Primary Care and Behavioural Health: Southcentral Foundation's Integrated Approach

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Primary Care and Behavioral Health: Southcentral Foundation’s Integrated Approach Donna Galbreath | Senior Medical Director of Quality Assurance David Lessens | Medical Director 65,000 voices

Transcript of Primary Care and Behavioural Health: Southcentral Foundation's Integrated Approach

Primary Care and Behavioral Health: Southcentral Foundation’s

Integrated Approach

Donna Galbreath | Senior Medical Director of Quality Assurance David Lessens | Medical Director

65,000 voices

Vision A Native Community that enjoys physical, mental, emotional and spiritual wellness

Mission Working together with the Native Community to

achieve wellness through health and related services

Goals S hared Responsibility

C ommitment to Quality

F amily Wellness

Customer Ownership

Operational Principles

Core Concepts

Define Southcentral Foundation’s Nuka System of Care

Describe Southcentral Foundation’s Primary Care and Integrated Care Teams

Share Southcentral Foundation’s Behavioral Health Integration Journey

Objectives

Notecards Turn in your questions at break

Evidenced-based, generational change reducing family violence

36% drop in both ER visits and hospital admissions from 2000-2015

75-90 percentile on many HEDIS outcomes

Benchmarked data nationally and internationally showing top in class performance in utilization, quality and satisfaction

Employee turnover rate decreased 15% from 2007-2015

96% customer satisfaction and 95% staff satisfaction

Baldrige Award 2011

Why listen to our story

Alaska Native People Shaping Health Care

Alaska Native people chose to assume responsibility

We Changed Everything

Timeline

Planning Transition Implementation

The next big change and the

next big change…

Listen FIRST

The Start of Our Big Change Journey

• Governance

• Leadership

• Customer-owners

• Employees

• Other organizations

Operational Principle Alignment

Aligns • Un-blinded

performance data

• Defined PCP responsibilities

No alignment • Group visits

• Nurse Call Line

Some alignment • Disease specific

approaches

Culture of Improvement

Improvement Advisors and Specialists

Quality Management Courses

Committee Structure

Tools, methods and processes • E.g., Baldrige

Infrastructure to Support Improvement

Customer-owner drives the system • Shared responsibility

Leadership must support and drive

Access and relationship

Messaging is critical

Pay attention to workforce

Data matters

Process for change necessary • Never done, always willing to adapt

Lessons Learned

Empanelled customer-owners: Ensures continuity of care

Builds relationships

Creates trust between customer and team

Progress/healthy outcomes

Open access to Integrated Care Team

Email, phone, talking rooms

Continuity

Governance History at SCF

Owned and managed jointly by SCF and Alaska Native Tribal Health Consortium (ANTHC) on a Joint Operating Board

• 4 SCF Board Members

• 5 ANTHC Board Members

SCF Board of Directors delegates duties to the ANMC Joint Operating Board for the operation of the campus

Integrated Care

Clinical Operational

Financial Structural

20%

20%

10%

Clinical Workload Prior to System Redesign

Provider

Chronic

Disease

Monitoring

Preventive

Med

Intervention

Mental Health

Provider

Referral to

Specialist

after

Assessment

Medication

Refill

New Acute

Complaint

Certified

Medical

Assistant

Case

Manager

Test Results

Healthcare

Support

Team

Traditional Methods of Managing Workflow

Healthcare

Support

Team

Chronic

Disease

Monitoring

Preventive

Med

Intervention

Behavioral Health

ConsultantProvider

Medication

Refill

New Acute

Complaint

Certified Medical

Assistant

Case

Manager

Test

Results

Point of

Care

Testing

Acute Mental

Health

Complaint Chronic

Disease

Compliance

Barriers

Parallel Work Flow Redesign

Primary Care Provider (1,100-1,400 empaneled customers)

1 RN Case Manager : 1 PCP

1.5 CMA : 1 PCP

1 CMS : 1 PCP

1.5 Midwives : 6 PCP

1 BHC : 6 PCP

0.5 RD : 6 PCP

1 PharmD : 6 PCP

Integrated Care Team Ratios

It’s all about relationships

What Works for the Customer-Owner

Case Management Support

RN Case Manager

Dietician

PCP

Coverage NP/PA

CMA BHC

Integrated Care Teams

Provider

RN Case Manager

Traditional Case Manager

Whole Person Case Management

Case Management Support (CMS)

Certified Medical Assistant (CMA)

Behavioral Health Consultant

Integrated Pharmacists

Dietitian

Integrated Midwifery

Integrated Care Team Current Work

Health care provider changes No longer a hero but a

partner

Control does not equal compliance

Replace blaming with understanding

Give customer options, not orders

Provider customer with resources

Make it simple

Customer-owner changes Actively involved in partnership with your Primary Care Provider

Take responsibility for your health

Get information about your health

Ask questions about advice

Ask for options

Information to Knowledge % SCF Central Pharmacy customer-owners requesting other

medications at dispensing

0%

10%

20%

30%

40%

50%

8/5/10 8/12/10 8/19/10 8/26/10 9/2/10 9/9/10 9/16/10 9/23/10 9/30/10

Percent

Average

Better

Source: Central Pharmacy-Pharmacy t ic-sheet 9.27.10

Change

Tested

Change

Implemented

% Employees with Current Annual Disaster Tng

53

74

94 98 100

0

50

100

2005 2006 2007 2008 2009

%

SCF Industry Best (100%)

Visits to ED/Fast Track Combined per 1000 Member Months

Native ownership begins

1998

ED Visits per 1000 Member Months (2015 HEDIS 25th Percentile=50.68)

Native ownership begins

1998

79.9%

87.5% 84.1%

98.4% 100.0% 98.2%

71.8% 68.9%

66.9%

92.7% 87.5% 89.5%

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%

70.0%

80.0%

90.0%

100.0%

Cervical Cancer Breast Cancer Colorectal Cancer Diabetes Annual A1c Diabetes LDL for CVD BMI Assessed

Pe

rce

nta

ge

of

cust

om

er-

ow

ne

rs

Eligible Customer-Owners Who Received Screenings: Those on Wellness Care Plans (WCP) vs. those who are not

On WCP ------ HEDIS benchmark(75%) No WCP

Sustained Improvements

95 96 % Employee Satisfaction

% Customer Satisfaction

36 36 % Reduction

ER Visits 2000-2015

% Reduction Hospital Admissions

2000-2015

Break

Behavioral Health is woven into the fabric of all the care at SCF

Relationships & Greater Awareness

Physical-Behavioral Connection

Increased Access

Why Integrate Behavioral Health?

Behavioral and psychosocial factors in etiology and treatment of physical disease

Primary Care as the location of treatment for mental health disorders

Financial advantages

Improved quality of care

Customer and provider satisfaction

Illustrates Biopsychosocial model

Meets patients “where they are at”

Unifies medical and mental health practice

Stigma surrounding going to “mental health”

Benefits of Integration

Behavioral Health Consultants (BHC) integrated into primary care clinics 12 years ago

How are we meeting the needs of customer-owners?

First steps – we started small

Ongoing

SCF History of Behavioral Health Consultant (BHC)

Behavioral Health Integration What We Do

Medical Behavioral Specialty

Collaborative Care

Shared goals and vision, but no financial or operational infrastructure

Flexible communication

Recruiting/training

Orientation and training of primary care providers

Maintaining strong connection to behavioral health

Proximity

Charting

Level of consultation/referral

Operational

Behavioral Health Integration Key Elements

Communication Model

Approach to Care

What We Found

Cost Efficiency Time Efficiency

Access Job Satisfaction

Customers present with a range of concerns

Meet them where they are at

Help to improve their overall health

Ex: Customer presents with chest pain, medical rule out, focus on stress

Grief, situational stress, etc.

Work with specific subpopulations

Targeted interventions for these

populations

Define treatment protocols and clinical guidelines

Ex: Depression screening and follow-up

Two approaches to clinical work

Not Targeted Targeted

• Depression (PrimeMD)

• Substance Use (SBIRT, CRAFFT)

• Cognition (MMSE)

• Development (ASQ, ASQSE, M/CHAT, SDQ, Vanderbilt)

• Chronic Pain

Behavioral Health Integration What We Assess

Referral From Provider

Introduction & Negotiating Work

Assessment

Intervention

Follow up Phase

Feedback to ICT Members

Phases of Brief Intervention

Clinical Access

Depression

Anxiety

PTSD/Acute Stress

Childhood Behavioral Concerns

Parent Coaching

Substance Abuse

Grief

Sleep Hygiene

Traumatic Brain Injury

Psychosocial Stressors

Family/Relational Stress

Specific age related concerns

• Women’s Health

• Children

• Elders

Clinical Areas in an Integrated Primary

Care Setting

BHC Training

Pe

er

Sh

ado

win

g

Primary Care Provider Orientation & Training

Needs Assessment

PCP Challenges

PCPs had difficulty with limited consult time

Visibility in primary care clinic was difficult with full caseload

Due to limited visibility referrals for medication stayed the same for those PCPs and BHCs who were not sitting directly next to psychiatry

Understanding how to use consultation and integration

Implementing this model secondary to Behavioral Health Consultants

Adding on additional responsibilities/tasks

Supervision of BHCs

Psychiatric case reviews

Too many cooks in the kitchen and steps in the process vs. collaboration to meet C-O needs

BHC Challenges

PCP providers used consult time

Most consults routed through BHCs

C-O getting behavioral health services when they need it

Better relationships between primary care and behavioral health staff

Increased capacity of PCPs to provide behavioral health

Start small, learn from failures

What Worked for Us

Success Data

77% Primary Care Clinic staff reported increased efficiency

88% Primary Care Clinic staff are more satisfied with their job since BHC Integration

91% increase in access to behavioral health service

31,224 customer visits to BHCs in 2014

Outcome data coming . . . PHQ-9, trauma scale, etc.

Increased access, capacity, quality and satisfaction

97% Customer-Owner Satisfaction

12-17% Reduced no Show/DNKA rates

15% Consultation Encounters/FTE increased

1 week Wait times down from 6 to 1 week

Clinical Access

Support for Change

91% attendance

Data analysis from the National Council initiative shows customers offered a same day appointment show up 91% of the time

20% decrease

Customers are 1% less likely to show up for their assessment appointment for every day they have to wait Based on SCF data history: Wait time for Primary Care Clinic (PCC) Intake Assessment was approximately 4 weeks

Behavioral Services Co-location with Medical Services Primary Care

More consultations between Behavioral Health Consultants (BHC) and Primary Care Providers (PCP) with on-site Psychiatrists

Shared pool/population of Customer-owners cared for in cooperation w/ PCP’s

PCP’s receive clinical chart reviews and treatment guidance regarding behavioral health issues and medications

Increased access/capacity with reduced wait time

Enhanced Integration

Outpatient BHC’s working with children, youth and families need more time for brief intervention (up to 45 minutes compared to 30 minutes for a BHC seeing an adult)

Finding the right fit for the BHC can be a challenge, since they often have experience working as a traditional therapist and may apply that perspective

Our Customer-owners are seeing more MSD-BHC’s than previously known

BHC Lessons Learned

Who really makes the decisions?

Acuity

“Control”

0 Low High

100%

1. Control – who makes the final decision influencing outcome? 2. Influences – family, friends, co-workers, religion, values, money 3. Real opportunity to influence health costs/outcomes – influence on the choices

made – behavioral change 4. Current model – tests, diagnosis, treatment (meds or procedures)

Shared Responsibility

Questions?

Come Visit Us in Alaska!

Training Dates

Learning Circles: Bringing People Together Webinar

Dates available soon

June Conference June 19th-23rd, 2017

London and Manchester Nuka Masterclasses

Oct. 2nd-3rd, 2017

Nuka Health Care Innovation Conference - Oregon

Oct. 23rd-24th, 2017

www.scfnuka.com @SCFNuka [email protected] 907-729-Nuka (6852)

Contact Us:

Thank You!

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