Recently Funded Projects: Improving Health Care Coordination

Connected Care: Improving Health Care Coordination and Outcomes for Underserved Individuals with Serious Mental Illness in Allegheny County, Pennsylvania

Funder: CVS Caremark Charitable Trust

Summary: Connected Care is a multi-stakeholder collaboration designed to achieve positive and measurable outcomes for an estimated 7,500 underserved individuals with serious mental illness (SMI) and chronic medical conditions in Allegheny County, Pennsylvania.

Initiated in July 2009 as part of a statewide quality improvement initiative organized by the Pennsylvania Department of Public Welfare and the Center for Health Care Strategies (CHCS), the Connected Care program is under the joint leadership of Community Care, UPMC for You (Allegheny County's largest physical health Medicaid managed care organization), and the Allegheny County Department of Human Services, Office of Behavioral Health.

Based on the principles of the Patient-Centered Medical Home model, Connected Care combines the data infrastructure and care management capabilities of managed care organizations with the clinical expertise of primary care providers and behavioral health specialists to address the complex behavioral, medical, and social needs of the underserved SMI population across outpatient, inpatient, and emergency room (ER) settings.

The program focuses on improving health care coordination and outcomes by bridging the historic cultural, education/training, and communication gaps between physical and behavioral health providers; overcoming traditional barriers to information sharing posed by confidentiality provisions; designing and implementing integrated, person-centered care plans that address each member’s unique needs; and facilitating care transitions (i.e., from inpatient to outpatient settings) and cross-system linkages (i.e., between primary care and behavioral health).

Internal analyses suggest that the program has reduced both physical and behavioral health hospital readmission rates, duration of inpatient stays, and ER usage while lengthening time in the community between acute treatment events and improving rates of metabolic screening for those taking psychotropic medications.

Mathematica Policy Research wrote a report evaluating a pilot project in Pennsylvania which was coordinated by the Center for Health Care Strategies and complemented the Connected Care initiative.

Download the report here.

About the report: Through the Serious Mental Illness (SMI) Innovations Project, Pennsylvania's Department of Public Welfare sought to improve the integration of physical and behavioral health services and reduce unnecessary utilization for Medicaid beneficiaries with both mental illness and chronic medical conditions. The two-year initiative, which began in 2009, included two pilots in the Southeastern and Southwestern regions of the state. It was part of the Rethinking Care Program, a national initiative coordinated by the Center for Health Care Strategies (CHCS) and supported by Kaiser Permanente Community Benefit to test new care management approaches for Medicaid's highest-need, highest-cost beneficiaries.