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Transcript of WBHC Conference
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Primary Care Integration for a Rural Community Behavioral Health Clinic
2015 Washington Behavioral Healthcare Conference: Fulfilling the Promise of Integrated
Care Vancouver, WA June 19, 2015
Who We Are!
A rural community behavioral health agency
Serving 1600-1700 clients currently
Outpatient Day Treatment program serving approximately 70-100 clients
Presenters
Christine Burnell FNP, DNP (Provider )
Ru Kirk MA (Clinical Director)
Sue Ehrlich MD (Medical Director)
Learning Objectives
Introduction of the Institute for Healthcare Improvement (IHI) Behavioral Health Integration Capacity Assessment (BHICA) Tool
Review structures that support an integrated model including organizational structures, interest of stakeholders (there are many)
Share integrated models for mental health and primary care in greater Puget Sound area
Share identified barriers of integrated model including organizational resistance to change, attitudes and beliefs about integrative care, licensing issues, physical plant changes, data sharing challenges, billing challenges
Reasons for Pursuing this Project
Passion and Compassion
FNP strategically placed to be a leader in change
Rural community offering challenges and opportunities for integration
Availability of a psychiatrist, Medical Director
Clinical commitment to treat most vulnerable
Reasons for Pursuing this Project
• Easy access• Customer service built on a
culture of engagement and wellness
• Comprehensive care• Excellent outcomes
• Excellent Value
• National Council’s Behavioral Healthcare Centers of Excellence framework
Complex Adaptive Systems
High
Professional and Social Agreement about Outcomes
Low
Plan & Control
Chaos
Zone of Complexity
Certainty About Outcomes
High Low
From Crossing the Quality Chasm, A New Health System for the Twenty First Century, Institute of Medicine
Problem StatementThose with Serious Mental Illness: Life expectancy – is up to 25 years
less than general population Live with physical health
comorbidities Experience fragmentation between
primary care and behavioral health Quality of life consequences. If left
untreated - experience negative social determinants of health
Cost – ER visits and hospitalizations
Purpose: To Develop a draft Implementation plan for the provision of primary care at the collaborative agency to serve those with serious mental illness.
Project Design
This was a quality improvement project to examine feasibility of implementing primary care in a rural community behavioral health setting.
Phase 1Clinic Assessment: The IHI Behavioral Health Integration Capacity Assessment (BHICA) tool was used to assess organizational readiness for integration at the collaborative agency.
Project Design
Phase 2 Interviews at Partner agency (KMHS) where an exemplar integrated model is
in use currently Federally Qualified Health Center (FQHC) Peninsula Community
Health Services NAVOSFocused interview questions were derived from the UW AIMS Center regarding integration readiness.
All data was collated and analyzed to create a draft version of an implementation plan for integrated care.
Project Design
Phase 3
All data was collated and analyzed to create a draft version of an implementation plan for integrated care.
IHI BHICA Tool
Assesses agency capacity for integration with leaders of organization utilizing the five steps:
Understanding the Population (for self-reflection as agency)
Assessing Agency Infrastructure Identifying the Population and Matching Care Assessing Three Approaches to Integration Financing Integration
IHI BHICA Tool: A SnapshotProcess Reliable Impact Resources Notes
2.1.1 Does your organization routinely collect individual-level data? Yes Yes2.1.2 Does your organization routinely aggregate individual-level data? Yes Yes2.1.3 Do you record the names of individuals' primary care providers? Yes Yes2.1.4 Do you record the date of individuals’ last primary care visit?
Yes No2.1.5 Do you record progress notes/the nature of the last primary care visit? Yes Yes2.1.6 Do you record the names of individuals’ home and community-based supports? Yes Yes2.1.7 Do you record the number of past-year hospitalizations for both psychiatric and medical reasons? Yes Yes Recorded not necc accessible/in chart2.1.8 Do you record the number of individuals' past-year ER visits for both psychiatric and medical Yes Yes2.1.9 Does your organization securely exchange individuals’ information with other practices? Yes Yes
Yes or No Notes2.1.10 Does your practice use an electronic health record (EHR)? Yes Yes2.1.11 Does your EHR meet Stage 1 meaningful use criteria? Yes Yes2.1.12 Are you able to manage chronic conditions in the EHR? No Higher Yes2.1.13 Is your EHR able to interface with other systems outside of the organization? No Higher No Only within RSN
Table 1 Self-Assessment: Your Infrastructure
2. Assessing Your Infrastructure2.1. Capacity to Collect Data, Exchange Information, and Monitor Population Health
BHICA Tool: Understanding the Population
Timeline: 4/1/14-3/31/15 1522 clients served 22,958 services of which 21,113 face-to-face 50-60 miles - average proximity to practice
BHICA Tool: Understanding the Population
Key Question Left Unanswered Unable to determine percentage of population with
multiple chronic conditions
Laying the Groundwork for a Draft Implementation Plan
• Problem: Inaccurate or insufficient data• Solution: Educate staff - PDSA Cycles to improve performance • Problem: Insufficient Reporting Capacity • Solution: Utilize IT Support to Identify Multiple Chronic Conditions
Identify Specific/Vulnerable PopulationsCreate and Utilize Registries/Other QI Activities Identify a Small Population for Focused BH/PH
Understanding the Population
Recommendations: Draft Implementation Plan
Assessing Your Infrastructure Capacity to Collect Data, Exchange Information, and Monitor Population Health • Establish Registries for Shared Populations • Electronic Health Record Sharing
Progress and Outcome Tracking Capability • Tracking Measures Related to Medications e.g. EMR and RxNT Prescribing Software Do Not
Interface = Robust Full Use of RxNT / Input All Medications • Track All Provider Satisfaction Measures
Process for Engaging and Communicating with Individuals and Family Members • Family Resource Coordinator • Family as a Client Model Could be Adopted vs Individuals When Requested
Recommendations: Draft Implementation Plan
Assessing Your Infrastructure Capacity to Provide Clients with Community Wellness Resources • Wellness Coordinator (Healthy Living Coordinator)• Utilize Outpatient Space in Afternoons to Offer In-House Wellness Program • Revitalize and Adapt Healthy Living Program as a Program Improvement
Plan engaging both staff and clients toward healthier lifestyles • Utilize Untapped Resources: Nursing Students UW, PMHNP Students to
Carry Forward this Capstone, Peninsula & Olympic Colleges • Strengthen Bi-Directional Community Referral and Tracking Systems
Recommendations: Draft Implementation Plan
Assessing Your Infrastructure Culture to Support Integration: Leadership Culture • Strong, active commitment by leadership toward integration -key component
organization’s strategic plan
• Education and Engagement of Staff re Integration and PH Indices at All Levels Critical
• Empower Staff via Feedback Mechanisms with New Initiatives
• Monthly Newsletters to Staff by Leadership
• Weaken Support for Status Quo / Sensitivity to Historical Organizational Shifts
BHICA Tool: Identifying the Population & Matching Care
Recommendations:
• Target population identified as day treatment outpatient program
• Most clients would be amenable to this model over seeing their PCP off-site
• Comprehensive case management in place
• A RN/Team approach to addressing individual’s unmet care needs would be a good pilot for moving toward integration
BHICA: Assessing Optimal Integration
Reverse Co-location
Level of Integration Partly integrated system-BH and PC in same facility with shared appointment and medical record systems. Physical proximity allows for regular face-to-face communication among BH and physical health providers. Collaboration is key
Populations Best Served Quadrants II and IV (High behavioral health needs)
Applicable to all ages with adaptations
Adapted from Milbank 2010 Table 12
BHICA: Assessing Optimal Integration
Implementation Barriers Records may remain separated Consent and privacy issues/meshing paperwork processes, differences in
culture BH/PHSame-day billing challenges
When new appointments required, issues with no-shows can increase
Economic Outcomes Generate savings because of leveraging and cost-effectivenessMay generate cost-offset savings
Health Outcomes Considerable potential to reduce lifestyle risk factors
Studies have shown reduction of ER visits and dramatic increases in screening of hypertension and diabetes (Boardman 2006)
Why Choose This Model? Through billing or partnership a more integrated model between primary care and specialty mental health is sustainable
Adapted from Milbank 2010 Table 12
Recommendations: Draft Implementation Plan
Financing Integration
• Optimize Existing Revenue Sources • Marketing and Development Director to Regularly Monitor Up and
Coming Grants • Champions to Work with Exemplar Sites (KMHS’s Bi-directional Model) • Engage in Discussions with Insurance Plans to Incentivize them to Pay for
Cost Savings • Study Billing Regulations that may Pose Restrictive Practice in Integration
Efforts (same day billing)
Exemplar Site Interviews
• KMHS: Donna Poole ARNP Prior Acting Medical Director
• Elena Argomaniz Project Director CMS Innovation Grant
• Peninsula Community Health Services (FQHC):
Health Administrator/Medical Director • NAVOS Burien Site: Paul Tegenfeldt Vice
President of Healthcare Integration
THE PATHWAY TO THE SUMMIT
• BHICA – First study • Exemplar site interviews • Identify strengths/barriers/lessons learned from exemplars to
collate recommendations• Hire consultant National Leader• Concepts of integration • Staff engagement Key Stakeholder Meeting• Bi-directional Model of patient centered care a focus
Learning Objectives
Introduction of the Institute for Healthcare Improvement (IHI) Behavioral Health Integration Capacity Assessment (BHICA) Tool
Review structures that support an integrated model including organizational structures, interest of stakeholders (there are many)
Share integrated models for mental health and primary care in greater Puget Sound area
Share identified barriers of integrated model including organizational resistance to change, attitudes and beliefs about integrative care, licensing issues, physical plant changes, data sharing challenges, billing challenges
“Do The Next Right Thing”
Do one physical thing Make one face to face consultation with a provider Participate in all opportunities for collaboration
regardless of format Shared risk is an opportunity to drive change