Session #G2 October 5, 2012 Integrated Care: Where Clinical Need Intersects Sustainability Collaborative Family Healthcare Association 14th Annual Conference October 4-6, 2012 Austin, Texas U.S.A. Integrated Care Where Clinical Need Intersects Sustainability Behaviorally Enhanced Health Care Home Shaping Healthy Communities Shaping Healthy Communities. Kimberly A. Arlinghaus, M.D. Medical Director, Behavioral Health Lone Star Circle of Care Department of Psychiatry and Behavioral Health 512-686-0207 ext. 10375 [email protected] Greg Jensen, LCSW, ACSW Vice President for Behavioral Health Lone Star Circle of Care Department of Psychiatry and Behavioral Health 512-686-0207 ext. 10135 [email protected] © 2009 Lone Star Circle of Care Brian … 17 y/o HM • PTSD, Bipolar d/o, Polysub abuse, ADHD • 4 SAs 12-16 y/o • Multiple psych hosp, BBT, PP therapists, primary care Carousel Pediatrics • Psych meds by Carousel • HTN, reflux, “passing out” w/hx of head injury © 2009 Lone Star Circle of Care 2 Psychiatrist-Therapist Collaboration • BH intake by therapist • Psychiatric evaluation—added hx psychosis, TBI, and changed BD to MDD; changed medications • Ongoing med management, psychotherapy, and encouragement to enroll in LSCC primary care © 2009 Lone Star Circle of Care 3 Psychiatrist-Therapist-PCP Collaboration • LSCC PCP visit • Facilitated neurology work-up for TBI and question of seizures • Obtained additional medical records • Assisted with checking drug screens and monitoring suicidality © 2009 Lone Star Circle of Care 4 Network Collaboration • Seton ER • Consultation with ER physicians • Hospitalization • IOP, 12-step • LSCC for therapy, medication management, primary care © 2009 Lone Star Circle of Care 5 The Bottom Line…Shared Care is Best Care Right thing to do for the patient Adds value to the community Sustainable and scalable © 2009 Lone Star Circle of Care 6 Goals For Today • Establish the vision and mission concepts necessary to create organizational commitment to integrated care • Define governance, operational, financial and clinical issues to implement a behaviorally enhanced community health center • Discuss critical sustainability success factors and challenges © 2009 Lone Star Circle of Care 7 Vision Every Central Texan who needs access to psychiatry and psychotherapy will have access to a fully integrated, behaviorally enhanced, healthcare home © 2009 Lone Star Circle of Care 8 LSCC Behavioral Health: Mission • Provide behaviorally-enhanced healthcare services to patients who have LSCC as their medical home • Provide access to BH services in collaboration with community partners who have aligned and complementary goals © 2009 Lone Star Circle of Care 9 LSCC Clinics LSCC services offered in each city: Killeen Austin ‒ Pediatrics ‒ Family Medicine Round Rock ‒ Behavioral Health ‒ Family Medicine Belton ‒ OB/GYN ‒ Pediatrics ‒ Senior Health Cedar Park ‒ Pediatrics (also Adolescent) ‒ Pediatrics ‒ Behavioral Health Georgetown ‒ Pharmacy ‒ Family Medicine Taylor ‒ Senior Health ‒ Family Medicine ‒ Pediatrics Temple ‒ Behavioral Health ‒ Family Medicine ‒ Pharmacy ‒ Dental Harker Heights ‒ Pediatrics ‒ Behavioral Health (child & adolescent) Hutto ‒ Pediatrics Lone Star Circle of Care / Locations © 2009 Lone Star Circle of Care 10 Locations of LSCC Dedicated BH Clinics © 2009 Lone Star Circle of Care 11 “The Usual Way” Psychiatry Outsourced Mental Health Stigma Medicine © 2009 Lone Star Circle of Care 12 “The Lone Star Circle of Care Way” Behavioral Health Providers (Psychiatrists and Counselors/Therapists) are members of LSCC medical team thereby leveraging ALL Integrated Delivery System benefits © 2009 Lone Star Circle of Care 13 Integrated Care: Why Do It? • Up to 70% of patients presenting for primary care have some type of behavioral health (BH) problem which impacts diagnosis and treatment • Patients are more likely to receive BH treatment if they are treated via an integrated model • Treatment of BH problems enhances medical outcomes and quality of life • Integrated care optimizes efficiency of health care delivery © 2009 Lone Star Circle of Care 14 Depression and Diabetes • 95% of diabetes management is conducted by the patient • If the patient is depressed… Poorer outcomes Increased risk of complications < glucose monitoring < adherence to diet, exercise, and medication regimens © 2009 Lone Star Circle of Care 15 Potential Systemic Effects of the “Depressed” Brain • Sticky platelets • Decreased heart rate variability (HRV) • Increased C-reactive protein • Increased cortisol © 2009 Lone Star Circle of Care 16 Systemic Effects of Cortisol • • • • • • • Redistribution of body fat High sympathetic tone Elevated noradrenaline Increased HR Reduced HRV Decreased insulin sensitivity Decreased bone absorption of calcium © 2009 Lone Star Circle of Care 17 Depression Worsens Outcome of Heart Disease • Depression worsens morbidity and mortality after myocardial infarction1,2 • Depression increases morbidity and mortality in patients with CHF3,4 1. Frasure-Smith N, et al. JAMA. 1993;270:1819-1825. 2. Penninx BW, et al. Arch Gen Psychiatry. 2001;58:221-227. 3. Jiang W, et al. Arch Intern Med. 2001;161:1849-1856. 4. Vaccarino V, et al. J Am Coll Cardiol. 2001;38:199-205. © 2009 Lone Star Circle of Care 18 Behavioral Cardiology (Pickering et al. 2003) • The causes of heart disease lie not so much in the heart itself, but in the brain, or more specifically, the mind. • The mind affects the heart via: Our lifestyles Effects of psychosocial stresses and how we cope with them © 2009 Lone Star Circle of Care 19 Integrated Care Outcomes Research Better Outcomes/Improved Functioning: Independent Three-year Process and Outcome Evaluation (Dr. Toni Watt, Texas State University. Commissioned by St. David’s Community Health Foundation, 2008) ‒ ‒ ‒ Statistically significant decrease in depression symptoms (32%) that remained constant over two, three and six month period Self-report measures showed patient’s physical health, daily living activities performance, ability to socialize improved significantly Treating BH illnesses does not cost the overall health system more money. While there was an initial increase in costs, from 6-21 months post treatment, the costs remained stable © 2009 Lone Star Circle of Care 20 Integrated Care: Solution An Institute of Medicine report in 2005 concluded that the only way to achieve true quality (and equality) in the health care system is to integrate primary care with mental health care and substance abuse services. (Institute of Medicine, “Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series”, November 1, 2005.) © 2009 Lone Star Circle of Care 21 Integrated Care: What Differentiates LSCC’s Model BH and medical providers employed by LSCC BH and medical providers on the same HER LSCC treats ALL psychiatric groups BH records fully open to the medical providers Medical providers have immediate access to psychiatrists BH specialists embedded into the medical clinics Single governance structure that develops the integrated services Active mental health screening in medical clinics Psychiatrists actively treating patients vs. consultant © 2009 Lone Star Circle of Care 22 Governance: Behaviorally Enhanced Healthcare Integration Council 1. 2. 3. 4. 5. Provide guidance to and oversee integration implementation Define and monitor outcome measures Set professional practice standards such as defining and utilizing screening tools, establishing interdisciplinary care conferences, etc. Establish reimbursement guidelines Provide recommendations to LSCC Senior Leadership pertaining to the ongoing practice issues, resources and/or enterprise-wide impact of integration © 2009 Lone Star Circle of Care 23 Addressing PCP Challenges: Time and Access • Embedding behavioral health specialists Provide “real time” consultation to medical staff Conduct crisis intervention for patients in the clinic Facilitate and expedite access to psychiatric services Provide brief therapy/counseling services to patients Coordinate care with the patient’s PCP Assist with efficient patient flow • Real time PCP consultation with child and adult psychiatrists • Telepsychiatry © 2009 Lone Star Circle of Care 24 The LSCC Integrated BH Model: Screening Medical patients for mental health concerns TeenScreen for 11-17 year olds PHQ 2 for depression CAGE for substance use Vanderbilt for ADHD AD8 for cognitive decline in older adults Edinburgh 3 for post partum depression MCHAT for autism Behavioral health patients for medical concerns Primary care service provider (medical home) Hypertension Obesity Diabetes Co-occurring substance use disorders Tobacco product use Pain © 2009 Lone Star Circle of Care 25 LSCC’s Integrated Care Model Providing holistic care by diagnosing and treating physical AND mental conditions … together BH screening in medical clinics Embedding BH providers using open access Providing PCPs direct access to psychiatrists Interdisciplinary collaboration Electronic health record © 2009 Lone Star Circle of Care 26 Easy Access to Clinical Information: EHR © 2009 Lone Star Circle of Care 27 Increasing Access Lone Star Circle of Care Behavioral Health Visits FY2005 - FY2012 (Projected) 2006-2012 1 to 17 prescribers 0 to 31 therapists 51,417 37,219 23,737 10,000 519 2005 1,119 2006 3,937 5,023 2007 2008 2009 2010 2011 Projected FY2012 © 2009 Lone Star Circle of Care 28 Behavioral Health Visits By Patient’s Residence Lone Star Circle of Care (LSCC) Number of Behavioral Health (BH) Care Visits by City of Residence Fiscal Year (FY) 2011 and FY2012 (Annualized) 15,000 FY 2011 Number of BH Visits FY 2012 (Annualized) 12,000 9,000 6,000 3,000 0 Austin Round Rock Georgetown Leander Killeen Cedar Park Pflugerville City of Residence Hutto Taylor Belton Behavioral Health as % of Total LSCC Visits Lone Star Circle of Care Visits Fiscal Year (FY) 2005 - FY 2012 (Projected) Behavioral Health Visits Fiscal Year Total Health Visits Number Percent 2005 24,895 519 2.1% 2006 35,348 1,119 3.2% 2007 74,224 3,937 5.3% 2008 96,131 5,023 5.2% 2009 127,121 10,454 8.2% 2010 202,568 23,737 11.7% 2011 298,264 37,219 12.5% Projected 2012 360,832 51,417 14.2% Source: Lone Star Circle of Care encounters occurring in FY2005-FY2011 and projections for FY2012. % of Behavioral Health Patients with LSCC Medical Home Lone Star Circle of Care (LSCC) Behavioral Health Patients Medical Home Utilization Fiscal Year 2011 (December 2010 - November 2011) Did Patient Have a Medical Health with LSCC in FY2011? Yes No Most Recent Behavioral Health Visit Paid By: Total Number Percent Number Percent Total, all Payors 6,801 4,337 63.8% 2,464 36.2% Medicaid/CHIP 2,745 1,795 65.4% 950 34.6% Uninsured 2,520 2,001 79.4% 519 20.6% 936 244 26.1% 692 73.9% Private Insurance Medicare 600 297 49.5% 303 50.5% Source: Lone Star Circle of Care encounters occurring in FY2011 (December 1, 2010 - November 30, 2011). Integrated Behavioral Health Sustainability and Scalability • Provider Mix • Payer Mix • Psychiatrists AND therapists with same employer as medical providers Leverage FQHC to increase access to mission patients Productivity Goals by provider type © 2009 Lone Star Circle of Care 32 Behavioral Health – Utilization (January 2012-August 2012) LSCC BH Utilization, Jan 2012 – Aug 2012 80.0% 78.4% 78.0% 76.0% 74.9% 73.3% 74.0% 71.9% 72.0% 71.9% 72.7% 72.5% 70.8% Utilization 70.0% 68.0% 66.0% No Show Rate January February 24.9% 23.9% March 24.9% April 26.3% May 26.9% June 27.9% July August 26.8% 26.7% © 2009 Lone Star Circle of Care 33 Challenges: No Shows and Utilization • No Show Policy • Confirmation Calls • Reverse Confirmation Calls • Therapist-Based Intakes • Same Day Call In List • Intakes at Same Time and Overbook © 2009 Lone Star Circle of Care 34 Integrated Behavioral Health Outcomes & Scalable Results • Quality Metrics • Operational Metrics • Symptom reduction Functional improvement (future) Access Assess safety at each visit Volume Productivity Satisfaction Metrics Patient satisfaction data © 2009 Lone Star Circle of Care 35 Integrating Education and Clinical Service BH Training Partnerships • Seton/UT Southwestern Psychiatry Residents • Texas A&M Medical Students • UT School of Social Work • UT School of Educational Psychology • UT College of Nursing © 2009 Lone Star Circle of Care 36 Psychiatry and Behavioral Health – Community Partners • • • • • • • • • • • • • • • • • • Texas A&M Health Science Center Seton Family of Hospitals University of Texas Southwestern /Seton Residency Program St. David’s Foundation Scott and White Bluebonnet Trials – Williamson County MH/MR STARRY Texas Baptist Children's Home Caring Family Networks Arrow Child and Family Ministries Lighthouse Family Network Central Texas Children’s Home Texas Star Recovery Center Department of State Health Services Texas A&M School of Rural Public Health University of Texas School of Social Work Williamson County Mobile Outreach and Wilco MH Task Force Wilco and ATCIC Community Providers © 2009 Lone Star Circle of Care 37 New Initiatives in Behavioral Health © 2009 Lone Star Circle of Care 38 Austin Independent School District (AISD) Grant funded 6 month pilot at Crockett HS March-August 2012 Clinic operational and seeing students © 2009 Lone Star Circle of Care 39 Austin Independent School District (AISD) Goals Evaluate model Sustainability Replicate © 2009 Lone Star Circle of Care 40 Foundations Communities Local non-profit providing housing and support services for thousands of lowincome families and individuals. © 2009 Lone Star Circle of Care 41 Foundations Communities Grant improves BH access ‒ Psychiatry ½ day/wk. ‒ Refer to therapy as needed Medical home provided through LSCC PCPs © 2009 Lone Star Circle of Care 42 Lifeworks Non-profit social service agency providing a continuum of services to youth and families transitioning from crisis to safety. © 2009 Lone Star Circle of Care 43 Lifeworks St. David’s Foundation funds Lifework’s Shared Psychiatric Services (SPS) for short term psychiatric care LSCC’s provides a medical and BH home for children and their parents transitioning from SPS © 2009 Lone Star Circle of Care 44 Family Drug Treatment Court/Parents in Recovery (FDTC/PIR) Families identified by judicial and Child Protective Services (CPS) due to mother’s substance abuse Reduce children in out-ofhome placements and increase children reunited with families © 2009 Lone Star Circle of Care 45 Family Drug Treatment Court/Parents in Recovery (FDTC/PIR) Partnerships with Austin Recovery and FDTC/PIR Transition mothers and her infant/children into our medical and BH home © 2009 Lone Star Circle of Care 46 Awards and Recognition • Joint Commission Accreditation • A nationally-recognized “gold seal of approval” for health care providers Signifies that the safety and clinical qualify of care provided is exceptional Patient-Centered Medical Home (Level 3) recognition A recognition awarded by the National Committee on Quality Assurance Less than 0.5% of all primary care providers in the nation have this prestigious designation © 2009 Lone Star Circle of Care 47 Please complete and return your session evaluation form before you leave this session Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!