Primary Care/Behavioral Health Integration (3ai)

Size: px

Start display at page:

Download "Primary Care/Behavioral Health Integration (3ai)"

Natalie Parks
6 years ago
Views:

1 Primary Care/Behavioral Health Integration (3ai) Standards of Care Summary Opportunity for PIC Input

2 Standards of Care - Workgroup Workgroup Charge It is expected that standards of care be developed around treatment planning, medication management, care engagement, communication of results, joint decision making, communication and collaboration, warm transfers, and referral to outside providers. Workgroup Membership Organizations Represented: Psychological Healthcare Hutchings Psychiatric Center Upstate St. Joes Lewis County General Hospital NOCHSI Oneida HealthCare Crouse Counties Represented: Lewis Oswego Madison Oneida Onondaga Dates Met 8 meetings between 3/31/16 and 6/3/16

3 Standards of Care Standard I Integrated Delivery System Workgroup Recommendations: Creation of formal, two-way lines of communication to support care across the continuum, rapid engagement into integrated care, and coordination of services provided outside of an integrated site. Two-way communication should include the frequent use of the Regional Health Information Organization (RHIO) (alerts, direct messaging, etc.) and CNYCC s Population Health Management System (PHM). Development of policies and procedures to support site use of information technologies in care delivery. Noted overlap with ED Care Triage (2biii) and Care Transitions (2biv)

4 Standards of Care Standard II Team Based Care Workgroup Recommendations: Development of patient Care Teams Regularly held Multidisciplinary Team Meetings that include Daily Huddles and larger Team Meetings Use of Integrated Care Plans to coordinate care Resource: Cambridge Health Alliance Toolkit Noted overlap with PCMH recognition, DSRIP Care Management (2aiii), Cardiovascular Disease Management (3bi), and Palliative Care Integration (3gi)

5 Standards of Care Standard III Screening (Model 1) Depression (DSRIP Project Requirement) Universal, short-form screening. If short-form is positive, long-form screening required. Ages: USPSTF recommends opportunistic screenings 18 & up Workgroup recommends screening patients annually at minimum, and more frequently based on patient life circumstances and clinical judgement. Recommended Screens PHQ 2/9/A Edinburg Postpartum Depression Scale Geriatric Depression Scale Columbia Suicide Rating Scales when nececcary

6 Standards of Care Standard III Screening (Model 1) Alcohol and Drug (DSRIP Project Requirement) Universal pre-screen at every encounter with 1 or 2 questions about use included in initial patient information gathering. Positive responses to pre-screen trigger screening with evidence based tool. 11 & up Tiered approach to screening: 1. Pre-screen questions asked at every encounter 2. Short form screening when triggered by pre-screen 3. Long form screening when triggered by short form Recommended Screen CRAFFT (adolescents 11-21) AUDIT & AUDIT C (adults) DAST-10 (adults)

7 Standards of Care Standard III Screening (Model 1) Anxiety (Workgroup Recommends) Pediatric Population Used if triggered by broader behavioral assessment. Adult Population Universal, short-form screening. If short-form is positive, long-form screening required. All ages Workgroup recommends screening patients annually at minimum, and more frequently based on patient life circumstances and clinical judgement. Recommended Screening SCARED (parent and youth) GAD 2/7

8 Standards of Care Standard III Screening (Model 1) Eating Disorders (Workgroup Recommends) Ages: General patient population: Annual health supervision examinations and pre-participation sports physical examination Patients w/ high risk factors: At routine office visits Recommended Screening ESP (short) EAT-26 (long)

9 Standards of Care Standard III Screening (Model 2) Workgroup Recommendations: Cardiovascular Disease Diabetes Hypertension Noted overlap with Cardiovascular Disease Management (3bi)

10 Standards of Care Standard III Screening (Model 2) Screening Age Frequency Weight/Body Mass Index All ages Quarterly Blood Pressure All ages Quarterly Fasting Lipoprotein Profile All Ages Varied based on age and risk factors Blood Glucose and up Quarterly

11 Standards of Care Standard IV Comprehensive Assessment Workgroup Recommendations: Screening positive for any of the conditions identified in Standard III (Model 1 or 2) results in the completion of an assessment to more fully understand patient needs. The assessment should be inclusive of identification of patient s eligibility or engagement in Health Homes or DSRIP Care Management services. Noted overlap with DSRIP Care Management (2aiii)

12 Standards of Care Standard V Treatment When needs can be met at the integrated site: Model 1 (BH-> PC): The primary care provider will drive care and coordinate with onsite specialty services, including onsite behavioral health staff. Model 2 (PC-> BH): At an integrated behavioral health site, care will be coordinated by the care team. When needs cannot be met onsite: The integrated site will coordinate care to ensure communication with outside care and to support patient engagement in services. Documentation of the outside care becomes part of the integrated patient record onsite.

Standards of Care Standard VI Warm Transfer An ideal warm transfer is a same-day, person-to-person introduction (See National Coalition for Behavioral

13 Standards of Care Standard VI Warm Transfer An ideal warm transfer is a same-day, person-to-person introduction (See National Coalition for Behavioral Health s video.) If the ideal is not available, the workgroup suggests a stratification and prioritization based on need and a patient s likelihood to engage.

14 Warm Transfer Diagram Workgroup Suggested

15 Warm Transfer Diagram Workgroup Suggested

16 Standards of Care Standard VII Documentation & Information Sharing Connection and regular use of the RHIO as an information source and as a mechanism of communication to/from other providers (Standard I) Screening results documented in the EHR (Project Requirement). Workgroup Recommends: Initial screening results are available to the provider to address in the visit. Warm Transfers documented in the EHR (Project Requirement). Medical and behavioral healthcare are documented in an integrated EHR (Project Requirement).

17 Standards of Care Standard VIII Standards of Care Review Reviewed at minimum, annually More frequently as needed to maintain up-to-date standards

18 Questions/Comments/Feedback

Central New York Care Collaborative (CNYCC) Oneida County Health Coalition Meeting June 30, 2016

Central New York Care Collaborative (CNYCC) Oneida County Health Coalition Meeting June 30, 2016 Agenda 1. Overview of the NYS DSRIP Program 2. History of Performing Provider Systems in Central New York