Esteban R. López, M.D., M.B.A, McKesson Health Solutions Dena Stoner, Sr. Policy Advisor, Department of State Health Ser

1. 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

2. Texas Medicaid Enhanced Care Program Whole person management: Addressing barriers Self-Management Coaching Medication Adherence Symptom Assessments Motivation and Confidence Facilitate access to community services Coordinate and Arrange Care Incentives Ensure appropriate Medical Home Self-Empowered Member Connection with Providers Lifestyle behavioral change Facilitate access to behavioral health services

3. 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

4. Claims Cost Distribution Population Distribution Highest Risk ~20% 50-80% of Claims Moderate Risk ~20% Lower Risk ~60% 10%-30% of Claims 10-20% of Claims Texas Medicaid Enhanced Care Program Delivery Model • Predicts/stratifies members who will: • Benefit most from DM services, education, & improved self-management techniques • Provide best opportunity to reduce costs & achieve savings • Intervention levels: • 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 This is the population where DM has the greatest savings impact

5. 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

6. Texas Medicaid Enhanced Care ProgramKey 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.

7. Texas Medicaid Enhanced Care ProgramAsthma Action Plan and Post Assessment Letter

8. Texas Medicaid Enhanced Care ProgramKey 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.

9. Texas Medicaid Enhanced Care ProgramOutcomes 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.

10. Texas Medicaid Enhanced Care Program Outcomes for Clinical Metrics *Self-reported data calculated from actively managed clients in program

11. Texas Medicaid Enhanced Care Program Outcomes for Clinical Metrics *Claims based measures calculated from all identified clients using reconciliation data

12. Texas Medicaid Enhanced Care Program Outcomes for Financial Metrics

13. 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.

14. 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 co-morbid conditions involving behavioral health, specifically depression and schizophrenia. • Dedicated staff to ensure appropriate interventions and care coordination.

15. 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.

16. Building BridgesThe Role of Public Mental Health Dena Stoner, Senior Policy Advisor, Mental Health and Substance Abuse Services Texas Department of State Health Services dena.stoner@dshs.state.tx.us

17. 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 TEXAS Department of State Health Services

18. 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. TEXAS Department of State Health Services

19. 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 TEXAS Department of State Health Services

20. 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 TEXAS Department of State Health Services

21. 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. TEXAS Department of State Health Services

22. 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) TEXAS Department of State Health Services

23. 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. TEXAS Department of State Health Services

24. CAT Interventions: Dressing Apathy Disinhibition Mixed TEXAS Department of State Health Services

25. 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. TEXAS Department of State Health Services

26. 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 TEXAS Department of State Health Services

27. 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. TEXAS Department of State Health Services

28. 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. TEXAS Department of State Health Services

29. 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. TEXAS Department of State Health Services

30. Disability Applications Reduced Texas Minnesota Hawaii 12 month national evaluation findings TEXAS Department of State Health Services

31. 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. TEXAS Department of State Health Services

32. 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.  TEXAS Department of State Health Services

33. 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. TEXAS Department of State Health Services

34. 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). TEXAS Department of State Health Services

35. 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 TEXAS Department of State Health Services

36. Future Possibilities… • New federal Medicaid option (in 2011) for individuals with serious mental illness to designate a health home • Medicaid and insurance expansions TEXAS Department of State Health Services

37. TexasMedicaid Enhanced Care Program • Transition to the Future • “Texas Health Management Program” • Anna Sicher RN, MPA • Clinical Program Specialist • Medicaid/CHIP Division

38. Texas Health Management ProgramNewContract 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 • Client self-management • Provider/practice delivery system design; and • Technological support 1 2 3

39. Texas Health Management ProgramContract 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: • Self-management education to all Texas Health Management (THM) Program clients • A health & wellness program for all HC/HR clients. • Behavioral & mental health management when needed. • 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.

40. Texas Health Management ProgramContract Requirements (con’t) • Provider equally important as client – vendor must: • Offer tools and educational resources to providers. • Provide practice facilitation (PF) to providers who may not be using evidence-based guidelines and who request PF. • 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: • Financial - 5% Total Annual Claims cost savings for the program (40% of overall at-risk fee). • Clinical Quality Indicators - with targets ( 50% of overall at-risk fee). • Humanistic Measures – client/caregiver and provider surveys (10% of overall at-risk fee).

41. QUESTIONS?