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

描述(由申请人提供)：拟议的为期一年的规划项目将利用联邦医疗保险和医疗补助创新中心(CMMI)赠款提供的前所未有的机会，在综合护理伙伴关系内实施社区行为健康之家(CBHH)的新型试点计划，为符合双重条件和高成本的医疗补助受益人提供机会。这一创新服务模式包括一个融入社区外展团队的“虚拟健康之家”、一名由远程保健支持的提供慢性病管理的嵌入式医务护士，以及一名接受过培训以提供综合疾病自我管理支持的健康外展工作人员。这项规划提案的目标是建立数据和研究基础设施，以扩展目前的CMMI试点(四个外展团队为480人提供CBHH)，以在新成立的综合护理伙伴关系中对CBHH模式进行全面的经验评估，其中包括20个外展团队，服务于n=2400名患有SMI和医疗合并症的双重符合条件和高成本的医疗补助受益人。AIM 1将开发和试行综合数据收集和管理基础设施，其中包括：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)编写数据使用协议和安全协议；d)创建并试行自动化数据收集；e)组织查明和整合索赔数据的协议；(F)完善风险等级的分配。AIM 2将对在新的综合护理伙伴关系中实施社区行为健康之家(CBHH)模式的结果和成本进行大规模经验性研究的规划进程，包括：a)建立和运作研究设计规划工作组；b)完善社区行为健康之家(CBHH)模式；c)为未来研究确定最佳研究设计；d)完善未来研究的招募和人类受试者IRB程序；E)准备投资回报研究项目赠款申请，以便今后对在20个团队中实施的CBHH模式进行大规模研究，为大约2400名SMI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.