Session #G3b
October 28, 2011
Wellness Recovery Teams –
An Innovative Approach to Integrated Health Homes
for Individuals with SMI
James Leonard, MBA, LCSW, Newtown Care Management Center Clinical Officer
Magellan Behavioral Health of Pennsylvania, Inc.
LeeAnn Moyer, Deputy Administrator of Behavioral Health
Montgomery County Department of Behavioral and Developmental Disabilities
Marylynn Windish, MS, LPC, CCDP-D, Adult Clinical Program Manager
Montgomery County Department of Behavioral and Developmental Disabilities
Sandra Zebrowski, MD, Newtown Care Management Center Medical Director
Magellan Behavioral Health of Pennsylvania, Inc.
Collaborative Family Healthcare Association 13th Annual Conference
October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Faculty Disclosure
We have not had any relevant financial relationships
during the past 12 months.
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Need/Practice Gap & Supporting Resources
• The needs of people with serious mental illness (SMI) present
unique needs to collaborative models of care because of the
multiple co-occurring issues they face.
• Individuals with SMI have a shorter life expectancy by 25 years.
• While persons may receive treatment and support from behavioral
health providers, connections to physical health providers and
communications among providers are often fragmented.
• Health care costs are high, and still the mentally ill are dying
younger.
• Research supports the value of enhanced coordination between the
physical and behavioral health systems as an opportunity to
improve the quality of care provided to individuals, while achieving
financial efficiencies.
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Objectives
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Participants will describe the characteristics of the Health Choices Health
Connections program.
Participants will describe the characteristics of the integrated team approach.
Participants will list three strategies for supporting collaboration across
multiple systems (i.e. physical health, behavioral health, residential, criminal
justice, etc.)
Participants will describe the advantages of a multi-level approach to
collaboration that includes:
– Physical health plan to behavioral health plan
– Agency internal function collaboration
– Community stakeholders
– Physical health & behavioral health providers
Participants will describe the strength of an integrated team approach in
dealing with multiple co-occurring disorders.
Participants will list three promising practice strategies for integrated care
planning and delivery.
Expected Outcome
Participants will learn promising practice strategies for:
• training
• information exchange
• member engagement
• clinical intervention
• integrated treatment planning
• outcomes monitoring
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Pennsylvania Serious Mental Illness (SMI)
Innovation Project
• In 2008, the Center for Health Care Strategies (CHCS) launched a
multi-state, national effort to improve quality and reduce
expenditures for Medicaid beneficiaries with complex medical
and behavioral health needs
• Pennsylvania was among the states selected to participate in the
effort
• SE Project Name: HealthChoices HealthConnections (HCHC)
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Pennsylvania Serious Mental Illness (SMI)
Innovation Project
SE Project Partners
• Department of Public Welfare
• Mathematical Policy Research and IPRO
• Center for Health Care Strategies
• Bucks, Montgomery and Delaware Counties
• Magellan Behavioral Health of Pennsylvania, Inc.
• Keystone Mercy Health Plan
Partner Vision
Group Meeting
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Criteria for Inclusion
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Ages 18+
Diagnosis of Schizophrenia (295.XX)
Diagnosis of a Mood Disorder (296.XX)
Diagnosis of Borderline Personality Disorder (301.83)
Program is voluntary and individuals may opt-out
Consent needed to release and share information
(includes MH, Substance Abuse (SA) and HIV-related
information)
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Program Goals and Objectives
Improve Health for Members
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Decrease gaps in care for behavioral and medical conditions
Improve the rate of medication adherence
Improve the rate of preventive services
Improve the rate of visits with providers
Reduce avoidable hospital admissions and emergency room visits
Improve Member Satisfaction
• Better access and services
• Improved coordination of care
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Pennsylvania SMI Innovations Project
Intervention Pillars
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Coordination of hospital discharge & appropriate follow-up
Pharmacy management
Co-location of resources
Focus on appropriate Emergency Department use for
Behavioral Health (BH) treatment
Focus on alcohol and substance abuse treatment/care
coordination
Consumer engagement
Data management and information exchange
Provider engagement/medical home
Montgomery County
Project Scope and Funding
• Total Consenting Member: 367
• Five Agencies and Two ACT Teams
• 2009-2010: Funded with Reinvestment
• 2010: OMHSAS approved service description;
HealthChoices funding effective October 1, 2010
• Funding: Per member per month case rate
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Plan Level Interventions:
Member Profile
Unique marriage of data between two independent health plans
Magellan and Keystone Mercy Health Plan
• Demographics
• Primary Care Provider (PCP) and BH provider contact
information
• Physical Health (PH) and BH diagnoses
• Service utilization of specialists
• PH and BH levels of service and claims information
• Hospitalizations; ER visits; BH Crisis Service
• Pharmacy data
• Gaps in routine physical health screenings/evaluations
• Includes D/A and HIV information
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Plan Level Interventions
• Easy access with plan-based case coordinators to
collaborate on the special needs of member
• Notify of BH & PH Hospitalization
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Recommend referrals as appropriate
Pharmaceutical Management
Access to BH & PH educational material
Joint Case Rounds (Includes plans’ case coordinators, plans’
physician advisors, Wellness Recovery Team and other
healthcare participants, as needed)
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Provider Level Interventions:
Wellness Recovery Team (WRT)
• Team of Navigators: RN, masters level MH or BH Professional, Administrative
Navigator
*Completed approved integrated PH/BH certification
• Phased approach to interventions with the goal of self-management
Member with her WRT and
Magellan HCHC Community
Support Partner
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Provider Level Interventions:
Wellness Recovery Team (WRT)
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Outreach and Engagement
Therapeutic alliance with WRT
Utilize Member Profile as tool to coordinate care
Assist member in creating individual Wellness Plan
Identification of “virtual team” supports-relationship building
Community-based, mobile
Member reviewing their
Wellness Plan with RN
Navigator and Therapist
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Provider Level Interventions:
Wellness Recovery Team (WRT)
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Notification of BH & PH hospitalization
Discharge planning and coordination
Linkage to community supports
Referrals as appropriate
Triage and planning
by WRT and RN
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Provider Level Interventions:
Wellness Recovery Team (WRT)
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Joint Case Rounds
Develop and maintain an ongoing relationship with a PCP and Psychiatrist
Pharmacy consultation and collaboration
Co-occurring substance use
screening and treatment
interventions
• Trauma-informed and
Motivational interventions
• Preventive care
WRT consultation
with Psychiatrist
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Provider Level Interventions:
Wellness Recovery Team (WRT)
• Continuity of relationships over time;
immediate re-engagement if needed
• Wellness groups
• BH and PH wellness checks
• Provide educational material
• Collaborative care management
activities are billable
Member monitoring
her wellness goal
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Advantage of Multi-Level Approach
to Coordination
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PH plan to BH plan to WRT
Coordination between WRT and PCP
Creating a “virtual team”
Specialist coordination
Achieving financial efficiencies
HealthChoices HealthConnections
Cost Impact Study
Selection of Population
• Members Consented for Participation in HealthChoices
HealthConnections (HCHC)
• Members Anchored in the Wellness Recovery Team (WRT)
• 137 Members identified as having active participation in the
WRT program as of November 30, 2010
Measurement Periods
• 6 Months prior to participation (anchor date) in WRT
• 6 Months during participation (anchor date) in WRT
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HealthChoices HealthConnections
Cost Impact Study
The change found in individuals’ use of treatment in 24 hour settings and Emergency Rooms while
participating in HCHC is substantially diminished compared with such need prior to HCHC involvement.
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The need for emergency care in a medical facility ER decreased by 11%
Admissions to medical facilities reduced by 56%
Admissions to psychiatric hospitals reduced by 43%
The need for an assisted residential environment declined by 14%
The support and proactive coordination of services and wellness activities found with the HCHC
approach has resulted in a reduced need for these high level and often invasive interventions.
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Continuous Quality Management:
Monthly Learning Collaborative
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Ongoing learning by sharing of collective experiences and challenges
Development and spread of promising practices and strategies
Network, relationship development and information/resource exchange
Identify and meet education and training needs
Learning
Collaborative
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Continuous Quality Management:
Monthly Onsite Meetings with Each Provider
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Provide Technical Assistance
Implementation of the Consumer Health Inventory (CHI) Tool
Conduct Quality Initiatives
Collaboratively Monitor Program
Member completing a CHI
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Continuous Quality Management:
Administration of the Consumer Health Inventory (CHI)
% of All Magellan PS Members
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Domain
% of HCHC Members Reporting
Progress
Reporting Progress
Behavioral Symptoms
29.03%
21.57%
Strength
38.71%
32.62%
Provider Relationship
80%
33.30%
Work-School Participation
22.58%
6.20%
Domain
% of Members with Improvement
% of All Magellan PS Members
with Improvement
Emotional Health
58.06%
38.05%
Physical Health
54.84%
35.16%
Continuous Quality Management:
Consumer Satisfaction Surveys
• Active involvement with HCHC Consumer Advisory Board
• Member Surveys conducted by Consumer Satisfaction Team
• Peer Specialist involvement with Quality Improvement activities
Consumer Advisory Board
Members (Person in
Recovery, Certified Peer
Specialist, and Montgomery
County QI Coordinator )
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Continuous Quality Management:
Consumer Satisfaction Surveys
How has your physical and mental health
changed since starting this program?
70.0%
62.5%
60.0%
50.0%
43.8%
Mental
Health
39.6%
40.0%
Physical
Health
25.0%
30.0%
20.0%
12.5%
8.3%
10.0%
2.1% 2.1%
0.0%
Improved
Stayed the same
Gotten worse
I don't know
Continuous Quality Management:
Consumer Satisfaction Surveys
Do you have a better understanding of the medications
you take as a result of using this service?
More
confused, 2.1%
Same as
before, 12.5%
Somewhat,
20.8%
I don't know,
2.1%
I don't take
medications,
0.0%
Definitely,
62.5%
Continuous Quality Management:
Consumer Satisfaction Surveys
Please rate the effectiveness of this
service on your quality of life
Not effective
6.3%
Somewhat
effective
37.5%
Highly
effective
56.3%
Learning Assessment
Questions and Answers
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Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!
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