Community-based Health Home in an Integrated Care Partnership for Adults with SMI
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DESCRIPTION (provided by applicant): The proposed one-year planning project will leverage an unprecedented opportunity afforded by a Center for Medicare and Medicaid Innovation (CMMI) grant implementing a novel pilot program of a Community Behavioral Health Home (CBHH) within an Integrated Care Partnership for dually eligible and high-cost Medicaid beneficiaries. This innovative service model consists of a "virtual health home" integrated into community-based outreach teams, an embedded medical nurse providing chronic disease management supported by telehealth, and a health outreach worker trained to provide integrated illness self-management support. The goal of this planning proposal is to build the data and research infrastructure to extend the current CMMI pilot (four outreach teams providing CBHH to 480 persons), to a full-scale empirical evaluation of the CBHH model in a newly formed Integrated Care Partnership including 20 outreach teams serving n=2400 dually eligible and high-cost Medicaid beneficiaries with SMI and medical comorbidity. Aim 1 will develop and pilot test an integrated data collection and management infrastructure including: a) establish an Outcomes and Data Informatics Workgroup; b) develop the relational database; c) prepare data use agreements and security protocols; d) create and pilot test automated data collection; e) organize protocols for de-identification and integration of claims data; and f) refine assignments to risk tiers. Aim 2 will engage in a planning process for a large-scale empirical study of the outcomes and costs in an implementation of the Community Behavioral Health Home (CBHH) model in a new Integrated Care Partnership for dually eligible and high-cost Medicaid beneficiaries with SMI and medical comorbidity, including: a) establish and operate the Research Design Planning Workgroup; b) refine the Community Behavioral Health Home (CBHH) model; c) identification of optimal research design for the future study; d) refinement of recruitment and human subject IRB procedures for the future study; e) preparation of an ROI research project grant application for a future large-scale study of the CBHH model implemented in 20 teams serving approximately 2,400 persons with SMI.
