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Colorado Behavioral Healthcare Council

How to Fix the Healthcare System and Create Healthy Communities September 30, 2012

Dale Jarvis, CPA dale@djconsult.net

Overview: Advanced Publicity

• All health care is local!

• It’s becoming clear that there are a small number of pieces in a rather tight puzzle that describes how to fix the U.S. healthcare system.

• This session will provide information participants can take back to their community to lead or participate in discussions in their local approach to build a more healthy community.

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This Session: Clinically Driven Design

Clinical

Planning

Utilization

Planning

Cost

Planning

Financial

Modeling

System redesign should be clinically driven and then supported by financial design; not the other way around!

My Next Session: How to Get Paid for This Work.

My Working Assumption • Rather than

assuming that you know nothing about what I have to say…

• I see this session as an opportunity for you to assess how far you’ve already come.

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Agenda – Two Chapters

• The Big Picture – What is a Healthcare Neighborhood?

• Building the Health Neighborhood: The Puzzle Pieces and How they Connect

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Prologue: Have you heard about Type 3 Diabetes?

Mark Bittman, NY Times, 9/26/12 • The connection between poor diet and Alzheimer’s is

becoming more convincing. (“Food for Thought: What You Eat May Be Killing Your Brain” New Scientist).

• When the cells in your brain become insulin-resistant, you start to lose memory and become disoriented. You even might lose aspects of your personality.

• Let’s connect the dots: We know that the American diet is a fast track not only to obesity but to Type 2 diabetes.

• We also already know that people with diabetes are at least twice as likely to get Alzheimer’s, and that obesity alone increases the risk of impaired brain function.

• What’s new is the thought that while diabetes doesn’t “cause” Alzheimer’s, they have the same root: an over consumption of those “foods” that mess with insulin’s many roles.

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The Big Picture – What is a Healthcare Neighborhood?

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Last Year I Talked About Atlanta • Fulton County Georgia’s Objective: create

health neighborhoods that contain one-stop centers where people receive a holistic set of services under one roof that are customized to the needs of the neighborhood

• Neighborhood Union Primary Care Partnership was the first of four one-stops.

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What’s in the Health Neighborhood?

• The Fulton County Georgia (Atlanta area) Neighborhood Union Primary Care Partnership’s One Stop Shopping: – Well patient care – Sick-patient care – OB/GYN services – Travel immunization

services – Communicable disease

intervention – WIC/nutrition education – Oral health services – Behavioral health services

– Employment assistance – Disability and vocation

rehabilitation services – Foreclosure prevention

services – Housing assistance

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What’s in the Health Neighborhood? • The second one-stop, The

North Fulton Government Service Center has all of the above plus: – A day center for the children

of parents receiving services – A branch of the public

library – A reading room/information

center that offers ESL classes – An office where you can pay

your parking tickets and taxes

– A farmer’s market – A community garden – A walking trail

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People Around the Country are Running with the Concept

• My neighborhood community behavioral health center in West Seattle has just opened a one-stop with embedded primary care and other community partners.

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People Around the Country are Running with the Concept

• The Center for Human Development in La Grande Oregon has combined Primary Care, Public Health, Mental Health, Substance Abuse, Developmental Disabilities, Parenting, Rehabilitation and Veteran's Services.

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Hypothesis: Urban and Rural Communities will continue to organize Atlanta-like one stop shopping sites that aggregate and integrate

services that help community members move toward health.

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School

Assisted Living

Facility

Apartment Complex

Community Center

Behavioral Health Specialty Clinic

Mobile Team

Health Neighborhood One Stop Shopping Site

The Future is…

• Not in Plastics

• Not in Medical Homes

• But in One-Stop Health and Wellness Centers (virtual and physical)

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My Predictions • 80-90% of Behavioral Health Disorders will be

served in health and wellness oriented primary care clinic settings, with the number of one-stops growing

• Community Behavioral Health Organizations will: – Be part of one stop settings

– Have many staff working at many types of satellite clinics

– Have many staff working on community-based teams

• There will be very few freestanding behavioral health centers where this is the only service provided

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My Predictions (continued) • There will be two types of one stops:

– Geographic-based neighborhoods

– Population-based neighborhood (e.g. for Seniors and persons with Serious Mental Illness)

• This future fundamentally challenges the trajectory of how Community Behavioral Health Organizations have historically designed programs, campuses, where staff work, what technology is needed, and more

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Questions and Comments

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Building the Health Neighborhood: The Puzzle Pieces and How they

Connect

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The Current Ecosystem

Hospitals

Hospitals

Specialty

Clinics

Specialty

Clinics

Primary

Care Clinics

Primary

Care Clinics

Social Service Agencies

Dental Clinics Housing Providers

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The current ecosystem is not getting us what we need…

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The First Layer of the Puzzle: Maintain Health/Primary Prevention

• Primary Prevention: A program of activities directed at improving general well-being while also involving specific protection for selected diseases, such as immunization against measles. (Mosby's Medical Dictionary, 8th edition)

Prevention/Early Intervention

Initiatives to prevent health

conditions before they begin

to develop

Wellness Programs

Programs that engage

individuals, helping them

move toward health

Housing, Social Supports

Efforts to Address the Social

Determinants of Health

Public Health

Monitor, investigate,

educate, mobilize, assure the

health of the public

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Tip #1. Self care is one of the most important things for your baby and for yourself. Remember how the airline host directs you to put your oxygen mask on first, then your child’s? You must be able to care for yourself first, in order to care for your child.

Tip #2. The year following a child’s birth is recognized to be stressful for parents and their relationship. In fact, a leading marital therapist says that partner satisfaction plummets during this time, due to all the new demands. It is very important to know this is a NATURAL phase that parents go through, and men and women respond differently! What makes it work is TALKING to each other - and LISTENING! The same therapist says the #1 factor that impacts a marriage is whether the wife feels listened to. Husbands, this could make a huge difference in YOUR first year as well!

“New Parent” Brochure with ACE Material

Wow, a new baby!! If this

is your first baby, you may

be wondering, “Why didn’t

they include the training

manual with this model?”

“You mean this lasts for 18

years??!!” “Will I ever

sleep a full night again?”

“Help!!”

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Survival Mode Response

• Respond

• Learn or

• Process effectively

Allow time to de-escalate

Stressed

Can’t:

Brains

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Prevention/Early Intervention

• Are you leading the effort or partnering with others in your community to promote targeted prevention and early intervention activities?

• Mental Health First Aid

• Resilience Trumps Aces

• Senior Reach

• Etc.

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Other Primary Prevention • Wellness Programs: Do you have and promote

wellness programs for your clients, staff and member of the general community?

• Housing & Social Supports: Does your organization provide or partner at the hip with organizations that provide these services?

• Public Health: Do you have robust partnerships with your local public health authority, supporting each other’s efforts?

Wellness Programs

Programs that engage

individuals, helping them

move toward health

Housing, Social Supports

Efforts to Address the Social

Determinants of Health

Public Health

Monitor, investigate,

educate, mobilize, assure the

health of the public28

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The current ecosystem is not getting us what we need…

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The Second Layer of the Puzzle: Interrupt Health Problems/Secondary Prevention • Secondary Prevention: A program of activities directed at

diagnosing and treating existent condition in early stages before they cause significant morbidity. (US National Library of Medicine)

• Examples: Prevent high blood pressure from becoming hypertension; high blood sugar from becoming diabetes, disruptive behavioral in school from becoming SED, minor depression from becoming major depression.

Person-Centered

Healthcare Homes

Cradle to Grave Well Care

(Secondary Prevention) and

Sick Care

School-Based Clinics

Provide health, behavioral

health and a host of other

services to children at youth

onsite at schools

Employer Clinics

Healthcare Homes and

pharmacies embedded in the

workplace

Retail Clinics

NP/PA-run clinics in shopping

centers; no appointment; treat

40+ conditions; 98%

satisfaction rates

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Workflow 1 for Person with BH Disorders

New Patient’s first

Visit to PCP includes

behavioral health

screening

Possible

BH Issues?

Behavioral Health

Assessment by BH

Professional working

in primary care

Need BH

Svcs?

Clients with Low to Moderate

BH need enrolled in Level 1;

to be case managed and

served in primary care by PCP

and BH Care Coordinator with

support from Consulting

Psychiatrist and other clinic-

based Mental Health Providers

Clients with Hi Moderate to

High need referred to Level 2

specialty care; PCP continues

to provide medical services

and BH Care Coordinator

maintains linkage; this is a

time-limited referral with

expectation that care will be

stepped back to primary care

YES

YES

Referrals to other needed services and supports (e.g. Social Services, Vocational Rehabilitation)

Clients with Hi Moderate to

High need transferred to Level

3 BH specialty care; takes over

ensuring that whole health

needs of clients are met

including primary care through

integration or partnership

model.

Integration Door #1

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New Patient’s first

Visit to BHP includes

physical health

screening

Has PCP?Wants BHP to

provide PC?

Linkage Model

Ensure PCP, health screening

and monitor health conditions,

co-management with PCP,

patient education

Partnership Model

Partner with PC Clinic to

embed medical services in the

BH Center

NOYES

Referrals to other needed services and supports (e.g. Social Services, Vocational Rehabilitation)

Full Integration

A single organization provides

all PC and BH services

Integration Door #2

YES NO

Workflow 2 for Person with BH Disorders

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Interrupt Health Problems/ Secondary Prevention Questions

• How far along is your organization in it’s strategy to embed behavioral health services in local primary care clinics to address the mental health and substance use needs of the practices’ patients?

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Interrupt Health Problems/ Secondary Prevention Questions

• Have you implemented a secondary prevention approach in your centers to identify and interrupt the progress of health problems for your clients before they become chronic health problems?

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The current ecosystem is not getting us what we need…

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The Third Layer of the Puzzle: The Creation of a Hospital/ER Prevention System

• An integrated system of care that contains new models of service delivery to identify those with complex health and behavioral health problems and wrap whole person care around them to help them move toward rehabilitation and recovery.

Hot Spotting

Identify and engage the 5%/

50% population

Community Health Teams

Connect patients to primary

care, get to appointments,

transition from hospital, stay in

their homes, etc.

Complex Care Management

Help patients with chronic

health conditions self-manage

their care and move toward

health

Specialty Providers that are

Health Neighbors to PCHHs

Providing high value services

that support health homes

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Stanford Social Innovation Review

• There are important lessons to learn from poor countries

• Expanding the definition of health care, including:

– The Product that is provided

– The People who provide care

– The Places where care is provide

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• Identifying the 1% of 100,000 people who use 30% of costs and wrapping care around them is an example of the expansion of product, people and place.

• Product: Helping with housing, food, other basic needs.

• People: Community health workers as part of the team.

• Place: Going to where people are including their homes.

• Question: Are you involved in hot spotting the most expensive and complex cases in your community?

Camden’s Hot Spotting

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Vermont’s Community Health Teams • Connect patients

to primary care

• Track patients overdue for appointments or tests

• Help patients being discharged from hospitals

• Health and nutrition coaching

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Question: Are staff in your organization part of interdisciplinary community health teams that fulfill the roles similar to Vermont?

Missouri’s Complex Care Management

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Question: Are you involved in providing complex care management for persons with BH disorders and complex health conditions?

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Person-Centered Medical Home Neighbor

• ACP’s PCMH-N Principles: To be recognized as a neighbor, specialists must demonstrate competency around: – Communication, coordination,

& integration

– Timely consultations & referrals

– Timely, effective exchange of clinical data

– Effective participation in co- management situations

– Patient-centered care, enhanced care access, and high levels of care quality and safety

– Supporting the health home practice’s work

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Health Neighbor National Council Healthcare Reform Readiness Assessment • We are well underway

developing the capabilities to be good neighbors to Person Centered Health Homes.

• Toward this end, we provide or have partnerships with other organizations to offer and seamlessly provide a full array of mental health and substance use services for persons with mild, moderate, serious and severe disorders.

Question: How would you score your organization: ready; almost there; working on it; contemplating it; haven’t thought about it?

Specialty Providers that are

Health Neighbors to PCHHs

Providing high value services

that support health homes

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Prevention/Early Intervention

Initiatives to prevent health

conditions before they begin

to develop

Wellness Programs

Programs that engage

individuals, helping them

move toward health

Housing, Social Supports

Efforts to Address the Social

Determinants of Health

Public Health

Monitor, investigate,

educate, mobilize, assure the

health of the public

Person-Centered

Healthcare Homes

Cradle to Grave Well Care

(Secondary Prevention) and

Sick Care

School-Based Clinics

Provide health, behavioral

health and a host of other

services to children at youth

onsite at schools

Employer Clinics

Healthcare Homes and

pharmacies embedded in the

workplace

Retail Clinics

NP/PA-run clinics in shopping

centers; no appointment; treat

40+ conditions; 98%

satisfaction rates

Hot Spotting

Identify and engage the 5%/

50% population

Community Health Teams

Connect patients to primary

care, get to appointments,

transition from hospital, stay in

their homes, etc.

Complex Care Management

Help patients with chronic

health conditions self-manage

their care and move toward

health

Specialty Providers that are

Health Neighbors to PCHHs

Providing high value services

that support health homes

Questions and Comments

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