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Reducing Fragmentation Through Coordinated Care Part 2
February 21st 2019
12-1pm EST
National Council for Behavioral Health
Montefiore Medical Center
Northwell Health
New York State Office of Mental Health
Netsmart Technologies
Today’s Panel Facilitator
Mindy Klowden, MNMDirector, Training and Technical AssistanceNational Council for Behavioral Health
Panelists
Mary Zelazny, CEOFinger Lakes Community
Health CenterDr. Inderpal Chhabra
Lefferts Medical Practice
CMS Change Package: Roadmap for Transformation
Patient and Family-Centered Care Design
1.1 Patient & family engagement 1.2 Team-based relationships 1.3 Population management 1.4 Practice as a community partner
1.5 Coordinated care delivery 1.6 Organized, evidence-based care1.7 Enhanced access
Continuous, Data-DrivenQuality Improvement
2.1 Engaged and committed leadership 2.2 QI strategy supporting a culture of quality & safety 2.3 Transparent measurement and monitoring2.4 Optimal use of HIT
Sustainable Business Operations
3.1 Strategic use of practice revenue 3.2 Staff vitality and joy in work 3.3 Capability to analyze and document value 3.4 Efficiency of operation
Milestone 9: Practice works with the
primary care practices in its medical neighborhood to develop criteria for referrals for episodic care, co-management, and transfer of care/return to primary care, processes for care transition, including communication with patients and family.
Milestone 10: Practice identified the
primary care provider (PCP) or care team of each patient seen and communicates to the team about each visit/encounter.
Defining “Co-Morbidity”
• The co-occurrence of mental and physical disorders within the same person, regardless of the chronological order in which they occurred or the causal pathway linking them.
• Having a mental disorder is a risk factor for developing a chronic condition, and having a chronic condition is a risk factor for developing a mental disorder.
• When mental and medical conditions co-occur, the combination is associated with elevated symptom burden, functional impairment, decreased length and quality of life, and increased health care costs.
Source: The Synthesis Project, Druss and Walker, 2011
Co-Morbidity of Mental Health Disorders and Other Chronic Conditions
Source: Druss, BG & Walker, ER (2011) RWJF. Adapted from the National Comorbidity Survey Replication 2001-2003.
People with mental illness disorders: 25% of adult population
People with medical conditions: 58% of adult population
68% of adults with mental disorders have medical conditions
29% of adults with medical conditions have mental disorders
Finger Lakes Community Health - Who We Are
• Community & Migrant Health Center (FQHC)• Serving mostly rural communities
• Agricultural Worker Voucher Program in 42 Counties of NYS
• 8 Full Health Center Sites• Medical• Dental• Behavioral Health (MH & SUD)• Nutrition• Care Management & Financial Advocacy
• Community & School Based Portable Dental• Mobile Medical Program• Telehealth (specialty & primary care)
• 2018 Stats:• 28,123 Total Users • 9,051 Ag Workers• 60% of patients want to be seen in a
language other than English
Who We Serve
Lefferts Medical Associates PC
• Community-based Internal Medicine practice consisting of an MD and a nurse practitioner.
• Located at the Queens/ Nassau county border.
• See a variety of illnesses such as hypertension, diabetes, COPD along with behavioral health issues.
• PCMH level III certified site.
• Serve a majority population consisting of immigrants from the South Asian region, along with a mix of general Caucasian,
African American and Caribbean American patients.
• Offer a large range of advanced testing in house, such as EKG, Echocardiograms, Stress Testing, Pulmonary Tests, Nerve
testing and POCUS. This is in response to patient’s needs and to avoid them having to travel far.
Lefferts Medical Associates PC
Discussion
Upcoming Events
Reducing Fragmentation Through Coordinated Care
• Part 3: the Behavioral Health Perspective – March 21 from 12-1pm
• Individual consultations with Mindy Klowden
Quality Improvement
• Implementing Quality Improvement: Introduction to the CTN Toolkit –
February 28 from 1-2pm
• Quality Improvement Office Hours – Throughout March
Health Information Technology
• New HIT Consulting Package: Introducing NYeC – March 6 from 12-1pm
• HIT 101 for Behavioral Health Providers – Tues., March 19 from 12-1pm
Don’t forget to enter “NATCON200” to get $200 off your registration!
Thank you!Contact: Mindy Klowden, MNM, Director, Technical Assistance and Training
www.CareTransitionsNetwork.orgCareTransitions@TheNationalCouncil.org
The project described was supported by Funding Opportunity Number CMS-1L1-15-003 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services.
Disclaimer: The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
