Integration of Primary and Behavioral Care In Eastern Tennessee

Plan of ActionWe are going to provide strategic guidance and performance improvement solutions - actionable insights and analytics, technology platforms, consulting expertise and IT development services for healthcare. We are going to outline our approach to addressing the compatibility issues between two different systems of clinical documentation as well as the discussion of the ongoing challenges and our rigorous solution.

Tennessee: Demographics

Demographics

Eastern Tennessee Eastern Tennessee is the most populous and most densely populated. At the 2010 census it had 2,327,859 inhabitants living in its 33 counties, which have a combined land area of 13,558.27 square miles. Its population was 37.25% of the state's total, and its land area is 32.90% of the state's land area. Its population density was 156.33 inhabitants per square mile.

Eastern Tennessee

Access to HealthcareTop Community Health Needs

#1 Nutrition/Obesity/Fitness

#2 After Hours Access

#3 Substance Abuse

#4 Mental Illness

#5 Diabetes

#6 Cancer

#7 Tobacco Use

Poor NutritionPoor nutrition was ranked as the #1 health priority

While there were positive comments regarding programs, such as, Go Red, Boys and Girls Club, organized youth sports leagues and Zumba, many respondents would like to see a greater variety in free and low cost exercise options including, club membership, city parks, bike and walking paths

One individual wrote on the survey, “Many residents can’t afford the exercise programs.”, “We need a place for kids to ride their bikes.”, “Each city needs a public swimming pool.”, “Our community needs more health fairs.”

SourcesNewspaper ads Literature Television ads Internet Direct Mailings Radio ads Billboards Health Fairs

Lifestyle changes are seen as one of the best indicators toward improving the health of the population. Not smoking, improved physical exercise, and a better diet, could increase quality of life and longevity

Eastern Tennessee StatisticsObesity Rates ➔ 69% of the Total Population Physical Activity – Percent Reporting No Physical Activity➔ 29% of Total Population High Blood Pressure ➔ 33% of Total Population Diabetes ➔ 10% of Total Population

After Hour Access to Healthcare After Hours Access to Care was ranked as the #2 health priority

61% Ranked accessibility as good

23% Ranked accessibility as fair

14% Ranked accessibility as poor

2% Ranked accessibility as unknown

Some specific comments regarding accessibility to care included, “Accessibility is adequate if you can afford it.”, “Accessibility is good unless specialty care is needed.”, “Care is very accessible.”, “There are not enough doctors in town.”, and “Need more health care clinics for faster service.”

The two most commonly cited reasons for self limiting of access to care were identified as:

1. Lack of any or adequate insurance coverage (affordability –

including medications)

2. Geographic – Travel distance too far or no transportation source

at all

Access to Healthcare●Lack of access to health care for the underinsured and the

uninsured has been and will continue to be an issue in the future●Individuals have limited options for obtaining health insurance●It is also anticipated that health care costs in the United States will

continue to spiral upward. ●It is unknown how the State of Tennessee, which is experiencing

budget constraints, will be able to pay its share of the Medicaid expense as the demand for insurance coverage increases.

●At the local level, more individuals will have difficulty paying for health care and will delay getting needed care which may mean that when they finally obtain care the condition may be more serious and thus, costly.

Some additional comments regarding access to care include:

“The public needs to be more informed about the services currently available in the county.”

“The county needs more early am and late pm clinic hours.”

“Need to expand the Health Department hours.”

“Need more transportation options.”

“Need health insurance options.”

“Wait times are too long in the provider offices. Need more providers.”

“Provider offices need better customer service skills.”

“Need more providers who are committed to keeping patients well.”

Substance AbuseSubstance Abuse was ranked as the #3 health priority

It is recognized that smoking contributes to many health diseases; that alcohol and drug abuse may affect brain development in the adolescent and young adult; and that the younger an individual is when he or she starts to drink, the higher the chances are he or she will have alcohol‐related problems later in life

Lack of resources for people seeking treatment; lack of enforcement of existing laws; lack of education in schools about alcohol and other drugs

There is a general lack of services available for substance abusers and no detoxification facility. It is limited to social services and NA meetings

One of many comments received from survey respondents, “alcohol is the major drug problem, and should be viewed as such...”

Access to Healthcare

Deslaurier Associates recognizes that: General health of the population is poor.

We need to come up with more health related education. There is nowhere for students to go in the summer while parents are

working. Each town needs bike trails and a public swimming pool. We to educate community and provide free diet counselingHealth insurance cost is too high.There needs to be a plan for moving forward into the future which

would include plans to recruit businesses and quality services. We need to come up with adequate resources and measurable

indicators

Eastern Tennessee: HIPAA LAWSHIPAA is the federal Health Insurance Portability and Accountability Act of 1996. The primary goal of the law is to make it easier for people to keep insurance, protect the confidentiality and security of healthcare information and help the healthcare industry control administrative costs

HIPAA LAWSHealth care providers must keep all patient records strictly

confidential and must have written policies in place to limit the use and disclosure of medical records, even if patient information is de-identified.

Provider may not sell or disclose a patient’s name or address, unless the disclosure is made to a government agency or a third party board for utilization, case management or peer review purposes. Patient information can be disclosed in response to a court ordered subpoena, or if requested by the Office of Inspector General.

These requirements apply not simply to practitioners, but to hospitals, nursing homes, ambulatory surgical centers, dentistry practices, health maintenance organizations, and laboratories as well.

Besides traditional patient medical records, Tennessee requires that additional patient information that is disclosed to the state or third-parties be kept confidential as well.

Overview of Health Problems: TN vs VA

In 2014, Tennessee ranked 45th and Virginia ranked 21st out of 50 states for overall health outcomes. Both states had high rates of adult obesity, cancer deaths, infant mortality, and diabetes. Though Virginia’s overall ranking is moderately low, the health outcomes in Southwest Virginia counties, where MSHA’s facilities are located, resembles those of Tennessee. After compiling the various sources of information, the top health priorities were identified for the communities that each of the MSHA hospitals serve. This effort has determined the top health priorities identified in Washington County, TN to include substance and prescription drug abuse, smoking, obesity/diabetes/physical activity and cardiovascular disease. There are certainly a number of other health challenges in this community, but these rise to the top based on this assessment. MSHA - Mountain States Health Alliance

Behavioral Health:Eastern Tennessee- Behavioral Health is a branch of interdisciplinary health which focuses on the

reciprocal relationship between the holistic view of human behavior and the well-being of the body as a whole entity. Behavioral Health are issues that can have a different outcome by changing "behavior".

- For example, giving up smoking can lessen the health problems or illnesses associated with cigarettes such as COPD and emphysema.

- Poor Mental Health is 33% compared to the national average of 34.9%. Reporting but not receiving treatment for Alcohol Abuse is 5.6% compared to the national average of 6.6%. These are just some examples how how the demographics can help exacerbate conditions that can be treated with professional guidance.

Behavioral Health: Problems and SolutionsChild and Youth Indicators

1. Nonmedical Use of Prescription Drug ( 20%)

Adult Indicators

1. Any Mental Illness in person 26+ yo ( 20%)2. Any Mental Illness in person 18+ yo ( 22%)3. Suicide Deaths (All ages) ( 15%)4. Primary Opioids Prescription (23%)5. Pregnant Women Opioid Prescriptions (35%)6. Alcohol Abuse in person 18+ yo ( 34%)

Solution:

Network with other community agencies to increase internal awareness of services already available in the community and to develop a community based action plan as appropriate. Focus on community based Adult and Youth education. Introduce mHealth based interventions that do not require constant wi-fi signals.

Primary Care: Eastern Tennessee-Primary care is that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the "undifferentiated" patient) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis.

- This also includes Women’s Health, Internal Health, Pediatrics and Geriatrics.

- According to a survey done by Avalere health, Nearly 1 in 5 Tennesseans live without adequate access to healthcare. Adding to that the top health issues being faced such as Health care-associated infections,Heart disease and stroke,HIV, Motor vehicle injury, Nutrition, physical activity and obesity, Prescription drug overdose,teen pregnancy and Tobacco use.

Primary Care: Problems and SolutionsMost Requested Additional Services

by Residents:

1. Cardiology

2. Urgent Care Clinic – Adult and Pediatric- preferable with reduced or free services

3. Oncology

4. Mental Health Services

5. 24 Hour-Pharmacy 6. More oncology services so patients

who are very sick do not have to travel out of the county for treatment.

Solution:

Increase awareness of the availability of specialty providers already practicing within counties of Eastern Tennessee. Continue to provide high quality care in an efficient manner to all patients who present to the ED regardless of the level of complaint or ability to pay. Sponsor community based fitness projects. This may also include introducing telehealth solutions that allow for monthly check ins via skype or other HIPAA approved interfaces. Focusing on collaboration between Primary care and Mental Health resources to make patients feel at ease.

Why integrate Primary and Behavioral Health?

- Physical, Mental and Social challenges are interrelated for today’s patients.

- In the intervening years, evidence has continued to mount that having two, mostly independent systems of care leads to worse health outcomes and higher total spending, particularly for patients with comorbid physical and behavioral health conditions ranging from depression and anxiety, which often accompany physical health conditions, to substance abuse and more serious and persistent mental illnesses.

- In spite of this, behavioral healthcare is mostly separated from the primary care system—a practice that the Institute of Medicine concluded nearly 20 years ago was leading to inferior care.

Problems with Integration1.Different Operating Systems

2.Different OS Versions

3.Different Browsers

4.Different Java Requirements

5.Time Inefficiencies

6.Provider Unawareness of newest clinical info

7.Increase provider frustration

8.Creation of shortcuts leads to data breaches

Different Operating Systems + Different OS Versions

Differing operating systems restricts hardware use and the use of medical devices that may have the potential to improve productivity.

-During moments of crisis or emergency it is hazardous to have a systems that are not adequately integrated.

Challenges: billing friendly EHR, data migration, and training

-One example of differing OS versions is recent technology versus older or outdated technology.

-Differing versions affect many necessary and useful functions

Time Inefficiencies + Different Java Requirements

-While two systems are integrated it often becomes more difficult to locate data than it would have if the systems stood alone.

The difficulty of finding specific information among the combined integration and the vastness of lines of data.

-Data that is expanding faster than it can be monitored and maintained.

-Problems with conflicting JREs and JDKs if the version stamps are outside of each other’s range

-incorrect cross compilation when methods are being translated into byte code

-May result in a runtime error

Differing Browser Versions + Unawareness of Newest Clinical Info

Web based applications are totally different from windows applications. A web application can be opened in any browser by the end user.

The integrated system can provide care providers with its ability to compile and filter through patient info and recommend treatment options.

-Clinical Decision Support

Lack of awareness concerning changes to clinical info decreases patient confidence in the care that is being provided to them.

Provider Frustration + Creation of ShortcutsAll of these factors and others combined cause provider frustration, issues with integration waste time, waste provider time, make the provider inefficient, and can affect patient interactions and health outcomes.

Users create shortcuts that put data at risk. Such as writing passwords on paper, writing information that is in the OS on paper, taking notes on paper rather than in secure location or documentation application in a computer, leaving files, profiles, or browsers open.

Our SolutionImplement the protocol within the Four Quadrant Clinical Integration

Model

Execute a Primary Care Behavioral Health Integration Model

Enact a Vendor Neutral Archive System

Achieve HL7 Status

Follow a Digital Imaging Adoption Model, perform training and a needs assessment

To address the issues in Tennessee currently in Primary Care and Behavioral Care, we used The Four Quadrant Clinical Integration Model:

● The Four Quadrant Clinical Model was developed by the National Council for Community Behavioral Healthcare.

● Model is representative of clinical service delivery based on the assessment of behavioral health and physical health risk

● Eastern Tennessee has high BH and PH risk/status, so we choose a fully integrated Mental Health/Substance Abuse Program to address set Behavioral and Primary Health issues.

Primary Care Behavioral Health Integration Model

A Primary Care Behavioral Health Model includes:

Warm Handoffs

“Curbside” Consultations

Service Delivery - patient interaction, case management, decrease number of no shows and increase skill coaching

A close collaboration in a fully integrated system - the primary care provider and behavioral care provider are apart of the same team.

Vendor Neutral Archive SystemA Vendor Neutral Archive System is technology used by healthcare

professionals that stores data in standard format and interface which makes the data accessible through different communication systems.

VNA uses neutrality to resolve workflow challenges, adheres to open standards which allows a VNA to manage large volumes of information.

VNA handles the data at a fast speed and you can set the importance of data

In short, A VNA can bring behavioral health and primary care information into one central database.

HL7 StatusHL7 Status also known as Health Level Seven International is a set of standards and definitions in order to exchange and develop electronic health records. We are making sure that after integration of two different systems, that these standards are met.

Some of the main standards are:

HL7 Version 2, query language that enables health providers to send messages about health data

Clinical Document Architecture that allows exchange of clinical documents such as discharge summaries and progress notes

Fast Health Interoperability Resources - Exchange language that allows interoperable healthcare applications faster and easier to write

Digital Imaging Adoption Model (DIAM)In a report done in 2015, 80% of

physicians use an EHR, the average engagement time is 3.3 hours a day.

HIMSS and the European Society of Radiology revealed this eight stage model in order to improve healthcare and patient outcomes.

The eight stages have compliance goals and you can specialize in different focus areas

The model helps take a viewer first approach instead of a data first approach.

Purpose of DIAMLeadership and guidance

Identify infrastructure or workflow gaps

Monitor technological process overtime

Create a roadmap for future investments

Learn from peers by sharing best practices

Push market via digital strategy in order to improve health outcomes.

Training + Needs AssessmentTraining is crucial in order make sure the workforce can meet the demands and specification of the newly integrated system. Training is crucial to prevent provider frustration and to keep key stakeholders up to date in current processes.

An example of a training program that we will look to follow comes from the National Naval Medical Center in Maryland for training their interns:

Start an integrated service

Manage acute assessments and interventions

Population Health Intervention

Use the train the trainer approach

Having employees do a forced needs assessment will allow the company to identify additional needs of training/education needed for their employees

ConclusionDeslaurier Associates recognizes the need for integrating behavioral health and primary health services together. Individually, we recognize the problems of the community in regards to primary care and behavioral health care. Our solution creates a vendor neutral archive system which causes both care units to work in a fully integrated system; it eliminates the technical issues that typically arise with integration. With consistent monitoring, training and key involvement of stakeholders, we believe the integration process can be an easy one and beneficial.

Referenceshttp://ruralhealthlink.org/News/FeaturedArticles/TabId/94/ArtMID/778/ArticleID/51/The-Integration-of-Behavioral-Health-and-Primary-Care-Services.aspx

http://www.sweetwaterhospital.org/CHNA.pdf

http://searchhealthit.techtarget.com/definition/Vendor-neutral-archive-VNA

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3698882/

https://www.tn.gov/health/topic/hipaa

http://www.milbank.org/wp-content/uploads/2016/04/EvolvingCare.pdf

http://www.auntminnie.com/index.aspx?sec=eba&sub=eml&pag=dis&ItemID=114401

Implementing a clinical information management strategy. James Gatson, July 12, 2016

The Digital Divide in the post-EHR Adoption Era, Scott Hessen

http://www.cdc.gov/brfss/