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

STEPPED CARE TO MATCH CONSUMER NEEDS AND AVAILABLE RESOURCES

ENGAGING CONSUMERS ACROSS THE CONTINUUM OF BEHAVIORAL INTEGRATION:

Phillip B. Hawley, Psy.D. Brian E. Sandoval, Psy.D. Angelina Thomas, MHA

WBHC 2017

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

• f care
• Describe specific strategies to use electronic medical records to
• btain and intelligently use data to work towards Quadruple Aim

initiatives

• Create solutions for achieving quality metrics across clinics and

behavioral health systems of care

• Identify strategies for effective resource allocation to remove

barriers and enhance access to services consistent with each consumer’s risk, severity of presentation, and life circumstances

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: YAKIMA VALLEY FARM WORKERS CLINIC

• Educational/Employment Training
• Weatherization
• Mobile Units

WHO WE ARE: SERVICES PROVIDED

• Pharmacy Services
• Community Health Services

(maternal health, outreach, “inreach”)

• Nutrition Services

(WIC and PCNS)

• HIV/AIDS specialty care
• Medical
• Behavioral Health

(PCBH and specialty BH)

• Dental Care

WHERE WE ARE

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

You are here

PRIMARY CARE BEHAVIORAL HEALTH: A PRACTICAL SOLUTION

Population-based BH Service Delivery to Match Community Need

PCBH

• MH Benefi

fits? – Free or Low cost

• Stigma

a – “Warm hand-off” – Preve vent ntat ative ve Visits

• MH Proc
• cess – Brief/s

f/same ame day interve vent ntion

• n
• Poor
• r Infor

format ation

• n - Short/e

/episod

• dic care

Sharing ng – Verbal al cons nsul ultat ation

• n with care team

am – Shared docum ument ntat ation

• n in EMR

Barri rrier ers PCBH BH

“Health” Care Beha havi viora ral l Health lth Care

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

Level of Intervention Level of Complexity

Low High

Primary Care BH YVFWC Outpatient BHS YVFWC Specialized BHS: Intensive Services

Crisis Services Inpatient 13 BHC Providers 11 Clinics 19,672 visits Annually* 13,176 Unique Patients* 30 BHS Providers 4 Clinics 25,000 Visits Annually 2000 Unique Patients Annually 21 Direct service staff 2 Clinics 16,600 Direct Service Hours Annually 300 Unique Patients Annually **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

*

* * * * *

*

*

* *

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

WHY

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

Astoria Granger

Clatskanie

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

North East: 1,552 Visits 24.4% Patient Penetration Mission: 390 Visits 5.6% Patient Penetration Nob Hill: 1,504 Visits 7.5% Patient Penetration Toppenish: 1,980 Visits 7.0% Patient Penetration Grandview: 1,305 Visits 8.6% Patient Penetration Family Medical: 1,461 Visits 18.8% Patient Penetration

WASHING SHINGTON ON

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

QUADRUPLE AIM

PCBH PATIENT SATISFACTION

Very Comfortable 72.2% Comfortable 23.8% How

• w comfo

forta table e were re you in in dis iscussing cussing your conce cerns rns wit ith h the BHC?

Some mewhat at Comf mfortab able le 3.3% Uncomf

• mfor
• rtabl

ble .7%

PCBH PATIENT SATISFACTION

Yes, Very Useful 66.2% Yes, Useful 32.5% Were the BHC’s recommendations useful?

Some mewhat at Usefu ful 1.3% Not

• t Useful

ful 0% 0%

PCBH PATIENT SATISFACTION

Yes 85.4% Probably 14.6% Would ld you recom

• mmend

end this is behavi vioral

• ral

health lth service vice to a frie iend?

Probabl robably y Not

• t

0% 0% No No 0% 0%

PCBH PROVIDER SATISFACTION

Consistently 77.8% Often 15.6% BHC makes es me more e effe fecti tive e at my jo job:

Some meti times mes 6.7% Rarely/Ne y/Never 0% 0%

 Meeting quality aims  Identifying and treating depression and substance concerns earlier  BHC involvement in PCHH to identify trends and provide

• ngoing SBIRT education/support.

SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT (SBIRT)

 “Process level” data

QUALITY – DEPRESSION/SBIRT 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)

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%
• f 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 are we measuring?

What did we learn?

Measu sure Total al Patient ents s Scr cree eened ned Patient ents s w/ Positive e Scr cree eens ns Patient nts s seen en by BHC Patient nts s with h 2+ screens ens # Positive ve Outco comes mes % posi sitive ve

• utco

comes mes # signi nifican ant improveme vement nt % signi nifi fica cant 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?

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

Evolution of Primary 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

• nlin

ine. e.or

• rg/

g/All All Hands ds on Deck

Enter Collaborative Care!

 Screening/ Tracking  Collaboration with Psychiatry  MH/ Depression Treatment  Risk Stratification/ Protocols

Registries/Tracking (for key conditions) Systematic Follow-up Condition-focused

• utcome goals

Chronic Care  Treat “All Comers”  High Volume  Brief, Episodic Care  Expedited Access (Same Day)  Health Behavior Change

PCBH Col

• lla

laborativ borative e Care are

Synergy Between Models

PCBH BH

Treat “All Comers” High Volume Brief, Episodic Care Expedited Access (Same Day) Health Behavior Change Screening/Tracking Collaboration with Psychiatry MH/Depression Treatment Risk Stratification/ Protocols

St Strength: ength: Integrates well into general primary care culture of care Weakness: ness: Challenges in population monitoring and follow-up

BHC

 Treat “All Comers,” High Volume  Brief, Episodic Care X 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

X Registries/Tracking (for key conditions)  Risk Stratification/Protocols Systematic Follow- up  Onsite/Close Collaboration with Specialists  Shared Care Plans in EHR X Focus on specific population outcomes

PCMH MH

X Effective Population Health X Quadruple Aim X Alternative Payment

Genera ral Primar ary y Care

Col

• lla

laborativ borative e Car are

Screening/Tracking Collaboration with Psychiatry MH/Depression Treatment Risk Stratification/ Protocols

St Strength ength: Does well in population monitoring , systematic follow up for identified populations Weakness ness: Challenge to fit into general PC delivery structure and serving a large population

Psychiatr trist st Care Coor

• rdi

dinat ator

• r

X Treat “All Comers,” High Volume X Brief, Episodic Care  Chronic Care X Expedited Access (Same Day) X Proactive and Reactive Treatment Strategies X “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/Close Collaboration with Specialists  Shared Care Plans in EHR  Focus on specific population outcomes

PCMH MH

X Effective Population Health X Quadruple Aim X Alternative Payment

Genera ral Primar ary y Care

Registries/Tracking (for key conditions) Systematic Follow-up Condition-focused outcome goals Chronic Care

Treat “All Comers” High Volume Brief, Episodic Care Expedited Access (Same Day) Health Behavior Change Screening/Tracking Collaboration with Psychiatry MH/Depression Treatment Risk Stratification/ Protocols

“Comprehensive” Integration

Utilizes strengths of both models to best align with PCMH service delivery

BHC

Psychiatr atrist st Care Coor

• rdi

dinat ator

• r

 Treat “All Comers,” High Volume  Brief, Episodic Care  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/Close Collaboration with Specialists  Shared Care Plans in EHR  Focus on specific population outcomes

PCMH MH

 Effective Population Health  Quadruple Aim  Alternative Payment

Genera ral Primar ary y Care

Collabo laborativ rative e Care PCBH

Registries/Tracking (for key conditions) Systematic Follow-up Condition-focused outcome goals Chronic Care

Int ntegrat egration ion Acr Acros

• ss

s De Deli liver ery Sy Syst stem em

THE ART OF NAPKIN PLANNING

MHIP Patient Example Medication Trial 03/09/2017: Fluoxetine

Patient starts medication trial for depression

In clinic MHIP initial visit Phone MHIP f/u call PHQ-9 Data

Possible Work Flows to Consider:  Patient identified by PCP, universal screening, or ED utilization reports  PCP refers patient to BHC or CoCM care manager for assessment, brief intervention, and to determine the appropriate level of care  Patient tracked – “stepped” into appropriate treatment track - depending on diagnosis and symptom severity, anticipated intervention required, other factors  Patients with more severe and persistent behavioral health needs connected to appropriate specialty resources

EVOLUTION OF PRIMARY CARE SERVICES

MANY…Assumptions!!

 Recognizing healthcare utilization patterns  Reducing cost to the healthcare system  Meeting measure to track patients and focus

• n population health

EMERGENCY ROOM FOLLOW UP

 Recognizing healthcare utilization patterns  Reducing cost to the healthcare system  Meeting measure to track patients and focus on population health

EMERGENCY ROOM FOLLOW UP

 Recognizing healthcare utilization patterns  Reducing cost to the healthcare system  Meeting measure to track patients and focus on population health

EMERGENCY ROOM FOLLOW UP

First BHC visit 2/24

REFERRAL FLOWCHART

PCP Identifies Possible Benefit from Specialty BH Referral

BHC Assesses for Eligibility & Motivation

Patient retained in primary care: BHC/PCP provide shared, episodic care

Patient referred by BHC for specialty BH

Patients not Eligible Patient Eligible & Motivated Patients Eligible & Unmotivated

Patient seen by BHC to enhance motivation for specialty BH

BHC and BHS meet regularly to discuss changes in eligibility and referrals Clinics w/o BHC support identify patient with BH needs

REFERRAL FLOWCHART

John Doe is a 10 y.o. male who is experiencing depression with suicidal ideation and a past attempt of suicide 2 years ago Safety Concerns: Suicidal Ideation: YES. Self-Harm: Not currently Past Attempts: Yes attempt 2 years ago Preferred Locations: Yakima: No Toppenish: YES Grandview: YES Language : Spanish

TEMPLATES

EHR UPDATES

P R OV I D E R T R A I N I N G S E L I G I B I L I T Y U P DAT E S

BHC and BHS meet regularly to discuss changes in eligibility and referrals

Staffing Challenges

• Difficult for 1.0 FTE BH clinicians to succeed in

a role as both consultant and collaborative care manager

• Too many trade-offs
• Stepped Work Flows and Protocols
• Well thought-out structure and work flows

To Tools for Te Team Communication Important

• Find common language and processes in

measurement-based care

SUCCESSES AND CHALLENGES

IMPROVING COMMUNICATION BETWEEN SYSTEMS

This initiative connected our consumers with needed behavioral health resources in the community, and aimed to ensure people were not falling through the cracks.

Met with Partner Agencies Gathered Data

• n Services &

Resources Finalized MOUs to Increase Communication

Partner Organizations:

 Hospitals,  Counseling Service Agencies,  Inpatient and Outpatient Substance Use Treatment Facilities,  County Health Departments,  Educational Centers and School Districts

Through our efforts, we:

• Expanded access to integrated

PCBH services

• Participated in quality

improvement studies

• Advanced the existing

infrastructure of integrated services to allow for consultations with YVFWC staff psychiatrists for clinicians at all clinic sites as needed for complex and/or urgent cases IMPROVING COMMUNICATION BETWEEN SYSTEMS

 Implemented universal screening for behavioral health indicators at all clinic sites.  Addressed the growing need for substance abuse treatment and off-site specialty mental health care by increasing collaboration and formalizing referral networks in the community.

IMPROVING COMMUNICATION BETWEEN SYSTEMS

Screening Brief Intervention and Referral to Treatment

PCP

Specialty Behavioral Health

Substance Use

Educational Systems

THE MODEL IN ACTION

Microsystem Macrosystem Exosystem Mesosystem Social Conditions Economic System School Neighborhoods

Microsystem Macrosystem Exosystem Mesosystem Social Conditions Economic System School Neighborhoods

Microsystem Macrosystem Exosystem Mesosystem Social Conditions Economic System School Neighborhoods

Microsystem Macrosystem Exosystem Mesosystem Social Conditions Economic System School Neighborhoods

Population Health

CHW

Patient

BHS

Medical Provider Dietitian BHC

Medical Assistant

Educational System External Healthcare Services Corre rect ctional ional System em Labor r System em Community Supports Peer Support

Cultural Systems Historical Factors Political/ Legal System

SUMMARY

QUESTIONS/DISCUSSION