Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
Building Interprofessional Teams: Lessons Learned from the Veterans’ Health Administration
• Laura O. Wray, PhD• Center for Integrated Healthcare, Veterans Health Administration• Jacobs School of Medicine and Biomedical Science, University at Buffalo
• Andrew S. Pomerantz, MD• Office of Mental Health and Suicide Prevention, Veterans Health Administration• Geisel School of Medicine at Dartmouth
• Stephen C. Hunt, MD, MPH• Post-Deployment Integrated Care Initiative, Veterans Health Administration• Department of Medicine, University of Washington
Session # E3
CFHA 20th Annual ConferenceOctober 18-20, 2018 • Rochester, New York
1
Faculty DisclosureThe presenters of this session have NOT had any relevant financial relationships during the past 12 months.
The opinions presented do not represent the viewpoint of the Veterans Health Administration
2
Conference ResourcesSlides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2018
Slides and handouts are also available on the mobile app.
3
Learning ObjectivesAt the conclusion of this session, the participant will be able to:
◦ Discuss common barriers experienced by professionals attempting to integrate new disciplines into existing teams.
◦ Describe at least three strategies to avoid pitfalls or overcome common barriers experienced when integrating new team members and changing practice patterns.
◦ List improvement strategies that may be helpful in advancing teamwork at their own site.
4
Gittell, J. H., Godfrey, M., & Thistlethwaite, J. (2013). Interprofessional collaborative practice and relational coordination: improving healthcare through relationships. Journal of Interprofessional Care. 27(3), 210-213. Kearney, L. K., Post, E. P., Pomerantz, A. S., & Zeiss, A. M. (2014). Applying the interprofessional patient aligned care team in the Department of Veterans Affairs: Transforming primary care. Am Psychol, 69(4), 399-408. doi:10.1037/a0035909 Molander, R., Hodgkins, K., Johnson, C., White, A., Frazier, E., & Krahn, D. (2017). Interprofessional Education in Patient Aligned Care Team Primary Care-Mental Health Integration. Fed Pract. 2017 June;34(6):40-48. Pomerantz, A.S., Kearney, L.K., Wray, L.O., Post, E.P., Mccarthy, J.A.(2014) Mental health services in the medical home in the Veterans Health Administration: Critical factors for success. Psychological Services. 11(3), 243-253 PMID 24841512 Spelman, J. F., Hunt, S. C., Seal, K. H., & Burgo-Black, A. L. (2012). Post deployment care for returning combat veterans. Journal of general internal medicine, 27(9), 1200-1209.Weller, J., Boyd, M., & Cumin, D. (2014). Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare. Postgraduate Medical Journal. doi:10.1136/postgradmedj-2012-131168
Bibliography / Reference
5
Learning AssessmentA learning assessment is required for CE credit.
A question and answer period will be conducted at the end of this presentation.
6
Who we are and why we care about teams:Laura Andy Steve
7
Integrated CareTHE VA APPROACH
8
How is the VA’s experience is it relevant?Risk adjusted capitated model but with increasing sharing with other systems and intense focus on wRVUs; So dependent on workload and “billing”
Defined population with disease burden equal to or greater than the Medicaid population
Higher prevalence of mental disorders than the general population
Usually once in the system (beginning in early adulthood), stay in the system
Regardless fiscal model, adjustment to collaborative team practice hinges on the development of effective interprofessional relationships
Bottom line: treating mental health conditions in a stepped care manner conserves specialty resources for those who need them most, improves the identification and treatment of those with previously unrecognized needs and leads to high patient and staff satisfaction.
9
INTEGRATED CARE: “…Unifies care for physical and mental concerns”
“…avoid Premature Orthodoxy”
B u t l e r M , K a n e R . L , M c a l p i n e D , K a t h o l R . G . , F u S . S . , H a d o r n H . & W i l t T. J . ( 2 0 0 8 ) . A g e n c y O f H e a l t h c a r e R e s e a r c h A n d Q u a l i t y. ( 2 0 0 8 ) . I n t e g r a t i o n O f M e n t a l H e a l t h / S u b s t a n c e A b u s e A n d P r i m a r y C a r e . A g e n c y O f H e a l t h c a r e R e s e a r c h A n d Q u a l i t y P u b l i c a t i o n 0 9 - E 0 0 3 . R o c k v i l l e , M D .
10
Mental Health Services in the Medical Home
“… the Patient Centered Medical Home will not reach its full potential without adequately addressing patients’ mental health needs. Doing
so, however, will likely shift responsibility for the delivery of much mental health care from the mental health sector into primary
care...
…a change that many stakeholders will likely oppose.”
Croghan TW, Brown JD. Integrating Mental Health Treatment Into the Patient Centered Medical Home. AHRQ Publication No.
10-0084-EF. Rockville, MD: Agency for Healthcare Research and Quality. June 2010.
11
Specialty Care Team Members
Interdisciplinary Team Members
Core Primary CareeTeamlet Members
Patient/family
VA Medical Home: The Patient Aligned Care Team (PACT)
Community
MH, BH, SW, pharmacy, etc.
Cardiology, podiatry, etc.
Outside clinics, etc.
Public health agencies, non-profit agencies, other social assets.Non-VA
Providers
PCP, RN CM, Health Tech/LVN, Clerk. Includes
significant others and caregivers
12
Department of Veterans Affairs
Operation Enduring Freedom Operation Iraqi Freedom
13
Post Deployment Health Clinic
Primary Care
Case Manager
Mental Health
OEF/OIF Veteran
Orthopedics Rehab Med/ Prosthetics
Comp & Pension
Women’s Health
Polytrauma Program Pain Clinic
Suicide Prevention CoordinatorDental
Post-Deployment Integrated Care Initiative
Department of Veterans Affairs
Operation Enduring Freedom Operation Iraqi Freedom
14
Post Deployment Clinic Model• Dedicated space• Dedicated staff
– Small group of dedicated, experienced primary care providers
– Primarily see recent combat veterans• Close partnership with
– Social Work– Mental Health
• Consultation to specialty services
Models for Integrated Post-Combat Care
Post-Deployment Integrated Care Initiative
Department of Veterans Affairs
Operation Enduring Freedom Operation Iraqi Freedom
15
Primary Care Clinic
Primary Care
Case Manager
Mental Health
OEF/OIF Veteran
Polytrauma Program Pain Clinic
Suicide Prevention Coordinator
Orthopedics Rehab Med/ Prosthetics
Dental
Comp & Pension
Women’s Health
Post-Deployment Integrated Care Initiative
Department of Veterans Affairs
Operation Enduring Freedom Operation Iraqi Freedom
16
Cohort Model• Selected primary care providers are identified to
develop skills and expertise • Most OEF/OIF patients are assigned to these
providers• Representatives from other disciplines similarly
identified
Models for Integrated Post-Combat Care
Post-Deployment Integrated Care Initiative
Department of Veterans Affairs
Operation Enduring Freedom Operation Iraqi Freedom
17
Consultative Model• OEF/OIF veterans are assigned to all primary care
providers• Most providers care for few combat veterans• Medical, Mental Health and Social Work resources
with specialized knowledge and skills are identified to assist in a consultative role
Models for Integrated Post-Combat Care
Post-Deployment Integrated Care Initiative
VA Primary Care Mental Health Goal: Improve health of the population by addressing mental health needs in
primary care
Key Objectives:◦ Provide Open access to mental health care◦ Conserve specialty resources for those who need them◦ Reduce stigma by co-locating in PC◦ Make MH care a routine part of primary care◦ Organize mental health care as a stepped care model
18
INTEGRATED CARE IN VA:Core ComponentsCo-located Collaborative Care (PCBH) ◦ Embedded mental health clinicians are part of medical home team◦ Consultative advice, assessment, brief interventions◦ Uncomplicated mental illness, Substance Use Disorders,◦ Other conditions (insomnia, stress, chronic pain, obesity, etc)◦ Initially based on White River Junction VA model of 2004
Disease specific Care Management (CoCM)◦ Guideline based treatment support, usually via telephone◦ Patient activation and education for self management◦ Ongoing structured assessment, monitoring treatment adherence◦ Behavioral activation◦ Referral Management when indicated
◦ Based on IMPACT, RESPECT and other RCTs
19
PCMHI’s role on the PACTPopulation-Based, Stepped Care
Clinical pathway following universal screeningSupport Patient Self-ManagementProvide brief assessment and MH interventionsSupport MH treatment provided by PCPMH subject matter expert in PACTSupport PACT after MH care completed(MH treatment plan is brief, problem focused and part of PACT care plan, not separate)
20
• Discipline-specific PACT includes Integrated Care for physical and mental health in one setting• Evaluation and treatment for mild to moderate
mental health conditions (depression, substance misuse, anxiety, PTSD)
• Follow-up evaluation for positive MH screens • Behavioral health interventions for chronic
disease• Care management• Referral management
• Screening for mental health conditions• Initiation of pharmacological
treatment for mild to moderate mood symptoms
• Co-management of Veteran care with PC-MHI and specialty MH providers
• Health Behavior and Prevention• Emphasis on wellness
Secondary and Tertiary Care:• Outpatient Care for treatment resistant, severe or complex
illnesses• PTSD specialty treatment; Substance dependence treatment
• Treatment of serious mental illness (including MHICM)• Full spectrum of psychosocial rehabilitation and recovery
services• Inpatient psychiatric care
• Residential treatment• Supported and therapeutic employment
• Homeless programs• Behavioral Health Interdisciplinary Program (BHIP)
PRIMARY CARE
SPECIALTYMH
BHIP
PC-MHI
21
22
PC-MHI Outpatient Encounters, Unique Patients, and New Patients, October 2007 – December 2017, by Month
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
110,000
120,000
Oct2007
April2008
Oct2008
April2009
Oct2009
April2010
Oct2010
April2011
Oct2011
April2012
Oct2012
April2013
Oct2013
April2014
Oct2014
April2015
Oct2015
April2016
Oct2016
April2017
Oct2017
Outpatient Encounters Unique Patients New patients
23
% Receipt of PCMHI Services in VA Primary Care
Data provided by Dr. John McCarthy,
Director - PCMHI Evaluation Office
24
Same Day PC/PCMHI Access
Data provided by Dr. John McCarthy, Director - PCMHI Evaluation Office
Good steady increase but we have a way to go to hit 75%...
ChallengesTO WORKING AS A TEAM
25
Common Challenges to Integration from Early Years of VA ImplementationStaffing◦ Not enough◦ Missing a key role (Therapy, Prescription Privileges, Care Management)◦ Lack of clerical or administration support
“Overselling”Delays in getting patients into more intensive MH servicesAttitudes and knowledge of MH leaders and colleaguesPoor understanding of roles; lack of available trainingTendency to form a Mini-Mental Health ClinicLeadership supportSystems challenges
NB: Few of these challenges are specific to team work.
26
What are your challenges to teamwork?
27
Lessons from High Performing TeamsGoal: Identify essential ingredients of high performing integrated teams. ◦ Discover how they overcame barriers to integration◦ Learn their perceptions of what makes them successful now◦ Garner advice from these expert teams on how to assist other teams
Methods:◦ Competitive selection process for team attendees◦ Attendees came with their team, variety of disciplines, roles◦ Structured exercises and group discussions used to gather team input◦ Captured output of all exercises and discussions◦ Rapid, informal, team-based qualitative analysis
28
Essential Characteristics of Successful Team FunctionProgram staff work well together and have clearly defined roles and shared goals
Programs have/hire the ‘right staff’ with the right attitudes/characteristics ◦ Flexible/Adaptable◦ Open-Minded◦ Reliable/Team Player◦ “Can Do” Attitude◦ Patient-Centered◦ Enthusiastic and Persistent◦ Good Communication Skills
Leaders support the program
Program staff are embedded in clinics and communicate with PC staff
29
How did they get there?Attitude and characteristics of the mental health professional
MHPs had to learn new roles AND adjust to that new role
MHPs built relationships and engaged other staff
Program leaders had the right data
Correct stakeholders were engaged, supportive
Being “tenacious with a smile”
PCP needs were met through open access and real-time consultation
Sufficient staffing
30
NB: Many of these comments are about teamwork!
How do we overcome or avoid pitfalls in the way of true collaboration?Case 1: Dr. Jones is a psychologist who has just come from an internship and postdoc where he worked on a successfully integrated primary care team. His first job is at a new academic primary care practice where the medical director, Dr. Janis, became interested in integration after attending a CFHA conference. She is convinced in the value of integration and is eager to see benefits. Dr. Jones has been in his new job for about 4 weeks and he has only seen a few patients on Dr. Janis’ panel. He’s wondering what he is doing wrong because he was always busy in his previous positions. He has tried to drum up business but the PCPs, other than Dr. Janis, don’t seem too interested.
Questions:
What is the pitfall?
How could this have been avoided?
What should Dr. Jones do now?
31
How do we overcome or avoid pitfalls in the way of true collaboration?Case 2: The Danville Clinic is a large, busy and growing primary care clinic that is well staffed with PCPs, nurses, and a team of behavioral consultants that includes psychologists, social workers, a psychiatrist and an advanced practice nurse with psychiatric expertise. Despite this wealth of resource, team members frequently disagree as to treatment plans and which patients should be seen by which member of the team. PCPs are saying that they no longer bother to start medications because no matter what they prescribe, it will be changed by the mental health team. The clinic director is concerned about the growing discontent in the clinic but unsure what to do. There never seem to be enough hours in the day!
Questions:
What is the pitfall?
How could this have been avoided?
What should the clinic manager do now?
32
How do we overcome or avoid pitfalls in the way of true collaboration?Case 3: The Smithtown Primary Care Clinic providers love their integrated mental health team. At any indication of a mental health symptom, they can call in a behavioral health consultant and know that they won’t need to worry again about the patient’s care. In fact, Dr. Everhart was just bragging to a friend that he can’t remember the last time he had to write for a psychotropic med!
Questions:
Is there a pitfall, is so, what is it?
If there is a pitfall, how could this have been avoided?
Should anything be done differently now?
33
How do we overcome or avoid pitfalls in the way of true collaboration?Case 4: The Doctors’ Hospital has decided to add a psychologist to the primary care team. Dr. Bennetti, a psychologist, was just reassigned from the general mental health clinic. He got the assignment based on seniority and was thinking that working in primary care will be a piece of cake because he will get all the “easy” patients. He has an office in primary care and a clinic grid that is set to schedule patients every hour. He has been sitting in his office (with the door closed) waiting for a consults. He has mostly spent his time reading journals and surfing the internet since his assignment in primary care began. His supervisor is noticing that Dr. Bennetti’s productivity is quite low but he is aware that integrated psychologists need to have open access and time to consult with the team.
Questions:
What is the pitfall?
How could this have been avoided?
What should Dr. Bennetti’s supervisor do now?
34
StrategiesTO ADVANCE TEAMWORK
35
Person centered, team based, coordinated, whole health oriented care
36
Veteran centered, team based, coordinated, Whole Health oriented care For All Veterans
to Optimally Reduce Suicide Risk
Primary CarePACT
MentalHealth
Pain CM/CCICMSUDs
AcademicDetailing/Pharmacy
Key Clinical Challenges:Pain Care TransformationOpioid SafetyStepped OUD Care(all primary drivers
of suicide risk)
37
Veteran centered, team based, coordinated, Whole Health oriented care For All Veterans
to Optimally Reduce Suicide Risk
Primary CarePACT
MentalHealth
Pain CM/CCICMSUDs
AcademicDetailing/Pharmacy
38
Veteran centered, team based, coordinated, Whole Health oriented care For All Veterans
to Optimally Reduce Suicide Risk
Primary CarePACT
MentalHealth
Pain CM/CCICMSUDs
AcademicDetailing/Pharmacy
39
Veteran centered, team based, coordinated, Whole Health oriented care For All Veterans
to Optimally Reduce Suicide Risk
Primary CarePACT
MentalHealth
Pain CM/CCICMSUDs
AcademicDetailing/Pharmacy
40
Veteran centered, team based, coordinated, Whole Health oriented care For All Veterans
to Optimally Reduce Suicide Risk
Primary CarePACT
MentalHealth
Pain CM/CCICMSUDs
AcademicDetailing/Pharmacy
41
Veteran centered, team based, coordinated, Whole Health oriented care For All Veterans
to Optimally Reduce Suicide Risk
Primary CarePACT
MentalHealth
Pain CM/CCICMSUDs
AcademicDetailing/Pharmacy
42
Veteran centered, team based, coordinated, Whole Health oriented care For All Veterans
p y
Primary CarePACT
MentalHealth
Pain CM/CCICMSUDs
AcademicDetailing/Pharmacy
43
Veteran centered, team based, coordinated, Whole Health oriented care For All Veterans
to Optimally Reduce Suicide Risk
Primary CarePACT
MentalHealth
Pain CM/CCICMSUDs
AcademicDetailing/Pharmacy
44
Veteran centered, team based, coordinated, Whole Health oriented care For All Veterans
to Optimally Reduce Suicide Risk
Primary CarePACT
MentalHealth
Pain CM/CCICMSUDs
AcademicDetailing/Pharmacy
Whole Health
45
Person centered, team based, coordinated, whole health oriented care
46
Person centered, team based, coordinated, whole health oriented care
Whole Health
47
Person centered, team based, coordinated, whole health oriented care
Case management/Care coordinationTelehealthSecure IT connectio
48
Person centered, team based, coordinated, Whole Health oriented care
49
Person centered, team based, coordinated, whole health oriented care
Whole Health
50
Person centered, team based, coordinated, whole health oriented care
Shared MissionCommitment
Clear Goals/ObjectivesRole Clarity (Individual and Team)Team as Form/Team as Function
Connection and Integration
51
High Performing TeamsClearly Define Roles◦ Service Agreements ◦ Understand differing scopes of practice◦ Communicate roles to all team members◦ Understand what each person needs to do his/her job◦ Some flexibility should be built in◦ Consider shadowing and/or collateral appointments
52
High Performing TeamsLeadership Support◦ ‘Hire hard, manage easy’ i.e., “Get the right people on the bus!”
◦ In addition to professional competency, flexibility and adaptability are essential◦ “Can do” attitude◦ Reliability◦ Excellent communication and relationship skills◦ Life long learners
◦ Set expectations for teamwork and collaboration◦ Value interprofessional practice and the varied strengths of individuals and disciplines◦ Be sure to include all the stakeholders when developing/changing practice◦ Support structures and processes that are designed to foster teamwork
53
High Performing TeamsFoster Professional Relationship Building◦ Preserve some time for both teamwork and team building◦ Work toward a shared vision of the team and its mission◦ Ensure that team meetings include roles for all the members (may need a formal structure)◦ Develop shared expectations for intra-team communication◦ Ensure psychological safety (development of group rules, insist on respectful language)◦ Expect some disagreements
◦ Forming, Storming, Norming◦ Consider how to handle turn over and orient new members◦ Social interchange is important; allow some time for team members to share personal
information when appropriate◦ “Breakfast Tacos” or other specialties to share◦ Hang out in the break room or other shared space when possible◦ Consider informal get togethers
54
Group Discussion and Questions:What has helped or will help your team advance?
55
Session Evaluation
Use the CFHA mobile app to complete the evaluation for this session.
Thank you!
56