This blog was first posted in November 2017. We are reposting an updated version here in honor of Mental Health Awareness Month.
I grew up as the youngest of 2 girls in a tight knit family in the Midwest. We were a pretty regular family by most people's definition. Though I went on to college, marriage and family and maintained a fulfilling career in software, my sister had a very different path. After a tumultuous period in late middle school, my sister began smoking, experimented with drugs and alcohol, skipped school, ran away several times and even tried to commit suicide more than once. In high school she found some equilibrium and graduated, in part, due to the steadying influence of a long-time boyfriend. However, she became pregnant shortly after her high school graduation and then, tragically, lost the father of the baby to a drowning accident. She struggled to provide for herself and her child. Like many with mental illness—in her case, depression, anxiety, borderline OCD and borderline bi-polar—she also wrestled with drug addiction, alcohol abuse, abusive relationships, and run-ins with the law. In addition, she dealt with chronic pain in her neck and severe asthma.
What does this have to do with Integrated Care, you might ask? Everything!
Because of her mental health diagnoses, my sister was on Medicaid and Supplemental Security Income (SSI). As a smoker with a co-existing anxiety disorder leading to panic attacks and shortness of breath, she experienced frequent breathing crises that led her to the Emergency Department for intervention.
While she took medicine for Asthma, anxiety, depression, and neck pain, it was clearly not controlling her illnesses. Like others managing multiple medications, she struggled with adherence. Ultimately, my sister died of an asthma attack at the age of 33 years old, leaving behind 3 children. Here's the question that kept running through my head:
"How can someone in this day and age die of asthma while under treatment and being seen regularly by physicians?"
The answer, of course, is that healthcare in our country is often fragmented. Physical health conditions are treated separately from mental illness and substance use, when, in fact, they all impact the success or failure of any single treatment plan. And, even when there is some coordination between a behavioral health provider and a medical doctor, social determinants, including economic insecurity and lack of social supports are still not considered.
Integrated care focuses care on the whole person by coordinating physical and behavioral health care, along with substance use. There are different models for how integrated care is delivered, but I believe that, in my sister’s case, Care Coordination could have made all the difference.
So What Exactly Is Care Coordination?
Care Coordination is the idea that by having someone focused on coordinating integrated health care for a population of members a payer is financially responsible for, they can expect to improve both the member health outcomes and the financial cost of those outcomes. Typically, Care Coordination is put in place by organizations participating in a value-based payment model for populations that are at high risk for comorbidities and/or have chronic physical and mental health conditions. Members assigned to this high-risk category are assigned a care coordinator, which is often paid for by the payer/health plan.
In these scenarios, a care coordinator can:
- Communicate across multiple providers within the continuum of care, especially with a primary care physician;
- Identify gaps or duplication in care in areas such as screenings, follow-up visits, medication reconciliation, etc.;
- Intervene with patients or providers to improve care for the sub-population as a whole, or on an individual patient basis;
- Provide patient education, improve engagement and ensure appropriate hand-off during transitions of care.
Why Is Better Coordination of Care So Important?
Better coordination of care for members can lead to a win-win for everyone (healthier members at a lower cost to the payer). The Care Coordination trend goes by many names and has been seen across the continuum of care, but has been most prevalent in the Medicaid world, in particular as part of the Health Home model.
The State of Missouri instituted Behavioral and Primary Health Care Homes using Care Coordinators (called Nurse Care Managers) that has seen phenomenal success. For their Behavioral Health Care Home population, which was defined as individuals experiencing Serious Mental Illness (SMI) in combination with one or more chronic illnesses, Missouri saw a cost savings of $31 million during the first year alone.
One way Missouri achieved this incredible cost savings is by requiring that all members receive a metabolic syndrome screening. This was prompted by the realization that only about 12% of their membership had a metabolic screening on file in the previous 12 months. To incentivize adherence to this requirement, Missouri did not allow new members to be assigned to a Health Home that did not keep its metabolic syndrome screening rate above 80%. Fewer members mean less funds to manage the population’s care, making this a powerful incentive. To reach the 80% threshold, each Health Home utilized Nurse Care Managers. Missouri attributes much of the overall financial improvement to a reduction in unnecessary hospitalizations and emergency department visits.
Accountable Care Organizations (ACO) understand this connection, as evidenced by a recent poll of ACOs by the National Association of ACOs (NAACOS) and Leavitt Partners, which found that close to 90% feel that Care Coordinators are "very or extremely important to the success of the ACO,” with one participant stating that coordinators are the “glue connect[ing] a disjointed care delivery system.”
My Personal Story
At this point, I'd like to return to my sister's situation. At the end of her life she was certainly experiencing Serious Mental Illness in combination with a chronic illness (Asthma). I can't help but wonder what would have happened if she had been under the watchful eye of a Care Coordinator such as the Care Managers employed in the Missouri Health Home model. Would her death have been prevented?
Using a Population Health management tool monitoring key metrics, they likely would have noticed that she was showing up in the Emergency Department on a regular basis. They surely would have noticed the combination of both physical and mental health diagnoses. Would her Care Manager have stepped in and communicated with a primary care physician (PCP), her psychiatrist and the Emergency Department where she was a frequent visitor to identify more effective ways to treat her chronic conditions? Would encouraging her PCP to take a closer look at her medications reveal the reason why her Asthma was so poorly controlled? Could she have been encouraged to make it through a smoking cessation program? Perhaps some patient education on controlling Anxiety would have led to fewer panic attacks and, subsequently, fewer panic-induced asthma attacks?
Sadly, I will never know; my sister did not have the opportunity to benefit from proper integrated care. She was never assigned a care coordinator. However, we can look at how care coordination has already had an impact on the healthcare industry. Beyond the Missouri example already discussed, the data show that care coordination makes a difference in the health of both patients and healthcare organizations.
Out of five care delivery innovations studied, a recent Health Affairs study reported that health IT and community health workers showed a cost savings of over $150 per beneficiary per quarter. Community Health workers were described as "unlicensed employees who helped patients move through the healthcare system". In one example detailed in an Institute for Healthcare Improvement Care Coordination white paper, an example of using care coordination to reduce hospitalizations in a population of 6,200 patients was estimated at about $1,000,000.
Given these results, imagine how much more care coordinators can accomplish in the future as a greater percentage of healthcare organizations move towards value-based payment models. While care coordination may not be reimbursable in a fee-for-service model, it can be of immense benefit in controlling costs while improving outcomes in a value-based payment world. There is a lot more to discuss on this topic, including how to get started, what tools an integrated care provider and individual care coordinators require, and some examples of the steps a care coordinator might take on behalf of their patient population.