Utilizing Bundled Technology to Prevent Re-Hospitalization Among Substance Dependent Patients At High Risk of Relapse
New Zealand Presentations August 2013
AGENDA
Brief Review of Loyola Model
Key Current Business Components
US and New York State Healthcare Environment
mPOWER—A Model Program Using the ACHESS Platform
ACHESS Details
Closing Thoughts on Health System Needs and the Need to Change Thinking on Addiction Treatment
The Challenge
Can outpatient mental health, primary care and substance treatment outpatient service arrays be altered or augmented with evidence based tools to minimize risk for chronically relapsing substance dependent patients?
Loyola Model Review
Provide an “Aspirin” for US Veterans Administration Healthcare “Headaches” for Veterans with Complex Care, Addiction, Housing, Employment and
Behavioral Health Needs.
Loyola Rubric: Better Care as Evidenced by Clinical Outcomes and Patient Satisfaction; Lower Price; Expanded Service; Proof of Concept that Evidence Based Medicine, Innovation and Integration are possible.
Loyola Model Review Continued
Maintain Rubric in Accordance with a Recovery Vision Veterans Support:
Recovery = Health, Job, Home, Relationships (“A Life in the Community For Everyone”—Charles Curie)
Care Questions Normalized to the Voice of the Veteran with Veteran Governance.
Services Build “Mutual Reinforcement” by providing Veteran Employment.
Loyola Service Matrix
• Employment • Modeling
Evidence Based
• Housing • Evidence Based
Addiction Medicine Inpatient Crisis Services and Outpatient Specialty Support (mPOWER) Permanent and Transitional Housing, Employment and Peer Support Mutually Reinforcing Model of Loyola Job Creation Teaching the “Loyola Method” for Community— VA Partnership
Loyola Model Service Components
50 Crisis Detoxification Beds (Bath, Albany VAMC’s 25 Each).
Eaglestar Housing 15 Transitional Beds in East Pembroke, 15 in Spencerport and SPARC.
mPOWER Outpatient Model for At Risk Veterans.
“VITAL” Intervention Project with Rochester General Hospital.
US and New York State Healthcare
Environment
Affordable Care Act seeks to “bend the cost curve”
through effective management of high risk/high need patients.
September, 2012 Presidential Executive Order directs VA to Contract with Community Healthcare Providers for Service needs not met by VA.
IOM Report (September 2012) indicating high
opioid/alcohol prevalence among veterans and low infrastructure
US and New York State Healthcare
Environment
Integrated Specialty Care Components based on evidence based models with “Pay for Performance” approaches Sought by Healthcare entities (“build or buy”) to capture savings.
Adoption of “Meaningful Use” EHR’s, Predictive
Analytics and Mobile Technologies Essential (Loyola has all three).
US and New York State Healthcare
Environment
All Services Being Shifted to Medicaid as enrollments begin in State Healthcare Exchanges; up to 30 Million New Enrollees Possible
Most State Medicaid Plans have moved to or are moving to Care Management
Technology is facilitating the development of Virtual Coordinated Care Management—EHR’s, Health
Information Exchanges, Remote Monitoring,
Key Assumptions in US Affordable
Care Act
Healthy, younger Americans will Enroll in Healthcare Exchanges to balance risk
Existing US Primary Care, Hospital and Behavioral Health System can absorb 30 Million more users
Existing High Utilizers of Healthcare will be managed into changing High Risk Behaviors
Employers will maintain coverage for employees throughout the transition
Physicians and Health Systems will engage incentives and build Accountable Care Organizations
mPOWER
In 2010, Loyola identified 43 Veterans with 3 or more Detoxification Hospitalizations in 18 months or less.
Similar profiles of chronic alcohol dependence,
trauma, mental health condition and physical illness
Every detox episode offered the “same thing” for a recovery support strategy
mPOWER
Loyola designed a “bundled” evidence based care and integration strategy combining cutting edge
technology in, smartphone recovery support (ACHESS), pharmacological recovery support
(Vivitrol), trauma support (Najavits, et.al.) and peer support (White, et.al.).
Strategy defined as “mPOWER” Program (Mobile
Patient Opportunities for Wellness, Empowerment and Recovery)
mPOWER
SAMHSA funded project for 3 years (2011-2014)
Service Partners: University of Wisconsin ACHESS Project, Westat (Evaluation).
Key metric for the program is to reduce inpatient hospitalization rate to 1 or less every 18 months.
Data Collected: GPRA, SF-36, Brief Alcoholism Monitor—BAM (weekly analytic)
mPOWER
Project integration strategy is that mPOWER medical providers are credentialed by VA Health System and project works as “collaborative care” model with VA Mental Health and PACT primary care teams.
All services delivered at Bath VAMC and supported by Loyola Transportation Network
Loyola staff paid for by grant. Medication prescribed out of and procured by VA pharmacy and labs paid for by VA.
mPOWER
Loyola staff enters notes in VA CPRS system capturing encounters for VA utilization data and Vivitrol ordered out of VA pharmacy
Loyola staff attends Behavioral Health and Primary Care team meetings.
Patients weekly survey mapping risk and protective factors are done on the smartphone (BAM) and staff responds to high risk situations
mPOWER
Key Results
44 Active Patients for 11 months (110% of 1st Projected
Enrollment)
Pre-Enrollment Total Hospitalizations in Patient Cadre = 147
Post-Enrollment Total Hospitalizations in Patient Cadre = 28
80% Reduction in Hospitalizations. Multiple relapses localized to 4 patients
mPOWER
Emerging data on Health Status Improvement, Treatment Compliance and change in symptoms available in October, 2013
Program Admission Demand, driven by veteran
patient “word of mouth” is double current capacity
VAMC’s recognizing need for more infrastructure;
seeking model development (1000 Patient Expansion)
Rest of Care Continuum must be developed (Housing, Employment)
Logic of the mPOWER Model
Collaboration/Co-Location Service Integration
Virtual Delivery of Care Management, Predictive Analytics and Recovery Support through Mobile Phone Platform (Self-Determination Theory)
Risk Sharing Model of Cost, justified by Cost Offset Deliverables
Mutual Accountability for Outcomes between Partners
Activated Patients will display greater motivation to manage their own care. They will articulate a
Three Essential Ingredients of Change
(CHESS Foundation)
Coping
Competence
Social
Relatedness
Autonomous
ACHESS
Monitoring and alerts
Reminders
Autonomous motivation
Assertive outreach
Care coordination
Medication reminders
Peer & family support
Relaxation
Locations tracking
ACHESS has better 30 day
abstinence
Differences significant at p = .03
0 10 20 30 40 50 60 70 80 90
Month 4 Month 8 Month 12
ACHESS Control
ACHESS had fewer heavy drinking days
Differences significant at p = .003
0.5 1 1.5 2 2.5 3 3.5
ACHESS Control
The Rest of the mPOWER Story
What Health System Administrators Care About
Patient Need/Community Public Health Profile Health Delivery System
Health Outcomes/Efficacy/Data/Metrics Cost/Reimbursement/Cost Offsets
Risk Management
Safety/Compliance/Accreditation Staffing/Staff Retention
mPOWER Story (cont.)
What DON’T Healthcare Administrators Care About?
Everything They Can’t Reconcile
Against the Preceding List of
Business Model Disconnect
Substance Use Disorders Co-Mobidities Clinical Intervention Social Determinants Spirituality Chronic DependencePhysical Cognitive Modalities (Ind./Family)
Housing Transcendent
Mental Health
Pharmacology Jobs Religious
Peer Support Non-Peer Relationships
Mystical
Creative Destruction of Medicine
Super Convergence New Medicine -Mobile Connectivity -Internet -Social Networking -Computing Power Data Universe Old Medicine -Wireless Sensors -Genomics -Imaging -Information Systems -Predictive AnalyticsStrategy—Von Blucher and the
Rear Guard Action
Von Blucher
Had given his word to Wellington to meet him at Waterloo
Army had been shaken on 16 and 17 June, 1815 by Napoleon
Had to Save the Army by marching to Wavre, leaving a Rear Guard Force and moving the main Army to
Waterloo
The Action tipped the balance and Napoleon was defeated
Von Blucher
A Rear Guard Action assumes the Rear Guard will fight to the last soldier to buy time. All of the Rear Guard is typically lost
The main fighting force is maintained but forever altered-focusing on movement as well as impact
A diminished army needs alliance to overcome a powerful force (military or market)
Adaptation and Perseverance are Key—Culture must rapidly eject all non-productive assumptions and
Closing
1. What Do Patients Need to Have the Highest
Probability of Attaining a Positive Health Outcome
2. What Does the Public Health Case Mandate?
3. What Do You Know How To Do?
4. Can You Operationalize It and Prove It Over the Long Haul?
5. Are You the Least Expensive, Most Effective, Most Valuable Thing They Have Ever Seen?
Contact Details
Christopher R. Wilkins, Sr., President Loyola Recovery Foundation, Inc.
1159 Pittsford Victor Road, Suite 240 Pittsford, New York 14534
PH: +1 585.203.1250 FAX: +1 585.203.1013
