Care Coordination Collaborative Learning Session #4

DAY 1: Wednesday November 12th , 2014

Welcome!

• Introductions• Day One and Two Agenda Review

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Agenda: Day 1Time Topic

8:30-8:45 Welcome, Introduction, & Overview of Learning Session #4

8:45-9:45 Open Plenary: Contextualizing CC within a Changing Health Care Environment

9:45-10:00 BREAK

10:00-10:45 Pilot Team Presentations and Discussion

10:45-10:50 BREAK

10:50-12:00 Opportunities for Integrating SUD Tx into CC Processes

12:00-1:00 LUNCH

1:00-1:45 Team Presentation and Discussion: Process Mapping and Integrating CC Processes

1:45-3:00 Change Idea Presentation: Ad Hoc Consultations and following up on Population Based Care Coordination

3:00-3:15 BREAK

3:15-4:45 Organizational Team Meeting #1: Finalize Agenda for Day 2 Organizational Team Meeting

4:45-5:00 A Look at Day 2 and Adjourn

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Agenda: Day 2 Time Topic

8:15-9:00 Continental Breakfast

9:00-9:15 Questions and Feedback from Day 1

9:15-9:45 Spread: After the target population implementation, what happens?

9:45-10:45 Organization Team Meeting #2: Planning for Spread

10:45-11:00 BREAK

11:00-12:15 CCC Team Panel: How do Peer Providers and Care Coordinators work together to provide Care Coordination?

12:15-1:15 LUNCH

1:15-2:30 Organizational Team Meeting #3: Planning for Final Action Period

1:30-2:30 Team Report Out

3:00-3:15 Wrap Up and Adjourn

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CCC LEARNING SESSION #4 OPENING PLENARY

Contextualizing Care Coordination Within a Changing Health Care Environment

Jürgen Unuzter MD, MPH, MAUniversity of Washington, AIMS Center

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BREAK

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PILOT TEAM PRESENTATIONS & DISCUSSION:

Partnership Health Plan, Anthem Blue Cross, Cal Viva, and California Health and Wellness

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Panel Discussion Questions1. We have heard from some Health Plans that getting data can be a challenge. What

success stories have you had in working with your Health Plan to access the data associated with Pilot?

2. What communication strategies have helped you to build more effective working relationships with your County Mental Health Plan and other CCC Partners? Are there particular strategies you consider sustaining after the Collaborative has finished?

3. What has been your learning about recovery supports and services needed for individuals with Serious Mental Illness (for example: outreach and engagement, self management, and social supports such as housing and education)?

4. What have you learned about integrating Health Plan responsibilities for individuals with mild and moderate mental health disorders and County specialty mental health care?

– Has your Plan developed strategies, in collaboration with County Mental Health and other CCC Partners, for facilitating client access and movement between levels of care?

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5 Minute Break

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OPPORTUNITES FOR INTEGRATING SUBSTANCE USE DISORDER Tx INTO CARE

COORDINATION PROCRESSES

Darren Urada, PhDUCLA Integrated Substance Abuse Programs

&Gale Bataille, MSW

California Institute for Behavioral Health Solutions

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Session Description 1. Update on Drug Medi-Cal Waiver2. SBIRT requirements 3. Challenges for SBIRT implementation4. Long Term Opportunities to Address Challenges5. Planning and Discussion

Drug Medi-Cal Waiver Update

• Draft form, likely 2015 implementation• Adds services, assessment requirements.• Better rates, more county control.

• Opt in counties would get:• Additional medication assisted treatment• Residential treatment• Withdrawal management• Case management• Recovery residence (block grant funded)• Physician consultation

Draft (October 16, 2014) http://www.dhcs.ca.gov/provgovpart/Documents/2nd-Draft-STCs-for-stakeholders.pdf

Reminder: DMC Waiver text onCoordination with Managed Care Plans and Primary

Care

The following elements should be implemented at the point of care:•Comprehensive substance use, physical, and mental health Screening;•Beneficiary engagement and participation in an integrated careprogram as needed;•Shared development of care plans by the beneficiary, caregivers and all providers;•Care coordination and effective communication among providers;•Navigation support for patients and caregivers; and•Facilitation and tracking of referrals between systems.•The participating county shall enter into a memorandum ofunderstanding (MOU) with any Medi-Cal managed care plan thatenrolls beneficiaries served by (Drug Medi-Cal).

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REQUIREMENTS ALREADY IN EFFECT!

“Beginning January 1, 2014, MCPs* are responsible to cover and pay for an expanded alcohol screening . . . Also, MCPs shall cover and pay for brief intervention(s). . . Any member identified with possible alcohol use disorders should be referred to the alcohol and drug program in the county where the member resides for evaluation and treatment.”

SBIRT Requirements

Source: DHCS ALL PLAN LETTER 14-004:http://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2014/APL14-004.pdf

*MCPs - Medi-Cal managed care health plans. MCPs must ensure that PCPs carry out the above.

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SBIRT Requirements

“When a member answers “yes” to the SHA alcohol pre-screen question, the MCP must ensure that the PCP offers the member an expanded, validated alcohol screening questionnaire.”

Source: DHCS ALL PLAN LETTER 14-004:http://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2014/APL14-004.pdf

“PCPs must offer the Staying Healthy Assessment (SHA) or other approved tool within 120 days after enrollment and every three years, with annual reviews of the member’s answers.”

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Feedback from Team Lead Call:

• No access to residential treatment• “Need to educate primary care that even if screening only

indicates a little problem, refer them.”• Data sharing - screenings in paper format, at PC location

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Long-Term Emerging Opportunities

Residential treatment• Drug Medi-Cal Waiver

Educate primary care• SBIRT trainings• DMC Waiver MOUs• Potential expansion

Data sharing• Support for data infrastructure under discussion

Process for Session

1. 5 mins: Participants move to your assigned tables (# assignment is on back of your name tag)

2. 15 mins: Update re: SBIRT & waivers

3. 30 mins: Table Top Discussion

4. 20 mins: Report Out18

Discussion Questions

1) How is your team integrating or planning to integrate SUD services into your partnership?

2) If you are not a specialty SUD provider, are you capable of providing brief intervention/brief treatment for alcohol or other SUD conditions at your program? What services do you provide? Do you provide Medication Assisted Treatment (for example Suboxone?)

3) If client/patient requires services beyond brief intervention, how do you make, complete and track referrals to specialty SUD?

4) What strategies has your CCC team used to share SUD information? If Primary Care Clinic is conducting SBIRT screening, how is that data shared with the other CCC partners?

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LUNCH!

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TEAM PRESENTATIONS AND DISCUSSION: PROCESS MAPPING AND INTEGRATING CARE

COORDINATION PROCRESSES

Inyo County Partnership, Fresno County Partnership, and Tuolumne County Partnership

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Inyo County CCC Process Map

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Tuolumne

Ad Hoc and Caseload Consultation

Wednesday, November 12, 2014

Jürgen Unützer, MD, MPH, MAProfessor and Chair, Psychiatry and Behavioral SciencesUniversity of Washington

Marc Avery, MDCIBHS CCC Faculty Co-Chair

Gail Bataille, MSWCIBHS CCC Faculty Co-Chair

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Objectives:1.Understand the different types of consultation

that are necessary in coordinated care.2.Learn what elements of consultation are

most effective.3. (During breakout) Explore ways for

testing/implementing ad hoc and caseload consultation in your location.

Collaborative Care Model Consutation

PCP

Patient BH CareManager

Psychiatric Consultant

CoreProgram

New Roles

Collaborative Team Model: Two Types of Consultation – Caseload and Ad Hoc

Patient

Psychiatrist

Substance Use

Counselor

Case Manager

Primary Care

Population Consultants

Care Coordination Team

Care Plan

Care Coordinato

r

Peer Counselor

Other

Psychiatrist

Mental Health Substance Use Primary Care

Other Other

PCP

Pay-for-performance cuts median time to depression treatment response in half.

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Estim

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0 8 16 24 32 40 48 56 64 72 80 88 96 104 112 120 128 136

Weeks

Before P4P After P4P

Unützer et al. 2012.

Effective Implementation: 9 Factors

29Whitebird, et al. Am J Manag Care. 2014;20(9):699-707

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Engagement/Activation and Remission: Key Factors

Whitebird, et al. Am J Manag Care. 2014;20(9):699-707

Common Consultation Questions

• Consider re-screening patient • Patient may need additional assessment

Clarification of diagnosis

• Make sure patient has adequate dose for adequate duration• Provide multiple additional treatment options

Address treatment resistant disorders

• Help differentiate crisis from distress• Support development of treatment plans/team approach for

patients with behavioral dyscontrol• Support protocols to meet demands for opioids,

benzodiazepines etc…• Support the providers managing THEIR distress

Recommendations for managing difficult patients

Key Elements of an Informal Consultation• Readily Accessible• Establish rapport and welcoming

stance• Concise feedback –

pharmacologic and nonpharmacologic

• If-then scenarios and next steps• Educational component

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Uncertainty:Requests for More Information

Complete informatio

n

Sufficient informatio

n

- Tension between complete and sufficient information to make a recommendation

- Often use risk benefit analysis of the intervention you are proposing

SUMMARY:  Pt is a 28yo male presenting with depression and anxiety.  Pt having trouble falling asleep (plays with laptop or phone in bed), sleeping 4-7 hrs/night. Depressive symptoms: Moderate depression; PHQ-9: 18 Bipolar Screen:  Positive screen; May be more consistent with substance use Anxiety symptoms:  Moderate to severe; GAD-7: 18 Past Treatment: Currently taking Bupropion and Citalopram (since 1/31) feels more in control, able to think before reacting, less irritable; Took Zoloft, Prozac, Wellbutrin at different times during teenage yrs. Doesn't recall effect Suicidality:   Denies Psychotic symptoms:  Denies Substance use: History of substance use/alcohol; Engaged in treatment Psychosocial factors:  Completed court appointed time in clean and sober housing; Now living back with parents in Carnation; Attending community college; Continues to stay connected to clean and sober housing; Attends Mars Hill Church Other: ADHD: ASRS-v1.1 screening – positive; Not diagnosed as a child; Now getting B’s at community college Medical Problems:  hx of frequent migraines

Current medications: Bupropion HCl (Wellbutrin SR)(Daily Dose: 450mg) †Citalopram Hydrobromide (Celexa) (Daily Dose: 40mg) Goals: Improve school functioning; Long term goal employment 

Sample Case Review NoteConcise Summary

ASSESSMENT:  Depression NOS , most likely MDD but cannot r/o bipolar disorder; Anxiety NOS,; Alcohol dependence, in early sustained remission; r/o ADHD

RECOMMENDATIONS:1)       Continue to target sleep hygiene2)       Options for antidepressant augmentation.  Engage patient in decision

making about which ONE option to pursue:a.       Option 1: Continue Celexa to 20mg as reported sedation on higher

dose;  Make sure he is taking dose at night and allow for longer period of observation to evaluate efficacy 

b.      Option 2: Increase Celexa back to 40mg to target anxiety as did not notice a change in sedation but noted increased anxiety when lowered dose.

c.       Option 3: Cross taper to fluoxetine;  Week 1:  Baseline weight.  Consider BMP for baseline sodium in older adults.  Start 10 mg qday. Continue Celexa20mg  Week 2:  Increase dose to 20 mg qday, if tolerated, and stop Celexa   Week 4 and beyond: Consider further titration in 10-20 mg qday increments. Typically need higher doses for anxiety Typical target dosage: 20 mg qday

3)       Continue close contact with care coordinator, supporting substance use treatment and behavioral activation. 

4)       Can consider Strattera in the future if poor concentration persists;   Would stay on 40 mg qday as combination with Wellbutrin can increase drug level.

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Brief & Focused

‘Disclaimer’ on Note

•“The above treatment considerations and suggestions are based on consultations with the patient’s care manager and a review of information available in the care management tracking system. I have not personally examined the patient. All recommendations should be implemented with consideration of the patient’s relevant prior history and current clinical status. Please feel free to call me with any questions abut the care of this patient.“

•Dr. X, Consulting Psychiatrist•Phone #. •Pager #.•E-mail

ROLE: Caseload Consultant

Caseload Reviews

• Scheduled (ideally weekly)

• Prioritize patients that are not improving

Availability to Consult Urgently

• Diagnostic dilemmas• Education about

diagnosis or medications

• Complex patients, such as pregnant or medical complicated

If patients do not improve, consider:• Wrong diagnosis?• Problems with treatment adherence?• Insufficient dose / duration of treatment?• Side effects?• Other complicating factors?

– psychosocial stressors / barriers– medical problems / medications– ‘psychological’ barriers– substance abuse– other psychiatric problems

• Initial treatment not effective?

Sample Consultations ~ 30 min

REASON FOR CONSULT

DIAGNOSIS

RECOMMENDATION

Side effects from lithium BP 1 Switch to valproic acid

SE from lisdexamfetamine

ADHD Try another per protocol

Lithium level is 1.2 BP 1 Cont unless having side effects

Inc depression symptoms

MDNOS TSH, if normal start lamotrigine

Poss SE from quetiapine BP 1/PD Decrease Seroquel to 100 mg

Paroxetine not effective MDD Add bupropion

Regular lamotrigine or XR?

BP 2 No difference

Side effects with citalopram

MDD Switch to bupropion

Depression symptoms increase

BP1 Check lithium level first, maximize if low, may need to add lamotrigine

Suicidal, acute distress PD Safety plan, DBT referral

High doses of meds, confused

MDD Stop hydroxyzine, reduce lorazepam, call collateral

Anxious, wants alprazolam, nipple pain

GAD No alprazolam, increase sertraline, coping skills

ROLE: Direct ConsultantSeeing patients directly in collaborative care is different than traditional consultation. Approximately 5 – 7 % may need this.

Patients pre-screened from care manger population

• Already familiar with patient history and symptoms• Typically more focused assessment, tele-video OK

Common indications for direct assessment

• Diagnostic dilemmas• Treatment resistance• Education about diagnosis or medications• Complex patients, such as pregnant or medical

complicated **Utilize televideo if warranted

Liability

INFORMALCONSULTATIVECurbsides, advice to PCP and BHP, no charting, not paid and not supervisor of BHP

COLLABORATIVECurbside with BHP, document recommendations in chart and paid

FORMALDirect with patient after other steps unsuccessful, written opinion SUPERVISORYPsychiatric provider administrative and clinical supervisor of BHP ultimately responsible

•Olick et al, Fam Med 2003 •Sederer, et al, 1998•Sterling v Johns Hopkins Hospital., 145 Md. App. 161, 169 (Md Ct. Spec. App. 2002

Consultation ranges from

informal to formal.

Is there a doctor-patient

relationship? 41

Collaborative care should reduce risk:

-Care manager supports the PCP -Use of evidence-based tools -Systematic, measurement-based follow-up-Psychiatric consultant

PCP: Oversees overall care and retains overall liability AND prescribes all medications/additional studiesCM/BHP: Responsible for the care they provide within their scope of practice / license

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AD HOC Consultation

Collaborative Care Model Consutation

PCP

Patient BH CareManager

Psychiatric Consultant

CoreProgram

New Roles

Collaborative Team Model

Patient

Psychiatrist

Substance Use

Counselor

Case Manager

Primary Care

Population Consultants

Care Coordination Team

Care Plan

Care Coordinato

r

Peer Counselor

Other

Psychiatrist

Mental Health Substance Use Primary Care

Other Other

PCP

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Example Vignettes:

Case #1:Your patient calls you, the care coordinator, complaining of feeling extremely anxious.  She states that this started yesterday when the PCP started a new diabetes medication.  She also is a bit dizzy.     Case #2:Your CC patient sees his PCP complaining of increasingly intrusive voices.  He tells the PCP that he always has more voices when under stress and he is about to be evicted from his SRO. He thinks his care coordinator is “working on it.” 

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Bi-Directional Ad Hoc Clinical Consultation – Breakout Session Case #1: Your patient calls you, the care coordinator, complaining of feeling extremely anxious.  She states that this started yesterday when the PCP started a new diabetes medication.  She also is a bit dizzy.  How would you obtain medical consultation from PC clinic? Case #2: Your CC patient sees his PCP complaining of increasingly intrusive voices.  He tells the PCP that he always has more voices when under stress and he is about to be evicted from his SRO. He thinks his care coordinator is “working on it.”  The PCP would like to consult with you and mental health.  How would this happen?

• How have you begun to test/implement population focused clinical care coordination meetings with your key CCC provider partners?

• How frequently are you meeting to develop/review Integrated Care Plans?• What criteria have you used for selecting patients for caseload consultation?    • Are you using population-based criteria to select patients for caseload

reviews? • If so, are there additional population-based criteria that you can

test/implement?• If not, what criteria can you begin to test/use? 

BREAK

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Organizational Team Meeting #1: Finalize Agenda for Day 2 Team Meeting

and Planning for Action Period 4

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A Look at Day 2

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Time Topic

8:15-9:00 Continental Breakfast

9:00-9:15 Questions and Feedback from Day 1

9:15-9:45 Spread: After the target population implementation, what happens?

9:45-10:45 Organization Team Meeting #2: Planning for Spread

10:45-11:00 BREAK

11:00-12:15 CCC Team Panel: How do Peer Providers and Care Coordinators work together to provide Care Coordination?

12:15-1:15 LUNCH

1:15-2:30 Organizational Team Meeting #3: Planning for Final Action Period

1:30-2:30 Team Report Out

3:00-3:15 Wrap Up and Adjourn

We’ll see you tomorrow, continental breakfast starts 8:15am.

Enjoy Los Angeles!

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