MAKE A GREATER IMPACT

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Frederick Holt
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1 0/29/208 Improving Access and Outcomes through Virtual Behavioral Health Integration into Primary Care Kate Rising, LPC Crystal Shirley, LCSW Now is the time to IMPROVE HEALTH FOR MORE PEOPLE MOVE BEYOND BORDERS PAR TNER WITH OTHERS MAKE A GREATER IMPACT Carolinas HealthCare System Is

0/29/208 Objectives Understand how care delivery systems focused on telehealth, virtual care, and skill optimization are driving access to behavioral health services in a financially sustainable

2 0/29/208 Objectives Understand how care delivery systems focused on telehealth, virtual care, and skill optimization are driving access to behavioral health services in a financially sustainable model targeting population health. Understanding how standardization of screening tools and treatment algorithms are critical to improving patient care. Knowledge of clinical skills needed for effective Integrated Care. Design quantifiable metrics relative to program impact on health outcomes, symptom improvement, resource utilization and overall cost of care. Behavioral Health Size and Scope 6 hospitals with over 0 beds Over 60,000 Outpatients served per yr Over,000 virtual consults provided a month in 2 EDs BHI providing care for over 29 clinics Over 36,000 calls received at Call Center Over 9,200 patients placed 5 Virtual Health Defined Telemedicine Telecommunication Connecting patients to care. Teleconsultation Teleconferencing Telemonitoring Greater than 5. million encounters annually 6 2

4 5 6 7 8 9 0 2 3 4 5 6 7 8 9 2 0 2 0/29/208 Virtual Care Not just Technology. Care is Care.

3 /29/208 Virtual Care Not just Technology. Care is Care. Core Competencies Benefits Evidence Based Timely Access Scalability Industry Alignment Sustainability 7 Population Health Management (Customized Coordinated Care) The Atrium BH Continuum Acuity/Resources Key Physical Service Locations Virtual Services Available Rely on Community Services 0. Brain 8. Outpatient Stimulation Behavioral Health Services (Therapy, Medication (ECT and TMS) Mgmt., Injection Clinics) 2. Employee 4. Care Assistance Management Programs 2 3. Mental 3. Primary Health First Care Aid Integration 6. School-Based Services 5. Nalaxone Project 7. Medication Assisted Therapy 7. Psychiatric Observation Unit 6. Psychiatric ED 4. Acute Care Hospital (C/L and Tele-C/L) 2. Crisis Line Call Center. Assertive Community Treatment Teams 9. Intellectual & Developmental Disabilities Clinic 8. Inpatient Psychiatric Services 5. Acute Care ED (Telepsych and BHPP) 3. Medical Detox 9. Partial Hospitalization Services (Adult & C/A) 20. Substance Use Intensive Outpatient (Adult & C/A) 2. Residential Hom e questions to Quiana.Smith@carolinashealthcare.org 3

0/29/208 The State of Behavioral Health One in five adults suffers from a diagnosable mental disorder. 43.8 million adults experience mental illness in a given year.

Even beyond the United States, mental illness is the # cause of disability life years worldwide, vastly outnumbering those caused by cardiovascular disease and cancer.

4 0/29/208 The State of Behavioral Health One in five adults suffers from a diagnosable mental disorder million adults experience mental illness in a given year. Untreated mental health and substance abuse disorders cost the US $250-$500 billion per year. $93 billion per year in lost workplace earnings due to untreated mental illness. Even beyond the United States, mental illness is the # cause of disability life years worldwide, vastly outnumbering those caused by cardiovascular disease and cancer. With proposer diagnosis and effective treatment, the recovery rate for patients with mental illness is 60-80%. But in today s environment, the effective recovery rate is only 5-0% due to such limited resources and infrastructure. Comorbid Behavioral Health and Chronic Medical Conditions 2006 Milliman, Inc US Health Care Study 4

Psychiatry Workforce Challenges US: 40,000 PSYCHIATRISTS Half of all the counties in the US don t have a single practicing Mental Health professional Concentrated in Urban Areas 48% of psychiatrists

5 0/29/208 Why Primary Care? Stigma 70% of visits are Psycho- Socially related Greater than 50% of all psychotropics prescribed by PCP s 40,000 Suicides annually 45% of patients completing suicide saw their PCP within 30 days Psychiatry Workforce Challenges US: 40,000 PSYCHIATRISTS Half of all the counties in the US don t have a single practicing Mental Health professional Concentrated in Urban Areas 48% of psychiatrists are over the age of Psychiatrists." U.S. Bureau of Labor Statistics. U.S. Bureau of Labor Statistics, n.d. Web. 30 Nov IMPACT PCP New Roles Core Program Patient BHP/Care Manager Consulting Psychiatrist Other Behavioral Health Clinicians Additional Clinic Resources Substance Treatment, Vocational Rehabilitation, CMHC, Other Community Resources Outside Resources 5

0/29/208 IMPACT / Collaborative Care Model 2 year Randomized Control Trial: 80 Adults with Depression 2 months: 50% reduction of depressive symptoms 45% IMPACT model 9% usual care

6 0/29/208 IMPACT / Collaborative Care Model 2 year Randomized Control Trial: 80 Adults with Depression 2 months: 50% reduction of depressive symptoms 45% IMPACT model 9% usual care participants 4 years $3,300 in savings in health care spend per patient Repeated in 80 Randomized Trials 6 24-Month Health Care Costs for IMPACT Enrollees Versus Control Patients Going Virtual 6

7 0/29/208 Why Virtual? 2 Timely Access Scalability 3 Sustainability 4 Industry Alignment Overview The Collaborative Care Model The Team Behavioral Health Professional PCP LCSW/LPC BHP/Care Patient Manager Other Behavioral Health Clinicians Substance Treatment, Vocational Rehabilitation, CMHC, Other Community Resources Consulting Psychiatrist Additional Clinic Resources Outside Resources Health Coach Bachelor level with two years experience Obtain Health Coach Certification within year of hire date Provider Adult Psychiatrist Child and Adolescent Psychiatrist Nurse Practitioner Virtual CHS BH Support Team Pharmacy Board Certified Psychiatric Pharmacist (BCPP) Our Model We ve got your back The key to making teambased medical care work is helping the patient feel that his or her relationship with the primary-care provider is at its center. What we want to accomplish: Improve early detection Timely access to services Reduce unnecessary referrals to higher level of care Drive cost effective & clinically Suzanne Koven is a primary care doctor at Massachusetts General Hospital in Boston and writes the column "In Practice" at the Boston Globe. effective treatment Support the Primary Care Provider 7

0/29/208 Screening is the Driver Treatment and Patient Engagement Evidenced Based Treatment Standardized tools in the PCP setting enhances screening diagnosis, and treatment planning Patient

8 0/29/208 Screening is the Driver Treatment and Patient Engagement Evidenced Based Treatment Standardized tools in the PCP setting enhances screening diagnosis, and treatment planning Patient Engagement Recovery Process. PCP consults BH Provider for curb side chart review 2. Elevated PHQ-9 Scores Captured in BH Patient Registry PCP initiates in office virtual visit if needed 4. Post Appointment Call Back Protocol PCP Office PCP Office Administers PHQ-9 3. PCP Appointment BH Patient Virtual BH Support Team questions to 36 8

9 0/29/208 Required Social Work Skills Social Work interventions do not take place of traditional psychotherapy, it is a missing entry point. Clinical skills required: Screening and Assessment Brief therapeutic interventions Documentation and shared treatment planning Crisis Intervention and safety planning Needed Knowledge Understanding of Population Health Self-management skills Psychopharmacology General understanding of common illnesses, normal health ranges, and effects of co-morbidity on mental health Health acronyms and jargon Community Resources for several counties Virtual Practice Personal skills and rapport Adaptable to Call Center environment Team approach Communication and documentation Multi-tasking Technology Data Tracking 9

10 0/29/208 Health Coaching Motivational Interviewing Sleep Hygiene Substance Abuse Movement vbhi Health Coaching Pain Management Nutrition Stress Management 0

0/29/208 vbhi Current State Entry Point vbhi by the Numbers (207) 73.7% Patient Registry 23.

8% CHS Care Management Access to vbhi 4,228 Unique Patients 0,73 Patient Encounters,8 Patients Active

Depression symptoms Anxiety symptoms Suicide ideations Weight/BMI Inpatient Visits Overall HgB AC

11 0/29/208 vbhi Current State Entry Point vbhi by the Numbers (207) 73.7% Patient Registry 23.5% Primary Care Provider 2.8% CHS Care Management Access to vbhi 4,228 Unique Patients 0,73 Patient Encounters,8 Patients Active Patients 2 Primary Care Practices 6 Pediatric Practices 70 Care Management Clinics questions to Quiana.Smith@carolinashealthcare.org Return on Investment Disease Severity Clinical Outcomes Healthcare Utilization Cost of Care Depression symptoms Anxiety symptoms Suicide ideations Weight/BMI Inpatient Visits Overall HgB AC Inpatient Days Inpatient Cholesterol Ambulatory Visits Ambulatory (Total, triglycerides, (Primary/Specialty) LDL, HDL) ED Visits ED Avoidable ED/IP Visits Clinical Outcomes 45% reduction in PHQ-9 score 58% decrease in suicide ideation 45% decrease in GAD-7 Score 33

0/29/208 Avoidable Inpatient Care and ED Visits There was 27% reduction in avoidable inpatient visits (from 33 visits pre- to 24 visits postintervention).

org There was 7% reduction in avoidable ED visits (from 62 visits pre- to 578 visits post-intervention, p=.

12 0/29/208 Avoidable Inpatient Care and ED Visits There was 27% reduction in avoidable inpatient visits (from 33 visits pre- to 24 visits postintervention). Inpatient visits were classified as avoidable using AHRQ Prevention Quality Indicator (PQI) methodology questions to There was 7% reduction in avoidable ED visits (from 62 visits pre- to 578 visits post-intervention, p=.883) Visits were classified as avoidable using NYU ED Algorithm (types of avoidable visits included: Non Emergent, Emergent but PCP Treatable and Emergent but preventable) vbhi Sustainability $300,000 Embedded: Atrium Health Clinic $250,000 $200,000 $50,000 $00,000 $50,000 $0 Embedded: Federally Qualified Health Centers 4.6 FTE Virtual Platform: CHS Behavioral Health Integration.5 FTE FTE Cost Comparison Burke et al.; BMC Health Services Research 203, 3: Next Steps Better study design for evaluating the program, possibilities include Randomized control trial: eligible behavioral health patients are randomly assigned to receiving BHI or not. Semi-quasi experimental design: patients from BHI clinics compared with clinically comparable patients from non-bhi clinics. Self-selected controls: patients who were screened but never enrolled in BHI. Due to self-selection bias, need to adjust for baseline comparability at data analysis stage.. Replacing billed charges with cost data for acute care utilization. Adjust for inflation while the study period expands across several years. Looking into secondary gains of the program, such as Appropriate diagnosing of depression among BHI clinics Appropriate referral to psychiatrists Pharmaceutical spend at BHI clinics Identify handful of factors that qualifies patients as high-risk for poor outcomes. Apply scoring algorithm to flag these patients at the time of care delivery 36 2

13 0/29/208 Key Takeaways... This work puts the patient first always integrated into the full continuum, including prevention and community health Standardized work in development and being refined (incl. teammate expectations and tools that need to be followed) Utilize data analytics to drive focus and improve outcomes Coordination is essential; expectation that as a team we make sure this happens 00% of the time Efforts to scale will be critical for success we will prioritize to ensure this happens vbhi Quarterly Webinar Occurs the st Wednesday every 2 months Contact Information: Brandt Bettilyon Project Manager, Carolinas Behavioral Health Collaborative Brandt.Bettilyon@atriumhealth.org 3

Session 84X Integrating Behavioral Health into Primary Care and Care Management

Prepared for the Foundation of the American College of Healthcare Executives Session 84X Integrating Behavioral Health into Primary Care and Care Management Presented by: Martha J. Whitecotton, RN, FACHE