DWMHA 2015 Accomplishments in Integrated Healthcare Initiatives Page | 1

Prepared by Audrey E. Smith, Director, Integrated Healthcare Initiatives 1/5/2016

Mission

To facilitate and create an infrastructure for coordinated and integrated mental health, substance use,

and physical health care for persons with serious persistent mental illness (SPMI)/Co-occurring mental

illness and substance use disorders, intellectual/developmental disabilities (I/DD), and serious

emotional disturbances (SED).

Vision

DWMHA Consumers will be able to enter at any door and receive recovery oriented services and

supports from health care professionals who are welcoming and trained to deliver integrated health

care that meets their mental health, substance use, and physical health care needs.

Overview

The DWMHA Integrated Healthcare Department has collaborated with other Departments of

DWMHA for several accomplishments over the past year to advance the infrastructure of DWMHA in

support of an integrated delivery system. The accomplishments are in the following areas:

I. Standardized Integrated Bio-Psychosocial Assessment (BPS) August 15, 2015 was the implementation date of the standard Bio-Psycho-Social

Assessment (BPS) in the EMR’s of MCPNs and Providers in the DWMHA network. With

the Dual-Eligible Project we recognized the BPS as the "Level-2" intake assessment to be

completed with a referral from the Integrated Care Organizations (ICOs). Our first step

was to develop the BPS in MHWIN so that we had at least one shared system for the

Providers to access the document. PCE has been busy delivering the new BPS Assessment

in EMRs for their client’s systems.

The implementation of the "Behavioral Health-TEDs" (BH-TEDs) record is a project that is

being driven by the Michigan Department of Health and Human Services (DHHS) and

DWMHA Information Technology Department. The BPS document collects some of the

BH-TEDs data and is also one of the triggering events for the submission of the BH-TEDs

record from the Providers and MCPNs. For these reasons the implementation of the BH-

TEDs project was linked to the delivery of the BPS Assessment. In addition, a “standard”

form presents a consistent representation across DWMHA in Care Coordination with

Physical Healthcare.

DWMHA 2015 Accomplishments in Integrated Healthcare Initiatives Page | 2

Prepared by Audrey E. Smith, Director, Integrated Healthcare Initiatives 1/5/2016

II. Coordination with Primary Care Providers/Levels of Integration in Behavioral Health

Centers

DWMHA Integrated Healthcare Department has worked diligently with providers to

increase the level of integrated healthcare delivery. Thirteen (13) comprehensive provider

have primary care provider presence on site to address the physical health needs of their

consumers with chronic medical needs. Seventy five percent (75%) of the comprehensive

behavioral health providers are at a level four (4). Level four means primary care and

behavioral health providers share the same facility and have some of the same systems in

common. Face-to-face communication or shared treatment plans may occur. Next steps

are to improve the actual practice of integrating primary care needs into the person centered

planning process in behavioral health.

DWMHA 2015 Accomplishments in Integrated Healthcare Initiatives Page | 3

Prepared by Audrey E. Smith, Director, Integrated Healthcare Initiatives 1/5/2016

III. The Integrated Care Capability in Behavioral Health Treatment instrument

(ICCBHT) aims to assess the extent to which mental health service providers provide their

consumers with integrated/coordinated care. Developed by Martena Reed and Detroit

Wayne Mental Health Authority.

a. Approximately ninety-five percent 95% of providers (MI, IDD, SUD) were trained and

implemented the DWMHA Integrated Healthcare Capability in Behavioral Health

Treatment Tool. The results from providers that implemented the ICCBHT indicate

that providers review of their level of integration at a slightly higher level compared to

the SAMHSA level of care integration.

b. To further support all providers in their journey to implementing integrated healthcare

practices DWMHA Clinical Practice Improvement Department supported the

development of the Integrated Health Care Tool Kit.

The Integrated Healthcare Tool Kit for providers to deliver integrated care: http://www.dwmha.com/Portals/0/Documents/IntegrationOfCare/2015-05-

26_Tool%20Kit%20Format%20V2.0-sw.edits-052115.pdf

IV. DWMHA Integrated Healthcare Learning Collaborative- DWMHA held several

Integrated Healthcare Learning Collaborative for DWMHA Providers, facilitated by the

National Council. The purpose of the Learning Collaborative is to assist our providers:

a. Understand elements of the MI Health Link Program and performance of providers

b. Update on the progress of DWMHA Integrated Healthcare Initiative

c. How to use the results of the Integrated Care Capability in Behavioral Health

Treatment Assessment Tool

d. How to use MI Care Connect to support integrated healthcare delivery

e. Sharing of information and refinement of organization goals toward advancing its

level of integrated healthcare delivery

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Prepared by Audrey E. Smith, Director, Integrated Healthcare Initiatives 1/5/2016

V. Coordination with Medicaid Health Plans, MCPNs and PIHPs

DWMHA Integrated Healthcare staff are actively engaged with six (6) of eight (8)

Medicaid Health Plans (MHP) in Wayne County. The expected outcomes of this data

sharing and care coordination project are: Improved Gaps in Care; Reduction in Inpatient

utilization and cost; Reduction in ER utilization and cost; Improve care coordination.

DWMHA, MCPNs and Providers work collaboratively with the MHPs to address high ER

utilizers that have behavioral health diagnosis and consumers who have not had an office

visit within the last 12 months and other gaps in care. CMT population health tools have

been used to support coordination of care with Medicaid Health Plans (see chart below).

The following chart describes outcomes related to utilization costs.

DWMHA 2015 Accomplishments in Integrated Healthcare Initiatives Page | 5

Prepared by Audrey E. Smith, Director, Integrated Healthcare Initiatives 1/5/2016

VI. Care Connect/Adult Mental Health Block Grant Achievement- DWMHA was awarded

the Adult Mental Health Block Grant to support the development and implementation of a

health information exchange, MI Care Connect, that will provide secure technological

platform where providers have easy access to both physical and behavioral health encounter

and medication data for Medicaid enrollees. MI Care Connect supports the CMS ”Triple

Aim: ” Improving the patient experience of care (including quality and satisfaction);

Improving the health of population; Reducing the per capita cost of health care. DWMHA

Integrated Healthcare and Information Technology staff have successfully accomplished

the following:

1. Rolled out of MI Care Connect to providers and MCPNs.

2. Successfully integrated data into MI Care Connect from Care Connect 360,

Medicaid physical and behavioral health encounter data. Successfully engaged Care

Management Technologies (CMT) that provides analytical tools for individual and

population care management.

3. DWMHA standardized assessment documents documents (Biopsychosocial

assessment, SIS, LOCUS) have been successfully loaded into MHWIN from the

provider organization’s electronic health record.

4. Staged roll-out in the 4th

quarter to a set of six (6) “Early Adopter” Providers. Data

Use Agreements, user IDs, and passwords have been created for six (6) early

adopter organizations. User IDs and passwords have been provided to

approximately 100 behavioral health clinicians. The users represent ACT teams, MI

Health Link Case Managers and Supports Coordinators, and Integrated Care Teams

with Primary Care Providers.

5. Identifies early adopter provider organizations. The organizations invited

represented providers that are at a variety of integrated healthcare levels and

disability populations. Providers were asked to identify teams that will use MI

Care Connect. Providers that partner with FQHCs are included in the early adopter

group. Clinicians are using MI Care Connect in the morning huddles, during

intakes, and population based health management. MI Care Connect is being

refined to be more user friendly. The Care Team functionality is being tested with

the Early Adopter group.

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Prepared by Audrey E. Smith, Director, Integrated Healthcare Initiatives 1/5/2016

VII. Implementation of the MI Health Link Program (Integrated Care for Persons with

Medicare and Medicaid)

As of November 30, 2015, DWMHA has received approximately 3,522 Level I referrals

from five (5) ICOs. DWMHA is considered a PIHP leader in the MI Health Link Program

in Michigan. DWMHA Integrated Healthcare staff continue to work with contracted and

non-contracted providers to train on the MI Health Link program, provide technical

assistance in completing the Level 2 Assessment, and continue to work with the ICOs to

improve the processes for the MI Health Link program and improve the health outcomes for

the enrollees. DWMHA has taken lead in implementing the Behavioral Health Consent

form for the exchange of 42 CFR Part 2 data. The electronic exchange of health

information for referrals between the ICOs and the PIHP is functioning well. The

following charts that provide analysis of eligible persons in Region #7 Wayne County and

those actually enrolled in the MI Health Link Program:

DWMHA staff has provided continued stay reviews and transition of care services to

approximately 444 MI Health Link inpatient admissions. Ninety-one percent (91%) of

discharges have been connected with outpatient services within seven (7) days of discharge.

Twenty-one (21%) of admissions were readmitted within thirty (30) days of initial

discharge. DWMHA Integrated Healthcare staff continue to work intensively with the ICO

Care Coordinators, MCPNs, and contracted providers to reduce readmissions.

Duplicate/Misdirected Referral to

PIHP, 1,299 , 37%

Not Linked to

Consumer, 153 , 4%

Pending Screening,

58 , 2%

Not able to Contact/Decli

ned PIHP Serices at

Access, 534 , 15%

Pending Level 2

Assessment, 199 , 6%

Not able to Contact/Declined PIHP Serices at

Level II Provider, 173 , 5%

Sent to ICO, 1,106 , 31%

MI Health Link- Status of All ICOs Referrals from Start of Program - November 30,

2015 N=3,522

0

100

200

300

400

500 444 403

94

MI Health Link- Inpatient Admissions and Transitions of Care Activity from Start of

Program through November 30, 2015

Admissions

91%

21%

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Prepared by Audrey E. Smith, Director, Integrated Healthcare Initiatives 1/5/2016

VIII. Summary Accomplishments in Integrated Healthcare at DWMHA Implementation of the MI Health Link Program

Increased Level Of Integrated Healthcare Delivery- DWMHA Providers to 75 %

Case To Care Management Training

DWMHA Integrated Healthcare Learning Collaborative Meetings

Data Sharing Care Coordination Project with Medicaid Health Plans- Improved

Outcomes and Savings

MI Care Connect/ Health Information Exchange

Integrated the Provision of SUD Treatment, Prevention, and Recovering Services

Standardized Integrated Processes & Assessments- Including SUD Providers

IX. Future Goals 1. Develop in implement departmental practices and policies that meet NCQA standards

2. Continue to improve the delivery of integrated health care with providers in the

development of care plans and care coordination.

3. Continue to managed the implementation of the MI Health Link program and improve

the outcomes of care and service utilizations.