From The Field N O V E M B E R 1 7 , 2 0 1 4 Demonstrating Behavioral Health Impact Using Intensive Community-Based Services JOANN BIRKHOLZ KATHY GREGERSEN Foundation Director, Medica Foundation Executive Director, Mental Health Resources T he Medica Foundation is the charitable giving arm of expand the ICBS program in the Twin Cities. MHR is a pro- Medica Health Plans, a Minnesota-based, regional gressive nonprofit organization that offers community-based nonprofit health maintenance organization. The mental health services. MHR specializes in serving complex Medica Foundation funds community-based initiatives that clients who need mental health services and may also have support the needs of customers and the greater community by co-occurring medical, substance abuse, or social barriers. improving their health and removing barriers to health care MHR’s ICBS program provides three to six months of services. Behavioral health has been a cornerstone funding area intensive case management services for high-risk adults with a for the Medica Foundation over the last 10 years. chronic mental illness and/or substance abuse problem. The program helps clients successfully transition from an inpatient RESPONDING TO A COMMUNITY NEED treatment facility into a community setting by coordinating complex health care and social services. These intensive ser- Individuals experiencing an acute episode of mental illness vices are not generally reimbursable by Medicaid or private often face challenges navigating a fragmented health care insurance. Medica introduced a unique reimbursement model, delivery system and overcoming barriers to access appropriate which allowed MHR to fill a gap in the current mental health medical and mental health services. The social impact on system. With funding support from the Medica Foundation, these individuals often includes a loss of employment, hous- MHR was able to offer ICBS services to a broader population ing, and relationships. Without appropriate treatment and beyond Medica members—people who otherwise would not medication, individuals frequently access the emergency be eligible for the services. department and are hospitalized for both medical and mental Many of MHR’s clients live on the margins of mainstream health conditions. The Intensive Community-Based Services society and lack natural supports, coping mechanisms, and (ICBS) program was created in response to this community insight to see the consequences of their choices. They often need. Short-term (two to six months) intensive services were have experienced abuse and neglect and grew up in poverty. provided through an innovative collaboration between When adverse experiences impact their lives, they do not have Medica, Medica Behavioral Health, St. Louis County the skills needed to access community supports, nor the (Minnesota), the Minnesota Department of Human Services, understanding that this support can improve their situation and two community mental health centers. and well-being. The beauty of the ICBS program is its flexibil- ICBS services were provided by community mental health ity to tailor the intensity and types of services to meet agencies to Medica members with complex conditions. ICBS individual needs. provided both case management and direct care to address the MHR’s case managers coordinated care and services, facili- specific barriers facing individuals whose needs often included tated the communication between providers and social mental health, chemical health, psychosocial, housing, and services, and frequently accompanied individuals to appoint- medical issues. Each ICBS provider had an identified Medica ments. This promoted treatment and service continuity, as behavioral health care advocate who supported their work well as treatment compliance, which prevented the need for with members. higher-level services. Evaluation of the ICBS program in St. Louis County showed significant reductions in hospital utilization for all members EVALUATION AND OUTCOMES living in the county. Based on this success, the ICBS program was expanded to the Twin Cities metropolitan area. To assess the impact of this program on clients’ lives, MHR tracked the progress of a sample of clients toward a variety of STRATEGIC PROGRAM GRANT self-reported outcomes while enrolled in the ICBS program, In 2011 the Medica Foundation awarded a three-year, which included: $300,000 grant to Mental Health Resources (MHR) to • 94 percent of the clients did not use acute crisis services. • 97 percent avoided detox centers. CHART 1: • 97 percent of the clients stayed out of jail. AVERAGE TOTAL COST PER MONTH • 82 percent of the clients took their prescribed psychiatric BY SERVICE CATEGORY medications. Inpatient Outpatient While these outcomes were impressive, MHR did not have Prescription access to the data needed to objectively analyze the clients’ Drugs utilization of health care services. Medica Foundation Emergency engaged Medica Health Plan’s evaluation team, who con- Dept ducted an analysis of medical claims trends for a small group Other of Medica members who received services through the ICBS Urgent program. The team studied the monthly costs and utilization Care data for 30 clients enrolled in the program. Data were $0 $500 $1,000 $1,500 $2,000 reviewed for a six-month period prior to the clients receiving Pre (6 months) Post (6 months) MHR services and the six months after they began receiving services. This represented a unique partnership between a nonprofit organization, funder, health plan, and behavioral NEXT STEPS care organization. MHR continues to share the ICBS program results with local CLAIMS ANALYSIS health plans, health systems, and funders. They are hopeful that the reimbursement model developed by Medica and As shown in Chart 1, Medica members in the ICBS program Medica Behavioral Health will become universally adopted in had a significant reduction in high-dollar claims, including Minnesota. With appropriate reimbursement and funding, inpatient admissions and emergency department visits. MHR has the opportunity to build on this project. The ICBS Conversely, there was an increase in the use of prescription model highlights the importance of integrating primary care drugs, which aligned with the goal of stabilizing clients’ and mental health care along with intensive care coordination mental health. Overall, there was almost a 50 percent that addresses the social determinants of health. reduction in medical spending for Medica members who The Medica Foundation is proud to fund innovative ideas participated in the program. that advance systemic change by ensuring higher quality care Specifically: and outcomes, at significantly reduced costs. • Inpatient hospitalizations were reduced by 72.2 percent. • Emergency room visits decreased by 35.4 percent. The authors would like to acknowledge Susan Voigt, Program • Urgent care visits decreased by 12.5 percent. Manager, Medica Foundation; Cary Zahrbock, Assistant Vice President, Medica Behavioral Health; Jesse Montgomery, • Outpatient visits decreased by 18 percent. Director, and Amanda Elkin, Manager, Medica Health Plans • Prescription drug usage increased by 57.2 percent. for their contributions to this work. Medica Health Plans contracts with Optum, a behavioral KEY LEARNINGS health managed care organization, branded as Medica These results demonstrate that MHR’s intensive case manage- Behavioral Health, to manage their behavioral health benefits. ment services helped stabilize clients’ lives during the recovery process and also reduced medical spending by 50 percent in a six-month period. The most significant impact on medical spending was reducing inpatient hospitalizations. Clients also substantially increased their prescription medication compli- SOURCES ance. A July 2014 issue brief by The Commonwealth Fund McGinnis, Tricia, Maia Crawford, and Stephen A. Somers. A states, “There is a growing recognition that social factors— State Policy Framework for Integrating Health and Social Services. such as individual behavior, socioeconomic status, and the The Commonwealth Fund. July 2014. http://www.common physical environment—have a greater impact on health out- wealthfund.org/~/media/files/publications/issue-brief/2014/ comes than medical care…However, policymakers must jul/1757_mcginnis_state_policy_framework_ib.pdf. contend with some challenges…There is little evidence to support a positive return on investment (ROI) for integrating services.” The program that MHR implemented with the Views from the Field is offered by GIH as a forum support of the Medica Foundation and Medica Health Plans for health grantmakers to share insights and experiences. If you are offers evidence in support of a strong ROI. interested in participating, please contact Osula Rushing at 202.452.8331 or orushing@gih.org.