Care Of Mental, Physical And Substance-use Syndromes
Claire Neely, MD Medical Director, ICSI
August 23, 2013
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Care Of Mental, Physical And Substance-use Syndromes
Claire Neely, MD Medical Director,ICSI
3 Year CMS Innovation Challenge GrantAwardee Objectives :
• Lower cost of care for people enrolled in government programs
• Leverage existing models to improve patient care quickly
• Engage broad set of partners to test new delivery models
• Identify workforce development opportunities to create jobs
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Scope of COMPASS workTo implement a collaborative care management
model for patients with depression and diabetes/CVD,
and optional risky substance use,
in primary care that accomplishes the Triple Aim
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Supported by Cooperative Agreement Number 1C1CMS331048-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services
Triple Aim Measures of Success
• Population health– Increase remission/response rates for
patients with depression– Improve control rates for diabetes and
cardiovascular disease and their risk factors
– Reduce risky substance use• Experience of care
– Improve quality for patient and provider satisfaction
• Affordability – Decrease readmissions, admissions and
ED visits to reduce health care costs
COMPASS Consortium: Overarching Scope
• Intervention– Develop an evidence-based model, train and facilitate
implementation and quality improvement
• Evaluation/Study– Develop multiple data collection and analysis approaches
for QI and for demonstrating triple aim success
• Communications – Marketing & messaging to multi-stakeholder audiences
• Payment methodology– Develop new financial models
• Spread and sustaining model– Systems approach to link with and embed in ongoing work
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COMPASS Consortium Partners
COMPASS Intervention Partners Community Health Plan of
Washington Institute for Clinical System
Improvement (ICSI) Kaiser Colorado Kaiser Southern California Mayo Health System Michigan Center for Clinical
Systems Improvement Mount Auburn Cambridge
Independent Practice Association Pittsburgh Regional Health Initiative
COMPASS Partners
ICSI Principal investigator for oversight of the award Design, train, implement and support this work across all
intervention partners
Advancing Integrated Mental Health Solutions Center Care Management Tracking System Advisor/trainer on development of COMPASS intervention Ongoing resources post-implementation for identified gaps with
individual practices
HealthPartners Institute for Education & Research Evaluation Quality improvement reporting
Work informing COMPASS
IMPACT & DIAMOND DepressionTEAMCare Depression + CVD/DiabetesSBIRT Substance UsePartners in Integrated Care
Depression + Substance UseMI Primary Care Transformation Multiple chronic conditions RARE, Project BOOST
Care Transitions
TrackingEnrollment
& Data Transparency
TransformationLeadership, Culture, Readiness
TreatmentIntensification
Triple Aim
TeamNew Roles & Relationships
COMPASS 4 T’s to Leverage
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EnrollmentProactive patient identification and outreach•Adult Medicaid or Medicare patients•With sub-optimally managed depression (PHQ-9 >9)•AND treatable medical comorbidities defined by one or more of the following:
– Diagnosis of diabetes with A1c >8.0% OR BP >145 mm Hg OR LDL >100 mg/dl
– Existing cardiovascular disease (e.g. history of ischemic heart disease diagnosis, coronary procedure, CHF or stroke) with BP >145 OR LDL >100 mg/d
– Uncontrolled HTN (>160) in those over 65 years of age– Recent hospitalization related to diabetes or cardiovascular disease
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EnrollmentStudy enrollment• Notify of study using script• Agree to be contacted by study team• Study team calls patients
• Further explain study • Get consent into study
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PRIMARY CARE TEAM
SYSTEMATICCASE REVIEW
TEAM withPsychiatric/Physician
Consultants
PATIENTPATIENT
CARE MANAGER
Team - Collaborative Care
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Ambulatory: Hospital Partnerships
• Partnering with hospital transition staff– Med Rec– Rehab units
• Visiting patients in hospital– Engage & Enroll– Follow-up
• Creating contingency plans– Use of alternative healthcare resources– Self-care
Challenges
• Program not for all patients• Targeted diseases (mostly)• Socio-economic • EHR and other systemic disconnections
• Patients disconnected from the healthcare system
Ongoing support for sustainability• Weekly enrollment reports
• Care manager networking calls
• Partner project manager calls
• Weekly newsletters
• Google site & other on-line resources
• Webinars & learning collaboratives
• Data feedback for quality improvement
• Practice coaching
• Building training capacity at the sites
Questions ?
Upcoming RARE Events….
• Stay tuned for the next RARE Webinar September 27, 2013!Topic: Implementation of the Care Transitions Innovation (C-Train) in Oregon
• RARE Action Learning Day – November 11, 2013
Future webinars…
•To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Networking Webinars, contact Kathy Cummings, [email protected]