Integrated Care: Where Clinical Need Intersects Sustainability
description
Transcript of Integrated Care: Where Clinical Need Intersects Sustainability
Integrated Care: Where Clinical Need Intersects Sustainability
Collaborative Family Healthcare Association 14th Annual ConferenceOctober 4-6, 2012 Austin, Texas U.S.A.
Session #G2October 5, 2012
Shaping Healthy CommunitiesShaping Healthy Communities.
© 2009 Lone Star Circle of Care
Integrated CareWhere Clinical Need IntersectsSustainability
Behaviorally Enhanced Health Care Home
Kimberly A. Arlinghaus, M.D. Medical Director, Behavioral HealthLone Star Circle of CareDepartment of Psychiatry and Behavioral Health512-686-0207 ext. [email protected]
Greg Jensen, LCSW, ACSWVice President for Behavioral HealthLone Star Circle of CareDepartment of Psychiatry and Behavioral Health512-686-0207 ext. [email protected]
3© 2009 Lone Star Circle of Care
Brian … 17 y/o HM
• PTSD, Bipolar d/o, Polysub abuse, ADHD
• 4 SAs 12-16 y/o
• Multiple psych hosp, BBT, PP therapists, primary care Carousel Pediatrics
• Psych meds by Carousel
• HTN, reflux, “passing out” w/hx of head injury
4© 2009 Lone Star Circle of Care
Psychiatrist-Therapist Collaboration
• BH intake by therapist
• Psychiatric evaluation—added hx psychosis, TBI, and changed BD to MDD; changed medications
• Ongoing med management, psychotherapy, and encouragement to enroll in LSCC primary care
5© 2009 Lone Star Circle of Care
Psychiatrist-Therapist-PCP Collaboration
• LSCC PCP visit
• Facilitated neurology work-up for TBI and question of seizures
• Obtained additional medical records
• Assisted with checking drug screens and monitoring suicidality
6© 2009 Lone Star Circle of Care
Network Collaboration
• Seton ER
• Consultation with ER physicians
• Hospitalization
• IOP, 12-step
• LSCC for therapy, medication management, primary care
7© 2009 Lone Star Circle of Care
The Bottom Line…Shared Care is Best Care
Right thing to do for the patientAdds value to the community
Sustainable and scalable
8© 2009 Lone Star Circle of Care
Goals For Today• Establish the vision and mission concepts
necessary to create organizational commitment to integrated care
• Define governance, operational, financial and clinical issues to implement a behaviorally enhanced community health center
• Discuss critical sustainability success factors and challenges
9© 2009 Lone Star Circle of Care
VisionEvery Central Texan who needs access to psychiatry and
psychotherapy will have access to a fully integrated, behaviorally enhanced, healthcare home
10© 2009 Lone Star Circle of Care
LSCC Behavioral Health: Mission
• Provide behaviorally-enhanced healthcare services to patients who have LSCC as their medical home
• Provide access to BH services in collaboration
with community partners who have aligned and complementary goals
11© 2009 Lone Star Circle of Care
LSCC Clinics
LSCC services offered in each city:
Austin‒ Family Medicine‒ Behavioral Health
Belton‒ Pediatrics
Cedar Park‒ Pediatrics
Georgetown‒ Family Medicine‒ Senior Health‒ Pediatrics‒ Behavioral Health‒ Pharmacy‒ Dental
Harker Heights‒ Pediatrics‒ Behavioral Health (child & adolescent)
Hutto‒ Pediatrics
Killeen‒ Pediatrics
Round Rock‒ Family Medicine‒ OB/GYN‒ Senior Health‒ Pediatrics (also Adolescent)‒ Behavioral Health‒ Pharmacy
Taylor‒ Family Medicine
Temple‒ Family Medicine
Lone Star Circle of Care / Locations
12© 2009 Lone Star Circle of Care
Locations of LSCC Dedicated BH Clinics
13© 2009 Lone Star Circle of Care
“The Usual Way”
Psychiatry Outsourced
Medicine
Mental Health Stigma
14© 2009 Lone Star Circle of Care
“The Lone Star Circle of Care Way”
Behavioral Health Providers (Psychiatrists and Counselors/Therapists) are members of LSCC
medical team thereby leveraging ALL Integrated Delivery System benefits
15© 2009 Lone Star Circle of Care
Integrated Care: Why Do It?
• Up to 70% of patients presenting for primary care have some type of behavioral health (BH) problem which impacts diagnosis and treatment
• Patients are more likely to receive BH treatment if they are treated via an integrated model
• Treatment of BH problems enhances medical outcomes and quality of life
• Integrated care optimizes efficiency of health care delivery
16© 2009 Lone Star Circle of Care
Depression and Diabetes
• 95% of diabetes management is conducted by the patient
• If the patient is depressed… Poorer outcomes Increased risk of
complications < glucose monitoring < adherence to diet,
exercise, and medication regimens
17© 2009 Lone Star Circle of Care
Potential Systemic Effects of the “Depressed” Brain
• Sticky platelets• Decreased heart rate
variability (HRV)• Increased C-reactive
protein• Increased cortisol
18© 2009 Lone Star Circle of Care
Systemic Effects of Cortisol
• Redistribution of body fat• High sympathetic tone• Elevated noradrenaline• Increased HR• Reduced HRV• Decreased insulin
sensitivity• Decreased bone
absorption of calcium
19© 2009 Lone Star Circle of Care
1. Frasure-Smith N, et al. JAMA. 1993;270:1819-1825. 2. Penninx BW, et al. Arch Gen Psychiatry. 2001;58:221-227. 3. Jiang W, et al. Arch Intern Med. 2001;161:1849-1856.4. Vaccarino V, et al. J Am Coll Cardiol. 2001;38:199-205.
Depression Worsens Outcome of Heart Disease
• Depression worsens morbidity and mortality after myocardial infarction1,2
• Depression increases morbidity and mortality in patients with CHF3,4
20© 2009 Lone Star Circle of Care
Behavioral Cardiology (Pickering et al. 2003)
• The causes of heart disease lie not so much in the heart itself, but in the brain, or more specifically, the mind.
• The mind affects the heart via: Our lifestyles Effects of psychosocial
stresses and how we cope with them
21© 2009 Lone Star Circle of Care
Integrated Care Outcomes Research
Better Outcomes/Improved Functioning: Independent Three-year Process and Outcome Evaluation
(Dr. Toni Watt, Texas State University. Commissioned by St. David’s Community Health Foundation, 2008)
‒ Statistically significant decrease in depression symptoms (32%) that remained constant over two, three and six month period
‒ Self-report measures showed patient’s physical health, daily living activities performance, ability to socialize improved significantly
‒ Treating BH illnesses does not cost the overall health system more money. While there was an initial increase in costs, from 6-21 months post treatment, the costs remained stable
22© 2009 Lone Star Circle of Care
Integrated Care: Solution
An Institute of Medicine report in 2005 concluded that the only way to achieve true quality (and equality) in the health care system is to integrate primary care with mental health care and substance abuse services. (Institute of Medicine, “Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series”, November 1, 2005.)
23© 2009 Lone Star Circle of Care
Integrated Care: What Differentiates LSCC’s Model
BH and medical providers employed by LSCC
BH and medical providers on the same HER
LSCC treats ALL psychiatric groups
BH records fully open to the medical providers
Medical providers have immediate access to psychiatrists
BH specialists embedded into the medical clinics
Single governance structure that develops the integrated services
Active mental health screening in medical clinics
Psychiatrists actively treating patients vs. consultant
24© 2009 Lone Star Circle of Care
Governance: Behaviorally Enhanced Healthcare Integration Council
1. Provide guidance to and oversee integration implementation
2. Define and monitor outcome measures 3. Set professional practice standards such as defining and
utilizing screening tools, establishing interdisciplinary care conferences, etc.
4. Establish reimbursement guidelines 5. Provide recommendations to LSCC Senior Leadership
pertaining to the ongoing practice issues, resources and/or enterprise-wide impact of integration
25© 2009 Lone Star Circle of Care
Addressing PCP Challenges: Time and Access
• Embedding behavioral health specialists Provide “real time” consultation to medical staff Conduct crisis intervention for patients in the clinic Facilitate and expedite access to psychiatric services Provide brief therapy/counseling services to patients Coordinate care with the patient’s PCP Assist with efficient patient flow
• Real time PCP consultation with child and adult psychiatrists
• Telepsychiatry
26© 2009 Lone Star Circle of Care
The LSCC Integrated BH Model: Screening
Medical patients for mental health concerns TeenScreen for 11-17 year olds PHQ 2 for depression CAGE for substance use Vanderbilt for ADHD AD8 for cognitive decline in older adults Edinburgh 3 for post partum depression MCHAT for autism
Behavioral health patients for medical concerns Primary care service provider (medical home) Hypertension Obesity Diabetes Co-occurring substance use disorders Tobacco product use Pain
27© 2009 Lone Star Circle of Care
LSCC’s Integrated Care Model
Providing holistic care by diagnosing and treating physical AND mental conditions … together
Embedding BH providers using
open access
BH screening in medical clinics
Providing PCPs direct access to
psychiatrists
Electronic health record
Interdisciplinary collaboration
28© 2009 Lone Star Circle of Care
Easy Access to Clinical Information: EHR
29© 2009 Lone Star Circle of Care
Increasing Access
2005 2006 2007 2008 2009 2010 2011 Projected FY2012
519 1,1193,937 5,023
10,000
23,737
37,219
51,417
Lone Star Circle of Care Behavioral Health VisitsFY2005 - FY2012 (Projected)
2006-20121 to 17 prescribers0 to 31 therapists
Behavioral Health Visits By Patient’s Residence
0
3,000
6,000
9,000
12,000
15,000
Austin Round Rock Georgetown Leander Killeen Cedar Park Pflugerville Hutto Taylor Belton
Num
ber o
f BH
Visit
s
City of Residence
Lone Star Circle of Care (LSCC)Number of Behavioral Health (BH) Care Visits by City of Residence
Fiscal Year (FY) 2011 and FY2012 (Annualized)
FY 2011
FY 2012 (Annualized)
Behavioral Health as % of Total LSCC Visits
Number Percent
2005 24,895 519 2.1%2006 35,348 1,119 3.2%2007 74,224 3,937 5.3%2008 96,131 5,023 5.2%2009 127,121 10,454 8.2%2010 202,568 23,737 11.7%2011 298,264 37,219 12.5%Projected 2012 360,832 51,417 14.2%
Fiscal Year Total Health VisitsBehavioral Health Visits
Lone Star Circle of Care VisitsFiscal Year (FY) 2005 - FY 2012 (Projected)
Source: Lone Star Circle of Care encounters occurring in FY2005-FY2011 and projections for FY2012.
% of Behavioral Health Patients with LSCC Medical Home
Number Percent Number PercentTotal, all Payors 6,801 4,337 63.8% 2,464 36.2%
Medicaid/CHIP 2,745 1,795 65.4% 950 34.6%Uninsured 2,520 2,001 79.4% 519 20.6%Private Insurance 936 244 26.1% 692 73.9%Medicare 600 297 49.5% 303 50.5%
Source: Lone Star Circle of Care encounters occurring in FY2011 (December 1, 2010 - November 30, 2011).
Lone Star Circle of Care (LSCC) Behavioral Health Patients Medical Home UtilizationFiscal Year 2011 (December 2010 - November 2011)
Most Recent Behavioral Health Visit Paid By: Total
Did Patient Have a Medical Health with LSCC in FY2011?Yes No
33© 2009 Lone Star Circle of Care
Integrated Behavioral Health Sustainability and Scalability
• Provider Mix Psychiatrists AND therapists with same employer as medical providers
• Payer Mix Leverage FQHC to increase access to mission patients
• Productivity Goals by provider type
34© 2009 Lone Star Circle of Care
Behavioral Health – Utilization (January 2012-August 2012)
January
February
March
April MayJu
neJu
ly
August66.0%
68.0%
70.0%
72.0%
74.0%
76.0%
78.0%
80.0%
71.9%
74.9%
73.3%
70.8%71.9%
72.7% 72.5%
78.4%
LSCC BH Utilization, Jan 2012 – Aug 2012
UtilizationLinear (Utilization)
January February March April May June July August No Show Rate 24.9% 23.9% 24.9% 26.3% 26.9% 27.9% 26.8% 26.7%
35© 2009 Lone Star Circle of Care
Challenges: No Shows and Utilization
• No Show Policy
• Confirmation Calls
• Reverse Confirmation Calls
• Therapist-Based Intakes
• Same Day Call In List
• Intakes at Same Time and Overbook
36© 2009 Lone Star Circle of Care
Integrated Behavioral Health Outcomes & Scalable Results
• Quality Metrics Symptom reduction Functional improvement (future) Access Assess safety at each visit
• Operational Metrics Volume Productivity
• Satisfaction Metrics Patient satisfaction data
37© 2009 Lone Star Circle of Care
Integrating Education and Clinical Service
BH Training Partnerships
• Seton/UT Southwestern Psychiatry Residents
• Texas A&M Medical Students
• UT School of Social Work
• UT School of Educational Psychology
• UT College of Nursing
38© 2009 Lone Star Circle of Care
Psychiatry and Behavioral Health – Community Partners
• Texas A&M Health Science Center• Seton Family of Hospitals• University of Texas Southwestern /Seton Residency Program • St. David’s Foundation• Scott and White• Bluebonnet Trials – Williamson County MH/MR • STARRY• Texas Baptist Children's Home• Caring Family Networks• Arrow Child and Family Ministries• Lighthouse Family Network• Central Texas Children’s Home• Texas Star Recovery Center• Department of State Health Services• Texas A&M School of Rural Public Health• University of Texas School of Social Work• Williamson County Mobile Outreach and Wilco MH Task Force • Wilco and ATCIC Community Providers
39© 2009 Lone Star Circle of Care
New Initiatives in Behavioral Health
40© 2009 Lone Star Circle of Care
Austin Independent School District (AISD)
Grant funded 6 month pilot at Crockett HS
March-August 2012
Clinic operational and seeing students
41© 2009 Lone Star Circle of Care
Austin Independent School District (AISD)
Goals
Evaluate model
Sustainability
Replicate
42© 2009 Lone Star Circle of Care
Foundations Communities
Local non-profit providing housing and support services for thousands of low-income families and individuals.
43© 2009 Lone Star Circle of Care
Foundations Communities
Grant improves BH access ‒ Psychiatry ½ day/wk.‒ Refer to therapy as
needed
Medical home provided through LSCC PCPs
44© 2009 Lone Star Circle of Care
Lifeworks
Non-profit social service agency providing a continuum of services to youth and families transitioning from crisis to safety.
45© 2009 Lone Star Circle of Care
Lifeworks St. David’s Foundation
funds Lifework’s Shared Psychiatric Services (SPS) for short term psychiatric care
LSCC’s provides a medical and BH home for children and their parents transitioning from SPS
46© 2009 Lone Star Circle of Care
Family Drug Treatment Court/Parents in Recovery (FDTC/PIR)
Families identified by judicial and Child Protective Services (CPS) due to mother’s substance abuse
Reduce children in out-of-home placements and increase children reunited with families
47© 2009 Lone Star Circle of Care
Family Drug Treatment Court/Parents in Recovery (FDTC/PIR)
Partnerships with Austin Recovery and FDTC/PIR
Transition mothers and her infant/children into our medical and BH home
48© 2009 Lone Star Circle of Care
• Joint Commission Accreditation A nationally-recognized “gold seal of approval” for health care providers Signifies that the safety and clinical qualify of care provided is
exceptional
• Patient-Centered Medical Home (Level 3) recognition A recognition awarded by the National Committee on Quality Assurance Less than 0.5% of all primary care providers in the nation have this
prestigious designation
Awards and Recognition
Please complete and return your session evaluation form before you leave this session
Please complete and return theevaluation form to the classroom monitor before leaving this
session.
Thank you!