Chesterfield CSB and Anthem Integrated Care Pilot Project

Chesterfield CSB and Anthem Integrated Care Pilot Project 2016

Anthem/MHSS Integrated Pilot Program (2016) Goals: This Photo by Unknown Author is licensed under CC BY-SA Delivering more “personalized” treatment inclusive of physical health care Informing and educating clients Closing gaps in care Taking real, measurable steps toward prevention Forging partnerships between public and private sector

Standards of Care • Physical Health • Eye exams • Breast Cancer Screenings • Cervical Cancer Screenings • Colorectal Screenings • Comprehensive Diabetes Care • Controlling High Blood Pressure • Behavioral Health • Antidepressant Medication Management • Adherence to Antipsychotic Medications – Schizophrenia • Diabetes Screening – Schizophrenia or Bipolar using Antipsychotics • Diabetes Monitoring – Schizophrenia • Cardiovascular Monitoring —Schizophrenia • Follow-Up with Licensed Clinician within 7 days post discharge

% Completed 100% 75% 50% 25% 0% 100% Diabetes Screening Diabetes Monitoring Cardiovascular Monitoring 100% Adherence to Antipsychotics Antidepressant Medication Mgmt. BHH Pilot: HEDIS MEASURES (BEHAVIORAL HEALTH) 100%

25% 0% 50% 66% 75% 86% Self-Management for High BP 100% Diabetic Eye Exam 86% 100% Comprehensive Diabetes Care Colorectal Screening 91% Cervical Cancer Screening Breast Cancer Screening Eye Exam % Completed BHH Pilot: HEDIS MEASURES (PHYSICAL HEALTH) 100%

Exceeded Benchmark! BHH Pilot All AHK 100% % Completed 75% 50% 91% 25% 53, 71% 0% Breast Cancer Screening

Better Health…. Lower Costs Behavioral Health Hospitalizations by 41% Costs from $139, 239 to $69, 044 Readmission rate from 24% to 0% Medical Hospitalizations slightly (3 to 4) Costs from $102, 055 to $94, 388

Significant paradigm shift for case managers Lessons Learned: Flexible RN needed – we would advocate for a Bachelors or Masters prepared nurse. They will be doing a lot of education to both staff and clients and in our case, be leading the integrated care initiative along with the program manager. You may need to look at the structure of how nursing services are delivered within the agency. Much of the change for consumers comes in a 1: 1 manner – through case manager’s and nursing contacts. Consumers are not eager to engage in groups to address health care issues.