Mark D. Valenti, Project Manager, Pittsburgh Regional Health Initiative Robert C. Ferguson, Program Manager, Jewish Healthcare Foundation

Disseminating CER-based Models in Primary Care for Depression and Substance Misuse through Multi-state Partnerships, Regional

Implementation, and Community Engagement

Mark D. Valenti, Project Manager, Pittsburgh Regional Health InitiativeRobert C. Ferguson, Program Manager, Jewish Healthcare Foundation

Collaborative Family Healthcare Association 14th Annual ConferenceOctober 4-6, 2012 Austin, Texas U.S.A.

Session #E6bOctober 6, 2012

Faculty DisclosureWe have not had any relevant financial relationships

during the past 12 months.

This project is supported by grant number R18HS019943 from AHRQ. The content is solely the responsibility of the authors

and does not represent the official views of AHRQ.

Objectives

• Discuss how to efficiently support primary care offices to implement evidence-based care delivery models that require organizational and implementation issues to be overcome

• Describe workflows and processes of the integrated care models

• Explain examples of how to involve consumers in the implementation process

• Describe examples of how health plans can support integrated care models

© JHF and PRHI 2012 4

Jewish Healthcare Foundation:“A Think, Do, Train and Give Tank”

A public charity with two operating arms• Pittsburgh Regional Health Initiative (PRHI)• Health Careers Futures (HCF)


Who Are We?

Pittsburgh Regional Health Initiative (PRHI) A not-for-profit, regional, multi-stakeholder coalition

formed in 1997 Started as an initiative of a business group, the Allegheny

Conference on Community Development

PRHI’s message Dramatic quality improvement (approaching zero

deficiencies) is the best cost-containment strategy for health care


Partners in Integrated Care (PIC) – Spreading through Collaboration

PRHI and the PIC Consortium were awarded a grant from the Agency for Healthcare Research and Quality (AHRQ) to disseminate and

implement IMPACT+SBIRT in primary care from 9/30/10 to 9/29/13.Screening , Brief Intervention, and Referral to Treatment (SBIRT) – SAMHSA

Improving Mood—Promoting Access to Collaborative Treatment (IMPACT) – University of Washington


PIC’s Deliverables under AHRQ-funded Grant

1. Oct. 2010 to Sept. 2011: Develop a streamlined method for implementing IMPACT+SBIRT

2. Oct. 2011 to Sept. 2012: Test dissemination protocol in 50-90 practices in PA, WI, and MN

3. Oct. 2012 to Sept. 2013: Successfully export methodology to MA and disseminate via NRHI

4. By Grant’s End: Position all sites for self-sustaining payment reform

7


PIC - Organizational StructureSteering Group

PI & PMChairs of Work

Groups

Eval. & HIT WGNancy Jaeckels, ICSI

Consortium Members

Practice Support WG

Richard Brown, WIPHL

Consortium Members

Marketing WGNancy Zionts, PRHI

Consortium Members

Nat. Imp. & Diss. WG

Harold Miller, NRHIConsortium Members

State Implementation Team Dissemination to RHICs in NRHI network

State Implementation Team State Implementation Team directed by Mark Valenti

Principal Investigator (PI); Project Manager (PA); Work Group (WG); Health Information Technology (HIT); National Implementation and Dissemination (Nat. Imp. & Diss.); Regional health improvement collaboratives (RHIC)


PIC Model Core Components in Primary Care

Screening for depression, and alcohol and other drug misuse

Dedicated role for patient engagement, behavioral interventions, monitoring, and facilitation of team-based collaboration

Weekly caseload reviews with a consulting psychiatrist Systematic follow-up and patient tracking Stepped care approach to modify depression treatment


Participating PIC Sites in PA


PIC Materials and Toolkits

Providers RHICs

Employers and

InsurersPatien

ts


PIC Training and Coaching

Role Play/Exercises

Didactic

Simulated Pts.


Tomorrow’s HealthCare™ On-line Community


PIC Clinical Work Flow

Pt. meets eligibility for depression

and substance use screening

Care manager provides brief intervention &

engages patient

Care team administers brief screens and then

the PHQ-9, AUDIT, and/or

DAST-10

PCP and care manager est.

depression and substance-related

risk/disorderCare manager

provides follow-up & monitoring

PCP modifies treatment based on

care team recommendations and

guidelines

Front Desk Triage Room Exam Room Follow-Up Visits (primary care office and phone)

Care manager reviews caseload with

consulting psychiatrist

Care manager and patient complete

maintenance plan & 6 and 12 mos. follow-up


PIC Clinical Work Flow:Implemented Model 1

Pt. meets eligibility

for depression

and substance

use screening

Care manager verbally

admin PHQ-9, AUDIT,

and/or DAST-10

provides brief intervention & engages

patient

PCP est. depression &

substance-related

risk/disorder

Care manager provides follow-up &

monitoring



guidelines



Front Desk Follow-Up Visits (primary care office and phone)

One provider in an office of 10+ providers



Exam Room

Clinical care team administer

s brief screens


PIC Clinical Work Flow:Implemented Model 2

Pt. meets eligibility

for depression

and substance

use screening

Care manager (CM)

provides brief intervention & engages

patient

Clinical care team

administers PHQ-9, AUDIT,

and/or DAST-10

PCP scores the full

screens and est.

depression & substance-

related risk/disorder

Care manager provides follow-up &

monitoring



guidelines



Front Desk Follow-Up Visits (primary care office and phone)

One provider office



Exam Room CM Office

Front desk administers

brief screens


Engaging Patients and Consumers

WIPHL Feedback from

the primary care offices’ patients

ICSI Patient Advisory

Council Consumer

awareness and engagement campaign

PRHI Consumer

Health Coalition’s training and focus groups


—Rev. Sally Jo Snyder, Consumer Health Coalition

Engaging Patients and Consumers


Consumer Health Coalition

Recognizes that people experience disparate access to resources

Dedicated to the eradication of disparities in health access and outcomes

Goal is to ensure every person has the health coverage and care they need


Consumer Health CoalitionConsumer Focus Groups

Three, 1 ½ - 2 hour sessions Six consumers Input on patient engagement and the PIC

process Feedback on PIC materials


Findings from Consumer Focus Groups

“When I go to the doctor, I fill out the forms, but nobody talks about it.”

“The first few interactions are critical; asking intrusive questions could shut me off.”

“Where does the information go?”


Findings from Consumer Focus Groups

“The dynamic of the relationship was interesting; it was like a dance.”

Suggestion to call the new role: “Your Health Supporter.”


Preliminary Findings: Recruitment

The time is ripe for implementing integrated care models (PCMHs, ACOs, etc.)

Finding a consulting psychiatrist and the reimbursement equation can present challenges However, strong leadership and an understanding of the

WIIFM can trump the concerns


Preliminary Findings: Implementation

Champions are needed at the staff, administration, and physician level in order to implement PIC

Even if a primary care site is simply adding SBIRT to an existing IMPACT infrastructure, implementation and training still require substantial effort, resources, support, and leadership


Preliminary Findings: Implementation

A registry is critical for care management, case load review, and quality improvement

Proactively address the following SBIRT-specific issues: Stigma around substance use may be higher in primary care sites

located in small, tight-knit towns Primary care staff may make assumptions that patients will not be

receptive to SBIRT (which is not the case) A best practice for SBIRT is to begin with universal screening. Behavioral health screens must be appropriately introduced to

patients, using motivational interviewing, and incorporated into existing forms


Engaging Other Local Stakeholders

PRHI Stakeholders

Group MCO Medicaid

Medical Directors Health Funders

Collaborative

Medicaid and State

DHS

Commercial Payers Employers Health

Funders

Patients and

Providers

ICSI Steering Group Department of

Human Services MN Community

Measurement

WIPHL Advisory Regional “Perfect

Storm Campaign” Employers


Current State of Billing for Integrated Care in Most Regions

Only certain provider types can bill for services (varies by practice type and health plan)

The existing codes are for specific services that do not fit the evidence-based IMPACT+SBIRT services


Breaking through FFS Limitations DIAMOND Payment Model in Minnesota

9 commercial health plans pay a PMPM fee Fee covers all IMPACT services as a bundle Certified medical groups are eligible for payment if

they complete ICSI’s standardized training Payment Model in Wisconsin

Medicaid and 13 commercial plans reimburse existing FFS codes for SBIRT services

Unlicensed professionals authorized to bill with 60 hours of training


Efforts to Create a Payment Model to Sustain PIC in Southwestern Pennsylvania

PIC PRACTICES

MEDICAIDPHYSICAL HEALTH

MCOs

MEDICAIDBEHAVIORAL HEALTH

MCOs

PRHI

Idea: As a neutral convener, PRHI could convene a collaborative meeting with all of the PH and BH MCOs in southwestern PA

Lesson Learned: PRHI cannot serve as a neutral convener under anti-trust laws

Disclaimer: This did not occur



PIC PRACTICES


MCOs


MCOs

PRHIState

Medicaid Office

New Strategy: The State Medicaid Office could convene a meeting with all of the PH and BH MCOs in southwestern PA

Lesson Learned: The Office of Behavioral Health at the State- and County-level should be at the table as well



PIC PRACTICES


MCOs


MCOs

PRHI

State Medicaid BH Office

State Medicaid

Office

County BH Office

Strategy 3: With oversight from the State, facilitate meetings with the PH MCOs, BH MCOs, and the State and County offices of behavioral health

Lesson Learned: Precedents do not exist that include a collaborative approach between all of these parties (to be determined)


Preliminary Findings: Dissemination

Train-the-trainer sessions must occur within the first few weeks when disseminating to multiple organizations

Common terminology is desirable but not attainable; however, operational definitions are attainable

Cultural and regional differences trump standardized terminology and training/implementation strategies.

It is important to have: A regional entity/forum that advances the model An entity/forum that provides training and coaching


PIC’s Anticipated Outcomes Using Required Data Fields and Measurements Specs

Depression process 20% eligible and 50% enrolled

Substance use process 20% eligible, 50% with brief intervention, 15% with specialty treatment

entry if recommended Depression outcomes (symptoms of depression)

50% in response (≥50% reduction in symptoms as measured by PHQ-9) and 30% in remission (PHQ-9<5) at 6 mos.

Alcohol and drug outcomes (quantity and frequency of use) 20% reduction in number of “binge drinking” days at 6 mos. 30% reduction in number of drug use days at 6 mos.


Next Steps

1. Continue practice facilitation and evaluation 2. Implement in MA around May 2013 with MHQP3. Create a sustainable payment paradigm4. Disseminate materials and tools through NRHI

As a Sub-awardee in the Health Care Innovation Award led by ICSI, implement a collaborative care model for depression plus diabetes and/or cardiovascular disease

Partners in Integrated Care (AHRQ)

Care Of Mental, Physical, And Substance use Syndromes (COMPASS) (CMMI)

Questions and Answersand Discussion

How could PIC be spread in your community through public policy, practice facilitation, and consumer engagement?

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!

Documents

Mark D. Valenti, Project Manager, Pittsburgh Regional Health Initiative Robert C. Ferguson, Program Manager, Jewish Healthcare Foundation