Community-based Health Home in an Integrated Care Partnership for Adults with SMI

描述（由申请人提供）：拟议的为期一年的计划项目将利用医疗保险和医疗补助创新中心（CMMI）提供的前所未有的机会，在综合护理合作伙伴关系中实施社区行为健康之家（CBHH）的新试点项目，为双重资格和高成本医疗补助受益人提供服务。这一创新服务模式包括一个与社区外展小组相结合的“虚拟保健之家”、一名在远程保健支持下提供慢性病管理的嵌入式医疗护士，以及一名经过培训提供综合疾病自我管理支持的卫生外展工作者。该计划提案的目标是建立数据和研究基础设施，以扩展当前的CMMI试点（四个外展团队为480人提供CBHH），并在新成立的综合护理伙伴关系中对CBHH模型进行全面的实证评估，其中包括20个外展团队，为n=2400名双重资格和高成本的医疗补助受益人提供SMI和医疗合并症。目标1将开发和试点测试综合数据收集和管理基础设施，包括：a)建立一个成果和数据信息学工作组；B)开发关系数据库；C)准备数据使用协议和安全协议；D)创建和试点测试自动化数据收集；E)组织索赔数据去识别和整合的协议；f)细化对风险等级的分配。目标2将参与规划过程，对社区行为健康之家（CBHH）模式的实施结果和成本进行大规模实证研究，该模式是针对具有严重精神障碍和医疗共病的双重资格和高成本医疗补助受益人的一种新的综合护理伙伴关系，包括：a)建立和运作研究设计规划工作组；完善社区行为健康之家（CBHH）模式；C)确定未来研究的最佳研究设计；d)为未来的研究完善招募和人体受试者IRB程序；e)准备ROI研究项目拨款申请，用于未来在20个团队中实施CBHH模型的大规模研究，为大约2,400名重度精神障碍患者提供服务。

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.