Transcript Family Healthcare,Inc

Jane Hamel-Lambert, MBA, PhD
Karen Montgomery-Reagan, DO, FAAP, FACOP
Sherry Shamblin, PCC-S
Dawn Murray, DO
March 20, 2009
Overview
IPAC: A Rural Health Network
 Integration Efforts

 Developmental Screening and Surveillance
 Co-Locating Mental Health in Primary Care

Co-Location Interagency Partnerships
 University Medical Associates, Inc
 Tri-County Mental Health & Counseling Services
 Family Healthcare, Inc.
Introductions
Jane Hamel-Lambert, MBA, PhD
 President, IPAC; Department of Family Medicine,
Ohio University’s College of Osteopathic Medicine
 Karen Montgomery-Reagan, DO, FAAP, FACOP
 Chair, Pediatrics, Ohio University College of
Osteopathic Medicine; University Medical
Associates, Inc.
 Sherry Shamblin, PCC-S
 Early Childhood Mental Health Consultant, Clinical
Supervisor, Tri-County Mental Health & Counseling
Services, Inc.
 Dawn Murray, DO
 Medical Director, Family Healthcare, Inc.

Integrating Professionals for
Appalachian Children
IPAC: A Rural Health Network

Interdisciplinary collaboration hinges on
interagency cooperation
MHPSA.
 Retention/recruitment


Thank you to Office of Rural Health Policy
(P10 RH06775, D06RH07920)
Integration Goals

Adoption of routine developmental surveillance
 Improves early identification
 Alternative to “wait and see”

Co-location of Mental Health Providers
 Improves access
 Improves quality through care coordination
Improves patient outcomes
 Developing common language

AAP guideline

Developmental Surveillance and
Screening Algorithm
 9, 18, 30 months give screening tool
 If at risk, refer for further evaluation

http://www.medicalhomeinfo.org/Screeni
ng/DPIP%20Follow%20Up.html
Adoption of the Ages and Stages
Questionnaires
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ASQ &
ASQ:SE
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Childcare programs
Primary care settings
Shift away from clinical impressions
(watch and listen) to using formal parentcompleted, normed screening tool.
 Reassurance and Risk
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SCREENS
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ASQ Screens 5 Domains
•
•
•
•
•
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Communication
Gross Motor
Fine Motor
Problem solving
Personal-social
ASQ:SE
• Social-Emotional development
Why ASQ Tools?
 CHEAP!
 ASQ – 3 (May 2009) … $249 and
ASQ:SE… $149.00
 Low
cost alternative—annual cost
of $25-50 for following children
 Permission
granted to photocopy
Quick and Easy
Utility Parent satisfaction survey
(N=731) (publisher data)
• How long did it take to complete the
questionnaire?
 70% Less than 10 minutes
 28% 10-20 minutes
 2%
More than 20 minutes
• It was easy to understand the questions?
 97% Easy
 3% Sometimes
 0% Not easy
Accurate: ASQ

Normative sample of over 8000
questionnaires, high reliability (> 90%),
internal consistency, sensitivity, and
specificity

See www.brookespublishing.com for
ASQ User’s Guide Technical Report for
complete psychometric data.
Parent Report: ASQ Research

As accurate as formal measures for
identifying cognitive delay (Glascoe, 1989,
1990; Pulsifer, 1994)

As accurate as formal measures for
identifying language delay (Tomblin, 1987)

As accurate as formal measures for
identifying symptoms of ADHD and school
related problems (Mulhern, 1994)

More accurate than Denver for predicting
school-age learning problems (Diamond,
1987)
Physicians trust it
Catches kid earlier than she may have
 Opens up conversations with parents
regarding observations
 Monitoring

Billable
 Generate Revenue

Billing

CPT Code: 96110 (limited evaluation)

E/M Modifier – 25: Significant Separately
Identifiable Evaluation and Management
Service by the Same Physician or the Same
Day of the Procedure or Other Service
 Document administration, interpretation (normal,
abnormal, parent discussion and referral/action)

Medicaid Relative Value (staff admin) =
$13.64 (2005)
Generalizability

Depression for adults: PHQ -9
 Patient Health Questionnaires
Improves identification
 Tool for communication

Co-location of Mental Health
Providers in Primary Care
UMA is a multispecialty group dedicated to serving southeastern
Ohio. Affiliated with Ohio University College of Osteopathic Medicine
Karen Montgomery-Reagan, DO, FACOP, FAAP
Motivation for Co-Location Program


Practice Group has a need for mental health
services
Difficulty with referrals; seems like a black hole..
 Making appointment calls
 CMHC required in person to schedule appointment

Families need access to service
 Waiting for appointments

Communication
 Did they go, what was the dx, were they discharged from
care?
 What was the Primary Doc role?
Family Benefits
Clients familiar with surroundings and
comfortable with office staff/patients
 Ease of scheduling for patient and
physicians

 Referral sheet to reception
 Families provided intake paperwork
 Appointment scheduled right then and there

Parents/patients more willing to try mental
health services provided at our office
Family Quotes

Patient: I’ve tried counseling before
 I have individuals that will fit your personality…
(choice)
 I will speak with the provider individually
 If it doesn’t work, I have other avenues
Patient: If you think this person will help, I will
give it a try…
 Patient: How soon? It always take so long to
get it

Physician Benefits
Physicians find mental health a benefit for their patients
 Physician have direct contact with provider
 Curbside consults, guides diagnostics, treatment
planning
 Communication easy on site, no phone message
 Don’t wait until it’s a disaster---crisis
 Appointment info is charted
 I know if they are going and continuing care
 Physicians are able to directly discuss cases with
the mental health professional on site

Infrastructure
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Scheduling
 On site facilitates follow through
 Sooner access is easier to negotiate
Office Space
 Location matters
 Shape, size and absence of medical gear
Private practitioner vs CMH clinicians
MH Practitioner Billing
 Providers are doing their own billing
Record Keeping
 Doc charts have mental health progress note
Real Numbers

Three Providers
 2 ½ days of service combined

Numbers of Families
 78 families have been provided service

Numbers of Visits
 Over 250 appointments (Jan08/May08)

No Show rates
 Medicaid (approx 29%) NS rate > than
privately insured NS rate (approx 10 – 12%)
TCMH-CS is a licensed Community Mental Health
Center serving four counties in southeastern Ohio
Recovery Model
Focuses on resiliency while reducing
symptoms
 All people have strengths to overcome
challenges
 Individuals are the experts in their
experiences so have the voice and
choice in services
 Values unconditional acceptance of the
individual

Implications of Differences in
Practice Models
Professional Culture
 Patient/Client
 Implications for Assessment/ Diagnosis
 Organizational Structure
 Physical Office Space
 Communication

Practitioner Work Style

Consultation

Collaboration
 Info goes back and
 Fuse ideas
forth
 Physician manages
case
 Mental health
 Jointly develop
treatment plan
 “our” patient
 Time to develop
 Has time efficiencies
relationship
 Build in
communication
strategies
Billing and Paperwork Procedures

Medicaid/Insurance
 Medicaid match
 Reimbursement by insurer, by who is
delivering services
 Electing to serve
Modifying structure of intake paperwork
and documentation
 Difficult to merge systems even when there
is duplication because of ODMH
requirements

Evaluate Your Practice Needs
Age
 Family Care versus Pediatric Practice
 Payee source
 Mental Health Needs

Laying a Good Foundation
Choose the right mental health partner
for your practice
 Build a working relationship
 Build time for communication/interaction
 Be prepared to develop joint vision and
goals for the partnership

Behavioral Health Integration …a work in progress
Dawn Murray, DO
MISSION of FHI
(Family Healthcare, Inc.)
The Mission of Family Healthcare, Inc. is to
provide access to high quality, affordable,
healthcare to everyone without discrimination.
 All Community Health Centers have a similar
mission.

Family Healthcare, Inc
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FQHC (federally Qualified Health Center)
Six sites in six counties in Southeastern Ohio
Behavioral health considered a core service,
provided on site or through referral agreement
Investigated many models of behavioral
health/primary care integration.
IPAC (Integrating Professionals for
Appalachian Children) involvement was
springboard for our current journey.
FQHC
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Federally Qualified Health Centers AKA
Community Health Centers
Receive 330 grant from federal government which
provides for uninsured care. (For FHI, this is about
20% of budget)
Sliding fee scale based on income
Accept most insurances including medicaid (and
Medicaid HMO’s), medicare.
Enhanced reimbursement through medicaid and
medicare.
Considered safety net providers
FTCA malpractice coverage
Different funding stream than Community Mental
Health centers
Behavioral Health/Primary care
Integration models in FQHC’s
Referral Agreements with Private Psychiatrists or
Community Mental Health Centers (no integration)
 Complete in house Mental Health program with
psychologists, social workers, and psychiatrists as
FQHC employees.
 In house Behavioral Health Program with Clinical
psychologists, LISW’s, counselors under
supervision of PCP’s
 FQHC contracting with Community Mental Health
Agency for mental health personnel
 All possible combinations of these.

IPAC-Colocated Providers
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Involvement in IPAC allowed more
collaboration between agencies for ideas to
develop.
We started with the original plan of a Tri
County counselor in one of our sites.
Quickly saw limitations of this arrangement:
Only available for kids. Not as many kids
as predicted. Bigger need for adult
services. Better if billing is through FQHC
due to another funding stream.
Began contract with Tri County, but still
kept IPAC involvement
Behavioral Health/Primary Care
model
LISW can triage for PCP’s which increases
everyone’s efficiency
 LISW will keep people for counseling at FQHC
and work with PCP to address goals to enhance
medical outcomes.
 If patient is outside of PCP scope for mental health
issues, LISW can start intake paper work, make
psychiatric referral and expedite patient care. She
can continue counseling at FQHC with support
from PCP. This is very important given the long
wait times we sometimes have for psychiatrists,
especially in rural areas. We can keep people from
falling through the cracks.

Concerns
Competition for patients/clients
 Supervision
 Reimbursement
 Integration

Win-Win

At a time when Mental Health funding is
being cut, it is good to have other
revenue streams. By contracting for
services of the LISW, she actually
increased her productivity at the Mental
Health Center. FHI is breaking even on
the deal, and getting excellent services
for our patients.
Next Steps
We are working on streamlining our
communication between the PCP and the
LISW.
 Developing a protocol and system to triage
more urgent psyche referrals into the
Mental Health Center.
 We are planning to spread to our other
sites.
 Continuously communicating between
Community Mental Health center, and
providers to foster trust, and better
integrate our cultures for improved access
to quality healthcare for all patients.
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CoLocation toward Integration
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Shift referring “my clients” to jointly taking care of
families
Co-Learning
 Understanding diagnostic paradigms
 Understanding professional biases
 MH builds medical knowledge; Doc gains mental
health knowledge
Communication Goals
 Shared language
 Participation in routine meetings
 Access to medical charts
Lessons Learned

Health delivery system dichotomizes MH and
Health
 Carve out billings
 Different govt oversight agencies (ODH, ODMH);
Mission and mandates
 Diagnostic tools are different
 Philosophies of care
Communication nourishes partnerships
 Tensions teach
 Build the relationships

Contact Information
Jane Hamel-Lambert
 [email protected]
Karen Montgomery-Reagan
 [email protected]
Sherry Shamblin
 [email protected]
Dawn Murray
 [email protected]