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Primary Care Integration for a Rural Community Behavioral Health Clinic

2015 Washington Behavioral Healthcare Conference: Fulfilling the Promise of Integrated

Care Vancouver, WA June 19, 2015

Who We Are!

A rural community behavioral health agency

Serving 1600-1700 clients currently

Outpatient Day Treatment program serving approximately 70-100 clients

Presenters

Christine Burnell FNP, DNP (Provider )

Ru Kirk MA (Clinical Director)

Sue Ehrlich MD (Medical Director)

Learning Objectives

Introduction of the Institute for Healthcare Improvement (IHI) Behavioral Health Integration Capacity Assessment (BHICA) Tool

Review structures that support an integrated model including organizational structures, interest of stakeholders (there are many)

Share integrated models for mental health and primary care in greater Puget Sound area

Share identified barriers of integrated model including organizational resistance to change, attitudes and beliefs about integrative care, licensing issues, physical plant changes, data sharing challenges, billing challenges

Reasons for Pursuing this Project

Passion and Compassion

FNP strategically placed to be a leader in change

Rural community offering challenges and opportunities for integration

Availability of a psychiatrist, Medical Director

Clinical commitment to treat most vulnerable

Reasons for Pursuing this Project

• Easy access• Customer service built on a

culture of engagement and wellness

• Comprehensive care• Excellent outcomes

• Excellent Value

• National Council’s Behavioral Healthcare Centers of Excellence framework

Complex Adaptive Systems

High

Professional and Social Agreement about Outcomes

Low

Plan & Control

Chaos

Zone of Complexity

Certainty About Outcomes

High Low

From Crossing the Quality Chasm, A New Health System for the Twenty First Century, Institute of Medicine

Problem StatementThose with Serious Mental Illness: Life expectancy – is up to 25 years

less than general population Live with physical health

comorbidities Experience fragmentation between

primary care and behavioral health Quality of life consequences. If left

untreated - experience negative social determinants of health

Cost – ER visits and hospitalizations

Purpose: To Develop a draft Implementation plan for the provision of primary care at the collaborative agency to serve those with serious mental illness.

Project Design

This was a quality improvement project to examine feasibility of implementing primary care in a rural community behavioral health setting.

Phase 1Clinic Assessment: The IHI Behavioral Health Integration Capacity Assessment (BHICA) tool was used to assess organizational readiness for integration at the collaborative agency.

Project Design

Phase 2 Interviews at Partner agency (KMHS) where an exemplar integrated model is

in use currently Federally Qualified Health Center (FQHC) Peninsula Community

Health Services NAVOSFocused interview questions were derived from the UW AIMS Center regarding integration readiness.

All data was collated and analyzed to create a draft version of an implementation plan for integrated care.

Project Design

Phase 3

All data was collated and analyzed to create a draft version of an implementation plan for integrated care.

IHI BHICA Tool

Assesses agency capacity for integration with leaders of organization utilizing the five steps:

Understanding the Population (for self-reflection as agency)

Assessing Agency Infrastructure Identifying the Population and Matching Care Assessing Three Approaches to Integration Financing Integration

IHI BHICA Tool

https://www.resourcesforintegratedcare.com/tool/bhica

IHI BHICA Tool: A SnapshotProcess Reliable Impact Resources Notes

2.1.1 Does your organization routinely collect individual-level data? Yes Yes2.1.2 Does your organization routinely aggregate individual-level data? Yes Yes2.1.3 Do you record the names of individuals' primary care providers? Yes Yes2.1.4 Do you record the date of individuals’ last primary care visit?

Yes No2.1.5 Do you record progress notes/the nature of the last primary care visit? Yes Yes2.1.6 Do you record the names of individuals’ home and community-based supports? Yes Yes2.1.7 Do you record the number of past-year hospitalizations for both psychiatric and medical reasons? Yes Yes Recorded not necc accessible/in chart2.1.8 Do you record the number of individuals' past-year ER visits for both psychiatric and medical Yes Yes2.1.9 Does your organization securely exchange individuals’ information with other practices? Yes Yes

Yes or No Notes2.1.10 Does your practice use an electronic health record (EHR)? Yes Yes2.1.11 Does your EHR meet Stage 1 meaningful use criteria? Yes Yes2.1.12 Are you able to manage chronic conditions in the EHR? No Higher Yes2.1.13 Is your EHR able to interface with other systems outside of the organization? No Higher No Only within RSN

Table 1 Self-Assessment: Your Infrastructure

2. Assessing Your Infrastructure2.1. Capacity to Collect Data, Exchange Information, and Monitor Population Health

BHICA Tool: Understanding the Population

Timeline: 4/1/14-3/31/15 1522 clients served 22,958 services of which 21,113 face-to-face 50-60 miles - average proximity to practice

IHI BHICA Tool: Top Mental Health Diagnoses

9% Schizoaffectiv

e

The BHICA Tool: Understanding the Population

The BHICA Tool: Top Physical Health Diagnoses

BHICA Tool: Understanding the Population

Key Question Left Unanswered Unable to determine percentage of population with

multiple chronic conditions

Laying the Groundwork for a Draft Implementation Plan

• Problem: Inaccurate or insufficient data• Solution: Educate staff - PDSA Cycles to improve performance • Problem: Insufficient Reporting Capacity • Solution: Utilize IT Support to Identify Multiple Chronic Conditions

Identify Specific/Vulnerable PopulationsCreate and Utilize Registries/Other QI Activities Identify a Small Population for Focused BH/PH

Understanding the Population

Laying the Groundwork for a Draft Implementation Plan

PDSA Model of Improvement

Recommendations: Draft Implementation Plan

Assessing Your Infrastructure Capacity to Collect Data, Exchange Information, and Monitor Population Health • Establish Registries for Shared Populations • Electronic Health Record Sharing

Progress and Outcome Tracking Capability • Tracking Measures Related to Medications e.g. EMR and RxNT Prescribing Software Do Not

Interface = Robust Full Use of RxNT / Input All Medications • Track All Provider Satisfaction Measures

Process for Engaging and Communicating with Individuals and Family Members • Family Resource Coordinator • Family as a Client Model Could be Adopted vs Individuals When Requested

Recommendations: Draft Implementation Plan

Assessing Your Infrastructure Capacity to Provide Clients with Community Wellness Resources • Wellness Coordinator (Healthy Living Coordinator)• Utilize Outpatient Space in Afternoons to Offer In-House Wellness Program • Revitalize and Adapt Healthy Living Program as a Program Improvement

Plan engaging both staff and clients toward healthier lifestyles • Utilize Untapped Resources: Nursing Students UW, PMHNP Students to

Carry Forward this Capstone, Peninsula & Olympic Colleges • Strengthen Bi-Directional Community Referral and Tracking Systems

Recommendations: Draft Implementation Plan

Assessing Your Infrastructure Culture to Support Integration: Leadership Culture • Strong, active commitment by leadership toward integration -key component

organization’s strategic plan

• Education and Engagement of Staff re Integration and PH Indices at All Levels Critical

• Empower Staff via Feedback Mechanisms with New Initiatives

• Monthly Newsletters to Staff by Leadership

• Weaken Support for Status Quo / Sensitivity to Historical Organizational Shifts

BHICA Tool: Identifying the Population & Matching Care

Recommendations:

• Target population identified as day treatment outpatient program

• Most clients would be amenable to this model over seeing their PCP off-site

• Comprehensive case management in place

• A RN/Team approach to addressing individual’s unmet care needs would be a good pilot for moving toward integration

BHICA: Assessing Optimal Integration

Reverse Co-location

Level of Integration Partly integrated system-BH and PC in same facility with shared appointment and medical record systems. Physical proximity allows for regular face-to-face communication among BH and physical health providers. Collaboration is key

Populations Best Served Quadrants II and IV (High behavioral health needs)

Applicable to all ages with adaptations

Adapted from Milbank 2010 Table 12

BHICA: Assessing Optimal Integration

Implementation Barriers Records may remain separated Consent and privacy issues/meshing paperwork processes, differences in

culture BH/PHSame-day billing challenges

When new appointments required, issues with no-shows can increase

Economic Outcomes Generate savings because of leveraging and cost-effectivenessMay generate cost-offset savings

Health Outcomes Considerable potential to reduce lifestyle risk factors

Studies have shown reduction of ER visits and dramatic increases in screening of hypertension and diabetes (Boardman 2006)

Why Choose This Model? Through billing or partnership a more integrated model between primary care and specialty mental health is sustainable

Adapted from Milbank 2010 Table 12

Recommendations: Draft Implementation Plan

Financing Integration

• Optimize Existing Revenue Sources • Marketing and Development Director to Regularly Monitor Up and

Coming Grants • Champions to Work with Exemplar Sites (KMHS’s Bi-directional Model) • Engage in Discussions with Insurance Plans to Incentivize them to Pay for

Cost Savings • Study Billing Regulations that may Pose Restrictive Practice in Integration

Efforts (same day billing)

Exemplar Site Interviews

• KMHS: Donna Poole ARNP Prior Acting Medical Director

• Elena Argomaniz Project Director CMS Innovation Grant

• Peninsula Community Health Services (FQHC):

Health Administrator/Medical Director • NAVOS Burien Site: Paul Tegenfeldt Vice

President of Healthcare Integration

THE PATHWAY TO THE SUMMIT

• BHICA – First study • Exemplar site interviews • Identify strengths/barriers/lessons learned from exemplars to

collate recommendations• Hire consultant National Leader• Concepts of integration • Staff engagement Key Stakeholder Meeting• Bi-directional Model of patient centered care a focus

Learning Objectives

Introduction of the Institute for Healthcare Improvement (IHI) Behavioral Health Integration Capacity Assessment (BHICA) Tool

Review structures that support an integrated model including organizational structures, interest of stakeholders (there are many)

Share integrated models for mental health and primary care in greater Puget Sound area

Share identified barriers of integrated model including organizational resistance to change, attitudes and beliefs about integrative care, licensing issues, physical plant changes, data sharing challenges, billing challenges

“Do The Next Right Thing”

Do one physical thing Make one face to face consultation with a provider Participate in all opportunities for collaboration

regardless of format Shared risk is an opportunity to drive change

Thank You ! Questions?