Leadership I

Leadership for Integration of

Behavioral Health and Primary

Care

Leadership Call Series: Call 1

Roger Chaufournier

David Bergman

Dirk Bokeloh

Laurel Simmons

Overview

• 12:05-12:15 Follow-up from Pre-work Assessment

• 12:15-12:30 Framework for Leading Change

• 12:30-12:40 Lessons from the Field-David Bergman

• 12:40-12:50 Action Period Exercises

• 12:50 – 1:00 Open Dialogue on Transformation

Journey

Roll Call

1. ACCESS Family Health Care

2. Corning Area Healthcare, Inc.

3. Custer County Community Health Center, Inc.

4. Flathead Community Health Center

5. G.A. Carmichael Family Health Center

6. Georgia Mountains Health Services, Inc.

7. Heart City Health Center

8. Manet Community Health Center, Inc.

9. Mary’s Center for Maternal and Child Health

10. Mid-Delta health Systems, Inc.

11. Myrtle Hilliard David Comprehensive Health Centers, Inc.

12. Northwest Community Health Center

13. Tillamook County Community Health Center

Prework

1. Complete an assessment of current

practice.

2. Define a short-term aim statement.

Prework Assessment

1. Integration Model

2. Aim Statement

3. Universal Screening for Substance Use

4. Universal Screening for Depression

5. Motivational Interviewing Implementation

6. Business case for BH Integration

7. EHR modifications to meet BH needs

8. Information and data flows

9. Communications plan

10.BH Integration measurement strategy

Assessment Results

Assessment Results

Assessment Results

Assessment Results

Assessment Results

Short Term Aim Statement

• What do you want to achieve by March 31?

• www.ihi.org/extranet

–Select your team at right-hand side

–In Administration, select Manage Aims

–Enter your aim and save

–SMART

13

PULL

PUSH

1. Set Direction: Mission, Vision and Strategy

3. Build Will • Plan for Transformation

• Set Aims/Allocate Resources

• Measure System Performance

• Provide Encouragement

• Make Financial Linkages

• Learn Subject Matter

• Work on the Larger System

5. Execute Change • Use Model for Improvement for

Design and Redesign

• Use Change Leadership Model

• Review and Guide Key Initiatives

• Spread Ideas

• Communicate results

• Sustain improved levels of

performance

Make the status quo uncomfortable

Make the future attractive

IHI Leadership Framework

2. Establish the Foundation

• Reframe Operating Values

• Build Improvement Capability

• Build Relationships

• Develop Future

Leaders

• Personal Preparation

• Choose and Align the Senior

Team

4. Generate Ideas • Read and Scan Widely, Learn

from other Industries/Disciplines

• Benchmark to Find Ideas

• Listen to Customers

• Invest in Research

&Development

• Knowledge management

• Understand Organization as a

System

Building Will

• Plan for Transformation

• Set Aims/Allocate Resources

• Measure System Performance

• Provide Encouragement

• Make Financial Linkages

• Learn Subject Matter

• Work on the Larger System

•Member/patient experience of care (CAHPS tool or similar)

•Health and functional status among CCO enrollees

•Rate of tobacco use among CCO enrollees

•Obesity rate among CCO enrollees

•Outpatient and emergency department utilization

•Potentially avoidable emergency department visits

•Ambulatory care sensitive hospital admissions

•Medication reconciliation post discharge

•All-cause readmissions

•Alcohol misuse-screening, brief intervention, and referral for treatment

•Initiation and engagement in drug and alcohol treatment

•Mental health assessment for children in DHS custody

•Follow-up after hospitalization for mental illness

•Effective contraception among women who do not desire pregnancy

•Low birth weight

•Developmental screening by 36 months

•Reduction of disparities; differences in these metrics among race and ethnicity

categories

•(Additional Year 1 Measures)

•Planning for end of life care

•Screening for clinical depression and follow-up plan

•Timely transmission of transition record

•Care plan for members with long-term care benefits

Oregon CCO Measures

21 Core/Performance Metrics

Building Will - Creating Your Dolly

• An effective way to build will is to create a “Dolly Case

Study” in your organization.

• Pick a complex patient with behavioral health needs that

has other comorbidities your are treating – someone who

is high cost and a challenge to manage.

• Follow that patient and try to create the ideal pathway for

support.

• Document the business case.

• Turn your “Dolly” into a case study for communicating to

your own stakeholders.

Our Subject

• 69 year old male

• New clinic patient (Established May 2012)

• Frequent user of the emergency room (HMC)

• Multiple chronic health conditions:

–Hypertension

–Right-sided Heart Failure; edema

–Renal failure

–Polysubstance abuse

–Undetermined psychiatric issues (auditory

hallucinations, signs of depression)

–Diabetes

Problems Identified

• Our subject has had multiple providers for short periods of time. No continuity of care from a primary physician.

• High use of ER as a result.

• Psychiatric problems hindering care of physical issues.

• Referrals not moving “smoothly”. i.e. 2nd echo not available for cardiologist and it was nearly double ordered.

• Difficulty with attaining bronchoscopy.

• Polypharmacy. Due to pt. frequenting ER and lack of PCP care, high risk of medication errors. Assisted by family.

Psychiatric Barriers

• Pt was deemed with an “organic” cause to his

psychosis, which disqualified him from state-provided

psychiatric care.

• No psychiatrists on island that accept the patient’s

insurance.

• Most providers at Clinic not comfortable treating outside

of depression and anxiety.

• Behavioral Health offered at Clinic is a clinical social

worker, no psychiatrist available.

• The psychiatric issues were causing problems with

caregiving and family members.

Working as a “neighborhood”

• We were committed to working together while

acquiring the appropriate services and care for

this patient’s specific needs.

–Team consisted of Hospital rep (HMC), PCP rep (Clinic),

Care coordination rep , Insurance rep (health plan).

• Goals of team:

– Enhance outcomes for patient and family.

– Reduce use of hospital.

– Develop correct active medication list, reduce if possible.

– Meet psychiatric needs through PCP or referral.

– Streamline referrals process for patient.

“Wins”

• Zero Urgent Care/ER/Hospital visits since collaborative began.

• Prevention of duplication of services.

• Neighborhood knowledge of community resources gained in collaboration.

• Identified health care gaps in available services r/t insurance and/or diagnosis.

• Possible prevention of CHF exacerbation by completing home visit and finding medication error (lasix) during med reconciliation.

• During home visits, psychosocial issues identified along with covered DME being purchased by family out of pocket. Also, signs of depression seen that patient and family did not report.

• Through the neighborhood, providers contacted in real time about missed appointments and had the ability to reschedule in a timely fashion.

Lessons from the Field

An Interview with

David Bergman

Action Period Guidance

for Over the Holidays

• Articulate the Transformation Needed

–Find the patient story (Your Dolly Story) that makes the

best case for change

–Draw a Picture of the Future State of the Practice

–Draft the Elevator Pitch

Action Period Guidance

for Over the Holidays

• Establish the Business Opportunity for Expanding the

Practice

–What is the average net collection for a patient visit

–What is the production cost of a patient visit?

–Calculate the business case impact on an annual basis of

adding one patient a day in additional volume

Action Period Guidance

for Over the Holidays

• Begin Clarifying the Business Case for BH Integration:

–Choose a provider or clinic and determine how many

of the patients have behavioral health issues

–Estimate how much clinical productivity time is taken

up with that work. It’s OK to use “guesstimates” for

this exercise.

–Translate that time into minutes spent each year

(Multiply: the number of patients with BH needs X the

average number of visits per year X the number of

extra minutes)

Next Steps

• Scheduling Coaching Calls

• Action Period Guidance Document can be found at: Resources -> Call Series -> Leadership Series -> Leadership I

• Assistance with Action Period exercises:

lsimmons@spreadinnovation.com or

dbokeloh@nachc.com

• Next meeting: proposing moving January 3 to

January 10, 2013 (Poll)