Overcoming Common Challenges: Maintaining Caseload and Engagement Issues. CHCCW KANA Bighorn

Transcription

1 Overcoming Common Challenges: Maintaining Caseload and Engagement Issues CHCCW KANA Bighorn

2 Overcoming Common Challenges: CHCCW Social Innovation Fund October 2016

3 Challenges Identified High turn over rates: providers, CMAs and dental assistants. Direct correlation with patients volume.

4 How Did We Know? Decrease in warm connections calls Drop in number of referrals Decrease in number of appointments Inconsistent screening Change in Care manager FTE, from 1.75 to 1.5 (October 2015)

5 Retention/Recruitment of Providers Recruitment to a rural place like Wyoming can be difficult. We definitely have shortages in the state, said Joe Steiner, dean of health sciences at the University of Wyoming. A lot of physicians are reaching retirement age. There s a pretty high demand for medical care across the state.

6 Recruitment Challenges in the Region The most often identified challenging position to recruit was Physician Family Practice without OB Clinical positions are much more difficult to fill than administrative positions The most often identified position with challenging turnover was Medical Assistant 2014 CHAMPS Region VIII Health Centers

7 Casper, Wyoming Industry Wyoming s economy is vulnerable to swings in commodities prices and global price competition. When the U.S. is doing well, Wyoming has more economic difficulties. Wyoming Department of Employment, Occupational Outlook 2010

8 Current Economic Environment Unemployment rates have increased with the decline in oil prices: statewide average in June was 5.7%, Natrona county 7.8%. Some individuals retained employment with a decrease in pay as high as 70%.

9 Weather Annual high temperature 59.2,low is 31.3 Average rainfall of inches Average snowfall of 75 inches We have the most wind in the US: average of 12.9 mph, but can reach 65 mph or higher.

10 The Challenge CHCCW s turn over rates between 2015 and 2016: 10 providers 8 dental assistants 20 Certified Medical Assistants OB/GYN department closed February 2016 Providers rotating between Quick Care and Family medicine Employees leaving town with spouses who lost jobs in the energy industry Employees leaving for other opportunities with higher pay/working multiple jobs to support families during difficult economic time

11 Turnover Last Day Job Title 1/2/ /25/ /31/ /30/ /9/ /18/ /27/ /11/ /30/ /8/201 5 Physicians Assistant Physicians Assistant Physician Physician Physician Nurse Practitioner Nurse Practitioner Nurse Practitioner Dentist Dentist

12 How the Challenge Looks in the Registry March 2015

13 Active Caseload 2015 April patients May June July August September PCP, NP left October 2015 November December IMPACT Champion PCP left OB/GYN left

14 Active Caseload 2016 January February 2016 March 2016 April 2016 May 2016 June July 2016 August 81 September OB/GYN department closed down 71 OB/GYN, CMO and PCP, NP left 71 RN Coordinator left 72 Hired MD, new CMO, Champion PCP 75 Hired NP, PCP

15 Addressing the Challenge Orientation to the IMPACT Model New Champion Provider Radke, MD (May 2016) New Primary Care Providers Quick Care Providers as PCPs Acclimating to the collaborative model Identifying schedule for consultation The cost benefit of collaborative care, 6:1 ratio Medical Assistants The importance of the MA role in identifying depression On going training Screening for depression is the 5th vital sign Communication with provider Not assuming the role of a mental health provider

16 Current Active Caseload

17 Discussion Is retention/recruitment a challenge in your clinic? What are some strategies you have used to minimize turn over?

18 IMPACT Challenges: Year 1 Kodiak Area Native Association SIF and John E Hartford Subgrantee Cohort 2 Year 2

19 Clinic Setting Kodiak Area Native Association is a non profit serving Alaska Natives, veterans and, since 2015, other community members in the Koniag region. KANA provides medical, dental, behavioral health and community services to citizens of Kodiak and the six rural communities on the island. In 2015, HRSA grant facilitated the opening of the new Mill Bay, which provides clinical services primarily to non Native patients. Total Patients at KANA 2789 Uninsured 45% Medicaid/Medicare 30% Commercial Insurance 25%

20 A Challenge We ve Identified Lower than expected enrollment numbers Anticipation that Mill Bay Clinic opening would increase enrollment. Monthly reports are not showing an increase. Today s Presentation Ongoing efforts to identify solutions Hypotheses moving forward Possible future solutions

21 How the Challenge Looks in the Registry SITE Care Mgr FTE Care Mgr Type Total Patients Treated Active Caseload Goal Minimum 1 Active Caseload 2 Contact >2months Active Caseload: % of Minimum 5+ Point Decrease 50%+ Decrease After at Least 10 Weeks Psychiatric Consultation 3 KANA June 2015 KANA Jan 2016 KANA April All in one % 46% 76% 83% 1 All in one % 36% 69% 69% 1.5 All in one % 47% 69% 63% Expectation that the opening of the Mill Bay clinic (October, 2015) would increase enrollment is not reflected in data. Note: data pulled from months when low enrollment could not be accredited to recent Care Manager turnover

22 Addressing the Challenge Hypothesis no.1: Low PHQ 9 completion rate: we aren t identifying clients in need of treatment. Solutions put into place: incorporate program information in to PHQ 9 so patients understand the purpose of the survey Remove patient name, use MRN to increase privacy Care managers will collect ALL PH 9s and count them against clinic visits to tabulate actual completion rate Re train front desk staff with script for delivering the PHQ 9 to patients

23 Data Obtained from PHQ 9 Collection May June July August Lost in the Workflow: Main 49% 61% 72% 65% Lost in the Workflow: MB 36% 45% 54% 52% These percents represent the proportion of PHQ 9s that don't get returned to the Care Manager. Reasons could include Patient leaves in waiting room, patient discardes, stuffed in pocket/bag, nurse doesn't get to review due to pressing medical issue, etc. Refused: Main 11% 15% 17% 20% Refused: MB 15% 15% 14% 20%

24 Addressing the Challenge cont. Hypothesis 2: Lack of collaborative approach Solution: Review workflow with front desk staff, ensure PHQ 9s are handed out every time. Ensure nurse staff gives patient PHQ 9 if is hasn t been completed in waiting room. Review language used by medical staff eliminate referral language and review team language

25 How it Looks Now in the Registry SITE Care Mgr FTE Care Mgr Type Total Patients Treated Active Caseload Goal Minimum 1 Active Caseload 2 Contact >2months Active Caseload: % of Minimum 5+ Point Decrease 50%+ Decrease After at Least 10 Weeks Psychiatric Consultation 3 KANA present 1.5 All in one % 42% 62% 65% Why no improvement? What we learned: While front desk staff and medical staff are all playing their part in the work flow, we have a high number of surveys that are not making it all the way through the workflow, and a number of clients declining to complete the survey which is limiting our new referrals. Hypotheses moving forward: 1. With a geographically limited population, do we have a limited number of people who will respond to our current approach 2. New cultural demographics added (military, Phillipino) means we have to explore cultural significance of reporting depression symptoms 3. Need to re examine program material may be too dense for patients

26 Continued Challenges, Questions, Concerns Work we plan to continue: Re examine IMPACT literature for maximum clarity and increased completion rates. Continue to hone teamwork efforts to unify all staff working on patients team. Work we plan to start: Take a deeper look at cultural and practical barriers that may be preventing patients from filling out the PHQ 9 and determine resolutions.

27 Discussion Interested in other clinics experience/success using PHQ 2 vs PHQ 9 Interested in other clinics experience with patients declining to fill out the PHQ 9 and solutions

28 Overcoming Common Challenges Social Innovation Fund October 2016

29 Clinic Setting Located In: Ashland, Montana Hardin, Montana Clinic serves 70% BVHC patients are Tribal Members 10% BVHC patients are 65 years and over 13% BVHC patients on Medicaid

30 Program Specifics 1 full time care manager/therapist 1 psych consultant 6 full time Primary Care Providers 3 part time Primary Care Providers

31 A Challenge We ve Identified Low Retention rates of patients IMACT program not reaching goal of minimum active case load Losing pt. in the IMACT program process Majority of pt. with high PHQ 9 also have chronic pain as chief complaint and were not returning to address depression symptoms

32 How it Looked in the Registry SITE Care Mgr FTE Care Mgr Type Total Patients Treated Active Caseload Goal Minimum 1 September 2015 Active Caseload 2 Contact >2months Active Caseload: % of Minimum 5+ Point Decrease 50%+ Decrease After at Least 10 Weeks Psychiatric Consultation 3 Bighorn 0.5 Shared % 64% 89% 88%

33 Addressing the Challenge Failures Wait for pt. to contact us after missing apt. Mail reminders Have only one contact phone number

34 Addressing the Challenge Successes Combined Care manger and Therapist one full time position Get everyone on board of understanding program Competition with PCP to see their referral stats Meet with team to identify trends (Chronic Pain and Depression) Large number of chronic pain patents not returning but the care manger gives the pt. their script after meeting with them. This has improved treatment outcomes!

35 How it Looks Now in the Registry

36 Chronic Pain and Depression in Registry Patient 1 Patient 2 DATE OF CONTACT CONTACT TYPE WEEKS IN TX PHQ- 9 DATE OF CONTACT CONTACT TYPE WEEKS IN TX PHQ- 9 12/2/2015 Initial Visit /31/2015 Psychiatric Consultation Note 4 1/11/2016 Follow Up /20/2016 Follow Up /25/2016 Psychiatric Consultation Note 7 2/29/2016 Follow Up /17/2016 Follow Up /25/2016 Follow Up /25/2016 Psychiatric Consultation Note 20 5/10/2016 Follow Up 22 5/17/2016 Follow Up /24/2016 Follow Up /14/2016 Follow Up /10/2015 Initial Visit /30/2015 Follow Up /7/2015 Follow Up /21/2015 Follow Up /31/2015 Psychiatric Consultation Note 7 1/4/2016 Follow Up /26/2016 Follow Up /2/2016 Follow Up /14/2016 Psychiatric Consultation Note 17 3/22/2016 Follow Up /20/2016 Follow Up 23 5/12/2016 Relapse Prevention Plan /7/2016 Discharge 30 6/15/2016 Relapse Prevention Plan 28 1

37 Chronic Pain and Depression in Registry Patient 3 Patient 4 Date of Contact Type Contact DATE OF CONTACT CONTACT TYPE WEEKS IN TX PHQ-9 7/31/2015 Initial Visit 0 9 8/6/2015 Follow Up 0 8 9/10/2015 Follow Up /19/2015 Follow Up /30/2015 Psychiatric Consultation Note 13 11/2/2015 Psychiatric Consultation Note 13 11/13/2015 Follow Up /20/2015 Follow Up /14/2015 Psychiatric Consultation Note 19 12/14/2015 Psychiatric Consultation Note 19 12/15/2015 Follow Up /22/2015 Follow Up /31/2015 Follow Up 21 1/20/2016 Follow Up /25/2016 Psychiatric Consultation Note 25 2/3/2016 Follow Up /17/2016 Follow Up /22/2016 Psychiatric Consultation Note 29 2/24/2016 Follow Up /23/2016 Follow Up 33 4/20/2016 Relapse Prevention Plan /11/2016 Follow Up /7/2016 Discharge 44 Weeks in Tx 6/4/2015 Initial Visit /25/2015 Psychiatric Consultation Note 3 10/20/2015 Follow Up /20/2015 Psychiatric Consultation Note 19 11/6/2015 Follow Up /9/2015 Follow Up 22 11/30/2015 Follow Up 25 12/4/2015 Follow Up /14/2015 Psychiatric Consultation Note 27 1/26/2016 Follow Up /22/2016 Psychiatric Consultation Note 37 2/29/2016 Follow Up /7/2016 Follow Up 39 3/15/2016 Follow Up /22/2016 Follow Up /5/2016 Follow Up /20/2016 Follow Up /2/2016 Psychiatric Consultation Note 47 6/7/2016 Relapse Prevention Plan /7/2016 Follow Up /28/2016 Discharge 60 PHQ 9

38 Continued Challenges, Questions, Concerns High Nomadic Population Chronic pain Depression or pill seeking? Poverty Phone coverage Internet access Mail Dispersed Population No Public Transportation Family Dynamics

39 Continue to Improve Continue to look at trends Continue to be flexible and make changes accordingly Continue to communicate with team and pt. to strive for improvement

40 Overcoming Common Challenges: Maintaining the Model of Care Issues SWMCHC Peninsula Partnership

41 Overcoming Common Challenges Social Innovation Fund October 2016

42 Clinic Setting Organization FQHC established 1986 Serves approximately 13,000 unique patients/yr Locations Butte, MT Dillon, MT Sheridan, MT (Pharmacy) Patients (2015 # s) 24% Medicaid 13% Medicare 31% Uninsured 32% Private Insurance (Increase ACA) Depression/Mood disorder Visits (2015) 5,742 Depression is the highest diagnosis in our clinic, close to half of all patients we see

43 A Challenge We ve Identified Reluctance to discharge patients with 2 months of no contact High need patients that we want to track but have not been able to successfully contact Many contacts attempts are made, but for a variety of reasons, we are unable to have that positive contact Due to busy schedules, multiple responsibilities, wanting to track patients this occasionally does not happen

44 How the Challenge Looks in the Registry

45 Addressing the Challenge Our Shared Care Managers have worked hard to manage their caseloads Implemented policy of 30 days and 3 contact attempts At 30 days from first contact attempt, if we are unable to contact the patient, then we will discharge them from IMPACT Always willing to re admit them into IMPACT

46 How it Looks Now in the Registry

47 Continued Challenges, Questions, Concerns Staff turnover Burnout

48 Discussion

49 Overcoming Common Challenges Peninsula Community Health Services October 2016

50 Clinic Setting PCHS opened its doors in 1987 In 1988 we had 11 staff Serving over 2,211 patients 87% of patients had a household income of less than $1,000 a month In 1993 became FQHC Fast forward to 2015: Nearly 200 staff Serving over 24,000 patients

51 A Challenge We ve Identified Maintaining a more even distribution of 2 contacts per month 1 via in person 1 via phone Phone contacts are difficult due to: Transient nature of patients Patients with limited phone minutes Time for Care Manager to make calls

52 How the Challenge Looks in the Registry

53 Addressing the Challenge Hired administrative staff to assist with other BH programs to free up Care Manager time Focus on schedule optimization Designated admin time for phone contacts

54 How it Looks Now in the Registry

55 Continued Challenges, Questions, Concerns Inaccurate contact numbers Challenge with connecting with patients in timely manner Access issues Continue scheduling optimization Consider expanding roles and responsibilities of non clinical staff to assist with contacts

56 Discussion How are you, as Care Managers, able to complete 2 contacts per month with one via in person and one via phone?

57 Overcoming Common Challenges: Partnership Social Innovation Fund October 2016

58 Partnership Health Center

59 Clinic Setting Location Missoula, MT Organization Established in 1989 FQHC established in ,092 unique patients in ,395 unique patients in 2015 Patients in 2012: 62% Self pay 19% Medicare 11% Medicaid 9% Private Pay Patients in 2015: 39% Self pay 14% Medicare 20% Medicaid 27% Private Pay

60 A Challenge We ve Identified PHQ9 completion rates lower in Behavioral Health compared to the medical clinic. Medical clinic completion rate 76.1% in Tracked using the depression screening UDS measure.

61 How the Challenge Looks in the Registry Completion of PHQ9 with Patients

62 Addressing the Current Challenge Discussing in staff meetings how care managers and therapists introduce the PHQ9 to patients. Identifying successful strategies for completing PHQ9 during follow up calls. Ex.: mailing patient a copy of the PHQ9.

63 How it Looks Now in the Registry

64 Continued Challenges, Questions, Concerns Continued Challenge Decreasing completion rates of PHQ9. Trying to identify what changed between the spring to now. Was the previous workflow more effective?

65 Discussion Have other clinics set goals for PHQ9 completion? Strategies used to engage patient in completing PHQ9 when they express screener burnout.