Transcript Patient Centered Medical Homes Model: The Role for SBHCs

Assessing the Primary Care
Practice to Enhance Integration
May 16, 2012
Rebecca Morin, Maine Primary Care Association
& Guests from Harrington Family Health Center
Today’s Objective
Illustrate ways to use self-administered assessment tools to
identify areas to advance integrated care, including the use of
cross-functional teams and care coordination.
MPCA
Harrington
Family Health
Center
Conclusion/QA
Maine Primary Care Association
(MPCA)

MPCA works with Maine’s Federally Qualified Health
Centers (FQHCs), also known as Community Health
Centers (CHCs)

They are:



Community-run non-profit primary care practices
In areas designated to be Medically Underserved Areas or
serving a Medically Underserved Population (HRSA)
Seek to improve quality and access to care for all
members of their communities
18 Members
-80% have co-located Behavioral
Health/Substance Abuse
Treatment Services
-Screening for depression is most
common
-Nationally, 90% of FQHCs
routinely screen for depression
and 65% for substance abuse.
Support to Adopt/Enhance/Sustain BHI
Summer
2011
• Initial BHI
SSA
• F2F Training
based upon
responses
Fall
2012
Fall –
Winter
2011
• BH Speed
Dating
• U Mass
PCBH
Course +
________
• U Mass
PCBH
Course
• BHI Summit
Winter
2012/13
Spring
2012
• BHI SSA
Mid-Course
Feedback
Report
• Medical
Leadership
engagement
• BHI
Summit 3
• BHI
Dashboard
The Players in FQHC Integration
Specialty
MH
MA
Psychiatry
PATIENT
RN
PCP
BH/MHC
Our Approach
Integration Concepts/Framework (5 Levels)
 Improvement Roadmap (BHI SSA)
 Improvement Strategies
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Staffing ratio
Types of referrals
Communication
Documentation
Space
Support to Adopt/Enhance/Sustain
Integration
5 Levels of Collaboration
Guiding the Work
The BHI Site Self Assessment (SSA)
Adapted from the PCRS – Developed by the Robert Wood Johnson Foundation Diabetes Initiative,
www.diabetesintiative.org; also adapted from the ACIC survey developed by the MacColl Institute for
Healthcare Innovation, Group Health Cooperative. ADAPTED FROM MeHAF.
Using the 1-10 scale in each row, circle (or mark in a color or bold, if completing electronically) one
numeric rating for each of the 18 characteristics. If you are unsure or do not know, please give your best
guess, and indicate to the side any comments or feedback you would like to give regarding that item.
NOTE: There are no right or wrong answers.
BHI SSA Continued
I.
Integrated Services & Patient/ FamilyCenteredness
9 Characteristics with descriptions across the 5
levels
1. Co-location…..
2. Emotional/behavioral health needs
3. Treatment plans….
4. Patient care informed by best
practice….
5. Patient/Family involvement….
6. Communication with patients…..
7. Follow up….
8. Social support….
9. Linking to community resources…
II.
Practice/Organization
9 Characteristics with descriptions across the 5
levels
1. Organizational leadership…..
2. Patient care team…
3. Provider engagement…..
4. Continuity of care….
5. Coordination of
referrals/specialists….
6. Data systems/ patient records…
7. Patient/Family input….
8. Education/Training….
9. Funding & resources….
Feedback Loop
Feedback Report Example
Characteristic 8: Physician, team and staff education and training for integrated care ….. . . is
provided for some (e.g. pilot) team members using established and standardized materials,
protocols or curricula; includes behavioral change methods such as modeling and practice for role
changes; training monitored for staff participation (self score of 2 out of 10).
Has your CHC……
•Located and connected PCPs with training in
Short-term interventions
Problem-focused Treatment
Motivational Interviewing
SBIRT
PTSD & Trauma Interventions
•Developed and implemented a strategy for sharing models & methods learned to enhance internal
expertise?
If a provider participates in a training – are they given the opportunity/time to act as an ambassador &
share this information across the practice?
•Researched and identified professional development opportunities for integrated care?
MPCA offers the U Mass Primary Care Behavioral Health Certificate course each Fall
Virtual offerings including webinars, additional research request etc.
•Set aside short periods of time for cross disciplinary participation in education and training?
Archived webinars with facilitated discussion
Case studies during lunch breaks one time per month
Works Cited for Feedback Report
•Blount, Alexander. “Integrated Primary Care: Organizing the Evidence”, Families, Systems & Health: 21,
121-134, 2003 found at http://www.apa.org/journals/fsh.html
•Bertakis, Klea, and Azari, R. “Patient-Centered Care is Associated with Decreased Health Care
Utilization” Journal of the American Board of Family Medicine (May-June 2011) Vol. 24 No. 3 found at
http://www.jabfm.org/content/24/3/229.full?sid=53483dda-1bd4-4e14-be93-c9189de2ec8a
•Lardiere, Michael, Jones, E., Perez, M., “2010 Assessment of Behavioral Health Services Provided in
Federally Qualified Health Centers” (January 2011), National Association of Community Health Centers
found at
http://www.nachc.com/client/NACHC%202010%20Assessment%20of%20Behavioral%20Health%20
Services%20in%20FQHCs_1_14_11_FINAL.pdf
•Miller, B., Kessler, R., Peek C.J., Kallenberg, G., “Establishing the Research Agenda for Collaborative Care”
found at http://www.ahrq.gov/research/collaborativecare/ *content specific to BHI SSA feedback
found in Practice and Performance Characteristics summaries.
•“Paying for the Medical Home – Part 2: Social, Behavioral, and Environmental Factors
in Payment Models” from the Safety Net Medical Home Initiative found at
http://pdfsbox.com/pdf/safety-net-issue-2.html
PCMH (+BHI) Transformation
Guided by the 8 Change Concepts of the Safety Net Medical Home Initiative (all 8 align
with the 10 Core Expectations of Maine’s Patient Centered Medical Home Pilot.)
Continuous and Team-Based Healing Relationships
Patient-Centered Interactions
Engaged Leadership
Enhanced Access
Care Coordination
Organized, Evidence-Based Care
The NCQA 2011 PCMH Standards is our chosen quality improvement strategy
PCMH Standard 1: Enhance Access & Continuity
PCMH Standard 2: ID & Manage Patient Populations (Element C, Factor 6)
PCMH Standard 3: Plan & Manage Care (Element A, Factor 3)
Leverage to Achieve Integrated Care
Patient Centered
Medical Home
(PCMH)
Accountable Care
Organization
(ACO)
Depression, Diabetes
and
CVD Collaboratives
Tobacco Assessment &
Cessation Support
Bill Wypyski, CEO
Connie VanDam, Mental Health Care Coordinator / Tobacco Cessation Counselor
Chris Skehan, QI/Risk Manager
HFHC -Who We Are
Mission:
Create a healthier community by
engaging each patient in making health
care decisions that reflect the highest
standards of care in conjunction with the
needs and desires of the patient and
his/her family, and by making this care
affordable based on patient’s ability to
pay.
Service Area : Columbia, Columbia
Falls, Addison, Milbridge, Steuben,
Harrington and Cherryfield.
Services:
~Complete Family Medical Care
for All Ages which also includes:
-Laboratory Services
-Prescription Assistance
-Tobacco Cessation
-Nutrition Counseling
-Maine Breast and Cervical Program
-Sports and DOT
Physicals
~Mental Health and Substance
Abuse Counseling
~Dental Services
~Podiatry
Our Journey
Towards Integration
 Self-Assessment
 Education
 Breaking Down Provider Barriers and Bias
 Pilot Program-Placing a Mental Health Clinician ½
day/week in primary care wing
 Emphasize already established tobacco cessation
program
 Hire new clinicians with integrated care model in mind.
Harrington BHI SSA
Component I: Integrated Services & Patient/Family Centeredness
Medical
Care
Manager
+
MH Care
Coordinator
=
Pt/Fmly
Centered
Solutions
Harrington BHI SSA
Component II: Practice/ Organization
Cohesive Pt
Care Team
Medical Providers
Engaged in
Integrated Care
BH/MH Clinician with
Integrated Care Experience
Improvement Strategies at the Practice Level

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BH/MH to Medical Staffing Ratio: 4 (includes 1 Tobacco Specialist) to 6
Types of referrals to BH/MH
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Communication

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Tobacco Cessation
Grief Counseling
ADHD
Substance Abuse
Depression
Trauma (Immediate & Long Term)
Anxiety
Situational Stress
Child Behavioral Issues
Couple/Family Issues
BH/MH have access to Medical Record but Medical staff do not have access to BH/MH
Records
Referrals: EMR using secure email to MH Coordinator, warm hand-offs, pt self-referrals
(phone or walk-ins), referral from non-HFHC providers.
Documentation
Space – BH/MH housed on 2nd floor  Future Plans for Brief Interventions
Behavioral / Mental Health
Warm Hand-Offs for the Referral Process
Process: Warm hand- off from PC Clinician to MH Coordinator to begin and complete a
Behavioral Health Referral either in house or to a Behavioral/Mental Health Specialist
outside of health center i.e. psychiatric.
Patient Need
Identified via
Medical Staff
MH Coordinator
Contacted
Patient Need
Assessed
Pt in CRISIS?
NO
Patient scheduled
to be seen w/in 23 days
YES
Pt seen by MH
Clinician and (if
needed) Crisis
services. MH
Coordinator/Nursing
staff attend to pt.
Tobacco Cessation Support &
“Different Shades” of Warm Hand-Offs
Plan-Do-Study-Act (PDSA) Cycle
Define the problem: Need for data to support the theory and
anecdotal evidence that patients referred for tobacco
cessation counseling are more engaged in their plans to
become tobacco free if the referral occurs as a “warm handoff” versus a “dry” referral (referral initiated via EHR with
no direct initial contact between counselor and patient.)
PDSA Continued
The Change:
Increase the # of referred patients who are engaged in their care, thereby increasing
their likelihood to keep appointments for counseling, and potentially increasing their
ability to “quit”.
Plan
(Data)
What are we testing?
On whom are we testing the change?
What do you expect to happen?
(Prediction):
What data do we need to collect?
Who will collect the data?
When will the data be collected?
Where will the data be collected?
Study
Act
What was actually tested?
What happened?
Observations/Problems:
Complete analysis of data,
summarize what was learned,
compare to prediction:
DO
What changes should we make
before the next cycle?
PDSA Snapshot
Plan
(Data)
10 pts who are referred by
other HFHC providers to
the HFHC Tobacco
Cessation Counselor as of
11/01/12
5 pts. w/ a referral for
counseling through EHR
referral system 
counselor,
5 with an introduction to
tobacco cessation
counselor via a “warm
hand-off.”
We predict pts w/ a “warm
hand-off” will keep more
appts for tobacco
cessation counseling thus
increasing the possibility
of ceasing tobacco use.
DO!
Study
Act
List of pts referred for
tobacco cessation
counseling beginning
11/01/12 (first 5 with a
regular referral and first 5
with “warm hand-off”;
appt dates for initial
sessions, follow-up
sessions, and notation of
“show” or “no-show”
We actually tested
Tobacco Cessation
Counselor to present these
PDSA findings at provider
staff meeting to encourage
greater number of “warm
hand-offs.”
Data collected from appt
schedule for Tobacco
Counselor over the length
of time required to
generate 5 of each type of
referral & to track f/u
beginning 11/01/12
Warm hand-offs increased
the # of pts who kept
initial and f/u appts for
counseling and increased
the “quit” rate.
-no-show rates for appts
for counseling for tobacco
cessation
-quit rates of pts who
received a “warm handoff” from the referring
provider to the Tobacco
Cessation Counselor
vs.
-no-show/quit rates of pts
who were scheduled for
counseling based on an email referral from the
referring provider to the
counselor.
In Conclusion
Warm hand-offs help reiterate medical home
“team” concept (Patient, Provider, Counselor)
Our data helped “make the case” for moving
towards more integrated care
We were able to identifying solutions to services
(BH/Medical) being in different spaces
Thank You
Questions & Answers
Contact Information:
Rebecca Morin – MPCA – [email protected]
Bill Wypyski – Harrington Family Health Center –
[email protected]