Integrated Care: Where Clinical Need Intersects Sustainability

Integrated Care: Where Clinical Need Intersects Sustainability

Collaborative Family Healthcare Association 14th Annual ConferenceOctober 4-6, 2012 Austin, Texas U.S.A.

Session #G2October 5, 2012

Shaping Healthy CommunitiesShaping Healthy Communities.

© 2009 Lone Star Circle of Care

Integrated CareWhere Clinical Need IntersectsSustainability

Behaviorally Enhanced Health Care Home

Kimberly A. Arlinghaus, M.D. Medical Director, Behavioral HealthLone Star Circle of CareDepartment of Psychiatry and Behavioral Health512-686-0207 ext. [email protected]

Greg Jensen, LCSW, ACSWVice President for Behavioral HealthLone Star Circle of CareDepartment of Psychiatry and Behavioral Health512-686-0207 ext. [email protected]

mailto:[email protected]

mailto:[email protected]

3© 2009 Lone Star Circle of Care

Brian … 17 y/o HM

• PTSD, Bipolar d/o, Polysub abuse, ADHD

• 4 SAs 12-16 y/o

• Multiple psych hosp, BBT, PP therapists, primary care Carousel Pediatrics

• Psych meds by Carousel

• HTN, reflux, “passing out” w/hx of head injury


Psychiatrist-Therapist Collaboration

• BH intake by therapist

• Psychiatric evaluation—added hx psychosis, TBI, and changed BD to MDD; changed medications

• Ongoing med management, psychotherapy, and encouragement to enroll in LSCC primary care


Psychiatrist-Therapist-PCP Collaboration

• LSCC PCP visit

• Facilitated neurology work-up for TBI and question of seizures

• Obtained additional medical records

• Assisted with checking drug screens and monitoring suicidality


Network Collaboration

• Seton ER

• Consultation with ER physicians

• Hospitalization

• IOP, 12-step

• LSCC for therapy, medication management, primary care


The Bottom Line…Shared Care is Best Care

Right thing to do for the patientAdds value to the community

Sustainable and scalable


Goals For Today• Establish the vision and mission concepts

necessary to create organizational commitment to integrated care

• Define governance, operational, financial and clinical issues to implement a behaviorally enhanced community health center

• Discuss critical sustainability success factors and challenges


VisionEvery Central Texan who needs access to psychiatry and

psychotherapy will have access to a fully integrated, behaviorally enhanced, healthcare home


LSCC Behavioral Health: Mission

• Provide behaviorally-enhanced healthcare services to patients who have LSCC as their medical home

• Provide access to BH services in collaboration

with community partners who have aligned and complementary goals


LSCC Clinics

LSCC services offered in each city:

Austin‒ Family Medicine‒ Behavioral Health

Belton‒ Pediatrics

Cedar Park‒ Pediatrics

Georgetown‒ Family Medicine‒ Senior Health‒ Pediatrics‒ Behavioral Health‒ Pharmacy‒ Dental

Harker Heights‒ Pediatrics‒ Behavioral Health (child & adolescent)

Hutto‒ Pediatrics

Killeen‒ Pediatrics

Round Rock‒ Family Medicine‒ OB/GYN‒ Senior Health‒ Pediatrics (also Adolescent)‒ Behavioral Health‒ Pharmacy

Taylor‒ Family Medicine

Temple‒ Family Medicine

Lone Star Circle of Care / Locations

http://www.lscctx.org/locations/


Locations of LSCC Dedicated BH Clinics


“The Usual Way”

Psychiatry Outsourced

Medicine

Mental Health Stigma


“The Lone Star Circle of Care Way”

Behavioral Health Providers (Psychiatrists and Counselors/Therapists) are members of LSCC

medical team thereby leveraging ALL Integrated Delivery System benefits


Integrated Care: Why Do It?

• Up to 70% of patients presenting for primary care have some type of behavioral health (BH) problem which impacts diagnosis and treatment

• Patients are more likely to receive BH treatment if they are treated via an integrated model

• Treatment of BH problems enhances medical outcomes and quality of life

• Integrated care optimizes efficiency of health care delivery


Depression and Diabetes

• 95% of diabetes management is conducted by the patient

• If the patient is depressed… Poorer outcomes Increased risk of

complications < glucose monitoring < adherence to diet,

exercise, and medication regimens


Potential Systemic Effects of the “Depressed” Brain

• Sticky platelets• Decreased heart rate

variability (HRV)• Increased C-reactive

protein• Increased cortisol


Systemic Effects of Cortisol

• Redistribution of body fat• High sympathetic tone• Elevated noradrenaline• Increased HR• Reduced HRV• Decreased insulin

sensitivity• Decreased bone

absorption of calcium


1. Frasure-Smith N, et al. JAMA. 1993;270:1819-1825. 2. Penninx BW, et al. Arch Gen Psychiatry. 2001;58:221-227. 3. Jiang W, et al. Arch Intern Med. 2001;161:1849-1856.4. Vaccarino V, et al. J Am Coll Cardiol. 2001;38:199-205.

Depression Worsens Outcome of Heart Disease

• Depression worsens morbidity and mortality after myocardial infarction1,2

• Depression increases morbidity and mortality in patients with CHF3,4


Behavioral Cardiology (Pickering et al. 2003)

• The causes of heart disease lie not so much in the heart itself, but in the brain, or more specifically, the mind.

• The mind affects the heart via: Our lifestyles Effects of psychosocial

stresses and how we cope with them


Integrated Care Outcomes Research

Better Outcomes/Improved Functioning: Independent Three-year Process and Outcome Evaluation

(Dr. Toni Watt, Texas State University. Commissioned by St. David’s Community Health Foundation, 2008)

‒ Statistically significant decrease in depression symptoms (32%) that remained constant over two, three and six month period

‒ Self-report measures showed patient’s physical health, daily living activities performance, ability to socialize improved significantly

‒ Treating BH illnesses does not cost the overall health system more money. While there was an initial increase in costs, from 6-21 months post treatment, the costs remained stable


Integrated Care: Solution

An Institute of Medicine report in 2005 concluded that the only way to achieve true quality (and equality) in the health care system is to integrate primary care with mental health care and substance abuse services. (Institute of Medicine, “Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series”, November 1, 2005.)


Integrated Care: What Differentiates LSCC’s Model

BH and medical providers employed by LSCC

BH and medical providers on the same HER

LSCC treats ALL psychiatric groups

BH records fully open to the medical providers

Medical providers have immediate access to psychiatrists

BH specialists embedded into the medical clinics

Single governance structure that develops the integrated services

Active mental health screening in medical clinics

Psychiatrists actively treating patients vs. consultant

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Governance: Behaviorally Enhanced Healthcare Integration Council

1. Provide guidance to and oversee integration implementation

2. Define and monitor outcome measures 3. Set professional practice standards such as defining and

utilizing screening tools, establishing interdisciplinary care conferences, etc.

4. Establish reimbursement guidelines 5. Provide recommendations to LSCC Senior Leadership

pertaining to the ongoing practice issues, resources and/or enterprise-wide impact of integration


Addressing PCP Challenges: Time and Access

• Embedding behavioral health specialists Provide “real time” consultation to medical staff Conduct crisis intervention for patients in the clinic Facilitate and expedite access to psychiatric services Provide brief therapy/counseling services to patients Coordinate care with the patient’s PCP Assist with efficient patient flow

• Real time PCP consultation with child and adult psychiatrists

• Telepsychiatry


The LSCC Integrated BH Model: Screening

Medical patients for mental health concerns TeenScreen for 11-17 year olds PHQ 2 for depression CAGE for substance use Vanderbilt for ADHD AD8 for cognitive decline in older adults Edinburgh 3 for post partum depression MCHAT for autism

Behavioral health patients for medical concerns Primary care service provider (medical home) Hypertension Obesity Diabetes Co-occurring substance use disorders Tobacco product use Pain


LSCC’s Integrated Care Model

Providing holistic care by diagnosing and treating physical AND mental conditions … together

Embedding BH providers using

open access

BH screening in medical clinics

Providing PCPs direct access to

psychiatrists

Electronic health record

Interdisciplinary collaboration


Easy Access to Clinical Information: EHR


Increasing Access

2005 2006 2007 2008 2009 2010 2011 Projected FY2012

519 1,1193,937 5,023

10,000

23,737

37,219

51,417

Lone Star Circle of Care Behavioral Health VisitsFY2005 - FY2012 (Projected)

2006-20121 to 17 prescribers0 to 31 therapists

Behavioral Health Visits By Patient’s Residence

0

3,000

6,000

9,000

12,000

15,000

Austin Round Rock Georgetown Leander Killeen Cedar Park Pflugerville Hutto Taylor Belton

Num

ber o

f BH

Visit

s

City of Residence

Lone Star Circle of Care (LSCC)Number of Behavioral Health (BH) Care Visits by City of Residence

Fiscal Year (FY) 2011 and FY2012 (Annualized)

FY 2011

FY 2012 (Annualized)

Behavioral Health as % of Total LSCC Visits

Number Percent

2005 24,895 519 2.1%2006 35,348 1,119 3.2%2007 74,224 3,937 5.3%2008 96,131 5,023 5.2%2009 127,121 10,454 8.2%2010 202,568 23,737 11.7%2011 298,264 37,219 12.5%Projected 2012 360,832 51,417 14.2%

Fiscal Year Total Health VisitsBehavioral Health Visits

Lone Star Circle of Care VisitsFiscal Year (FY) 2005 - FY 2012 (Projected)

Source: Lone Star Circle of Care encounters occurring in FY2005-FY2011 and projections for FY2012.

% of Behavioral Health Patients with LSCC Medical Home

Number Percent Number PercentTotal, all Payors 6,801 4,337 63.8% 2,464 36.2%

Medicaid/CHIP 2,745 1,795 65.4% 950 34.6%Uninsured 2,520 2,001 79.4% 519 20.6%Private Insurance 936 244 26.1% 692 73.9%Medicare 600 297 49.5% 303 50.5%

Source: Lone Star Circle of Care encounters occurring in FY2011 (December 1, 2010 - November 30, 2011).

Lone Star Circle of Care (LSCC) Behavioral Health Patients Medical Home UtilizationFiscal Year 2011 (December 2010 - November 2011)

Most Recent Behavioral Health Visit Paid By: Total

Did Patient Have a Medical Health with LSCC in FY2011?Yes No


Integrated Behavioral Health Sustainability and Scalability

• Provider Mix Psychiatrists AND therapists with same employer as medical providers

• Payer Mix Leverage FQHC to increase access to mission patients

• Productivity Goals by provider type


Behavioral Health – Utilization (January 2012-August 2012)

January

February

March

April MayJu

neJu

ly

August66.0%

68.0%

70.0%

72.0%

74.0%

76.0%

78.0%

80.0%

71.9%

74.9%

73.3%

70.8%71.9%

72.7% 72.5%

78.4%

LSCC BH Utilization, Jan 2012 – Aug 2012

UtilizationLinear (Utilization)

January February March April May June July August No Show Rate 24.9% 23.9% 24.9% 26.3% 26.9% 27.9% 26.8% 26.7%


Challenges: No Shows and Utilization

• No Show Policy

• Confirmation Calls

• Reverse Confirmation Calls

• Therapist-Based Intakes

• Same Day Call In List

• Intakes at Same Time and Overbook


Integrated Behavioral Health Outcomes & Scalable Results

• Quality Metrics Symptom reduction Functional improvement (future) Access Assess safety at each visit

• Operational Metrics Volume Productivity

• Satisfaction Metrics Patient satisfaction data


Integrating Education and Clinical Service

BH Training Partnerships

• Seton/UT Southwestern Psychiatry Residents

• Texas A&M Medical Students

• UT School of Social Work

• UT School of Educational Psychology

• UT College of Nursing


Psychiatry and Behavioral Health – Community Partners

• Texas A&M Health Science Center• Seton Family of Hospitals• University of Texas Southwestern /Seton Residency Program • St. David’s Foundation• Scott and White• Bluebonnet Trials – Williamson County MH/MR • STARRY• Texas Baptist Children's Home• Caring Family Networks• Arrow Child and Family Ministries• Lighthouse Family Network• Central Texas Children’s Home• Texas Star Recovery Center• Department of State Health Services• Texas A&M School of Rural Public Health• University of Texas School of Social Work• Williamson County Mobile Outreach and Wilco MH Task Force • Wilco and ATCIC Community Providers


New Initiatives in Behavioral Health


Austin Independent School District (AISD)

Grant funded 6 month pilot at Crockett HS

March-August 2012

Clinic operational and seeing students


Austin Independent School District (AISD)

Goals

Evaluate model

Sustainability

Replicate


Foundations Communities

Local non-profit providing housing and support services for thousands of low-income families and individuals.


Foundations Communities

Grant improves BH access ‒ Psychiatry ½ day/wk.‒ Refer to therapy as

needed

Medical home provided through LSCC PCPs


Lifeworks

Non-profit social service agency providing a continuum of services to youth and families transitioning from crisis to safety.


Lifeworks St. David’s Foundation

funds Lifework’s Shared Psychiatric Services (SPS) for short term psychiatric care

LSCC’s provides a medical and BH home for children and their parents transitioning from SPS


Family Drug Treatment Court/Parents in Recovery (FDTC/PIR)

Families identified by judicial and Child Protective Services (CPS) due to mother’s substance abuse

Reduce children in out-of-home placements and increase children reunited with families


Family Drug Treatment Court/Parents in Recovery (FDTC/PIR)

Partnerships with Austin Recovery and FDTC/PIR

Transition mothers and her infant/children into our medical and BH home


• Joint Commission Accreditation A nationally-recognized “gold seal of approval” for health care providers Signifies that the safety and clinical qualify of care provided is

exceptional

• Patient-Centered Medical Home (Level 3) recognition A recognition awarded by the National Committee on Quality Assurance Less than 0.5% of all primary care providers in the nation have this

prestigious designation

Awards and Recognition

Please complete and return your session evaluation form before you leave this session

Please complete and return theevaluation form to the classroom monitor before leaving this

session.

Thank you!

Documents

Integrated Care: Where Clinical Need Intersects Sustainability