Integrated Care:A MeHAF ProjectWHEN THE HEAD IS ATTACHED TO THE REST OF THE BODYKathleen L. Webster RN, MSN PMHNP-BC

MEHAF GRANT

•MaineGeneral ACT TEAM selected to participate in a 3 year Grant funded project with the Maine Health Access Foundation (MEHAF)•MEHAF’s Mission:• Promote affordable and timely access to

comprehensive, quality health care • Improve the health of Maine residence

MeHAF GRANT

• Systems transformation grant • Jan 1/09-Dec/11•ACT TEAM one of 6 community

agencies selected• Focus of grant-consumers with DX of

SMI in addition to diabetes or metabolic syndrome

6 Community Agencies

•Common Ties •Crisis and Counseling•Kennebec Behavioral Health•MaineGeneral ACT TEAM•Motivational Services• Tri-County ACT TEAM

MeHAF GRANT

• Key Objectives:• Link consumers to PCP• Care Management for consumers with SMI and

chronic medical diseases• Peer Support systems enhanced or developed • Develop screening tools• Develop Tracking systems for clinical workflow• Training and education for both consumers and

providers• Communicate and collaborate with policy makers

MaineGeneral ACT Team Members• The ACT TEAM CLIENTS• Emilie Van Eeghen• Barbara Crowley • James Schneid • Nancy Weingarten• Susan Albano• Jessica Ruth • Louise Gephart• Nina Miller• Louisa Barnhart• Maria Beauregard

• Amy McKenna• Debbie McGuire• Marc Gallant• Susie Carlsen • Jane Cloutier• Renee Quirion• Georgette Roy• Sheila Worth• Heidi Little• Stacie Dennett• Kathleen Webster

Target Population

• MaineGeneral ACT Team 93-100 persons who are cared for by the ACT

team in Augusta and Waterville participated in this grant project over a 3 year period.

ACT team clients by definition have a severe and persistent mental illness as well as co-morbid substance use disorders and chronic medical illnesses.

Significance of Clinical problem •People with SMI die 25 years earlier

than people without SMI•Average age of 53 years old•A Maine Study of Medicaid Recipients

revealed 87% of lives lost to premature death are not due to suicide but rather chronic medical conditions Maine CDC 2004

SMI & Non SMI MaineCareMaine CDC 2004

Utilization of ServicesMaine CDC 2004

Diabetes & SMI- MaineCare

SMI -$5,360•NON – $3,930•Double the prevalence •High risk – Smoking, Obesity, dyslipidemia•Less Access to a medical home•Poorer Outcomes

Maine CDC 2004

Body-Mind-Spirit• Hypertension• Diabetes• Obesity• Cardiovascular Disease• Access to primary and specialty care often hampered• Poverty• Substance Use/Dependence inclusive of nicotine• Poor Nutrition• Inadequate exercise• Exposure to psychotropic medications• Stigma• Socially marginalized• Support System often limited to care providers• Disconnect between mental health and physical health care

systems

IOM: 6 AIMS for IMPROVEMENT

IOM: 10 RULES for REDESIGN• Care is based on

continuous healing relationships• Care is Customized to

patient needs & values• Patient is the source of

control• Knowledge is shared &

information flows freely• Decision making is

evidence based

IOM:4 Areas of Redesign

ACT Team MaineGeneral ACT Team

Approximately 93-100 persons who are cared for by the ACT team in Augusta and Waterville participated in this grant project over a 3 year period.

COMORBID ILLNESSES

ACT TEAM COMORBID RATE

ED VISITS 12/09-11/11

Data

A Run Chart was utilized to study one outcome related to ED usage.Time studied was 12/09-11/11 representing 24 data points representing time.The Number of ED visits by ACT team clients per month was manually counted and plotted against the time variant.

Data: Analysis & Interpretation• Test #1 Presence of too much or too little variable• There are 24 data points, excluding 1 point on the median, in which there are 9

runs. The probability table shows that with 24 points at least 8 runs are needed and no more than 17 therefore no special causes are present only common cause.

• Test #2 Presence of a shift in the process• There are no runs with more than 4 data points, at least 8 are necessary to

demonstrate a shift in the process therefore common cause only present• Test #3

• No evidence of a trend as there are no more than 4 consecutive data points

Data: Analysis & Interpretation

• Common Cause Variation in the number of ED visits.• This number of visits is worthy of a change process for

improvement• NOTE addition of 4 hours per week of FNP starting in July

with an increase in communication and expectation of collaboration between the ACT team clinical/support staff and the PCP clinical and support staff.

Chronic Care Model

• Community• Resources and Policies

• Health System• Self Management• Delivery System Design• Decision Support• Clinical Information Systems

• Productive Interactions• Informed, Activated Patient• Prepared, Proactive Practice Team

• Outcomes• Improved Outcomes

Safe: Avoid injuries to patients from the care that is intended to help them

Treatment Evidence BasedLabs as per recommended protocolsF/U w/ Psych Providers- Case ManagersF/U w/ Medical Providers- Case ManagersAvoid ED utilization as an intervention for Primary care needs – Access to PCP key

Effective: Provide services based on scientific knowledge to those who would benefit - refrain from those not likely to …..

•One goal - to develop ways to track health issues and workflow•Development of a Screening Tool•Request report from MaineGeneral system related to ED visits

PATIENT CENTERED: Respectful and responsive to individual needs/values that guide the care The 4 Quadrant Clinical Integration Model Quadrant I BH PH

>PCP (screening tools & BH practice guidelines)>PCP based BH consultant/care manager>Psychiatric Consultation

Quadrant III BH PH >PCP (screening tools/BH practice guidelines)>PCP based BH consultant/care manager>Specialty Med/Surg>Psychiatric consultation>ED>Med/Surg Inpatient>Nursing Home/Home based care>Community Resources

samhsa.gov 2010

4 Quadrant Clinical Integration Model

Quadrant IV BH PH

>PCP (screening tools / guidelines)>Outstationed medical provider in the BH site>BH Clinician/case manager>External Care Manger>Specialty med/surg>Specialty BH>Residential BH>Crisis/EDBH/Med/Surg Inpatient>Community Supports

Quadrant IIBH PH

>BH Clinician/CM coordinating with PCP>PCP (Screening tools/guidelines)>Outstationed medical provider at BH site>Specialty BH>Residential BH>Crisis/ED>BH Inpatient>Community Supports

samhsa.gov 2010

Timely and Efficient

Tracking of consumers who access ED to notify provider in real time.Linking the screening tool to Clinical support tools Consumer Access of training optionsSystem that would notify team of pertinent thresholds

labsBMIlatest f/u per treatment guidelines

Diabetes Screening and TreatmentRecommended Labseye examsfoot exams

Equitable: care that does not vary in quality due to gender, ethnicity, geographic location, socioeconomic status

Linking consumer to a welcoming PCP one of the primary intents of the MeHAF project.•At the end of the 3 year project• 100% of clients reported having a PCP• 80% reported having seen PCP in past year• 69% reported ED visit

OUTCOMES

Health Screen • Developed in the Second Year of the Project• Has increased the dialogues between team members, both

clients and staff.• Has established some baseline data that is now informing the

practice in the office.• Has created an opportunity for improved care outcomes • Has created an opportunity for integrated care concepts

Health Screen• Of 81 clients surveyed in the past 2 years • 53% have 5 or more co-morbid medical illnesses• 15% have 4 • 14% have 3• 11% have 2• 7% have 1• 2% have none documented• 4 people have passed away in the past 15 months

Health Screen• In the first 12 months • 69 clients screened

• 59% had BMIs > 25• 38% had BP > 130/80• 96% had a PCP • 86% seen in past 12

months• 44% seen in the ED for

both mental health and medical care

• The following 9 months • 64 clients screened• 61% had BMIs >25• 25% had BP> 130/80

• 100% had a PCP • 80% seen in past 12

months• 69% seen in the ED for

both mental health and medical care

Take Away• The dialogue with the client regarding their physical as well

as mental health concerns increased in frequency and structure

• A richer base for patient education was established • An increase in collaborative dialogues with health care

providers in the community who are also caring for the ACT client

• An opportunity to have an FNP 4 hours per week in the ACT team office as a result of dialogues with leadership bringing us closer to an Integrated Care Model

Next Steps• Formally establish health education groups in addition to 1:1

delivery of patient education• Establish a physical health group (2nd Y-Group started 2/12)• Increase FNP time at the ACT team office site to enable care

for both Waterville as well as the Augusta Case Load• Continue to work on the Integrated Care Model as many

clients see this as their medical home

Bibliography• Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). Improving primary care for patients with chronic

illness. JAMA, 1775-1779.• Coleman, K., Austin, B. T., Brach, C., & Wagner, E. H. (2009). Evidence on the chronic care model in the new

millennium. Health Affairs, 28(1), 75-85.• Colton, C. W., & Mandersheid, R. W. (2006, April 05). Congruencies in increased mortality rates, years of

potential life lost, and causes of death among public mental health clients in eight states. Retrieved from http://www.cdc.gov/pcd/issues/2006/apr/05 0180.htm

• Dutta, T. (2010, October 21). Retrieved November 15, 2011, from SAMHSA: http:www.samhsa.gov• Freeman, E. (2009). The Poor Health Status of Consumers of Mental Health Care the Interaction of Behavioral

Disorders and Chronic Disease. Department of Health and Human Services. Augusta.• Freeman, E., Presley-Cantrell, L., Edwards, V. J., White-Cooper, S., Thompson, K. S., Sturgis, S., & Croft, J.

(2010). Gathering partnerships to bridge gaps among mental health, health care and public health. Preventing Chronic Disease, 1-7. Retrieved Nov 05, 2011, from http://www.cdc.gov/pcd/issues/2010/jan/09_-127.htm

• Institute of Medicine, Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: a new health system for the 21st century (executive summary).

• Murphy, J. (2011). Patient as center of the health care universe: a closer look at patient-centered care. Nursing Economic$, 35-37.

• Wagner, E. H., Austin, B. T., Davis, C., Hindmarsh, M., Schaefer, J., & Bonomi, A. (2001). Improving chronic care: translating evidence into action. Health Affairs, 64-78.

• Weinstein, L. C., Henwood, B. F., Cody, J. W., Jordan, M., & Lelar, R. (2011). Transforming assertive community treatment into an integrated care system: the role of nursing and the primary care partnerships. Journal of the American Psychiatric Nurses Association, 64-71.

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