Giving our Best for Those Most in Need - MemberClicks 27 2018... · Giving our Best for Those Most...

www.cherokeehealth.com© Cherokee Health Systems 2016

Giving our Best for Those Most in NeedImproving Access and Outcomes for the Underserved Through the

Integration of Primary Care and Behavioral Health Care

Joel Hornberger, MHSChief Strategy Officer

National Training and Consulting [email protected]


Operations Topics• Planning• Culture • Staffing • Facilities

• Challenges • Risk Stratification


Quick Introduction to Cherokee Health Systems and to

the Integrated Care Clinical Model


Quick Introduction to Cherokee Health Systems


Our Mission…To improve the quality of life

for our patients through the blending of primary care and behavioral health.

Together… Enhancing Life


Strategic Emphases

• Blended behavioral and primary care• Go where the grass is brownest• Outreach and care coordination• Telehealth• Training healthcare providers • Value-based contracting• Healthcare analytics


Primary Service Area

HAMBLENGRAINGER

CLAIBORNE

HAMILTON

MCMINN MONROE

LOUDON BLOUNTSEVIER

KNOXCOCKE

JEFFERSON

UNION

CAMPBELL

ANDERSON

Te n n e s s e e

K e n t u c k y

N o r t hC a r o l i n a

V i r g i n i a

G e o r g i a

A r k a n s a s

M i s s i s s i p p i A l a b a m a

M i s s o u r i


Cherokee Health Systems (An FQHC and a CMHC)

78,611 Patients 409,363 Services 25,242 New Patients26 Clinic Locations & 23 Telemedicine Clinics

Number of Employees: 703

Provider Staff:Psychologists - 46 Cardiologist - 1 Psychiatrists - 8Primary Care Physicians - 22 Nephrologist - 1 NP (Psych) - 13NP/PA (Primary Care) - 54 Pharmacists - 13 Social Workers- 65Community Workers - 41 RNs - 83 Dentists - 2


Quick Introduction to the Integrated Care Clinical Model


The Integration Stampede


“The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and

families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care

may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical

illnesses), life stressors and crises, stress related physical symptoms, and ineffective patterns of health care utilization.”

Peek CJ and the National Integration Academy Council. Executive Summary - Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. AHRQ Publication No.13-IP001-1-EF. Rockville, MD: Agency for Healthcare Research and Quality. 2013.

http://integrationacademy.ahrq.gov

What is Integrated Care?

http://integrationacademy.ahrq.gov/


Integration vs. Co-Location

Integrated Care• Embedded member of

primary care team• Patient contact via hand off• Verbal communication

predominate• Brief, aperiodic interventions• Flexible schedule• Generalist orientation• Behavior medicine scope

Co-Located Mental Health• Ancillary service provider• Patient contact via referral• Written communication

predominate• Regular schedule of sessions• Fixed schedule• Specialty orientation• Psychiatric disorders scope


Who is on the team?I. Clinical Therapist/Psychologist/BHC

• Communicating with prescriber to clarify diagnosis and unify treatment plan

• Monitor symptoms and functioning and communicate concerns/progress to prescriber

II. PCP/Specialty Medical Provider • Assessing and treating acute and chronic health problems with assistance

of a BHC or specialty behavioral health, as clinically indicatedIII. Psychiatric Provider

• Communicating with co-prescriber (PCP) regarding medication concerns• Providing diagnostic clarification• Offering psychotropic medication recommendations to PCP


Who is on the team?Each team member has a unique role

IV. Patient Service Representative • Coordinating the scheduling of same-day appointments• Obtaining medical/behavioral releases for outside agencies

V. Nurses • Identifying presenting problems during visit• Administering behavioral health screening tools• Coordinating with multidisciplinary staff to manage clinic flow and delivery

of multiple services on single date of service


So what does it look like in real life? • A picture is worth a thousand words…


Patient Check-in

(integrated consent form)


Medical Vitals

HeightWeight

Blood PressureHeart Rate

Temperature


Behavioral Vitals

PHQ2/PHQ9Cage AidOther screening as needed


Shared Space

(Close encounters!)


PCP sees the Patient

(99213, 99214,99215, etc.)


PCP Consults

BHC

(No code)


BHC Reviews the Chart

(no code)


BHC Transitionsinto the Exam Room

(can take the patient to their office if the exam room is needed)


BHC Sees Patient

96150 -155 (if medical dx) 90832 (if behavioral dx)

90791 (if evaluation)

(“feels like” primary care to the patient)

(concurrent documentation)


BHC Feedback to PCP

(no code)


Patient and BHC/PCP

Coordinate Follow –Up

(appointments, tests, meds,

community health coordinator, etc.)


We want it to be like this…


But it’s really like this!


Operationalizing the Integrated Care Model


Desired Future State: “Where we want (or need) to be in 3 yrs”

Current State:“Where We Are”

• Finances• Practice

Transformation• Policy• Metrics

• Workforce

STRATEGIES

GAPS

Strategic Planning Model


Planning• Integrated Care is our core

(not just another “program”)• Where we are now?

(SWOT analysis, Board planning, staff focus groups, patient and stakeholder interviews)

• Where do we want (or need) to be in 3 years? (Visioning, predictions, trends, etc.)

• What are our gaps? (Workforce, Finances, IT)


• How are we going to fill the gaps? (Goals, Objectives, Actions, Timelines) (Strategic and Tactical Plans)

• How do we know if we’re succeeding (or have succeeded)? (Key Performance Indicators)• HEDIS measures tied to performance contracts• UDS measures tied to our federal grant• Patient Satisfaction – Net Promoter Scores (plus

PCMH questions)

Planning


CultureThe way of life of a particular people, especially as shown in their ordinary behavior and habits, and in their attitudes towards each other (Norms/Values)

• The integrated care model drives everything we do• Put the patient first and at the center of his/her care team• Never compromise quality (evidence-based care, best

practices, built into our EHR)• “Tweak” our systems to improve quality and access


Culture• Try new ideas and if they work, great; if not, we’ll learn

and try something else• Maintain a psychologically “safe” place to work, where

everyone has each other’s back• Goal: make a positive difference in people’s lives –

especially for the underserved


Culture Drives Staffing

The Right People:• Are excellent at what they do• Enjoy change• Attentive to details• See the big picture • Are flexible/willing to try new ideas• Want to make a difference• Enjoy working in teams• Are good communicators• Are computer literate• Have fun/upbeat/lift others up

Get the “right” people on the bus, and the “wrong” people off the bus.

The Wrong people:• Resistant to change• Negative• Inflexible• Risk-averse • Protective of “their” turf• Defenders of the status

quo• Scowl a lot!


The Integrated Care Clinical Team

• PCPs (FP, IM, Peds, OB/GYN) (MDs, DOs, NPs, PAs) • BHC Staffing ratio: 1 BHC/4 PCPs (1 BHC/3 Pediatricians)• Consulting Psychiatrists (real time, tele-psych, referrals) • Therapists (LCSWs, PhDs) – When needed for longer term• Community Health Coordinators (BS, BA)

Staffing


• Nurses (RNs, LPNs, CNAs) (1.50 Nurses per FP/IM/FNP/PA; 1.7 Nurses per Pediatrician/PNP)

• Front Desk and Support Staff 1.00 X + .50 Y = Number of Administrative Support

X = Number of Primary Care FTEsY = Number of Behavioral FTEs

Staffing


• Train all staff in integrated care• Basic understanding of the model and roles of team members

• Create strong Clinical-Administrative Teams• Get Front Desk and scheduling staff on-board early• Hire strong Practice Administrators with clinical and

management experience

Staffing


Facilities• Three (3) exam rooms per PCP • Embed the BHC between (or close to) the PCP exam rooms• If you don’t have the ideal space, keep the following in

mind:• Proximity matters! Close physical proximity between

PCPs and BHCs enhances interaction. Ideally, the PCP can see the BHC.

www.cherokeehealth.com© Cherokee Health Systems 2016 © Cherokee Health Systems 2016

1. Meeting Demand/Increasing Access to Care• 25,000+ new patients last year• Constant pressure to meet demand for new patients• “No wrong door”– medical or behavioral doors are both OK • “Come on in” attitude for schedulers and staff (build work flow around access)• Increasing provider capacity

2. Recruiting and Training PCP’s and BHC’s• Finding well-trained BHCs -- One of the most challenging pieces of the puzzle

• Most academic programs are still producing traditional therapists; not many are producing BHCs for integrated care.

• Look for personality, pace and passion. We can train BHC skills.

Top 5 Integrated Care Operational Challenges


3. Scheduling!Get the schedules right. (Note: the schedule is the largest driver of patient and staff satisfaction, productivity, quality and financial results)• PCPs – 15 min established/30 min new• BHCs – same as the primary care schedule• Specialty BH – 30 min or 45 min. Clinician and patient choice.• Psychiatry – 20 min established/45 min new• Piggy-back BHC follow-up visits with PCP follow-up visits • Schedule BHC follow-ups during “slow” PCP times (early AM and late PM); blocks

during “hot” times

Integrated Care Operational Challenges


3. Scheduling (continued)• Advanced Access Scheduling Primary Care (30 days out/track)• Engagement Clinic (1 RN; 1 BHC; 1 PCP available if needed)• Extended Hours

4. Productivity• 20 primary care physician visits/day• 16-20 primary care NP visits/day• 12 BHC visits/day• 7 behavioral specialty visits/day• Will likely change as value-based deals become more prevalent

Integrated Care Operational Challenges


Integrated Care Operational Challenge: 5. Communications• Patient Dashboard

• Huddles

• EHR (tasking, mobile, community, “no glass walls,” etc.)

• Treatment Team Meetings (all staff, tough cases, weekly)

• Standing Orders (“automatically” know what to do)

• Sharing HEDIS Results/UDS Results/VB Contract Results with all staff (built in reporting within EHR)


Risk Stratification

Bio-Psycho-Social Assessment (BPSA)


Our Challenge: Effectively Manage an Assigned Population to Improve Quality and Reduce Costs

• 35,000 assigned Medicaid lives• Value-based contracts put us at risk (both upside and

downside) for quality targets and cost targets (quality bonus and shared savings)

• Who are these patients?• What is driving their use of services? Medical? Psych? SDOH?• Who are the sickest and what resources do they need? • Who are next sickest and what resources do they need?


BPSA Factors

BPSA Score


BPSA Results: Top 10 PatientsRanked Active Patients (mean = 5)

50

Rank Bio Psych Social Total Score Primary Resources

Needed

Secondary Resources

Needed

1 11 19 12 42 Psych CHC/PCP

2 17 11 12 40 PCP CHC/Psych

3 15 19 5 39 Psych Less CHC

4 5 19 15 39 Psych CHC

5 14 18 6 38 Psych PCP

6 14 17 7 38 Psych PCP

7 21 11 5 37 PCP! Psych

8 11 17 9 37 Psych PCP

9 16 13 8 37 PCP Psych

10 11 17 9 37 Psych PCP


CHS 20 Highest Ranked Assigned PCP

51

Rank Provider Patients Avg Score

1 A 501 40.12 B 1,698 39.23 C 268 38.64 D 1,306 38.55 E 1,490 37.66 F 1,175 36.87 G 1,501 34.48 H 709 33.99 I 921 32.0

10 J 1,476 32.0

Rank Provider Patients Avg Score

11 K 954 30.412 L 445 30.113 M 1,387 29.114 N 497 27.515 O 829 25.916 P 902 25.217 Q 1,633 24.818 R 413 24.519 S 914 23.820 T 851 23.1


Questions/Discussion

Giving our Best for Those Most in Need - MemberClicks 27 2018... · Giving our Best for Those Most...

Documents

Transcript of Giving our Best for Those Most in Need - MemberClicks 27 2018... · Giving our Best for Those Most...