NAVIGATING THE CLINICAL BARRIERS IN THE MANAGEMENT OF SEVERELY AND PERSISTENTLY MENTALLY ILL PATIENTS

Verena Roberts, Ph.D. Integrated Care PsychologistElizabeth Lowdermilk, M.D., PsychiatristElaine Hess, Ph.D., Post-Doctoral Fellow

Collaborative Family Healthcare Association 15th Annual ConferenceOctober 10-12, 2013 Broomfield, Colorado U.S.A.

Session #B2b Friday, October 11, 2013

Faculty DisclosureWe have not had any relevant financial

relationships during the past 12 months.

Objectives 1) Attendees will learn about the current state of

integrated care at Denver Health, an FQHC 2) Attendees will identify and learn about barriers to

successful integrated care, including the treatment of the severely and persistently mentally ill patients

3) Attendees will be able to form ideas and develop a framework around how to enhance collaborative patient care and move current integrated behavioral health approaches to the next level

4) Attendees will leave with concrete ideas beyond the basic model on how to integrate specific practice options at their own site

Learning Assessment

Audience Question & AnswerWe will provide time for questions and in

depth-discussion at the end of the session, but please feel free to ask some

questions as they come up.

DH intro Denver Health – Overview CHS

Clinic make up Eastside Clinic is a federally qualified

community health center which provides services for low income patients in central Denver.

Services include: Primary care/medical Integrated BH Integrated pharmacy services Navigators – self-management goal setting and

f/u / in-between care services

Clinic make up cont’d The patients seen:

low income (97% are <200% of the federal poverty level), uninsured or on public insurance (25% Medicare, 32% Medicaid, 32% CICP, 8% DFAP)

are mostly under-represented racial/ethnic minorities (41% African American, 34% Hispanic/Latino)

Managing SPMI patients – current status at Denver Health

Basic model (How we started)BHC (FT Psychologist and PT psych. Student)

2 scheduled 30 min. behavioral health appointments per session (for further evals, tx) Allows for overbooks for pt. with high follow-up needs

Scheduled and unscheduled (warm-handoffs) integrated visits with PCPs

Identifying patients: By PCPs during visits BHCs would also scan provider schedules and discuss possible

same-day referrals in mini huddles with PCPPT Psychiatrist & PT psychiatry resident

1 pm session a week in clinic 3-4 40 min. scheduled appointments (3 + 1 OVBK) E-mail/phone consults about patients - ongoing

Managing SPMI patients – current status at Denver Health – cont’d Clarification of Roles: BHC vs. Psychiatrist

Dx clarification Appropriately triage/refer or f/u with “high-risk” patients

some case management as related to managing such patients (incl. 3 calls and a letter if pts no-show for f/u)

Treatment (4-6 sessions ideally max.) Delegation of services for higher level care to:

Psychiatry Linked to psychiatrist via e-mail or appt. (1-3 visits) Routine or Crisis evals Ability to overbook urgent med evals (1 per week) Urgent phone calls/pager for instant med changes/start via

psychiatyr consult and PCP (who starts med) Linkage to outside tx – referral heavy

Managing SPMI patients – current status at Denver Health – cont’d Summary of key points of basic model at

Denver Health utilizing a step-wise approach BHC acts as “gate keeper” to psychiatry as well as has ability to

“instantly” connect patient with psychiatry to initiate med changes, etc.

Model heavily relied on: Provider referrals to BH fact that patients ideally have an outside specialty network

of BH services available to them in case of need for intensive counseling continued medication management ongoing crises.

Identified difficulties in the management of SPMI to date

SPMI/unable or unwilling to go to specialty MH for variety of reasons as simple as vicinity/location, transportation issues,

mistrust of MH Chaotic lives

Multiple ongoing crises PHQ-9/GAD-7 tracking/general screening

may never show improved scores because of ongoing situational stressors

Identified difficulties in the management ofSPMI to date (cont’d) Other Issues:

Safety (lack of time for f/u or no timely f/u with specialty MH due to month long waiting lists or cumbersome appointment access)

Psychosis (lack of insight) High substance use issues Basic needs: housing, food security

Questions raised: How do we ensure continuation of care? Who tracks high risk patients in terms of f/u outside of

system? Or return visits in our system? Original model calls for BHCs not to have a case load.

How does managing such patients fit with this or not?

Identified difficulties in the managementof SPMI to date (cont.’d)

What is lacking in the current/basic model: care coordination in general coordination with probation officers more frequent visits if needed time for phone calls, education re: case conceptualization w/ PCP drop in patients who urgently present to clinic (but are not

“hospitalizable”) and need psych med adjustments or urgent intervention

System problems Little MHCD access % Eastside patients seen by BHC

32% CICP, 32% Medicaid, 25% Medicare, 8% DFAP, 3% Other ES has 7027 pts., BHC saw/ had involvement with 595 unique pts

(8.5% of total)

Identified difficulties in the management of SPMI to date

No MH access on CICP Patients “kicked” out of specialty care for non-adherence or

threats Low staff to high patient ratio

Cannot see patients 1x week We see 1x month at most (occasionally with

ICVs 2x)

Lessons from Other Systems Management of SPMI in other integrated

behavioral health systems: Access Community Health Center (Madison,

WI) St. Charles Health System (Oregon) Cherokee Health Systems (Tennessee) IMPACT Model

Khatri, Perry & Wallace (2008)Unützer et al (2001)Personal communication, Robin Henderson, PsyD, St. Charles Health SystemPersonal communication, Neftali Serrano PsyD & Meghan Fondow, PhD, Access Community Health Centers

Challenges in Other Already over-taxed primary care providers

struggle to manage SPMI on their panels Specialty systems are either limited or

non-existent For un- or under-insured

Inability to bill mental health codes in community health

Too few prescribers specializing in psychiatry

Creative Solutions from Other Systems Stepped care approach Disease management

IMPACT: emphasizes depression E.g., any new anti-depressant starts

Utilize a care manager Preferably with mental health background

Risk stratify care Targeted interventions

Creative Solutions from Other Mental health day treatment program

Include on-site primary care services 1-2 days/week

Complex treatment team meetings Troubleshoot barriers for complex patients Process improvement

Telehealth for integrated psychiatrist Flexible access crucial for those in crisis In-house 340B pharmacy w/ federal drug

pricing

It’s All About the Data Create registries to track highest acuity patients Track percentage of mental health burden on

PCP’s panel Ensure not overwhelming particular providers

Track outcomes Functional and symptom improvement

Assess degree of integration E.g. Atlas of Integrated Behavioral Health Care

Quality Measures http://integrationacademy.ahrq.gov/

Changing Policy Ensure MH billing can occur in primary

care setting Pay flat rates for specialty providers

Spend 1 day/wk at FQHC Colorado’s SHAPE initiative—global

payment model for integration Sustaining Healthcare Across Integrated

Primary Care Efforts Rocky Mountain Health Plans Oregon

Model Adjustments We have adjusted our model to address

several key areas Use of modified registry Risk Stratification Flexible Access

Model Adjustments – Modified Registry

Priority Level System Addresses patients with acute safety issues

or significant psychosis Pts ranked 1-4 based on our clinical

evaluation BHC caseload = 3s and 4s Priority 4: expectation is weekly contact,

typically near need for hospitalization Priority 3: expectation is monthly

contact, and follow up on no shows/ lack of engagement

Model Adjustments – Risk Stratification

Identification of patients using data systems – Who do we not know about and need to? Psych hospital/ ER DC list

BHCs intervene on those who’s follow up is with the PCP

Assess current clinical status, knowledge of medication changes, ability to get meds, follow up care & barriers; link to RN/ pharmacy/ navigator as needed

Being done by navigators for medical DCs We have repeatedly found that specific people with some

MH knowledge are needed to do this type of work for the BH population

Intend to propose BH specific navigators

Model Adjustments – Risk Stratification Identification of patients using data systems

(cont) Daily List

Patients with visits scheduled that day MH Flag Tier 3 & 4 (CMMI tiering intervention)

BHCs are asked to: Review the list daily and ID pts that they will try to meet

with Known patients who need follow up Screen unknown patients for MH needs

It remains to be seen if we are identifying the “right” patients

Model Adjustments Identification of patients using data

systems (cont) The trials and tribulations of screening

Large population Can we address all the need we find? How much time will we spend screening/ how many patients will

we ID who actually are appropriate for BHC services Who should do the screening?

Two clinic pilots – tried to incorporate screening into the general clinic process using navigators and HCPs have failed

We have temporarily settled on the BHCs screening the Tier 3 & 4 patients

Screen for depression, anxiety, PTSD, bipolar & substance abuse Will take time to screen this population Hope in the future to use BH specific navigators in this role

Model Adjustments – Risk Stratification

High Risk Case Conference CMMI intervention

Identifies patients at the clinic/ PCP level By diagnosis data (DRG) & utilization

4 Current Clinic Pilots to ID the best model One theme so far has been that a lot of the

changes made to plans of care involve significant SW and BH involvement

Drop in access – Psychiatry & BHCSuccessfully pilot at one clinic – one half day a week

Addresses high no show ratePatient Centered - allows for care at the time the patient needs it most

Has sig. increased the number of patients actually seen by psychiatry

Model Adjustments – Flexible Access

Future Directions Tighter coordination of services

SW, navigator role, pharmacy Better utilizing specific skill sets

Broadening walk-in access Identification of patient preference for treatment

modalities Telephonic interventions Groups Brief therapy

Identification of the “right” group of patients to outreach Better coordination with and flow between specialty MHCs

Questions & Discussion

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.Thank you!