CJ Peek, PhD

© 2010 NC Center of Excellence for Integrated Care icarenc.org1

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NC Center of Excellence for Integrated Care: Advocates for

Practice Change

Regina Dickens, Ed.D., LCSWMaria Dover, MS, LMFT


CJ Peek, PhD

What is our history?


The North Carolina Center of Excellence for Integrated Care builds on the work of a Foundation-sponsored program, The ICARE Partnership, which

pioneered the integration of care in primary care practices between 2006 and 2010 through a broad

inter-agency, multi-disciplinary partnership.


Rene Descarte (1641)Philosopher & mathematician

Commonly given credit for establishing separate domains for the physical and mental-- and the philosophical basis for the "mind-body split".

CJ Peek, PhD


“Integrated Care” is an effort to better match or blend clinical services to the realities that patients and their

clinicians face daily.”

Medical Care Behavioral Health Care

A legacy of separate and parallel systems

A forced choice between:• Two kinds of problems• Two kinds of clinicians• Two kinds of clinics• Two kinds of treatments• Two kinds of insurance

CJ Peek, PhD


Why the system doesn’t work…


Common clinical presentations don’t stay neatly in those medical or BH boxesBehavioral / psychosocial is part of medical care

• 70% of all PC visits have psychosocial drivers• 50% of all BH care is done by PCP’s• 67% of all psychoactive drugs prescribed by PCP’s• Referral to BH/CD hard to navigate; often doesn’t

connectCJ Peek, PhD


Untreated Depression = More Healthcare Use• Depressed patients use 3 times more

healthcare services

• Depressed patients have 7 times more emergency visits

• Depression is associated with longer hospital stays


Trauma associated with Intoxicant Use:

• In 2005, up to 60% of US trauma center patients tested positive for one or more intoxicants

• Of these 1 in 4 had a second drug and alcohol related injury in the same year.

Maier, 2009


NC primary care providers (PCPs) and behavioral health providers agree that:• There is difficulty finding a referral for publicly or

uninsured patients

• There are few opportunities to develop relationships with primary care providers

• There is a huge benefit to community psychiatrists being available for consultation and establishing a working relationship with the PCPs.


One Solution is Integrated Primary Care

Integrated primary care is a service that combines medical and behavioral health services to more fully address the spectrum of problems that patients bring to their primary medical care providers. It allows patients to feel that, for almost any problem, they have come to the right place.

Alexander Blount

A definition…


A look at integrated care…


Patient Centered Care includes:INTERNAL COLLABORATION

OPERATIONAL

CLINICAL

FINANCIAL

- quality care- patient driven

- systems- organization- process improvement

- coding- billing- reimbursement


Patients

Medical Records

Nurses and medical assistants

Receptionists

Psychiatrists

Behavioral Health Therapists

Physician

ON-SITE Integrated Care Team

All supported by common chart, documentation standards, billing procedures,

and clinic management system

NP’s PA’s


Integrated Care ProgramNurse screens clients at establish care and

annual appointments

Physician sees clientand validates screening

Physician introducesclient and therapist

Physician and therapistprovide team approach

for coordinated care

▪Screening▪Assessment▪Brief supportive

counseling▪Therapy▪Case management▪Medication monitoring▪Coordinated team care

Behavioral Health Services integrated with Primary Health Care:


Integrated Care WorksRandomized Control Trials demonstrate:• More effective medication treatment• Reduced depression severity• Improved general health status• Decreased disability• Better occupational function• Improved patient satisfaction• Cost-effectiveness

http://www.photostogo.com/store/Chubby.asp?ImageNumber=956313


Our Current Projects


CHIPRA: A Quality Demonstration Grant

The CHIPRA statute mandates the

‘experimentation’ and ‘evaluation’ of several

promising ideas related to improving the quality of children’s healthcare.

Slide by Stacy Warren


Needs of America’s Children American children

experience worse health and higher levels of mortality than do children from most other developed nations and receive recommended care only 42% of the time

UNICEF, The State of World’s Children, 2009 (visited April 10,2009

Mangione-Smith R, Decristofaro A, Setodji C, Keesey Jl, Adams The Quality of Care Received by Children and Adolescents in the US. Pediatric Academy Societies, E-PAS2006:59:4500.1



Medicaid Enrollees on the RiseIn 2009, 60 million people were on Medicaid and over

half of them were under 18.

1 in every 4 American children are on MedicaidApproximately 31% of NC children are on Medicaid

www.statehealthfacts.org 2008-2009


http://www.statehealthfacts.org/


Center for Medicare and Medicaid Services (CMS) is committed to demonstrating improvement in Medicaid/CHIP systems through:

• The synthesis of data and activities from diverse Medicaid/CHIP systems

• Providing Technical Assistance to States • Tracking improvement using metrics• This includes addressing health care disparities, long term health

care needs supports and services and builds on the synergy and coordination of efforts with public health agencies, education and mental health care systems to improve the health care outcomes for children.



CHIPRA Categories:

• A - Experiment with and evaluate the use of new and existing measures of quality for children

• B – promote the use of health information technology (HIT) for the delivery of care for children

• C – evaluate provider-based models to improve the delivery of care

• D – demonstrate the impact of model pediatric EHRs (electronic health records)

• E – creating targeted models to demonstrate their impact on health, quality and cost.


Category A Core Measures

• NC will use its Community Care infrastructure to implement and evaluate the use of the new set of 24 quality measures identified by AHRQ and CMS.

• NC will expand upon the current data collection system to incorporate the core set of children’s health measures and will work with local practices on the implementation, feedback and the meaningful use of the quality information for improvements in performance.


CHIPRA Category A Measures Update• Categories for the 24 Core Measures

– Prenatal, Immunizations, Screening, Well Child Visits, Dental, Availability, Upper respiratory, ED, Inpatient Safety, Asthma, ADHD, Mental Health, Diabetes, Family Experience

• Unique to North Carolina– EPSDT Report Card, Dental Varnishing, MCHAT, Adolescent

and School Age Screening, Obesity, Foster Care Kids Linked to a Medical Home

• Reporting Timeline– Reporting a subset of the measures annually to CMS as of

12/2011 and quarterly to practices starting 6/2011


24 Core MeasuresThree stages of progress….

We’re currently reporting on 8 of the 24 core measures requested by CMS through the IC.

We’re attempting to report on an additional 8 of the 24 core measures using paid claims.

Working with DMA, SCHS and Vital Records to capture the remaining eight measures.

Potential roadblocks…• The identification of current sources for PICU/NICU data

• CAHPS is only reported once every three years

• Transition from old to new systems makes data collection problematic..immunizations and birth certificate data

• It’s difficult to identify CHIP recipients in the claims system


New Measures• EPSDT Report Card

– Lead, vision, well visits, developmental screening, autism

• Dental Varnishing – Pediatric preventive measure from IC

• 99420 Reports X 3 – MCHAT, School Age Screen, Adolescent Screen

• Obesity– Follow up for clients with an obesity diagnosis

• Foster Care– Kids Linked to a Medical Home


Quality Improvement• Quality Improvement will focus on…

Measure Description

#7 Weight assessment for children/adolescents

#8 Screening for social/emotional development

#10 - #12 Well Child Visits for 15 months, 3-6 years and 12 – 21 years

#18 ED Utilization

Unique to North Carolina: Dental fluoride varnish, Follow-up for obesity, MCHAT, School Age and Adolescent Screening


Reporting• Reporting to CMS through CHIP Annual

Reporting Template (CARTS) system• Reporting to practices through Provider Portal


Category C--CHIPRA ‘Connect’

NC will strengthen the medical home for children and youth with special health care needs (CYSHCN) by testing and

evaluating provider-led, community-based models that will identify, treat and coordinate the care of CYSHCN,

particularly children with developmental, behavioral and /or mental health disorders



CHIPRA Connect Demonstrate a provider-based model of

care for CYSHCN by testing and evaluating provider-led, community-based models

Practices will utilize the AAP Mental Health Toolkit

Emphasis on linkages and reliable communication systems


CHIPRA CONNECT PROJECT

Learning Collaborative for Cohort I begins

PCMH Certification

Medical Home

2015

2014

2013

2012

2011

Learning Collaborative for Cohort II beginsObesity

Oral Health

PCP Pre-Work

Mental Health Toolkit

Mental Health Toolkit

Obesity

Oral Health

Risk Stratification Tool


Cohort 1 ParticipantsCommunity Care of the Sandhills• Dr. Masoud Ahdieh• ABC Pediatrics• Sandhills Pediatrics• Harnett County Health Department

AccessCare

• Goldsboro Pediatrics

Community Care Plan of Eastern Carolina• Washington Pediatrics• Surf Pediatrics

Northwest Community Care Network• Surry County Health and Nutrition Center • Kids Count Pediatrics • Westgate Pediatrics • Robinhood Pediatrics


Each strategy will propel quality improvement both independently and in concert with the other strategies

AQuality

Measures

CMedical Home

Measures enable ongoing, flexible tracking of Medical Home Impact

Medical Homes provide data on feasibility, cost and value of measures

EHR supports Medical Home

implement quality care

EHR enables will enable

efficiencies and timely tracking

and meaningful use of quality

measures

Measures inform and evaluate

impact of EHR

Medical Homes will d

rive

service-oriented, quality EHR

developmentD

PediatricElectronic

HealthRecord



Category D-Pediatric Electronic Health Record• Existing EHR systems often do not optimally support the provision of

health care to children. • The goal of Category D is to develop a model EHR Format for

children, demonstrate that it can be readily used, and package it in a way that facilitates broad incorporation into EHR systems.

• NC, through its Community Care program, will work closely with the NC Regional Extension Center (REC) in the implementation of the model Electronic Health Record for Children (EHR).

• PEHR consultants in all 14 Networks will work with providers/medical homes interested in implementing the model PEHR.


How do we implement practice change?


Steps to Practice Change• Identify and Convene stakeholder groups to:

– Design/update needs assessments for each targeted practice group

– Identify current and emerging evidenced based best practice models

– Set quality assurance/ model fidelity measures for targeted practice areas

– Monitor the process– Identify ways to improve family involvement in

healthcare


Steps for Practice Change (continued)• Establish learning collaboratives• Establish a cadre of experts to deliver training and

TA• Establish Evaluation Protocols with outside Evaluator

to monitor Center of Excellence goals and outcomes• Establish procedures to monitor lessons learned and

adjust for needed changes on a quarterly basis


How Can Families Be More Involved?


The Medical Home Family Index• Purpose: to better understand how families of children and

youth with special healthcare needs view the services they receive from their PCP.

• As a practice moves to become a ‘Medical Home’ it is important to capture how the family perceives those efforts and where there is room for improvement.

• Ex. of question: I am asked by our PCP how my child’s condition affects our family (impact on siblings, the time my child’s care takes, lost sleep, extra expenses, etc).

• Survey is provided in both English and Spanish.


CHIPRA TEAM• Dr. Marian Earls, Physician Champion• Stacy Warren, Project Director [email protected]; (919) 715-1088• Janie Shivar, Category A Clinical Coordinator [email protected]; (919) 863-0063• Marla Satterfield, CHIPRA Connect Pediatric Program Manager [email protected]; (919) 863-0063• Maria Dover, CHIPRA Connect Clinical Coordinator [email protected]; (919) 863-0063• Kern Eason, Category D Pediatric EHR Consultant [email protected]; (919) 745-2426

mailto:[email protected]



CJ Peek, PhD

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