UR OARHS Office for Aging Research and

Health Services

Michael Hasselberg, PhD, NPP-BC

Assistant Professor of Psychiatry

Director of Project ECHO®

Director of Telepsychiatry

Extension for Community Healthcare Outcomes

in Geriatric Mental Health (ECHO® GEMH)

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Disclosures

I have no financial relationships with a

commercial entity producing health-

care related products and/or services

to the content I am presenting

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Acknowledgements

Supported by funding from

o The New York State Health Foundation

o The Health Foundation of Central and Western New York

o Greater Rochester Health Foundation

Infrastructure support from

o Project ECHO®, University of New Mexico (UNM)

(Slides adapted from those of Sanjeev Arora, MD, UNM Professor)

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Growing Need

Aging and disease impact in New York State

(NYS)

o Population age ≥ 65 years will rise from 2.5 to 4 million by

the year 2030

o Elderly with mental illness will rise from 495,000 to 772,000

by the year 2030

Costs of inadequate care in NYS

o In 2011, health care costs for elderly with dementia alone

was $690 million

• Value of unpaid care exceeded $13 billion

New York State Office of Mental Health, 2013; Alzheimer’s Association, 2012

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Alliance for Aging Research, 2002

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Geriatric Psychiatry Shortage

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• Only 1,596 physicians are currently certified in geriatric psychiatry

• One for every 11,372 older Americans

• By 2030 that total is predicted to rise to only 1,659, which would then be only one for every 20,195 older Americans (ADGAP, 2007b).

• Half of fellowship positions go unfilled nationwide

• General psychiatry is a partial solution

• 71% feel very prepared to dx and treat delirium

• 96% to dx and treat major depression

• 56% to diagnose and treat dementia.

Retooling for an Aging America: Building the Health Care Workforce http://www.nap.edu/catalog/12089.htm

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The mission of Project ECHO® is to expand the capacity to provide best practice care for common and complex diseases in rural and underserved areas and to monitor outcomes.

Goal is to touch the lives of 1 billion people by 2025

Supported by New Mexico Department of Health, Agency for Health Research and Quality, New Mexico Legislature, the Robert Wood Johnson Foundation and the GE Foundation.

One solution: Project ECHO®

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In 2004 less than 5% of patients with HCV in New Mexico had been treated o Estimated 28,000 people with HCV in New Mexico

o No Primary Care Physicians treating HCV in New Mexico

Good news … o Curable in 70% of cases

Bad news … o Severe side effects:

anemia (100%)

neutropenia >35%

depression >25%

Project ECHO® Hepatitis C (HCV)

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Methods of Project ECHO®

Use Technology (multipoint videoconferencing and Internet)

Disease Management Model focused on reducing variation in processes of care and sharing “best practices”

Case based learning: Co-management of patients

HIPAA compliant web-based database to monitor outcomes

Arora (2013); Supported by N.M. Dept. of Health, Agency for Health Research and Quality HIT Grant 1 UC1 HS015135-04, New Mexico Legislature, and the Robert Wood Johnson Foundation.

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Project ECHO® HCV Outcomes

Sustained Viral Response (SVR): no detectable

virus 6 months after completion of treatment

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Project ECHO® in New Mexico

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ECHO® Replication in United States

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• University of Washington (HCV, Chronic Pain, HIV, Multiple Sclerosis) – Seattle, WA • University of Chicago (Hypertension, Breast Cancer Survivorship/Women’s Health, Pediatric ADHD, Childhood

Obesity, HCV) – Chicago, IL • University of Nevada (Antibiotic Stewardship, Autism (closed group, by invitation only), Diabetes/General

Endocrinology, Gastroenterology, Rheumatology, Sports Medicine, Mental Health: Professional Development Groups (closed groups, by invitation only), Mental Health Clinic Director’s Group (closed groups, by invitation only), Marriage & Family Therapy Intern Supervision Clinic (closed groups, by invitation only) – Reno, NV

• University of Utah (HCV, Advanced Liver Care, Chronic Pain) – Salt Lake City, UT • Florida/Caribbean AIDS Education and Training Center, University of South Florida (General HIV,

Adolescents/Pediatrics HIV, HCV/HIV Co-Infection, Psychiatry & HIV, Spanish Language HIV) – Tampa, FL • Harvard/Beth Israel Deaconess Medical Center (HCV, Gerontology – ECHO AGE) – Boston, MA • St. Joseph’s Hospital & Medical Center (HCV) – Phoenix, AZ • Community Health Center, Inc. (HIV, HCV, Chronic Pain, Opioid Addiction – Buprenorphine, Coaches

International—supporting Quality Improvement and Specialists) – Middletown, CT • LA Net (AAPA Preventive Care, Nephrology, Adult Psychiatry) – Los Angeles, California • UNM: Center for Development and Disability (Autism) – Albuquerque, NM • UNM: Envision NM (Childhood Overweight Medical Management, Pediatric Nutrition, Psychiatry,

Asthma/Pulmonary) – Albuquerque, NM • CHI St. Luke’s Health (HCV, HBV, Infectious Disease) – Houston, TX • University of California Davis (Pain Management) – Davis, CA • University of Wyoming, Wyoming Institute for Disabilities (Assistive Technologies) – Laramie, Wyoming • Ochsner Health System (Liver Care) – New Orleans, LA • University of Texas MD Anderson Cancer Center (Cervical Cancer Prevention) – Houston, TX • Oregon Health and Science University/Health Share of Oregon (Psychiatric Medication Management) –

Portland, OR • University of Rochester Medical Center (Geriatric Mental Health) – Rochester, New York • Visiting Nurses Association Health Group (Care Transition) – Red Bank, New Jersey • Missouri Telehealth Network/University of Missouri (Autism) – Columbia, MS • University of Colorado School of Public Health (Children and Youth with Epilepsy) – Denver, CO

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ECHO® Replication Worldwide

National AIDS Control Organization and Maulana Azad (HIV) – New Delhi, India Institute of Liver and Biliary Sciences (HCV) – New Delhi, India Universidad de la República (Liver Disease) – Montevideo, Uruguay West/North West Hospitals Group (Diabetes) – Galway, Ireland ECHO Ontario (Chronic Pain) – Queens University & University of Toronto Ontario, Canada Northern Ireland Hospice (Hospice Care) – Belfast, NI National Institute for Mental Health Services (NIMHANS) (Mental Health and Drug Addiction) – Bangalore, India B.J. Medical College (HIV) – Ahmedabad, India Vietnam National Lung Hospital (TB) – Hanoi, Vietnam Hospital Italiano (HCV) – Buenos Aires, Argentina PUCRS Brazil-( Depression and Dementia)

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Geriatric Mental Health

&

Memory Care

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Project ECHO® GEMH Goal

To support the delivery

by primary care practices (PCPs) in

underserved and rural areas of New

York State (NYS)

of expert care

to older adults with dementia or

mental disorders.

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Project ECHO® GEMH

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PC Practice

PC Practice

PC Practice

PC Practice

PC Practice

URMC Hub Site

• Geriatric psychiatry • Geriatric medicine • Geriatric psychology • Social work • Pharmacy

PC Practice

PC Practice

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Current Participants

Primary Care Practices

o Hospital system affiliated

o Accountable care affiliated

o Provider owned group

Federally Qualified Health Centers

Health Service Corporations

County Department of Aging Centers

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Workforce Development

UR School of Medicine

o Medical School Program

o Family Medicine Residency Program

o Psychiatry Residency Program

o Geriatric Psychiatry Fellowship

o Interdisciplinary Geriatric

Medicine Fellowship

o Clinical Psychology Fellowship

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UR School of Nursing

o Undergraduate Nursing Program

o Family Nurse Practitioner Program

o Adult Nurse Practitioner Program

o Psychiatric Nurse Practitioner Program

o Graduate Nurse Leadership Program

St. John Fisher Collage of Pharmacy

Niagara Falls Medical Center Family Practice

Residency Program

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UR Medicine Project ECHO® Hub Site

Health System Affiliated Primary Care Site

Primary Care Practice Group Site

Federally Qualified Health Center Site

Health Care Service Corporation Site

County Department of Aging Site

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Program Evaluation

First TeleECHO™ clinic was held on

September 18, 2014

To Date:

24 TeleECHO™ clinics

546 participants

181 Continuing Medical Education (CME) credits

49 patient case presentations

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Preliminary Outcomes

Overall Rating/Content Poor Fair Good Very Good Excellent

How well were objectives met 0% 0% 2% 19% 79%

Objective/evidence-based content 0% 0% 2% 17% 81%

Opportunities to ask questions 0% 1% 7% 17% 75%

Appropriate pace 0% 0% 4% 29% 67%

Organization of presentation 0% 0% 1% 16% 83%

Presenter clearly communicated 0% 0% 1% 13% 86%

Relevance of presentation 0% 1% 0% 13% 86%

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n = 181

CME Survey Results:

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Preliminary Outcomes

Participant Qualitative Interviews:

Most feel clinics are useful, some do not

Of those who could implement suggestions, they often saw results

Most feel that they will use learnings in future work

Clinics are considered particularly useful for complex cases, poly pharmacy, reducing reliance on antipsychotics

Clinics can be perceived as validating for participants in that cases are complex and it’s normal to struggle with them

Major value – access to specialists otherwise unavailable

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Sustainability

External cost evaluation being conducted by the

New York Academy of Medicine

Collaboration with Excellus BCBS o Practice level claims data

Fee-for-service versus

Accountable Care

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Accountable Care

An accountable care organization or network is a healthcare organization characterized by a payment and care delivery model that ties provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. A group of coordinated health care providers forms an ACO, which then provides care to a group of patients.

UR Medicine– Accountable Health Partners (AHP)

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Private MDs &

Community Hospital

Employed MDs

UR Medical Faculty Group

Community Hospitals

Highland, Thompson,

Jones Memorial, Noyes, Arnot Ogden

Strong Memorial Hospital

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NYS Delivery System Reform Incentive

Payment (DSRIP) Program

o Restructure the health care delivery system

• To create an accountable, coordinated network of care that improves

access, quality and efficiency of care for patient populations

o Reinvesting in the Medicaid program

• Up to $8 billion dollars are allocated to this program

o Primary goal of reducing avoidable hospital use

* DSRIP Project Toolkit (page 39) “Modeling of Project

ECHO is encouraged where appropriate.”

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How do we integrate Project ECHO®

into Accountable Care

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Finger Lakes Performing Provider System (FLPPS)

Rochester Regional Health System

(RRHS) and UR Medicine

o Lead implementation of DSRIP

o In partnership with over 600 organizations

30 http://flpps.org/

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FLPPS DSRIP Project 3.a.v

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Behavioral Interventions Paradigm in Skilled Nursing Facilities (SNF)

Vision:

1. Build an education, consultation & training

infrastructure for SNF clinical and non-clinical staff

2. Improve access to psychiatric expertise and

behavioral health sub-acute care

3. Modify facilities to assure that adequate recreation

and holistic interventions can be carried out

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SNF Needs Assessment NYS Statistics

Approximately 30% of new

nursing home admissions are

among persons with mental illness

Older adults with dementia have

a three-fold increased risk of

hospitalization

1 in 5 residents will be given an

antipsychotic medication, though

only 1% will ever be diagnosed

with a psychotic condition

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FLPPS Region Statistics

Hospital readmissions following

discharge to a SNF account for

about 16% of all Medicaid

readmissions

o Behavioral symptoms are within the Top 11

reasons for readmission

Greatest and most consistent

increase (58%) in citations for

inappropriate antipsychotic use

from 2011 to 2012 across NYS

Grabowski, et. al., 2009.; Becker, et. al., 2009; The Long Term Care Community Coalition, 2014; NYSDOH, 2012

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SNF Needs Assessment

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ALLEGANY

CHEMUNG

ORLEANS

SCHUYLER

SENECA

STEUBEN

WYOMING

YATES

CAYUGA

GENESEE

LIVINGSTON

ONTARIO

WAYNE

MONROE

Entirety as lacking mental health services

In need of additional mental health services

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Harvard ECHO® AGE in SNFs

Geriatric mental health and dementia ECHO® to New

England SNFs associated with the Beth Israel Deaconess

Medical Center

o 34% discontinuation or reduction of antipsychotics

o Behavioral interventions recommended in 72.3% of patient cases

o 74% patients had clinical improvement when recommendations

were followed

- Significantly lower mortality (p < 0.03)

o 60% reduction in hospitalizations when recommendations were

followed Catic, et. al. 2014

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ECHO® GEMH in DSRIP Project 3.a.v

Implementation underway

Participants to include all staff with patient care

responsibilities

Rollout to begin November 2015?

o Year 1: 30 SNFs participate in biweekly clinics

o Year 2: Additional 30+ SNFs to participate on alternating weeks

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Potential Benefits to the Participant

access to consultation re: effective management of

gero-psychiatric disorders and dementia.

burden on family caregivers (with resulting health

benefits).

quality (didactics and care target quality metrics).

cost across the system, with unnecessary care.

provider satisfaction – engagement in community of

practice.

CME credits (1 hr/hour of participation).

NO COST

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Potential Benefits of Project ECHO®

to the Health System

• Quality and Safety

• Rapid Learning and best-practice dissemination

• Reduce variations in care

• Access for Rural and Underserved Patients, reduced disparities

• Workforce Training and Force Multiplier

• De-monopolize Knowledge • Improving Professional Satisfaction/Retention

• Cost Effective Care- Avoid Excessive Testing and Travel

• Prevent Cost of Untreated Disease

• Integration of Public Health into treatment paradigm

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ECHO® PSYCH (General Psychiatry)

o Funding from New York State Health Foundation

o Expected launch in November 2015

ECHO® GEMH in Long Term Care

o Funding from Greater Rochester Health Foundation

o Expected launch in November 2015

ECHO® Pal (Palliative Care)

o Funding from Greater Rochester Health Foundation

o Expected launch in June 2016

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ECHO® Expansion in NYS

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ECHO® model is a robust method to safely and effectively treat common and complex diseases in underserved areas and to monitor outcomes

UR Medicine - expansion to other disorders may soon follow

Sustainability

Conclusions