Moving from Co-location to Integration: Collaboration Between a Health Plan

(Managed Care Organization) and a Federally Qualified Health Center (FQHC)

David Johnson, MSW, ASW, Director of Health Services, Anthem, Inc.Sean M. Benedict, Psy.D., LMFT, Clinical Supervisor, WellSpace Health

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session # H2aOctober 16, 2015

Faculty Disclosure

The presenters of this session• have NOT had any relevant financial

relationships during the past 12 months.

Learning Objectives

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

• Define three components in building a collaboration between a payer and a provider.

• Identify at least two strategies to move from co-located to integrated health services.

• List three outcomes of a collaborative integrated health program

Bibliography / Reference

1. Angstman, KB, Rohrer, JE, and Rasmussen, NH . PHQ-9 Response Curve: Rate of Improvement for Depression Treatment with Collaborative Care Management 2012 ;Journal of Primary Care & Community Health 2012; 3(3) 155-158

2. Kroenke, K and Spitzer, RL. The PHQ-9: A New Depression Diagnostic and Severity Measure Psychiatric Annals 2002;32(9) 1-7.

3. Katon, WJ, et al. Collaborative Care for Patients with Depression and Chronic Illnesses. New England Journal of Medicine 2010; 363(27) 2611-2620.

4. Pratt, LA and Brody, DJ. Depression in the U.S. Household population, 2009-2012, 2014 NCHS Data Brief, No. 172: National Center for Health Statistics.

5. Waxmonsky, JA., et al Evaluating Depression Care Management in a Community Setting: Main Outcomes for a Medicaid HMO Population with Multiple Medical and Psychiatric Comorbidities. Depression Research and Treatment, 2012: Article ID 769298

Bibliography / Reference

6. Nutting, PA., et al, Care Management for Depression in Primary Care Practice: Findings from the RESPECT-Depression Trial. Annals of Family Medicine, 2008; 6(1) 30-37.

7. Whitebird, RR, et al Effective Implementation of Collaborative Care for Depression: What is Needed? The American Journal of Managed Care, 2014; 20(9) 699-708.

8. Linde, K, et al, Effectiveness of Psychological Treatments for Depressive Disorders in Primary Care: Systematic Review and Meta-Analysis. Annals of Family Medicine, 2015;13(1) 56-68.

9. Linde, K, et al. Efficacy and Acceptability of Pharmacological Treatments for Depressive Disorders in Primary Care: Systematic Review and Network Meta-Analysis. Annals of Family Medicine, 2015;13(1) 69-79.

10.Coventry, P, et al. Integrated Primary Care for Patients with Mental and Physical Multimorbidity: Cluster Randomised Controlled Trial of Collaborative Care for Patients with Depression Comorbid with Diabetes or Cardiovascular Disease. British Medical Journal, 2015; h638.

Learning Assessment

• A learning assessment is required for CE credit.

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

WellSpace Health

• Serving the Greater Sacramento Area since 1953

• Serving 35,000 unique patients a year in 13 health centers

• Over 400 employees

WellSpace Health

Services Include:• Medical, Dental, Women’s Health, Pediatrics• Behavioral Health includes: Psychiatry, IBH (PC

Consults), Psychotherapy, Group Therapy, AOD Services, Case Management, ED Navigation, Transitional Housing, Suicide Prevention.

Anthem Inc. Fast Facts

Purpose

Statement

Together, we aretransforming health care with trustedand caring solutions

51,000 associates are employed by Anthem =1,000

OUR MEMBERS

37 milliontotal medical members

1 in 9 Americans

active dollars in local communities

$45.9 millionpledged associate

giving (includingFoundation match)

$5.6 millionin grants to local and

national initiatives since 2000

$160 million

19 states $73B

14 states

BC or BCBS plan

Medicaid presence

total operating revenue

68Mindividuals

served

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Anthem, Inc. Government Business Division

• 5.2 million Medicaid members in 19 states

• 580,000 Medicare members in 20 states

• 204,000 MLTSS program members in eight states

• Older adults and people with disabilities

• Low income families

• Other government-sponsored enrollees

Anthem, Inc. affiliated health plans serve 8.1 million people in state and federal government health programs, including:

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Why Establish Integrated Behavioral Health?

“No health without mental health” Quality of lifeMorbidity Impact on prognosis of other medical conditions

(Prevalence 2 to 3 times higher for individuals with chronic pain, cancer, diabetes, heart disease, and other chronic health conditions)

Prevalent• Up to 26% of the US population suffers from a

behavioral health disorder annually• The prevalence for any mood disorder is 9.5%

– 6.7% Major Depressive Disorder; 1.5% Dysthymia; 2.6% Bipolar I and II

Demands on physician time

Core Program Components

• Universal Screening or targeted screening• Identification/assessment of persons screening in

clinical range• Interventions—collaboration between BHC and PCP

– Health Coaching– Short-term, solution focused counseling– Medication– Referral to specialty MH

• Consistent measurement and monitoring (registry)• Psychiatric Consultation

Getting StartedHealth Plan• Collaboration• How many members by Provider• Staffing—”who owns the staff”• Training• Agreement—Contract, MOU• Finance Issues • Documentation and expected

outcomes

Health Center• Administrative Support• Introduce program concept to

staff• Review agreement• Physician champion• Logistics—space, phones, EHR

forms• Hiring process

Roles and ResponsibilitiesActivity BHC Psychiatrist Health Center Anthem

Program Planning

Review program Operational\Logistical issues

Identify Health Center.Draft agreement

Pre-implementation

Complete IMPACT Training

Complete IMPACT Training

Hire staffPhysician Champion

Training and consultation with clinic

Implementation

Screening, assessment & intervention

Consultation on complex situations

Process and procedure for screening

Reinforce best practice and treatment guidelines

Implementation Challenges

Program Launch

The path to implementation is not likely to be straight

All staff awareness

Process in place for screening—if paper and pencil forms printed, know who will administer and what to do when patient scores in clinical range

Ability to track agreed upon process and outcome measure

Implementation Challenges

Health Center• Trust• More work for everyone• EMR/EHR modifications• Not the way we practice• Patient flow and process• Location of BHC• If single payer initiative how

does program impact flows with other patients

• Lack of staff experience

Health Plan• Who supports implementation• Moving beyond “cost offset”• Role of Health Plan case

managers• Billing issues• Training and orientation for

health plan clinical services and provider relations

• If single payer, resolve that program will flow over to other payer’s members

Addressing Challenges

• Training—the model is an Evidence Based Treatment physicians can grasp

• Meet– Frequent meetings early on– Reduce to monthly meetings to review program

operations and data• Maintain flexibility and adaptability to reflect

the health center culture

Member/Patient Engagement• Response to screening• Engaging members when in the clinical range• Diamond project noted an engagement rate of

15%. Whitebird, et al 2014

• Respect project reported 68.5% engagement Waxmonsky, et al 2013

• Organizational support (screener: “do you want to speak to BHC?”)

• Physician support• Strong BHC

Moving from Co-location to IntegrationHealth Center• Philosophy, a team

approach• Parsimony—screening and

assessment • Evidence-based• Staffing• Team huddles• Documentation, EHR• Flexibility and adaptability• Outcomes and benefits

Health Plan• Philosophy, a provider

collaborative approach• Financial model—value-

based purchasing• Consultation—technical and

clinical expertise • Data sharing & care

coordination• Quality management and

outcomes

Outcomes• Improved detection and

identification of depression• Improved health services—

reduced wait time for specialty MH services

• Decreased patient severity of depressive symptoms

• Improved care coordination

Screening Program Initiation to June 15, 2015

Health Plan Start Date New Screen PHQ-9 Clinical Audit C

Sacramento CA 6/1/14 1,086 42% *

Tulare CA 11/1/14 435 26% 7%**

Maryland 6/18/13 904 34% 18%***

Tennessee 9/16/13 1,021 24% 4%

Texas 8/26/13 769 15% 4%

Total 4,215 29% 9%

• Clinic has not been able to extract Audit C scores from their EMR** Clinic only reported 25 members with Audit C screening*** MD in an HIV Clinic with higher rates for positive Audit C screening**** Total Screened for Alcohol =2,520 as this screening was added later into the program

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Severity of Depressive Symptoms

44%

27%

14%

10%

6%

Percent

Non-Clinical (0-4)Mild (5-9)Moderate (10-14)Moderate Severe (15-19)Severe (20+)

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Severity by Program Site

Non-Clinical (1-4) Mild (5-9)

Moderate (10-14)

Moderate Severe (15-19)

Severe (20+)

Total 44.0% 27.0% 14.0% 10.0% 6.0%MD 46.0% 21.0% 19.0% 11.0% 4.0%TN 46.0% 30.0% 14.0% 8.0% 2.0%TX 40.0% 45.0% 6.0% 6.0% 4.0%Tulare CA 50.0% 23.0% 12.0% 8.0% 6.0%Sacramento CA 38.0% 19.0% 16.0% 15.0% 12.0%

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Overall, a total of 1,260 members (30%) met our criteria for scoring in the clinical range with depressive symptoms. A multi-site program serving Medicaid members in Colorado screened 1,758 individuals, 36.9% scored a 10 or higher.

Member Prior Diagnosis and Treatment of Depression

Prior Diagnosis Prior RX0%

10%

20%

30%

40%

50%

60%

70%

28%

19%

64%

43%

All MembersMembers in Clinical Range

25

Depression and SUD

Alcohol Prescription Rx Illegal Drugs0%

2%

4%

6%

8%

10%

12%

14%

16%

9%

2%

7%

14%

4%

12%

Total ScreenedPositive Depression Screen

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Clinical OutcomesChanges in PHQ-9 ScoresIndex Visit to most recent

Degree of Change Number Percent

Significantly Worse (Score +5or higher) 54 7%

Worse (Score of +2 to +4) 59 8%

No Change (Change of +1 to -1) 202 26%

Slight Improvement (-2 to -4) 154 20%

Sig. Improvement (Score -5 or lower) 308 39%

Total 777 100%

The change score is based on the difference from the index visit to the most recent administration of the PHQ-9. A score of 10 or higher is considered in the clinical range for depression, the higher the score the greater the severity. A decrease in score reflects improvement.

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Sample Response Curve PC-INSITE

Index 4 weeks 6 weeks 24 weeks 28 weeks 32 weeks0

5

10

15

20

25

30

24

15

63

6 6

PHQ-9

PHQ-9

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Sample Response Curve PC-INSITE

Index 12 weeks

16 weeks

20 weeks

24 weeks

28 weeks

32 weeks

36 weeks

40 weeks

45 weeks

02468

1012141618

13

98

1112

10 10

17

98

PHQ-9

PHQ-9

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Non-Response or Treatment Resistant Depression

• What about members who get significantly worse?• WellSpace review of 26 members in which symptom

severity increased by 5 points or more– 17 Females; 9 males– Two-thirds did not engage, but continued to return for

medical reasons– 22 of 26 meet criteria for SMI – 5 chronic pain; 2 presenting for controlled substances only– 3 of the 26 have reflected some improvement since these

data were reported

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Sustainability• Value-base as best practice• Improves the person’s experience as an active

participant in addressing health issues• Clinical outcomes—improvement in health

and well-being• Financial outcomes—physicians in clinic

greater efficiencies; service utilization of emergency department and inpatient admissions decrease

Summary

• Depression and SUD are significant factors impacting a person’s health and their health services utilization

• PC-INSITE provides services in primary care settings to specifically address these conditions

• Over 4,215 members have been screened since the launch of PC-INSITE in four states

• 30% screened positive for depression• 9% screened positive for SUD• 60% of those members in the clinical range have had at least one

follow-up contact and completed a second PHQ-9• 59% Experienced at least some reduction in symptom severity at

follow-up

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Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!

PEC-ALL-1661-15