IMPLEMENTING HEALTH HOMES: TARGETING HIGH-RISK, HIGH-COST PATIENTS AND COORDINATING THEIR CARE

By: Dennis L. Kodner Plus a commentary by: Arthur Y. Webb April 2012

SUMMARY The Affordable Care Act of 2010 (ACA) offers state Medicaid programs the option to establish health homes1 for people with multiple chronic conditions and/or severe mental illness. Health homes are person-centered systems of care that are designed to enhance access to and the coordination of a wide array of primary and acute physical health services, behavioral health care, and communitybased long term care services and social supports. These programs are accountable for improving patient outcomes; reducing avoidable health care costs; providing timely post-hospital discharge and follow-up; and, supporting independent living and family caregiving. The success of the health home will depend, in no small measure, on how well it identifies high-risk, high-cost patient subpopulations, and addresses their differential needs in a targeted, coordinated way. This is the subject of this paper. First, it will briefly describe the health home model of coordinated service delivery. Then, against this background, it will examine how the use of predictive modeling and risk stratification techniques should be used in the health home to enhance the identification of high opportunity patients for care management, as well as group and prioritize individuals according to levels of risk and service need, and assist in building the actuarial foundation for efficient and equitable Medicaid payment. And finally, on a related issue, we will consider the importance of using appropriate comprehensive health assessment tools to ensure that health home patients receive the services they need. The following discussion touches on the implications and concerns related to meeting the unique needs of the behavioral health and developmentally disabled (DD) populations.2 People with these conditions present significant co-morbidities and multi-system needs that require especially complex and expensive care. As such, they will challenge the ability of the health home to meet its clinical, quality and cost-containment goals.

1 Health homes should not be confused with medical homes, which are a new approach to organizing and delivering comprehensive primary care services. They should, however, be viewed as complementary strategies. Indeed, some medical homes may opt to also serve as health homes. For more details on the medical home model, see the reference under footnote 4 below. 2 The discussion is also broadly applicable to other patient groups with chronic and complex needs.

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This is the fifth in a series of papers that critically examine key policy and service delivery issues and options related to various special needs populations. The first paper looked at New York States People First Waiver for people with developmental disabilities from the perspective of Medicaid managed care.3 The second paper in the series focused on the dual eligible dilemma and the strategic implications for integrated models of care which bring together Medicare and Medicaid.4 The third paper examined the medical home model and its fit with various special needs populations.5 The fourth paper analyzed the issues and options related to integrated care for adults with behavioral and physical health needs.6 HEALTH HOME MODEL The health home provision was authorized in ACA (Section 2703). The Medicaid-funded model of patientcentered, coordinated care is designed to provide a cost-effective home to facilitate the delivery of a coordinated range of medical care, behavioral health care, and community-based long term care services and social supports on a longitudinal basis for individuals with chronic conditions and/or severe mental illness. The expectation is that the health home model will result in the following outcomes7: X Lower rates of emergency room (ER) use; X Reductions in hospital admissions and re-admissions; X Reduction in health care costs; X Less reliance on long term facility care; X Improved patient experience of care; and, X Enhanced quality of care outcomes for the individual. To achieve these outcomes, health homes are required to provide six (6) services8: X Comprehensive care management; X Care coordination and health promotion; X Comprehensive transitional care and follow-up; X Patient and family support; X Referral to community and social support services; and, X Use of health information technology (HIT) to link services.

3 Kodner, D., New York States People First Waiver: Concept Paper on Strategic Issues and Options Related to the Development of Innovative Medicaid Managed Care Models for Developmentally Disabled Adults, Arthur Webb Group, Inc., July 2011. 4 Kodner, D., Dual Eligibles: Understanding this Special Needs Population and Options to Improve Quality and CostEffectiveness of Care Through Integrated Solutions, Arthur Webb Group, Inc., September 2010. 5 Kodner, D., The Medical Home: Improving Its Fit with the Frail Elderly and Other Special Needs Populations, Arthur Webb Group, Inc., October 2011. 6 7 Centers for Medicare & Medicaid Services (CMS), Center for Medicaid, CHIP and Survey & Certification, Letter to State Medicaid Directors and State Health Officials Re: Health Homes for Enrollees with Chronic Conditions, November 16, 2010. 8 See Center for Health Care Strategies, Inc. (CHCS), Health Homes: Opportunities for Medicaid, Fact Sheet, March 2011.

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To qualify for services in a health home, Medicaid beneficiaries must have at least two (2) chronic conditions9; one (1) chronic condition and be at risk for another; or one (1) serious and persistent mental health condition.10 The program is open to children and adults, as well as to the dual eligible population. States pursuing the option have the flexibility to target specific populations, diseases, and geographic locations. IMPORTANCE AND APPLICATION OF TARGETING IN THE HEALTH HOME Targeting is a key characteristic of successful coordinated care programs like the Health Home.11 Highquality evidence also provides strong support for the positive effects of targeting efficiency on both clinical outcomes and cost-effectiveness. 12 Targeting refers to a complex, proactive population health management strategy that is designed to accurately identify high-risk individuals in a given population, stratify them according to level of risk, and allocate resources accordingly. Its most important function is to group, prioritize and match patient needs with care management interventions and services. However, targeting also plays a very important role in predicting and controlling the costs of care, and risk adjusting payments for services. Programs can be targeted to individuals who are high-risk, high-cost and/or high-utilizers. Various methods are available to identify and stratify individuals, including the use of claims data analysis, predictive modeling, and risk assessment stratification tools and models; predictive modeling and risk stratification methods are discussed below. In examining these approaches, it should be recognized that individuals with complex co-morbidities, including those with DD and behavioral health disorders, demand a depth and breadth of analysis that takes into account all aspects of their health and mental health status, including clinical profile, gaps in care, and other information that is not readily available through traditional data sources (e.g., functional status, social context, caregiver support, and health behaviors and attitudes13). As the brief profiles below suggest, numerous challenges will be involved in targeting and stratifying the DD and behavioral health patient groups: DD is a diverse set of severe chronic conditions that are due to mental and/or physical impairments which generally begin early, but last a lifetime.14 First and foremost, people with DD (about 1.6 percent of the population) experience problems with major life activities such as language, mobility, learning, self-care, independent living, and economic self-sufficiency. Depending on the specific syndromes and diagnoses involved, however, there can be a host of physical health problems and psychiatric illnesses. The group is one of Medicaids most expensive; it is the costliest population in New York State. 15

9 Chronic conditions include asthma, diabetes, heart disease, obesity, mental condition, and substance abuse disorder. 10 New York State focuses on individuals (referred to as enrollees) with behavioral health and/or chronic medical conditions. While the states program is not specifically tailored for meeting the needs of the DD or long term care population, Health Home providers can focus on these groups; see NYS Department of Health, Interim NYS Health Home Provider Qualification Standards for Chronic Medical and Behavioral Health Patient Populations, n.d. 11 Kodner, D., Key Characteristics of Successful Co-ordinated Care Models: Lessons from the International Literature, The Kings Fund, March 2012. 12 Ibid. 13 CHCS, Predictive Modeling: A Guide for State Medicaid Purchasers, August 2009. 14 The DD cohort includes people with mental retardation (MR), cerebral palsy (CP), autism spectrum disorders, Downs syndrome, Spina Bifida and other complex genetic, chromosomal and fetal disorders. 15 Kodner, D., op cit., July 2011.

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Behavioral health conditions encompass mental health and substance abuse disorders. About one in four adults suffer from these disorders, but the main illness burden is concentrated in 6 percent of the population with serious and chronic mental health problems. This group suffers a wide range of problems in areas such as feeling, mood and affect; thinking; turbulent family and interpersonal relationships; disruption in role performance; and, inability to care for themselves. Less than half of these adults do not receive the treatment they need. Furthermore, behavioral health disorders often co-occur with costly, life-long physical illnesses such as cardiovascular, pulmonary disease, diabetes, arthritis and other chronic illnesses. Medicaid is the largest payer of behavioral health services.16 PREDICTIVE MODELING Predictive modeling is a data-driven, algorithm-based decision support technique that is designed to prospectively estimate an individuals future potential for health care costs and/or opportunities for care management.17 It employs current administrative and claims data and other sources of information to identify and classify populations into clinically meaningful groups for risk stratification, risk adjustment, and other related purposes.18 Predictive modeling is designed to: X Minimize financial incentives for adverse patient selection; X Provide increased incentives to treat patients at high risk; X Promote clinical effectiveness and financial efficiency; X Provide a methodology to group patients for retrospective analysis, e.g., risk profiling, benchmarking, epidemiological analysis, and rate-setting; and, X Target patients for care management and packages of care. To be effective, predictive modeling must be sensitive to the complex needs of Medicaid beneficiaries with chronic illnesses and disabilities such as the behavioral health and DD populations briefly profiled above. Adjustments for disability, dual eligibility status, and other defining population characteristics have been shown to increase the performance of predictive modeling. Above all, this means that the resulting clinical groups should be able to forecast the most complete and reliable picture of each risk groups future health care utilization and/or costs, as well as assignment to the most appropriate level of health care management. 19 New York State plans to use the Clinical Risk Group (CRG) classification system.20 Without the health homes use of a carefully designed predictive modeling tool, there is the danger of
16 Kodner, D., op cit., November 2011. 17 CHCS, op cit., August 2009. 18 Agency for Healthcare Research and Quality (AHRQ), Designing and Implementing Medicaid Disease Management and Care Management Programs: Identifying and Stratifying Members. Available at: http://www.ahrq.gov/ qua/medicaidmgmt/medicaidmgmt3a.htm. 19 CHCS, op cit., August 2009. 20 Treo Solutions, a health information services company, is working on the development of a CRG classification system for the state; the system will consist of three (3) levels. Whether the resulting risk groupings produced are sensitive enough to the complexities of the behavioral health and DD populations remains to be seen. For a detailed description of the CRG framework, see Hughes, J. et al., Clinical Risk Groups (CRGs): A Classification System for Risk-Adjusted Capitation-Based Payment and Health Care Management, Medical Care, 42:1:81-90, January 2004.

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homogenizing populations, thus driving care and payments for care to the average.21 RISK ASSESSMENT TOOLS Risk assessment tools22 provide an individualized assessment of risk; they are administered faceto-face with the patient. Used in lieu of predictive modeling or sometimes as a supplement to such a model, the tool facilitates the stratification of individuals into high-opportunity groups using factors drawn from the exiting program evidence base, patient experience in similar programs, and/or analyses derived from a predictive model. While a number of states rely on instruments developed in-house, others use off-the-shelf toolsespecially to collect supplementary details on risk factors not adequately addressed elsewhere.23 RISK STRATIFICATION MODELS Whether based on the results of predictive modeling and/or the outcomes of individual risk assessments, risk stratification models allocate patients into low- to high-intensity care management interventions and/or service packages.24 The best example of a risk stratification model is the widelyused and -adapted Kaiser Triangle or Pyramid. Developed by Kaiser Permanente, their Chronic Conditions Modelillustrated belowstratifies health plan members according to the risk level presented by their chronic condition(s) and specifies the type of intervention required for each level:

21 Webb, Arthur, Commentary: Safeguarding persons with special needs as New York State transforms its Medicaid program, n.d. Available at: http://www.arthurwebbgroup.com. 22 Also known as health risk assessment tools. 23 Most commonly used off-the-shelf risk assessment tools include EuroQol, Short Form Health Survey, Patient Assessment of Chronic Illness Care (PACIC), Patient Health Questionnaire (PHQ), and Patient Activation Measure (PAM). 24 Some suggest that patients should be stratified into high touch and low touch categories, an approach being followed in New York. This is an unfortunate use of language which goes against the grain of programs with a whole person, patient-centered philosophy and approach.

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According to Kaiser Permanente, about 1-5% of the at-risk chronic disease group is found in Level 3; 15-20% in Level 2; and, 70-80% in Level 125. Each of these risk levels is associated with a specific clinical intervention: Level 3 (intensive case management); Level 2 (specialist disease management); and, Level 1 (primary care plus supported self care). Kaisers Chronic Conditions Model looks simple, but represents a very powerful tool to organize chronic care services of various kinds around the individuals level of risk/need. Overall, the model is associated with enhanced coordination of care, improved Quality of Life (QoL), and fewer hospital admissions and days.26 As such, the approach should be adapted by health homes. What would a comparable risk stratification model look like for persons with DD or a serious behavioral health condition? Answering this question would first require a careful analysis of risk-related outcome data derived from predictive models and/or individual risk assessments. Then, the standard of care for each of the resulting risk levels would have to be developed from evidence-based practice and/or professional consensus. COMPREHENSIVE HEALTH ASSESSMENT27 Once the health home carefully targets and stratifies its patient population, it must perform a comprehensive assessment of the individuals being served in the program. The comprehensive health assessment systematically gathers information on the individuals health status, functioning (physical, mental and cognitive), social situation, availability of informal help, home environment, and current service use. Information on patient and family values, goals and expectations are also obtained. Considered the initial stage of the care management process, this multidimensional baseline is designed to provide an overall picture of the individuals strengths and problems, as well as identify specific service needs (medical, mental health, chemical dependency, long term care, and social supports). As such, it forms the foundation for an individualized care plan, and ultimately the package of services to be delivered to the patient. The first issue is the choice of the assessment tool itself. The standardized instrument selected should represent the gold standard: target population-focused or -sensitive, comprehensive, flexible, and reliable. General assessment tools for all-population use should be avoided, especially in the case of individuals with DD or behavioral health disorders. The following briefly describes examples of assessment tools used for these special needs populations: ASSESSMENT OF PERSONS WITH DD More and more states are using the Supports Intensity Scale (SIS) for people with DD.28 Through a positive interview process; the SIS measures practical support requirements in 57 life activities, as
25 Singh, D. & Ham, C., Improving Care for People with Long Term Conditions, University of Birmingham Health Services Management Centre, 2006. 26 Ham, C., Learning from Kaiser Permanente, unpublished paper, Department of Health. 27 This should not be confused with the risk/health assessment tools discussed in the previous section. 28 New York States Office of People with Developmental Disabilities (OPWDD) proposes to use the SIS as the primary assessment tool for the proposed Developmental Disability Individual Support and Care Organizations (DISCOs), although supplementary sources of information will also be included (e.g., OPWDDs Developmental Disabilities Profile).

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well as in behavioral and medical areas.29 While the SIS could serve as the core of a comprehensive assessment for DD patients, more detailed clinical information would be required to round out the tool.30 Another option is the InterRAIIntellectual Disability that is currently in the final stages of development; the system evaluates sixteen (16) domains most relevant to adults aged 18 and over with DD.31 ASSESSMENT OF PERSONS WITH BEHAVIORAL HEALTH DISORDERS There are numerous comprehensive behavioral health assessment tools for children and adults; many of them have been developed by the states. Like the aforementioned DD instruments, supplementary sources of information will be needed to assess the domains not covered by the tool. The InterRAI Mental Health tool, developed in Canada and in use for over ten years, has become increasingly popular internationally, and offers a solid alternative to other assessment instruments.32 In concluding this section, two other points are important to mention: 1. The integration of the InterRAI Intellectual Disabilities and Mental Health/Mental Health System tools described above with the Community Health Assessment and Self-Reported Quality of Life components33 of the InterRAI Assessment Suite would form the best basis for a comprehensive needs assessment system in New York States health homes.34 2. Virtually all of the health assessment instruments discussed in this section are deficit-oriented. While assessment tools that identify and address deficits improve the treatment and management of complex conditions, behavioral health and DD disorders included, they also tend to create negative biases which end up dis-empowering individuals and becoming clinically counterproductive.35 Strength-based assessment, on the other hand, identifies positive resources, abilities and skills that individuals and their families have and which can be mobilized to creatively address clinical and other challenges of independent living. No matter what toolor combination of toolsis selected by the state and/or the health home provider as the comprehensive assessment instrument, serious effort must be invested in making the process and outcomes as strengthbased as possible. ISSUES IN CARE COORDINATION Care coordination is a core activity of the health home. Its purpose is to coordinate/ integrate and provide access to appropriate, high-quality, person-centered health care services that are informed by the comprehensive assessment, individualized plan of care, and evidence-based clinical practice
29 For a more detailed description of the SIS, see Kodner, D., People First 1115 Demonstration Waiver and the Establishment of Developmental Disability Individual Support and Care Organizations (DISCOs): A Resource Guide for Responding to the November 2011 Request for Information (RFI), Arthur Webb Group, Inc., n.d. 30 Some states use the Health Risk Screening Tool (HRST) in addition to the SIS. HRST is a web-based rating instrument to screen for health risks related to a wide range of disabilities; for further information, see http://www.hrstonline.com. 31 For a brief summary of the instrument, visit http://www.interrai.org/section/view/?fnode+24. 32 A related tool, Community Mental Health, is part of the InterRAI suite. 33 For a description of the Community Health Assessment and Quality of Life components can be found at http:// www.interrai.org. 34 Indeed, state agencies have embraced this approach for the People First Waiver system reforms; beta testing of a version of the InterRAI integrated assessment system is proceeding. 35 For an excellent discussion of this issue, see Rashid, T. and Ostermann, R., Strength-Based Assessment in Clinical Practice, Journal of Clinical Psychology, 65 (5):488-498, 2009.

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guidelines. The care coordination process is carried out by an interdisciplinary team of providers under the direction of a dedicated care manager. SUCCESSFUL CARE COORDINATION MODELS A major question is whether there are successful care coordination models that are designed to address the special needs of individuals with behavioral health disorders or DD. If there are, lessons from these models should be incorporated into the health home design. A recent study by Kodner (2012) examined successful U.S.- and U.K.-based care coordination programs for a wide range of at-risk populations.36 It found that irrespective of the specific individuals targeted, these programs share a great many of the following 20+ characteristics: X Well-defined target population X Risk stratification systems/tools X Multi- or inter-disciplinary team care X Comprehensive health assessment X Care management X Engagement/involvement of primary care physicians X Case conferencing and coordinated consultations X Inter-professional communications system X Access to a broad, personalized package of services X Disease management X Transitional care management X Evidence-based decision support X Patient self-management support X Focus on outcomes management X Involvement of family caregivers X Arrangements for swift referrals to services X Organized provider network X Formal provider linkages X Integrated information system X Continuous quality improvement (CQI) X Strong administrative and clinical leadership X Organizational, clinical, quality and financial accountability X Funding flexibilities

36 The programs examined programs targeted to the frail elderly and people with other chronic, disabling and complex conditions, including individuals with severe behavioral health disorders and developmental disabilities.

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The fact is that most of the above attributes are built into the health home model. OTHER SPECIAL ELEMENTS A CHCS-sponsored webinar in October 200937 does shed some light on the unique challenges involved in coordinating the care of individuals with behavioral health needs or DD. First, confidentiality requirements present a legal hurdle to the coordination of services beyond the traditionally-defined health arena, e.g., with housing providers. As these patient groups often need such services, a solution must be found for this potential impediment. Second, most care managers are not adequately equipped to address the needs of, or work closely with, people with these special needs; care managers must have more specialized knowledge, skills and abilities. CONCLUSIONS In this paper, we explored the health home and ways to build a better model for individuals with behavioral health disorders, DD and other complex conditions. While the health home model embeds many of the components and characteristics known to be associated with successful coordinated care programs, more can be done to enhance its effectiveness. Targeting efficiency could be improved. A combination of risk modeling, risk assessment tools, and risk stratification models should be used to more accurately identify high-risk individuals, stratify them according to level of risk, better allocate care management interventions and services, and help form the actuarial basis for fair and efficient Medicaid payment. These methods must be carefully calibrated with the unique set of clinical and non-clinical characteristics that best explain the totality of resource use and need for each special population. Since comprehensive health assessment plays a key role in driving the individualized care planning process, careful attention should also be paid to the selection and/or development of an appropriate, standardized instrument. The tool should be target population-focused or -sensitive, comprehensive, flexible, and reliable. The InterRAI Assessment Suite is emerging as the gold standard in comprehensive health assessment technology. The multi-component suite is capable of evaluating the individuals full range of health and related needs, including those specifically related to behavioral health and DD. Care coordination in the health home can also be improved by training care managers so that they are more knowledgeable and skilled in working with individuals with behavioral health problems, DD, and other complex conditions. Moreover, confidentiality concerns arising from collaboration across the health care and social service divide must be identified and addressed. Finally, the health neighborhood is a new idea on the horizon. The concept, an analogue of the medical neighborhood model already being tested in conjunction with existing medical homes, offers a framework for stronger, more effective links between health homes and the wide array of clinical and non-clinical providers in the surrounding community; this promises enhanced care coordination and more holistic, person-centered care. COMMENTARY BY ARTHUR WEBB
37 CHCS, Responses to Unanswered Questions from the CHCS Webinar: Establishing Accountable Physical/ Behavioral Health Care Homes: Medicaid Innovations, October 27, 2009. While the focus is on serving individuals with physical and behavioral health needs in a health home, they are also applicable to people with DD.

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The series of articles on special needs that I have sponsored is intended to offer clear policy advice based on evidence and best practices to public officials, mainly New York State officials, and provide specific guidance to providers as they confront the myriad of policy initiatives flowing like a Class Five white water through the Hudson River Gorge requiring courage, competence and vision to transform their services. In this article I wanted Dennis to dig deeper into the requirements of care coordination and shine light on the grey areas of implementation especially around health homes. This article is relevant to managed care implementation, as well. I wanted him to lay out the principles and uses of predictive modeling, risk stratification, targeting and assessment so that policy makers and providers understand how complex a proactive population health management strategy is. It is essential that we can accurately identify high-risk individuals in a given population, stratify them according to level of risk, and allocate resources appropriately. For providers, they need to build provider-based data warehouses to create the database for analysis. We need the state to share state data and algorithms they are using to establish levels of care as they are attempting to do in health homes. In examining these approaches, it should be recognized that individuals with complex co-morbidities, including those with DD and behavioral health disorders, demand a depth and breadth of analysis that takes into account all aspects of their health and mental health status, including clinical profile, gaps in care, and other information that is not readily available through traditional data sources (e.g., functional status, social context, caregiver support, and health behaviors and attitudes. As you see in the article, I wanted to promote the concept of modeling as developed by Kaiser. (Reference is to the pyramid) In a recent Health Affairs (February 2012) article, Susan Dentzer, Editor-inchief, interviews Chet Burrell, President & CEO of CareFirst BlueCross BlueShield. In this interview Chet presents his Pyramid of Illness Burden. This is another useful application of stratification thinking that is quite relevant for public policy and providers organization of services. The New York State Department of Healths implementation of health homes is one of the best examples of an effort at policy levels to take the concept of stratification and apply it those with serious mental illness. It establishes the basis for levels of care and the reimbursement associated with each level. I would strongly encourage the state to share the data base they are using and the algorithms used to help providers replicate this at the provider level. We will continue to probe and examine the concept of modeling in subsequent articles.

This paper was authored by Dr. Dennis L. Kodner and prepared with the support of the Arthur Webb Group, Inc. Dennis L. Kodner, PhD, FGSA is a global thought leader on health systems/services integration. Dr. Kodner is an expert on coordinated and managed care systems for people with chronic, disabling, medically complex, and high-risk conditions, including the frail elderly and other individuals with needs that cut across the health, long term care, behavioral health, and social service systems. He is currently an International Visiting Fellow at The Kings Fund, London, U.K., where he co-directs the Aetna Foundation project on co-ordinated care for complex populations. Arthur Y. Webb Mr. Webb has extensive experience in the policy and practice areas of serving high needs, high cost individuals. See www.arthurwebbgroup.com