you integrate treatment guidelines and best practices

into your clinical program?

50

Issue 7: Data Strategic Planning• How will you be capable of providing service remotely via

patient portals and telehealth?• How can you offer patient portals to pre-populate

information into assessments?• How will you do HRA so that you know if patients have had

all required immunizations and also know about health risk issues?

• How will you provide best practice patient educational materials based on clinical record inputs?

• How will you use CDS tools so you know if treatment is working in real time?

51

Essentials for preparedness in the post health reform world

• Use of flexible clinical tools that can be easily adapted and updated

• Integrated analytics within the EHR • Integration of physical and behavioral health

indicators and reporting capabilities through HIEs• Using applications which are integrated with

patient engagement portals• Any EHR being considered today should be

focused on 2013 & 2015 meaningful use criteria