Extension for Community Healthcare Outcomes in Geriatric Mental (ECHO® GEMH)

Michael Hasselberg, PhD, NPP-BC Assistant Professor of Director of Project ECHO® Director of Telepsychiatry

UR OARHS Office for Aging Research and Health Services Disclosures

I have no financial relationships with a commercial entity producing health- care related products and/or services to the content I am presenting

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OARHS Acknowledgements . Supported by funding from o The New York State Health Foundation o The Health Foundation of Central and Western New York o Greater Rochester Health Foundation

. Infrastructure support from o Project ECHO®, University of New Mexico (UNM)

(Slides adapted from those of Sanjeev Arora, MD, UNM Professor) 3

OARHS Growing Need

. Aging and disease impact in New York State (NYS) o Population age ≥ 65 years will rise from 2.5 to 4 million by the year 2030 o Elderly with mental illness will rise from 495,000 to 772,000 by the year 2030

. Costs of inadequate care in NYS o In 2011, health care costs for elderly with alone was $690 million • Value of unpaid care exceeded $13 billion

New York State Office of , 2013; Alzheimer’s Association, 2012

OARHS Alliance for Aging Research, 2002

OARHS Geriatric Psychiatry Shortage • Only 1,596 physicians are currently certified in geriatric psychiatry • One for every 11,372 older Americans • By 2030 that total is predicted to rise to only 1,659, which would then be only one for every 20,195 older Americans (ADGAP, 2007b). • Half of fellowship positions go unfilled nationwide • General psychiatry is a partial solution • 71% feel very prepared to dx and treat delirium • 96% to dx and treat major • 56% to diagnose and treat dementia.

Retooling for an Aging America: Building the Health Care Workforce http://www.nap.edu/catalog/12089.htm 6

OARHS One solution: Project ECHO®

The mission of Project ECHO® is to expand the capacity to provide best practice care for common and complex diseases in rural and underserved areas and to monitor outcomes.

Goal is to touch the lives of 1 billion people by 2025

Supported by New Mexico Department of Health, Agency for Health Research and Quality, New Mexico Legislature, the Robert Wood Johnson Foundation and the GE Foundation.

OARHS Project ECHO® Hepatitis C (HCV)

. In 2004 less than 5% of patients with HCV in New Mexico had been treated o Estimated 28,000 people with HCV in New Mexico o No Primary Care Physicians treating HCV in New Mexico

Good news … o Curable in 70% of cases

Bad news … o Severe side effects: . anemia (100%) . neutropenia >35% . depression >25%

OARHS Methods of Project ECHO® . Use Technology (multipoint videoconferencing and Internet)

.Disease Management Model focused on reducing variation in processes of care and sharing “best practices”

. Case based learning: Co-management of patients

. HIPAA compliant web-based database to monitor outcomes

Arora (2013); Supported by N.M. Dept. of Health, Agency for Health Research and Quality HIT Grant 1 UC1 HS015135-04, New Mexico Legislature, and the Robert Wood Johnson Foundation. 9

OARHS OARHS Project ECHO® HCV Outcomes Sustained Viral Response (SVR): no detectable virus 6 months after completion of treatment

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OARHS 12

OARHS Project ECHO® in New Mexico

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OARHS ECHO® Replication in

• University of Washington (HCV, Chronic Pain, HIV, Multiple Sclerosis) – Seattle, WA • University of Chicago (, Breast Cancer Survivorship/Women’s Health, Pediatric ADHD, Childhood Obesity, HCV) – Chicago, IL • University of Nevada (Antibiotic Stewardship, Autism (closed group, by invitation only), Diabetes/General Endocrinology, Gastroenterology, Rheumatology, Sports Medicine, Mental Health: Professional Development Groups (closed groups, by invitation only), Mental Health Clinic Director’s Group (closed groups, by invitation only), Marriage & Family Therapy Intern Supervision Clinic (closed groups, by invitation only) – Reno, NV • University of Utah (HCV, Advanced Liver Care, Chronic Pain) – Salt Lake City, UT • Florida/Caribbean AIDS Education and Training Center, University of South Florida (General HIV, Adolescents/Pediatrics HIV, HCV/HIV Co-Infection, Psychiatry & HIV, Spanish Language HIV) – Tampa, FL • Harvard/Beth Israel Deaconess Medical Center (HCV, Gerontology – ECHO AGE) – Boston, MA • St. Joseph’s & Medical Center (HCV) – Phoenix, AZ • Community Health Center, Inc. (HIV, HCV, Chronic Pain, Opioid Addiction – Buprenorphine, Coaches International—supporting Quality Improvement and Specialists) – Middletown, CT • LA Net (AAPA Preventive Care, Nephrology, Adult Psychiatry) – Los Angeles, California • UNM: Center for Development and Disability (Autism) – Albuquerque, NM • UNM: Envision NM (Childhood Overweight Medical Management, Pediatric Nutrition, Psychiatry, Asthma/Pulmonary) – Albuquerque, NM • CHI St. Luke’s Health (HCV, HBV, Infectious Disease) – Houston, TX • University of California Davis (Pain Management) – Davis, CA • University of Wyoming, Wyoming Institute for Disabilities (Assistive Technologies) – Laramie, Wyoming • Ochsner Health System (Liver Care) – New Orleans, LA • University of Texas MD Anderson Cancer Center (Cervical Cancer Prevention) – Houston, TX • Oregon Health and Science University/Health Share of Oregon (Psychiatric Medication Management) – Portland, OR • University of Rochester Medical Center (Geriatric Mental Health) – Rochester, New York • Visiting Nurses Association Health Group (Care Transition) – Red Bank, New Jersey • Missouri Telehealth Network/University of Missouri (Autism) – Columbia, MS • University of Colorado School of Public Health (Children and Youth with Epilepsy) – Denver, CO 14

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OARHS ECHO® Replication Worldwide

National AIDS Control Organization and Maulana Azad (HIV) – New Delhi, India Institute of Liver and Biliary Sciences (HCV) – New Delhi, India Universidad de la República (Liver Disease) – Montevideo, Uruguay West/North West Group (Diabetes) – Galway, Ireland ECHO Ontario (Chronic Pain) – Queens University & University of Toronto Ontario, Canada Northern Ireland Hospice (Hospice Care) – Belfast, NI National Institute for Mental Health Services (NIMHANS) (Mental Health and Drug Addiction) – Bangalore, India B.J. Medical College (HIV) – Ahmedabad, India Vietnam National Lung Hospital (TB) – Hanoi, Vietnam Hospital Italiano (HCV) – Buenos Aires, Argentina PUCRS Brazil-( Depression and Dementia) 16

OARHS Geriatric Mental Health & Care 17

OARHS Project ECHO® GEMH Goal

To support the delivery . by primary care practices (PCPs) in underserved and rural areas of New York State (NYS) . of expert care . to older adults with dementia or mental disorders.

OARHS Project ECHO® GEMH

PC PC PC Practice Practice Practice

PC PC Practice Practice URMC Hub Site • Geriatric psychiatry • Geriatric medicine • Geriatric • Social work PC PC • Pharmacy Practice Practice

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OARHS 20

OARHS Current Participants

. Primary Care Practices o Hospital system affiliated o Accountable care affiliated o Provider owned group

. Federally Qualified Health Centers

. Health Service Corporations

. County Department of Aging Centers

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OARHS Workforce Development

. UR School of Medicine . UR School of o Medical School Program o Undergraduate Nursing Program o Family Medicine Residency Program o Family Nurse Practitioner Program o Psychiatry Residency Program o Adult Nurse Practitioner Program o Geriatric Psychiatry Fellowship o Psychiatric Nurse Practitioner Program o Interdisciplinary Geriatric o Graduate Nurse Leadership Program Medicine Fellowship

o Clinical Psychology Fellowship

. St. John Fisher Collage of Pharmacy

. Niagara Falls Medical Center Family Practice Residency Program 22

OARHS UR Medicine Project ECHO® Hub Site Health System Affiliated Primary Care Site Primary Care Practice Group Site Federally Qualified Health Center Site Health Care Service Corporation Site County Department of Aging Site

OARHS Program Evaluation First TeleECHO™ clinic was held on September 18, 2014

To Date:

24 TeleECHO™ clinics 546 participants 181 Continuing Medical Education (CME) credits 49 patient case presentations

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OARHS Preliminary Outcomes

CME Survey Results:

Overall Rating/Content Poor Fair Good Very Good Excellent How well were objectives met 0% 0% 2% 19% 79% Objective/evidence-based content 0% 0% 2% 17% 81% Opportunities to ask questions 0% 1% 7% 17% 75% Appropriate pace 0% 0% 4% 29% 67% Organization of presentation 0% 0% 1% 16% 83% Presenter clearly communicated 0% 0% 1% 13% 86% Relevance of presentation 0% 1% 0% 13% 86%

n = 181

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OARHS Preliminary Outcomes Participant Qualitative Interviews:

. Most feel clinics are useful, some do not

. Of those who could implement suggestions, they often saw results

. Most feel that they will use learnings in future work

. Clinics are considered particularly useful for complex cases, poly pharmacy, reducing reliance on antipsychotics

. Clinics can be perceived as validating for participants in that cases are complex and it’s normal to struggle with them

. Major value – access to specialists otherwise unavailable

26 OARHS Sustainability

. External cost evaluation being conducted by the New York Academy of Medicine

. Collaboration with Excellus BCBS o Practice level claims data

Fee-for-service versus Accountable Care

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OARHS Accountable Care An accountable care organization or network is a healthcare organization characterized by a payment and care delivery model that ties provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. A group of coordinated health care providers forms an ACO, which then provides care to a group of patients.

. UR Medicine– Accountable Health Partners (AHP) Private MDs Community & Hospitals Strong UR Medical Community Memorial Hospital Faculty Group Highland, Thompson, Jones Memorial, Noyes, Hospital Employed MDs Arnot Ogden 28

OARHS How do we integrate Project ECHO® into Accountable Care . NYS Delivery System Reform Incentive Payment (DSRIP) Program o Restructure the health care delivery system • To create an accountable, coordinated network of care that improves access, quality and efficiency of care for patient populations o Reinvesting in the Medicaid program • Up to $8 billion dollars are allocated to this program o Primary goal of reducing avoidable hospital use

* DSRIP Project Toolkit (page 39) “Modeling of Project ECHO is encouraged where appropriate.” 29

OARHS Finger Lakes Performing Provider System (FLPPS)

. Rochester Regional Health System (RRHS) and UR Medicine o Lead implementation of DSRIP o In partnership with over 600 organizations 30 http://flpps.org/ OARHS

FLPPS DSRIP Project 3.a.v Behavioral Interventions Paradigm in Skilled Nursing Facilities (SNF)

Vision:

1. Build an education, consultation & training infrastructure for SNF clinical and non-clinical staff

2. Improve access to psychiatric expertise and behavioral health sub-acute care

3. Modify facilities to assure that adequate recreation and holistic interventions can be carried out 31 OARHS

SNF Needs Assessment NYS Statistics FLPPS Region Statistics

. Approximately 30% of new . Hospital readmissions following admissions are discharge to a SNF account for among persons with mental illness about 16% of all Medicaid

. Older adults with dementia have readmissions a three-fold increased risk of o Behavioral symptoms are within the Top 11 reasons for readmission hospitalization

. 1 in 5 residents will be given an . Greatest and most consistent antipsychotic medication, though increase (58%) in citations for only 1% will ever be diagnosed inappropriate antipsychotic use with a psychotic condition from 2011 to 2012 across NYS

Grabowski, et. al., 2009.; Becker, et. al., 2009; The Long Term Care Community Coalition, 2014; NYSDOH, 2012 32

OARHS SNF Needs Assessment

ORLEANS

MONROE WAYNE

GENESEE

SENECA ONTARIO CAYUGA

WYOMING YATES LIVINGSTON In need of additional mental health services

SCHUYLER ALLEGANY STEUBEN Entirety as lacking mental health services CHEMUNG

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OARHS Harvard ECHO® AGE in SNFs . Geriatric mental health and dementia ECHO® to New England SNFs associated with the Beth Israel Deaconess Medical Center

o 34% discontinuation or reduction of antipsychotics

o Behavioral interventions recommended in 72.3% of patient cases

o 74% patients had clinical improvement when recommendations were followed - Significantly lower mortality (p < 0.03)

o 60% reduction in hospitalizations when recommendations were followed Catic, et. al. 2014 34

OARHS ECHO® GEMH in DSRIP Project 3.a.v

. Implementation underway

. Participants to include all staff with patient care responsibilities

. Rollout to begin November 2015? o Year 1: 30 SNFs participate in biweekly clinics o Year 2: Additional 30+ SNFs to participate on alternating weeks

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OARHS Potential Benefits to the Participant .  access to consultation re: effective management of gero-psychiatric disorders and dementia.

.  burden on family caregivers (with resulting health benefits).

.  quality (didactics and care target quality metrics).

.  cost across the system, with  unnecessary care.

.  provider satisfaction – engagement in community of practice.

. CME credits (1 hr/hour of participation). . NO COST

OARHS Potential Benefits of Project ECHO® to the Health System

• Quality and Safety • Rapid Learning and best-practice dissemination • Reduce variations in care • Access for Rural and Underserved Patients, reduced disparities • Workforce Training and Force Multiplier • De-monopolize Knowledge • Improving Professional Satisfaction/Retention • Cost Effective Care- Avoid Excessive Testing and Travel • Prevent Cost of Untreated Disease • Integration of Public Health into treatment paradigm

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OARHS ECHO® Expansion in NYS

. ECHO® PSYCH (General Psychiatry) o Funding from New York State Health Foundation o Expected launch in November 2015

. ECHO® GEMH in Long Term Care o Funding from Greater Rochester Health Foundation o Expected launch in November 2015

. ECHO® Pal (Palliative Care) o Funding from Greater Rochester Health Foundation o Expected launch in June 2016 38

OARHS Conclusions . ECHO® model is a robust method to safely and effectively treat common and complex diseases in underserved areas and to monitor outcomes

. UR Medicine - expansion to other disorders may soon follow

. Sustainability

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