Session #C1b October 28, 2011 11:15 AM San Diego System Transformation: Implementation Lessons Learned, Approaching the Tipping Point Lauren Chin, MPH, Health Planning & Program Specialist, Health & Human Services Agency, County of San Diego Nora Cole, MEd, MFT, Associate Director, Mental Health Services, Family Health Centers of San Diego Shelly Tregembo, M.A., Administrative Analyst Health & Human Services Agency, County of San Diego Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months. Need/Practice Gap & Supporting Resources 25 year mortality disparity for those with Serious Mental Illness (SMI); increased mortality is primarily due to chronic physical conditions ( heart disease, stroke, diabetes, etc) – Improved physical health care is important for this population. Public Specialty Behavioral Health is a scarce commodity; improved access for those who need specialty services is achieved when stable SMI are managed in a primary care medical home rather than specialty care. Objectives • Describe the integration of behavioral and primary health care on site at three rural clinics. • Describe a process for linking SMI with chronic health conditions to primary care more successfully by accelerating the eligibility process. • Explore issues related to the transition of “stable” SMI to primary care medical home for ongoing medication monitoring and physical health care. • Describe a system for pairing of mental health and primary care clinics by region and neighborhood for coordinated treatment and bidirectional referral Expected Outcome Identify resources and tools to develop or strengthen relationships between behavioral health and primary care providers; to increase capacity for mutual engagement in shared population management to meet the physical and behavioral health care needs of the SMI population. Live Well, San Diego! San Diego County • Population: 3.2M; 4,300 sq. miles • Urban, suburban, and rural communities • Ethnically diverse; 68 languages • No county-run primary care services Complex Web of Safety Net Services Physical Health Behavioral Health • 17 separate primary care organizations (FQHCs / non-profit clinics) • Approximately 100 individual primary care sites • Children/Youth: FQHC’s and other health systems (numerous providers) • County funded Mental Health: 61,000 clients / year • ADS serves 12,000 clients / year • Most services contracted to organizational providers and/or FFS (Dozens of clinics & programs) Wagner Chronic Care Model Community Health System Resources and Policies Health Care Organization SelfManagement Support Informed, Activated Patient Delivery System Design Productive Interactions Clinical Decision Support Information Systems Prepared, Proactive Practice Team Improved Outcomes San Diego Paired Provider Model © • Different governance & payment • Generalists and Specialists Paired/partnering provider organizations • Continuum of care - Virtual PCMH’s • Shared management of a SINGLE population, “owned” jointly – Bi-directional Flow (Clients and Info) – Continuous access for all BH needs Copyright © 2011 San Diego Health and Human Services Agency Integrated Care System Bi-directional, seamless flow of clients and information Behavioral Health Consultant RN Care Coordinator BH MD Only FQHC BH Program Severity / Acuity Recovery / Stability Community / Peer Supports PC San Diego Paired Provider Model © What’s in it for Behavioral Health? – Less acute clients to FQHCs – Improve access for the most SMI – Now have partners to attend to the physical health needs of our shared population Copyright © 2011 San Diego Health and Human Services Agency San Diego Paired Provider Model © What’s in it for Primary Care? • “The Triple Deliverables” – Access for clients needing specialty MH – Consultation » Not just for SMIs – Education of providers AND support staff Copyright © 2011 San Diego Health and Human Services Agency ICARE Integrated Care Resources Nora Cole, MEd, MFT Family Health Centers of San Diego ICARE Integrated Care Resources • Collaborative Pilot Project – Family Health Centers of San Diego (FHCSD) – Community Research Foundation (CRF) • Funded by County of San Diego Staffing • • • • • • • Nurse Care Coordinator Project Manager Peer Specialists (3) Eligibility Specialist Behavioral Health Consultants (3) Alcohol and Other Drug Counselor Data Entry/Project Support Sites • CRF: – Areta Crowell Center • FHCSD: – North Park Family Health Center – City Heights Family Health Center – Logan Heights Family Health Center How it Works CRF Discharge Planner (DP) meets with client ready to transfer care to FHCSD If uninsured, potential transfer is linked to CRF Eligibility Specialist (ES) DP notifies FHCSD site Behavioral Health Consultant (BHC) of potential transfer; BHC makes initial assessment appointment BHC schedules transfer an appointment with the Alcohol and Other Drug Counselor (AOD) for an assessment, unless AOD met with transfer at Areta Crowell BHC makes First Appointment with Physician Champion (PC) or alternate BHC introduces transfer to Peer Support Specialist (PSS) for support, resource information, etc. PC refers to specialty care as needed NOTE: Nurse Care Coordinator (NCC) out-stationed at CRF for health screening of CRF participants and facilitate link to FHCSD primary care if emergent health care issue is identified – accessible to Areta Crowell program participants regardless of transfer readiness. Keys to Success • Shared refinement of referral criteria • Mutually developed referral process • Well-rounded referral information packet at transition • Availability of same day consultation by transferring party • Expedited re-entry to CRF if needed • Regular communication How it is working so far • Change is difficult for some; others are confident their overall health will improve • Physicians like having a team to work with, especially the added AOD resources • Therapists understand and value the model; occasionally feel like salespeople with those struggling with the transition • Peers enjoy helping clear up misunderstandings about systems Workforce Issues • • • • • Education Training Orientation to team concept Personal beliefs about mental illness Turf System-Wide Integration Efforts in San Diego County Shelly Tregembo, MA HHSA Behavioral Health Services System-wide Integration Efforts Several pilots launched: – Mental Health and Primary Care Integration Services – East County Integrated Health Access pilot (ECIHA) – MHSA PEI Rural Integrated Behavioral Health & Primary Care Services (SmartCare) – MHSA Innovations- ICARE System-wide Integration Efforts • Mental Health and Primary Care – 7 clinic organizations – MHSA-funded – SPS, Senior Promotoras, IMPACT • SmartCare – 3 rural clinics – MHSA PEI – behavioral health screening, evaluation, education, short term counseling and wellness activities Recent Developments • Integration Summit • Integration Institute (I2) • Psychiatric Consultation to Primary Care (PC2) • Low Income Health Program (LIHP) Emerging Best Practices • Find your champions of integration • Employ the “right” people • Develop MOUs and SOPs • Deliver support to providers The Road Ahead • Patient-Centered Medical Homes • 2014 and Healthcare Reform • Outcomes-driven funding • Accountable Care Organizations How San Diego is Preparing • Gaining system-wide buy-in for shared population management • Providing Access, Consultation and Education • Convening the first Integration Institute Contact Information • Lauren Chin, MPH 619-563-2702 email@example.com • Nora Cole, MEd, MFT 619-515-2318 firstname.lastname@example.org • Shelly Tregembo, MA 619-584-5049 email@example.com Live Well, San Diego! Questions & Discussion Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!