WBHC 2017 Learning Objectives At the conclusion of this - PowerPoint PPT Presentation

ENGAGING CONSUMERS ACROSS THE CONTINUUM OF BEHAVIORAL INTEGRATION: STEPPED CARE TO MATCH CONSUMER NEEDS AND AVAILABLE RESOURCES Phillip B. Hawley, Psy.D. Brian E. Sandoval, Psy.D. Angelina Thomas, MHA WBHC 2017

Learning Objectives At the conclusion of this presentation, attendees will be able to: -Understand how consumers’ needs, motivation, and stepped -care work together in a consumer-focused FQHC -Develop workflows to improve communication within and between systems to help consumers receive the appropriate level of care -Describe specific strategies to use electronic medical records to obtain and intelligently use data to work towards Quadruple Aim initiatives -Create solutions for achieving quality metrics across clinics and behavioral health systems of care WBHC -Identify strategies for effective resource allocation to remove barriers and enhance access to services consistent with each 2017 consumer’s risk, severity of presentation, and life circumstances

WHO WE ARE: YAKIMA VALLEY FARM WORKERS CLINIC  Founded in 1978 to serve migrant and seasonal farm workers  Now serve Medicaid, the underserved, and refugees  Accredited by TJC and NQCA  Focus on population health and communities we serve  One of the largest community health centers in the nation • 141,500 + people 19 medical clinics • • 10 dental clinics • 57 programs in WA & OR

WHO WE ARE: SERVICES PROVIDED  Medical  Behavioral Health (PCBH and specialty BH)  Dental Care  Pharmacy Services  Educational/Employment Training  Community Health Services  Weatherization (maternal health, outreach, “ inreach ”)  Mobile Units  Nutrition Services (WIC and PCNS)  HIV/AIDS specialty care

WHERE WE ARE

APPROACH  We have addressed the behavioral health needs of our population by, “meeting patients where they are at.” You are here

PRIMARY CARE BEHAVIORAL HEALTH: A PRACTICAL SOLUTION Population-based BH Service Delivery to Match Community Need Beha havi viora ral l Health lth Care “Health” Care PCBH PCBH BH Barri rrier ers - MH Benefi fits? – Free or Low cost - Stigma a – “Warm hand - off” – Preve vent ntat ative ve Visits - MH Proc ocess – Brief/s f/same ame day interve vent ntion on - Poor or Infor format ation on - Short/e /episod odic care Sharing ng – Verbal al cons nsul ultat ation on with care team am – Shared docum ument ntat ation on in EMR

PRIMARY CARE BEHAVIORAL HEALTH (PCBH) - Behavioral Health Consultants (BHCs) provide brief assessment, intervention, and consultation - Service is at the point of care and routine part of medical visits - 15-30 minute visits in exam rooms - Care model is brief and episodic - Goal is to provide MH access for large segment of population - Intended to improve PC and BH system efficiency - Emphasis on engagement and decreased stigma

PCBH Workflow Adapted from Serrano, 2011

YVFWC BH CONTINUUM Primary Care BH YVFWC Outpatient BHS 13 BHC Providers YVFWC Specialized BHS: 11 Clinics Intensive Services 19,672 visits Annually* 30 BHS Providers 13,176 Unique Patients* 4 Clinics Crisis Services 21 Direct service staff 25,000 Visits Annually 2 Clinics 2000 Unique Patients Inpatient 16,600 Direct Service Annually Hours Annually 300 Unique Patients Annually Level of Complexity Low High Level of Intervention **Current BHC Staffing 14 BHC Providers 11 Clinics

YAKIMA VALLEY FARM WORKERS CLINIC * NE Clinic ic * Mis issio ion Clinic inic West Central * BHC Services * BHC+BHS Services * * * Open Position * * *

WHY The pacific northwest is an area with a higher prevalence of behavioral health conditions as well as an area with lower access to care.

ADULT PREVALENCE OF MENTAL ILLNESS

YOUTH PREVALENCE OF MENTAL ILLNESS

Washington State prevalence of youth with at least one Major Depressive Episode in the past year: 12.05%

IMPACT 13, 3,176 6 Unique ique Pat atie ients nts Ser erved d in in 2016 6 ac across ross al all l YVF VFWC C BHCs WASHING Granger SHINGTON ON Mission: North East: 390 Visits 1,552 Visits 5.6% Patient 24.4% Patient Astoria Clatskanie Penetration Penetration Nob Hill: 1,504 Visits 7.5% Patient Toppenish: Penetration 1,980 Visits 7.0% Patient Penetration Family Medical: 1,461 Visits 18.8% Patient Grandview: Penetration 1,305 Visits 8.6% Patient Penetration

QUADRUPLE AIM  Provider satisfaction data  Patient satisfaction data  Cost of integrated care versus TAU  Outcomes (PHQ-9)

PCBH PATIENT SATISFACTION How ow comfo forta table e were re you in in dis iscussing cussing your conce cerns rns wit ith h the BHC? Some mewhat at Uncomf omfor ortabl ble Comf mfortab able le .7% 3.3% Comfortable 23.8% Very Comfortable 72.2%

PCBH PATIENT SATISFACTION Were the BHC’s recommendations useful? Not ot Useful ful Some mewhat at 0% 0% Usefu ful 1.3% Yes, Useful 32.5% Yes, Very Useful 66.2%

PCBH PATIENT SATISFACTION Would ld you recom ommend end this is behavi vioral oral health lth service vice to a frie iend? Probabl robably y Not ot 0% 0% Probably No No 14.6% 0% 0% Yes 85.4%

PCBH PROVIDER SATISFACTION BHC makes es me more e effe fecti tive e at my jo job: Some meti times mes Rarely/Ne y/Never 6.7% 0% 0% Often 15.6% Consistently 77.8%

SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT (SBIRT)  Meeting quality aims  Identifying and treating depression and substance concerns earlier  BHC involvement in PCHH to identify trends and provide ongoing SBIRT education/support.

QUALITY – DEPRESSION/SBIRT DATA  “Process level” data  Enh nhance anced Workf kflo lows ws: 73% SBIRT screening rate (1242/1685)  Impr proved ed Depre ressio ssion Care:  Depression F/U – 25% Oregon CCO benchmark  **First 3 months = 34.5%,  **Last 6 months = 74% **Looking only at BHC participation in measure (visit w/ in 2 weeks)

What are we measuring? PCBH is “integrated” and provides good access to BH  13,176 patients seen across 10 clinics  Average of 10 visits per BHC per day  Average of 14% Service Penetration (24.4% high, 7% low)  Model adherence: ≤4 visits per patient per quarter, for 95% of patients √ PCBH leads to good clinical outcomes and decreases utilization Pre/post BHC Visits:  PHQ9 ≈ 44% significant improvement (≥ 5 points)  GAD7 ≈ 50% significant improvement (≥ 3 points)  Utilization – Decrease in 2 visits/patient for highest 100 medical utilizers

What did we learn? Patient ents s Total al w/ Patient nts s Patient nts s Patient ents s Positive e seen en by with h 2+ # Positive ve % posi sitive ve # signi nifican ant % signi nifi fica cant nt Measu sure Scr cree eened ned Scr cree eens ns BHC screens ens Outco comes mes outco comes mes improveme vement nt improveme vement nt PHQ-9 4432 2555 1891 570 366 64.2% 253 44.4% GAD-7 4236 2129 1623 489 317 64.8% 246 50.3% • Missing depression screening, especially by non-BHCs • Not as many positive screens are going to BHCs as expected • Not doing a good job of reassessing patients not coming into the clinic We e are doing g we well, l, but t there ere is cons nsider iderabl ble e roo room for impr provement! ement! Whe here re can n I fi find nd exempl emplars s to mitiga igate e our we weaknesse knesses? s?

Evolution of Primary Care Genera ral Primar ary y Care  Treat “All Comers,” High Volume  Brief, Episodic Care and Chronic Care  Expedited Access (Same Day)  Proactive and Reactive Treatment Strategies  “Front Line” of Care  Shared Records/EHR among PC Staff Ad Advanced nced Primar ary Care e Ac Activi viti ties es  Registries/Tracking (for key conditions)  Risk Stratification/Protocols  Systematic Follow-up  Onsite or Close Collaboration with Specialists  Shared Care Plans in EHR Pa Patient tient Cent ntere red d Medical ical Home  Effective Population Health  Quadruple Aim  Alternative Payment/ VBP

Enter Collaborative Care!  Disease Management model  Registry Driven and Systematic Follow-up up  Care management contacts  Re Re-administration of screening instruments (PHQ-9/GAD-7) 7)  Protocol based on level of improvement and patient motivation  Psychiatric Consultation for those not improving (via PHQ9/GAD7 ) Further her Reading: ding: Psych chiat atryonl onlin ine. e.or org/ g/All All Hands ds on Deck

Synergy Between Models Col olla laborativ borative e PCBH  Screening/ Care are  Treat “All Comers” Tracking  High Volume  Collaboration  Registries/Tracking with Psychiatry  Brief, Episodic Care  MH/  Expedited Access (for key conditions) Depression  Systematic Follow-up (Same Day) Treatment  Condition-focused  Health Behavior  Risk outcome goals Change Stratification/  Chronic Care Protocols