Assessing the Primary Care Practice to Enhance Integration 

May 16, 2012

Rebecca Morin, Maine Primary Care Association

& Guests from Harrington Family Health Center

Today’s ObjectiveIllustrate ways to use self-administered assessment tools to identify areas to advance integrated care, including the use of cross-functional teams and care coordination. 

MPCAHarrington

Family Health Center

Conclusion/QA

Maine Primary Care Association (MPCA) MPCA works with Maine’s Federally Qualified Health

Centers (FQHCs), also known as Community Health Centers (CHCs)

They are: Community-run non-profit primary care practices In areas designated to be Medically Underserved Areas or

serving a Medically Underserved Population (HRSA) Seek to improve quality and access to care for all

members of their communities

18 Members-80% have co-located Behavioral Health/Substance Abuse Treatment Services

-Screening for depression is most common

-Nationally, 90% of FQHCs routinely screen for depression and 65% for substance abuse.

Support to Adopt/Enhance/Sustain BHI

• Initial BHI SSA• F2F Training based

upon responses

Summer 2011

• U Mass PCBH Course

• BHI Summit

Fall –Winter 2011

• BHI SSA Mid-Course Feedback Report

• Medical Leadership engagement

Spring 2012

• BH Speed Dating• U Mass PCBH

Course + ________Fall

2012

• BHI Summit 3• BHI Dashboard

Winter 2012/13

The Players in FQHC Integration

PATIENT

PCP BH/MHC

RN

MASpecialty

MH

Psychiatry

Our Approach Integration Concepts/Framework (5 Levels) Improvement Roadmap (BHI SSA) Improvement Strategies

Staffing ratio Types of referrals Communication Documentation Space

Support to Adopt/Enhance/Sustain Integration

5 Levels of Collaboration Guiding the Work

The BHI Site Self Assessment (SSA)

Adapted from the PCRS – Developed by the Robert Wood Johnson Foundation Diabetes Initiative, www.diabetesintiative.org; also adapted from the ACIC survey developed by the MacColl Institute for Healthcare Innovation, Group Health Cooperative. ADAPTED FROM MeHAF.

Using the 1-10 scale in each row, circle (or mark in a color or bold, if completing electronically) one numeric rating for each of the 18 characteristics. If you are unsure or do not know, please give your best guess, and indicate to the side any comments or feedback you would like to give regarding that item. NOTE: There are no right or wrong answers.

BHI SSA Continued II. Practice/Organization

9 Characteristics with descriptions across the 5 levels

1. Organizational leadership…..2. Patient care team…3. Provider engagement…..4. Continuity of care….5. Coordination of referrals/specialists….6. Data systems/ patient records…7. Patient/Family input….8. Education/Training….9. Funding & resources….

I. Integrated Services & Patient/ Family-Centeredness

9 Characteristics with descriptions across the 5 levels

1. Co-location….. 2. Emotional/behavioral health needs3. Treatment plans….4. Patient care informed by best practice….5. Patient/Family involvement….6. Communication with patients…..7. Follow up….8. Social support….9. Linking to community resources…

Feedback Loop

Feedback Report Example Characteristic 8: Physician, team and staff education and training for integrated care ….. . . is provided for some (e.g. pilot) team members using established and standardized materials, protocols or curricula; includes behavioral change methods such as modeling and practice for role changes; training monitored for staff participation (self score of 2 out of 10). Has your CHC……•Located and connected PCPs with training in

Short-term interventionsProblem-focused Treatment Motivational InterviewingSBIRTPTSD & Trauma Interventions

•Developed and implemented a strategy for sharing models & methods learned to enhance internal expertise?

If a provider participates in a training – are they given the opportunity/time to act as an ambassador & share this information across the practice?

•Researched and identified professional development opportunities for integrated care? MPCA offers the U Mass Primary Care Behavioral Health Certificate course each Fall Virtual offerings including webinars, additional research request etc.

•Set aside short periods of time for cross disciplinary participation in education and training?Archived webinars with facilitated discussionCase studies during lunch breaks one time per month

Works Cited for Feedback Report•Blount, Alexander. “Integrated Primary Care: Organizing the Evidence”, Families, Systems & Health: 21, 121-134, 2003 found at http://www.apa.org/journals/fsh.html

•Bertakis, Klea, and Azari, R. “Patient-Centered Care is Associated with Decreased Health Care Utilization” Journal of the American Board of Family Medicine (May-June 2011) Vol. 24 No. 3 found at http://www.jabfm.org/content/24/3/229.full?sid=53483dda-1bd4-4e14-be93-c9189de2ec8a

•Lardiere, Michael, Jones, E., Perez, M., “2010 Assessment of Behavioral Health Services Provided in Federally Qualified Health Centers” (January 2011), National Association of Community Health Centers found at http://www.nachc.com/client/NACHC%202010%20Assessment%20of%20Behavioral%20Health%20Services%20in%20FQHCs_1_14_11_FINAL.pdf

•Miller, B., Kessler, R., Peek C.J., Kallenberg, G., “Establishing the Research Agenda for Collaborative Care” found at http://www.ahrq.gov/research/collaborativecare/ *content specific to BHI SSA feedback found in Practice and Performance Characteristics summaries.

• “Paying for the Medical Home – Part 2: Social, Behavioral, and Environmental Factors in Payment Models” from the Safety Net Medical Home Initiative found at http://pdfsbox.com/pdf/safety-net-issue-2.html

PCMH (+BHI) Transformation Guided by the 8 Change Concepts of the Safety Net Medical Home Initiative (all 8 align with the 10 Core Expectations of Maine’s Patient Centered Medical Home Pilot.) Continuous and Team-Based Healing RelationshipsPatient-Centered InteractionsEngaged LeadershipEnhanced AccessCare CoordinationOrganized, Evidence-Based Care

The NCQA 2011 PCMH Standards is our chosen quality improvement strategy

PCMH Standard 1: Enhance Access & Continuity PCMH Standard 2: ID & Manage Patient Populations (Element C, Factor 6) PCMH Standard 3: Plan & Manage Care (Element A, Factor 3)

Leverage to Achieve Integrated Care

Depression, Diabetes and CVD Collaboratives

Tobacco Assessment & Cessation Support

Patient Centered Medical Home (PCMH)

Accountable Care Organization (ACO)

Bill Wypyski, CEOConnie VanDam, Mental Health Care Coordinator / Tobacco Cessation Counselor

Chris Skehan, QI/Risk Manager

HFHC -Who We AreMission:Create a healthier community by engaging each patient in making health care decisions that reflect the highest standards of care in conjunction with the needs and desires of the patient and his/her family, and by making this care affordable based on patient’s ability to pay.

Service Area : Columbia, Columbia Falls, Addison, Milbridge, Steuben, Harrington and Cherryfield.

Services: ~Complete Family Medical Care for All Ages which also includes:

-Laboratory Services-Prescription Assistance-Tobacco Cessation-Nutrition Counseling-Maine Breast and -Cervical Program-Sports and DOT Physicals

~Mental Health and Substance Abuse Counseling~Dental Services~Podiatry

Our Journey Towards Integration

Self-Assessment

Education

Breaking Down Provider Barriers and Bias Pilot Program-Placing a Mental Health Clinician ½ day/week in primary care wing

Emphasize already established tobacco cessation program

Hire new clinicians with integrated care model in mind.

Harrington BHI SSAComponent I: Integrated Services & Patient/Family Centeredness

+Medical

Care Manager

MH Care Coordinator =

Pt/Fmly Centered Solutions

Harrington BHI SSAComponent II: Practice/ Organization

Cohesive Pt Care Team

Medical Providers Engaged in Integrated Care

BH/MH Clinician with Integrated Care Experience

Improvement Strategies at the Practice Level

BH/MH to Medical Staffing Ratio: 4 (includes 1 Tobacco Specialist) to 6 Types of referrals to BH/MH

Tobacco Cessation Grief Counseling ADHD Substance Abuse Depression Trauma (Immediate & Long Term) Anxiety Situational Stress Child Behavioral Issues Couple/Family Issues

Communication BH/MH have access to Medical Record but Medical staff do not have access to BH/MH Records Referrals: EMR using secure email to MH Coordinator, warm hand-offs, pt self-referrals (phone or

walk-ins), referral from non-HFHC providers. Documentation Space – BH/MH housed on 2nd floor Future Plans for Brief Interventions

Behavioral / Mental Health Warm Hand-Offs for the Referral Process

Process: Warm hand- off from PC Clinician to MH Coordinator to begin and complete a Behavioral Health Referral either in house or to a Behavioral/Mental Health Specialist outside of health center i.e. psychiatric.

Patient Need Identified via Medical Staff

MH Coordinator Contacted

Patient Need Assessed

Patient scheduled to be seen w/in 2-

3 days

Pt in CRISIS?

NO YES

Pt seen by MH Clinician and (if needed) Crisis services. MH

Coordinator/Nursing staff attend to pt.

Tobacco Cessation Support &“Different Shades” of Warm Hand-Offs

Plan-Do-Study-Act (PDSA) Cycle

Define the problem: Need for data to support the theory and anecdotal evidence that patients referred for tobacco cessation counseling are more engaged in their plans to become tobacco free if the referral occurs as a “warm hand-off” versus a “dry” referral (referral initiated via EHR with no direct initial contact between counselor and patient.)

PDSA ContinuedThe Change: Increase the # of referred patients who are engaged in their care, thereby increasing their likelihood to keep appointments for counseling, and potentially increasing their ability to “quit”.

PlanWhat are we testing?On whom are we testing the change?What do you expect to happen? (Prediction):

(Data)What data do we need to collect?Who will collect the data?When will the data be collected?Where will the data be collected?

StudyWhat was actually tested?What happened?Observations/Problems:Complete analysis of data, summarize what was learned, compare to prediction:

ActWhat changes should we make before the next cycle?

DO

PDSA Snapshot Plan (Data) Study Act

10 pts who are referred by other HFHC providers to the HFHC Tobacco Cessation Counselor as of 11/01/12

5 pts. w/ a referral for counseling through EHR referral system counselor,5 with an introduction to tobacco cessation counselor via a “warm hand-off.”

List of pts referred for tobacco cessation counseling beginning 11/01/12 (first 5 with a regular referral and first 5 with “warm hand-off”; appt dates for initial sessions, follow-up sessions, and notation of “show” or “no-show”

We actually tested

-no-show rates for appts for counseling for tobacco cessation-quit rates of pts who received a “warm hand-off” from the referring provider to the Tobacco Cessation Counselor vs. -no-show/quit rates of pts who were scheduled for counseling based on an e-mail referral from the referring provider to the counselor.

Tobacco Cessation Counselor to present these PDSA findings at provider staff meeting to encourage greater number of “warm hand-offs.”

We predict pts w/ a “warm hand-off” will keep more appts for tobacco cessation counseling thus increasing the possibility of ceasing tobacco use.

Data collected from appt schedule for Tobacco Counselor over the length of time required to generate 5 of each type of referral & to track f/u beginning 11/01/12

Warm hand-offs increased the # of pts who kept initial and f/u appts for counseling and increased the “quit” rate.

DO!

In Conclusion Warm hand-offs help reiterate medical home “team” concept (Patient, Provider, Counselor)

Our data helped “make the case” for moving towards more integrated care

We were able to identifying solutions to services (BH/Medical) being in different spaces

Thank YouQuestions & Answers

Contact Information: Rebecca Morin – MPCA – rmorin@mepca.org

Bill Wypyski – Harrington Family Health Center – bill.wypyski@harringtonfamilyhealth.org