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![Page 1: Behavioral Health/Pediatric Primary Care Integration at Geisinger: Year 1 Implementation & Evaluation Shelley Hosterman, PhD Paul Kettlewell, PhD Christine.](https://reader030.fdocuments.us/reader030/viewer/2022032723/56649d135503460f949e777c/html5/thumbnails/1.jpg)
Behavioral Health/Pediatric Primary Care Integration at Geisinger:
Year 1 Implementation & EvaluationShelley Hosterman, PhD
Paul Kettlewell, PhDChristine Chew, PhD
Tawnya Meadows, PhD
Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Session #D3October 28, 20113:30 PM
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Faculty Disclosure
We have not had any relevant financial relationships during the past 12 months.
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Need/Practice Gap & Supporting Resources
• Parents often bring their children to primary care physicians first (Smith, Rost, & Kashner, 1995)
• 15% to 21% of primary care visits are for behavioral
health concerns (Kelleher, Childs, Wasserman, McInerny, Nutting, Gardner, 1997; Lavigne, Gibbons, Arend, Rosenbaum, Binns, Christoffel, 1999; Williams, Klinepeter, Palmes et al., 2004).
• During 50% to 80% of child health care visits, parents or physicians raise concerns of behavioral or psychosocial issues (Cassidy & Jellinek 1998; Fries et al., 1993; Sharp, Pantell, Murphy, & Lewis, 1992).
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Need/Practice Gap & Supporting Resources
Problems with seeking behavioral health services from PCP:
• Increased number of medical visits
• Increased time spent with the physician
• Lost revenue if a patient takes more time than scheduled
• Lower reimbursement rate for mental health issues
• Limited training in mental health treatment (Connor, McLaughlin, Jeffers-Terry, O’Brien, Stille, Young, & Antonelli, 2006; deGruy,
1997; Leaf, Owens, Levelthal, Forsyth, Vaden-Kiernan, Epstein, Riley, & Horwitz, 2004; Strosahl, 2002; Young, Klap, Sherbourne, & Wells, 2001)
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Need/Practice Gap & Supporting Resources
Problems with seeking behavioral health services from PCP:
• Decreased number of patients seen
• Increased risk of physician burnout
• Unsatisfied patients
• Increased impairment in patient health and functioning
• Increased use of acute and emergency care (Connor, McLaughlin, Jeffers-Terry, O’Brien, Stille, Young, & Antonelli, 2006; deGruy,
1997; Leaf, Owens, Levelthal, Forsyth, Vaden-Kiernan, Epstein, Riley, & Horwitz, 2004; Strosahl, 2002; Young, Klap, Sherbourne, & Wells, 2001)
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Objectives
• Understand the collaborative development process with the Geisinger Health Plan & Pediatric Partners
• Describe Geisinger’s pilot model
• Describe program evaluation plans for this project
• Review baseline data for the program
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Agenda
• Developing the model – Process & Supports
• Details of pilot model
• Program evaluation & research
• Baseline data & future directions
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Development: Previous System
• Outpatient mental health services, inpatient psychiatric unit, & consultation/liason in major hospital
• 3 pediatric psychs, 1 family therapist, 1 psychiatrist, 3 pre-doctoral interns, & 2 postdoc fellows
• Serving all children/adolescent in 5 counties, all patients with Geisinger PCPs, specialty patients
• Concerns with system: Waitlists, no shows, patient travel, caseloads, problems recruiting psychiatrist
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Development: Model Prototype
Munroe-Meyer Institute – Inspiration for our modelUniversity of Nebraska Medical Center; Omaha, NE
http://www.unmc.edu/mmi/behavioral/
Joseph H. Evans, Ph.D. Director, Psychology DepartmentRachel Valleley, Ph.D.Outreach Behavior Health Clinics Coordinator
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Development: Model Prototype
• Behavioral health services in primary care
• 23 outreach clinics across Nebraska
• Reaching underserved, rural populations
• Co-located & collaborative clinics
• Interns/postdocs trained in the setting
• Education for PCPs• Frequent contacts
regarding referrals• Research & program
evaluation• Promising outcomes –
Discussed later
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Development: Our System
Geisinger Health System - •Integrated health network•Serves 43 counties; 20,000 sq miles; 2.6 million people•Nearly 60 community practice sites across the state•System-wide electronic medical record
•Geisinger Health Plan – Among nation’s largest rural HMOs (270,000 members)
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Development: Marketing Change
Step 1: Approached psychiatry administration (10/09)•Response – Excellent concept, but no way to proceed within budget
Step 2a: Presentation at psychiatry grand rounds (2/10)•Response – Excellent concept•Possibility #1 – Private donor looking for a way to support mental health of children/adolescents•2b: Private meetings & additional presentation to private donor secured substantial gift
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Development: Marketing Change
Step 3: Presentation to Pediatric Grand Rounds (03/10)•Response – Pediatrics enthused & many requested
Step 4: Presentation to Geisinger Health Plan (Spring ‘10)•Summary – Model offers better care, may save money, & carve out model of payment does not make sense•Response – We agree, what should we do?•Key message – They believe is better care & will support if we can break even or save money
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Development: GHP Proposal
Monthly planning meetings with GHP administration
Data review process:•Medical expenses for pediatric patients with ≥1 BH visit double those of comparison patients•Key cost differences: Outpatient, pharmacy, & ED•Potential for cost off-set?
Outcome: GHP funded pilot project & program evaluation
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Development: GHP Proposal
Proposal objectives:1.Improve quality of behavioral health care2.Reduce medical expenses & utilization of patients with BH concerns3.Increase physician, parent, & patient satisfaction with service model & delivery4.Expand PCP knowledge of BH assessment & intervention5.Improve access, adherence, efficiency, & integrity of BH services & intervention
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Development: Task Force• Key stakeholders
• Review problems & solutions in our system & state
• Information gathering & review of other models
• Focus on partnership, collaboration, & consultation to help children & adolescents
• Electronic survey of primary care providers
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Development: PCP Survey
Most common problems
• ADHD (77%)• Obesity (72%)• Depression (57%)• Anxiety (47%)• Disruptive Behavior
(44%)
Most want training/assistance
• ADHD (45%)• Disruptive Behavior
(43%)• Anxiety (32%)• Obesity (29%),• Depression (26%)• Eating Disorders (26%)
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Development: PCP Survey
Barriers to service:• No local resources (94%)• Getting appt (55%)• Insurance issues (46%)• Travel for families (35%)• No time to address (24%)• No training (20%)• Patient Follow (11%)• No collaboration (11%)
Desired Models:• On-site services (76%)• Training in assessment &
diagnosis (65%)• Medication consults (64%)• Screening tools (49%)
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Development: Task Force
Follow-up interviews with primary care:•Additional input•Assess site specific enthusiasm, barriers, and % GHP•Identified three sites Presented to CPSL
Three goals:1.Behavioral health providers on-site in PCP sites2.Support PCPs with screening tools & training3.Case consultation with child/adolescent psychiatrist
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Clinic Structure: Team Planning
• Team planning meetings – Psych & PCPs, office staff
• Shadowing PCPs
• Billing discussions
• REACH Institute training – PCPs & Psych’s together– Focus on screening & psychopharm
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Clinic Structure: Services
Report templates: Concise, completed during visit, structured for brief review
Clinician schedules: 1 psychologist + 1 psychology fellow•75 min evals, 45 min returns•75% scheduled – Always available to PCP
Warm hand-offs & consultations:•Join visits, education, pass patients on, simple recommendations, immediate eval•Tracking details
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Clinic Structure: ServicesHandouts – Common for psychologists & PCPs
Crisis evaluations as needed
Communication – Medical record & constant contact
Ongoing training for PCP’s•Monthly case conferences•Presentations on request
Relationship building – Join clinic community
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Clinic Structure: ServicesCommon screening tools
Anticipate high-volume issues•ADHD evaluations•Weight management•DBC groups
Psychiatry consultation – Case review & phone consultation
Electronic screening tools – Results directly in medical record
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Clinic Structure: Services
Brief Case Examples
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Program Evaluation: Key Domains
• Satisfaction
• PCP comfort/knowledge in assessment & intervention
• Quality of life
• Clinically significant symptoms
• Medication use
• Utilization data
• Clinic efficiency data
• Quality of Care v. Practice Standards
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Program Evaluation: Tools & PredictionsSatisfaction: Pre & Post questionnaires for parents & PCPsIncludes: •Convenience, time to first appointment, Stigma/Comfort•Communication with PCP•Perceived BenefitPredict increased satisfaction relative to traditional model
Comfort and Knowledge: Physician survey•Pre & post training, pre-integration, & yearlyPredict increases across each measurement
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Program Evaluation: Tools & PredictionsQuality of Life: Peds QL-4•Pre & post intervention•School questionnaire – attendance, performance•Predict improved QOL & school attendance•Predict match results from other CBT outcome studies
Clinical symptoms: Target behavior ratings•5 point Likert Scale at every session•Dual purpose - research outcomes & tracking treatment goals•Most immediate/likely measure of change•Predict steady reductions across course of treatment
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Program Evaluation: Tools & PredictionsMedication use•Chart review – Pre and post integration, per diagnosis•Predictions – More appropriate use (sufficient trials, monitoring change, appropriate match to symptoms)
Utilization data: Chart Review•# Medical visits: Frequency PCP visits reduced pre v. post•Specialist visits: Frequency reduced pre v. post •Time to first visit – Reduced delay between physician referral & assessment vs. traditional model in our system•Out of network – Pre & post insurance company data. Predict reduced out of network
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Program Evaluation: Tools & Predictions
Efficiency data•Time study: Pre, yearly, post•Code: Medical, Beh, & Med/Beh visits• Appointment duration: no change on medical appointments,
less time on behavioral & med/behCost savings & cost effectiveness: Pre, yearly, post•Predict increase in overall clinic revenue, reduced PMPM cost for patients with BH issuesQuality of Care•Identify AAP standards of care•Chart review assessing adherence with standards
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Time Study Data
Table 1
Minutes Spent Per Visit
Type of Concern
Percent of Total Visit Types Observed
(N)
Mean
Medical 301 14.04
Behavioral 10 13.60
Medical and Behavioral
34 12.99
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ResultsPercentage
0123456789
10
AD
HD
Anx
iety
Dis
orde
rs
Aut
ism
Tic
Dis
orde
r
OD
D
Dev
elop
men
tal
Dis
orde
r
Elim
inat
ion
Dis
orde
r
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Referral to Pediatric Psychology
• 2.9% of all patients observed were referred to peds psych
• 28% of those diagnosed with a psychological disorder were referred to peds psych
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Baseline data: Referrals & HandoffsConsults Warm
HandoffsNew Appointments
Return Appointments
Crisis
Clinic 1 19 16 23 39 0
Clinic 2 23 31 59 36 6
Clinic 3 38 14 31 35 3
Total80 61 113 110 9
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Learning Assessment
Questions?
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Session Evaluation
Please complete and return theevaluation form to the classroom monitor
before leaving this session.
Thank you!