Governor's Health Summit September 30, 2014

1. Governor's Health Summit September 30, 2014 Collaboration. Quality. Outcomes. Brenda Reiss-Brennan, PhD, APRN Mental Health Integration Director Primary Care Clinical Program Intermountain Healthcare

2. Population Health “the health outcomesof a group of individuals, including the distribution of such outcomeswithin the group.” Kindigand Stoddart (2003)

3. What Shapes Population Health?

4. Primary Care is the front door to realize the transformational changes possible within systems of care

5. Families come to this front door as ‘whole persons’ seeking respect, kindness and a solution for continued or better health. “The Doctor’s Team will see you now” WSJ, 2-17-2014 Medicare to Start Paying Doctors Who Coordinate Needs of Chronically Ill Patients NY Times, 8-16-14

6. Impact of transformed team care on cost and quality is inconclusive “participating practices adopted new structural capabilities and received NCQA certification (recognition), was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years.” Association between participation in a multipayer medical home intervention and changes in quality, utilization and costs of care. Friedberg, MW etal. JAMA 2014 Interventions need refinement and achieving significant outcomes take time

7. Integration • To form, coordinate, or blend into • a functioning or organized whole: Unite

8. Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C.SAMHSA-HRSA Center for Integrated Health Solutions. March 2013

9. Our efforts are ultimately centered around what matters most to our patients, families, employees, members and communities Core Business The IntermountainWay Perfecting the Clinical Work Process Improved quality & service Evidence-based practice Best clinical care in the world doesn’t matter if no one can afford it. Always do the right thing! Systematic approach- measure & improve Culture of Learning Success is always led by clinical team but must include operational, financial , governance and patient engagement

10. The clinical and financial case for providing high quality care and outcomes for our communities and patients. Mental Health Integration (Perfecting the Clinical Work Process Overtime) Problem • Mental Health awareness and diagnosis is increasing • Limited integration and services are provided for Mental Health • Effective integration across a healthcare systemis complex and challenging Solution (Standardized & Flexible) • Collaborative mental healthcare integrated into a primary care practice • Outcome oriented & metrics driven framework • Standardized team approach, yet flexible process that facilitates communication and coordination of quality of care • Triple aim focus (i.e., high quality, customer experience and a lower cost of care) Results • Better outcomes – Patients with depression in routinized MHI clinics were 54% less likely to use higher-order ED visits. • Higher satisfaction – Patients and provider satisfaction surveys were higher after integration than before. • Higher quality care – Studies show that an organized system of collaborative mental health care can improve every phase of care

11. Mental Health Integration provides a framework, team-based approach and tools for caring for patients and families. What is Mental Health Integration? Integration Steps 1 • Leadership and culture – champions establishing a core value of accountable and cooperative relationships 2 • Workflow – engaging patients on the team and matching their complexity and need to the right level of support 3 • Information systems – EMR, EDW, registries, dashboard to support team communication and outcome tracking 4 • Financing and operations – projecting, budgeting and sustaining team FTE to measure the ROI • Community resources – who are our community partners to help us engage our population in sustaining wellness 5 A standardized clinical and operational team process that incorporates mental health as a complementary component of wellness & healing

12. Our framework for Mental Health Integration is focused on clinical quality, the patient experience and decreasing overall costs. Strategy : Mental Health Integration – A team approach to clinics. Integration Personalized Primary Care Community Resources Care Manager Specialty Care Our Families & Patients Health Advocates NAMI Psychiatrist or Psychiatric NP Community Therapists Therapist (Psychologist, LCSW, EAP) Physical Therapists Peer Mentor Nutritionist Clinical Staff (RN, MA, Reception, Billing) Clinic Manager Pharmacists • Information Technology / EMR / Data / TeleServices

13. Team performance towards routinization Count of practices by MHI levels Planning Score: 0-20 Adoption Score: 21-40 Routine Score: 41-60

14. Multiple Team Touches(p < .001) Multiple Connected Team Touches (p < .001) ‘we are on the same page‘

15. Team performance towards routinization Count of practices by PPC levels Planning Modified NCQA Score: 35-64 PPC Level 1 Adoption Modified NCAQ Score: 65-84 PPC Level 2 Routine Modified NCAQ Score: 85 - PPC Level 3

16. High Performing Team Based Care (TBC) = Mental Health Integration (MHI) + Personalized Primary Care (PPC) Count of practices by Team Based Care (TBC) levels Planning TBC Level 1 Adoption TBC Level 2 Routine TBC Level 3

17. “A scientific step towards planning for the future needs of our populations” Key Research Aim • “Do clinics with high performing team-based care provide greater value compared to other clinics operating under a more traditional patient management approach—as measured by quality/clinical outcomes, cost, utilization, patient and family service and staff outcomes?”

18. Clinical Cohort and Inclusion Criteria Exposure to (TBC vs no TBC) Clinical Cohort • Longitudinal closed cohort • At least one visit to IMG PCP within 2003 – 2005. • Adult patients (≥ 18 years of age) in 2003 – 2005. • Stable, consistent relationship with Intermountain • Patients who access care within IH facilities for ≥10 years allowing for 1 year gap after filling some missing years. • Size • ~130,000 patients

19. Continuous Connected Relationships Impact Outcomes % Change n Quality Among all Payers • Annual visit with PCP • HTN in Control • PHQ9 Screen • AdvanceDirectives • Adherence to DM Bundle l% Change in Utilization among All Payers • Emergency Visits • Ambulatory Sensitive Admissions • Instacare Visits • Hospital Admissions • PCP Visits • Specialty Visits

20. Leveraging Social Influence : Growing High Performing Teams • Behavioral Economics is transformational – (Kahneman, D.) • We learn by example, not argument. • 90% behavior is copying what • other people do • that appears • to work • (habits overtime)