Integrated Behavioral Health Care in a Federally Qualified Health Center (FQHC): Pilot Test of Two

Behavioral Health Delivery ModelsJennifer DeGroff, PhD

Director of Healthcare Development and IntegrationAspenPointe, Colorado Springs, CO

Collaborative Family Healthcare Association 15th Annual ConferenceOctober 10-12, 2013 Broomfield, Colorado U.S.A.

Session #_E3c____ Friday, October 11, 2013

Faculty Disclosure

I have not had any relevant financial relationships during the past 12 months.

Objectives

• Compare and contrast the Integrated Practice and Co-located Models of integrated physical/behavioral health care in a physical healthcare setting.

Peak Vista and ASPENPOINTE

Established in 1971, became a FQHC in 1976.

We provide medical and dental services to people facing health care access barriers in the Pikes Peak Region.

In 2010, we served 58,922 unduplicated users with 68 providers in over twelve sites.

Established in 1875 as Colorado Springs Relief. Merged with two organizations to form the MHC.

We provide behavioral health and substance abuse services, housing and employment training / work opportunities that that empower the people we serve.

In 2010, we served 21,000 unduplicated users with 120 providers in over 18 sites.

ASPENPOINTE/Peak Vista StoryThe First Integration Project (2001)•Vision: Co-located and partially integrated model•Staffing: Therapist only•Location: Peak Vista CHC Women’s Health Center•Buy-In: Initially present for staff and leadership, but waned over time•Project fell apart

The Second Integration Project (2006)

•Drivers that brought us together again:• CEO’s had many concerns regarding future of Mental

Health and Physical Health•Vision: Close Collaboration and Partially Integrated System•Location: Peak Vista CHC Family Health Center @ Union•Staffing: Started with a therapist and then added in psychiatrist time •Buy-In: Clinical and administration, BUT increased commitment to success by leadership

• Regular corporate and management meetings• Clear-the-path attitude • This project will not fail!

The Current Model• Fully Integrated • Staffing: 9 licensed BHCs from ASPENPOINTE • Referrals: Directly to the BHC by the primary provider• 52,080 BH contact since 2006

• 2006: 3 staff• 2007: 4 staff• 2008: 6 staff• 2009: 6 staff• 2010: 7 staff• 2011: 9 staff• 2012: 9 Staff

MH/Primary Care Integration Options

Function

Minimal

Collaboration

Basic Collaboration

from a Distance

Basic Collaboration On-

Site

Close Collaboration/

Partly Integrated

Fully Integrated/Merged THE CONSUMER and STAFF PERSPECTIVE/EXPERIENCE

Access Two front doors; consumers go to separate sites and organizations for services

Two front doors; cross system conversations on individual cases with signed releases of information

Separate reception, but accessible at same site; easier collaboration at time of service

Same reception; some joint service provided with two providers with some overlap

One reception area where appointments are scheduled; usually one health record, one visit to address all needs; integrated provider model

Services Separate and distinct services and treatment plans; two physicians prescribing

Separate and distinct services with occasional sharing of treatment plans for Q4 consumers

Two physicians prescribing with consultation; two treatment plans but routine sharing on individual plans, probably in all quadrants;

Q1 and Q3 one physician prescribing, with consultation; Q2 & 4 two physicians prescribing some treatment plan integration, but not consistently with all consumers

One treatment plan with all consumers, one site for all services; ongoing consultation and involvement in services; one physician prescribing for Q1, 2, 3, and some 4; two physicians for some Q4: one set of lab work

Funding Separate systems and funding sources, no sharing of resources

Separate funding systems; both may contribute to one project

Separate funding, but sharing of some on-site expenses

Separate funding with shared on-site expenses, shared staffing costs and infrastructure

Integrated funding, with resources shared across needs; maximization of billing and support staff; potential new flexibility

Governance Separate systems with little of no collaboration; consumer is left to navigate the chasm

Two governing Boards; line staff work together on individual cases

Two governing Boards with Executive Director collaboration on services for groups of consumers, probably Q4

Two governing Boards that meet together periodically to discuss mutual issues

One Board with equal representation from each partner

EBP Individual EBP’s implemented in each system;

Two providers, some sharing of information but responsibility for care cited in one clinic or the other

Some sharing of EBP’s around high utilizers (Q4) ; some sharing of knowledge across disciplines

Sharing of EBP’s across systems; joint monitoring of health conditions for more quadrants

EBP’s like PHQ9; IDDT, diabetes management; cardiac care provider across populations in all quadrants

Data Separate systems, often paper based, little if any sharing of data

Separate data sets, some discussion with each other of what data shares

Separate data sets; some collaboration on individual cases

Separate data sets, some collaboration around some individual cases; maybe some aggregate data sharing on population groups

Fully integrated, (electronic) health record with information available to all practitioners on need to know basis; data collection from one source

©2006 Kathleen Reynolds (Integrated Care Adaption Only) Adapted from: Doherty, McDaniel and Baird, 1995.

Pilot Project:Introduction

• 10 week pilot program running two behavioral health models within the same clinic: Full Integration and Co-Location

• We were not aware of any studies running a comparison between models in the same clinic

Pilot Project:Method

• Conducted at the largest clinic with 3 AspenPointe BHCs and 16 medical providers – 2 of the BHCs did “business as usual”, meaning that

they continued to do co-visits and follow-ups, with a focus across all behavioral health needs.

– One BHC worked as a co-located therapist, meaning that she operated a mini-AspenPointe clinic within Peak Vista and followed all AspenPointe procedures and processes for opening and treating clients.

• 10 week pilot period (October – December)

Pilot Project:Results

BHC Model Co-Located Therapist Model

Encounters 468 (between 2 staff) :69 follow ups, 399 co-visits

57

Unique Clients Served 399 12

No show Rates N/A 43% for intakes19% for therapy

Productivity 92% (468 encounters, 507 expected based on MOU)

25% (75.25 of 296 available hours was spent with clients)

Diagnoses Served All Diagnoses, including medical only Primarily PTSD and MDD

Outcome Measure Not able to get data – most clients not seen multiple times

8 of 12 clients had improved scores, thought some were very small improvement (12 to 13.9)

Pilot Project: Results Continued

• Pro’s of Co-Location:– 11 of the 12 patients were uninsured and may not

have been able to afford care – More uninterrupted time for each patient.– Many patients who attended the co-located

therapy sessions seemed to prefer traditional therapy over the integrated model

– Most clients who attended their intake seemed grateful for the opportunity and became engaged in treatment (with two exceptions)

Pilot Project:Results Continued

• Con’s of Co-Location:– Took more time – full opening process to

AspenPointe and navigating 2 EHRs– Decreased communication to providers because of

2 EHRs– Wait time to get into co-located BH services – High no show and cancellations rate in the pilot

program – Clients (and staff) confusion with two separate

organizations

Pilot Study:Results

• Following the pilot, the Peak Vista Medical Providers were asked which model they preferred and they unanimously reported that they preferred the integrated model over co-located. Additionally, the BHC’s unanimously reported that they preferred the integrated model.

Conclusions

• Fully Integrated care model serves significantly more patients than co-located care

• The productivity of staff is maximized using an integrated approach

• Provider and BHC satisfaction is high using a fully integrated approach

• Satisfaction with clients in each model is high

Further Research

• Replicate in other clinics over a longer period of time

• Use research when establishing practice models to best meet the needs of the clinic and patients

Learning Assessment

Audience Question & Answer

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!