Prior to the development of the CMHC Healthcare Home initiative, the Department of Mental Health and Mo HealthNet collaborated to reach out and engage high cost individuals in service who had a psychiatric diagnosis but who had not previously been connected with a CMHC. On average these individuals had cost Medicaid more than $38,000 in the year prior to the outreach initiative. In addition to their psychiatric diagnoses, about one-third also had diagnosis of diabetes, one-third had a diagnosis of asthma, one-third had a diagnosis of COPD, and more than 10% were suffering from congestive heart failure. This initiative has been called the “DM 3700” project, with “DM” standing for ‘disease management’, and “3700” representing the initial cohort of individuals who were thought to qualify for outreach and engagement.

Each quarter, beginning in November, 2010, each CMHC was given a list of individuals who met the criteria and who had addresses in their service area. CMHCs then made an effort to locate and engage these individuals in service. Some individuals could not actually be located, and some refused to engage in care. But each quarter, new individuals were enrolled in service.

The DM 3700 project showed immediate and significant improvement in the health status of the individuals that were engaged in service and significant reductions in the cost to Medicaid for their care. In fact, the early success of the DM 3700 was one of the factors contributing to Missouri’s enthusiasm for establishing CMHC Healthcare Homes, and much of the work being done with DM 3700 enrollees drove the design of the CMHC Healthcare Homes.

DM 3700 enrollees were among the cohort of individuals auto-enrolled in CMHC Healthcare Homes. CMHCs continue to receive lists of individuals to locate and engage in service on a quarterly basis, and individuals who are engaged are expected to be enrolled in the CMHC Healthcare Home program. In effect, DM 3700 has become the outreach arm of the CMHC Healthcare Home program.

The following report summarizes the clinical and financial outcomes associated with the DM 3700 clients who have been enrolled in a CMHC Healthcare Home.