Freescale PowerPoint Template - Collaborative Family Healthcare

Report
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
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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
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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
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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:
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 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
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“The Usual Way”
Psychiatry
Outsourced
Mental Health Stigma
Medicine
© 2009 Lone Star Circle of Care
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“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
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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
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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
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Potential Systemic Effects of the “Depressed” Brain
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Sticky platelets
• Decreased heart rate
variability (HRV)
• Increased C-reactive
protein
• Increased cortisol
© 2009 Lone Star Circle of Care
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Systemic Effects of Cortisol
•
•
•
•
•
•
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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
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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
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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:
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
Our lifestyles
Effects of psychosocial
stresses and how we cope
with them
© 2009 Lone Star Circle of Care
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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)
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‒
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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
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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
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Integrated Care: What Differentiates LSCC’s Model

BH and medical providers employed by LSCC
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BH and medical providers on the same HER
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LSCC treats ALL psychiatric groups
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BH records fully open to the medical providers
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Medical providers have immediate access to
psychiatrists
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BH specialists embedded into the medical clinics
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Single governance structure that develops the
integrated services
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Active mental health screening in medical clinics

Psychiatrists actively treating patients vs. consultant
© 2009 Lone Star Circle of Care
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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
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Addressing PCP Challenges: Time and Access
•
Embedding behavioral health specialists
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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
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Telepsychiatry
© 2009 Lone Star Circle of Care
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The LSCC Integrated BH Model: Screening
Medical patients for mental health concerns
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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
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Primary care service provider (medical home)
Hypertension
Obesity
Diabetes
Co-occurring substance use disorders
Tobacco product use
Pain
© 2009 Lone Star Circle of Care
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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
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Easy Access to Clinical Information: EHR
© 2009 Lone Star Circle of Care
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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
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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
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Provider Mix
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Payer Mix
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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
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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
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Challenges: No Shows and Utilization
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No Show Policy
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Confirmation Calls
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Reverse Confirmation Calls
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Therapist-Based Intakes
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Same Day Call In List
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Intakes at Same Time and Overbook
© 2009 Lone Star Circle of Care
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Integrated Behavioral Health Outcomes & Scalable Results
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Quality Metrics
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Operational Metrics
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Symptom reduction
Functional improvement (future)
Access
Assess safety at each visit
Volume
Productivity
Satisfaction Metrics
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Patient satisfaction data
© 2009 Lone Star Circle of Care
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Integrating Education and Clinical Service
BH Training Partnerships
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Seton/UT Southwestern Psychiatry Residents
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Texas A&M Medical Students
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UT School of Social Work
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UT School of Educational Psychology
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UT College of Nursing
© 2009 Lone Star Circle of Care
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Psychiatry and Behavioral Health – Community Partners
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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
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New Initiatives in Behavioral Health
© 2009 Lone Star Circle of Care
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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
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Austin Independent School District (AISD)
Goals
Evaluate model
Sustainability
Replicate
© 2009 Lone Star Circle of Care
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Foundations Communities
Local non-profit
providing housing
and support
services for
thousands of lowincome families
and individuals.
© 2009 Lone Star Circle of Care
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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
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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
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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
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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
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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
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Awards and Recognition
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Joint Commission Accreditation

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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

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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
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session.
Thank you!

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