Retaining & Strengthening the Primary Care Workforce

Community Health InstituteMay 16, 2018

Mind and Body Wellness Clinic

(Obesity Management Project)

Gvantsa Didebulidze, MD

Brockton Neighborhood Health Center

Obesity in Primary Care Setting

High prevalence globally especially in medically

underserved areas

Lack of patient awareness about its detrimental

effects on health

Often neglected as a medical condition

Lack of supporting services to assure proper

follow up.

Multidisciplinary Approach for Obesity

Management

We based our project based on Guidelines(2013) for management of Overweight and Obese in Adults published by OS/ACC/AHA task force.

Our team was completed by Nutritionist, Behavioral Health Clinician, Community Health Worker, NP and physician.

Curriculum was created for biweekly group visits and biweekly telephone encounters for a follow up

Each group visit covered topics related to Comprehensive lifestyle intervention.

Criteria for Patient Selection

BMI >30 with or w/o Comorbidities

Motivated patients willing to make a change were referred by internal referral system

CHW provided screening by phone questionnaire to assess willingness and readiness to attend sessions

1. In the past month, have you been trying to lose weight?

2. Are willing to enroll in a group weekly visits that that involves visit s every 2 weeks in a group setting and follow up phone calls every 2 weeks for 3-6 months?

3. What time would work for you AM vs PM hours?

Our Goal

Educating our patients about

healthy weight and lifestyle

Realistic expectations: even 3-

5% of total body weight loss

can improve overall wellbeing

and underlying comorbidities

Understanding and revealing

factors and barriers affecting

weight management

Prescribe a calorie restricted diet based on the patients’ preference and health status.

“Obesity” Unhealthy weight as a complex chronic disease

Determinants of Obesity-genetics, lifestyle, medications, sleep and stress

Treatment- Comprehensive lifestyle intervention and other treatment options

Team Member Roles

RD

Learning about food groups

Plate model

Importance of breakfast

Learning how to read labels

and making smart choices

during food shopping

Low budget healthy eating

Challenging situations

Eating at fast food restaurants

Portion management

Simulated menu cases

Food shopping with dietician

Group activities: like making your own snack during group visits

Food diaries

One on one visits with RD

CHW

Point of contact for enrolled patients

Patient assessment for specific needs and barriers to attend group visits

like lack of transportation, housing etc

Weekly phone call reminders about upcoming group visit appointments

BHC

Chart reviews and assessment for underlying mental health comorbidities

Connecting patients in need to MHD

Motivational interviewing

Stress management

Using behavioral strategies to assist our patients in adherence to prescribed

diet, exercise and overall lifestyle changes.

Mindfulness and self care

MD/NP roles

Chart review/medical history/weight history

OSA screen

Medication review and identification of weight promoting agents

Assessing comorbidities

Obtaining (A1C, TSH, Lipid profile) if not done within 12 months

Prescribing physical activity based on each individual patients n

Assessing patients for adjuvant therapy (weight loss medications) and bariatric surgery.

Interactive learning through clinical vignettes

Open discussions and Q&A

Developing curriculum and hand outs for each session, including behavioral health tips, Nutritional guide, medical facts and physical activity guidelines.

About Pilot

March 5th-May 14th

About 20 English speaking

patients were selected

Age 19-59

BMI 32-51

Attendance 1-5 sessions

* Weight change +3lbs, O and

-4 lbs.

Almost 100 % admitted to be stressed

>40% had known mental health condition

* >40% had medical co-morbidity

* 3 patients were diagnosed with night eating syndrome and Bulimia Nervosa

Future of Mind & Body Wellness Clinic

• After Pilot clinic will be open throughout health center

• Sessions will be available in different languages (Haitian Creole, Cape Verdean Creole and Portuguese)

• Clinic will be self-sustainable as encounters are billable.

• We are exploring opportunities to acquire space for exercise studio

• We are working on development of support group using Social Media to engage enrolled patients in group activities and information sharing.

• Our clinic has success history with organizing cooking and diabetes groups, before we didn’t have any recourses for our obese patients, our clinic is the first initiative with this perspective.

• Main Challenge - High no show rate

Thank You!

Massachusetts League of Community Health Centers’ Annual Community Health Institute

Wednesday, May 16, 2018

Sea Crest Hotel , Falmouth , Massachusetts

Brent A. Fryling MD

Objectives:Background, history, and mission of Lynn

Community Health Center

The need for treatment of Hepatitis C

Project description: Access To Hepatitis C Testing, Treatment, and Cure at the Commnunity Health Center

Lessons learned

Background, History, Mission

Background, History, Mission Began as storefront

mental health counseling center in 1971

Now providing over 280,000 patient visits to over 60,000 patients

Services in primary care, OB/Gyn, complex addictions, behavioral health and dental

Hepatitis C – the need for treatment

Hepatitis C – The need for treatment

WHO estimates 170 million (3%) of the world population is infected with Hepatitis C

Highest infection rates in Egypt

Lowest infection rates in Sweden

In USA, CDC estimates 2.7 – 3.9 million people infected with Hepatitis C.

People born from 1940 – 1965 have highest incidence rates

25,000 people die of cirrhosis and chronic liver disease each year

Hepatitis C – The Need for Treatment

Hepatitis C – The Need for Treatment

Hepatitis C – The Need for Treatment

Hepatitis C – The Need for Treatment

Hepatitis C – The Need for Treatment

Hepatitis C – The Need for Treatment

Massachusetts League of Community Health Centers’ Grant has allowed Lynn

Community Health Center to respond to the call to treat and cure Hepatitis C

The Project-Data

-Champions

-CME

-Address Obstacles

-Sustainability

The Project:Data-Hepatitis C diagnosis and viral load check = 1437

-- Hepatitis C patients treated:

- 2015-2016 21

- 2016 – 2017 81

- 2017 – 2018 98

The Project: Hepatitis C Champions

Hanna Haptu - Pearl team

Clark Van Den Bergh -Blue team

Sara Nakhal - Purple team

Marianne Bauer –Sunflower team

James Nicholson –Orange Team

Brent Fryling - Green Team

The Project: Hepatitis C Champions

For 6 months provided 3 hours each week dedicated Hepatitis C time to each champion

Included every other week Hepatitis C case conference

At first hours used for data and CME, later used for patient care

The Project: CMETwo CME sessions presented by Dr Camilla Graham, BIDMC

The Project: CME

The Project: CME

The Project: Obstacles

-Provider time away from patient care hours

-Prior authorization process

The Project: ObstaclesProvider time:

Schedulers were able to reserve Hepatitis C slots and then fill with other patients if not needed

Scripts written were a help to our pharmacy and therefore the bottom line of the health center as well

Prior Authorization:

-Staff PharmD has been able to utilize time of pharmacy students to streamline prior authorization process for providers

--Hep C “smart phrases” helpful for prior authorization process.

The Project: Sustainability-When grant ends, the only thing that will change is the protected hepatitis C time.

-Providers are keeping gained knowledge and experience

-Organization is keeping gained knowledge and experience

-Many staff involved in grant work were not supported by the grant so their work continues

-This grant has truly “primed the pump” for hepatitis C treatment

and cure at Lynn Community Health

Center.

Lessons Learned

Lessons Learned

Acupuncture & Community

Health in 2018

Jiani Guo DO

Charles River

Community Health

5/16/18

What Is Acupuncture?

Meridian

Qi

The Origins of Acupuncture

Earliest Evidence of Acupuncture and Meridians:

East- Huang Di Nei Jing (Yellow Emperor’s Inner Classic)compiled during 1st century BC and early 1st century AD

West- Otzi the 5300 year-old mummified Iceman from the Austrian Alps had numerous tattoos, with about 80% that coincided with acupuncture meridian lines

Acupuncture Points or Tattoos?

Auricular Acupuncture

Possible Complications● Pneumothorax

● Visceral Complication: pneumoperitoneum, hemothorax, cardiac tamponade, and penetration of the kidney and bladder.

● Local inflammation, bacterial abscesses, and chondritis from needling points on the ear.

● Minor sensory impairment from penetrating peripheral nerves

● Infections

Is there a Role for Acupuncture in American Healthcare Today?

The Acupuncture Evidence Project

Can Acupuncture benefit Community Health patients?

Can Acupuncture help our Community Health Centers?

$$Cost-Effectiveness$$

Grant Project Summary

● Medical Acupuncture For Physicians Course (Helms

Medical Institute): 300 CME hours

● Helms vs. Harvard

● Acupuncture for Primary Care and for Pain

Management.

Sustainability Plans

Challenges/BarriersInsurance Coverage

Cultural Misconceptions

Needle-shock!

Pregnant Patients

Pediatrics

References

● https://www.ibtimes.co.uk/new-tattoos-found-otzi-iceman-support-prehistoric-acupuncture-theory-1485224

● http://blogs.discovermagazine.com/d-brief/2015/01/30/scientists-mapped-otzi-icemans-61-tattoos/#.WuvDYi-ZORs

● Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. Medical Acupuncture Publishers. 1st Edition. 1995

● McDonald J, Janz S. The Acupuncture Evidence Project: A Comparative Literature Review (Revised Edition). Brisbane: Australian Acupuncture and Chinese Medicine Association Ltd. 2017

Paying Attention to Our Children: ADHD as a Model for Collaborative Care in a Pediatric Medical Home

D A N A S . R U B I N M D , M S W

D O T H O U S E H E A L T H

P E D I A T R I C I A N / C H I L D P S Y C H I A T R I S T

B O S T O N U N I V E R S I T Y S C H O O L O F M E D I C I N E

C L I N I C A L A S S O C I A T E P R O F E S S O R O F P E D I A T R I C S A N D C H I L D P S Y C H I A T R Y

Our Medical Home: DotHouse Health Fields Corner, Dorchester, MA

Project Goal: Improve Care for Children with Attention Deficit Disorder (ADHD)

ADHD and Collaborative Care

ACCT: ADHD Collaborative Care Team

Quality Improvement

Based on NCQA* ADHD quality measures, created database for children with ADHD, ages 6-12 yo

Professional Development/Education

*National Committee for Quality Assurance

ADHD Collaborative Care Team(ACCT)

LCSW – D. Meji-Tejeda

Case Manager – Maria Ortiz

Pediatric Nursing Staff

Pediatric providers

ACCT Algorithm Visit 1 Visit 2 Visit 3 – follow up in < 30 days

PCP

ADHD /BHI Clinician

Pedi triage nurse: Consultation only

Case Manager

BH= Outpatient BH at DotHouse health; BHI= ADHD Behavioral health integration clinician: EMR referral with some capacity for on site visits: CBHI: Child Behavioral health initiative referrals

1. Call family to remind

about need for refills

and face to face

appointments.

2. Facilitate 504

accommodations

with family and

school

3. IEP as needed

4. Make other referrals

as needed

Family

presents

with

concern

about ADHD

1.Vanderbilt screen 2. Release for school 3. EMR /live

ADHD referral

for BHI clinician

Referral for

outpatient BH or

Case management

for CBHI services.

1. Call family with general information about ADHD and confirm follow up appt 2. Call school for feedback including previous testing and Vanderbilt 3. Remind family about follow up Appointment and enter data for Vanderbilts prior to next visit 4. BH and CBHI referrals as needed 5. Consult with Pediatric nursing and /or provider with specific medication questions

1. Vanderbilt forms + observations to determine DSM5 diagnosis of ADHD 2. Medication for ADHD prescribed 3. Route chart to ADHD BHI 4. If other concerns consider specific screens, such as SCARED, MFQ, PHQ9 Adol (>12 y.o.) and BH referral

1. Call family to see if any questions 2. Call in 2 weeks to confirm family has picked and starting medications 3. Confirm apt for 1 month check 4. Call to remind about 1 month apt 5. If medications or medical questions refer to ADHD nurse 6. Facilitate 504 letter to school and educate (re: process)

1. Follow up with families who have questions 2. Support ADHD Clinician Re: information about medications for medical issues

1. Check for improvement 2. Monitor side effects 3. Resend Vanderbilts once on stable dose 4. Monitor wt, ht and bp and pulse 5. Make referrals as appropriate

Refer to CBHI services

Example of ACCT coordinator work flow

Encounter #1

Call family and send introduction letter

Family has Vanderbilt forms for school

Enter Vanderbilt scores in EPIC

School consent signed

Contact school for forms and past evaluations

Follow up appointment made

Questions about ADHD, diagnostic process, medications , educational supports

Provider Work Flow ChangesNEW: Internal referral for ADHD care coordinator

Epic based workflow for ADHD

Vanderbilt forms for assessment of ADHD

Letters to request school support for students ( 504 plan and IEP )

Coming soon: AAP toolkit handouts for parents Toolkit

Insurance Based ADHD Quality Measures

DHH database with NCQA specifications to monitor compliance Measure 1: Percentage of patients 6-12 years old on medication who had a follow up visit after 1st prescription within 30 days: 43%

Measure 2: Percentage of patients 6-12 years old on medications who had 2 follow up visits in the following 270 days after first visit follow up visit: 100%

Is NCQA measure best way to monitor quality care for our patients ?

Data is a “snap shot” of our performance over year Number of patients who qualify is VERY small (M1= 16 , M2= 5) Difficult to get true picture of our practice Hard to assess practice changes with interventions

Quality Improvement: Practice Database

Data includes children with ADHD diagnosis in problem list and in medical visits, Ages 6-12 years old Ethnicity

Date of first Diagnosis

Date of first prescriptions and last prescription

Initial and follow up visits for ADHD

Intervals between visits

Providers

How Are We Doing at Baseline?

Stratified ADHD group to those actively on medication247 children ages 6-12 with ADHD

95 currently prescribed medications in last 3 months

Measured Interval in days from first prescription to first follow up visit

NCQA goal is less than or equal to 30 days

Median interval in days: 45

Plan to track this interval with addition of ACCT protocol.

Challenges and Lessons Learned

Database

Many steps to translate NCQA measure

Defining cases and meaningful measure of ‘good’ care challenging

Data has brought to light other concerns, such as problems with tracking children with ADHD or ADHD concerns if they are NOT on medications

Staffing

Set up team including nursing and case management; within 1 month, 2 members of staff left

Shifted resources to add Global Health Intern for help with data management and expand conference opportunities to staff

Reconfigured staffing to utilize newly hired BHI provider with both case management and clinical experience

2017 2018

Today

Sep Oct Nov Dec 2018 Feb Mar Apr May Jun

Cherokee Conference Sep 15

Cherokee Conference staffJun 22

Hire Global Health Fellow Feb 1

Hire LCSW for BHI and Care coordinator Feb 2

PIC- ongoing QI project at DHHMay 25

Go LIVE Apr 2

Provider education - Baseline ADHD data and project

Dec 14

Provider education - Diagnosis of ADHD and treatment

Mar 15

Provider education - PMT - BMC psychologist

Mar 28

MGH ADHD conference Mar 4

Pediatric Academic Society -QI conference May 4

Care coordinator - changed positions

Jan 8

Nurse left Health Center

Jan 15

Internal referrals unable to be accessed by LCSW

Apr 3

Sep 7 - Jun 1100%ADHD data

Sep 7 - Jun 195%NCQA

Sep 5 - Jun 190%ACCT Protocol

Nov 16 - Jun 1ACCT Workflow

Jan 8 - May 2960%Patient Education

Education and Professional Development

Patient education:

• AAP ADHD toolkit license

• Phone or face to face contact with ACCT care coordinator

Professional development:

• Cherokee conference/training Behavioral Health Integration

• Academic Pediatric Association: Quality improvement

• MGH-ADHD Across the Lifespan= Psychopharmacology

DHH Staff Education

• Lunchtime seminars: Diagnosis of ADHD, Parent management training and ADHD Medication Management

• Staff offered opportunity to attend Cherokee Health systems Behavioral Health Integration training

Next Steps….Project will continue in the form of Quality Improvement Project Goal of decreasing time from first prescription to follow up visit with

provider by 20%InterventionACCT protocol –Go Live : May 1 Run database monthly to track changes EducationContinue staff education for psychosocial and psychopharmacological treatment Continue to develop patient education material around ADHD and school

advocacy

Special Thanks

Bethel Aklilu, MPH; Global Health Fellow at DotHouse Heatlh

Huy Nguyen, MD; CMO , DotHouse Health

Emily Feinberg, ScD,CPNP; PCP , DotHouse Health and Associate Professor , BU School of Public Health

Digna Mejia-Tejada and Maria Ortiz: the backbone of our clinical support to families

Rima Klevsky, Do Quyen Pham– IT/Quality Improvement DotHouse Health

Mass League of Community Health Centers for support for improving the care of children in their Medical Homes

Michael Tang, MD

Adult Psychiatrist, Child Psychiatrist and Pediatrician

Clinical Director of Behavioral Health Integration

The Dimock Center

Massachusetts League of Community Health Centers

Special Projects Grant Presentation

May 16, 2018

1. Screen for depression

2. Screen for social determinants of health

3. Integrate our Substance Use Disorder Outpatient Clinic

4. Manage inpatient psychiatric hospital notifications

5. Design a Behavioral Health Care Manager role

• Team includes:• Chief Medical Officer

• Psychiatrist / Associate Clinical Director

• Social Worker / Program Manager

• 4 Community Health Workers

• Nurse Care Manager

• Primary care providers, Nurses, Medical Assistants, Behavioral Health clinicians

0

20

40

60

80

100

120

Wee

k 1

wee

k 2

wee

k 3

Wee

k 4

Wee

k 5

wee

k 6

wee

k 7

wee

k 8

wee

k 9

wee

k 1

0

wee

k 1

1

wee

k 1

2

wee

k 1

3

wee

k 1

4

wee

k 1

5

wee

k 1

6

wee

k 1

7

wee

k 1

8

Provider #1 Provider #2 added All Providers

Over the past 10 months: 354 patients seen 3,000+ visits Moved onto EHR More access, less stigma

MBHP manually compiles

CHC psychiatric admissions

into a spreadsheet

MBHP sends spreadsheets

via secure server to Dimock

forwarding emails

DimockIntegrated Therapists

receive emails and

login to secure server

Therapists call inpatient

units and follow-up on admissions

and discharges

• Insurance company (MBHP) notifying Dimock in real-time about inpatient psychiatric admissions

• During pilot: 44 total admits (including 30 adults)

• Developing workflows:

Reviewed charts of 99 high-risk patients

Designed workflows; began 1st pilot

Hired Behavioral Health Care Manager

Began 2nd pilot February 2018

Outreached to 13 BH patients, conducted intakes with 6 patients and completed care plans

Intensity: 29 contacts, including 13 face-to-face integrated visits

Adult Medicine Clinic Director

MEDICAL:

5.0 FTE MD Internists

1.0 FTE Nurse Practitioner

Nurses

Medical Assistants

BEHAVIORAL HEALTH:

1.2 FTE Access Therapists

4.0 FTE BH Clinicians

3.0 FTE Substance Use Disorder Clinicians

1.1 FTE Psychiatrists

2.0 FTE MAT Team

RESOURCE SUPPORT:

3.0 FTE Resource

Specialists

CARE MANAGEMENT

TEAM:

1.0 FTE NP

1.0 FTE Integrated Behavioral Health

Care Manager

1.0 FTE Community

Health Worker

Screening for depression & social needsInpatient psychiatric notifications

Questions?