Can a Family-Centered Workflow Work for Flow? How to Enhance Show Rate (Flow) for Behavioral Health Visits in Pediatric Primary Care

Andrew Cohen, PhDCoordinator, Integrated Pediatric Primary Care

Patricia Corbett-Dick, RN MS, PNP-BC, PMH NP-BCPediatric Primary Care and Psych-Mental Health Nurse Practitioner

Linda Alpert-Gillis, PhDDirector, Pediatric Behavioral Health & Wellness Outpatient Services

University of Rochester Medical Center

Session # I2a

CFHA 20th Annual ConferenceOctober 18-20, 2018 • Rochester, New York

Faculty Disclosure

The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

Conference ResourcesSlides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2018

Slides and handouts are also available on the mobile app.

Learning ObjectivesAt the conclusion of this session, the participant will be able to:

• Identify factors that may impact attendance to behavioral health appointments within the integrated pediatric primary care setting.

• Describe how patient satisfaction scores and patient / family completion of the satisfaction items may enhance show rate to behavioral health appointments within integrated pediatric primary care.

• Discuss how team-based workflow enhancements can serve as family engagement interventions to increase behavioral health appointment show rate and sustainability of behavioral health integration within pediatric primary care.

1. Asarnow, J., Kolko, D., Miranda, J., Kazak, A. (2017). The pediatric patient-centered medical home: innovative models for improving behavioral health. American Psychologist, 72, 13–27.

2. Brown, G. S. ( J.), Simon, A., Cameron, J., & Minami, T. (2015). A collaborative outcome resource network (ACORN): Tools for increasing the value of psychotherapy. Psychotherapy, 52, 412-421.

3. Carman, K., Dardess, P., Maurer, M., Sofaer, S., Adams, K., Bechtel, C. & Sweeney, J. (2013). Patient and family engagement: a framework for understanding the elements and developing interventions and policies. Health Affairs, 32, 223-231.

4. Dantas, L., Fleck, J. Fernando, J, Cyrino Oliveira, F., & Hamacher, S. (2018). No-shows in appointment scheduling –a systematic literature review. Health Policy: 122, 412-421.

5. Higgins, T., Larson, E., & Schnall, R. (2017). Unraveling the meaning of patient engagement: a concept analysis. Patient Education and Counseling, 100, 30-36.

6. Lidia, B., Vegna, E. & Galli, F. (2016). The patient-centered medicine as the theoretical framework for patient engagement. In Promoting patient engagement and participation for effective healthcare reform (pp. 25-29). Hershey, PA: IGI Global

7. McAllister, J., Cooley, W., Van Cleave, J, Boudreau, A., & Kuhlthau,K. (2013). Medical home transformation in pediatric primary care--what drives change? Annals of Family Medicine, 11, S90-8.

8. Molfenter, T. (2013). Reducing no shows: going from theory to practice. Substance Abuse and Misuse, 48, 743-749.9. Samuels, R., Ward, V., Melvin, P., Macht-Greenberg, M., Wenren, L., M., Yi, J., Massey, G., & Cox, J. (2015). Missed

appointments: factors contributing to high no-show rates in an urban pediatrics. Clinical Pediatrics, 54, 976-82.

Bibliography / Reference

Learning Assessment

A learning assessment is required for CE credit.

A question and answer period will be conducted at the end of this presentation.

Overview

The need for strategies to improve show rate for Behavioral Health in pediatric primary care

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UR Medicine: Pediatric Practice at GCHPatient Centered Medical Home (PCMH):

• A patient-centered, coordinated, comprehensive, team-based, accessible, high-quality, and safety-driven medical home for the patient

• Care delivery at the right place, right time, right manner to suit the patient / family needs

Level III PCMH x 8 years:• Level III: highest level PCMH (strongest performance or significant improvement on above measures)• Safety net practice: a practice that organizes and delivers care and services to vulnerable populations

Patient/Family Characteristics:• 13,000 patients (0-21 years)• 85% Medicaid• 30% food insecurity• Race: 80% African American, 10% Caucasian, 10% other• Ethnicity: 90% Non-Hispanic, 10% Hispanic

8www.AHRQ.com; www.PCPCC.com

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UR Medicine: Pediatric Practice at GCHCurrent integrated Behavioral Health team:

• Psychologists, staff clinicians, NP, child psychiatrists, trainees

History of Behavioral Health in General Pediatrics:

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Timeframe(Dec thru Apr)

Time 1 (2016/2017)

Time 2 (2017/2018)

Model of Care Co-located IntegratedClinical FTE 2.7 4.6 (1.7x)Volume / visits 774 1394 (1.8x)

UR Medicine: Pediatric Practice at GCHCurrent integrated Behavioral Health team:

• Psychologists, staff clinicians, NP, child psychiatrists, trainees

History of Behavioral Health in General Pediatrics:

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Timeframe(Dec thru Apr)

Time 1 (2016/2017)

Time 2 (2017/2018)

Model of Care Co-located IntegratedClinical FTE 2.7 4.6 (1.7x)Volume / visits 774 1394 (1.8x)

Missed Appts: “Can’t Treat the Empty Chair”• Common, longstanding issue for health care

• Decades of study, few clear solutions

• Complex interplay of multiple factors

• Difficult to consistently define, measure, and compare missed appointment data

• Costly for patients, providers, health care system

Molfenter et al., 2013; Samuels et al., 2015

Missed Appts: “Can’t Treat the Empty Chair”Wide variation reported for non-pediatric rates in literature

Overall• Range 5-55% -- US, primary care studies (2015)• Most investigated -- Psychiatry and primary care (2017)

Rate• 23% -- International, systemic review, all ages, all specialties (2017) • 30% -- General medical practice (2013)• 33% -- Substance abuse (2013)• 37% -- Mental health, first appointment (2013)

Dante et al., 2017; Molfenter et al., 2013; Samuels et al., 2015

Missed Appts: “Can’t Treat the Empty Chair”

www.solutionreach.com; Samuels et al., 2015

Setting Missed Appt Type Missed Appt Rate Practice DescriptionUS, national average Primary + Specialty 30% Aggregate Boston Children’s HospPediatric Primary Care

Primary care overall 20% 13,000 patientsUrban Academic Diverse 67% Public insurance

UR Medicine:Pediatric Practice at GCH

Primary care overall(well, Illness, follow up)

33-40% 13,000 patientsUrban Academic Diverse 85% Public insurance

UR Medicine: Pediatric Practice at GCH

Missed appointment data:• Missed appointment = appointment not kept • Missed appointment = does not include cancelled appointments

Missed appointment by type Missed appointment rateAll medical – well child, illness, follow-up (does not include BH) 33-40%

Well baby / well child 30% / 40%

Illness 10%

Follow-up 50%

Behavioral Health 34%

Missed Appts: “Can’t Treat the Empty Chair”

Missed Appts: “Can’t Treat the Empty Chair”Primary patient-reported reasons for missed appts *

• Forgot -- 27%• Transportation problems -- 21%• Time off work -- 14%

Primary factors predicting missed appts **

• Longer lead time• Prior no-show history

16* Samuels et al., 2015; ** Dante et al., 2017

Patient characteristics and missed appts **

• Public or no insurance• Lower SES• Younger adults• Greater distance• Psychiatric disturbance• Psychotropic meds• Substance use

Missed Appts: “Can’t Treat the Empty Chair”

17Samuels et al., 2015

Significant, costly impacts on patient, provider, and health care setting:

• Interrupts relationship building, decreases continuity• Increases ED visits, length of hospitalization• Worsens clinical outcomes• Reduces clinical capacity• Decreases productivity• Lost revenues• Interrupts clinic workflows • Reduces provider satisfaction

Missed Appts: “Can’t Treat the Empty Chair”

18Dantas et al., 2018; Mofenter et al., 2013; Samuels et al., 2015

Strategies generally shown to reduce missed appts:• Reminders

• Mail, phone, text (most common)• Welcoming environment

• Décor• May be a satisfier; without other interventions, no change

• Decrease wait time to appt• Add provider capacity, overbook, offer walk-in appts• If 0 days, appt keep rate increases markedly

• Identification of patients with high rate of missed appts• Targeted interventions

Theoretical Frame: Patient-Centered MedicinePatient-centered medicine

• Health care revolution of the 1970s

The Pediatric PCMH • Whole person care for children and families with complex, comorbid, chronic

conditions considering the patient / family agenda and provider and setting• Roots in Dr. George Engel’s biopsychosocial model (1977)• Relational concept of patient engagement can be realized in the pediatric

medical home

19Carman et al., 2013, Lidia et al., 2016

Theoretical Frame: Patient EngagementPatient Engagement:

• Widely used term, has become a “buzzword”• “Holy grail” • “Blockbuster drug” • “Critical to health care learning” • “Necessary to health care redesign”

• Includes patient’s experience of the disease or condition AND provider’s skill and experience

• Patient / family are active participants in shared decision-making• Adherence, satisfaction are associated concepts

• Defining attributes of patient engagement:• Personalization, Access, Commitment, Therapeutic Alliance

20Higgins et al., 2017, Lidia et al., 2016

Theoretical Frame: Patient EngagementBehavioral engagement strategies• Strongest evidence base for reduction of missed appointments

• Make the patient WANT to attend the appointment!• Motivational interviewing/relationship based interventions• Contingencies/rewards

Is there a personalized, activating strategy that improves access, builds rapport, and improves workflow for BH appointment?

Project Green Sheet

21Lidia et al., 2016

Project “Green Sheet”• Goal

• Improve scheduling process and show rate for Behavioral Health appts• Consistent with mission of maximizing “Behavioral Health availability, quality,

benefits and cost effectiveness” within PCMH

• Rationale• Patient centeredness, further integration in clinic, efficiency, and sustainability• Consistent with “patient engagement strategy” from missed appt literature

• Target outcome• Improve show rate to Behavioral Health appts (decrease canceled / no-show appts)

22Asarnow et al., 2017

Project “Green Sheet”Intervention!• Behavioral Health “Green Sheet” Checkout Form

A. Scheduling instructions

B. 3 ACORN patient satisfaction items: 1. Today’s Behavioral Health provider(s) and I are working toward the same goals.

• Shared goals2. Today’s visit helped me move in the right direction.

• Treatment progress3. Today’s Behavioral Health provider(s) understood and respected me during our visit.

• Therapeutic alliance

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Project “Green Sheet”Intervention!• Behavioral Health “Green Sheet” Checkout Form

A. Scheduling instructions

B. 3 ACORN patient satisfaction items: 1. Today’s Behavioral Health provider(s) and I are working toward the same goals.

• Shared goals2. Today’s visit helped me move in the right direction.

• Treatment progress3. Today’s Behavioral Health provider(s) understood and respected me during our visit.

• Therapeutic alliance

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Project “Green Sheet”• Intervention!• Behavioral Health “Green Sheet” Checkout Form

A. Scheduling instructions

B. 3 ACORN patient satisfaction items: 1. Today’s Behavioral Health provider(s) and I are working toward the same goals.

• Shared goals2. Today’s visit helped me move in the right direction.

• Treatment progress3. Today’s Behavioral Health provider(s) understood and respected me during our visit.

• Therapeutic alliance

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Project “Green Sheet”• Intervention!• Behavioral Health “Green Sheet” Checkout Form

A. Scheduling instructions

B. 3 ACORN patient satisfaction items: 1. Today’s Behavioral Health provider(s) and I are working toward the same goals.

• Shared goals2. Today’s visit helped me move in the right direction.

• Treatment progress3. Today’s Behavioral Health provider(s) understood and respected me during our visit.

• Therapeutic alliance

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Project “Green Sheet”Data

• Time 2• Dec 2017 through mid-Apr 2018• 4.5 months

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Behavioral Health Visits # %Total attended 1394 --Green Sheets 1079 77%Analysis (1st follow-up) 540 50%

Project “Green Sheet”Satisfaction

• Very high across all 3 ACORN items• Ceiling effects for satisfaction

• No statistically significant difference• Prescriber / non-prescriber• Visit type (WHO, NPV, FUV)

• Yes, statistically significant difference• Only ACORN #1• Level of provider experience

• Intern < Faculty, Fellow• Intern ~ Staff

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Experience Mean SD n

ACORN#1

SharedGoals

Faculty 4.68 .645 152

Fellow 4.65 .597 49

Staff 4.57 .712 109

Intern 4.08 1.256 13

Total 4.62 .701 323

ACORN#2

Treatment Progress

Faculty 4.56 .698 152

Fellow 4.37 .951 49

Staff 4.47 .834 109

Intern 4.31 .751 13

Total 4.49 .790 323

ACORN#3

TherapeuticAlliance

Faculty 4.80 .623 152

Fellow 4.94 .242 49

Staff 4.79 .492 109

Intern 4.62 .650 13

Total 4.81 .541 323

Project “Green Sheet”Show RateTime 1 (no intervention) vs. Time 2 (Green Sheet)

No statistically significant difference in show rate• However…2018 included…• …new scheduling software, 2 schedules, increased FTE / volume

No statistically significant difference regarding:• Satisfaction• Prescriber / non-prescriber• Experience (Faculty, Fellow, Intern, Staff)• Visit type (WHO, NPV, FUV)• Time to FUV (M = 26.16, SD = 14.63)

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Project “Green Sheet”ACORN Items

ACORN Ratings• No statistically significant

association with show rate

ACORN Completion• 60% completed• 40% did not complete

• Yes, statistically significant association with show rate• 44.3% vs. 27.4%• B = .741, p < .001, odds ratio = 2.099

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Attended

F U V

No Yes Total

Co

mp

lete

d

AC

OR

N

Yes 170 135 305 44.3%

No 148 56 204 27.5%

Total 318 191 509 37.5%

DiscussionHypothesis

• Completing ACORN items increases motivation to attend follow-up appt

Possible factors for not completing ACORN items• Family

• Level of resources, coping• Dissatisfied family (who did not want to report)• Literacy or language barriers

• Behavioral Health provider• Gave ineffective directions for completing the Green Sheet• Forgot to give directions

• Scheduler• Gave ineffective prompts for completing the Green Sheet• Forgot to prompt

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Difficult to assess and address attendance in a safety net practice

Difficult to assess and address attendance in Pediatrics• Complexity of patient, parents/guardians, family, school

Scheduling Speedbumps (Time 1 Time 2)• New scheduling software, 2 schedules, increased FTE

Business and financial aspects of integrated care• Prevention / early intervention > reactive services• Gatekeeping / limit setting

Reflections• Green Sheet was instructive• Not sufficient to overcome barriers and “background noise”

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Discussion

Future Directions: “Green Sheet”Debrief families who do not complete ACORN items

• e.g., at point of checkout, call family after appt

1. “You had the opportunity to complete 3 satisfaction items at the bottom of the Green Checkout Form. What suggestions do you have to make the form more family friendly?”

2. Ask 3 ACORN items (i.e., shared goals, treatment progress, therapeutic alliance)

3. Inquire about family level of stress, coping, resources

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Current Efforts / Future Directions: Show Rate Access to on-site child care Increase day-of access via Behavioral Health “flex” provider Increase PMH NP consult time for availability of real-time consult visit or WHO Increase phone RN staff to decrease phone call wait time Conduct WHO at illness, well child, and follow-up medical appts Utilize 1-week “frozen” Behavioral Health slots Train Behavioral Health providers in self-scheduling Implement TeleVox reminder calls for BH Ongoing targeted education and reinforcement at all opportunities

Implement HealthySteps to facilitate Behavioral Health / well child co-visits Update contact / cell phone number at all opportunities Train Behavioral Health team for enrollment in MyChart access, text reminders Conduct targeted assessment of barriers Increase targeted case mgmt from Behavioral Health provider

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