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Michigan Pathways to Better Health September 2015

Michigan Pathways to Better Health September 2015. Partners. Acknowledgement. The project described was supported by Grant Number C1CMS331025 from the Department of Health and Human Services, Centers for Medicare and Medicaid Services.

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Michigan Pathways to Better Health September 2015

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  1. Michigan Pathways to Better HealthSeptember 2015

  2. Partners

  3. Acknowledgement The project described was supported by Grant Number C1CMS331025 from the Department of Health and Human Services, Centers for Medicare and Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

  4. Overview • MPHI, in partnership with MDHHS and multiple agencies and organizations in Saginaw, Muskegon, and Ingham Counties, received a Health Care Innovations Award from CMS over $14 million to implement the Pathways Community HUB model in three Michigan counties • Michigan Pathways to Better Health (MPBH) is a 4 year grant beginning July 1, 2012, extended through June 30, 2016

  5. Project Goals & Target Population • CMS Health Care Innovation Award: • Better care for patients • Better health for communities • Lower costs through health care system improvement • MPBH focuses on • Social determinants of health • Integration of health care and social services • Targets at-risk population • Adults with two or more chronic conditions • Enrolled in or eligible for Medicaid and/or Medicare

  6. Pathways Community HUB Model • The Pathways Community HUB Model • A centralized community resource that utilizes care coordinators (CHWs) to link individuals to health and social services • Model based upon 3 principles: • Find those at greatest risk • Serve to ensure individuals receive evidence-based health and social services • Measure and evaluate benchmarks and final outcomes

  7. Pathways Community Hub Model Health Care Services CCAs CHWs HUB Social Services

  8. Roles within Pathways model • HUB • A central point of entry that links participants with needed community services • Evaluates the participant’s needs and assigns to the appropriate Care Coordination Agency (CCA) • CCA • Accepts assignments from HUB • Recruits, hires, manages, and deploys CHWs • CHW • Serves as “Care Manager Extender” • Meets with clients in their homes • Coordinates with case managers from other agencies (PCMHs, Medicaid Health Plans)

  9. Counties served As of 9/1/2015, MPBH has served over 7,400 individuals

  10. Ingham Partners* Lead Agency/Fiduciary: Ingham County Health Department Community HUB: Ingham Health Plan Corp, Convener: Power of We Care Coordination Agencies: • Allen Neighborhood Center • Barry-Eaton District Health Dept. • Capital Area Community Services • Ingham County Health Dept. • Mid-Michigan District Health Dept. • National Council on Alcoholism • NorthWest Initiative • Southside Community Coalition • Tri County Office on Aging • Volunteers of America Additional Referral Partners: Lansing Fire Department, Ingham MiPCT, PHP Medicaid, McLaren Greater Lansing ED *For Year 3

  11. MuSkegon Partners* Lead Agency/Fiduciary:Muskegon Community Health Project Community HUB: Muskegon Community Health Project Community Convener: Muskegon Community Health Project Care Coordination Agencies: Additional Outreach Partners: Muskegon County Homeless Continuum of Care Network, Muskegon County Cooperating Churches, MiPCT, 1 in 21, Wellville Initiative, United Way of the Lakeshore, Community Coordinating Council, Great Start Collaborative, Family Resource Centers • Call 211 • Access Health • Community enCompass • Disability Connections of West Michigan • District 10 Health Department • Every Woman’s Place • HackleyCommunity Care • Mercy Health Partners • Lakeshore Health Network • Mission for Area People • Muskegon Community Health Project • Pro-Med • Senior Resources of West Michigan *For Year 3

  12. Saginaw Partners* Lead Agency/Certified HUB: • Saginaw County Community Mental Health Authority Co-Conveners: • Alignment Saginaw • MiHIA Care Coordination Agencies: • Covenant HealthCare/Visiting Nurse Special Services • Health Delivery, Inc. (FQHC) • Saginaw County Department of Public Health • St. Mary’s of Michigan/Center of HOPE Outreach Agency Partners: • Mobile Medical Response (ambulance) • 2-1-1 NE *For Year 3

  13. Community Impact • The Ingham HUB has developed a partnership with Lansing Fire Paramedics • Muskegon Community Health Workers are now embedded in the Housing Assessment Resource Agency • The Saginaw HUBhas become the place stakeholders look to for organizing service delivery

  14. Clients Served since Feb 2013:insurance Status

  15. Referral sources Results as of 9/5/15

  16. Top 10 Chronic Conditions: Percent of Clients Reporting Results as of 9/5/15

  17. Pathways and Tools • Social Service Referral • Medical Referral • Tobacco Cessation • Medication Assessment • Medication Management • Medical Home • Health Insurance • Chronic Disease Education • Healthy Changes Plan • Healthy Homes Checklist • PHQ-9 Screening • Fall Prevention • CAGE-AID • Pregnancy, Postpartum, Family Planning • Healthy Michigan Plan – Health Risk Assessment

  18. Top 10 Needs Identified:Percent of Clients Reporting Need Results as of 9/5/15

  19. Addressing Social Determinants:Number of Clients Linked to Social Services Results as of 9/5/15

  20. Connection to Care:Number of Clients Linked to Healthcare Results as of 9/5/15

  21. Addressing other needs:Number of Clients receiving additional services Results as of 9/5/15

  22. Data Sources • MiPathways • A customized data system used by HUB staff and CHWs for case tracking and management • Medicaid claims data • Medicare FFS claims data • Quarterly reporting from partner sites • Other data collection activities: • Satisfaction surveys • Qualitative interviews • Focus group discussions

  23. Measures Being Tracked Currently tracking 46 measures: • Participant characteristics • Workforce transformation and productivity • Participant health status and other clinical metrics • Characteristics and intensity of the intervention • Integration of the program within the community • Client satisfaction • Clinical and preventive care outcomes (e.g. blood pressure management, LDL control)

  24. Measures Being Tracked • Cost and utilization measures: • Total cost of care population-based PMPM index • Emergency Department utilization • Hospital utilization • All cause inpatient admissions • 30-day hospital readmissions

  25. Pathway Participants matched to Medicaid and/or Medicare claims data • Cohorts defined based on the 6-month period in which they were enrolled in the project: • Cohort 1: Jan. 1, 2013 to June 30, 2013 • Cohort 2: July 1, 2013 to Dec. 31, 2013 • Cohort 3: Jan. 1, 2014 to June 30, 2014 • Cohort 4: July 1, 2014 to Dec. 31, 2014 • Disclaimer: The described results need to be confirmed by independent CMS evaluators.

  26. MEDICAidCOSTS: per Member per Month Full-Benefit Medicaid Participants Disclaimer: The described results need to be confirmed by independent CMS evaluators.

  27. MEDICAreCOSTS: per Member per Month Disclaimer: The described results need to be confirmed by independent CMS evaluators.

  28. Emergency Department Utilization: Number of visits per 1,000 Member Months Disclaimer: The described results need to be confirmed by independent CMS evaluators.

  29. Inpatient Utilization: Number of Admissions Per 1,000 Member Months Disclaimer: The described results need to be confirmed by independent CMS evaluators.

  30. 30 Day Hospital Readmissions: Number of Hosp. Readmissions within 30 days of a Hosp. Admission Disclaimer: The described results need to be confirmed by independent CMS evaluators.

  31. Client satisfaction • Client satisfaction surveys were mailed quarterly to individuals who received services in the past 3 months; a total of 639 surveys (31%) were returned in Year 3: • 91% were happy or very happy with CHW services • 89% would recommend the service to family or friends • Of those needing specific services, most clients indicated their CHW was helpful or very helpful with: • Connecting to people who can help (91%) • Making a medication list (91%) • Providing information on managing their health (90%)

  32. Sustainability efforts • Engaged over the past year in a variety of sustainability efforts: • Developing and testing outcomes-based payment model • Aligning Pathways with the State Innovation Model (SIM) Initiative • Collaborating on efforts to acquire and leverage local funding sources, community benefit programs, foundation grants and state funding to ensure ongoing support for the project

  33. Stories from the field • A provider referred a client to Pathways because of the client’s hygiene issues and it was preventing the doctor from providing optimal care. • Because of the CHW’s unique position to be able to enter the client’s home, she saw that the client’s shower head and toilet were broken and the cause of his poor hygiene. • A new shower head and toilet were donated by a local home improvement store and installed by volunteers. • The CHW also provided food, financial, and transportation assistance to the client and his family. Now the client and the provider can better focus on the client’s health.

  34. Stories from the field • One of our clients facing chronic homelessness was also dealing with money management issues and a history of substance abuse. The client had received housing assistance many times but each time ended up homeless again because of her other barriers. • The CHW, building on the trusting relationship she had nurtured, referred the client to a substance abuse treatment program and helped her set up a payee to manage her finances. When she successfully completed her rehab, the CHW helped her find supportive housing. • As a result, the client is more stable than she has been in a very long time and her utilization of emergency services was reduced dramatically.

  35. Positive benefits for chws • CHWs begin to recognize their ability to improve their well-being • Actions taken to improve personal health status • Family sustainability • Seeking new training and education opportunities • Learning and applying new skills • CHWs further their connection to the community they serve • Reaching beyond the model to improve the health of their community • Bridging barriers with the community at large “…we build trust and knock down barriers…” Dave, CHW

  36. summary • MPBH Pathways Community HUB model • Valuable community resource for improving health • Aim to incorporate Pathways services into primary care • Outcomes Data and Cost Savings Analysis • Targeting social determinants of health while identifying gaps in community resources • Cost trends are promising • Additional data needed • Community Impact • Fosters development of new partnerships to advance community health

  37. contacts Michigan Public Health Institute Clare Tanner ctanner@mphi.org Elaine Beane ebeane@mphi.org Michelle Maitland mmaitlan@mphi.org Ingham Debbie Edokpolo DEdokpolo@ingham.org Sarah Bryant SBryant@ingham.org Lori Noyer lnoyer@ihpmi.org Muskegon Judy Kell Judith.Kell@mercyhealth.com Vondie Woodburywoodburv@trinity-health.org Saginaw Barb Glassheim barbglassheim@comcast.net Sandy Lindsey slindsey@sccmha.org

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