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Service Delivery Innovation Profile

Mental Health Center Provides Integrated Primary Care and Care Coordination to Medicaid Beneficiaries With Severe Mental Illness, Enhancing Access to Services and Improving Outcomes


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Snapshot

Summary

As part of Rhode Island’s implementation of the “health home” provision of the Affordable Care Act, The Providence Center (one of seven community mental health organizations in the State) offers integrated mental health, primary care, care coordination, and wellness services to Medicaid beneficiaries with severe and persistent mental illness and one or more chronic physical health conditions. For a fixed monthly per-beneficiary payment, The Providence Center provides a comprehensive array of services through multidisciplinary teams in collaboration with a local federally qualified health center. As part of this arrangement, the two partners co-locate staff and services within each other's facilities. The program has enhanced access to primary care and chronic care management services, which in turn has had a positive impact on chronic disease outcomes.

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of pre- and post-implementation comparisons of several process and outcome metrics, including the proportion of health home enrollees receiving a physical examination and depression screening and the proportion reporting that they smoke. Additional evidence includes post-implementation data related to chronic disease management and control, including the following: the proportion of eligible enrollees with a diabetes treatment plan in place; the proportion of those with a diabetes treatment plan who have the disease under control; the proportion of enrollees with hypertension receiving two or more followup visits; and the proportion of those receiving these visits with their blood pressure under control.
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Developing Organizations

The Providence Center
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Use By Other Organizations

As noted, the State of Missouri also received approval to implement the health home provision of the Affordable Care Act.

Date First Implemented

2011
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Patient Population

Vulnerable Populations > Co-occuring disorders; Insurance Status > Medicaid; Vulnerable Populations > Mentally illend pp

Problem Addressed

Medicaid beneficiaries with severe and persistent mental illness often have co-occurring chronic medical conditions that do not get adequately managed. As a result, they frequently experience acute episodes that require costly emergency department (ED) or inpatient care. Poor management stems largely from inadequate primary care and a lack of care coordination and self-management support. Most beneficiaries have a regular source of mental health care, but these centers generally lack the resources and expertise to address physical health needs.
  • Small, poorly managed population: A small proportion of Medicaid beneficiaries have severe mental illness, and these individuals often suffer from co-occurring chronic physical conditions.1 In Rhode Island, approximately 2 percent of beneficiaries (5,200 out of 228,000 in fiscal year 2012) suffer from severe and persistent mental illness along with one or more co-occurring chronic conditions, such as diabetes, obesity, high blood pressure, high cholesterol, and coronary artery disease.2,3 Due in large part to their mental health issues, these individuals face significant challenges in managing their physical health conditions on an ongoing basis.
  • High costs, driven by acute episodes: Poor chronic care management leads to frequent acute episodes that require expensive ED visits and inpatient care. Nationwide, the 5 percent of Medicaid beneficiaries with behavioral health needs account for more than half of all Medicaid spending,4 and beneficiaries with severe and persistent mental illness represent a particularly expensive subset of this population.
  • Little access to primary care and support services: Many individuals with severe and persistent mental illness do not have a regular source of primary care, nor do they have access to support in managing their chronic conditions, navigating the health system, or accessing needed community-based services.
  • Unrealized potential of integrating physical and mental health care: While they may not have a regular source of primary care, many Medicaid beneficiaries with severe and persistent mental illness do have access to behavioral health services through a community mental health center. Integrating physical health care within these centers has the potential to improve care and reduce costs1, yet very few centers have the resources or expertise to do so. Recognizing this potential, the Affordable Care Act includes provisions designed to promote the integration of physical and behavioral health care. 

What They Did

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Description of the Innovative Activity

The Providence Center (TPC) created a health home for Medicaid beneficiaries with severe and persistent mental illness and one or more chronic physical health conditions. Working under an arrangement that provides a fixed monthly per-beneficiary payment from the State, TPC provides a comprehensive array of primary care, care coordination, and wellness services through multidisciplinary teams, in collaboration with a local federally qualified health center (FQHC). As part of this partnership, both organizations co-locate staff and services within each other's facilities. Key program elements are detailed below:
  • State-initiated enrollment and fixed monthly payment: The State automatically enrolls qualified individuals in the program and pays a fixed monthly fee to TPC and other community mental health organizations (CMHOs) that meet established requirements related to the provision of care coordination and wellness services. Unlike in the past, this arrangement allows centers to be paid for services provided outside of a face-to-face visit. (More information about enrollment and payment processes and associated requirements can be found in the Planning and Development Process section of this profile.)
  • Health home integrating physical and behavioral health services: TPC upgraded and revamped its services to create a health home offering integrated behavioral and physical health services, including a comprehensive array of mental health, primary care, care coordination, and wellness services delivered through multidisciplinary teams. Key components of the health home model are detailed below:
    • Multidisciplinary teams focused on physical and mental health: TPC created seven multidisciplinary teams that are each responsible for providing services to as many as 250 enrollees. Five teams cater to “typical” enrollees with severe and persistent mental illness. Two teams take care of specific subgroups with special needs—one bilingual team cares for Spanish-speaking enrollees, and a second team serves clients who have frequent involvement with the courts. (Made up of staff with experience in civil and criminal court proceedings, this latter team cares for roughly 150 enrollees, as these individuals tend to need more support, such as a team member accompanying them to court appointments.) Unlike traditional teams employed by mental health centers, these teams are staffed and organized to focus on both physical and mental health issues, as outlined below:
      • Expanded staff to address physical health issues: In addition to traditional mental health personnel (a therapist, substance abuse specialist, vocational specialist, and part-time psychiatrist), each team has four full-time care coordinators, 2.5 full-time registered nurses (RNs), and a part-time peer specialist. Prior to implementation of the model, existing multidisciplinary teams had significantly fewer nurses and care coordinators and did not have any peer specialists. The care coordinators, RNs, and peer specialists focus for the most part on primary care and care coordination related to physical health issues, as outlined below:
        • RN activities: RNs address physical health issues at every appointment, focusing primarily on chronic conditions such as diabetes, obesity, heart disease, and high blood pressure. The nurses educate enrollees about self-management of these conditions (e.g., adhering to prescribed medication, diet, and physical activity regimens) and identify needed medical care (e.g., specialty appointments, laboratory tests), wellness services, and community-based support.
        • Care coordinator activities: The care coordinators support the RNs by coordinating all needed care, including mental health, primary care, and wellness services; specialty care; hospital care; and postacute care, including transitions between settings. (A hospital liaison assists with postdischarge transitions, as described in more detail in a separate bullet below.) Typical care coordinator activities include helping to schedule needed medical appointments; arranging transportation to those appointments; following up with laboratories and pharmacies about test results and prescriptions; and, in partnership with the nurses, educating enrollees about self-management issues and connecting them to needed community-based services.
        • Peer specialist activities: A new position under the health home model, each team has a part-time peer specialist who provides counseling and mentoring from the perspective of an individual living with severe and persistent mental illness. Peer specialists focus on helping clients establish a link to primary care and engage in health promotion activities. Peer specialists also help clients reduce high-risk behaviors such as smoking, poor self-management, inadequate nutrition, and infrequent physical activity. They work with clients to set wellness-related goals and provide support and encouragement in achieving them.
      • Tools and processes to support integration of physical and mental health: The teams use standardized tools and processes to support the integration of physical and mental health services, as outlined below:
        • Comprehensive treatment plan: Teams work with enrollees and their family/caregivers to develop comprehensive treatment plans that address all health needs, including primary care, mental health and substance use treatment, chronic disease management, and needed nonclinical support. The plans identify mutually agreed-upon goals related to self-management and health-related behaviors, such as quitting smoking, getting more exercise, eating more healthfully, and adhering to prescribed treatment regimens. All team members regularly consult this plan to gauge client progress and to identify and address barriers to meeting established goals.
        • Morning meetings: Each team meets for approximately 30 minutes every morning to discuss enrollees who may need assistance with plan-related challenges, such as adhering to medication regimens or accessing medical appointments.
      • Additional shared staff to support teams: TPC employs additional staff who support the teams, as outlined below:
        • Hospital liaisons: Three hospital liaisons support the teams, each covering a specific set of psychiatric and general medical hospitals. Liaisons take charge of coordinating transition-related care whenever an enrollee is admitted to or discharged from a hospital. (Under an agreement negotiated by the State, Rhode Island’s two Medicaid health plans notify TPC whenever an enrollee is admitted to a medical or psychiatric hospital.) The liaison works with discharge planning staff and the teams to ensure that appropriate support services are in place after discharge. The liaison makes phone contact with enrollees within 2 days of discharge, and meets face-to-face with them shortly thereafter (within 7 days for discharges from a psychiatric hospital and within 14 days for discharges from a medical hospital).
        • Medical assistants: TPC employs medical assistants who routinely provide care to health home clients. At every visit, the medical assistants measure and record the patient’s vital signs, including weight, height, body mass index, and blood pressure. They also assist in care coordination activities, such as securing prior authorizations for needed medical or mental health services.
    • Bidirectional co-location of primary and mental health services with partner FQHC: As detailed below, TPC partners with a local FQHC, the Providence Community Health Center (PCHC), to co-locate primary care and mental health services within each organization's facilities. 
      • Mental health specialists as part of primary care team: TPC provides mental health specialists who work as part of PCHC's primary care teams, both in a small primary care clinic located within TPC and a separate facility run by PCHC.
        • Onsite clinic: PCHC runs a small primary care clinic within TPC that allows health home enrollees to receive coordinated physical, mental health, and substance abuse care under one roof. A case manager from TPC participates as part of the primary care team, assisting team members in understanding the client’s mental health issues and ensuring that the TPC team understands his or her physical health needs. 
        • Offsite clinic: A full-time masters-level behavioral health clinician from TPC serves as part of the primary care team at PCHC’s main clinic, located roughly five miles from TPC. This individual helps primary care clinicians understand the behavioral health issues facing clients (e.g., depression, stress, substance use, sleep problems) and makes sure these clients have access to needed mental health services. TPC recently bolstered its mental health capacity at the clinic by installing a small health home team that can treat mental health issues. This team serves those who prefer not to come to TPC for such care (e.g., due to the stigma associated with doing so). The team includes a masters-level nurse with expertise in mental health, two case managers, and a part-time psychiatrist.
      • FQHC nurses to support TPC teams: Two PCHC-employed nurses support the seven TPC teams, providing guidance and support on physical health issues that may be affecting enrollees.
      • Onsite pharmacy for psychiatric and medical medications: TPC has an onsite pharmacy (operated by a partner organization, Genoa Healthcare) that traditionally filled both psychiatric and medical medications but did not manage the medical medications. Under the health home model, the pharmacy now manages medical medications using prepackaged bubble packs with day and color prompts that make it easy for enrollees to take medications as prescribed (and for care teams to monitor adherence). The onsite pharmacy also makes it possible for TPC case managers and nurses to pick up medications for clients and for pharmacists to provide inservice training related to medications and medication adherence to TPC staff.
    • Comprehensive wellness and other support services: As part of the health home model, TPC added an array of new wellness and support services tailored to individuals with severe and persistent mental illness. Major service enhancements are outlined below:
      • Wellness activities: Through its InSHAPE initiative, TPC provides one-on-one and group physical fitness classes and other wellness activities tailored to adults experiencing mental health and substance abuse problems. Five certified trainers and bachelors-level case managers with mental health training lead group classes (e.g., Zumba, yoga) and engage in individual counseling and support of clients who want to improve health-related behaviors, such as quitting smoking and losing weight. TPC also partners with the YMCA and other local organizations to offer wellness services within the community. For example, TPC staff may take a client to the YMCA to work out or engage in water aerobics. TPC originally started InSHAPE with support from a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) and now provides the program as part of the care coordination and wellness services covered by the State under the health home model.
      • Support groups and services: TPC staff coordinate or lead various support groups that meet regularly, including two women’s groups (one main group and one for those who speak Spanish), a gay/lesbian/transgender group, an expressive art therapy group (which engages in jewelry making, drawing, crafts, and other art-related activities), and various classes related to managing chronic conditions. For example, a nurse educator teaches a class on healthy eating for those with diabetes. TPC staff also periodically lead vocational/job training sessions and provide assistance with activities of daily living.

Context of the Innovation

Opened in 1969, TPC serves as one of the State’s seven CMHOs and hence is responsible for the provision of outpatient mental health services and for management of admissions and discharges from inpatient psychiatric care units for Medicaid beneficiaries within one of eight designated catchment areas in Rhode Island. The center serves more than 12,000 children, adolescents, and adults each year, providing an array of patient-centered, recovery-oriented behavioral health services, including support with food, housing, and education; job training; legal services; and primary care and wellness services.

The impetus for this program began in 2011, when the State of Rhode Island got approval from the Centers for Medicare & Medicaid Services (CMS) to implement the health home option, a provision of the Affordable Care Act that allows a single provider to coordinate all medical services for clients with chronic illnesses. Rhode Island was one of the first two States to adopt this initiative (the other was Missouri). In 2012, the Rhode Island Department of Behavioral Healthcare Services, Developmental Disabilities and Hospitals (BHDDH) implemented the model with the seven CMHOs (including TPC) and two specialty providers.

Did It Work?

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Results

The program has enhanced access to primary care and chronic care management services for Medicaid beneficiaries with severe and persistent mental illness, which in turn has had a positive impact on chronic disease outcomes.
  • Enhanced access to primary care: In an analysis of 287 Medicaid beneficiaries with severe and persistent mental illness enrolled in the health home, 70 percent reported having had a physical exam in the past 12 months, up from 43.4 percent 6 months earlier. (Initial assessments took place between January 2011 and September 2012, with followup occurring 6 months after the baseline assessment.) An increase also occurred in the proportion of enrollees being screened for depression, which rose from 80 percent at baseline to 91 percent 6 months later. 
  • Enhanced access to chronic care management: Of the 95 enrollees identified as having diabetes at baseline, 78 percent had a treatment plan in place at followup. Similarly, 91 percent of the 138 enrollees identified as having hypertension at baseline received at least 2 followup visits over the subsequent 6 months that focused on managing this condition. In the absence of this program, many of these individuals likely would not have received these care management services.
  • Positive impact on chronic disease outcomes: Various metrics illustrate the program's positive impact on chronic disease outcomes, as detailed below:
    • Fewer smokers: Between baseline and followup, the proportion of health home enrollees reporting that they smoked fell from 48 percent to 42 percent.
    • High levels of diabetes and blood pressure control: At followup, roughly two-thirds (66 percent) of enrollees with diabetes who had a treatment plan in place had hemoglobin A1c levels below 8.0 percent (indicating adequate control of the disease). At baseline, only 42 percent had achieved this level of control. Overall, 82.5 percent of enrollees with hypertension who received two or more followup visits had their blood pressure under control (defined as blood pressure below 140/90 mm Hg).

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of pre- and post-implementation comparisons of several process and outcome metrics, including the proportion of health home enrollees receiving a physical examination and depression screening and the proportion reporting that they smoke. Additional evidence includes post-implementation data related to chronic disease management and control, including the following: the proportion of eligible enrollees with a diabetes treatment plan in place; the proportion of those with a diabetes treatment plan who have the disease under control; the proportion of enrollees with hypertension receiving two or more followup visits; and the proportion of those receiving these visits with their blood pressure under control.

How They Did It

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Planning and Development Process

TPC began the process of integrating behavioral and physical health services several years before the health home model came into existence, and TPC leaders actively encouraged State leaders to apply to CMS under the aforementioned Affordable Care Act provision. Key steps in this integration process, including formal implementation and roll-out of the model, are outlined below:
  • Creating a few multidisciplinary teams under earlier program: TPC initially created two multidisciplinary teams that focused on integrating physical and behavioral health as part of Rhode Island’s Assertive Community Treatment (more commonly known as ACT) programs. These teams cared for roughly 450 of TPC’s approximately 2,000 clients with severe and persistent mental illness and served as a model for the other teams that formed after health home funding became available. 
  • Opening primary care clinic within TPC site: With funding from SAMHSA, TPC partnered with PCHC to open a small primary care clinic inside TPC’s main facility in 2010.
  • Launching formal health home model: As noted, BHDDH entered into agreements with TPC and eight other organizations in 2012, marking the official launch of the health home model in Rhode Island. At the launch, the State enrolled all eligible beneficiaries in the program and initiated a fixed monthly per-beneficiary fee to cover care coordination and wellness services, as outlined below:
    • Automatic enrollment: The State enrolled approximately 5,200 beneficiaries with severe mental illness and co-occurring chronic conditions in the program, including the roughly 1,400 Medicaid-eligible beneficiaries served by TPC. These enrollees received a letter informing them of the new program, which entailed no new requirements and offered the opportunity to receive additional services from their designated CMHO.
    • Fixed monthly payment, with associated requirements for CMHOs: The State established a monthly payment of $444.21 per enrollee to CMHOs that meet certain requirements related to the provision of services. To qualify each month, the CMHO must provide at least an hour of any type of care coordination or wellness service to every enrollee and an average of 3 hours of services per enrollee across the entire population. Under old payment rules, CMHOs were reimbursed only for services provided during face-to-face visits. Under new rules, care coordination services performed outside of office visits qualify for payment, including time spent scheduling appointments, following up on test results, and providing coaching and education over the phone. (The State does require that each enrollee receive at least an hour of face-to-face care coordination or wellness services each quarter.)
  • Participating in State-led training: The Rhode Island Council of Community Mental Health Organizations worked with BHDDH to provide training on the model to staff at TPC and the other CMHOs. Training focused on how to manage chronic care, collect and report data on performance measures, bill for services, and formalize agreements with hospitals and primary care practices.
  • Hiring additional staff: TPC hired a significant number of additional staff to upgrade the multidisciplinary teams and to expand service offerings, including RNs, care coordinators, peer specialists, and hospital liaisons.
  • Providing internal training focused on culture change: The integration of physical health services represents a marked change for a community mental health center. To promote that change, TPC leaders invested significant time and resources in training existing and newly hired staff. For 18 months, those serving health home clients attended monthly sessions in which they learned about motivational interviewing, management of chronic diseases, and other issues. For the most part, various in-house staff led these sessions, including a doctorate-level specialist in integrated health, a substance abuse specialist, an expert in addictions, and an expert in motivational interviewing. Refresher sessions are held on an as-needed basis.
  • Providing initial and ongoing peer specialist training and support: Peer specialists received initial training and certification from the State on how to provide services, including how to engage peers through motivational interviewing. On an ongoing basis, TPC provides peer specialists with opportunities to meet as a group and support each other. These sessions are needed because peer specialists sometimes become anxious and symptomatic as they do their work, and hence turnover rates tend to be quite high. TPC initially hired five specialists; two have since left, and finding replacements has proven difficult because relatively few individuals have completed the State-run training and certification program.
  • Creating electronic billing and documentation tools: TPC developed several electronic tools that facilitate the tracking of time spent on care coordination and wellness services, thus making it easier to meet State requirements related to billing submission and documentation. These tools include a special form that medical assistants use to document time spent taking vital signs and other measurements, as well as features within the electronic medical record (EMR) that track time spent on various care coordination activities.
  • Expanding and remodeling facilities: As part of the transition to the health home model, TPC has expanded and remodeled its facilities on several occasions to handle the additional staff and service offerings.
  • Coordinating exchange of information: TPC installed an EMR system in 2007, whereas PCHC only recently did so. The two organizations are developing processes to allow for the efficient sharing of information while still maintaining adherence to confidentiality requirements (which tend to be particularly rigid for behavioral health information). This effort involves coordination with Current Care, Rhode Island’s health information exchange. (TPC is one of two CMHOs to have completed the appropriate processes and requirements to participate in the exchange.)

Resources Used and Skills Needed

  • Staffing: Overall, roughly 100 full-time equivalent (FTE) staff are dedicated to the health home model, including members of the seven teams (each with approximately 11 FTEs), 3 hospital liaisons, 7 medical assistants, and other staff who support the teams, including “floating” nurses and case managers who cover for team members who are on vacation or sick. While many of these staff already worked at TPC prior to implementation of the model, TPC also hired a significant number of new employees, including peer specialists, nurses, care coordinators, and hospital liaisons.
  • Costs: Data on the costs associated with implementing and operating the health home model are not available. The primary operating expenses consist of salaries and benefits for the staff (including time spent in training), along with other costs associated with the new service offerings, such as increased travel expenses for team members. Major one-time costs include expenses associated with facility expansion and remodeling and time and resources spent creating electronic billing and documentation tools.
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Funding Sources

Substance Abuse and Mental Health Services Administration (U.S.); State of Rhode Island
As noted, SAMHSA provided grant funding that allowed for the opening of the primary care site at TPC, and the State of Rhode Island now pays for care coordination and wellness services provided through the health home initiative.end fs

Tools and Other Resources

More information on TPC can be found at: http://www.providencecenter.org/.

Adoption Considerations

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Getting Started with This Innovation

  • Invest in upfront training: Any mental health center adopting this type of program needs to be prepared to make a significant investment in training. The organizational culture in these centers has historically focused on mental health issues. Consequently, staff need support and supervision as that culture and their roles and responsibilities transition to a “whole-person” perspective. The new roles typically entail significant expansions in job descriptions and responsibilities for most if not all staff.
  • Invest in electronic systems to facilitate billing: The billing and documentation requirements set up by Rhode Island tend to be quite cumbersome, and electronic tools can be very helpful in meeting them without creating an undue burden on staff.

Sustaining This Innovation

  • Provide staff with safe places to discuss and solve problems: Working with clients who have severe and persistent mental illness can be quite challenging, and staff need support in dealing with difficult clients and cases. The morning meetings provide this type of support, as do regular meetings where therapists and substance abuse specialists discuss cases and help each other in various ways.
  • Offer refresher training: Over time, staff turnover and other issues may have a negative impact on the degree to which staff adhere to the health home model and maintain their focus on both physical and behavioral health issues. Consequently, periodic refresher training sessions should be held to keep staff focused, energized, and engaged.

Use By Other Organizations

As noted, the State of Missouri also received approval to implement the health home provision of the Affordable Care Act.

More Information

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Contact the Innovator

Deborah O’Brien
Vice President and Chief Operating Officer
The Providence Center
528 North Main Street
Providence, RI 02904
(401) 528-0181
E-mail: dobrien@provctr.org

James Pinel
Director of Child, Family & Adult Services
530 North Main Street
Providence, RI 02904
(401) 276-6375
E-mail: jpinel@provctr.org


Innovator Disclosures

Ms. O’Brien and Mr. Pinel reported having no financial or business/professional relationships relevant to the work described in this profile, other than the funders listed in the Funding Sources section.

Footnotes

1 Ohio Governor’s Office of Health Transformation. Report shows Medicaid beneficiaries with mental illness also likely to have chronic physical problems: coordinated care critical to improve health outcomes and reduce costs. Press release. 2011 February 24. Available at: http://healthtransformation.ohio.gov/LinkClick.aspx?fileticket=O-Sw9NVqnfI%3d&tabid=72.
2 Boss R. The future of service delivery for complex consumers: Rhode Island’s program for Medicaid Health Homes. Presentation slides. Available at:
http://mehaf.org/media/rhode_island_updates,_rebecca_boss_%5Bcompatibility_mode%5D.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
3 Rhode Island Executive Office of Health and Human Services. Rhode Island annual Medicaid expenditure report. 2013 June. Available at: http://www.ohhs.ri.gov/documents/documents13_3rdQ/Medicaid_Exp_Report_June_2013.pdf.
4 The Providence Center. Improving care and saving money with Health Homes. Available at: http://providencecenter.org/news/post/improving-care-and-saving-money-with-health-homes
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: May 21, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 13, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.