Partners in Recovery, based in Peoria, Arizona, is an outpatient behavioral health provider organization serving more than 8,000 patients in the Phoenix area. The organization’s unique service focus is treatment for persons with chronic and severe mental illnesses, including conditions such as schizophrenia and schizoaffective disorder, bipolar disorder, and major depressive disorder.
Partners in Recovery recognized that a large portion of its patients also had undiagnosed and untreated chronic medical conditions, including hypertension, respiratory illness, diabetes, heart disease and obesity. Together, these factors contributed to significant overutilization of the emergency department and hospitals – with some Partners patients visiting EDs 70 or more times per year.
“A high rate of undiagnosed and untreated health conditions is common among individuals with mental and behavioral health conditions, with one study attributing 60% of premature deaths to these causes,” said Christy Dye, CEO of Partners in Recovery.
“Medical costs among these patients also are far higher than their mental healthcare expenditures alone, so effectively treating both types of conditions are crucial to driving down the overall cost of care,” she said.
"The population health management IT platform that supports this effort helps teams seamlessly share data and reports and communicate while they continue to monitor patients throughout the care continuum."Christy Dye, Partners in Recovery
To identify and intervene with frequent utilizers of ED and inpatient settings, understand their comorbid medical conditions, and align them with primary care services, Partners in Recovery needed to collect, aggregate and analyze data from numerous sources, including area hospitals, the managed care organization that funded the practice, and the State of Arizona’s Health Information Exchange (Health Current), among others.
“Combining and analyzing data from these disparate sources was time-consuming, which made identifying high-risk patients in a timely fashion more challenging,” Dye explained. “Partners also lacked predictive analytics capabilities that would offer insight into higher-risk patients who would be more likely to visit the ED and require a medical intervention.”
So Partners in Recovery implemented a population health management platform from vendor Lightbeam Health that allowed its providers and care managers to identify and intervene with its most at-risk, high-cost patients.
By combining data from multiple sources and using proprietary predictive algorithms, Partners’ care managers created a high-risk panel of approximately 115 patients that received intensive analysis and clinical engagement.
Care managers conducted root-cause analyses of patients that factored their behavioral and medical conditions, in addition to their social determinants of health issues, to help understand and prevent ED and hospital visits.
“Care managers most often found untreated or undiagnosed chronic medical conditions were the cause of overutilization, followed by opioid seeking, living in housing located near an ED, as well as several social determinants of health factors,” said Dye said.
“To support patient success, rather than requiring visits to a separate primary care physician’s office, Partners began integrating primary care providers within their clinics,” she explained.
These primary care physicians’ staff collaborate with psychiatrists, case managers and a patient’s family/advocate/guardian to establish a comprehensive integrated assessment and service plan that allows the clinical care team to address all of a patient’s needs from a single plan of care.
There is a variety of population health IT vendors on the market today, such as Caradigm, Cerner, Experian Health, Forward Health Group, Geneia, GSI Health, Health Catalyst, Interpreta, Lumeris, Medecision, Medicity, Optum, Orion Health, Philips Wellcentive, Transcend Insights and ZeOmega.
MEETING THE CHALLENGE
Partners in Recovery’s integrated, multidisciplinary approach is helping achieve optimal outcomes and lower costs through collaborative teams of behavioral health providers and medical physicians, as well as case managers, care managers, and family members, advocates or guardians of the individual being served.
The provider organization developed a 14-step high-risk functional analysis and treatment planning protocol rooted in multidisciplinary and multi-stakeholder communication and collaboration that has resulted in improved engagement among patients.
“The integrated teams communicate and collaborate on care delivery as well as assessments and service plan design,” Dye explained. “The population health management IT platform that supports this effort helps teams seamlessly share data and reports and communicate while they continue to monitor patients throughout the care continuum.”
Research shows that integrated care teams, such as those incorporating primary care, specialty physicians, behavioral health providers and community services professionals, deliver the highest-quality outcomes among patients with multiple comorbid conditions, she added.
“Partners’ integrated care teams align with those integrative and collaborative best practices,” she continued. “In addition, across the healthcare industry, stakeholders have concluded based on overwhelming evidence that social determinants of health bear a much larger impact on patient outcomes than medical services alone.”
Overcoming the SDOH obstacles that are preventing higher-risk, higher-cost patients from achieving improved outcomes requires an integrated team that can align patients with services, education and support so they can foster stable living environments, positive behavior adjustment and healthier decisions, she added.
To gather insight on patients’ medical, behavioral and SDOH, Partners leveraged the real-time analytics tools available in its population health management IT platform, which is less common among mental and behavioral health clinicians. Partners also incorporated data analysis and reporting into provider and staff workflows to improve care utilization monitoring and patient adherence to service plans.
Engaging patients and helping them access appropriate primary care services instead of visiting the ED or hospital delivered significant utilization and outcome improvements for Partners and its patients.
“Since integrating five of its locations with primary care providers, Partners has been able to successfully enroll more than 41% of its eligible patients to receive primary care services within its integrated health homes,” she reported.
“Likewise, from October 2017 to August 2018, Partners reduced its psychiatric hospital admissions by 50% and saved $119,000 in ED facility costs due to its high-risk functional analyses and integrated treatment plans.”
Overall, Partners in Recovery reduced ED spending from $2,265 per patient per month in January 2018 to just $875 per patient per month in September 2018. That is a total ED cost savings of $326,014 in nine months and overall cost savings of $375,321 among just Partners’ high-risk panel over 12 months.
“From a qualitative perspective, conducting the data analysis and patient outreach offered clinicians new, valuable perspectives on ED and hospital utilization among their patients,” Dye said. “For example, one patient with no record of ED activity began visiting 10 to 15 times a month. After this activity emerged in the data analysis, Partners clinicians engaged the patient and learned that his new housing was located next to a hospital.”
Educating the patient about appropriate care access and aligning him with primary care services in the Partners clinic helped eliminate the overutilization, she added.
ADVICE FOR OTHERS
“Integrating behavioral health and primary care is so crucial to improving outcomes because patients with behavioral health conditions often have worse physical health than the rest of the population,” Dye advised. “For example, behavioral health problems are associated with increased rates of smoking and deficits in diet and exercise.”
In addition, patients with behavioral health problems are less likely to receive preventive services such as immunizations, screenings and smoking cessation counseling, and overall worse quality of care, all of which exacerbates their physical health conditions, she added.
“This health inequity must be corrected,” she stated. “As such, integrating more behavioral health services in medical settings and vice versa must become a more frequently utilized best practice across all healthcare provider organizations.”