Www.icarenc.org © 2007 ICARE Partnership 1 © 2007 ICARE Partnership Russet Hambrick, MLS Jennifer...

www.icarenc.org© 2007 ICARE Partnership

1


Russet Hambrick, MLS

Jennifer Borton, RN, MSN

June 22, 2010

2010 National AHEC Conference

The ICARE Partnership: AHEC’s Role in Achieving Integrated Care in North

Carolina


2

Objectives:

• Describe how integrated care increases the capacity of primary care providers to provide appropriate, evidence-based behavioral health services to their patients.

• Describe how AHEC can help foster collaboration and communication between primary care and mental health providers that improve patient outcomes.

• Identify ways to create access to the mental health services by providing primary care providers with the knowledge to diagnose and treat, when appropriate, mental health and substance abuse disorders.


3

Rene Descarte (1641)

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

CJ Peek, PhD


4

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

clinicians face daily.”

Medical Care Mental 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


5

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

• 50% of all MH care is done by PCP’s• Top ten most common physical complaints have no

biological basis 80% of the time• 67% of all psychoactive drugs prescribed by PCP’s• Referral to MH/Substance Abuse hard to navigate; often

doesn’t connect CJ Peek, PhD


6

Common Chronic Disease and Depression Major

Depression

StrokeMulti-condition Seniors

Diabetes

23%

11-15%

30-50%

Heart Disease

15-20%


7

The Financial Impact….

• Out of the top 10% of the highest utilizers of medical care, 80% of them had a co morbid mental health diagnosis.

• Depressed patients use 3 times more healthcare services and have 7 times more emergency visits.

• Depressed patients have longer hospital stays• Depression causes more work days to be missed

than any other chronic disease.


8

ANNUAL MEDICAL COSTS FOR ADULTS Without MH With MH• All adults $1,913 $3,545• Heart Condition $4,697 $6,919• High BP $3,481 $5,492• Asthma $2,908 $4,028• Diabetes $4,172 $5,559

Robert Graham Center for Policy Studies in Family Medicine and Primary Care, March, 2008. Information from US DHHS 2002 and 2003 MEPS AHRQ


9

What are we doing to help? Developing an environment that will allow providers to treat the mind and body of patients by making care:

ICARE I NTEGRATEDC OLLABORATIVE A CCESSIBLER ESPECTFULE VIDENCE-BASED


10

IN THE BEGINNING……


11

ICARE: A Brief History• 2005- Group of state leaders ( DMA, Office of Rural

Health, AHEC, NC Foundation for Advanced Health Programs) identify the need:– Decreased public mental health services– Increased patients arriving at Primary Care with

behavioral health issues– Primary Care Providers limited capacity to treat

patients– Early regional successes in integration


12

Brief History ( Cont)• Pulled together the Advisory Committee-an

interagency, interdisciplinary group of state leaders• Sought and received funding with the help of an

interim project director in summer and fall of 2005• Late 2005-Contracts were written and staff hired to

carry out the implementation plan• Regularly scheduled meetings of all committees

began late 2005 with funding in place January 2006.


13

An NC SolutionIn 2006, led by the NC Foundation for Advanced Health Programs, a group of state wide organizations dedicated to integrating medical and mental health care of North Carolinians initiated a program called ICARE.

Core Partners:

• NC Academy of Family Physicians

• NC Pediatric Society

• NC Psychiatric Society

• Southern Regional AHEC


14

ICARE Funding PartnersOver $ 3 Million Committed

• The Duke Endowment

• The Kate B. Reynolds Charitable Trust

• AstraZeneca

• North Carolina Area Health Education Centers

• North Carolina Department of Health and Human Services

• The North Carolina Foundation for Advanced Health Programs


15

The Vision • The ICARE Partnership seeks to increase access to

quality, evidence-based behavioral health care services for North Carolinians

The Goals1. Increase collaboration and communication between

primary care and MH/DD/SAS providers.

2. Increase the capacity of primary care providers to provide appropriate, evidence-based behavioral health services to their patients and the capacity of MH/DD/SAS providers to screen and refer for physical illness


16

• ARC of North Carolina• Duke Department of Psychiatry• ECU Dept Child Dev and Family Medicine• NC Area Health Education Centers• NC Council of Community Programs• NC Department of Health and Human Services: DMA, Div of

MH/DD/SAS, DPH• NC Community Care Networks• NC Medical Society• NC Psychological Association• Wake Forest University Health Sciences Department of Pediatrics

Advisory Committee• NC NASW• NC Hospital Association• National Alliance On Mental Illness- NC ( NAMI)• NC Nurses Association ( NCNA)• Governor’s Institute on Alcohol and Substance Abuse• Carolinas Health Care System• Mental Health Association of NC• NC Community Health Care Association• NC School Community Health Alliance


17

The ICARE Partnership: Design

Training and TA

Processes and Policies

Local Model Development

•Remove/Reduce barriers

•Provide tools and information to practices

•Encourage relationships

•Build capacity

•Test models


18

Local Model Development• Four areas of the state• Different approaches• 19 practices• One pilot site coordinator • Two years• Evaluation• Second round of funding for 3 Eastern sites began

January 2009- designed for SA screening, treatment, referral


19

NC Integrated Care Projects


20

State Collaboration• Community Care of North Carolina ( CCNC)

– Providing $25,000 grants to support practice infrastructure for co-location of behavioral health providers in 65+ practices

• The AHEC System- Convenes, trains, neutral party• State MH System- Local Management Entities ( LME)

– State MH Reform has allowed the state to look at integrated care as being part of the solution

• FQHC’s – State internal workgroup


21

Pilot Outcomes:Integrated Care resulted in:• Improved patient outcomes as reported by consumer

and practitioners• Increased utilization of evidenced based screening

tools • Improved communication among the patient, PCPs,

and BH providers• Improved access to BH care• Reduction of stigma associated with BH care


22

Pilot Outcomes (continued)• Decreased wait times between BH referral and initial

appointments with specialist• Development of individualized care plans with clear

lines of responsibility for follow-up• PCPs reported an increased awareness of community

supports available to patients


23

Training and Technical Assistance

• Educational opportunities for PCP and MH Providers

• On-site technical assistance for some practices

• Psychiatric Consultation for identified practices

• Other collaborations with state organizations such as the ORHCC, The Governor’s Institute on Alcohol and substance abuse and regional AHEC’s


24

Training and TA• Offer evidence-based content • Offer content appropriate for the primary care

setting• Panels offer knowledge, expertise and

resources available locally • Offer networking opportunities for primary

care and mental health professionals


25

Modules: Statewide and On-line

– Managing Crisis Patients– Anxiety Disorders– Autism Screening Guidelines– Motivational Interviewing– Collaborative Models– Billing and Coding– “How to” Guide for Integrated Practice– Maternal Depression– Depression

• Adult and Pediatric– Substance Use/Abuse and Addiction Disorders

• Adult and Pediatric – Bi-polar Disorders

• Adult and Pediatric


26

Training and TA Opportunities• Offered throughout the state via a variety of

formats:

– Centralized or statewide conferences

– Regional programs

– Web-based conferences

– Online via a content management system

– On-site provider training / technical assistance

– TA to individual practices


27

Training and TA Outcomes• Over 115 trainings for Primary Care and Behavioral Health

Providers• ICARE has provided training to over 7,000 human service

provider participants (medical and behavioral health)– Over 3,000 participants have been either primary care

doctors or psychiatrists– Over 1,500 participants have been mid-level primary care

providers or medical residents• Technical Assistance to 54 individual practice sites• 9 Grand Rounds for psychiatrists in NC


28

www.icarenc.org• Partnership contacts• Practice models across the state• Practice tools - screening tools/algorithms• Training calendar/online courses• News/job postings• Research – ADL and bibliography• User forums• Links• Resource Directory


29

On the Website (icarenc.org): repository of training materials, practice tools, and local resources

Hits Over 2 million

Visitors Over 200,000

People who bookmarked the site Over 27,000

Downloads Over 97,000

Recorded online training modules offering CME 8 trainings with over 1,500 participants

Live Webinars offering CME Over 1,100 participants


30

Clinical Consultation Use of Psychiatry• On site and telephone consultation

• Telepsychiatry

• Psychiatrists in PCP’s

• PCP’s in mental health setting

• Rapid Evaluation and Stabilization- Psychiatrist available for urgent referrals from PCP for diagnostic work up and care until return to PCP or referred psychiatrist


31

Process and Policy Change• Purpose: To identify barriers that prevent

integration and implement strategies to reduce or remove these barriers.

• Committee members included interdisciplinary and interagency representatives

• Met monthly• Developed ad hoc committees as needed


32

Identified Barriers• There is a lack of a system of communication

between the specialty mental health and the primary care providers

• There are inadequate resources to treat complicated patients with MH/DD/SA diagnoses

• There needs to be a consistent training model for those working in integrated care settings

• The behavioral health system is too complicated, fragmented and unresponsive for primary care to utilize


33

Positive Process and Policy Changes

• Same day billing for medical and mental health-DMA• Universal consent forms established• Increased communication between CCNC and the

LME networks• Regional development of relationships between

specialty mental health and primary care


34

Positive changes ( cont)• University systems looking at internships, integrated

care curriculum needs for the future• New behavioral health codes opened- DMA• Preliminary talks with commercial insurance re: value

of integrated care• Building consensus on what components are

necessary for an evidence-based integrated care practice


35

WHAT DID WE ACCOMPLISH?


36

The Results - 3 years later….• Strong branding of ICARE name-nationally seen as a leader• Popular website • Successful pilots• Identification and work towards removing process and policy

barriers through policy brief submitted to governor of North Carolina

• Solid relationships with CCNC and Division of MH/DD/SAS and most professional associations

• Early evaluation info shows increased provider and patient

satisfaction with integrated care efforts.


37

The Vision – (Moving Forward)

• In North Carolina, there is a culture that ensures collaboration in patient centered care.

The Goals1. All health professionals have the skills to screen,

identify needs and appropriately treat or refer their patients

2. Every health care professional has a system of communicating and collaborating with other professionals in their community to provide patient care


38

Transforming ICARE into:

The NC Center of Excellence in

Integrated Care


39

Center Of ExcellenceIn close collaboration with multiple stakeholders:• Develop consistent standards for integrated care

across multiple patient care settings• Establish evidence-based clinical protocols and

procedures to support integrated practice• Provide training and technical assistance across

practice settings and medical disciplines


40

Targeted to:• Non-CCNC practices serving Medicaid patients• LMEs - BH network providers• Hospital Emergency Departments• DMA - targeted case management providers

And coordinated with CCNC Networks


41

Methods:• Form learning collaboratives that provide training, supervision,

TA, and address barriers• Identify and convene stakeholder groups to

– Identify current and emerging evidence-based best practices

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

– Design and deliver training and technical assistance across medical settings

• Establish a cadre of experts to deliver training and TA• Monitor lessons learned and adjust for needed changes


42

Evaluation:

• Contract with experienced external evaluator• Establish evaluation protocols and methods

with external evaluator, stakeholders, and funders

• Select data points and pre- post measures and metrics

• Utilize DMA patient data resources


43

Proposed Outcomes:• Improved patient outcomes resulting from use of SBIRT and other

integrated care techniques• Stabilize or decrease hospital admissions and ED utilization for

patients with BH conditions • Increase in identified medical homes and annual exams for patients

with chronic MH/DD/SA conditions• Increase in medical and behavioral health practices which incorporate

integrated care policy and procedures into their practice settings• Documented evidence of practice changes supporting integrated care

models by various disciplines and sites • Positive provider evaluation of training and technical assistance;

positive evaluation by targeted case managers


44

Outcomes (continued):• Positive patient satisfaction with integrated care at PCP and BH

sites

• Improve HEDIS measures for severe and persistent mentally ill patients

• For patients on atypical antipsychotics, increase the number of metabolic screenings

• Increase the number of BH providers, PCPs, and EDs that adopt tobacco and substance abuse screenings as evidenced by CPT codes

• Increase training and TA for targeted case managers on integrated assessment and care planning

• Build learning collaboratives to adapt and implement best practices; evaluate using data and other evidence of change in healthcare delivery models


45

Governor Perdue’s vision forQuality Care in NC

• “My background in health care tells me it makes no sense to separate mental from physical care. The best research confirms that many patients have mixed mental and physical health issues.”

• Further, North Carolina can “establish the national model for an integrated approach to behavioral and primary health services for patients with mental health, developmental disability and substance abuse problems.”

Www.icarenc.org © 2007 ICARE Partnership 1 © 2007 ICARE Partnership Russet Hambrick, MLS Jennifer...

Documents

Transcript of Www.icarenc.org © 2007 ICARE Partnership 1 © 2007 ICARE Partnership Russet Hambrick, MLS Jennifer...