Integrated Health Services at Winters Healthcare FoundationJ. JAVIER LUNA, PH.D. DIRECTOR OF INTEGRATED HEALTH SERVICESWINTERS HEALTHCARE (FQHC)

“Its very hard to do integrated care and still think of “mental health” and “physical health.” The categories just begin to break down because they don’t describe the way people present. They don’t describe how problems form over the years.”

Alexander Blount EdDUMASS The Center for Integrated Primary Care

Winters Healthcare FoundationSmall Rural Clinic (FQHC) in Northern California3000 patients approximately served annuallyBHC services since Oct 2012Integrated Health Coaching Program since Oct 2013Average of 3-4 Primary Care Providers in clinic

Integrated Health Services includes our behavioral health consultant service and health coaching program1 Behavioral Health Consultant (BHC) and 2 Integrated Health Coaches (IHC)Implementation of BHC model started in October of 2012Health Coaching program started in October of 2013

Integrated Health Services at WHF

Models of integration include Primary Care Behavioral Health (PCBH or BHC), Collaborative Care (IMPACT Model), SBIRT

Programs are site specific efforts to integrate primary care and behavioral health services

Population Penetration is the degree of in-reach into the general population

Before we get started….Some Vocabulary

BHC is a member of the primary care team (not specialty care)Provides consultations, (not “therapy”)or “counseling”- avoid these terms)◦Brief visits, limited and flexible follow-ups◦Prompt feedback to PCPGoal is immediate access for any and all health issues-not just MH disorders and crisis mgmt!! Emphasizes population mgmt, psychoeducationFocus on improving QOL and health care

The PCBH or BHC Model

Integrated Health Coach (IHC) is a member of the primary care teamCoach patients with chronic conditions to improve their self-managementUse various Motivational Interviewing strategies, behavior change techniquesFunctionally work like BHC’sThink of a on-demand Health Educator, Nutritionist Diabetes Educator, Patient Navigator, Panel Manager, all in one!!!

Health Coaching Program

To serve our primary care teams and patients with immediately-accessible

behavioral health, chronic disease, and self-management support through timely,

flexible, and innovative services

Mission of Integrated Health Services

Population FocusIntegrated GeneralistProvide services on-demand in real timeOperate with assumption that patients will not come backUse vertical and horizontal strategiesFlexible schedule template for follow up visitsUtilize registry and other care management strategiesUse simple data design and collection strategies

Core Tenants of Integrated Health Services

Stepped Care

Step 2: Step 1 plus + Stress, Signficant Barriers, Behavioral

Issues, Medical Complexity, History of Mental Health issues

HealthCoaching

BehavioralHealthConsultation

Horizontal vs. Vertical InterventionsHORIZONTALNot targeted Customers present with a range of concerns Meet them where they are at Help to improve their overall health Ex: Customer presents with chest pain, medical rule out, focus on stress

VERTICALTargeted Work with specific subpopulations Targeted interventions for these populations Define treatment protocols and clinical guidelines Ex: Depression screening and follow-up

BHC and IHC Referrals Typical psych issuesChronic PainSmoking cessationObesity/weight managementSleep disordersDiabetesHeadaches

Hyperlipidemia and hypertensionFatigueParenting and pediatric behavioral issuesSexual healthMedication/treatment compliance

No caseloadLess “Assessment”Faster paceTransparencyWorking as part of a teamBilling issuesAmbigous clinical situationsProfessional identity Open Schedule/Varied Day

Challenges for New Integrated Professionals

Clinical (e.g., pre-post, PHQ9, GAD-7)

Financial (e.g., cost per pt or cost per visit/Revenue, Cost of program/unique patients or total visits

Process (e.g., population penetration, depression and alcohol screening)

Satisfaction (e.g., provider or patient satisfaction)

Metrics

Behavioral Health

53

71

59

3745

63 65

21

11

2113

1819 1621

9

75

10093

51

0

20

40

60

80

100

120

Feb March April May

Unique Pts Per Month WHO BH Scheduled WCC Visits Total Visits (WCC included)

Population Penetration (Behavioral Health)

21%

26%

21%

0%

5%

10%

15%

20%

25%

30%

2013 2014 2015

Health Coaching Program

64

84

4146

2833 35 38

13 11 70

105

128

83 84

0

20

40

60

80

100

120

140

Feb March April May

Same Day Visits Scheduled Visits Total Telephone Vists Total Touches

Scheduled vs. WHO’s (Behavioral Health)

654

539

181

228

0

100

200

300

400

500

600

700

2013 2014 2015

Warm handoffs Scheduled

Model Fidelity (Behavioral Health 2015)

296 296317

124

154

24

0

50

100

150

200

250

300

350

Visits Patients

Chart Title

1 2-4 5+

Provider Satisfaction

50%50%

All things considered, how satisfied are you with having BHC services in your clinic?

Completely Dissatisfied

Very Dissatisfied

Somewhat Dissatisfied

Neither Dissatisfied Nor Satisfied

Somewhat Satisfied

Very Satisfied

Completely Satisfied

Provider Satisfaction

Robinson & Reiter.Behavioral Consultation and Primary Care: A Guide to Integrating Services, 2nd Ed

Collaborative Family Healthcare Association (CFHA)

Helpful Resources

J. Javier Luna, Ph.D.

Thank you!