Behavioral Health/Pediatric Primary Care Integration at Geisinger:
Year 1 Implementation & EvaluationShelley Hosterman, PhD
Paul Kettlewell, PhDChristine Chew, PhD
Tawnya Meadows, PhD
Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Session #D3October 28, 20113:30 PM
Faculty Disclosure
We have not had any relevant financial relationships during the past 12 months.
Need/Practice Gap & Supporting Resources
• Parents often bring their children to primary care physicians first (Smith, Rost, & Kashner, 1995)
• 15% to 21% of primary care visits are for behavioral
health concerns (Kelleher, Childs, Wasserman, McInerny, Nutting, Gardner, 1997; Lavigne, Gibbons, Arend, Rosenbaum, Binns, Christoffel, 1999; Williams, Klinepeter, Palmes et al., 2004).
• During 50% to 80% of child health care visits, parents or physicians raise concerns of behavioral or psychosocial issues (Cassidy & Jellinek 1998; Fries et al., 1993; Sharp, Pantell, Murphy, & Lewis, 1992).
Need/Practice Gap & Supporting Resources
Problems with seeking behavioral health services from PCP:
• Increased number of medical visits
• Increased time spent with the physician
• Lost revenue if a patient takes more time than scheduled
• Lower reimbursement rate for mental health issues
• Limited training in mental health treatment (Connor, McLaughlin, Jeffers-Terry, O’Brien, Stille, Young, & Antonelli, 2006; deGruy,
1997; Leaf, Owens, Levelthal, Forsyth, Vaden-Kiernan, Epstein, Riley, & Horwitz, 2004; Strosahl, 2002; Young, Klap, Sherbourne, & Wells, 2001)
Need/Practice Gap & Supporting Resources
Problems with seeking behavioral health services from PCP:
• Decreased number of patients seen
• Increased risk of physician burnout
• Unsatisfied patients
• Increased impairment in patient health and functioning
• Increased use of acute and emergency care (Connor, McLaughlin, Jeffers-Terry, O’Brien, Stille, Young, & Antonelli, 2006; deGruy,
1997; Leaf, Owens, Levelthal, Forsyth, Vaden-Kiernan, Epstein, Riley, & Horwitz, 2004; Strosahl, 2002; Young, Klap, Sherbourne, & Wells, 2001)
Objectives
• Understand the collaborative development process with the Geisinger Health Plan & Pediatric Partners
• Describe Geisinger’s pilot model
• Describe program evaluation plans for this project
• Review baseline data for the program
Agenda
• Developing the model – Process & Supports
• Details of pilot model
• Program evaluation & research
• Baseline data & future directions
Development: Previous System
• Outpatient mental health services, inpatient psychiatric unit, & consultation/liason in major hospital
• 3 pediatric psychs, 1 family therapist, 1 psychiatrist, 3 pre-doctoral interns, & 2 postdoc fellows
• Serving all children/adolescent in 5 counties, all patients with Geisinger PCPs, specialty patients
• Concerns with system: Waitlists, no shows, patient travel, caseloads, problems recruiting psychiatrist
Development: Model Prototype
Munroe-Meyer Institute – Inspiration for our modelUniversity of Nebraska Medical Center; Omaha, NE
http://www.unmc.edu/mmi/behavioral/
Joseph H. Evans, Ph.D. Director, Psychology DepartmentRachel Valleley, Ph.D.Outreach Behavior Health Clinics Coordinator
Development: Model Prototype
• Behavioral health services in primary care
• 23 outreach clinics across Nebraska
• Reaching underserved, rural populations
• Co-located & collaborative clinics
• Interns/postdocs trained in the setting
• Education for PCPs• Frequent contacts
regarding referrals• Research & program
evaluation• Promising outcomes –
Discussed later
Development: Our System
Geisinger Health System - •Integrated health network•Serves 43 counties; 20,000 sq miles; 2.6 million people•Nearly 60 community practice sites across the state•System-wide electronic medical record
•Geisinger Health Plan – Among nation’s largest rural HMOs (270,000 members)
Development: Marketing Change
Step 1: Approached psychiatry administration (10/09)•Response – Excellent concept, but no way to proceed within budget
Step 2a: Presentation at psychiatry grand rounds (2/10)•Response – Excellent concept•Possibility #1 – Private donor looking for a way to support mental health of children/adolescents•2b: Private meetings & additional presentation to private donor secured substantial gift
Development: Marketing Change
Step 3: Presentation to Pediatric Grand Rounds (03/10)•Response – Pediatrics enthused & many requested
Step 4: Presentation to Geisinger Health Plan (Spring ‘10)•Summary – Model offers better care, may save money, & carve out model of payment does not make sense•Response – We agree, what should we do?•Key message – They believe is better care & will support if we can break even or save money
Development: GHP Proposal
Monthly planning meetings with GHP administration
Data review process:•Medical expenses for pediatric patients with ≥1 BH visit double those of comparison patients•Key cost differences: Outpatient, pharmacy, & ED•Potential for cost off-set?
Outcome: GHP funded pilot project & program evaluation
Development: GHP Proposal
Proposal objectives:1.Improve quality of behavioral health care2.Reduce medical expenses & utilization of patients with BH concerns3.Increase physician, parent, & patient satisfaction with service model & delivery4.Expand PCP knowledge of BH assessment & intervention5.Improve access, adherence, efficiency, & integrity of BH services & intervention
Development: Task Force• Key stakeholders
• Review problems & solutions in our system & state
• Information gathering & review of other models
• Focus on partnership, collaboration, & consultation to help children & adolescents
• Electronic survey of primary care providers
Development: PCP Survey
Most common problems
• ADHD (77%)• Obesity (72%)• Depression (57%)• Anxiety (47%)• Disruptive Behavior
(44%)
Most want training/assistance
• ADHD (45%)• Disruptive Behavior
(43%)• Anxiety (32%)• Obesity (29%),• Depression (26%)• Eating Disorders (26%)
Development: PCP Survey
Barriers to service:• No local resources (94%)• Getting appt (55%)• Insurance issues (46%)• Travel for families (35%)• No time to address (24%)• No training (20%)• Patient Follow (11%)• No collaboration (11%)
Desired Models:• On-site services (76%)• Training in assessment &
diagnosis (65%)• Medication consults (64%)• Screening tools (49%)
Development: Task Force
Follow-up interviews with primary care:•Additional input•Assess site specific enthusiasm, barriers, and % GHP•Identified three sites Presented to CPSL
Three goals:1.Behavioral health providers on-site in PCP sites2.Support PCPs with screening tools & training3.Case consultation with child/adolescent psychiatrist
Clinic Structure: Team Planning
• Team planning meetings – Psych & PCPs, office staff
• Shadowing PCPs
• Billing discussions
• REACH Institute training – PCPs & Psych’s together– Focus on screening & psychopharm
Clinic Structure: Services
Report templates: Concise, completed during visit, structured for brief review
Clinician schedules: 1 psychologist + 1 psychology fellow•75 min evals, 45 min returns•75% scheduled – Always available to PCP
Warm hand-offs & consultations:•Join visits, education, pass patients on, simple recommendations, immediate eval•Tracking details
Clinic Structure: ServicesHandouts – Common for psychologists & PCPs
Crisis evaluations as needed
Communication – Medical record & constant contact
Ongoing training for PCP’s•Monthly case conferences•Presentations on request
Relationship building – Join clinic community
Clinic Structure: ServicesCommon screening tools
Anticipate high-volume issues•ADHD evaluations•Weight management•DBC groups
Psychiatry consultation – Case review & phone consultation
Electronic screening tools – Results directly in medical record
Clinic Structure: Services
Brief Case Examples
Program Evaluation: Key Domains
• Satisfaction
• PCP comfort/knowledge in assessment & intervention
• Quality of life
• Clinically significant symptoms
• Medication use
• Utilization data
• Clinic efficiency data
• Quality of Care v. Practice Standards
Program Evaluation: Tools & PredictionsSatisfaction: Pre & Post questionnaires for parents & PCPsIncludes: •Convenience, time to first appointment, Stigma/Comfort•Communication with PCP•Perceived BenefitPredict increased satisfaction relative to traditional model
Comfort and Knowledge: Physician survey•Pre & post training, pre-integration, & yearlyPredict increases across each measurement
Program Evaluation: Tools & PredictionsQuality of Life: Peds QL-4•Pre & post intervention•School questionnaire – attendance, performance•Predict improved QOL & school attendance•Predict match results from other CBT outcome studies
Clinical symptoms: Target behavior ratings•5 point Likert Scale at every session•Dual purpose - research outcomes & tracking treatment goals•Most immediate/likely measure of change•Predict steady reductions across course of treatment
Program Evaluation: Tools & PredictionsMedication use•Chart review – Pre and post integration, per diagnosis•Predictions – More appropriate use (sufficient trials, monitoring change, appropriate match to symptoms)
Utilization data: Chart Review•# Medical visits: Frequency PCP visits reduced pre v. post•Specialist visits: Frequency reduced pre v. post •Time to first visit – Reduced delay between physician referral & assessment vs. traditional model in our system•Out of network – Pre & post insurance company data. Predict reduced out of network
Program Evaluation: Tools & Predictions
Efficiency data•Time study: Pre, yearly, post•Code: Medical, Beh, & Med/Beh visits• Appointment duration: no change on medical appointments,
less time on behavioral & med/behCost savings & cost effectiveness: Pre, yearly, post•Predict increase in overall clinic revenue, reduced PMPM cost for patients with BH issuesQuality of Care•Identify AAP standards of care•Chart review assessing adherence with standards
Time Study Data
Table 1
Minutes Spent Per Visit
Type of Concern
Percent of Total Visit Types Observed
(N)
Mean
Medical 301 14.04
Behavioral 10 13.60
Medical and Behavioral
34 12.99
ResultsPercentage
0123456789
10
AD
HD
Anx
iety
Dis
orde
rs
Aut
ism
Tic
Dis
orde
r
OD
D
Dev
elop
men
tal
Dis
orde
r
Elim
inat
ion
Dis
orde
r
Referral to Pediatric Psychology
• 2.9% of all patients observed were referred to peds psych
• 28% of those diagnosed with a psychological disorder were referred to peds psych
Baseline data: Referrals & HandoffsConsults Warm
HandoffsNew Appointments
Return Appointments
Crisis
Clinic 1 19 16 23 39 0
Clinic 2 23 31 59 36 6
Clinic 3 38 14 31 35 3
Total80 61 113 110 9
Learning Assessment
Questions?
Session Evaluation
Please complete and return theevaluation form to the classroom monitor
before leaving this session.
Thank you!
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